WEBVTT 00:01.737 --> 00:46.878 [music] 00:47.188 --> 00:51.869 -What I plan to do is just to give you a few of the statistics. 00:52.020 --> 00:53.849 I don't want to belabor the statistics. 00:53.850 --> 00:56.729 You've all read the newspapers and The Time, and Newsweek articles, 00:56.789 --> 00:57.789 probably. 00:58.109 --> 01:02.790 Then I want to go into the type of persons that are affected by this disease, 01:03.209 --> 01:07.079 and then we will go a little tiny bit into the immune system, 01:07.080 --> 01:10.589 just to give you a background of what is happening, and then go 01:10.590 --> 01:11.609 into the nursing care. 01:12.570 --> 01:15.988 I need to thank CDC for these slides on statistics. 01:15.989 --> 01:17.279 The rest of the slides were prepared 01:17.280 --> 01:19.289 by the Crawford Long Staff Development Department. 01:20.249 --> 01:21.815 I'll show you just a few of the statistics, 01:21.816 --> 01:22.889 just to start off. 01:26.340 --> 01:29.760 Let me start by giving a definition of AIDS. 01:30.239 --> 01:31.949 The CDC definition, 01:32.579 --> 01:37.174 and this definition has to be utilized in order to classify 01:37.175 --> 01:38.272 as a patient with AIDS, 01:38.714 --> 01:42.780 is that the patient must have a reliably diagnosed disease 01:43.140 --> 01:48.299 that indicates cellular immune deficiency such as Kaposi's sarcoma, 01:48.330 --> 01:50.219 Pneumocystis pneumonia, or something like that. 01:51.390 --> 01:54.990 Also absence of other known causes of these diseases. 01:55.170 --> 01:59.308 These two elements must be present in order for the patient to be diagnosed 01:59.309 --> 02:00.309 as having AIDS. 02:00.599 --> 02:03.509 You may have many patients who come in with FUO, 02:03.510 --> 02:05.700 who are not diagnosed as having AIDS. 02:06.240 --> 02:09.538 On the other hand, you may have a lot of patients coming in with FUO, 02:09.539 --> 02:12.598 and just because of what you know about these people, 02:12.599 --> 02:15.090 you may automatically assume they have AIDS. 02:15.929 --> 02:17.430 I'm going to speak to that later. 02:17.699 --> 02:19.678 We are tending to put people in categories, 02:19.679 --> 02:21.808 and it tends to hamper our nursing care. 02:21.960 --> 02:23.080 I'll speak about that later. 02:26.010 --> 02:33.208 This is also a slide from CDC speaking to the reported cases through March of 83. 02:33.209 --> 02:35.220 You see, we started out with very, very few, 02:35.760 --> 02:37.949 and it has increased significantly. 02:39.990 --> 02:42.959 I do not have the statistics on this slide for-- 02:42.960 --> 02:46.019 I got this slide in early August, so that's a little bit outdated. 02:46.311 --> 02:47.399 We are up into-- 02:48.089 --> 02:51.688 Through August, we had another 360 cases. 02:51.689 --> 03:00.062 This past month, there were 287 cases, to make a total of 2,259 people 03:00.180 --> 03:01.409 have had AIDS. 03:02.010 --> 03:07.466 Of that, 48% of the patients have been diagnosed in 1983 alone. 03:08.155 --> 03:10.376 We are seeing a great increase, 03:10.377 --> 03:13.859 and I think we have just seen the beginning. 03:13.920 --> 03:16.230 We have seen the tip of the iceberg, so to speak. 03:16.979 --> 03:18.840 That's on the last slide, I'll show you. 03:19.589 --> 03:20.700 As we go along, 03:21.240 --> 03:24.360 how many more people are coming along and being diagnosed as having AIDS? 03:25.530 --> 03:29.249 Of these patients, 41% have died, 03:30.960 --> 03:34.380 so we're dealing with a devastating illness, 03:34.800 --> 03:37.890 and it's devastating not only in the mortality, 03:38.099 --> 03:39.990 but in what it does to the patient. 03:40.530 --> 03:42.479 It's very difficult to work with this patient, 03:42.480 --> 03:47.459 especially during the last few days, because many of these people are alert 03:47.520 --> 03:50.009 and oriented up until the last few moments. 03:51.929 --> 03:53.789 This shows you just demographically, 03:54.659 --> 03:58.139 what states we have found, where patients have AIDS, 03:58.170 --> 04:00.778 and you see that almost every state in the United States has had 04:00.779 --> 04:01.779 at least one patient. 04:02.070 --> 04:05.608 Again, this has been updated, and I believe we have a patient 04:05.609 --> 04:06.609 in Mississippi. 04:07.799 --> 04:09.659 Somebody's been diagnosed in Mississippi 04:11.700 --> 04:13.140 and Utah, I believe. 04:13.949 --> 04:15.779 It's being updated all the time. 04:15.989 --> 04:19.259 One of the things that's frustrating about presenting something about AIDS is 04:19.260 --> 04:21.838 that we are finding out so much, so fast, 04:22.241 --> 04:24.588 that I'm trying to give you as current information 04:24.589 --> 04:27.300 as I have, but tonight, we'll probably find out something new. 04:27.870 --> 04:30.689 I think you need to realize that as healthcare providers, 04:31.379 --> 04:35.788 things are changing, and the only way to care for these patients is to keep up 04:35.789 --> 04:36.789 to date. 04:37.500 --> 04:40.198 Things change all the time, so some of my information 04:40.199 --> 04:41.369 may be even outdated. 04:41.962 --> 04:44.817 I've studied up until the last couple of days, 04:44.818 --> 04:46.059 but it may be outdated already. 04:48.479 --> 04:51.510 The risk groups that are being divided, it's interesting. 04:51.576 --> 04:52.739 This slide was-- 04:53.040 --> 04:55.470 Again, I got it in August from CDC. 04:56.790 --> 05:03.178 The percentage of cases are homosexual, bisexual men are 71%, IV drug users, 17%, 05:03.179 --> 05:06.509 and the statistics in the latest MMWR, which is The Morbidity 05:06.510 --> 05:11.730 and Mortality Weekly Report from the CDC, agree with these two percentages, again. 05:12.719 --> 05:17.850 The last MMWR did not include Haitians as a separate group. 05:19.320 --> 05:23.849 What they said is that we are having so much political problems with that, 05:24.269 --> 05:27.839 that Haitians are probably in some of the other groups also. 05:27.840 --> 05:35.039 5%, actually 7%, now, of the people with AIDS, have been Haitians, 05:35.340 --> 05:38.039 but we are finding out more and more that they do say 05:38.040 --> 05:40.889 they have used drugs in the past, or homosexuality, 05:41.220 --> 05:43.109 because of the taboos of their culture. 05:43.350 --> 05:48.270 The Haitians in the past have not admitted to having had homosexual tendencies 05:48.540 --> 05:50.309 or having used drugs. 05:50.817 --> 05:52.487 Hemophiliacs, 0.8%, 05:52.578 --> 05:54.538 and then the rest are no apparent risk group. 05:54.539 --> 05:57.148 Although the more and more we delve into it, 05:57.149 --> 06:02.309 we find that in most of the people, there is some risk involved. 06:02.580 --> 06:04.230 They belong to one of those groups. 06:06.300 --> 06:09.509 Okay, what I want to do, just as a background, is 06:09.510 --> 06:14.729 to quickly go over, and this is very, very brief, go over the immune system. 06:16.230 --> 06:18.630 I've not even included the entire immune system, 06:18.659 --> 06:21.629 because I'm not even speaking to the phagocytic activity or any of that. 06:21.630 --> 06:25.228 I'm just going to speak to the humoral and the T-cell activity 06:25.229 --> 06:26.880 of the immune system. 06:27.539 --> 06:30.959 The B- cells in the humoral part of the component 06:30.960 --> 06:35.550 of the immune system create B-lymphocytes and antibodies. 06:35.670 --> 06:40.978 They simply function to neutralize the antigens to remove the foreign bodies 06:40.979 --> 06:41.979 from the system. 06:42.870 --> 06:48.029 The B-cells are the cells that send out the immune globulins to get rid 06:48.030 --> 06:49.320 of the foreign antibodies. 06:49.980 --> 06:52.949 The cellular level, which is literally that, 06:52.950 --> 06:56.789 it's on the cellular level of the different cells, 06:56.790 --> 06:58.261 is the T-lymphocytes. 06:59.100 --> 07:02.308 What they do is, they are sensitized to recognize and attack 07:02.309 --> 07:03.309 the foreign antigen. 07:04.619 --> 07:06.150 That's exactly what they do. 07:06.659 --> 07:07.659 They regulate 07:08.219 --> 07:09.990 and suppress the cells. 07:10.889 --> 07:13.468 They have two different kinds of T-cells. 07:13.469 --> 07:16.116 I know you've read about the T-cells. 07:16.710 --> 07:20.489 Some of them are suppressor cells, and some of them are helper cells. 07:20.940 --> 07:22.935 The helper cells help the B-cells. 07:23.340 --> 07:27.419 They literally assist the B-cells in destroying the foreign antigens. 07:27.780 --> 07:31.410 The suppressor cells arrest the B cell activity. 07:31.620 --> 07:33.840 What it is, is they create a nice balance. 07:34.680 --> 07:36.089 The normal ratio 07:36.659 --> 07:39.989 of the helper to suppressor cells are two helper cells 07:39.990 --> 07:41.223 to one suppressor cell. 07:42.870 --> 07:45.000 Normally, you have more helper cells, 07:45.839 --> 07:51.089 which help with the humoral activity, or the B cell activity, 07:51.990 --> 07:56.310 and one suppressor cell, which will decrease that stimulation, 07:56.609 --> 07:57.870 and that keeps a balance. 