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Being human Medicine Reflections on Life, Being Human, and Medicine

I am a Goldblatt Dog – Or – Lessons from Harry on How to Learn in Life

It was 1916. Harry had graduated from medical school and was doing his residency in general surgery. He took care of all sorts of patients, but one changed his career. One patient, and one physician who asked questions, provided treatment for millions of patients – including me.

Harry’s patient experienced a tremendous tragedy. 

The patient had his kidney removed because of a cancerous tumor. After the kidney had been removed, the surgical team realized too late that the patient only had one kidney. It was years before the technology was available that made hemodialysis possible. With no technology to replace the missing kidneys the patient was doomed to certain death. Harry was tasked with taking care of this patient and doing whatever he could to help him. The patient died 6 days later. But as Harry took care of him, he found a surprise. The patient did not develop high blood pressure.

Harry had seen many patients die of kidney failure before. Each and every time the patients developed tremendous elevations of their blood pressure. His patient who had no kidneys did not develop any high blood pressure. Harry reached an interesting conclusion: the kidneys must be responsible for causing high blood pressure.

Harry got called to serve in World War 1. In 1924 Dr. Harry Goldblatt returned from the war to Western Reserve University. There he began to research his theory that the kidneys were the cause of high blood pressure. He developed a clever technique of applying clamps to the renal arteries (the arteries that supply the blood to the kidneys) of lab animals. He found that by restricting the blood flow to the kidneys he could cause the animals to develop high blood pressure. Once he developed this consistent reproduceable model of high blood pressure, research was able to move forward. Eventually this led to the understanding of the renin angiotensin aldosterone system. 

In October 2018 I went to surgery for resection of a large mass near my left kidney. At the time of the surgery they noted that my cancer shared a blood supply with part of my left kidney. My surgeon called a urologist to the operating room to discuss options. They clamped the artery and waited. The kidney looked ok. It is not unusual for our organs to have collateral (duplicate) blood vessels. This means that the organ can have two different blood supplies. They concluded that I might have enough collateral blood flow to protect my left kidney. They tied off the artery to the cancer and removed it. They didn’t really have any choice and it looked like it was not going to cause a problem. 

I went home from the hospital two days later. Three days later I developed progressively worsening back pain along with shaking chills and fever. I had my wife bring me back to the hospital. In the emergency department I told the physician that I thought I might have a renal infarction (death of part of the kidney due to impaired blood supply). They gave me some morphine and took me to the CT scanner. I was right. The upper half of my left kidney was dying. 

I was like a Goldblatt dog. Like Harry’s dogs, part of the blood supply to my left kidney was blocked off. I had never had high blood pressure before. Would I get high blood pressure I wondered? 

I went to the pharmacy with my wife and bought a blood pressure cuff. I started monitoring my blood pressure. Just as consistently as in Harry’s experiments my blood pressure starting rising. The next week I was going to have an appointment with Dr. Hammer at the University of Michigan. I became worried that if I showed up with my very high blood pressure they might end up hospitalizing me. I called one of my colleagues on a Saturday and asked her if she would be willing to prescribe a high blood pressure medicine for me. She phoned in a prescription for amlodipine and I started on it right away.

Amlodipine works by acting directly on the arteries to cause them to dilate (enlarge). It is a safe and effective high blood pressure medicine. But it does not directly counter the activation of my renin angiotensin system.  The amlodipine helped but it didn’t completely control my blood pressure.

A few months later a vender for a new home monitoring system for heart failure patients was meeting with us. Their device included a blood pressure cuff. To demonstrate the system, they put the cuff on me. The machine registered a blood pressure of 205/115. I laughed that maybe I had a little too much caffeine that morning. I reassured them that I was fine.  After the meeting I went up to the clinic and measured my blood pressure again. It was 185/105. That was a little bit better but still not good enough. My amlodipine alone was not doing the job. 

I called my primary care physician. I asked if he would consider prescribing an angiotensin converting enzyme inhibitor for me. He put me on lisinopril. That medicine blocks the hormone that Harry discovered in his dogs that would cause high blood pressure. 

