Actually, I don’t like the very name!  Patients understand failure as fatal, but we doctors mean it as less than adequate pumping, a chronic manageable condition.

So my patient brought in his mother RW one day.  He had gone to OR to move her because she had been in and out of the hospital several times.  At the time, treatment for “right sided” congestive heart failure relied on diuretics, a low salt diet, weighing oneself, and taking some other daily medications, most commonly then, ACE inhibitors.  Well, most hospitalizations occur from not following the regimen, which stems from many causes, chief among them unaffordable drugs and not understanding the regimen nor the reasons for it.  The latter is teachable, but not intuitive.  Folks do not follow directions that do not make sense, or for which there’s no reason given.  I wouldn’t either!!

OK, so I taught this 85 year old and her son a few things.  Take all your meds daily.  No skipping!  Weigh yourself in the am every day, the same way:  AFTER using the bathroom, and either naked or always wearing the same thing.  Then the big trick:  if your weight goes up 2 lbs. in one day, take one extra diuretic (usually furosemide), and if your weight DROPS below your treated “dry” weight by 2 lbs in a day, then skip the diuretic.  The pill removes excess salt and water from the kidneys.  You can’t always SEE that you’re bloated with too much or dehydrated with too little, but without adjusting and watching….you end up in the HOSPITAL!  No one wants to do that!

OK, long story short, over the next few YEARS, RW had no further hospitalizations.  I’m not claiming to be the best family doc, just A family doc, and what I did is simple.  The most important parts are delivering the right info and testing that the patient “gets it”, and trusting the patients to ADJUST themselves!

I did the same for years with hypertension treatment, before the data was solid:  BP too high after a month?  Double your pill.  Too low?  Cut it in half.  Research now not only supports that, it also shows that HOME BLOOD PRESSURES ARE MORE PREDICTIVE THAN OFFICE BLOOD PRESSURES!  Why?  Because offices NEVER take them correctly:  feet flat on the floor, after FIVE MINUTES of REST, and NOT when stressed, angry, anxious.  Who comes to the doctor?  The stressed, anxious, and angry….And what office lets you REST for 5 minutes?  Nope.  Stick out your arm the second you sit down, wrap up the cuff, and take the BP, usually too fast to actually be accurate.  My last office visit my pressure was about 30 points higher than it is at home…..

Back to heart failure.  This one if more fun and less informative, but has a moral.  We used to take call for “unassigned” patients coming to the ER.  One night, I got an older gent, overweight, and met him already tucked into the ICU, generally blue from lack of oxygen.  The cardiologist and I tuned him up, he came back to my office, looked great, and all was “copasetic.”  Right up until the same thing happened and I met him, blue again, in the hospital.  

“What happened?”

“I was doing so well I thought I was fine so I stopped taking those pills!”

Cardinal error!!!  

“Well, don’t you EVER do that again unless you want to be back here like this again, short of breath and trying to die!”

He didn’t.  He cruised, for about 5 years.

“Doc, I’m leaving your practice…”

“OK, why?”

“I met a lady.  She lives in Las Vegas.  We love to go dancing together, and I’m moving there to be with her.”

Some kind of a definition of successful chronic disease management.  My favorite stories make me look terrific, right?

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