Prosody
A MEASURE OF LIFE
Dear Readers,
Welcome to the third edition of Prosody, Dell Medical School at the University of Texas at Austin’s official student-run literary and arts magazine. Here, we showcase creative works by students, residents, and faculty and create a platform for the Dell Medical School community to share and reflect on their experiences through artistic expression.
Our mission is to amplify the creative works of those in healthcare as we view the arts to be a form of processing and celebrating the unique challenges and experiences healthcare workers face. Incorporating the humanities within medicine provides an outlet for our peers to share their hardships and triumphs in a way that speaks to others on a level a simple conversation often cannot reach. It touches and elaborates on the emotions elicited by the journey of medicine and the honor of caring for others. We cherish the opportunity to provide a platform for our artists and enable them in their chosen medium for communicating their lessons learned.
This year, we are grateful to showcase the themes of embracing humanity in patient care and medical training. By pausing to listen, we gain the opportunity to learn from our patients and cultivate the intimate connection between patient and physician. In MS3 Chandana Tetali’s “the ampersand”, the titular symbol is used to remind the author of humanity within each patient during each encounter. Meanwhile, MS2 Richard Same’s “Legacy” eulogizes the death of a cadaver, recognizing hints of a former life behind the formaldehyde and honoring the donor patient’s final gift towards education. Finally, Dr. William Tierney’s “My Calling” recognizes the overwhelming complexity of embracing and trying to understand the pain and suffering of the sick. Together, these pieces remind us that medicine is a profound human endeavor—one that demands empathy, reflection, and a willingness to truly see those in our care.
We invite you to listen in on our internal dialogue as we embark on our journey through medical education. Join us in a reflection, celebration, and elegy of human emotion!
MASTHEAD
Executive Board
Editors-in-Chief: Victoria Siu, Alexis de Montfort Shepherd
Managing Editor: Molly Van Dyke
Submissions Editors: Richard Sames, Emily Lehrer
Design Editors: Sahana Prabhu, Evelyn Syau, Shoshana Zhang
Social Media and Website Editor: Jackie Castillo
Graduate Staff
Submissions Associate Editors: Fatema Dohadwala, Ria Nuna
Readers: Prachi Khanna, Roba Abousaway, Dhruva Athreya, Edwin Ruiz Fuentes, Emma Ableman, Noor Shabaneh, Matthew Taing, Dana Antinozzi, Ryan Leung, Kwisha Patel, Thao Le, Austin Herrmann, Ashwin Jhawer
Undergraduate Staff
Historian/Photographer: Saanvi Seth
Social Media/Website Associate: Angie Kim
Community Outreach Associates: Rhea Lazar, Abigail Norris
Internal Affairs Associates: Ananya Tirumala, Hira Umer
Design Associates: Ayla Farzamnia, Ismael Duran
Faculty Advisor
Thomas Vetter, M.D., M.P.H., M.F.A.
Advisory Board
Steve Steffensen, M.D.
Victoria Siu, Alexis de Montfort Shepherd, Co-Editor-in-Chief Co-Editor-in-Chief
Molly Van Dyke Managing Editor
The works published in this journal were selected based on literary and artistic merit and do not reflect the views of The University of Texas at Austin, Dell Medical School or the editorial staff.
Dell Med Communications
Allan Cole, Ph.D.
Gregory Wallingford, M.D., M.B.A.
Swati Avashia, M.D.
Phil Barrish, Ph.D.
Craig Hurwitz, M.D.
Stephen Sonnenberg, M.D.
Rick Peters, M.D.
