The Pulse - Spring 2019 by Temple Health

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PULSE Lewis Katz School of Medicine at Temple University SPRING 2019

Welcome to The Pulse, the literary magazine for the Lewis Katz School of Medicine at Temple University. The Pulse is a student-run publication featuring poetry, prose, and artwork by medical students. Our mission is to promote humanism in its various forms and to create an environment in which creativity and medicine are celebrated and shared. This year our magazine begins with a series of reflections by medical students at various stages of their training. Junior medical students reflect on the formative experience of beginning medical school working directly with a cadaver in anatomy lab, while a senior student explores the decisive steps that led to her decision on a particular medical specialty. This section is followed by a feature of photo essays entitled “Neighbors of North Philly,” a narrative medicine project currently in its third year which celebrates community members living in the vibrant neighborhoods surrounding Temple. Wrapping up this year’s issue, we’ve chosen pieces that both give voice to and thoughtfully consider some of the complex realities of life within our community, namely gun violence, opioid use, and the end of life.

Modern medicine is often accused of being unfeeling, cold, and devoid of emotion. Truthfully, it’s a commentary we would all do well to reflect upon as future clinicians. Nevertheless, we hope the stories and art contained within this issue serve as a reminder that through humanism, creativity, and appreciation of our community we can begin to shift this paradigm. We want to acknowledge and thank all of the students who submitted writing, art, and photography. Special thanks to Mai Stewart, Temple MS4, for allowing us to publish art from her Instagram account @maidoodles. Check out her Instagram for more comics related to the journey through medical school! As always, we welcome you to explore and share! The Pulse Team

Photograph by Eric Curran

CONTENTS 6 8 11 12

Reflections Knives, Jessica Gude Final Practical, Phil Delrosario Made in Haiti, Danoucheka Gelin White Coat, Emilie Decoppet

14 16

White Coat Quotes, various students Superheroes, Nonyerem Okwukwe Acholonu

Neighbors of North Philly, Volume III Poetry

36 37

ABCs of Being an Alien, Lorena Walker Days with Dr. B, Hena Cebeci

40 42

Social Awareness Trauma Bay, Rennette N. Zavala Kensington Avenue, Spencer McCaffrey

46 49 50

End of Life Code Blue, Danielle Verghese Miracles, Danielle Hu The Last Four Hours, Ghazal Khorrami

Art by Mai Stewart. @maidoodles

Reflections

Knives

Jessica Gude I have held so many knives. My brother and I are standing in the kitchen. He has been cooking professionally for a year or so, and he loves teaching me things. He shows me how to hold the knife, how the cutting motion should be continuous, and most importantly, how to curl my fingers so that only my knuckles face the blade, as to avoid cutting myself. At my own restaurant job, years later, I learn to always announce the fact that I have a knife by shouting, “sharp around the corner” or “knife behind you” and walk with the blade down, held tightly to my side. I learn that sharp knives are safer than dull ones; you have to wrestle with dull ones and you’re more likely to slip. Serrated knives are best for cutting citrus fruits because the teeth give you traction. Limes are safer to cut than lemons, since lemon seeds like to jam up the blade. Always use the smallest knife you can for a task; if a paring knife will do, don’t use a chef knife--save your shoulder and your fingers. Even after years of working together, the chef always watches my first few cuts and implores me, “please don’t cut yourself.”

“

There is an integral wrongness, a sense of doing something you know you’re not supposed to. But it is accompanied by a strange feeling of special permission and privilege.

”

Because cutting through our flesh is inconvenient. It leads to blood that needs to be cleaned up, knives that need to be sanitized, cutting boards that need to be bleached, and medical attention that needs to be received. Cutting flesh is some sort of inherent violation. Skin is a boundary; it keeps your body in and the world out. But when we need to see the body and bring the inside out, this entire premise is flipped on its axis. This all goes through my mind as I pick up the scalpel and intentionally cut through flesh. I have held so many scalpels, cut open dozens of frogs, helped college freshmen skin sharks, performed an oophorectomy on a mouse. Of course, inherently, this is no different. The sensation is disturbingly similar; the blade glides through, like it does for frog bellies and focaccia bread. There is a similar sense of intention, a calculated and known reason for the cut. It represents another task to be completed, another item checked off the prep list, another step in the lab guide. However, on some emotional level that transcends the physical and cognitive, this is a different experience. There is an integral wrongness, a sense of doing something you know you’re not supposed to. But it is accompanied by a strange feeling of special permission and privilege. In the interest of our education, people gave their bodies so that we could see things that we would normally only see in dire situations. We reverse the order of nature so that in the future we know how to maintain it. So I accept this temporary upending of everything I know about knives, finish the cut, and ask, “now what?” ■

