27 year old male. When you hear that, you have a picture in your mind. I do too. Strong, robust, healthy, athletic, smart. Prime time. The world yours to capture!
I quickly looked through his chart. Only one prior visit to our ED. No medical history, surgeries, allergies or medications listed. Being seen today for an abscess. No big deal. I've incised and drained many on many different parts of the body. Yes, even breasts, scrotums and rear ends. This guy was going to be in and out of the ED without a problem!
Then I read his last visit. He was seen for thrush. Not common in a healthy 27 year old. Now my investigator hat was on and I went into the room.
This was not the robust man I imagined. This was a frail, ill appearing man. There were stains on his bottom where the abscess was draining. His sweatpants too baggy and just fell over his bony knees. This was not a well man.
He was sick. Very sick. He had a fever, his heart was beating too fast. He had lost 30 pounds in the last month. His eyes were sad, his face withdrawn. He had been dealing with this drainage for over a month. He was adament that he had no medical issues. He was so, so very sick.
If you have heard of the word sepsis, you probably know what a big deal it is. I ordered a full sepsis work up on him. I didn't need results; I knew I would have to admit him to the hospital. It was the only chance we could have at saving his life.
I was working with an attending I don't usually work with. In the nurse practitioner/physician world, this can add another challenge. I wasn't getting the help I needed from him. Fortunately, I have a good relationship with the hospitalist NP and was comfortable calling and asking for direction. I needed to call the surgeon. It was a frustrating conversation; he told me to send the patient home. I stood my ground and said absolutely not. He agreed to be a consult and I called the hospitalist back. After three different antibiotics given intraveneously, fluid boluses and additional meds, this patient's vital signs had improved but he was still so very ill.
Sometimes we have to have very difficult conversations with patients. This was one of them. I sat down on the stool and pulled up to the stretcher. I told him my plan to admit him. I asked him again about medical history. None. I asked him if he was an IV drug user. Never. I asked him if he had sex with other men. Yes. I asked if he used condoms all of the time. No. I asked if he's ever been tested for HIV. Years ago. I asked if there was any chance. He hoped not.
HIV testing is not something we do in the Emergency Department where I work. It was on my mind as soon as I saw his previous visit. My suspicion grew stronger after seeing the patient.
My first exposure to HIV/AIDS was in the early '90s. We had a ninth grade English project and somehow my friend and I chose this topic. I always had this I'm going to save the world streak running through me. I proudly wore a red ribbon on my jean jacket. I'll never forget my mom saying, "oh boy, wait until Father Jeff sees that" when we were on our way to our Catholic Church. I didn't understand. I also didn't care what Father Jeff thought. To me, there were a lot of people getting sick and dying horrible deaths and we didn't have the medicine to help. I was wearing that ribbon for them. Shouldn't all Catholics care about other human beings? To me that was simple.
In 2019, we have come a great way from those early '90s. The antivirals are incredible. Clinics and financial aid are available in many areas. We have campained for safer sex practices and safer drug use practices. But still, as I looked at this 27 year old, all I could think is how could he be in this situation in 2019? Have we failed him as a society? Has he failed himself?
Bottom line was it didn't matter. We were not going to fail him that day. We were going to do our part to save his life. Acutely, we were going to tackle that infection. Concurrently, he would get the testing and treatment that he needed. I know I will forever remember how his bent knees jutted out through his sweat pants. I will forever hope that he heals and gets the treatment he needs.
If you're curious, that friend who did the project with me... she went into the Peace Corps and then med school. She became a trauma surgeon, world traveler and I believe active in doctors without borders.
Be a good human. Do the right thing. Speak up for those who can't help themselves.
I quickly looked through his chart. Only one prior visit to our ED. No medical history, surgeries, allergies or medications listed. Being seen today for an abscess. No big deal. I've incised and drained many on many different parts of the body. Yes, even breasts, scrotums and rear ends. This guy was going to be in and out of the ED without a problem!
Then I read his last visit. He was seen for thrush. Not common in a healthy 27 year old. Now my investigator hat was on and I went into the room.
This was not the robust man I imagined. This was a frail, ill appearing man. There were stains on his bottom where the abscess was draining. His sweatpants too baggy and just fell over his bony knees. This was not a well man.
He was sick. Very sick. He had a fever, his heart was beating too fast. He had lost 30 pounds in the last month. His eyes were sad, his face withdrawn. He had been dealing with this drainage for over a month. He was adament that he had no medical issues. He was so, so very sick.
If you have heard of the word sepsis, you probably know what a big deal it is. I ordered a full sepsis work up on him. I didn't need results; I knew I would have to admit him to the hospital. It was the only chance we could have at saving his life.
I was working with an attending I don't usually work with. In the nurse practitioner/physician world, this can add another challenge. I wasn't getting the help I needed from him. Fortunately, I have a good relationship with the hospitalist NP and was comfortable calling and asking for direction. I needed to call the surgeon. It was a frustrating conversation; he told me to send the patient home. I stood my ground and said absolutely not. He agreed to be a consult and I called the hospitalist back. After three different antibiotics given intraveneously, fluid boluses and additional meds, this patient's vital signs had improved but he was still so very ill.
Sometimes we have to have very difficult conversations with patients. This was one of them. I sat down on the stool and pulled up to the stretcher. I told him my plan to admit him. I asked him again about medical history. None. I asked him if he was an IV drug user. Never. I asked him if he had sex with other men. Yes. I asked if he used condoms all of the time. No. I asked if he's ever been tested for HIV. Years ago. I asked if there was any chance. He hoped not.
HIV testing is not something we do in the Emergency Department where I work. It was on my mind as soon as I saw his previous visit. My suspicion grew stronger after seeing the patient.
My first exposure to HIV/AIDS was in the early '90s. We had a ninth grade English project and somehow my friend and I chose this topic. I always had this I'm going to save the world streak running through me. I proudly wore a red ribbon on my jean jacket. I'll never forget my mom saying, "oh boy, wait until Father Jeff sees that" when we were on our way to our Catholic Church. I didn't understand. I also didn't care what Father Jeff thought. To me, there were a lot of people getting sick and dying horrible deaths and we didn't have the medicine to help. I was wearing that ribbon for them. Shouldn't all Catholics care about other human beings? To me that was simple.
In 2019, we have come a great way from those early '90s. The antivirals are incredible. Clinics and financial aid are available in many areas. We have campained for safer sex practices and safer drug use practices. But still, as I looked at this 27 year old, all I could think is how could he be in this situation in 2019? Have we failed him as a society? Has he failed himself?
Bottom line was it didn't matter. We were not going to fail him that day. We were going to do our part to save his life. Acutely, we were going to tackle that infection. Concurrently, he would get the testing and treatment that he needed. I know I will forever remember how his bent knees jutted out through his sweat pants. I will forever hope that he heals and gets the treatment he needs.
If you're curious, that friend who did the project with me... she went into the Peace Corps and then med school. She became a trauma surgeon, world traveler and I believe active in doctors without borders.
Be a good human. Do the right thing. Speak up for those who can't help themselves.
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