what i could do

I walked into the clinic chart room where the list of patients with appointments to see me that day was thumbtacked to the corkboard. I was both happy and sad to see his name. The last time I saw Mr. Brown was 2 years ago. He was 90 years old then. I assumed he stopped returning to clinic more because he didn’t want to rather than that he had died. After all, it was his primary care doctor who had insisted that he see me in the first place. Mr. Brown lived independently, drove himself to his appointments, and walked with the help of a cane. Therefore, in the mind of the primary care doc, there was no reason why Mr. Brown should not be considered for dialysis.

Mr. Brown had different ideas. The swelling on his legs wasn’t so bad. He would just continue to wear the white knee-high compression stockings that helped push the fluid up out of his legs. And he would just continue taking the low dose water pill. No, he didn’t want to increase the dose, even if that didn’t mean more pills or would mean his blood pressure would be better controlled. What he was doing was working well enough.

I had different ideas too. I hoped something quick and decisive like a massive heart attack in his sleep would take Mr. Brown’s life before his kidneys failed to a point that fear and expectations would make him and others push him to accept dialysis. Because dialysis could take away the extra fluid and make the blood test results look better, but I feared it would also take away his independence and make him feel worse. Since Mr. Brown had about 30% kidney function, my chances were good. A lot of time could pass between 30 and 5. A lot could happen long before 5.

So my heart sank a bit to see him on my list. Was his kidney function much worse now, sparking the primary care doc to refer now 92-year-old Mr. Brown back to my clinic?

This time Mr. Brown was accompanied by a caregiver. This time he was in a wheelchair. And he had lost quite a bit of weight since I last saw him. His knees hurt. He didn’t remember me, but smiled when I said I remembered him.

I held my breath as I opened his electronic medical record. I exhaled. His kidney function was about the same. But his anemia was much, much worse and his iron levels were half what they should be. Perhaps he was bleeding internally, like from a stomach or colon cancer. Perhaps his kidneys simply were no longer making enough of the hormone needed along with iron to make blood.

Treating his anemia was something I could do. Wanted to do. Treating the anemia could help him feel better. I could have the nurse give him a man-made version of the hormone in the form of a shot. The iron pills constipated him, so I could send him for intravenous infusions of iron that would not constipate and would be much more effective.

“Is this something you want to do?” I asked Mr. Brown. “It would mean you would need to come in every month.”

“Oh I can do that,” he responded without hesitation. “That would mean I could come look at your pretty face.”

“Are you trying to flirt with me, Mr. Brown?”

His shoulders shrugged as he drew his hands up to his mouth, looked at me out of the corner of his eye, and giggled like a little boy.

I smiled again.