Agora Magazine 2022-2023

AGORA

AGORA // SPRING 2023

New York University Grossman School of Medicine

Office of Student Affairs

Humanistic Medicine Program

550 First Avenue

New York, NY 10016

ADVISOR

Jordan Reif

EDITORIAL BOARD

Daniel Alber

Emily Bi

Arundhati Chavan

Nikita Chintalapudi

Sabrina Chen

Diego Laboy Morales

Reagan Menz

Ashwath Muruganand

Christina Oh

Christine Olagun-Samuel

Alex Prete

Corinne Rabbin-Birnbaum

Noor Abi Rached

Rubin Smith

Chidera Ubah

Christina Woo

COVER ART

Claire Young, Sagittal Plane

AGORA LOGO

Ashwath Muruganand

SPECIAL THANKS

Office of Student Affairs

Humanistic Medicine Program

Copyright 2023 NYU Grossman School of Medicine

I N T R O

Weexploredifferentkindsoftransitionseachday Eachtransitiongrantsusinsight Theyrecur,assert,andstabilizethenotionthatitisatemporaryphaseofacyclic process.Orderandinterruptionareembeddedwithineachother.Inthecaseof diseases,interruptionscanquicklygofrombeingamedicalproblemforafew individuals,toaglobal,social,andeconomicconcern.Inthepastthreeyears,the pandemicchangedourrelationshipswitheachother,ourinstitutions,andourselves

Whileemergingintothisnewphaseofthepandemic,weneedtotaketimetoreflect onhowwe'vechanged asindividualpeopleandasacommunity.Wealwayshavea choiceonhowtoconfrontthesenever-endingloopsoftransition.Ourprofoundly changedrealitiescanbeembracedbyhowwerespond,reflect,andreact.We determinewhetherwemakeormarthefutureforourselvesandourchildren Wecan growdespiteuncertaintimeswhilepausing,listening,andbeingempathetictothe experiencesandperspectivesofothers

ThisissueofAgora thefirstsince2018 hasthethemeof"Transitions."Wewidened theauthorshiptoexplorehowrecenteventshaveimpactedstudents,patients, healthcare,thescientificcommunity,andsocietyatlarge Wesharethechanges experiencedbyNYUGrossmanSchoolofMedicine,NYULangoneMedicalCenter, andthelargerNewYorkCitycommunity Agoraisapublicplacethatgracefully articulatesliterary,audible,andvisualartstoconsiderthehumanisticelementsof medicineandhealthcare.

Whilegarneringglimpsesofhowrecenteventshaveimpactedtheworldanddreams forthefuture,wewereunabletoanswerthequestionofhowtobetterprepare ourselvesforchange Weaimedtobringfortheveryauthor'swayofdealingwiththe changesthatlieahead.Anapproachtogetupendedlivesbackontrackwhile recognizingthattransitioncreatesopportunitiestothinkdifferentlyaboutthepresent. Publishedherearesomereflectionsonhowwehaveeachchangedandhowtonurture ourselvesandourcommunities

Aswemoveforward,let'sapproachtransitionswithpurposeandstandtogetherforan equitablefuture.Whilelisteningtodiverseperspectivesandworkingcollaboratively, hopefully,Agorainspiresyoualltolearnandgrowintheprocess.

ThankyoutotheentireAgorateamformakingtheseparallelshappen Tothose biddingadieusinthefaceofgraduation,wehopeyourememberthisissueofAgoraand continuetoevolvewithourtime,place,andcommunity

AgoraEditorialBoard

AUTUMN IN CENTRAL PARK

Assummerquicklycomestoaclose

Autumnboldlyentersthescene

Thebriskdawnsandvibrantcolors

MakeCentralParkutterlyserene

IgototheParktoescapethechaos

Thatlivesoutsidemydoorandinmyhead

Comfortedbythechangingoftheleaves

Oncegreennowyellow,orange,andred

Steppingintothecrisp,colderair

Feltuncomfortableatthestart

Butsoonmylungshappilybreatheinthisnewness

Healingbothformymindandheavyheart

Ifoundbeautyinthechirpingofthebirds

Iwalkedthroughthecozy,autumnwood

Naturewasmorphingintosomethingbeautiful

Showingmethatchangecanbegood

Whenuncertaintysweptthroughtheworld

Acollectiveanxietyabouttheunknown, IstayedclosetothecommunityofParkgoers

Whosepresencemademefeellessalone

Asthetreeswatchtheirleavesfalltotheground

Andmakepeacewiththemdriftingaway

Iamempoweredtoletgoofmyfear

Replacedwithhopethatallwillbeokay

Natureembraceschangeeveryyear

Itpersiststhroughthecoldandtherain

Ithastaughtmethatinordertogrow

Onemustfacelife'shardshipsandpain

RobertFrostknewwhatIdidnot

Thatnothinggoldcanstay

Butiftransformationsdidnotoccur

TherewouldbenocherryblossomscomeMay

Beatrix Brandfield-Harvey

SabrinaChen

SLIPPING

WhenIfirstmether,shegrippedmyhandso tightlythatthetipsofmyfingersturnedwhite.I didn'tthinkshewouldslipaway,untilshedid.

Someoftheresidentsbetonwhenshewouldtire outandgiveup Afewdays?Aweek?Mypatient hadbeenrapidlydecliningsincecontracting COVIDtwomonthsago.Herunderlyinglung diseaseinconjunctionwithheresophageal dysmotilitycausedhertoaspirateanythingshe triedtoeat,andshehadtobeputonincreasing amountsofoxygen EverydayIcalledherson andpresentedthefacts "She'ssuffering Sheis displayingdiscomfortandseverebreathlessness. Herscansshowthatherlungswillnotrecover." Everyday,hepickedupthephoneinonering andwhispered,"Iknow,Iknow I'mjustnot readyyet"

Webothknewthateventhoughshemightget better,itwouldonlybeweeksifnotdaysbefore shedecompensatedagain.Shewouldliveina revolvingdoorbetweenthehospitalandthe nursinghome alwayswaitingforthenextbomb todrop Andyet,forbothofus,itwaseasierthis way,turningupheroxygenbitbybit,feelingfor herpulseseachmorning,seeinghersmilewhen weallowedhertodrinkasmallsipofachocolate shake

ShecamebackonlydaysafterIdischargedher thefirsttime.Thistimeitwasdifferent.Shewas onthehighestamountsofoxygenthehospital couldoffer.Still,shewasn'tgettingenough.Her heartmonitorshowedabnormalrhythms afib,a flutterandthenvtach Everymorningshewould pleadwithmeinafewwords,"Can'tbreathe Help.""Eat.Please."

Onemorning,hersoncametoherbedside "It's time,I'mready,"hetoldme.Asmuchofareliefas itwastohearthosewordscomeoutofhismouth, Iwasn'treadyforwhatcamenext.

Losingalovedoneispainfulandsignificant,butI hadneverexperiencedthesenseofresponsibility thatcomeswithcaringforadyingpatient.There isafineline,aslipperyslope,betweenprolonging thedyingprocessandkillingapatient.Those moments whenwediscontinuedtheantibiotics, steroids,andothermedicationskeepingheralive, whileinstructingthenursestopushmorphine andAtivan,slowingherbreathingandslowly makingherunconscious Iwalkedthatline.AsI turnedofftheheartratemonitor,Iturnedmy headtohersonandwhispered,"I'msosorry"This man,whohadtrustedmeoverthepastmonthto careforhismother,wouldnotlookatme

Irememberedthefeelingthatdrovemetostudy medicine.Itwastheconfusionanddismay watchingmygrandpalosehismemory the paralyticnumbnesswitnessingmycousin'sorgans shutdownasthecancertookover Iwentinto medicinebecauseIbelievedthathelplessnesswas theworstfeelingintheworld.Foryears,Ipored overthediseasestatesandthetreatment algorithms Ihadstudiedandwatchedand trained Iknewtheanswers Yetsomehow,this newfeeling knowingthatIhadthepowerto keepheralivewhileallowinghertoslipawayin frontofmyeyes feltworse.

Westoodatherbedsideforthelasthoursofher life Ifelthergriponmyhandstightenandthen loosenasweturneddownheroxygen,herlast lifeline.Slowly,Iletherhandslipoutofmine.

