Agora 2023-2024

AGORA // Fall 2023-Spring 2024

New York University Grossman School of Medicine

Office of Student Affairs

Humanistic Medicine Program

550 First Avenue

New York, NY 10016

EDITORIAL BOARD

Noor Abi Rached

Daniel Alber

Emily Bi

Isabella Cuan

Spencer Frome

Camila Hernández Blanco

Diego Laboy Morales

Rebecca Lisk

COVER ART

Karl L Sangwon, The Dance

AGORA LOGO

Ashwath Muruganand

ADVISOR

Jordan Reif

SPECIAL THANKS

Office of Student Affairs

Elizabeth Markowitz

Reagan Menz

Christina Oh

Christine Olagun-Samuel

Corinne Rabbin-Birnbaum

Chidera Ubah

Christina Woo

Humanistic Medicine Program

Copyright 2024 NYU Grossman School of Medicine

INTRO

Intheintricatetapestryofhumanexperience,connectionandisolationare woventogether,strikingadelicatebalancethatdefinesourexistence.Each threadtellsastoryofwarmthandsolitude,ofunityandseparation,each momentofferingaprofoundlessoninthecomplexityofourshared journey Withinourmedicalcommunity,thependulumswinging perpetuallybetweensicknessandhealthcaststhesethemesintosharprelief, alteringthewayswerelatetooneanother,ourinstitutions,andthevery essenceofourselves.

ThiseditionofAgoraembracesthedualityofconnectionandisolation

AnsweringthecallofUSSurgeonGeneralDr VivekMurthytoaddressthe epidemicofloneliness,weembarkedonajourneytoexplorethesethemes inthecontextofourexperiencesasmembersoftheNYUGrossmanSchool ofMedicine,NYULangoneMedicalCenter,andgreaterNewYorkCity communities.InFall2023,wedelvedintothedepthsofisolation,capturing theessenceofsolitudeandthestarkrealitiesofseparation InSpring2024, weshiftedourfocustothelightofcommunityandthewarmthof companionship Throughthesereflections,wefindthepowertoboth connectdeeplyandembracethelonesomeself.

Withinthesepages,youwillfindamosaicofvoices,eachcontributinga uniqueperspectiveontheinterplaybetweenconnectionandisolation Theseperspectivesilluminatethewayswenavigateourinterconnectedness, offeringinsightsintohowwecanbuildbridgesoverthechasmsofisolation, fosterconnection,andnurtureourcommunities.Weinviteyoutoimmerse yourselfinthisexplorationandconsiderhowthesethemesresonatewithin yourownlife.LiketheAncientGreekforumwithwhichitsharesaname, Agoraaspirestobeagatheringplaceforadiversityofmindsandabeacon ofinspirationandgrowth,guidingyouthroughthecomplexitiesofthese dualthemes

OurdeepestgratitudetotheAgorateam,whosededicationandcreativity havebroughtthisissuetofruition,andtotheartists,poets,authors,and thinkerswhosecreationsgivelifetothefollowingpages Letuscontinueto reflect,toconnect,andtofindstrengthinoursharedhumanity

AgoraEditorialBoard

AWOMAN’SISOLATION

KateTolleson

You can follow me back to the room now

Did you bring anyone with you for your visit today? No

I’ll just have you sit up on this table. Are you sure about this?

Do you have any questions?

No, I don’t have any questions

I know how difficult this can be

No, you don’t

I’ll just have you undress behind this curtain. I’ll be right back

It’s cold in this room

Okay, I’ll just have you spread your legs now

This is just going to be a bit of pressure

You can grab onto the table if you need.

This is not just a bit of pressure

I know.

I know, take deep breaths

Take deep breaths. Keep breathing

Almost there. You’re doing so well

All done

Take all the time you need.

I’ll leave you alone for a few minutes to gather yourself.

Alone Wasn’t I already?

BRANCHINGTOGETHER

CamrynKenkel

A Signal Transduction Pathway Infinitely More Painful for Me to Learn than Any Pathway in Introductory Biochemistry:

Seeing the new pack of Pokémon cards at Target

A quickening pace away

In the pediatric cancer unit

Some of the other kids ask me if they are going to be okay

The clack of a dropped plastic shopping basket

Thankfully he never asks, and we are both spared from hearing my broken voice

Catalyzed by memories of little giggles that will never kiss the air again

“You don't look like an adult

You look like a big kid!” he tells me

I laugh and say,

“I think all adults are big kids on the inside ”

Inhibiting the protein that holds back stockpiled tears

He giggleswhen we play with Pokémon figures his favorite

Increasing the flux of fluid out of lacrimal glands

I accidentally break the tail off of a toy and

Increasing [Concerned Looks from Strangers]

I promise to get him a new one for the next time

Ending - for now - with three final products:

1) dampening t-shirt sleeves, the next time

2) regret over a broken promise, and the next time.

BROKEN

Christopher Lee

3) a big kid who wonders if he is cut out for being cut up like this again

AWAKENING MargotA.Gardin

Morning peeks through the window shades, caressing the walls with soft golden strokes.

Raising myself out of darkness, I open my eyes

The tulips resting on the windowsill gracefully lift their heads, stretching toward the warmth, their faces a blaze of scarlet red, canary yellow, bursts of tangerine so sweet, my mouth begins to water.

Shaking the slumber from my skin, my bare feet meet the icy alabaster tiles I move toward the mosaic of brilliant blues arranging itself beyond my bedroom window.

As I watch the sun blink away its drowsy blackberry skies, I think of you, and allow my eyes to linger on the azure waves washing over an early morning, led by a tide of sea foam clouds

--

You taught me to live in color when you told me you could not

HEBIRD

Sorrentino

THEDAYTHEWORLDBURNED

Isabella Cuan

I On this day, the world burned from the outside in or from the inside out? and within this glass house you called God, we wept with the knowledge of your goodness and the inevitability of our grief. Through your only window, the glow of orange embers bathed us, blanketed us, slowly, surely suffocating us in quiet darkness until the hazy memory of childhood campfires turned into the acrid aftertaste of manmade devastation Who knew wildfires could burn bodies without ever touching them

II Our ancestors said that sometimes things must be burned to be saved but I think about how much we burn in this temple, and I must confess I do not know what or who we are saving or why we are told to save a body that was lost and not soothe the soul that is here. This inferno feels like hell, but maybe they were right and you are gold and this will be your salvation whispered from the lips of the priest purging you of pollution that was never yours, and I want to ask: Who said we needed to be clean to feel whole?

III Sontag says we all hold dual citizenship in the kingdoms of the well and of the sick, but I think she forgot you need a key to belong to a kingdom. You traveled on foot, outrunning fires from island rainforests to a this concrete jungle that said you could stay but never gave you a home. And now this house is the closest thing

to a home and the closest to God you have ever been, and I turn to your sister who finally sees you through the flames the same way humans don’t believe in disaster until the sky bleeds orange and they smell what it means to drown in smoke.

IV. The match was lit many years ago Did you know? We knew it was too late to extinguish what was, what would be, what is; too late to reverse the great flow-path of history

And so, your bones fractured in the heat and your tissues cauterized themselves, leaving microscopic debris behind while little flames licked at your heels until they decided they wanted more; and now your liver is licking up oxygen as if it cannot breathe and your fiery heart is loving itself to death and the ballad of your breath is sounding more and more like a prayer.

V. The last words that left your body Gracias a Dios, Gracias a Dios now inhabit mine the way a migrant inhabits foreign land: persistently, uncomfortably, traumatically God willing! Thank God! Thank God?

What is God or who is God if God is not this Mother killing you, liberating you Thank you!

I look at you, wondering if you too feel nature’s chokehold on humanity, or if these flames have always been yours and we were the foolish ones thinking they had ever been about us.

LOST

Chidera Ubah

Bustling city, Roaring and pretty,

The chaos passes me by Thrills with no ends, Potential new friends,

But no, they don’t see me cry

Gardens and flowers, Bridges, high towers, Apartments with too great a cost. Mentors beside me, Maps that may guide me, And still, my soul feels lost.

We came for our futures, For scrubs and for sutures, for patients finding their way

But these ivory walls, these competitive halls, My courage is still stuck at bay

Waiting on saviors, Sitting in failures, No clue on how I'll survive

The fears are still rippling, Anxiety? Crippling! Too long since I last felt alive.

They tell me to speak, Too frightened, too meek.

My reputation is falling apart.

My teachers, my peers, Would they care for my tears?

Would they care for what’s in my heart?

I’m living yet dying,

But I guess I’ll keep trying, Marking and shaping my place

To my patients I vow, This will work out somehow, But for now?

I’ll be lost in this space.

