by Atul Kumar
Our JD just vomited all over the floor next to his bed. Another good reason never to sit down on any floor space in the ER. Ever.
JD didn’t look so good. His skin was pale with a slightly green hue. He was covered in oily sweat with specks of his recent upchuck all over his face and chest. Despite this, one could tell JD took care of his physique; he was quite the specimen with all his muscle groups well-defined and a trim waist. He clearly wasn’t a stranger to the gym.
Just like you can’t judge a book by its cover, don’t try to assume anything about a patient by their external appearance. Just because JD appeared fit did not preclude any number of medical conditions. The fact that he just lost control of his bowels and soiled his jeans reinforced that something was seriously wrong with him.
But it did provide some insight into whatever was going on, namely, it was bad and moving fast. The ER team rushed into the room and began a repeat evaluation before I could even get gowned and gloved up.
One of the nurses yelled out to the nearest attending, “His pupils are fixed and dilated and he’s not responding to pain.”
The ER attending, someone whom I didn’t recognize, rushed over in his blood streaked scrubs and took in the situation. “Any results from his toxicology screen or CT scan yet?”
“Tox is pending, CT scan of his head showed no herniation but radiology suspects some kind of infection based on a possible abscess. Unfortunately, they said the scan quality was extremely poor due to motion artifact. Lungs were clear.”
JD began to seize.
“Get the crash cart. We’re going to intubate and then perform a LP. MOVE people! I want to get this done in the next five minutes.”
The crowd dispersed with vigor, as they now all had something to do. The attending positioned himself at the head of the bed in preparation for the intubation when a cough of blood escaped from JD’s mouth followed by a gush that immediately covered his face, neck, and continued to flow onto the gurney. The attending wasn’t fazed at all; nor did the added blood change the appearance of his already soiled scrubs.
I guessed JD must have bitten off a good portion of his tongue as he began to seize, because the blood kept pouring out of his mouth with no indication of slowing.
The convulsions began to subside after about 15 seconds, which is when everybody regrouped with all the equipment that the attending had requested.
“Crash cart’s here doc, you ready?”
“This is a fucking mess. Get me suction, STAT! Then a 7 French tube with a straight scope. Go ahead and give him some heavy sedation and induce paralysis. If I don’t get it on the first try we’re just gonna trach him.”
The equipment materialized out of nowhere. The suction cannula was placed in JD’s mouth, which was now more like an erupting volcano spewing hemoglobin everywhere. Somehow the attending was able to locate the pharynx. But from where I was, all I could see was blood and more blood.
He plunged the tube into the middle of the eruption. He connected it to a bag and began manual ventilations.
“I got breath sounds, Doc. You’re a magician, how the hell did you get that tube in?”
The question went unheard; the attending was too focused on what to do next.
“Connect him to the ventilator. Place him on his right side and get him prepped for the LP.”
About 20 seconds elapsed and a voice rang out, “He’s all ready for you, Doc.”
“Next time make it faster. Get the manometer set up, I want to measure his opening pressure.”
With the efficiency that only comes with experience, the attending plunged the long needle deep into JD’s lower back, through his spinous processes, and into his spinal canal in one single fluid motion. Slightly turbid CSF began to gush out.
“Connect the manometer!!”
The pressure measuring device was immediately connected to the needle in an effort to determine the opening pressure of the CSF.
The only problem was the pressure was so high that the CSF coursed up through the first manometer and erupted through the top like Old Faithful.
“HOLY-FUCKING-SHIT … attach another one on top of this one now!”
A second one was quickly affixed and the pressure measured.
“God damn! The pressure is 68!” exclaimed the attending. “Give me five tubes. I’m gonna collect the samples, and we’ll pray he doesn’t have a continued leak or herniation with that pressure. Where’s the ICU team?? I want him out of here yesterday.”
While he was collecting the samples Cindy arrived at my side.
“Hmm … that doesn’t look so good. I’m guessing he’s our admission?” asked Cindy.
