The ER

We went to the ER, with me wearing my coziest pants and a soft, loose shirt. Flip-flops. Easy, loose, comfortable. I felt smart for bringing a cardigan because I often I forget about air-conditioning--I doubt hospitals in San Francisco even have A/C because it's just never that hot. Well, except now it's hot all the time thanks to global warming. I digress.

The cardigan did nothing for me so it was lucky Stephanie had one of her homemade fleece blankets in the car--I was freezing. (She doesn't make the fleece, she ties two big pieces of fleece together and makes the best blankies.) She got me a wheelchair which I remember thinking was kinda silly. . .until I sat it in and felt relieved that I didn't have to walk anywhere. Note: it's a humbling experience to get pushed in a wheelchair by your friend. It's also a nice experience to be that taken care of.

I signed in and got a wristband, happy I was already in the computer system because I'd had my baby girls in the affiliated hospital--the better one--up the hill in the richer town a few miles away. We sat to wait. The ER is a good place for people-watching. It's tempting to think the population of an emergency room would give you a good snapshot of the population of a town but I find that's not always the case. As a generalization you're probably seeing the grungier, rougher, less well-off folks with the few exceptions being minor accidents that bring people into the closest hospital they can find. There are always at least a few kids, sick or injured, with their parents. Ours had an adorable blond, chubby-faced toddler wearing Jordans whose tattooed father kept following him around with a cell phone trying to show him what I'm guessing was a YouTube video of Watch Me, presumably in the hopes that his kid would learn how to do the Nae Nae?

The most interesting guy to me was a really skinny, brown-skinned man with close-cropped hair, a cane, a rolling, bouncing gait and what I knew to be an AV fistula--what looked like a bulging vein in his right arm. An AV fistula is created when they directly connect a person's artery to their vein to create a stronger portal for dialysis. Dialysis, if you don't know, is the the process of getting hooked up to a machine that clears the toxins out of your blood when you have kidney failure and your own kidneys can't do it. I can't remember what exactly what he was wearing but he was pretty well-dressed. He didn't look homeless or crazy, but he did look agitated.

This guy was pacing back and forth in the lobby and I could tell he looked like trouble. Not trouble like I'm worried he will do anything to me or anyone else, trouble as in the hospital staff does not want to deal with him.. I'm not saying that is the hospital staff's fault or the patient's fault--I bring it up as an example of what is often a disconnect between the person seeking care and the people providing care. It's not easy for either side. Plus he could have been a frequent-flier--someone they all knew and were tired of.

I am an eavesdropper. A people-watcher. An observer. Other people would probably call me a nosy, starer because I often forget that I'm watching and people can see me. I was huddled in my wheelchair, wrapped in Stephanie's blanket, drinking icy Gatorade that she'd brought me in her water bottle, watching. At some point the man picked up the phone hanging from the wall, the equivalent of the house phone in a nicer hotel, and made a call. His voice was frustrated as he talked to the person on the other end, explaining that the hospital was telling him they couldn't dialyize him. The person on the phone obviously didn't believe him. The guy put the receiver on top of the phone and yelled out to a young doctor on the other side of the room "Hey! Can you talk to my brother? He doesn't believe me when I tell him you can't do my dialysis here."

I thought to myself "They don't have a dialysis machine here? Um. What kind of a hospital is this?"

The doctor looked annoyed. I know I'm missing parts of the story because it clearly wasn't the first interaction these two had had, even just that morning. It was also clear that this young doctor a) did not want to keep dealing with this patient b) did not appreciate getting summoned with a yell from some dude across the room, especially as he clearly had been on his way elsewhere. He looked like a nice guy; they both did.

At first the doctor tried explaining to the patient again that he had to go to a dialysis clinic to get his treatment. Phew, I thought. It's not that they don't actually have the machine here. Okay, we can stay. Not that I thought I needed dialysis but I would have been concerned about getting treated in a hospital that didn't have a basic, oft-used albeit expensive machine. Unless I was in the middle of the country-side or a very tiny town.

After a few minutes the doctor resignedly got on the phone to talk to who turned out to be the patient's brother. (I know this because the patient asked "Will you explain it to my brother? He doesn't believe me.")  The one-side conversation we could hear was civil, involved a lot of nodding, a bit of explaining and finally an "Oh, he didn't say that to us." He hung up the phone and led the patient back up to the admitting desk to get admitted.