Final Practical Phil Delrosario

Final practical day. 65 students spread out among 35 cadavers. All wanting to pass. One minute per body. Look, identify, write, ring, move on. Next. Brisk walk. Look, identify, write, ring, move on. Next. Look, puzzle for 50 seconds, guess blindly, write, ring, move on. Next. Ten bodies later. Look, identify, write, change an answer from 10 stations ago, ring, move on. Walk, look, write, nerve, look, walk, write, rami, write, look, artery, recess, identify, identify, identify, walk, write, ring. Then, a pause. I find myself at a rest station. It’s one of the rare moments in which I’m actually resting instead of calculating which lung lobe a penetrating knife entered. My eyes explore the room in front of me: bodies clad in blue peering into a sea of gray. I notice a few folks on stools, their heads craning into cavities and peering into pouches, Some so absorbed, I swear that the tips of their noses are 5 centimeters from touching bowel. I imitate the posture of my classmates. I bring my head to my right shoulder – or should I say, I laterally bend my cervical spine. The world tilts into a new view. The students above the horizon of the lab are now on my left; the cadavers below, now on my right. I sit in the moment, struck by the peculiarity of it all: of humans looking into corpses; of students facing their teachers; of life mirrored by death; two sides separated by an invisible window, which we call many things: dying, traveling to a better place, passing. The timer rings. The moment breaks. We’re one minute closer to finishing, to completing, to passing. 8

I walk. I arrive at the man we dissected. Table 3. I peer in. I identify his left gonadal vein which joins his left renal vein. From my angle I look at his face, barely visible beneath our dissection. He bares half a toothy grin as if to say, “yes, you’ve got it.” I write my answer. I say thank you, and then goodbye. I wonder if he knows just how much his death could teach me about my life. The last few bodies in the exam whisper their own lessons as I pass by: “This is how you run, jump, and skip on warm, summer days,” “this is how you grin when you hear your favorite song,” “this is how to not pee your pants during a scary ride,” “this is how your nose gets stuffy after you’ve cried for hours,” “this is how your brain can tell your heart to flutter when you see her walk into the room,” and “this is how you laugh at a pitch so much higher than your normal voice.” Eventually, I finish. We anxiously shuffle out of the lab, and I look back one last time. I say thanks, again. Silently, they seemed to say: Remember, all this is how you’re alive. Smile, because you are alive. Breathe, stay alive, alleviate suffering, and help all those who are also alive. You’re welcome. ■

Art by Daniel Reiners

Made in Haiti Danoucheka Gelin

From the first moment I received my coat I noticed the tag in it that stated “Made in Haiti”. This made me smile because this coat could have been made by my grandmother, a Haitian-born woman who had a knack for sewing. It’s as if this coat in particular was made just for me. This moment gave the coat an even greater sentimental meaning for me. Since then the coat has served as a constant reminder to me of the great responsibility that comes with wearing it. It reminds me of the look on my parents’ face when they first saw me in the coat. It reminds me of the pride that I feel in them. Two Haitian immigrants who were not only able to dream but were able to push me to achieve my own. I have heard countless stories of other people like myself, black women and children of immigrants who did not feel they were capable of becoming doctors because they did not see the visual representation of themselves in these positions. Putting on this coat that was created in Haiti makes me think of the two people who created the environment for me to believe that I was just as capable as anyone else of achieving the dream that I had talked about for as long as I can remember. I feel pride in wearing the coat and a responsibility for all others who look at me and have hopes of pursuing the same dream. I know that when I wear this coat I am not only able to serve as an example of what I did not see growing up but also as an individual who has the ability to make a difference in this world. It gives me hope that I can use the knowledge and the skills that I acquire while I am here to potentially make a difference in the lives of those I come across throughout my career. ■

White Coat Emilie Decoppet

Throughout my life strangers and not so strangers have approached me with their woes. Cashiers expound upon the difficulties of diabetic diets. Cafeteria workers gleefully discuss bowel movements and the scandalous price of crutches. Security guards chat a mile a minute about their daughter’s cough, their back pain, their mother’s failing memory. And I’ve loved it all. I thought, naively perhaps, that the hospital would bring more of the same, just with me in a white coat. Before entering medical school, I had always liked the image of the doctor’s white coat. I liked the crisp pleats and the cinched waists. A starchy white uniform befitting the soldiers of medicine as they glided soothingly down the corridors. I imagined myself with a yet unchosen specialty embroidered in glowing letters on the sleeve, the tangible threads of a nebulous future. I imagined myself striding about, my breast pocket busy with pens, a pretzled stethoscope in my left pocket, an entire medical library stowed away in my right. And yet, my own abbreviated version of the real thing has only ever been a hinterland of snowy formality between myself and the patient. With my white coat on nobody approaches me with the same eager expansiveness as they do on the street. It has become a silent injunction against befriending me. The easy chatter is gone. Strangers no longer approach me with simplicity and relief to disgorge, unprompted, their stories of knee pain and diabetic diet plans. I must pry out with delicate fingers stories they would have been so willing to divulge had we both been sitting on a park bench. In my white coat, I must send out my questions like sheep dogs, carefully shepherding their story my way.

