Coolest Phone Call Ever

I got a call today from the wife of a man who used to be my patient.

Five years ago he had come to me peeing blood. Gross hematuria, as we docs call this condition so you know we're special, in this context is cancer (either kidney or bladder) until proven otherwise, so I got started on the workup. In this case I started with a CT scan to look at his kidneys and a urology referral for a cystoscopy to look into his bladder.

Everyone over at CT started getting jumping up and down, though, when they couldn't visualize his left kidney. Was its blood flow completely occluded? His right kidney was quite large, so after lots of excitement and everyone staring at the CT, the diagnosis of a solitary right kidney with compensatory hypertrophy was made. I remember specifically asking the radiologists, "But how does his right kidney look?" "Oh," came the uninterested response, "It's fine."

Urology checked out his bladder and to my surprise, found nothing abnormal. No tumor anywhere; no explanation for all the blood in his urine. The urologist suggested repeating the scans in three months and sent him on his way.

I was not happy. I just wasn't.

Two weeks later he showed up in my office again with abdominal pain and diarrhea. Even though it was likely a viral gastroenteritis, I wanted to rule out hepatitis or gall bladder disease and make sure he wasn't too dehydrated, so I sent off some blood work. Imagine my shock at finding a creatinine of 3.2 (normal 0.7 - 1.4) and a BUN of 32 (normal 7-25), when both had been normal less than three months earlier! This time I sent him for a renal ultrasound, and got this call from the radiologist:

Positive for right renal vein thrombosis extending into the inferior vena cava, possible ["overwhelmingly likely" were the words used by Urology, Nephrology and Surgery] tumor thrombosis.

I started to ask about further imaging, but she said, "This was present on the CT scan two weeks ago." She was looking at the film; I was looking at the report that said no such thing. My breath caught in my chest. It didn't matter too much that the diagnosis had been delayed two weeks, but now the unimaginable worst case scenario was about to play out: the man had only one kidney, and there was cancer in it. It was going to have to come out.

Everyone knows that renal dialysis is a procedure where machines are used to clear the blood of toxins that are usually excreted by the kidneys. So they take out his kidney and start him on dialysis; no big deal. Turns out it's a hugely big deal.

The vast majority of dialysis patients suffer from end stage renal disease, the final result of years of progressive kidney damage, usually from diabetes and/or hypertension. As such, the nephrologists usually have a chance to prepare them for dialysis both mentally (dietary restrictions and such) and physically (surgical creation of a connection between an artery and a vein in an arm, called a fistula, into which needles can be inserted to allow the machine access to the blood stream.)

Not this guy. He went from being basically healthy, able to walk around, travel, eat and drink what he pleased one minute, to -- wham! -- anephric (no kidneys); a dialysis patient, completely dependent on three-to-four hour sessions tethered to a dialysis machine three times a week, just to stay alive. It turns out the kidneys do lots of other things too, and even when they're not working well enough, they still perform many of their other functions. Not having any kidneys at all was a very big deal. Then there was the cancer; thank goodness his metastatic workup was negative. Still, it was a helluva thing to bear. Needless to say, he was miserable.

Here's the thing: I never liked this guy. He was arrogant and condescending, and he refused to work. He had somehow finagled a full Social Security Disability pension for a minor leg injury, and told me point-blank that even though he *could* work, he wasn't going to. I never said anything to him about it, but he always rubbed me the wrong way. I just didn't care for him.

But when the cancer was discovered in his solitary kidney, my distaste for him abruptly vanished. The phrase "I wouldn't wish this on anybody" took on the ring of purest truth. Nowhere in my soul was there even the barest hint of schadenfreude; of cosmic karma; of "he deserved it." And believe me, when I explore my heart of hearts, I am ruthless. I grilled myself: wasn't there even the least little bit of "so there!" to be found? There was not. I confess that I was relieved to find my character was of that caliber.

Over the next year or so he landed in the hospital several times, and eventually switched his primary care over to the main group there that included his pulmonologist (of course his 100 pack/year smoking history had left him with COPD), oncologist and nephrologist. I was sorry to see him go, but I understood.

He continued to have a very tough time with dialysis, its restrictions and its side effects. I kept in touch through his wife, who is still my patient. She always tells me that he continues to sing my praises, telling everyone he meets how he wouldn't be alive if it weren't for me. I don't necessarily agree, but it feels good to hear it, and it makes me smile.

She called again today: he got a kidney transplant last week.

Very cool.