He was Cuban, homeless, and a Tolkienian dwarf of a man; round paunch, bulbous nose, bald-head but plenty of hair around his ears and on his face. I sent the student in to interview him but he shooed her away and continued to shuffle back and forth in the hallway making a nuisance of himself and hogging the community telephone. Earlier that day he and his wheelchair had taken a tumble down some stairs. His knees were bloodied and his back was sore. Drawn in by his charm and his elfin impishness, I needed to know his story. As for my patient, finally, he had a captive audience.
His father, a military officer, bought him a car, “because you make good grades!”
He said to his mother, “But I don’t even have a license. I’m only 14!”
Her response, “Everyone knows you are my son! That alone will vouch for your character!” As if character was sufficient experience to drive a car.
With his new car, he drove straight to the whorehouse. And back and back and back he went. At 77 years of age, he had fathered 17 children with 16 different women. Once, when he was 18 years old and in New York City (pre-Castro), he looked out his hotel window and an older woman, in a hotel across the street, waved back to him. The next day he looked out and she was standing naked in the window. The third day, he stood naked in his window while she stood naked in her window across the street. On the fourth day he went outside, grabbed her by the wrist and took her to his room and they proceeded to make love for 4 hours. She, the older woman, had been with a Negrito (his words, not mine), her boyfriend, on the day he grabbed her by the arm. Several years later he discovered she had returned to Cuba with the Negrito and given birth to his son. Before immigrating to America, he met this son while he was in jail. Comically, he had judgment in his voice as he lamented his son’s incarceration. As though he would have been the better parent. My patient, too, had been to jail, for gambling. The judge gave him a choice; serve 4 years or forever be banished to Florida with all of his family. He chose the latter. His family never arrived in Havana to sail with him on that steamer ship to Miami. The judge had lied. That had been 41 years earlier and he never saw his parents or his family again.
He had 3 wives. I couldn’t tell if the 3 wives had been consecutive or concurrent, but it didn’t really matter. His children lived in Miami and Orlando and New York and San Francisco and Germany but he spoke with none of them. Not only did he have wives but he also had a series of girlfriends with whom he’d have sex for hours. “I never have troubles getting an erection. Every morning I have an erection. I don’t know. I just never have troubles.” He wasn’t bragging. He was simply stating a fact, a piece of medical history for me. He sold newspapers for $50 a day and some nights he’d go downtown on Main Street and dance with women for $10 a dance and on these nights he could earn another twenty to thirty dollars. He could dance the tango, the salsa, the mambo, the cha-cha-cha. But what he liked the best was Benny More and the danzon.
As though this had been the most fantastical part of his story, his dancing abilities, I asked him to prove to me he could dance. The student was trapped in our interaction, this dance of our own, and I made her fetch my phone. I played the music he mentioned; the danzon and the Benny More that just a minute before I thought he had been confabulating. And we danced.
“You dance good” he told me. “Give me your phone number so I can take you dancing.”
“My husband wouldn’t like that.”
“But your husband is a modern man. I’ll talk to him. It will be okay.”
After 30 seconds of dancing he was winded; short of breath with a twinge of chest pain. We had to stop. Once again I was the doctor and he was the patient. We were no longer in Havana but room 7 of the ER. My shift ended that night and I signed him out to the following provider. I looked up his record the next day, to see what had happened to him. He had been kicked out of the ER like he had been so many previous times. I’m sure he’ll be back.
For the record, I don’t think most of his story was true. It wasn't the many wives or the sexual prowess or the innumerable children that made me suspicious. If his story had been true he wouldn’t have needed that nitroglycerin while we were dancing. No one on Main Street is going to pay $10 for half a minute of dancing.