INACLINIC,1971

Howard Owens

You watch the difficult truth befall him

A cold lump

Like the meat of a cracked egg, Dropped on the table before us

Quietly it confronts him:

A tumor, removed with hope some months agoAn age ago, it seemsHow fondly he had hoped

You feel it now under your fingertips, A hard knot come back to tie up his belly.

You tell him only of “another operation”, Uncertain, through the translation, Of how much he understands.

You would not, after all, pin down the facts at once,

Would not see him struggling to escape,

When there is no escape

But he also knows

He sits, his legs crossed tight,

Bent a little, his arms hugging his chest

His jaw trembles ever so slightly

And the muscles of his cheek

Draw tense in slender cords

In the chill of the overcast day

You see him grow thinner before you.

Already his skull seems brittle as eggshell,

The blue veins tortured and alive with meaning.

No, better not say, “meaning”.

(It is but the surface you can see; I only hint at what happened there )

You sit, secure in the comfort of your next meal, Warm to the core, turning soon to other tasks,

While he enters a most private place

Where no one goes beside him;

And we know only of his going

And of the vague awakening of terrific fear

SPEAKING MEDICINE

Alison Cline

I’mstill,myhandhovering,readytoknockatthedoor It feelslikethescreamfloorfromMonster’sInc.That’swhat myfriendpointedoutafterourfirstonelastyear.So stressful,socontrived Thereisn’treallyapatientbehind thedoor,justanactortobeinterrogatedforathorough history,tobemanipulatedforacompleteexam Sounds socold,soclinicalwhenwethinkaboutitlikethat But–“youhave5minutesremaining”–notimeforchit-chat, pleasestoptalkingsoIcanauscultateproperly.

Inthebeginning,therewassomuchwedidn’tknow It waseasiertotalkaboutthethingsweshared our hobbies,ourlovedones,theYankeesgamelastnight thantothinkofquestionstoaskaboutyourconfusing symptoms.Now,we’velearnedthelanguageofmedicine. Wehaveschemas,differentials,andagendaschockfullof alonglistofquestions Wedon’treallycareaboutwhat youdoorwhoyoureallyareuntilwe’vemarched throughacompleteHPI,PMH,PSH,Meds,Allergies, FH…thenpleasetellmeaboutyoursexlife,and,don’t worryweaskeveryone,substanceuse.Then,weassure youwearenotconcernedforastrokebecausewefindno evidenceoffocalneurologicdeficitsonexam Orthat youremesisanddiaphoresisislikelyacaseofviral gastroenteritis,nothingthatwarrantsadditionalworkup Whydoweusefancywordswithextrasyllablesfor thingsthatalreadyhaveperfectlygood,easy-tounderstandnameswhenwespeaktoyou?Emesis, diaphoresis,lacrimation Isittoelevateusabovethe peopleweserve?Orisitsowecansoundconfidentand intelligentwhenwereallyaren’tsosure?Becausethe moreweknow,itseemsthemorewehavetolearn.And that’shumblingand,honestly,quitescary.So,welearnto fakeitortoacceptuncertaintyoralittleofboth

I’mreadytoknockonthedooroncemore Thistime,I’m confident.I’vethoughtthroughalongdifferential.Iknow whattoaskandhowtointerpretyouranswers.Nomore awkwardpauseswhileIstoptothink Nomoremaking smalltalkwhileIstallfortime,rackingmybrainfor questionstoaskaboutyourchestpain Thistime,I’m crispandefficient Justlikeadoctorshouldbe Smart, knowledgeable,quicktosolvetheproblem.Itwasthe firsttimeIfelttrulycompetent,likeIhadtheskillsand knowledgetomakeanaccuratediagnosis Anditfeltso good Andyet,youtoldmeIwasrushed,thatIwasn’t empathetic,thatyouwerehopingforabitmorewarmth Iwasshockedandashamed I’veneverreceivedthatkind offeedback.Butisn’tthiswhatwe’vebeenwarnedabout? Thatinbecomingdoctorswelosesightofthepatientin frontofus Thatinlearningtospeakprecisely,toexercise shrewdobservationalskills,andtorunthrougha differentialwhileyoutalk,westoplistening,and,far worse,westopcaring HowsadthatinthedayIfeltmost likeadoctor,Ifelttheleastlikemyself.

Weekslater,I’mperchedatthebedsidewithmy attending Thepatientissittingupinbed,tearfully explainingthatshejustgotoffthephonewithacousin concernedabouttheupkeepofherhouseandbelongings Shedoesn’tcareaboutmaterialthings,shesays.Shejust wantssomeonetoaskabouther.Tocareaboutherand howsheisdoing,howsheisfeeling Iglanceatmy attending,waitingforhimtoaskabouthersymptoms overnight,toredirecttoassessherclinicalcondition It’s 11am,andwe’vebarelyseenathirdofourlist Buthe doesn’t.Hesitsquietly,waitingforhertocontinue.She does,andhedoesn’tinterrupt.So,welisten,not interrogatingorexamining Eventually,afterofferingour silenceandafewwordsofcomfort,weleavetheroom “That’smedicine,”myattendingsayssoftly Reliefwashes overme Iagree

It was a clear morning and Brooklyn had that particular feeling that you don’t get in any other part of the city. A little wider and breezier, so different from the chaos and rush surrounding my publishing office downtown. I boarded the subway car closest one to the stairs and you were climbing those steps trying to make it to the train like many others. The bell went off and the door started creaking. There was only a few seconds for you to go through those doors and make it to work on time. I placed my hand to hold the narrowing doors, you came in, said ‘thank you ’ and we went our ways.

The next morning you were on time and when you crossed those doors again, you saw a familiar face and thanked me once more. The chaos faded and time seemed to slow down.

I learned about your job in fashion, and you became acquainted with my work in publishing. Our strolls on the city streets became dates and our dates turned into travels that led to a beautiful binding of our lives. You got to know every nook and cranny of our home, every day and night of our lives, every tab and blank that made us who we were.

At times we would have a hard day or may have an argument but no matter what, we would finish our day with a kiss good night and start the next day with a coffee at the kitchen table Sunlight would gently hit our kitchen table, we’d talk about what the day had ahead and any pending things from the day before I can’t forgive myself that I missed to notice the faint shade obstructing the sunlight by the window Our home was always busy and this shade was so subtle at first that we didn’t think anything when it would show in the corner of your eye causing hesitation At times it would make you uneasy and other times you could ignore and keep on caring for our beloved home It was not until the shade became dark enough that a shadow was looking directly into your eyes That moment you became frightened

It was my fault not seeing it I couldn’t understand it or act on it It dug inside of you so deeply that it was not going to let go Days became longer I spent every minute of every hour of every day soothing your fear of uncertainty and confusion Nights were becoming a blur of pacing and fear and I would walk along you making sure that you had everything to keep you safe

It would devastate my heart when the shadow would take my features, my eyes, my voice and my hands making you run away from me The wooden spoon was your best weapon to release yourself from my stranger arms I wanted to help, I begged, sought and pleaded for someone, for something, for anything to strengthen me to save you, to comfort you, to abet our happily ever after

Seeing you present but no there has been the hardest time of my life You were my responsibility, and I made sure you were taken care of, that there was no suffering Those glimpses when you called my name would pierce me with immense joy just to be pulled out leaving another bleeding wound in its place The shadow slowly dissipated leaving a void of absence in its place When your time came, our pain went along

A year has passed I grew old, same as our home Our children come and go, but I still long for your company Every day I feel you by my side and all the memories flow like rivers through my eyes Just the other day our little sweet granddaughter asked me if someone will hold the train door for her someday It is a pleasant memory that I cherish while I lie down in this hospital bed I know it won’t be long The doctors say my heart is failing but I know it is my broken heart

I hear the end of the bell Would you hold the door for me?

Jesus Garcia SHADESOFASHADOW

NATUREKNOWSLOVE

Kendra Ray

The Morbid Anatomy of Disconnection: Musings of a Forensic Neuropathologist*

Rebecca Folkerth

The decedent is a 72yo WF with hx of hypertension, found decomposing in her locked apartment Neighbors noted a foul odor, and the building super, who had not seen her for several days, opened the apartment for a wellness check. She was seen lying supine amid hoarder materials and trash on the floor in her unkempt apartment. EMS pronounced without resuscitative efforts. Prescription anti-hypertensive medication noted. No drug paraphernalia or alcohol at scene Cigarettes and ashtrays present No known next-of-kin; will try to locate before referral for city burial Identified by building super despite decomposition

How can this happen, you might ask? Was this woman invisible? How did the last fiber of her life’s rope fray and split with no one ’ s awareness? While I do not know or understand how, it is a scenario repeated on a daily basis, with minor variations, throughout the city that is my home. It has led me to muse on the degree of disconnection that seems to be at the heart of our world’s problems.

