The Diuretic Debacles

Pee pee. The best feeling when you have a full bladder. The annoyance when your dog is overdrinking because of a medication and can’t wait to go outside. The desire when one’s prostate is enlarged and won’t allow the flow to flow. The necessity when a heart is overloaded…preloaded, to be more precise.

When a patient is admitted with fluid overload, every prescriber has a comfort level on how to treat it. There are usual types and ranges of doses of diuretics, guidelines, and experience. Some prescribers have favored strategies, and some will get a consult from a specialist.

Regardless of the tactic, there is science behind it all. Very clear concepts guide the use of diuretics. However, a lot of people just observe and emulate, not knowing the why or when or how of it all.

The problem is not everyone gets the science. Enter PHARMACOLOGY.

Today I heard, “On a patient last week, Dr. D ordered Drug P at 100mg and the patient peed a lot. So, I thought we should do the same thing for this patient. He’s only on 40mg of Drug J, but Drug P is so much more potent. If we give a more potent drug at a higher dose, I’m thinking we’ll have a much faster pee pee for this patient.” I’m paraphrasing.

Again, the problem? This is not how diuretics work. In short, there is a maximum dose of sorts. And it’s different for every patient. A higher dose will not achieve a greater effect. There’s also a dose too low to be effective, and that’s also different for every patient. You have to find the right dose to cause the pee.

So, what would happen if Drug P at 100mg was ordered? You’d probably make the patient pee pee. But you could also cause a lot of other problems. First, do no harm, right? Besides, Drug J is working at its 40mg dose, and our current patient is different from last week’s patient.

This reminds me of my mom’s gourds. She’s an artist. A hobbyist who doesn’t get properly reimbursed for her talents…and skills. She’s like the consultant. If someone needs something artistic, they call her.

She paints gourds. People love her gourds. People want to learn how to paint gourds just like hers. People ask for tutorials. And my mom teaches them for the joy of it. That’s it. No pay. Her gourds are truly a work of art.

When the ladies who beg my mom to teach them how to paint gourds try to paint their own, the result is amateur, like an arts and crafts project from summer camp. They are rough and bumpy, lack the mingling lines of color, and do not have the same mirror-like finish.

They tried to emulate my mom’s carefully created product without employing her intentionally ordered process. They didn’t see the importance, or perhaps didn’t understand it, of the intermediary steps that made the gourds smooth and expert.

Her art has a method. It has a science. Enter the ARTIST.

They say imitation is the sincerest form of flattery, but it’s not really. When the result is poorly executed, it is insulting. Frankly, no one wants to be associated with it. When the patient is readmitted for complications of the diuretics, it’s aggravating. I back up slowly, hands up in feigned ignorance, turn on my heel, and exit the room…probably to got to the bathroom…to pee pee.

The Third Side of Dying: The Daily Reel

The last three weeks were pathetic. Every image, every action, every word added to evidence of a life ending. A life that could no longer live but had just enough energy to fade. Here is my account:

For months all I could remember was him sleeping in the recliner or the hospital bed we had placed in the middle of the living room. We raised the head of the bed in the morning to welcome the day and lower it in the afternoon and evening. He invariably repositioned himself to where his head was wedged between the pillows and the bedrail and to where his feet would start to dangle off the corner of the mattress, uncovered. I can say I don’t think the bed was comfortable.

Before he landed permanently in that bed, we got him up to his favorite recliner that usually resided in the basement. He was a little more interactive then. He didn’t talk much, but he would react. A few old friends, the pastor, a cousin, or grandchildren would come to visit, sharing stories and photos. A sepia-toned picture of the old farmhouse and general store brought a smile to his face and, surprisingly, a tear to his eye. At that point I’m not sure he knew he was actively dying, but his tears were rare. I saw them as a gift–a connection to something deeper he didn’t like to expose, just in time.

