Seven Patients

by Atul Kumar

  “So it was either let him leave the hospital AMA and infect other innocent people and ruin their lives like a serial killer, or think outside the box. I noticed, in his fit of rage, a twitch in his leg. Given his documented substance abuse history and elevated liver enzymes, I deduced he might have been withdrawing from alcohol. Thus, I started him on IV Valium. While the Valium was kicking in and he was in la-la land, I snuck a consent form under his pen and told him to sign for HIV testing. He readily agreed. Of course he’d have agreed to live on Mars at that time too, but that wasn’t what I asked. And if you look clearly at the times on the notes, the consent was signed a full 15 minutes before the Valium was administered. Again, it’s all about what’s documented; what really happened is irrelevant.”

  I wasn’t sure how to respond. There was something so wrong with using power like that to coerce somebody into doing something they didn’t want. It was not unlike using GHB as a date rape drug or sodium amytal as a truth serum to obtain information via enhanced interrogation techniques.

  “It’s going to take some time to get your head around this new way of thinking and patient management, but you’ll learn. After all, the story you told me earlier is what the chart indicates occurred. What I just confided in you now was what actually transpired. Of course, if you tell anyone there’s no way to prove your story. And just FYI, keep in mind that it’s illegal to record conversations about patient care unless you have a court order prior to the time of recording.”

  I just stared blankly, trying to process what I’d been told. My immediate interpretation was that medical charts are not necessarily what they appear to be. Sure there is a lot of documentation, but there’s a lot that goes on in between the lines.

  “Think of it this way Raj, if we’d let Jacob walk out last night, he’d call up one of his girls and have unprotected sex or share drug needles with her. She’d be unaware that she’s infected and the cycle would just repeat. More and more people will become infected all BECAUSE Jacob is aware of his condition but REFUSES to notify sexual partners as required by law.

  “So you tell me who’s the good and who’s the bad guy in this scenario?”

  He went on, “That’s why Clyde put me as lead on this case. He knows I can get things done that most others have a very hard time with. He also doesn’t want to be involved because of liability reasons … the joys of academic medicine. As residents we’re totally protected by virtue of our training status and humongous malpractice insurance. So he’ll support us to an extent, but try not to ask him too many questions. You’ll just end up getting answers you might not want.”

  My brain was in information overload mode; I couldn’t grasp what was happening. Jack seemed to realize this and started on his breakfast, allowing my brain some time to process. Eventually my dendrites and neurons rebooted and I could again form a thought.

  Essentially we were taking care of a potential murderer who was more than happy to leave the hospital and continue on with his life, not caring for the lives of others. On the other hand, he might not know he was a murderer if he didn’t know he had HIV. Also, what if he never actually infected anybody else? We were making a lot of assumptions without data to back up our conclusions. We were basing our opinions of Jacob on emotions, not from objective data.

  Once I formulated my thoughts I summarized them for Jack.

  “That’s why I like you Raj, you’re practical. I agree with you 100% … while we’re pretty sure he knows that he has HIV or AIDS, we aren’t certain. Thanks to his consent, we now know of his diagnosis.”

  “How does that help us?”

  “In many ways. We have to report it to public health authorities and they might question his sexual partners. However, if he doesn’t volunteer contact information about his partners, there’s nothing further we can do. Also, if he infects any further individuals going forward without telling them of his disease status, that’s certainly grounds upon which to take legal action. But that’d require us to follow him at all times, not very practical.”

  “I don’t know about the future, but what about the people he already infected? He’s so smug about it.”

  “Whoa, hold up there. You’re being emotional now. What people? Do you know of any? I sure don’t.”

  “Well, there were those four numbers in his phone. Can’t we just call them and ask them if they knew he had AIDS or have been tested?”

  “Sure you can, if you want to go to jail.”

  “Huh?”

  “You can’t just call up somebody’s contacts without their consent or look through their personal belongings without the appropriate search warrants or psychiatric hold.”

