Becoming a Hematologist

By Noel Pingoy

(This essay won the third prize in the 2002 Palanca Awards.)

What eloquent echoes in the mind can a tempest foment?  This is the second day typhoon Iliang is passing through Manila, and I am midway my three-year fellowship training in hematology at the country’s largest government hospital. There is a somber gray in the constant pouring of the rain, punctuated by paroxysms of strong wind, casting an eerie gleam on the cream-colored wall of the Philippine General Hospital (PGH). Outside, the trees are a wretched sight, most of the leaves are gone; they all shudder with every blast of gale. Most of the patients are still asleep, huddled together with their bantays, while sharing the warmth and comfort of their bodies.  Except for the lonesome Ward 1 nurse on the graveyard shift, bless her lovely soul, who takes a patient’s temperature here and gives another’s medication there, the earth tethers on a tranquil, delicate thread. Gone is the desultory hubbub of strangers who, thrust for the first time into each other’s company without almost nothing in common except for the hope that their respective patients are coming home soon, alive and well, thank God, have congregated into a Babel of pilgrims in search of a miracle, transforming this particular ward into an ashram of sorts.

Forget about the hysteria and the bedlam of daily ward life at the PGH, for at this hour, this very moment, the mood is somnolent and the milieu, doleful. For time to time, a wayward thunder vaults from the shadows of the cold, wind-battered night, and lunges forward with a swift deafening bellow and a blinding flash of silver and ochre, only to be quenched seconds later as if embarrassed by its own impertinence. There is a ghostly glow and an unfamiliar hush all around; even the crickets choose not to stir, they all stoop low to the earth in their refuge from the fury of this thoughtless storm. There is something lugubrious about daybreak in a tempest—it is always a time of dreadful uncertainty, of profound introspection, of a foreboding that unnerves even the bravest and sturdiest of souls.

It is still dark—after all, it is only 3:45 am—and I have just arrived here at the Medical Research Laboratory. I have to be at the hospital before Taft Avenue swells into a knee-deep morass of murky water, of indescribable floating objects, and of who-knows-what’s-in-there, especially that this is leptospirosis season again. The vermin are in their revenge mode once more, a phenomenon that plagues Manila and its suburbs at the beginning of every wet season. In the next two months or so, at least two scores will perish from complications of this foudroyant illness, acute kidney failure primarily.

Crouched in front of the monitor, cupping my palms around a mug of warm brew, while allowing the tepid terra-cotta to pierce my skin in an invigorating sort of way, I delight in the succor it brings at a time like this. From the fragile comfort of the lab’s thick glass walls, I resign to the chilling thought that at this very moment the sun is powerless to lift the darkness’ heavy veil, and except for the adjoining Endocrinology Office that a forlorn flickering bulb can hardly illuminate, there is frighteningly only more darkness. Horripilating by just looking at my reflection on the computer monitor, framed by what seems like a vast, all-embracing lightlessness, it is as if then night finds its meandering way into my medulla oblongata until the darkness without asphyxiates the darkness within, and the mental struggle to keep afloat this illusory fen becomes agonizingly genuine. The cumbrous beating of the rain and the furious rapping of the wind engulf the building, muffling even the grunts of an overworked electric fan that aches for a long-overdue oiling. All I can hear is the thump-thumping of a heart that is midway between panic and chaos, and I am astonished to realize that it is actually my very own.

As my resolve ploddingly wavers I think of the usual mornings that are bathed in the serene radiance of an orange dawn, a subtle portent of a warm and limpid day ahead, and subsequently find myself reminded that even for doctors like me, life is unpredictable as the weather that one has to be well prepared for it—edges, frills, and all. There is something both gravely appalling and lusciously fascinating in the pitipat throbbing of a myocardium that appreciates how pain and suffering can very well provoke a litany of signs and symptoms, both real and imagined, sometimes bordering on the esoteric and ignominious. When mortality is at the crux of the matter, sometimes one forgets to elucidate the substance of pain in terms of endorphins, cytokines and prostaglandins; instead it is a slow, careful untwining of an elaborate tapestry of a singular life, into which its very fabric are woven the sights and sounds of people and places, of pleasures and the pains of the then and now.

I decided to pursue fellowship training in hematology after practicing internal medicine for a year in my hometown in Koronadal, South Cotabato. It is a small but bustling community of just over ninety thousand of the most hardworking and caring people this side of the globe. While it lacks the historical charms of the old Filipino towns or the effervescent hullabaloo of the cosmopolitan cities, its strength lies mainly on a steadily germinating economy that seduces professionals and blue-collar workers alike, from as far as Luzon and the Visayas, to exploit its promise of a better life. It also boasts of a populace that is punctiliously heedful of its social and moral responsibilities, as well as of its duty in securing peace and order as both a collateral and a remuneration for the steady progress that this hometown we affectionately call Marbel is blessed with.

