WE THE INTERWOVEN

Table of Contents


CVA

MELISSA PALMA

 
 

1 | The father’s stroke

Dr. Danilo Socorro Magno woke up on a Thursday morning. The room was silent around him, save for the quiet echo of a distant radio from the kitchen downstairs. He wiped the rheum from his eyes and rolled over to greet his wife. His hand lay empty in the soft impression where she had risen from bed hours before. “I forgot,” he thought to himself. “She must be teaching her tai chi class at the senior center today.”

The physician’s hand fumbled for his eyeglasses on the bedside table. He placed the wire frames on his wide nose bridge, and the world came into focus. He smiled at the platter of coffee and soft-toasted bread laid out before him. As was their ritual, his wife had prepared breakfast at the bedside for when he awoke.

“Salamat, ha. I’m thankful she knows I like my toast with both butter and sugar, even though I’m sure my primary would prefer she didn’t,” he said to himself. Chuckling at the idea of a doctor who needs a doctor, he added, “At least I don’t take creamer in my kape!”

Dr. Magno consumed his black coffee and pandesal while listening to the morning news on public radio. He rose from bed, massaged the cricks from his right knee, and made his way to the shower before dressing in a crisp shirt and an unassuming pair of slacks. Kneeling to rub the calluses on his heels from decades of long-distance running, he quietly traded his house tsinelas for proper loafers at the door. Always planning his next actions, the physician envisioned himself taking the road leading away from their sleepy subdivision as he had done without fail for the past twenty-six years in the country.

The jolt of caffeine was invigorating as he started the car. His amplified sensory acumen detected the trace scent of freshly laid fertilizer that wafted over from the farm down the road. He ran through a brief mental list of patients he planned to see that morning.

“My 34-year-old female with granulomatosis with polyangiitis and a penchant for jazz music. My 55-year-old female with stage V CKD on dialysis who painstakingly knit wool hats for each of my nurses last Christmas. My 89-year-old male with uncontrolled hypertension who races turtles with his grandson at the Rotary Club.”

As a practicing nephrologist taking care of chronically ill patients, Dr. Magno had come to know many details of his patients’ personal lives. Always with the utmost professional candor, of course. Both he, and the community, would expect nothing less.

On his way to clinic, he drove past alternating postage-stamp plots of corn and soybeans on either side of West 4th Street. He revved the engine for a bit of fun as he was nearing the familiar turn and the driveway of United Medical Park.

But then, in a second, he wasn’t.

Overcome by dizziness, he found himself in the parking lot of the Hy-Vee several blocks away without knowing how he got there. His mouth curled around an unrecognizable sound thrust out by his tongue.

His clinician’s mind quickly built a differential. Sudden-onset unilateral vision loss accompanied by vertigo and slurred speech. Transient ischemic attack, central retinal artery occlusion, generalized seizure, cerebral vascular accident. An ominous voice that he could not recognize as his own portended, “Ay naku po. I think I’m having a stroke.”

 

2 | The daughter learns

The physician’s daughter was sitting in the third-floor atrium of the medical education library. She liked to study in the sunlight, looking out across the Iowa River and daydreaming about being anywhere but here. The table was strewn with reams of course notes, each page meticulously highlighted, color coded, and categorized.

Jojo Magno was waist deep in renal physiology, rapidly calculating acid-base practice problems and trying to remember whether Winter’s formula was to be applied before or after the correction for bicarb. A fourth-year medical student at the University of Iowa, she was studying for the medical boards, a twenty-six-day marathon that would be the culmination of everything she and her parents had hoped to achieve by moving to the States.

The musical crescendo of Debussy’s “Arabesque No. 1” rang in the background; instinctively, she rummaged through the backpack to answer her phone. Her fingers fumbled over the cool steel of her stethoscope, the gummy triangular head of her reflex hammer, before finally reaching the smooth glass of her cell phone. A missed-call notification from her mother flashed on the screen.

She swiped through her voicemail transcription and sighed. It never could decipher her mother’s accent. “Transcription Beta (low confidence). Hi          Joy. You might be          driving          careful                   love         . Bye.”

