we all walk the long road

The job of the intern on night float is to cover all the patients in the hospital on the Medicine service. This means that, should anything come up, the nurses page the night float intern. But it also means that most of the decisions of treatment and management have been made during the day. There is a slang among us, to do with how well you care for patients during the day: if they are well-managed and treated, they are considered "tucked in" for the night, and you tend to hear little about them over the course of the night.

The "untucked" patient at night, on the other hand, can be traced to one of two causes:

• The team did not properly "tuck" them in during the course of the day.
  
• The patient is very sick and "tucking" is therefore impossible.

It is hard to hold it against anyone if the latter reason is the cause of the various phone calls. But often it is the former that leads to the cacophony of a screeching beeper in the wee hours of the night. Last night, as the night float intern, I wound up having two extensive discussions with patients who had cancer, and it was evident that communication had not been good with the team during the day. One of the patients was an unfortunate 27-year old Punjabi woman who had recently been diagnosed with stomach cancer. Her belly is riddled with tumors. She is getting chemotherapy to keep her symptoms managed, but there is no chance that it will be curative. She asked to speak with me about why her belly continued to hurt. I was surprised to find she had not had much of a discussion about her cancer with the physicians taking care of her during the day. I had a frank conversation with her about the tumors and how she would likely continue to have swelling in her belly, and that our best bet was to manage her pain with medications as best as we could. She was startlingly young.

Looking at her, I was reminded again of why I would never want to do Pediatric Heme/Onc. I know that kiddos bounce back fast, but seeing someone that young face a terminal diagnosis takes a more palpable toll than much else I have seen in the hospital. The next morning, the physician who cares for her during the day, an intern herself, told me that she knew someone needed to have a conversation about the cancer and how bad it looks with the patient, but that she "just couldn't do it." The idealistic, wide-eyed intern I was 9 months ago would have given her the stink eye and yelled at her for being a wimp. Truth be told, it was inappropriate to put off the conversation. I couldn't yell at her today though. I felt like she was recognizing limitations in herself, maturity that she did not yet possess, and it was perhaps too demanding to want her to be as comfortable with the conversation at this stage.

An uncle of mine had a child who was born with a congenital abnormality, which affected the child's development significantly. Sometimes people would ask my uncle how he dealt with it. He never looked at it that way, though. He always said he felt lucky, he felt he had been entrusted this person with extra needs, and it was a privilege, a blessing to be able to take care of this special child.

It's not really the same, but I do sometimes feel that way about oncology. It's not that anyone savors having conversations about death and dying, about bad news and hard fights with poor odds. But it truly is a privilege, it is a blessing. If you're not equal to the opportunity, if you can't see it that way, if you find it daunting to fight the urge to flee from the conversation, perhaps it's best to let someone else do it.