07:58.230 --> 08:01.770 The foreign antigen is removed because of both of those working together. 08:02.340 --> 08:06.000 In the patient with AIDS, that may be totally reversed. 08:06.689 --> 08:08.879 I'll show you a slide later that speaks to that. 08:10.109 --> 08:14.459 The problem is with the T-cell activity, the ratio is changed. 08:19.868 --> 08:25.529 When your immune system is intact, as our immune systems are intact, 08:25.980 --> 08:28.499 the B-cells and the T-cells function adequately. 08:29.086 --> 08:33.899 If we were to be exposed to an opportunistic infection, 08:33.914 --> 08:38.039 such as pneumocystis carinii, which is one of the usual ones, 08:38.730 --> 08:41.390 we would ward off that infection, we wouldn't have 08:41.391 --> 08:42.660 any problem with it at all. 08:43.019 --> 08:45.658 However, if the patient is immunosuppressed, 08:45.659 --> 08:49.890 if there's a problem with a T-cell, B-cell ratio, suppressor cell, 08:49.949 --> 08:54.149 helper cell ratio, then they cannot ward off that problem, 08:54.510 --> 08:57.269 so we'd speak of them as being immunosuppressed. 08:57.510 --> 08:58.859 There's a potential triad. 08:59.250 --> 09:00.549 One of the researchers speaks 09:00.550 --> 09:02.789 to a potential triad of biological sequelae. 09:03.510 --> 09:05.489 You have an immunodeficient state 09:06.750 --> 09:09.540 that may lead to an autoimmune disorder 09:10.259 --> 09:13.170 and it may lead to another neoplastic disorder. 09:13.949 --> 09:16.500 That is often seen in patients with AIDS. 09:16.936 --> 09:22.356 Nobody has said that this is true, that this is actual truth. 09:23.069 --> 09:25.379 When you see the patients that you're dealing with, 09:25.380 --> 09:29.130 you'll realize that almost always, with the immunodeficient state, 09:29.969 --> 09:33.718 that you may have an autoimmune disorder, and often, the lymphoreticular 09:33.719 --> 09:36.026 or neoplastic disorder, such as the Kaposi's sarcoma, 09:36.546 --> 09:41.190 seen with a patient with AIDS, usually, immunosuppression 09:41.836 --> 09:45.120 has a congenital component, which is right in the middle. 09:45.540 --> 09:48.000 All of these things stem from congenital problems. 09:48.539 --> 09:52.978 However, AIDS is just what the name says, it is 09:52.979 --> 09:55.770 an Acquired Immunodeficiency Syndrome. 09:57.341 --> 09:59.639 Here, before, the patient has been healthy, 09:59.909 --> 10:03.869 their immune system has worked correctly, and suddenly, the immune system 10:03.870 --> 10:06.598 is impaired and you have what might be called 10:06.599 --> 10:10.076 as a sick immune system, leading to these possible sequelae, 10:10.586 --> 10:12.986 the immune disorder, and the neoplastic disorder. 10:13.826 --> 10:19.196 Anticipate seeing one or all three of those problems with your patients. 10:22.076 --> 10:24.390 What happens when you're having immunosuppressed patient 10:24.442 --> 10:25.646 is that the patient 10:26.279 --> 10:28.316 can be called a compromised host. 10:29.006 --> 10:34.076 That is simply any person whose resistance to infection is impaired by disease, 10:34.346 --> 10:35.936 or treatment, or both. 10:36.893 --> 10:38.666 We frequently 10:39.896 --> 10:42.056 have patients in hospitals who are compromised hosts 10:42.066 --> 10:43.316 because of the things we do. 10:43.826 --> 10:47.905 They are compromised iatrogenically because we give them steroids, 10:47.906 --> 10:51.595 for example, that's a compromised host just as the AIDS patient is 10:51.596 --> 10:52.596 a compromised host. 10:53.366 --> 10:55.856 That patient cannot resist infection. 10:56.066 --> 10:57.656 The key is, 10:58.166 --> 11:00.625 with a compromised host, they cannot resist infection 11:00.626 --> 11:02.906 because of either disease or the treatment. 11:03.446 --> 11:05.546 We'll see as we go along, with the AIDS patient, 11:05.550 --> 11:06.910 they have the combination of both. 11:07.736 --> 11:11.936 Not only do they have a diseased and impaired immune system, 11:11.966 --> 11:14.726 but with the treatment modalities, cause more problems. 11:17.156 --> 11:20.276 The defects that are present in the compromised host are many. 11:21.656 --> 11:25.225 You may have a decreased number of phagocytes. 11:25.226 --> 11:27.806 Your phagocytic activity is greatly diminished. 11:29.246 --> 11:32.216 You may have a decreased cell-mediated immunity, 11:32.246 --> 11:35.576 and that is the problem with the patient with AIDS. 11:36.596 --> 11:41.276 The cell mediated immunity, again, speaks to the B-cell, T-cell function, 11:41.786 --> 11:43.736 and it's the T-cells that are impaired. 11:44.936 --> 11:46.826 May have faulty antibody production 11:47.396 --> 11:50.516 that may stem from decreased cell-mediated immunity. 11:50.666 --> 11:51.832 They all go hand-in-hand. 11:52.676 --> 11:55.376 You may have a damaged mechanical barrier against infection. 11:56.606 --> 12:00.026 This has been one of the things that has been proposed by the CDC, 12:00.326 --> 12:05.696 that there is some damage in the normal cellular level, 12:06.626 --> 12:10.016 and the normal mechanical barriers, such as in the rectal mucosa. 12:10.496 --> 12:16.616 This is one of the concerns that they have about homosexuality and the lifestyles, 12:16.886 --> 12:20.088 that perhaps it's the damage mechanical barrier 12:20.140 --> 12:21.146 that's causing a problem. 12:22.046 --> 12:26.306 Again, what the major problem is, is a decreased cell-mediated immunity. 12:30.086 --> 12:32.336 When you have a compromised host, two things happen. 12:33.536 --> 12:36.296 You may have opportunistic infection set in 12:37.076 --> 12:39.626 and you may have nosocomial infections. 12:40.616 --> 12:44.516 I'm not going into great detail, I could show how much they both compare. 12:45.116 --> 12:47.156 Many of the opportunistic infections 12:47.666 --> 12:51.236 are caused in the hospital as nosocomial infections. 12:51.836 --> 12:53.546 I'm not going to go into all of that. 12:54.686 --> 12:58.825 Specifically, you need to be aware that opportunistic infections, as I said, 12:58.826 --> 13:02.456 are those that come because the immune system is sick. 13:03.421 --> 13:06.716 We are exposed constantly 13:07.376 --> 13:09.386 to opportunistic infections, 13:09.896 --> 13:11.996 either here in the hospital, or out on the street. 13:13.466 --> 13:15.896 We don't get them because we have normal immune systems. 13:16.646 --> 13:18.326 They are literally opportunistic. 13:18.711 --> 13:23.305 The nosocomial infections I speak to, in that, as hospital workers, 13:23.306 --> 13:25.046 we can prevent some of those things. 13:26.126 --> 13:29.305 They're not just airborne, they're often contact problems, 13:29.306 --> 13:32.126 and problems because of the devices that we use. 13:36.596 --> 13:40.736 Okay, I want to really speak mostly to the nosocomial area, 13:40.766 --> 13:42.865 because that's the place where our nursing care 13:42.866 --> 13:44.276 and prophylaxis comes in. 13:45.566 --> 13:48.296 There are several causes of endogenous transmission, 13:48.476 --> 13:52.886 you may have previous colonization, which simply means that you may have 13:53.006 --> 13:55.826 a latent infection that is suddenly reactivated. 13:56.156 --> 13:59.276 Probably, the most typical example of that is tuberculosis, 13:59.996 --> 14:03.685 that has remained latent for years, and years, and years, and suddenly, 14:03.686 --> 14:08.125 all of the activities are together and the patient has tuberculosis. 14:08.126 --> 14:14.096 Another good example, either Cytomagalo, and the Varicella-Zoster viruses 14:14.546 --> 14:17.966 that the patient has had before, and suddenly, they become active. 14:18.476 --> 14:21.926 Another example of previous colonization is prior exposure. 14:23.096 --> 14:25.285 The patient has not been sick, and yet, 14:25.286 --> 14:28.376 when the immune system diminishes its functioning, 14:28.706 --> 14:33.206 will suddenly develop toxoplasma or pneumocystis. 14:33.681 --> 14:35.408 The P should be the pneumocystis. 14:38.336 --> 14:42.865 Another type of endogenous transmission are those things that comes straight 14:42.866 --> 14:44.036 from the Normal Flora. 14:44.486 --> 14:49.135 From the mechanisms that are present on all of our bodies, 14:49.136 --> 14:50.756 to prevent infection, 14:51.476 --> 14:58.076 such as in surgical wounds, Staph aureus, is a prime example in surgical wounds. 14:58.196 --> 15:03.386 Staph aureus is normal on our skin, but if we have a surgical intervention 15:03.806 --> 15:07.975 and something happens during the surgery, you might get an infection 15:07.976 --> 15:09.054 from Staph aureus. 15:09.326 --> 15:13.406 Another prime example, and this is where we really need to think 15:13.556 --> 15:16.886 of our care in nursing, is IV therapy. 15:17.666 --> 15:22.465 A great cause of nosocomial infections from endogenous transmission 15:22.466 --> 15:26.005 is IV therapy, again, from the Normal Flora on our skin, 15:26.006 --> 15:29.426 the Staph epidermidis is 15:30.176 --> 15:33.326 a good way to get IV-related sepsis. 