It was midnight and I had just been jarred out of a sound sleep by the startlingly repetitive beeping of my pager.
It was midnight and I had just been jarred out of a sound sleep by the startlingly repetitive beeping of my pager. I fumbled for it on my nightstand and glanced at the display. It was the hospital’s emergency department. “Damn,” I thought.
Half asleep, I wandered downstairs. I tried not to trip on the stairs as I prepared my foggy brain for the medical conversation I was about to have. I successfully navigated the steps and sat down at my desk. My home “office” is actually in my kids’ playroom, though it doubles as my workspace. (Ah, the oncology fellow’s life of luxury….)
I picked up the phone and dialed. “Hello?” said the emergency department physician on the other end. “Yes, this is Dr Mendler, the oncology fellow who is returning your page,” I replied. (I was relieved that I was waking up enough to put a full sentence together.)
The physician said, “Dr Mendler, I was hoping to run a case by you that we have here in the ED. The patient is a 35-year-old man who had a bone marrow transplant about 2 months ago and is now presenting with a lowgrade fever. He’s had some sinus congestion but no other localized signs of infection. Do you think it’s okay if we send him home with close follow-up, or should we admit him?”
At this point I was fully awake. I had been on the inpatient transplant service 2 months ago and had spent 1 day each week in one of the transplant clinics. I knew many of the transplant patients very well.
“Who’s the patient?” I asked.
The physician responded, “His name is Jonathan, a guy with a history of acute lymphoblastic….Wait a minute, his labs just came back. His white blood cell count is 100 and his platelets are 15. His counts were normal 5 days ago.”
I was hit by a wave of nausea. I could not believe that Jonathan was potentially relapsing. It happened too fast. Please, God, don’t let this be a relapse, I prayed.
A Lone Wolverine Among Buckeyes
My mind wandered back to everything I knew about Jonathan. He was a young man whom I had fi rst met a few months previously, toward the latter stages of his myeloablative, allogeneic stem cell transplant for acute lymphoblastic leukemia. In the transplantation ward he would often bang away on his laptop, preparing lesson plans for when he would return to his job as a high school English teacher.
Jonathan also had moxie. He took an unabashed, unapologetic stance as a Michigan Wolverines fan among a sea of Ohio State Buckeyes fans on the ward. (For those of you who have never spent time in Columbus, Ohio, there is no mercy for Michigan fans, even for those in the midst of a bone marrow transplant.) His wife was often there with him, and they spoke frequently of their 1-year-old daughter and how much he missed her during the weeks of his transplant. I remembered his exuberance on his day of discharge, when he was going back home to see her, having survived another stage of his battle against leukemia. I also recalled the day in the transplant clinic, a few weeks after his discharge, when he brought the attending physician 2 model race cars, each of which was personalized with the name of the attending’s 2 children. I remembered thinking, “What a hell of a nice guy. Not only is he appreciative of everything we’ve done for him, but he’s taken the time to get to know the names of his doctors’ kids and give them gifts.”
And now, after all that Jonathan’s been through, could he really be relapsing? After speaking with the ED physician, I paged the hospital’s attending transplant physician, who is a mentor, and filled him in on everything. He said to me, “You know, Jason, we’ll give him salvage therapy, but he’s almost certainly going to die from this. It just sucks.” I paused for a moment to digest this. After receiving his life-altering diagnosis, Jonathan had had to deal with months of intensive chemotherapy treatments, brutal side effects, bone marrow biopsies, remissions, and uncertainties. But through it all, he had retained hope for the future.
Now it was all being blown to hell by one blood draw in the emergency department. The transplant attending physician and I philosophized for a few moments about the nastiness of a disease that relapses after total body irradiation, myeloablative doses of chemotherapy, and an allograft. There would be no silver lining in this cloud.
I hung up the phone and all was quiet. I climbed back upstairs and lay in my bed. I wanted someone to tell me that everything would be okay and that this had all been a bad dream. That voice never came. I ached for Jonathan, for his wife, and especially for his daughter, who would never really get to know her dad. “How will his family go on?” I thought. “How will I go on?”
How will I go on? I pondered this question as the clock struck 4 AM. I was drained, not simply because of tonight’s news but from a year of experiencing a multitude of young, vibrant people fighting losing battles against cancer. I wondered how I would provide optimism to my patients the next day with the hurt of Jonathan’s relapse still drenching my soul. I wondered how I could spend a career doing this. How could I continue to bear witness to the worst of what cancer does to people and still push on? Was I resilient enough? Was I courageous enough? Was I selfless enough?
My body and mind finally succumbed, and I fell asleep. My alarm woke me a couple of hours later, and I groggily got up after a few thumps on the snooze button. My insides felt like a sour brew of exhaustion and despair. I desperately needed a dose of perspective. I flipped through the pages of a book of quotations that I keep beside my bed and came across one from Mahatma Gandhi:
I have found that life persists in the midst of destruction, and, therefore, there must be a higher law than that of destruction.
I thought about this for a moment and felt a twinge of hope. Despite all the cancer-induced destruction I see every day, there must be a way to see the persistence of life. I was not sure how I would find it, but it seemed well worth a try. I resolved to look for this life force in each patient I saw that day. I realized that these signs would appear differently in each person, and would be hard to find in some, but I felt confident that it was there in everyone. A sense of well-being came over me and I began to mop up the hurt. I felt hope take hold more fully in my body. “I can do this. My patients need me to do this. I need me to do this,” I thought. I straightened my tie, grabbed my coffee, clipped on my pager, and walked out the door, on a mission to find life.
Jason H. Mendler, MD, PhD, is a clinical fellow in the Division of Hematology & Oncology at Th e Ohio State University in Columbus.
This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.