Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
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Jan - 21
Feb - 8
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15 days at the VA – day 6
22 Dec2009
Yesterday we had admission duty. As of last night we were up to 7 with a max of 10.
I got a question about palliative care that bothered me.
Palliative care discussed when there are potential therapeutic options available?
This patient has end stage liver disease. We can only treat his complications, not his underlying disease. I believe that defines palliative care.
We have become aggressive about palliative care. We try our best to treat the patient rather than focusing solely on the disease.
I got another question about the cause of the hyponatremia:
And what is decreased intravascular volume anyway? It can't be directly measured unless you have massive acute fluid losses. IT's a pretty nebulous concept in the chronic state.
I urge the commenter to re-read yesterday's post. I never used the phrase intravascular volume. I provided a reference to the concept of decreased intra-arterial volume. The idea is that the arterial volume is decreased in end stage liver disease or end stage CHF. The venous volume is increased. The decreased intra-arterial volume stimulates ADH and thus the patient develops hyponatremia. Our patient's sodium was 131.
We had an admission yesterday afternoon that required another palliative care consult. The patient had a renal transplant 21 years ago, but now stage IV CKD due to slow rejection. He tells us that he will not do dialysis.
We are asking palliative care to see the patient so that we can evaluate his 5 wishes.
Now off to the VA to care for our new patients and the hold overs.
Related posts:
- 15 days at the VA – day 5
- Ineffective intraarterial volume
- 17 days at the VA – Day 4
- Acid base answer
- 17 days at the VA – day 13
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- In: Medical Rants
3 Responses to 15 days at the VA – day 6
cory
December 22nd, 2009 at 8:14 am
Sorry. when I used the term intravascular I was referring to arterial blood volume, but my question still remains.
What constitutes decreased effective arterial blood volume? How do you measure it in a complex system of pipes that are quite elastic and subject to all sorts of forces?
Low blood pressure? But many of these people don't have low blood pressure – unless you are saying it is relatively low, which sort of begs the question.
You may tell me increased BUN/Cr or decreased Fe Na but those are quite indirect measurements and are neither sensitive nor specific.
Yes , we often have increased ADH in "low EABV states" but what does that specifically correlate with? What measurement?
Low PCWP? Working in intensive care for many years I found that quite unreliable
In the absence of acute bleeding, it's still unclear to me what constitutes decreased effective arterial blood volume in a chronic situation.
pcb
December 22nd, 2009 at 8:40 am
shouldn't decreased arterial volume also stimulate aldosterone secretion which should cause retention of sodium to match the ADH related retention of water? (if the patient is not drinking too much free water)
rcentor
December 22nd, 2009 at 9:29 am
Please read the article that I linked to yesterday. These patients actually have decreased arterial volume. They do also have increased aldosterone, but that has no impact on serum sodium. Aldo does not adjust free water excretion. Hyponatremia results from decreased free water excretion.