In between the challenges of residency training, one realizes that life has its rhythms, its ups and downs, an evolution; but with some things remaining unchanged, like one’s love and longing for home
By Thaddeus C. Hinunangan, M.D.
The rain beat mercilessly on the glass windows. It was colder than usual, darker than usual, and doubly hard to get up for work. On the streets below I heard the soft drone of traffic. As I crossed Taft Avenue to Philippine General Hospital (PGH), the electric lanterns bearing the letters “Sulong Maynila” were still lit, the neon contrasting brightly against the gray skies.
Life in the laboratory in the past year had been far from routine. From the initial euphoria of being admitted to one of the best programs in Pathology, to disillusionment (Is this what I signed up for?); to despair, after being two months in Anatomic pathology with solo cutting for service patients during exam season—which meant a large volume of work and no study time for all important in-service exams; to more anxiety (Will I be promoted to the next year level; to feelings of inadequacy and doubt as to having completed the first year and being equipped with enough skill for the next level.
I remember a mentor who once remarked at how volatile I was, too careless, too whimsical, too emotional. One moment happy at ranking fourth in a blood bank exam, the next moment wallowing in the depths of melancholy after a less-than-ideal conference. At least I am not a clinician, I reasoned.
Just imagine if I had to treat patients all the time. I remember as a medical clerk and intern, that didn’t work out too well. I was too emotionally invested, constantly swept up in some mad instinct to try to save all patients, and feeling bad when we failed. I wanted to give patients a voice by writing about them. Essentially, I was more storyteller than scientist.
Ties that bind
Hematology cases were always difficult. Rina (not her real name) was a teenager who presented with an anterior mediastinal mass. Because of her age, the mass could be anything from a lymphoma to an extra-skeletal primitive neuroendocrine tumor. The diagnosis was an “atypical round cell proliferation”, and a battery of immune-histochemistry studies were recommended.
Immuno-staining relied on the principle of antigen-antibody reactions, and the basic concept is that cells that express a specific antigen are targeted and made to “light up” against a background of a pale blue counterstain. For example, in round cell tumors, if leukocyte common antigen (LCA) would light up then it is most likely of hematopoietic cell in origin, distinguishing it from neuroendocrine or epithelial-origin tumors which would be negative for LCA. In neoplasms where morphology is not determinate, immunostains are most useful.
Rina’s immunostains supported the diagnosis of a lymphoma, unfortunately, the specific chemotherapy would depend greatly on sub-classifying the type of lymphoma. Lymphoma are generally divided into two broad categories: Hodgkin and Non-Hodgkin, and the prognosis and treatment are different.
A second panel of immunostains were ordered. The hema-pathologist and I were on the cusps of discovering the type of lymphoma Rina had, when the clinicians informed us she began having difficulty of breathing. The mass was compressing Rina’s lungs and great vessels. The clinicians did emergency chemotherapy which caused the tumor to shrink dramatically.
Rina and her companion, another lanky teenage girl, were advised to proceed with the immunostains so she could be given definitive treatment. The costs amounted to almost eight thousand pesos, which according to Rina’s friend, was a cost they could not afford. They were lost to follow-up.
In the middle of the year, my first leave from work was granted, and I was able to go to America for my brother Ted’s graduation together with Tyrone. It was one of the happiest occasions in our lives as brothers, because for the first time since our parents passed away, the three of us were together.
The two weeks that passed were blissful and idyllic under the Florida sun, far from the troubles of work and PGH, but when I returned I had a message waiting for me from the doctor in charge of Rina. She was admitted at the Hematology-Oncology ward, and was in bad shape.
Her companion Malou went to the lab to facilitate the immunostains that would help subclassify the type of lymphoma. Curious, I asked Malou what her relationship to Rina was, because she seemed like a family member. Her dedication to take care of Rina was remarkable, and it turned out, Malou and Rina were a lesbian couple.
I went to the ward to see Rina first hand. Malou told me Rina had steadily declined in health after they were lost to follow up. I was initially shocked at Rina’s appearance, far from the pretty girl that Malou described.