UNTITLED

Paul Gerhard Fritz

Victor Sanchez

PARTING WORDS / PALABRAS DE DESPEDIDA

In my younger days I did not have a care Dancing until sunrise under the music's spell A drink in hand I tossed my worries to the air And embraced instead the stories I would tell

Those bygone nights of sins sublime

Before my skin captured the sun's bright rays And my body swelled with beers of former times Of memories made long before this hospital stay

I know the reaper must collect his dues When he knocks, just let me be Because every sinner pays for his booze Every soul must be set free

So, as I depart do not lament, I would not change a thing

Except for one more shot of bourbon, before I get my angel wings

Me despedí de ti mí amor, en un distante verano Desconociendo cuando te volvería a ver Viviendo en las sombras de un país extraño Encontré mi refugio en el beber

Laborando, sosteniendo con penas esta carga Noches atrapado en las garras de el diablo Ahora me encuentro solo, sangre tan amarga Y el lejano recuerdo de tu abrazo

Que no diera yo, por una noche mas O el mas breve momento de claridad El poder de regresar mi tiempo atrás Antes de enfrentar mi mortalidad

Pero si el frio recorre ya mis sabanas y estoy llamado a la noche mas callada Que los últimos recuerdos sean de ti, mi amada

Naina Rao

EVEN IF NinaSingh

Beforethepandemichit,thehabitof subconsciouslyusing"If ,then "conditionsto understandmylifewasverymuchbuiltintome Aseverythingaroundmestartedclosingand changing,Iwasforcedtoconfrontalotofthe"If ,then "statementsthatwerenolonger possible."IfIdothein-personresearchprojectmy PIandIproposedoverthesummer,Iwillhavea greatstarttomyresearchcareerinmedical school""IfItrymybestinmedicalschool,I'llbe abletomatchatmydreamresidencyprogram"

Asthepandemicragedon,Ireceivedtheadviceto framethingsin"evenif"statementsinsteadof"if then"ones Giventhatmanyofmy"If ,then " statementsseemedlesspossibleduringthe pandemic,Idecidedtostartcompromising,which involvedmany"Evenifs."First,withrespectto medicaltrainingasapreclinicalstudent:"Evenif wedon'tlearntheabdominalexaminperson,we willhaveplentyofopportunitiestopractice duringclerkships" Then,tomore‘bigpicture' aspectsofmylife:"EvenifIdon'tmatchatmytop choiceresidencyprogram,Iwillbedoinga specialtyIlove."

Andfinally,IbeganapplyingmyCOVID-19 copingmechanismtoclinicalpractice AsIwent throughclerkships,Irealizedthatratherthanjust asatooltopreservemymentalhealth,"evenif" wasamuchmoreaccuratewayoflookingat clinicalpracticethan"ifthen."Statementslike"If wegetthislumbarpuncture,thenwe'llfigureout whatiscausingthepatient'snew-onsetneurologic deficits"and"Ifwegivethisulcerativecolitis patientIVsolumedrol,thentheywillrecoverfrom theirflare"weretenuousatbest.

Instead,seniorcliniciansthoughtin"evenifs." "EveniftheLPresultsdon'texplainthepatient's neurologicsymptoms,wecanmoveontoother optionslikenerveconductiontesting""Evenif theIVsolumedroldoesn'thelp,wecouldtry infliximab."Irealizedthatalthoughthemultiple choicequestionsstudentsspendhourspracticing areintheformat"ifyouseethefollowingclinical scenario,thenyoushould ,"medicineitselfis verymuchafieldof"evenif's"inpractice Clinical practiceisamatterofdifferentialdiagnosesand contingencyplans,anditrewardspeoplewholet goofthe"if ,then "mindset.

Furthermore,"evenif"presentsamuchmore compassionatewaytoframethingstopatients "EvenifGIcan'tgetthe50polypsoutofyour colonduringcolonoscopy,westillhavesurgical optionstooffer"ismuchkinderthan"IfGIcan't getthe50polypsoutduringcolonoscopy,thenwe willhavetotakeyourcolonoutsurgically" Framingoptionstopatientswith"evenif"restores hopeandrelievessomeofthetensionassociated withthecalculatedextremes.

Somemayfeelthat"evenif"statementsrepresent toomuchofaconstantcompromise ButIwould arguethattheuncertaintyreflectedinthese statementsdoesnotmakeoneanyweakerorless likelytoachievegoals.Instead,knowingthat thereisnotasingleend-allbe-alloptionallows onetofocuswithouttheparalyzingpressureof"if ,then "Thetransformativeexperienceof trainingduringtheCOVID-19pandemichas taughtmethat"evenif"iskeytonavigating personalandprofessionallife.

AlexanderPrete

WHEN LESS BECOMES MORE

ThefirstthingthatInoticedwashereyes They werethecoolestofblues,brightunderthepale fluorescencefromthelightsabove.Areminder ofherstrongIrishroots,mydadwouldalways say However,mygrandmother'sactions sufficedinvalidatingherheritage:shewas stubbornandstrong,neveronetoyieldin protectingherfamilyasthematriarchofour clan.Iwastoldthatshefacedmanyobstacles alongtheway.Afterall,sheraisedmyfather andhissiblingswhilePopwasservingin Vietnam Followingmanyyearsofchildrearing,shewashappywithherlife, comfortable,andatpeace.Sheletherguard down,andthenshestartedtoforget.

Atfirst,itwaslittlethings:abill,apill,some keys Initially,wecuthersomeslack;shewas75 afterall "Thisisnormal,"wewouldsaytoeach other.Slowly,slip-upsgavewaytoconfusion, withquestionsof"whatdoyoucallthisthing again?"becoming"whoareyou?"Gramhadmet hermatchwithAlzheimer's

Sittinginfrontofhernow,surroundedbythe sterilewallsofhernursinghome,bombarded byacacophonyofbeeps,Iwasfixatedonher eyes.MaybeIwaslookingforsomething. PerhapstheoldGramwassomewhereinthere, dressedintheredvelvetblouseshewouldwear tofamilyChristmas,smilingonthecouchby thetreeasweopenedpresents.Isearchedfor signsofrecognition,acomfortingglanceora twinkleinhereyethatsaid"yes,Iknowyou, youaremygrandchild!"JustasIwaslookingfor aninklingofhopeinhereyes,shewassearching mineforthereassurancethat,attheendofall ofthis,shewouldbeokay.

Atthetime,Iwastooyoungtounderstand exactlywhatwasgoingon.Isawmy grandmotherwhenvisitinghoursallowed,butI wasblithelyunawareofwhathadbeentaking placebehindthescenes:discussionsofifPop couldcareforGramindependentlyathome; searchesforanursinghome;decisions concerninggoalsofcareandend-of-life planning.Iwasblindtotheamountofwork requiredtoprepareformygrandmother's peacefulpassing,thestridesthatweremadeto ensurethat,despitethecircumstances,she wouldgo"thewayshewouldhavewantedto"I simplyofferedahugtomyfatherandashoulder tomymotherwhenwefinallyreceivedthecall thatshehadbreathedherlast.

Manyyearslater,Ifoundmyselfonthe17th floorofBellevueHospital,peeringintoasetof eyesthatwerealltoofamiliar;however,theface thatworethemthistimewasdifferent.Around usweresimilarpalewalls;betweenus,similar barriers Withmygrandmother,itwasher mutism;withmynewpatient,itwasherPolish language Thepatient'sblueeyestookmeback tothenursinghome,communicatingfearand confusion.

Herchartsaidthatshehadsufferedafallat home;herCTscanrevealedthatthefallwasjust thetipoftheiceberg Herbrainwasatrophied andhersulcienlarged,corroboratingreports fromfamilythattheirgrandmother'smemory hadbeendeclining.Inherchest,amediastinal masswasencasingthesuperiorvenacava Inan 88-year-oldwoman,cachecticandbearingthe scarsofapreviousmastectomy,thelikelyculprit wasclear:cancer.Toourpatient,dementedand

disoriented,itwassimplyaword:"Iamold,and oldpeoplegetlumps"

Ourteamneededtoknowhowtoproceed,and itwasclearthatshedidnothavethecapacity decide "Wouldyoufeelcomfortablebreaking thisnewstoherfamily?"Theresident'swords resoundedinmyears Comfortable?Icertainly wasnot.However,Iwasfacedwitha responsibilityuniquetothemedicalprofession: thevocationtoserveasahealerandguide,to delivernewsbothgoodandbadtothosefacing theuncertain Thisiswhathaddrawnmeto medicine ThisiswhyIamhere So,Ipickedup thephone.