  “Great, the 5150 again. Why don’t we just put him under hold and call them up?”

  “Dude, you’re going in circles here. No reason to put him on a psych hold.”

  “Fan-fucking-tastic! So basically our job is to help him get better and let him go so he can do whatever the hell he wants, and he’s off the hook? All he has to do is notify future sexual partners of his HIV and he gets a free pass for all his previous infractions? He’s not responsible for the lives he knowingly destroyed?”

  “Pretty much.” He said it so simply that I knew there must be more. “He might not have known in the past. All we can do is document we told him during this hospitalization. Innocent until proven guilty remember? Been a law for hundreds of years.”

  “But … there’s gotta … I mean …” I wanted to say something else, but I was at a loss. Wasn’t involuntary manslaughter a charge? I guess the girls on his phone would have had to have died of HIV, and somehow it’d have to be proven that they were knowingly infected by Jacob. That was nearly impossible.

  “This sucks.” My brilliant conclusion sounded pretty lame, especially when said out loud.

  Jack leaned in closer; there was a glint in his eyes. He lowered his voice to a conspiratorial tone, “Well, if you’re interested, there is something we can do.”

  Ah ha, this was it! I knew there was more than meets the eye.

  Of course I was now committed after he whet my appetite. But I didn’t want Jack to think I was too eager, so I tried to play it cool, “What do you mean?”

  “Well, remember how I said Clyde had me take over this case ‘cause I get things done. Well, I’m proposing you help me take care of this case, if you’re up for it. Otherwise you can back out now and plead the fifth should anything happen or anyone question you.”

  I didn’t like the sound of that, but curiosity had already won me over. I knew it was likely an emotional response, but I figured, worst case scenario, I could always plead I was a med student. I didn’t have a medical license or anything else to lose.

  “I’m in.”

  “Well, you know how I said we can’t call the numbers on Jacob’s phone now that he’s alert and oriented?”

  “Yeah.”

  “Well, I already called all four of them when he was in the ER. I left messages saying that his life was imminently in danger and they all called back. So now that the lines of communication are open, all we have to do is convince them to get tested for HIV. If they’re positive I’m sure it won’t be hard to professionally imply that recent sexual contact might have caused their infection. They will naturally assume it’s Jacob and he’ll be cornered.”