15:36.176 --> 15:38.936 Exogenous transmission, you see, the very top. 15:39.419 --> 15:43.436 The key here is cross-contamination by hospital personnel. 15:45.506 --> 15:46.591 How do we do that 15:47.059 --> 15:50.456 by contaminated invasive medical devices? 15:52.046 --> 15:55.586 Such anything we do, IV therapy is linked with nursing, 15:55.798 --> 15:59.245 NG tube therapy might be something that causes it, if you have a breakdown 15:59.246 --> 16:00.656 in the mucosal linings, 16:01.826 --> 16:05.665 any type of testing that the patient might be going for, 16:05.666 --> 16:09.037 diagnostic testing, such as colonoscopy, ERCP. 16:10.136 --> 16:13.976 Those types of things. Bronchoscopy is a prime example of how you might 16:14.306 --> 16:18.896 have cross-contamination, how you might cause problems exogenously. 16:21.356 --> 16:24.655 Contaminated medications and IV fluids are pretty low on the list. 16:24.656 --> 16:26.606 We don't usually find that many problems. 16:27.056 --> 16:29.066 Airborne and waterborne infections, 16:29.726 --> 16:31.316 usually, we find that pretty fast. 16:31.676 --> 16:34.346 If we have a patient, say, in an intensive care area, 16:34.676 --> 16:39.116 that ends up with an airborne infection, we're going to check out the others also. 16:39.776 --> 16:43.285 The prime problem here is cross-contamination 16:43.286 --> 16:44.426 by hospital personnel. 16:44.876 --> 16:47.376 The easiest way to fix it is simply hand washing. 16:48.596 --> 16:50.456 Who is this person who's affected? 16:50.576 --> 16:55.196 I think this will help us look really at how we take care of this patient. 16:56.876 --> 16:58.316 In looking at the overall, 16:58.886 --> 17:03.490 the majority of patients afflicted with AIDS are in the 20s to 40s. 17:05.036 --> 17:06.926 We're speaking of a young population. 17:08.276 --> 17:12.385 These people are previously healthy, they're not used to being hospitalized, 17:12.386 --> 17:15.895 they have not been chronically ill, they've had a good immune system 17:15.896 --> 17:17.216 and they've warded off infection. 17:17.276 --> 17:18.656 They're not used to being sick. 17:19.346 --> 17:21.896 Usually, the onset of symptoms is very slow. 17:24.176 --> 17:27.625 Someday you may wake up with a cold, who goes to a doctor with a cold? 17:27.626 --> 17:30.150 It's not very often that you really get that much treatment 17:30.228 --> 17:31.228 for that type of thing. 17:31.766 --> 17:36.925 Frequently, symptoms have been present for a long time before this patient 17:36.926 --> 17:38.306 has gotten any medical care. 17:40.406 --> 17:42.116 Usually, the patient is middle class, 17:43.976 --> 17:45.026 very knowledgeable, 17:45.686 --> 17:47.966 usually has a high degree of education. 17:49.286 --> 17:51.926 This patient is going to look into what's going on. 17:53.547 --> 17:57.686 As far as the homosexuals are concerned, they have chosen an alternate lifestyle 17:58.046 --> 18:01.496 and really feel good about who they are and what they're doing. 18:02.366 --> 18:04.436 Usually has an urban home setting. 18:06.116 --> 18:10.376 You're speaking of an individual who is very educated, 18:11.156 --> 18:14.335 who knows what's going on, who has everything in the palm 18:14.336 --> 18:17.486 of his hand, so to speak, as far as where he plans to go with his life. 18:18.026 --> 18:23.066 Suddenly, just because of a few things, like a cold or maybe some diarrhea, 18:23.126 --> 18:25.407 some things that usually you don't even get treatment for, 18:25.706 --> 18:27.836 suddenly he's faced with a life-threatening illness. 18:28.312 --> 18:32.816 I think we need to realize what that does to an individual who is normally healthy. 18:34.676 --> 18:37.919 They're interested in health maintenance, we've had patients who have come in 18:38.738 --> 18:41.126 for treatment and for diagnosis 18:41.312 --> 18:42.992 who will bring a running machine with them. 18:43.916 --> 18:46.817 They're that interested in keeping up and going on. 18:46.834 --> 18:50.006 They feel like they can really keep their lifestyle in order. 18:50.456 --> 18:52.526 We need to realize what's happened to them. 18:54.236 --> 18:55.476 They're going to ask questions, 18:56.276 --> 18:59.786 they know that their lifestyle may be threatened very quickly, 19:00.296 --> 19:02.276 or it may take two or three years. 19:02.636 --> 19:04.435 They may think back on, "Why didn't I go 19:04.436 --> 19:06.556 to a doctor two years ago, when I had these symptoms?" 19:06.776 --> 19:10.466 The incubation period has been known to be as long as two years. 19:11.726 --> 19:14.395 That's why I say I believe we're really seeing 19:14.396 --> 19:15.416 the very beginning. 19:15.716 --> 19:19.459 When you see over 1,000 new cases in 1983 alone, 19:20.006 --> 19:23.286 I think we're just seeing the beginning, we're going to see more and more patients. 19:25.136 --> 19:26.654 They're going to have questions, 19:27.005 --> 19:29.644 questions about what's going on with them as individuals, 19:29.969 --> 19:31.486 about their medical care, 19:31.746 --> 19:35.636 about how to keep up with their lifestyle that they're accustomed to. 19:35.966 --> 19:38.606 They're going to have questions about their home, their job, 19:39.326 --> 19:41.816 are they going to be hired or fired. 19:42.506 --> 19:44.185 They're going to have questions about the significant other 19:44.186 --> 19:45.186 and the family. 19:46.526 --> 19:51.025 You are treating not only the individual, but the entire family 19:51.026 --> 19:52.436 and the significant other. 19:53.216 --> 19:55.855 I'll speak to the emotional aspects a little bit later, 19:55.856 --> 19:58.285 when we get into the nursing care, because I think that's probably 19:58.286 --> 20:01.585 the greatest thing we need to really focus on for these patients. 20:01.586 --> 20:04.567 We know the physical care that is needed, pretty much, 20:04.568 --> 20:07.076 but I think we need to be very aware of the emotional aspects. 20:08.250 --> 20:11.486 Let me go into what is involved in the immune system, 20:12.116 --> 20:16.496 what is the defect, and then keep on going and get into the nursing care. 20:16.916 --> 20:19.406 The humoral immunity, as I said, is normal. 20:19.646 --> 20:21.805 The cell-mediated immunity is impaired. 20:21.806 --> 20:23.276 There's a difference in the balance. 20:23.546 --> 20:28.525 The normal balance, like I said before, normally, you have two helper cells 20:28.526 --> 20:31.436 to one suppressor cell, that may be totally reversed. 20:31.916 --> 20:33.776 Normal number of suppressor cells 20:34.556 --> 20:37.286 and normal function, and a decreased number of helper cells. 20:37.976 --> 20:40.585 This was what was originally forecast. 20:40.586 --> 20:43.646 Now we're seeing that any number of combinations may happen 20:43.796 --> 20:45.356 with the T-cell problems, 20:46.076 --> 20:51.529 but usually, we have more suppressor cells than helper cells, 20:52.526 --> 20:53.886 and that's why you have a problem. 20:55.706 --> 20:58.016 The infections associated with AIDS, 20:59.246 --> 21:02.276 and this is by sight, I'll get into the specific infections in a moment. 21:02.846 --> 21:06.056 The lungs, the central nervous system, and the bloodstream, 21:06.146 --> 21:08.636 are the usual areas that are affected. 21:09.037 --> 21:11.637 In the lungs, you have pneumonia. 21:12.557 --> 21:15.686 50-some percent of the patients have pneumocystis pneumonia. 21:16.226 --> 21:19.736 As I said, the mortality rate is tremendous. 21:20.276 --> 21:23.246 It's the most frequently fatal problem, and it's the most common. 21:23.696 --> 21:25.286 We had a patient who came in, 21:26.096 --> 21:28.676 I believe it was June, 21:29.486 --> 21:30.805 with the first symptoms. 21:30.806 --> 21:33.295 The first time, he had been diagnosed as having AIDS. 21:33.296 --> 21:36.266 He went through all of the testing, did well, and went home. 21:36.386 --> 21:42.295 He came in three weeks ago, and within one week was sent 21:42.296 --> 21:46.796 to the intensive care unit, intubated, and he died within 10 days of admission. 21:47.366 --> 21:48.806 It can be very, very fast. 21:48.956 --> 21:50.066 He had pneumocystis. 21:50.336 --> 21:53.035 He was not diagnosed as having pneumocystis 21:53.036 --> 21:57.176 until this past hospitalization, but within 10 days, he had died. 21:58.646 --> 22:02.066 The other site is the central nervous system. 22:02.396 --> 22:04.316 Herpes meningitis is not unusual. 22:04.616 --> 22:08.905 Cytomegalovirus in the bloodstream from fungal infections, 22:08.906 --> 22:10.766 candidiasis is not unusual. 22:11.096 --> 22:12.096 Septicemia, 22:12.596 --> 22:14.876 and of course, as you know, with all septic patients, 22:15.086 --> 22:16.736 that carries a high mortality rate. 22:17.606 --> 22:20.910 The difficulty with the patient with AIDS is that it is difficult 22:20.911 --> 22:22.076 to diagnose and treat. 