Inmyconversationswithmypatient'sfamily,I learnedalotaboutherlife Muchlikemy grandmother,shewasthecornerstoneofalarge family Strong-willed,perseverant,andattimes stubborn,shelivedlifecherishingthelittle things:makingpierogisforhergreatgrandchildren,Sundaymass,tripstothemarket withfriends Sheneverlongedtoreturnto Poland;shehadherownclose-knitgroupin Brooklyn ShelovedlivinginGreenpoint; despiteherdisorientation,hearingtheword madehersmilewidely."Greenpoint,tellme howIknowGreenpoint!"Althoughstruggling tounderstanditstruemeaning,thewordmeant somethingtoher Itmeantpeace,familiarity, andcomfort Farawayfromthisstrange, foreignplace.

AsIlearnedmoreaboutmypatient,the conversationconcerninggoalsofcarebecame lessscaryandmorefulfilling Itwasclearto bothmeandhergrandsonthatshewouldnot benefitfromfurtherworkupofhermass.The risksofbiopsy,thetolloftreatment,thelong hoursspentinandoutofthehospital;noneof thisfitwiththefutureshehadenvisionedfor

herself Shesimplywantedtospendherlast daysathome Webothdecidedthatshewasthe perfectcandidateforhomehospice.Herpain wouldbemanaged,andthequalityofher remainingtimewouldbeoptimized.Shewould becaredforinawaythatreflectedthestrength anddignitywithwhichsheimbuedherlife Althoughdifficult,wehadmadeadecision

Indiscussingend-of-lifeplanningformy patient,IrealizedthatIhadbecomethe healthcareprofessionalontheotherendofmy Pop'sphonecallsmanyyearsago Iwasthe personcalledwhenadvicewasneeded,Iwasthe guidepresentwhendecisionsbecametough.I tookresponsibilityformypatient,andforthe firsttime,ItrulyfeltlikeIwasaprovider. Strangelyenough,itwasthemedicaldecision nottotreatthatmademefeelthisway

Recently,Ireadaninterestingstatistic:inmy careerasaphysician,Iwillcarefor approximately20,000patients,address500,000 problems,andwriteabout240,000 prescriptions However,regardlessofhowmany testsIorder,medicationsIprescribe,or proceduresIperform,thisexperiencetaughtme thatqualitycareisnotalwayssynonymouswith morecare.

Amy Bleasdale

DEATH, THE MAIDEN, AND HER MEDICAL TEAM

DER TOD UND DAS MÄDCHEN

Das Mädchen: Vorüber! Ach, vorüber!

Geh wilder Knochenmann!

Ich bin noch jung, geh Lieber!

Und rühre mich nicht an

Der Tod:

Gib deine Hand, Du [schön und zart]1 Gebild! Bin Freund, und komme nicht, zu strafen.

Sey gutes Muths! ich bin nicht wild, Sollst sanft in meinen Armen schlafen!

The Maiden:

"It's all over! alas, it's all over now!

Go, savage man of bone!

I am still young go, devoted one! And do not molest me."

Death:

"Give me your hand, you fair and tender form! I am a friend; I do not come to punish Be of good cheer! I am not savage You shall sleep gently in my arms"

Translation copyright © by Emily Ezust from the LiederNet Archive

Themorningofthefamilymeeting,theresidents andIpreparedtheconferenceroomforthe solemnevent.Wetookdownstreamersand poppedballoonsfromarecentstaffbirthday party Afreshboxoftissueswasopenedand placedatoneendofthetable;itwastheonly decorationneededforthisnextevent.

Thepatientwasapreviouslyhealthymiddle-aged womanwhowasstilltryingtomakesenseofthe devastatingnewsshehadreceivedafewweeksago stageIVtriple-negativebreastcancer They triedtoactquickly;shehadonedoseof pembrolizumab,butherdiseasesubsequently progressed.Sheeventuallycametothehospital whenmassivepleuraleffusionsmadeit frighteninglydifficulttobreathe Thoracentesis broughtsomesymptomaticrelief,buther effusionswerereaccumulating.Shewantedtodo everything;thiscouldnotbetheend.

Sinceshehadbeenadmittedtoourteam, mutteringsofa"goalsofcarediscussion"cameup almostdaily Asmyattendingputit,"things weren'tlookinggood,"whicheveryoneseemed awareof,exceptthepatient.Myattending encouragedmetojointhefamilymeeting."Itwill beagoodlearningexperience"

Everyonetooktheirplaceatthetable Theaunt, thecousin,thefriend.Theoncologist,the hospitalist,theresident,me.Ithadtaken45 minutes,twonurses,andanextradoseofAtivan togetthepatientfromherhospitalbedtothe conferenceroom Finally,shesatpoisedattheend ofthetable,enrobedinblanketsandIVtubing, thenasalcanulaprecariouslyinplaceathernares.

Poetry by Matthias Claudius

Beforeanyonefeltready,theoncologistbegan. "Youknewfromthebeginningthatyourdisease wasadvanced,butweweregoingtotry…but thingshaveprogressed atthispoint,treatment mightmakeyoumoresick whatdoyouwant?"

"Soyou'retellingmeI'mgoingtodie?"Her breathingbecameevenmoreshallow,thepitchof hervoicecreepingupwardasshefinishedasking thequestionnobodywantedtoanswer Her familycouldn'tmakeeyecontactwithher

"Wetalkedaboutthis…"

Thereweremoremutteringsof"whatdoyou want,"butI'mnotsureweeverheardananswer Inthebackground,weheardthesoftweepingof hersisterwhohadbeenphonedinfrommany, manymilesaway.Thegroupconsensuswasthat thepatient'sneedswerenowtoogreatforherto everreturnhome.

Withouttoomuchresistance,thepatient surrendered Herposturesoftenedandher breathingslowedaswediscussed"comfortcare." Shewasofficially"DNR,DNI."

Afterthemeeting,myresidentaskedmewhatI thoughtofthemeeting Ihadbeentakenabackby thestern,pragmaticapproachoftheoncologist Myhearthurtforthepatient,whosefearand vulnerabilityhadbeensopalpableearlyinthe meeting.Icouldnotunderstandwhathadhelped hercrossovertoacceptance Hadsomeonereally saidsomethingthatchangedherperspective?Had shejustbecometootiredtofight?Iquestionedif ourteamshouldhavebeenmoredirectin addressingherprognosisinthedaysprior.

IfoundSchubert'sDerTodunddasMädchen comingtomindasmythoughtsaboutthe meetingpercolatedoverthenextfewweeks

Intheintroduction,thepianoischallengedto deliverathemefullofsolemn,heavychords, muchlikeherdoctorstryingtospeakhonestly aboutaharshrealitythroughthemosttenderof terms Bythetimethepianoreachesitscadence, itseemstherecouldbenoquestionaboutwhatis tobedone,butthenthemaidenspeaks.Her childlikeandfutilepleawastooakintothe patient'sowndisbelief.Themaidendoesnoteven getachancetofinishhercryforhelpbeforethe voiceofthemedicalteamcreepsbackintothe piano,likeagentleoceanwavewashingoverany effortshemaymaketoresistdeath'spull,because theyknowitwillonlyaddtohersuffering.

Thendeathhasitschancetospeak Likeher disease,itplowsforwardwithitsemotionless drone Butunderneathit,thereasoningvoiceis stillthere,providingharmoniccontext,perhaps makingitpalatableenoughthatshecouldengage inthisbriefbutintenseconversationwithdeath. Itultimatelyreaffirmswhatweallnowknowto betrue;shewill,eventually"sleepgentlyin[the] arms"ofherdisease Butdeathdoesn'tgetthelast word.Thepianoreturnswiththesametheme fromtheintroduction,butnowintherelative majorkey.Itsharesthesamenews,butnowwith reassurancethatitwillnotbeafrightfulend ThelasttimeIsawthepatient,shewasresting comfortablyinherhospitalbed.Theoxycodone seemedtohavesoftenedheranxiety.Withachest tubeinplacetodrainhereffusionsonaregular basis,shewasbreathingeasily Providersand familynolongertiptoedaroundherreality;our mindswerenowfreetoattendtohercomfort Hercousinwasatthebedsideperformingreiki. Thesmelloflavenderwaftedabovealltheusual hospitalodors.Deathnolongerseemedtohave suchafrighteninggripoverher Herinitial anxietyanddenialseemedtohavetransformedto peaceandacceptance

IMPERMANENCE

Jesus Garcia

Alex Quan

THE WOMAN WHO FELL OUT OF THE SKY

" In Breughel's Icarus, for instance: how everything turns away Quite leisurely from the disaster; the ploughman may Have heard the splash, the forsaken cry, But for him it was not an important failure; the sun shone

As it had to on the white legs disappearing into the green Water, and the expensive delicate ship that must have seen Something amazing, a boy falling out of the sky, Had somewhere to get to and sailed calmly on"

