Nutrition Support Blog: Micronutrient Mindfulness
July 16, 2014
One adage heard frequently in hospitals is, “If all you have is a hammer, you treat everything as a nail” (often mistakenly attributed to Mark Twain). I was the personification of this adage when I started my first job in clinical nutrition, because I expected to be able to use my new nutritional superpowers to uncover obscure nutritional issues and unrecognized deficiencies in many patients--OK, most patients :)
I quickly realized that most hospital nutrition issues were much more obvious. After all, this was still back in the dark ages when diets were often not restarted until bowel sounds (or “movements”) were evident, or patients were threatening to go AWOL to the cafeteria. The vast majority of my patients needed all nutrients, and there was nothing hidden about their malnutrition. At times it has felt like a victory just to get some consistent calories and protein in, reasonable glucose control to allow for actual nutrient utilization, and fend off those unnecessary nutrient restrictions (isn’t a hospital diet restriction enough??).
Some years ago, during one of our clinical case presentations, we discussed a patient where dermatology identified a case of severe zinc deficiency. Even though this was not my patient, I was thunderstruck to consider that I was now not considering micronutrient deficiencies enough, and wondered if I would have missed this one. We vowed then to hold more “flash case reviews” when someone had an interesting learning case, so that all of our nutrition staff could stay sharp. Our assistant director also invited dermatology to present to us, so we were better able to recognize micronutrient deficiencies on physical exam.
It is clear that if you keep them in mind, there are deficiencies out there. With increasing bariatric surgery and TPN additive shortages, perhaps now more than ever.
This past year alone we have identified Wernicke’s encephalopathy, neutropenia and cardiac abnormalities from severe thiamine, copper, and zinc deficiencies and a possible case of scurvy from vitamin C deficiency. I think it is important to keep deficiencies in mind, and share cases with everyone, so that you will be able to recognize the micronutrient “nail” when you see one.
“Kaplan’s Law of the Instrument: Give a boy a hammer and everything he meets has to be pounded.”
-Abraham Kaplan, Journal of Medical Education, 1962
“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”
-Abraham Maslow, “The Psychology of Science:A Reconnaissance” 1966.
“…You've been Thunderstruck”
-Thunderstruck, AC/DC, 1990
P.S. If you have never heard the rendition of Thunderstruck on cellos, this is worth a few minutes: http://www.youtube.com/watch?v=uT3SBzmDxGk