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A Piece of My Mind
June 21, 2000

Blood Lines

Author Affiliations
 

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.

JAMA. 2000;283(23):3043-3044. doi:10.1001/jama.283.23.3043

I couldn't believe what just happened. I closed my eyes and hoped it was a nightmare so that when I looked again, I'd find myself at home in my bed. Instead, there was a jagged scalp wound and a sobbing patient.

Stop the clock. Go back just a couple of seconds. Please don't let this be happening. I sat quietly beside the patient, unable to move. My hearing started to fade as the examination room darkened around the edges. Putting my head between my knees, I vowed not to lose consciousness.

The patient was drunk, uncooperative, and HIV positive. He was also my "donor" for an occupational blood-borne pathogen exposure, a stranger who previously had a life entirely separate from mine, but temporarily needed my help, and who might now be with me for the rest of my life. I told him I would return shortly and found that my legs, though feeling like wood, still functioned. Entering the employee lounge, I mumbled, "I need the needlestick protocol." The nurse, a dear friend, was speechless. When she handed me the unit dose packet of the three drugs recommended at that time, she embraced me.

I wanted someone to make it all better. I really wanted to go home immediately and find the comfort and reassurance that my husband has provided on countless occasions. Instead, I had several hours remaining in my shift and several patients waiting to be seen. Even my "donor" needed me to complete his care. Somehow I managed to get through the shift, but it was nearly impossible to auscultate a patient's heart when the stethoscope amplified my own.

At the end of my shift, I walked to Employee Health and surrendered to protocol, paperwork, and pills. All the way home I cursed myself for being so stupid and careless. I pictured my beautiful redheaded children and wondered how much time I might have left with them. What life lessons did I need to impart? What would they remember about me? I didn't want to be morbid, but my only other thoughts were equally negative because they were angry and bitter: Why me?

Arriving home, I tore off my clothes, contemplated burning them, then stood in the shower for 20 minutes as if I could rinse away the whole encounter. From the time I stepped out of the shower, and segregated my towels, nothing was to be the same. I made certain my toothbrush was not hung near my husband's since my gums sometimes bleed. When I had my period, I double-wrapped the used tampons and put them in plastic in the outside garbage—they had become toxic waste. When I shaved my legs, I scoured the tub with a bleach solution because I generally nick myself. I continued to eat and drink from the same dishes as my family but felt obligated to ask my best friend if she and her children wanted to separate their dishes from mine during our joint vacation.

I chose not to tell my young children the truth, and even tried (for one day) not to smother them with the usual kisses. But I weakened—not because science and truth won out, but because I needed them now more than ever. Knowing that condoms weren't 100% safe in preventing transmission of the virus, my husband and I realized abstinence was our only responsible choice. I couldn't bear the thought of our children potentially losing us both.

The medications were another story—they controlled me. I set alarm clocks to ensure I took the pills appropriately, endured intense nausea, drank a gallon of water daily, and tolerated periods of clouded thinking. I told my children I was taking all of these pills so I wouldn't get sick. However, as I became increasingly nauseated and less energetic, my daughter said, "Why don't you quit taking the pills and just get sick—the pills are making you sick anyway." Ah, the wisdom of a child. Ultimately, I took her advice and did not complete the month of treatment.

I began praying and going to church regularly. I hoped He was still the same forgiving God I remembered from Sunday school. In some way, I was beginning to fill any gaps in my life with moments of gratitude. I looked at things differently, and savored common occurrences as special experiences I had been given as blessings to complete my life. As an emergency physician, I had always preached to friends that life is too precious, too short, and too uncertain. Don't wait to say the things you want to say to those you love. Make each day count. I thought I had been living this philosophy, but only after my HIV exposure did I realize that I could improve.

My one- and three-month HIV test results were negative.

The week before I was to have my six-month test, I received a job offer that would involve administrative and teaching duties and no direct patient contact. Was this the answer to my prayers? Was God giving me an opportunity to keep practicing medicine even if I were HIV positive? At the same time, I developed a sore throat, body aches, and a low-grade fever. I had been told 6 months ago to report directly to Employee Health if these symptoms occurred. Pushing aside my negative thoughts, I called the nurse, hoping she'd offer me a strep throat culture. "Don't bother to come in today," her cheery voice replied. "You're due for your 6-month HIV test in a couple of days. If this is your conversion reaction, we should have a high viral load to test!" I had sought reassurance from my worst fear and she offered no words of consolation or hope. I kept this detail and its implication from my husband. After all, we'd know soon enough.

The day of my blood draw, I was scheduled to work afterward. It was a precious shift to me because I knew it could be my last. If in two days, my test result was positive, it would be impossible for me to continue as an emergency physician—no patient would knowingly want me to perform an invasive procedure if the risk might include contact with my blood. How ironic that I was not given the same option. My naive concept of being a physician had never included the scenario of dying as a result of helping others.

Only minutes from shift's end, I was paged stat to the ICU. A nurse met me with the briefest of facts: an HIV-positive patient with liver and kidney failure, pneumonia, drug-resistant tuberculosis, syphilis, and refractory seizures, who now required intubation. I looked at her in disbelief when she informed me there was not a valid do-not-resuscitate order on the chart, nor was there any documentation of such a discussion by the physician with the patient or his family.

I asked the respiratory therapist to continue bagging and assisting the patient while I sought the family's permission not to proceed with intubation. The patient was completely unresponsive and so weak that the respiratory therapist filled his lungs easily with oxygen and effortlessly maintained good oxygen saturations. There was no family involved, only a lover, who stood weeping at the bedside pleading with someone, anyone, to "do something." My attempts to reason with the lover failed and I wondered whether he would have legitimate grounds to sue me if I refused to intubate. It seemed cruel to prolong this patient's dying when there was no hope of recovery. I thought the patient's primary physician was guilty of bad practice by failing to obtain and document a code status.

I phoned the attending physician at home explaining why I felt it would be morally and medically wrong to put this patient on the ventilator. His response: "If you don't, I will."

Returning to the patient's room, I removed my lab coat and glimpsed the fresh Band-Aid on my own elbow crease. As I put on protective gown, goggles, and mask, I hoped I was not seeing my future in the wasted body of the patient. His eyes were expressionless and his lips were cracked and crusted with dried blood.

I positioned the laryngoscope, visualized Candida-laden cords, and inserted the endotracheal tube; the nurse removed the stylet while I held firmly to the tube. At this moment, the patient had a grand mal seizure and my index finger remained caught between his teeth and the tube. Using both hands on his jaws, the nurse could barely open the patient's mouth to release my finger. Only a few hours earlier, I had had my blood drawn thinking that the whole nightmare would be over soon—for better or for worse, I was going to have my HIV test results from my exposure six months ago. Now, the clock might have to restart. My aching finger hurt like hell and behind my goggles, the tears began to flow. After I checked for equal breath sounds, the respiratory therapist taped the tube in place. I leaned back against the wall and slid myself gently to the floor, unwilling and unable to remove my glove to see if there was blood on my bare finger.

Editor's Note: Dr Bell's 6-month HIV test results were negative.

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