It was a story I'd seen before: 19-year-old airman, T-cell lymphoma, air evac'd from overseas after a plethora of symptoms led to the discovery of his cancer .I headed boldly into the room, my orientee close behind me. A young black male, no older than my younger brother, sat in bed, large headphones on his ears. A teenaged boy slept on the couch. Both of them looked up as I entered the room with suspicion in their eyes.
I introduced myself. I asked about his pain. His voice was quiet, his eyes avoiding mine, his body language closed. As I assessed him, listened to his heart, listened to his lungs, checked his pulses and asked him questions, he muttered his replies, his eyes flickering downward toward the white sheets on his bed. He was distant in his answers, as though replying from somewhere out of his body.
Unruffled, I reminded him of his NPO status for his pending bone marrow biopsy that morning and headed back to the computer to chart. Poor kid, I thought. He's clearly afraid. I showed my orientee how to chart the assessment, put in the vitals, and together, we continued on our way.
An hour or so later, the physicians called. They were ready for the bone marrow biopsy. My orientee and I premedicated the patient for the procedure, took our time with answering his questions and put him in the hands of the oncology fellow, a short, bubbly lady physician who was only too happy to answer his questions and hold his hand. My orientee and I returned to our other patients.
An hour later, he returned to the floor. He was just in time to order breakfast. I gave him the menu and he called downstairs for his food as I stood next to the bed. Once again, we asked him if we could get him anything, and upon his denial, we encouraged him to call and headed on our way.
Forty-five minutes passed. We returned to the room to see him and he had no tray. I called downstairs to order; the kitchen had closed. No more diet techs were leaving for the wards for food delivery. My 19-year-old bottomless pit would have to suffer through the next hour and a half on an empty stomach, all because the diet techs were too lazy to bring up his tray.
This was not right. My orientee once more on my heels, I took to the elevators, the two of us storming the galley. I was frustrated and outraged on behalf of my patient. As we entered the galley, two young enlisted sailors met us at the door, ready to deny us entrance. I don't know if it was the determination in my eyes or the fire in my tongue that convinced them to open the doors to the food prep area, but there we were, donning hairnets and traveling through the forbidden bowels of the basement.
The sailors took me to their civilians counterparts, the phone-answering folks and those responsible for assesmbling and dispatching the trays to the inpatient wards.
"Ma'am, the kitchen is closed." A civilian was barreling my way, her tone haughty.
"My patient didn't get his tray. I'm here to get it for him." I said, turning to face my opposition.
"I'm sorry, ma'am, the kitchen is closed." She insisted.
I squared off. "And I'm sorry, ma'am, but I'm not leaving until I get his food. You still have food out in the prep area. I'll put the tray together myself. But understand this--I'm not leaving without his food." I replied evenly.
Her eyes darted from my face to my rank. I was just another second lieutenant at the time, one of hundreds at the command, but apparently the gold bar was enough to convince her that I'd take the matter higher if it wasn't dealt with immediately.
"All right." She conceded. Within ten minutes, we were on our way back upstairs with our hard-earned tray.
My orientee brought him the tray, presenting it like the trophy it was. He barely looked at us, murmured a thank-you as we left his room, both of us admittedly disappointed at his response to our heroic efforts.
A half hour later, his call bell rang and we returned to his room. The pain from the biopsy was intense, much more intense than I'd seen in any patient before. I got an order for breakthrough pain meds, overrode the order in the Pyxis and began to push his morphine.
As I delivered the dose, he began to whimper, suddenly asking me to stop.
"What's wrong?" I asked.
"It burns!" He exclaimed through tears.
I felt irritation flash through my chest. Here I was bending over backward for this kid, charging the kitchen and fighting with the pyxis and putting on my happiest face, and he was complaining about the pain meds he had just been crying for? I choked back my frustration and flushed the line, the pain abating instantly as the saline replaced the narcotic.
At the desk, I explained what had happened to our intern, who rolled his eyes. "Fine. Percocet. It's not nearly as strong or as fast-acting, but if he can't take the IV narcs, it's the best I've got."
I returned to the room, provided the once again overridden med, and left the room after making sure he was all right. Not so much as a thank-you followed me to the nurse's station.
For the sake of my orientee and my pride, I held it together. On the surface, I was frustrated with his lack of response to my compassion. I was irritated by his apparently impervious take to my Herculean effort to make him comfortable. What I wouldn't realize until much later is that I was really just afraid.
The shift continued similarly. I did my best to reassure him, to calm him, to sit with him, but he wanted none of my empathy. When his mother arrived, he collapsed onto her chest, and I was relieved that he finally had someone who he trusted to fall against. But the frustration I had felt earlier still grated against me and against my genuine efforts to secure a good rapport.
The next day, I had him back. All day, I medicated not his pain, not his physical body, but his fear. With incredibly diluted IV pushes of dilaudid, I realized that I numbed his mind from the reality of his physical state and induced the sleep that spared him from the mental agony of his cancer.
My coworkers, nurses and doctors alike who were familiar with the situation, sighed in a similar frustration. When was this airman going to man up? When was he going to accept this diagnosis and snap out of it? We aired our grievances privately to each other, and I though I knew full well that what we were witnessing was simply the ineffective coping mechanisms of a patient who was not yet truly an adult, his inability to accept our kindness and his own disease still poked at me like a thorn in the side. Perhaps I'm becoming too jaded, I told myself. Perhaps it's time for me to get out of oncology.
