22 July 2012

...before beauty

So many more patients on our service are my age than I'd like to count. They're all older – by 6 months, 3 months. There's an age I don't have to think about, looking at the year*. I know.

It's an adult service, and I'm going into adult medicine. But none of them, right now, are younger than me. No one should be and be this sick.

*yes, other times I get the subtraction wrong…

It’s HIV, AIDS, whatever CDC or WHO classification you’re using these days. Every patient I have, right now. Without exception.

When I was at the VA, first for emergency psych, and then later for surgery, it used to surprise me how all of my patients had been “in the service.” (strange thing to forget, when working in a hospital for veterans). Mostly in Vietnam, as the stereotype goes. History of mental illness, mostly, substance use, and then everything else that happens to so many sixty-odd-years old men. If you have private insurance, you don’t go the VA. There’s your demographic.

I’m not used to working with homogenous populations - by which I mean - when any of the rote descriptors were the same. The problem was partly surgery, where I barely knew the patients, anyway, didn’t meet them for much time prior to them being wheeled into the OR, and the surgeries would often repeat, within a day (if the patient comes in for surgery; ie, it’s not emergent, you might just meet them in anesthesia pre-op). And it’s the same procedure. Had I actually known them, had the time, the wherewithal to come in before 5 to have enough to do so and get the requisite work done - it would have been different.

Funny thing about the HIV** service, actually. I’m in the county hospital – where I want to be. Where I’ve wanted to be for so many years. We have translators on staff and on phones for a reason. But in 3 weeks, I haven’t used any of those resources. It’s not the demographic of the epidemic here – and that isn’t even true. Is it the demographic of those who are less likely to have been tested? Or, for some reason, not as many are as almost-dying? (Because more newly infected, maybe, relatively newer in the epidemiology?) I don’t know.

**I change how I answer the phone and introduce myself to patients, at times. “HIV consult room/ AIDS.” “with the HIV doctors.” And what do you say when the patient has a roommate? But doesn’t that apply to all conditions, really? No HIPAA in a hospital. Not within the rooms, among patients, their family and friends. 

 I’ve only done two weeks of inpatient medicine at the university hospital, for pediatrics. Kids, kids that sick, are eligible for Medicare. So they weren’t anyone in particular. There was the patient who lived on a reservation. The few in foster care/ adoptive situations suspicious of abuse or neglect. It’s the “better off” ones I don’t understand. Rather, I don’t understand why I’m there. Why there. I’m not needed. (and “I”, in this case, am anyone. Nothing in particular about me). It’s not what I want to be doing.

One thing about HIV is that Occam’s razor**** doesn’t apply. Ever. There is no need to connect a constellation of disparate symptoms – rather, you try, but it could very well, very likely, be multiple processes. Our service has been about three times busier than usual, apparently. I’ve seen almost every major opportunistic infection, at this point. With HIV, that’s the dangerous part, that’s what kills you – it’s not the virus itself. It’s the lack of immune system induced by the virus. Things that don’t make most people sick, do. Things that are rare, aren’t. You cease to be able to fight back – and everything, greedy everything – bacteria, viruses, fungus, parasites, and your own cells working against you (cancer) – takes advantage. Opportunistic. Opportunists. Who else preys on the down-and-out.

****House talks about this a lot. It’s more likely to be one process than many. Not here.

Why so sick. Why here. And why, with this disease, are they eligible for more services than people without this disease. In some ways. You can get aid to buy medication. You can get into clinics with multi-disciplinary services – the one here and another one I worked in have a psychiatrist on staff, social workers, case managers, people to help with housing, etc. There are pharmacies that are specialized in HIV medications (in this city, at any rate. But this was one of the initial epicenters), and you can ask them to make “blister packs” for patients. It’s a disease with many medications, but not always, not anymore. It was, what, 30 pills at one time. Now, you can get away with one per day. And depending on how good/bad your immune system is, a few more. Some patients are on seven, ten or so. And as the people, as the epidemic ages, they’ve got high cholesterol, maybe diabetes***, a lot have mental health issues as well, high blood pressure, etc etc etc…

***Though, in general, it’s one of the adult populations in the US with the lowest rate of obesity. The sickest ones, anyway.

