Becoming a Hematologist (NOEL PINGOY)

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.