“Morbid anatomy” is the old-fashioned term for “pathology”, the study of organs and tissues in disease (literally, “the study of suffering”) As a forensic neuropathologist, it is my job to examine the brains of individuals who have met an unwitnessed, violent, or otherwise suspicious death, and to assist the medical examiner performing the complete autopsy as they formulate the anatomic cause of death (in the above scenario, it was a hypertensive brain hemorrhage – a stroke), and the manner of death (here, natural) We are part of a large cohesive network of forensic biologists, toxicologists, medicolegal investigators, police detectives, and scientists and technologists of all stripes, united in the cause of truth-seeking. Our agency motto is “Science Serving Justice”.

However, what we do, together, is as much art as science The work requires a degree of humanism and fortitude that, in my opinion as someone who trained and practiced for 3 decades on the hospital side of medicine, is not appreciated adequately by society, who attributes greater compassion to caretakers of the living. We are caretakers of the dying.

To care for the dying is a process extending beyond the last breath The breaking down of the body, the dissemination of the belongings, the dispersal of the friends and family held together by this person – they are also part of the dying And in situations as in the above illustration, when a person dies alone – disconnected - we are the ones who try to complete the process for them We can only do this by compassionately viewing their final situation in the light of our expertise, while drawing on our own personal experience.

This woman easily could have been my mother. Struggling with cardiovascular disease, diabetes, respiratory illness from smoking, and the beginnings of dementia, my beautiful, brilliant, and multi-talented mother became more and more isolated She had taken early retirement, which meant she lived in poverty on a miniscule Social Security check She couldn’t go to lunch with her upper middle class friends anymore She stopped singing in her church choir She had her 2 dogs put to sleep without telling any of us She started going to rummage and yard sales, acquiring an astounding number of things she didn’t need My four siblings and I knew we had to do something, but it literally took us years to convince her to move 70 miles away to be near one of us. (Did I mention she was stubborn?) We quickly realized her hoarder tendencies, and when my sisters and I

tried to edit her things as we packed for the move, she actually said “But ‘things’ are all I have” A child of the Great Depression, every little piece of string or remnant of soap was kept for potential later use Deconstructing her hoard was a monumental task

The stress of the moving day landed her, that very night, in the hospital, where she went on to get a quadruple bypass. While she never fully recovered, she at least was in care when she died the following year.

“Things are all I have.” Those words haunt me. Had I as her eldest daughter, pursuing an academic medical career in Boston, far away from her in Ohio, not shown her enough love? I had orchestrated family vacations with her, taken her on trips - I even bought the condo in Columbus she never got to occupy fully But what I could not give her was my constant physical presence And as a busy physician trying also to “have a life”, I am not very good at calling my family Disconnection

The decedent is a 24yo AM, found hanging by housekeeping staff in a midtown hotel room. A climbing-type nylon rope was around his neck, and was secured to the clotheshanging rod in the closet. A Chinese passport, local community college ID card, and suicide note (vouchered for evidence) were on the bed. According to the agency ’ s translator, his note describes having a difficult time with classwork and with making friends after having moved here 4 months ago Next-of-kin are in China, and consulate will make contact

In such a scenario, we examine the body to exclude some unknown illness (such as a tumor or infection affecting the nervous system that might alter one ’ s behavior), as well as evidence of foul play or drugs Overwhelmingly, though, in such cases the cause and manner of death are easily determined: hanging by the neck; suicide. The more compelling and unanswerable question is, why?

We all have such high hopes for our lives, and for the lives of our loved ones. “Dream big”, we may be told from a young age. “Commit yourself!” “Go out on that limb!” “Your father has worked for years so you can have a better life!” Or, the only thing worse: “You’ll

never amount to anything ” “Loser!” “No one cares about you ” Then, our hopes take on an even more desperate dimension of pure survival, akin to an animal in the wild

And yet, animals in the wild do not kill themselves Just the opposite - instead they will chew their own limb off to survive being caught in a leghold trap. How is it that we can consciously choose to bring about our own death? If one has never felt the lure of suicide, it is difficult to understand. My mother used to say, “Suicide is a permanent solution to a temporary problem ” I was never able quite to accept that formulation I offer my own experience with depression and suicidal ideation: it is most simply a way to escape from excruciating pain, which, after it goes on long enough, starts to feel permanent And splintered dreams and broken hearts create excruciating pain

The summer I finally began dating after my traumatic divorce, I fell instantly in love with a handsome, charismatic artist. We rode bikes in the cemetery, kissed beside the mausoleums, drank wine and watched a young cardinal fledge its nest in my lush back yard. The next day I saw the little fledgling, twisted and stiff, with ants where its eyes used to be, in the grass far from its nest. I gently picked it up and reverently laid it out for my mourning, knowing full well its larger meaning My artist lover moved to the West Coast in the fall My heart felt broken all over again

Our lives are a series of fledges, each with its risks for failure Aside from our essential fortitude (a product of both nature and nurture), we rely on the safety net of love and connection that we weave with one another Stretched by distance and hardship, this net may not always hold We may be unable to endure the pain of separation, disappointment, the shattering of dreams large and small. The human soul can withstand only so much disconnection. And phone calls, texts, virtual electronic facetime can substitute only so much.

Continued on the next page

The decedent is a 29yo WM with a history of autism and seizure disorder, found at 0800 by his family face down in bed No alcohol or drugs, drug paraphernalia, suicide note, or other suspicious circumstances noted He was last seen by his father at 2330 the previous night, playing video games on his computer, which he spent most waking hours doing He did not attend school and was unemployed (he was nonverbal and very anxious in social settings) Medications included anticonvulsants, and the pill counts were appropriate His last seizure (tonic-clonic type) was one week ago

The challenge of understanding autism, now among the most common diagnoses made in medicine, affects us all. Where did this epidemic come from? Is it (as some assert, despite no scientific evidence) because of vaccinations? Cell phones? Cosmic radiation? Chemicals in our food? Are we just more aware of it than we used to be (“ascertainment bias”)? Whatever the reason, autism spectrum disorder is a disease of disconnection, apparently at a neural level

The fact that 50% of individuals with autism have seizure disorder (or epilepsy, an equivalent medical term that to some may have a pejorative ring) lends support to the idea of a primary neural defect In experimental animal models of autism, abnormalities in “mirror neurons ” have been found. These are a cell type in the brain that mediates the ability to imitate our parents and family members as a means of learning survival skills, may help us comprehend, at least in part, the deficit among persons on the autism spectrum. Could those on the autism spectrum lack this neural capability, becoming overwhelmed and disadvantaged by the challenge of attuning to others and modeling their behavior in the usual ways?

Among animal societies, attunement is key to survival: school swimming in fish, swarming in bees, coordinated flight among starlings If an individual cannot participate in social engagement, they may suffer from selection bias, starve or become prey Without attunement, we become disconnected

The decedent is estimated to be in his 30s, possibly of Hispanic ancestry, apparently undomiciled, found on a park bench in Central Park He is unkempt/dirty, very thin, with headlice Missing one shoe, the left foot is wrapped in newspapers and brown paper bags, around an oozing wound on the heel He is inappropriately dressed for summer weather (2 jackets; 1 wool) Contents of pocket: Michigan driver’s license (expired 8 months ago), prescription for antipsychotic medicines from 1 month ago, receipt for malt liquor from nearby deli dated from the day before Homeless Services will be contacted in attempt to identify him and his next of kin.

Our bodies are our homes. And yet we still require shelter from the elements, from dangers of all kinds. For us to flourish in the world, we depend on others –to launch us in life with education and opportunities, to employ us based on our skills, to tend to us when we are sick Physical illness challenges all of us from infancy, while mental illness, such as depression, schizophrenia, or anxiety disorder, to name just a few, affects at least 20% of us during our lives, often beginning in early adult life But to be mentally ill and without support is to be cast adrift on turbulent waters in a leaky raft – how long can we hang on before we are swept overboard? Before untreated conditions, abusive self-medication, and the weight of loss become too much to endure?

I recall times in my life of few material resources, of being floated by family, and, when finally on my own, of living meagerly on peanut butter and rice. But I was never truly at risk of homelessness. I have had, though, more than a few friends, including some with serious mental illness and substance abuse issues, face this rock-bottom reality There is only a thin safety net beneath any of us It is so hard, an existential crisis, really, to know how to help them

My grandparents used to tell us of when, shortly after the Great Depression and into the era of World War II, various cousins and maiden aunts lived with them, in their tiny shotgun house in Louisville, Kentucky, sometimes for years on end I have dear memories of some of these old great aunts and second or third cousins. To leave a family member on the streets was simply not done.