  I was taken aback by Jack’s foresight and how he’d taken the initiative to call the numbers I’d retrieved. And thus, our plan to fight fire with fire was born.

  ~~~~

  “How’d it go?” I asked Jack.

  “Well, he was pretty pissed that I tested him for HIV and even more pissed that his test came back positive, though he wasn’t surprised—just angry. Of course he calmed down when I showed him his signature on the consent form.”

  “Guess he couldn’t argue that, huh?”

  “He claimed it was forged, but I showed him the witness signature, date, and time. He said he didn’t remember signing, but I simply countered that he didn’t remember co
ming to the ER either. That shut him up. Pretty easy. How about you, any luck?”

  “Definitely. I followed up with all four ‘girlfriends’ that you’d called earlier. Since then they have all called Jacob and he’s refused to allow any to visit. But I planted the seed that they might have some kind of infection due to their recent close contact with him. I was very vague just like we rehearsed. They are all coming in this week for a full physical exam. I placed them all in different clinics; I figured it’d look suspicious if they all saw you. They’ll be sure to get tested for HIV and other sexually transmitted diseases.”

  “Nice work.”

  “Dr. Flanders,” one of the nurses shouted out. “Isolation room two is complaining of chest pain and shortness of breath.”

  We looked at each other and both rolled up our eyes. Jack said, “Why don’t you help out Cindy and I’ll take care of our friend. She’s on call tonight so I want her to get done with her work so she can catch a few winks before the pain begins.”

  Who was I to argue with that decision? Cindy was just finishing up her notes for the evening when I came by. Even in scrubs and after a 12 hour day she still had a vitality that was infectious.

  “Anything I can help with?”

  “Oh, hey, Raj. Sure, I could use some company for dinner, if you got the time?”

  Gee, that was a hard question. Though I might have blushed. “I’m all yours.” Now I definitely blushed at my stupid response and rushed to try to cover it up. “We better hurry; the cafeteria closes in like five minutes.”

  “I was thinking we could leave the hospital for a bite. The ICU is completely full, so we don’t have much to worry about acutely.”

  I liked what I was hearing, and we were off to a delicious dinner at the gourmet Subway down the street.

  It was nice to chat about topics other than medicine for a while. We covered recent movies, celebrity sightings, hiking trails, and favorite foods. We were just taking our last bites as Cindy’s pager went off. “Good timing, at least we made it through dinner.”

  I couldn’t quite make out the whole conversation she was having due to the traffic noise as we were walking back to the hospital, but it sounded like Jack giving her an update on Jacob.

  “Well, it appears as though your first HIV case just got more interesting. I guess you know that Jack somehow got him to agree to HIV testing, quite impressive how he got that done. Anyhow, he just became febrile with chest pain and shortness of breath. Jack thinks he might have some sort of bacterial sepsis and perhaps pneumonia—not surprising given how low his CD4 count was. The chest pain is probably just from some pleurisy; it got better with IV Toradol and his initial cardiac enzymes were negative.”

  “Why didn’t we catch that earlier?”

  “Well, he probably had a low grade PCP when he was admitted and the steroids that he was placed on to treat his brain swelling caused it to get worse. No big deal, we’ll just start him on some appropriate antibiotics and get a chest x-ray. The chest pain is likely nothing, but given his young age, we’ll stop feeding him and get him a cardiac catheterization tomorrow if his enzymes bump up. The fever is concerning; he must have something active going on for his limited immune system to get all riled up.”

  “Wow, you sure know your AIDS.” Not the best line to use on a girl to express your interest in her. Luckily she wasn’t offended by the comment.

  “We saw a lot of it in New York. What pisses me off is that all this testing costs a ton of money, and Jacob wasn’t the least bit appreciative. Has he been better lately?”

  “Not really, he was pissed off about the HIV results and hasn’t been allowing any of his ‘girlfriends’ to come visit.”

  “He’s just an unhappy person, but, then again, he’s going through a lot.” She didn’t know the half of what he was about to go through, I thought to myself. She continued, “Why don’t you talk to him about our plan of getting blood cultures and treating his pneumonia? I’ll go write the orders.”

  I entered Jacob’s room after donning my cap, gown, gloves, and mask, even more important now that he had a suspected pneumonia. My guess was that he had acquired a MRSA infection either due to an abrasion from falling down in the dirty West Hollywood streets or from the hospital itself, where the bacteria was ubiquitous. While I had hoped that my last patient with MRSA did well, I had no such kind thoughts about Jacob.

  Duane, my last patient with MRSA, was still in the hospital a full three months after he had a terrible MRSA infection and developed a horrific complication from the treatment in which his skin literally peeled off. I hadn’t checked up on him in a while and added it to my list of things to do.

  “Knock knock,” I verbally announced to indicate my presence.

  “What do you want now?” grumbled a voice from under the covers. His tone indicating he didn’t want to be bothered.

  “Hi Jacob, Raj here, remember me from the other day? Jack went home for the night and I just wanted to let you know what the plan was.”

  He removed the cover from his head and I saw that his whole face was glistening with sweat. The monitor beeped and informed me that his temperature was close to 102°F, and his breathing a bit shallow with poor oxygen saturation for somebody who was supposed to be getting better. In a nutshell, Jacob was one sick cookie and about to go downhill fast if we didn’t do something.

  He looked a little paler than when I had last seen him. His hair was matted down with a combination of grease and perspiration. But he still wanted to be anywhere than here. “I’m betting you’re going to steal some more of my blood and tell me I still can’t go home?”

  “If you mean take a sample of your blood for laboratory evaluation in an effort to help you get better, yes.” Not even a vampire would want to suck his blood given all the pathogens having a party in his circulatory system.

  “Whatever man, not like you guys care what I think or want.” He was starting to get under my skin; he still had no appreciation for anybody else other than Jacob. I took a breath and calmed myself; there was no point in letting him get to me. That was his goal after all. I just had to keep reminding myself of that and remain professional.

  “I see you haven’t eaten your dinner. It might be a good idea to eat some of it now because I’m going to have to keep you NPO after midnight tonight. We might have to perform a cardiac catheterization tomorrow morning to make sure your chest pain wasn’t caused by something serious, like a heart attack.”

  “If I wanted to eat my food, I would have eaten it. In fact why don’t you take it with you on your way out?”

  I wanted to remind him that was housekeeping’s job, but I bit my tongue. “Sure, no problem, we’re going to get those blood samples and X-rays, and start you on another couple antibiotics—Vancomycin and Bactrim—they can be toxic to your kidneys so I’m going to increase your IV fluids.” I was very well acquainted with how life threatening Bactrim could be.

  “Yeah, yeah. Also, tell them to stop transferring calls to my room. Just take down the messages and read them to me when you get back.” He buried his head in his sheets, indicating our conversation was over.

  Another deep breath and I left his room carrying out his uneaten dinner tray.

  I touched base with Cindy and since all was quiet we retreated to the lounge to grab a snack and chill out until we were paged. Amazingly there were no pages that night, allowing Cindy to be well rested for the worst morning of her life.

