Agraphia Medical Tragicomedy

11Sep/09Off

Two Steps Forward, One Step Back

And just like that, I felt like it was my first day of internship all over again.

The patient was a middle-aged, obese, ill-appearing diabetic woman in chronic kidney failure. Thrice-weekly dialysis was all that was keeping her from spilling so much water into her lungs that she drowned in her own fluids.

I walked in the room and realized I had no idea what to do with this woman. "That damn dialysis ain't workin' no more, doctor." she said, "and them fluids, they jest keep buildin' up. Jest buildin' on up."

To my best exam, there was not much wrong with her except some soggy-sounding lungs, and possibly a swollen ankle from where she had sprained it a few days before. Even with her extensive medical history, I couldn't make a good case for a heart attack or lung clot causing her breathing difficulties.

So, I sent her off for an X-ray and some basic lab work. An hour and a half later the tests came back stone cold normal - except the aforementioned soggy lungs. I called the kidney doctor who regularly dialyzes her, to see if we could get her in that night for an extra treatment. He called back 30 minutes later. I had interrupted dinner with his family.

"Well, she's scheduled for dialysis at 6:30AM tomorrow morning. Didn't you bother to check? Can't she just wait until then?" He was not happy with me.

I paused. She could probably wait until morning, I thought. I apologized, and told him I'd call back after I asked my attending.

It was another 30 minutes before I got a chance. My attending, an impeccably brilliant man, asked me a few pertinent questions... and came to the conclusion that there were many plausible explanations for her progressive shortness of breath. Including a heart attack or lung clot.

Her emergency department stay ballooned into 6+ hours, what with the leg ultrasound and the cardiac lab studies tacked on after the fact. All negative, of course. She was admitted to the hospital anyway.

I suspect, in the end, that she's right. Her dialysis "jest don't work no more". People aren't meant to function without kidneys. But that horrible feeling that I made a mistake today, and overlooked something potentially life-threatening... that doesn't sit well with me.

She'll die soon... I wonder if she knows? Once you start failing dialysis it's pretty much end-game, and she's not a candidate for a kidney transplant. She just wanted me to help her. I had nothing to offer.

Frustrating patient. Frustrating workup. Frustrating day.

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  1. That is a tough one to see, alert and oriented, yet her days are few. Very similar to those with end-stage CHF, many are so vibrant but their hearts just can’t keep them alive.

  2. At some point our bodies just stop working, one part or many at a time, whether we will or no. I’d be surprised if she didn’t know.


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