2021 ChART E-Journal

CELEBRATING THE HUMANITIES AND ARTS (CHART) Journal of the Phoenix Biomedical Campus

ChArt (Celebrating the Humanities & Arts) The Humanities Journal of the Phoenix Biomedical Campus

Volume 8, 2020-21 ©Copyright, All Rights Reserved

Celebrating the Humanities & Arts is an interprofessional, peer-reviewed/juried journal devoted to sharing the insights and experiences of the Phoenix biomedical community (students, staff, faculty and patients) through original works of personal expression, including original art, essays, motion media, photography, poetry and prose.

The Journal is a publication of The Program for Narrative Medicine & Health Humanities, Department of Bioethics and Medical Humanism The University of Arizona College of Medicine-Phoenix 435 N 5th St. Phoenix, Arizona 85004

Email: PBC-Journal@email.arizona.edu E-Journal: www.tinyurl.com/pbc-journal2021 Website: www.narrativemedphx.com

Dear Phoenix Biomedical Community, Greetings! We are pleased to present our seventh annual humanities and arts journal. Our mission is to celebrate the diversity of perspectives, ideas and experiences of our campus with you and present both the familiar and extraordinary moments in human experiences.

Representative pieces are drawn from the genres of prose, poetry, photography, painting and motion media. They showcase the many creative and artistic talents of our community.

This print edition is a selection of editor favorites, carefully woven together for your enjoyment. We hope that you feel inspired by the unique perspectives of the authors and artists presented. May these works lead you to a renewed level of commitment to self-expression and artistic exploration, and may your own endeavors create harmony, balance and joy in your life.

On behalf of the editorial board – enjoy!

Jennifer R. Hartmark-Hill, MD Editor-in-Chief

Meher Rakkar Student Editor-in-Chief

2021 Editorial Board Tanner Ellsworth Dara Farhadi Tiffany Harmanian Jennifer Hartmark-Hill Catherine Lockmiller Meher Rakkar Special Acknowledgements Dr. Jacqueline Chadwick – with appreciation for support for the founding of this journal; Dr. David Beyda, Chair, Dept. of Bioethics & Medical Humanism Chair - with appreciation for ongoing support; Ellen Cyrier – Cover Art 2021 Dr. Rosemarie Dombrowski– Keynote speaker - Celebration & Gallery Event 2021

TABLE of CONTENTS

1. FAITH

by Ellen Cyrier

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2. MY FIRST STROKE PATIENT

By Dara Farhadi

12

3. TWENTY TWO UNITS

By Michelle Arnold

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4. GERMINATION

By Marcus Childs

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5. REFLECTING ON YEAR ONE: A BEGINNING AND AN END

By Caitlin Parke

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6. REBIRTH

By Dr. Susan Kaib

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7. AFTER THE FIRE

By Dr. Steve Lieberman

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8. FLYING ACROSS THE COVID19 PANDEMIC

by Julie Tran

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9. REFLECTING ON MORTALITY

By Michelle Arnold

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10. PLANET X

By Dr. Steve Lieberman

30

11. REFLECTIVE PEARLS

By Alyson Tukan

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12. THANK YOU LETTER TO A DONOR

By Anonymous

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13. ASHES TO ASHES

By Isabel Strouse

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14. WHAT YOU KNEW (A THANK YOU LETTER)

By Meher Rakkar

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15. DEAR DONORS, THANK YOU

By Erik Garber

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16. HIGH TOPS TO SHORT COATS

By Alexis Bailey

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17. CONNECTIONS

By Daniel Oheb

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18. A PATIENT OF A DIFFERENT KIND

By Sarah Pousti

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19. SICK OR NOT SICK

By Dr Richard Cunningham

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20. ENCOUNTER

By Dr. Jonathan Cartsonis

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21. PB&J

By Dr. David Beyda

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22. BACK COVER ART

By Ellen Cyrier

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Title: F A I T H Materials: Canvas board, acrylic, matches This piece was originally started over 4 years ago on the precipice of the 2016 U.S. presidential election. At a point in which the country seemed poised to welcome it's first female president, and amidst months of fiery debate, this work was created as a representation of how during dark and tumultuous times, it's vital to hold on to hope and faith in what's to come. After the surprising election results, this piece went unfinished.

As COVID changed the way we all lived in 2020, and with another election upcoming, I began to think back to this artwork. This piece is made up of hundreds of burned matches, placed together to form the word FAITH. Given all that had happened in the world, the country, my personal life, to everyone's daily life and beyond, I found myself in an incredible full circle moment, drawn to complete this. There are many great quotes about struggle, strength, and faith, and to me, this piece represents that. Although it may be hard, and times may be dark, I have faith that things will be better, and I hope you do too. ______________________________________________ ELLEN CYRIER is a Senior Coordinator of Undergraduate Recruitment at the University of Arizona. Before moving to the Grand Canyon state, Ellen obtained her undergraduate degree in Fine Art at the University of Iowa. Since then, she has continued her artistic efforts, creating an art business and website while also pursuing her interest in higher education. She loves working with students and helping them through their college journey. In the realm of art, Ellen enjoys exploring almost every medium from painting to ceramics to photography, with a particular focus on texture and light in each piece. When not clicking through her film camera, she can be found on the tennis court or enjoying the outdoors.

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Title: My First Stroke Patient This piece was originally published as part of the AAMC FRAHME Initiative as part of the Meaning Making During Times of Uncertainty site.

Available from: https://frahme-aamc.org/ ______________________________________________ DARA FARHADI is a third-year medical student at the University of Arizona College of Medicine-Phoenix 12

My First Stroke Patient

“COVID-19, alone, intubated.

Young Black Female, BLM protests outside.

