Failure:
JC is the third or fourth patient I see in clinic today. He sits down, shows me his ultrasounds report, asks me his CD4 count, wants to know what is the next step. I'm caught off guard, because I don't even know what step we're on. And I'm pleasantly surprised. I find his direct questioning a deviation from the usual patient encounters. It shows he is concerned about his health. I glance over his details, I realize his birthday is a year and a day after mine. I can't explain why, but I know I'm going to like him.
He's new to our clinic. Yet he has been on antiretroviral treatment for 6 months, which was started at an outside clinic. This is pretty unusual for persons who have been initiated at a clinic to be referred to us; mainly they end up here if they move closer to our clinic, or if there is a problem. And JC is here because there is a problem. Though, I think "problem" is a bit of an understatement.
I needed a minute to digest the note from his visit 2 weeks ago. He was seen by one of the attendings/consultants, and there is a detailed note. Something really isn't right. JC was started on treatment with a viral load of 60,000, and a CD4 count of 20. After the usual 8 weeks, his viral load plummeted, but his CD4 never picked up, and in fact, testing 2 weeks ago shows that his viral load is suppressed (less than 25), and his CD4 count is 24. He seems to have immunological failure (his CD4 count hasn't risen), but has a good virological response (his viral load is undetectable).
But there is more. Way more. He's lost a significant amount of weight. Actually, he's lost a shit load of weight in the past 6 months. He's gone from 63 Kg (138 lbs) to 49 Kg (108 lbs) in the past 6 months. He has lost 14 kg (or 30 lbs). No cough, no fevers, no sweats. TB would be the main culprit causing the weight loss in him. But his work up for pulmonary TB was negative.
When our doc saw him last week, she noted his complaints of stomach pains for the past 6 months, as well as back pains. These have been treated with pain medicines and anti-ulcer treatments, and they haven't gotten better-at all. And then she examined him.
I flipped back through his notes from the other clinic. Nobody has listened to this man. For months he has been saying he isn't well, and nobody has listened. For 6 months they watched his weight plummet. For 6 months they gave him antacids. For 6 months they continued to note that his CD4 wasn't picking up like it should.
And for 6 months, they didn't notice the mass in his abdomen. Which he has known about. Back in March, it was mobile. But for the past 3 months it has been fixed-- unable to be moved about. The doc last week noticed it. Unfortunately, the abdominal ultrasound shows lots of abnormalities, but didn't mention this mass.
I sympathize with this man. Sitting with him, I had flashback to where I was 5 years ago. In the GP office in Ireland, explaining how all of a sudden I couldn't run, how I was winded just trying to go up stairs, and how miserable I felt with a persistent cough. I told him there was something wrong. I was given a script for allupent (which is basically a placebo medicine-technically an expectorant), and sent out the door. It's the exact treatment that JC has been getting. A dose of failing to really care about the patient, and pacification with placebo medicines. There are so many red flags in his story, that I don't even know where to start explaining things to him, partly because I know the outcome isn't looking too good.
We talk, I tell him my frustration that he has been literally wasting away for 6 months and nothing has been done, and that I think it's best that I admit him to the hospital so that he can get a CT scan, a endoscopy, and more work up. I tell him that based on the ultrasound results, it looks like he may well have TB in the abdomen, but that the biggest concern is that he also has a lymphoma or other cancer in the abdomen as well. We negotiate. He'll spend the weekend with his wife and 2 year old child, and then will be admitted on Monday. I give him my mobile number so that he can call if anything changes. Initially I balked at handing out my number in clinic, but I'm realizing that negotiating/manipulating the system here is beyond the capability of many people (as it is in the US as well), and that most will likely be too embarrassed to actually call, but at least they will have the option.
Success:
It's mid-afternoon, and I scan the people sitting in the waiting room for VM. She has been sick since she came to the clinic three weeks ago. I'm relieved she made her appointment today. I call out her name, and watch as she walks toward me, and she smiles. She looks completely different. For a minute, I wonder if it was her I really saw at that initial visit.
It was late in the afternoon three weeks ago. She had decided to not start HIV treatment back in November, and then had changed her mind and came to the clinic. And she was ill. Chronic diarrhea. Losing weight. And she was coughing, with sweats. She had horrible thrush, and wasn't able to drink enough to make up for the lost fluid of the diarrhea. She really needed to be admitted. But she declined. (I almost said refused, but that's medico-legal speak, which means if something bad were to happen because she didn't go into the hospital, then it's her own fault, and the clinic/hospital/doctor aren't responsible). But she couldn't go into the hospital. If she did, and were away from her home at night, it would be likely that her home (shack) would be broken into and her stuff stolen. She needed to be home. It was too late in the day to do labs, or get medicines, or get xrays, so she would have to take 3 mini-bus taxis home, and return the next day to do the stuff, and then return the following week for results.
When I saw her 2 weeks ago, she looked even worse. And I feared that she wasn't going to make it. Her chest xray confirmed likely pulmonary TB, which would mean she would need to be on TB treatment for 2 weeks before starting her HIV treatment. And so that's what we did. Gave her the pills for TB, and said we'd see her again in 2 weeks to start her HIV treatment.
And today, after 2 weeks of TB treatment (as well as treatment for diarrhea) she finally feels a bit better. It was a huge relief to see how well she was feeling. Again, I found myself thinking back 5 years, and retrospectively realizing how lousy I felt when I had TB. Once the TB treatment kicked in, and breathing became less laborious, and I had energy, it was easy to smile. You literally feel like you get your livelihood back. And I completely understood why she was smiling.
Three weeks ago I wondered if she would really have the strength to take the 3 mini-bus taxis back to Bara. Or would she simply resign herself to what she saw as her fate, stay in bed as the TB continued to consume her, as the diarrhea wreaked havoc on her electrolytes, and at some point die at home. She's going to make it. And having the privilege of helping somebody like VM get healthy is the most rewarding aspect of this job.
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