Imelda Vetter, MLIS
TABLE OF CONTENTS
4 Hands of Healing | Ayla Farzamnia, Undergraduate
5 the ampersand | Chandana Tetali, Ms3
6 Cozy and Rough | Sam Burr, MS4
7 Modern Austin | Jackie Castillo, Undergraduate
8 Bald Eagle Dropping Sticks for Nest, Alaska | Kent Ellington, M.D.
9 Donny Smithereens | Sam Burr, MS4
10 solivagant | Emma Lehrer, MS2
11 Between Breath and Silence | Victoria Siu, MS3
12 Surgery is an Art | Mamadou Balde, MS3
12 The Art of Precision and Perseverence | Mamadou Balde, MS3
13 White | Thomas Varkey, M.D., M.B.A., M.Ed.
13 fernweh | Emma Lehrer, MS2
14 Sunflower Serenade | Edwin Ruiz Fuentes, MS1
15 Juno and Susan | Thomas Vetter, M.D., M.P.H., M.F.A.
16 Seasonality of Medical Education | Sara Yue Tao, MS3
17 Turtle Tears Give Salt to Butterflies in Peru | Kent Ellington, M.D
18 Natural Bridge | Thomas Varkey, M.D., M.B.A., M.Ed.
19 The Slow Down | Richard Sames, MS2
20 On Legacy | Richard Sames, MS2
21 Piece of Mexico | Jackie Castillo, Undergraduate
22 Grayness Out My Window | Thomas Varkey, M.D., M.B.A., M.Ed.
22 Le Chat et Les Fleures | Thomas Vetter, M.D., M.P.H., M.F.A.
24 Sestina Sobre el Amor | Thomas Vetter, M.D., M.P.H., M.F.A.
25 Evening Oasis | Edwin Ruiz Fuentes, MS1
26 Neuralgia | Victoria Siu, MS3
27 Eye of Caiman, Peru | Kent Ellington, M.D.
28 suprise guest | Fatema Dohadwala, MS1
29 Here for the Duration | Evelyn Syau, MS4
32 Mono-a-Mono Sunrise | Thomas Vetter, M.D., M.P.H., M.F.A.
32 Projection | Irfan Hydari, M.D.
34 Grief Unspoken | Ayla Farzamnia, Undergraduate
35 My Calling | William Tierney, M.D.
Cover: sonder | Emma Lehrer, MS2 Icons: Noun Project
the ampersand
15 year old boy with a mechanical heart valve
— & a tennis ball on the ground
38 year old woman with breast cancer
— & a fuchsia lipstick by her bedside
72 year old man with COPD
— & a worn guitar propped up on the chair
4 year old girl with epilepsy
— & a Nintendo switch lying nearby
when I don my white gown & snake the stethoscope around my neck
I see the patient lying in the bed in front of me, tired of suffering & weathered from battle, who still contains multitudes within themselves
so I always ask about his favorite tennis star, her supermodel career, his first love music, & her highest score yet.
for the ampersand — adds back their humanity.
Chandana Tetali, MS3 HANDS
COZY AND ROUGH
So you’re 29 now say it loud with your chest
Another 30 years left and you’ll be numb as it gets
You thought your journey back then would yield riches til the end
But goddamn, it only lasts about ten years
You’re older now, falling back into place,
Just another lonely kid with fuckin’ tears on his face
And shit you face em down but they train to come back,
Drown ‘em in the water they grow gills in the splash
And you wonder all along if I told you the truth
Did I let you get close so I could tighten up the noose
And we
all make it back to that cozy back porch
Where our hearts ache, oh for the dream that could be
Yeah I wanna believe there was a time in your life
When you used to be free
Another sunny day to shine down on me
But I’ve got a jaded disease
Let me pause on this life and take it in with the breeze
And you say stay with me
Thought it was do or die
Had to lock in thought
I’d climb
To the top
And make em stop yeah
All the bleeding wounds
Heard ‘em screaming from the womb
I scream louder from the sky
As I fall back down with a pipe and a couple lines
What does it take after all this time?
Was it my fate did it all unwind?
I wasn’t careful enough
Vigilance probably thought I didn’t care enough
Mom painted a stool that says I am enough
Guess I really shouldn’t have called that bluff
So here I cling to the cusp
Caught in sin drown in lust and Looking down it looks cozy and rough
I picture my bones smashing
I picture faces and they’re all laughing
So here I am lost in the sauce
Avoiding friends, ignoring fam and
Putting off actions with bluffs
I stay in my room gasping
Projected women on my walls
laughing
Fuck all these roads and the time that it takes to be fake
But you say stay with me
Tap tap tapping away on this Mac Mac Mac and my cuffs won’t break
It’s Plato’s cave and they tell me lies
And even though I know better I guess I’ll always choose to stay
In this compact box
While my mom walks the same route every day
I’m only 10 miles away
In this compact box
While by brother lies
In a bathtub fading away
And I still don’t have much to say
I tell him I still can’t come out to play
So much for playing it safe
Paparazzi wants to see the one who gave it away for some money and some extra brains
He didn’t know it would cost him so many days
I’m talking bout so many ways
He could’ve pulled the ripcord
Float back to the ranch
Where a woman with a vape smiles, “Welcome back champ”
But here I just fall on my sword
Writing songs that no one thinks are important
I feel something as I prepare to leave Austin,
The city that doted on me,
Where I found peace, and something to believe in
So no, I don’t wanna leave
Do you think I’ll still be lonely?