The influx of professionals into town had found me staring at a vast blank wall, both literally and figuratively, as starting a career in a municipality with twelve internists before you was not a languid walk in the part, so to speak. And having been the thirteenth was not heartening, friends and kin would apprise me. For the superstitious, it was not at all encouraging, to say the least. Much to my consternation, even a certificate from one of the country’s best training institutions did not guarantee a steady flow of patients. I realized for the first time in my life how many precious man-hours were spent in putting up an issue of a newspaper; how this exact number of characters was fitted into a given square centimeter while allowing a picture or a cartoon to complement the story. And I even found myself reading the obituary page while reflecting on the gradual and frightening demise of my own practice. I was inclined to believe that this inactivity hebetated my supposedly trained clinical acumen. Duh!  I didn’t survive the torture I went through for more than ten years only to end up like this, a dignified and stethoscoped bum-in-white perhaps, but a bum just the same. I felt like an appendix, to which medical textbooks would ascribe no particular function in the body. Alas, the torment of disuse!  I was destined to become gangrenous in a manner of speaking, and so before I rupture I decided to excise myself from the system. Autohemolysis, they would say.

Given the current landscape of the medical profession in the country, with its cutthroat competition and a seemingly enshrined fixation on titles and accolades, it became clear that getting a subspecialty is a foolproof license to a secure future. After all, even in the remotest of communities, a paradigm has shifted towards patients preferring somebody with several letters after the MD than the old reliable family doctor. Gone are the days when a physician is trusted with removing a boil from an uncle’s back or with delivering the family’s newest angel while prescribing a salve for the patriarch’s arthritis. Nobody even makes house calls anymore. Nowadays we need a doctor for every symptom, and finding comfort in the knowledge that we can easily find one at most centers, at a flip of a page or with a click of a mouse, the concept of a generalist-doctor is not only anachronistic but also deemed foolish.

Yet it was this very same environment that fanned my desire to embrace a subspecialty that is among the least taken in internal medicine. Along with immunologists and rheumatologists, hematologists or “blood doctors” are so few in this country that their annual convention can be held in a function room of a hotel, unlike, say the cardiologists or the pulmonologists who can easily fill up the PICC. Hematology is also one of the least understood of the subspecialties, the last frontier for the adventurous, the ultimate dare for the challenged, or even the singular way out for the pococurante who cannot decide on where to go. While hordes of graduates of residency training programs all over the country claw their way in order to get into a slot in pulmonary medicine or in gastroenterology, few would admit to ever considering hematology as an option. To some it has the least number of patients, and they are not exactly misinformed; most hospital censuses reflect the rarity of blood diseases in this country, at least among adults. The other way to look at it, as my mentors would later point out, is that most cases remain undiagnosed, and subsequently untreated, because there are just a few specialists in the field. To the poor misguided others, it is a boring subspecialty, what with most of one’s hours spent deciphering thin smudges of blood on glass slides under the microscope, and differentiating a lymphoblast from a myeloblast, a basket cell from a true monocyte. Or why this multinucleated cell is simply an osteoclast (a bone cell) rather than a nonhematopoietic element (like a cancer cell from other diseased organs in the body that have lodged in the bone marrow). This is a subspecialty where you wish you were indeed seeing those screaming “faggots” because these immature cells with opalescent, bright orange sticks in their cytoplasm are basically what one needs to clinch a diagnosis of acute promyelocytic leukemia, a highly curable subtype among the acute leukemias in adults.

No fluid has bewitched, bewildered, and beguiled man since the beginning of time more than blood; literature abounds with accounts of its unique power to restore life, to bring manifold suffering and death, and to unleash unbridled passions in men and women, even children, to make life-defining and history-changing acts for the better or even for the worse. Prehistoric man left many drawings in caves depicting wounded tribesmen in battles with either their fellowmen or the beasts of yore, some of them were shown bleeding to death, perhaps the earliest chronicle of man’s acceptance that loss of blood meant loss of life.

This theme is also seen in the Holy Bible as references of “to shed blood” actually meant “to kill.”  One finds in Leviticus 17:11 the admonition that “it is the blood that maketh an atonement for the soul.”  In the same chapter, in the fourteenth verse, it concludes, “The life of all flesh is the blood thereof.”  The descendants of Israel were spared of the ninth plague when the Angel of Death passed over their abodes upon recognizing the blood of lamb smeared on the door of every Jewish household. Egyptians took blood baths for their recuperative effects, while the Chinese believed that blood contained the soul (Neiching, 1000 BC). For the Romans the practice of “taurobolium” was aimed at spiritual restoration. Citizens in ancient Rome seeking rebirth descended into a pit called fossa sanguinis where above him, a priest slaughtered a bull and allowed the animal’s blood to cascade down in a shower upon the beneficiary. In Ovid’s Metamorphosis, Medea was asked by Jason to restore his father Aeson’s life by “taking years off his life and adding them to his father.”  Instead, Medea prepared an alembic of sheep’s blood, wolf’s entrails, magic herbs, and hoarfrost gathered by moonlight, and poured it into the old man’s mouth after she had cut his throat and let out all his blood. Aeson immediately recovered his youth, strength, and vitality.

