As a medical student a decade earlier, stroking brains, failing hearts, phlegmy lungs, inflamed pancreases, and even diarrheal colons dominated my experience of the hospital wards. The kidneys didn’t win my attention. And because I could graduate without spending a month on the renal service focused only on dysfunctional kidneys, that’s exactly what I did.
But after medical school, there is residency—and no one escapes renal in an internal medicine residency, especially at Alameda County Medical Center, Highland Campus, in Oakland, California, where I trained. While Highland was affiliated with the prestigious University of California, San Francisco, we knew that our large number of foreign medical graduates made us internal medicine residents the bald-headed notch below redheaded stepchildren of UCSF. At Highland we didn’t even have fellows around who were specializing in anything—so everything down to subspecialty level calls in the middle of the night fell directly to the resident.
I remember being on call my first night as a resident on the renal service. Only the team accepting patients being admitted to the hospital spent the night there, so when my pager went off shortly after 1 a.m. I was in my own bed at home. I cringed when the beeping pager startled me awake.
I called the number back and was told about a man who drank antifreeze. The kind with ethylene glycol in it. Besides children and animals who sometimes drink antifreeze accidentally, I knew alcoholics who couldn’t get their hands on anything else would sometimes resort to drinking antifreeze because the ethylene glycol made it sweet. I also knew antifreeze could kill a person quickly, not from the ethylene glycol itself, but from the glycolic and oxalic acids the body breaks it down into. It is these that wreak all kinds of havoc—shutting down brain, heart, and kidneys. The patient I was hearing about had already gone from intoxicated to unconscious. Not a good sign.
While the medication fomepizole prevents ethylene glycol from being broken down, it is very expensive and doesn’t just come off the shelf in places like Highland Hospital. It would take hours to get it, and my new patient didn’t have hours. Hopefully he had bought himself some time by getting drunk first, as ethanol, the poor man’s antidote, also prevents ethylene glycol from being broken down. But hemodialysis could filter away the ethylene glycol and all the ensuing badness from his blood and save his life—if he got it quickly enough. It was my job to get to the hospital and get the patient started on dialysis before it was too late.
But I didn’t know how to put in a dialysis catheter, much less how to write dialysis orders. The bore of a dialysis catheter is like the thickness of a pencil. A simple IV wouldn’t do. I could feel my heart racing, pounding, and my armpits getting sticky.
I hung up and called the renal attending, Dr. Ling, the supervising doctor scheduled to be on call with me, and explained the situation. The patient’s blood showed a high anion gap, a large difference between positively charged sodium and negatively charged chloride and bicarbonate. The difference, the gap, is larger when there are a lot of other negatively charged substances in the blood—like the acids ethylene glycol is broken down into. He sighed. Like he really didn’t want to be bothered. He sighed again when I told him I didn’t know how to put in a line. Like he suddenly realized he couldn’t just tell me what to do from his bed. He would have to come in to the hospital too.
“What is the osmolar gap?” he asked. “Because if the gap is closed, it’s already too late.”
My eyes shifted left from the darkness before me to stare in disbelief at the receiver. Are you really trying to find a way out of this situation? I thought.
But what I said was, “Um,” feeling very stupid because not only did I not know the answer to his question (the least a doctor in training can do is gather the necessary data), but I also didn’t know that a closed osmolar gap—no difference between how many dissolved substances we calculated were in the blood versus those measured—meant all the ethylene glycol had been broken down and the damage was done.
“I don’t know,” I admitted.
I called the ER back. Those results weren’t back yet and the patient was being moved to the ICU. Weren’t we wasting time? I called the attending back. He sighed again, but agreed to meet me at the hospital.
It took me fifteen minutes to get there. I hurried in through the entrance at the back of the building adjacent to the employee parking lot, my heart pounding beneath by scrubs and white coat, my pager, stethoscope, penlight, reflex hammer, keys, a few pens, three pocket-size medical quick-reference guides, and a dozen or so large index cards each scribbled with the details of my patients weighing me down. Squares of linoleum rushed by beneath my sneakered feet. A few yards ahead a tall, older Black man in dark brown coveralls was mopping the floor in front of the elevators, a big yellow bucket with wheels and a careful wet floor sign propped nearby. I paused, looking for a dry path to tiptoe across.
He stopped mopping and looked at me, one eye squinted. “Nah-uhn,” he said. “You need to go ’round to the other side of the building,” as if keeping the floors clean was the most important activity of the hospital, trumping why I was running.
“I’m sorry, sir, but I’m trying to keep someone from dying!”
He brought the mop handle to his chest, conceding to my made-for-TV drama if nothing else, and I did my best not to leave footprints on his freshly mopped floor. The elevator ride to the fourth floor was quick, in my mind sped up by my incessant pushing of the brightly lit 4 button.
In the ICU, I gathered the supplies to put in the dialysis catheter. Catheter kit. Sterile gowns. Sterile gloves. Protective face shields. A dialysis nurse had been summoned and was setting up the machine and awaiting her orders. Dr. Ling arrived shortly thereafter. He was a good-looking Chinese man. Tall, slim, muscular, in his mid-thirties. He was part of the private nephrology group that the hospital contracted to provide nephrology services. I hadn’t met him before.