22:22.706 --> 22:25.976 There are so many infections going on in this patient, 22:26.546 --> 22:29.246 that it's hard to find out what is the real infection. 22:29.846 --> 22:32.726 Often, the patient will be asymptomatic as far as fever. 22:33.056 --> 22:35.605 That will not be the telltale sign all the time. 22:35.606 --> 22:39.986 He may run a fever all the time, or he may be subnormal much of the time. 22:40.646 --> 22:43.900 If you wait to find a high fever, you may be waiting too long to find 22:43.901 --> 22:44.901 the diagnosis. 22:45.656 --> 22:49.346 This is where our assessment skills come in to be so important. 22:49.856 --> 22:53.906 We need to assess for the occult signs of problems. 22:54.326 --> 23:00.175 We need to do in-depth assessments daily on these patients, and see if there 23:00.176 --> 23:03.506 are changes either in the pulmonary status, 23:04.526 --> 23:05.846 or the oxygenation, 23:06.656 --> 23:10.106 look at the central nervous system, check mentation and changes there, 23:10.466 --> 23:14.065 and look for any occult signs in the bloodstream that you might have 23:14.066 --> 23:15.066 some problems. 23:15.819 --> 23:17.486 Are they having any GI bleeding? 23:17.936 --> 23:20.246 All sorts of occult signs that we need to look for. 23:22.297 --> 23:26.414 The specific infections, parasitic infections, pneumocystis, again, 23:26.415 --> 23:27.415 the major culprit, 23:27.986 --> 23:30.286 cryptosporidium, or Toxoplasma. 23:30.746 --> 23:32.905 Toxoplasma gondii, to the central nervous system, 23:32.906 --> 23:34.076 is especially devastating. 23:34.706 --> 23:36.656 Fungal infections, Candida, 23:37.376 --> 23:39.566 the cryptococcal, and histoplasmosis. 23:40.046 --> 23:41.046 Candida, 23:41.696 --> 23:44.356 often, the first thing that happens with this patient is, 23:44.408 --> 23:46.196 a patient will come in with a sore throat 23:46.796 --> 23:49.855 and you find out that he has Candida. 23:49.856 --> 23:54.415 What will ensue is the following workup, is the workup to find out where did 23:54.416 --> 23:56.336 the Candida come from, why. 23:56.396 --> 23:59.010 Normally, healthy people do not have Candida. 24:00.566 --> 24:02.846 That may be one of the first signs. 24:05.396 --> 24:08.455 Viral infections, we've spoken to this in the parasitic and fungal. 24:08.456 --> 24:11.216 You also have viral opportunistic infections. 24:11.454 --> 24:14.935 The cytomegalovirus, the perineal herpes simplex. 24:14.936 --> 24:18.326 That's another classic, that many of the patients-- 24:18.896 --> 24:23.966 I believe every patient we've had with AIDS has had herpes simplex, 24:24.416 --> 24:25.766 at one time or another. 24:26.216 --> 24:31.916 The other thing is that 95% of gay males have 24:32.936 --> 24:35.156 an antibody to the cytomegalovirus, 24:35.756 --> 24:37.586 and we don't really know what that means. 24:37.616 --> 24:41.906 We're not really sure what that's saying, but that's something to be aware of. 24:42.236 --> 24:43.646 Bacterial infections, 24:44.486 --> 24:45.895 not always opportunistic. 24:45.896 --> 24:48.145 Some of these we may get, but the others, the ones 24:48.146 --> 24:51.955 that are specifically opportunistic, are the mycobacterium, which is very, 24:51.956 --> 24:57.962 very similar to the tuberculosis bacillus. 24:58.365 --> 25:02.846 Miliary tuberculosis is rarely seen in the United States. 25:02.906 --> 25:05.602 It's rarely seen amongst Americans, but it is seen amongst Haitians. 25:05.603 --> 25:08.575 We're finding more and more that some of the AIDS patients 25:08.576 --> 25:11.786 have miliary tuberculosis, which is simply disseminated TB. 25:14.366 --> 25:15.366 Symptoms. 25:15.566 --> 25:19.436 As I said earlier, the symptoms may be very, very vague. 25:20.006 --> 25:22.976 It's something that you don't frequently get treatment for. 25:24.193 --> 25:26.216 General malaise and weakness, 25:30.026 --> 25:31.196 he just doesn't feel good. 25:32.726 --> 25:33.956 May have night sweats. 25:34.166 --> 25:35.186 That's not unusual. 25:38.096 --> 25:39.556 Fever at any time. 25:40.916 --> 25:45.056 Diarrhea is often a normal presenting symptom. 25:45.596 --> 25:48.175 Again, frequently, they don't get treatment for it. 25:48.176 --> 25:49.998 If you have diarrhea once or twice a month, 25:49.999 --> 25:51.654 you know it's rare that you get treatment for it, 25:51.655 --> 25:52.855 you live through it and go on. 25:53.546 --> 25:56.516 Weight loss is often 25:57.056 --> 25:58.875 a thing that people will go get checked for, 25:58.896 --> 26:01.870 but it's usually weight loss that's fairly significant before 26:01.871 --> 26:02.871 the going to the doctor. 26:03.266 --> 26:05.272 A mild U.R.I. 26:06.166 --> 26:09.536 is a cough, non-productive usually, at first, but it may increase. 26:10.092 --> 26:11.336 Then dyspnea on exertion. 26:12.296 --> 26:15.175 As I said, you've had a normally healthy person. 26:15.176 --> 26:17.666 He may have some of these symptoms, but none of them fit. 26:17.936 --> 26:19.765 They don't fit a symptomatic pattern. 26:19.766 --> 26:21.087 They don't fit a systems pattern. 26:22.976 --> 26:26.071 It's something that they just keep living with and go to the doctor late. 26:26.666 --> 26:27.666 Other symptoms, 26:28.406 --> 26:29.456 lymphadenopathy, 26:30.386 --> 26:31.886 and then skin lesions. 26:33.086 --> 26:37.046 The skin lesions are of two kinds. 26:37.346 --> 26:38.696 The Kaposi's sarcoma 26:39.896 --> 26:41.816 is like a raspberry. 26:42.026 --> 26:43.226 It's been described like that. 26:43.436 --> 26:44.773 It is non-painful. 26:45.086 --> 26:46.282 It doesn't itch. 26:46.466 --> 26:48.266 It's just like a bruise, really. 26:49.526 --> 26:50.906 The patient may have one or two. 26:51.153 --> 26:53.216 Kaposi's sarcoma has been known 26:53.786 --> 26:56.786 to be endemic to some areas of Africa. 26:58.436 --> 27:02.666 Usually, it affects males over 60, or tiny children. 27:03.566 --> 27:07.616 That's why it's so unusual to have problems in this age group 27:07.856 --> 27:10.765 with Kaposi's, and that's why people started really investigating 27:10.766 --> 27:13.526 to see what was going on, that we've had that type of thing. 27:14.246 --> 27:15.326 Then it starts spreading. 27:15.866 --> 27:18.355 It's non-symptomatic, really. 27:18.356 --> 27:21.475 It's just this bruise-like appearance, this raspberry-like. 27:21.476 --> 27:25.226 Then it starts spreading, and the patient will have it all over. 27:26.366 --> 27:29.455 The other kind of skin lesion that I don't have mentioned up here, 27:29.456 --> 27:31.406 are the lesions like from herpes 27:32.426 --> 27:33.517 or mouth lesions. 27:33.686 --> 27:38.036 Any mucosal lesion may be present, and that's something to be aware of. 27:40.616 --> 27:43.496 The prognosis is not a nice one. 27:45.236 --> 27:48.176 The prognosis for these patients is repeated infection 27:48.236 --> 27:49.916 with or without malignancies. 27:52.676 --> 27:54.056 Progressive weight loss. 27:55.736 --> 27:57.806 Eventually, multisystems failure, 28:00.116 --> 28:01.136 and then death. 28:02.876 --> 28:06.536 I've said that 41% of the patients thus far diagnosed 28:06.746 --> 28:07.746 have died. 28:08.366 --> 28:09.926 However, when you take away 28:10.466 --> 28:13.465 the year of diagnosis, we find that there's a greater 28:13.466 --> 28:15.326 than 70% mortality rate. 28:15.571 --> 28:20.005 I also said that 48% of those diagnosis has been since 1983 alone. 28:20.756 --> 28:23.966 The mortality rate is higher than that first figure would indicate. 28:24.266 --> 28:28.226 It's greater than 70% in within two years of diagnosis. 28:28.916 --> 28:31.375 If they have the complications of the opportunistic infections, 28:31.376 --> 28:32.856 then this is what you can anticipate. 28:37.136 --> 28:41.065 There are some medications and CDC is working constantly to provide 28:41.066 --> 28:42.877 more medications. 28:43.556 --> 28:46.346 These change, they change all the time. 28:47.137 --> 28:49.976 Bactrim is classically given 28:50.516 --> 28:53.516 for the pneumocystis. 28:53.868 --> 28:56.305 That'll probably be the first drug of choice that you'll see. 28:56.306 --> 28:57.926 Septra is the other name. 28:58.886 --> 29:02.366 Pentamidine is still in the experimental stages, 29:03.056 --> 29:07.826 and that can be given for the pneumocystis that must be obtained from the CDC. 29:09.386 --> 29:11.636 It is a very, very potent drug. 29:11.936 --> 29:15.565 One of the concerns that you need to be very aware of with Pentamidine is 29:15.566 --> 29:18.206 that there are anaphylactic reactions to that, 29:19.166 --> 29:21.686 and that they may not come with the first dose. 29:22.346 --> 29:24.505 We had a patient who had been receiving Pentamidine 29:24.506 --> 29:27.416 for about three or four days, and in the middle of the night, 29:28.436 --> 29:30.476 suddenly developed respiratory distress. 29:32.066 --> 29:37.016 He was intubated immediately and transferred to an intensive care area. 29:37.766 --> 29:39.446 The next night, the same thing happened. 