The Pulse - Spring 2020 by Temple Health

the Spring 2020

Lewis Katz School of Medicine at Temple University | Spring 2020

the pulse

Update after March 20, 2020: Our Spring 2020 issue arrives in the midst of a worldwide pandemic. Everyone is affected in some way or another, not least our healthcare workers and everyone working at the frontlines. We hope that this issue finds everyone in good health and will offer a moment of comfort.

Welcome to The Pulse, the literary magazine for the Lewis Katz School of Medicine at Temple University. The Pulse is a studentrun 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. Medicine is not easy. Some of our stories this issue echo this sentiment—one writer recounts the rough transition into medical school; another writer is shaken when a routine surgery goes terribly wrong; a third writer grapples with a tragedy that hits closer to home. We see and deal with many difficult situations in the career of medicine, and because we are human, we are bound to feel. Narrative medicine is just one way to process and

express what we feel. Everyone is different, so every voice and every story is unique. We are grateful for the opportunity to share these stories with you. Yes, medicine is not easy. But this only serves as a reminder that we chose this career not because it was easy or simple to do, but because we believed there was something for us in medicine. We believed this “something” would be worth our time and hard work, worth our journey. We want to acknowledge and thank all of the students who submitted writing, art, and photography. As always, we welcome you to explore and share!

The Pulse Team

CONTENTS 4 6 8

Photograph by Danielle Hu

The Sacred and Profane, Daniel Joseph del Alcazar The Moment, Khyati Harshita Somayaji The Chest, Eric D. Gramszlo

Photography by Eric Curran

12 16

This Too Shall Pass, Anonymous My Own Backyard, Michael D. Creager

Neighbors of North Philly, Volume IV

32 36 40

My Heart, KerriAnn Finnegan Smoke Break, Miranda Haslam Itâ&#x20AC;&#x2122;s Okay, Danielle Hu

Photography by Shuning Li

46 50

Time, Gillian Saldanha The Sun, Franzes Anne Liongson

The Sacred and Profane I’ll be frank, I didn’t expect to be affected by anatomy. I had just spent five years dissecting mice and extracting their viscera for inconclusive research. My boss often surprised me with trips to the morgue to collect primary samples. I watched the disaffected pathologists all too casually excise lymph nodes from a fresh corpse—placing them into a conical tube of liquid media with the grace of a butcher wrapping a piece of meat in newspaper, all the while unconsciously bobbing their heads to Led Zeppelin. Maybe it was tough-guy bravado, but I had thought I had done the mental gymnastics and desensitization necessary to normalize this profoundly abnormal act. I was wrong. It was the initial body flip that got to me, even before any incisions. It was our first activity as a group, a strange and arcane initiation ritual of sorts. I was struck by the weight of the body, despite our cadaver’s bony and petite frame. She was elderly, and at 93-years-old, she was the same age as my still very much alive grandmother. I imagined the body upright, resting her weight on a walker affixed with tennis balls, draped in some gaudy floral print sweater. This was someone’s grandmother, mother, sister, aunt. And now I’m looking at her intimately, more intimately than any of her loved ones ever did. Did she know I was going to see her like this? Vulnerable, nude, shrouds covering her face, hands, and feet like ceremonial death masks. Shriveled and discolored, she looked like a humanoid approximation. There is a concept in robotics called the “Uncanny Valley,” in which slightly imperfect

Daniel Joseph del Alcazar representations of humanity are met with fear and unease. Upon looking at my cadaver, I felt a similar feeling—she simultaneously looked unsettlingly human and like an eerie husk of a human. After the first incision, it became easier. As she was increasingly dissembled, she seemed less and less human, less and less like someone’s grandmother, my grandmother. It felt less like a violation, and I was able to mentally detach myself from the act. I made jokes as a defense mechanism, my way of coming to terms with what I was doing. The act of dissection is so deeply bizarre and alien, it borders on absurdity. Yet, it is also a necessity. It is important. Without her sacrifice, I wouldn’t be able to do my eventual job, the path for which I’ve spent half a decade preparing. I am deeply thankful for this, a gift so generous it’s almost biblical. I will never forget our first meeting, nor the lessons she taught me. ■

The Moment I lie here still, but please, don’t fear the glistening scissors that gently brush my side as if intentionally placed, For my own comfort. But really, they bring a sense of acceptance; I have waited for this moment for a while. The moment where I am able to show YOU What I have shown no daughter, cousin, coworker, friend – An intricate map of vessels and nerves that Enabled graceful movements and life-defying ideas. Don’t be hesitant; hold that blade with dignity, For I understand your pain as my own. But you are selfless, you try to feel my pain, anguish, happiness But I am selfish – those are mine to hold for now, in this moment, When I want your apprehension to take a seat And let me drive. I am your teacher.

Khyati Harshita Somayaji

My feet you have opened up, once touched the grainy, sweltering sand, And walked across cold marble floors The hands you delicately first touched slapped a stranger in the face When his indecent actions brought me rage. Honestly, I feel suffocated Under my own skin as I sit here pondering the decisions I made in life, I think about each individual I helped Get off the streets Find a home Play with their kids again. My work in the community never seemed to be enough. People felt indebted to me, For I gave them a life again. But what is a life? That doesn’t continue to mend others After death.

