"Please tell me the test ain't right"

Medicine can be tough. Really tough.

I've had to do things on this internal medicine rotation that I didn't want to do. Not because it's uncomfortable or because I thought I wasn't qualified, but because I didn't want to be the one to tell my patients the bad news. As paradoxical as it seems for a doctor, I want all my patients to come in healthy. I don't want to have anything to treat. I don't want to give them terrible diagnoses that we can only "manage" and MAYBE "cure."

My FIRST patient that I saw on this rotation had some suspicious lymph nodes in his belly. We did a biopsy, and I was the one to tell him the news...he had lymphoma.

That was tough, but not as tough as today.

I first saw her a few days ago. On getting her story and presenting the case, it seemed pretty straightforward. 56 year old female, shortness of breath, swelling in the legs, crackles and S3 heart sound on exam, all led to the diagnosis of heart failure. Heart failure is one of the most common conditions you see in the hospital. Straightforward, except not in this case. They were all little things. These little things that didn't quite add up. A chest xray that didn't look quite right. A strange bacteria causing a UTI. An anemia that wasn't fully explained by a folate deficiency. A gamma gap. A patient that seemed just a little too thin. My attending said, "Why don't we get an HIV test on her?"

She didn't seem to have many risk factors. Just a sweet 56yo women who didn't drink, smoke, use drugs and was just trying to raise her children and grandchildren right. Not currently sexually active but always used condoms. "Always?" I asked. "Always."

I was the one who went in and got her consent. My first time asking a patient's consent for an HIV test. I was nervous, and probably made it seem more serious than it was. I sat down beside her and told her that we would like to get an HIV test "to make sure that it wasn't part of what was causing her symptoms" and that "most people in the hospital get it" and "it's good to know your status." She responded like I had given her a heart attack by just mentioning the word "HIV." My attending went back with me later to explain how everyone should get an HIV test as it is recommended by the CDC. At that point, my patient was much calmer, saying, with a smile, that I had just scared her because I seemed so serious. At the time, I thought it was a good lesson about asking for HIV testing consent. Don't act like it's the end of the world, discuss the CDC recommendations, etc...

The HIV test was taking longer than expected to come back. "Maybe they didn't process it because of the holiday weekend," we thought, we hoped. When an HIV test takes longer to come back it generally means it was positive on the initial test and the extra time is because they are doing a confirmatory test (a Western Blot).

I called the lab today, she said she would call me back. I returned her call as soon as I felt my pager buzzing. "That patient you were asking about? They're doing the western blot." My heart sank. I felt a lump in my throat. My first thought was "please let the western blot be negative." Later that afternoon, I was telling my attending about the western blot and the phone rang. It was the lab. The test was positive.

We went in to tell her together. Closed the door behind us. Pulled the curtain dividing her and her roommate  We sat down on the bed. My attending says "We have something to tell you. The HIV test came back. It was positive." My patient balled her hands into fists and threw her arms over her face. A look of shock came over her. Tears streamed down her cheeks. She kept repeating over and over, pleading with us "Please tell me the test ain't right?" I so wished that is what I could have told her. I wanted to tell her more than anything that the test wasn't right. She was fine. She didn't have HIV. She could go back to her normal life taking care of those grandbabies she loved so much not worrying about the word HIV ever again. But I couldn't tell her that. Yes, HIV isn't the disease it used to be. Yes, it's no longer a death sentence. Yes, it's treatable. Yes, you can live longer. Yes, the stigma is less, BUT the stigma is still there. All these things don't make hearing you are HIV positive any easier. I sat there with her for over an hour, just holding her hand and telling her all these reassuring things that didn't even reassure me. Before I left, I hugged her as tight as I could, somehow trying to make it better.

Her life is forever changed, and I'm part of the team that changed it. Not for the good. There is a silver lining. Finding out now means she is starting treatment earlier. She has a better chance. But right now, it's hard to see that silver lining. Right now it just feels very dark.