  ~~~~

  Because it was Jack’s day off, Cindy and I were in charge of Jacob. Given we already had a plan that Jack approved of, we didn’t mention anything about him to Clyde on rounds.

  “Dr. Lee, isolation room 2 is complaining of being hungry again.” Announced one of the nurses who saw us nearby working on some orders.

  “Well, his repeat cardiac enzymes were elevated, so he’ll need a cardiac cath today. Do you know when his cath is scheduled for? Wasn’t it supposed to be early this morning?” Cindy asked the nurse.

&nbs
p; “Yeah, it was, but there were three code whites. All three cath labs are open and are running way behind, they had to cancel all routine stuff. The cardiologists reviewed his EKG and because it didn’t have any acute changes he won’t be able to go until sometime early this afternoon.”

  “Raj, would you mind telling him?”

  “No problemo, I’ll notify him about the delay.”

  I entered Jacob’s room to find him sitting up in bed and looking annoyed while furiously surfing through channels. It’s impressive how the hospital affords extended cable service and flat screen HD televisions for ICU patients. Yet that still wasn’t enough to please Jacob. As soon as I entered he barked, “Why the hell are you starving me?!”

  I wanted to counter that he brilliantly refused his meal last night after my advice to eat up. But he did look quite ill last night. In fact, he looked significantly better this morning; much of his color had returned and he was no longer sweating. I figured his improvement in health had reminded him of his empty stomach.

  “Sorry about that, Jacob, there were some emergent cases that required immediate attention and your procedure has been delayed …”

  “So that’s what it is, huh? Skipping over me because you don’t take my symptoms seriously?”

  “That’s not it at all; we take your symptoms very seriously. Hence we got you scheduled immediately.”

  “Harrumph … some immediate. You guys are the worst businessmen; can’t even keep an appointment. If you were my clients I’d fire you.”

  Oh believe me, the whole ICU staff wanted to fire him.

  “Well, we’re in the business of saving lives, and the fact that you’re talking to me and asking for food is a testament to the excellent job we’ve done. Left to your own vices, you’d have died a few nights ago when you partied too hard.”

  “Hey, fuck you, man! You’re just doing your job. Don’t patronize me by pretending you care. Go check how much longer the wait is for my cath. And while you’re at it, tell the nurse I want my bed made and a new hospital gown.”