Kidney Transplant

A new day dawns tomorrow. And with it, a new rotation. This time I'm going back to Brigham & Women's Hospital and trying my hand at the Kidney Transplant service. I've already done 2 weeks of Transplant but at a different hospital (Mass General) where I'm sure the protocols are a little bit different.

One of the fun things to think about with the field of Kidney Transplant are all the juicy ethical issues it brings up. For instance, there is a big gender inequality in terms of who gets a kidney transplant: women are much less likely than men to get a kidney transplant. The reasons are both biological and societal. On the biological side: one of the biggest barriers towards being a good immunologic "match" towards a potential donor kidney is if you have pre-formed antibodies circulating in your blood. Most people don't have these, but if you've had blood transfusions before--or, if you've had children and have been exposed to their foreign material--you may develop antibodies. So women who have had children are at a disadvantage in terms of being able to accept a kidney from the pool of donors out there. Societally, women also get the short end of the kidney transplant stick. It is becoming increasing common and possible for one to donate his/her kidney to a spouse. For reasons that are not entirely clear, wives donate to their husbands about ten times more commonly than husbands donating to their wives.

Preparing for Sophie's First Halloween

It's the day before Halloween. Sophie's going as a little piggie, courtesy of Aunt Susie's gift. It's an appropriate choice.

Nate's Dialysis Catheter Count: is up to 21! And getting better with each one.

I have one more day on the "Consult" service at Mass General Hospital, then on Thursday I switch to the "Kidney Transplant" service at Brigham & Women's Hospital! Hopefully will be good for some interesting transplant stories.

Big Red Sox victory parade down the streets of Boston. It was apparently a beautiful New England afternoon; of course I'm not allowed to experience daylight so I wouldn't know. Heard a discussion between nurses today talking about how they really should have given all Boston area public schools the day off to celebrate the Red Sox World Series victory.

A random list of Halloween costumes I remember wearing: a devil, a knight, a wizard, Egon from "Ghostbusters", a bum, the painting "American Gothic" (my personal favorite and most elaborate Halloween costume ever), the Scooby Doo gang (with my college roommates; I was a mummy whose plan was foiled by those meddling kids), Austin Powers, and a gringo (this consisted of putting on a Mexican sombrero and that's about it). For this year's Halloween costume I'm going as a Nephrology fellow.

Weekend Off!

My first full weekend off for the month! One positive aspect of working hard: the few days off you get feel like gold. This weekend has been positively glorious, even the nap I took while watching the Colts game was a great experience. Overall it's been a pretty productive Saturday and Sunday as well. Stuff I've done already (and it's still only 5pm on Sunday):

1) Bought the book "The Complete Idiot's Guide to Buying and Selling a Home." That's right, Claire and I are considering exploring the real estate market in Boston sometime this year. And "complete idiot" would adequately describe my current knowledge of this subject matter, so I have some reading to do...

2) Had a bunch of the renal fellows over for dinner last night! Six of the nine were able to make it over, which is pretty good considering that two are on call and one is on vacation. It's quite an international bunch: this year's fellows come from Brazil, Hong Kong, Germany, Greece, Canada, and (of course) the U.S.

3) Drafted my 2007-08 Fantasy Basketball team, the Boston Nephrons. I wound up with the 3rd pick overall and was happy that LeBron James was still available. I'm also excited by my 2nd round pick, Dwight Howard (seen here jumping so high he can kiss the rim), who I think will have a monster year, and my 3rd round pick, Al Jefferson, who has a chance to be a very good player on a terrible team (the Minnesota T-Wolves).

Link of the Day: the Papelbon Dance. Perhaps you'll see it again tonight at the end of Game 4, who knows?

