Jackson’s blood pressure was low, and this had the emergency room physician scrambling, barking orders.  A nurse was busy at each arm, attempting to place large-bore IV’s so that fluids could be given rapidly and thus improve the low blood pressure.  Other nurses were preparing strong antibiotics for immediate administration.  An automated blood pressure cuff was attached to the left arm, inflating every 3-4 minutes with a characteristic grinding sound.  Monitoring leads attached to Jackson’s chest gave real-time information regarding the heart rate and rhythm.  This was emergency room chaos of the organized type that happens when young people with advanced AIDS become gravely ill.  Without an effectively functioning immune system, these patients can succumb quickly to infection.  Under the bright lights of the ER, medical personnel were expertly trying to save Jackson’s young life.  Another day in the county ER.

While this was going on, I reviewed Jackson’s electronic medical record.  He had a disastrous medical history, due to a combination of noncompliance with his prescribed HIV medications and excellent compliance with his methamphetamine habit.  Here was one more irresponsible patient rotating through the county hospital, failing to take care of himself, and asking to be rescued when the inevitability of disease strikes.  These are avoidable strains on the health care system.  Over time, these types of cases stack up like an oppressive weight on one’s empathy, threatening to obliterate it.  But the sequence of life events that precipitate these moments can be powerfully influential, reminding us that, in matters of human behavior, things are not always straightforward.

The second child of a health care worker (mom) and a counselor at a private high school (dad), Jackson had a happy upbringing.  Although he did not formally announce it, by high school everyone knew that he was gay.  Jackson was not ashamed of this; his only regret was that he fit too closely society’s stereotype of being gay. For as long as he could remember, Jackson had a strong effeminate side.  As a child, he loved to put on an over-sized, flowing t shirt and spin around like a dancer to his favorite song on the stereo. Later, when he was a straight A student in school, he always asked for a My Little Pony when his parents offered a gift for his excellent grades.

Upon graduation from high school, Jackson worked as a waiter in a restaurant while pursuing his dream of being a photographer.  He was in a stable relationship with a man, and his family had fully accepted his sexual orientation.  His life was unfolding nicely until one fateful night when he decided to attend a party being thrown by a friend.  As it happened, Jackson’s boyfriend had planned on meeting him there after work.   Needing a ride, Jackson carpooled with a friend, and he figured since his boyfriend would be driving him home, he could drink some beer.  But he drank way too much, leaving him stumbling drunk and sick.  His boyfriend called; he couldn’t make it because his car wouldn’t start. The host of the party, recognizing Jackson’s sad state, directed him to the basement, where he promptly passed out on a couch.

At some point, Jackson woke up to find a man pulling off his underwear.  Before he could comprehend what was happening, the man was raping him.  He tried pushing the man off, but Jackson was too drunk and the man was too strong to dislodge him.  And then as suddenly as it started, it was over and the man was gone, leaving Jackson trembling with fear.  The rape was Jackson’s first real sexual encounter, and the damage inflicted by that violent event would resonate for years to come.  For one year later, during a routine medical examination, Jackson discovered that he was HIV positive.  When his boyfriend’s results came back negative, Jackson knew the only possible source of the infection was the man who raped him.  In almost inexorable fashion, his life began to unwind.

Within a month, his boyfriend had broken up with him.  Jackson was devastated; this was his first true love.  Feelings of worthlessness and fear, fear that no one would ever want an HIV-positive partner, washed over him.  He would die a lonely death, he was certain. His decline was dramatic, and Jackson had trouble completing even the simplest of tasks, such as taking a shower or washing his clothes.  He became desperate for help and in this most vulnerable of moments, someone suggested that he try a great pick-me-up:  methamphetamine.  And he was right! Smoking meth brought magical relief of his depression, and the effect lasted for hours.

Initially, he used meth only on those days he felt particularly down.  But then he discovered that there was a let-down effect the day after, so he started smoking on those days too. Within six months, smoking meth had become a regular part of his daily routine; it was his morning energy jolt, like coffee, but way better.  And so it went for the next nine years.  In typical addict behavior, his days developed a structure around the procurement and use of this highly damaging drug. He began hanging out with meth abusers, otherwise known as tweakers.