But do pharmacies make blister packs for those patients? A Monday, Tuesday, etc; at least what I’m picturing. Is it available for anyone else? I’ve never heard of that. Not until now. I could be wrong.

Why this disease. Why now. I’ve seen babies die – almost never happens here, anymore. The rate I calculated for our health district in Cameroon was about 10%. One village was 25, 30%. But that’s one village, one place where truckers went through to Gabon. The country itself, though, is between 5 and 6% - lower than East, Southern Africa. When I was in Kenya, the rate in that health district was about 30%, over tens of thousands of people. Or more. For one island, it’s 90%, actually. One good thing – there’s no stigma at that point. Little. We had an obvious tent (and a few interior rooms) at a large hospital in town, everyone knew it was AIDS, but so many, so many people were there….

I don’t know what to say here. Or what not to say. What is the stigma, here. I’m sheltered, I’m in the health care system at a technically liberal, open-minded school in a technically liberal, open-minded city. A city with one of the highest prevalences of HIV in the US. I don’t know.

One patient, who’s been in the hospital a few weeks now, not getting better (I hope. I hope he is this weekend, did this weekend. Otherwise, he says he’s leaving on Monday), has started refusing daily labs because he’s so tired of getting stuck with needles. Bleeding, being bled. He’s a difficult stick, it seems, and in him, not because of IV drug use. (That’s the case for many patients I’ve seen. They “have no veins,” even for small blood draws, you have to put a central line in one of the largest neck veins. A jugular line, maybe. To have any access at all. The arm veins are all too scarred. When that isn’t the case, though, they’re less likely to create an easier port of access). But I’m a “difficult stick,” too. I could commiserate on the multiple times his skin was pierced to get one vial in the morning. (Up to seven, once, for me). I’ve since learned exactly which vein is easiest, and I show the phlebotomist every time. He does that too, but they’ve already used those many times. One morning, he told me how they missed, or didn’t get the tube connected (or disconnected) in time, and his blood spurted. I had a moment of terror. The interior recoil of “…it wasn’t me.” His blood, in my face, and as I pictured it, in my eye. It happened with a patient of mine, once, but she wasn’t HIV positive. (Actually, we didn’t test her. The potential exposure was essentially nil. It wasn’t worth it to go on post-exposure prophylaxis, not for that). What he described was maybe more, though. Knowing what’s in his blood. A lot of virus, maybe, probably, still. Rafael Campo has a story about that – it happened in the same hospital where I am now. Exactly one floor above, I imagine. Where the initial AIDS ward was. Exactly one floor above where this patient is now. It was the early nineties then, though. So much less known, so much less treatment at all. A poet exposed, my mentor exposed. I wasn’t, not this time. We-are-our-patients-are-us. What’s more human than that? A disease, an infection anyway, can jump. Person-to-person. It happens with non-human primates, too (current theories on how HIV mutated to be able to infect human hosts, from simian immunodeficiency virus (SIV). Another story). Monkey diseases can make us sick. Goat diseases. Pig diseases. Bird diseases. (Easy argument for evolution).

One of the intimacies of medicine. It’s amazing to listen to hearts, lungs again. To see, hear, feel, think, and learn. From all of that. But with this—the thing making my patient sick, the thing that’s been inside of so many of his cells, that’s been there (in his case) since at least the early eighties, when he was first diagnosed, that’s been making uncountable copies of itself, using him. Intercalating into his DNA, into the substrate that made him, him. And that thing, exactly, going into other people. Host to host. That little not-even-alive strand of molecules that starts to define him, in hospital (and elsewhere) parlance. “HIV patient,” “patient with HIV,” in the HIV/AIDS clinic, 58 year old man with HIV (and then we cite the current numbers of his infection. Disease). How many other, unchosen, permanent connections.


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