High Hopes For Bobo

"We cannot prepare you for finding out that
you do not much like person you are becoming..."

J. Murray Longmore, The Oxford Handbook of Clinical Medicine

As I mentioned, I am currently working on the renal service and I don't like it very much.  Fortunately I will switch services tomorrow, but until then I remain Dongo the Dialysis Monkey.  I have adopted this sobriquet to foreground the fact that a trained ape could do most of my jobs.  (Actually this is not entirely true, as I discovered when Gorgo (left), the ape I trained to do most of my jobs, was suspended because of certain unmentionable irregularities in his bedside manner.)

The renal service has given me multiple opportunities for insecurity about the person I am becoming.  Most of these arise from a basic tension between the exigencies of county hospital life, and our pretensions about what we do on the renal team - a tension which is often transferred to the doctor-patient relationship.

While the renal service is theoretically also here to give an expert opinion on baffling kidney problems, mostly what we do is outpatient and emergency dialysis.  The former is a regular and predictable affair which involves evaluating patients' needs and filling out a bunch of paperwork every morning, the latter a completely unpredictable one which involves doing the same thing in the middle of the night after being awoken at home by the shrieking renal pager.

Ideally, inpatient dialysis should avoided insofar as is possible in view of other medical conditions - patients in end-stage renal disease should get their treatment in dedicated outpatient centers - and emergency dialysis should be rare and only rendered necessary by some peculiar and unpredictable circumstance.  But two uncomfortable realities vitiate this ideal and create the tension I referred to.  The first is that many of our ward teams put too much stock in the phrase "no acute medical issues" as a magic formula for discharge while paying insufficient attention to the fact that end-stage renal disease is always one missed dialysis session away from being an acute medical issue.  They are therefore prone to discharge dialysis patients without paying enough attention to what will happen in the three days after they leave.  The second is that receiving dialysis is essentially a part-time job - one has to attend a range of outpatient medical and surgical appointments, undergo recurrent elective surgeries, and show up for dialysis for at least three hours at a time three days a week; most of our chronic dialysis patients already have several part time jobs, if they are lucky enough to be employed.  More often they are not and are intensely financially unstable, living lives punctuated by evictions, forced migrations, interruptions in transportation, and undeferable obligations which conflict with their rather demanding dialysis-related schedules.

You might think that if your life depended on doing something three times a week, you would make time for whatever that thing was - but when you imagine trying to keep regular three-hour appointments while you're in the process of being evicted from your apartment, trying to re-establish your lapsed Medi-Cal coverage so that you can get refills of your HIV medication, and dealing with your twenty-nine year old son who has moved home after being released from jail and is trying to balance the reality of his paraplegia with his efforts to control his diabetes which has already rendered him partially blind and is pushing him steadily along the road to dialysis, (with all the guilt and fear that trajectory would entail for you,) you can probably think of some potential pitfalls in scheduling.

Here is an example each of these two realities, which give rise to reflections on the person all house officers are in danger of becoming and whom I "do not much like":


1) Mr. C is a 27 year old gentleman whose kidneys were destroyed by an immune disorder.  His body rejected a kidney transplant back in 2005, and now he's on dialysis for life.  He came to the emergency room in hypertensive crisis (everybody with kidney failure develops high blood pressure) and the admitting team looked at a prior discharge summary and immediately put him on the rather extreme regimen of medication documented there without really verifying that that's what he had been taking.  He was then dialyzed, and four liters of fluid were removed from his blood.  It turned out that actually he had only been taking one medication, which he had run out of, and which is known to cause vicious hypertension as a withdrawal effect.  Because of this overzealous therapy, at around seven O'clock,  his blood pressure fell through the floor and he actually went into cardiac arrest and was barely resuscitated (regular readers may remember him from the post before last).  He was discharged a few days later and, not wanting a repeat of his near-death but also not wanting to keep him in the hospital to titrate his medications, the admitting team, as they documented in their discharge summary, advised him to "follow up with his nephrologist."  In any sane healthcare system this would have been only slightly risky, but in the county system "advised to follow up" is actually a secret, if inadvertent code for "advised to go die somewhere quietly, preferably in another county."  Unsurprisingly, he returned a few days later in another hypertensive crisis, having been unable to get an appointment with his nephrologist on such short notice.  This was so unsurprising that I felt stupid for not having followed my initial impulse when he was discharged, which was to write an undated emergency dialysis order so that when I was called at 3AM I could just mumble, "it's in a ziploc bag in the emergency room toilet tank - just date it call the dialysis nurse."