In the fifth century, a Sicilian philosopher named Empedocles introduced the idea of the four humors corresponding to the four elements that were respected and feared by man since the beginning of time: fire, air, water, and earth. These four humors were blood from the heart and said to embody fire, yellow bile from the liver (air), black bile from the spleen (earth), and phlegm coming from the brain (water). From the principle of the humors, later thinkers were able to derive the basic human characters which everyone is familiar with nowadays. From the Latin word for blood sanguis sprung the word sanguine to describe a lively, ardent, or optimistic personality.

For Christians, the blood behooves a deeper, more spiritual understanding as it symbolizes the passion, death, and eventual triumph of Jesus Christ over evil. The word first appeared in the New Testament in Matthew 26:2 during the Last Supper. Picture this: in a scene straight from Da Vinci’s famous painting, which also happens to be a ubiquitous fixture in many a Filipino dining room, Jesus raising his cup and proclaiming, “This is the blood of my covenant, which is poured for many for the forgiveness of sins,” probably to the discomfiture of Judas Iscariot.  In many of the church rituals, especially of the Roman Catholic faith, the blood bespeaks an inner cleansing that is not unlike the ceremonies observed by the pagan cultures centuries ago. In Hebrew 9, “the law requires that nearly everything be cleansed with blood and without the shedding of blood there is no forgiveness.”

Legends of werewolves and of vampires flourished during the medieval period. While these tales may have factual basis, many historians believe that these stories were encouraged by the leaders to sow fear in the hearts of their people, and for the citizenry to completely bequeath its unflagging faith on the state. The thirst for blood of these malevolent creatures of darkness was only surpassed by the insatiable greed for wealth and power of these “emissaries of light,” as Conrad, in “Heart of Darkness,” called them, people cloaked by the Church and the State with authority and with respectability, purportedly to improve the way of life of the savages and of the common man.

The nineteenth century was characterized by the weakening of the conventional Victorian ideals on behavior and conduct. Women started demanding equal rights with men, persons of all persuasions challenged sexual mores, and social freedom and responsibility became fashionable among the elite. It also saw the birth of two literary creations that have frightened readers from the time the books first saw print, and have continued to do so even until the present, spawning countless versions in every known culture on earth, in every medium possible, film, television, radio, books, magazines, stage, etc. Frankenstein, or The Modern Prometheus, by Shelley, first published in 1818, and Stoker’s Dracula in 1897 both captured the imagination of millions of readers, and brought the significance of blood, albeit in an egregious mien, on the essence of the living, of the dead, and yes, more so, of the undead.

The ancient Filipinos, especially the datus, sealed their most sacred covenants with elaborate rituals that were highlighted by the drinking of each other’s blood, an act known to students of history as blood compact. Andres Bonifacio and his Katipuneros etched their signatures in blood to solemnize their acceptance into the secret society that was aimed at toppling the Spanish regime in the islands.

The investigations of Whipple, Minot, and Castle in the 1920s signaled the birth of modern hematology. What started as an entirely laboratory endeavor that described the different blood elements in terms of shapes, sizes, colors, and other physical peculiarities and, later, their participation in the various processes in the human body, became a dynamic and all-encompassing science that seeks to shed light on the whys and wherefores of diseases, death, and decomposition. Over the last century, hematology has evolved into a subspecialty that employs all the advancements and the technological advantages of manifold disciplines like nuclear medicine, molecular biology, genetics, immunology, biochemistry, pharmacology, and pathology in its quest for answers. Right now, hematologists are at the forefront in mankind’s war against the most dreadful and formidable diseases known to man: cancer, AIDS, congenital anomalies, etc.

In this country, Filipino hematologists organized themselves in 1960, and their society counts less than a hundred fellows and diplomates in its roster as of latest count. Compare that figure with over two thousand cardiologists all over the country. This means that every hematologist is tasked to take care of the needs of over half a million Filipinos; worse, more than half of this number holds clinics in Metro Manila. Wretchedly, an area as vast as Mindanao is served by less than ten hematologists, practicing in only two cities, Davao and Cagayan de Oro.

