Tuesday, January 09, 2007

New Year, New Life

He and his wife have had AIDS for years. Did they infect one another? I think so. At any rate, here they are with school-age children and a life to live. What to do?

She is a model patient, taking her meds religiously, showing up for appointments and labs, doing everything she can to succeed. Her work and diligent focus have paid off and her virus has been completely suppressed for years. Free of opportunistic infections and other complications, her HIV lingers in the background like controlled diabetes and hypertension---it's there, but there's little to worry about. Barring unforeseen circumstances or aberrations, she will be a member of this generation that dies of heart disease along with her non-HIV infected peers, Goddess willing.

On the other hand, her husband is far from the model patient. Having gone off and on his meds for years, he has basically "blown" a number of meds for himself forever, the virus in his body building resistant mutations to any number of combinations of medications. One or two entire classes of meds may now be out of the question for him, and the new classes of drugs are slow to make it onto the market. Having failed to take his current regimen of five drugs for almost two months, he landed himself in the hospital with pneumonia, although he miraculously avoided pneumocystis carinii pneumonia (PCP), the most lethal for people with HIV infection. Lucky for him, it was run-of-the-mill community-acquired pneumonia (CAP), and Levaquin, a popular and powerful antibiotic, will eradicate that bug in a flash.

So, four days out of the hospital, today was Check-Up Number One with his favorite Nurse Care Manager. Lungs were OK, although he has some intercostal pain between some ribs from the weeks of coughing. No fever, normal vital signs, weight surprisingly steady but well below his optimal goal: things look pretty good. While hospitalized, an HIV Genotype was drawn, so that in two weeks or less, we will have a list of the many mutations created by the particular brand of HIV virus inside of his body, helping us choose which meds might still be efficacious, if any. The news may be surprisingly bright, but could also be rather grim. Only time will tell.

Meanwhile, back in the exam room....

"It's the New Year, and I'm ready for a new life," he says. His skinny frame is racked by coughing and I wait for him to catch his breath.

"You know this is serious, right?" I ask in Spanish. "We've had this talk before and you were ready to go, but then you got lost and here we are again."

"It's not like before," he says while looking down. "This time I'm going to do it. I have to."

"Well," I say in response, "that's great, but it will take alot more talking before we make any decisions about medications." I look at his wife, and she's nodding knowingly.

"Look," I add, "you cannot be having unprotected sex---not now, not ever. You could pass your HIV mutations on to her, and then you'll both be in trouble. She's in great condition---let's keep it that way."

"Yes, yes," they both say. "We need condoms."

"That's what I want to hear. I'll give them to you before you go." I close down the computer after I finish entering the vital signs and a brief note.

I walk down the hall next to his wife and he lags behind, as usual, winded and tired.

"What do you think? Is he serious?" I ask.

"I think so," she replies. "He says the New Year is his time to start again."

"I hope so," I say as I open the door for her.

"A million thanks," she says as she grabs my hand.

"My pleasure." I squeeze her hand and then shake his, as well.

"I want to see you every week---don't disappear!" I say to his back.

"Don't worry," he yells back. "We'll see you."

I smile as I open the door and head back towards the office. I think about their kids, one a teenager and the others some years younger. Do they know their parents' diagnoses? How much have they surmised? Do they know how their father's been playing Russian Roullette with his life?

I can't do all the work. The patient has to meet me half-way. Some do, some don't, others do for a while but lose their focus. If they only realized how easy we make it, what an embarrassment of riches is at their disposal in terms of the system set up to help them succeed. We've lost so many, and continue to do so. Will this couple both live long enough to tend to one another as old age sets in? Can they be one couple of their generation that survives that long, intact and relatively unscathed and unwidowed? As for the wife, I put my money on her living to be quite old, with grandchildren to coddle and grown children to enjoy. And for the husband? My jury is out, but the track record does not bode well. Still, I hold out hope as this New Year gets underway.

New Year, new life? Let's hope so.


Mother Jones RN said...

Once again, you've written a very moving post. I hope all of our patients have a good new year.


Jessica Gottlieb said...

Moving and articulate.

Thank you for all you do