STUBBORNNESS IS THE BACK SIDE OF
A VIRTUE (Congestive Heart Failure)
This insight arose decades ago from a farm patient with congestive heart failure. She was a widow who had been running the farm herself for some years. Her heart failure was severe and demanded hospitalization, which she stubbornly refused. Her situation was complicated by rapid irregular heart action, probably of recent onset that had set the stage for her dropsy, the old name for congestive heart failure. When we doctors realized that modern diuretics were quite successful as a treatment, we started calling it congestive heart failure to avoid consternation of old timers who remembered dropsy as a death sentence.
Out
of respect for her autonomy, and realizing that no other physician was going to
persuade her to accept the hospital, I immediately gave her long, detailed oral
and written instructions which she followed stubbornly. Her rapid irregular heart action called
auricular fibrillation was treated with digitalis in those days before
cardioversion. To avoid overloading her
mental circuits, I didn’t try to explain loading dose used with long acting
medications such as digitalis when a prompt effect is essential. So I gave the loading dose as a “separate”
treatment using different colored pills from the maintenance dose of
digitalis. But she mastered the concept
of using diuretics (water pills) depending on “dry weight”. Dry weight is what daily weighings settle
down to as the swelling of the legs subsides.
At that point, she reduced the dose of diuretics to avoid overdose
effects. With continued daily weighings
to guide her, the perfect dose was achieved in a few weeks. Later on, she learned just how much extra
diuretic to take for a restaurant meal or a church potluck because there, she
got much more salt than at home where she was following instructions about low
salt. The benefits of low salt were
discovered when I was a medical student in the 1940's. This was the beginning of the modern
treatment of dropsy.
When
I ask older folks for their recollection of which of their classmates were sent
to the principal’s office for misbehavior, they can scarcely remember a girl
being sent. This, I explain, is because
girls have more respect for authority than boys. But this respect has it’s backlash when it comes to the printed
word in the recipe book versus the doctor’s instructions. I have found that the vast majority of the
ladies make the same compromise: half the salt specified in the recipe. I usually get my way when I explain that
only sauerkraut and pickles demand salt and it can be left out of all other
recipes. Salt free bread is hard to
obtain unless you make it yourself.
Don’t write to me to explain that the yeast won’t rise without salt
because I make the bread in our family with and without salt and it rises just
the same.
Congestive
heart failure starts with reduced blood flow (cardiac output). In the kidneys, the result is reduced salt
and water elimination leading to the accumulating swelling. In recent years, we have found that some of
the new blood pressure medications increase cardiac output even when given in
the absence of high blood pressure thus getting at underlying causes better
than diuretics do.
Now
back to stubbornness and digitalis.
Because of it’s prolonged action, missing a dose or two or three is not
a test of whether it is still needed.
In this lady’s case, a few weeks after stopping digitalis, the rapid
heart action would have recurred.
Digitalis merely controls the rate, and the irregularity from auricular
fibrillation persists. Her stubbornness
also prevented this hazard. She
returned for annual checkups and refills and died of old age many years later. Ever since meeting her, I have enjoyed
defending stubborness. I have decided
that I might be called an honorary farmer but that is another story.
John
A. Frantz
Chairman,
Monroe Board of Health
March
30, 2001