The Sickest of the Sick

Perhaps I hadn't completely realized it before starting fellowship...but in inpatient Nephrology (that is, patients who are sick enough to be admitted to the hospital--I'm not talking about the renal patients I see in clinic, who often have normal jobs and a good life), we are often dealing with the Sickest of the Sick. That is, patients who are so ill they are often at the very cusp of life and death. Their existence is dependent upon a series of tubes, machines and carefully adjusted infusions which take the place of their organs as they are failing. Sometimes, you make a save, and the patient comes out of the ordeal okay in the end, and you feel great about your contribution as a doctor. But often, there's not much you can do and, admittedly, morning rounds can be a tad on the depressing side when the vast majority of your patients are getting worse, not better, despite your best efforts. A quick tally of my current patient census reveals that I am able to have a conversation with only 7 out of my 16 patients: the majority are hooked up to ventilators, sedated, or worse.

Before I get to experience my weekend off in all its glory, I'm on-call tonight (Friday night), officially 'til around 5 in the am. To illustrate the point I was trying to make in the above paragraph, about having to deal with the sickest of the sick, I recently got woken up by a page saying that they needed me to start emergency dialysis on a new patient who had just arrived at the hospital. Her potassium was more than 9 and the level of acid in her blood was extremely high. After a few brief words with the resident taking care of the patient in the hospital, I rapidly ascertained that this was the real deal, called my attending, and hopped in my car to drive the 20 minutes or so to Mass General Hospital in downtown Boston. Just as I was pulling into the parking lot, I got another page: the patient had just died. These are indeed the sickest of the sick. Gave me something to think about on the lonely drive home.

2007 World Series: Go Rockies!

It's the 2007 World Series and everybody around here is pretty damn giddy. I actually heard a conversation the other day during which one nurse asked another, "Would you rather have the Red Sox win the World Series or see the New England Patriots go undefeated for the entire season?" What with the buzz surrounding the Boston Celtics upcoming season with new additions Kevin Garnett and Ray Allen, the Bostonian sports fans are getting spoiled...

Nate's Line Count: is up to 17

Starfruit Intoxication

Made a fun diagnosis about a week or so again: starfruit intoxication! The starfruit (also called "carambola") is a star-shaped tropical fruit which is popular in southeast Asia. Interestingly, it also contains an chemical which, when ingested by individuals with kidney disease, acts as a neurotoxin. In this particular instance, a man with advanced kidney disease (but not yet on dialysis) became more and more lethargic while on vacation--he became so lethargic, in fact, that he could no longer breathe on his own and had to be intubated (placed on the breathing machine). We were called as the kidney consultants (since his kidneys weren't all too hot either) and after some sleuthing around elicited a history from his wife of possible starfruit ingestion while on vacation. He was placed on dialysis (which effectively removes the starfruit toxin) and, when the patient had completely regained his mental status (yay! a happy ending for once), he was indeed able to confirm that he had eaten some starfruit. Definitely one to save for the teaching files...

The Beat Down

I've suffered The Beat Down as an intern and as a resident. Now, it's time to experience The Beat Down as a fellow and take it like a man.

I am referring to a particularly brutal weekend call which has left me feeling like I live in the hospital and that there is a seemingly limitless supply of diseased kidneys everywhere you look. On the plus side, I have next weekend off to lick my wounds and recover...

Other news:

*I found out that the Red Sox won Game 7 of the NLCS when I awoke up at night to the hooting and hollering of Boston fans in our neighborhood celebrating their victory.

*I'm pretty sure little Sophie is experiencing her first-ever cold.

*I can't wait to eat the pork chops that Claire is cooking for dinner as I finish this blog entry up.

Dysmorphic RBCs

Had an awesome day in clinic the other day, there were a ton of interesting patients. One of had a good example of dysmorphic red blood cells on her urinalysis. Nephrologists, you see, love to look at pee. "The urine is a window to the soul," as I've heard said before. Anyways, if somebody has blood in the urine (a relatively common problem), one of the first steps is to determine whether that blood is coming from the kidneys (an "upper tract" problem) or coming from the ureters, bladder, or urethra (a "lower tract" problem, aka a plumbing problem). One way to do this is by looking at the red blood cells in the urine under a microscope. If the red blood cells are normal-looking with smooth counters, they are probably coming from the plumbing. However, if the red blood cells are deformed with little blebs and "Mickey Mouse ears" (see photo), they are passing through the defective filter in the kidneys, and there is a strong change that there is an inflammatory disorder of the ol' beans.

