The pieta.

Abstract

December 1986, my first job after residency. The medical community in Southeast Florida was overwhelmed by an explosive and frightening AIDS epidemic. The first antiviral drug active against HIV, known as AZT, would not be released until the following year. In the 1980s, AIDS was a relentless killer. The average time from diagnosis to death was 8–10 months. Before antiretrovirals, those with advanced AIDS presented with wasting, PCP pneumonia (now known as Pneumocystis jirovecii) and, in some, the disfiguring purple tumors of Kaposi's sarcoma. That evening, I was in the middle of a busy shift when I first saw him, a young man with lumpy violaceous growths across his face. He was painfully thin, and his face was sharp with sunken eyes and temporal wasting. He was small and almost lost in the in the large chair. His vital signs were unstable, but he had refused an IV or a resuscitation room. “I want a closed door” he told the nurse. In those early days of my career, I was quick and blunt. “What do you need?” I said. “I have AIDS. I am near the end and I don't want to die alone,” he whispered. “You are not in a gown,” I observed. “Everyone has to be in a gown.” “I don't want to be in a gown.” “Well how can I examine you? Draw blood, take x-rays?” “I don't want any of that. I just can't be alone tonight.” I started to get angry. “This is an emergency department. If you don't want tests or treatment, why don't you go and be with your friends? Your family?” He looked at the floor. Years later I reflected that it was ironic (and more than a little sad) that someone who did not want to die alone came to a busy urban ED and got me. I felt slightly remorseful. After all, I would soon be going home for Christmas and he was sitting alone staring at the floor, fading. In those days, most people with AIDS were often shunned by friends and family. During the mid-1980’s, the public (and even some doctors) worried that HIV could be transmitted by casual contact. “OK,” I said gruffly. You can stay for now, but you have to be in a gown. Every patient in my ED has to be in a gown.” (Thirty-two years ago, I imagined I could control the chaos by my “rules”—hence, the gown.) Things got busy and for the next several hours, I forgot about the young man. Near the end of my shift, I went back to his room. We needed to make some decisions, either he gets admitted or he goes home. In those insensitive days, I did not always knock before entering a room. When I opened the door, I saw a scene that remains as clear to me now as if only days have passed, rather than decades. A large, roughly dressed older man sat cradling the young man lying across his lap. My insistent gown had become a shroud. The scene mirrored Michelangelo's Pieta, with the older man looking tenderly at the motionless body in his arms. The violet flame of his sarcoma was extinguished in death, and those same stigmata now sparkled with his father's tears. I quietly closed the door and left. I never spoke to the father, ashamed I had not shown more compassion to his son. I turned over my patients to the oncoming physician and went home. Thirty years later, growing grayer (and thankfully kinder), I still think of that tableau. Emergency medicine grinds down even the most optimistic of us. Between the assaults, shootings, child abuse, self-destructive behavior, and other daily cruelties, we struggle to remain hopeful. But sometimes, in a quiet room, we see examples of humanity that restore us. Then we go home and hug our loved ones just a little bit tighter, for just a little bit longer.