I gave her a quick rundown of what had taken place so far.
“What’s your diagnosis, Dr. Mok?”
“Well, there’re only a couple things I know that can cause a CSF pressure that high along with a fever and seizures. And given he didn’t have any signs of tuberculosis on the lung scan, I’m going to go with Cryptococcal meningitis.”
“The accolades I’ve heard about you have just been validated.”
The pandemonium around JD had calmed down now and one of the nurses was calmly cleaning him up in preparation for his transfer to the unit. The attending was headed towards us. He had so much blood on him that the only part of his name badge I could make out was Dan.
Cindy was quick to greet him. “Hi, uh, Dr. Dan; we’re here from the ICU.”
“Pleasure, I’d shake, but I think you’d prefer I decontaminate first. I don’t know what half this shit is that splattered on me.” He proceeded to scrub his arms in the sink while talking. “Well, I can’t tell you much. You must have heard the LP fluid was dirty and the pressure was sky high. He seized down here and bit off about 20% of his tongue. Somehow we managed to intubate him. He’s paralyzed, sedated, and all yours.” With that he rushed over to attend to his next bloody mess. Literally.
If nothing else, Dr. Dan was competent and efficient.
“I saw ENT on their way over when I was coming down. I’m guessing they are going to fix his tongue so he doesn’t exsanguinate before we even get him to the unit. So what do you want to do for this guy?” asked Cindy.
“Well, I already checked his belongings. I found a driver’s license that says Jacob Winters. If that’s him, he lives in Santa Monica. I also found his cell phone; it only had four numbers on speed dial, “Claudia, Rachel, Patricia, and Amber.” He’d called Claudia several times during the last couple days. His phone didn’t have the typical “Home” or “Mom” or “Dad” entries in the directory.
“My guess is he was partying all night in Hollywood and passed out from the festivities. The names are either his drug dealers or booty calls. Ecstasy overdose can certainly cause hyperthermia and seizures in a young healthy guy and isn’t uncommon in this area.
“Thus, we should follow up on the drug screen and get an MRI of his head to evaluate for Crypto.” Cindy nodded her approval.
“I’m assuming routine labs and cultures have been drawn, but we should double check to make sure. Let’s see if we can get the MRI done now; it’s on this floor and it’d be easier than transporting him back down from the ICU later. Anything else you can think of?”
“Yeah, let’s start him on Amphotericin B.” Too bad it’s such a terrible medication. It has horrible side-effects. Some of the worst are renal failure, liver failure, blood dyscrasias, cardiac arrhythmias, heart failure, rigors, headache, and death—to name just a few. “Perhaps we could also add a couple broad spectrum antibiotics as well as large amounts of IV fluids.”
“Good show, Dr. Raj.”
“I suspect he might have HIV or AIDS. But I don’t think we can test for that without consent. And while he’s like this with no family present, our hands are tied.”
“We can deal with that later. Let’s see about this MRI first.”
He arrived in the ICU three hours later. ENT had managed to suture up his tongue and packed his mouth with some gauze. The MRI “w
et” read was consistent with a florid Cryptococcal cerebral infection complete with several abscesses and associated meningitis.
We got him situated in the ICU with an isolation room, ventilator, his medications, and ample IV fluids.
I tried calling the number on his license, but it was a cell phone with no greeting. Having no next of kin or emergency contacts, it was just a matter of ‘hurry up and wait’ for Jacob to either wake up or go to sleep permanently.
Finishing up the admission paperwork, I ran into Jack and told him about the case and how we couldn’t ascertain his HIV status until he woke up.
“That’s bullshit man; you can easily figure out if he’s got the ‘HI-5’ without his consent. You just gotta order the right tests,” winked Jack.
“I don’t follow. Federal law states that we must have patient consent to order HIV testing or share results of such testing.”
