AIDS: Thru a glass darkly

S.E.S. Medina
Benbrook, Texas, United States

 

AIDS Cases by Exposure Category and Year of Report 1985-1996, United States, Center for Disease Control graph

AIDS Cases by Exposure Category and Year of Report 1985-1996, United States. CDC/NCHSTP/DHAP/Jean G. Smith. Courtesy of Public Health Image Library. Via Public Domain Files. Public domain.

I sat in the deep, cool shade of a stout, leafy Texas cedar escaping the torrid summer heat, idle thoughts meandering. Cotton-ball clouds grazed lazily across their azure prairie.

The pervasive insane miasma swirling like a whirlwind around COVID-19 reminded me of days past when a very different virus dominated public discourse: HIV.

I swallowed hard, recalling my first case of AIDS—the Acquired Immunodeficiency Syndrome—although neither I nor the physicians treating him knew it at the time.

It was the fall of 1979.

A static-infused fanfare from the intern’s pager announced a new ER admission. He called Emergency: “What are we getting?”

Despite a raspy connection, the Emergency Room Attending voice bled excitement: he had a genuine “fascinoma”—a fascinating case of unknown cause.

I was a green first-year medical student on call with a team of Bellevue Hospital residents. The emergency room (ER) attending led us to our new admission: a handsome young man on a gurney, intubated, on a mechanical ventilator. The patient’s partner, disheveled but vigilant, stood alongside the stretcher and watched us approach through brimming eyes.

The ER physician presented the patient: “A 26-year-old Caucasian male with no prior medical history was brought to Bellevue with a story of rapid onset, progressive, left-sided paralysis. His weakness first manifested as difficulty holding objects in his left hand, progressed to dropping pens, cups, and other minor items, and was followed by an ascending paralysis of the left leg. The patient refused to consult a doctor about these unusual problems, despite his partner’s insistence, until this morning when he was found unresponsive in bed. The obtunded male was transported to Bellevue via ambulance.”

“Obtunded?” I mouthed to the intern beside me.

“Completely unresponsive,” he mouthed back.

“Upon arrival,” droned the ER attending, “the subject’s breathing was shallow and irregular; the pulse oximetry showed an oxygen saturation below 70%.”

My eyebrows shot up.

“A stat blood gas confirmed hypoxia and respiratory acidosis, so the patient was immediately intubated and connected to a ventilator. Preliminary labs were notable for an abnormally low total white blood cell count with profoundly depressed lymphocytes. The blood count was also noteworthy for anemia and a platelet count of only 66,000.”

The intern elbowed me. “That’s almost a third of the low end of normal,” he gasped.

A CT-scan of the head gave us the biggest surprise. The films hung on an X-ray display box next to the trauma room’s main doorway. The huge, gray tumor was impossible to miss.

“As you can see,” he said, “this unfortunate fellow has a lobulated mass the size of a fist causing a marked pressure effect on the brain, accompanied by a surrounding rim of cerebral edema in the right parieto-temporal region. I’ve arranged a transfer to the MICU and a neurosurgery consult has been ordered. The neurosurgery chief resident recommended starting high dose Decadron to help decrease the swelling around the tumor.”

Dark, cavernous circles under my eyes betrayed how difficult it had been to stabilize the patient through the night. My job was to slowly push lots of intravenous Valium to suppress seizures during the elevator transport up to the MICU. He continued convulsing anyway, despite all the Valium. A Dilantin drip finally ended the shaking.

The neurosurgeons took him the next morning for a brain biopsy after preliminary results of a spinal tap showed no infection. The biopsy specimen revealed a poorly differentiated, non-Hodgkin’s lymphoma. This was a highly unusual presentation for this type of cancer, as it rarely appears as a primary tumor of the central nervous system, usually starting in the lymphatic system, and then spreading. Little did we realize at Bellevue, and subsequently at other hospitals in New York City, that this was only the start of a terrible new epidemic.

The ensuing months were punctuated by an alarming number of extremely ill, young homosexual men with unusual treatment-resistant infections like Pneumocystis carinii pneumonia, and rare cancers such as Kaposi’s sarcoma. When Bellevue’s medical residents noted similar infections appearing in intravenous drug users, senior attending physicians suspected the existence of a transmissible blood-borne agent.

I recall many morning reports where the on-call residents presented the night’s admissions to the chief medical resident and everyone engaged in lively debates trying to figure out what these individuals suffered from. We correctly surmised that something was causing an immune system collapse, since the infectious pathogens afflicting them had only been seen in our sickest blood cancer patients. Sometimes the overwhelming infections were inexplicably caused by animal parasites.