In the hospital a day before we brought him home to die, the hematologist/oncologist brought us news of a rare and rarely recognized condition. All I could do in the hallway was ask her questions about her, where she did her training and how long she had worked there. My dad’s relationship-discovering personality is where I default when I have nothing else to say. My dad was dying. What else was there to say? The situation hadn’t found a resting place in my mind yet, but my dad’s compulsion to find out about people had roots in me.

He wasn’t talking much those last weeks, and his protests to our care were mostly carried out in grimaces and shut eyes. One morning about a week before he died, I saw him stretched out diagonally in his bed to avoid propping up his head on the pillows. The stack of pillows had been placed there in an attempt to entice him to arouse, to perhaps eat something soon or interact with people. His objection was displayed by refusing to comply with the perpendicular lines of his bed. I pushed the button to lower the inclined head of his bed and took out a pillow or two. “That’s just what you needed,” I said as I saw him relax his posture and scoot back to the center.

“That’s just what I needed,” he managed to whisper as he glanced at me through slit eyes. Although this is a memory mired in the piteous, it will always be a perfect interaction and indelible memory.

I remember feeding him food I hoped he would adore. Barbecue, beans, roast beef sandwiches, cornbread, chili. He would only take a few bites before closing his eyes and refusing to eat more. I think he was trying to eat, not because he was hungry but because I was caring for him. I both appreciated and loathed this. Why couldn’t he feed himself? His arms still worked. Alas, he dwindled to only taking sips of the vanilla protein drinks. We eventually remembered his love of ice cream. How could we forget? Frozen protein drinks saved the day…not really…but we felt better about the situation because he actually took them in with some assumed pleasure.

I don’t know why we kept on doing it, but caring for his diet was futile. He was taking in less than 500 calories a day and little to no water. It was time for a urinary catheter and morphine. The pain we could not relieve with acetaminophen was relieved when the brown liquid drained from his bladder. The morphine made him sleep, his blood pressure started to drop, and his temperature started to rise. An infection, maybe? Dying? Yes.

The jerking of his hands, the dryness of his mouth, the gurgling in his throat, and the persistence of his lungs. All were disorienting. Contrary to expectations he kept living for 48 or 72 hours longer than expected. He was placating us, and I don’t understand why. We waited. Took turns on the death watch. Pushing morphine. I pushed morphine. Enough to kill a horse.

I don’t know when these memories stopped playing on an endless loop. Every day for so long the images, sounds, and feelings rushed behind my eyes. The ensuing tears and denial amplifying the injustice of his death. Eventually, the muggy discomfort gave way to something else. Something less.

The Third Side of Dying (a prologue)

It’s taken me awhile to write this post. Even as I type out the words now, I’m not sure how to proceed or how much to divulge. I suppose I should set the agenda by saying my dad died a little over a year ago. He wasn’t the first loved one’s death I’ve ever experienced or even the most premature. His was one that was tragic, and not in the platitude sort of way you might say about a young man who crashed his motorcycle into oncoming traffic. At least in that scenario, actuarial tables would tell you the death was fairly precedented and in no way unexpected at any age.

No, my dad’s death was the lesser of two evils and an end to suffering. It was the dying part that was tragic. Unbearable. Undeserved. For all of us.

What I want to describe is how losing a parent, experiencing the process of dying, begging for it all to be different, and how being the caregiver to a hospice patient slapped my head around 180 degrees–how all of this that I have observed, taught, counseled, cared for in my professional role–rushed over me this time like 50,000 tons of water breaking free from a dam. I am drowned yet alive.

So, maybe I’ll stop there for now. Consider this an introduction. It’s not all gloomy–some will also be downright aggravating (Can I just cancel his cell phone, please?), some will be ironic (funeral food to the rescue!), and some will just soothe (she’s turned into a hugger).

I’ll end this post by resolving how I began. This is merely an intro, a prelude…or simply a map to areas yet to be defined. I will stick with it if you do, following the water where it leads.

