Cancer Ward. I am always momentarily confused by these vivid murals. The multitude of smiling figures positioned haphazardly on an empty background seem ...
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Lessons From the Practice Good Night, Joyce GLENN FLORES, MD, New York, New York
As I step off the elevator, colorful cartoon characters, animals, and balloons greet me as I enter the Children's Cancer Ward. I am always momentarily confused by these vivid murals. The multitude of smiling figures positioned haphazardly on an empty background seem at first glance to be hovering and darting menacingly, but when I look again, the figures greet me cheerfully and placidly. The hallways here are airy and well-lighted, even now in the early evening. I like the Children's Cancer Ward. Most of my physician colleagues detest it. They say it is too depressing. They assert that it is too overwhelming, that they would soon "burn out" if they worked here every day. But I look forward to working on this ward because to be with children with cancer is to be immersed in the realities of life. A gaunt, bald 8-year-old child in a flowing, oversized white hospital gown trudges by me. She pushes a stainlesssteel IV pole from which hangs a large bag of hideously yellow fluid. A tube parasitically enters beneath her gown. As she passes me, she flashes a smile full of chemotherapystained teeth, and I glimpse mysterious bruises and scars on her face and neck. I smile back at Joyce. She is one of my favorites. Joyce has acute myelogenous leukemia. Despite a bone marrow transplant and the most intensive chemotherapy regimens we can offer, her disease has recurred twice. Her prognosis is bleak. During this stay she has brushed aside yet another serious infection that easily could have killed her. It still might in the months to come. Our team of physicians gathers around Joyce's bed today, as we do for each patient on morning rounds. Some of the younger children here dread this part of the day. They whimper and frantically search for their mother, or lie still, sobbing, convinced that they will be subjected to some new unpleasantness. It hurts me each time I see these reactions, but I understand, and they are justified. Young children with cancer associate their physicians with the most terrifying and painful experiences they have ever endured. When they see me, they remember only the harsh chemotherapy that burns their veins, causes them to vomit for days, and makes them lose all of their hair. Or they remember the days of hip soreness following the time I forced anesthesia on them so that I could drive a needle into their bones to draw out marrow. Or they remember that each time they enter the hospital with a life-threatening fever, I get others to hold them down so that I can stick them with a needle to take their blood. They will never know that I have stayed up all night, fighting cancer and infection in their bodies with hours of careful monitoring. They will never know how much I might have come to care about them.
Joyce awaits the last person on our team to approach her bedside. She sits upright in her bed, pillows carefully propping her up, sheets and blankets neatly tucked in around her, as if she has been anticipating our arrival with great relish. "Which one of you doctors put me on this stupid diet?" she demands imperiously, addressing us with studied circumspection, as if holding court. We all burst into laughter. A small smile creeps into her face as she disdainfully directs her attention to a bowl of soggy rice in front of her. When we finish laughing, Don, a fellow resident and now the obvious culprit, timidly tries to defend himself, armed with a fatuous smile. "This is a special yummy diet we give all the kids when they have problems with going poo-poo too much, Joycey." Joyce scowls at Don. "Have you ever tried to eat rice for breakfast? You call that a breakfast!" We laugh again. I turn to Don. "Dr Daniels, how about letting Joyce have some real breakfast food, like Fruit Loops?" Joyce's eyes light up. "Yeah! Or an Egg McMuffin, or french fries. Get real, Dr Daniels!" It is obvious Don is a beaten man. As we file out, Don apologizes and assures Joyce of a more appetizing menu for lunch. As he leaves her room, she blurts, "OK, but don't forget, or you're in trouble!'" It's night. I'm on call. A nurse asks me to check on Joyce's complaints of pain. I find Joyce awake, sitting up in her bed in the dark, alone. Her mother frequently stays overnight in a recliner next to her bed, but she has gone home tonight. I can tell Joyce is awake by her movements, but until I reach the light I cannot discern her facial expression or mood. For a moment I feel in my gut a chill of desolation and sadness. I can only wonder what it is like to be a child of eight, alone in the darkness of a strange hospital, constantly reminded by pain, uncomfortable procedures, and other ravaged children that they have some gravely serious disease called cancer. Too many times the false comfort of narcotics is all these children have as they are insidiously devastated by the pain and progression of the disease. I turn on the light. Joyce sits happily in front of me, smiling. My attention is drawn to the gold-speckled nail polish on her fingers and toes. "What's up?" I ask. "I have a little sore throat, and it's keeping me up." I am relieved. Maybe she just has a sore throat. I decide to examine her lymph nodes anyway. Her nodes are huge on both sides at the jaw angles and all over her neck. Indeed, any nodes I check are grossly enlarged. She is having a relapse on her last chance at a cure. I am upset but determined not to let it show. "Do you want some morphine for the pain? I already told your nurse that you can have it almost any time you need it." She replies without a pause, "Nah. Tylenol is fine. But don't give me any of that baby's Tylenol. I'm old enough to take
(Flores G: Good night, Joyce. West J Med 1992 Apr; 156:439-440) From the Department of Pediatrics, New York Hospital-Cornell Medical Center, New York. Reprint requests to Glenn Flores, MD, 1303 York Ave #4B, New York, NY 10021-5673.
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pills, and they're always giving me that baby stuff. Why can't they just gimme a pill?" She violently emphasizes the last word while imploringly holding her open hands skyward, like a seasoned New York City cab driver. "Don't worry, Joyce, I'll make sure that the only Tylenol you get is a pill. No baby stuff for you." She flashes a little smile. I go to turn off the light above her bed, but she balletically flicks off the switch and lies down in one motion. "Oh, Dr Flores, don't forget that you guys promised me a real breakfast tomorrow." "No problem, Joyce. You can count on it. Just save me a little bit." I see her turn her head slightly in the dark. "Maybe. I'll think about it." I walk toward the doorway, and almost make it out. "Oh, Dr Flores!" she shouts. I turn and walk back in the room towards her bed. "What, Joyce?" She pauses momentarily. "Good night, Dr Flores." I reflect in the darkness. "Good night, Joyce." My colleagues ask me why I like working with children with cancer. These children teach me about dealing with death. Children express feelings in the purest human form. They are not fettered by the propriety and repression of
adults. I learn from the fearful children, the ones who sense death's imminence despite their parents' well-intentioned attempts at cover-ups. From them I reaffirm life's immediacy and vitality and how integral a part of life family is. And I learn from the determined strength of children like Joyce. They teach me that you must defy life's misfortunes with fundamental passions. Joyce's insistence on dignity is the flower that grows in spite of the desert. *
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"Lessons From the Practice "presents a personal experience ofpracticing physicians, residents, and medical students that made a lasting impression on the author. These pieces will speak to the art of medicine and to the primary goals of medical practice-to heal and to care for others. Physicians interested in contributing to the series are encouraged to submit their "lessons" to the series' editors.
ONE CANDLE AND TWO RED BALLOONS A black flame of resentment Smolders in the twigs of passing years, Crackles in the tall grass of middle age: My son will never Be one again, And I am growing old. His birthday candle Flickered at blue icing Just when the nurse called that night. I had to go. We tried for hours To save edematous lungs. I went home almost as dead as them, Found some colored paper, a ribbon, Red balloons popped like shreds of pleura Scattered in the quietness where my son slept. I went to the kitchen, Found a clean knife and plate, Ate a piece of chocolate cake alone. He is now grown, and The old man died so much more easily Than the memory of that one candle. Yet I chose this work, Would choose again this way To become old myself. ERIC DYER, MD) Nashville, Tennessee
JONATHAN E. RODNICK, MD STEPHEN J. McPHEE, MD Series' Editors
