Staff Concern : AIDS Fears--Hospitals Seek to Cope

The arrival of an AIDS patient several years ago caused a minor uproar at a small Northern California community hospital. Several nurses refused to care for him. Housekeepers would not clean his room or empty the trash. Several other employees became convinced, after fixing a clogged toilet in the patient’s room, that they would acquire the deadly acquired immune deficiency syndrome disease.

In a Los Angeles hospital, a nurse asked a dying AIDS patient if he had sought God’s forgiveness for being homosexual.

At the UCLA Medical Center, some surgeons wore two sets of gloves while operating on an AIDS patient.

And at San Francisco General Hospital, some doctors and nurses have had nightmares and have even developed abnormal fears so that every cold, pimple or bout with fatigue or depression has seemed a harbinger of AIDS.

No Immunity From Fear

As such incidents illustrate, health care workers, like the public, have not been immune from a fear of AIDS since it was identified in 1981.

But such fears appear to be subsiding as more is learned about how difficult it is for such workers to contract the AIDS virus from patients.

Because of the epidemic, however, many doctors and nurses are reporting a myriad of effects on their professional and personal lives. The very nature of the disease is forcing these workers to confront their feelings about their own sexuality and about homosexuality. And because AIDS is an invariably fatal disease, typically striking down victims in the prime of their lives, those working with its victims have also had to grapple with a sense of helplessness as their patients waste away.

“Sometimes I’m depressed not only because of patients that are dying, but because of the social and political problems--discrimination against the patients, the pressures of the media, patients who lose their jobs,” said Willy Rozenbaum, a leading AIDS researcher in Paris.

‘A Throwback’

“AIDS is a disease that is not forgiving,” added Dr. Charles Levy, chief of the infectious disease section at the Washington Hospital Center. “It’s almost a throwback to practicing medicine in the 1930s--when all you could do was make the patient and his family as comfortable as possible.”

Dr. Robert Wachter, a medical resident at the University of California, San Francisco, Medical Center, one of the busiest AIDS treatment centers in the country, put it this way: “Not in recent memory have so many relatively young, previously healthy people died so quickly, with care-givers seeming powerless to influence the eventual outcome.”

As a result, he wrote in a recent issue of the New England Journal of Medicine, the training of a whole generation of physicians at some urban medical centers is being profoundly altered. Not only is the care of AIDS patients allowing less time for the study of patients with more classic medical illnesses, but the emotional and physical toll of residency has increased as well.

And hospitals throughout the country are increasingly recognizing the need to head off unfounded fears about AIDS and discrimination against its victims by their medical personnel.

For instance, after its AIDS patient transferred himself to another hospital, the Northern California community hospital’s psychologist and a physician visited the AIDS ward at San Francisco General. They later produced an educational film for the hospital staff. “The level of anxiety was reduced and the quality of care for AIDS patients improved significantly,” the physician said.

The Hospital Council of Southern California, meanwhile, is recommending that each member hospital designate two or three in-house AIDS training officers. The California Institution for Men at Chino is requiring all prison guard officers to attend a two-hour educational session on the disease that addresses such practical issues as what to do if a prisoner with AIDS spits in a guard’s face. And the Chicago-based American Hospital Assn. is targeting a Thursday telephone conference, “The AIDS Dilemma: Confronting Fears with Facts,” at small and medium-size hospitals throughout the nation. About a quarter of the 6,300 institutions that belong to the association have signed up to participate in the three-hour program even though most of them have never treated an AIDS patient.

“Knowing the agent is very helpful psychologically,” said Dr. Molly Cooke, an assistant clinical professor of medicine at San Francisco General. “AIDS no longer seems like a visitation from some mystical realm.”

But she cautioned that in caring for AIDS patients, “the experience of the experienced hospitals doesn’t necessarily do inexperienced places a lot of good” because physicians have to learn for themselves about the patients’ medical and social needs. Cooke said this process could take up to several years.