My grandmother used to say “We were poor, but we didn’t KNOW we were poor. ” And sharing everything one had, without expectation of return, was just normal.

There are no homeless birds, or so the Bible says (Luke 9:58). And the lilies of the field, “they toil not, neither do they spin” (Luke 12:22) The assumption is that God provides for all Except when He doesn’t

Then we must provide for each other This requires a tradition of connection, both familial and societal The casualties of this disconnection are seen in my work every single day, and break my heart every single day

The decedent is an 8-month-old infant, brought in by EMS after a call at 1925 from mother’s boyfriend that the child started “vomiting while being fed”. Boyfriend had been left with the infant at 1400 when mother went to work as second-shift nurse ’ s aid in nursing home. ED personnel noted bruising of left ear and beneath chin, and on extremities in a concerning pattern. Retinal hemorrhages were documented by ophthalmologist in ED. Head CT shows subdural blood over cerebral convexities Police and child protective services notified Two other young children in household

These are truly the most dreadful cases How, one asks, can anyone harm a child, a helpless baby? In some animal groups, overpopulation and scarcity of resources lead to mass suicide, homosexual behavior, or eating of young Eagles will kill the weaker of two nestlings, to allow the stronger the better chance to survive. But that scenario, while disturbing, is at least “rational” in a Darwinian sense.

Maya Angelou, the great poet, said “We are all human; therefore, nothing human can be alien to us. ”

As a Buddhist, I have tried in my practice to feel compassion for an adult who embodies so much rage, frustration, sense of powerlessness or insecurity, that they relinquish all perspective around their actions

When pushed to our limit, we all have said hateful, harmful things, and some of us may have acted out in hurtful ways Can

we understand the emotional state of a fellow human being driven to this extreme, lacking the skills to handle these dangerous emotions? Can we forgive, educate, and prevent such tragedies?

As one whose chosen profession is the study of suffering, I do not have the answers. But I do feel that, as long as we continue to be so profoundly disconnected from one another, the morbid anatomy of our sad human frailties will be our legacy

*Scenarios are fictionalized composites of actual cases, and do not represent specific individuals

EITHER

So tell me, friend,

In the time it takes to brew my coffee

Or boil an egg

Or skim a short story

What plagues you?

Allow me to reference my mutable chart

And follow the flow

To a singular part

That subsumes you.

I invite you to cry, revert, languish, and rage

As I cast from my perch

An academized gaze

That discerns you

ORMorning came, he stretched away

The brittle peel of sunbaked day

And picking up the Times, he read

Each line through different eyes

Collecting some things, jotting some plans,

He caught the first train to the sacred land,

Where, waiting for him, were souls to sing,

And he to harmonize.

He weathered through the morning hours

With flourishing care, and mounting towers

Of this-or-whatever to fax and file

And just crusting catharsis to show

Place the weight of your world now under my command

As my mad mind unearths

Its own haunting demands,

In the gleam of your eyes

My gaunt silhouette stands,

The strings’ sharp crescendo

Stirs needle-blue sands

But the truth in you harkens

To warm, native lands

Where the birds sing the songs

Of mysterious plans

That call us to be here

Youthful hearts, untrained ears,

Empty hands.

It struck him like a pang of light

That giving himself was not best done outright

In a grand display, but through changing his mask

For another, fine-carved for the tactical task

Of lending a spark to let the world ask:

Must I ignite myself?

Bryce Saba

For years, I dreamt of you. Where we would meet, and what would I feel If it would take time or happen all at once How old we would be, and what your friends would call you

Whether your eyes would evoke memories of deep Pacific waters or steady chestnut hills, and if there would be obsidian or silver locks atop your head

Impatient

I tempted fate, signing up for events where our paths were likely to cross Anxious I controlled details, coordinating dates and times when we might meet Naive to think it would work like that You became a reality without my permission It was late on a Friday night. So late that I am left unsure whether it was February 3rd or 4th. I arrived first, with a friend telling me about you on the way over I knew we were both in our twenties, you slightly older, but that was it No name or description

Beads of sweat dripped down my spine as I adjusted my gown and fastened my hair Then you arrived with an entourage, making my heart hammer hard and fast Disrespectful, considering yours could not.

Compressions replaced contractions until the algorithm told us to stop Your death announced

It was supposed to be different; generations apart, worn, wrinkled, your name and your story indelibly etched into the walls of my heart Remembered, never forgotten

Instead it was onto the next patient, leaving you tucked away and folded neatly in the corner Why was that so easy? It’s not supposed to be that easy. It was only when I tucked myself away at 3am in the amber glow of the bathroom that I felt you tapping me on the shoulder

Two tears on two cheeks, wiped away but never forgotten

For years, I will dream of you

MY FIRST

Natalie Kennedy

LIFE IN JULY Parma

J. Zahid

Melody was nodding off when all the pagers in the room went off simultaneously, jolting her awake Raj, her senior let out a huge sigh and looked at her with tired eyes “Seriously?” he mumbled In two short minutes they would be off the clock after working all night, but at 6:58 AM, they were being summoned to the other side of the hospital

It didn’t take long to figure out where exactly the emergency was. On the cardiac unit, the crash cart, nurses, and physicians were huddled outside a hospital room. Melody and Raj entered a gruesome scene. On the bed was a man, very thin, and completely uncovered. The primary team had already started chest compressions. Over his mouth was a bag mask underneath which blood streamed from his mouth, down his neck, and onto the bed.

The resident at the bedside quickly explained the situation to the code team The patient was a 42-yearold man with a history of severe cocaine use, which had caused perforation of his hard palate and nasal septum He was admitted two nights ago with a myocardial infarction He had been improving, but suddenly a few minutes ago his heart stopped

“Take over the chest compressions,” Raj instructed As Melody approached the bed, her own heart drummed loudly in her ears She leaned forward and used all her weight to push down on his chest He was so thin that the pressure cracked his rib cage and with each compression she felt as if she was squeezing his heart A lot of people moved around her- inserting IV’s, hanging blood, giving instructions, but none of this interfered with the trance Melody seemed to enter She pushed rhythmically on the patient’s chest, only stopping to see if his heart would re-start and switching off with another team member. All she could see was this man ’ s face, his eyes staring blankly back at hers. Sweat beads lined Melody’s forehead as she used all her might to keep this person alive. Raj’s words cut through the air and broke her concentration, “I don’t think we ’ re going to get him back. Let’s call time of death. Melody, call it.” Melody gulped, not realizing how dry her throat had become. “Time of death 7:48 AM”

She followed Raj robotically out of the room As an intern in July this was one of her first codes and she had not realized until that moment that being a doctor sometimes literally means having a life in your hands

When Melody arrived home that morning after her long overnight shift, she felt numb So much had happened, but she could barely process it She showered, ate, and crashed into bed, falling into a deep slumber and entered a vivid dream

In the dream, she saw a young version of the patient she tried to resuscitate His name was Terrence She knew everything about him and could feel all his feelings He looked happy as he held hands with a girl he loved very much. Terrence and his lover were swept up in a euphoric storm and carried high above the ground, floating up towards the sky. The happier they grew, the higher they went until suddenly the girl disappeared and Terrence fell, crashing at a great speed back to Earth. A deep fear and loneliness engulfed him because he knew his lover was dead. Then, Terrence was in a room by himself, doing lines of cocaine, trying his best to numb the pain. But the pain only grew until the feeling of a million bricks squeezed his heart. Then, he was in the hospital bed and Melody above him, screaming, telling him to wake up

Melody woke with a start, her alarm ringing, telling her it was time for her next overnight shift She sat in her bed and began to cry It seemed so horrible to her, everything she had been through She felt terribly lonely and exhausted from being an overnight intern She was working days on end with barely any time to register her feelings, missing fun summer days, and dealing daily with the gravity of life and death She felt that something grotesque had been revealed to her about life, about its decay and brevity, and that it was something peers her age could not understand or relate to Her soft tears turned to sobs and her heart felt heavy. She was not sure anyone else could understand where she was coming from or if she had the words to explain it. She dressed in a clean pair of scrubs and began to get ready for her next shift.

A few nights later, Melody was in the hospital cafeteria eating dinner when she felt a light tap on her shoulder. “Hey! You’re the intern that was in that awful code the other morning right?” A tall and slender young man with dark brown hair asked her. “Ah.. yeah that was me ” “Nice to meet you, I’m Ted I was one of the interns on the primary team I don’t think you saw me during the code, but man I can’t stop thinking about it Ok if I sit here?”

