That Good Night

by Sunita Puri

  Around fifteen million people lost their homes, including my grandparents, who barely survived their migration to independent India. After a Muslim neighbor warned my grandfather of an approaching mob, he and my grandmother left their home empty-handed, desperate to reach the border with their young daughter, my mother’s oldest sister. Years later, my grandfather would learn that a mob torched their entire neighborhood just fifteen minutes after they fled. My grandparents went from one refugee camp to another, moving through Punjab and Delhi, eventually staying for five years in Deolali, once a transit camp for British troops in the western state of Maharashtra. Desperate for money and work in a new land, my grandfather decided to change his surname to that of a powerful, well-connected family in Mumbai, hoping that perhaps the illusion of a relationship with them would result in employment opportunities or even a refugee flat. Neither hope materialized, though my grandparents somehow made their way to Mumbai and raised five children in a two-room flat on my grandfather’s erratic and meager earnings as a taxi driver. My grandmother found solace in prayer, firmly believing that God would help her and her young family endure and possibly even transcend the hunger and deprivation that marked their first years in a foreign city, still reeling from the aftershocks of upheaval.

  My mother was born in the corner of a room where she and her four siblings and parents slept next to one another on scratchy mattresses. Because she was born at home, my grandparents never knew her birthday with certainty. It was one of the many unknowns in my mother’s early life, far less consequential than the daily uncertainty of my grandfather earning money, of a warm evening meal, of enough clean water to bathe. But one certainty that emerged early in my mother’s life was her desire to become a doctor.

  She found her calling at age seven, when she met the family physician who visited their flat with a shiny black bag whenever someone fell ill. He had soft hands and a quiet manner. His bag had a copper clasp that snapped open and shut with a professional click. She imagined it was a magic bag, full of pills and potions that scared away the illnesses that made people sick. She sat next to him as he sewed up her brother’s chin after he tumbled down a flight of stairs, and watched as he offered cool towels and a bottle of bright blue pills to her mother when her face burned with fever and her throat swelled. Just being around him made my mother feel better. She peered into his magic bag and thought that it was bottomless. Maybe when he put his hand in, she wondered, he actually reached into secret worlds. Once she reached into his bag to see what she might find, but quickly withdrew her hand when he turned around. She wanted to comfort people the way he did, to shoo away fevers and to sew up people’s accidents. She wanted a magic bag of her own.

  Her dream buoyed her through discouraging stretches of bleak monotony. There was the incessant honking of cars and metallic scuttle of rickshaw motors, the relentless sonic chaos of Mumbai that greeted my mother when she awoke and persisted after she fell asleep. There were her father’s outbursts—screaming matches with her mother followed by cool silences—when the humiliation of having gone from a thriving business owner to a struggling taxi driver consumed him. There were the fumes from her mother’s stove, vapors that stung her nose and made her dizzy. The fumes meant her father had earned enough money for her mother to make daal and rice for dinner, eventually filling the small flat with the comforting scent of garlic, ginger, and onions. No fumes meant the sharp twisting of her stomach turning on itself as she read her schoolbooks at night, remembering the magic bag when sleep seemed the preferable alternative to studying. She thought of the magic bag on Sundays as she picked lice from her siblings’ hair, crushing their small black bodies between her index finger and thumb, rinsing her hands in a bowl of blood-tinged water.

  Prayer brought my mother peace. She placed vines of jasmine atop a silver figurine of Lord Ganesha and a framed picture of Goddess Durga perched on a small bench in her mother’s kitchen. She and my grandmother sat together on the dusty floor of the gurdwara, a Sikh temple steps away from their flat that they entered with solemnity, their heads bowed and covered with thin cotton dupattas. She considered the practice of medicine holy, and begged God for the chance to become a doctor, keeping the image of the magic bag in her mind as she whispered prayers in Sanskrit and Punjabi.