I answered the call of hematology even though there are other summonses in several directions where the future seems certain. Maybe I decided to be a fool for adventure’s sake although poets on the other hand call it sweet inspiration, even providential perhaps. To go where only few have ventured before, to confront windmills along the way, and to attain my own redemption in the end. After much thought I knew that I can be of more use to the community by choosing a path less taken, though a bit dangerous in its uncertainty, when others would opt for the tried and the tested, and at the same time, be trusting enough of myself to know which door to open, whose hand to take, possibly what flight of fancy to indulge in, in such a way that it will make me weep that it seems utterly possible, just a heartbeat away from one’s embrace, but at the same time as unreachable as the farthest star.

Why hematology? most people would ask, often times sardonically. And the only plausible answer is:  Why not hematology?

One of my patients who will not sleep through this storm is M, a bright-eyed, intelligent, twenty-eight-year-old agriculture graduate from Nueva Ecija. Barely out of college, she has been in and out of the hospital for over two years. The truth is she has been more in than out of it. She has acute myelogenous leukemia, the type which textbooks call the aggressive form having evolved from myelodysplastic disease which initially presented with abnormal-looking cells in the blood. This secondary form of leukemia is even more difficult to treat because it is less responsive to chemotherapy than those who had de novo leukemias.

The disease was first recognized in 1845 by Craiege and Bennett, but it was a German pathologist named Rudolf Virchow who proposed the name leukemia, a Greek term for white blood. How this disease came about it still unknown, but it is a common observation that leukemia, as most malignancies behave, arises from a proliferation of clones of a single white cell. This means that somewhere along the way a mutation has triggered the white cell to shift its demeanor from a well-behaved entity into a shrewd, rapidly multiplying, and pestiferous ogre in the bloodstream. Several studies have linked radiation, exposure to certain chemicals, or inherited genetic abnormalities as culprits in this transformation, although most Filipino patients would deny exposure to these precipitating factors. This transformed white cell called blast is a prolific, insatiable, and puissant bully that deprives the other blood elements, particularly the red cells and the platelets, of their food and shelter in the bone marrow. Not content with merely invading the marrow, the blasts spill out into the bloodstream and cause serious damage to distant organs like the liver, spleen, and brain. When the red cells are decimated, the patient develops anemia and its consequences: pallor, easy fatigability, shortness of breath even on minimal exertion, generalized malaise, and lethargy. As platelets are the primary cells involved in the prevention and control of bleeding, a reduction in its effective circulating population imperils the hapless individual to hemorrhage from any imaginable site, although most commonly from the mucosal surfaces of the gums, nose, and the gastrointestinal tract.

While modern medicine deserves a pat on the back because it has made leukemia among children a curable illness, sadly the same cannot be said for leukemia of adult-onset. Most patients are doomed to die unless they undergo bone marrow transplantation (BMT), a process that purges the body’s entire blood-forming factory, the bone marrow, of its previous contents with megadoses of radiation and cytotoxic chemicals and then replacing it with healthy, viable seeds called stem cells from a matched donor. While this is a standard method of care in most centers abroad for more than a decade, the procedure is still a rarity in the country. Only five BMTs have been done in the Philippines so far, and only one for acute leukemia with, woefully, unsuccessful outcome. What hematologists in the country can offer is a sort of a temporary fix, a shot in the dark, albeit an expensive attempt to obliterate the leukemic blasts with the hope of allowing the normal bone marrow elements to retain a sense of equilibrium that governed the internal milieu before the blasts overturned everything. This is achieved through chemotherapy, the administration of powerful drugs intravenously. The goal is, as a rule, not complete cure, because sooner or later, the blasts are destined to bounce back into the circulation like a nightmare that could not just be shooed away; doctors can only expect a remission, a technical term for restoration of the normal cell populations while keeping the leukemic blasts under restraint. How long can the drugs keep the blasts at bay is still a matter of conjecture even to the most seasoned of hematologists.

Where cheer previously resided, her eyes, now jaundiced and forlorn, betray an exhausted gladiator who has seen several battles and is on the verge of giving up. Her skin is bronzed from what doctors diagnose as iron overload from multiple blood transfusions; as of last count she has received no less than eighteen bags of packed red cells, not to mention over thrice as many platelet transfusions!  Not that she minds this at all. M is one person who is not impressed by outward appearances, and she could not care less about what others would say about how she looks so long as she is in the thick of her battle for life. She has simple dreams of finding employment in Cabanatuan in order to help her father send the younger siblings to school, and she could have easily done so having been gifted with charm, intelligence, and character. But fate seems to have other plans for her.

