quinta-feira, junho 23, 2016

A likeable boy

There are some patients that awake paternal feelings, and we find ourselves caring for them in a somewhat tender way, even if rationally we sometimes feel annoyed by their mistakes or behaviour.

I first met this patient at the ER - a type 1 diabetic in his early twenties, blind from diabetic retinopathy, pale from a hemoglobin under 7 g/dl, swollen from accumulated fluid, vomiting from a urea level above 300 mg/dl, with a sky high blood pressure. A classic case of end-stage renal disease caused by diabetic nephropathy, that for lack of timely treatment had reached an advanced stage we fortunately seldom see today. My first reaction was to feel angry: "how on Earth someone reaches this state nowadays?". Then I talked to him. He came from a lower-class family; his mother had just died a few days before, his father had left them long ago, and he lived with a younger brother. His mother was his caretaker, not a very efficient one, struggling with the depression that drove her to suicide, and his care had been haphazard, he didn't even know he had renal disease. He was combative and argumentative, he didn't want to start dialysis at first - such is the bad reputation this treatment has, even if it's so undeserved and mostly based on ignorance - but of course he yielded, and we started to treat him. He was discharged from the hospital after a few days, slimmed down to his normal weight and mostly asymptomatic.

He has been my patient since then, and a difficult patient. Being blind and living most of the time by himself - his younger brother, though affectionate and caring towards him, is away most of the time, and he stubbornly refuses his father's help, who is not that interested in him anyway - his medication is totally haphazard, not to speak of his diet, and he often comes to dialysis with a 4 or 5 kg weight gain, a glycemia above 300, and a blood pressure in its 200s/100s. No matter how many medication charts we'd send home, we always knew he took his pills or his insulin in a completely aleatory way, and of course his diet was appalling.

But then, even as we nag him, we cannot stop ourselves from liking him. He's a young man from a tough neighbourhood, and he always tries to play the ruffian - he even managed to get himself arrested once, for stealing at a convenience store, which puzzled me, with him being blind and at the time in a wheelchair - he is always combative and argumentative, and sticks small rolls of toilet paper in his ears during dialysis, which make him look like a funny young Yoda. He's terribly resilient, the only diabetic I know to survive a Fournier's gangrene. But even when I joke with him about his getting an ear piercing to look prettier I'm always worried, I'm always waiting for the day he will have a brain bleeding because of his uncontrolled blood pressure, a ravaging sepsis or a fatal hypoglycemia.

So yesterday I was really happy because, after the nth medication change (I always try to make it as simple as I can), his blood pressure was perfect. I heartily congratulated him, and he smiled a proud grin, saying: "yeah, it looks like you got it right this time!", and I somehow felt moved, felt like stroking his head and giving him a fatherly kiss - which of course I didn't. Like so many of my patients, I feel responsible for him, and every therapeutic success, how small or short-lived it may be, feels like a victory. I know this will be short-lived, I know he will die soon, from one of the many complications he is vulnerable to, and I feel angry about my helplessness to help him, as to help so many other of my patients. This kid is old enough to be my son, I would like to protect him, to care for him,but there is so little I can do.

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