So today was my first day of Oncology posting, a new day after thesis submission. The last two weeks were a rollercoaster for me. So many thesis corrections, so many edits, so many overnight SPSS runs and rewriting the results and discussions again and again. At one point I was almost sure I wouldn’t be able to submit on time, but somehow I did, and so this new ward posting of mine was filled with excitement.
Back to this morning. The Oncology ward was new to me, and so were the patients, staff, and co-residents of that ward. I started writing notes and tried to understand the cases. I have seen cancer patients before, but never so many kids with diagnosed cancers all at once. So, I had to read up the diagnosis and treatment protocol, so I don’t seem lost during the rounds. Sometimes I don’t understand how, if there is a God, can be so cruel that these little kids have to suffer so much from these demons called cancer.
The second patient I saw was Khushi. I remembered her at first glance. A few months back I had admitted her in our ward. She had a history that I still cannot forget.
A few months ago, she developed pain in her right hip. Her sister had also had trauma to her right hip and was being treated in a hospital in Kathmandu. During her sister’s stay, Khushi also started saying her right hip was painful. Initially everyone thought that she developed pain because her sister also had similar pain and she was emotionally upset about her sister. The pain of Khushi then progressed to her right hip joint and later to multiple joints. She also started losing her appetite and would get fatigued easily. She used to have episodes of fever where she would be treated with antibiotics and get relieved. She was also taken to a very famous pediatric rheumatologist, where many tests for connective tissue diseases and rheumatologic conditions were done, but nothing was found.
She was taken to the same hospital multiple times and some workup was done. Unfortunately she was usually accompanied by her relatives during her hospital visits and after they’d consult a doctor, she would be advised to come for follow up if not improved but next time they’d go to another physician. After multiple investigations revealed her blood counts and CRP to be normal, she was labelled as having some psychiatric illness. And once this tag was added to her diagnosis, every hospital she visited counselled her that it was psychiatric and treated her as such.
But nobody noticed that her hemoglobin was slowly dropping and her counts were increasing.
Then she came to our ER. On taking a proper history, it was clear that it was never joint pain. It was bone pain throughout her illness. So we planned to do investigations with the suspicion of hematological malignancies. That day, when we told the patient’s mom that she might have blood cancer, she was sad, but not to the extent we thought she would be. I still remember one of our residents saying, “Dai, hami le soche jatiko dukhi hunuvayena ni usko mummy.”
The next day, when the PBS report came, it showed eighty-seven percent blasts, the most we had ever seen. We went to counsel her, thinking she had already accepted it, and maybe that was our mistake. We sat with her, explained her symptoms again, and tried to make her comfortable before breaking the bad news. After we told her that the report now shows like she had blood cancer, she became silent at first. Then the tears came. And then it happened. She cried with that sheer emotional pain, the kind that pierces through you. Because she had not responded with the grief we had expected earlier, we thought it would be the same this time too. But the mother in her couldn’t take it anymore, and it erupted like a violent cry.
PBS: 2082/05/19
WBC: 87% blasts, high N/C ratio, inconspicuous to 1–2 nucleoli, scant cytoplasm
RBC: anisocytosis, normocytic normochromic to microcytic hypochromic, polychromasia
Platelets: reduced
Serology: negative for HIV, HBsAg, anti-HCV
Bone marrow aspiration (2082/05/27): Suggestive of acute leukemia
Flow cytometry: 25.50% blasts with CD45 dim expression. Positive for CD19, CD20, CyCD79a, sCD22, CD38, and precursor markers HLA-DR and TdT.
It felt like we failed her. If someone at some point had thought of bone pain instead of joint pain, things might have been different. She is on chemotherapy now. Textbooks say B-cell ALL has a better prognosis, but let’s see what fate has for her. Maybe she actually becomes khushi!