When reviewing her medical records one cannot help but wonder how life can harshly turn its back on one person after sealing a covenant of a cloudless future with her. While not necessarily living comfortably, her parents saw to it that M and her siblings receive the best education Nueva Ecija has to offer. I still do not understand why life can be so generous with one person yet take away just as much, even more, in a wink of an eye. Yet for some strangely blithe reason, M has never uttered a word of despondency; for her, every trip to the hospital, however difficult and painful, is merely a step to wellness. Needles are constantly inserted in search of those elusive veins or into her hipbone to draw out her marrow, with nary a word of complaint or resignation. And for several months, she has been confronting her illness with the heart of a true warrior—relentless, confident, and determined.

Every bone marrow aspiration—the process of puncturing the bone on the backside to extract the very substance from which all blood elements originate to evaluate disease progression—is for her an almost solemn ritual of exorcising the demons of this disease that consumes the body of its strength and robs the skin of its color. The procedure is not altogether painless despite a few milliliters of an anesthetic called lidocaine, a puncture remains a puncture, and the anesthesia may not work sometimes. But she regards pain as an indubitable catalyst for holding the fort in this struggle to remain alive. She may be wondering now how long she can hold on; how hope can sustain her protractedly enough to endure every pain, to force herself to stay awake, wide-eyed and fretful, through tedious and fearsome nights lest she forgets to wake up in the morning, and to thank every friend and kin who has gone out of his way to donate blood, to offer a word of encouragement, to shell out a modest amount for her hospital needs, and still come out triumphant in the end over this dreadful illness.

Her father has already given up since the other day when this storm emerged from nowhere and lashed out its fury outright without trepidation; their properties have either been sold or mortgaged, and still without a slightest improvement in sight. Every day, she seems to be getting worse despite the multiple transfusions and extensive antimicrobial coverage. A vial of an antibiotic like a third-generation cephalosporin costs approximately three days of a minimum wage earner’s labor, and M needs at least three vials daily. The land has been left untilled, the weeds have long grown tall, and her siblings have temporarily left school as the family’s finances have been drained by M’s frequent hospitalizations. Her father has arranged for the local ambulance to transport her back to Nueva Ecija, against doctors’ advice, as “it is cheaper to bring home the dying than the dead.”  This will officially be entered in the hospital records as HAMA, “Home Against Medical Advice.”

Unknown to most people outside of the health profession, this term is one of the most abused and bastardized excuses when doctors fail, when they do not know where else to turn to, or simply when science is all but helpless to come up with answers. When I was a resident-in-training, few colleagues would rather choose that their terminally ill and difficult-to-diagnose patients go HAMA than face the wrath of the gods of Science Hall, a.k.a. consultants during the medical audit. Most physicians in this situation hardly know whether to laugh or weep for it scares the daylights out of them to realize how infinitesimal their grasp of the basics is despite years of training, especially in dealing with pain and dying, perhaps in the context of medicine being a calling basically to improve life, to prolong survival, and to alleviate suffering. But aren’t these the very things patients expect from their doctors?

Society has inducted doctors into an exalted position, to almost supernatural status in every known social order, but in return also expects physicians to wield not only control and mastery over disease and death, but sometimes even extraordinary and metaphysical powers over them as well. And this is where the problem lies. All of a sudden the physician is thrust into a predicament, both sublime and grotesque at any given  moment, surreal and very real in the same breath, where he is confronted with the very same fiend that appalls him—to look inside himself and recognize that beneath the veneer of knowledge, of authority, and of respectability, there is something in him that remains ignorant, unsure, and even wicked.

Unconsciously, mortality is one word a doctor would take great pains to avoid in his practice. This fear may be deftly concealed under the strange sounding and difficult-to-pronounce medical terms, all that gobbledygook, or behind the most sophisticated of gadgets and the most modern of diagnostic examinations. It must be remembered that however farfetched, at the end of each day, when the last drop of medicine has been given and the final test has been run, every physician longs for a knowledge far more powerful than what he has in his grasp, just to be able to explicate every symptom, to comprehend in a clinically sound approach a new-onset sign, and to confront not only the slightest pain of the patient and of the patient’s family, but his own personal demons as well. One thing is certain:  While a physician may venture into the most comprehensive of differential diagnoses with the most advanced battery of tests in his armamentarium and with the most powerful drugs in the pharmacopoeia, and even pursue with relentless passion the most exotic and improbable of a working impression, the thought that the patient is going home alive and well and that he is able to return to a normal productive life remains, certainly for physicians, the central joy of every voyage, the Shangri-la of every clinical adventure.

M may be wondering about how slowly death will descend upon her, claim her from the land of the living, and transport her to some unknown planet. Heaven, as the children’s song goes, is a wonderful place, full of glory and grace. But she will surely miss her family, her brother most especially.