I tracked my blood pressures. Within a few days my blood pressure was trending down very nicely. Eventually my blood pressure was low normal. I talked with my PCP again. He told me to start reducing my dose of amlodipine while I continued to monitor my blood pressure. Eventually he had me stop the amlodipine and my blood pressure remained in good control. Later I changed to the medication candesartan (an angiotensin receptor blocker). This is another medicine in the class of medicines discovered because of Harry’s work with the dogs. I continue to take candesartan to this day.

The other evening, I was taking my evening pills. As I grabbed my bottle of candesartan it occurred to me. I am like a Goldblatt dog. I laughed and wrote it down and promised myself that I would someday write a blog post about it.

  1. Because of an inquisitive mind that asked questions, Harry Goldblatt concluded that high blood pressure must come from the kidneys.
  2. Because of his clever techniques, Harry proved his theory with his special clamps on the arteries of lab animals.
  3. Later Harry isolated a chemical from the kidneys of his lab animals that later led to the discovery of the system that drives a lot of the cases of high blood pressure.
  4. Because of all of this work, and dozens of clever scientists, I have one tiny little single pill that effectively and consistently controls my blood pressure.

I am like a Goldblatt dog. Thank you Harry Goldblatt for what you did. You would have never realized that your work would change the life of a cardiologist become patient in 2018.

But why do I write this post? Is it just about the one tiny pill that controls my blood pressure? There is more to it than that.

Because Harry was curious he did a tremendous amount of good. He was bothered by the one thing that didn’t fit. 

Let me explain more. 

When I was in medical school we had huge amounts of material to learn. In class we would take notes. Later I would go through the notes studying. When I did I would look for the things that I didn’t know. There were things that made sense, things that I had already learned or things that I could determine by common sense or logic. But the things that I hadn’t remembered or seemed to not make sense or surprised me, those were the things that I needed to learn. I developed a technique of taking notes off of my notes. As I went through the all the material I would end up with just a few pages of things that I really needed to learn. I could then go through those notes again and again and even once more just before the test.

That is a valuable principle in life.  Look for what surprises you or doesn’t fit. 

We can spend our lives only looking at what fits nicely and comfortably into what we expect. But if you look for what doesn’t fit – that is when you will learn and grow.

In medical practice we look for abnormal labs or test results. The important ones are often the ones that don’t fit or make sense. When we see those, they can drive us to look harder. It might be the key to finding the problem that has been missed.

When I study the Bible, I look for things that surprise me or catch me off guard. This then drives me to start digging deeper and asking questions. When I do I am rewarded with insights I would not have gained if I had just read looking for only what made sense to me. 

You are sitting at coffee with a friend. They are telling you about something they have done. I would encourage you to look for things that surprise you or don’t quite make sense. Tease those things out. When you do I suspect you will be nicely surprised with wisdom and insights that you might have otherwise missed.

Harry noticed what didn’t fit. His patient didn’t develop high blood pressure. He asked questions. Because he did, my blood pressure is nicely controlled on a single tiny little pill. 

Thank you Harry Goldblatt! 

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Being human Reflections on Life, Being Human, and Medicine Updates on my health

Life Lessons from an Old Diesel Engine (or How to Live a Wise and Sustainable Life)

Our sailboat has a 3-cylinder Universal M25 diesel engine. The engine is the same engine that is used in Kubota tractors. It is rugged and reliable. It is designed to run for hours and hours and just work. It is what you would expect from a farm tractor. It is like a mule or a work horse. It is not intended to be a racehorse. 

We use the engine to get in and out of the marina. We commonly will motor our way around Lake Macatawa and down the channel to Lake Michigan before we raise the sails and turn the engine off. Other times if the wind is too weak or in an unfavorable direction we will opt to just motor, or do a combination (motor/sail) to get where we want to go.

If I push the throttle all the way to its stop, I can get the boat to do about 7.3 miles per hour (about 6.3 knots). If your goal is to get somewhere quickly, a sailboat is not generally your best way to do so. That is not really the point when you go sailing. You go for the experience more than the destination. It is the joy of being there (on the water with the wind, the waves, and the quiet) and the people that you are with, more than where you end up. 

Sailors sometimes talk about how hard you should push the engine when you are motoring. Some have noticed that the difference between full throttle (at 2400 rpms) is not that much greater than partial throttle (at 2000 or 2200 rpms). You end up going about ½ to 1 mile per hour slower. The engine runs cooler. You burn a lot less fuel. 

