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Medical Humanities

True Strength

Kevin J Zhang

June 25, 2018

The last day of my away elective at Bellevue Hospital’s oncology ward was coming to a close. It was an incredible experience but carried a heavy toll. But I could handle it. I knew I could. I was strong.

One by one I made my personal rounds - first the intern, the senior, the fellow, and the attending. And finally to my patients — Eve, Jose, and Joon. I never had the chance to say bye to Elrayes but I knew, as of this morning, that he was finally at peace.

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 two blocks of my apartment, I decided to stop at The Bean, the café that had become my local hideout. I wanted to take a break to jot down all the memories I had experienced that month.

I smiled internally with each memory I inscribed in that notebook. But as I wrote about Joon, I began to experience a different sensation. I felt my face flushing, my jaw clenching, and my eyes tearing — my eyelids nearing capacity, soon reaching the point of being unable to dam the ensuing flood. I tried to be strong but I had to quickly gather my belongings and dart in the direction of my apartment, shielding my embarrassing demeanor from public view. As I collected myself back at my apartment, my elbow crease soaked, I tried to understand why that had happened. He was my patient zero at Bellevue – a person with whom I’d interacted from my very first day up until my last. It was only then that I realized that my goodbye held immediate permanence.

*   *   *

Joon was born in Korea and moved to the United States with the promise of the American dream. He had hopes of making a living so that he could foster a world of opportunity for his children. He would work tirelessly at a dry cleaner for years to fulfill this dream he held so dearly. His daughter had been accepted to NYU for a Masters in Education. His son would be starting a family of his own, as Joon’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 had 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 was high. He had an elevated number of blasts, immature precursors of white blood cells. As the 8cm needled drilled into Joon’s iliac crest to reveal his condition, oncologists already knew what the 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 4–8 months. And so Joon 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. Second-line salvage chemotherapy was thrown hopelessly at the reinvigorated beast, barely making a dent in the number of blasts. Third-line therapy was attempted, with Joon and his wife Min looking helplessly on. We scheduled a family meeting for them. They knew that we were harbingers of bad news.

*   *   *

I entered the family counseling room with the attending and the fellow. 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 Joon. Fatigued. Patchy hair. Pale. Smiling.

Min 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, producing a syncopated beat like the tick-tock of a grandfather clock, ominously counting down.

*   *   *

I’d like to note that Joon speaks little English. His broken English would suffice for brief morning updates regarding his chemotherapy side effects. He knew how to talk about abdominal pain, nausea, vomiting, diarrhea, platelets, and blood transfusion. But two of the earliest words he learned remained his favorites —“thank you.” The family meeting was conducted with a 2nd-year fellow who is a native Korean speaker. But there was one gesture that I found especially touching. Each morning we’d ask about his bowel movements, especially after he developed diarrhea from the chemotherapy and typhlitis. And once his diarrhea dissipated and his stool became more formed, he began to respond by straightening out his fingers in an open palm, touching the tips of his fingers together in an almost meditative form and saying, “together.” 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 would be all right—that regardless of the outcome, he had collected everything he needed emotionally, mentally, spiritually, and physically. It gave me 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 any more 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?”

“That’s fine.”

“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 could see Min 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 complacency. But now without Joon working, his daughter had had to turn down NYU’s offer. How would Min support herself? Would Joon live to see his grandchild? And there was also the question of what had caused the leukemia. There is some evidence that the chemicals used in dry cleaning can increase one’s risk of several cancers, including leukemia. If this were the case, then the very thing that made their American dream would also take away Joon’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 Joon nor the attending could answer. Regardless of how Joon’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 Joon’s family’s lives, they would rebuild from what Joon had established — I was sure of its structural integrity.

I thought I had resilience. I thought I knew what it meant to endure. Fourteen years of training—four years of college, four years of medical school, and then six years of residency and fellowship ahead of me. But no matter how hard I worked, no matter the intensity of my diligence, I would always be outdone. On average, I would dedicate approximately 2 hours to Joon each day. But he was battling 24/7—no weekends off, no lunch breaks, no respite whatsoever. I intermittently dipped my toes while Joon only knew inundation.

*   *   *

Min’s cries, thoroughly muffled in the clumped handful of tissues, were amplified by the loudest silence I’d ever heard, filling the room deafeningly. Everyone’s gaze was cast downwards. And as if to signal the final act, Joon covered his face as his eyes began to well up with gratitude, but he found the strength to maintain his composure. He lifted his head up and simply repeated his favorite words, “Thank you.”

In that moment, from a seemingly hopeless perspective he found an angle from which to thank us. I wanted to thank him in return. For something that couldn’t be taught in the classroom. For a perfectly crystallized moment that beautifully exemplified how medicine differs from science. The human element of medicine transforms something static into a field constantly moving in real time, impossible to truly master or predict. I wanted to thank him for his lesson on perseverance, because it gave me yet another mode of impetus to be better. I realized yet another reason I had fallen in love with medicine—patients always made me strive to be better. And no matter how insurmountable it seemed, I wanted to be good enough for them, in the conditions of adversity where our mettle is truly tested. I had not personally experienced such circumstances, but I could learn from Joon. I could hopefully one day impart to my future patients the same strength Joon demonstrated amidst pure, unyielding turmoil. Joon had transcended my naïve definition of a patient.

*   *   *

They could handle it. I knew they could. They were strong.

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Blair, A., Decoufle, P. and Grauman, D. (1979). Causes of death among laundry and dry cleaning workers. American Journal of Public Health, 69(5), pp.508-511.