By the way, how to do a urinalysis on yourself: (1.) pee into a cup. (2.) take 10 milliliters of urine and put it into a tube. (3.) centrifuge the urine for about 5 minutes. (4.) there will be a small pellet at the bottom of the tube. Pour out the liquid on top (the supernatant) so that only a tiny amount of liquid remains in the tube. (5.) tap the tube several times with your finger to resuspend the pellet. (6) take a drop of the urine and put it onto a slide. (7.) look under a microscope and let the fun begin!!

Nate's Line Count (the # of dialysis catheters he's inserted thus far during fellowship) is up to 15. Yowza.

Sophie Pics of the Day: leg lifts!

Line List

A major part of my job as a renal fellow is to put in dialysis catheters. Before I am allowed to put them in myself, I have to have the first 10 catheters (also called "lines") supervised by a senior nephrologist. Today was a landmark day in that I put in my 10th (the last supervised) and my 11th (the first unsupervised) catheters.

You can put catheters either into the intrajugular vein, with the tip of the catheter sticking just above the right atrium of the heart, or alternatively they can be inserted into the femoral vein, in the groin, which is slightly easier technically but has a higher risk of infections over the long term.

For posterity, here's the list of the first 10 lines and where I've put them in:
1. right femoral vein
2. left intrajugular vein
3. right intrajugular vein
4. right intrajugular vein
5. right intrajugular vein
6. right intrajugular vein
7. right femoral vein
8. left intrajugular vein
9. left intrajugular vein
10. left femoral vein

Blue Hills Photos

Searching for a place to hike that wasn't too far from Boston (I have a stretch of about 21 days with one sole day off...hello, work hour rules!...so I was quite adamant about sleeping in), we decided upon the Blue Hills Reservation, about a 30 minute drive south of Boston. It contains >125 miles of trails and by the end of the day all of calves were pretty sore. Except Sophie, that is, as I carried her the full way in her Baby Bjorn.

Some more pics, courtesy of Laure. Here we are making the descent...

On the shores of Lake Ponkapoag...
Nice view of the city skyline of Boston from atop the weather observatory on Great Blue Hill (the oldest continuous weather observatory in the U.S.):

Les Deux Soeurs:
And a special plea to all dialysis patients, or anybody thinking of going into renal failure this Sunday night, in the Boston area: don't get sick tonight. Please, I'm on call, and I'm really hoping that I can lick my wounds after a particularly brutal Sunday...

I've Achieved You Tube Fame

I'm not sure who leaked this You Tube video out onto the 'net, but it would appear that I've now achieved one of my life-long ambitions to be featured on a You Tube clip. It's part of a skit our residency program did at University of Pennsylvania...not sure if it will be funny to those outside the medical community, but even if you're not a doctor hopefully you can derive some enjoyment of seeing me wear an old-man wig.

http://www.youtube.com/watch?v=xskFo75Wdhs

Tata Laure Visits!

Aunt Laure is visiting now and with that comes....pictures! Lots and lots of pictures (particularly valuable since our digital camera is about to be shipped off to Canon to hopefully get fixed). We're just about to go for a hike on the crisp, sunny New England Day which is gloriously my well-earned DAY OFF, but before I go, I'm going to post some Sophie pics.

According to her favorite toy (the caterpillar which doubles as a measuring stick), she's growing!
Generally, Sophie is a big fan of bath time....
Except for the times that she's not...
Peeking out of her drying towel after bath time....

CABG gone bad

First things first: I have my first day off in two weeks. And I'm ecstatic. Unfortunately, my freedom will be short-lived as I am slated to work on Sunday...I'm going to have to make this blog entry short as I want to get an early start tomorrow; we're planning on doing some hiking around New England.