Certainly, with a white coat I have both knowledge and authority. The responsibility both to ask questions and to answer them. It gives me power, but it gives them less. As a passerby on the street with a round pleasant face and an easy smile, I am harmless. My only role in their life is to hum reassuringly as their tales of medical woes land lightly on my ears. Easy to talk to because I carry no consequence. But it is different with my white coat. My white coat is my consequence. When they come to me in my white coat, they know, as I do, that their future depends upon the expertise of a perfect stranger. And the white coat is a symbol of both the expertise and the strangeness. I recently shadowed a primary care physician who swore like a sailor, threw around stories about his family like confetti at a parade, and never once wore his white coat. It hung, old and unused, on the back of the door. And his patients talked to him with desperate volubility—as though he were their priest confessor, their last stop before salvation. Had he worn his white coat would his patients be as eager to confide in him the shamefully guarded afflictions of their body and soul? Maybe. Maybe not. Without his white coat, he was just a man in jeans with three daughters and a passion for the Eagles taking their blood pressure. A man no different than them. A friend as well as a doctor. ■

“

Certainly, with a white coat I have both knowledge and authority. The responsibility both to ask questions and to answer them. It gives me power, but it gives them less.

” 13

White Coat Quotes Various Students

“Have I learned enough to be worthy of wearing it? Will I live up to the expectations that this patient and my resident and attendings have of me? Will I live up to my own expectations?“ - Mary Ahern “It’s a long journey with a lot of hard work and the white coat reminds me of how much work I’ve put in and the work I have ahead of me. It also means responsibility. I am incredibly privileged to get to be here.” - Abrar AlAbdulhadi “To me its purpose is to keep my clothes clean and to hold my notes and instruments within its generous pockets. In that role, the white coat performs admirably.” - Mirza Ali “It soaked up the moisture when I broke into a profuse nervous sweat while doing my first physical exam on a real patient in the hospital...There is evidence on the collar of my nervous sweats, you can tell it’s been worn for 2 years, there is an outline of my pocket notebook on the front pocket, and you can see some of the threads in the seams coming out. Each one of these imperfections represents a challenge I’ve overcome or a skill I’ve learned. When I put it on, I’m reminded of what I’ve already accomplished, giving me the confidence to overcome the next challenge.” - Andrew Beckman “I have begun to settle into my white coat. It soon becomes what keeps me warm when I am crossing Broad Street in the middle of winter.” - Giuliana Berardi 14

“Some people see those who wear the white coat as important, busy and worthy of respect. Others, who are skeptical of institutions, power and class are also skeptical of those who wear the white coat. When I wear the white coat, I can feel the identity I assume in the way the people look at and respond to me.” - Peter Eisenhauer “While wearing a white coat, I’ve been called nurse, honey, sweetie pie, and many other names that people would not use to describe their doctors.” - Brittney Bunkis “I view the white coat now as a reminder to the physician of why he or she pursued the path of medicine. Its white color represents the purity of the field, one in which the patient comes first before all else. Its coffee stains, wrinkles, and imperfect stitching remind us that doctors, too, are humans.” - Adam Adika

Art by Mai Stewart. @maidoodles

Superheroes

Nonyerem Okwukwe Acholonu The moment my mother found out she was having triplets, she knew she would have to move to America. At the time, she had been living in Nigeria as a young, successful banker with many friends. However, she knew that the physicians in her town could not handle the birth of triplets. My father was already living in America, doing research at an academic institution which is how my mother was able to come. Days later, she flew to Nevada, leaving everything she knew behind. Even with my father there to help, in this new land my mother felt terrified, alone, and worried that she could trust no one—that is, until she met her pediatricians. Pediatricians not only deal with their constantly developing patients, but they must also handle new, terrified parents like my mother. After our delivery at 32 weeks gestation, my mother met the neonatologists. Being the second set of triplets ever born in St. Mary’s Hospital in Reno, NV in 1992, we were cared for by physicians who came from all over the West Coast. These physicians helped oversee our care, from the many intubations and ultrasounds to the countless X-rays and blood gasses. Due to my mother’s preeclampsia and gestational diabetes, both my identical twin sister and I were small for gestational age with my sister weighing about 1160 grams while I weighed a little under 2000 grams. My brother, though normal size for gestational age, was persistently hypoglycemic. My twin sister also required additional operations to remove various tumors on her lower extremities, keeping her in the NICU for 18 days longer than my brother and me. The neonatologists sat with my mother day in and day out, explaining the most complex concepts to her and making sure she understood every aspect of our care. Including her in every 16

