Chapter 7: Infusion Day
Oliver pulled up in front of the familiar clock building. The windows of Queen's Jubilee were dark in the autumn morning dimness. Oliver rarely drove, but it hadn't felt right to take a taxi or a driver to pick Thea up this morning. Diggle hadn't even hesitated when Oliver had asked to borrow Digg's SUV.
Thea appeared from around the side of the building, a large bag swung over her shoulder. She pulled open the door, setting her bag down and letting out a sigh as she settled into her seat.
"Good morning," Oliver said lightly, hoping that Thea wasn't holding onto a grudge from his radio silence over the past week. He had seen her following her skull fracture at her apartment, then texted her briefly to let her know what time he would pick her up, but that had been the extent of their communication. And Oliver refused to feel badly about that – he had been busy researching clinics and making plans with Diggle on accessing Phillips or Cisco's list.
"Thanks for picking me up," Thea replied, her voice sounding every bit as intentionally over-bright as his own. "Usually I have to take the bus."
Oliver grimaced. "I wish you wouldn't," he said automatically.
"What do you think is going to happen?" Thea asked rhetorically. "I already have HIV." Oliver winced at Thea's dark humor. "Too soon?" Thea asked weakly at Oliver's ensuing silence.
Shaking the comment off, Oliver pointed at the vehicle's cup holders. "I got you a coffee from that shop you like."
"Oh," Thea sounded chagrined. "That was really nice. Thanks."
"What's wrong?" Oliver asked, glancing over to her from the road, trying to understand her reticence.
"It's nothing," Thea said quickly. "I just try to avoid coffee on infusion days."
"Should you not have the caffeine?" he asked, confused.
"No, I'm allowed to, it's just I get some GI stuff with the infusions and the coffee doesn't help."
"Like it makes you nauseous?"
"Ollie," Thea said, sounding exasperated.
"I'm just trying to understand, Thea," Oliver said.
Thea groaned. "Fine! I shit water for, like, the entire day after an infusion, okay? And coffee does not help."
"Oh, god," Oliver said, horrified. "That can't be okay!"
Thea defended it quickly, "Look, it's fine! This treatment actually has really minimal side-effects even compared to a lot of the other drugs I've taken. It always clears up by the next day."
If Oliver had been doubting that he should be along for this appointment before this moment, the brief discussion of Thea's side effects was just tipping the scales.
The SUV travelled down quiet streets under multistory apartment buildings next to the shorter profiles of one-story businesses. Occasionally they would pass a person bundled into a jacket scurrying on the sidewalk, but mostly it felt like they were alone, pushing through the cool Fall mists. Oliver glanced at the SUV's clock to see that it was 6:48 am. The outside world was just starting to slowly settle into its day.
As Oliver pulled the SUV into the empty Rebecca Merlyn Memorial Clinic parking lot, Thea directed, "Drive around back." Oliver complied and discovered a secondary lot behind the building. There were two other cars here, each positioned under a single overhead light. Oliver parked and Thea threw open her door, settled her bag on her shoulder, and took a few steps to the front of the car, waiting for Oliver.
Oliver caught a glimpse of his sister's face and noticed she looked apprehensive. He wasn't sure if she was anxious to go inside, or if she was nervous having him there with her. Oliver shot her a quick smile as he approached which Thea matched before turning and leading Oliver towards the entrance.
The chilly Fall air was immediately engulfed in warmth from the entryway. Oliver glanced around, noting that the odd morning quiet had followed them inside. There was an unmanned window in the wall before them with a sign above reading "Check In". To the left was a door, and to the right was an open room lit by fluorescent fixtures with four vinyl-covered, light blue recliners. Oliver was unsettled, realizing there was no one else there.
Thea, on the other hand, seemed unconcerned and walked up to the window. "Good morning!" she called out cheerfully.
"I'm coming!" a voice answered from some unseeable place within the office space through the window. A woman came through an open doorway and said brightly, "Thea! Good morning! Casey's going to meet you in bay one. You can set your things down." The woman seemed to suddenly notice Oliver's presence. "Oh, and I can bring a chair over for your guest."
"Thanks, Mary!" Thea said with a warm smile. "Come on, Ollie," Thea said glancing at Oliver with a little more trepidation before leading him to the first of the vinyl recliners. As Mary entered and provided Oliver with what looked like a vinyl waiting room chair, Thea began to dig around in her bag, setting a thin blanket and a book on the recliner and pulling out a bottle which she placed next to the chair. Oliver sat down uncertainly onto his provided seat.