From

Musee de Beaux Arts by W H Auden

Inmyfirstyearofcollege,onmyfirstrotationin theER,Iencounteredmyfirstdeadbody Mylife hadalwaysbeensomewhatremovedfromdeath beforethen;thankfully,we'vehadnomajor deathsinourfamily,andtheclosestproximityI'd beentolifelessnesswasbehindthescreenin moviesandTVshows.WhenIsignedupforthe nightshiftatourcountyERasanEMTstudent,I expectedtoseethelarger-than-lifestruggle betweenlifeanddeath,perhapsacode,and maybeIwoulddochestcompressionsandsavea patient,orsitbackexhaustedwhenthedoctors calledthetimeofdeathwiththesecretcomfort ofknowingthatI'ddoneallIcould WhatI encounteredthereinsteadwastheaftermath:

unexpectedserenity

AsIwalkedintotheERinmynewuniformand mybackpackfilledwithbottlesofDunkin' Donutsicedcoffee,Isensedanimmediate heavinessintheroom.MyEMTschoolclassmate, agirlwhoIonlyknewinpassing,waswrapping uphershift.Shegavemeaweaksmileand steppedout.AsIintroducedmyselftotheER techs,Ilearnedwhathadjusthappened.A90yearoldwomanhadbeenwheeledintothe buildingonacode,thedoctorshadattemptedto bringherbackwithcardiopulmonary resuscitation,andformaybe10minutestheyhad labored,unsuccessfully,torestartherheart It wasnouse,Iheardlater Shewaslikelygoneeven intheambulance Thegirlbeforemehaddone compressionsonthatlifelessbody Nowonder hersmilewassoweak Iwonderwhatmine wouldlooklikeaftergoingthroughthat Then camemyfirsttaskasafledglingEMT:bagand tagthebody.

TheERtechguidedmeovertowhereshelay beneathablanket.Firstcamethetag.Likethey dointhemovies,Iattacheditaroundhertoe. Herskinwascold.Bodiesaresupposedtobe warm,anythingelsesimplyfeelswrong.Next,we pulledherontoherside.Rigormortishadnot entirelysetin,sorollingherintothesleekblack plasticbagtookmoreeffortthanIhadimagined

"Treatherwithrespect,"cautionedtheERtech Hemusthavenoticedmestrugglingtomoveher body Gingerly,wemovedherintothelargerbag andpulledtheheavyzipperclosedfordeliveryto themorgue.Aroundus,thedoctorsandnurses wentabouttheirbusiness,seeingpatients, wheelingmonitorsfromroomtoroom,writing notesonthehospitalcomputers.Someonehad fallenoutoftheskyjustmomentsbefore.Icarus haddrowned,andjustlikeinBreughel's renditionofthefable,theshipcontinuedtosail, thefarmercontinuedtoplow

Iunderstandwhy,Ithink Doctorsandnurses mustmoveonquicklytoprepareforthenext patient,orforthenextcode Therestofmyshift waschargedwithnervousanticipationthatI mighthavetospringintoactionatanytime Instead,itwasquiet Meanwhile,fortheERstaff, thetimeforreverenceandreflectionwas minimal.Inaclinicalworldwhereschedulesand linesofpeoplewaitingtobeseendemandthe utmostpresenceofdoctorsinthehereandnow, the15-minutes-agomustbeleftinthepast,the expensivedelicateshipmustsetsail,thefarmer mustplow.ButasIlearnedthatday,evenin thosetinyin-betweenmomentsofabusyday,we canslowdowntimesomewhatwiththosesimple words:"treatherwithrespect"

Sheneverknewme Ineverknewher Ididn't evenparticipateinhercode,butafterthatday, practicecodesbegantofeelreal AsanEMT,I latertreatedmanyalteredandunconscious students EverytimeItouchedormovedthem,I thoughtofthosewordsagain "treatherwith respect" andthepersoninfrontofmebecame almostsacred.Everyencounterhasthepossibility oftransformingus.Evenifthenextpatientis waitingandwemustmoveforward,wedon't simplymoveon.Howmanylivesandstorieslive withinus,influencingourwordsandactionsfor everynewpatientwemeet?Shewasn'tevenmy patient,andyetIcarriedthememoryofherwith measIbecameanEMT Icarryhermemory withmetodayasamedicalstudent

Adam Skolnick

if we don't see them

The doctor will see you now Mrs. P walks in with head laid low, She introduces herself to me Sorry

He was a really nice guy, a mensch March 2020: ShouldZoomvisits suffice, what do you think, Syd? "If we don't see them, no one will" We did our best, But we did not know what we were up against Once a doctor, now a patient Panting, gasping for air, No one seemed to care Dr. Mehl was on a ventilator Six weeks later aZoomshiva

His name. Removed. From his door. From the hospital directory. Now Mrs. P. was coming to see me "If we don't see them, no one will."

Amy Sevick

transition

Tell me your understanding (of their condition) What are your biggest concerns? I see

You care a lot (about them)

You have done so much (to care for them) I want to share some information

It may be hard to hear. Are you ready?

Would you like to sit down?

We are in a different place (than two months ago). This new issue makes the other more complex

It is not clear if it can return to how it was Or if this is the new normal Or if it is time to talk about what matters most. What matters most?

Tell me more

I want to understand what you are thinking

Jairo Triana

THE BROKEN SCALE

Balance,"tobringorkeepinequilibrium"isthe definitionofferedbytheOxfordEnglish Dictionary.PerhapsyoupreferMerriamWebster'sdefinition,"equipoisebetween contrasting,opposing,orinteractingelements"

Eitherway,therolesweplay,ourlifeexperiences, andourspecialinterestsareelementsthat constantlyintersecttoprovidestructureand balanceinourlives.Morethanjuststudents,we areathletes,artists,dancers,etc.Thesepiecesform acomplex,evolvingpuzzledefiningouridentity

Sohowdoesonetraintobeaphysician a conceptdetachedfromourtruenature without discardingthepiecesthatmakeusunique?

Enter,the"work-lifebalance"Beforebeginning medicalschool,thepredominantadviceofferedby mypeerswastomaintainwork-lifebalance This isgenerallywell-intendedadvice,butadditional contextualclarityisneededtoproperlymanage expectationsthroughouttraining.

Imagineworkinganinetofivejob,arrivinghome, exercising,havingdinnerwithyourfamily, perhapschattingwithalovedone,andwatching Netflixbeforegettingseven-eighthoursofsleep.

Forsomepeoplethisisagoodexampleofworklifebalance Buthowrealisticisittothinkwecan maintainthisscheduleasphysicians?Iproposea differentschedule Wakeupat5:30,workonthe hospitalflooruntilpastsunset,arrivehomeand studyforthreehours,workonapresentationfor nextday,eatsomewhereinbetweenwhileflipping throughflashcardsinanattempttofallasleepata reasonabletime Somemaydescribethisschedule asanexampleofadisequilibratedscale,butI wouldargueagainstthat.

Myviewonwork-lifebalancebegantochange whenamentoroncetoldmetothinkofworklifebalanceasapenduluminsteadofascale.I begrudginglyconsideredpendulums they remindedmeofphysicsincollege;however,the moreIpondered,themorecorrelationsImade Apendulumusesitsowninertiatoswingfrom onesidetotheoppositewithsequentialchanges characterizedbyaculminationofmaximum potentialenergyatthemostelevatedpositionof eachswing.Atthelowestpositionoftheswing,a positionofequilibriumisfound Let'scallthis point"balance"Ifweweretorandomlystopthe bobofthependulumatanypointwithinits swing,itwouldoverwhelminglynotbefoundat theequilibriumposition.Similarly,ifyouwereto askastudentabouttheirlife,chancesare,their personallife,educationalperformance,ormental healthisnotinperfectbalance

Eventhroughoutourtraining,weencounter topicsthatareexcitingtolearnabout,butalso thosethatmakeuscringeuponmention.But everymomentinourtraininghasitsown purpose Eachexperiencemarksapointalongthe trajectoryofourownpendulumbutdoesnot definetheequilibriumpointofourlife.Insteadof tryingtoconstantlyadjust,byaddingor subtractingfromourlifescaletoachieveperfect work-lifebalance,Ibelieveitismorevaluableto understandwhereyouarewithinyour"swing"to haveaclearvisionofyourdirection

Balanceisdifficulttoachieveifwedonotset realisticexpectationsofwhatitmeans.Reflecting onwhatcanbelearnedateachpointinour pendulumswinghelpsusembracecurrent experiencesandaddsyetanotherpiecetothe puzzlethatmakesuswhoweare.

