Thread by @TheRealDoctorT

John doesn’t have many joys left in his old age. His wife died a year ago, and it turned his world to monochrome.

Now the only place he sees vivid colors is the garden she planted once upon a time.

He was never great at gardening, but it’s become his singular happiness. 1/

It’s early morning and John is in his routine.

He takes his morning medications, including a two-drug combo pill for blood pressure. It’s going to be hot today so he drinks an extra glass of water.

And then he steps out into the back yard, and picks up his gardening tools. 2/

Several hours later and the mercury in the thermometer has crept up to 105 degrees.

John doesn’t pay attention to the heat. All his focus is on the task at hand, as he scoops up clumps of earth with a trowel.

He doesn’t know it yet, but his kidneys are failing. 3/

The average human will sweat about 1.5L an hour (this figure is widely variable) in temperatures over 100 degrees.

John’s perspiration is depleting his intravascular volume. This is decreasing blood flow to his kidneys.

He wipes the sweat from his brow and exhales deeply. 4/

Normally John’s kidneys would attempt to compensate for their suddenly low perfusion, but the blood pressure medication he’s taking is effectively interfering with this.

By the time he goes back indoors, a potentially lethal chain reaction is taking place silently inside him. 5/

He feels light-headed, and starts experiencing a series of excruciating muscle cramps. Crying out in pain, he grabs a bottle of water and collapses on his couch, trying to stretch out his legs.

Hours pass.

His light-headedness turns to an overwhelming headache, and nausea. 6/

He realizes he is having trouble thinking. It’s almost like being in a heavy fog. Everything seems unfamiliar.

A random thought occurs to him:

“Who am I?”

He has to concentrate, and sees his name swim out of the shadows:

“John.”

Something is terribly wrong.

He dials 911. /7

I don’t hear my pager the first time it goes off. It takes several cycles of beeps and alarms before it registers and my eyes slowly open.

I’m still half asleep as I fumble with my bedside lamp and squint at the message.

Emergency room, STAT.

Yawning, I call back. 8/

“Dr. T. Got an urgent consult for you, 80 year-old, AKI, dehydration, on ACE and thiazide, creatinine of 6.”

I can hear the ER doc speaking to me over the phone but my brain isn’t in gear yet.

I rub my eyes savagely, trying to wake up.

I have one question. “What’s the K?” 9/

K is the elemental symbol for potassium.

An alkali metal, it’s critically important.

The human body maintains a series of electrical and chemical gradients that are crucial for nerve conduction and muscle function.

Potassium is a major player in this. 10/

Our bodies tightly regulate potassium levels, primarily through shifting it around in our cells and excreting it through our kidneys.

Too much or too little potassium can quickly be fatal.

There’s a reason potassium is the final drug given in a lethal injection cocktail. 11/

John’s potassium level is 7.8, very high. He’s feeling slightly better since he came to in the ER and received IV fluids, but everyone around him seems worried.

Something about his heart rate.

He lays his head back and closes his eyes, still feeling strangely disconnected. 12/

I arrive in the hospital and review the labs. All our efforts to reverse the kidney failure and correct the high potassium levels aren’t working.

And there are other problems, acid build-up, sodium.

My job is often to be a chemist, but I can’t catalyze my way out this time. 13/

We need to proceed with emergent hemodialysis. I ask John if there’s someone he wants me to call, any family.

He’s drifting in and out of lucidity, and murmurs a name.

“Sara.”

He recites a phone number and I dial it.

It rings, and then a cheerful sounding woman answers. 14/

I start to talk, but quickly realize it’s only a voicemail greeting. I leave Sara a message, not knowing she died a year ago.

“John, I called Sara and left a message. Is there anyone else?”

The old man’s eyes open slowly, his gaze is hollow.

“No, there’s nobody else.” 15/

We start dialysis that night. He tolerates it well. Gradually, his kidneys start to improve also.

After several days in the hospital he is discharged home. His kidneys have recovered.

When I discover he is a widower, I think of the voicemail, and my heart aches for him. 16/

He follows up with me in clinic, a week later, and instead of the usual follow-up time slot I book him for an hour.

We talk about anything and everything. His past. How he met Sara. How their son died as a child, and it broke them both. How they were able to slowly heal. 17/

I realize this wonderful human being has so much love to give, and so many lessons to share, as he spends his days in the garden that was once a metaphor for a beautiful future... and now a memory he can’t leave behind.

He asks me if he can come back sooner than four months. 18/

I tell him of course he can.

If “loneliness” was an ICD-10 code, then it would probably be the most common diagnosis I see.

The next time he sees me in clinic, a few months later, he brings the entire office greatest gift he can give.

Flowers.

(Note: Yes, I’m aware that there IS an ICD 10 code, Z60.2, “problems related to living alone.”

This narrative leaves out a ton of clinical details.

There’s nothing wrong or harmful about ACE/HCTZ meds, the issue here was volume depletion triggering everything else.)

(Also this will be my last narrative for a little while. I’ll retweet some older ones and other posts. I’ll be back, soon enough. Thanks again for the overwhelming support.)

(Omg, I just noticed the missing word in the final tweet.

“The next time he sees me in clinic, a few months later, he brings the entire office THE greatest gift he can give)