Heard a bit of funny medical vocabulary the other day. One very common term that we used is "CABG". It stands for "coronary artery bypass graft", a surgery which is done when the arteries which supply your heart are blocked and need to be bypassed, and is pronounced like the leafy vegetable, "cabbage." Bill Clinton had a CABG a few years back.

Anyways, I heard a funny term relating to CABG the other day. I told one of my co-fellows: "I have to see this patient with a CABG whose surgery had complications and now he needs dialysis." To which she replied, "Oh, you mean a sauerkraut." Huh? "Sauerkraut: a CABG gone bad!" Groan....

The Routine...

So I'm slowly settling into a routine during my rotation in the ICU's at the Brigham & Women's Hospital. Fortunately, I'm starting to feel more and more comfortable in my role as a fellow, which is quite different than that of being a resident.

The routine: wake up a shade after 5am, sneak out of the house without waking up the little one, ride my bike (more on this later) to work, and usually work from about 5:45 am 'til about 6pm or so. Every fourth night I'm on-call (fortunately, I don't have to stay overnight in the hospital--I just have to return phone calls every so often and be ready in case there's an emergency and I actually do have to come in) and every third weekend I have to work the entire weekend which bites the big one but at least it means I get the other two weekends off. Even if it's hard work, having a routine helps.

Anyways, I'm still biking into work. It only takes about 15 minutes to get into work (mostly downhill) and about 20 minutes to get back (mostly uphill). I'm not sure how long I will be able to continue this--probably until the first time I get to work with muddy slush all over my pants.

Zeus Does Duluth

My parents took some great photos of their trip to Duluth, which their dog Zeus fell in love with. Apparently my parents think that he wants them to move there since he enjoyed his hikes around Congdon Creek (where I have fond memories of walking our old dog Zoey so many times before) so much.


He also enjoyed watching the boats come into the harbor.
In other Zeus-related news, when my nephew Henry visited my parents' house in Indianapolis a few weeks ago, he was completely enthralled by Zeus' doggie door that he uses to go from the porch to the yard. My mom estimates that Henry crawled through Zeus' dog door approximatley 150 times throughout the weekend.

Henry's Favorite Vocabulary Words from last weekend consisted of the following: Mama! Daddy! (of course) Zeus! Door! Rick! (grandpa) Myum Myum (grandma, evidently), baby! Sopie! (our daughter), and jeep! jeep! (for my Dad's jeep).

100% Fromage Filant

Alert Nate's Blog reader Kurt Foster sends in some oustanding images of the Spider-Man burger featured at French "Quick" restaurants (a French fast food chain) which I thought I'd share. I had written about the Spider-Man burger, featuring 100% fromage filant (translation: 'stringy cheese') back during my year in Paris. Evidently Kurt was as captivated as I was at the utter grotesqueness of this seemingly American yet French fast food invention and, unlike myself, actually had the courage to taste said burger.



I've got a busy weekend ahead of me, on-call for the Brigham & Women's Hospital Nephrology service. Fortunately I was able to leave at a reasonable time (e.g., there was still sunlight out, for once) and have some beers with some of the other fellows at a nearby bar called "The Squealing Pig".

And why not another picture of Nate, Claire, Sophie, and cousin Henry to put everyone in a good mood?

The Good, The Bad, and the Ugly.

The Good: I got two unexpected days off and little Sophie was finally able to meet her sole nephew, Henry O'Malley. Saw a bunch of other family as well, which was just phenomenal.

The Bad: the reason for our gathering was that unfortunately my grandma passed away and we were all gathered for her funeral in Joliet, Illinois. She will be missed.

The Ugly: I'm starting my first "real" rotation as a Nephrology Fellow, this one in the ICU's at Brigham and Women's Hospital. The patients in the ICU are the sickest of the sick, and often their kidneys are not happy. Interesting medical problems, and I'm sure I'll learn a lot, but this will unfortunately come at the expense of me being able to witness sunlight for the next several weeks.

Some more pics from the past few days. First, the family portrait:

Sophie playing in the park.
Dad serenading Sophie with the ol' banjo (she really liked it!)

The Hellman Girls.
Henry and Tim