“Exactly, you have to have consent for HIV testing. But I never said to order an HIV test. Just order a HIV viral load and CD4 count. Neither test requires specific consent. If he has a positive HIV viral load and low CD4 count, you can essentially make the diagnosis of HIV or AIDS. Gotta think outside of the box, my man.” He patted my back and took off to wherever he was headed.
Now I knew where Jack got the reputation of being clever and knowing how to get out of work.
But what he said was brilliant. If we did what Jack recommended we could get our answers and circumvent the whole consent issue. Sure, it was a little shady, but it was very legal and would help us with JD’s management and care. At least that’s how I rationalized it immediately before I ordered the tests.
The tests would take at least 24 hours to perform. In that time Jacob continued to steadily improve throughout the day such that he was starting to wake up and respond to pain. To help decrease some of the cerebral edema caused by the infection steroids were started the following morning. The result was quite profound. By the end of that day Jacob was responding to verbal commands and trying to pull out his endotracheal tube.
During evening rounds Dr. Clyde decided we’d leave Jacob on the ventilator overnight and extubate him first thing in the morning if he continued to show such dramatic improvement. His labs had not returned by the time we rounded.
I completed my work and was ready to head out of the hospital. The rest of the team had already called it a night long ago, except for Cindy who was double checking her orders. Figuring I’d keep myself busy until she was done and walk out with her, I decided to check up on Jacob’s labs once again. BINGO, the results were in, less than 36 hours after being placed.
Jack was one sharp cookie. Jacob did, in fact, have a severely decreased CD4 count of 36 and a raging viral load of over 110,000 HIV RNA copies per milliliter of blood.
“Eek, you scared me,” I manly whimpered. Cindy had startled me by tapping my chair while I was engrossed with Jacob’s lab results.
“Whatcha looking at there?” She asked.
“Guess what? Jacob is, in fact, HIV positive. Take a look at these values.” I nudged the monitor in her direction.
“OH WOW, his viral particles are having one big party. That certainly explains his Crypto meningitis. Though he doesn’t have that characteristic look of someone with HIV wasting syndrome, nor that lipodystrophic look that people on anti-HIV medications develop from fat redistribution.”
“In other words Detective Lee is saying he’s never been on a HAART treatment protocol?”
“Doesn’t look like it. Anyway, let’s get outta here. It’s already 9 p.m. and we gotta be back too soon.” We headed out of the ICU and before going 20 feet, our discussion was back to medical topics, and Jacob in particular.
“How do you think he got AIDS?” I asked, “He seems like such a normal guy.”
“NEWS FLASH, normal people have sex and do drugs! Take your pick. It’s one of those two. The era of HIV from blood transfusions died in the mid 1980s, and I doubt he was but a toddler in those days. And if he had contracted it then, he wouldn’t be around now without being on treatment.”
“Think he’ll make it?”
“I suppose if he really gets off the ventilator tomorrow and continues to recover well, he’ll do just fine. Once he gets on a HAART regimen, his CD4 count will essentially normalize and he’ll easily have a good 30 years or more to live. You know, these days it’s rare to die of HIV/AIDS or its associated infectious complications. Most people with HIV die of something unrelated to the actual disease itself.”
“I read that somewhere. I guess it’s fascinating because this is the first time I’ve seen AIDS diagnosed.”
“Technically we haven’t diagnosed it yet. But I hear ya; it can be exhilarating. Just remember, he’s got enough viral particles flowing through him to infect everyone in the hospital several times over. You have to treat him like a biological weapon.”
“Good point, I’ll make sure to double glove. Do you think he knows what he has?”
“I’m sure. He’s probably known for a while but was in denial, probably why he never sought medical attention. I just hope he hasn’t knowingly ruined anybody’s life by fucking around without protection. He’s a good looking guy and girls aren’t going to think twice about shagging him.”
“I guess I never thought about that.”
“About shagging a guy?”
“Perhaps I should think about it. It’s too hard to meet a decent girl in this city.”
“I don’t believe that. You’re a good looking guy; you must have to run away from the girls chasing after you.”
