for better or worse

“Excellent!” Mr. F says in his raspy voice. This is always his response to my, “How are you today?”

The side table of his recliner is littered with tootsie rolls and nickel bubble gum, but mostly their wrappers. A few lie on the side tables of most of the other patients there too. He has made his candy rounds as usual before taking a seat for his hemodialysis treatment.

“What movies did you see this weekend?” I ask. Mr. F loves movies. I hear he has been banned from a few theaters because he buys one ticket and one popcorn and tries to stay all day.

“I don’t remember the NAME of it,” he says, emphasizing words often for no apparent reason. “The one with the TIGER!”

“Oh, Life of Pi?” I ask. “I liked that movie. Did you?”

“Yes. YES. I liked that MOVIE.”

“Good. Good. Let me listen to your lungs now,” I say, moving on.

“OK. O-KAY!” he says and leans forward. I place the bell of my stethoscope over the back of his right lower lung. “OK. One-Two-Three,” he revs up to breathe in and out through his mouth as I have asked him, but I mostly just hear him counting and grunting in preparation of a new count. Bless his heart.

Mr. F is in his sixties and has dementia. He is mostly pleasantly demented, usually bothering no one. But sometimes… “Don’t TOUCH me!” while flailing his arms, or “It’s my TURN! I was here FIRST!” he’ll rant, never quite grasping the concept of the dialysis shift schedule.

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He started dialysis under my care a little over a year ago with the 2 clasped plastic tubes of a tunneled dialysis catheter dangling below his right scapula.  Each clamp is opened and connected to the dialysis machine. On the other end, the tubes combine into one just before the skin. The one has entered the chest and burrowed beneath the skin a few inches before it dove into the large vein below. Its tip rests in the upper right chamber of his heart.

The catheter damages the blood vessel. It is commonly the source of infections in the blood. It increases the risk of death compared to a fistula. A fistula is created when a vein and artery in the arm are surgically connected. No foreign material for the body to attack. The blood pulsating fast through the artery thickens the vein over time, making it sturdy enough to withstand the 2 dialysis needles at least three times a week for years.

A fistula is the standard of care. A fistula is better.

I imagine the scene of Mr. F with a fistula. He looks at the clock and sees that it is time for his treatment to end. “Take me OFF. It’s my TIME!” he shouts. The technician is finishing up with another patient. “I’ll be there in just a minute,” she responds. “NO! NOW!” He jerks his arm. Needles tear through tape and skin. Blood streams and splatters. A lot of it. Onto himself. Onto the dialysis chair. Onto nearby staff and patients. Next time we’ll have to tie the arm with the fistula down to the chair. And probably the other one too. And he'll probably need to be sedated too, in order to tolerate being restrained. For his safety and ours. For three hours. Three times a week. For the rest of his life.

I will not refer Mr. F to the surgeons for evaluation.

The nurse is glad and begs me to keep him on my shift of patients. She imagines the same scene. The nephrologist taking over his care would refer him, she says. He would believe a fistula would be better for Mr. F, for anyone on hemodialysis, she says.

“I need to examine your catheter now,” I say as my hand moves to the bandaged area on his chest.

“My what?” he looks at me, confused, brows wavering.

I don't repeat myself. He has forgotten the catheter is there.