Sunlight inhale day's heart beating nature's time clock

pulsing fleeting sunset sigh splashed through the sky exhaled twilight waves goodbye

spring wind whispers breath in bubbles

bursting blossoms day's length doubles firefly blink

firework gasp sands slip through midsummer's grasp

coy striptease of autumn trees skeletons

bare in cinnamon breeze icy frostlace frozen fingers

winter's breathcloud lightly lingers

floating snowflakes heaven sent we too are transient

Natalie Bertrand

while there is so much

What medicine is, you decide It, medicine, feels worth less if suffering is the inevitable

I want to stop, cease caring.

I can't hope while there is so much pain and greed rules over compassion

We are human but broken

Caring for the strong even though we are weak seems too much

I don't believe it matters what I do. What I do matters.

I don't believe it seems too much, even though we are weak caring for the strong, but broken

We are human Compassion rules over greed and pain

While there is so much hope I can't cease caring.

I want to stop the inevitable.

If suffering is less, medicine feels worth it You decide what medicine is

Mason Blacker

THE NOW

Althoughtheairwaswarmthatnight,asI steppedoffthehelicopterinacountrythousands ofmilesfromhome,Iwasshivering.Iwas coveredinbloodthatwasnotmyownandIwas physicallyandemotionallydrained Pushed beyondmylimits,Ihadbeenforcedtodigdeep withinmyself Asmyteammatewasfightingfor hislifeinthesurgicalroomwhereIhadlefthimI wasfightingtoholdbackmyemotions wonderingifIhadknownenoughandifIhad doneenough Ourlivescanoftenbementally segregatedintofragmentsbyaseriesofdefining events Therearethethingsthathappenedbefore theseevents,theeventsthemselves,andthenlife aftertheevent.Eachphasehasapresent,anow.I hadjusttransitionedintothepost-eventnow.

Thiswasn'tmyfirstcombattrauma Inthenow ofmypre-eventlife,Ihadfinishedthespecial operationscombatmediccourseandspenttime atalevelonetraumacenter.Afterwhich,myfirst deploymentwastoIraqandonmyfirst operationoneofourKurdishcounterpartswas shotthroughtheshoulderandthebulletexited hischest Itwasmyfirsttraumapatient Laterin thedeployment,Iwasprivilegedtoprovidecare aspartofaforwardsurgicalteamtoIraqikids andotherciviliancasualties.However,noneof thesepatientsweremyteammates

BymyseconddeploymenttoIraqIfeltlikeI couldhandleanytraumathrownmyway.I believedittobeconfidence,butperhapsitwas hubris.WheneverIwasn'toutonoperationsI foundmyselfinthecasualtycollectionpoint All myfreetimewasspenttryingtolearnfromthe surgeonsattachedtous Whilethereweremany Americanservicemembercasualties,stillnoneof themweremyteammates.

Thatnightduringthenowofthislife-altering event,however,wasdifferent.Myfriendhad beenshotinthefaceandtheforceoftheround hadknockedhimunconsciousandalsoblewa massiveholeinhisfaceandneck Thistimeitwas personal Thiswasafriend,ateammate,apatient withafamilyIknew Myheartratespiked,my pupilsdilated,andIbegantoshake.Iquestioned myself.HowharddidIstudyinmymedic course?HowmuchreadinghadIdone?HadI trainedenough?WasItrulypreparedforthis?I didmybestinthatcold,loudhelicopter Finally, wereachedthespotwhereIwouldturnhimover tothesurgeonsonthelargerhelicopter.Iwas relievedtonolongerberesponsibleformy friend'scare.Theonlyproblemwasthatthe surgeon'shelicopterhadjustcrashed Nowitwas uptometotreattheinjuredteamandkeepmy friendalive Mymedicalskillswerepushedtothe limit.IwasscaredthatIwasn'tgoodenough,I didn'tknowenough,andIhadn'tdoneenough.

Standingthereinthepost-eventnow,Iwas completelyoblivioustothehelicopterbehindme oranythingelseintheworld Irealizedthatwhat Ihadlearned,howhardIstudied,andhowmuch effortIhadputintomytraininghadreal consequences.Consequencesformyfutureand formypatient'sfuture Itmeantthedifference betweentellingmyfriend'sfamilythatIjust couldnotsavetheirhusband/fatherversussitting downtoamealwithmyfriendandhisfamilyas herecoveredfromhisinjuries.InthismomentI understoodthatmypersonaldecisionsandmy effortsorlackthere-ofwouldmakeasubstantial differencetomypatients Whenthenowofthe presentcallsonetoperform,thenowofthepast willbetheonlythingonecanrelyonto determinethenowofthefuture.

Bruxelles

Andrew Scheinfeld

"C'estbienMonsieur"

Exhausted

Myoralexamover

Idriftedoutside

IntoabrightSpring

sunlight

Euphoric

Iwalkedthecobbled streets

TowardAvenueLouise

Wherethetrams

Weavedtheirway

Towardthe"Boisdela

Cambre"

Oppositetoles

Chocolatieres

Wasaquainthotel

Curiousandhappy

Iwalkedthelobby

Towardagreengarden

Andit'shiddencafé

Whitetablecloths

Andfragrantflowers

Backdropto

Ayoungprettywaitress

Whosaid"Bonjour"

Isatdown

Adisheveledstudent

Outofplace

Amidsttheelegantdiners

Myheavybagofbooks

Aquietcompanion

Lunchwasdelicious

Andmywaitress

Beautiful

Ishylyaskedher

"Tuaimebienlecinema?"

Shereplied"biensur"

Afterward

Iwalkedtomyfavorite

Parcdepoche

WhereIwatched

Andlistened

Asoldmen

Inberets

Playedbocce

Untiltwilight

EricaSinner

THE ROAD TO BALTIMORE

MostpeoplewhoknowmenowwouldsayI don'tshyawayfromtransitions.Stagnation makesmerestless,andnewadventures enticinglycallout anywherebuthere. However,Ilivedthefirst22yearsofmylifeina small,safecornerofruralMinnesota Mylast monthofcollegewasfilledwiththemeparties, camaraderie,andthetriumphantfreedomof belonging.

Iwasgoingtobeachemist Mysisters,both PhDsintheirrespectivefields,hadstayed closedtohomeforgraduateschool IfeltlikeI wassupposedtodothattoo,butIdidn't.Ihad beenacceptedtoachemicalbiologyPh.D. programatJohnsHopkins,anddespitemy family'sreservations,Iwasleavinghome

Iwasontheprecipiceofsacrificingmycomfort andconfidenceforthesakeofindependence andadventure.Butfirst,Ihadtospendan unmooredmonthatmyparents'house.Ihad beenstrugglingwithpersistentnosebleeds,soI sawanENTphysicianwhowasthefatherof oneofmycollegeclassmates

Duringtheexam,hefeltamassonmyneckand toldmetocomebackintwoweeksifithadn't gottensmaller Ilaughednervously Theround lumpontherightsideofmyneckhadbeen growingsteadilyforatleastayear

Overthenextweek,thelumpthatIhadbeen quietlyignoringformonthsstartedtoassert itself Iwasnolongerabletoholdmyheadina naturalpositionwithoutcompressingthemass Iwasfeverish,Iwasuncomfortable,andIwas supposedtobemovingtoBaltimoreinthree weeks.

Icalledthedoctorandheagreedtoseemethe followday.Intheexamroom,hewascalm,but therewasanewsenseofurgencyinhis questions.Iwashavingsystemicsymptoms,and Ihadaunilateral,painlessneckmass He stoppedtyping,madeeyecontact,andtoldme, veryseriously,thatlymphomaandleukemia wereatthetopofhisdifferentialdiagnosis.My lifeturnedupside-downinthatmoment,butI didn'tunderstandthesignificanceofmy symptoms Now,afterjustafewmonthsof medicalschool,InowknowhowwellIfitthe clinicalpictureofHodgkinlymphoma Hewas preparinghimselftogiveme,agirlthesameage ashisdaughter,theworstnewsofherlife.

Withanempiricalclindamycinprescriptionand aknotinmystomach,Iwalkedoutofhisoffice Theweekendlastedforever Iwasunabletoface thepossibilitythatinsteadofbecominga graduatestudent,Imightbecomeacancer patient.

