Monday, February 25, 2013

Nephrology Merit Badges, an update

Six months ago I proposed nephrology merit badges:
One of the common resident complaints regarding nephrology is that it's too hard. The nephrologist response to this complaint  is usually to deny the difficulty, because its not hard for the nephrologist. Perhaps that denial is counterproductive, first it's hard to disrupt a widely held belief that is continually reinforced by the community of medicine, secondly when you deny the difficulty you insult the intelligence of the student struggling with new concepts. Its essentially saying, "Hard? differentiating among the pulmonary renal syndromes is easy, what are you stupid?"

Instead of denying the difficulty we should re-frame the meme. Yes, nephrology is hard and look how cool it is that you mastered these concepts.

Merit badges, or pieces of flare as my fellow interjected, would add levity and encourage residents to tackle deeper concepts.
Since that time a number of residents, fellows and students have earned nephrology merit badges. The concept has evolved a bit as the badges are being awarded to comemorate specific patient encounters rather than general concepts. So it's still a work in progress. Here is a summary of the badges:

Sodium Ninja. See this post.

Master of Electricity. This badge was awarded to the residents who were able to quickly and professionally handle a shocking situation. A patient in the acute dialysis unit was repeatedly being shocked by her malfunctioning ICD. Every five to ten seconds, BAM another electric boot to the chest. This went on for what seemed like hours, bit was only a few minutes until the residents were able to procure a magnet to place on the chest and reset the ICD.

Sweet as Black Coffee. This badge was awarded to the residents who were able to accuratly diagnose the etiology behind a case of hypoglycemia. The hypoglycemia was due to adrenal insufficiency and once this hormone was properly replaced the patient's mood improved as much as his glucose did. Seeing him come alive was almost like Gandolph releasing Theoden from Saruman's control. The name of the badge comes from one of my favorite brain teasers: what has more sugar, lightly sweetened coffee (one teaspoon of sugar) or all the blood in the body? The answer is the coffee:

Hepatorenal Syndrome. This badge was awarded to the residents who successfully guided their patient through the trecherous waters of hepatorenal syndrome. The symbol behind the organs is supposed to be specter of death but may actually be a heavy metal band symbol. I have not been overly impressed with the quality of research which supports the use of midodrine and octreotide in HRS(PubMed1 PubMed2), but there is no doubt in my mind that HRS was nearly universally fatal when I was a resident in the late 90's and now I have a hard time remembering the last time I saw a patient die of the condition.

Orthostatic Hypotension. This badge is awarded to the residents who successfully managed resistant orthostatic hypotension. Once the patient has failed midodrine, sodium supplements, elevating the head of the bed, florinef, and waist high compression stockings, you are left with pyridostigmine (Mestinon). This cholinesterase inhibitor, used most often in the treatment of myesthenia gravis, can be used in orthostatic hypotension. The other use of pyridostigmine is an organophosphate antidote, hence the joke.

Koch meets Cochrane. This merit badge was created for the team that did the core research on the data backing up the AHA and ISDA recommendations to use ampicillin and gentamicin for enterococcal infective endocarditis. I plan on posting a follow-up on that situation shortly. I love the illiteration of this badge.

Scout Master's iPad with a full complement of merit badges
All the badges can be downloaded here as a PDF.
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