Thursday, September 13, 2012

No stranger bond - 4

(This is the fourth part of a short story No stranger bond. You can find the full story here.)

"Wheelchair!", shouted Masih at the entrance of the Gangabai Memorial Hospital. Three months had quickly passed since Shuja Mohammad was wheeled into the casualty. Shuja's fistula had matured11 by then and he was now on regular thrice weekly dialysis sessions. Masih would drive him down and then wait until the four hour session would be completed and then drive him back. Masih somehow managed to convince his boss that he would make up for the lost time by working late.

Shuja had overcome the initial frustration associated with being diagnosed with kidney disease. He was slowly settling into the dialysis routine and diet and fluid restrictions. He had also come to terms with the fact that he would be dialysis dependent for his entire life. He would spend a lot of time reading the  Holy Quran and in prayer.

Sharada Subramanyam came in the same shift and days as Shuja. They would always be in neighboring  dialysis machines. Patients often get used to certain beds and machines in units12. This happens for no particular reason. The machines are almost always the same. The beds are also the same. However, patients still feel comfortable dialyzing in their usual beds.

Call it a strange co-incidence or call it a quirk of fate. Shuja Mohammad and Sharada Subramanyam both of whose lives were going to get so entangled in the coming weeks happened to have their 'usual' machines next to each other.

For the first few times this happened, neither noticed the other. They would come for the session, get their dialysis and go back home. Both would have complications from time to time13. Nothing major though. They were generally compliant. A little cramp here. A bit of hypotension there. Nothing that couldn't be managed comfortably.

Then one morning, Shuja had a terrible bout of cramps. About three hours into the session, he yelled out, "Sister, cramps!" The staff on duty found that shout quite scary. It was not like Shuja. Three of them instinctively ran towards him. The lead technician immediately stopped the ultrafiltration and started infusing saline. Shuja was crying out in pain. Masih rushed in hearing his father's voice. The techs requested him to wait outside. One nurse started massaging his feet and calves, areas where the cramps can be felt most severely. About 100 ml of saline14 was administered. The cramps did not subside. Shuja was in terrible discomfort. Another 100 ml of saline was pushed in. No relief.

The techs made Shuja sit up. It often helped to cause blood to travel to the lower limbs. Another 100 ml of saline was also infused. Shuja was held up by three technicians. After another five minutes of excruciating pain, the cramp finally subsided. All the patients were looking at Shuja with eyes filled with empathy. Many people face cramps now and then on dialysis. What they had seen that day was an extreme bout.

Once Shuja had settled back in his bed, Sharada asked him, "Abhi accha hai?" Shuja looked towards the female voice he had heard and responded, "Haan." Sharada continued in Hindi laced with an unmistakable South Indian accent, "I had similar cramps once about 5-6 months back. They just wouldn't go. They pushed in almost half a liter of saline. Only after that did it become any better. I would have rather drunk half a liter of water. Imagine receiving that much fluid through the veins! What a waste!"

"Hmmm", Shuja nodded.

Sharada asked him, "Have you noticed any change in your appetite recently?"

"Yes, I feel quite hungry these days."

"That's it! Your dry weight15 has probably gone up! So what these technicians are seeing as fluid weight which they are trying to remove is actually your dry weight going up. Ask them to remove less fluid from next time."

Shuja had no clue about what the old lady was saying. Dry weight, fluid weight, what was all this?

He remained silent.

Shuja was getting a little irritated. Why did this old lady have to talk so much? As it is I have had these horrible cramps. I could really do with some peace.

Sharada continued about how she dealt with the problems she faced during life with dialysis. Shuja stopped reacting. Sensing this, Sharada stopped after a while. She was wondering why this old man was so rude.


11 - AV Fistulas take time (four to six weeks typically) to mature before they can be used. This is to make the veins large enough to effectively pump out the blood and pump it back in to give effective dialysis.

12 - Dialysis units have a series of dialysis machines arranged in a line with a bed or a dialysis chair next to each machine for the patient to sit or lie during his or her session. In countries such as the US, most units have chairs - recliners rather, while in India, most units have beds.

13 - Dialysis is generally quite a violent process. Blood is pumped out and passed through an artificial kidney. A lot of biochemical changes happen during this process. Toxins and water are removed at a very rapid rate, much higher than the rate at which they are removed from the blood naturally by kidneys. This causes many side effects, some more perceptible than others. the most common complications are cramps in the legs and hypotension or low blood pressure (both caused due to rapid removal of water from the body).

14 - Saline or Normal Saline is a solution of common salt in water used to treat cramps and hypotension rapidly.

15 - Dry weight is the weight of a dialysis patient assuming all the excess fluid in the body has been removed. The amount of water to be removed during dialysis is calculated by subtracting the current weight of the patient from his or her dry weight. For example, if a male patient has had 2 liters of water and other fluids between two dialysis sessions, his weight would be 2 kgs more than his dry weight. Typically, the technicians would target to remove about 2 liters of water during the dialysis sessions. Dry weight changes are not immediately recognizable. So, if a patient's dry weight has gone up, it is typically construed as fluid weight and is targeted for removal during dialysis. This causes the actual water in the blood and muscles in the body to be removed causing cramps!

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