She has heard numerous stories of mute resignation, of complete surrender and of utter powerlessness in face of death among her fellow Ward 1 occupants, especially those blessed with a spirit that has continued to be unbowed to the ravages of disease on the body, those who stubbornly remained unyielding to Death’s siren song, but without financial competence to bear the medications and the laboratory tests. She cannot forget Divina, a widowed mother of three who was sent back from the Middle East after her employers found out she had leukemia. She has long exhausted the hard-earned savings she had carefully kept while working as a domestic helper in faraway Bahrain. Now what will happen to her kids’ education?  Then there’s Juliet, a washerwoman who boasted she could finish off a ton of laundry with nary a sweat, but who could now barely wipe the blood off her swollen and foul-smelling gums, her hemoglobin level is so low she sometimes speaks incoherently. Another friend is Veronica whose bone marrow has long ceased to function, making her vulnerable to even the slightest insults of disease, changes in weather, or minimal physical activity. Time is running out even faster for Veronica, but her mother is not giving up, not yet, she says. “I still believe in miracles, so we’re fighting back the illness,” she would tell anybody who dares apprise her of her daughter’s prognosis. Her hurt is palpable, her fear, unnerving, but she refuses to let go, constantly bargaining with anybody who cares to listen, with a resilience that is simply beyond belief.

Oftentimes, the minutes surrounding a patient’s death are characterized by several renderings of bargaining: the patient wishing to stay behind, but also praying that should she go, may it be swift and painless; the family fighting for survival in the face of physical, emotional, and financial exhaustion, waiting for a miracle of restoration and wellness and leaving everything under God’s supreme will and tender mercies, but at the same time questioning His providential wisdom why this grave adversity should befall the best and the most benevolent of individuals; the doctor hoping to revive the patient in one instance, but disbelieving the usefulness of all these efforts in the next.

Then there is the drawn-out, oftentimes ardent, and impassioned tug-of-war for the patient’s cadaver for an autopsy. Medical science has long accepted the need for a postmortem examination (1) to determine the actual cause of the patient’s demise, (2) to establish several theories of disease causation that were never fully explored during the patient’s stay in the hospital, cases that were simply beyond the realm of human knowledge to explain or of the most modern technology to elicit the basic answers to the ultimate question why the deceased had this disease at all, and (3) to simply reassure themselves that doctors did nothing to cause or to hasten the patient’s death. Medical residents would take pains to beg, to bribe, or to bully the surviving members just to obtain that most precious consent.

M is relieved she will never go through all this vivisection and pathologic analyses as she is going home anyway. But for Divina, Juliet, Veronica, and several others, most of whom she knows only by face, the likelihood of an autopsy remains a forthcoming circumstance. Given the chance, she would like to ask, with all the courage she can muster: “Doctors, when you cut my friend with the sharpest of your scalpels, mount them on glass slides with the most vivid and intelligible of stains, and look under your most powerful microscopes, will you be able to tell me what I knew all along: that Veronica or Juliet or Divina died of a broken heart?”

She has seen death one too many, and while accustomed to the impetuous rush of adrenaline that possesses not only the medical staff but onlookers as well during the preterminal minutes, she may be agonizing about how swift will her own be. Will the resident on duty be earnest enough to squeeze her heart during the cardiopulmonary resuscitation and propel ample blood to reach the brains and other vital organs, but also gentle enough not to fracture her ribs while doing so?  Will their resolve be stronger than their physical strength, and their hearts, softer than their minds?

They say that people on the throes of death witness snippets of their lives in two minutes. What will M see in that penultimate moment?  A hand guiding her as she takes the first step?  Maybe palms that rub her back to comfort her during the first heartbreak?  Will she be seeing the knuckles of an intern as he draws out blood for the post-transfusion platelet count?  Or perhaps the touch of a physician in one of his rounds in the morning?

That M should remember the hospital, this ward particularly and its colorful denizens, where she has spent most of the last fourteen months of her brief life, infuriatingly perhaps, painfully to most extent, but fondly above all, challenges all but the remotest explanation, and in a night made more heartfelt by the soaring chorus of rain, wind, and thunder, this is an occurrence worth celebrating. Knowing how fervently she longs for home, I am certain M is praying that the final scent she will derive joy from is that of her own room in the outskirts of Cabanatuan, with the sweet-piquant fragrance of freshly threshed rice stalks wafting through her bedroom window and occasionally perfumed by the faint bouquet of jasmine and ylang-ylang.

But she has also come to love the alternating smell of disinfectant and of body fluids, of bodies rotting away and of bodies recovering, of lives that ebb and of hopes that eddy at PGH. I guess this is the very essence of my being here notwithstanding the shadow of death that pervades this place like a proverbial Damocles’ sword:  PGH even in a storm as malevolent and as forgiving as this is no less essentially meaningful or inherently awe-inspiring than St. Luke’s Medical Center or Massachusetts General Hospital, or any other antiseptic piece of land and sky in the world.

