Saturday, October 29, 2011

Pediatric Impressions

“Mi hijo, tu amigo esta aquí.”
His first day in the hospital was my first day on pediatrics.  I sat in a meeting room full of doctors and soon-to-be doctors—all on duty for the pediatrics inpatient service.  Every morning the team on call ran through the new admits.  “This is an 8 year-old male presenting with knee pain.”  We discussed the boy’s symptoms, came up with a list of diagnoses, and looked at radiographs.   An hour ticked by as discussions were held and decisions made.  People scratched their heads mining for answers.  Some rubbed their chins sifting through thought.  It was my first day and I mined the corners of my head and sifted through the hairs on my chin for anything.  It was his first day and he was the topic of our discussion and decision-making.
He was a kid with knee pain, abdominal discomfort, and subjective fever.  X-rays showed there was something disrupting the bone in his knee.  Maybe infection.  Possibly cancer.  We needed a bone biopsy and orthopedic surgery had already been consulted.  It was my first hour on pediatrics—I had yet to meet him—but his was the first story I knew.  He was a lytic bone lesion awaiting biopsy to rule out malignancy.
We walked in for the first time.  He sat up and shot us a tense glance.  It was our first meeting and I supposed that six white coats marching single-file into my room might make me tense, too.  But there we were—a combined one hundred and sixty-three years of experience all draped in the sterility of white.  He was eight, draped in a hospital bed sheet.  He was a large kid, carried a barrel-shaped torso and was a solid foot taller than most second-graders.  His dark eyes stared out over the baby fat on his face in a look of wide-eyed innocence.  It was day one.  He was our interesting new case, and he was in the corner room.
I walked into his room two weeks later by myself.  Two weeks on the pediatrics floor had taught me to leave my white coat at home.  Kids don’t like it.  He smiled at me.  “Your doctor friend is here,” mom announced and he smiled some more.  I felt proud because shy kids do not smile for everyone.  I sat down with a book in hand and greeted mom.  No, still no word on the biopsy results but they should be back soon.  I had been reading aloud in my spare time.  He wasn’t very good at sounding out the big words yet and I wasn’t too busy.  In our second week, we were working to remedy our situations together.
Week three.  The final pathology results came back positive for cancer.  He was in a lot of pain and playing a lot of video games.   We still read together and he still smiled when I poked my head in.  But he was having nightmares and throwing tantrums.  Requesting pain meds by name.  We needed to run more tests—more blood draws, more scans.  The pediatric oncologist was now calling the shots.  Time to start chemotherapy.  Time to cut down the IV fluids.  The parents remained always at bedside.  Sometimes mom and dad would take shifts but mostly, they were there together.  I learned about metastatic acute lymphoblastic leukemia.  He learned about the cancer in his knees, his hip, his pancreas, his jaw.  I thought about how pancreas was too big a word for an eight-year-old.
“Hey buddy, how you doing?”  His face was blank.  I wondered if four weeks in the hospital had begun to hollow him of the things that make children jump and play.  He looked at me, and through me.  No answer.  I talked about his favorite TV shows and brought his favorite book.  I looked at the corner of his lips.  No response.  He shook his head when I asked to read to him.  He shook his head when I asked to play with him.  So I sat with him and I talked into the air.  Mom smiled at me.  “Your doctor friend is here.”  I looked at the corner of his lips.  No movement.  He wanted to go to sleep, wanted to go home.  Mom looked at me and I kept talking into the air.  Mom smiled at both of us and I paused to stare at the book in my hand.  She kindly inquired about the treatments—if they were helping, why was there so much pain?  She wanted to know how much longer.  We’d been there for four weeks, and I had no answers.  Four weeks, and I just had big words.  Shy kids do not smile for everyone.
Dysthymic, listless, blunted, anergic, depressed.  These were our words.  “What’s wrong?” we prodded every morning.  We smiled and offered and reassured every morning.  We felt our efforts graze his hollow stare, leaving untouched the painful frown beneath.  His vocabulary for describing thirty days in a hospital was painted in his eyes and in his face.  It floated upon his screams, picked up by nurses down the hallway.  He screamed through most of the night and slept through most of the day—except when he screamed during the day as well.  I sat down with a book.  He closed his eyes.  “Hey champ, you want to read this with me?”  He blinked and rolled over.  Mom leaned over him.  “Mi hijo, your doctor friend is here.”  He screamed that he wanted to sleep.  I leaned over him.  Let’s work together.  No.  You are being a baby.  No.  I will bring you a bottle and we will have to feed you like the little babies.  No, no, no.  I made him angry and anger made him sit up in bed and look at me.  The chemotherapy is working and you will be going home soon, I told him.  No.  If you do not walk, we can bring you a stroller to sit in.  No!  His screaming and crying fueled his walking.  He walked to the window and looked outside the hospital.  At the freeway.  At the houses across the freeway.  He wanted to go home.  Yes.  Yes, in five days I said.  Yes, you will go home.  His eyes met mine.  “Five days?”  I explained that if everything went well, he might go home in five days.  His frown softened.