Do you think life just repeats itself?
But here I cling to the cusp
Caught in sin, drown in lust
And looking down it looks cozy and rough
I picture my bones smashing I picture faces and they’re all laughing
So here I am lost in the sauce
Avoiding friends, ignoring fam and Putting off actions with bluffs I stay in my room gasping
Projected women on my walls laughing
Sam Burr, MS4
FOR NEST , ALASKA
DONNY SMITHEREENS
Sam Burr, MS4
Donny, you’re playing too rough with your brother
And where’d you learn to talk like that?
This house is old, but the paint hasn’t set in yet
You’re still young, and I haven’t given up on you yet
You yell at your father, but you play piano like an angel
Who knew gentle hands could belong to a violent heart
The rose wilts, it’s pedals won’t get far
Planets die, but you don’t give a fuck
I know the place that you go when you sneak off to get high
You’re angry ‘cause you don’t know how to cry
You think you’ll live forever, so sunsets don’t evoke a sigh
When it dawns on you, you suffer fits and you ride
A book of poems, you identify, how limited, language is sublime
I taste the rise of the voice from your lips
And they’re so trite, the people telling all those gracious lies
And Donny you’re not selling anything that they’d want to buy
And people die,
And you
But you
You still don’t give a fuck
Because it won’t be you
The Immortal Donny Smithereens
It won’t be you
No it won’t be you
The Immortal Donny Smithereens
There’s no one like you
You’ll make it
Oh, you’ll make it to the other side
I feel the chords you play when you’re lost and serene
I’ll hide the truth from you, that I died long before I took my leave
That light from dead planets persist long after they’re gone
I hope you never learn…
Rage on, Donny Smithereens
solivagant , Emma Lehrer, MS2
BETWEEN BREATH AND SILENCE
Victoria Siu, MS3
It was some guy she met 2 weeks ago
Taking pictures at a park
When the sky blackened against eclipsed sun and howling dogs
Ants blanketed her feet
And he dusted them off her dress
Rosy red bites, tightening breaths in the car seat
The EMS report is as troubling as ever
Irreversible brain injury begins 4 minutes without oxygen
Death follows 4 to 6 minutes later
We poke, we prod, we prognosticate
Yet Thanatos and Hypnos like brothers appear the same
Look her eyes are opening
She withdraws to pain
What does it mean?
I stumble over words trying to explain the MRI
Her eyes rove around the room of family and strangers
All we can say is I don’t know
There was enough technology to prolong goodbyes
Humanity is a false God
at the mercy of nature’s inflammatory response
A nurse signals the alarm
Her eyes are dilated now
Tissues slowly bloomed, compressing petal from stem
The ventilator in unfamiliar quietude
Goodnight to you who were beloved by many
After the tears, your memories remain
SURGERY IS AN ART
Mamadou Balde, MS3
“On one side, you have a 3 by 4-meter square OR, no electricity, an engine that can only carry a few lamps, a manual antiquated suction that requires someone to keep applying pressure on the gauge in order for it to work, 10 compresses per case because the next shipment arrives in 6 months…and on the other side you have a
Abdoulaye K Balde M.D., General Surgeon
Surgery is an art that anyone can master regardless of the differences in resources, if one has the passion and the willingness to put in the hours for it. Malcolm Gladwell coined the 10,000 hours theory as the cause for anyone to master anything. No matter where one’s corner of the world is, if they focus on their craft and put in the hours, they can become the best. Contrary to common belief, I believe that people with less resources may have some hidden advantages that are beneficial to their development. Surgeons in developing countries have the incentive to learn as much as they can and not memorize short cuts or algorithms, as the challenges in which they work requires them to do so. They have the advantages of learning from the many complications of a specific disease process, and understanding the pathophysiology of the complications; unfortunately, the best way to learn how to be good is learning how not to be bad. An excellent education and a vast experience provides them the incentive to be good problem solvers and prepared during difficult situations.
