I heard him before I saw him. Laughter wasn’t common on the internal medicine floor. James sat at the edge of his bed, a deep, resounding chuckle traveling across the hall as he joked with the nurse measuring his blood pressure. It was the first time I had the responsibility of learning about a patient, presenting their case, and contributing to their care.
His laugh eased my nerves as I pushed open the door.
Every day at 4 p.m. for the past two weeks, James got an hour of chills. He felt nothing else: no fever, chest pain, or shortness of breath. When he went to urgent care, they drew some blood and sent him to the ER. What they found — or didn’t find — concerned them.
Pancytopenia. James had practically no cells in his blood.
“They say maybe some sort of infection or, you know, cancer,” he said, “but I got three kids and three weddings to pay for, so it better not be cancer!” We both laughed.
Dutifully, I listened to his heart and lungs, my stethoscope gentle on his skin. My fingers fluttered down the sides of his neck, tracing in front of his ears and above his collarbones. My mind raced through what I would present later on rounds, rehearsing a script for the differential on pancytopenia.
Three hours later, a smear revealed immature white blood cells, confirming our worst suspicions. When the team broke the news that he likely had leukemia, James went quiet.
“OK,” he said after a moment. “How do we fight this?” There was no panic, no emotional outbursts. He was measured and calm. To get more information, we explained, we would need more diagnostic testing.
“Do whatever you need to do,” James said. “I’ll be here.”
That afternoon, I helped an oncology fellow perform James’ bone marrow biopsy. He unsheathed a needle as long as my palm as I helped James lie on his stomach and sponged orange iodine on his back.
The fellow handed me the vials that would hold his samples. I opened the vial and moved to set it over the open blue flap of the bone marrow tray.
“No!” the fellow snapped. “You’ll contaminate the sterile field.” I cringed under my mask, clinical naivete on full display. My eyes darted to James, who lay motionless. I hoped he didn’t feel the weight of my inexperience. The fellow braced his leg on the bed as he drove the needle deep into James’ flesh. I watched it disappear, inch by inch.
“Once we get the blood, make sure to shake the vials — it stops the clotting.” My hands were already trembling at the violence of it all, white from how hard I grasped the tube. A gush of thick red blood filled the syringe as the fellow yanked at the stopper, using his entire body as a counterweight. Vial after vial, we extracted white splinters of bone. James lay on his belly, head turned toward the wall.
“How are you feeling?” I asked meekly.
“I’m good, Doc. I feel good,” he said. My stomach churned. I couldn’t say the same.
For the rest of the day, I hovered outside his door, wondering if he might need company. He sat quietly, calling his wife or perusing television channels.
Before I left, I stopped by. “How are you feeling? Is there anything I can do for you?”
“I’m good, Doc. I feel good,” he said once more. Overnight, he was transferred to the oncology floor.
On the medicine ward, things moved at a whirlwind pace. I saw code strokes, sickle cell pain crises, pneumonias, patients whose hearts barely pumped blood. I juggled notes, medication lists, clinical histories, and physical exam findings, bouncing from room to room. Time and again, as I found myself thinking, “What am I doing?” my mind returned to James.
A week later, after a shift ended early, I stopped by the oncology ward. His face had grayed. Hard lines set underneath his eyes. His hair had thinned and whitened.
“How are you doing?”
“I’m good, Doc. I’m good.” A familiar refrain. It was Day 5 of his chemotherapy. In a week, his life had completely changed. I was overwhelmed just navigating the profession I had chosen. How could he, faced with mortality, take it in stride?
It became a routine. I visited him in the mornings before rounds, after long shifts, and on weekends. Each time, he smiled and said he was fine, even as his legs swelled into thick tubes, skin cracking and red. Some days, he spiked worrisome fevers, and the list of medications penned on his whiteboard grew longer.
We talked about football, the books on his bedside table, his son who had just started college. When I asked how he did it, he said, “I’m just thinking about the next steps, taking it day by day.”
As James took infusion after infusion, he told me about small victories: shaving for the first time, showering unassisted, finding a good chicken salad on the hospital menu. His wins began to parallel mine: learning where to grab warmed blankets, how to order CT scans, calculating the right dose of insulin. We grounded each other.
I found myself repeating James’ mantra on the wards. Being calm wasn’t his form of denial. What I needed was not to mask my own uncertainty, but to exist in it with patients. In the coming weeks, I knelt next to a patient for an hour waiting for HIV results, sat with a grandmother during the biggest snowstorm to hit Boston in four years when no visitors were allowed, and embraced a patient’s daughter in the hallway, trying to explain that no, we didn’t yet know why her mother didn’t recognize her.
At the end of the 21 days, James’ repeat bone marrow biopsy showed a good enough response to warrant outpatient treatment. I visited him the morning before he was discharged.
“You’ll be good, Doc. You’ll be good.”
Sophia Li is a student at Harvard Medical School. Her work has been previously published in places like NPR and Cambridge Press, and she currently edits nonfiction for the Intima.
All names and identifying information have been modified to protect patient privacy.
Image by J_art / Getty
