Sunday, April 8, 2012

On Starving and Smuggling

At the beginning of my years of practice, I noticed that there was a certain number of patients hospitalized for heart failure, who remained resistant to treatments, especially to diuretics, the main weapon at that time. Rigorously low sodium diets were standard as even tiny amounts of salt will oftentimes sabatoge the effectiveness of diuretics.  Nonetheless patients who seemed like they should respond did not.  It was a puzzlement.
It was while interning at a predominantly Jewish hopsital that the explanation for this became apparent. One day I walked into a room to find heart patient Irv, surrounded by his loving family, with his oxygen mask off, wolfing down a bagel with lox and cream cheese.  With the normal heart this is one of life’s great pleasures, with a weak heart lox, suffused with salt, is toxic.
Irv and his family turned out to be the tip of the iceberg, many families, upon investigation, were smuggling in salt laden food, a mainstay of Jewish cuisine.  The contraband poured into the hospital despite regular alerts to families regarding the dangers of salt for failing hearts.
Given the ubiquity of tasteless and ropey hospital cuisine it is therefore not  at all surprising that food came into the hospital, under the radar, giving pleasure where it was otherwise in short supply, while hopefully harnessing the magical healing powers of mother’s chicken soup.
In some cases where there was marginal heart function this trafficking in salt was tantamount to “killing with love” and shows that dietary retrictions can be very important.
But not always.  Sometimes they are so Orwellian as to make compliance nearly impossible.  Consider the low sodium, low potassium diet, commonly deployed in  hospitals for cardiovascular and or renal patients.  For some of these patients the restrictions are key.  More often the dietary bans amount to painting by the numbers, producing dietary decisions that lack common sense and balanced thought.
Sometimes caregivers will bend, but there are a good many who strictly follow the rules.  The result is that a number of patients find their diets so objectionable that they choose not to eat.  After drawing on, and depleting, sugar and starch stores, protein is marshalled by the breakdown of muscle, leading to profound weakness, which compromises healing, decisively at times, along many fronts.
So there are times where we, despite the best of intentions, starve patients by not allowing them foods they enjoy or can tolerate.  When it comes to this, smuggling pastrami, raisins, bananas and avocados into the hospital just might be life-sustaining and certainly humane.