Monday, March 16, 2009

Difficult Decisions

Sometimes people have so many different diseases that it's difficult to decide which one to treat. For example, one common conflict is between the heart and the kidney. If you have too much fluid in your blood vessels, and if your heart is weak already from other processes, that can make your heart even weaker and it can't pump all that fluid around. As a result, the fluid can build up in your legs and arms, and in your lungs, making you short of breath. The treatment for that is to "diurese" a patient - that is, use medications to make people urinate and decrease the amount of fluid in their veins. However, if your kidneys are sick, you need a higher dose of these medications, which can actually harm your kidneys even more. However, the higher doses may be a necessity to keep your heart healthy. It is not uncommon for there to be a natural conflict between the cardiologists (heart doctors) and the nephrologists (kidney doctors) over this very situation. In the end, often the cardiologists win out because while we can treat kidney failure (at least temporarily) with dialysis, if your heart fails, we don't have any sort of substitute for that.

There are many such decisions that clinicians often have to make. I tend to think that usually things work out ok - if we see signs that we made the wrong decision, we can always change and go the other way the next day. Unfortunately, some people are on such a fine balance that choosing the wrong path for even a few hours can sometimes be hugely detrimental. Hopefully through collaboration and talking together with many specialists, we can make the right decision the majority of the time.

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