WhenthecallfinallycameonMonday afternoon,thedoctorstartedtheconversation byaskingmehowIwas.Ididn'tknowhowto answer.Wasthequestionaformality,something youreplytowith"good"andmoveon?Ichoked out"fine,"whichhardlyfeltlikethetruth He thentoldmethebeautiful,wonderfulnewsthat itwasnotcancer,butinsteadabrachialcleft cyst.Ifranticallyscribbleddownnotesashe explainedinlaytermstheembryologicalflaw thatledtoitsformation.Anevolutionary remnantofastructurethatformsgillsinfish hadfailedtocloseproperlyduringmy development,leavingaspacethatformedacyst Itwasbenign,butthesizeandlocationofthe

cystmadesurgicalremovalthebestcourseof action Ihungupthephone,tryingtoprocess therollercoasterofemotions Ididn'thave cancer elation Ihadagill what?Ineeded surgery well,shit.Iwasmovinginlessthan threeweeks,andthenextopeninginthe surgeryschedulewasseveralmonthsaway.

Thenextfewdayspassedinablur Ihalfheartedlystartedtopackmythingsandsentmy Baltimorelandlordasecuritydepositeven thoughIcouldn'timaginemoving.ThenIgota callfromthedoctor'sofficethattherehadbeen alast-minutecancellation So,withonlyaweek beforesurgery,packingbeganinearnest

Onthedayofthesurgery,Itriedtoremain stoic.Thesurgeon'senthusiasticdescriptionof theprocedureinvolvedhimworkingaround mycarotidartery,whichwasnotespecially reassuring Thesurgerywentwell,butthe disconcertingnumbnessinmyneck,jaw,and eartookweekstofullyresolve.Myparents, sister,andIleftforBaltimorewhileIwasstill immersedinpost-surgerypain/painkillerfog.A rowofblackFrankensteinstitchesstoodouton myneckasIgotgingerlyintothecar Aftertwo daysofdriving,wearrivedonasteaming BaltimoreJunedayatmyapartmentbuilding. Thebrickfaçade'sintricatedecorationswere lovely,buttheinsidewasbleak.Thecreepy lobby,terrifyingelevator,andminuscule kitchencouldallbeoverlooked,butthelackof air-conditioningwasoppressive

Afterafewdayshelpingmesettlein,myfamily left.Imetmynewadvisorandcolleagueswith anangryredscarprominentlydisplayedonmy neck Afterafewawkwardquestions,I reassuredthemthatIhadnottriedtotakemy ownlife.However,Iwashesitanttotellthe

storyofwhathadhappenedintheweeksbefore myarrival Ididn'tknowhowtodescribethe feelingthatmybodyhadbetrayedme,andthat, despiteagoodoutcome,Iwouldneverbethe same.

Inmyfirstmonthofgraduateschool,Ispentalot oftimepeople-watchingthroughthewindowof myapartment Iwonderedifmovingto Baltimorehadbeentherightchoice,orifIwould havebeenbetteroffstayingclosertothereliable supportnetworkIwassoluckytohave.But duringtheyearsIspentuncoveringenzyme mechanismsinthelab,Ialsodiscoveredthedepth ofmyownresilienceandtherichnessof experiencethatcamewithexpandingmycomfort zone.

LIGHTINGSKY Alan Jacobson

Graceann Forrester

the wagon

Not too long ago I fell off the wagon. I sat for a while thinking that I would be fine without the wagon.

I thought I could get back on the wagon any time I wanted

I pouted for a while because the wagon did not seem to care that I was no longer one of its riders The wagon had the nerve to move on without me Reluctantly, I began to search for the wagon

I was insulted that it did not come to me when I called

When I found the wagon, my pride would not let me hop back on.

I walked beside the wagon, saddened that there was no welcome back parade. The wagon did not even offer me a cookie. The wagon did not understand. I cussed the wagon

Yesterday, I took the leap of faith and hurled myself back up and onto the wagon I have remained on the wagon having exercised twice in as many days

I remain disappointed that the wagon was not more sympathetic at this prodigal's return But yes, (SIGH), for now, (SIGH), I remain on the wagon.

Porsche Scott

the hamster escapes the wheel

In my search of greatness, I revert to the wheel of safety Subconsciously repeating the cycle that leads to complacency

Enhancing my stamina and endurance by practicing daily

To develop the skills to move forward, yet I remain stationed Outside of the hamster cage foreshadows all of which I long to be

But how can I leave, when this is all that's familiar to me?

With one leap I jump off of the wheel of comfortable confinement

Completing the first phase in my quest of aspirational alignment

No longer needing to validate what's already mine With each revelation, I inch closer to the finish line The hamster wheel granted me strength, but also kept me still

Now I have earned the freedom to explore what my heart needs fulfilled

Using my fears as stepping stones of faith

From a pessimistic state of mind of limited space I have graciously escaped

TAKEMYHAND Heather Brody

DROWNING Heather Brody

RebeccaKrasnoff

QUIET

ThemomentsIrememberbestaretheones spentinquiet oratleast,whatfeltlikequiet. Hospitalsfeelchaotic Freneticenergyfillsthe halls,especiallyatBellevue Rapidresponse teamsandstrokecodesareconstantlyheard overhead.Theoccasional"missingperson" announcementjoinsthem."

Sometimes,Ithriveonthisenergy Bothfeetare neverfullyplanted onealwayslifted,in waiting,inready Feelingunsettledhasstarted tofeelsafer.Thisisn'tbad it'snecessary.Ihave tolearntofeelateasewiththeuneasiness.

Otherdays,Iyearnforasenseofmasterythat nevercomes AsIchasethisfeeling,Ilosetrack ofwhyI'mhere It'snotaboutme Asuneasyas ImayfeelwhenIamunpreparedforrounds, todaymightbethescariestdayofmypatient's life.AsmuchasImaycraveamomentofquiet, theydesperatelyneedone

Thehallsmayneverbequiet,buttogether,we findpeaceandmeaninginourmomentsof connection.

InmymonthatBellevueasamedicine clerkshipstudent,severalofmypatientscould notorwouldnotspeak Sometimeswedidn't knowwhy.Pain?Confusion?Onepatientin particularjustliedinbedandoccasionally moaned.WhenIfirstmethim,hewouldonly mutter,"I'mokay"inabarelyaudiblerasp

"Areyouinpain?"

"I'mokay"

"Weneedtodrawsomeblood"

"I'mokay"

"Doesthatmeanit'sokaytodrawyourblood?"

"I'mokay"

Sometimes,hewouldnodorshakehisheadin suchawaythatitseemedheunderstoodus. Othertimes,Iwasn'tsosure

Herefusedallinterventions IVplacement, blooddraws,evenhavinghisbloodpressure taken.Herefusedmostmedications.Hewore mitts24/7(notbychoice)andhadapatientcare associatebyhissidealldayandnight;stillhe pulledouthisIVmorethanonce Heseemed lost,scared,morethanjustuneasy So,myfirst fewdays wheneverythingwasnewandthe hallsfeltespeciallyloudandespeciallybusy I satwithhim.Iheldhismittedhand.Wedidn't speak Inthosemoments,thehospitalfeltstill I thinkhestartedtorecognizeme IliketothinkI madethe(sometimesoverwhelming)hum quieterforhimaswell.Occasionally,ifIwas there,hewouldletusdrawbloodwithoutbeing helddown.

Oneday,itwasdecidedthatwewouldplacea nasogastrictube Ihelddownhisleftleg

Someoneusedthephrase"moralinjury."Our effortstohealhimfeltbrutal.Thenextday,he wouldn'trespondtome Histoewasbloody thepatientcareassociatedsaidhehadtriedto pullthetubeoutwithhisfeet Helayinafetal position,unwilling(unable?)tointeractatall.A curbsideconsultcluedusintoatrulydismal prognosis weeks,maybeamonth.Hesomehow pulledouthisNGtube Wedidn'treplaceit

Itriedtofindtimetositwithhim.But,now weeksintomytimeatBellevue,IfeltIwas becomingpartofthenoise.Itfollowedme.I feltrushedtoseemyotherpatients Ifelt pressuredtopracticemypresentations How couldIcreatestillnessformypatientwhenI wasswirling?

Overthenextfewdays,hestartedtorespondto meagain Wetransitionedtocomfortcare One afternoon,hespokeafewwords "Iwantto stopthepain,now Pleasehelp"Iaskedifhe knewwhoIwas,hesaidyes.WhenIhadto leave,hesaidthankyou.

Earlythenextmorning,beforeIarrivedatthe hospital,hedied

Itooksolaceinthequietmomentswehad together.Thepolishofmypresentations,the narrativeofmynotes,feltunimportant.They werejustnoise HowcouldIeverthinkthey weremoreimportantthanholdinghishand?

