Education of a cancer nurse

(Salon) Excerpted from “I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse

I walk a fine line, as a nurse, between saving lives and pissing people off. Jim’s face is brick red. His neck veins bulge as thick as rat tails when he coughs. I’m elbow deep in frothy mucus, suctioning his tracheal stoma, the permanent breathing hole in his neck. The suction tube slurps the remaining juice with a satisfying sloosh. His coughing slows and he blinks tears from his eyes. If his voice box hadn’t been surgically removed, yesterday, a slew of profanities would escape him. Instead, he looks at me with eyes that teeter between “I hate you” and “Thank you.”

“How long have you been a nurse?” Jim’s wife, Debby, asks from the other side of the hospital bed.

I’m tempted to answer, “First day on the job!” Her face is soft and flushed from her fear of having to learn to suction her husband’s airway. She’s up next. She buries her hands in the pockets of her cardigan as if she could make them disappear. I’ll save that joke for another day.

I tell the truth. “Just over a year.”

When I was fresh out of nursing school, a year ago, I would have hugged her. Part of me would like to, even now, but I know better. In school, nurses are taught to be gentle but professional. A nurse is to be poised, polite and unbiased. A nurse is to love no patient, but care for them all. Words like empathetic and sympathetic are discussed and debated so frequently that their meanings are tangled in my mind. No professor teaches ruthlessness to nursing students, yet after thirteen months on this unit, it’s become second nature. It’s not in the glossary of any guide to nursing interventions, but it’s as important as any other skill. A good nurse must know how to attack.

I take a breath and brace myself. It’s time to pick my first fight with Debby and Jim. “You’re going to suction Jim’s airway,” I tell Debby, with no inflection of a question in my voice.

“Have you always wanted to work with head and neck cancer patients?” Debby asks. She shields herself from the strike with distraction.

Yes, while other little girls were dreaming of becoming movie stars, I was dreaming of dodging mucus bullets in a hospital room. Of course I didn’t always want to do this! More than that, I never wanted to do it. I opt for selective honesty: “While in nursing school, I wanted to work in labor and delivery.”

As a student, I dreamed of coaching soon-to-be moms as they brought their gooey, screaming babies into the world. I would hold the mom’s hand, help her through labor, witness the miracle of life, clean that little miracle and hand over the baby to the parents. Babies—pink and soft and new. I couldn’t help but love them. There was only one flaw in the plan: no job availability. So here I am on this post-operative unit, working with cancer patients who have disfiguring and life-altering surgeries. My patients have had their eyes, tongues, ears, and noses surgically removed. They’re real-life Mr. Potato Heads, a piece always missing. It’s not the cozy blue-and-pink world of nursing in which I had envisioned myself. Instead of holding hands and instructing my patients to push, I’m pushing them to be independent, to let go of my hand.

“Labor and delivery?” Debby questions. “That’s a whole different world!” I nod and hand her a twenty-two centimeter suction tube. I know her type. She’ll talk for minutes, stalling, if I allow her. She pinches the tube between a finger and thumb, dangling it away from her body as if it’s a slimy worm.

“Use both hands, like I showed you. Remember, you can’t harm him.” Jim’s eyes spring wide with alarm, and I direct my comments to him. “Harming and hurting are different. She won’t hurt you any more than I do.”

“You get paid to hurt me!” Jim mouths. I laugh, unsure if he’s joking.

“I get paid to keep your airway from clogging up with mucus so you don’t suffocate. You can’t take me home with you next week, so you both must learn to do this.”

“I really wish we could take you home!” Debby’s voice bursts with longing. I stifle a laugh. She’s not the first to request my services as a medical butler. Her shiny eyes focus on the quarter-sized hole in his neck. It’s the price he paid for the removal of his cancerous vocal cords. Also, for the reward of continued life. With the flashlight, we can see three inches down into the tunnel before the trachea curves. The surrounding skin is raw, swollen with sutures, and crusted with snot. “I can’t do it.” Her face scrunches up, on the brink of tears. She’s never felt so vulnerable. She’s never felt so helpless. I attack.

