Medical School 2020, Year 4 Week 10 (Nephrology elective)

Picking up with our medical school diary, authored by our anonymous mole inside the system… It’s the fall of 2019.

I meet at 9:00 am in the hospital dialysis unit with nurse practitioner (NP) Nora. She’s 34 and has worked at the nephrology practice for four years, progressively taking on more responsibility. She is my contact during the two-week nephrology rotation. The attending, a 42-year-old interventional nephrologist, is on call at the hospital and performs procedures at the nearby clinic. NP Nora and I hold down the fort.

We run the list of patients in the hospital who will need dialysis today, and go over the consults from overnight and this morning. Consults come in three flavors: 

  1. The most common consult is for patients with end-stage renal disease (ESRD) who are admitted to the hospital for an unrelated reason, such as a GI bleed, myocardial infarction, or pneumonia, and need their dialysis while in the hospital. We try to continue their standard schedule, e.g., “TTS” for Tuesday, Thursday, and Saturday, about two hours on the machine per session at an outpatient dialysis center. Five clicks in Epic and the dialysis nurses will know what to do. 
  2. Acute renal failure. These patients are typically unstable, e.g., from septic or cardiogenic shock that resulted in such poor perfusion to the kidneys that they shut down. These patients have electrolyte derangements and toxin buildup that is not being filtered by the kidneys. They need either intermittent hemodialysis (IHD) or CRRT (continuous renal replacement therapy; “slow” dialysis). 
  3. The last type of consult is for electrolyte abnormalities, frequently low or high sodium. These are usually “tea and cracker” old ladies who do not eat enough, alcoholics, and the occasional ultra distance runner. If the sodium is corrected too fast, the osmolarity change can result in brain damage. (A University of Virginia fraternity contributed the highest recorded sodium to the medical literature: “Survival of acute hypernatremia due to massive soy sauce ingestion” (Carlberg, et al. 2013).)

We get six consults throughout the day, four of which are for ESRD admits. I watch Nora’s exam on the first ESRD consult. She examines the patient’s vascular access, an arteriovenous (AV) fistula, and determines his schedule and typical net volume change from the outside records. We get these on paper because the patient’s dialysis center’s electronic medical record does not interface with our Epic system. It takes 20 minutes to find the needles we’re looking for in the haystack of paper. We evaluate his volume status by listening to the lungs and checking for peripheral edema in the legs. I do everything on the next ESRD admit, with NP Nora watching and helping.

An AV fistula is a surgically-created connection between a large vein and artery in the arm that is brought close to the skin for cannulation with a needle. This fistula is allowed to mature until there is adequate blood flow for dialysis, while ensuring adequate perfusion to the distal limb. 

In the afternoon, we get a consult for acute renal failure in a 42-year-old uncontrolled type 2 diabetic patient who presented yesterday evening in septic shock from a necrotizing soft tissue infection of the leg. He probably stepped on a sharp object and did not notice the wound for a few days. He underwent a below the knee (BTK) amputation of the right leg, and was sent to the ICU. His kidneys have not recovered, and they are starting him on CRRT because his blood pressure drops too much with the two-hour iHD.

The most interesting consult during the week is on a 58-year-old patient with metastatic bladder cancer. The prognosis is that he is likely to live only one or two additional months. The cancer has obstructed both ureters, resulting in progressively worsening kidney failure. The tumor responded to first-line therapy, but recurred three months later, and did not respond to second-line therapy. The patient presented to the emergency room with left flank pain from hydronephrosis, a kidney ballooning from distal obstruction. He underwent placement of a nephrostomy tube (a catheter that the interventional radiologist pokes into the kidney to drain urine) to drain the kidney and prevent further deterioration of his last remaining functional kidney. We explain that we could start dialysis on him, but would need to coordinate with the oncologist given a palliative approach may be a better path for him. He will likely have end stage renal disease within a few weeks.