What defines a hospital is the manner it enshrines itself in the heart of those who have been there, not whether it is poorly lit or amply lighted, high-tech or just being able to make do with the available resources, extensive or limited, equipped with a centralized air-conditioning system or simply ventilated with ceiling fans. Every hospital, like any person, caregiver or cared for alike, is characterized by the love and compassion that flow in it, by the hope it kindles even in the most emaciated of bodies, and by the simple joy it nurtures from the lysis of fever or from the mere alleviation of pain, like the burst of warm sunshine on a cloudy day. For the patients, it is basically how their doctors “treated” them, that beyond the relief from physical suffering and the treatment of an affliction, they are not seen as mere case numbers in his list of urgent aggravation for the day; instead, they are also regarded as breathing and feeling human beings capable of getting hurt and of being happy. These acts of loving-kindness, both random and deliberate, will always be remembered first and forgotten last.

This calls to mind a portion of Rabindranath Tagore’s “Fruit-Gathering” that can very well be the prayer for both doctors and patients alike:

Let me not pray to be shielded from dangers but to be fearless in facing them.

Let me not beg for the stilling of my pain but for the heart to conquer it.

Let me not look for allies in life’s battlefield but to my own strength.

Let me not crave in anxious fear to be saved, but hope for the patience to win my freedom.

Grant me that I may not be a coward feeling your mercy in my success alone; but let me find the grasp of your hand in my failure.

The rain continues to pour with nary a sign of ever abating, but the thunder seems to have slipped away. Despite the lingering cold and darkness, there is something encouraging now about the newfound stillness, a sense of quietude that carefully strips away layers of malaise and of hopelessness limning the scene just moments ago, bequeathing each individual who happens to witness this changing of the milieu a heart of raw courage and a soul of palpitating expectations. Then one realizes how once in a while life can be so eloquent it speaks powerfully that it catches him off-guard, forces him to sit up and listen with open-mouthed wonder, and like the docile schoolboy that he once was, allows each word to sink in deliberately, with such explicitness and authority, with neither quandary nor skepticism.

Another day is drawing near. Time is impetuously knocking at morn’s door, it cannot conceal its impatience, the abrupt shift in temperature from chilly to lukewarm is discernible. Amidst all these musings and perturbations, life goes on, yes, even in the middle of a raging storm. There are other patients to attend to, tasks to carry out, forms to fill out, medical records to review, bureaucracy to wrestle with, peripheral blood smears to scrutinize, and coagulation tests to process; the list is downright endless. One looks forward to these duties with a sense of exasperation, these predicaments simply cropping out of nowhere to becloud an already gloomy day, tagging along problems as dark and as uncertain as the landscape one sees outside the lab’s windows. And when all seems lost and senseless, it is as if an unseen hand sweeps one’s vision with an unexpected pause. Suddenly, the heart skips a beat, the tense muscles slacken, the spirit soars, and the mind clears. The problems ahead may indeed be dark, but at this very moment, they are nowhere to be seen.

Instead, one witnesses with an open mind and a welcoming heart lessons which his patients have been telling him for some time now, things that matter most, values that mirror each individual’s loftiest yearning, not only of the patients, but of physicians as well, his own including. Hope. Duty. Love. These things he discovers in this hospital, right now, inside this small laboratory, in the middle of a powerful storm, though none as powerful as the realization that everything happens for a purpose, which neither chance nor coincidence can claim for itself. These are sublime gifts entrusted to a physician, especially to a hematologist, by M and all other patients: the opportunity to improve their lives, the power to take away their pain and suffering, and that singular shot at a second chance for life. To be reunited with their loved ones. To consummate a significant unfinished business. To see the children grow up and watch the garden bloom. Simply, to live. What powerful men do doctors, particularly hematologists, make!  And it seems ironic that amidst the emaciation of the human flesh and larceny of life itself, there are defining moments when hope overcomes, when duty overpowers, and when love overflows, like the one that keeps him in glorious contemplation. Technical jargon and supposedly scholarly pyrotechnics may leave one cold, but a mother’s extremely pale, outstretched hand in need of transfusing so that she can tie a ribbon on her little girl’s hair, a young lady’s pair of jaundiced eyes, despondent at first glance but Pollyannaish on the next, or an unexpected rush of restoration that accompanies every dribble of the platelet concentrate it is so overwhelming one can actually hear it swirl and ramble inside the intravenous tubing, painting a tableau of unmistakable eloquence that simply takes the breath away.