Wednesday, April 6, 2016
Glass Houses
The potassium is 5.9 and the lungs are clear but only because he can't take a deep breath. It's a tough call, but not really. His legs are edematous and his abdomen is tense with the fluid distention. He feels like retching and no matter how many layers he wears, he can't get warm. He can't urinate. He hasn't been able to pee in 2 years. Maybe some drops but not a stream. The stream stopped long ago. And now he has this catheter that is tethered to his chest like a leash. It's a shitty existence, running up to the hospital every 4 to 5 days. Begging to have your body rid of its toxic waste. To him, the rules that have been made are arbitrary and make little sense. And he's a pariah. Some people are accusatory. Obviously he is sabotaging his kidneys to get dialysis. Someone saw him eating McDonald's french fries last time he was here. He probably loaded up on bananas early this morning. He ate the bananas before he arrived at 5 am this morning. He arrived at 5 am because he knows that if he gets there at 9 am all the chairs will be full and he'll have to sleep sitting up one more night, drowning in his own urine. It doesn't matter that he used to be a landscaper; that he worked his whole life to provide for his family. The only thing that matters now is that he is trying to get something for free when he has no legal rights for anything. At least that is what it seems like to him every time he goes up there and he has to justify the severity of his symptoms. On a scale of 1 to 10 he feels like a 100 on an average day. On the days that he makes the drive to the hospital he feels a logarithmic degree of crappiness. But it's the Hunger Games of health care and he didn't pay a mule $5000 25 years ago to come to this country to get sacrificed in the arena.
If she had the chance, she do the same thing all over again. Her daughter needed that kidney. Her crystal ball didn't tell her that she'd develop cancer in her remaining kidney and they'd take that one out too. And then there'd be none. Having none kidneys is a problem. Even with a 3rd grade education, she could tell you that. One of life's cruel jokes. No good deed goes unpunished. When you are missing a limb it's obvious. But when you are missing both of your kidney's you feel like you're the urban myth everyone talks about; you went to Mexico for vacation and you woke up in a bathtub full of ice and you had a huge scar across your abdomen and both of your kidneys were gone. Except you're from El Salvador and you had to leave because your ex-husband tried to kill you. You had been working as a housekeeper to send money back home to the daughter in possession of your good kidney but the frequent trips to the ER started to irritate your employer and you were let go. Now you live with your aunt who has health problems of her own but she dutifully carries you up to the hospital every time you get that unmistakeable nausea and you start vomiting. Your potassium never goes above 4.5 so often times you get sent right back home. It's the worst when the doctor just looks at the numbers and doesn't ask you any questions. You know you shouldn't but sometimes you cry. The tears add emphasis and emphasis gets you the golden ticket to the 6th floor and the hemodialysis unit.
Sitting in that triage room you sit on the throne of judgment. It's an onerous task. The guidelines are meant to be a tool to make the job easier, or at least more objective. But objectively, when every single patient has a GFR of 2 they all meet criteria for hemodialysis regardless of their potassium level. Everyone is volume overloaded. Everyone is uremic. The greatest common denominator is a lack of documentation of legal entry into the United States of America. We can split hairs over the politics of this all day long. Bernie Sanders and Hillary Clinton and Donald Trump and Ted Cruz and Gregg Abbott and Rick Perry and Barack Obama and Oprah Winfrey and the Pope can all sit down in that triage room with me or any other provider for 3 days in a row and then we can have a nice round table discussion. It's hard to tell someone with that much desperation in their eyes, "Too bad!" Even the most soulless of individuals have a hard time telling an 80 year old grandfather or a 23 year old son or a 46 year old mother to go home. "Sorry sir or ma'am. There will be none for you today."
It's even worse now. The resources are more limited. There are less chairs. No one is happy. The patients aren't happy. The nurses aren't happy. The doctors aren't happy. The administrators aren't happy. An undocumented, ESRD patient who happens to fulfill the arbitrary requirements (can we all just admit we are playing God and we're not half as convincing as Morgan Freeman) that sorts him or her into the "NEEDS EMERGENT HEMODIALYSIS" pile is more contagious than Ebola or meningococcal meningitis. We'd all just as soon let the next person deal with the patient. Inevitably you're going to be stuck calling the cranky renal fellow or stuck calling the transfer center to arrange for your patient to go to Galveston or San Antonio or Conroe or the hospital across the street (because there are no more hemodialysis chairs in your hospital). Meanwhile your patient would do anything in the world to sit on the toilet and take a pee just one more time. Or not have a garden hose flopping out of his chest. Or not have skin 80 shades darker than the deepest tan she ever had. Or not wear a winter coat and a wool hat in the middle of July. Or beg for mercy every time he comes to the hospital. He's not trying to game the system. She's not trying to manipulatively score hemodialysis. They are just trying to live one more day so they can drink coffee on the patio with their spouse or walk in the park or go to the birthday party or the family gathering or the grandkid's high school graduation. We need to get over ourselves and our hierarchical mind frame. Some day we might be the dog begging for the table scraps. And we are going to want mercy. So lets all put down our rocks and clean the windows our our glass houses.