29:39.866 --> 29:43.915 The Pentamidine was discontinued, and he went back to backroom 29:43.916 --> 29:44.902 and did go home. 29:44.903 --> 29:47.215 He has not been back in since then. 29:47.216 --> 29:48.216 That was in January. 29:48.296 --> 29:51.686 We're hoping that perhaps he has had some good effect from that drug. 29:52.196 --> 29:55.375 It is something that you need to be very aware of, assessment-wise, 29:55.376 --> 29:59.096 that the reaction doesn't always come at the beginning of the dosage. 30:00.296 --> 30:01.346 Amphotericin B 30:02.216 --> 30:04.496 is given for any of the fungal infections. 30:05.996 --> 30:09.206 Amphotericin also has an allergic-type reaction, 30:09.716 --> 30:15.767 and it is wise to ask for prescription for Benadryl and Tylenol 30:15.832 --> 30:17.036 before giving this drug. 30:17.576 --> 30:19.886 Most of our patients receive that beforehand, 30:20.126 --> 30:24.217 because if you've ever seen a shaking chill, 30:24.218 --> 30:27.818 after having given a patient Amphotericin, you'll never forget it. 30:28.148 --> 30:29.648 The entire bed shakes. 30:31.238 --> 30:34.448 Some of that can be prevented with Benadryl and Tylenol. 30:35.498 --> 30:37.268 Amphotericin B is frequently used. 30:37.728 --> 30:43.508 ARA-A is the drug for herpes zoster, and it is used quite frequently. 30:44.318 --> 30:47.917 They may receive some of the other anti-cancer drugs, 30:47.918 --> 30:51.278 such as bleomycin, vinblastine, or doxorubicin. 30:51.788 --> 30:54.372 That depends on what's been diagnosed. 30:54.437 --> 30:57.578 Then, interferon has been used for Kaposi sarcoma. 30:57.908 --> 30:59.197 I've not myself seen it. 30:59.198 --> 31:04.748 I know that it is being used frequently, especially in California and in New York. 31:05.828 --> 31:08.917 That's specific for Kaposi, the idea being 31:08.918 --> 31:12.217 that it has antiviral activity and that it'll stop 31:12.218 --> 31:14.078 the foreign body reproduction. 31:16.028 --> 31:20.317 The thing to be aware of with these drugs is to realize that probably, 31:20.318 --> 31:23.042 the patient will not be receiving only Bactrim, 31:23.918 --> 31:25.238 only Amphotericin, 31:25.748 --> 31:28.888 or only Pentamidine, he will probably be receiving 31:28.959 --> 31:30.968 a multitude of medications, 31:31.898 --> 31:34.267 all of which have major side effects. 31:34.268 --> 31:36.488 He's receiving some of the anti-cancer drugs 31:36.728 --> 31:41.227 and the Amphotericin, you're going to need to watch white cell activity 31:41.228 --> 31:42.228 and all of that. 31:42.570 --> 31:46.177 When he has a combination, there are all side effects that you have 31:46.178 --> 31:47.228 to be very aware of. 31:51.158 --> 31:52.158 Precautions. 31:54.818 --> 31:59.378 I think with all of the media, we need to be especially careful. 31:59.528 --> 32:02.737 When I say precautions, I'm not speaking only to the precautions 32:02.738 --> 32:03.738 for the patient. 32:03.938 --> 32:05.828 We need to be very cautious 32:06.158 --> 32:09.008 that we don't isolate this patient unnecessarily, 32:10.058 --> 32:13.611 and that we don't isolate the patient who comes in with an FUO. 32:15.578 --> 32:18.277 One of the major things that we might be doing 32:18.278 --> 32:19.278 to these people is-- 32:19.538 --> 32:23.678 If you have a doctor who normally admits patients with AIDS, 32:24.368 --> 32:30.457 if another patient comes in with an FUO, it's very easy to immediately classify 32:30.458 --> 32:31.898 that patient as having AIDS. 32:32.678 --> 32:35.708 I think this has a very detrimental effect on the patient and the staff. 32:36.248 --> 32:38.498 We must be able to wait 32:38.558 --> 32:42.007 until we have significant diagnostic material available 32:42.046 --> 32:45.368 before that diagnosis is made. 32:45.818 --> 32:49.217 Precautions speak not only to how to care for the patient, 32:49.697 --> 32:51.827 but precaution as far as the emotional aspect 32:51.879 --> 32:53.039 of that patient is concerned. 32:53.648 --> 32:57.547 The other thing that's really important with precautions is that, as nurses, 32:57.548 --> 32:59.977 we know what the precautions are. 32:59.978 --> 33:03.997 We can look at them, we can understand why we're taking 33:03.998 --> 33:04.998 those precautions. 33:05.138 --> 33:07.478 We can be careful with when we use them, 33:08.138 --> 33:10.058 but the other departments don't. 33:10.988 --> 33:13.628 If you have somebody coming in to draw blood from a patient 33:13.658 --> 33:18.848 and that patient has a note on the door that says blood precautions AIDS, 33:19.208 --> 33:21.278 imagine what it does to the blood draw. 33:23.258 --> 33:25.538 A lot of it is simply out of ignorance. 33:25.808 --> 33:28.778 A lot of it is because they don't know what that means, 33:29.018 --> 33:31.238 because of a lot of the news media. 33:32.858 --> 33:37.747 I probably shouldn't even say this, but I really get angry when I read a lot 33:37.748 --> 33:40.383 of the reports and see some of the things on television, 33:40.461 --> 33:42.968 because I think only half of the truth is given. 33:43.358 --> 33:46.085 Unless we investigate, we can't find the final answers. 33:47.768 --> 33:51.757 We're speaking to precautions for the patient and for us. 33:51.758 --> 33:53.857 We need to be very aware of where we're coming 33:53.858 --> 33:55.018 from and what we're thinking. 33:56.318 --> 33:59.287 If you have somebody who's coming in to draw blood, yes, they do need 33:59.288 --> 34:01.328 to have blood precautions, they need to wear gloves. 34:01.898 --> 34:05.168 It's the same precaution they would take with a patient with hepatitis B. 34:06.488 --> 34:12.097 If you can let people know that, that the precautions for the patient 34:12.098 --> 34:15.788 with AIDS are the same as those for the patient with hepatitis B, 34:15.998 --> 34:18.008 I don't think the stigma will be as great. 34:18.098 --> 34:19.928 I don't think it'd be as difficult. 34:20.618 --> 34:23.352 The other department that you need to be-- 34:23.353 --> 34:27.128 Well, several, but be especially aware of housekeeping department. 34:27.698 --> 34:31.477 Again, the only information the housekeeping folks have are 34:31.478 --> 34:32.638 what they read in the papers. 34:33.908 --> 34:37.058 We need to help them understand what's going on with this patient. 34:37.448 --> 34:39.398 It is all right to go in and clean the room. 34:40.148 --> 34:41.858 You can take the linen out of the room, 34:42.518 --> 34:45.545 and there are some precautions to be taken with that if the patient 34:45.546 --> 34:46.868 has a lot of secretions. 34:47.318 --> 34:51.127 If not, if the patient is in the diagnostic stages, 34:51.128 --> 34:54.068 is getting up and walking around, and take caring for himself, 34:55.598 --> 34:58.807 we don't need to go into all of the detailed gowning 34:58.808 --> 35:00.098 and gluing, and all of that. 35:00.368 --> 35:02.708 We need to be aware that we can treat them 35:03.488 --> 35:04.898 as we normally would. 35:05.378 --> 35:08.227 Be aware of housekeeping, be aware of those 35:08.228 --> 35:09.388 who are doing vena punctures. 35:09.675 --> 35:11.858 Be aware of respiratory therapy personnel. 35:14.198 --> 35:18.398 To this date, there is no evidence that AIDS is transmitted 35:18.608 --> 35:19.958 by an airborne cause. 35:21.787 --> 35:25.388 Nobody believes that it's airborne. 35:25.418 --> 35:30.128 The latest MMWR, which came out yesterday, states that it is not airborne. 35:31.358 --> 35:34.687 The only reason we would need to wear masks, really, is if there is 35:34.688 --> 35:38.228 a productive cough and there's another opportunistic infection going on. 35:39.248 --> 35:41.017 We're protecting ourselves from the infection. 35:41.018 --> 35:43.928 We're also protecting the patient 35:44.618 --> 35:46.568 from something else we may be carrying in. 35:46.838 --> 35:47.838 It's a two-way deal. 35:48.248 --> 35:50.767 Be aware of respiratory therapy and all the other departments 35:50.768 --> 35:54.068 that might be coming in, and please, don't isolate this patient unnecessarily, 35:54.278 --> 35:56.918 and don't frighten all the other departments unnecessarily. 35:57.488 --> 35:58.688 Let me go back to this slide. 36:00.308 --> 36:03.848 What you need to do, of course, to prevent any nosocomial infections? 36:04.123 --> 36:08.078 Main thing is hand washing with disinfectant before patient contact. 36:08.798 --> 36:13.507 If you are having close patient contact, then you will wear gloves, 36:13.508 --> 36:17.618 if you're handling blood specimens, body secretions, or excretions, 36:18.068 --> 36:20.168 and if you're examining and touching skin lesions. 36:20.648 --> 36:23.257 Otherwise, it's really not necessary to wear gloves. 36:23.258 --> 36:25.718 If you're going in to have a conversation with this patient, 36:25.748 --> 36:29.918 which I would really encourage to just go in intermittently and just talk, 36:30.248 --> 36:32.707 you don't need to wear gloves, you don't need to isolate them 36:32.708 --> 36:33.708 at that point. 