As Jackson’s drug use escalated, his sense of self-responsibility unraveled.  He stopped taking his HIV medications, which were effectively controlling the disease, and stopped attending his doctor appointments.  And Jackson engaged in impossibly irresponsible, unprotected sexual activity, and in the process, he contracted multiple sexually transmitted diseases, including chlamydia, gonorrhea, syphilis and an unusual low grade malignancy called Kaposi’s sarcoma.  This latter condition causes unsightly purplish lesions on the skin, and since it occurs primarily in HIV positive men, it serves as a scarlet letter of sorts.

Now in emotional freefall, Jackson stopped working and moved in with a new boyfriend, who supported him financially.  Together with other members of the underbelly of societal parasitism and personal irresponsibility, they smoked meth daily.  Jackson’s typical day consisted of waking up around 11:30 am, hitting the meth pipe around noon, watching television during the afternoon or going to hang out at the house of one of his tweaker friends, then preparing dinner for his boyfriend each evening.  On some days, he allowed himself a “touch-up” meth hit late in the afternoon.  By this time, he had advanced AIDS.

Then one day, Jackson woke up with a headache.  He didn’t pay much attention to it, telling his boyfriend, “Must have been the alcohol from last night”.  By the afternoon, the headache had worsened, he felt feverish and his neck was really sore.  When he sat down for dinner, he felt lightheaded and then promptly vomited.  His boyfriend noticed that Jackson seemed confused and insisted on bringing him to the ER, where I was called to admit him to the hospital.

Jackson was sweating profusely when I walked in on the activity surrounding him in the ER.  The bright fluorescent lights of the ER made his face look particularly pale.  He was agitated and confused, arguing with the nurses trying to place IV’s in his arms.  His long brown hair was soaking wet and his nonsensical words tumbled across rotten teeth, a typical consequence of long-term meth use.  His face was gaunt and his body thin, which was not surprising given the appetite-suppressing effects of meth.  Most concerning, his neck was rigid like a board.  It was clear that Jackson had meningitis, a serious infection of the membranes that cover the brain and spine.  The spinal tap confirmed the diagnosis, and Jackson was started on multiple antibiotics and admitted to the ICU.

Jackson was not expected to survive.  He had a poor immune system due to his advanced AIDS and the infection, pneumococcus, was a dangerous one.  When informed of the prognosis, his mother simply shook her head, as if to say, “I expected this”.  Jackson remained in the ICU for 11 days, receiving antibiotics, steroids, special medications to support his blood pressure, feedings through a tube placed into his stomach, and for several days, ventilator support to protect him from pneumonia.  To everyone’s surprise and relief, Jackson recovered completely.

Once stabilized and now in the regular medical unit recovering, we worked hard to arrange for various resources for Jackson, including outpatient drug treatment, HIV clinic appointments, HIV medications, eye appointments, immunizations, and referrals for psychotherapy.  One of our staff psychiatrists, a brilliant and pragmatic physician known for her ability to connect with patients, spent numerous hours with Jackson.  She was concerned about his emotional disconnection and apparent lack of insight into the genesis of his current predicament.

Lack of insight is problematic when a physician is working to modify a patient’s self-destructive behavior.  Attempts to really connect with Jackson on a deep emotional level were onerous and largely unsuccessful.  His blunted affect thwarted and frustrated us in our efforts to reach him.  The violence and tragedy of the rape had inflicted a deep psychological wound and the methamphetamine had destroyed his soul, leaving a vacuous robot of a man.  The remnant was a man devoid of an accurate, honest self-appraisal and the ability to understand that.  And I think it was my inability to connect emotionally with this man that left me with the unsettling feeling of wanting and needing to feel real empathy for him, but in the end the empathy experienced was mostly intellectual.  I thought empathy, but barely felt it.  In the end, I was left with the genuine hope that the gravity of his recent medical illness combined with ongoing outpatient psychotherapy and sobriety would provide the impetus for change.  A fool’s heart, perhaps.

There were lots of hugs and thank you’s and promises the day Jackson was discharged from the hospital.  He had 3 scheduled appointments within 2 weeks of leaving the hospital.  He did not go to any of those.  I called the pharmacy a month later, and they confirmed that Jackson had not picked up any of his medications.  I called his cell phone; it was disconnected.  A subsequent conversation with his mother confirmed my worst fear:  Jackson had resumed his meth use.

Jackson will be back, in one form or another.  Sadly, that is part of the inevitability of AIDS, especially in the presence of addiction.  We will be here, of course, to help him.

“The American Doctor” is a physician who blogs at his self-titled site, The American Doctor.

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