  When my mother earned a spot at a medical school in Mumbai, my grandmother cried tears of pride and shame. She and my grandfather could not afford the mandatory admission fee. Later that day, quietly determined, my mother pleaded for help from a wealthy neighbor, who listened to my mother’s predicament and gave her the money she needed. Every time my mother had to pay school fees that she lacked, she begged the dean of the medical school for a scholarship. A combination of her insistence, determination, and excellent grades swayed him each time. Throughout medical school, my mother continued to live with her parents, taking two trains and a bus to and from school each morning, returning as she always had to the smell of her mother’s stove and the scratchy mattresses on the cold floor.

  * * *

  During my childhood, my mother and medicine were inextricably intertwined, sometimes indistinguishable, each shaping and shaped by the other. It was almost as though medicine was the fifth inhabitant of our home, living quietly alongside my parents, my younger brother, Siddarth, and me. Medicine lived in our hallway closet, where my mother stored the green operating room scrubs that I occasionally wore as pajamas. Medicine carpeted my mother’s car, long strands of her black hair stuck to the wispy blue operating room caps and shoe coverings always underfoot in the passenger seat. Medicine even made its way into my father’s wardrobe. In a number of family photos taken in the 1980s, my father is wearing a shirt my mother gave him, one that advertised a medication she’d started to use in the operating room: “I’m in Control: Tracrium.”

  The hospital was my second home, and my mother’s colleagues became my aunties and uncles. On school holidays, she would bring my brother and me to the hospital with her, leaving us in the surgical lounge under the not-so-watchful eyes of surgeons who snacked on doughnuts and chips between their cases in the operating room. They gave my brother and me operating room hats and gowns so that we could pretend to be just like them. I examined my face in the mirror in hospital bathrooms, hoping that I would one day have my mother’s long black hair, her hazel eyes and long eyelashes, her smile so wide and warm that it could both comfort and disarm anyone. I helped her to pack suitcases full of sterile gloves and needles and operating room equipment to donate to Indian hospitals where she volunteered as an anesthesiologist every year, treating patients who lived in the poverty she had escaped. Medicine hovered over my shoulder when my mother and I sat together studying biology and physiology when I was in middle school, reviewing what I still consider to be the awe-inspiring mechanisms of the heart pumping, the kidneys filtering, the liver cleaning, the brain commanding.

  In high school, when I told her what I was learning in biology, she told me I finally knew enough for her to share with me the details of her everyday work. She traced her finger along the side of my neck, showing me how she found a patient’s jugular vein, and telling me why she had to place IVs there to give powerful blood pressure medications to patients undergoing surgery. She traced a similar path along the artery lining my wrist, and showed me where and how she put in a thin, flexible catheter that would sense and report changes in blood pressure. She taught me to trace a path down the front of my neck, showing me the anatomic landmarks she used to insert a breathing tube into a patient’s throat, which would connect him to the ventilator, a machine that would assume the work of his lungs during surgery. She pulled out her stethoscope from her purse and showed me how to listen to my own heart, and then hers, the heart that had nourished me in her womb.

  Her heart made the two distinct sounds that my high school physiology textbook described: Lub-dub, the steady, reliable sequence of the closure of one set of heart valves and then the second, ensuring that blood flowed
in one direction, from atrium to ventricle to the rest of the body. Years later, in medical school, I would remember the sound of her heart as I learned how to read an EKG, its elegant tracings corresponding to the electrical impulse that blazed a path across the heart’s tissue eighty times a minute. During periods of sadness and stress, I would place my hand on my heart, marveling at the fist-shaped muscle that pumped inches below, reminding me that I was just as strong and capable of resilience as the woman whose own heart gave life to mine.