discussion helped build my mother’s trust to the point that she was no longer fearful—instead, she felt hopeful. Through stomachaches, ear infections, strep throat, and our teenage years, pediatricians were always there to help. My mother loves to tell the story about the time my twin sister, older sister, little sister and I all had chickenpox. Can you imagine being a mother of five kids all under 12 years old and having four sick at the same time? My mother was at her wits’ end! Because we weren’t allowed into the office given our infection, our pediatrician came out to the parking lot all gowned up, examined myself and my sisters, gave my mother recommendations, and administered a vaccine to my healthy twin brother. Because of all this, I always knew I wanted to be a pediatrician. But actually doing it? Becoming one? Ha. I just had no idea. Getting into medical school was hard enough, and then mastering all that material in the first two years was a major pain. But it was really on my rotations, in my third year, on the floors, that I truly realized this was going to be so much harder than I thought. The combination of skills, knowledge, compassion needed to care for premature and sick babies, and the dramatic range of medical and social circumstances I encountered—how would I ever be able to handle all of this? These pediatricians were superheroes! Time and time again over the last two years, I struggled with uncertainty and self-doubt. I felt I wasn’t strong enough or capable of being a lifeline for children. I worried I would never create such strong bonds with my patients as my attendings all had. The way my mother spoke about her pediatricians, I couldn’t help but doubt if I would ever be that person. 17

Probably everybody has felt like I did at one time or another. But what got me through was thinking about my mother. I knew I would encounter patients with mothers like mine, and I needed to shape up. In the NICU, I took time to learn and explain every treatment plan to families who were scared. On the floors, I sat with parents and families from all walks of life. I calmed a little boy with severe asthma who was hysterical with a panic attack and let his mother know everything would be all right. In the clinic, my most rewarding encounter was discussing sexual development and how to go about having intercourse to my wheelchair-bound patient with muscular dystrophy and to her concerned yet optimistic mother. I began to realize that maybe I could become a pediatrician. Not just any pediatrician, but a good one! I realized I could not possibly become a superhuman like my attendings overnight—but working every day to accomplish that was the best thing I could do for myself and for my patients.

“

I realized I could not possibly become a superhuman like my attendings overnight— but working every day to accomplish that was the best thing I could do for myself, and for my patients.

”

What I learned through my own childhood and have reinforced in medical school is how a pediatrician can be a pillar in a growing family’s life. I’ve also learned that being a pediatrician takes stamina and constant flexibility. My advice for anyone tackling a career in medicine—especially in pediatrics—is to be human and treat your patients like family. Be the kind of doctor who sits with families. Be the kind of doctor who isn’t too busy to listen and explain. Be the kind of doctor who would even treat patients in your office parking lot! Give your patients a chance to trust you because, at the end of the day, so many people are in my mother’s situation—scared, confused, and desperate to receive care for themselves and their loved ones. No matter how scared you are, no matter how much Imposter Syndrome swallows you whole, just remember that being human is the most important part of being a doctor, everything else is just sprinkles on top of a birthday cake. My interest in becoming a pediatrician began with my own life experience. I know my childhood and my mother’s experiences are where it all began. But now that I truly understand what’s involved, what the potential can be, I can’t wait to get started. ■

Photograph by Eric Curran

Neighbors of North Philly Neighbors of North Philly is an annual project inspired by Humans of New York. It emerged in the fall of 2016 as a photography class offered by Lewis Katz School of Medicine as part of its series of humanities electives. Each year, students visit the streets of North Philadelphia near the school and spend time photographing portraits of our neighbors and getting to know their stories. 2018 Neighbors of North Philly, Volume III class: Connor Hartzell, Ali Abdullah, Sydney Ehrman, and Michael Creager. Stories have been edited for The Pulse.

Cherry and Wine Betty Jones hosts a state-funded free lunch program all summer. She also sports colorful hair that she dubs â&#x20AC;&#x153;cherry and wine,â&#x20AC;? which happens to match her tattoos. She has 10 siblings, 7 children, a rescue dog named Chance and a kitten named Mittens.

Wheelies Sabir Spann learned to ride a bike when he was 5 years old and now, at 21, he’s ready to ride out of North Philadelphia. Exhausted by the senseless fighting, he explains, “The body count’s going up, and they’re not finding or looking for the people!” Despite his frustration, Sabir believes in the potential for positive transformation for himself and his community.

Barber Dolls Deserie “Dezzy” Baker is an aspiring barber from California. She currently juggles working at Blade Runnerz seven days a week and attending barber school. She dreams of one day opening and owning her own shop, which she will call “The Barber Dolls.”

Tammie A nurse by night, Tammie Haskins spends her days working and volunteering at Kenderton Elementary School. What started as something to get her out of the house has turned into a love of her relationship with the students. She sees her role not as a teacher or a principal but as someone the kids can come to as a friend. Tammie has two children of her own in the school. “Where I’m needed,” she says, “I’m there.”

Coach Joe Daniels spent his youth trying to avoid school and was kicked out of two high schools before finally graduating. Now heâ&#x20AC;&#x2122;s a single dad raising his son and spends the majority of his time in the very place he was trying to escape. The only active, male parent volunteer at Kenderton Elementary School, Mr. Daniels mentors and coaches a basketball team.