Moreover, the lack of resources incentivizes surgeons or people in general to be innovative. Allow me to elaborate: one can make the argument that we grow to become smarter than our parents, grandparents, and ancestors, but it was Edison and Tesla who discovered a way to put electricity in people’s homes when the common use were lamps. It was Henry Ford who invented the car when the common mode of transportation were horses. It was Dr. Blalock who decided to operate on the heart when no one dared. It was people like my grandfather who found a way to make a pilgrimage to Mecca, all the way from Guinea before anyone thought it was possible. It is not smarts or resources, but an intense need that inspires someone to dare to innovate something that never was before.
WHITE
In silence the snow did fall. Everything moves yet at the same time not at all. Color eaten in a world of snow.
The trees are tall and at the same time very small. The business of the fall must come to a stall.
The distant mountains covered loom like large white walls. And I in my cold dark room at the center of it all.
THE ART OF PRECISION AND PERSEVERANCE: SURGERY IN THE WORLD’S TOUGHEST CORNERS, Mamadou Balde, MS3
Thomas Varkey, M.D., MBA, MEd
fernweh Emma Lehrer, MS2
JUNO AND SUSAN
Thomas Vetter, M.D., M.P.H., M.F.A.
For my father, traveling the forty miles by car from our home in Akron to any attraction in Cleveland was on par with a NASA Apollo mission to the Moon: a rare, perilous endeavor. My directionally challenged father shook his head and said, “We could get lost, Tom. End up in a really bad neighborhood. What would we do then? Well, maybe another time.” My stay-at-home mother did not get her driver’s license until age forty-three, in 1973. She helped wear him down, so we visited the Cleveland Health Museum, once, one chilly, rainy, autumn Saturday in 1969. The Cleveland Health Museum relocated in 1945 to deserted Lyman Treadway House. Built in 1911, forty-threeroom Lyman Treadway House was once one of 250 mansions lining a four-mile stretch of Cleveland’s Euclid Avenue, known in its heyday from 1870 to 1929 as Millionaires’ Row. By the 1960’s, Lyman Treadway and its surroundings suffered urban decay. The faded mansion smelled musky— musty mixed with an acrid odor like my father’s pipe tobacco smoke, yet it felt like a fairy tale place to me—living in a six-room, ranch-style house.
I was introduced to Juno on my 1969 visit to the Cleveland Health Museum. When I met her, Juno was standing atop a pedestal in the museum’s Wonder of Life room. I was enraptured by her. In Roman mythology, goddess Juno was the protector of women. The accompanying souvenir pamphlet, Juno: Symbol of All Women, quoted Saint Augustine: “Man wanders over the restless sea…the flowing water and the sight of the sky…and forgets that of all wonders, man himself is the most wonderful.” Heady stuff for twelve-year-old on verge of puberty.
Juno was a life-size, transparent model of a twenty-eightyear-old woman and the museum’s most iconic, celebrated display. Handcrafted in Cologne, Germany, Juno depicted in Teutonic fashion, “the human body as a machine.” Under her clear, rubber composite skin, Juno’s white bones were painted metal, her organs made of multicolored plastic, and her vast network of arteries, veins, nerves, and lymphatics comprised of eight miles of red, blue, yellow, and green plastic-coated wire. Juno talked, so to speak, describing her twenty-one organs, as each was illuminated. Her brain and heart: loci of mind and soul, jumped out at me.
My other souvenir, from the museum gift shop, was a copy of the paperback Atlas of Human Anatomy, with “104 Accurate and Vivid Illustrations Including 49 Charts in 8 Colors.” I digested and memorized the contents of this 180-page primer. As a kid, I read my family’s Compton’s Encyclopedia—cover to cover—particularly marveled at its multilayered, double-sided, acetate transparencies of the human body.
That same school year, Susan Newman was my sixthgrade teacher. An Akron native, she was just twenty-three, in her second year of teaching: filled with passion, patience, and compassion. I had an innocent, schoolboy crush on her.
One winter morning, Miss Newman was teaching us human anatomy, using a limbless plastic model, whose hollow yet lifelike molded organs could be removed one by one. After I corrected her three times, Miss Newman asked, “Well, Mister Vetter, why don’t you come up here and instead teach the class?” I scrambled from my seat and took her up on her offer. I described each organ in perfect detail. Goddess Juno was proud of me.
At the end of my impromptu presentation, Miss Newman smiled and said, “Very well done, Tom. I knew you could do it.” Then she asked, “So, what do you what to be when you grow up?” I replied, “A doctor!” She nodded approvingly. My classmates applauded. I felt elated. My budding career aspiration was validated.