As their conversation continued, Melody felt grateful that someone else shared parts of her experience She began to feel a comfort in the camaraderie between interns that starts in July across hospitals in the United States She felt herself at the beginning of the metamorphosis from student to doctor as she continued her journey into the world of medicine

STROKE 2

Batán Silva

WORDS FOR THE WORDLESS

Camila Hernández Blanco & Elizabeth Markowitz

My mother is sitting in a chair, laughing at a text message.

As I waited with my husband I couldn’t help but laugh at his ears sticking out of his surgical cap.

A simple genitourinary surgery, in and out. General anesthesia.

A simple genitourinary surgery, in and out General anesthesia

I wish I was with her when those three surgeons stepped into the waiting room, with faces as pale as their white coats

I might buy an $8 latte to study here, in this white room –endless outlets, pillowy chairs, so many chairs but in them only one person, per patient, is allowed to sit

on a firm pillowless couch by the window, we strap into our seats for the next five days a rollercoaster of emotions, struggling to unbuckle and not ready to release

I hear a husband updating his children by phone: “Hi honey, mom just went into surgery. ” His voice is clear and steadied

Entering the ICU is like falling into a nightmare

The air is heavier, the space tighter

The sterile walls alive with machines

Tubes like slithering snakes, wrapping around my neck

My footsteps unsteady

MY FIRST

faces, faces, so many faces racing in, racing out

Insert author

one of us “sleeping” in the ICU the others in the waiting room the monitors like a bedtime story

But when I felt my body drifting into sleep I awoke, panicked: still breathing? Still beating?

As he glances at the neat notes beside him, I startle at his eyes – ablaze with emotion –sorrow-singed fear only strangers like me can see

I step inside his kind eyes and see his grandchildren racing to greet him at the door, asking him to read a bedtime story, please, grandpa, just one more!

I can still hear the steady beeps, the rhythmic ventilation

My textbooks lay beside me, unopened when will I hear my phone ring when will I hear the voice of the doctor in my ear saying: it went OK

craving: he is OK

Buenas noches Papa, I would say time to let go a circle of hands grasping each other, a circle of love we hug him goodbye

I can’t bear to let my eyes seek this stranger’s gaze. he will see my fear and waste his steadiness on me. I study his steadiness – the still of his hands –and will myself to imitate.

I can’t believe this is happening

I lay my eyes on him for the last time, electric candles laying by the door the nurses gift us a beautiful vial of his last heartbeat, to hold with us forever

If imitation is the sincerest form of flattery, then flattery is lying, lying to myself with my husband laying flat on an OR table

I can’t believe this is happening

Finally, the call from the surgeon it went perfectly, he is in recovery a 42-minute forever, finished

The chapel says it fits 100 300 came for his Celebration of Life how many people he touched from all corners of the world–it was surreal but their stories were real

I feel disbelief, and loved,

He was so loved, loved

There are no words

The pathology report says stage 1 seminoma active surveillance recommended: not radiation, not chemo, just scans, scans, scans

I feel disbelief, and relief, relief, relief

There are no words but here’s a few words, between us, from us

WHAT THESE GLASSES HAVE SEEN

Christina Oh

Arnaud Brohe THE DOCK

PROFOUND EXPERIENCE

Mariya L. Fabisevich

It’s funny how medicine can be both a cure and a poison at the same time, and medical experiences can run deep in your veins long after your treatment finishes. My most profound experience with medicine doesn’t come from medical school, or even residency, but comes from a hospital bed, similar to the ones I stand next to during my rounds, except during that experience, I was the one being rounded on.

If we ever were to meet, you would likely be able to declare with confidence that I am the only person whom you ’ ve ever met who survived acute appendicitis for three weeks without any antibiotics, or even painkillers When I was a teenager, I developed abdominal pain, and was evaluated three different times in the ED, and three different times I was told (without imaging or blood tests) that I had either stomach flu or period cramps I eventually developed septic shock from a ruptured appendix, and was hospitalized for a month When I had returned to school three months later, life looked a lot different, both as changes happened around me (as three months can be a long time at that age) and changes that happened within me

My ordeal was not the cause of being born in a place lacking basic medical care, nor was it the result of a cryptic and unusual presentation, but was simply due to a series of unfortunate medical errors caused by carelessness and greed.

I imagine that in a parallel life I had actually died, and I feel it in my soul, because part of it is missing too. The part of me that had entered that hospital was a young 13 year old girl, who dreamed of finally kissing her crush, who loved to ride on her bike to the beach with her friends, who was looking forward to picking her dress for her middle school prom; that part had died The part that lived was the one, the one who had to endure being violated by countless rectal exams, nasogastric tubes, IVs and blood draws from every part of her body, who had to live with contemplating suicide to end the physical pain, the one begging my mother for a drop of water from the towels used to cool my overheated body, the one being restrained on the surgical table wide awake, the one having to learn to walk again after 3 months That part, it lived, and it had to grow stronger in order for me to survive, and it took over me for the next decade or so in the form of severe health anxiety and mistrust in doctors

Although I have learned to heal bit by bit, late at night, I still cry sometimes when I remember that 13 year old girl who had dreamed of kissing her crush on that day that the belly ache came; I mourn her, and I hope that somewhere, in some version of her life, she got her surgery and went on to kiss her crush at the middle school prom, and both of them joined the rest of her friends and rode their bikes all the way to Brighton Beach. And the girl that stayed, for her I pray that she can finally begin to be released from her grief by sharing with others her most profound medical experience

LOSE YOURSELF

Andrew Kelleher

Several minutes pass as I fumble to tie the gown behind my neck, wondering why the equipment was ever designed to tie a knot you can’t see The mask feels hot on my face and fogs my glasses My fingers have become less nimble since my first year of medical school shrunk me to the size of a cell. The patient lies on his back in front of me, now a giant from my perspective, unconscious. “This will be a good case for you, ” the attending tells me. She towers over me, peering down through a magnifying glass. “Thirty-seven-year-old male found unconscious in his room by his family Go see what you can find ” She loads me up into a syringe of clear fluid and injects me into his antecubital vein without hesitation

It is all still strange to me, the feeling of going through IV tubing into a vein It’s not quite like going down a water slide, where gravity pulls you down in one direction, the slide slowing you as it levels off Instead, gravity no longer matters at this size--you become one with the fluid, at mercy to the pressure from the medical team pushing you forward, the patient’s plasma enveloping your existence. “Don’t lose yourself!” my attending calls out. I cringe at the feeling of the medical team having to fish me out because I got lost They still talk about that student from last year who spent several hours stuck in the colon Instead, I rely on a map I was given during my first year of medical school

My task is to inspect the various organ systems, traveling through the tortuous collection of highways, avenues, and side streets I am an inspector, adventurer, record-keeper, entrusted to observe and report I peer into the patient’s heart, a labyrinth of chambers with walls that squeeze and relax. These chambers continue

without compromise despite the insults that may befall them until one day, obligingly, they cease. These walls keep a fossil record of the state of his bloodstream what’s this? Pinholes in the tricuspid valve? Note it and move on

My attention turns to his lungs, my next stop in an exercise of multisensorial perception This capillary I occupy is encapsulated by a constellation of air-filled sacs that line the bronchioles that supply them Eddies of air permeate these spaces through the ethereal membranes, blurring the line between this body and the universe The walls around me expand and contract, yet between these expansions, there is a pause long enough to feel like the universe around me is holding its breath. I find myself holding my breath, too. My heart pounds in my chest: one, two, three, four times, still nothing. Six, seven, eight, finally, these walls expand around me once more I find myself again, catching my breath Remember, you are not this person Don’t lose yourself I file this away and head toward the brain

I leave the steady flow of the bloodstream through the choroid plexus to immerse myself in the calm lagoons of the ventricles It’s quiet here The water is calm, clear, and through this membrane, I take in the elaborate design of my patient’s brain. Surrounding me are huge swaths of twisting, branching cables that tangle to create a universe of their own. Then, the curtains of reality draw themselves back to reveal the night sky. Scatterings of stars reveal themselves, pulsating, shooting across my field of view in continuous communication with one another. I am sure there are patterns to understand in these pulsations, a complexity beyond my comprehension that cannot see the universe of logic in front of me Several stars coalesce into beams of light that shoot toward me I think I will touch it this time, but the light is just off target, shooting past me to a distant forever

Floating above me, just within reach, are scenes from a distant past. I must not dwell here; it is easy to get lost in memories. I can make out a scene of the beach, waves washing over the sand, the water lapping over a small crab. I see the empty orange eyes of a pigeon staring up from below a park bench as an arm reaches out to feed it I am at the museum holding hands with someone I vaguely recognize, peering together into the jaws of a megalodon I see a mother (my mother?) with her arms wide open as I run toward her I see a friend I shouldn’t recognize, but I do He wraps the tourniquet around an arm Is it mine? I look down and see the needle in my arm, the rush of warmth enveloping me I know I need to get out of here; we are becoming one

The scenes swirl around me in that nebulous ether, my body slowly approaching them. I feel the richness of his life pulling me in. I feel the tides of his joy, betrayal, regret, despair, renewal, and relapse become my own. If I stay a little longer, I can finally understand him.