This minute won’t last long but I want you there. As you peel – rib by rib – to observe what powered my arms That held my babies hands on their first day of school And the life that was brought to my legs, To run after them.

The Chest I don’t remember the first incision. I don’t remember the first day. I remember the day before we began when we went to “meet” our donor—unzipping the bag with one-tenth the vigor we would employ by the second week—because everything was grayer than I’d imagined. I remember that. The first visceral reaction I can recall came with about six minutes left in the course. On the final practical exam, with maybe five stations remaining, waiting out my minute-per-question of time, I took a moment to pore over the donor before me. The body appeared destroyed. Skin and disarticulated limbs strewn about, muscles dried like jerky, the head split in two planes, and the image that I think really triggered my new appreciation of the annihilation—the detached chest wall floating loosely off to the side of the abdomen. Much of our discussion about gross lab focuses on the desensitization of handling a human body in this way. I stared down at this body and didn’t recoil in horror, didn’t vomit, didn’t get weak in the knees; no doubt that’s desensitization. Through my work as an EMT I was good and desensitized before ever setting foot in the lab (the reason why the grayness of my donor stood out was because it was alien compared to the newly dead I’d seen). But the level of my desensitization wasn’t what struck me in this moment. This was a moment of clarification of a hazy feeling I’d harbored since we began: the intimate connection between desensitization and humanization. There is a desire to establish a connection to the humanity of the donor, whether it’s achieved through naming, attempted correlation of anatomical findings with their life, or fantasy of their personality. I’m guilty of these protective actions. And that’s exactly what they are, actions to protect me from the desensitization I feel creeping in. To

Eric D. Gramszlo give me one last hope that maybe I’m normal and maybe I can look away when I see blood spurting. At best these actions help me to connect to and appreciate my future patients’ full lives; at worst they are plastering fiction over the true lived experience of our donors. When I looked down at this donor, I stopped seeing an imagined life and saw instead a fullness that I had no purpose, and no hope, trying to recreate. I saw a deidentified, not unidentified, person. They were not robbed of their humanity by this process. Instead, they completely gifted it to us, locked away in a chest to which we’ll never have the key. There is no abandonment of humanity in the treatment of the body, but the exact opposite. We fully embrace the humanity of another when we recognize their body—in our case, the entirety of our donor—as just that. Our bodies, though sacred in many ways and deserving of care and respect, are only our bodies. Life is robust and complex and meaningful beyond its physicality. With the life gone out of our donors, there was nothing left but the fullness of their lived experience, entrusted to us to honor with our ignorance. This too seems incredibly important for our future as physicians. We will manipulate the bodies of our patients, whether by scalpel or pharmaceutical, for medicine. Desensitization allows us to realize that this is necessary treatment, not infliction of harm. But desensitization shouldn’t, as it often can, cause us to see our patients as just the bodies—just the procedures, the drugs, the disease—before us. They are humans, embodied. They are the donor I will never know. I didn’t say goodbye to my donor on the last day. I finished my exam, handed it to the proctor, and went to change out of my scrubs. I didn’t express my gratitude for her body, for her life, for her gift. But I think she knew. ■

Philadelphia, our city

Photography by Eric Curran

This Too Shall Pass As I clicked on my final answer, I knew I had failed my first anatomy exam. I kept refreshing the online anatomy class page. Finally, the grade popped up—an incriminating bold, red 67. I tried not to let my devastation show, but as soon as I opened the door to my apartment, I ran to the couch and started sobbing. “This is the first time you’ve failed anything,” my boyfriend told me. Which was true. I wrote a chapter book in third grade, finished high school with a 4.12 GPA, graduated college magna cum laude. Blah, blah, blah. But after this first anatomy exam, I felt so stupid. Most of the class was meeting up for happy hour and I was sobbing into my boyfriend’s chest, “I don’t belong here.” During medical school orientation, they told us about online study tools, tutors, and therapists, and warned, “many of you will feel lonely and depressed and like you don’t belong at some point throughout your first year.” I had said to myself, “that won’t be me.” Eventually, I figured out how to pass my exams. Saying questions and answers out loud helped me learn the material in a way that reading a textbook did not. I adapted to the increasingly difficult coursework and sought help from personal tutors. Most importantly, I did not give up. By the end of first year, all images of myself as smart or exceptional were gone. In addition to intensive coursework, medical school is a constant stream of comparisons—somebody got a better

Anonymous

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It was me recognizing that perfection was not all that it was hyped up to be, and that I was exceptional because I was me.