Crepuscular rays from the setting sun cast shadows on Jojo’s computer screen. Her mind was full and she took a much-needed break to call back hours after the initial message. The phone rang once on the other end of the line. Her mother’s hurried voice explained in a flurry of English and Tagalog. The daughter was dumbfounded. “What do you mean, he’s been in the hospital for three days already? Why didn’t anyone tell me?”

Maria Milagros Hilario Roque Magno was once a lawyer herself in the Philippines before relinquishing her profession to become a mother in a foreign land. She attempted to calm her increasingly histrionic eldest child. “Anak, we didn’t want to worry you. We know you are studying very hard and we didn’t want to distract you.”

In an instant the young medical student, who had spent years accumulating objective scientific knowledge of the human body, knew absolutely nothing. Only that her father was seriously ill and she was powerless to change it.

 

3 | The daughter returns

The future Dr. Josefina Nyota Roque Magno sped ten miles over the speed limit along the entire length of I-380 north on her somber sojourn home to Waterloo, Iowa. The gleaming silver grain silos and majestic timber-frame barns on the roadside became an imperceptible blur. She received updates from her mother via speakerphone and immediately regretted the first thought that came into her mind: “Oh my god, he needs to be transferred to the university.”

In a reversal of roles, she had become one of her patients’ concerned family members. An instant archetype, the ones who looked to the storied University Hospitals and Clinics as a cathedral of healing. To them, it was a place where miracles happened, where people were given a second life.

Intimately familiar with the personal sacrifices required to achieve such miraculous recoveries, her reasoning was much less noble. Even to Jojo, ever the optimist, the hospital was a place where souls, of both patients and providers, went to die.

Instead, she simply told her mother, “I’m afraid he won’t get impartial care at home.”

It was true. The distinguished Dr. Magno knew all of the physicians in their midsized Midwestern city where he had built his practice and raised his family for the past two decades. Many of them, like him, were international medical graduates who migrated to rural parts of America where doctors are scarce and need is always growing.

Their office parties were a veritable United Nations of the heartland. The Cuban family doctor married to a Filipina oncologist met on a medical mission trip. The Sikh nephrologist who oftentimes covered her father’s call schedule, but only if her own kids weren’t sick. The Bosnian neurologist who, when she was seven years old, would bring chocolate milk to the call room as Jojo and her four-year-old brother invented puppet shows with no-slip hospital socks while their father was busy seeing consults late into the night.

Although the daughter had not visited any other countries besides her parents’ native Philippines, she traveled extensively via her taste buds throughout childhood without ever leaving the Cedar Valley. Whenever a new physician’s family moved to town and came over for dinner, their home would be filled with a joyous blend of her family’s suka and patis along with the inviting aromas of their guests’ garam masala or berbere or za’atar spices. Jojo wondered which one of their former houseguests was presiding over her father at this very moment.

Her mother’s disembodied voice interrupted the memories. “Everything will be fine, anak. Bahala na. Just pray to God, He will provide.”

 

4 | The father pronounced

Jojo arrived at the ICU to the sound of her mother wailing.

She had flashbacks to her last rotation as a medical student in the MICU of the tertiary care center. Her first patient was dead before the team had even started rounds. She was an 89-year-old female with past medical history of rheumatic heart disease admitted for dyspnea on exertion, hypoxic respiratory failure, and a not-so-surprising acute on chronic loss of moxie.

 In the dawn of the morning while scrolling through masses of data at her computer workstation, she had dutifully gathered vital signs of one already devitalized. Sketching out blank templates in the shape of fishbones and crosses, she copied down the patient’s electrolyte and hematologic laboratory values. All that was missing to complete her pre-rounding was a perfunctory interview to listen to the heart and lungs.

But unbeknownst to Jojo, her patient had already passed sometime in the night. Startled by the absence of the familiar S1-lub and S2-dub, she strained her ears and pressed firmly with the diaphragm. Still a learner, she adjusted the rubber ear tips of her stethoscope. The student took a sharp breath of her own and hoped to become attuned to the unmistakable clarity of lungs by auscultation, but she instead found fixed and static silence.