Rina had her eyes half open, drifting in and out of consciousness. An oxygen mask helped her breathe. She was almost skin and bones from so much weight loss. The bony chest heaved as she breathed. I asked her a few questions, but careful not to tire her. I directed all my questions to Malou and let Rina rest. They were like the dynamic duo, impossible to separate.
Tears under a hail of bullets
I will never forget my tenth and last autopsy. The bodies had come a week after they died from gunshots. The stench was strong because the bodies were in various stages of decay.
I came in at 10 p.m. the night before as the bodies arrived. Since they were gunshot wounds, we had to establish the position and path of the bullets. A skeletal survey would be done. The radiology department was cleared of patients as post-mortem x-rays were done.
Dragging the stretcher from the morgue was the easy part, positioning the body while holding one’s breath was the hard part. Until of course the actual autopsy, where an external examination revealed one of the bodies with open wounds had maggots in them.
”Essentially, I was more of a storyteller than scientist”
Thankfully the one assigned to me, a petite young girl we will call Eva, was better preserved. She was formerly a student. The external examination showed a single bullet wound which entered the right shoulder. On the radiographs, there was a comminuted fracture on the proximal humerus, with an opaque metallic density in the shape of a bullet lodged somewhere in her posterior spine.
We traced the path of the bullet from the entry wound, documenting the trajectory. The organs which were transected by the bullet showed hemorrhage. Parts of the spine were shattered by the path of the bullet, and we were able to retrieve the bullet after dissecting the soft tissues.
As the bodies were cleaned and sutured, we went outside to speak with the family. The mother had arranged for my patient to be dressed in her best white dress with white plastic earrings. She told the mortician to put makeup on the face for viewing.
As the coffin was being wheeled to the vehicle, I asked her to identify the body to make sure it was her daughter. The mother, comforted by the patient’s relatives, cried as she saw her daughter’s face through the glass. It was a heartwrenching wail, almost the sound of an animal in pain. It was hard to watch, I had to excuse myself and walked away. I hated funerals.
Storms that change us
I once asked our long-time neighbor, who, like me, had relocated for some time after Super typhoon Yolanda, “You and your family from Mindanao, why come back to Tacloban after the storm?” “My work is here,” she said simply. She owned an academic tutorial school which had done very well, all her students were topnotchers in different schools in Tacloban.
After Yolanda, some doctors and citizens of Tacloban moved to either Manila or Cebu to practice. Some even went to live in the States and left their practice in the Philippines altogether. I left Tacloban for specialty training in Manila, but often I would dream of coming home to Tacloban’s placid bays and the green canopies of trees near our home.
Yolanda, Ruby, Urduja—those were few of the typhoons which wreaked havoc on our beloved Leyte and Samar, and yet we still return. Wherever fate might bring me, I know I will always seek home at some point. Recently, Urduja had caused major flooding in Tacloban, with flood waters in our subdivision reaching waist deep.
After the storm, my relative showed me photos of the house. I spent most of my monthly wages in the repair of our roof. I asked myself one day, why spend so much effort and money at trying to hold on to our childhood home. Then I realized, it was all that was left of our past, my brothers and I, the place where we planted a mango tree, raised chickens, learned our letters, it was where I grew up and fell in love and had my first heart break. Despite many calamities that try to wipe out the Tacloban that I know, the city that is in my heart will always be the cradle of my life’s happiest moments.
As the year came to a close, bringing with it the cold, rainy weather, I am filled with appreciation of both the ups and downs of 2017. It was a season of evolution for me, not just at work but as a whole, and yet some things remain utterly unchanged, like my love and longing for my home.
The rain had stopped, and for a moment, rays of sunshine outlined the gray clouds. As I stood still on the pavement, I looked somewhere in the heavens and wondered—whatever Eva was fighting for, was it worth dying for? A memory of Rina whispering to her companion flashed on my mind, and I’ve always wondered what she said, as she lay dying in the arms of her lover.
May 2018 Health and Lifestyle