Pop Pop Charles White’s great-grandchildren know him affectionately as “Pop Pop.” Others know him as a hard worker; he spent his life in construction. He reminisces of the old days: “If you was a man, you used your hands, and afterwards, you was best friends,” he said. “We didn’t have all that killing people with guns and stabbing people. We bring them up with manners like I was brought up.”

Famous BBQ Sauce Meadowlane Bar-B-Que is owned by the Cambodian-born Chan Pen and his wife Chany, who runs the fruit truck parked out at Broad and Erie. Mrs. Pen begins making smoothies and fruit salads at 5:30 am and Mr. Pen keeps the restaurant opened sometimes till 1 am. “My passion is being me,” he says. “Test yourself!” We sample his BBQ chicken and instantly understand why he claims his hot sauce is renowned.

Love is Everywhere Trevor Roseborough was wearing rock star shades and a pink kufi for Breast Cancer Awareness Month. His grandmother is a breast cancer survivor, and a close friend died from it. Still in his scrubs, he works as a home health aide for two companies. â&#x20AC;&#x153;Love is everywhere. To me it is a part of life.â&#x20AC;?

The Flea Market Whatever you need, you might find it at the Ghetto Workshop Flea Market. From fans and air-conditioners to coffee makers and dish soaps, they have it all. Two young men, Tyquan and Angel, both 19 and aspiring musicians, help run the sidewalk operation and will happily help you find what you need next time you stop by.

Halloween Every Halloween, children from Help Energize and Rebuild Ourselves (HERO) after-school program visit the medical school and have fun with medical student volunteers. Many children come in costume and others wear expressions that are beyond priceless.

Birthday Grills Clint Walker Jr., North Philadelphia born and bred, was arrested at age 14 and spent the next six years in jail. Now 26, Mr. Walker has changed his life around. He now owns a local clothing store that features his own designs and employs neighborhood kids, with the hope that giving them something to do will help “kill the violence.” As he recounts his journey from convict to anti-violence advocate, he reveals a pair of shiny grills, replaced on each birthday. His birthday grills, he boasts, are “what makes me stand out.”

Portraits This woman, Anonymous, is a portrait of North Philly. A kitty tattooed on her arm tells a story of her best friend. Ribbons tattooed on her legs honor her parents, in love for 50 years before each died at Temple Hospital. She inherited the house she grew up in and hopes to leave it one day for her kids. â&#x20AC;&#x153;It was good and it was bad at the same time,â&#x20AC;? she says of growing up here. A dialysis technician, she is also working toward a bachelors in education.

Photograph by Danielle Hu

Poetry

ABCs of Being an Alien Lorena Walker

Awful aroma Bare branches Cold concrete Darkness never comes Empty ethanol Frequent flyer Going going Home away from here Itching Juvenile judgment Knock knock my name is Lorena, Iâ&#x20AC;&#x2122;m a first year Medical student Nausea? Nerve? Occurrence is 1 in 300,000 Put it to memory Quiet never comes either Restlessness is recycled Sob every other Sunday Tuesdays are better Urban urine Vain but virtuous Whining wonâ&#x20AC;&#x2122;t work XYZ Philadelphia is an alien Or maybe I am

Art by Mai Stewart. @maidoodles

Days with Dr. B Hena Cebeci

1. The Beginning It was a late January morning soft flakes of snow danced outside the office window crystals against the green hills giving the unlit room bright depth.

So are you looking for a mentor?

I was not prepared for his honesty. Too shy to reveal my need I smiled speechlessly.

2. meet Teacher meet Student I sat at a desk in his office not on a stool or a chair in the hallway a whole desk with a lamp and a laptop and the first book. How strange to have found this to have been found.

So youâ&#x20AC;&#x2122;re trying to get started in all of this? Iâ&#x20AC;&#x2122;m trying to figure out how to stop. Maybe we can help each other along this path?

Photograph by Eric Curran

Social Awareness

Trauma Bay Rennette N. Zavala

During my first year, I met my first trauma patient. An announcement was made on the intercom. â&#x20AC;&#x153;Level 1, male, GSW, unstable.â&#x20AC;? Shot three times, he had lost a pulse on his way to the hospital. Once at the hospital, there was rush of movement as the team of trauma providers immediately began chest compressions and tried to get IV access to do everything they could to save the patient. The patient could not be resuscitated and was declared dead. As I spent more and more time seeing similar patients in the trauma bay, I wanted to learn more about the care of such patients, most of whom were young, black teenagers from North Philadelphia. I pursued a trauma surgery rotation in my third year and was astounded to see the amount of damage that can be done to the body with a bullet. It is at once incredible and terrifying. The protocol during my month in the Trauma bay soon became routine. First, cut off any clothing the victim wears. Second, do a quick trauma physical exam to assess the extent of the damage. Simultaneously, get IV access, hook the victim to the monitors and activate the mass transfusion protocol, make sure that enough blood products are available. Ignore the blood on the floor. Mark the locations at which a bullet could have entered and left a body. Decide whether the patient is stable or needs to go to the Operating Room. If he had to be taken, surgeons would spend hours trying to fix the damage that had been done to numerous vital organs and vessels. Lastly and most importantly, inform the family that this piece of metal and the terrible damage it has wrought are the reason we are unable to bring back their child, their significant other, their source of love and light back into this world. They say that physicians should stay in their lane when it comes to gun violence. However, a motherâ&#x20AC;&#x2122;s cry, the last breath a 15year-old takes, and the months of lasting damage that a survivor endures, has made me determined to fight for change. As long as 40