Socrates, Myers-Briggs, and Dog-Training: Languages I Speak

via Daily Prompt: Translate

Over the years I’ve significantly improved my relating abilities. Whether or not you give credence to the Myers-Briggs Personality Types, it has been my Rosetta stone. INTP. Probably one of the more misunderstood personalities, in a woman it has much more brutal implications. Unfeeling, aloof, blunt, overly analytical, indecisive. It’s not all that bad, most of the time, and especially since I’ve unlocked the mysteries surrounding my affect and those around me. After several conversations and with enough information, the four letters of my acquaintance beg me to label them. I’m not a savant, just a studier.

When I “rescued” a puppy from the farm several years ago, as a studier I immersed myself in all things Dog. Puppy training classes, dog parks, clicker commands, Animal Planet, socialization, polite introductions, enzymatic urine cleaner, and so on. All of this training was actually for me, not my dog. As a human, I had to learn to interpret and relate to my dog. To anticipate her behavior in certain situations and to use her psychology to our mutual benefit (“sit”, click, treat) was a skill I didn’t realize I desperately needed. Even the simplest of gestures and one that makes me most proud as a dog mother (ick, hate that term), is when she goes to the back door when she needs to do her business. She also goes to the door for about 13 other reasons that infuriate me, but at least she doesn’t relieve herself indoors. Raising and training my dog, my protector, created a new facet in my comprehension of the world. It made me more human and bilingual.

Make that trilingual. I studied Spanish for a few years in high school. It was enough for me to test out of my college credit requirements. While most people forget the languages they learn, I think the reason I held on to much of Spanish is because English was always intuitive. A second language is inherently more difficult and requires logic, at least for me, the INTP. A few times in my career I’ve attempted some translation at the bedside of a Spanish-speaking patient, but I never advertised. Completely rusty and insecure in my overall ability to speak it, my attempts are generally feeble. A resident physician turned to me in a patient room, indicating I spoke Spanish. I never told him this, so, I really think he jumped to a conclusion in an attempt to deflect attention from him not securing an interpreter before rounds. “Tiene usted dolor?” I asked. A confused furrow of the brow and darting eyes from me to the resident confirmed my fear that I should practice more, or at least not try to be the hero anymore.

At times conversing across disciplines requires overcoming a language barrier as well. Words typed into a chart may hide true intent, feelings, or conclusions and instead provide only facts and clearly defined outcomes. Although electronic medical records improve the quantity of communication, I argue that the quality lacks, especially for third parties like me who scour the pages like forensic scientists trying to piece together a mystery. Adding a complication, pharmacists are precise when it comes to pharmacology, especially when communicating with physicians. Prophylaxis and prevention on the surface connote similar meanings, but guidelines use them differently in specific scenarios. Patients admitted to the hospital usually receive some sort of DVT (deep venous thrombosis) prophylaxis, and it’s often enoxaparin or heparin at prophylactic doses, not therapeutic anticoagulation doses. A patient who’s had a blood clot in the leg (a DVT) in the past may continue on long-term anticoagulation for DVT prevention. This is not the same as DVT prophylaxis. A prophylactic dose is much lower and ineffective for anticoagulation. This is the language of pharmacology that prevents misinterpretation, but not everyone speaks it. Not everyone realizes the breach exists. So, when I hear from someone that a patient is on DVT prophylaxis but are taking a therapeutic anticoagulation dose, I first have to translate for myself the intent of treatment so I can then evaluate therapy (and on the down-low, suggest alternative verbiage).