"Come on, lady!" a voice called out. Oliver turned to see a new woman standing on the other side of the room by a set up with a computer, scale, and chair. "Let's get your vitals."
Thea turned to Oliver and said, "You can wait here – I'll be right back." Oliver nodded gamely and tried not to listen as Thea made small talk with the nurse as she stepped up onto the scale. He looked around at the room. It was comfortable enough – nicer than he had imagined a community medical center in the Glades would look. Everything seemed clean and the two staff members had seemed nice enough.
Thea returned to the recliner and this time took her seat. With a graceful flick of her wrist, the blanket unfolded and settled onto her lap. Thea tucked it around her legs and then reclined the chair with a small button on a remote she had found in the side of the chair. She pulled up her book and held it on her lap. Oliver gave her a look and then nodded at her book.
"We're going to be here for awhile," Thea explained. "It's two thirty-minute infusions. I like to make the most of my time." She seemed to think for a moment and then reached back into her bag, coming out with a book of crossword puzzles and a pen. She held them out to Oliver.
Oliver smiled and shook his head. "I'll just catch up on some of my briefings on my phone. Thank you, though."
"Well, if you want them later, just ask," Thea said agreeably.
The nurse who had called out to Thea for her vitals came over and hung an IV bag onto a hook at the back of Thea's chair. Oliver eyed it suspiciously. "Name and date of birth," the nurse directed Thea. She listened for the answer and used a small scanner from the wall to scan the bag's label. The nurse spent a few minutes tinkering around with the IV bag and a long tube. "And who did you bring with you today?" she asked.
"Casey, this is my brother Oliver," Thea introduced. "He was nice enough to drive me today."
"So no new adventures from the bus line today?" Casey asked with a grin. In a genuine tone, she said, "It's nice to meet you, Oliver. Thank you for being here. We all love your sister."
"Me too," Oliver said with his best polite smile.
Casey vanished to wash her hands and when she returned, she opened a foil bag, removing a towel and laying it on the table beside Thea before pulling out the rest of the bag's contents. She used a pump of alcohol-based hand sanitizer, then pulled on a mask and set of nitrile gloves. "Okay, let's see your port," Casey said cheerfully.
Thea unzipped the hoodie she was wearing down to her stomach and then tugged the neckline of her tank top down, revealing the region below her clavicle. Oliver squinted his eyes, noticing that the skin's color was just a little different – it was like there was something bumping out from just below its surface.
"Okay," Casey said. "Let's find this bad boy." With gentle, probing fingers, Casey pressed around the area, and honed in on the unusual bit of skin that Oliver had noticed.
"Okay, I've got it." Casey grabbed up a wand with a damp gauze pad on the end and announced, "Cleaning," and began rubbing it over the skin. Reaching back to the table, she picked up a circular button with a needle on one end and a long tube connected to a vial on the other. "Inserting," Casey declared, and then pressed the needle end into Thea's body until the circular button pressed against Thea's skin. Thea's expression didn't even flicker despite the needle looking disturbingly large. The tube immediately filled with blood. Oliver found himself darting between watching Thea's and Casey's faces and the procedure, trying to decide if this was something unusual or if this was routine.
Casey calmly plunged the depressor on the vial and clear liquid pushed the blood back through the tubing and into Thea's body. Oliver was disturbed but couldn't look away. "We're in!" Casey crowed, letting the tube dangle on Thea's front. Thea gave her a little affirming smile and then grimaced as Casey deftly connected the tube from the IV to the access point on the tube connected to Thea.
"That's all she wrote," Casey said, sounding pleased with herself. "Anything you need right now?" she asked.
Thea shook her head and after a moment Oliver realized Casey was also waiting for him to respond. "Oh, no thank you," Oliver said, shooting Casey a dapper Oliver Queen smile.
"I'll be around – ring me if you need me," Casey said while gathering her supplies, throwing used items into the trash along with her peeled off gloves.
Thea looked over at Oliver as if she was nervous for his reaction. Oliver tilted his head, fixing her with a look. "Do you have … something in your chest?"
Thea winced. "Yes, sorry – that's my port catheter."
"What is that?"
"It's just a more direct way to deliver IV meds than blowing all the veins in my arms. Once I was put on this new therapy a month ago, it made the most sense to get a port."
"You had surgery?" It was dawning on Oliver that his sister had a double-life in the truest sense – how had he missed all of this?
"Yeah, a really minor one," Thea said almost flippantly. "Caitlin Snow was here – she drove me to and from the surgery. It was outpatient and really quick."
Despite losing his cool inside his head, Oliver said calmly, "So – what's that?" nodding at the IV bag.