Dead? Her first patient on her first day of her first ICU rotation in medical school? Instead of helping the resident document the progress of her patient’s notable recovery, she learned how to write a death pronouncement. She feared that once-buried knowledge would now resurrect itself.

“Ano ang nangyari?” asked her mother’s shaking voice as she watched her firstborn stand frozen in the doorway. The daughter stepped over the sterile threshold and noticed her little brother, still in his work uniform, asleep on the couch.

Jojo gazed downward in shame at her mother’s inquiry. She didn’t have an answer. She didn’t have any answers.

In the ICU of the medical floor where she once played make-believe, her father lay still in a hospital bed. His eyes were closed, but she could still discern a slight asymmetry of his facial muscles, a laxity of limbs on his left side. Instead of the man who had taught her how to expertly mix a sidecar and change a car tire, in his place she saw a ghost in a shell.

Periwinkle gown askew, his body was unceremoniously uncovered like a child who had outgrown his favorite clothes. The man who boasted about running a ten-minute mile on his fifty-fourth birthday was now propped up by pillows on either side of his torso. Like so many other patients she examined in the wee hours of the morning, he would have looked completely anonymous were it not for her own mother sobbing at his bedside.

Still coping with the gravity of the situation, she did what she was conditioned to do in times of crisis. She dissociated herself from the sentiment and immersed herself in the technical to become her family’s advocate. Although they were trained professionals, it had been over a quarter century since anyone else in her family had staffed the inpatient units. They needed someone, they needed her, to interpret his maladies. Moving methodically, Jojo began assessing her father’s deficits.

Once conscious, Danilo became more alert and keenly responsive. He could blink his eyes and follow the tip of her finger with a smooth gaze both horizontally and vertically. Peripheral confrontation testing revealed that his field of vision was much reduced. Although he could squeeze her hands upon command, she noted a much looser grip on the left. The patient was able to achieve grade four motor strength in the right arm and leg but could only muster grade two range of motion with gravity eliminated on the left side. When asked to name the month and state his age, she could barely make out a garbled phrase.

Startled by his loss of language, Milagros brought her daughter closer and asked her husband, “Sino ang siya? Danilo, who is this?”

His mouth pursed to point in her direction as he struggled to speak.

“Oo. Oo.”

Milagros nodded and leaned in, removing herself from her husband’s newest blind spot. “Yes, yes? Can you understand me? Who is she?”

Danilo scrunched up his face with great effort and attempted again, ”Yo-yo, yo-yo.”

Her mother’s eyes lit up. “Mahal, I think he’s trying to say Jojo.”

While clinically predictable given the diagnosis, the father’s physical exam was devastating to the daughter. Dysarthria, homonymous hemianopsia, facial hemiplegia, unilateral hemiparesis. These were all words she had seen hundreds of times in lecture notes and textbooks, but they did not become real until applied to her beloved Tatay as he faced an end of the life they had once lived.

When Dr. Sharma came in the next morning to convey information from her latest consultations with the neurologist and the cardiologist, Jojo had given up all pretense of objectivity. The only thought running through her head was, “He can’t even pronounce my name anymore.”

 

5 | The rehabilitation

In aftermath of the cerebral vascular accident, details emerged that Jojo wished she did not know. On the third day, she was told that her father arrived to urgent care and was quickly identified by the triage nurse as having an acute stroke. Hurriedly ambulanced to the local emergency room for evaluation and a CT scan, he was given antiplatelet medications and clot-busting injections within two hours of symptom onset upon consultation with Dr. Sarkic.

As a professional courtesy, he was directly admitted to the inpatient medical floor, but to the dismay of his care team he was never issued a hospital ID band identifying him as a patient until well after his admission.

Tying her box braids out of her face, the nurse questioned, “How am I supposed to take care of my patient when I can’t even open a package of gauze without any identification?” Exasperated, she continued, “No ID band, no MRN, no nothing. What do y’all think this is, a hospital or a hotel?”

From her introduction to health systems course, the daughter knew this was how medical mistakes happened. First the deviation from protocol, then inadvertently missing important allergies, then a near miss, and then a catastrophe. Like perfectly aligned holes in Swiss cheese, the culmination of errors would haunt her father as he was whisked away to the MRI suite.

