Sunday, December 30, 2007

Bad, bad news (A Distressing Symptom (tm) Moment)

Let's say you have a patient, and that patient is peeing. Or rather, was peeing. Yesterday, she was a veritable fount of pale gold urine, the color of a nice Riesling. Today, she's barely put out 200 ccs, and it's closer to the color of a dark ale, or God forbid a merlot. What the hell? We can't serve that with fish! With salmon maybe, but not tilapia...oh, wait. The patient. Right.

You're looking at hematuria, my friend, from the Old Greek and/or Latin "Holy crap, they're peeing blood." Now, there are several kinds of hematuria--The first type is gross, in which you have actual red blood cells in the urine (there's an injury somewhere in the urinary tract, and whole blood is leaking into the system. To the person who said, "This all sounds gross," well, we'll see how funny it is when you come face-to-face with a foley bag full of merlot, young man). The second (sub)type is hemoglobinuria, where you have hemoglobin--the pigment that makes blood red and also ferries oxygen through the cardiovascular system--present, but no red blood cells running around in the urine. This happens when there's an excess of free Hb knocking around; if you drew off a blood sample and let it settle, the plasma would be red (normally it's a clearish yellow color). Last, there's myoglobinuria. Myoglobin is a specific kind of hemoglobin that's found in skeletal muscle, and it's liberated when there's trauma to a muscle, or the muscles begin wasting like crazy for some reason. In most cases liberation is a good thing; this is one of the times when it isn't. Why, you ask? One, when muscles start breaking down, you have a lot of protein rushing into the blood at once, and the kidneys have to filter all that crap. Does the liver bitch about that kind of stuff? No, of course it doesn't, but the kidneys do, and if they're peeved enough they'll shut down altogether (why your patient isn't the open tap she was yesterday). This is why, if you know any nephrologists, they're probably uptight and stressed out people. You would be too if you had to deal with kidneys all day. [Disclaimer: I have thus far been lucky enough not to know any nephrologists, so I have no basis for that statement. I'm just guessing].
So what do you do? Hang a bag of saline! And another! And another. Saline bags for everyone! Rhabdomyolysis due to malnutrition? Have a banana bag--and another bag of saline! NB: A banana bag is a solution of vitamins, especially thiamine and folic acid, and sometimes of magnesium too. It's yellow, hence the name banana bag.

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