"Ibalizumab," Thea said. "It's a second-generation HIV med because my HIV is resistant to most typical therapies. It's supposed to stop T-cells from being changed by the HIV virus."
Oliver's brow furrowed as he tried to understand. "So … it doesn't attack the existing virus?"
Thea nodded in agreement. "No, it doesn't. But it is preventing the spread of additional virus. That's what any HIV med is designed to do – they just all do it a little differently. The viral load decreases as the existing virus dies off and no new virus can be manufactured."
Oliver was doing his best to grasp all of the new medical information that Thea was throwing at him. He tried to summarize. "So … you're in treatment failure from other medications, but you're on one that works?"
Thea seemed to hear the note of optimism in her brother's question. "Technically, yes. But look, I don't know that you're quite getting it -"
Thea was interrupted by a new voice. "Thea, good morning." Oliver turned around to see a man who appeared to be only a little older than Oliver, maybe in his thirties, wearing a tidy polo shirt and khakis. "And who did you bring with you today?"
Thea turned away from Oliver and smiled. "Dr. Henson, this is my brother Oliver. Oliver, this is Dr. Henson. He's been my doctor since … well, always, I guess!" Dr. Henson stuck out his hand and Oliver responded with a firm shake.
"Glad you were able to join us," Dr. Henson said. "I always think that the best recipe for success for our chronically ill patients is having a strong support system." Oliver wrinkled his brow, feeling the sting from being reminded that Thea had been pursuing medical treatment for years on her own. "Thea, I still plan to see you for a follow-up appointment after your infusion." Thea nodded in affirmation.
Oliver interjected, "I have some questions regarding Thea's health and treatment options. Would the follow-up be a good time to discuss them?"
Dr. Henson looked prepared to respond, but Thea answered first: "If it's all the same to you both, I would rather not be a part of that."
"Why is that?" Dr. Henson asked gently.
Thea gave a wry smile. "I think I've had enough of those 'health-status' conversations – I'm not really up for the reminder today. I'd prefer we just have a typical follow-up."
Oliver looked at Thea, trying not to seem angry. "And I get that, but I'm new to all of this and I think Dr. Henson can give me some answers."
Thea looked like she was about to rebut his statement, but Dr. Henson interjected first. "Mr. Queen, if you would like, I can give you some of my time to answer questions now. Of course, that is only with Thea's permission."
"You have my permission," Thea said quickly. "I just don't want to have to hear it."
"Would you like to come to my office now?"
Oliver glanced apprehensively at Thea. "You're sure?"
Thea nodded. "Yes, go. You want answers and I want some peace to read my book."
Dr. Henson led Oliver to a hallway every bit as quiet as the rest of the building. The fluorescent lights shone with artificial brightness as if taunting the darkness of the morning outside. He was guided into a small office. Oliver took a seat across the desk from Dr. Henson, glancing around the tidy but sparce office. Some medical degrees hung on the walls alongside a few awards for outstanding service to the community. A few thick books were tucked on one end of the desk, held up by a bookend shaped like a tiny cartoon astronaut. Oliver didn't see any personal pictures.
"I appreciate your time," Oliver started.
"It's my pleasure, Mr. Queen," Dr. Henson said quickly. "I have treated your sister for a long time and I am glad to see she has started to open up and accept some support from her family and friends."
Oliver felt immediately defensive. "I would have supported her before now if I had known."
"I understand that, Mr. Queen – it wasn't an accusation. Just a comment that Thea will need all the support she can get."
"And that's exactly what I need to talk about," Oliver said, picking up easily on what Dr. Henson left unspoken; that Thea's condition was serious and she would need her family and friends with her. "I need to understand my sister's condition and her options for treatment. Thea was telling me that she is seriously ill – that didn't make sense with what I know about HIV with current medications."
Dr. Henson seemed to consider Oliver's words for a moment. He nodded. "Then let me start with a little about HIV. All of our bodies have white blood cells called CD4 cells which act as the base of our immune systems. They attack infections and viruses as they enter the blood stream. The HIV virus attacks CD4 cells and commandeers them to replicate HIV virus. This both spreads the virus and effectively kills off the CD4 and T-cells, so that there is no protection against other infections." Oliver nodded, already understanding the basics from spending time online throughout the week.