Vulnerable to Infection

The AIDS virus attacks the body’s immune system, leaving the victim vulnerable to infectious diseases and tumors. There is no effective treatment. As of Jan. 13, doctors have diagnosed 16,458 Americans as having the disease and 8,361 have died, according to the federal Centers for Disease Control. Of that number, 669 have been health care workers. But, according to the federal centers, more than 95% of them have been identified as homosexual or bisexual men or intravenous drug users, the highest risk groups in the population. The centers has identified only two cases of “probable” occupational transmission of the AIDS virus and none of the disease itself. In contrast, about 25% of workers comparably exposed to the blood or body fluids of patients with hepatitis B, which causes liver inflammation, will become infected with the virus.

The accidental transmission of AIDS in a hospital is “incredibly unlikely, and less likely if people would be careful,” Dr. Julie Gerberding of San Francisco General said.

She is closely monitoring 300 workers who have been extensively involved with AIDS patients, including 89 who have sustained 308 needle punctures or blood splashes from these patients. No workers without other risk factors for infection with the AIDS virus had tested positive as of early January. Gerberding said medical personnel should be trained to safely handle blood-drawing equipment used for AIDS patients and disposable needle containers should be placed in patients’ rooms.

Mouth-to-Mouth

In North Carolina, physicians are closely monitoring two nurses who delivered mouth-to-mouth resuscitation to a patient who, it turned out, had an AIDS-related illness. The nurses, who tested negative for infection with the AIDS virus nine months after exposure, are being followed.

And as a further precaution, the federal centers is expected to recommend that dentists and surgeons wear protective clothing as a standard procedure to protect both themselves and their patients from the transmission of the AIDS virus.

A UCLA physician who developed hepatitis several years ago from a needle puncture during emergency surgery said most surgeons are already taking extra precautions.

“Most surgeons here will operate on AIDS patients, but they will wear two sets of gloves and let the interns hold any of the sharp instruments,” said Dr. Larry C. Ford, an assistant professor of obstetrics and gynecology. “I would want it to be my fault if I got stuck.”

Could Not Utter the Word

Just such a needle puncture accident involving an AIDS patient so unnerved a Washington Hospital Center nurse that she was unable to utter the word AIDS or even aid . Accidents like that “seem to unmask people who aren’t well put together to begin with,” Levy said.

But it doesn’t take such an accident for nagging doubts to develop, as Dr. Paul A. Volberding, the director of AIDS activities at San Francisco General, and his wife, Dr. Molly Cooke, learned. The couple have two young children.

“In 1982, six months after Paul began working with these patients, we became very anxious as a couple that he had been infected,” Cooke said. “It caused stress within our relationship. Nine months later, I began to see the same sort of fears in interns and residents. Many had nightmares. Doctors without a risk factor in the world for AIDS were coming to see me as patients and attributing colds and fatigue and depression to the disease. It was well beyond the limits of reason.”

In 1984, after the blood test for antibodies to the AIDS virus became available, Volberding tested negative.

‘Much Calmer Now’

Cooke described most physicians at the hospital as “much calmer now.” She said interns and residents, including pregnant women, are no longer avoiding AIDS patients.

“Physicians couldn’t stay at that level of psychological dysfunction. They either had to stop caring for AIDS patients or make some adaptations,” she said.

Medical experts believe that physicians, nurses and other workers, like the public, find AIDS less fearful as they learn more about the disease. At the same time, however, polls also show that considerable misperceptions about AIDS exist among both the health care profession and the public.

Dr. Charles E. Lewis, a UCLA professor of medicine, in a random survey of 635 primary care physicians in Los Angeles County in the fall of 1984, found that a third of the internists, family practitioners and general practitioners in Los Angeles had “insufficient knowledge” about the symptoms and risk factors of AIDS. Lewis found that another third had what he regarded as very good knowledge about AIDS. The most knowledgeable doctors, he said, were those who had seen the most cases of the disease. Female physicians felt more comfortable with AIDS patients than male physicians, and younger doctors more comfortable than older doctors, according to Lewis.