”

grade, is doing more interesting research, has parents who know the chair of surgery… It is no surprise that the rate of depression and even suicide in medical school is many times higher than that of the broader population. I was no exception. Within my first months of school, I found myself lonely, withdrawn, and no longer wishing to be a physician. I was too embarrassed to talk to my friends and family about how much I was struggling; I was supposed to be the first doctor in my family. How could I tell them that I wasn’t who they thought I was? I reached a point where I was disappointed to realize I was still alive the next morning. As someone who had always been viewed as successful, I did not want to do anything that could be seen as a sign of weakness. I told myself there were others far worse off and that I did not deserve help. Surely a therapist’s time would be better spent on someone else. However, as emails from

administrators kept reminding me of free therapy services and stories of physician depression continued to surface online, I became more open to the idea of seeking help. It couldn’t hurt, I thought. No one would have to know. My first therapy session was awful. I sat across from the therapist, stared at the floor, and remained completely silent. Inside, I was screaming; I nearly ran the entire way home. The session the following week was not much better. I sat silently and stared at the ground. She sat in silence across from me, only speaking to announce the end of the session. I was frustrated because I thought she was supposed to ask me questions or at least provide some advice. I was embarrassed—Maybe I couldn’t even do therapy correctly. By the third week, I was fed up. I did not want to waste time when I could be studying. So, I started talking. I rambled on about my Mennonite upbringing, the religious rules that kept me sheltered for the vast majority of my childhood. I spoke of seeing the world in black and white, right and wrong. Of my extreme all or nothing mentality that made anything less than perfect unacceptable. It was just me, showing up every week, and talking for sixty minutes about whatever came to my mind. It was me recognizing that perfection was not all that it was hyped up to be, and that I was exceptional because I was me.

temporary and only a different song in the musical of life. My first year of medical school put this to the ultimate test. But I persevered. I endured. I got better, and I am on the verge of becoming a doctor. I’ve thought a tremendous amount about how far I’ve come since failing that first exam. My story is proof to new and future students that success does not mean being a member of alpha omega alpha or being elected student president. Success is showing up every day and being yourself, embracing a flaw as an opportunity for growth, giving yourself the grace to make mistakes, and seeking help when you need it. I love medicine for the way it forces me out of my comfort zone and exposes my vulnerabilities; through this I am best able to provide care for patients at their own most vulnerable moments. Here’s to life’s challenges, like memorizing all the vessels in the popliteal fossa, and to the great future physicians of our generation—which happens to include me. ■

Whether it was recovering from my messy college breakup, watching my grandma fight pancreatic cancer, running mile twenty-three of my third marathon, or failing my first anatomy exam, I have held onto the motto, “this too shall pass.” Perhaps it is some reiteration of a Bible verse I memorized as a kid or a challenge from my Dad. I have repeated this phrase over and over to myself as consolation that the struggles in life are 14

My Own Backyard

Michael D. Creager

Names have been changed to protect the privacy of individuals.

“

I listened to his story, his exhaustion so pervasive that I too began to feel it, and I tried to reach out, to tell him we gave a damn, I gave a damn, to tell him we were doing all we could with the resources we had.

”

The rusting bus, a relic from the 80’s and one strong gust of wind away from breaking apart, rumbled down the Lima city streets. The bus was crowded, and I was pressed up against its side by the bodies standing around me; I cracked the window to get just a touch of freedom. The landscape reminded me of home, of my own backyard. Outside lay the districts of Lima, Peru. Row houses lined the street, each building a tower of precariously stacked concrete and stucco blocks, unfinished, with rebar sticking out the top, as if wishing for an out of reach future. Faded pastel colors chipped away to reveal concrete walls. The street level shops spilled their

contents onto the sidewalks and added to the piles of goods— trash, vegetables, napping dogs—that lay on the ground, as people weaved their way among it all. Carts were filled with oranges for sale. A soft blanket of desert dust seemed to rest on everything. I yelled out “Baja! Baja!” for the bus to stop and stepped off. In front of me, yellow walls enclosed the national hospital in Agostino. It was where the poor people went for care, those who couldn’t afford the private hospitals in the center of the city. Patients sat outside under canopies waiting to be seen. Healthcare workers walked from building to building with masks covering their noses and mouths for protection against multi-drug resistant tuberculosis. I was a medical student volunteer that summer, doing research on treating that MDR-TB. Inside, patients covered by a Peruvian blankets lay on left-over gurneys, rusting at the rails and often unable to be repositioned. Beds lined the hallways. Some patients were hooked up to medicine drips and IVs. Some patients held bleeding arms, or legs. Some were coughing uncontrollably, or were keeled over clutching their stomachs, or stumbling towards the bathroom, or lay shirtless and asleep on their sides. Each person was there for his or her own reason, each one sicker than the next, and each one unable to afford the expensive and fully stocked private hospitals in the center of the city. Carlos was 20 years old when I met him. He sat in one of the hallways in a wheelchair. He wore a black zip-up hoodie, dark

blue jeans and black sneakers. He had straight black hair that glistened with sweat as it obliquely draped over his forehead. His head was hanging down, and his chest was heaving. He came from a group home, brought in by the priest who worked there, because of a bloody, sputum-filled cough and a fever. Later that day he would be diagnosed with TB. He was not able to sign the consent as he couldn’t read, nor did he know how to write. His parents died when he was young, and he’d been living on his own and then in this home. Most of this was relayed by the priest, as Carlos was spending all his energy just trying to breathe. He looked scared. Tired. Fatigued. I was worried he might be unable to continue breathing on his own. They didn’t have the resources to intubate and ventilate him here. Carlos was the sixth patient I met that week who presented like that. When I walked away, I knew the chance I would see him the next day was about 50 percent. He died that night.