gun violence continues to dominate the trauma bay, and as long as the repercussions of the violence continue to be so devastating for those left behind, gun violence will continue to be well within a physician’s lane. “Level 1, GSW, unstable” - how can someone’s life be reduced to these three phrases? These words, the look of pain and disbelief stay with me as I continue to advocate, learn and try to figure out the various ways we can continue to save lives from this public health crisis. ■

Photograph by Danielle Hu

Kensington Avenue Spencer McCaffrey

Names have been changed to protect the privacy of individuals.

It’s Thursday morning and Dave is anxiously awaiting his appointment at Prevention Point. This will be just his second visit, but he hasn’t had his medication for the last four days. He’s nervous to see how Dr. B will react to him having used heroin every day since then. It’s hard to make up excuses as to why his medication unwillingly went missing. He knows the immediate assumption is that he sold it, or that he’s just too much of a “druggie” to keep track of it. But the truth is that he has nowhere to keep it. Dave lives on a mattress underneath the elevated train tracks near the corner of Kensington and Lehigh Avenues. Kensington Avenue is a scary place to visit. It aligns directly under the MFL train tracks, which gives it an inherent sense of darkness and gloom. The trains run overhead constantly, disrupting any sense of quiet or peace one might try to attain. Cold water drips from the bottom of the tracks, adding a dampness to the scene. The street is lined with small businesses – appliance stores, laundromats, pawn shops – most of which look closed or shut down. There’s one or two Chinese restaurants with no seating, otherwise not a restaurant or grocery store in sight. Even in the winter, the street is filled with people. Not people heading to work, but people either slumped over trying to keep their heads up or lying in the middle of the sidewalk. Crowds linger at the bottom of the Somerset train station offering “smack,” while pot and cigarette smoke fill the air. Just north of Lehigh Avenue there is an underpass. The sidewalk is lined with tents, mattresses, and sleeping bags; there doesn’t seem to be a square inch of free space. This is where Dave calls home. Dave is 27 years old. Handsome, polite, and mild-mannered, he started taking opioids as a teenager and injecting heroin in his early 42

20’s. He grew up in Northeast Philadelphia, but did not move to Kensington until he was desperate enough to need daily quick and easy fixes. Dave had lived a modest life in a predominantly white neighborhood with his mom and younger sister. While he didn’t see his father much, he describes his upbringing as pretty stable and his mood through childhood as “good”. He started smoking marijuana socially with friends in high school. That turned to the occasional cocaine use at parties, followed by the crushing and snorting of opioids. He doesn’t even remember the first time he injected heroin, but he knew it made him feel better than he ever had before, and that instantly he needed more. Dave found himself travelling down to Kensington to buy heroin, ended up meeting “friends”, and spending more and more of his time there. While some of his classmates were applying and getting into colleges, Dave dropped out of high school in his senior year and moved out of his mother’s house. He thought he’d get a job, but his addiction – his disease – had him using up to 10 bags a day. Between the effort of obtaining the drugs and the effects from using them, he was incapable of working. His addiction had taken over, and everything else – family, friends, education, a home – fell further and further away.

“

Ryan taught me that his life, where he lives, and how he lives, is a constant upward battle, and that people like him – people living under train tracks or in subway stations – care about their own well-being.

” 43

When I meet Dave he is a little anxious but extremely patient and cooperative. You can tell in his voice that he wants to be healthy. We talk about shelters and why he lost his medicine. He explains that once a week the city of Philadelphia attempts to remove the people living in “tent city.” Without explanation, on any given night, tents, mattresses, and all personal belongings are taken. If you happen to be lucky enough to be there at the time, you at least have a chance to save your possessions. However, if you are not there at the time the raid takes place, everything, including medication, gets taken. The city offers no alternative solution. Week after week, possessions are removed, yet week after week, there are more people that call Kensington Avenue their home. Dave has just one medication to keep track of, and when it gets taken unexpectedly, he has no choice but to use it illegally. Unfortunately, the stigma against opioid maintenance medication is such that he has no way to get another prescription until the following week; however, just like any other disease, he needs his medication daily. And while he seems to be barely maintaining his own health in this situation, I cannot imagine him doing so if he had all the comorbid health problems that Temple’s patient population faces. If Dave were on insulin, how would he get his missing doses? How would he get to the doctor? To the pharmacy? How would he pay? Temple has done a decent job trying to teach us all the barriers that our patient population faces in order to maintain their health, but what we haven’t learned much about is the homeless population. Dave taught me that his life, where he lives, and how he lives is a constant upward battle, and that people like him – people living under train tracks or in subway stations – care about their own well-being. It is our job as physicians to recognize that medical care is often dictated by societal norms, and to take into consideration the efforts and barriers that all patients, homeless or not, must face in order to be healthy. ■ 44

