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As originally published in The Atlantic Monthly, January 1975

Innocent Bystander

Extreme Mercy

by L. E. Sissman

Sitting here at my typewriter, thirty-five miles and forty-eight hours from the hospital, I can still see their faces. Some of their features blur in my short memory, but their smiles are indelibly printed on my mind. Kindness is not fakeable, not transferable and when -- so rarely in this time and place -- it is encountered in its full and genuine force, it is not quickly forgotten.

I'm talking about a remarkable group of women, of nurses, who take care of me and perhaps a hundred other chemotherapy patients at the hospital where I've been treated for Hodgkin's disease, on and off, over the last nine years. To bring you up to date -- if you've charitably wondered about my medical progress since I last wrote about my illness in this space a couple of years ago -- I didn't quite make it out of the grace period of three years, at the end of which I was expected (or hoped, anyway) to be free of symptoms. Instead, I turned up sick again in the fall of 1973. After a number of weeks in hospital, featuring innumerable tests and something called an exploratory laparotomy, I was officially discovered to be suffering a third onslaught of Hodgkin's. This time, since I had had all the radiation allowable, it was decided by my eleven doctors that I would have to undergo a course of chemotherapy instead. Have you heard about chemotherapy? I had, and it sounded grim. So much so, that at one point I debated refusing it. But when the moment came, I steeled myself, and so began eighteen months of injections and ingestions of four neoplasmicidal drugs, i.e., four chemicals that kill the cancer cells. I had been warned that these might make me, at the least, nauseated, at the worst, miserably ill; that I might lose all my hair almost overnight; that I might be so weakened as to have to give up work at least part of the time; that I might even be bedridden directly after the hospital injections twice a month.

None of this, I'm happier than anybody else to say, came to pass. Instead, I turned out to have an unusual amount of resistance to the side effects. My nausea confined itself to a brief period late in the afternoon of the day of an injection -- so brief, in fact, that I found myself able to enjoy a fancy lunch and/or dinner on the same day. My hair, or most of it, stayed fairly firmly on my head; a little came away on brush and comb, but now, twelve months into the treatment cycle, there is still quite a lot of it up top, and it looks to remain until I finish my bout with cytocidal chemicals. Finally, far from being bedridden, I am disgustingly active even on injection day, sometimes driving my own car to and from the hospital.

There is a serious side effect, though, of which I didn't take the warnings seriously. I was told repeatedly by my various physicians that chemotherapy is a rigorous treatment, and that I might become either tired or depressed or both after a long siege of it. This has more or less proved to be true; the first six months seemed a breeze, but the second began to take a noticeable toll on me. For one thing, there is something spirit-killing about a cyclic medical routine; several years ago, when I had to undergo perfectly painless radiation treatments I found the experience somehow both shaking and shaming, perhaps in part because my daily fellow patients were so obviously sick, so patently terminal. This time, the chemotherapy sneaked up on me in slow motion. Only in recent months have I found myself dreading a small thing: the prolonged prick of an I.V. needle feeling its way into a vein. Only in the last weeks, really, have I admitted to a certain fleeting dread that tomorrow (or next Friday, or whenever) was my next date in the hospital. And only today, as I think about it and write about it, does it seem scary and dooming that I will have to re-enter the hospital for a few days next spring to be "restaged" -- that is, to be retested to determine the efficacy of the treatment -- after the chemotherapy ends in April. But, let's face it, I have felt the heat of all this ordered yet somehow desperate activity in the interest of my continuance on this earth; I have finally recognized myself, sadly, both as a victim and as the object of a cure.

My doctors and nurses have no need to feel ashamed of this. Theirs has been not a failure, but, given my responses and the long interval before I became disturbed by these curative events, an almost unqualified success. And, if these things are relative, I must be in the ninety-ninth percentile of good care. I say this because, at the urging of a couple of good friends, I recently read an interesting new novel by a young Harvard Medical School graduate named John Hejinian. The book, entitled Extreme Remedies, is a deadpan account of patient care in a large city hospital in San Francisco. While it is not a novel of great originality or brilliance, it conveys with grim conviction the possibly necessary expediency of doctors and nurses in such a place. The centerpiece of Hejinian's revelations is the treatment, or lack of same, of a group of patients who have lost brain function through age, or strokes, or tumor. These are called "gorks," a noun akin to geeks -- the freaks in sideshows who eat whole chickens live. Since they are unsavable except by egregious accident, the main activity among the medical people who treat and serve them is "waiting for the gorks to box," that is, to die and be placed in coffins in the morgue. The implication is that this once affluent society is now so hard pressed for time and money that there is no alternative to waiting; steps to resuscitate and revivify the terminal cases would seem quixotic and vainglorious. Hejinian is a little hard on the callous ones. He leaves the distinct impression that they could do more. Yet, looking at America's current disarray, it is hard for me to find great fault with them.