A look inside the hospital in Lima, Peru. Photographs courtesy of Michael D. Creager

A few months later, after the summer ended, I met Andre. Andre was 27 years old. He sat in a wheelchair in his red hoodie, chest heaving and struggling to breathe. He had asthma and was recently diagnosed with diabetes. He told me about how he was supposed to be taking care of his mom, who couldn’t get out of bed due to her own breathing problems, and his three younger siblings. He worked at a corner store but didn’t earn enough to afford health care. The last time he took his meds was a few weeks ago. I sat there as he told me how he felt like he was always letting everyone down. How his younger brothers were getting into street fights, how he had been in the hospital before after getting shot. How he felt like it would be better if he just didn’t make it through this admission, if he could just die in the hospital. How he was tired all the time.

I knew I would see Andre again. He wasn’t as bad as Carlos. But I didn’t know how much longer he could go on living like this – feeling alone, let down, unsupported, like there was no one who gave a damn about him. I listened to his story, his exhaustion so pervasive that I too began to feel it, and I tried to reach out, to tell him we gave a damn, I gave a damn, to tell him we were doing all we could with the resources we had. His gaze stayed distant, looking towards a respite he knew he might not see. At a certain point, emotions seem to lose their meaning. Leaving Andre, I passed patients lying in beds in the halls, waiting for care. Some had bloody bandages. Others were asleep. Some were moaning, crying, coughing. They looked fatigued. I wondered if they would have preferred, had they the resources, one of the hospitals in the center of the city, where they might have their own room. I walked through the gray concrete walls of the hospital. Exiting, I passed patients sitting on benches, waiting for a bus or an appointment or maybe just a moment of relief. Litter was everywhere, on the sidewalks and the streets. I walked past the fruit carts, where venders were selling mango drinks, falafel, and chorizo. I walked past crumbling rowhouses with boarded up windows, and graffiti lining their red-brick walls. I walked past people sleeping outside shops, a man wearing only one shoe. Before going down the steps to catch my crowded ride home, I looked back and saw the sun setting on the hospital. And I saw not Lima, Peru, but my school’s hospital, Temple, in North Philadelphia. My own backyard. ■

Neighbors of North Philly Neighbors of North Philly is an annual project inspired by Humans of New York. It began in the fall of 2016 as a photography and writing 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 listening to our neighbors, getting to know their stories, and taking their portraits. 2019 Neighbors of North Philly, Volume IV class: Megan Patton, Henry Cohen and Briana Lee Stories have been edited for The Pulse. All subjects have given their permission for their photograph and story to be published.

Vernon Clark Vernon Clark says the toothpick in his mouth “replaced the Marlboro back in 1998.” Mr. Clark used to cover North Philadelphia for The Philadelphia Inquirer and visits this neighborhood, where his wife grew up, to hang out with old friends. He encourages students to walk around, to try and become familiar with the community, and develop contacts with somebody we can call and trust. “This isn’t a war zone,” he says. “Just say hello. You’d be surprised how far that goes.”

Kia Dupree Ms. Dupree is sitting on her front porch on Sydenham Street, around the corner from where, this past August, a 7-hour standoff occurred between law enforcement and a gunman who ended up injuring six police officers. She has lived in the same house for a decade. Now the block is divided between people that have been there for a long time and people that are new. “I love the block,” she says, and often greets her neighbors passing by. She describes the area as “fairly quiet until we had that chaos.”

Kevin Sobol Kevin Sobol enjoys a bike ride on a beautiful sunny afternoon. He moved from New Jersey almost a year ago after his company relocated. He has worked as a heavy equipment operator for 27 years. His wife passed away 12 years ago. “Every time I go back to New Jersey, I’m thinking about my wife again,” he says.

Shakia “Kia” Allen For Shakia “Kia” Allen, there is nothing quite like coming home after a long week. Ms. Allen grew up in North Philly and has since moved away. Here she is on a Friday afternoon with her childhood friend, Eric Williams. They are sitting across from what used to be a popular neighborhood hangout and is now a convenience store. Ms. Allen works as a certified nurse aide and likes her job—it lets her help others. Her advice to future doctors: “Whatever path you choose, just make it positive.”

Ahmed Lateef Without a need for prompting, Ahmed Lateef, 29, strikes a pose,resting his chin on his thumb and pointer finger, and asks, “Do you want to take my picture?” Mr. Lateef works three jobs in home healthcare, inventory and construction to support his twoyear-old daughter and five-year-old son. He just helped a friend launch an app that assists people in managing their diet. Mr. Lateef’s advice to future doctors: “Just make us feel comfortable. It’s scary enough to go to the doctor as it is.”

Felek, Ziyonn and Zakah

Felek, 13, Ziyonn, 10, and Zakah, 7, shoot hoops after school one day. Felek and Ziyonn are brothers and Zakah is their cousin. Felek wants to be a veterinarian and will be getting his braces off the following month. He just got the rubber bands changed and now they were green, which he liked. Felek and Ziyonn are fans of the Sixers, but little Zakah prefers the Golden State Warriors.

