The night before I start my month as Heme-Onc senior, I am up tossing and turning for hours. I know it’s the anxiety about starting something new that’s preventing me from relaxing into precious sleep, but I can’t turn it off. It’s a routine I know well; this is how every rotation starts.

What if I make the wrong treatment decision? What if I can’t answer my intern’s questions? What if my patients are super sick and I don’t know what to do? What if someone DIES? Around and around I go.

Finally the morning comes, and I arrive at 6:00 am to take the reins with great hesitation. I’m a little excited, but mostly nervous. I’m not totally ready, but I think to myself, well, here goes nothing. Then, the day goes pretty well. I find my stride as a leader and suddenly, it’s not so bad. I can do this; I AM doing this. I have a stellar intern T, and my favorite set of attendings and APPs lined up for the month. Nurses on this floor are super communicative, and I feel like I have a handle on my patients. I feel supported by my team, and nobody balks when I ask (a lot of) questions. The first week and a half is pretty smooth, and before long, I feel much less nervous.

Thursday morning, things change. I got to work and heard from the night resident that I had a new patient waiting for me. They were sent to the emergency room because of prolonged fevers and some worrisome blood work. The ED did a little more workup, and it was looking like the little boy had leukemia. The admitted him to the oncology floor for a bone marrow biopsy, which would confirm or rule out cancer. That’s all I knew, and my heart beat a little faster walking up to that room, expecting to see tears and terror when I walked in. Instead, the scene was…calm? Pleasant? So… normal? A smiling mother was helping her toddler into a teeny blue gown, while he giggled and drummed his hands on his exposed belly. It was nice to see, but I had a niggling feeling that something wasn’t quite right. I introduced myself to the pair, and THANK GOD I had the instinct to open the conversation with, “So can you tell me what your understanding is of what is going on with D?”

“Well,” the mom began, “he has something wrong on his blood numbers so we were told to come here.”

“That’s right,” I answered, “his infection fighting cells are very low, and when kids have that along with fevers we get worried about bigger problems.”

“Ok, doctor,” mom responded, “and what can they do to fix it?”

“Well, the procedure today will help us know what we are dealing with, and that will determine our treatment plan. They explained the procedure to you, no?” Mom shook her head, narrowing her eyes like she was suddenly suspicious of everything I said.

Oh no. My heart sank into my stomach as I realized why they seemed so unfazed. She doesn’t know. We think her son has leukemia, and she has no idea.

I suddenly felt so incompetent, so woefully unprepared. My spectra started buzzing and I frantically tried to silence it. Nurses came in and out to hook little D up to the monitor and I realized it was already change of shift, and I was running late. I turned away from the computer where I was starting to enter orders, and took a shaky breath.

“Mom, I want to explain something to you.” I sat down on the edge of the hospital bed. “When we see kids like D, with fevers, and concerning labs like the ones he has, we get suspicious. We can’t know for sure at this point, but I’m worried he has something very serious. We need to do a biopsy today to see if he has blood cancer.”

It took her a second to process. I was the first person to say the word cancer in reference to her precious, bubbly 2 year old. I sat there and watched her world stop turning. She hugged him a little tighter, tears welling up in her eyes.

“Is he going to die?”

A lump rose in my throat. What do you even say to that? God, I thought, count your blessings Nikki. I did my best to finish the conversation as gently and honestly as possible. I knew I had several other patients waiting, and I felt so guilty dropping that bomb on them and leaving. We learn about breaking bad news in medical school, but I had not followed any of the basic recommendations just then. I should have sat them down in a comfortable, private space, and offered to call her partner or support person. I should have prefaced the news with wording that told her I had some heavy information to share. I should have given them space to express their emotions, whatever they may be, without rushing to finish the conversation. I tried, I really tried, but my heart still hurt.

“Nikki, I’m so sorry that fell on you,” offers J, the badass heme-onc NP and angel of a coworker, when I tell the team what happened. “Yeah, it’s done now. I’m capable of having that conversation, but I would have done things very differently if I had known what I was walking into. Their world is forever turned upside down, and I feel very yucky about how that went.”

At the end of the day, it’s not about how I feel. I get to go home at night with a healthy, happy family. I get to discharge a patient and wish them the best, not seeing the consequences and struggles they face after. I know we can’t save everyone, from disease, from death, from heartbreak. But yet again I am reminded to count my blessings. What strikes me most about this experience though, is that everyone is just a few seconds, a few words, a few choices away from their world being turned on its head. I had the opportunity to be the one to witness that moment for someone else that Thursday morning, and well, wow. Keep your eyes open, friends, be as present as you can. Life can change in the blink of an eye.