Usually, physicians try to place a patient’s condition into an orderly box called a diagnosis in order to plan and prescribe appropriate treatment. But in spite of our best efforts, we could not. No known diagnoses fit these protean illnesses: some aspect of the clinical or laboratory findings would throw us off.

People came up with colorful terms like GRID, which stood for “gay-related immunodeficiency disorder.” “Gay bowel syndrome” was used to describe the unremitting diarrhea resistant to treatment. Someone even declared it “The Wrath of God,” as if these individuals were being punished for risky sexual lifestyles or drug-related activities.

Back in those somber days, HIV-positive patients were admitted to the hospital for one episode of illness after another. They would be discharged, improved and clear of a specific infection, only to return with the same problem a week later. Unlike COVID-19, HIV had a mortality rate of 100% until the development of antivirals kept the virus at bay, allowing these poor people a chance at life. Treating these individuals imbued me with traits that have served me well as a physician: non-judgmental compassion, diagnostic aggressiveness, and a fearlessness of the germ.

By training at New York City’s world-famous Bellevue Hospital in tandem with clinical time spent at NYU University Hospital, I learned from a cadre of physicians who understood a key aspect of caring for HIV-positive patients: the need for a hyper-aggressive approach to correctly diagnose the specific condition or infection. The severity of the underlying immune deficiency did not allow the luxury of delay. Each second was precious. Accurate diagnosis and the institution of rapid treatment meant increased survival.

So, we poked, prodded, biopsied, aspirated, X-rayed, and checked every possibility, hoping to give these patients an opportunity to live another day. A cautious lack of fear toward the circulating virus tempered that diagnostic aggressiveness. The medical staff was not foolhardy—we wore double latex gloves, donned protective plastic face guards, and practiced meticulous sterile technique. But we were never reluctant to touch people.

Drawing blood from an AIDS patient for the first time, I struggled to control my shaking hands while tying a rubber tourniquet around his upper arm. An intern standing behind me placed a hand on my shoulder. She whispered into my ear: “Don’t be afraid. I’m here.”

Trembling fingers inserted the needle; a squirt of dark purple meant success!

Another time, while replacing the needle of a blood gas with its protective plastic cap, I accidentally stuck myself in the finger. Heart racing, I ran to tell the resident what had happened.

“Nothing we can do about that now, Ricky,” he replied dryly. I was a poor medical student and could not afford to get an HIV test. My practical solution was to donate blood every six months as the blood bank tested for the presence of HIV antibody.

Thank heavens the test always came out negative!

Ignorance and fear walked the halls of hospitals, though. Countless times, as intern, resident, and then as Chief Medical Resident, I counseled members of the hospital’s housekeeping and dietary staff that the conditions afflicting the AIDS patients, short of active tuberculosis, were harmless to them.

Food trays were abandoned on the floor outside the patient’s doorway. Beds left unmade. Rooms dirty and cluttered because the ancillary personnel were paralyzed by fear to enter the room.

These patients often suffered from explosive diarrhea, a common affliction in the early days of the epidemic. It was a revolting side effect that further marginalize AIDS patients. The nursing staff, however, was always ready to care for these individuals. Their compassionate ministrations complemented our diagnostic aggressiveness in a magnificent testimony to their professionalism and dedication, for they spent far more time with AIDS patients than we physicians did.

These intense experiences and professional relationships shaped the doctor I became. I found that the most powerful tool I had was empathy. I always hugged HIV-positive patients, an action that elicited broad smiles or copious tears. Regardless of whether a physician can cure a patient, compassion should always be the first prescription.

There is no higher calling in life than this.

I am humbled and grateful to have had the opportunity to practice it.

 


 

S.E.S. MEDINA, MD, is a retired Internal Medicine specialist with a sub-specialty in Infectious Diseases. His initial medical training took place at the New York University School of Medicine in the late 1970s when the AIDS epidemic was just beginning, working with severely ill HIV infected patients. Clinical research under Dr. Linda Laubenstein during his fourth year at the NYU Medical School resulted in a contributing paper which was included in the first medical textbook on AIDS.

Acknowledgement: Dr. Medina would like to acknowledge the creative and editorial contributions of his nephew and godson, David I. Banchs, in the writing of this piece.

 

Winter 2022  |  Sections  |  Infectious Diseases