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Wednesday, July 28, 2010

Life at Grady: Salt in the wound

The following post, by Kimberly Manning, FACP, first appeared on the blog Reflections of a Grady Doctor.

True story--this week at Grady:

Me: "We could probably get your blood pressure down quite a bit by making some changes to your diet. That can be as helpful as adding a medication."

Patient: "Oh, I already eat a no-salt diet, so that definitely ain't my issue."

Me: "Wow...I've heard of a low salt diet, but seems like it would be tough to have a no-salt diet."

Patient: "Yep, well it ain't that hard. You just gots to put your mind to it, you know what I'm sayin'?"

Me: "I hear you. You know, sometimes salt can be hiding in stuff."

Patient: "Not my food. I prepares all the food in my house. So it ain't no salt in none of it. Matter of fact, we don't even have no shakers in our house." She smacked her lips between each sentence for emphasis.

Me: "Wow, that's impressive. . . uh. . I mean, great. What do you season your food with?"

Patient: "Mostly Accent or Zatarain's."

Me: "Umm, Accent or Zatarain's?"

Patient: "Yeah ma'am. Or just bouillon. You don't never cook with no bouillon? I drops me a block off in jest about everything. Make it taste so good without salt." Alrighty then.

(Click "more" below to continue reading this post.)

Me: "Umm, bouillon? In everything?"

Patient: "Oh yeeeeeeaaah. Vegetables, rice, all that stuff."

Me: "Uhhh. . . . okay. . . so. . .tell me this--what'd you have for breakfast this morning?"

Patient: "A sandwich and some coffee. Biscuit with a little piece of meat...some leftover fatback, tha's all. But I didn't sprankle no salt, though, and this time, no bouillon." She smiled and still smacked her lips with each point.

Me: "What about dinner last night?" I could feel myself breaking out in a cold sweat.

Patient: "Chicken and some butterbeans, oh and some white rice."

Me: "The chicken. . .baked, fried? And how'd you season the butterbeans?" Please don't say it. Please don't say it.

Patient: "I ain't gon' lie, it was fried. But I seasoned it only with the Zatarain's. The butterbeans just had a ham hock in it, tha's all." Tha's all. Sigh. I looked at her stout middle, and thought about her initial complaint, How can I lose some of this weight? I keep trying but nothin' is happening....

Me: "A ham hock...did you...eat it?"

Patient: "Ummm hmmm. I ate only part of it, but not all of it. But no salt, though. Definitely no salt."

She was so proud of herself. Chest all poked out and proud about her no-salt diet. It hurt my heart to have to burst her bubble about the foods she'd grown up on like ham hocks and fat back. This particular patient was low-literate, and wasn't very good at reading labels. It felt so enormous, trying to think about how to start explaining sodium intake to her. Like Zatarain's is seasoned salt. And a bouillon cube is pretty much dehydrated chicken or beef stock and, well, salt. And Accent? It wakes up the flavor because of the sodium. Sodium wakes everything up.

Sigh. The fat back is salt cured, and so is the smoked ham hock. So, in other words, don't eat any of the things that you call comfort foods. Your specialty? Don't cook it. And all those foods that don't perish in 3 days that your fixed income can afford you? Out of the question.

Some of these interactions start out funny, but then quickly evolve to not funny at all. Fresh food costs money. Education and exposure to different things in life is a privilege that often comes with, well, money. I truly believe that this woman was really giving her personal best. She deeply believed that her diet was indeed a "no-salt diet."

And so, first, I congratulated her on her effort. I told her that effort is where it all starts, and that she was ahead of most for that reason. I silently berated myself for allowing the six ridiculously expensive organic peaches I bought from Whole Foods last week go bad. Then I took a deep breath and then slowly began explaining sodium to her. Showing her labels so that she could know the word by sight. And after looking crestfallen, she finally said, "Damn, I can't eat nothing."

And you know what? Considering that I was sitting across from her in a public hospital where she'd just told me that she could barely afford her medicines, the co-pays for her visits, or even the cost of public transportation to come and see us, it was hard to argue with her.

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posted by Jessica Berthold at 7:00 AM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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