The Written Smile

The Written Smile

Sikandar Imran

First place, non-fiction, Heard/Arlington County Detention Facility writing contest, August 2019

As I was driving to work on a crisp winter morning, mechanically consuming my usual breakfast of coffee and a protein bar, my mind was filled with a number of distractions. I had recently moved to Virginia from upstate New York for a clinical fellowship and training in Hematology and Oncology at a university hospital in Washington D.C. I was taking my time getting used to the intricacies of daily life in a bigger city. The familiarity of my old life and routine had been replaced with a nervous anxiety of even mundane things such as figuring out the nearest grocery store or the cheapest gas station.

My mind raced randomly between distressing thoughts as I moved at a snail’s pace through bumper-to-bumper rush-hour traffic. I had multiple valid reasons for consternation: I had left my brother and his family and many of my close friends behind in New York; I was going through a terrible break-up; my cost-of-living had gone up considerably and my earnings had drastically reduced in the new training job; my car needed repairs as did the ventilation system at my apartment; I kept putting off seeking medical attention for the unremitting back pain going down my leg; I was struggling to find time to prepare my talk on HIV associated cancers; I was gaining weight due to my unhealthy eating habits paired with a lack of exercise and was very self-conscious about my appearance; I felt a gnawing sense of underachievement at having reached the third decade of my life and being single and without a family of my own; my rigorous working hours were leaving me drained and spent and I still wasn’t sure if I was making adequate progress in my learning and expertise.

It was the first day of my rotation at the head and neck cancer clinic. As a trainee, my assignment was to study each patient’s file, interview and examine the patient, discuss my thoughts and findings with my attending physician and subsequently go see the patient again with my attending in tow to have an all-encompassing discussion.

“Why don’t you review the chart for the next patient first and then we can go together and see her. She’s been through a lot and we have really run out of options. Her cancer came back recently and I really don’t know what else to offer her. She’s so young and so strong, but her cancer has been very aggressive. Let’s talk to her together once you review her chart.” My attending, Dr. Smith, said with a furrowed brow and concern in her voice, an emotion which is not unusual for an oncologist to express, but I could sense added pain and empathy in her voice.

I nodded and started reviewing the chart. Kelly was a 34 year-old woman who had been diagnosed with cancer of the mouth about a year and half prior. She had developed an ulcer in her mouth initially which upon further investigation proved cancerous. She had gone through four different grueling chemotherapy regimens, each with its own set of challenging side effects ranging the gamut from hair loss to painful numbness and tingling in her arms to loss of fertility; all with short-lived disappearance of disease and recurrence with a vengeance shortly thereafter. She had just finished her last treatment about a month prior and unfortunately had started experiencing difficulty swallowing leading to imaging scans which revealed return of the cancer yet again. A student at a local university, Kelly had been married for about 4 years, and had a 2 year-old son. She was now coming in to discuss her new symptoms and further options.

I registered this and other pertinent information in my brain and quickly looked up key points about cancer of the oral cavity so I could better understand the case and keep up with what Dr. Smith was saying and answer her questions.

“Is there nothing else we can offer this patient Dr. Smith?”

I asked with both concern and curiosity.

“I am going to offer her immunotherapy which has been beneficial in recent studies, but I’m not entirely confident it will make any difference. Her cancer has been relentless from day one and I’m afraid this is turning out to be one of those cases where we are helpless.”

Dr. Smith said.

“But if you think it’s not going to work, why put her through another treatment? She has had so many adverse effects with her prior treatments. She couldn’t even complete some of them because of toxicity.”

I asked.

“That’s a very valid point. I think we have to make some tough choices. The one thing we don’t want is for our treatment to add to her suffering for no good reason. But this is usually a curable cancer, and keep in mind that her youth and lack of any other medical issues means that she can tolerate much more therapy compared to an older patient. I want to try absolutely everything even if the odds are against her.”

Dr. Smith said, with discernable ache in her words, a glaze setting over her eyes.

“That makes sense.”

I said.

“Let’s go and see her now if you are ready.”

Dr. Smith Said.

I knocked on the door and entered the room to see Kelly with Dr. Smith.

There was a young woman sitting in the room with a man by her side who she introduced as her husband, Mark. She was dressed in loose clothing with a surgical mask over her nose and mouth to conceal the devastation cancer had wreaked over her face. Her head was covered by a scarf; an attempt to hide alopecia due to chemotherapy. Part of a long-term use catheter poked out from her shirt. Most of her body was covered by clothing to reduce photosensitivity. Her emaciated frame, wasting temples, pitted nails and prematurely aged skin were testament to the fact that her body had become a battlefield. Her big eyes conveyed anxiety, hope, anticipation, sorrow, and exhaustion…all at the same time.

Dr. Smith introduced me to the couple and then started talking to Kelly, like two best friends having a focused conversation. Kelly couldn’t speak comfortably or coherently because of the destructive anatomic effects of her cancer. Mark answered most of our questions and Kelly added her input through written notes and gestures.

Kelly was dying, and it was slow and agonizing, more like drowning in quicksand instead of a car accident. She had no appetite and was readily losing weight. She was unable to chew and swallowing was painful; mostly pureed food through a straw. Her pain was better with a hefty concoction of painkillers and sedatives but the numbness and tingling in her limbs had worsened to the point where she couldn’t fasten the buttons on her shirt or tie shoelaces. Persistent foul smelling nasal and oral discharge distressed and embarrassed her. Her short term memory and cognition were worse. She was especially sensitive to changes in temperature. Her frailty resulted in a challenging instability at home; she had dropped out of school and mark had reduced his working hours to take care of her and their child.

Kelly and mark looked at Dr. Smith with cautious hope in their eyes, imploring and pleading with their gaze, understanding that our attempts at fighting the cancer had been in vain. Not only had we run out of options but Kelly’s physical, emotional, financial and mental resources were all fading away. They comprehended their choices, or lack thereof, but were not ready to accept them yet. Dr. Smith offered them immunotherapy as a last resort and discussed associated side effects but was realistic about outcomes; she did so in the manner of both an intellectual expert and a commiserative comrade, a skill which takes years of honing and similar heart wrenching encounters.

There was an uncomfortable silence in the room for what felt like a very long time. Kelly reached for her note book and pen and scribbled something. She held the paper up in front of her masked face for us to read as a tear rolled down her cheek.

“I’m smiling.” The note said.

Dr. Smith smiled and embraced Kelly and mark. There wasn’t a dry eye in the room. In that moment, with Kelly’s inability to convey emotion through her face and yet show such resilience and strength in front of everything life had flung at her, to continue standing up to cancer with dignity and courage, I forgot all my worries. Everything about my life that I thought was problematic or went wrong fell apart and seemed trivial. I lowered my head in sympathy and vowed to exercise more gratitude for all that I had. We exited the room and I moved on to the next patient, hoping and praying I didn’t have to witness someone else’s pain, suffering and fortitude before realizing my own blessings again.

(The names and any other identifiers of individuals in this essay have been changed in order to protect their privacy)