Weeks later, he returned to our ward. He was early for his chemo admission, still withdrawn and difficult to illicit even the most basic responses from. It was as though he had regressed to his early teenaged years under the stress of his disease. He was not my patient, but when he reacted to his blood transfusion on the weekend, I, as charge nurse, assisted his primary nurse and my good friend in collecting the necessary samples and setting up the IV fluids that were warranted. He was just as I remembered him from before: a quiet, whimpering little brother, afraid, alone now that his mother was 500 miles away, and painfully withdrawn.
But this time, I recognized the emotion that hid behind the veil of my old frustration. It had been fear. I was afraid that, as a nurse, my care was ineffective and inadequate to soothe his fears. I was afraid that I didn't have the emotional capacity to calm him. I was afraid that if I were to find a way to reassure him, I'd lose the bubble that insulated me from the cruel reality of my patients' often grim conditions.
It was fortuitous that I had the weekend to consider these facts, because today, Little Brother returned from the PICU to our ward. Despite my hesitation to take him as my patient, all the other nurses were busy. His care fell to me. I prepared myself emotionally for the long haul.
I was exiting another room when I saw the PICU nurses in their maroon scrubs returning down the hall with an empty wheelchair. I got a quick follow-up report, bid them farewell and met my tech outside the room. We entered together, fully ready to continue cajoling this adolescent-like young adult into cooperating with our care.
To my shock, he sat up on the bed, fully emerged from his blanket-like cocoon, and he smiled as we entered.
"Good afternoon. How are you feeling?" I asked him.
He looked me square in the eye. "Much better, maï¿½m." He replied.
I almost fell squarely on my fifth point of contact. He spoke! "Any pain today? Any nausea?" I asked.
He shook his head. "Nope. I've been able to eat now and keep it down for a day or so."
And on went the discussion. I set up his IV antibiotics, explained what they were, and as I did so, he talked. We found that we both had very particular taste in water of all things. While he preferred bottled, I was staunchly in favor of tap. He told me about a girl on facebook who had friended him. "Do you ever have it happen where you see someone and you know you've met them before, but you don't remember when?" He asked. "It's awful, isn't it?" I empathized. "Oh, it's terrible!" He exclaimed. He told me about how things were going outpatient, about how he missed his mom, about how he was glad to be back on our floor because he had been lonely in the PICU.
I listened and nodded, interjected my opinion when it seemed warranted, and eventually, as I programmed the pump for his vancomycin, he asked me a question.
"How do you do this?" He asked, his tone suddenly serious.
I stopped my work and made eye contact with him. "What do you mean?"
"I mean this." He said, looking around. "How do you work with people who have cancer and diagnoses like this all day?"
I sighed. It was a question I'd been asking myself a lot, lately. "Well, I guess practically speaking, people are going to get sick. I figure they'll get sick whether I'm there to help them or not, so I'd rather be there and have a chance at making it better than just giving up." I said.
He nodded, visibly chewing on my words.
I continued. "As for patients--I guess I can't really come at it from that angle. I know it's got to be difficult to be young and have cancer, especially when you were in such good physical shape before. I have a friend who survived leukemia and he told me he had similar struggles, but y'know, he's healthy now. He's been in remission for a few years. It's not like this diagnosis is a death sentence."
He nodded, his eyes flickering with the thinly veiled hope in my words. "I just hope it doesn't come back."
I wanted to tell him it wouldn't, but I knew better than to make promises. So I nodded in return. "Me, too."
"I was so angry when I found out I had cancer. I mean, why me? Why am I the one who gets this at nineteen?" He said. "It's just not fair."
I was amazed at what I was hearing. To listen to him discussing what he had been feeling and what he had been through was therapeutic to be certain--for him and for me.
"No, it's not." I agreed.
"I guess I'm just coming to terms with it now. I didn't realize I could be depressed and angry." He told me.
"Acceptance usually comes after going through many stages, and not always just once. It's not quite as tangible or definable as some people will have you believe, and it's very normal to go back and forth. Some days will be better than others." I reassured him.
He nodded. "I'm just ready to get this chemo over with."
The rest of the shift only improved. Every time I went to see him, I stuck around to talk. He made me laugh, I made him laugh, and eventually, I'd say goodbye and see him in the next hour only to repeat the previous interaction with different jokes and discussion topics. By the end of the day, I introduced the night nurse and said goodnight, genuinely looking forward to seeing him again.
So tonight, I sit here to write about things that I know I must remember. The girl who graduated nursing school two years ago and found herself unwillingly placed on an oncology ward met me today. She shook me by the shoulders and reminded me that pain is often masked in anger and fear, that sarcasm and cynicism do not often improve patient outcomes, and that a little patience with the most difficult patient goes a long way. She reminded me of the longsuffering nature she had entered her field with, of how she could often see through the coping mechanisms that those more experienced and more calloused had lost the ability (or at least the willingness) to identify, and how she had hoped as a young nurse that she might never lose that talent when it came to understanding the pain of others, however masked or distorted.
Tomorrow, the day will dawn new. And I'll return with the most knowledge, the most skill and more compassion than I've ever known to the care of Little Brother and countless others like him.