Don’t lose yourself here. The memories surround me, every choice, every connection, every regret within my grasp. The tides of his consciousness wash over me. The stars return, and the lights flash again, eddies swirling in the night sky. This time, the beam of light is heading straight toward me Do I go for it? Don’t lose yourself here

I reach toward the light Time slows The light appears so warm, so inviting It is swirling towards me I am stumbling towards it It would be so easy to stay here, in a body that is not mine, in a mind that I do not understand Isn’t that why I’m here? To understand? Not just physically, but emotionally? We are so close, about to touch I reach a little further and

This world fades to black.

I blink, and my attending stands before me, eagerly looking at me. “So, what did you find?” I’m about to tell her but don’t know where to begin.

ROOM 1453

Christina Oh

Stoicism (n) The endurance of pain or hardship without the display of feelings and without complaint It is the art of disguise, the very definition of dissonance, a faceless marble statue of emotion

Anxious (adj) Experiencing worry, unease, or nervousness, typically about an imminent event or something with an uncertain outcome It is a description of a rising sense of uncertainty deep within the core, threatening to bubble to the surface

And then, there is everything else in between. The mother clutching her newborn child close to her chest, worry evident in her brow The elderly gentleman staring out the small Bellevue window in silence after hearing his worst fear had come true, a diagnosis of malignancy The young adult, sitting alone in the busy emergency room, waiting for an opening in the already bustling and dynamic hospital And then there was me, a tentative clerkship student, entering through what seemed like enormous hospital doors, just hoping to aid this huge array of individuals.

Young or old, stoic, or anxious, everyone arrives at the hospital with one goal in mind – to alleviate. Health care practitioners who wish to alleviate their patients’ symptoms, patients who wish to alleviate their unknown worries, and families who wish to alleviate and support their loved ones This want to alleviate is something that I quickly learned from Ms R as a medical student in internal medicine

Every morning, I would walk into Ms R’s room after reviewing the events the night before, ready to discuss with her how she felt that day A 49-year-old woman who had arrived septic with Klebsiella pneumoniae bacteremia, with the source identified incidentally with a computerized tomography scan of her abdomen – a liver abscess. I would check on her every day. She was my first patient, someone I felt intrinsically connected with.

But over time after being stabilized, the interdisciplinary team taking care of her eventually would shake their head when discussing her case She refused to talk with certain physicians, nurses, or

staff and adamantly requested to continue staying in the hospital The social work team worked hard to obtain a rehabilitation program for her, but she denied all offers And day by day, the need for discharge grew Suddenly, I found myself at her bedside with physicians, social workers, and patient advocates, watching as they discussed the need for her discharge Her expression gnawed at me When the meeting was over, I followed my team out, glancing behind me at her frustrated expression

The hospital flow continued to ambulate around me, rapid response teams rushing past to get to the room next to me and the hospital staff busily administering medications. I continued my responsibility as well, trying to embody the role of a student dedicated to learning. But her expression continued to imprint on me.

I stepped out of the workroom, quickly heading to room 1453 I stopped in front of her door, staring at the sign that was placed on it “do not enter until after 11:00 AM” as per her request Tentatively, I announced myself to Ms R, peeking through the curtain Her pink pajama pants were rolled up and she was staring intently at her hands Upon entering, she glanced up at me, tears welling in her eyes I pulled up a chair next to her bed.

As I looked for something to say, I realized I did not know her reasoning behind her discharge refusal. Lightly touching her shin in reassurance, I asked “Ms. R, why do you not want to go home?”

“I don’t know how to take care of myself I’m in pain, and I don’t know how to do anything ” She was scared She was worried about the unknown She

believed that administering her IV antibiotic alone in her home would be near impossible, and it would be too complicated for her to do it correctly

“Ms R, how about I show you what it would look like? I think you might see that it is simpler than you think.”

As we talked, I watched as the furrow in her brow slowly softened. A hint of a smile behind her tired face arose to the surface, and I sat with her, continuing to answer her questions. I realized then that she had not been given enough time to discuss the whirlwind of what had happened to her at the hospital She had come in incredibly sick and treated in the intensive care unit for her ketoacidosis She was one of the many that got caught up in triage, a woman now lower on the priority list amongst a sea of pneumonias, bleeds, and cardiac complications

As a medical student, I realized I was lucky to have the luxury of something scarce I had time I could spend it with her, and I could help her in this small way.

Stoicism (n) An art of disguise, the very definition of dissonance, a faceless marble statue of emotion

Anxious (adj) A rising sense of uncertainty deep within the core, threatening to bubble to the surface

For Ms. R, she was a patient labeled as the latter. A patient who is colloquially known as “ a difficult patient.” Abrasive, loud, and worried. But behind each patient is a reason, and behind each reason is the answer. She reflected me, a mirror to my frenetic workflow as a medical student, too tunneled on writing notes and preparing presentations But in this moment, she was a reminder; she was a recognition of the innate need for human contact in an environment that is often frightening to patients

Ms R hugged me “Thank you doctor I want to go home ” Although I am far away from being the physician I wish to be at this stage in my training, in that one instance, I felt just one step closer to truly being a doctor I hugged her back, remaining stoic But inside, I could not stop smiling.

RAINY DAY ON THE LATE BUS

Olivia Schaffer

TOMORROW IS A SERIES OF NOWS

Marmie Newton

I started yesterday in my childhood, yearning for privilege that only time could yield I screeched and stomped and screamed when my frivolous desires were curtailed by those who had time on their side

Summer touched my wondrous soul

The grass became my sanctuary and the beach sand laid next to me at night, consoling my nightmares

Father brought me food and mother’s loving touch quenched my fevers

I started yesterday in a cradle of safety, I felt yesterday in an agony of wonder

I spent today in my girlhood, yearning for purpose to my youth. I sobbed and sniveled and screamed when I wised up to the world, yet the world would not stand by my side.

Autumn’s fog came with the first sign of cold.

The leaves became bright, then became dead the death of the green reminded me of the turn of time.

Father brought me counsel and mother’s wit gave me wisdom that quieted my monsters.

I spent today in a marshland of wonder, I felt today in a cloud of confusion

I squandered tomorrow understanding adulthood, yearning for peace in the face of strife I screeched and sobbed and stomped when I was encased in a maze deficient in maps

Winter came and laid its icy hands on my loved ones, I screeched Winter came and froze my wondrous soul, I sobbed I stomped in winter’s snow and summoned my childhood

Father bid his farewell to the world and mother grew cold

I squandered tomorrow in an abyss of darkness, I felt tomorrow speak to me but I heard nothing

I summarized my last days of parenthood, yearning for the freedom of my childhood. I recalled the days of Spring when green was birthed anew.

I surmised every season of strife was the same.

Yesterday was today, today is tomorrow, and tomorrow is a series of nows.

QUACK

KINSHIP: A FEATHER’S BREADTH APART

Nick Roig

CONNECTIONS

Francine Blei

The VA elevators are quick, but the air is sticky. The chillers are still out, and the head of the hospital sends another email about them

Yesterday he said they would be up and running today; today he promises tomorrow The interns are new, uncertainty still in their voices as they present plans on rounds, but they have worked enough for the beginnings of fatigue to set in And we all sit there in our sweaty scrubs, baking in the July heat

The patients feel it, too. One wrestles to maintain his cheeriness, telling me about being on tour in the desert, where it reached 120 degrees. “This is nothing,” he says, laughing. But the next day, a fan is plugged in at bedside, and his smile seems less strained. Another patient yells about something new every day, and every day he ends with a comment about the temperature Late one afternoon, an industrialsize fan has appeared in his hallway, sending what feel like gale-force gusts down the whole ward When we check on him, I can’t tell

if his complaints are calmer, or simply drowned out The team lingers for a minute outside his room, though, soaking in the cool

And then the chillers are fixed, and the whole hospital breathes a sigh of relief I spend my last days at the VA focused on notes and physical exams and causes of acute kidney injuries, grateful to be thinking about anything other than the heat

***

Bellevue’s air conditioning feels like a dream, but the elevators are slow. I’ll take this any day, I think to myself as I wait with a crowd.