Thechaosofthehospitalcanbemagnetic.I hopeIrememberthatthepeaceIfoundwith thispatient.Ihopetocontinuecreating connectionsthatmakethehallsfeelalittlebit slowerandalittlebitquiet

OBSTETRICS

Andrew Scheinfield

IthoughtIwasdonewiththis

Sortofthing

WhenIstuckmyself

Withtheneedlefrom

ThetoddlerwithAIDS

Whoseheartmadewrong

Wasfailing

Hegotitfrombadblood

Isawhismotherpre-chewhisfood

"Ifyouhadababyyou'dunderstand"

NowImightbutthenI

Didn't

NordidIdie

Orevengetsick

Buthedid

Aftermyshiftoneday.

Ortheteenwith Thalassemia

Hegotsickfrom

Badbloodtoo

Andthenthepainfulbumps.

Ithurthimsomuchwhen Ididthebiopsy

Thatwebothcried

Leiomyosarcomastheywere

Heislonggone,too

Onlythecasereport

Liveson.

SethOrlow

I DIDN'T

Andnow

HereIamwritingthis

Thefog

Onmyglassesand

Themasks

Onmyfaceand

Theirs

Therabbi

Thehospitalchaplain.

Healwaysstoppedbytotalktomymother

Whenshewasadmitted

Forherheart

Hewentfast,inthefirstfewweeks

Andmycolleague'sfatherinlaw

OnedayworkingintheICUinBrooklyn

Nextdayintherehimself

Gaspingandthengone

Andourbuildingporter

Helivedtoobutnot

Hisbrother,hisin-laws

Orhiswife.

Keepinmind

I'mnotcomplaining

Justwritingdown

Somememories

Thattroubleme.

DiegoLaboyMorales

PERMANENCE

"Hello?Isthisthingon?"

"YesBuelo,it'sworking.Youcancomeoutnow."

"Hello!Isanyonethere!"

"Yes,Buelo,I'mrighthere!"

"Agh!GoodnessVickieyou'regonnagivemea heartattack!Wheredidyoucomefrom?""Sorry Iwaswaitingoutsidebutyoudidn'thearme"

"It'sokaymija…Uh,canwehuginthisthing?"

"Wesurecan!"

" ... "

"I'vemissedyousomuch,Buelo You'rethelast onetovisitmeyaknow?""Really?IthoughtTony stillhadn't-"

"Nope,Tonyvisitedthreemonthsago.""…"

"Itdoesn'tmatter.I'mstillgladyou'rehere."

"Gee,IcanbarelybelieveI'mactuallydoingthis.I mean,lookatyou!Youlookso real""It's becauseIam real"

"Ofcourse,ofcourse Idon'tmeananyoffense byit.It'sjustdifferentthanwhatIexpected."

"Don'tworry,everyone'sfirsttimeislikethis. Thankfully,Iwasabletoaffordahigh-fidelity reconstruction,soI'mbeyonduncannyvalleybut justshyoftherealthing You'llgetusedtoit prettyquick,trustme"

"Itrustyou…"

"JustsoI'maware,didyoubuyaguestpass,ordid yougoallinforthesubscription?"

"Iwannaseehowitgoesfirstbeforepayingthe heftysubscriptionfee Ionlygotatwo-hourguest passfortoday Ihopethat'sokay"

"Totally,totally,thatmakessense.""…"

"Okayyyy,well,sinceweonlyhavetwohours,do youwanttogototheparkandjusttalk?Catch up?"

"Uhhh,yeah,Ithinkthatwouldbenice""Great! Youcanfollowmeoutthisdoor"

"Wheredoesthi-Oh!We'realreadyhere!We werejustinthatroom,howarewe-"

"Convenient,right?Isetourliminalegresspoint tomyfavoritespotinthepark,rightbythelake. It'soneoftheperksoflivinginthedigitalworld." "Nifty…"

"Come,let'ssitatthisbench" " "" "

"So,areyoustillworkingasasoftwareengineer?"

"Yeah,I'mstillatthesamecompanyIwaswith pre-upload.Myteamiscurrentlyworkingon improvingourconsciousnessencryptionsystems, sincethey'regoodatstoppinglow-gradeidentity theftbuttherehavebeengrowingissueswith illegalcopiesroamingaround"

"Iheardaboutthatonthenews.Thethoughtof runningintoanothermegivesmetheheebiejeebies."

"Youandmeboth Idosympathizewithillegal copies,though Theydon'tknowthey're doppelgangersuntilonedaythey'reconfronted withthetruthandsentencedtodeletion."

"Huh…"

"Ihopeonedaywe'llfindabetterwayofdealing withthem Maybebuildaseparateserveror-" "Vickie IthinkI'mgonnagobacknow""What? Youjustgothere"

"Yeah,Ijust…"

"Iseverythingokay?Ifyoudon'tliketheparkwe cangosomewhereelse.Here,letmepullupa liminalentrypointandwecangotomyapart-" "Please,no,Ijust Iwannaleave this HowdoI leave?""Idon'tunderstand,Buelo IsitsomethingI said?"

"Uh…I…no…Ican'tbehereanymore.Ineedto leave.HowdoIleave?""Buelo,what'sgoingon?It's okay,youcantalktome"

"Idon'twantto Ineedtoleave Takemeout This wasamistake Ishouldn'thavecome HowdoI leave?Takemeout.Please,howdoIgetout!Take meout.Takemeout!"

"Abuelo,calmdown!Everything'sokay"

"Ican'ttakethis!Onesecondyou'reonyour couch,thenextyou'restandinginanemptybeige roomtalkingtoyourdeadgranddaughter.The park,thecopiesofcopiesofpeople.Ineedtogo back!Noneofthisisreal!Takemeout!HowdoI getout!"

"Abuelo,please!Peoplearelookingatus!"

"HowdoIgetout!"

"It'sokay,Buelo,it'sokay.Igotyou.""Takeme out…"

"Everything'sokay,Buelo I'mhere You'reokay I gotyou""HowdoI "

"Somepeoplehaveahardertimeadjustingtothis space.It'sokay,Buelo,I'mherewithyou.I'llhelp youthroughit."

"Take…""Everything'sokay…"

Duringthehorriblemonthsofchemo,shewasn't there Noonecametodrinkcoffeewithme Did shedie?Areyoureallyher?"

" … "

"Igotyourletters.Ireadthemall.Younever broughtupmycancer"

"Isawthereadreceipts Iwantedtogiveyouthe chancetotellmeaboutit Whydidyounever writeback?"

"Iwasafraid…Angry…Confused.""…"

"IknewthatifIwroteback,Iwouldbeadmitting thatyouare,infact,myVickie AndthatifI admitit,Iwouldbeaccountableforthegrowing gapbetweenus Betweenmeandwhateveryou are."

"Sothenwhydidyoufinallydecidetowritetome andvisit?"

"MycounseloraskedmeifIwantedtoupload myself"

"Oh"

"Momtoldmeaboutyourdiagnosis.I'veknown sincethestart.""Whatexactlyhasshetoldyou…" "Everything.Iknowaboutyourmetastaticbladder cancer Thatyourthirdlinetreatmentwasn't successful"

"Thatsoundsaboutright"

"I'mreallysorrythatyou'regoingthroughthat, Buelo.Icanonlyimaginewhatitmustbelike."

"Areyouthough?"

"Excuseme?"

"Areyoureallysorryforme?Doyouevenfeel anything?""Whyareyou-"

"Areyoureallymygranddaughter?"

"Whyyouareyouaskingallofthis?""Whydidyou uploadyourself?"

"Buelo,Idon'tknowifthisisthebesttimetotalk aboutthat"

"I'mserious Iusedtoreadbedtimestoriestomy granddaughter.Isawherwalkacrossastageand getherengineeringdegree.Iwasproudofher.She visitedmeeverySundaytodrinkcoffeeandtell

meaboutherlife Ilovedherintensely Thenshe leftme,andIneverunderstoodwhy

"ShesuggestedthatIshouldvisityoubefore makingupmymind."

"Ithinkthatwasagoodideaonherpart."

" "" "

"Whatwasitlike?Whenyouuploadedyourself" "Well Itwasn'taneasychoice Iknewfromthe startthatitwouldalienatemefromcertain people.Thepre-uploadcounselingdidagoodjob ofpreparingmymind,ofsettlingmydoubtsand concerns WhenIfinallyuploaded,Ihadashort periodofadjustment,butIwasatpeacewithmy decision Peoplevisitedmeoccasionally Imade newfriendshere,Imadealife."

"Howdidyougetpasttheproblemof permanence?""Youmeanmaintainingcontinuity ofconsciousness?""Yeah,thatthing"

"Soundslikeyou'vebeendoingyourresearch, that'sgood Unfortunately,Ican'tgiveyoua straightanswer.Noonecanproveit.ButIcantell youthatwhenIuploaded,Ifeltlikemyself,I knewIwasmyself.Andthat'swhatIchooseto focuson"

"Youdon'tcarewhathappenedtoyourbody?"