Sandra Smalls Sandra Smalls waits for a bus back to her home. She is a member of Oasis of Faith, a church at the corner of 17th and Venango. “God led us here,” she says of the church’s present location in a converted two-story brick building. “I’ve experienced some supernatural things there.” Each year the church hosts an event in nearby Jerome Brown Playground to bring its message to the neighborhood. Ron Anderson and Joseph Brown Ron Anderson (left) and Joseph Brown (right) relax with a group of friends. These friends grew up together in the same neighborhood 40-50 years ago and still meet every week. Mr. Anderson, who worked for decades in central supply at Temple University Hospital, says they used to hang out at a nearby corner called “The Rock.” “It’s our comfort zone,” Mr. Anderson says. “A lot of us are just like family.” Both Mr. Anderson and Mr. Brown lost sons to gun violence. Mr. Anderson’s son was killed delivering pizzas. Mr. Brown’s son was shot during a basketball game at a neighborhood playground. Mr. Brown’s advice to future doctors: “What you’re doing is a good start. Getting to know folks. If you haven’t really been in the neighborhood you don’t know what folks are going through.” 28

Julie Marie Brown and son, Jayden Julie Marie Brown had premature twins, both weighing under two pounds, but one died after eight months. Jayden, the twin who survived, is now one day short of turning seventeen. They plan to go to Six Flags to celebrate. Ms. Brown calls him her miracle. “As long as Jayden is all right, I’m all right,” she says. She works at McDonald’s and lives with her mother. Ms. Brown enthusiastically speaks of her Temple doctors, rattling off their names and praising them for always calling her back. “We love, love, love you all.” Her advice to future doctors: “Just do a good job. Stay focused.”

Algie Cuffee Algie Cuffee wears an Eagles lanyard the day after an Eagles game. He has been a fan all his life, “win or lose,” he says. Mr. Cuffee spent his career with the city’s Department of Licenses and Inspections. His job was to go into buildings declared uninhabitable, clean them out and board them up. “I done seen it all, brother,” he says. His advice to future doctors: “Stay close to your patients. My doctor, I tell her everything. I believe in my doctor. I will never change her for nobody. And be honest, but you all should know that already.”

My Heart

“

KerriAnn Finnegan bed and watched as they took samples of her massive station 4 lymph node. After collecting enough biopsies, the scope was removed from her neck. Final hemostasis was the last step before closing the minor incision above her sternal notch.

Sometimes this world of medicine will shake you to the core and break your heart. Sometimes it won’t make sense and you’ll want nothing to do with it because the hurt is just too much. But when you show up, when you care, when you listen, when you take an extra moment to hold a hand—people notice and it makes a difference.

” This comes from earlier this year while on my surgery rotation and I wrote this because I needed to. A young woman came into the thoracic surgery clinic with her parents, eager for answers. She had enlarged lymph nodes in her chest and recent unintentional weight loss. The concern for malignancy was high and she was to return the next day for a procedure to biopsy the lymph nodes. The residents told me this would be an interesting case to watch; I had never seen a mediastinoscopy before. I stood behind the head of the 32

A rocket of bright red came spewing straight up out of the patient’s neck. My heart skipped a beat. Quickly the surgeon’s finger pressed against the vessel and stopped the bleeding momentarily, but every time he tried to lift it, blood came pouring out. Pressure was held and everyone in the room was silent. The OR phone rang. The frozen pathology results—positive for carcinoma. My heart fell to the floor. My head couldn’t quite comprehend what was happening, but I grabbed the cross around my neck and I prayed, the only thing I knew to do in that moment. Red was everywhere now, the surgeons’ gloves dripping, their shoes stained, even their masks spotted red. I was shaking, but I scrubbed in thinking maybe they would need another set of hands. Stupid me. I soon realized my inexperienced hands would be of no use. With his finger still holding pressure, the attending called for the other thoracic and cardiac surgeons and then suddenly 30 people filled OR5. The next thing I knew they called for a sternotomy saw to open her chest. It was all I could do to hold back tears as I stood there remembering the pathology report. All of this to find out she has cancer. My heart broke. I left at 9p.m. after she was transferred to the surgical ICU, still intubated, still sedated. I drove home

crying, still shaking and grasping for hope. The next morning, I logged into Epic from home to check her chart. I learned that when she woke up, she couldn’t move her right side. I read the overnight note: Emergent mechanical thrombectomy. She had a stroke. A gut-wrenching pain fell to my chest and I choked back more tears. I was just talking to her in clinic, a vibrant young woman. My heart shattered. That day, I visited her room and saw her parents, their eyes red and heavy, their voices hoarse. She was still intubated and sedated; I don’t think she even knew I was there. But I held her hand as I talked with her parents. I could tell they were grateful to see a familiar face. I cautiously answered some of their questions, not knowing what to say. I wasn’t sure how to comfort them; what do you say to parents whose child had a stroke while being diagnosed with cancer? My words seemed beyond inadequate. But something came over me and I asked them if I could pray for them. With gratitude, they accepted. I crouched down next to where they were sitting, put my hand across her mom’s back and prayed. Over the next few days I visited them at least twice a day. The team swept by quickly every morning, but I lingered to make sure they were okay.I felt helpless. I was a third-year medical student who had never been in an ICU before. I didn’t have any answers. But I was there. I was present. I listened. I comforted. I held their hands and I prayed.