Resting somewhere among the pillars of interpreting behaviors, words, and intent, is the practice of effective teaching. I lecture pharmacy students in the classroom several times a year, but I mostly teach, instruct, and guide them in a clinical setting during their last year of school. Real, live patients are the case studies, self-directed research is the lecture, and patient presentations are the exams. Translating classroom knowledge into clinical practice in the hospital presents some level of difficulty for students. I question the students to assess foundational knowledge, ability to evaluate known and potential factors affecting pharmacotherapy, and critical thinking. I explain concepts to reinforce or to correct deficiencies in knowledge. Sometimes I ask questions that yield left-field answers that I have to admit my students would have to be clairvoyant to answer correctly. (I’m working on my Socratic method.) Frustration strikes when a student commits the same errors over and over. Either I am not conveying information in a way they grasp, or they are drowning in a sea of unfamiliarity. In the case of the latter, my INTP-lack of compassion kicks in. (How did they make it to their 4^th year of pharmacy school?) But if it’s my inability to uncover the disconnect, to focus the blurry lens, then I have to find alternative inroads. I study my students, their behaviors and reactions, to identify the cause and whether the fix should be my responsibility or theirs. Ultimately, I can’t force a student to learn (clicker-treats are not appropriate in this scenario), but I do my due diligence to bridge the language barrier.

Interestingly, INTPs often become professors…of the absent-minded variety. I wish.

Translate I’m not a savant, just a studier

White Coat Nuttiness & Dental Care

When I was in pharmacy school, we learned and were subsequently certified to take blood pressure–the precise way to take blood pressure. It’s a two-fold method, where you have to pump up the cuff two different times and noting when the pulse disappears and reappears on the first go. Really, it’s long and complicated, and there are shortcuts, but this was a) school and b) pharmacy school, where we’re taught to check, recheck, and be as accurate as possible by adhering to systematic processes at the outset. It’s no wonder I border on obsessive precision disorder.

When I settled into a new town at about 10 years into my career, I decided to establish care with a physician. I was relatively young and didn’t have any major problems, but it’s still a good idea. The nurse checking me in took my blood pressure. It was elevated above the point where you need to treat it. For me though, it was way higher than it had ever been. In school when we practiced taking each other’s blood pressure, mine was typically around 100/70. How could it be so high now? Sure, I had gained weight since then and had just left a very stressful job in search for a more balanced existence, but I had also started running, losing weight, and eating better. My physician and I agreed to just keep an eye on it and get a home blood pressure monitor. Okay, check. Follow-up in 6 months…. Umm, we’ll see. I’m not a good follower-upper where my own health is concerned.

Several months later I went to the dentist. With adults I guess they take more precautions. I admit it had been about 7 years since my last dental appointment. They took my blood pressure. It was high! More than a little high. Almost stroke range high. Seriously? I had been checking at home, and it was what I expected–120s/80s and lower especially right after a cardio workout. The answer had been confirmed for me. Yes, I had White Coat Hypertension.¹

Well, the dentist, a seemingly caring man about my age, asked me about my life, stresses, hobbies, etc. I thought he was just trying to get to know me and calm me down, but, no. He was gearing up to give me advice on my blood pressure because he would not be able to work on me with it that high. Yes, stress can do a lot of bad things, but he proceeds to tell me a good way to handle stress is exercise. Did he not just hear me tell him that I ran a half-marathon a few months ago?! I exercise. Furthermore, I know these things. I’m in the healthcare biz.

I followed up with my physician a few weeks later to tell him the saga. I brought my home machine and showed him my numbers, including the one I took right after the dental visit because my blood pressure had stayed elevated for 2 hours afterward. Typical for WCH. We agreed, yes, it’s White Coat Hypertension (read: you get really, really anxious at dr’s offices, and your adrenaline starts pumping), and perhaps something should be done. At work I spend my entire day around white coats. I work in a hospital. With physicians, nurses, pharmacists, mid-level practitioners, etc. How could I have this White Coat Nuttiness?

It’s simple. I’m human. I’m afraid of being judged, evaluated, criticized. I had done all the right things by changing my job, my lifestyle, my diet, my weight. I’m still afraid of someone discovering a disease, uncovering an ugly truth, shining a light on something inside that I don’t want to know.

Well, the result? I got a prescription for a blood pressure pill. Regardless of the cause of my hard-pounding vessels, that trauma to my vasculature and vital organs will eventually lead to badness. Treatment. Prevention. …but I have yet to return to the dentist. Bad patient.

Shimbo D, Abdalla M ,Falzon L, Townsend R, Muntner P. Role of Ambulatory and Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review. Ann Intern Med. 163(9):691-700.

