Sunday, April 10, 2011

Wet or Dry?

You'd think distinguishing wet from dry would be straightforward. All you need do is open your eyes and take in the view. The extremes of wet and dry paint unmistakable pictures in our brains. Even less dramatic images than these provide a fairly accurate interpretation of what is and what isn't wet or dry.

Did you know (medical types will agree with me; I hope) that distinguishing wet from dry in medical practice is likely the most challenging day to day dilemma we face?  After over 30 years of  "doctoring" and sub specializing in a field where making this distinction between wet and/or dry is of critical importance, I'm eternally humbled. Seems I get it wrong way more than I think I should. Sometimes in the midst of emotional exhaustion after a week on call, I consider my decades of experience with thousands of patients worth very little when it comes to making the call regarding the fundamental question: wet or dry?.

Why is this seemingly straightforward diagnostic decision so difficult?

I'll take a stab at it answering this question. I certainly had my head buried in the problem all week as the hospital consultant for the Nephrology service.

The problem is:

1. Too much fluid (wet) and too little fluid (dry) is relative.

2. What is too much for Peter may be too little for Paul. What is too little for Mary Kate may be too much for Ashley.

3. The physical exam gets you only so far; someone can be "swimming" (as I like to say) in water but be dry where it counts (perfusion of critical internal organs). The flips side is a physical exam with relatively normal findings with regard to fluid but meanwhile the wet is insidiously attacking the one organ that can tolerate it the least, the lungs. Wet lungs are never a good thing.

4. A little wet can turn deadly wet just because. A little dry can turn deadly dry just because.

5. Treating dry with fluids can easily turn sour. Treating wet with drying agents (diuretics, dialysis or other physical removal of fluid) can easily turn sour. Why? Just because.

6. Wet may be just what the doctor ordered to fix the problem. Dry may be just what the doctor ordered to fix the problem. Sometimes it's best not to intervene at all but let the wet or the dry just be and wait it out. But, all too often we try to fix the wet or the dry and that leads to issues that further compound the problem.

Last evening, after a long 7 day on-call stretch, I had had it up to my eyeballs in this morass of fluid, slogging my way through the wet and dry fields and making decisions based on gut feelings, experience, and a small dose of science. I get it wrong as often as I get it right, I thought at which point I lamented to my husband that I really don't have what it takes to do this kind of work.

His comment?

"Who do you know that gets this wet/dry stuff right? Anyone?"

The answer is that no one gets it right all the time or even most of the time. We all try. We genuinely try our best but the pathophysiology of each situation; the time, place and person, the unique moment creates a minefield waiting for a misstep.

I'm glad the week is almost over.

1 comment:

  1. The week is over. Glad you've had a couple of down days. Hope they were dry and sunny?


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