I have taken to doing this on our boat. I pull the throttle back a little bit. The engine runs a little bit quieter. It is easier for people to talk. We go a little bit slower. It is not really very much of a difference. We may get to the end of the channel 2-3 minutes later than we would have otherwise. That really doesn’t matter so much.

The idea is that maybe you shouldn’t just peg the throttle the entire time. Instead perhaps you should count on the trip taking a bit longer and settling in with some margin on what your engine (and boat) are capable of.

That concept might make sense in the context of motoring on a sailboat. When it comes to our own lives, however, it seems we have a lot harder time doing this. 

I have had times in my life when I was just crazy busy. I deprived myself of sleep and heaped stress upon stress on top of myself. I can remember feeling overwhelmed at times. I would get up in the early morning feeling the weight of the things undone and the coming day. I would step into the shower and try to have the hot water wash away the fatigue. As I did so I would wonder if I was approaching my breaking point. I thought that if I did, then I would be forced to stop and rest, and back off in the intensity in my life.

Everyone has a limit. That is obvious. You are human. There is only so much you can achieve. 

So let’s just say that you could quantify your breaking point. Let’s say that your breaking point is at a level 100. You can operate at a level 99 but feel very stressed and be dangerously close to your breaking point and personal tragedy. Someone else might have a breaking point of level 80. Perhaps they too are getting pressured (either internally or externally) to deliver their most. So they push themselves to a level 78 or 79 all the time. The funny thing is that no one really knows what everyone else’s breaking point is. To be honest, most of us don’t really know what our own breaking point is. But the important thing is that we accept the level 78 or 79 from the second person as giving their all. But what would life be like if you (a person with a breaking point around level 100) lived your life with limits set at 78? I suspect you would be happier. It clearly would be safer. Your life would be much more sustainable. Some research data suggests you might actually achieve more by being less stressed and more focused. You would also have reserve. When a real crisis hits, you will have a reserve that you can draw upon to counter the crisis.

A wise sailor doesn’t feel the need to push the throttle to the max. He knows it is okay to set the engine at a nice sustainable level and leave a little bit of margin left. He can use the extra throttle if or when there truly is a crisis. The majority of the time crisis mode is not needed. The engine is happy doing what it was designed to do. The sailor is happy living with reasonable expectations for the journey.

A wise person sets limits in their life that allow for margin. While everyone around them might push them or insist that they give their all, they choose to instead set their limits wisely. While their internal drive may tell them to say “yes”, “yes” and “yes” they know that they do ultimately have a limit to what they can do. They choose to define that limit carefully. They look to having a sustainable life.  

It doesn’t mean that they are lazy or neglect what is important. It does mean that they seek to avoid overcommitting and burning their reserve. They resist the urge to try to overdeliver.

There is always a limit. Everyone has a limit. That is not a question. The question is where the limit is set. Is your limit set wisely? Or do you live your life forever in crisis mode?

This is for me easier said than done. 

I have been an optimist. Whenever I would see something to do, I would really want to do it. But at times I really pushed my limits. On top of being a husband and father, a cardiologist, and building and growing a transplant program I would commit to research, writing textbook chapters, speaking events, and a host of other things. I wanted to do them all. In the end I mostly pulled them all off. But I am not sure that I should have.

Now my world has changed. Cancer, surgery, radiation, mitotane and recovery were definite limits. Persistent adrenal insufficiency was not a limit I counted on but one which has become a reality for me. A level 100 person has become a level 50 person. 

What do I give up? How do I set limits? I routinely hit the limit now. Navigating this has been a much bigger challenge for me than it was to just work really hard and really long hours. I am not good at setting priorities. I don’t know how to set limits on myself. I am struggling to learn. It feels like it would be easier to just run away from everything than to figure out how to prioritize and set more reasonable limits.

We pull out of the marina with the engine running at a slow speed. I push the throttle all the way to its stop. The engine pulls hard and the boat picks up speed. I intentionally pull back on the throttle a little bit. The engine quiets down. We make a reasonable speed. All is good.

Can we be wise? If you have pushed the throttle to the max, can you pull it back a little bit? Can you let your engine settle in at a reasonable and sustainable level? Your boat may not move as quickly. You will have to change your expectations. But maybe that is okay. If people ask, “Is this as fast as we can go to get there?” You can answer, “This is the exactly the speed that we should go to get there. It’s all good. I am doing my best.”