A few months later, on a warm, humid, sunny afternoon in early May, another young teacher came into our classroom. She whispered something to Miss Newman, who grimaced and said, “Oh no! Why?!” They hugged, started to sob, left the classroom. Twenty miles away, members of the Ohio National Guard had fired their weapons that day into a crowd of anti-war demonstrators at Kent State University, killing four students and wounding nine others. I too wanted to give Miss Newman a hug, but I knew better. She got married that June and left Akron.
I was in sixth grade, acme of my youth, when I first tasted the nectar of nirvana. Juno and Susan were protagonists in fermenting that intoxicating nectar. I never got to thank Susan for being my ally—to convey how Juno protected us both during our common loss of innocence.
SEASONALITY OF MEDICAL EDUCATION
Fall of first year
Crisp fresh breaths
Finding oneself in the midst of finding others
Winter of second year
Bone chilling challenges
Dying to see the change we wish to be in the world
Summer of third year
Boiling with differences
Glimpses of other worlds that
tempt to lead us astray
Spring of fourth year
Blooming of a new life
Yet to come…
Sara Yue Tao, MS3
THE SLOW DOWN
Richard Sames, MS2
On a day like today anything can happen,
But the odds don’t look good that it’ll be any different.
Martha says that I should look for the joy hidden in everything,
As if the dust particles floating gently upward toward the ceiling,
Made visible by the morning now breaking through our bedroom window,
Are somehow part of some beautiful human experience.
I am only on my second cup of coffee, but dust looks like dust to me,
And the light coming through the window is blinding in the morning haze.
When I was younger I believed I was the only one who could see the clouds move.
I don’t know if it was developed or granted at birth,
But I spent hours in the soft spring grass,
Watching the sheets of white creep toward the horizon.
It wasn’t until my first date that I realized that this gift was given to everyone.
In five minutes my alarm will tell me it’s time to get ready,
It insists that I continue to move forward.
And maybe that’s what it’s all about,
Not the expectation of joy,
But rather in appreciation of the brief moments that slow us down
Long enough for us to catch our breath.
I slide into scrubs.
I grab my ID and stethoscope.
I arrive at their door and in a shaky voice introduce myself,
A bouquet of tubing and wires stretching across their body
As I ask about their night and listen as their heart beats against their chest.
On a day like today anything can happen,
But it doesn’t and in the grand scheme of things would it matter?
We’d still sit here holding our own hands
Staring into a world that unravels like a poorly made scarf,
Promising so much for our time but giving almost nothing,
Until it’s all behind you, unwound and presented,
Showing you everything that’s come before
As if to say, “Wasn’t everything enough?
Come now, move forward.”
ON LEGACY
Richard Sames, MS2
In the summer hills, where the tall tough grass
reminds you of persistence and the endless wind reminds you of indifference,
Ruth brings batches of white roses
I must admit, I wasn’t thinking about legacy
When you drove me to the west side to town, Between river and the golf course,
To show me that someone has written J and P forever
In lime-green, capitalized rushed blocked script
On an aging cinderblock wall.
You shifted into park.
You said, this is what you wanted.
Something amplified and abrasive in its permanence.
The next day, across town, on the fourth floor,
In the building between the hospital and the homeless encampment, Someone is holding up a dissected heart,
And a first-year medical student
Is rolling their shoulders back in the heaviness of the fluorescent lighting,
And quietly losing their mind,
As another student rattles off heart valves
Like they’ve been doing this their whole life.
Who were you and what are you doing here?
Supine and pale, scars on your hands and kidneys,
Marking the place where memories don’t exist anymore,
But we know they do.
That somewhere, a worn photo album,
Might show you
In a fading and fingerprinted picture
As a green Tea Aficionado,
With a passion for Geocaching And dedication to composting
That did not translate to gardening.
And maybe it’s the formaldehyde,
Or the way my shoes squeak as I shift my weight
Against the dissection table,
But I imagine that a few months before it could have been you,
In a black backpack and surgical gloves,
Vandalizing the neighborhood,
Heart thick in your chest,
Blood rushing to your forearms and fingertips
As the nozzle depresses
And green aerosol plastered the cinderblock in the fading Texas summer.
You could have been anyone.
And in the stillness of the laboratory
Where what remains lies before 53 medical students, I remember exactly this,
That whoever you are
Gave one final gift so that we,
As we accelerate through our education
Might stop for long enough,
That you might depress the nozzle one last time
And make whatever it is we’ll take with us,
In lime green, capitalized lettering.