  Yet along with my mother’s intense presence was her absence. Even though medicine fostered our bond, the demands of her career also tested it, keeping her at the hospital for stretches of time that felt endless. I was always the last child picked up from an after-school day care program if she was in a complex or emergency case. The hospital operator recognized my voice because I would call to talk to my mother every night she was on overnight call, which for a time was every third night. When I came home from school and found her asleep after working a thirty-hour shift, I would jump on the bed to wake her up, wrapping my arms around her and hoping she would take me to the beach or the park. I would breathe in the scent of her damp hair, freshly washed before she napped, and try to burrow my head in the narrow space between her jawline and collarbone. She would push me away, barely awake, and groggily ask me to let her rest.

  I couldn’t be without her, but I came to realize that she couldn’t be without medicine. I followed my mother into medicine because that’s where she was.

  * * *

  Six months into my internship, the grueling first year of internal medicine residency training, I met John Tan.

  Because Mr. Tan couldn’t speak, he wrote me notes instead. He lay in a bed in the intensive care unit of the university hospital, steps away from the ward where I’d met Donna and Julia. He was a thin man in his early sixties with a fringe of gray and black hair that lined the lower edges of his skull. About a year before I met him, he’d survived an aggressive cancer that grew from the lining of his nose and pharynx. But the chemotherapy and radiation that treated his cancer left him vulnerable to infection. A fungal infection invaded the base of his skull and eventually made its home in the lining of an artery feeding his brain. Periodically, pieces of the fungus would break away from the wall of the artery and, carried upward by tides of blood into his brain, lodge in tiny blood vessels that fed his delicate brain tissue. The resulting unpredictable strokes he had suffered robbed him of his ability to walk independently, swallow food, and speak.

  “There’s no surgery to remove the infection,” our hospital’s neurosurgeon told me when I asked if there was a way to remove or reduce it. “It’s just a matter of time before he has another stroke. All we can do is continue the antifungal medications and hope that that will slow down its growth and buy him time. But in the long run he isn’t going to do well.”

  Though it posed a constant threat to his life, John’s fungal infection wasn’t the reason he had been admitted to the hospital this time. He’d developed a severe pneumonia and was in the hospital for powerful intravenous antibiotics. But as his pneumonia began to resolve, he suffered a life-threatening bleed from an ulcer in his stomach. I ordered multiple blood transfusions for him and he underwent CT scans and endoscopies to identify and stop the bleed’s source. Shortly after he stabilized, his heart started racing, portending another infection, this time in his bladder.

  Mr. Tan was one of ten patients I’d been assigned. The time I spent with him, and every one of my patients, was brief and hurried. Efficiency was every intern’s holy grail, and patients could slow us down by talking for a very long time. Despite convincing myself I wouldn’t follow in the footsteps of the residents I’d learned from, I spent far more time on paperwork and note writing and studying than I did talking with and examining patients. My habits troubled me, but I’d remind myself that I’d need to survive residency in order to practice medicine the way I wanted to. After all, my residency classmates and I joked that we were experts in delayed gratification. But Mr. Tan’s situation set off an internal alarm I couldn’t ignore, the severity of his condition convincing me that taking care of him required me to stop glancing at the clock when I was in his room.

  Every morning when I examined him, he greeted me with a crooked smile on his stroke-struck face, left cheek higher than the right, his bright eyes lined with deep crow’s-feet. He extended his left hand, every blue vein visible and protruding, and motioned for me to sit down and join him. His perpetually chapped lips, always partially open, revealed thinning gums and teeth covered in thick saliva, which pooled on the side of his face and collected in the crevice of his collarbone as he napped. The sick-sweet stench of bloody stool, a result of the internal bleed he’d recently suffered, filled his room as I examined him, pressing my stethoscope along the points on his torso where I could best hear his heartbeat and breathing. Again with his left hand—the hand unaffected by his most recent stroke—he picked up the whiteboard and red dry-erase pen that lay at his bedside, next to a navy blue UC Davis mug and what appeared to be a letter written in Chinese characters, and began to write to me.

  My mouth feels very dry. Can you give me some gel for it?

