Tuesday, June 6, 2017

Salt of the Earth

“I think he’s dehydrated,” said the young woman, sitting in the industrial-strength plastic chair next to her boyfriend.

It was far too early one weekday morning, and the patient in question, the potential dehydratee, was sitting up on the cot eating Cheetos.  Fried, not puffy.  (Personal note:  All Cheetos should be puffy.  Both orange and white cheddar are acceptable flavors.)

“Okay, what’s been going on?” I said.

“He’s been throwing up all day.”

“Uh-huh,” agreed the object of her affections.  Thin, wiry, he spoke while exposing a thick tartar of Cheeto residue between his sparse remaining teeth.  “I’ve been throwing up all day.
“How many times have you thrown up today?”

“A lot.”

Last time I checked, “a lot” was not a number.  “How many is a lot?”

“Twenty.  Maybe forty. “
“You must be feeling better.  You’re eating a Cheeto.”

“Yeah, but just now.  Besides, I think the Cheetos are what make me throw up.” 

At a certain point in the conversation, you know you’re not going to win.  All that time you spent learning about effective techniques for patient education and empowering individuals to be responsible for their own health become just more hours in your life you’ll never get back.  Kind of like the first time you saw Avatar or the thirteenth time you saw Team America: World Police.

(Okay, I lied about that latter one.  Team America:  World Police is funny EVERY time.

Lisa:  “If you could promise me that you would never die, I would make love to you right now.”

Gary:  “I WILL NEVER DIE.”  And it’s all puppets.)

So instead of prolonging the conversation, I default into what is formally called my “Medical Screening Exam.”  For those not in the know, when a patient comes to the door a federal law called EMTALA directs that a ”qualified provider“ needs to perform a “medical screening exam” to determine the presence of an “emergency condition” in any patient who presents to the ER.  The active ingestion of Cheetos is enough to convince me, as a skilled and experienced observer, that there is no emergency medical condition present.  However, unless I acquire additional historical information and perform a physical exam, there is nothing I can really charge for. 

The Medical Billing Exam completed, I sit down on a rolling stool and prepare to deliver Canned Speech #12, the one where I say “I’m sorry you were throwing up at home, but everything looks good now.  I could get labs and x-rays, but I don’t think they’ll be helpful and I hate to stick you full of holes or blast you full of radiation if we don’t need to.  Whatever it was seems to have gone away, and the fact that you’re able to eat now is a good sign.  Rest, drink clear liquids…that’s something you can see through, not a Coke…yes, you can see through vodka but that’s not the same.  Anyway, please follow-up with your own doctor or come back and see us if you need to.”  (Sometimes I have to add on to the speech, like with Addendum 3A:  “I’m sorry, I can only write a work excuse for the time you were in the ER, not for the last three days you didn’t go to work, Addendum 4c:  “Yes, I know your aunt is a nurse, but…” or Addendum 2B:  Yes, I also know the CEO.”)

As I’m accessing the mental file, the young woman speaks up again, a bit of hesitation and worry in her voice.  “But I know he’s dehydrated.”

She seems nice, nervous, a little wet behind the ears, looking for reassurance.  I’ll give it another try.  “I understand your concern.  But he’s eating fine right now, his examination’s normal, and I think whatever it was has probably run its course and he’s gonna be fine.”

“But it was salty, and when you get dehydrated it gets salty.”

A pause.  If I could raise a single eyebrow, I would have been Spock-like.  
“What was salty?” 

There’s a brief moment of doubt, but I forge ahead because I can feel there’s a story here.  I just don’t know it yet, but I’m willing to incur the wrath of my Charge Nurse by prolonging my patient throughput times to find out.

She looked at me, then cast her eyes sheepishly to the ground.  He begins to smile, the Cheeto ooze tracing across his lips.

“Well, he wasn’t feeling good…”

His grin expands to span his orange-dusted face.

“And I thought maybe, as a special treat…to make him feel better…and it was almost Wednesday, and we do that once a week…”

The moment of revelation.  “And it was salty.”  I nod my head knowingly.

“Yes.”  She murmurs, then steels her gaze with a knowing look.  “And everybody says that you have a lot of salt in you when you get dehydrated.”

It’s kind of nice to know that in our age, when the internet arms every man with just enough knowledge to be their own doctor but not enough experience to know what any of it means, that the spirit of personal inquiry and those resulting “eureka moments” still prevail.  And when someone learns something new, we in medicine usually honor them accordingly:

Hail to thee, Discoverer of the Viking Test.  You know, the Vikings. From that high school in Topeka.  The one north of the river.  I think it’s called Seaman.


Hypernatremia is a condition where the body’s sodium content is abnormally high.  Sodium is critical to the body in maintaining fluid balance.  When it rises, it’s usually not because someone has been feasting at the salt lick.  When someone is severely dehydrated and as water leaves the system, the concentration of sodium in the blood rises.  It’s pretty common in nursing homes, where the ill and infirm often can’t satisfy their own thirst. 

Last month a patient was sent in from the nursing home for hypernatremia with a sodium of over 170 (normal tops out at about 150).  Looking through his records, we found the usual potpourri of medication lists, Powers of Attorney, and an Out-of-Hospital Do Not Resuscitate Order (DNR) forms.  This prompted the following conversation at the nursing station:

“He’s pretty salty.  Like that place where you float.”

“You mean the Dead Sea?”

“Yeah, but he’s not dead yet.”

"Maybe we should just call it the DNR Sea.”
"Whatever floats your boat."

(Yes, this is a real conversation.  Do you doubt?  "Vas you dere, Charlie?")