Four days passed.  I didn’t know if he was counting, but I knew I wanted to keep my word.  On the fifth day he had a seizure.  It was the beginning of my last week on pediatrics.  I walked into a room full of doctors and nurses bustling in organized chaos.  White coats were discussing and deciding.  Lights were being shined into both pupils.  He wasn’t frowning.  He wasn’t moving.  Doctors were talking.  “Can you hear me?  Squeeze my hand if you can hear me.”  I sat down next to mom and she was trembling.  I went to look for some tissues and returned with a box.  She squeezed my hand and we stared at him and all the concerned faces huddled around him.  We listened to the beeps of the monitor.  We gathered his belongings as he was rushed back to the PICU.  A tube was placed down his throat and more monitors were hooked up.  I sat with mom.  The doctors were not ready for her to visit in the PICU yet. 
“He was mad at you, you know.”  He had been counting.  I nodded.  I knew.  She smiled through her tears.  “I told him that he had to be good and everything had to go right, but he was mad.”  I understood.  “He said you had told him that he was going home.  And he said you lied and you weren’t his friend anymore.”  I blinked.  “But I know you were just trying to give him hope.  I was trying to get him to be good and trying to support you.”  I told her I was sorry.  I told her when he woke up, I would apologize to him as well.  We sat together.
Posterior reversible encephalopathy syndrome.  The doctors mentioned that it was not uncommon in our kids with cancer.  Most recover completely, but not all.  We would wait and see.  I visited him on my last day with pediatrics.  I put on the sterile yellow disposable gown.  The blue gloves.  He slowly opened his eyes and met my gaze as I slid in past the glass doors.  The tube was still down his throat.  Mom smiled at me.  I touched his arm and spoke to him directly.  He made a weak attempt to gesture with his left hand, shot a weak glance down at the tube coming out of his mouth and then steadily closed his eyes and turned away.  I told him that if he could hear me, I wanted to apologize.  
I talked, hoping that he could understand me.  Hoping that I wasn’t simply talking into air.  I said I understood he could not speak with the tube, and I understood he was mad at me.  I apologized for lying to him.  I told him he had a seizure, a setback.  Then I explained that I would not be seeing him every day anymore—that a new team would be taking care of him.  I said I would try and visit often.  But I wanted him to know that everyone was working together to help him get better.  I wanted him to know it wasn't going to be easy, and that I didn’t know how many more days.  But that he would not be in the hospital forever.  He would get better and leave the PICU.  That he would get better.  Go home.  Mom asked me why they were changing doctors, and who would be on the next team, and where I was going.  I told her that students rotated to a different service every six weeks.  “That is too bad,” she said.  She gave me a hug.  We allowed gown and gloves to wrap snuggly in a single embrace as I smiled and blinked.  I fought to hold her gaze as she thanked me.  I turned, felt my breath waver, and stepped quietly out of the room.  I washed my hands, wiped my face and exhaled steadily to clear the tightness in my throat.  Then I turned back around to wave goodbye through the glass doors of his PICU room.  
I visited again a week later after the tube came out and he could whisper short phrases.  I visited again a couple weeks after that when he left the PICU and was back into his old room—the one in the corner, the one where he started.  I visited again this week.  Mom recognized me, smiled and turned to him.  "Mi hijo, your doctor friend is back."  It was his eleventh week in the hospital.  His hair was thinning and his cheeks ballooned with all the weight he had gained.  The ugly effects of chemo.  On his bedside table was a small laptop playing old home videos.  Mom told me that family members had compiled a DVD of memories to help him remember.  Help him feel at home.  He sat and stared silently at a younger version of himself blowing out candles for his fourth birthday.  Chasing his cousins around a park near his home.  Then dancing with a girl in kindergarten.
“Dude, you are a really good dancer, huh?”
He nodded.  Then after a pause, “She...she was my girlfriend."
“Your girlfriend?  She is pretty.  Well, I bet when you are a good dancer, all the girls want to dance with you, huh?”
Another pause.  “Yeah,” a bashful smile spreading across his face.
“Hey, I brought a book for us to read.  Is that okay with you?”
He nodded again.  He looked at the book as I turned open the cover.
“Alright.  But you are going to have to help me with the big words, okay?”

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