the cutest

Another day. Another nonagenarian. Ninety-year-old Mr. V sat in his wheelchair, his son seated in the burgundy office chair beside him when I walked in the room.

Mr. V had about 30% of his kidney function left and had been referred to my clinic for blood pressure management. He sat contentedly in his wheelchair, his face freckled and jowls hanging. He was slender with the exception of a painless pot belly. He was arguably The Cutest and I smiled his way frequently.

He was also hard of hearing, there was no good ear, and he only understood Vietnamese. His son occasionally shouted into the right one when I asked questions, to which he shouted back a few Vietnamese words, which his son translated to me in English at a normal decibel.

The son was pleasant and intent on caring for his father and his mother who was just 83. He insisted that his father walk every day.

“It is his physical therapy,” he said. “He uses his walker to walk up and down the block one time every day. There is a seat on it and he has to sit down halfway to rest.”

Mr. Vu loved his half-glass of wine at lunch and dinner, but his son limited it to every few days because it seemed to bring on a gout attack, which made him not want to walk, interfering with his physical therapy. He had gout attacks every 2 weeks.

His last uric acid level, which causes gout attacks, was measured two years ago and was high. Getting his uric acid controlled would prevent gout attacks and might slow down the worsening of his kidney function. A win-win in my mind because the last thing I ever wanted to do was to hear anyone asking about dialysis for this 90-year-old man mostly in a wheelchair.

But then I examined his urine sample. A routine thing, really, just to make sure there was no sign of infection. Something that could be easily treated. And then a surprising thing—sugar in the urine of a person without uncontrolled diabetes. Multiple myeloma, a bone marrow cancer, could cause sugar in the urine of someone without uncontrolled diabetes.

To diagnose multiple myeloma, one would send specific blood and urine tests, which if suggestive of myeloma could be followed by a bone marrow biopsy—a needle in the hip. A bone marrow biopsy showing myeloma could be followed by chemotherapy in hopes of extending a life a few years.

In that moment I had to decide if I would be “the one” that would start a cascade that could lead to things at least as aggressive as dialysis. Dialysis. Something I didn’t want to do.

I printed out the orders, telling myself if they were suggestive of myeloma, we didn’t have to go further; we would just know what could be expected for Mr. Vu. I wondered if Mr. Vu was a little less functional or even a little less cute if I would have been less conflicted; no qualms about dismissing the sugar in the urine as something that didn’t really matter.

Mr. Vu turned his head to the left and belched loudly as I talked to his son. No hand to the mouth. No apology. Still The Cutest. I smiled, hoping the test results would not be suggestive, or at least the next doc would be able to let it go.