The characters in the following story are fictionalized versions of patients we have managed on the hematology service. The title “What We Carried on Christmas” is a tribute to “The Things They Carried,” Tim O’Brien’s critically acclaimed short story from 1987 that uses the list as a writing form to tell a powerful story of a platoon in Vietnam. The commentary following this piece provides my perspective on how hematology advances, including 2015 Year's Best selections, weave together with the compelling narratives of our patient's lives.

My Christmas morning commute to Stanford Hospital felt like a post-apocalyptic odyssey. I didn’t spot a single car or human being on the eight-mile stretch of Interstate 280. However, shortly after taking the off-ramp to Sand Hill Road, I came upon a freshly struck deer lying in the left lane. I slowed down and surveyed the carnage. Its warm entrails formed an accidental palette with the shoulder’s yellow border. Along this corridor of venture capital firms, a Tesla sped off from the scene. It carried dollops of the deer on its front grille, while leaving an electric hum in its wake. The driver would hide this accident from his family so it couldn’t taint the splendor of the holiday. I drove away, carrying the vicissitudes of this deer’s life with me to inpatient hematology rounds, along with my stethoscope and iPhone.

On Christmas morning, Paul carried an extra 5 kg of fluid from his AML induction. The edema made little difference on the 6’6”, 120-kg frame that he sculpted during Army Special Forces training in the early 1990s. His physique blended a perfect combination of slow-twitch and fast-twitch muscle memory that made it easy to double-tap a target while hanging upside down in the dark. Paul carried the tip of the spear as a member of Delta Force during two Gulf wars and numerous clandestine ops around the globe. The team stared at his massive figure when he lapped around the hematology unit with his diminutive IV pole; the nurses and other patients gawked, too, like rubberneckers transfixed by that swirl-cake of a deer. When United Airlines flight 77 tore into the Pentagon, Paul had scooped up workers and carried them to safety before the ceiling of their office collapsed. For a few hours, he inhaled a plume of super-heated dust consisting of incinerated concrete, fuselage, and parts of people’s souls. His lungs carry the scars of that day. A few months after 9/11, he developed pneumonitis and lost a quarter of his pulmonary function. It’s possible the toxic brew also may have corrupted his bone marrow.

During morning rounds, Paul shared tidbits from some of his Delta Force missions, including Operation Gothic Serpent in Mogadishu and Operation Enduring Freedom against the Taliban. During treatment, his waning appetite made him think of meals at home and abroad. He joked about the similar textures and tastes of combat MREs and our cafeteria’s selections. He reminisced about toppings that presaged the dinner menu at his base in Kabul: horseradish on the tables was followed by prime rib, and applesauce heralded pork chops. For worsening trismus related to mucositis, ENT had him bite down on a stack of tongue blades to exercise his jaw. This wasn’t very difficult for him. Muscle memory. I imagined a celluloid version of Paul clenching the blade of a knife between his teeth while scaling a wall just before snatching a high-value target.

Paul’s three children and wife spent Christmas day with him in his room. He hopes that his illness will bring them closer together. In two weeks, he’ll leave the hospital. When I have the results of his remission marrow, he’ll be studying my face for clues about good or bad news. Reading microexpressions is part of his training. Paul carries the unflinching faith that he’ll dodge another bullet. He visualizes a military retirement, lounging at his beachside home, out from the shadows and cured of AML. In this future, he’ll make the choice to sport a buzz cut, despite it occasionally reminding him of the time when nurses carried away clumps of his hair.

Olivia is a 32-year-old blonde with television good looks who came in carrying a new quilt of bruises. She and her husband, owner of a private equity firm, live in an 8,000-square-foot home in Atherton. They are warm and soft-spoken. Their two girls, ages three and six, are angelic clones of their mother. Photos of the kids and their crayon drawings blanket the walls of her hospital room. When the resident and first-year fellow first spied her D-dimer of >20,000 ng/mL, fibrinogen of 42 mg/dL, platelet count of 19 × 109/L, and white blood cell count of 77 × 109/L, they understandably carried apprehension and urgency. I felt the same. They heard of the head bleeds; I managed them; our APL patients died of them. We started ATRA and successfully FISHed for t(15;17).

Olivia steadied her shaky voice; she carried guilt, fear, and many questions about things she was afraid to ask since she first heard the word “leukemia.”

    “I dyed my hair,” she said. “Did this cause my leukemia?”    “No,” I firmly replied.    “Six months ago I went vegan.”    I almost cut her off. “No connection,” I replied.

She inspected her bruises. She was unconvinced that she wasn’t to blame. Tears welled in her eyes.

    “Am I going to give this to my kids?” she asked.    “No. None of this is your fault. This is an acquired blood cancer. You can’t pass this on to your children,” I comforted her.

We commenced a protocol for high-risk APL and reassured her that she has an excellent chance of being cured. However, we all knew that she wasn’t out of the woods.

A year ago, I lost a mother of three young kids to relapsed acute lymphocytic leukemia. Soon after, her husband reconnected with me. While he was thankful and trying to move on, Olivia’s case reminded me that I hadn’t. I still carried an insidious melancholy that bubbled to the surface. It hung on to my conscience the way dried silicone gel sticks to jeans despite repeated washings.

I felt that this was a good time for bargaining. I rationalized that if all creatures are equal in God’s eyes, maybe he would agree to a zero-sum arrangement: Olivia for the deer. I turned to her husband to make sure there would be no last-minute hiccups: “Do you drive a Tesla?”

Commentary: Our patients remind us daily of what we are fighting for. While there may be “eight million stories in the naked city,”1 we are privileged to be witnesses to a few thousand of them during our careers. In some cases, we can extend patients’ quantity and quality of life so that new epilogues and second chances can be written.

2015’s Year’s Best in Hematology is a subjective list that highlights the achievements of our profession. Our choices mark time and allow different arcs of progress to reveal themselves. However, these choices are most relatable and personal when we can identify specific patients who are beneficiaries of these breakthroughs. Olivia’s promising outlook reflects a narrative of incremental progress in APL throughout the past 30 years. I remain hopeful for Paul. Genomic studies are helping to inform druggable pathways for different subsets of patients with AML. Separately, a day before Christmas, a man with a white blood cell count greater than 100 × 109/L walked into our emergency department. He left a day later with a diagnosis of chronic phase CML, a TKI prescription, and unexpected hope. The transformative success of CML therapy could not have been fleshed out nor appreciated in a single Year’s Best article. I am curious to see how studies of clonal hematopoiesis, myeloma antibodies/immunotherapy, techniques to enhance stem cell engraftment, and the other Year’s Best selections featured herein pay dividends for our patients over the long haul. I will let you know when I am on service again during Christmas 2025.

1. From Jules Dassin's "The Naked City"

Competing Interests

Dr. Gotlib indicated no relevant conflicts of interest.