Welcome to Puppygeddon

A text then a ringing doorbell did not send me into panic as it normally does. The house and my self were a mess. Technically, I was clean. I did shower and brush my teeth that day, but the absence of makeup and a frizzy topknot contradicted any attempt to impress. This was in contrast to my house. The floor hadn’t been swept in nearly 2 months. Dust accumulated everywhere. Even worse, though, was just the clutter. Remnants of dog toys and shed fur blanketed the carpet. Fur would line my socks if I chose not to wear shoes while walking through the house. When my guests walked in, I saw their eyes widen and jaw slightly drop. “Welcome to Puppygeddon!” I said sarcastically, to set the mood and their expectations for comfort. “You should see the backyard.”

Oh, puppies. This was my second but the first one in my own house. New carpet. Mortgage. Nice furniture. You get the picture. My first beast, A, is 5 & ½ years old, and I raised her from 9 weeks old in a third-floor apartment. Imagine carrying that now 90-lb creature as a 3-month old puppy up and down 3 flights of stairs 5 or 6 times a day, only to have her poop on the carpet despite just having roamed the miniature lawn at the foot of the stairs. This puppy, W, is 6 or 7 months old, and I’ve only had him a month. He’s house-trained for bowel purposes, and he is much smarter than A ever was…but he is still a puppy.

The world is his playground, and he explores it with his mouth. When A was a puppy, she did this too, but the carpet was old, the furniture was to be donated at the next move, and the digs were rented. She taught me a lot about what to expect, but Puppy W is a disrupter. I had to recalibrate and puppy-proof the house. His propensity toward tv remotes and electrical wires was one I had not encountered before, but his fascination with shoes and stinky socks and underthings, I should have anticipated. I had to close doors, place hard plastic things above the level of the coffee table (and his eyes), and be ever aware of new or absent puppy noises. Both signal destruction.

The backyard was another new experience for me. Dog A never had a backyard as a puppy. She is now a more mature, wandering dog. Sure, the yard is a minefield of poop (as the guy who mows my lawn likes to remind me), but I didn’t have to worry about freshly dug holes and plants being ripped out of the earth. Now, Puppy W had a reputation of digging holes when he arrived, but as I expected Puppy W plus Dog A equals endless wrestling and chasing. No time for holes. Sort of. There had been black weed cloth to cover a flower bed I never used. It was well-buried and immovable from my perspective, but W had his way. Now there are little shredded black pieces of cloth as well as double the amount of landmines lining the yard from fence to fence. At least it’ll be well-fertilized.

Puppy W is cute. His personality is that of a charmer. He knows when it’s time to go to his crate for the night, and lies limp on the floor in the corner, daring me and knowing that I will strain my back to pick him up or at least get him started in the right direction. Dog A is cute, beautiful even, but she is definitely not a charmer. She is my protector and much like me. Her personality is so deeply rooted in what she is, what she does, that the social easiness required of a charmer in seemingly unproductive situations eludes her. She’s an introvert. She has a job, she knows what it is, she can do it, but it’s also all or nothing. It’s either turned on or turned off. As for her barking and growling at passersby, it’s mostly turned on. And it’s loud.

The disruption of an extroverted, lovely puppy and all the exuberance that comes with puppyness, has taken its toll on us, A and me. But it’s good. A definitely needs to learn that other animals can share our space without assault. I suppose it’s always good for a singleton to invite more living beings into one’s sphere, but I truly believe A took up enough space that I didn’t need more. Oh well, I’m a sucker. It’s a lesson and a friend for A and a distraction and destruction of expectation and routine for me. So, the other day when another friend came over and gasped at the strings extruded from rope knots, cotton stuffing strewn about, and dismembered toys all over the floor, she immediately began cleaning my puppygeddon. I just laughed at how normal it had become. I also know that puppygeddon will soon end. I can clean my house then.

The Other Side of the Posts

Category: Luci Life