discharge, I went to see her to say good-bye. It took her a few minutes to find the words and I could tell she wanted to say more, but she looked at me with a big smile and said, “Thank you.” As I was heading to the elevator, her parents were arriving, and stopped me. Her mom embraced me in a hug, and with tears running down her cheeks she said, “Thank you so much for what you’ve done for us. You’re going to make a wonderful doctor.” Sometimes this world of medicine will shake you to the core and break your heart. Sometimes it won’t make sense and you’ll want nothing to do with it because the hurt is just too much. Sometimes there will be nothing you can do to change a diagnosis. But when you show up, when you care, when you listen, when you take an extra moment to hold a hand—people notice and it makes a difference. What a gift it was to be a source of comfort and consistency for a family experiencing crisis, for them and for me. Amid a grueling surgery rotation, I was graciously reminded of why I was called to medicine. Compassion matters. It matters for our patients and it matters for ourselves. So show up. Be present. Listen. Hold a hand. You’re going to make a wonderful doctor if you do. ■

Over time she improved; I was there when she left the unit and came to the floor. She could smile and squeeze back as I held her hand. She continued to have some weakness on the right side and word-finding difficulties, but not long after, she was well enough to transition to rehab. On the day of 34

Smoke Break “Can I go out to smoke one last cigarette?” the patient asked with an expectant smile on his face. I was sure my attending was going to say no. One room over in the small Episcopal Emergency Department, a woman was struggling to breathe due to an exacerbation of her COPD, a disease likely caused by her 60+ year smoking history. When I examined her, I couldn’t distinguish her coarse breath sounds from her soft whimpering cries. “That’s what end stage COPD looks like,” my attending had told me just moments before. But to my surprise, my attending responded to the first patient’s inquiry with a reciprocal smile. “I’m not really supposed to do this,” she told him. She agreed that he could go out for a supervised smoke break before his admission and transfer to another hospital. When my attending asked if I would be willing to serve as his supervision for the smoke break, I eagerly agreed. I wanted to learn more about this patient. I knew from his chart and the case manager who accompanied him to the ED that he had a history of schizophrenia. But unlike the patients I was taking care of on the inpatient unit upstairs as part of my psychiatry clerkship, this man’s schizophrenia was not his chief complaint. In fact, his schizophrenia seemed as much of a side note as the well-controlled asthma of a patient with acute appendicitis, or the chronic migraine headaches of a patient with a broken leg.

Miranda Haslam On the inpatient floors, I took care of patients caught in a seemingly endless cycle of hospital admission, stabilization on medications, discharge back into a society with inadequate social supports and unquantifiable structural inequality, eventual (or not so eventual) decompensation, and subsequent readmission to our hospital floor. Exasperated by witnessing the same pattern play out again and again, even over the course of my few short weeks on the inpatient floors, I was eager to learn about this man who somehow managed to escape the cycle. “My name is Miranda, I’m a medical student,” I formally introduced myself to the patient as we walked towards the hospital doors. “We are the M&Ms!” He laughs at his own joke about our shared first initial. Despite his physical illness that landed him in the emergency room, sick enough to merit an in-patient admission, this man had been nothing but cooperative and kind during his multi-hour stay in the chaos of the Episcopal ED on a Friday evening. As I tapped my ID badge to let us out of the ED, I knowingly smiled at the security officers so they understood the patient wasn’t eloping from the hospital. I imagine we looked like quite the unlikely duo. My somewhat disheveled patient, wearing his hospital gown over his own worn out jeans, the gown open in the back and blowing in the breeze as we stepped outside; my hospital-issued scrubs under my fleece jacket, having conveniently “forgotten” to put on my white coat.

As we sat on the wooden curb outside the hospital doors, a group of police officers mingled nearby. They had recently dropped off a highly combative patient, aggressive and yelling, high on PCP. They chuckled as we approached, my patient pulling out his pack of cigarettes. “Don’t worry man, you’ll be feeling much better soon!” they joked, and we both laughed.

Perhaps guided by my wandering thoughts, our conversation drifted to the topic of family.

“It’s such a nice night,” I said, commenting on the crisp air, the clear sky, the unique peace of a cool summer’s evening. My patient agrees, then points to the stars, barely visible despite the lack of clouds in the sky. “It’s hard to see the stars here, with all of the light from the city,” I replied to his gesture, his unspoken thoughts.

And yes, we even talked about smoking cessation. He told me about all of the times he quit before, for up to years at a time. He only picked up the habit again a few months ago. I suggested that his upcoming hospitalization might be a good time to try to quit again. He seemed open to the idea, maybe this would actually be his “one last cigarette” after all.

For a moment, I silently missed my home in rural Pennsylvania, where the innumerable stars light up the sky in the absence of any surrounding civilization. “Have you always lived in Philadelphia?” I asked my patient. He tells me yes, that he has always lived in Philadelphia, calling many of its neighborhoods home over the years. I wonder if he had ever seen the stars the way I am imaging them now in my mind. It is a privilege, I realized, to have called a place home where the stars light up the sky more brightly than any buildings or street lights. Where on this cool summer’s evening, barely 70 miles away, my family was having a campfire in our backyard. Where the crisp and cool air was filled not with the wail of sirens or the cries of intoxicated patients, but with the chirping of crickets, the rustling of animals moving through the woods, the crackle of the fire.

I was surprised to learn that he also has siblings with whom he is close. They have families of their own and live in the suburbs. He talks to them almost every day and visits regularly.