"Itrynottobesentimental.Ithinkmyorgans weredonated, theynevertoldmetowhom."

"Soyoudon'tcarethatyoumightbeacopy?"

"Buelo,wecoulddebateforhoursonendabout thisandneverreachaconclusion MaybeVickie diedandI'masoullesscopyofneuralpatterns livinginaserver.MaybeI'mthesamemefrom beforeuploading.Eitherway,Istillgotowork,I stillreadbooksinthisparkbythislake,Istillget visitsfrommyfamily,evenTony!Howmuchdoes solvingpermanencereallychangeanyofthat?"

"Isee"

"I'msorry…"

"For?"

"I'msorryforlosingitjustnow…Andfornever respondingtoyourlettersuntillastweek And thatInevervisitedyouuntilnow Istilldon't understandwhatyouare,whatI'msayingsorryto, butI'msorry."

"AyBuelo.Thisthingthatyoudon'tunderstand forgivesyou.Iforgiveyou,becauseIstillloveyou."

" … "" … "

"I,uh,stillwanttoleavenow.Allofthisisstilla lottotakein.Nooffense."

"Iunderstand Letmepullupaliminalentrypoint foryou"

"Thanks"

"Allset.Whenyou'reinside,justcloseyoureyes fortenseconds.Whenyouopenthem,you'llbe backinthephysicalworld."

"Therealworld "

"Oneofthem"

"Sure,oneofthem"

" … "

"Hey,uh,IthinkImightgetthesubscription.Can Icomebacknextweek?"

"Thatwouldbenice Wanttohavecoffeeinmy apartmentthistime?"

"Yeah,let'sdothat"

"Soundslikeaplan.Bye,Buelo.Seeyousoon."

"Bye,Vickie.Iloveyou…Ithink…"

Kimberly Ho

a life once so full

Some things when gone, I can still carry on. I would go around my room on the third day after some infinite forevers, opening jars with familiar scents. I took the biggest whiff I could of almond scented lotion, a fragrance I've been fond of for many years, and it smelled like absolutely nothing

The next day on Thanksgiving Day at my doorstep, shredded chicken breast my mom dropped off and on the phone she asked, "How does it taste?

How about the new spices?"

I sampled another piece,

still warm and tender, but nothing more.

"It tastes great Mom." I try another piece, pressing it against the sides of my cheeks, and letting it sit just a bit longer but my mouth doesn't water like it used to with scrambled eggs, strawberry sponge cake, chocolate chip cookies, roasted Brussel sprouts, or even an apple Oh dear smell, please don't go, some things when gone, the flash of life that was once so full

REFLECTIONOFTHEHEART

Anne-Marie Prekezes

HEARTOFMANYMEANING Seonjae (Esther) Park

AlyssaPullano

WOULD YOU BE SURPRISED

Wouldyoubesurprisedifthispatientdied withinthenext6months?

Itwasmyfirstweekofinpatientmedicine,andI waspeeringovertheintern'sshoulderasshe clickedaroundEpic,fillinginallofthe informationwehadjustobtainedfromournew admittedpatientdownintheED Medications: reviewed.Problemlist:reviewed,updated. Surgicalhistory:reviewed.Thequestionpopped up;tome,itseemedsortofjarring We'dknown thepatientfor20minutes Werewequalifiedto answerthisbasedonthefirst-week-of-clerkshipslevelhistoryIgotfromthepatient?Atthesame time,Ifeltrelievedbythenextclickofthe mouse,relievedbyherresponse.Yes.Shewould besurprised

OnmyMedicineclerkship,Ilearned aLOTof medicine Standard,universal,well-validated medicine.Illnessscripts,calculations,differential diagnosesforcommoninpatientproblems,how tointerpretlabs,whentocallconsults,whattests toorderandwhentoorderthem

Iwastaughtwhichclinicalappstodownloadand whentousethem,thebestwebsitesforevidencebasedrecommendations,andthestandard protocolsforACSandpulmonaryembolism rule-outs Somanyaspectsofinpatientmedicine hadananswer,andbytheendofmyfirstmonth, Ieitherknewtheanswertoaclinicalquestion,or Iknewwhotoask,orwheretolookitup.

Duringthistime,Ialsolearnedaninfinite amount–butnotnearlyenough–aboutthe nebulousaspectsofmedicine Theuntouchable, undefined,humanistic,ethical,existentialparts

thatcanbeuncomfortabletoapproachand impossibletomaster,especiallywhenexpertiseis expectedinsomanyotheraspectsofmedicine. Thepartswithnoalgorithm,evidence-based solutions,nodefinitivenextstep ThepartsthatI wastoldtoreachoutforhelpwith Canweloop inthepalliativecareteam?MaybePsychshould comeseethepatient?IsthisaquestionforEthics? Maybethepreviousoutsidehospitalhadabetter grasponwhatmightbegoingon.Canyoucallthe sisterandsetupagoalsofcarediscussion?

"Goalsofcare"wasparticularlyundefined

Throughoutmytimeoninpatientmedicine,I heardthese3wordsseveraltimesaweek.Where shouldwegonextwithapatient'scare?What wouldtheywant?Howcanweindividualizetheir planofcaretomeettheirphysical,emotional,and spiritualneedsandvaluesduringatimeofserious illness?

Doc,Ijustneedtogethome.

Myfatherwouldneverwanttobekeptalive underthesecircumstances

ThisisnotthequalityoflifeIwant.

Wejustwanttokeephimhere,alive,withus

Therewasseldomarightansweroreasysolution; wecouldonlytakewhatthepatientsandtheir familieshighlightedasimportanttothemand shapeourplantomatchtheirneeds.Weoften discussgoalsofcareasapatient'sconditionis worseninginthehospital,butlessoftenwhen theyarearrivingfromtheEDseeminglynot"sick," orwhentheyarehealthyandstable

outpatientsintheclinic weseemtodoalotless "goalsofcare"whenthepatientisfartherfrom theend Ontopofthat,advancedcareplanning, endoflifediscussions,andfeelinguncertain aboutthenextbeststepisn'tcoveredmuchinthe science-filledyearsofpre-clinicalmedicalschool.

Ifoundmyselfinsertedintoafewgoalsofcare andterminalillnessdiscussions Ifelt unequipped,withnoevidence,algorithms,or clinicalexperiencetofallbackon.Inone particularcase,theresidentandattending deliveredthenewsinthemostempatheticway possibleandofferedtoinvolvethepalliativecare team Palliativecare?Idon'tthinkIneedthat doc,Iknowthisistheend Thisisit,right?

Therestoftheteamreassuredhimthatthey wouldmakehimascomfortableaspossibleinhis remainingdays Andwhatdoyouthink?The patientturnedtowardmeandraisedhis eyebrows,awaitingmyinputonhispredicament IfelthotundermyPPE,rackingmybrainfor whattangiblesupportIcouldadd.WhatdoI think?Intheend,Ineededonlymycompassion, empathy,andhumanexperience Somethings, wearenotexpertson

Wouldyoubesurprisedifthispatientdied withinthenext6months?

Bytheendofmyfirstmonth,wehadanswered thatoriginalquestionwrongafewtimes Patients whohadcomein,acutelyill,butwithcomplaints thatIwassurewecouldhandlebasedonmy studyingandexperiencesofar.Shortnessof breath?Wehavetoolsforthis.Footulcerbut otherwisewalkingandtalkingjustfine?We knowhowtoworkthisup Ifoundthat, sometimes,wedidn'tknowthenextstep,orthe rightthingtodo,ortherootofthepatient's

symptoms.Wedidn'tknowwhattheirprognosis wouldbe,orwhattheirqualityoflifewouldlook likeontheothersideofthisadmission Wedidn't quiteknowhowtograpplewiththethingswe havenopersonalexperiencewithoralgorithmfor, likeend-of-lifeissuesorwhatitmeanstolivea goodlife.Ourintentionswereinfinitelygoodyet oftenlimitedbythefinitedegreeofmedical knowledgeandhumaninsight

Medicineisunpredictable,humbling,andjust whenwethinkwehaveagrasponthings,weare surprisedbyhowlittleweknowcomparedtothe vastexpanseofphysiologyandcomplexitiesof humanexistencethatwehaveyettodecipher Thehumilityandintrospectiveawarenessthatwe willnotalwaysknowtheanswerorthebestthing tosay,isastrengthinitself.

VENUSUNDRESSING

Audrey Chang