Fallout

You assume it's going to be the sadness of patients dying. That's the obvious emotional burden, the one that people are thinking of when they say things like, "I guess you have to be a special kind of person to work in oncology." And the truth is, I haven't gotten to that part yet.

Some of "our" patients have died, of course, since I've been working on the floor, but I'd only actually even met one of them, and I didn't know her well. I'd never taken care of Mrs. W myself, though on one occasion she did graciously allow me to come watch the process of flushing her double-lumen urinary catheter (she had terrible hemorrhagic cystitis, a bleeding bladder, and required frequent flushing to get the clots out--they caused her great pain). She was clearly a warm and lovely person, but my own sadness at her death felt distant--there were so many nurses who had genuinely been close to her, and I just hadn't been.

I have started to notice, though, occasional surprising flares of anger. Hatred, even. I spend most of my time in a reasonable, therapeutic, compassionate mindset. Here I am, being there for my patients, providing all I can in terms of understanding, comfort, and care. You know. Professional and warm-but-detached. This is not my suffering, and it's almost presumptuous to take it on myself. But. But every so often, this eruption of red-hot feeling comes through. It fortunately lasts only a couple seconds at most, but it tends to catch me off-guard, even though the kinds of things that provoke it are kind of predictable. The dad getting a bone marrow transplant is visited by his two small children, and has to put on a mask and gown and gloves to spend time with his own babies, and then they go away again, and he waves bye-bye to them through the glass window in the door of his positive-pressure hospital room. I stop in to say hi and chat briefly with N, a rebellious and funny 30-year-old with lymphoma in his own mask and gloves, sitting at the computer in the patient lounge, and as I leave, I pass G, a 21-year-old with metastatic osteosarcoma, who measures his time left in months. I hear from J, a woman in her late 20s with newly diagnosed leukemia, about her lack of health insurance. She's smart and thoughtful and incredibly sweet. In her hospital bed, she knits because her chemo has messed with her vision, and it's hard for her to read. She has amazing tattoos on her arms. She's been finishing up her bachelor's, and next year, she would have been moved into a job category with benefits. The people at the school where she works held a big raffle to raise funds for her care.

And then I get this flash of blind rage. For a moment, I just hate cancer with everything I've got. I want to get a torch and rally a bunch of villagers to TAKE THE FUCKER DOWN. And then before I even take another breath, I realize that's ridiculous, and cancer is not a very well defined villain, and I simmer down, and I go on with my day. But for a while, a kind of unsettled feeling lingers. Who knew I had that kind of anger?

And then, yesterday, the tears came for the first time. Pete had taken Cassie to a children's concert, and I had the house to myself for a couple hours. I was picking out some music to put on to clean by, and I noticed my Norah Jones cd. I don't play it very often, but now I wanted to. Julie, my preceptor, had told me a story that her patient Mrs. G had told her. Mrs. G is a lady in late middle-age, built like a fireplug and now also entirely bald from the chemo. She has a fairly thick accent I haven't yet identified, and is warm and funny and outgoing and generally a real character. She has a framed picture of herself mugging with a lollipop because she thinks that without hair, she looks just like Kojak. She's had a long course, and now she's in for a bone marrow transplant, which entails a grueling and somewhat dangerous regimen, with a hospital stay of at least 5 weeks. She told Julie that a couple days before she came in to the hospital to begin the process, her whole big extended family had gathered. The occasion was maybe some grandchild's first communion or something, but because of Mrs. G's situation, the party was more on the scale of a wedding. Everybody was there. And when the dancing was going to start, the floor cleared, and Mrs. G's son came to get her to dance, and the dj put on Norah Jones's "Come Away with Me." There wasn't a dry eye in the place. (This, of course, extended to Julie and me, misting up talking about it in the clean utility room as we got supplies for a dressing change.)

So I decided to put on Norah Jones, in honor of Mrs. G, as I tidied the living room. And when "Come Away with Me" came on, I indulged myself in a good wallow, summoning a cheesy mental montage of Mrs. G being in the hospital and getting chemo, with all the concomitant boredom and discomfort and frank suffering, as her loving son invited her "come away with me," even though he knew she couldn't. And what I found myself thinking, as I sobbed at my own generated pathos, was not just "how sad," but "I'm sorry." I'm sorry, I'm sorry, I'm sorry.

The emotional difficulty in being an oncology nurse is not just in the grief and sadness, I realized. Part of it is that being a person who administers chemotherapy implicates you in the suffering. Chemo sucks. And yes, you can take a step back and think about how it's the best chance, the only chance, for many of these patients. It could buy them months, years, of life--in many cases, symptom-free life. Sometimes it, along with surgery and radiation therapy, even cures. And that the patients have chosen this route as the least of the possible evils; they actively want this treatment.

But still, chemo sucks. And there is fallout from giving people incredibly toxic substances, putting these vile chemicals right into their veins. And then watching their blood counts fall, watching their liver function test numbers rise, watching their electrolytes get out of whack. Watching the nausea, the fatigue, the mouth sores, the diarrhea, the rashes. Administering packed red blood cells when the hematocrit falls below 25 (normal is around 40), platelets when that count falls below 20 (normal is over 150). Bringing in handfuls of pills, giving medications to control the side effects from the medications you gave to control the side effects of the chemo. And even though you know why, there's still something in knowing that you did this to them. You, personally. You hung up that bag, you strung the tube through the pump, you attached it to the catheter or the port leading directly into their bloodstream. Cytoxan, ifosfamide, etoposide, cytarabine, high-dose methotrexate. You punched the numbers on the pump's keypad to administer the carefully calculated number of cc's per hour of the poison.

Meanwhile, at the end of my shift on Friday, I heard two of the older nurses talking. I didn't know who they were talking about at first, because I always call this particular patient by his last name, and they were using a diminutive of his first name. His mother is in the patient lounge now, crying, they said. Of course you can't blame her. He still has blasts in his periphery. There's nothing more the oncologists can do. It finally dawned on me who "he" was. It was N, the 30-year-old at the computer.

Fuck cancer. Fuck. Cancer.