I was doing a cheeky locum shift today. The NHS has made lots of junior doctors unemployed in the UK, in order to save money. This has resulted in there not being enough junior doctors left to staff hospitals. So they hire existing staff to work locum shifts, at extortionate rates. This makes it more expensive to staff the hospital at any given time than it was when there were more doctors. This is the National Health Service for you. You're best not to question it. Thinking about it can actually make you blind.
Anyway, I was in A+E seeing a toddler. He was pretty well. Very mild ear infection, but happy, smiling and alert. Feeding well. I took a history and examined the child. Aside from his red eardrum, he had some unusual findings. Swollen, non-tender glands all over his body. His spleen was slightly enlarged. It could be argued that this may simply be part of a viral illness, but I was suspicious. His dad had been an asylum seeker from Sub-saharan Africa. Mum was caucasian, born and bred locally. They met 3 years ago, got married quickly, and had a baby.
They had told me initially that they were both in good health. I asked again. "and you're both completely healthy?"..."Yes", they replied in unison."Neither of you have ANY medical conditions, then?". They glanced sideways at each other, and dad said "No". I don't know why I pushed it, but I did...."So, neither of you are on any medication?". Dad said "No". Mum hesitated, and said "well, actually, I'm on medication for HIV". Dad looked angrily at her. Not because he didn't know, but because they don't like telling people.
The three of us had a chat about it. Mum didn't get tested for HIV during her pregnancy. She had a normal delivery. She doesn't know if she was HIV positive when the baby was born. Her own consultant says she probably was. If she was, and it was known about, she would have had a caesarian section, and intravenous drugs during delivery. This would reduce the risk of passing the disease onto the baby from about 25% to 1% or less.
She had become seriously ill about a year ago, was admitted to hospital, and was diagnosed as being HIV positive. Dad also has the disease.
I told them that swollen glands and an enlarged spleen can be a sign of HIV. I told the child's parents that we should probably test him for the virus. They had been asked to bring the baby for tests after mum was diagnosed, but they never did. I spoke to the infectious diseases consultant, who happened to be in the hospital today. She kindly agreed to see them in clinic, for proper pre-test counselling, and we allowed them home until monday.
What struck me was that these people were willing to keep their HIV status a secret from the doctor who was treating their child. They must have known that he could also have the virus. But the stigma was greater than that. Think about that for a minute.Imagine having a disease, that you may have passed onto your child. But you feel you can't even tell the doctor who's looking after the little one, in case he judges you. I would like to think I don't judge people, regardless of their illness. But maybe I do. Maybe I touch them less. Maybe I take less blood tests than I do on the other kids. I don't know.
I'd also be interested in why people think there's still such a stigma surrounding this disease. I've known of children who were diagnosed in hospital, but have never told their GP. They sometimes don't allow the hospital doctors to write to their local surgery.
I understand people wanting to hide the diagnosis from their neighbours and work colleagues. Possibly even their family. But, why do people hide their most significant illness from those looking after their medical needs?
Maybe, as doctors, we're not as good at being non-judgmental as we'd like to think. Do we treat HIV positive people different to our other patients? Do we assume they're drug abusers? Do we make assumption about their sexuality? I don't know. I do know that this consultation will make me take a long look at how I act around these people.
I used to work in Africa, where people were sometimes literally disowned, or banished from their homes if they were found to have HIV. I have to say I've no idea what they go through over here. I always though we were more civilised than that. But in Africa, nobody was afraid to tell the doctor of their diagnosis.
Now that HIV has become more of a chronic illness, maybe things will change. On second thoughts, when I see how society treats those with other long-term illnesses, I'm not so sure. I do know that we can't expect affected patients to feel at ease in society if we can't make them feel at ease in our hospitals.
On a lighter note.......
I saw a kid today who was referred to me by a very sensible local GP. He thought the child had Henoch-schonlein purpura, which is a vascular condition that often presents with a rash on the legs.
Anyway, at first glance I thought he was right (he usually is). But on closer inspection, I started to have my doubts. This was, in fact, hand foot and mouth disease, although a slightty atypical presentation. I told mum. She started to cry. I wondered why, as she'd initally been convinced the rash meant her kid has meningitis. I thought she'd be relieved by the fact that her little boy had a self limiting viral infection of the skin.
"Will we be on the news?", she sobbed.
Ahhhhhh, I see what's happened here.
"are you thinking of foot and mouth disease?" I asked. "like the cows have in Surrey".
She was. I cleared up the matter, and we had a chuckle about it.
"No incinerator for you, Timmy*" I joked. Timmy loked up at me, confused, and continued chewing on our opthalmoscope.
All's well that ends well.
*As is always the case in this blog, I have used a false name.