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.