He finished his cigarettes and we left the peaceful night to reenter the chaos of the ED. The same police officers we had encountered earlier outside greeted us as we entered the hospital, “see man, aren’t you feeling better?” “Yep, look, I cured him!” I played along with their joke. The next day, I opened the patient’s chart to check on how my friend was doing. As I read his history and physical as written by the admitting medicine physician, I smiled to myself when I reached the section about social history. “Patient reports that he has quit smoking… last cigarette December 19, 2016.” Our secret was safe with him. ■

It’s Okay

Danielle Hu

Names have been changed to protect the privacy of individuals.

“I came here to tell you how proud of you I am. Not because you did the best you could for those patients, but because after twenty years of being a doctor, when things go badly you still take it this hard. …That’s the kind of doctor I want to be.” - Scrubs, “My Fallen Idol” I can be a crybaby. I cry when I watch movies. I cry when I read books. I cry when I’m upset or even laughing too hard. The first time I found out that my patient died, I thought I would cry too. But even though I was stunned and shocked, I shed no tears. My initial reaction was denial. It can’t be true—even though there was no reason why my friend on the team would lie to me about this. I had to log onto the EMR to read the notes penned by the resident and nurse to confirm that, yes, Mrs. Gomez was dead. She had been left alone in her room for a few hours. By the time the nurse checked on her, she was already unresponsive. They called a Code Blue and my night team was there, doing chest compressions, pushing epinephrine. Nothing helped. She was gone. 40

As I walked to the subway stop that morning, I was simply numb. I thought back to yesterday when I had last seen her. Never had it once crossed my mind that she wouldn’t be there today. I knew she hadn’t been doing that well, that she had been the sickest patient on our service, with multiple organs failing at her advanced age. She always looked frail and tired and spoke in a hoarse voice. Still, I never thought she would die suddenly in the middle of the night. Had I known—I would have visited her more often yesterday, tried harder to elicit complaints… She had been my patient over the last three weeks but I had never had a real conversation with her, about her life,her family, or whatever was important to her. Not because I was too busy, but because she spoke Spanish and I didn’t. Many things I felt I should have done that were now too late. When I got to the hospital workroom, one of my residents asked how I was doing. “It’s okay to not be okay… and also okay to be okay,” she told me. “Both are fine.” I thanked her, but my mind quickly drifted away from Mrs. Gomez. There were tasks to do and other patients to see. I pocketed my patient list and went onto the floors. I soon ran into another resident on my team, who had also cared for Mrs. Gomez. Unlike me, he had checked on her frequently yesterday including right before he left for the day.

“I heard what happened,” I said, and he replied with, “Yeah? What did happen?” He went through several theories. Maybe she had a pulmonary embolism… but she had a gastrointestinal bleed, so could we have given her blood thinners? Maybe she had moved herself from the chair, where my resident last saw her, to the bed, where she was found. Maybe she choked on something as she lay down flat. There were many “maybes” and no clear answer. Later on, when my attending spoke of Mrs. Gomez during rounds, he was just as stumped. In fact, he said he couldn’t fall asleep last night after he received the call. “I just kept thinking, what did I miss?” He told us he had another patient last month on his service who had died unexpectedly. “Now her, too,” he said, shaking his head. “You just can’t help but think…”

their most vulnerable state. I didn’t consider that I would be vulnerable at times too. The easy thing to do is to keep moving on, because there would always be something else to distract myself, some other patient who would require my attention. The harder thing is to reflect back on the hard truths and remember how I felt. In the end, it was the collective voices of my medicine team that gave me the greatest comfort. My resident was right. It was okay no matter what reaction I had to my patient’s death. It was also fine not to have answers. And it will all be okay, because I will never be alone. ■

Is it me? There it was, the same question that had echoed in my mind, a question that all logic and rationality could not truly erase. It wasn’t purely grief that I felt for Mrs. Gomez. It was grief colored by a selfish shame and guilt—as if I had personally failed her. I wasn’t there that night and was not shouldered with the task of telling her daughter and granddaughter what happened; I couldn’t imagine what I’d do if I had to. I was sure no amount of words could have expressed the heavy regret that all of us felt for Mrs. Gomez and the haunted question of what could we have done. I went into medicine for the people and the patients, for the hope of connecting with strangers and helping them in 42

Photography by Shuning Li A Color stands abroad On Solitary Fields That Science cannot overtake But Human Nature feels. - A Light Exists in Spring, Emily Dickinson

Time

Gillian Saldanha

“

After a long pause, I asked the question that you never want to ask, even when it’s burning in the back of your mind: “How long?”

