September 22, 2017
And so my last day on my away elective at Bellevue Hospital’s oncology ward was coming to a close. Honestly a dream come Belletrue, albeit one that carried a heavy toll to it. But I could handle it. I knew I could. I was strong.
And one by one, I made my own personal rounds. I found Karen, the senior resident, to thank her for her whimsical nature that lightened the mood for the entire team. I caught Colleen, the intern, to express how much I appreciated her showing me all the diligence and duties I would take on next year. I hunted down Folu, the fellow, to gift him a tie of mine that he was particularly fond of, being indebted to him for his immense guidance and thoughtfulness. I thanked Dr. Nierodzik for showing me what it meant to be a meticulously passionate and overall wonderful person, ensuring the best care for each and every patient. And finally to my patients — McCune, Navarro, and Soong. I never had the chance to say bye to Elsaeed, but I knew, as of this morning, he was finally at peace.
So as I left the hospital, I could already feel the familiar shroud of nostalgia enveloping me, fueling my drive to become an oncologist. And as I came within 2 blocks of my apartment, I decided to stop at The Bean, the café that had become my local hideout. I decided to take a break to jot down all the salient and impressionable memories I’d experienced that month.
Such as with Elsaeed. He was a 37-year-old Egyptian man estranged from his family. His sister was the only blood relative he was in contact with but she was far away in the land of pyramids and sphinxes. But his charismatic nature helped him create a makeshift family of his own. Each day multiple people would come visit him. Colleen had come to talk to the patient when one of Elsaeed’s friends visited along with her child. Colleen had mistaken the 3-year-old for Elsaeed’s own child, constantly referring to him as “Daddy” when talking to the child. When the friend and her child left, Elsaeed revealed that he was, in fact, not the father — he had no children. “So why didn’t you correct me,” asked Colleen. “Because it was nice. It was nice being called father,” he said, not knowing he would pass away the following morning.
Or with McCune. She was a 6'1'’, sarcastic but endearing dog groomer who came in with leukemia. Moments with her included me showing her videos of cats puking set to techno music and of my 7-year-old sister dancing on my phone to get her mind off the excruciating pain of her bone marrow biopsy. She’s a Jets fan and I’m a Patriots fan. Early morning banter would typically include me walking in and reminding her how miserably her team would lose this weekend with her retorting, “You guys are all cheaters!” And every time I left her room, she would remind me, “Remember to put at the bottom of your progress note — Patient not done!”
And so a mental, nostalgic smile flit through my mind with each awe-inspiring or heart-tugging memory I inscribed in that notebook. But as I wrote about Soong, I began to experience a different sensation. I felt my face becoming flush, my jaw was clenching, and tears began to well up — my eyelids nearing capacity, soon reaching the point of being unable to dam the ensuing flood. I quickly gathered my belongings and darted in the direction of my apartment, shielding my embarrassing demeanor from public view. As I collected myself back at my place, with my elbow crease soaked, I tried to understand why that happened. Then I realized, it’s because out of everyone I said bye to today, Soong was the only for whom that word held immediate permanence.
Mr. Soong was born in Korea and moved to the United States with the promise of the American dream. He had hopes to start a living and a family so that he could foster a world of opportunity for his children. He would work tirelessly at a dry cleaner for years to uphold this image he held so dearly. And as compensation for his toils, life would be good. His daughter had been accepted to Columbia University for a Masters in education. His son would be starting a family of his own, as Mr. Soong’s daughter-in-law was pregnant with his first grandchild.
But gradually, he felt himself getting weaker, experiencing debilitating fatigue with the simplest of activities. He would have increasingly frequent episodes of seemingly unceasing nosebleeds. His gums would bleed heavily every morning after brushing his teeth. He’d begun to notice numerous bruises all over. He arrived at the ED where he was found to have alarmingly low blood counts. Low hemoglobin. Low platelets. But one value stood out. He had an elevated number of blasts, immature precursors of our white blood cells. And as the 8cm needled drilled into Mr. Soong to reveal his condition, oncologists already knew what the pending results would confirm — he had leukemia. He was immediately started on induction chemotherapy.
The goal of induction therapy is to send a patient into remission, but the battle isn’t done after that. Without consolidation chemotherapy or a bone marrow transplant, nearly all patients will relapse in 4–8months. And so Mr. Soong attained remission after induction therapy, clearing his first hurdle. But as he was forced to sit idly by due to insurance issues, waiting for approval for a bone marrow transplant, the leukemia found the perfect time to mount its counterattack. Relapse presented itself with a vengeance, emerging with over 80% blasts. 2nd line salvage chemotherapy was thrown hopelessly at the reinvigorated beast, barely making a dent in the number of blasts. 3rd line therapy was attempted, with the Soongs looking helplessly on. We scheduled a family meeting for Mr. Soong and his wife on the afternoon of September 22, 2017. They knew what it was for.