Anti-Homosexual Comments

While that telephone survey was in progress, Lewis was called to a special meeting with the interviewers, many of whom were disturbed by the anti-homosexual comments of some physicians.

“One doctor said he hadn’t seen any AIDS patients and he wouldn’t treat them anyway because they deserved to die,” Lewis said.

Lewis said he was particularly surprised to learn that no more than 6% of the surveyed physicians even bothered to take a sexual history when seeing any new patient, although another recent study suggested that more than 90% of patients consider such discussions appropriate.

“Sexual history-taking is one of the big taboos in medicine,” Lewis said. “We don’t teach it and we don’t practice it. Physicians can’t counsel patients about AIDS or sexual issues unless they feel comfortable with the subjects themselves.”

Overwork, Stress Cited

Sexuality and negative reactions to homosexual patients are only two issues for medical personnel that are raised by AIDS. Overwork and the stress of caring for young, dying patients are further concerns.

Most physicians typically use elaborate defenses--such as intellectualization, peer support and even gallows humor--to soften the inevitable blow of a terminally ill patient’s death, Wachter said.

“It is often not difficult for a (medical) resident to accept the death of an elderly patient with widely metastatic cancer as a welcome reprieve from suffering. . . . (But) dealing with AIDS patients stretches these defenses to their limits,” he said.

Until recently, AIDS has largely been seen as a problem in urban areas. But as the disease continues to spread to regions where physicians have less AIDS expertise, it raises the issue of whether patients should be cared for in their communities or referred to more experienced treatment centers.

‘Easy Out or Legitimate’

“This could either be an easy out or a legitimate thing,” Steve Heilig of the San Francisco Medical Society said.

Transfer in the short term might seem in the patient’s best interest, he said, but it delays the diffusion of knowledge about the disease and may prevent patients from being cared for near home. An extreme example of the transfer issue occurred in 1983 when a Florida hospital chartered a plane to fly a terminally ill AIDS patient to San Francisco to die.

Problems may also occur when patients are well enough to leave the hospital but continue to need specialized nursing care at home. In Los Angeles, for example, Progressive Nursing Services, which specializes in providing home nursing care for AIDS patients, can find only half of the 40 full-time nurses it needs.

Because of what she terms “the leper syndrome”--that is, nurses avoiding AIDS patients--Porter Warren founded the Florence Nightingale Nursing Service in the San Fernando Valley in 1984. The agency, almost entirely staffed by male and female homosexual nurses, accepts only patients with AIDS and AIDS-related diseases. It employs 35 to 50 nurses, depending on the caseload.

‘Neglect and Abuse’

“I’ve been offended professionally and personally by the neglect and abuse some of these patients have suffered,” Warren said. “A nurse in the hospital asked one of my dying patients if he had asked God’s forgiveness yet for being gay.”

Los Angeles-area dentists have also been singled out for criticism in recent months. AIDS Project/L.A. has set up a special clinic in West Hollywood to treat patients shunned by some private dentists. Darlene Warning, a dental assistant who coordinates the clinic, said she has fielded phone calls from more than 20 dentists in the last two months seeking to refer patients.

“Most had been seeing these patients in their offices for quite some time, but (after the clients developed AIDS) they were flatly refusing to treat them,” she said.

Leaders in AIDS treatment say it is important to counteract discrimination against AIDS patients by setting good personal examples.

“The laying-on of hands is important,” said Dr. Michael Gottlieb of UCLA, one of the first U.S. physicians to see AIDS patients. “It can be a therapeutic intervention. Gloves can be used if the patient has an infection. . . . Interacting with an AIDS patient as we would with any other patient or human being is expected of health care providers.”

Times staff writer Marlene Cimons in Washington also contributed to this story.