PIECE OF MEXICO , Jackie Castillo, Undergraduate
GRAYNESS OUT MY WINDOW
Small Dog begins to bark, the light flicker on and off.
The man with his umbrella through the water
Thomas Varkey, M.D., M.B.A.
LE CHAT ET LES FLEURS Thomas Vetter, M.D., M.P.H., M.F.A.
Drip Drop.
Drip. Drop.
Slosh.
The smell of rain, without sunshine today.
Goodbye day, hello grey.
SESTINA SOBRE EL AMOR
To My Dear Luna, With Love, Papa
The eastern sky, chasing the sunset, is a deep, indigo blue.
Against this backdrop rises the orb of night, a creamy full moon,
Playing hide-and-seek in the high branches of the big oak tree,
A rhythmic game played out, again and again, across all time.
La luna echoes our earthborn yearning and universal search
To discover its wellspring—there to imbibe nourishing love.
Keep faith, hope, love—but the greatest of these is love.
Without love and belonging, you are left feeling blue,
So you embark on your own quixotic, romantic search,
Headlong chasing shooting stars, lassoing the moon,
Not pausing to savor this but one precious moment in time,
Marked by rings in heartwood, sapwood of the wise oak tree.
Strong, stormy winds often blow through the mighty oak tree,
And a tempest of troubles dashes your desired everlasting love.
Falling down, be undaunted—pick you up, try again, for time
Heals the pain from your heart being bruised, black and blue.
Like its ever cycle of waxing-waning, leading to a new moon,
There are peaks, valleys along your enduring journey and search.
There is no map to find your buried treasure, so best search
Whiling away the hours beneath the bows of the wide oak tree.
Being affected by Selene’s spell, for the goddess of the moon
Will make you a moonstruck lunatic—wildly, madly in love,
Yet such lunacy is a far better fate than being Little Girl Blue, Who runs out of luck or pluck before running out of time.
You will find yourself in another place, in another time, Where you never know when a fruitful lunar search
And rescue will take place—coming out of the blue,
Spurring you on, to plant the seed of a new oak tree
That will grow, will flower, will bear the fruits of love, Whose flesh is sweetest eaten under the full moon.
Like the cycles of the tides, the phases of the moon
Dance through the night sky and across all time.
You there, my dear lost soul, pining for elusive love,
But adrift in the midst of an uncertain sea—search
Instead, after making landfall, under the old oak tree,
Looking upward, to the parting clouds, revealing skies blue.
Once in a blue moon—my Dear Luna, your quest, your search,
Given due, ample time—like the old, wise, still mighty, big oak tree,
Will fill your heart with love—pumping bright red, not dusky blue.
Thomas Vetter, M.D., M.P.H., M.F.A.
NEURALGIA
When galaxies collide
Comets streak against the fabric of cold nights like tears
Spilling glittering jewels into skin and ash
Tell me why are we made of starlight
And where are you going
ten seconds stretch into a thousand years
But I’ve found eternity in this moment
With our hands clasped together
Bring me back to the time
You were telling me about the Pleiades
Seven daughters of Atlas
What do they know
Of tragedy
Yesterday my mind decided to shatter
Into shards of crystalline rhomboids
They glitter like jewels of what once was
The mind is broken in an inflammatory process
The cycle repeats in prostaglandins
Can this ever truly end
I ask my physical therapist
Who tells me about the wonders of neuroplasticity
The resilient neurons they grow and reroute
And so I too must learn
How to patch together myself again
And become a hero
EYE OF CAIMAN, PERU , Kent Ellington, M.D.
Victoria Siu, MS3
HERE FOR THE DURATION
Evelyn Syau, MS4
“New one for today. Don, with ALS. We have him as inpatient respite for now…”
It was my first day on the inpatient hospice service. Earlier that morning, I had gotten a run-down of the different levels of hospice care, ranging from routine home care (when patients are relatively stable and receive hospice services at their homes) to general inpatient care (when patients’ symptoms can no longer be managed at home and they receive hospice services in a hospital setting). Inpatient respite was within this continuum, providing a 5-day stay for patients to help relieve caregiver burnout.
“...but based on what we heard from family overnight, he might be here for the duration.”
On any other rotation, the phrase “here for the duration” might have meant receiving treatment for a reversible condition and recovering sufficiently to return home. In the context of hospice, however, it meant that patients would be spending the last few days or weeks of their life under our care.
