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All that is wrong with current American medicine, all that is to come, can be illustrated by a wonderful pimping question which I was given on rounds, one that I cheerfully gave back to the interns.

Q:What is the normal daily output of potassium by the healthy kidney?

A: Autem quod est necessarium.

That which is necessary to retain proper homeostasis in the body, no more and no less.  That’s the answer.  It is easy to think and guess – 50 mEq?  40 mEq?  Every numerical answer is wrong.

In fact, the more predictable the output of potassium is by the kidney, the sicker it is.  A kidney that pumps out 40 mEq every day is likely one that is in failure, and tries to maximize its potassium output, given that many people eat diets rich in potassium.

That goes for any output of the kidney.  The concept of “normal output” is treacherous, and people assume that just by stating such a thing, it has meaning.  It does not.  It is a purely statistical aggregate, without further meaning.  One may classify the outputs within a distinct aggregate of persons, and gather the numbers, and do statistics upon them.  But the values obtained tell nothing about kidneys.  They speak of average daily ingestion, which implies average daily output.

For water, by example, human physiology can adapt to a range of about 800 mL/day, to 20,000 mL/day.  That is indeed a miracle of efficiency.  Below that target, or above, the kidneys cannot maintain homeostasis, and the body fails from the imbalance – not the kidney.

For example, the “Grand Canyon Seizure” is not unusual among very fit athletes who hike down the Grand Canyon to the water’s edge, and then run a road race uphill.  If they do not ingest the proper quantity of salts along with water, they can sweat out their Na+ and thus their osmoles, and come to the top with a sodium concentration of 115 mEq/L, and promptly seize.  Treatment involves guesstimating the patient’s total body sodium, and gently restoring any deficit, bringing the concentration up to about 125 mEq intravenously, and then simply allowing the body to handle the diuresis back to normal when euvolemic.

Why is American Medicine suffering?  The “quality movement” is set up on the implicit premise that some number can be sanctified as the “best number” to achieve; all other numbers fail from the mark, in proportion to their deviation.  This is toxic nonsense.

Autem quod est necessarium.  How much time does a patient need in clinic?  What should be done to reduce their hypertension?  There is no standard, and erecting one simply allows one to create a benchmark by which all patients can be insufficiently treated.  50 mEq?

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