HIV Clinical Story
I have never seen this patient before, yet she is like many others. She lies on a hospital bed clinging to life by a thread. But even that will soon be taken from her. By the time we see her on our medical rounds, there is very little we can do. Her death this morning, like that of so many others, will be caused by a combination of two treatable diseases: an HIV infection and extreme poverty.
We come upon her in the far corner of the medical ward halfway through our morning rounds. Immediately, I am stunned at the general presentation of this woman. She holds a blank stare out an open window. Her eyes are shifted back in their sockets. Her breathing is rapid, but regular. Her pulse is also rapid, and it’s not beating in a normal rhythm. She's in real trouble.
I had recently completed my training in the core areas of clinical medicine at the best medical school in the country for teaching clinical medicine. I felt that I was generally equipped and capable of approaching complex medical patients like this one. The key was being systematic in the approach, but a systematic approach relies on having certain resources available to diagnose and treat the patient. However sound my US medical training has been, I have been repeatedly unprepared to handle the difficult situations that arise when the resources aren’t available.
We have few precious minutes with this patient. Since there is no supervising physician, I tell the intern that we need to ‘call a code’. This should have set off a flurry of activity, such as supplying oxygen, gathering several cardiovascular medications, and obtaining a defibrillator in case we need to shock her heart. Two people should be ready to start CPR. However, we’re in Africa, and, here, there are no ‘codes’. In fact, there is no CPR training and only one portable defibrillator for the entire hospital. As a result, patients like this young woman typically die quietly in a corner.
Immediately, we need to give her some oxygen and intravenous fluids. While every second counts, the resident, intern, and nurses are not prepared to act quickly. After a minute or two, the nurse eventually wheels over the one tall, rusty oxygen tank that resides on the floor. One tank of oxygen doesn’t last very long on a ward with 42 beds. A glass bottle with ‘sterile’ water hangs by a rope from the tank. There is a long rubber tube, which pierces into the glass bottle, that will carry the outflow of oxygen. After looking more closely at the tube, I realize that this particular piece of rubber tubing is normally used to suction out stomach contents. Furthermore, it is dirty and has clearly been used for another patient. What this woman needs is a high flow of oxygen through a full face mask, not some thin tube with someone’s dried phlegm on the end.
Her respirations were now becoming slow and shallow. Ideally, we would want to put a tube down into her lungs and hook her up to a ventilator so we could take control of her breathing. It was already clear that none of those resources or equipment would be available. Even if there was an artificial ventilator, there is no electricity in this area of the hospital. Her breathing is rhythmic, and gradually becomes more delayed with each breath. Her eyes are fixed and dilated. I can feel the pulse in her neck as she remains motionless on the bed.
She is a 31-year-old woman who is known to be HIV-positive. She has been married for seven years, but has no children. She was admitted to the hospital four days ago after she had been suffering from a week of diarrhea and vomiting. Since she was admitted, she has received one unit of blood. Nothing else has been done for her.
She should already have an intravenous line in her arm, so we can quickly give her fluids, but she doesn’t. A nurse will spend our remaining time trying to insert a line into a vein in her arm. The one portable heart monitor for the entire medical block is not on our floor.
Our activity is becoming futile. Her pulse continually weakens. Her breathing gradually becomes more delayed. I hold her wrist with one hand and feel for the pulse in her neck with the other. She is now getting some oxygen through the small tube, and a nurse is trying to put in the intravenous line. She hasn’t been given any heart stimulating medications. As I watch her life slip away, I realize there is little reason to take this any further. We don’t have the resources and without them there is nothing we can do.
Although nothing is said, the resident stops giving her oxygen, the intern stops preparing an injection, and the nurse stops inserting the intravenous line. She has no family around and this is no way to die. I hold onto her wrist as she finally stops breathing. I watch, feeling helpless. I feel for the pulse in her neck, but it’s not there. “She’s died,” I whisper.
After a few moments, the group of 7 white coats move on to the next patient. I stay behind to look over her chart. Her CD4 T-cell count is 17, which is extremely low (a T-cell count <200 is low), and she had not been receiving HIV medications. She died because she had too few immune cells to fight off any infections. She also died because she is poor and didn’t have more immediate access to HIV care and medications.