But it isn't just that things like this happen that bothers me - it's that people are so inured to it that the intern who discharged him for the second time apparently felt no qualms about writing in the second discharge summary "admitted for hypertensive crisis secondary to medication non-compliance."  I have been trying to come up with ways to ameliorate my over-use of the phrase 'Kafka-esque' at work, but I struggle for an equally concise way to describe being tacitly condemned for failing to take medications you were never prescribed.

2) Mr. D. is a 50 year-old Jehovah's witness who was recently admitted having developed a considerable upper gastrointestinal bleed and a concurrent blood infection from his indwelling dialysis catheter.  All renal patients are anemic, bleeding makes that worse, and sepsis lowers blood pressure catastrophically; which is to say that he didn't have enough blood in the first place, he lost a lot, and then he lost the ability to move it around.  All in all a very bad situation.  Moreover, Jehovah's Witnesses observe an inflexible religious prohibition against receiving blood transfusions (a fact which many doctors seem to resent as though it represented some kind of perverse caprice) so there wasn't much that could be done for his increasingly profound anemia.  Everybody involved was quite surprised that he survived.

On Sunday, about a week after he was discharged, I was at home.  I had worked through the weekend and would be working through the next week.  My parents were coming over for dinner, and my wife had arranged for us to meet before hand at the summit of a tall hill in a beautifully laid out cemetery near our house to enjoy a panoramic view of the sunset, which would crown a remarkably beautiful crisp November day, with some olives and a bottle of wine.  I had just gotten up from a much-needed nap, and was trying to contribute in some small way to the preparations for dinner, when the infernal renal pager went off.  The emergency room resident who had paged me told me that Mr. D. was back, and that he needed emergency dialysis.  His hemoglobin was even lower than it had been, and his potassium was dangerously high.  In fact, his potassium level (which is supposed to be around 4 mmol/L) was higher than his hemoglobin, (which is supposed to be at least 13 g/dl) a reliable clinical indicator of terrible evil which I am going to try to popularize as Benway's 'Oh, Shit' Ratio.

When I asked the ED resident how this had come to pass, she told me that he had missed his last two sessions of dialysis.  And my reaction clarified to me further exactly who this person is that I don't like and am trying not to become, because there was a split second where I almost said, "Ok, here's what we're going to do - give him a gun, and he can just shoot himself."

This is an awful, selfish thing to think, and all I can say in my defense is that I realized it immediately and instead said, "All right, I'll be there in fifteen minutes."  And when I talked to him, of course, it was immediately clear that there were a number of reasons why he had missed his dialysis and all of them were poignant and understandable.

Thank God I have clinic twice a week - pediatrics on Monday, where I mainly see vibrant Chicano health, and my own clinic on Thursday, where I see my increasingly well-known and well-managed panel of primary care patients.  In clinic I can see many potential futures where I'm a compassionate physician working together with the sick to overcome the barriers between them and the health they want.  And it's nice to be reminded that there are many alternatives to becoming was the intern who blithely accused Mr. C. of "medication non-compliance" after discharging him with no prescriptions, or the resident who almost said something horrendously insensitive about inciting the suicide of a poor devout man who's just trying to live with an awful disease in a world which makes insane and unfulfillable demands on him.

I leave the renal service on Thursday, but much to my chagrin I will have to do this again at least one more time before I finish residency.  I was tortured by this inevitability. . . and then I met Bobo.  Bobo is an adolescent bonobo interned at the San Diego Zoo, who is much more personable and intelligent than Gorgo.  He shows real potential, and after I liberate him tonight and install him in the modest but adequate quarters I have prepared for him in my closet, I will have a full year to teach him how to respond to patients' concerns with empathy and sophistication.  Depending on how he looks in a lab coat (after I wax him,) there may even be a permanent position in it for the enterprising young thing.  And a bonobo could do worse in the present economic crisis.