End of Life

Code Blue

Danielle Verghese We were in the middle of the mid-morning routine – sign out between mouthfuls of eggs and homefries – when the call came in overhead, “Code Blue, 9 West. Code Blue, 9 West.” Just like that, our team snapped into action, the continued banter only thinly concealing a change in demeanor: backs straight, jaws set, quickened steps with a sense of purpose. There was a life on the line. By the time we arrived at the room, there was already a crowd spilling out into the hallway. A tapestry of healthcare providers extended from the patient’s bed, woven together by the blue scrubs of the nurses, reds of the medical assistants, grays of respiratory therapy, and of course, the gray-blue of the residents. The code team worked in perfect synchrony. At the head of the bed, the respiratory therapist peered down a laryngoscope, ducking under the outstretched arm of the pharmacist, who handed bicarbonate to the nurse, who in turn stepped aside for a resident to administer the next round of compressions. In the repetition of each failed resuscitative attempt, I started to piece together what the team needed, when they needed it, and where to find it. Suddenly, I, too became a member of this lively choreography, swept up in the thrill of our collective mission. Backs straight, jaws set. There was a life on the line. With dogged persistence, our code team reached its bittersweet conclusion. The patient’s heart resumed its normal rhythm, her lungs inflating and deflating to the beat of a mechanical metronome; however, her brain had been starved of oxygen for too long. The stable vital signs belied the fact that this was now just a body, stripped of the cortical function and neural networks that made her, her. 46

Shoulders slumped, faces worn. There was a life on the line, and we had lost it. We have been warned about this moment from the first day of our training. Death in medicine is an inevitability, a matter of “when”, not “if”. With this in mind, I prepared myself for what I would encounter when I returned to the patient’s room. Everything was just as we left it. Pooled blood by the wall, a ransacked code cart pushed to the corner, the discarded packaging littering the floor like fallen leaves in winter – it was a pristine crime scene in which this patient had been robbed of her life. I made my way over to the patient’s windowsill, where a loved one had carefully arrayed “Get Well Soon” cards and photos of a happier time. I had never met the patient, so I found myself staring at her face in the photos, trying to imagine it on the body I glimpsed under the mess of equipment and providers. I braced myself to feel a rush of emotions, to be crushed by the gravity of the situation, but I simply felt empty. The windowsill mementos stood testament to a life well-lived, a person well-loved, and yet her final moments were spent in the company of strangers who could never appreciate the impact she had on those she left behind.

“

The windowsill mementos stood testament to a life well-lived, a person well-loved, and yet her final moments were spent in the company of strangers who could never appreciate the impact she had on those she left behind.

”

This thought continued to haunt me throughout the day. When I chose to pursue medicine, I knew that I would be there for some of the most vulnerable and inglorious moments of patients’ lives, but I imagined that I would earn this right by getting to know the patient and establishing a strong physician-patient relationship. What right did I have to be there with a patient I didn’t know? Certainly, when this patient contemplated her mortality, she didn’t picture me at her bedside, watching as a pair of trauma shears sliced through her hospital gown and exposed her bare chest to a room full of strangers. I don’t know if this question can ever be answered, although I hope my future practice will at least help elucidate the issue. For now, I’ll content myself with what I did later that day – talking to the friends and family members who came to pay their respects, trying to appreciate the privilege of being there at her final moments. There was a life on the line, and it deserved to be recognized. ■

Miracles Danielle Hu

“I believe in miracles,” said the elderly gentleman. He was sitting by the bed looking at his wife, who was lying there in the dark, surrounded by machines, with several tubes attached to her body. She looked so peaceful, eyes closed and jaw slacked, belly rising up and down rhythmically. If I weren’t a medical student on this service, I might have thought she was only sleeping. But I did know a little about this patient. I’d heard the doctors and physician assistants discussing her at sign out; I’d read the notes from the neurosurgery consult in the medical records system. Her prognosis was poor. She was breathing now, but with the support of the machines and not much else. The words “Gift of Life” have already been brought up (as tactfully as possible) to the family. But here was her husband who still wanted to believe in miracles. I tried to imagine what that was like: just a perfectly normal day in which your wife complains of a headache and goes to take a nap. Then you can’t wake her up. She’s rushed to the hospital where she gets scanned and prodded and hooked up to things. The doctors come and try to explain to you that a vessel bled in her brain, causing enough damage for her to be essentially “gone”… and that there is nothing much they could do at this point. “Poor guy in denial”- even though no one explicitly verbalized that, I got the feeling this was how the medical team labeled the husband’s reaction. It’s fair. They must have seen so many previous family members who were like this, unwilling to listen or unable to fully understand the situation, stubbornly holding out and refusing to accept reality despite evidence to the contrary, and wasting valuable medical resources in the process. 49