36:34.448 --> 36:37.267 If you do have gloves, certainly wash your hands after removing 36:37.268 --> 36:38.268 the gloves and gown. 36:38.555 --> 36:42.891 Hand washing, wearing gloves when you're handling the normal secretions 36:42.943 --> 36:46.868 when you would wear gloves, certainly, if they're having diarrhea, wear gloves. 36:46.898 --> 36:48.368 We would do that with any patient. 36:50.018 --> 36:51.018 Gowns. 36:51.518 --> 36:55.807 If the linen is soiled with blood or other body fluids, then it's wise 36:55.808 --> 36:56.808 to wear gowns. 36:57.308 --> 37:00.428 Usually, this does not happen with this patient until the patient 37:00.458 --> 37:01.458 is very, very ill. 37:02.138 --> 37:05.767 When the patient is on bedrest, then you may start having some trouble 37:05.768 --> 37:06.968 with body secretions. 37:07.988 --> 37:09.938 If they're in for diagnostic testing, 37:10.688 --> 37:13.838 you probably won't have to use all of these great precautions. 37:15.908 --> 37:19.208 Needles should be placed in a contaminated box. 37:19.298 --> 37:21.974 You should have one box in the room for that patient. 37:22.942 --> 37:26.288 All the thing about needles is, you should not recap them. 37:27.068 --> 37:28.625 The box should be so equipped 37:28.677 --> 37:32.288 that you can just stick the needle in it without putting the top on. 37:32.588 --> 37:35.168 The major thing, the major time 37:35.378 --> 37:37.328 that nursing personnel get puncture wounds, 37:37.358 --> 37:38.918 is when they recap the needles. 37:39.908 --> 37:41.828 Don't recap them, just place them in the box. 37:42.153 --> 37:44.978 They should be labeled contaminated. 37:45.248 --> 37:48.697 I don't think we have to label them with the patient's illness. 37:48.698 --> 37:51.248 I think that segregates the patient even more. 37:51.788 --> 37:54.061 Soil linen should be double-bagged. 37:55.958 --> 37:59.648 These are the precautions that are stated by CDC. 38:00.638 --> 38:04.478 We don't have to put this patient in the full regale of isolation. 38:05.078 --> 38:07.916 Let me speak, just for a moment, to a personal experience 38:07.917 --> 38:09.128 I had with isolation. 38:10.328 --> 38:13.087 I was in Africa teaching nursing for a while, 38:13.088 --> 38:16.298 and I came back with encephalitis, and immediately was in isolation. 38:17.108 --> 38:18.368 I was in a coma when I arrived. 38:18.488 --> 38:20.108 When I woke from this coma, 38:20.678 --> 38:23.498 I was in another country, and I was in isolation. 38:25.088 --> 38:27.578 It was one of the most devastating feelings in my life. 38:27.608 --> 38:30.158 I knew why, intellectually. 38:30.925 --> 38:34.688 As a nurse, I understood all of the reasons, 38:35.018 --> 38:39.620 but I felt so segregated that it made me feel like a non-person. 38:40.358 --> 38:43.342 Everybody that came in would come in and stand like this, 38:43.680 --> 38:45.441 and they'd wash their hands real good beforehand, 38:45.442 --> 38:46.658 my mother, my father, 38:47.288 --> 38:48.848 my friends, everybody. 38:49.058 --> 38:51.007 Then they'd walk out and be sure, "Have you washed your hands? 38:51.008 --> 38:52.128 Have you washed your hands?" 38:52.405 --> 38:53.405 [laughter] 38:54.638 --> 38:57.307 Even though I knew why, and I certainly didn't want them 38:57.308 --> 39:00.038 to get whatever I had, it made me feel terrible. 39:00.518 --> 39:03.938 I've been ever conscious since then, of how we make our patients feel. 39:04.088 --> 39:06.907 That's why I'm really speaking to this, especially with a disease 39:07.414 --> 39:08.978 that can be so devastating. 39:09.008 --> 39:11.617 Anyway, please be aware of how you're coming 39:11.618 --> 39:14.228 across to that patient, and don't isolate them socially, 39:14.918 --> 39:17.317 as well as isolating him for his own protection 39:17.318 --> 39:18.438 and for your own protection. 39:18.938 --> 39:22.088 Much of the isolation for this patient is for the patient's protection 39:22.838 --> 39:26.018 because of the problem with the opportunistic infection. 39:26.648 --> 39:27.878 Please be very aware of that. 39:28.298 --> 39:30.218 The patient is going to get progressively worse, 39:30.338 --> 39:32.338 may come in with weakness in all of these symptoms. 39:32.348 --> 39:35.288 You may see the patient at different times during the illness, 39:35.558 --> 39:37.597 and in different parts of the hospital. 39:37.598 --> 39:39.637 You're going to see him during different stages. 39:39.638 --> 39:42.877 Certainly, if you work in intensive care, the patient is going to be much sicker 39:42.878 --> 39:44.168 than on a general area. 39:45.248 --> 39:48.427 One of the unique things that'll happen is the patient usually will come 39:48.428 --> 39:49.448 in several times. 39:49.928 --> 39:53.288 Hopefully, you can establish a really good rapport with this patient 39:53.528 --> 39:56.252 so that when he comes back in, you'll be able to say, 39:56.253 --> 39:58.808 "Well, hi, how have you been doing? 39:59.528 --> 40:00.528 How did your--" 40:00.698 --> 40:01.478 You can speak 40:01.479 --> 40:03.548 to specific discharge planning you've done. 40:03.908 --> 40:05.738 What is it that has broken down? 40:05.948 --> 40:09.307 You can talk to them on an intellectual plane and they'll feel 40:09.308 --> 40:11.188 a little bit more accepted and more comfortable. 40:12.758 --> 40:14.857 With the weakness, in general, malaise, frequently, 40:14.858 --> 40:19.177 the patient has lost a lot of weight, and often, they should be immediately put 40:19.178 --> 40:21.668 on a high-calorie diet within between meal feedings. 40:22.568 --> 40:24.428 TPN has been considered. 40:25.508 --> 40:28.508 It's something that often we wait to do until a little bit later, 40:29.258 --> 40:32.702 and it's something just to keep in mind, that you might want to put them 40:32.703 --> 40:35.912 on total parenteral nutrition, but usually, the high-calorie diet 40:35.913 --> 40:37.683 within between meal feedings suffices. 40:38.853 --> 40:42.693 As far as the fever, certainly, your goal is to return to the afebrile state. 40:43.263 --> 40:48.692 Another goal that isn't spoken to here, is that you want to realize that fever 40:48.693 --> 40:51.183 is not the only indication of infection. 40:52.683 --> 40:55.893 I am constantly more and more impressed at how much 40:57.303 --> 41:00.466 a hypothermic state indicates pre-sepsis. 41:02.133 --> 41:04.922 Very frequently, just in the past two or three weeks, 41:04.923 --> 41:08.883 we've had patients with hypothermia, who are suddenly agitated, 41:09.543 --> 41:13.178 and the temp is 95.6 rectally, 41:14.186 --> 41:17.463 and within 48 hours, that patient is septic. 41:18.483 --> 41:19.952 Realize that, think about that. 41:19.953 --> 41:21.914 If you have a patient who is suddenly hypothermic, 41:22.113 --> 41:23.913 start thinking of some other problem. 41:24.123 --> 41:27.393 Again, with the patient with AIDS, if the immune system is malfunctioning, 41:27.663 --> 41:29.013 you may not see a high fever. 41:32.103 --> 41:34.383 The other time to assess for that is during drug therapy. 41:34.773 --> 41:37.412 You may have to really warm them up during drug therapy. 41:37.413 --> 41:39.853 If you give them Amphotericin and they've got a lot of chills, 41:40.407 --> 41:44.342 or even if you're giving Amphotericin at all, be aware that they may chill 41:44.343 --> 41:45.513 and become hypothermic. 41:46.203 --> 41:47.403 Force fluid certainly, 41:48.813 --> 41:51.483 we put juices at the bedside, so they're going out of style. 41:52.193 --> 41:53.222 Just keep them there. 41:53.223 --> 41:56.762 Something very simple, and also a very simple thing that can make 41:56.763 --> 41:58.523 the patient have increased confidence in you. 42:01.293 --> 42:04.022 The other thing you need to watch for, as far as the fever is concerned, 42:04.023 --> 42:08.942 is if they're not showing a febrile state, be sure you look at the white blood count 42:08.943 --> 42:12.444 and the absolute granulocyte count, to see if there's something going on 42:12.501 --> 42:14.073 with the immune system at that time. 42:14.223 --> 42:16.833 Watch the white count and see what's happening there. 42:18.177 --> 42:21.505 Most of this stuff is self-explanatory. 42:22.383 --> 42:24.692 I'm not going to read over everything, but I did want to speak 42:24.693 --> 42:26.069 to some of the specific things. 42:26.070 --> 42:28.830 Certainly, you're going to do chest auscultation, 42:29.194 --> 42:32.492 even if the patient doesn't have any problems respiratory-wise. 42:33.243 --> 42:35.882 If you have a patient who's diagnosed as AIDS, you're going to want 42:35.883 --> 42:38.617 to pick up any changes in the pulmonary status 42:38.618 --> 42:40.893 before it's diagnosed as pneumocystis, 42:42.483 --> 42:44.913 and avoid activities that cause dyspnea on exertion. 42:45.273 --> 42:47.973 The patient we had, who brought in his own running machine, 42:48.723 --> 42:51.239 really got tired out, more tired than he anticipated, 42:51.291 --> 42:52.665 and he kept trying. 