Thus I marvel doubly at the splendid care I -- and the other chemotherapy patients in my outpatient unit -- have had over the last year. Has this country behaved so, in recent years, as to deserve such a cadre of dedicated people as those who bind up my wounds and strive to make me whole the first two Fridays of each month? Have I done anything myself -- besides paying my Blue Cross premiums -- to secure such loving care? I think not in both cases. But these realities have nothing, it seems, to do with the events that take place on those mornings when I surrender myself to the nurses' ministrations.

It is a Friday morning again. I have been for two weeks on my "off cycle," taking no medicines at home, staying well away from the outpatient unit, going about my business as if I were a well man. Now all this changes. I rise early, take a smorgasbord of pills, and drive -- or am driven by my faithful wife -- in to the hospital. First, at ten o'clock, I go to the admissions laboratory for a small blood sample. This, test-tubed, smeared on slides, and counted by a smart but sickly machine (it often breaks down causing long and drowsy delays), forms the basis for the size and strength of my injections. Then I ride an elevator up one floor to the observation unit, which, in a nongeneral hospital, is tantamount to the emergency-ward-cum-outpatient department. Immediately, I am surrounded by those nurses' smiles I spoke of at the beginning of this column. They are smiles of kindness, yes, love, yes, but also of complicity: These women and I are embarked together on a great emprise, to see if I shall live. Their smiles will it as surely as their matter-of-fact voices classify and pigeonhole the nature of the weather just outside. There is no mistaking the airy hope -- and, at the same time, the pragmatic bluntness -- of their conviction.

These women are worth a second glance, a third, a lifetime of meditation on their purpose. Entirely worldly, they are otherworldly in their laughing dedication. First comes Jean, the head oncology nurse, a slim blonde with frosted hair and archipelagoes of freckles out of her whites, she might equally be a student or a stewardess. She banters with the patients, even -- especially -- the sickest ones. Her small talk is heartening; more, it disguises her discipline and seriousness, the drives that make her prodigiously efficient at her job. I'm sure that, though she'd never say so, she's proud of the fact that her needle sticks are marginally less painful than most nurses'. Next is Mary, tall, big- framed, as dark Irish as Jean is pale Irish. Mary is like a comfortable big sister, though she is probably under thirty; she chats along quietly about trivia -- the wind, the weekend, a bicycle outing with her sister -- and, with a still-shy smile, conveys the momentous import of the small change of the world. Like Jean, she conceals her neat and quiet efficiency under a show of unconcern. But her sympathy, when needed, is as quick and unforced as the blink of an eyelid; her warm smile holds the promise of light at the end of the tunnel, of wishes coming true. Sarah, an older woman, is slight and trim. She comes on, when you first meet her, as a formal, old-fashioned nurse, who calls both patients and doctors "sir." But with familiarity, this little by little slips away, and Sarah metamorphoses into a kindly, motherly mentor of her flock, open, generous to a fault if generosity could be a fault, a woman who applies her years of education as a wife and mother to the touchy job of shepherding her fearful and unwilling patients through the flaming hoops of treatment, appointment after appointment, month after month.

There are many others as well. Marcia, a dark siren who might be Latin but is not, and whose warmth is entirely and unashamedly North American. Helen, who at first seems dour behind her spectacles, but evinces poise and concern with the second visit. And -- a jolly squad of white-winged girls who drop of a sudden, like parachutists, into the ward -- the I.V. nurses, called down from their roving stations throughout the hospital to set up our I.V.'s. Skinny or chubby, young or not-so, they dispense more cheer than dread; their grins more than outweigh their #21 siliconed butterfly needles.

Though it is they who set the pace for the ward and its work -- and leave me and, I'm sure, most other patients feeling foolishly in their debt -- their job is really not explainable in chilly terms of hours put in and patients treated. While they and the doctors who supervise the chemotherapeutic care are undoubtedly pushing the frontiers of medicine forward -- during my experience with Hodgkin's, the hospital I go to has made remarkable strides in understanding the disease and its arrest and (we all hope) its eventual cure -- they are also pushing something else forward: the frontiers of communication, of human understanding. Hardly a grim or serious word is spoken in that outpatient department; most words spoken are, as I've said, both trivial and in jest; but these nurses are deeply engaged in providing a kind of psychological support that science has, as yet, no word for. I've called it love, and it is that, but it is a unique form of love, not reserved for the usual objects of love: husbands, family, and friends. Instead, it goes out, seemingly unwilled yet totally unerring, to console the inconsolable, to jolly the terminal patient, walking the last mile alone, into a renewed and vivid sense of what life should be -- and can be, in such rare moments.

It could be said, in a way, that these nurses, to their extreme mercy to their morituri, make their patients -- me included -- want to live for them, want to make them right in their high, unfeigned, audacious hopes for us.



Copyright © 1975 by L. E. Sissman All rights reserved.
The Atlantic Monthly; January 1975; Volume 235, No. 1; pages 16-18.

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