Before this, my only encounter with hospice occurred the summer before high school. At the time, my grandmother had just been diagnosed with late-stage glioblastoma, which presented itself as a 6 cm mass pressing into her brainstem. Faced with the options of either surgery or hospice, our family ultimately chose home hospice to prioritize her comfort and quality of life. My grandmother ended up dying six months later on her birthday, a full-circle moment that felt symbolic amidst the grief that followed.
Unlike my grandmother, Don did not have an aggressive form of cancer. However, he did have amyotrophic lateral sclerosis (ALS), a fatal, progressive disease that affects the nerve cells in the brain and spinal cord that control voluntary muscles. With Don, I was curious to know what his goals were in seeking out hospice. If he initially came in as an inpatient respite patient, what had he and family shared with the intake staff that suggested otherwise? Had he, like my grandmother and our family, already considered the trade-offs that he was willing and not willing to make?
surprise guest , Fatema Dohadwala, MS1
Upon entering the room, we were greeted by Don, his wife Gia, and various family members. Don was sitting up in the hospital bed, dressed in a black hoodie with a cycling team logo across the front. He had a nasal cannula in, and otherwise appeared comfortable. In talking with Don and Gia, we learned that Don had been diagnosed with ALS one year ago. The diagnosis had been difficult for Don, an avid cyclist his whole life, to accept.
The ALS started in his vocal cords first, impacting his ability to speak and communicate like he used to. Then the swallowing difficulties started, and his doctors eventually placed a percutaneous endoscopic gastrostomy (PEG) tube for long-term nutrition support. Though the past year had been difficult, Gia said she thought things had been improving – just last weekend, Don had cooked a meal for her. Earlier this week, however, Don told his wife that he wanted to stop his tube feeds. He had done some research on inpatient hospice, and expressed a desire to come to our facility. Gia acknowledged that she brought him in as inpatient respite at first because she thought he might change his mind. Still, she emphasized that Don had always made good decisions and that she trusted him this time too. She, like the rest of us, just wanted to make sure Don was sure.
And he was. When Gia asked if he wanted to wait until tomorrow for a few more friends and family members to visit, Don repeatedly shook his head. When presented with options of next steps – one where he would be sleepy on low doses of benzodiazepines but still responsive, versus another where he would receive higher doses of palliative sedation and not retain consciousness –Don chose the latter without hesitation. He expressed understanding that he would die if his tube feeds were not restarted (i.e. voluntarily stopping eating and drinking, or VSED). His request to us was consistent and clear: he wanted to finally receive rest. My attending told Don that he would write down the orders in the chart as discussed. It was only when Don felt ready, however, that we would initiate the process. We soon excused ourselves from the room so that he and his family could talk in private.
The following morning, I checked in on Don. Like the day before, he looked comfortable – only this time, his eyes were closed in sleep, his mouth slightly open. Gia was in the room with him, having returned from home with some additional belongings. From talking with his nurse, I learned that the orders were carried out around 6 pm last night.
Sitting down on the chair near Don’s bed, Gia confessed that she had little understanding of hospice prior to all this and asked if I had ever gone through something similar. I talked about my grandmother and our family’s experience with hospice, and also answered her questions about what physical changes she might expect to see as Don’s body began shutting down. We ultimately ended the conversation on a bittersweet note, with Gia sharing her favorite memories with Don, how much he enjoyed cycling and meeting new people on their travels together, and how much she already missed him. ***
With terminal, irreversible conditions like late-stage cancer and ALS, there are constraints to what medicine can offer. Still, one might wonder why Don chose hospice when he was objectively quite “alive” – still living and breathing, able to reflect and engage thoughtfully in conversation. It was certainly something that many of us in the room with Don were trying to reconcile. In this situation, however, only Don knew what it was like to live with his condition each day. Based on what he shared with us, it was clear that ALS had already taken away much of his autonomy and independence. But by choosing how and when he wanted to go, Don still had control over his last moments. Altogether, this experience demonstrates the value of empowering patients during endof-life, providing them with agency to choose at least some aspects about how their story will end. And we in healthcare can do so with compassion and a willingness to understand who a patient is, what their unique hopes and needs may be, and how that shapes the care we provide.
PROJECTION
Irfan Hydari, M.D.
