Wednesday, May 28, 2008

He has AIDS

Truth be told, newFNP generally loves to be right.  It's not her best personality trait, but it is what it is.  She's working on it and nursing school certainly helps one learn how to say, "I was wrong."   

This is one case in which newFNP wishes she were wrong.  She had almost convinced herself that her patient was just seroconverting and that was why he had this malaise, this acute drop in immunocompetence.  As if all of her worry and her wishes and her day-off appointment coordination and letter writing could change the course of the pathophysiology at work throughout this young man's body.

But newFNP got her CD4 count today.  It showed his absolute CD4 count as less than 20.  His percentage of CD4s was three.  The low end of normal is 20%.  NewFNP's heart broke.

This patient has really touched newFNP.  It is probably for his loneliness, his isolation.  NewFNP has always been drawn to these people and has always wanted to show them that there is someone in this world who cares for them.  This is perhaps a result nature (newFNP is what she is) and nurture (losing her mom at a young age and all its subsequent emotional detritus).   Whatever the psychoanalytical insights, newFNP is willing to go the extra mile for these people.

It is probably also because this patient knows that newFNP is there for him and newFNP knows that he knows that he can count on her.  Today he told newFNP that she was the only one to visit him in the hospital and that he never feels shame when he sees newFNP.  NewFNP knows that he is keeping his diagnosis from the majority of people in his social circle so it felt good to hear that he felt cared for by newFNP and her staff.  He gave newFNP and her MA heartfelt thanks and a warm hug as he was preparing to exit the exam room.

Which was where the hug-fest ended and the pissed off newFNP began.  Her lab MA refused to draw his blood.  If he would have refused in front of the patient, newFNP would have stroked out.  Thankfully he had the good sense or good luck to refuse while the patient was still in the room.  He knew that the patient was HIV-positive because newFNP didn't want the patient exposed to all of the ill people in the clinic until he is on PCP prophylaxis and ART.  Therefore, newFNP's MA asked him to either clear the lab or draw the blood in the room.  

NewFNP is in a quandary.  She supposes that an MA may refuse to do a task.  But can the lab MA refuse to draw blood?  We have and use universal precautions for a reason.  We treat all patients with dignity and we treat all of their blood as potential pathogen-carrying fluid.  So how does newFNP approach this?  Education, newFNP supposes.  But she is just so pissed!  Is de-stigmatizing HIV only an activity for educated people?  God, newFNP hopes not.  We need some ACT UP in the lab!

Furthermore, why was this man discharged from the hospital without PCP prophylaxis and an appointment with an HIV specialist?  NewFNP is awaiting the hospital records, but is pretty frigging disappointed that he left only with a repeat prescription for his original fungal infection. Is it possible that the hospital staff chose to ignore his HIV status and not at all assess his immunocompetence?  Is that the care newFNP can expect when she sends her patients there?

More and more, newFNP is missing real public health.  She is missing the sense that her work is saving people, is preventing illness.  NewFNP is generally not to full of self-inflation, but she didn't go into healthcare to diagnose HIV when it is actually AIDS, to diagnose diabetes when it has already impacted eyes and kidneys and feet.  

It is so sad, so utterly disinflating.

NewFNP left work an hour after the clinic closed tonight.  She relished the only quiet time of her day as she made the abnormal lab list, she wrote a couple of e-mails that she hadn't been able to get to earlier in the day and she updated this patient's confidential HIV report, noting his AIDS-defining CD4 count.

She feels like shit tonight.  Calorie restriction be damned!  Ice cream, anyone?


Joan said...

When I was in nursing school there was a sort of older lady in school with me who was assigned a patient with HIV. She refused the assignment. The teacher tried to turn her thinking around, but to no luck. She received a "clinical unsatisfactory". (She also never finished nursing school)

I say, "clinical unsatisfactory" to your MA!

Rick said...

I suppose his health insurance didn't cover it. What's that? No health insurance?

Hospitals... not just for the sick anymore; only for the insured, and/or for the sick AND insured.