42:52.746 --> 42:54.878 He kept saying, "I'm going to be able to keep up my body. 42:54.879 --> 42:57.483 I'm going to maintain what I can do." 42:57.693 --> 42:59.403 Once he got on treatment, it was hard. 43:00.423 --> 43:02.702 He went home and was able to pick up again. 43:02.703 --> 43:05.943 We were able to say, "Hold off right now. 43:06.633 --> 43:07.653 Let us slow you down," 43:08.853 --> 43:09.853 and you need to do that. 43:10.413 --> 43:13.923 With skin lesions, certainly, you need to be aware of where they are. 43:13.983 --> 43:18.543 Check the skin daily to see if there are any new lesions open or not open. 43:18.843 --> 43:20.703 See if there's more problem with Kaposi. 43:22.503 --> 43:24.753 Another thing too, just an anecdotal thing, 43:25.413 --> 43:28.203 the patients are certainly aware of when they have skin lesions. 43:28.373 --> 43:31.382 We are aware when we scratch ourselves, but often, 43:31.383 --> 43:34.113 they may not know exactly what's the best treatment for that. 43:34.173 --> 43:38.583 We had a patient who came in with a blister on his toe, 43:39.213 --> 43:40.373 and he was going to lance it. 43:41.583 --> 43:45.462 He said, "Well, my grandmother used to do that and so I'm going to lance it, 43:45.463 --> 43:46.593 and it'll be all better." 43:47.703 --> 43:51.813 Of course, I was astounded and I said, "Please, let us take care of that." 43:52.329 --> 43:57.482 Even though he knew a lot about AIDS, it never entered his mind that lancing 43:57.483 --> 43:59.343 that blister would cause another infection, 43:59.853 --> 44:01.353 or could cause another infection. 44:01.443 --> 44:04.442 How he was going to do it is, he was going to light a match and take 44:04.443 --> 44:07.953 a pin, get the match sterilized, and lance his little blister on his foot. 44:08.583 --> 44:10.382 These are things that you need to be aware of, 44:10.383 --> 44:12.153 as far as patient teaching is concerned. 44:13.053 --> 44:15.693 Just the little things that may cause problems. 44:15.753 --> 44:19.833 Just be very aware of other lesions. 44:19.893 --> 44:23.972 After the patient goes for colonoscopy, be sure to see if they have any pain 44:23.973 --> 44:26.432 or anything like that, there may be some occult lesions 44:26.433 --> 44:27.593 that you need to be aware of. 44:29.793 --> 44:32.073 Mouth lesions, again, watch the platelet count. 44:32.943 --> 44:35.463 Be very aware of your platelet count, your white count, 44:35.823 --> 44:40.053 and if the platelet count is down, put the patient on precautions 44:40.503 --> 44:42.513 for low platelet activity. 44:42.873 --> 44:45.692 Put them on precautions, not blood precautions, speaking of that, 44:45.693 --> 44:48.333 as for drawing blood, but put them on precautions 44:48.341 --> 44:52.773 so that you will avoid any undue problems with the bleeding. 44:53.553 --> 44:55.923 Don't let them shave with a straight razor. 44:57.063 --> 44:59.263 The precautions that you would normally follow for that. 45:02.133 --> 45:03.133 Let's see. 45:06.153 --> 45:07.713 Let's get to the emotional state. 45:07.863 --> 45:10.922 Certainly, we have spoken to prevention of infection and being aware 45:10.923 --> 45:13.473 of the problems that can cause infection. 45:15.543 --> 45:19.113 The emotions that this patient may exhibit are amazing. 45:19.413 --> 45:25.473 They go from anger, to frustration, to feelings of isolation and abandonment. 45:26.433 --> 45:31.443 Frequently, the patients who have come in have not told their families 45:31.923 --> 45:33.333 of the alternative lifestyle. 45:34.443 --> 45:36.737 We have had patients' family members come in 45:36.738 --> 45:38.013 just screaming, 45:38.253 --> 45:39.813 because they were unaware 45:40.323 --> 45:42.033 that the patient was homosexual. 45:43.413 --> 45:44.413 That does nothing 45:44.853 --> 45:46.023 to get this patient better. 45:46.743 --> 45:51.032 It does nothing for the family, except that they have these emotions 45:51.033 --> 45:52.113 that they have to get out. 45:52.653 --> 45:55.742 Be aware that those things might come about, 45:55.743 --> 45:58.173 and that perhaps you may need to intercede. 45:59.403 --> 46:00.403 That's hard. 46:00.693 --> 46:03.063 You're a nursing personnel. 46:03.993 --> 46:06.213 It's hard to know when to intercede and when not to. 46:06.633 --> 46:08.732 We have to be aware of the significant other 46:08.733 --> 46:11.642 who may suddenly decide that no longer is he interested. 46:11.643 --> 46:14.133 He's scared to death. He's scared that he may get AIDS. 46:17.493 --> 46:18.993 Of course, the fear of the unknown. 46:19.053 --> 46:20.053 What's going to happen? 46:20.283 --> 46:21.723 Everybody's read the newspapers. 46:22.203 --> 46:23.203 The fear of death. 46:23.793 --> 46:25.772 As I said before, frequently, when these patients get 46:25.773 --> 46:28.892 to intensive care areas, they are alert and oriented. 46:28.893 --> 46:30.093 Even though they're intubated, 46:30.783 --> 46:31.863 they know what's going on. 46:32.403 --> 46:34.413 They send messages even 46:35.223 --> 46:37.606 while they have the tube, and even while they're tracked 46:37.607 --> 46:38.607 or intubated. 46:40.173 --> 46:43.838 What happens physiologically, or pathologically, 46:43.903 --> 46:48.752 is that the lungs literally fill with bacteria to the point 46:48.753 --> 46:50.133 that the patient suffocates. 46:51.603 --> 46:53.672 This is the type of thing that they're looking forward to, 46:53.673 --> 46:56.073 that they're afraid of, and we need to be aware of that fear. 46:58.623 --> 47:02.575 What I would really encourage as far as emotions are concerned, 47:02.952 --> 47:06.422 is to be honest, be very honest with the patients. 47:06.423 --> 47:07.503 Answer the questions. 47:09.123 --> 47:10.123 Be open with them. 47:10.323 --> 47:12.753 You must get in touch with your own feelings. 47:14.641 --> 47:17.720 If you have some real feelings about the lifestyle, 47:18.028 --> 47:20.095 you must get in touch with those and decide 47:20.459 --> 47:22.833 how you can approach this patient and family. 47:24.192 --> 47:25.832 Be very open and honest, but be in touch 47:25.833 --> 47:28.983 with your own feelings before trying to be real therapeutic for the patient. 47:30.783 --> 47:32.403 Visit with nothing to do. 47:33.483 --> 47:36.272 How often I'll go into a patient's room and I have nothing in my hands, 47:36.273 --> 47:38.583 and they'll say, "You're not going to do anything to me?" 47:40.023 --> 47:41.096 It's nice. 47:41.097 --> 47:44.787 I happen to be in a position as a coordinator that I can do that. 47:44.788 --> 47:47.763 That I don't have to take an injection every time I go into a room. 47:48.423 --> 47:50.132 It's a freeing experience for me. 47:50.133 --> 47:51.133 It's very nice. 47:51.453 --> 47:54.693 I would encourage all of you to do that same thing. 47:54.723 --> 47:56.462 Just go in and contract with them. 47:56.463 --> 48:00.093 Say, "I'm going to have some free time at X hour. 48:00.663 --> 48:01.663 Let's talk. 48:01.713 --> 48:02.713 Let's plan to talk." 48:04.242 --> 48:05.163 You can take five minutes 48:05.164 --> 48:07.682 and you will have given them something that's 48:07.683 --> 48:09.093 as valuable as a medication. 48:10.864 --> 48:12.033 That will help them a lot. 48:12.183 --> 48:14.023 I've had many patients say that that does help. 48:14.103 --> 48:15.773 The nurses who do that say, 48:15.851 --> 48:18.693 "Wow, that makes me feel so much a part of the care. 48:18.933 --> 48:21.423 I know more who they are, and they know who I am." 48:21.693 --> 48:22.803 That helps tremendously. 48:23.629 --> 48:29.492 Your goal for your discharge planning, and this is probably as important 48:29.493 --> 48:32.508 as anything you do while the patient is hospitalized, 48:32.586 --> 48:34.183 is prophylaxis. 48:34.469 --> 48:38.043 Simply to prevent the spread and to prevent rehospitalization. 48:39.619 --> 48:43.481 We are hoping that we'll find a miracle drug that will prevent 48:43.520 --> 48:44.462 that rehospitalization. 48:44.463 --> 48:47.312 We haven't yet, but we can certainly try healthcare measures 48:47.313 --> 48:48.313 that will. 48:49.233 --> 48:50.523 Limit the number of partners. 48:52.143 --> 48:54.002 I've talked to some folks who say they believe 48:54.003 --> 48:55.533 that has already changed tremendously. 48:56.253 --> 49:00.032 The statistics about how many partners patients with AIDS 49:00.033 --> 49:01.833 may have had are absolutely astounding. 49:02.553 --> 49:05.073 Some statistics say up to a thousand partners. 49:05.613 --> 49:10.383 It's almost impossible to isolate the other people that may be affected. 49:11.373 --> 49:17.493 Again, I'm speaking to the 71% of patients with aids who have been homosexual. 49:18.063 --> 49:19.563 Know the partner's health status. 49:20.583 --> 49:21.843 Certainly, be aware of that. 49:22.923 --> 49:25.653 Use condoms, a simple request. 49:26.313 --> 49:27.753 Eat a well-balanced diet. 49:28.653 --> 49:31.802 Some folks suggest cooking meats, washing fruits 49:31.803 --> 49:33.003 and vegetables very carefully. 