The Great Valerio

The HIV gosling improved at first, but for the past four days his white blood cell count’s been dropping and he’s now neutropenic.

His breathing’s slowly worsened also. A blood gas today finds he’s developed a methemoglobinemia. This is certainly from the trimethoprim/sulfamethoxazole we’re using to treat his Pneumocystis pneumonia. I suspect it’s also causing his neutropenia. Unfortunately, it’s one of the few drugs that will treat his infection. There’s a few other drugs I can try, but when I see his X-ray, I’m less enthusiastic.

His X-ray looks like shit. I suspect his initial improvement was from the steroids and not the antibiotics. Pneumocystis, if you’ll recall, kills about 20% of people who get it. If you change antibiotics because of their side effects, it doesn’t change survival rates. But if you change them because of a treatment failure, his odds of dying increase to somewhere between 75 and 100%. And his X-ray looks like a treatment failure.


Explaining things are looking bad without removing hope is, as far as I can tell, an impossible tightrope act. Each family has their own length of despair, their own thickness of denial, and you have no idea what kind of rope you’re dealing with until you’ve lost your balance.

‘You’re always giving me such fucking horrible news,’ the gosling says to me, angrily, ‘can’t you even give me one good thi—’ but he’s coughing too badly to finish his sentence.

‘Your kidneys are doing okay,’ I offer.

‘Oh, well, that’s something,’ one of the younger geese says, ‘isn’t it?’

She’s ignored by the others, who are, in their usual manner, trying to stare me down.

‘I think we need to discuss what you’d want done if things continue to get worse,’ I say.

‘No, Doctor, we don’t,’ says one of the older geese, I think it’s the one named Sheri, ‘because what’s making him sick is your pessimistic attitude. My brother’s going to get better and just because one drug didn’t work doesn’t mean that the next one won’t.’

I don’t say anything for a moment. I don't want a rapid back and forth. I allow silence to serve as a pressure valve to dissipate some of her anger.

‘I hope you’re right and he responds,’ I say, slowly, ‘but if—god forbid—he doesn’t, I don’t want you to have to make decisions in the heat of the moment. I’d like you to be able to talk about things.’

‘Doctor,’ another of the geese says, in a way that John Grisham would probably describe as steely, ‘he’s going to get better.’

I run a quick algorithm of the different possible conversations that could follow from this point. None of them lead to a good outcome. Sheri and the other geese are too powerless. Unable to hate God, I have become their enemy. They need a small victory, so I acquiesce and give them some control over the situation: I ask them if it’s okay to start the new antibiotic. I spell the name so they can look it up on the internet later. They give me permission to start it.


At the nurses’ station, I’m calling the ID fellow and asking her to see the patient, while trying to figure out how I can salvage some therapeutic relationship with this family.

I continue to think about their flightless form into the late afternoon when I run into the ID fellow. She tells me she was thrown out of the room entirely and the geese were refusing to let her come back.