He fumbled with putting in the line as if it had been a while since his last one. Hard sighs, but few words. We didn’t talk much. Looking back, the few minutes after getting the line in and the patient on dialysis would have been an incredible opportunity for Dr. Ling and me to take a sample of urine to the lab’s microscope to see the envelope-shaped oxalate crystals in real live urine, not just in pictures. Maybe even break out the black light of the Wood’s lamp to see if the urine would be fluorescent under it like the books said it would. This is the kind of sexy stuff that attracts medical students and residents to nephrology.
But Dr. Ling didn’t even ask if the patient was still making any urine. It was sometime after 2 a.m. and it seemed to me that he was not interested in teaching or recruiting a scared little resident who didn’t even know to ask the ER doctor if the serum osmolarity had been measured. My impression was that he just wanted to get the work done and get back to his bed.
We were too late. The patient died before morning.
Perhaps if the patient hadn’t died or if Dr. Ling had seemed the slightest bit interested in teaching me, I would have been drawn to the sexy side of nephrology in that moment. But the patient did die and Dr. Ling wasn’t interested, so I wasn’t drawn. Nephrology made me feel stupid and useless, yet years later there I was starting a nephrology fellowship with six other wannabe nephrologists. They were all straight out of their residency programs, where they had no doubt focused on everything kidney for at least a year or two, while I had spent a couple of years as an internal medicine attending at Highland followed by two years as a general medicine clinical research fellow with no desire to focus on anything kidney. So by the time I reached the nephrology fellowship, I felt even dumber about the kidney, but maybe slightly less useless because at least my new kidney-focused research would help somebody someday, I hoped.
That I started with the research year rather than the tough clinical year fellows usually started with didn’t help my confidence. By the time I expressed interest in the fellowship, the program had already filled its clinical positions. I could have postponed a year
, but I was eager to get on with my research career.
My decision not to postpone a year turned out to be a poor one because the research fellow takes over the responsibilities of clinical fellows on vacation. Since the research fellow is usually in her second year, she already knows a lot of nephrology and is almost ready to function independently, without attending nephrologist supervision. I could not have been further from functioning independently. This not only undermined my confidence in nephrology but also negatively affected my first impression on attendings. I felt I was in the way, like the attendings’ time spent taking care of patients would be much more efficient if the fellows—especially the ones who weren’t all about nephrology—would just step aside.
The fact that I was the only Black person in the entire division of nephrology across the program’s three hospitals didn’t help my confidence. When a person sees no one who looks like them, they question if they belong. It was the reason becoming a doctor hadn’t crossed my mind until my brother suggested it.
I remember getting my first hint that I was the only one like me on the first day of fellowship. That first day was to be filled with paperwork and the start of the crash course on how to be a renal fellow at the University of California, San Francisco. I wasn’t late, but I was the last to walk in and felt very late to the party because they were all nearly a decade younger than I was. A large white rectangular table filled most of the small conference room. My new colleagues sat quietly around it, already busily filling out their forms. All but one had a brown face, but none like mine. One Chinese man. One Indian man. Three Indian women. Only the fifth brown face looked up as I entered. It belonged to a plump Latina. She beamed. Her eyes stretched wide and her mouth even wider to show upper and lower teeth. I understood her joy in seeing a brown face more like hers. It dulled the feeling of oddness, of aloneness. I nodded back a close-lipped smile and sat in the empty chair at the end of the table where my paperwork awaited.
I worked steadily on my research project and did the best I knew how to do when on clinical service, but it would be months into the fellowship before I gained any real attraction to the kidney. After that first day of paperwork, we fellows would continue to gather around the conference room table every Tuesday morning at 7:45 for the fellows lecture. A lecture on everything kidney in forty-five-minute chunks. Electrolyte disorders. Acute kidney injury. Renal causes of hypertension. They tended to be PowerPoint presentations, from super-smart faculty who were often less than super at captivating me with the detailed information littering each of their slides.
I remember one lecture that did capture my attention. Renal pathology. It was at the fingertips of Dr. Sipos, a small, white-haired pathologist who stretched his mouth purposely so that each European-accented word was clear, punctuated English. With a click on the computer, his finger summoned a gray-scale scanning electron micrograph of the normal glomerulus, the kidneys’ filtering unit, magnified eight hundred times then projected onto the screen.
I was mesmerized by the beauty in its design. The glomerulus was stripped of its cap and looked like a ball of tightly coiled yarn. Each strand like interlaced fingers. Hundreds of them, all emanating from the large lumps of podocyte cells scattered across the surface. The podocyte was like a mama octopus trying to hold all her babies at once, each tentacle with a set of fingers and each finger with another set of fingers, until all the fingers of all the podocytes clasped and touched every curve of the tuft at once. So tight the clasp, only the tiniest bits could slide through, only to be captured by the ill-fitting cap of the glomerulus.