Outside, the heat wave continues, and orange advisories flash across patient TVs I joke about it with bravado born out of a childhood in Texas’ sweltering summers, but I’m glad my commute is short

The hospital is full, and my team is busy. One patient is a middle-aged man, just transferred from the ICU. We go to see him, a cachectic man with a kind smile, who tells us he’s feeling better and just wants to get home to his daughter We ask if there is anything we can do for him, and he says no, unless we can make the room cooler “It’s so hot in here,” he tells us I hadn’t noticed, but he sighs in relief when we pour him ice water

The whole team goes to see him on rounds

The intern presents his history of metastatic cancer, bilateral amputations, and the wound that brought him from hospice to the hospital. “We’ll try to get you headed home,” the attending tells him. He gives a thumbs up and a half-smile. Then the attending asks him to raise his legs, and his expression changes as the legs don’t lift. “Why can’t I move my legs?” he asks We test sensation; he can’t feel anything below his belly button And he is lying in his own incontinence My heart sinks as I process what this means We tell him we have to talk to neurosurgery, and then we head to lunch

Later, at teaching with other medical students, I suggest visiting my patient, but he doesn’t want to talk I’m initially surprised by the change in his demeanor “Are you in any pain?” I ask. He shakes his head but gestures sharply at his legs. My short-sightedness hits me. I am thinking about physical pain, but he’s dealing with much more than that: the loss of control over his legs, already half-gone, and yet another delay in getting home. And I can tell he’s still hot. He’s afebrile, but he lies listless, gown down to his waist This time, I feel the stifling air too, the air conditioners overpowered by the violence of the afternoon sun

I return with the intern, passing the neurosurgery residents on their way out The patient is upset, and he says he doesn’t want any more pokes or procedures I offer an ice pack as a peace offering; it’s moderately cold at best, and he doesn’t want it.

His anger breaks into sadness as he asks if I have children. “I don’t,” I say. “Then you can’t know how I feel,” he replies. A phlebotomist comes in to draw blood, and he grimaces while she tries one vein, and then another I leave with a pit in my stomach

I relay all this to the mentor for my small group of medical students She asks me if I’m okay, and I realize that my voice has a shake to it I tell her I’m alright, but I wish I could do anything, at least to make him more comfortable I can’t imagine the pain of what he is going through, the pain of a whole family’s heartbreak. I only know what it feels like to be hot.

“I have an extra fan,” she says. “You can bring it to him, if you want.” I hesitate. But then I think of the fan roaring in the VA hallway and how it felt to stand before it I take it, carrying it self-consciously through the halls “I brought a fan,” I tell the patient His eyes close, and for a second, I think he doesn’t want to talk to me But then he smiles and nods “Thank you ” he says, opening his eyes as I plug it in On the way up, I had been worried that I would get in trouble or he would get too cold But then I hear him laugh, and I’m not worried anymore “That’s so much better,” he sighs, his eyes closed again.

And then I leave for the weekend, but the pit in my stomach is gone. Maybe he’ll be there when I return, and maybe he won’t be. He’s a dying man. I can’t change the cancer in his spine, the loss of his legs or his dwindling time I can offer no cure, only the simple solace of a borrowed fan

ILLNESS IN ISOLATION

Heidi Dong

demoralization (noun) | a dysphoric state encountered in both psychiatric and medical populations, characterized by the individual's sense of disempowerment and futility

I met her in clinic A mother, bringing her baby to the pediatric ophthalmologist He had been diagnosed with a rare genetic syndrome, one that manifested in multiple symptoms across the body: the heart, the brain, the face, the eyes Hence this appointment. She made a half-joke about running between doctors’ offices. We halflaughed.

The ophthalmologist finished his exam. The baby was too young to test his visual acuity in detail, but the structures seemed healthy, he reassured her

She listened to his explanation Then she asked, “Have you seen patients like this before?”

It was a rare disease The doctor said that he had seen a few “And how many of them have had good function?”

In those few words, the ache and hope and fear trembled Her baby cried in her arms She looked so tired

As the doctor explained the spectrum of disease, the reasons for hope, the unknowns, she cried silently, rocking her baby, stifling sobs.

He finished talking. She wiped the tears from her eyes, smiled weakly. “Well, off to PT.”

In hospitals and clinics, as we churn through dozens of patients with varying problems, the heartache blends together There are thousands of ways to be sick There is a spectrum of tragedy, from the cold that passes in a day to the devastating stroke, from cataracts to cancer The edges of these diseases are dulled for us; we see the patient in room 808, we think to ourselves “how awful, I would hate if that was me, ” and then we turn and move to the next Rounds cannot stop for us to mourn

But for the patients whose rooms we pass, for the family members at their sides, this could be the biggest struggle of their lives The woman whose intestines refused to accommodate more nutrition, so that every day was a battle between the distended loops on X-ray and the feeding tube. The dad who brought his child from Guyana for cancer treatment, leaving the rest of the family, spending every day alone in the hospital as his son went through scan after scan. The woman, still in scrubs from her nursing job, tears streaming down her face as inside the room, the rapid response team surrounded her father

For the mom holding her baby, it is her struggle too She had plans for her life, dreams for the future Maybe seeing her child graduate college, or cheering at a soccer game, or sitting at the kitchen table teaching him to read Now she is here, with her reality, coping with endless appointments and fearful hopes and secret worries Her center of gravity has changed; her universe is this child, and his galaxy of specialists and treatments.

These are the images of my clerkship year. They are a reminder that empathy has its limits. I can empathize, extend a kind word, hold a hand but I cannot truly know these pains. That is one of the curses of illness. We can be surrounded by family and friends, but in the end, we suffer alone.

In my psychiatry rotation, I was introduced to the concept of demoralization It is everywhere in the hospital One of its pillars is isolation: that an illness must be experienced alone, sometimes away from home, in a hospital bed, perhaps surrounded by the walls of stigma, or the false promises of strength “She’s so brave,” we say, watching her fight cancer “He’s so strong,” we say, watching him on the ventilator Our words do not touch the illness

Yet there is a way to combat demoralization, and in particular isolation It is called communion: “the felt presence of a trustworthy person. ” That is what I hope to be: present. Trusted. I want to remember that as I continue down this path to be present with each patient, to take a moment and hold their suffering with them, to acknowledge the undercurrents of fear. It’s true, I cannot imagine what they are going through. But I will try.

I think of that mother sometimes. I hope she and her family are well. I hope she has found a community of caregivers, a network to soften the isolation, a kind hand reaching out through the clouds to say, you feel alone. But you are not.

Emily Bi

LONG DIVISION

Sofia Castiglioni

She gripped the handlebars harder as the cobblestones sent vibrations through the bicycle tires that made her teeth chatter and the beads of sweat on her back trickle down like raindrops racing down the car window in a storm She peddled faster until finally l’Arena came into view on the far end of the piazza The anticipatory buzzing of the crowd steadily grew as she got closer and found a spot to lock her 30-year-old garage-sale-it-breaks-a-lot-but-was-such-a-good-deal-bicycle She hurriedly flung her tote over her shoulder, flashed the security her library-printed concert ticket, and ran into l’Arena bathroom to change from her biking shorts and tank top to a two-piece linen set that she had sewed herself She leaned closer to the bathroom mirror, sucking in her stomach to avoid the puddles of sink water, and painted her parted lips crimson She pulled out a comb to attempt to control the remaining rebellious strands of hair, and satisfied, waltzed out of the bathroom and climbed the giant pink limestone steps to her assigned seat as Adriano Celentano’s orchestra tuned their instruments one last time. And then she sang Il ragazzo della via Gluck, Pregherò, and Impazzivo per te as loud as if she were a 20-year-old again, going through her first breakup. As she biked home at 2AM still levitating from excitement, the cobblestone vibrations became the bass accompaniment to her one-woman-concert.

But pancreatic cancer doesn’t discriminate. It’s terrifying and humbling to know that no matter how healthy and fit you can be at age 83, that at the end of the day everyone ’ s cells divide And a couple might keep dividing even when they are not supposed to

Divide, divide, divide

Naturally, my 83-year-old nonna does not possess a cellphone Or computer On the first day of my ambulatory care rotation, I received a single text from my mother who got a WhatsApp message from her sister who received a call from my grandmother’s physician saying they had found a tumor in her pancreas

Divide, divide, divide

I squinted to read the pixelated radiology reports that had traveled 5,931 miles to my mother and another 2,519 miles to me. Inoperable. I’m not sure how many other -word phrases hold the same gravity. “We did everything we could” is five words, “Will you marry me ” is four words, “I got in!” is three words, and “I’m pregnant” is two words. Maybe defendants who stood before a judge and held their breath as the gavel struck wood would argue that “guilty” holds the same weight in a courtroom as “inoperable” does in a doctor’s office

Divide, divide, divide

1

Who gets to deem a tumor inoperable? How do you know on what side of the five-year-survival rate my otherwise-healthy-zero-medications nonna will land? The UpToDate searches became a staple; CA 199 levels, vascular involvement, gene-profiling of tumor tissue What about all the big academic centers in the United States that are redefining what is considered inoperable? I wished I had rotated on the Ranson service during my surgery rotation so that I could be more knowledgeable on the trials and treatments

Divide, divide, divide

What role does a medical student play when she is the only person in medicine in her family? How does she respond when her mother sends her articles from Frontiers in Oncology about treatment? How does she navigate the underlying familial sentiment that bringing her to the United States would be more optimal for her care? “Nonna should be taking pancreatic enzyme replacements, right? She is losing too much weight and they haven’t prescribed anything, should I get the generic supplements from Amazon since the Italian pharmacies don’t have the medication in stock?” Universal healthcare is great except for when a patient with metastatic cancer needs to advocate for basic medications, wait one month for imaging and another two months for a biopsy. “What will the biopsy results tell us? Should I still be holding on to hope? What should I tell my sisters? When do I need to drop everything and book a plane ticket?”

