“Vivo frustrado todo el dia” – Dr Arathoon

“I live frustrated all day long” said Dr Arathoon, the director of CFLAG after hospital rounds one day. The doctors at CFLAG act as consultants for all of the HIV patients in the hospital, and as consultants they cannot write orders, but only suggestions. It often happens that the suggestions of the CFLAG doctors are not followed by the floor attendings until the suggestions have been made every day for 4-5 days, while the patient continues to deteriorate. For example, there is a man on the floor with presumed Pneumocysits Pneumonia who has been treated with Bactrim for 5 days without improvement. On admission his arterial blood gas demonstrated significant hypoxia, as well as an elevated A-a gradient, both of which are criteria for adding prednisone to the Bactrim regimen, but the prednisone has not been added. When we saw the patient on Thursday with Dr. Arathoon, he was breathing 45-60 times per minute – clinically in severe respiratory distress. I asked why he had not been transferred to the ICU for his respiratory distress and hypoxia, and I was told that HIV patients are not admitted into the ICU because HIV is considered a “poor prognosis.” Poor prognosis?!?! Are you kidding?!?! I was infuriated. In this era of Highly Active Antiretroviral Therapy (HAART), patients with HIV are living decades with their disease. HIV is becoming more and more of a chronic disease like diabetes, that if well controlled does not hinder the life of the patient. To think that a patient with hypoxic respiratory failure would not be allowed in the ICU because he is HIV+ is like saying that your grandmother with Diabetes should not be allowed in the ICU either. Frustrating.

And for another incredibly sad and frustrating story – a young 14 year old girl was admitted to the hospital for 2 years of nausea, vomiting, diarrhea, and weight loss. Her mother brought her to the hospital when she had lost so much weight that she could not walk. During her hospital course she was tested for HIV and found to be HIV+. When asked if she had ever had sex, she denied it. She had no other risk factors for HIV. She continued to deteriorate in the hospital – she stopped talking, she developed nystagmus, and she was barely able to move by the time that I saw her. After 5 days in the hospital without any improvement, the mother wanted to take her daughter back home. Not really understanding the significance of HIV, she felt that her daughter would be better off at home. It just so happened that the day after I saw the young girl in the hospital, her uncle came to the clinic at CFLAG, and was found to be HIV positive. It is most likely in this case that the uncle was one who gave this young girl HIV. The day after her mother found out that her husband’s brother was HIV positive, her daughter died. I arrived at the hospital the next morning only to find the bed empty. “What happened?” I asked. “She died,” I was told. But of what? Why? What happened? No one knew. There was not a doctor on the floor when it happened. She was just found dead by a nurse. There was no effort made to determine the cause of death. The chart was gone, and so was she.