On the eighth day of his recovery, Jojo sat for the medical boards. That morning, her hands wouldn’t stop shaking to the point where she would have failed a test for dysmetria. Over the course of nine hours she miraculously managed to complete all of the questions on the exam without bursting into tears. She would do her fair share of crying when the scores were released in four months’ time. But at that moment, when the emotions got hold of her, all she could think about was how her life of privilege was so closely teetering on the edge.

Before the event, she thought her margin of error was as wide as the continents her family migrated across, fleeing oppressive regimes. The guilt of her complacency was drowning. “My parents were my age when they started over.” She wiped away the salinated liquid pooling in her eyes and chastised herself for being so selfish. “I knew one day I would have to take on familial obligations. I just didn’t think it would be so soon.”

Thirteen days after, she crossed herself and began her neurology rotation on the stroke service. She was privileged to witness a seasoned attending gather the family of a recently transferred patient. Kneeling to eye level with those seated before him, he looked directly into their eyes with intention before calmly counseling all present, including her.

“There are three stages of treatment after a stroke. The first stage is here in the hospital where she will be monitored until stable by my excellent care team. The second stage is at the rehabilitation center to learn anew her activities of daily living. And the third, and most important treatment of all, is when the patient returns home to grapple with a host of marital, social, and spiritual issues that lie within the stewardship of you all, her beloved caregivers.”

On day 34 in rehab, Danilo was brought to daily speech therapy. His diet was advancing, albeit slowly, from liquid to soft mechanical. He was in physical therapy (ter in die), and his wife was closely taking notes during each session as they recorded his gait velocity. Milagros was determined to augment her enfeebled husband’s physiotherapy and learned techniques to encourage predictable, repetitive movements and exercises. They would shape his brain circuits with the right experiences to rewire them, akin to infant development. It was not the first time she had taught someone how to walk.

The patient returned home on day 89. In preparation, his son removed all area rugs to protect against bone-breaking falls. A family friend installed a wheelchair ramp in the garage and handrails in all of the bathrooms. Unanimously, the remaining members of the household decided to retrofit the elder daughter’s old bedroom on the ground floor with the hydraulic patient lift and hospital bed.

Instead of celebrating a joyous reunion with her family on the day of his homecoming, Jojo was sitting in an empty hotel room in Minnesota on the interview trail for residency positions. She called her brother to video chat to remind him to save her a plate of pancit. It was the first time she saw the sterile railings of the patient’s new bed juxtaposed against the ballet-pink flounces framing her childhood window.

Without a greeting, she commanded, “Let me talk to Tatay, Paolo.” Flipping his Panthers baseball cap from backward to forward, the younger sibling snipped back, “Okay, okay. Ate, don’t have a carabao,” as he positioned the screen in front of his father’s body.

By all accounts, he was in a recovery of sorts. Conversations with her father had become easier to understand but more painful for her to endure over the past few months as his speech difficulties ossified.

Danilo used to cherish the turn of phrase or a play on words in any language. He would devise games to quiz his children on the Latin roots of medical terminology. When concocting bedtime stories, the purported monster would be banished by the heroine’s bilingual declaration, “You shall terrorize children no more across this land, by the powers that be, ang nakakatakot is now nakakata-cute!”

As time passed and his English began to fail him, it was her strange language that was taken only literally. With her mother and her brother at her side at the medical college on day 233, Jojo called to tell her father she had matched to the family medicine residency in Waterloo. She was coming home!

One month prior, compiling her rank list was an agonizing task. Although she had once dreamed of attending a prestigious residency at Mayo Clinic or Mass General to study geriatrics, their new life and her reduced stock required a recalibration of priorities. Her dreams were different now. She would be there for them, and for him, until the end. Duty, honor, service. Always.

 Disappointingly, but as expected, their family’s inside jokes and her good news fell on a stranger’s ears over the phone. She feared he now had difficulty understanding humor, that he was immune to joy. The daughter wondered how much longer they had until he no longer recognized her face. Until he no longer recognized any of their faces. Until he no longer recognized himself.

