It was a day of rounding on my dialysis patients with routine monthly lab results in hand. My patient, Book of Eli Denzel Doppelgänger, was doing better. His last several months of adjusting to being on dialysis after years of hoping he would never have to, had been slow going. “I’m realizing that this is a life and death situation,” he said to me in those first few weeks after starting dialysis.
“Yes, I know. Hence the name ‘end-stage’ kidney disease’,” I nodded, almost surprised that this hadn’t come across to him in the several months prior to his starting dialysis, when every few weeks I said it as I pleaded with him to allow me to help him avoid the hospital. Or worse, not make it there in time.
He smiled, as if he read my mind. “But I guess that is what you were trying to explain to me all along, huh, Dr. Grubbs.”
“Yes, but it’s OK. Most people don’t want to hear it. At least you were able to avoid the Emergency Room.”
This day I was happy to let him know that his anemia was well controlled. That his phosphorus and potassium levels were where they needed to be. That his fistula was finally working well enough to allow him to get efficient dialysis in the 9 hours he sat in the recliner each week.
It’s not often that I get to give any good news. Mostly I feel like I am just painting on another coat of sugar to the shit. It would be wonderful to tell a patient something so great that it makes us both want to break into our happy dances.
And then he showed me his finger.
“Oh, before you go, Doctor, I wanted to ask you what you thought of this,” he said, holding his left thumb towards me.
From cuticle to a bit over halfway up his thumbnail coursed a dark, almost black line. I had never seen anything like it before. I had seen horizontal lines across the nails of some people with chronic kidney disease. I had seen the pitted nails of some people with psoriasis. I had seen the humped nails of some people with cancer. This was new.
This presented another opportunity for me to kick myself for not knowing something—because not knowing could mean someone being diagnosed with the wrong thing, someone’s diagnosis taking longer than it should, someone dying. But although I have been known to kick my own ass black and blue for days on end, at least I felt I could rely on my Spidey sense, my gut instincts that at least let me know when I needed to look it up or ask somebody who might know.
My Spidey sense was not alarming so I said, "I’ve not seen that before, but I don’t think it’s badness. I’ll try to figure it out and let you know what I find out.”
And then I promptly forgot about it and went out of town for a month.
While I was away, the physician assistant covering for me took a look at his thumb. She didn’t know what it was either, so referred him to the Dermatology clinic. They saw him while I was away.
When I returned, I felt badly (translation self-ass kicked) that I forgot to look it up and that I hadn’t referred him myself. But then I saw the dermatologist’s note. He thought it was benign, nothing to worry about, and would check it again in 6 months. I was able to stop questioning my Spidey sense and pause my self-ass kicking foot in mid-air.
Still, when I saw Book of Eli again, he wanted to know what it was. This time I remembered to look it up. I found pictures showing fingernails that looked like his and learned that severe disease of an artery could cause it. His was on the same side of his fistula, which had been slow to be ready to use and the hand was still swollen and cramped on dialysis. I also learned that subungal melanoma, a very rare—and deadly— type of cancer, could cause it too, but quickly dismissed the thought. After all, the dermatologist said it was nothing to worry about. I emailed a picture of Book of Eli’s thumb to the surgeon who created the fistula.
“Looks like Hutchinson’s sign to me,” he responded promptly. Hutchinson's nail sign can mean subungal melanoma.
I looked at my own picture more carefully. The line was longer than I remember it being a month prior. And the skin below the cuticle did look darker now. I didn’t remember that being there before. And was the line wider too?
I emailed Dermatology with my concerns. They saw him in clinic a few days later and documented that the line was longer and thicker since they saw him just a couple of weeks prior. It was growing. Fast. Not good.
He was scheduled for a nail biopsy 3 days later. He was told the results would be back in 2 weeks. Two weeks to wait, wondering if end-stage kidney disease was all he would have to try living with.
I checked the computer for the results every day. One week later they were back. Melanocyte activation. A benign process. No big deal.
I got to do a happy dance with Book of Eli.