I force her hands into position on the catheter and shove them toward the hole. “I’m going to help you this first time,” I say. That’s what they want to hear, that you’re the one in control. The part I leave out is that I’m going to let go, like a first ride without training wheels. Tough love. It’s the only way.

We’re nine centimeters into the trachea when I instruct Debby to press the suction gauge and begin swirling the tube around. Jim coughs from the agitation, and yellow froth spits out onto his chest hairs. Debby looks directly at Jim’s face, thereby committing the cardinal sin of learning to suction your loved one. His features are contorted in pain, like a cartoon character being strangled. Her focus drops like a bowling ball. Her eyes mirror his panic, and she freezes, a deer in headlights.

“Don’t stop! Swirl!” I demand.

“I’m stealing his oxygen!” she squeals. No, she isn’t. I have already promised her that this is impossible. But in this moment when I set her free, adrenaline and emotion ricochet off the walls in the hospital room. It’s complete pandemonium. Anything is possible, in her mind. She could go too far and jab his lung, stop his breathing altogether, even suck out his soul with that damned suction tube.

“Swirl!” I order.

Her wrist jerks in a frenzied side-to-side motion. One pivotal thing is missing: the sloosh sound of the mucus being sucked up through the tube. She’s completely let go of the suction gauge. She whips the catheter out with blood-red cheeks, wild eyes and a hint of breathless triumph.

In nursing school, I was taught to reassess after an intervention. Was the goal met? Yes or No? Success or failure? Debby did not, in fact, suction the airway. She also did not faint. It was really the most I could hope for on the first time.

“Perfect!” I say. More selective honesty. I’m sure that something about her effort was, indeed, perfect. I can’t take the time to figure out exactly what. I’m a nurse, for God’s sake; I have charting to do.

Jim gives a last hacking cough. A mustard-yellow snot rocket cannonballs out of his neck and splatters onto his white linen sheet. Debby looks to me for a reaction.

I smile encouragingly. “That’s nothing. I’ve seen those suckers hit the wall. That’s why we always stand to his side while we suction.” She takes one look at the distance between her husband’s neck and the wall, about ten feet, and turns too pale for my comfort. I pull up a chair. “Sit down. You’ve earned it.” I know when to pull back. I’m an occasionally ruthless nurse, not a drill sergeant.

Jim glares at his wife with more of the “I hate you” and less of the “Thank you” in his eyes.

“You’re doing great, Jim.” I place my gloved hand on his shoulder. “Each day will get better. I promise.” He nods his head and closes his eyes.

I turn my attention to Debby. “Really awesome job! I knew you could do it!” I cheerlead. “The more you suction him, the easier it will be. You’ll be a pro in no time.” If she doesn’t become a pro, she will at least learn to suction during the suctioning process, but that’s my secret to keep. For now, she needs to soak in the victory of success to build her confidence. She deserves it.

My pager vibrates inside my scrub pocket, and I walk next door where a green call light is blinking over the doorframe. Roger raises his creaky body from the stiff visitor’s chair. “Can I trouble you for some juice? I think my sugar is low.” Roger is the husband of my patient, Rose. He’s tall and thin with symmetrical features. I imagine he was attractive, years ago, before that demon leech named Old Age latched onto him and began to slowly drain his life.

“You’re no trouble at all!” I wave a hand at him. “Sit down, and I’ll be right back.”

When I reenter with juice, Roger is hovering over Rose, suctioning out her tracheal airway as I taught him three days ago. He’s a fast learner and good with his hands, which I attribute to his lifetime spent as a farmer. I wish Rose would fare as well. She’s been mostly lifeless since surgery. There was no indication of stroke. The doctors say she’s just not fighting. Giving in. Playing possum, if you will.

Roger is at her side day and night. He is my true patient. Rose is a body in a bed, and for her I am the robot nurse I was taught to be. Assessing, tasking, gentle, but not overly compassionate. Roger, however, has worn a soft spot in my heart. For him, I am human. He wets gauze with saline and begins to wipe Rose’s neck where her incision seeps pink drainage. If this were Debby performing Jim’s incision care, I would leave the room to chart.

