The patient on the service has AIDS. A new diagnosis of AIDS. No HIV, no careful months of monitoring viral loads and CD4 counts – and when the CD4 counts reach the level where opportunistic infections become more likely antiviral medications are started… and more careful monitoring… just AIDS. And an infection that is an AIDS defining illness – one that means your immune system is compromised and cannot fight something off that a normal immune system would fight off easily.

The patient looks like they have had a hard life. They act like they have had a hard life. When they don’t like what you say, they meet you with stony silence. They don’t have the boundaries of proper society, they get angry and become overally abrasive. They blame the medical establishment for not listening to them. They have a history of leaving the hospital against medical advice.

But the thing that breaks your heart is the questions they ask in those honest moments where they are vulnerable and desperate. Can’t you just order dialysis and cure them? They heard that worked. Or how about just removing all of my blood? And it’s clear that they never had the chance that you did in life and you’re standing there in your nice clothes, brain full of education, and a support system there behind you… and you just feel like all the chances you had in life they never had weren’t really fair but isn’t that just how life is?

You know you’ll go home, and cry like you do over these conversation you hear. It’s not the first time, and certainly not the last. Wolfie will come running over, concerned, and lick your entire face over, with special attention to that spot at the corner of your eye where the hot tears come from – and you’ll never feel those tears turn cold because a poodle licks them up to fast. And it doesn’t matter to Wolfie when you begin to sob about the injustice of it all – his tear roundup service is always ready.

Then a few days later when the patient’s family member begins to ask about using herbal treatments, special diets and you watch the attending patiently explain that they won’t cure HIV or AIDS. You watch the group of attending, resident, students walk away – and see the family member wipe tears away. You feel unsettled, because you know this situation repeats over and over again.

Everyone wants to know outcomes – what will happen to this patient? It depends – but the biggest barrier for these types of patients will be themselves and the rough tough exterior they have used to get them where they are. Hope for the best.