The oncologist agrees that palliative is the best option given that the patient has only about a 10 percent chance of some response from rescue or “salvage” chemotherapy. This will entail three months of debilitating pain (at a cost of over $100,000 to Medicaid). The oncologist did not sugar coat matters for the patient: “This is probably the worst case of bladder cancer I have ever seen. If you don’t go on dialysis, the way you will die is you’ll become very tired. You’ll have periods where you are lucid, and then you will go back to sleep. This will happen over a few days, until you fall asleep. Your body will begin to realize it is dying, and release its natural endorphins to help with the pain. We’ll give you pain medications until that kicks in.” As we walk down the hall, he explains to me, “Kidney failure is a good way to die. It’s quite peaceful.”

By the end of the week I am appreciating the teamwork of the NP and attending. She gets things done around the dialysis unit, puts in orders, and helps organize the nephrologist. When a consult comes in for something atypical, the consult is sent to the nephrologist. During rounds she will ask about the management of these patients, and seems to learn something new every week.

After work, Sarcastic Samantha, Lanky Luke and I grab drinks with the nephrology NP at our favorite burgers and beer joint. Samantha comments how she does not see many PAs and NPs that are happy in their job, including herself. The nephrology NP responds, “I’ve gone through so many mundane ACP [Advanced Care Partner] jobs in which I was miserable. It’s all about finding a partner in a doctor. I think that’s the beauty of the ACP is that you can mold into the role – find your niche. You need to find a physician that will build you up so you are a smooth team.” She adds, “We are trying to hire another ACP to work under me. The problem we have is that new ACPs switch jobs so frequently it’s hard to justify investing time in them.”

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 1 night. Jane and I went on a weekend Airbnb cabin getaway.

The rest of the book:

5 thoughts on “Medical School 2020, Year 4 Week 10 (Nephrology elective)

  1. It’s not supposed to be funny, but I had to stop reading at this point, calm down, and come back later to finish the post.

    >(A University of Virginia fraternity contributed the highest recorded sodium to the medical literature: “Survival of acute hypernatremia due to massive soy sauce ingestion” (Carlberg, et al. 2013).

    From the link: “Case report: A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce.”

    How does one explain this to people afterward, assuming one survives? “I just REALLY love soy sauce. Even all by itself! A little too much, I guess!”

    The University of Virginia doesn’t even have a Food Science program (VA Tech does.) The closest thing UVA has are “food-related courses” like this one about Non-Violent Organizing:

    “Non-Violent Organizing ENWR 2559”

  2. > Samantha comments how she does not see many PAs and NPs that are happy in their job, including herself.

    I’ve noticed this too, during my travels and travails through our healthcare system. Even in a relatively “good” hospital the PAs and NPs seem cranky and upset quite a bit of the time. I start to think maybe it’s “contagious” in the sense that someone can set the tone and then others will go that way, too, but that’s a little too easy.

    The only thing I’ve been able to realistically do is try to reward some of the people who have helped me, even in a small way, to let them know I appreciate their work. I’ve bought a couple of really nice pastries and cakes for some people who have been there for me, along with a couple of cards and so forth. I also try to be upbeat and thank them for their efforts. I can’t give them a raise or make their work easier, but I can thank them and tell them I appreciate them. You have to treat people with respect if you expect them to care for you. I’ve seen my share of really troublesome, upset patients who never say a single kind word.

    • True example: recently I was in the hospital relatively late at night and by the time I was ready to go I was absolutely exhausted, so I needed a wheelchair to haul me out to the exit nearest my parking garage location. The guy who showed up does this all day long, basically pushing people from place to place, most of whom never say a single thing to him. It was a relatively long trek through the hallways so I struck up a conversation with him and when we got there, I thanked him for bringing me there. He said: “I hope you get home safe. I like working here but most people don’t thank me.” In other words, the guy who pushes you around in a wheelchair is still a person who has feelings, and they can tell who appreciates them and who doesn’t.

  3. From the time I was recovering in a 4-bed room of a Toronto hospital, I still remember, 13 years later, two immigrant staff members who, whenever they entered the room, made me feel like the sunshine had entered with them. Their job? cleaning the bathroom.

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