“Let me get that for you,” I say. “You sit down and drink up.”

In our exchange, the straw is dropped and rolls under the bed. Roger bends to retrieve it. I can almost hear his spine and knees scream in protest. “No! I’ve got it!” I drop to my knees, but he follows suit right beside me.

“It was my own fault. I’ll get it.” His voice is gruff and determined. I am horrified as he sinks, lower, on to all fours to retrieve the straw. It’s within my grasp, but I can see he needs this moment. I allow him to have control of this one small thing. Having solved that problem, he pulls himself up and takes a seat next to his wife, whom he cannot fix.

I do not promise Roger that every day will get better.

I ask him about his farm, his grandchildren and the tattoo on his forearm. I won’t remember his answers, but this room needs to be brightened with sounds of life, if only for a few minutes. I bathe Rose and change her Depends despite Roger’s protests that he can take care of it. The room falls quiet while I work through my tasks. Roger has fallen asleep in the chair. It’s a sad quiet, but a peaceful one. As I crush medication to put in Rose’s feeding tube, Roger’s voice breaks the nothingness in my head.

“Are you doing anything fun after work tonight?”

I laugh, caught off guard by his question. “After a twelve-hour shift, sitting on my couch with a novel is all the fun I can handle.”

“Ah, youth is wasted on the young, they say.” He rubs his hands over his bony knees. Our eyes connect. His are foggy blue over brown, a result of his cataracts, and glossy with fatigue. They open wider for a moment, clear and yielding truth. “Getting old sucks.” The three words fly across the room and pierce my heart. They travel from right atrium to ventricle to lungs, and I can’t breathe. Left atrium to ventricle to limbs, and I feel weak. I’m acutely aware of every miserable thing in this hospital room: the lifeless body, slack and pale, the ripe odor of fungal infection under layers of baby powder, the clicking machines feeding fluid into her nose and veins. All the things to which I’m conditioned to be numb jump out at me. My neck flashes with heat. For three fleeting heartbeats of a moment, I think I might cry. I pity Roger, yes, but equal to that—or perhaps more so—I fear becoming him.

“I think I’ll stretch my legs,” he announces as he always does before taking a lap around the unit.

Feeling disturbed, I shut the door and approach Rose; I lean in close. “Rose!” I hiss in a whisper. “Listen to me. Are you faking it? Rose! You need to open your eyes and get out of bed soon, or you’ll grow too weak. If you’re going to choose life, you need to hurry up and do it, already. Or else.”

Or else death. As usual, Rose is unresponsive. No surprise there, but maybe she heard me. Advocating for patients and threatening them with the truth can be one and the same. Of course, I never read this in Bedside Manner 101, but maybe I’ll write out my own rules of nursing one day.

***

A few hours later, I’m changing out the linen basket in Jim’s room when his very pregnant daughter waddles in. Helium balloons float from one hand. “Happy number sixty-three, one day early, Daddy!” She kisses him on the forehead. “How’s it going today, Mom?”

“I suctioned Dad!” Debby blurts, rising to her feet. “Three times so far today!”

The daughter looks to me with disbelief, and I nod my head in affirmation. “My mother, who didn’t like to clean the blood from our scraped knees? That’s a miracle!”

“Why don’t you explain the process to your daughter? See if you remember the steps,” I suggest.

Ms. Timid transitions into Ms. Take Charge. “OK. Well, you always stand to the side of him so he doesn’t cough up that gunk on you.” She says it like she’s said it a hundred times. The daughter crinkles her nose. “It’s impossible to steal his oxygen, even though his face will turn red.” Of course she remembers this time around. I listen to her full explanation before adding my two cents.

“His nurse wants to work in labor and delivery one day,” Debby tells her daughter, nodding at her protruding belly.

“Babies versus Dad. I can’t imagine you plan to stay on this unit for long. I mean, there’s no common thread.” The daughter is blunt. I feel a small ache at the thought of little newborns with their wrinkly feet.