But as a newbie, I couldn’t help but find the situation just as difficult to grasp as the patient’s husband surely did. While I may know slightly more medical jargon and have more scientific knowledge on what was going on, the situation really struck me as incredibly insane: the notion of giving up on your loved one when they still appeared, for all intents and purposes, to be alive. They were warm, they were breathing, they might even give a muscle twitch now and then. Yet you’re asked to consider taking all of that away- unhooking the support that seems to be their only tether to life. Even with my medical training, I wondered if I would ever be completely immune to that horrible poison known as hope. A few days later when I returned to this service, I learned that the family had already pulled off the life support. The woman was pronounced dead shortly after. Just as I thought, this story wasn’t unique. There was an almost identical case a week later, only the patient this time was merely thirty-six years old, a young mother with young children. Same ending. Another family who had to accept a terrible verdict brought on by strangers in white coats. Another family who had to say goodbye to a loved one, to work up the incredible courage and strength it takes to let go. “I believe in miracles.” It probably wouldn’t take long, working in this field, to become too skeptical to share this belief when things go really bad. But maybe this hope or denial, or whatever you want to call it, doesn’t have to be something sad and pitiful. Maybe it’s natural and inevitable. Maybe it’s a simple reflection of your love for someone important. I think there’s some beauty in that. ■ 50

Photograph by Shuning Li

The Last Four Hours Ghazal Khorrami

“Hey, it’s me again. I gave her Haldol it’s not working.” “Give her one dose of morphine.” 20 minutes pass. “Hey, it’s Ghazal. Nothing is working. She is suffering. She is gasping for air. She can’t breathe. What should I do? She is suffering! Where are you? What should I do? She is suffering.” “I am on my way,” says the at home hospice nurse. “Go ahead give her a full syringe of morphine.” I hang up. “Mamaan, it’s gonna be okay. I am here, I just talked to the nurse. I am giving you medicine. You’ll feel better. I love you so much. Just stay calm. It’s gonna get better. I love you, my angel. You are gonna feel better. I love you so much.” I give her the full syringe of morphine. Suddenly, in a few seconds the body that woke up right at midnight after being asleep for three days went back to sleep again. This time it was different. Right before she went back to sleep, her beautiful eyes, searching for something in the room that our eyes couldn’t see, fixed on one point right in front of her. She is breathing. I can see it. I have to look closely, but she is breathing. 52

My cousin, the cardiologist, arrives. Listens to her heart. I look at him. I see the pain in his face. He doesn’t have to say anything. But he does. “Sorry, she is gone.” Her face looks so calm. No pain, no suffering. God she is so beautiful. A true angel. I couldn’t bear to wait for the nurse to arrive at our home. But it is such a heavy burden to carry. “Mamaan! Did you see what happened? I took your life away with my own hands. The hands that tried so hard to save you. The ones that held you so tight for hours. I took away the life that I tried so hard to save.” My brain knows this is not true. My heart doesn’t accept it. My cousin tells me, “I did the same thing for my dad. You didn’t kill her. The cancer killed her. So many loved ones feel guilt. But you freed her from pain. She would have died in minutes, hours.” They tell me people from the funeral home are coming. We start removing the orange nail polish I put on her hand just a few days ago. Her soft hands. One of them is in a fist. How much did you suffer while saying nothing, Mamaan? I lay down with her. It is just the two of us on her bed cuddling. Like every other day. I kiss her, hold her hand and feel her soft skin. The warmth is leaving her arms, and her body is getting stiff. I feel it happening. I touch her head and give her a kiss, but she doesn’t 53

feel like my mom anymore. She feels like the body I worked on in the anatomy lab. She isn’t there anymore. Then where is she? Two years ago we were sitting in the hospital, holding hands, and she was getting chemo. I looked at my phone with my free hand, and there was the email. “Oh my God, Mamaan, I got accepted to medical school!” We were crying, nurses were crying, everyone was so happy. I hadn’t yet realized it then, but my mom was my first patient. Early on, she let me give her injections in the stomach. The first few times I hurt her, but after few tries and some guidance from her I got faster and less scared. “Remember, I taught you how to give shots,” she told me once. Of course you did, Mom. Like you taught me how to walk, how to love and how to be strong, everything. “When life knocks you down,” you said, “get right back up and wear your red lipstick.” The two big guys with their red bag come from the funeral home. They don’t let me go with her to make sure everything is fine and she gets everything she needs. I get reminded that she doesn’t need me anymore. This time I have to carry on without her. ■

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How much did you suffer while saying nothing, Mamaan?

”

Ghazal Khorrami is a second year medical student at the Lewis Katz School of Medicine at Temple University. She is pictured here with her mother weeks before her motherâ&#x20AC;&#x2122;s death. Photograph by Ghazal Khorrami

BUSHRA ANIS

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DANIELLE HU

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SHUNING LI

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Cover art by Hannah Cheng