 

6 | The emissary

The young medical student, Danilo Socorro Magno, thumbed through the pages of his DeGowin Bedside Diagnostic Examination guide to the physical examination by flashlight during the latest brownout in Quezon City, Philippines. He was studying for the FLEX test, the first step in applying for medical residencies in the States.

He knew the odds were poor for a scholarship kid from the baryo who never quite fit in with the upper-crust families at school, but that never stopped him from achieving top marks. Even when his batch mates would snicker behind his back at the second-hand polos he bought from the ukay-ukay, it only drove him to work harder.

There were no tourists in Project 6. The tiny barangay, squeezed between Mindanao Avenue and Visayas Avenue, was constructed in the same utilitarian brutalist concrete as the rest of Metro Manila just north of EDSA. Next to the abandoned lot with the barking street dogs, the apartment block was dotted by sari sari stores of enterprising Filipinos hawking cola in plastic bags impaled by a straw.

The next morning as he hopped off the jeepney riding to campus, it happened again. Snatching the Coke-bottle glasses off his face and knocking over the tower of books he was carrying, his bully taunted, “Danilo was hit in the head with a dictionary!” He kneeled to gather his discarded spectacles and his copies of Robbins Basic Pathology, The Silmarillion, and The Foundation series. He found solace in the writings of Tolkien and Asimov. In both fantasy and science fiction, you could count on the brainy misfits to contribute more than just comic relief. Despite their so-called physical deficiencies, they were heroes. Heroes celebrated in song and lore.

Shoving his backpack into his locker at the University of the Philippines, Danilo raced from one end of campus to the other while devouring a quick snack. He nearly tripped over the rut in the sidewalk kinked by the root of the banyan tree. Milagros was waiting for him at the bottom of the steps to the library by the Oblation statue and heard his rapid footfalls approaching. Mimicking the posture of the bronze figure facing upward with arms outstretched, she warned him with her eyes closed. “Uy, Speedy Gonzalez, sandali lang. You might hurt yourself.”

Milagros and Danilo were meeting for their usual run along Roxas Avenue from UP Diliman. Both professional students taking up law and medicine, respectively, they were constant companions since becoming partners for their organic chemistry laboratory as undergraduates. Danilo was in awe of her superb percent yields; she gained top marks reconstituting colorless, odorless liquids into iridescent dreams. Milagros was drawn to his kindness, a quiet constancy in the chaos of their mega metropolis.

The young woman brushed off the lengua de gato crumbs from her running partner’s Fernando Valenzuela jersey, which he wore religiously to their weekly ritual. She asked playfully, “Hoy pare! Do you ever wash this thing?” He looked down at his Dodger-blue garment with the number thirty-four emblazoned on his chest. A gift from his cousin, an OFW living in California, it was a souvenir from a trip that represented his most cherished memory. Or at least, it would be until the end of today.

Jogging through the oppressive smog and congestion of the city center, the pair settled into an easy rhythm. She was the only one of their batch mates who matched his cadence, though he towered at least a good 14 centimeters over her. Growing up in the mountain highlands of Cagayan gave her the advantage, he assured himself.

Their usual route was shaded by the occasional palm tree and interrupted by the more frequent traffic jam. His heart quickened even though their pace slowed rounding the park in QC Circle.

Danilo reviewed the plan over and over in his mind. He had arranged for a taho vendor to meet them at the halfway point. He would suggest they stop for refreshments at the lake near the wildlife center and take in the sights. While she paused to enjoy the sweet, silken tofu drink, he would bend down on one knee to propose a lifetime of partnership. After pooling their savings for a few years and praying to avoid the growing power of Marcos’s martial law, they would go to America together once he passed the boards and she passed the bar.

Lost in thought, he didn’t even realize Milagros had picked up speed and was now 50 meters ahead entering the Hardin ng Mga Bulaklak. Surrounded by orchids and sampaguita blossoms in the sanctuary, she turned back to look at him as if to say, “I dare you to catch up, pogi.” The future physician filled his lungs with the smell of jasmine and ran after her. In her eyes he saw their future, and their future was limitless.

 

Melissa Palma is an Iowa-raised daughter of Filipino immigrants. She was privileged to grow up in a multi-generational household with her grandparents, parents, and little sister in Waterloo, Iowa.