Wednesday, April 1, 2009

The Prisoner

I have been completely obsessed, in my head.  I was listening to a lecture in chest conference yesterday, about tuberculosis.  The speaker was a beautiful pulmonology fellow (or possibly new attending) from India.  I love listening to lecturers from India -- sometimes their lilting voice lulls me into a parallel universe.  They sing our language, in a beautiful way that is probably only a tiny fraction of how wonderful they sound in their native tongue.  

Here is some of what I learned:  mycobacterium tuberculosis inhabits one of three humans worldwide (WHO 2007).  It is an international epidemic, mostly in underdeveloped countries.  So widespread that massive efforts have been instituted in attempt to eradicate this bug.  We don't see it so much in the U.S., but it is pervasive enough that we perform acid-fast stains on many lung biopsies, stains specially designed to penetrate their lipid shell and highlight their miniscule rod-shaped bodies a bright cherry red in a background of cerulean blue counterstain.  We hunt and peck through the microscope for the sometimes dearth of organisms that requires careful screening on high power, all the while adjusting the focus in and out.

Once I became extremely paranoid that I was missing an organism, a needle in a haystack, since I had searched the lung tissue twice and couldn't find anything.  This person had a history of infection, so I was extra worried I was missing something, and passed it onto a senior partner for his inspection.  He said, "Why don't you perform a fluorescent?"  

I asked, "What is that?"  

A fluorescent stain is much easier to read -- looking for a bright white organism against a black background.  We had never done those in our training.  Mine came back positive, just two or three organisms, but enough to make me self-flagellate and re-screen the acid fast (the gold standard stain) for twenty minutes.  I found one organism -- one that was easy to lose even while focusing up and down between my carefully placed dots with a marker.  I was mortified.  I showed it to my consultant, full of chagrin.  "It was there.  I missed it."

He smiled at me compassionately.  "Gizabeth, I never would have seen that in a million years."

In order to facilitate eradication, a policy called directly observed therapy (DOT) has been instituted worldwide.  The Indian doctor was discussing this, and mentioned in passing a case where DOT had failed her.  A prisoner, diagnosed with TB and treated, had his symptoms return in a few months.  The guards were watching him take the meds - he should have been staying in remission.  Everyone was stymied.  Turns out, he was pocketing the pills in his cheek.

I have been obsessed with this guy - for the past 24 plus hours.  One thing I have learned about obsessions - write about them, talk about them, they will go away.  Leave them secret, and they will grow and fester like an open wound.  I've been thinking about him - going to sleep, in my car, on the treadmill.  Not so much what he looks like, or why he was in prison, or even how old he is.  I much prefer him as a blank slate.  Better to climb inside and try to deduce his motivations.  That is my real obsession.

Why would someone in a prison cell pocket his medication for TB?  Surely he was told of his diagnosis and knew the meds would make him better - make his lung symptoms disappear.  The cough, the night sweats, the shortness of breath, the bloody expectorants.  From what I understood, he had been treated enough to go into remission, then started pocketing furtively for three months until he once again had full-blown TB, the kind that rendered men in the early 20th century to be banished to sanatoriums to die, before the advent of medications, within six months to a year.  He allowed the necrotizing granulomas that we see under the scope, the hallmark of the disease, to take over his lungs.

Was he psychotic?  That would certainly explain it.  Many psychiatric patients pocket their meds - he may have thought that he was being poisoned.  Maybe he was exerting the only semblance of control that he could create in his imprisoned state, even if the ultimate outcome was self-abuse.  Did he enjoy slowly experiencing the advent of his symptoms, day by day, charting their progression internally?  Was it attention-seeking?  Did he think that if he got sick enough he might be transferred to a health facility where he would experience a much needed change of environment and personnel?

Or maybe his motivation was artistic.  Many pills are coated with dyed material that could be used for art.  Crush, add water, and voila.  A medium.  Probably hard to come by, in a prison cell.  Alternately, he could be a mathematician, interested in higher theory, which requires a visual aid in order to advance thought.  Pills, beans, what's the difference?

As the Indian tied down her lecture, advancing a couple of new techniques that may render the painful subcutaneous TB skin test we receive yearly as hospital employees obsolete, I was thankful that I was in a developed country, where we have few cases of TB.  The highly drug resistant strains, ones so prominently displayed on exhibitionist news networks, had not even hit Arkansas, according to the maps.  The few reported cases skirted the outside of the US - countries receiving the most immigrants.  Hopefully, when she learned the prisoner was pocketing his pills, she was able to convince him the folly of his ways.  Unless he had given up.  The last motivation -- the lack thereof.  Perhaps he had his ticket out, and he was taking it slowly but surely.






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