Sunday, June 5, 2011

Pediatric Oncology, the game

My son Joshua has his 1 year off treatment scan tomorrow, June 6th, o'dark hundred.  It's also eerily close to the anniversary of his relapse in 2009, my son has Wilms Tumor, cancer of the kidney that metastasized to his lungs, one of those lung nodules regrew after therapy was discontinued the first time.  The scan will be a chest/abdominal/pelvic CT.  The big donut as he used to affectionately call it.  That was back when we were frequent flyers, when he had a port, when the NG tube placement was just part of the intriguing ride that is the big donut.  Back before he realized he wasn't normal.  Back when "big heart hospital" (named after the logo) was all he could remember other than our house and costco.

Now he has a semester of pre-school under his belt, and he has visited the long forgotten land of the pediatrician's office.  He's had playdates and learned not to stand two inches from your peers' faces.  Joshua has come off treatment to find regular sleep patterns, and nightmares, and anger management, and all the other emotional milestones in line that he paused in progressing through while on treatment.  Joshua has scanxiety.

The kid who feared nothing, the kid who was a veteran, a pro at this oncology thing.  This sweet little curly haired 4.5 yr old melted into hysterics at bedtime, sobbing "I can't take it anymore."  It's been three months since his last scan, an ultrasound, and 6 months since his last CT.  He remembers, and he is afraid.  

We talked.  Eventually.

His biggest fear: Getting an IV in the knee.  He didn't get an IV in the knee last time but he did get it in his foot.  The radiologists like the foot, it's easier to immobilize, if they have shoes and socks on it's warm and the veins are right there, no missing, right there.  If you use emla, they retract, digging on a foot is no fun.  The foot is a wham bam thank you ma'm site.  No anesthetic, but no mistakes, and you take it out immediately, as in it's in for less than 5 minutes.  It's a tough call, but we have gone with it since back when they practically insisted on it for his GFR scans.  

Josh is opposed to this.  Josh does not want an IV.  At all.  He misses his port, his best friend (a topic for a whole other post, suffice it to say he needed therapeutic intervention after his last port removal).  This is where my job as an oncology parent sucks.  I have some choices, but in the end, tomorrow morning, that CT is going to happen, whether Josh likes it or not.  I'm not going to pass the blame and vilify a nurse or a doctor and say I don't want to do this to him, that it's them.  

I've heard day pass-ers (one time visitors to the radiology dept) use that.  It's so not helpful.  "Honey mommy doesn't want to hurt you but the doctors are going to poke you with a needle, it's their job."  That pretty much makes that child hate doctors forever.  I talk straight with my kids.  "Josh, we need the pictures from the big donut to make sure there is no cancer.  We are getting the pictures buddy, and to do that you have to put the red juice in your tummy and get a tubey (IV)."  

More crying.  I concede the foot battle.  I tell him we'll use emla this time, no feet.  I hope they won't dig or use his elbow.  That's not good enough.  What if Mr. Mike or Mrs. Mike (they are a married couple, he came first into our lives, she'll always be Mrs. Mike) or the other nurses in radiology don't listen?  I flounder. . .uh. . .my mind is racing, they'll listen to me isn't good enough.  He wants concrete tangible "no IVs here."  My mind has a moment of brilliance, I tell him I'll get a drawing of a body off of a computer and he can put x's where they aren't allowed, they'll listen to the paper.  Done.  Hurdle 1 down.  

I decided to make him a prince. . or maybe a king. . .they can make edicts.  And this is Josh's edict, no IVs in the foot. . .or the knee.  He's already x'ed up his chart, and I have it clipped to a half sized clipboard ($1.25 at office supply store) that I can fit in my bag.  

Phew, that's done.  And because I made it clear this was happening he accepted it and didn't x the entire chart (I had worries about that).  That's how he works, how a lot of kids work.  Be straight with them, this is happening, but you have a choice in how it happens.  This is all Josh needs, a touch of control, and assurance that he can avoid his worst case scenario if he cooperates.

Onto the other problem.  The oral dye laced fruit punch.  At our institution Josh has to drink 3 doses, 45 minutes apart of about 4 oz (~118 mL) of  punch.  And he needs to consume each in less than ten mintes.  That's less than a standard juice box, but it's still a heck of a lot when you have puked it up a couple times and had it forced on you another few and NG tubes for the rest.  Not to mention he'll be NPO.  Josh wants nothing to do with the fruit punch.


Tube or drink buddy?  
Tube in the nose or drink it Josh, one way or another it has to get in your tummy.
Do you just want to do the nose tube (we ended up with it after two sips in december)?  
Then you have to drink it.  
But it's gross. (the only other options are radiology has are carbonated, he hates soda)
Then you'll have to get a tube.  
Well then we are back to drinking it Josh, those are the only options.
But I don't want to.
Sorry buddy, those are the choices.

Josh has recently switched to fluoride toothpaste, he misses being able to lay in bed and get his teeth brushed.  We've turned spitting into a bullseye-esque points game.   My kid is obsessed with numbers.  He thinks learning multiplication is fun, in fact I just printed off a multiplication table because he'll think it is AWESOME.  I go with it.  

What if we make it a game and you get points? The crying stops.  Ok, we have a door, a small one.  Now it's the game or the tube.  As of this afternoon, the tube is still looking probable.  We don't mess around.  We aren't going to throw off the whole radiology schedule.  He gets 10 minutes to comply, then it's the tube.  They use a numbing gel, it's not barbaric, and after that he doesn't have to do a thing, we do it for him, no taste.  Today I made the tally sheet, rules, and score card.  I used mL/cc increments for points as we usually score a giant 60cc syringe to drink from. . .because it has numbers and plastic cups don't.

I showed it to Josh.  He is intrigued.  "What if I can't hide?"  Wow, I almost forgot that, several eons ago he had a head CT (low platelets many bruises, started acting funny) and he watched the device inside the CT spin and almost hurled, so we covered his face with his security blanket.  That's how he has done it ever since.  Under a blanket, but no sedation.

So I pull out a piece of paper to make his packing list.  Something from 19 months-4 years I have always handled myself.  Now he needs it, he needs to make it himself and reassure himself that everything he needs will go with us.  This is a whole new ball game.

You have to find what works for your child. What works for my son would probably not work for my daughter.  If our therapist that we had been assigned to and used extensively for 2.5 yrs hadn't moved, I would have emailed her and involved her (we meet our new one tomorrow, and he gets to start the bravery beads program).  Your techniques and coping skills have to evolve through your treatment and with your child and family.  

The key is to walk that line between choice and reality.  Our previous therapist was firm on that.  New nurses used to ask "Is it ok if I take your blood pressure?"  Wrong, Josh's answer, "No."  The correct question was, "It's time for your blood pressure check Josh, which arm do you want to get the hug?"  

Be honest with them about what is negotiable and what is not.  At the end of the discussion, they have to know this is going to happen, that you will do your best to make it pleasant, but this is not about mean doctors and nurses poking them.  Plain and simple.  Tomorrow is scan day.  He will get a CT scan.  Oral dye will find a way into his stomach and intravenous dye into his body.  He can choose how/where the latter two happen, but if he doesn't make a choice we will.  I prefer he cooperate, but that scan is happening.

This is just pediatric oncology, we can hate this reality all we want, how we have to force our kids through stuff, through not normal, but we still are going to have a scan tomorrow.  One way or another.

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