  His main discomfort seemed so small in light of his pneumonia, bladder infection, stomach bleed, and the ever-present possibility of another stroke. I glanced at his medication list and noticed that the gel I’d ordered had somehow expired. I promised him I’d reorder it. He never had many questions for me. But as he developed one new malady after another and two and a half weeks in the hospital passed by, I realized how many questions I had for him, questions that I’d first heard Dr. McCormick ask: Did he understand how sick he was? How would he want me to take care of him if he got sicker? Had he and his family ever discussed what quality of life he valued, and what decisions he would want them to make on his behalf if another stroke destroyed his ability to communicate? Would he want CPR if his heart stopped? Though I had watched Dr. McCormick open these conversations with a graceful ease, I doubted my ability to do the same. Just as I began to tell Mr. Tan that I’d be back later in the afternoon to make sure his mouth felt better, he started to write me a note.

  Do you ever go home?

  I chuckled and promised him that I did.

  You are here in morning, afternoon, night. When do you go home?

  “Okay, now you sound like my mother!” I joked with him, and we both laughed. A patient had never conveyed concern about my own well-being, and I was touched. “I promise you I go home. And it’s very kind of you to even ask me about that!” What I didn’t tell him, what I was ashamed to admit, was that a part of me preferred being at the hospital rather than outside it. Within these walls, I had a clearly defined role, one that brought me a degree of purpose even when it frustrated and exhausted me. Outside in the world, I was uncertain of who I was: I’d invested so much time studying and preparing for work that I no longer knew what to do with myself when I had free time. I became synonymous with my work, even in the moments when I doubted that medicine was the right profession for me. Becoming a doctor had taken up so much of my life that I promised myself I would find a way to make it feel like the right fit. Outside of the hospital, I had been fighting with my boyfriend at the time, an engineer who had come to resent the emotionally depleted intern who took hours to respond to text messages and who sometimes fell asleep in the middle of a phone call after work. I was impatient in grocery store lines and curt to cashiers. My friends from college slowly stopped calling and emailing me because I mostly didn’t write back; there was always something more pressing—a test, a research project—that seemed to get in the way. I wasn’t good at my life. But I thought I could be good at medicine. I reminded myself to embrace the concept of delayed gratification. What I’d sacrificed now could be mine when I finished my training.

  Thank you for helping me, he wrote, giving me a thumbs-up sign.

  “You are very, very we
lcome, Mr. Tan. I promise you I’ll take care of that dry mouth for you.”

  As I left his room, I knew I had to muster the courage to have an honest talk about his condition with him and his family. Nobody on the long roster of physicians who treated him—surgeons, neurologists, infectious disease specialists, and oncologists—raised a concern that he might die during this hospital stay. Or that he might survive but leave weaker and more debilitated than he’d been before. Of my ten patients, he was the one most vulnerable to catastrophe. And if he suffered a complication we couldn’t control, we had no plan in place other than to sustain his dying body with every possible invasive machine and technology, regardless of their benefit to him at this late stage of illness. I found myself wondering if I was just treating one of his maladies to buy time for another one to manifest. Yet with many more experienced doctors involved in his care, I felt the least qualified to voice this observation.

  Was Mr. Tan slowly dying? I wondered after observing the setbacks he had suffered in the weeks since I assumed his care. And if indeed his time was short, would he want to spend it in the hospital as we chased one problem after another without changing where things were heading? Instead of fearing his mortality, what if I respected him enough to name it, to invite the end of his life into the conversation I knew I’d have to have with him? Would he be alarmed or relieved to know what I was thinking?

  I wanted more than anything to be a good doctor—to Mr. Tan, to every patient I’d see now and in the future. But what did it mean to be a good doctor to a patient in his predicament? Was a good doctor the one who promised to do everything in her power to save his life, or the one who was honest about medicine’s limits? Was the good doctor the one who maintained a hopeful silence about Mr. Tan’s uncertain future, or was she the one who broke it?