Blog | Wednesday, August 8, 2012

Itinerant workers can't settle down for dialysis

Chico (names and identifying features changed to protect patient privacy) was a patient we cared for in the hospital.

Carny by Kevin Dooley via Flickr and a Creative Commons licenseAdmitting diagnosis: "acute kidney injury," medical-speak for kidney failure. He would need dialysis.

From my point of view as an instructor teaching residents and medical students, there were two key questions about Chico:
1) What caused his kidneys to fail?
2) Given his kidney failure was "acute," was there any chance that it'd be reversible? Could Chico's kidneys heal to the point where he could resume normal life away from dialysis?

The answers came with time. A biopsy of his kidney showed "interstitial nephritis," damage caused by calcium oxalate crystals in his kidneys. This type of damage was characteristic of poisoning by ethylene glycol (anti-freeze). Had Chico been suicidal?

"No," came the answer. Chico was a carny, on the road 40 weeks a year. Part of the lifestyle involved him and his buddies kicking back a few when the show closed each night; his best guess is that someone had spiked a few of his drinks along the way. Anti-freeze is a lot cheaper than good hooch, after all.

Chico was already missing one leg below the knee. He had diabetes and didn't take the best care of it. Given that, it wasn't a surprise that his kidneys would be more susceptible to injury than average.

After a few days in the hospital, it became clear that Chico was going to continue to need dialysis. Usually patients are ambivalent about this. They feel better physically and mentally from having their toxins filtered out, but there's also a sense of loss as life becomes dependent on a machine treatment three times per week. Usually those affected are grateful for the life extension, which predominates their emotions.

But Chico was tearful. No matter how many times we tried to explain to him that dialysis was his ticket to continue living (absent a kidney transplant), the thought of being tied down to a dialysis chair was incompatible with the lifestyle he led.

As an itinerant worker, he had no place to settle down and begin the sedentary life of a dialysis patient.

On a logical level, his tears made me feel like he wasn't comprehending how lucky he was to live in an era with such technology and medical treatment available. Emotionally, I understood his existential sadness. He was a bird whose wings had been clipped. His freedom was gone. The carnival was the only life he'd known.

My hope for Chico is that he is able to find a new equilibrium. If he can't, he's not long for this life.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.