49:33.243 --> 49:36.393 It's a simple thing that we all think of, but it's good to tell the patients 49:36.453 --> 49:37.683 that that's important too. 49:38.313 --> 49:40.383 Minimize the use of recreational drugs. 49:42.993 --> 49:46.053 Nitrous is one of the drugs that has been implicated so frequently. 49:47.043 --> 49:48.883 Then the other things that you would teach them 49:49.492 --> 49:50.973 have to do with the immune system. 49:51.303 --> 49:54.693 Certainly, avoid contact with people with colds and flu. 49:56.283 --> 50:00.722 Something simple, a simple cold may be the thing that puts them back 50:00.723 --> 50:01.723 into the hospital. 50:02.283 --> 50:03.783 Avoid contact with those folks. 50:04.173 --> 50:05.390 Do not self-medicate. 50:06.273 --> 50:09.663 It says here, with antibiotics, I would say with most anything, 50:09.933 --> 50:12.433 even if they self-medicate with Tylenol for a fever, 50:12.745 --> 50:17.943 they may be decreasing the time that they have to get to medical help. 50:18.693 --> 50:21.723 Certainly, see the doctor for any changes in the medical condition. 50:23.193 --> 50:24.872 If your partner develops symptoms, certainly, 50:24.873 --> 50:28.023 the partner should seek medical help. 50:30.123 --> 50:33.783 We're speaking to a large population of people with many problems, 50:34.023 --> 50:36.663 and I've spoken, like I said, primarily to the patient 50:37.923 --> 50:40.892 who is homosexual, and there are others. 50:40.893 --> 50:41.893 There are many others. 50:43.906 --> 50:46.185 These are the people that we are seeing most frequently, 50:46.186 --> 50:48.286 so that's why I'm speaking to that population. 50:48.864 --> 50:53.205 We have not seen it that much in the population at large. 50:53.206 --> 50:55.276 There have been a few isolated cases. 50:55.636 --> 51:01.335 I know the fear is rampant, that AIDS will extend outside 51:01.336 --> 51:03.496 of the populations at risk. 51:04.126 --> 51:08.625 If we carry out the precautions, if we're wise in how we care 51:08.626 --> 51:12.676 for the patients, we are not anymore at risk with a patient with AIDS 51:12.693 --> 51:15.046 than we are with a patient with infectious hepatitis. 51:16.276 --> 51:18.046 I think if we can look at it that way, 51:18.586 --> 51:22.066 as hospital personnel, we won't have the fear of caring for them. 51:22.726 --> 51:27.045 Another thing, for those of you who are staff nurse, 51:27.046 --> 51:31.305 head nurse capacity, one good thing that would help too is to pull aside 51:31.306 --> 51:34.275 all the nursing assistants working with these patients and give them 51:34.276 --> 51:35.536 a brief explanation. 51:36.046 --> 51:37.046 They are frightened. 51:37.981 --> 51:38.981 They're very frightened. 51:39.286 --> 51:44.656 The only group that CDC recommends not care for patients 51:45.136 --> 51:47.986 with AIDS is, the person who is pregnant 51:48.736 --> 51:50.836 should not care for the patient with pneumocystis. 51:51.976 --> 51:53.476 The CDC recommends that. 51:54.226 --> 51:56.507 No, it's not CDC, I think it's the National Health Center. 51:58.846 --> 52:00.633 Other people should be able to. 52:00.826 --> 52:02.595 If you can talk with your nursing assistants 52:02.596 --> 52:03.958 and just give them some information 52:03.959 --> 52:05.299 so they feel a little bit more comfortable, 52:05.300 --> 52:09.045 they will not have the fear that has been exposed 52:09.046 --> 52:10.686 in many other parts of the United States. 52:12.556 --> 52:13.606 One last slide. 52:14.103 --> 52:15.103 Oops. 52:18.132 --> 52:21.165 I said earlier and I didn't realize I was coining a phrase 52:21.166 --> 52:22.996 that many other people have used, also. 52:23.781 --> 52:25.366 This is a CDC slide. 52:25.846 --> 52:28.636 We are seeing probably the very tip of the iceberg. 52:29.236 --> 52:32.296 What we know is that we have Kaposi sarcoma 52:32.326 --> 52:33.916 and opportunistic infections. 52:34.816 --> 52:39.436 What we anticipate may be possible are the other sarcomas, 52:40.126 --> 52:45.345 other thrombocytopenic problems, other immune effects, and then we may even 52:45.346 --> 52:46.966 have some asymptomatic carriers. 52:47.176 --> 52:51.196 Nobody has proved that yet, but I would expect and anticipate 52:51.586 --> 52:54.585 that within the next year or so, we will see many, 52:54.586 --> 52:56.566 many more people with AIDS. 52:57.136 --> 52:59.806 What I would challenge you to do is to keep up to date, 53:00.436 --> 53:02.720 and keep up to date not only from the newspaper articles 53:02.721 --> 53:03.721 and stuff like that. 53:04.216 --> 53:07.587 Try and keep up with some of the morbidity and mortality reports 53:07.925 --> 53:12.526 and all of the other information that is available in medical journals. 53:13.379 --> 53:15.075 Now, I don't know if I've got time for questions. 53:15.076 --> 53:16.076 I hope I do. 53:16.876 --> 53:19.936 -Yes. I'm Tia Riley and I work here with diabetics. 53:20.266 --> 53:21.535 I'd like to compliment you 53:21.536 --> 53:22.965 on an excellent presentation. -Thank you. 53:22.966 --> 53:26.475 -I'd like to also know if there has been seen in your investigations 53:26.476 --> 53:29.835 a higher incidence of AIDS among persons with diabetes 53:29.836 --> 53:32.296 because of their increased susceptibility to infections. 53:32.806 --> 53:36.315 Also, question two, has there been any investigation 53:36.316 --> 53:40.095 of other refugee groups such as the Cambodians or Laotians 53:40.096 --> 53:42.046 as to the incidence of the disease AIDS? 53:42.556 --> 53:46.306 -Good questions. I work a lot with diabetics too. 53:47.155 --> 53:52.125 To my knowledge, I have never seen anything spoken to, 53:52.126 --> 53:55.006 as far as diabetes is concerned, but I would expect that we might. 53:56.476 --> 53:59.355 I've not seen any literature at all that speaks to the diabetic. 53:59.356 --> 54:01.606 I have seen literature that speaks to the hemophilia, 54:02.716 --> 54:03.946 but not to the diabetic. 54:04.066 --> 54:05.570 It would be something that we should watch for 54:05.571 --> 54:06.812 in our assessment. You're right. 54:07.486 --> 54:11.790 The other patient that I'm thinking that we need to watch for, 54:11.856 --> 54:12.975 and again, this is just me. 54:12.976 --> 54:14.416 I've not seen any literature at all. 54:14.716 --> 54:17.596 I would want to watch the sickle cell patient too. 54:18.856 --> 54:22.456 This is just something that some of our nurses have talked about, 54:22.846 --> 54:26.506 that we need to be aware of, maybe a problem with sickle cell. 54:27.316 --> 54:31.516 No, I don't know of any investigations of other refugee groups. 54:32.266 --> 54:38.315 The Haitian government certainly is very upset at being isolated. 54:38.926 --> 54:42.046 I don't know of any other groups that have been isolated. 54:43.636 --> 54:49.066 The reason they did is that there were 5% of people in Miami who had AIDS, 54:49.156 --> 54:50.506 who were Haitian immigrants. 54:51.316 --> 54:52.636 I don't know of the other groups. 54:53.926 --> 54:55.101 -I thoroughly enjoyed the lecture. 54:55.102 --> 54:57.826 All through your lecture, you kept using the term he. 54:58.066 --> 54:59.667 Have they ever been any women with AIDS? 54:59.986 --> 55:01.696 -Yes, and I apologize. 55:01.906 --> 55:02.843 Yes. 55:02.844 --> 55:06.676 I think it's something like 3.2, but I'm not good on remembering numbers. 55:06.826 --> 55:11.385 Yes, there have been some women with AIDS and they have been part of the risk groups 55:11.386 --> 55:12.386 for the most part. 55:12.736 --> 55:17.325 They have either been IV drug abusers, or they have had sexual contact 55:17.326 --> 55:18.886 with AIDS patients. 55:19.276 --> 55:20.296 I apologize. 55:20.416 --> 55:21.416 Thank you. 55:23.386 --> 55:24.386 Any other questions? 55:33.856 --> 55:37.905 -At this point, do you know what stage these lesions occur in the mouth, 55:37.906 --> 55:39.256 and what they may look like? 55:39.676 --> 55:42.376 I'm especially interested, since I work in oral surgery. 55:43.006 --> 55:47.296 -Okay. If it's a Kaposi's lesion, it would be the raspberry-like lesion 55:47.776 --> 55:49.186 that looks like a bruise. 55:49.456 --> 55:52.185 If it's another kind of lesion, it would be the lesions that you see 55:52.186 --> 55:53.186 with Candida, 55:53.596 --> 55:56.056 or just with the mucosal breakdown. 55:56.656 --> 55:59.021 If it's Kaposi's though, it is raspberry-like, 55:59.776 --> 56:02.416 and pretty obviously different from the other lesions. 56:02.686 --> 56:03.686 If it's herpes, 56:04.546 --> 56:07.606 what it is, is the lesion depends on the causative organism. 56:09.016 --> 56:11.451 It varies with the cause. -Even in the mouth? 56:11.542 --> 56:13.816 -Even in the mouth, it varies with the cause. 56:14.446 --> 56:16.231 What you're going to have to do with any problems 56:16.232 --> 56:19.366 with the patient with AIDS is look for the cause before treating it. 56:20.236 --> 56:21.646 Find out what the problem is.