Dr. Henson seemed to realize that Oliver was easily following Dr. Henson's explanation. "You understand that, when HIV treatments are effective, we want to see high T-cell numbers and low viral loads?" Oliver nodded. "A typical person without HIV has CD4 counts well over 500. Thea's CD4 count is just above diagnoseable for AIDs, sitting at 209 cells/mm3." Oliver felt like his heart had stopped. But Dr. Henson wasn't finished. "We look for a suppressed viral load which has appropriately responded to ART therapies to be uncountable or effectively 0, but certainly under 75 copies/mL. Someone with 200 copies we would consider quite ill. Thea's viral load has exceeded 800 copies." Oliver felt sick.
Dr. Henson's eyes were sympathetic, but his words pulled no punches. "Thea's condition is serious. She has developed multiple drug-resistances to typical HIV suppression therapies. Thea is currently on a second-tier HIV medication, ibalizumab, which, at a month in, seems like it may provide her some benefit. I have also been receiving consultation on Thea's case from peers within the infectious disease field, and myself and my colleagues are actively searching for appropriate studies in which Thea could enroll."
"Who are you consulting with?" Oliver asked numbly, thinking about the list of specialists he had begun to reach out to. Of course, each of them had asked that Thea or her physician contact them directly.
"My main contacts have been with Dr. Marlinson at Coast City Clinic and Dr. Rubek at Metropolis General Hospital." Oliver was familiar with both names and felt like his heart sank a little further. "As Thea has become more immunocompromised, I've also formed a relationship with Dr. Ruiz at Starling General. He is an infectious disease specialist and is known as a foremost expert on the treatment of HIV/AIDs in our region."
Oliver swallowed around the dryness in his throat. "It sounds like the ibalizumab is working, though? So she'll be able to recover?"
Dr. Henson nodded slowly. "Perhaps. That is a pretty optimistic take, though. In trials of ibalizumab, it takes 6 months for half of participants to reach a viral load under 50 copies/mL and after a year, there were still 30% of participants who couldn't reach that milestone. If her viral loads don't drop, she'll continue to lose T-cells. Even if we can get her viral load under 75 copies, her T-cells won't bounce back. You see, T-cells do not regenerate quickly and Thea's system is already severely compromised."
Through the fog that was settling in Oliver's mind he managed to ask, "What exactly are you telling me about my sister?"
"Our treatment goal right now is keeping your sister as healthy as we possibly can for as long as we possibly can. Your sister is already severely immunocompromised - she is very close to an AIDs diagnosis. If she loses 9 more T-cells which she could easily do with one bad infection, that would place her in diagnostic range. Also, one opportunistic infection unique to AIDs would also qualify her for an AIDs diagnosis."
"And what's the difference between HIV and AIDs?"
"AIDs is the last stage of the HIV virus. Individuals with AIDs have vulnerabilities to anemia, malnourishment, physical and cognitive impairments, and particular vulnerability to infection. We have come a long way with HIV and AIDs treatments, but even still, we see survivability after an AIDs diagnosis of three years. Half of those with AIDs will live more than three years, while half will die within three years."
Oliver felt dizzy. He had been so sure Thea had been exaggerating – not because he thought she would, but because he had needed her to be exaggerating this. But hearing the severity of Thea's health stated in black and white terms - Oliver felt sick.
"What … what are you telling me? That my sister could die in the next three years from this thing?"
"I don't find it beneficial to try to put time frames on our chronic illness patients; so many things can impact outcomes. But her five-year survivorship score is much lower than we'd like, at 40%." Oliver's face showed his confusion. "Meaning that she has about a 40% chance of living for five or more years and a 60% chance of dying within the next five."
It was like something had descended and wrapped his ears in cotton. Dr. Henson's voice became muffled and was overshadowed by a high-pitched ringing. Oliver felt like he was floating, his body not tied to the ground. Dr. Henson spoke a few more words that Oliver couldn't catch and then waited, looking at Oliver. Oliver gathered he was supposed to respond and shook his head. It must have been the correct response, because Dr. Henson nodded and stood up. The muffled voice said, "I'm so sorry, Mr. Queen," and then Oliver was somehow standing and following Dr. Henson to the office door.
Without remembering how he got there, he found himself standing in front of Thea. She was reclined, with her feet up and the thin blanket covering her legs. The IV tubing connected to her chest was still full of liquid, steadily entering her body. Thea looked up at him from her book, her face relaxed and quizzical. Sounding blurry to his ears, Thea asked, "Ollie?"
Oliver continued past her and sat in the chair next to her. His body couldn't sense the chair under him – he didn't even feel like he had a body. He stared at the room, unseeing.
With a sudden jerk, Oliver became aware of a sensation on his leg. He tilted his entire head down to look. A hand rested on his knee. He slowly raised his eyes, following the hand to its owner to see Thea, looking at him with concern.
