Salt II

This is a continuation of yesterday's case. In the morning, the attending saw and evaluated the patient and felt that the patient was hypovolemic. At that time, the attending actually decided to give hypertonic saline. The sodium increased ever so slightly. I still felt the patient was hypervolemic and I held my ground. In my note, I put that my exam was consistent with a hypervolemic hyponatremia though certainly there was a degree of uncertainty.

Finally, we got a formal echocardiogram. It showed that the patient was markedly volume overloaded and in systolic and diastolic acute on chronic decompensated heart failure. Her heart could not adequately pump blood forward to her kidneys, and so her kidneys were failing; her sodium was being diluted in the setting of too much fluid on board.

With cardiac and renal consultations, we began dobutamine and an aggressive diuretic regimen. Unfortunately, the kidneys suffered and she eventually required dialysis. She was transferred to the cardiology service for further management of congestive heart failure.

I write these two blogs not to say that I was right and the rest of the team was wrong, but instead to point out the extraordinary difficulty of clinical medicine. This was an excruciatingly difficult case because it pins the diagnosis on a subjective physical exam in an era when we rely more on our fancy tests than our hands and eyes. It is so hard because the patient had a poor outcome from a delayed diagnosis. Who could say whether she would have done differently had I instituted earlier diuretics and inotropic support?

But the more important point is to say this: whether you are a medical student, intern, resident, fellow, or attending, you could be wrong. Our judgment is imperfect. We must allow differences of opinion and check ourselves to see whether everything fits. But on the other hand, we must take a stand. I don't fault anyone else in this case. Everyone else put the evidence together and came to another conclusion -- and that's fine. You absolutely have to go down one path and see whether it's right or not. Medicine is hard. It is an enterprise of judgment, experience, passion, and resolution, and when we are wrong, we must look at what happened and try to understand how to prevent future lapses.

Image of salt mounds in Salar de Uyuni, Bolivia from Wikipedia. shown under Creative Commons Attribution Share-Alike License.