Chapter 4
I will never forget our first nephrology case. To start with, I thought nephrology would mean fewer hours on my feet. There are way more nephrologists than infectious disease specialists. I did the math and figured there'd be a smaller caseload, and less need for me to be on my feet 12 or more hours a day.
Cuddy looked at it like I'd have more time to spend (waste, actually, but let's not quibble over semantics) in the clinic.
Which led to a very fun game, finding new and ever more interesting ways to hide from Cuddy.
See, our new patient was a minister. Well, sort of, anyway. Whoever heard of a minister who no longer believed in God? I found him in the clinic. He was there because he was having pain while urinating. I was hiding in the men's room in the clinic. Cuddy would think I was working in the clinic, and wouldn't bug me, so it was a win-win situation. I was in the men's room, in a stall, with my PSP playing Need for Speed, and this guy started screaming in the stall next to me. One thing led to another and voila', we had our new patient.
Painful Pee guy had been to at least three emergency rooms and five different doctors in the last few days, and told all of them that it felt like he was being cut with knives every time he urinated. All of them apparently did like most doctors would do, they got urine cultures and started treating him for what was presumed to be a urinary tract infection. Nobody followed up adequately with him, however, or else they would have known that his pain was only getting worse. On his last visit to another emergency room, the doc there called security and had him escorted off the grounds, because the patient was yelling that he needed narcotics for his pain. They told him he hadn't given the antibiotics enough time to work, and that he shouldn't need narcotics for pain relief, and that he was just a drug seeker.
So Painful Pee guy winds up screaming in the stall next to me, in the men's room in our clinic here at Chez PPTH.
I briefly considered doing our DDX right there in the men's room, but with Cameron and Thirteen in there too, Cuddy would have followed the long line of guys waiting to get in and then, she would have found me. I had to move on to Plan B – get the guy admitted and do our differential diagnosis in our plain old boring office.
Cameron did the guy's initial history, and my other fellows helped with the physical exam. Cameron found out the minister who no longer believes in God had just been handed divorce papers, and tried to kill himself with a big bottle of antifreeze. Antifreeze is sweet, which is why it should be kept out of the reach of babies, dogs and cats. They love it. The label on the bottle didn't say anything about keeping it out of the reach of morons. See, if you're going to try to off yourself, there are faster and less painful ways to do that. Drinking antifreeze will do the trick, but not without days of agony first. Antifreeze causes crystals to form in the kidneys and bladder, blocking the flow of urine. Painful Pee guy was trying to pee crystals. When enough crystals have formed in the kidneys, they don't even produce urine anymore. Painful Pee guy had gone about four days before he showed up in our clinic and we diagnosed the renal failure caused by antifreeze ingestion.
We started treatment right away with IV alcohol (ethanol) and temporary dialysis. The guy recovered physically.
As I wrote earlier, I'm not much into visiting patients if I don't have to. Hearing someone scream bloody murder in the stall next to me in the men's room did, however, peak my curiousity. After he was admitted, I snuck in to his room to see him after I told my team I was going home for the day.
The guy saw my cane, which is usually the first thing anyone sees about me and usually immediately makes them change their expression and treat me differently. Not this guy, though. The first thing he screamed at me was to give him a shot of morphine and let him die, because God didn't give a damn about him so why should anyone else. My team had just started the IV ethanol, which causes the pleasant (or unpleasant, depending on how you look at it) side effect of making the patient drunk. I knew the ethanol would hit him soon, so I needed to talk to him before he drifted off to sleep. I also knew any more morphine, beyond what my team had already given him, would potentiate the sedative effect of the ethanol, and wouldn't be good for him.
While he could still stay awake long enough to listen, I plopped down on a chair next to his bed, put my feet up on his bed and asked him why he did it. I won't go into the details about why he did it here, save to say that my team found me in his room hours after the patient went to sleep, still sitting in the chair with my feet up on his bed, thinking about what he told me.