Once his eyes met hers, Thea said, "Hey," her brow furrowing as she studied him.
Seeing his sister grounded him. His hearing cleared and the world felt like it resumed its normal speed. He could feel the plastic seatback pushing on his body. He released a shocked burst of air at the suddenness. In the place of the numbness, steadily building in intensity, was a deep, deep sadness. He looked back at her and, with great effort, replied, "Hey."
Thea seemed at a loss of how to respond, reading the melancholy on his face. She said softly, "Want to do a crossword puzzle?"
Oliver was unprepared for the offer – the humor from the dichotomy between his thoughts and Thea's suggestion might have made him laugh if he wasn't so despondent. Instead, he shook his head 'no'.
Thea withdrew her hand and nodded. She looked at him uncertainly for another moment, then turned her eyes back to her book.
Thirty minutes of silence later, Oliver found himself in an exam room while Thea sat on the raised table. Dr. Henson was asking Thea about a whole range of symptoms in a warm voice and Thea responded in a fairly upbeat tone. Oliver was having trouble following their conversation, in part due to the ire filling his chest as the two seemed to be completely ignoring the fact that they were in the middle of an exam for a dying woman.
Oliver did manage to focus when he heard Dr. Henson say, "You're BMI indicates you are approaching an undernourished state. I think it's time we make a plan to supplement what you're already eating. Have you been drinking any of the supplement shakes we talked about at your last appointment?"
"Yes," Thea said. "The Ensures aren't bad. I had one this morning before coming in."
"Good!" Dr. Henson enthused. "I'd like to see you maintaining your current diet and then adding at least one Ensure a day." Thea nodded in understanding. "At your next appointment in a month, we can see how things are going. As we head into cold and flu season, we'll discuss if we want to start a prophylactic antibiotic, or an antibiotic that you would take daily to assist your immune system in fighting infections before they can get a foothold."
That raised a red flag with Oliver. His brow furrowed and he asked, "I thought you're not supposed to use antibiotics that often?"
Dr. Henson looked like he was trying to think of how to answer. He finally said, "You're correct – but I believe in Thea's case, the benefits of avoiding opportunistic infections outweigh the risks."
"If she's taking them constantly, won't that hurt her more?" Oliver asked.
Thea jumped in, directing her comment to Oliver. "Dr. Henson is trying to subtly say that I don't have to worry about the risks – I likely won't live long enough to be bothered by them."
The reminder of why they were there felt like a stab in Oliver's chest. Oliver matched Thea's sharper tone and said, "If that's the case, then why are the two of you acting like everything is fine? If this is an appointment for someone who is dying, why are we giving blood test results like everything is good news?"
Dr. Henson interjected before Thea could, trying to deescalate the tension in the room. "Mr. Queen, your sister is very sick, but she already knows that. She is aware of her current health status, and we are viewing successes and setbacks within that framework. Thea's test results today show that the ibalizumab is working as it should and that is good news. We are going to take every victory we can."
Oliver went silent, but shook his head to indicate he disagreed. Thea and Dr. Henson finished up their conversation and he confirmed her upcoming infusions and follow-up appointment.
Oliver and Thea were silent as they climbed back into Diggle's SUV. Oliver looked at the time on the dashboard clock. It was only 8:45 am. That felt impossible – the last hour felt like one of the longest in his life.
As Oliver started the car, he asked hollowly, "Do you want to grab breakfast?"
Thea said, "I really should head to work."
"You're working today? What about your concussion?"
Thea shrugged, "I rested the last two days and I'm ready to get back. I'm not supposed to look at screens, but I can make phone calls and Sin will help if I need it." Oliver was frustrated again and Thea could tell. "Ollie, I'll be fine. I'll take it easy today, and my place is just upstairs if it becomes too much. Okay?" Oliver shook his head, still unhappy. "Look, Ollie – I can't put my life on hold because of all of this. If I don't go to work on the days I don't feel great, or have an infusion, or an appointment, I would never go."
Oliver turned to look at her sadly. "Then don't go."
Thea returned his look with a determined one, "I'm not letting HIV stop me. I haven't before, and I won't just because you know now." She shook her head. "However you feel about it, I'm sorry. But I just won't."
Oliver silently drove her back to Queen's Jubilee and parked the car on the street. He didn't look at her as Thea opened the door and began to climb out. He expected to hear the door slam shut, and when it didn't, he looked back.
Thea held the door open and was watching him. Finally, she said in a quiet voice, "I love you, Ollie."
Oliver felt his heart throb and some of his anger flowed away. He let out a long sigh. "I love you too, Thea – so much."