“Now you’ve proven that you’re delusional.”
“Most delusions are based on some kernel of truth.”
“Then I should take advantage of your current state of mind. Would you be interested in further exploring your delusions over dinner sometime?”
“What an interesting proposition … I look forward to it.”
“Ditto.” I began to blush, but before I had the opportunity to screw up this harmless flirting, we entered the parking structure and headed our separate ways. The good news was that I’d see her again in a mere eight hours.
~~~~
I arrived in the ICU to see that Cindy was already there. Seeing me enter she rushed over and immediately started to update me on Jacob.
“So last night your friend tried to pull his ET tube out again. Apparently his sedation got a little light and he woke up enough to start tugging on it. He did that despite being on high dose narcotics, telling us he likely has a history of drug use. If you or I got half the dose he did we’d be out for a solid 48 hours. Anyway, he pulled the tube so hard that he partially dislodged it, and the resident on call decided it was safer to extubate him; repositioning the tube wasn’t possible.
“Once Jacob got his voice back he was extremely rude to the female nurses and required sedation to shut his ass up. He should be waking up soon. Would you mind interviewing him this morning? I think it’d be easier if you talked to him given his chauvinistic behavior. I’ll take care of all the other paperwork on everybody else.”
“Sure, I can help out with that stuff, too.”
“No, just take your time. I know you were excited about your first AIDS case, so go slow and learn as much as you can. You have almost a full hour to chat with our friend.”
This was sure shaping up to be a good month; a whole hour with a patient without having a dozen other things to do was a rare treat. I made a mental list of what I knew before I entered Jacob’s isolation room. He had AIDS, possibly previously undiagnosed, meningitis which almost killed him, a history of drug use, and likely a penchant for sex and partying given where he was found down.
I reviewed his vitals before entering his room. Jacob seemed to be doing better, his temperature was just below 100°F, the other vital signs were essentially normal with good oxygen saturation on nasal cannula and only a mild tachycardia.
His labs were another story. The drug screen was positive for opioid derivatives, ecstasy,
cocaine, and alcohol. Cindy was right about the drug use. His blood cultures were negative, but his CSF cultures were positive for Cryptococcus. Speciation and drug sensitivities were still pending.
With technology and lab testing, speaking to a patient is almost unnecessary in modern medicine.
I put on my personal protective equipment in the anteroom of Jacob’s isolation chamber, which consisted of an N95 face mask, eye shield, gown, and gloves; being that they were all disposable, this meant that the mere act of entering Jacob’s room cost about five dollars every time somebody went inside. Jacob was asleep but easily aroused when I nudged his shoulder.
“Good morning, Jacob.”
I waited for a response, but he just shifted position and rubbed his eyes, trying to sit up.
“Just relax, let me help you. I’ll elevate the head of your bed for you so you don’t have to strain yourself. There, how’s that?”
“Who are you?”
“Name’s Raj, I’m the medical student on the team taking care of you.”
“What?”
“Do you know where you are?”
“Naw man, I don’t remember much. I remember some hottie here a while ago. I tried to hit on her, but she got real mad at me. I realized something wasn’t right. Next thing I know I’m talking to you.”
“You are in the hospital, in the intensive care unit to be exact. You’ve been here for the past two days.”
That got his attention, and he sat bolt upright. “SHIT, where’s my car and clothes?”
He looked around in a confused manner taking everything in and began to reach for his IV line. I stopped him and did my best to comfort him, but his agitation grew.
“Jacob, listen to me for a second, try and relax …”
“I can’t relax! I’m late for work; they’re gonna can me if I miss another day. I need to get out of here. Shitshitshitshit … where are my clothes?”
“Take a deep breath and calm down, I’ll answer all of your questions. You are in a hospital.”
“I can’t calm down, damn it! I need to get outta here and get my car and get to work. Fuck, you don’t understand, I’m going to lose my job if I miss another day.” He was throwing off his sheets, searching the room for something, I presumed his clothes.