If she had the chance, she do the same thing all over again. Her daughter needed that kidney. Her crystal ball didn't tell her that she'd develop cancer in her remaining kidney and they'd take that one out too. And then there'd be none. Having none kidneys is a problem. Even with a 3rd grade education, she could tell you that. One of life's cruel jokes. No good deed goes unpunished. When you are missing a limb it's obvious. But when you are missing both of your kidney's you feel like you're the urban myth everyone talks about; you went to Mexico for vacation and you woke up in a bathtub full of ice and you had a huge scar across your abdomen and both of your kidneys were gone. Except you're from El Salvador and you had to leave because your ex-husband tried to kill you. You had been working as a housekeeper to send money back home to the daughter in possession of your good kidney but the frequent trips to the ER started to irritate your employer and you were let go. Now you live with your aunt who has health problems of her own but she dutifully carries you up to the hospital every time you get that unmistakeable nausea and you start vomiting. Your potassium never goes above 4.5 so often times you get sent right back home. It's the worst when the doctor just looks at the numbers and doesn't ask you any questions. You know you shouldn't but sometimes you cry. The tears add emphasis and emphasis gets you the golden ticket to the 6th floor and the hemodialysis unit.
Sitting in that triage room you sit on the throne of judgment. It's an onerous task. The guidelines are meant to be a tool to make the job easier, or at least more objective. But objectively, when every single patient has a GFR of 2 they all meet criteria for hemodialysis regardless of their potassium level. Everyone is volume overloaded. Everyone is uremic. The greatest common denominator is a lack of documentation of legal entry into the United States of America. We can split hairs over the politics of this all day long. Bernie Sanders and Hillary Clinton and Donald Trump and Ted Cruz and Gregg Abbott and Rick Perry and Barack Obama and Oprah Winfrey and the Pope can all sit down in that triage room with me or any other provider for 3 days in a row and then we can have a nice round table discussion. It's hard to tell someone with that much desperation in their eyes, "Too bad!" Even the most soulless of individuals have a hard time telling an 80 year old grandfather or a 23 year old son or a 46 year old mother to go home. "Sorry sir or ma'am. There will be none for you today."
It's even worse now. The resources are more limited. There are less chairs. No one is happy. The patients aren't happy. The nurses aren't happy. The doctors aren't happy. The administrators aren't happy. An undocumented, ESRD patient who happens to fulfill the arbitrary requirements (can we all just admit we are playing God and we're not half as convincing as Morgan Freeman) that sorts him or her into the "NEEDS EMERGENT HEMODIALYSIS" pile is more contagious than Ebola or meningococcal meningitis. We'd all just as soon let the next person deal with the patient. Inevitably you're going to be stuck calling the cranky renal fellow or stuck calling the transfer center to arrange for your patient to go to Galveston or San Antonio or Conroe or the hospital across the street (because there are no more hemodialysis chairs in your hospital). Meanwhile your patient would do anything in the world to sit on the toilet and take a pee just one more time. Or not have a garden hose flopping out of his chest. Or not have skin 80 shades darker than the deepest tan she ever had. Or not wear a winter coat and a wool hat in the middle of July. Or beg for mercy every time he comes to the hospital. He's not trying to game the system. She's not trying to manipulatively score hemodialysis. They are just trying to live one more day so they can drink coffee on the patio with their spouse or walk in the park or go to the birthday party or the family gathering or the grandkid's high school graduation. We need to get over ourselves and our hierarchical mind frame. Some day we might be the dog begging for the table scraps. And we are going to want mercy. So lets all put down our rocks and clean the windows our our glass houses.
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