1 in 4: Lessons in reality on the transplant unit.

I have spent the last almost month now on a bone marrow transplant elective.

I always throught I would like to be involved in transplantation.  I get that in my field, it is a small role, total body irradiation for certain indications, but nonetheless, it is a contribution, and I thought being a part of that team would be fascinating.

I have obviously been working more from the hematologist (and thus, the more involved) side of things.

I love it.  I might end up stuck at work late most nights and skip meals because it is too busy to eat properly (but really, how is it that much different from most rotations), but it is fascinating stuff.

The thing is, it is different from what I expected.

My perspective of bone marrow transplants is romanticized.  When I thought transplant, I (despite my previous criticisms of the realism of the books) pictured something from the pages of My Sister’s Keeper or one of Lurlene McDaniel’s books.  I saw them as tough and filled with complications, but also as a cure and this glorious saving grace.

Transplants are these things.  But, there is so much more to them than what the books suggest.  I feel like books and movies make them seem like a cure-all thing, but they aren’t all the time.  And although complications are addressed, I feel like they aren’t portrayed as the potentially fatal things they can be.

You don’t just go getting transplants all willy-nilly.  They are for people meeting specific criteria.  For people who are otherwise healthy and for people who have some baseline reserve.  They are generally for people who are at risk of dying from their disease sooner rather than later if they don’t go to transplant.  They are serious business.  And continue to be long after the transplant is done.

The bone marrow transplant hematologist I am working with this month is cautious to remind us regularly that there is a good chance any one of our patients could die.  Even if we do everything right.

He says it is one of the toughest parts about doing transplants  1 in every 4 or so people he develops a relationship with dies.  This is tempered with some lower risk transplant variants where it is only 1 in every 10.  But still, average that out and you still have 1 in every 5 or 6 dying.  And there is still the risk of relapse and such in the long term.

Kids do better than adults.  These odds are adult odds.  Kids tolerate everything better.  That is just how kids roll.  They can take so much more than adults can.  I am glad for that.

I know, this from the oncology resident who loves palliative medicine where 99.9% of people die.  But, you know that going in.  You know there is no cure.  This is a potentially curative treatment.  That is tough to go through and a good chunk of these people die.

I am okay with the odds.   I get that the odds of survival in transplant in the setting of malignancy are better than the odds of surviving their disease without treatment or with other treatments.  That is the only way you can really justify going through it.  People are referred for transplant only when survival post-transplant are higher with than without it.

Plus, flip the odds around… 3 in 4 survive, 9 in 10.  That sounds decent, I think.  Especially compared to what it would be without treatment.  Tough stuff, but realistic stuff.

I have watched people do well with transplants.  I have seen people come in with brutal side effects and consequences of transplant.  But, they are alive.  I have had people horrendously sick one week come out of it looking great and running into me on the street after they get out.  I have had others who came in looking great and have tanked.

Known risks.  Known benefits.

Everything in life is like that.  In the oncology world, these risks and benefits can be extreme.  Sometimes the odds and the risks blow my mind.  Seeing us making people so sick with toxic doses of chemotherapy and then saving them with stem cells.  Watching someone hover at risk of infection, of bleeding trying to keep them comfortable and safe and hoping that their body recovers their blood cells before things get out of control.  Watching someone recover their counts and their life day by day.

When it comes down to it, when you look at the data, some risks are worth it.  And there are always those who defy the odds in either direction.

The transplant patients I have worked with have been some of the toughest, bravest and nicest people I have worked with.  That is probably part of why I shudder when my staff doc reminds me again that there is a chance the person won’t survive, even if I do everything right.  At least, I am learning how to do things right.  And be realistic while being supportive and caring.

I am glad for this experience.  For the realistic perspective I have of bone marrow transplants I have gained.  And I still want to be involved with them because they save lives and buy time for so many.

Sometimes, I still wish it somewhere near as simple as it seems in fiction books.

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