THREAD 4

#ALEPH2020:

In medicine, reckoning with racism includes reappraising the very syntax we use every day. Proud to add my voice w/ @J_Ikeme and @RWGrantMD in this @JAMAInternMed pub addressing:

Does race/ethnicity belong in the first line of the patient

Some background: I’ve struggled with this question since early in medical school

Medical syntax is designed to communicate information in a predictable sequence with key elements prioritized to facilitate efficient communication and formation of an assessment and plan

2/

From preclinical lectures to Qbank questions to clerkship rotations, race/ethnicity was often prioritized in the same sentence as age + gender.

I grew accustomed to reading/hearing: a 70-year-old Black man w/ history of x, a 50-year-old Hispanic woman presented w/ y.

3/

However, when it came time for me to use race/ethnicity, there was always tension. Race/ethnicity are self/socially-ascribed identities that in clinical practice are almost always assumed by providers based on appearance. I was also concerned about the potential for bias

4/

I wondered how my own care would be impacted or not impacted by my ethnicity (Hispanic) – I have light skin so I’m not sure if my doctors would even identify me as such – but how would my care be different if I was presented as a 30-year-old Hispanic male?

5/

“Should I give them more fluid?”

Extremely common question during AKI referrals from junior docs.

⛔️ Fluid management is tricky, often misunderstood, & can cause huge iatrogenic harm ⛔️

We try to convey important principles in THREAD 👇

#tipsfornewdocs #medtwitter #tweetorial

Currently too often patients with high creatinine are given too much IV fluid, driven by an AKI ➡️ fluid reflex

We’ve seen 7 litres be given in one shift.

Medics & surgeons, juniors & seniors, it seems everyone loves to reach for extra IV fluid (especially if urine output poor)

Why does huge volume IV fluid ‘resuscitation’ consistently occur?

Lots of reasons, including FALSE beliefs:
🛑 IV fluid always “treats AKI”
🛑 Hypotension = hypovolaemia
🛑 Lactate >2 means fluid deficiency
🛑 Septic patients are very hypovolaemic

The rule with IV fluids and AKI is to remember this 5 word phrase:

💥 💥 Aim for euvolaemia, then stop💥 💥

Fluid status is like Goldilocks - hypovolaemia is bad for the kidneys BUT excess volume is also harmful for renal function and will cause other complications too.

It is easy to say “target euvolaemia” - but we agree it is more difficult to do!

Fluid status assessment is certainly made harder by a belief that we must only rely on a snapshot assessment of examination features which are NOT specific / sensitive / reliable to elicit like.…

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