The Dialysis Patient

I got the call at 3 pm as I was back at the office, feet up on my desk, lightly sleeping. The nurses used to tease me about this activity, but now are protective of my nap time. I can sometimes hear them whispering or moving quietly near my desk so as not to wake me up. The 3 O'clock nap is one of the high points of the day. The rounds are done, but you can't go home yet as you are responsible for any new admissions or consults until 4:30. You're exhausted from the grueling days and nights on call. A twenty minute nap at the desk is pure bliss.

The call came from Interventional Radiology. Hmmm. A call from IR can be routine, a question about a vascular access procedure on a dialysis patient, fro example. Or it can be a disaster. The IR guys do some incredible things, snaking around the arteries and veins, using the blood vessels of the body like a highway. They get to where the trouble is and then dilate arteries with balloons. deploy stents, embolize bleeders. But they can also get into horrendous complications. Sometimes they dilate the vessel a little too much and it bursts. They call the surgeon first and me second.

This call was a complication, but not too bad. They were draining fluid off the lung of a dialysis patient, a procedure called a thoracentesis. During the procedure the initially clear fluid had turned bloody, and the patient had complained of pain and started coughing. This is when the doctor starts to sweat. The follow-up chest xray had showed a partially dropped lung or pneumothorax. Since I was the nephrologist covering I got the call.

The patient was, at best, a trainwreck. He was a former smoker with obstructive lung disease. He had congestive heart failure with a left ventricle that twitched and quivered rather than pumping. He also had end-stage renal disease and was on dialysis. The reason he accumulated fluid around the lungs and in the belly was that he had a bad heart. Whenever we tried to take off fluid with the dialysis machine his heart couldn't compensate and his blood pressure dropped. We never were able to get him to his dry weight and he progressively swelled up with fluid.

He also had the angry wife syndrome. When I began to take the history she jumped right in with a tirade about his last hospitalization and how the doctors had screwed everything up. You see, his problems were not the result of 60 pack years of smoking, coupled with bad diet and lack of exerecise, It was because the doctors had let him sit in the ER for 10 hours before ordering the right xrays, blood tests, blah, blah, blah. Since that hospitalization he had been in a nursing home, being fed through a tube, transported to dialysis three times a week. He didn't walk and it quickly became obvious to me that he was relatively out of it as well.

Ok. So what the hell are we all doing here with the dialysis and invasive procedures in Radiology? I mean here is this poor loxed out guy: laying in bed, can't walk, can't talk, can't eat. I mean really, what the fuck?

I soothed the wife as best a possible, ordered some pain meds so a least the old guy wouldn't suffer, and admitted him to the ward. She asked me if I planned on surgery for his dropped lung. Yeah, lady, totally, I'll call the OR right away, because they love operating on cadavers.

My plan was to make him comfortable and see if the lung re-expands. At most he'll get a chest tube, but even that could be trouble. Hopefully I can get him back to the nursing home and he can live the rest of his days in peace.