I remember the first birth I witnessed as a student. The mother’s fear. Her clenched teeth. The screaming. The father’s bewilderment. His hands, which couldn’t stay still. The dancing green line on the monitor that measured contractions. My counting out loud as I coached the mother to push. The doctor pulling the baby out and holding the little girl in the air like she was a trophy. The splash of surprise on the mother’s face, as if she didn’t truly believe there was a tiny person inside of her until it appeared. My cheeks were wet with tears, and I was embarrassed for crying. When the doctor looked at me, he gave me a knowing smile and said, “Amazing, right?” As I left the hospital that day, I walked through the parking lot with my heart full and pounding. The summer sky was blue and heaven twinkled above me, unseen. One day, I would get paid to do that. Deliver babies. Witness brand new life, straight from God. I laughed out loud to myself. How lucky was I?

Obviously, that hasn’t happened yet. Maybe it never will. Maybe that’s OK with me. I’m still figuring it out.

“Your dad is kind of a big baby, so it’s not entirely different,” I tease. The mother and daughter hoot. Even Jim cracks a smile. “I’m not sure how long I’ll stay on this unit,” I tell them. “I need to get back to the nurses’ station for shift change.”

Nursing isn’t what I pictured as a student. Caring isn’t always about holding someone’s hand. At the end of the day, I know I’ve done my job when my patient wants to let go of me. The harder I fight for Jim and Debby to be independent now, the better off they’ll be in the end. Nursing surgical cancer patients isn’t so different from nursing a newborn. Life is always a celebrated miracle on day one; is it any less a miracle after sixty-three years? And when a scary and disfiguring surgery buys new life, is that day any less special? More special? It’s different. Miracles aren’t always awe-inspiring. They aren’t always beautiful and obvious. Sometimes they’re sticky and gross. Sometimes they’re painful and full of loss. Sometimes you’ll miss them if you blink. My eyes are wide open today.

“Wait,” the daughter calls out. I turn at the door. “Dad’s asking if you’ll be his nurse again tomorrow.” Jim looks at me with bushy eyebrows raised.

“You’re stuck with me for a little while yet,” I answer.

He winks and nods his approval.

“Don’t think I’m taking it easy on you tomorrow because it’s your birthday. You’re going to learn to suction your airway.” Because you’re lucky, I think to myself. Because you’re able. Because you beat cancer. Because you were granted a new life, and you’re going to take better care of your body the second time around, if I have anything to do with it.

His wife smirks. “If I did it, you can do it.” He pouts his lower lip.

***

With my jacket on and keys in hand, I pass Rose’s room. Roger sits with his chin resting on his chest. I knock lightly on the open door, and his gray face rises to mine.

“You headed out for the night?” he asks.

“Yeah. I was thinking you ought to do the same. Go home tonight and get a good night’s rest. The pull-out beds are lousy.”

He sighs. “Nah, I’m good here with Rose.” I give him a tight-lipped smile. No use in arguing.

“I wish you’d take care of yourself like you take care of her,” I say. “I worry about you.”

“You’re a good girl,” he tells me. “You’re a good nurse.”

***

Am I? Maybe Roger is right to say so, but he told me I was a good person, first, and for me this is a valuable distinction. I have a lifetime of learning ahead of me. I apply many of the things I learned in school, but I’ve forgotten most. Random snippets of the rules come back to me, at times, but my mind will eventually eradicate them all, relearn them, and reinvent them. I remember two rules that always seemed tricky. First, a good nurse is unbiased. Yet, there’s a universal rule that you don’t choose who you love. Even strangers in a hospital room can steal your heart as quickly and easily as dropping a straw. Second, there’s a difference between empathy and sympathy, and a good nurse solely empathizes. I haven’t figured out how to be that sort of nurse, yet; honestly, I’m not interested in learning.

Excerpted from “I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse,” edited by Lee Gutkind. Copyright © 2013 Creative Nonfiction Foundation. Excerpted by permission of In Fact Books. All rights reserved. No part of this excerpt may be reproduced or reprinted without written permission from the publisher.

Laura DeVaney has been an RN for four years and works on a radical head and neck unit in Indianapolis. She secretly favors patients who are old men because they always make her laugh. When she’s not in scrubs, she writes young adult fiction.

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