Every once in a while you wonder if people actually understand what they are dealing with and whether or not they really understand what's going on. A recent encounter with another physician perplexed me.

A patient is brought to the ER because he or she is found unconscious by a family member. It turns out the EKG looks "scary" and they call cardiology. What the ER thought they saw on the EKG was an entity called "ST Elevations" which typically means someone is having an acute heart attack and needs to go to the cath lab to get the artery opened up.

We arrive. It turns out the patient is in acute renal failure, with a creatinine of 3.5, the potassium is over 8 (which gives you a similarly bizarre EKG pattern), and has a blood sugar of over 1300, and a bicarbonate of 5. The ER also ordered a troponin which was indeterminant and a BNP which was 1300.

The patient on paper looks like he is in Diabetic Ketoacidosis, dehydrated as hell, and has gone into acute renal failure from the severe dehydration. Yes, the elevated potassium is very high and at such high levels you get EKG changes which look very abnormal. A potassium over 7.5 gives you wide QRS complexes, wide T waves (the QRSs and Ts look similar), lack of P waves (or very blunted), bradycardia. 

We rehydrate the patient, his potassium quickly comes down (as is expected, because they are really potassium deficient), treat his DKA, and over the next few days his kidneys resume normal function.

A few days later one of the physicians from the ER saw me in the hallway and asked me, "Hey, how do you explain the CHF in that guy?"

I asked, "CHF? Why do you think he was congested? You think he is volume overloaded?"

"His BNP was like 1300"

"He was in acute renal failure."

"So, why was he volume overloaded?"

"He wasn't. He was about as dry as they come. You coulda given him 10 Liters and he'd be fine."

"And the BNP?"

"You can't really evaluate a BNP with renal failure. Nor troponin for that matter. Just toss those two out the window."

Sometimes you just think to yourself, "Wow!" Sometimes things that you think are common knowledge may not always be. We can't rely on merely tests and numbers. We can't be robots. We have to understand what happens behind the numbers.

Medicine humbles you every day! There isn't a day that goes by that I don't learn something new.

Eating cholesterol does not raise your cholesterol! People need to stop worrying about eating cholesterol! Eat all the eggs and shrimp you want!

What raises your cholesterol is saturated fats! These are fats that are SOLID at room temperature. Butter, margarine, cheese, fat on steak, bacon, chicken skin, pork, goose fat, cream, ice cream, and the fat in milk (even though it looks like liquid, it's actually solid fat particles floating around in liquid).

Eighty-five to ninety percent of your total cholesterol comes from your liver. Our liver makes over 85% of our cholesterol! Only a small percentage comes from food you eat. If you don't eat cholesterol, your liver makes more to make up for the difference. If you eat cholesterol, your liver will make less. So it doesn't matter how much you eat!

What tells your liver to make cholesterol?

SATURATED FAT!

Fats that are solid at room temperature. Avoid those and you will be ok! If you remember that, you will be fine.

We always tell our patients to first try diet and exercise to help improve their cholesterol numbers. So they go around and stop buying foods that say "cholesterol" on the label, or buy "cholesterol free" foods. Bad idea! You liver will just make up the difference.

What we should tell them to do is to avoid foods that have saturated fat in them. Solid at room temperature! Remember that!

Saturated fats are found in high amounts in:

Butter, Coconut, all those butter substitutes, Cheese, Pork, Beef, Chicken skin, Goose fat, veal, sausage, hot dogs, bacon, processed meats, cream, milk and other dairy products, ice cream, etc. You get the picture. SOLID FATS! When you look at that steak and see the marbelling and fat in between the muscle fibers, or the fat on ribs and lamb chops....  IT's SOLID FAT!!!!!

Avoid Solid Fat!

But, there are two liquid fats that contain a lot of saturated fat; coconut oil and palm oil. But my guess is no one really eats those. Especially, not here in the United States. Butter, cheese, cream, bacon, pork, and beef are our main problem.

What about trans fats?

These are liquid fats (like vegetable oil) that are heated in the presence of hydrogen to make them semi-solid. Like all those butter substitutes. These are awful!

Trans fats are even worse for cholesterol levels than saturated fat and cholesterol itself because they raise LDL ("bad") cholesterol AND lower HDL ("good") cholesterol.