The cap funneled these liquid bits into the tubule, a half-untwisted paper clip maze of a tiny tube. Together the glomerulus and its tubule made up the nephron. Each tubule lined with a single layer of different kinds of cells along its length, each type of cell distinct in appearance and the work it did. I imagined each cell was like a factory worker stationed at a fluid conveyor belt. I imagined the workers of the proximal tubule as muscle-bound, doing the bulk of the lifting, removing almost all of the blocks of amino acid and glucose and a large portion of the small blocks of salt, potassium, water, phosphorus, and bicarbonate from the fluid conveyor belt while placing medication leftovers and wastes on it. Next, in the still-twisted part of the paper clip, the Loop of Henle, the workers selectively pulling salt or water from the conveyor belt as it dove deep into the kidney and back. I imagined the workers near the top bulked up in rain gear; no water slipped by them. The workers in the last untwisted part of the paper clip, the distal nephron, were supervised by the hormones aldosterone and vasopressin, which made sure workers pulled or added blocks of potassium, salt, and water as ordered to fulfill the needs of the rest of the body. Finally a set of workers interacted with the fluid so that the body’s excess acid was released. What was left on the fluid conveyor belt was passed into its collecting duct, which met other ducts to eventually leave the kidney through the largest tube, the ureter, funneling the end product, urine, into the bladder. What was removed from the fluid conveyor belt was returned to the tiny capillary blood vessels that wrapped around it and the workers.
Dizzying it was to think about how this glomerulus bobbing in its cap funneling into its tubule all wrapped in its capillaries was just one filtering unit. One nephron. How in life it was repeated two million times over—one million in each normal kidney. I tried to imagine the capillaries tying it all together. Two webs of them, coursing through every glomerulus and around every tubule. One receiving blood, the other ushering it out. Like a blood vessel Autobahn.
Each web merged into larger vessels, then still larger ones, then even larger ones, then larger ones still—until one web of capillaries of all the nephrons of each kidney met at the renal artery branching directly off the aorta, the largest artery in the body, pushing about a half cup of blood into the kidney every minute of every hour of every day. And the other web of capillaries of all the nephrons in each kidney met at the renal vein situated just below the renal artery and branching directly off the vena cava, the largest vein in the body, running alongside the aorta and returning the blood, almost all protein, and everything filtered through the glomerulus but removed from the conveyor belt to be put back into the body’s circulation.
One million nephrons, all packed into a bean-shaped sheath less than five inches long and weighing only about a third of a pound. Times two. Each kidney wrapped in a padding of fat and tucked beneath the ribs and muscles of the lower back, on either side of the spine, working as one unit. My thoughts spun with the microscopic complexity and precision of it all. Yet there was still so much more left to wrap my brain around. Like how the juxtaglomerular apparatus included a clump of specialized cells beside the glomerulus entry that produced renin, an enzyme that activated a hormone that controlled blood flow into the glomerulus by making blood vessels smaller, and another clump of specialized cells that connected the thick part of the paper clip loop to its glomerulus and controlled the speed of the conveyor belt based on how much salt was going by. Like how the early tubule cells converted regular vitamin D into an active version that helped to regulate the body’s calcium and phosphorus. And like how the cells between nephrons made the hormone erythropoietin, which prompted the bone marrow to make blood. As if the production of urine wasn’t enough. It was in that moment that I began to appreciate the kidney and all it did. I was in awe.
My attention zoomed back to the image on the screen. How beautiful it was. Intricate. Curved. Complex. Multitasking. Like a woman, I thought. Nothing this beautiful is just an it.
The kidney. She is a thing of beauty.
But anything so beautiful and so complicated is bound to get hurt. And so She does in many ways.
11
Babies
There’s no good time for a woman doctor to have a baby. Men doctors have wives to do it for them. But neither all-night studying nor hundred-hour weeks on the hospital ward is good for pregnancy. Babies sometimes get too sick for day care. And peers tend
not to love taking extra call nights because somebody decided to try to have a life outside the hospital.
I got pregnant with Avery on purpose as an intern. While my program director was wonderful, attempting to adjust my schedule to be the best for my pregnancy with the least impact on my peers, someone had to pick up the baton when I walked out of the ER in the middle of an on-call day because my baby was sick. I hoped to not repeat history with the fellowship as much as possible by at least getting pregnancy out of the way before July 2007 rolled around.
But when pregnancy didn’t happen in our first two years of marriage and I was well into my fellowship, we began to worry something was wrong. I was pregnant with Avery two months after stopping birth control pills. Granted, I was only twenty-eight years old then, so there could be my advanced maternal age of thirty-seven to blame for our troubles, but Robert and I had other cards stacked against us too.
Men with kidney failure are often infertile. Sperm can be defective and low in number. Transplant restores fertility, but in Dr. Cheng’s efforts to save the kidney transplant, she accidentally cut Robert’s right vas deferens, the duct responsible for allowing sperm to move from his right testicle to his penis, so only one of Robert’s testicles was contributing to our baby-making efforts.
Hundreds of Interlaced Fingers Page 10