What happened, in a nutshell, is that this patient who obviously regularly gets dialysis for kidney failure (because he has a dialysis-ready arm which doesn't happen over night) came to the ER to get treated. What's supposed to happen is that patients who get dialysis go regularly to a clinic, usually three times a week, where they sit in a chair and get their blood filtered. The process takes about four hours and the dates are scheduled--you don't just walk in and say "I feel like some dialysis today!" My guess is that this patient either missed his usual appointment or something unusual happened where, even having his regular appointment he was feeling shitty and knew he needed help.

What the hospital staff sees and says is basically "Hey dude, we are not a dialysis clinic. You can't just come in here and expect that we'll do that for you. We are busy! We are an emergency room!" Some hospital staff might also be thinking "Hey, just because you forgot to go to your appointment or didn't do what you were supposed to do doesn't mean it's an emergency that we should have to deal with." Not because the hospital staff is bad but because that's not how it works. And they're not prepared with the appropriate staff, dialysis set-up, time, etc. Plus I'm sure there is a financial aspect to it but I can't speak to how that breaks down. I can say, as someone who works in health care, it is annoying to have to deal with patients who don't do what they are supposed to do.

What the patient probably thinks is "I know I need dialysis because either a) I know I missed my appointment or b) this is not my first rodeo and I recognize my symptoms and my body is telling me I need it. I either can't get to the clinic because it's Saturday or it's too far or I don't want to. I'm coming here and I know you can do it here." I can say, as a patient it is annoying to have to jump through hoops to get what you know you need.

What the brother on the phone knew to do was to explain whatever symptoms the patient was currently having in such a way that the doctor couldn't deny that they needed to admit him and treat him. Because that's how it works. You as a patient don't get to go to an ER and order off a menu the treatment you need. You have to go, describe what is happening, answer the questions the care provider thinks or knows to ask, and let them determine your treatment. And not just in the ER--there's nowhere you can just ask for and get what treatment you need, even if you know for sure what you need because you know your body and you know what's wrong. And to be fair, and as this story will keep showing, you may not be as smart and dialed in as you think you are so it's probably a good idea to let the trained, medical professionals take a look and diagnose you. And to be fair in the other direction, the doctor or the nurse or the whoever may not think or know to ask the right questions. They don't know you, they know systems and protocols and they use their experience, knowledge, test results and their team to make the best diagnosis they can. It's a dance, and a complicated one.

So all that happened, but the entire exchange didn't take long. I got called back soon--because saying you've had diarrhea for a week and you're feeling weak and light-headed when you're sitting in a wheelchair, bumps you up a bit on the triage list. I also looked like shit--pale and wan, though I didn't know that or notice it. They checked my vitals. They gave me an IV. They drew some blood for labs. Took urine and stool samples. (The process and the actions I'm describing took much longer than it may appear by the short, snappy sentences.) A doctor who looked approximately thirteen came to see me (and hey, no judgement. I'm thirty-eight, I understand there are and will continue to be more and more doctors who are younger than I am). He reported that I was in acute renal failure with a creatinine of 2.0 (normal is 0.7-1.3) and I was severely dehydrated. They were going to admit me. Regarding the diarrhea and the colitis flare, they didn't have a gastroenterologist on staff at the hospital but they would page the one on call at their sister hospital and he/she would call back or come see me within 24 hours. Note: a gastroenterologist is a doctor who specializes in bowel disease, also known as the GI tract, and will from now on be known as a GI doctor because that word is long and hard to spell.

Acute renal failure. Huh. Didn't see that coming though it made sense with how dehydrated I'd gotten. I thought they'd just give me an IV and send me home. See: don't think you can diagnose yourself. See also previous post: I apparently underestimate how sick I am.

This will become a familiar theme.

It was good that I had come in because no amount of Gatorade would have fixed that problem for me. I didn't expect them to do anything for the colitis because I still assumed it would pass like it always does. And unless this random GI doctor was going to come do a colonscopy on me I wasn't sure exactly what they were calling him/her for but I was not in charge.

"Renal failure," I said. "It would probably be a good idea to call my transplant team to let them know that."

The young doctor looked up from his clipboard and asked "You had a transplant?"

Sigh.