Dr. Nierodzik, Folu, and I enter the family counseling room. Located at the northeast corner of the hospital on the 16th floor, light infinitely ricocheted off the white tiles and white walls as if to symbolize our patient’s destination. There sat Mr. Soong. Fatigued. Patchy hair. Pale. Smiling.
Mrs. Soong entered soon after, armed with a box of tissues she must have initially forgotten, preparing herself for the inevitable. The click of his two infusion pumps fastened to his IV pole were offset by fractions of a second. As if producing a syncopated beat or like the tick-tock of a grandfather clock, ominously counting down.
I’d like to take a quick aside to note that Mr. Soong speaks little English. His broken English would suffice for brief morning updates regarding his chemo side effects. He’d know how to talk about belly pain, nausea, vomiting, diarrhea, platelets, blood transfusion, and, his favorite, thank you. The family meeting was conducted with a 2nd year fellow who is a native Korean speaker. For convenience sake, I’ll imbue Mr. Soong with flawless English. But the reason I’m taking this aside is for one manifestation of his broken English. Each morning we’d ask about his bowel movements, especially after he developed diarrhea from the chemo and typhlitis (an inflammation of the gut). And once his diarrhea dissipated and his stool became more formed, he began to respond by straightening out his fingers in an open palm and touching the tips of his fingers together in an almost meditative form and saying, “together.” And I always found something so endearing about this. As if he was trying to symbolize that despite the grave nature of his situation, that everything was all right. That regardless of the outcome, he had collected everything he needed emotionally, mentally, spiritually, and physically. It gave a sense that no matter what happened, everything would come together in the end. And with that, he would always conclude with a heartfelt thank you.
“So Mr. Soong, what is your understanding of the situation?”
“I know that the chemo isn’t working. I know that we’re out of options.”
“Well the research protocol here isn’t taking anymore patients but we can look into other institutes to see if you’re eligible for any other experimental studies. But for the time being, we can undergo another round of the 3rd line chemo. The median number of cycles demonstrated to show a response is 2 after all.”
“Well what if I do go through chemo again? Or these experimental studies? How much longer will I live? I’m just so tired. What are the side effects? I’m not sure if I want to go through that again.”
“I can’t really say how much time this will buy. How about let’s wait for the results of your bone marrow biopsy and then let’s decide from there?”
“Okay, well next I’d like to ask you…what’s your goal? I understand that you have a grandchild on the way. She’s due for late November, is that correct?”
“So is it safe to assume that your goal is to make it till then?”
“I would like to see my first grandchild. But I also do not want to darken the time surrounding her birth if I’m dying around then.”
Everyone can see Mrs. Soong grab an extra handful of tissues as her silent sobs bolster a second wind. Just 3 months ago, everything seemed fine. Everything seemed within reach — within their control. The American dream lulled them into what seemed perfect. Seemed. But now without Mr. Soong working, his daughter had to turn down Columbia’s offer. How will Mrs. Soong support herself? Will Mr. Soong live to see his grandchild? And there’s also the question of what had caused the leukemia. There’s some evidence showing that the chemicals used in dry cleaning can increase one’s risk of several cancers, including leukemia. If this is the the case, the very thing that made their American dream would also take away Mr. Soong’s life. He had sacrificed so much, unknowingly leading himself to make the ultimate sacrifice.
And there we were. There were many unanswered questions left on the table that day that neither the Soongs nor Dr. Nierodzik could answer. Regardless of how Mr. Soong’s treatments turned out and the timing of his death, I had faith that his life would not be in vain. He had built the foundation his family needed. Although the leukemia had wreaked havoc in the Soongs’ lives, they would rebuild from what Mr. Soong had established — I was sure of its structural integrity.
Mrs. Soong’s cries, thoroughly muffled in the clumped handful of tissues, are amplified by the loudest silence I’ve ever heard. Inaudible yet ambient with a certain cadence. Everyone’s gaze is cast downwards. And as if to signal the final act, Mr. Soong covers his face as his eyes begin to well up with poignancy and gratitude. He simply repeats his favorite words, “Thank you.”
They could handle it. I knew they could. They were strong.