”

I was standing in my freshman dorm room in the afternoon when my mom called me, crying. The only intelligible words were, “How could this happen to someone a second time?” It was enough for me to know what she was talking about. Ever since my mom was diagnosed with breast cancer five years earlier, she went in for a CT scan annually; this time the CT scan and follow-up tests revealed that she had Stage IV endometrial cancer. After days of deliberation, the doctors suggested that my mom undergo four rounds of chemo, followed by surgery and four more rounds of chemo. Scans taken after the surgery showed no remaining cancer cells, which even greatly surprised her doctors. Things were looking up. Yet a few months later, we were told that even with all traces of cancer gone, she was still considered to be “in remission.” 46

We learned that women with endometrial cancer typically see their cancer return within 4-6 years. A whirlwind of emotion shook my family again. Back then, four years seemed like too soon, to all of us. She was only 50. In hindsight, if only she had actually gotten those four years. During March of the following year, only 6 months after she was in remission, the cancer was back. Once again, she began going in for chemotherapy. The doctors decided against surgery because the cancer cells had already spread into her liver. My mom received 16 rounds of chemotherapy over the course of her life. The 16th time, she coded. They resuscitated her, but she decided to stop treatment. We didn’t vocalize it, but we all knew that there was no coming back this time. About a year later, I was home from college for spring break. My parents were in the ER; my mom was experiencing a lot of pain. I drove there and spent about an hour with my mom as they waited to speak to a doctor. “Hi sweetie,” my mom said to me softly, and gently gripped my hand. When I got home, my brother Gavin asked if my parents talked to me. I told him they hadn’t really. “It’s not looking good,” he admitted. After a long pause, I asked the question that you never want to ask, even when it’s burning in the back of your mind: “How long?” “Three months,” he whispered. That night, I stared at the ceiling, tears rolling off the side of my face until sleep took over.

My parents decided to do hospice care. I flew home every 2-3 weeks. Each time, my mom’s condition worsened as the cancer continued to creep around her abdomen. One visit, I walked into my parents’ bedroom to see my mom connected to an oxygen tank. On another visit, I saw my mom bedridden, no longer able to eat food. The next visit, she was unable to drink water. A small popsicle-shaped sponge over her lips was the sole source of moisture, and her skin had turned a greenish color. The three months mark approached. My mom weighed less than 80 pounds, spent all day lying in bed, and could not speak except to whisper the words “I love you” to us over and over again. Every night for the following week, we thought it would be my mom’s last. This is it, we said to ourselves. For many nights, she would pull through. We would return to our beds at 3am, at 4am, at 6am, dazed and exhausted, and fall into troubled sleep until the morning came. I wanted more time with her, but I was also begging for it to end.

We Meet Again!” Throughout her life, and especially towards the end, she remained optimistic, caring, and able to deal with whatever unexpected hurdles she faced. I think of her when the stress of medical school gets to me, when I wonder why I chose to do this, and it’s always exactly what I need to push on. I also think of her surgeons who continued to visit her in the hospital for years after she left their care... I think about the emails they sent, having done the best they could but wishing they could have done more. In the most difficult moments, they were a source of knowledge and strength. I think about the lasting impact physicians are able to have, not only on patients, but on their families, and I am grateful for having chosen this career. It really is a privilege to be on this side of medicine. ■

On June 20th, 2016, my mom took her last breath. My brother called the night hospice nurse, who said she would head over right away. “Whenever you’re ready,” she told us softly once she arrived. My dad nodded in affirmation. “Time of death,” she said. “4:15am.” It was finally over. *** My mom drafted an email that she asked my dad to send to my brother and I after she passed. The subject line was “Until 48

Gillian’s mother. Photograph courtesy of Gillian Saldanha

The Sun It’s been one hundred and fifty days since it happened. Since your world fell apart. My apologies, but I lost your name while trying to leave that day behind me. I have not forgotten your face. Never your face. I remember your face when I walked into the Labor and Delivery triage room. Some people glow as if they carry around their own light. You had that. You probably always had that, brighter on days that made you laugh. Everything looked good, so good we almost promised. Promises we want to make but never should. We told you it was happening. “Today?!” “Well, most likely.” The love of your life was in that room as well, but his face? I remember a little less. His face wasn’t glowing, a sleepy moon to your quietly roaring sun. On that day, we revolved around you. You told me your story on how you came to be here. A story of a life with love, uncomplicated. This was your first time. Your happiness was contagious, your hands were trembling

Franzes Anne Liongson because they could no longer hold your joy, and your face, it was glowing. I checked on you a few times, but you were asleep. That’s good, I thought. Sleep because you are going to need all the strength you’ve gathered from all the women you’ve ever loved. Upon my return, you were ready, or better yet, she was ready to meet you, the woman who glows from the inside. You were about to show her all your strength. Strength she may use one day if she ever found herself without you. The smell of the room was familiar, it smelled of earth and metal and wet. With every push, you moved the world and stopped the air from flowing. This was my first time “catching” a baby, as one does when they find themselves in the rye. She did not cry and her body felt cold as if she were no longer basking in your warm sun. And although this was my first, I knew that something was wrong. Did you hear my heart fall to the floor amidst your tears? You held her close to you, whispered in her ear. Promises you made which you could not keep. “You are my perfect

little girl,” you said in a voice that was reminiscent of the final droplets after a storm. At that moment, she sipped at your whispers and melted under your breath. Shaking, I patted your knee, squeezed his shoulder, picked up my heart from off the floor, and walked away to give you three your time and space. We heard the news four hours later. May the earth and moon and dust of stars bring you comfort and carry you until your loss no longer devastates your every breath because you find yourself without her. May you, one day, when you’re ready, glow again. ■

Photograph by Danielle Hu

SHUNING LI DANIELLE HU

Editor in Chief Editor in Chief & Layout

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Cover Art by Hannah Cheng