Can this be true, that my choice of specialization is correct, however painstakingly and determinedly I rationalize this action?  This is a rather strange profession to be in, and an even stranger calling to pursue what others call a tedious and adynamic subspecialty, where financial rewards are few and far between. This might be madness. It might even be foolishness. But one can always afford to be mad, to be a fool, in order to hear the barely perceptible whispers from afar, cries for comfort, and summonses for survival, than pay attention to the reproach and pontifications of others, no matter how well meaning they might be. The final truth remains: one may hear a patient’s plaintive cry, or take a fleeting glance on M’s (and several others’) morbid pallor, or grieve over the utter impotence of the present setup to cure diseases like leukemia, and yet is able to appreciate what hope promises, what duty stands for, and what love represents, because these are precisely the very same things—hope, duty, love—that bring enough warmth and comfort to endure this storm, or any of life’s for that matter.

In a couple of hours, M will say goodbye to her ward mates, to the nurses, and to the interns. The discharge papers will be released, and the ink for the final signature will have long been dried. Then father and daughter will take the painful, bittersweet journey home. M will become another statistic in the hospital records, another case number in the computer file. I will bid M farewell, and before she leaves, we will say a prayer together. We will ask for an improved weather, for a smooth ride home, and for the miracle of healing. For the gift of stillness. For tender mercies and for divine graces. For acceptance of things that will remain the way they are. With heads bowed, we will say a prayer of thanksgiving, how knowing each other has enriched our lives far stronger than any storm that has ever traversed our paths.

I will hold her hands, clasp them tightly between mine, and be awed at how gaunt they have become since that first meeting at the clinic, how may months of affliction have stripped away their fullness and their strength, how somebody this fragile can display so much determination and courage to face this seemingly hopeless battle. Had I been a good and caring physician?  Had I treated her kindly enough despite the poor prognosis, and competently enough despite the limited resources?  I do not know, and I may never will; M is not the kind of patient who bothers physicians with such questions. Looking at those soulful eyes, I can only but wish that someday I might know the answers.

Deciding to become a hematologist in this country exposes a physician to a lot of risks. It simply becomes an adventure, a well-calculated wager, in which the stakes are high, but the rewards are gratifying. The tasks ahead are daunting enough, but a matter of faith it is apt to be because, however ambiguous and frightful, a doorway was opened, an artery was lacerated, blood was shed, and however precarious, one has to hem the crimson torrent in. There will certainly be hardship and woe along the way, but even behind the many walls of doubt and of ignorance the questioning mind has to go on searching for answers. It is concerned specifically with the unfortunate few who are afflicted with leukemia and other life-threatening diseases of the blood. And when one is blessed enough to realize that the power he holds in his hands to make a difference in his patients’ lives is at the very heartbeat of this adventure, there starts pulsing from it a kind of promise and conviction that everything will be just fine.

It may take an entire lifetime for me to fully comprehend the wisdom of my decisions, of my actions, or even of my indiscretions, but I am not in a hurry. The world outside is still dark, and I can well afford to tarry until the path is brighter, until the road is clearer. Time when used wisely remains a faithful friend, and enduring a waiting game is perpetually a virtue of conquerors. I will meet more patients whose stories may be as tragic as M’s, but I no longer need to be afraid. They have taught me well, and I am eternally grateful for that. In the future, science will certainly unlock the disease’s deepest secrets and eventually unearth the answers. All it takes is a simple faith. The storm will come to pass, and it will be morning again.

There will be countless and equally life-affirming stories of man’s audacity, his fortitude in the face of sickness and death, of heartwarming tales of each patient’s struggle to survive. Blessed are the patients who come into a doctor’s clinic, brimming with hope, awash with joyful expectation, to bare their life’s histories and their own mortal bodies down to the minutest blood cell in search of a cure, but more blessed is the physician who earns their confidence and fealty, the patients will lay open their hearts and minds to be probed and to be studied. They will literally entrust their lives to him. They will ask him to remember them always, and I honestly believe that after memorizing every sulcus and gyrus in the human brain, as well as the kinetics and dynamics of each drug listed in the manual, most doctors have the gift of remembering. And what about M? She will be special, for experience has a strangely bittersweet way of telling us that in the conduct of human relationships, the one who is never forgotten is usually the one who never asks.

I look out of the window and recognize a fragile streak of light hovering in the horizon.

Choosing the path “To serve Humanity!” is, by any standard, a way of life. To share the patient’s burden is to remember that warm sunny day when one entered medical school, innocence and dignity intact, armed with the values from home and fueled only by the desire to be of use to others. This is the direction of every doctor’s goal—the future seen from afar from his highest ambitions and his truest dreams. By becoming a blood doctor, one of the few hematologists in the Philippines, I am bound to claim that promise, and seeing my patients water the earth with tears of joy and of pain, through their bruises, nosebleeds, and even mortal hemorrhages, as well as their remission and their healing, I share in their laughter as well as in their grief, and in the process, even without my realizing it, make their prayers my own. My very own.

 

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