Ms. P did not enjoy running. Her two toddlers and their feisty “Cat” the cat didn’t give her much choice in the matter. All three were committed to getting into trouble. That morning, one of the three had made a mess at breakfast, and she missed the bus. She was almost back to her jolly self that evening when she walked into a free community clinic. She had no medical conditions and was only here for a checkup. She was happy to let two med students tag-team a simple blood pressure. Though I was only a few weeks into medical school, I had taken a few hundred as an EMT, and was now teaching another student. His gloves trembled with uncertainty. “160/155.” I put my finger on Ms. P’s wrist to verify the systolic.
Ms. P looked uncomfortable. “Shouldn’t you be wearing gloves?” “I can, but it’s safe,” I replied. She began to cry, “No, no, I have bad blood – I’m so sorry.” She was HIV+ and had forgotten her meds with the morning rush. She had come in to reassure herself that she was safe, but was now feeling guilty that she had exposed us. I tried to verbally reassure her. Even if she hadn’t been on a powerful combination of antiviral drugs stopping the virus from reproducing, it was impossible to get infected from touching her wrist.
For a split second, however, I had a doubt. She said something akin to “I think you have it now,” but what I heard was “You will die a slow and painful death” like the two loved ones I’d lost to the same virus as a child. I looked down, but I did not see the kind and joyful mother of two toddlers and Cat. I don’t think I even saw an arm. In that fleeting, regrettable, irrational, and inevitable moment, I felt a threat.
It is a distinctive, visceral uneasiness. The perception that a patient may present a threat has time and time again led to discrimination, stigma, and substandard care for patients with infectious conditions. People with HIV, especially, were neglected and abandoned by the medical system in droves. But it goes beyond that. I recently witnessed an entire team of nurses refuse to lend care to a patient with bed bugs. In retrospect, I think they feared bringing it home and spreading it to their children and communities. Underneath the disgust and the jokes they expressed, I recognized fear.
As an EMT, I grew accustomed to that sensation. I dodged blood, mucus, and unattached body parts in houses, alleyways, and street corners. I had no idea who had what, so I had to assume that every drop of blood had everything. I was trained to ensure “scene safety” and don PPE before even looking for a patient. In med school (especially as someone interested in anesthesiology), I have been reconditioned to start my patient encounters with the “ABCs” – or “Does this patient have a patent airway?” To be sure, hospitals and clinics tend to be safe environments, and donning PPE is standard procedure before starting an encounter. Even viruses, originally defined by their ability to sneak through filters, are held back by our N95s. But those masks cannot filter out fear.
We are evolutionarily predisposed to scan our environment for threats – and protect ourselves accordingly. Our self preservation instinct responds to perceived threats, like an invisible virus bent on using our organs as disposable copy machines, poisoning our lungs, our mind, and ultimately, our compassion for our patients. That night in the clinic, I almost let it come between me and Ms. P.
The all-too-familiar feeling of danger kicked in. I tried to remember whether HIV was +ssRNA or not, enveloped or not, helical or not – and whether that meant skin-to-skin transmission. Somewhere in that search, I found my old training and just thought “scene safety.” I was able to take a second and rationally think through the exposure risk. It was negligible. I was safe. It was only then that I was able to see Ms. P, still sitting in front of me. Here was this wonderful human being who lived unduly terrified of her own blood. I assume a well-intentioned provider had scared her into adherence, making her think that even one missed pill could make her hurt the people around her. But what she as a patient and as a human needed was compassion. I was able to take her hand and tell her the truth she needed to hear, “You’re okay. We’re safe.”
We all strive to provide compassionate care to every patient. In a pandemic with incalculable asymptomatic carriers and healthcare workers dying from the virus, it is difficult not to perceive every person as a threat. This thought inevitably jeopardizes our ability to be empathetic providers as we put physical and emotional barriers between ourselves and our patients. But that fear, caused by an instinctive drive towards self-preservation, can instead be harnessed to ensure we take the necessary precautions and do no harm – to ourselves or our patients. All it takes is an intentional, deliberate assessment – when you ask yourself “Am I safe?” make sure that you can hear it, and answer.
Jay Garcia is an MS3 at the Perelman School of Medicine. Jay can be reached by email at [email protected].