Divide, divide, divide

A physician-in-training A granddaughter Can I be both objective and data-driven, and immersed and emotionally involved? Is it inauthentic to use PEARLS statements when my mother shares updates on the phone? Is it inauthentic to give her displaced hope when she asks what the future will look like? I’m constantly code-switching to balance what she brings If she is focused on the literature, then I focus on humanity If she is caught up in circuitous emotions, then I focus on facts Maybe being a physician makes me a better granddaughter Maybe being a granddaughter makes me a better physician

Divide, divide, divide

No matter my role, one thing is certain If I had pancreatic cancer, I would want my daughter with me. And I would want her to forget about the diagnosis and the prognosis and the appointments and the treatment. I would score us tickets to Adriano Celentano’s concert, paint each other’s lips crimson, go to l’Arena (perhaps take a cab part-way this time) and sing and dance until my voice becomes a raspy whisper and my limbs meld into a blissful blur. Because I can’t keep those cells from dividing. But I can choose what to do with the rest.

Divide, divide, divide.

NUDE DESCENDING A LOCKED WARD

Woods Nash

(No. 6)

The automatic doors kiss behind us, and we walk through the hospital’s flower garden A few steps along the path, mom stops to sprawl beneath a thorny bush Where she rests her head, red petals fleck the mulch Her fingers flutter like Chopin I wait, watch Two weeks on the ward, I think, and she’s nostalgic for sun and green growth Which might be how psychiatry heals. Or she’s just putting the roses back in neuroses. Either way, we only have an hour for lunch what her nurse called our midday outing. So I offer mom a hand. Let’s go to the restaurant, I say. Mom doesn’t budge. She stares past me at an empty sky. I flew in this morning and leave tomorrow. A quick visit Which is fine Because it’s painful seeing mom like this For three decades, she’s been receiving care But I’m not convinced anyone ’ s helped her I’m not sure we even know how

*

The first time we locked mom in a hospital was after she slit her wrists A month later, home again, she told me an orderly had tried to rape her. Said it plainly, without preface. We were sitting on the porch. Sixth grade would begin soon. I wasn’t sure I knew that word, so I filed it with others I’d heard recently: bipolar, psychosis, mood stabilizers. I know I should’ve replied. I can see that now. I could have asked a question. Something. Maybe when you ’ re older, she said, I’ll try to tell you more She turned away then, shaking her head It feels like she hasn’t looked back

*

At last, mom takes my hand I pull her up from the matted grass, pick bits of mulch from her short gray hair, which is oily, like she hasn’t showered in days.

I can remember her arms so strong I could hang from them like monkey bars. These days, her shoulders slump like sandbags. Her feet shamble. Her eyes never look certain.

I beseech thee, gods of all logics and weird etiologies: grant us the comfort of swordfish, collard greens, and garlic cheese biscuits

*

In the restaurant lobby, while waiting for a table, we stare at a tank of lobsters We listen to water gurgle and suck The crustacean-warriors teeter on the bottom, claws forward, showing off their rubber bracelets. The fluorescent lights leave nowhere to hide. I look around. Emergency Exit Only. Alarm will sound if door is opened. Mom’s orange sweatsuit makes her look like an inmate.

Or a caution cone someone misplaced. Me, I suppose. At room temperature, good chemists assure us, lithium is a stable solid But that depends on the room, now doesn’t it? This way to your table, says the rhythmic waiter I see him catch a glimpse of mom ’ s hospital bracelet, a cloud of concern crossing his face Then he grins, waves us on a sweeping gesture, as if he could conjure hors d’oeuvres from disorder

*

The fifth time we let mom leave the hospital, a few years back, her friend told me something I had never considered. She cornered me at dad’s retirement party. Your mom, she whispered, is the bravest person I know. I was dumbfounded. Really? I asked How’s that? Across the room, mom was pouring tea for a guest The task demanded her complete attention Because, the friend went on, every time she comes home, she knows that we know where she’s been folks at church, bridge club, everyone But what does she do? She jumps back in! Gives it all another go Her eyebrows arched significantly Don’t kid yourself, she said That takes some serious guts

*

If someone doesn’t help her order, mom will gaze at a menu forever How about the crab cakes? I suggest With grilled asparagus You’ve always liked crab

Grilled, mom mumbles, suddenly distant Your father liked to grill, didn’t he? Your father She trails off, as if trying to remember him This is disconcerting Dad’s been to visit her every day, bringing cookies for the staff. Cutting her spaghetti with a plastic fork. Sipping weak tea from Styrofoam cups. Today, needing a break, he’s on the golf course.

Yes, I tell her. He did like to grill.

*

When I was little, maybe four years old, mom once let me shower with her, my eyes agog at waist-level The taut skin over her abdomen I saw the pale grin of a scar It’s called a Caesarean, she explained The doctors had to cut me open And that’s how you came out

How you were born The scar seemed broad and exotic, its edges slightly rough I thought: I used to be in there

Inside Part of her It’s OK, mom told me, you can touch it

So I did, gently, water beading my fingertips. In all the years since, I’ve never wanted a Caesar salad.

*

I dollop remoulade on mom ’ s crab cakes, cut her asparagus into chewable lengths. Her white napkin is a flag her throat is waving Sometimes, when I’m ruthlessly honest, I think she’s gone that whatever’s left is a flickering ghost Or the slowest imaginable avalanche But the atomic weight of lithium, we ’ re told, is let’s all just take things day by day

Mom prods her baked potato, but she doesn’t take a bite

Instead, she seems to focus on her fork Then, at last, she lifts her chin and looks at me The intimacy of her expression is jolting There is, I can see, nowhere else she’d rather be What’s the difference, she asks me flatly, between being embarrassed and being just plain bare-assed? This is far from whatever I’d been expecting. A joke. She’s telling a joke. I don’t know, I say, already grinning, what’s the difference? Something we never had, she chuckles. A Stairmaster! Wow, I say, laughing with her. That’s pretty good. Who told you that? She shrugs, a slight smile in her eyes The doc who does electroshock

CONFINEMENT

Heather Brody

THE FIRST

Alessandra Marcone

Is this your first code?

One man in scrubs says to the room with authority, “What is this patient’s name?” No response The overcrowded bustling of busy bodies accomplishing seemingly nothing continues

First rotation First day First patient encounter Yes, this is my first code

Is this your first time performing compressions? Sing “Staying Alive” in your head and get your weight above the patient’s body.

He has no family to notify.

We need another IO! What’s an IO?

A lot of people “do” or seem like they are doing. Some interns and students watch, like me. Unlike me, they watch their supervisors They observe and learn from the actions of physicians I cannot do anything but watch him In this moment, I find I identify more with the person on the table than I do with those rushing around him It feels urgent that I stay focused on him; that someone doesn’t forget who he is, that I SEE him while he dies

His name replays in my head over and over His eyes are open

I have nothing to keep my hands busy, no tasks to take on, all I can do is watch and think The first hour goes by Someone needs to be here for him I know they’re trying urgently to keep him alive, and that effort is all consuming, but does that excuse their apparent forgetfulness of his identity, his humanity? Can he hear us?

Does everyone agree it would be medically futile to continue compressions if he codes a third time? Yes. A nurse aside, “at this point he will have brain damage if he does wake up. ”

Our team was dismissed before they declared him dead. The machine compressing away after the third code Futile effort, I suppose Does this still count as the first? The first death I will see?

What about the second? The third? The fiftieth?

Will I still care that no one knew his name? That no one spoke to Mr Smith while he was dying? Mr Smith, you have a lot of people taking care of you right now Mr Smith, we are here for you

The first A big deal Does the second get to be a big deal? Is it a normal human experience to watch people die, and modern society has removed it from our lives?

Would my superiors understand or only be concerned? Can I handle this?

How was your first day?