Mid-afternoon sunlight peers through the closed blinds wanting to dance with the man in the bed who refuses her advances. Panday’s wife with his daughter, they pose smiling modestly behind a cake that reads “45”, white frosting on chocolate. The photo is home printed on a sheet of 8x11 white paper, pixelated and blurred. A lone thumbtack pierces the upper border of the paper, the corners drooping inwards as if protecting the women in the photo. Three feet below the picture lays Panday in a single metal-framed bed, thin white mattress exposed beneath disheveled beige sheets. A chair folded shut rests on the wall beside the cot, memory of the last visitor distant and forgotten. A urinal filled halfway with dark amber urine rests at the foot of the bed, nitrogenous fumes saturating the barren space. No TV, no lamp. Nary a rug nor a radio.
I introduce myself as one of the hospice doctors, pry open the folding chair and seat myself next to the bed, the urinal wafting its reminder of companionship.
“How are you feeling?”
My first question initiates a series of them answered in curt monosyllabic responses. “I’m fine.”
Are you having any pain? No.
Are you short of breath? No.
Any nausea? No.
Are you having any trouble eating? No.
Sleeping okay? Yes.
Would you like me to open the blinds?
No.
“Sir, tell me a bit about yourself – where are you from?”
Doctor Panday, turns out, is originally from Chennai, India. He immigrated to the United States in 1965 at the age of 22, pursuing higher education and opportunity, trading subcontinental monsoons for Texas rainstorms. He completed a PhD in chemistry and subsequently worked in the pharmaceutical industry, researching and developing drugs to treat hypercholesterolemia.
I immediately cringe at my question, the meaning of which has befuddled, irritated, and threatened me for over 40 years when directed at me. Where was I born? Where do I live currently? Where is my family from? Where you from, boy? I dismiss the memory in my head with a “Go fuck yourself” and return my attention to Panday.
His atrophied contractured legs exhibit 2+ pitting edema, musculature swapped for third spaced fluid. His primary diagnosis is end stage congestive heart failure, a death sentence with very low predictability for how much time truly remains. His weakened heart could beat for months or tucker out tomorrow, his plaqueencrusted coronaries ignoring the “-statin” drug he helped develop decades ago now coursing through his very bloodstream. My cardiovascular diseaseprone South Asian genes let out an atherosclerotic groan, acknowledging Panday’s predicament as a foreshadowing of my own eventual demise.
Dr. Panday refuses my offer to treat his depression with medication, refuses my offer to play sitar-laden music from my phone fondly reminiscent of what his father used to perform, refuses my offer to merely bring him a book to read, a television to watch; I feel an immigrant’s martyrdom, I sense an immigrant’s regret, from my own first-generation broken heart via my parents’ route to these united states.
Dr. Panday lays supine in the dark, punishing himself for the decisions he’s made. For leaving his Mother and Motherland. For absconding his duties to care for Her through old age and demented brain. For willingly moving to a country where he was repeatedly told to go back to where he came from, for chasing the dream of American independence and frontierism that ultimately led to the nightmare of this dingy desolate nursing home. For swapping mountain peaks and lush green valleys for slabs of concrete and strip malls. A familial legacy that died with his mostly lethargic sperm, on the vine of his lone offspring’s choice to keep an empty nest. Panday withers in a bed of guilt, decades of resentment for vices and an anger unmanaged, his wife’s decision to displace him to the emptiness of this hollow chamber at first chance an easy one. He is convinced of the rightfulness of this lonely death.
MONO-A-MONO SUNRISE ,Thomas Vetter, M.D., M.P.H., M.F.A.
MY CALLING
William Tierney, M.D.
I am to be the one who is there when pain, fear and angst prevail and overwhelm and frighten the sick, the desperate, and those whose needs must be first, must be met, but met with inadequate time, space, knowledge, love, and compassion that can only come from a calling to serve, to be there, to hold hands and comfort eyes that have seen too much, understood too little with a dearth of patience, caring, wanting to be the one in the breech, holding back the dark, pain, and a lack of trust in those who have promised much and delivered little to ease the miseries of life that they share and we can only try to understand through caring for and about them during difficult, fearful times, sitting anxiously in our waiting rooms, waiting for the doctor.
Prosody, the student-run literary and arts magazine of Dell Medical School, brings together student, resident, fellow, faculty and staff voices to explore the intimate connection and meaning inherent in the practice of medicine through prose, poetry and visual arts. Read Online: Prosody.DellMed.org