Significant anemia. Blood ordered post-procedure.

I check on her. Sedation wearing off.

I explain.

She panics.

“I never want blood!” she writes.

“Why?” “Religious—Spiritual” I panic.

RN, PRBC bag in hand.

“No blood,” I say.

I alert MD. On rounds— “Thank you, Dara,” she writes.”

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Title: Twenty Two Units This poem is based on an experience scrubbing in on a trauma surgery on the last night of my general surgery rotation. Finding out that I really enjoy being in the operating room was one of the biggest surprises of this initial burst of rotations. With every surgery I got to scrub in for, I found myself appreciating all of the carefully followed steps of a surgery as almost a ritual or dance with carefully measured steps (and, of course, spinning around with a ‘dance partner’ to tie up the sterile gown). This surgery described in the story made a particularly strong impression on me, both because of the calm efficiency of the surgical team in searching for and managing the patient’s sources of hemodynamic instability and because it was easily the bloodiest surgery I had seen to date. I checked the charts for several days after the surgery to see how the patient did afterwards – he survived and first night and it looked like he stayed in the hospital for several days and had several more surgeries after I saw him. ______________________________________________ MICHELLE ARNOLD is a third year medical student at the University of Arizona College of Medicine-Phoenix. She obtained her undergraduate degrees from Arizona State University in Biochemistry and Spanish and a Master’s from the same university in Biomedical and Health Ethics. She plans to pursue a career in Obstetrics and Gynecology.

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Twenty-Two Units The team performs their intricate dance – Memorized steps adapted to evolving would-be crises – As they do damage control on a midnight GSW, Intestines, kidneys, a still bleeding IVC all receiving their ministrations.

One surgeon astutely observes, “Someone wanted him dead.”

I’m not sure if the taste of blood in the air Is real or imagined.

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Title: Germination ______________________________________________ MARCUS CHILDS is a 1st year medical student at the University of Arizona College of Medicine Phoenix hoping to pursue a career in primary care to better help the community he was raised in. When he needs a break from school or wants to express himself, he turns to photography. Portraiture, landscapes, macro, still life, wildlife,and more interpretive genres are all things he likes to learn and play with.

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Title: Reflecting on Year One: A Beginning and an End This essay was selected as the 2020 First Year Medical Student Reflection & Growth Award ______________________________________________ CAITLIN PARKE is a third year medical student at the UA College of Medicine-Phoenix, Class of 2023. She double-majored in Anthropology and Integrative Biology at the University of California Berkeley and received a Masters in Biomedical Sciences at Tufts, University. She is passionate about improving health literacy, caring for underserved populations, and improving access to primary healthcare. In her spare time you can find her practicing yoga, journaling or wandering around on AZ trails with her cocker spaniel, Elliot.

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Whenever I come home after a while away, the first thing I do is my usual sweep of the house. I'm not usually looking for anything in particular. Just the hidden treasures that I've forgotten about. Old diaries, forgotten T shirts, things I had once determined useless but now have a sudden need for. The week I returned home after finishing my first year of medical school was the same. I was looking for an unused journal, something I could scribble notes in while looking over incorrect Q bank questions. I checked the toy closet, nothing. My old desk was empty too. Then I moved on to the filing cabinet in the storage room. Nothing. But as I was sliding the drawer closed, a folder tag caught my eye. Alexander. I had heard about my brother before. I knew my mom had a miscarriage before my sister and I were conceived. I knew he was cremated. His ashes were spread in a cove near the cliffs by my house. I remember asking her about him when I was in high school. “What went wrong?” “A lot of things. That is why I’m so lucky to have you.”

Seeing his name written in the familiar script of my dad's handwriting, he was suddenly more real. Not just a memory, but a real tangible loss. I peeked in the folder. For the first time, in a home that's been mine since childhood, I felt unsure of whether or not I should look. Or whether I could look. It felt private. In the folder I found grief cards and ultrasound films, complete with arrows pointing out his spine, his two tiny hands and little head. There was even a film with a little quote “Hi Mom and Dad!” Three Polaroids showed a tiny blurry baby wrapped in blue surgical cloths. A stack of papers was clipped together at the back of the folder. Autopsy Report.

Expired: 1/20/92. Male. Gestational weeks: 20. Brain: holoprosencephaly. Lungs: hypoplastic, left; aplastic, right.

Diaphragm: absent, left. Ears: low set. Eyes: aplastic. The sticky note on the cover carried my mom's careful notes.

“Two problems: brain, diaphragm. No known genetic condition.”

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I put the papers back in the folder and slid the filing cabinet closed. And it all hit me. Not for the first time, but with a force much more powerful, having just finished my first year of medical school. I was struck by a wave of humility and understanding of why I am studying so hard. For months I spent countless hours in lecture halls and the anatomy lab. I pored over notes and textbooks with the occasional stress spiral about test scores. Much of the time it felt like running on a treadmill that was moving too quickly. Slow down a little bit and you’re dangerously close to slipping and tumbling off the back. But standing there with my brother's autopsy report in my hand, I was reminded of how far I’ve come. I knew the images were ultrasounds and I could find the spine without the arrows. Holoprosencephaly, I remembered, was a defect in prosencephalon development that usually occurs around week five or six in utero. I recalled that the diaphragm relies on nerve roots three, four and five to keep you alive. It separates the thoracic and abdominal cavity. Without it you can’t breathe. I could read the report. I knew what it meant. I felt what it meant.

After the brief thrill of understanding the diagnosis, I felt the weight of the knowledge. This wasn’t just a report or a list of terms to memorize for an exam. This was a description of someone’s baby. My mom’s baby. Because of the clinical experiences that I have been fortunate enough to have during my first year of medical school, this isn’t a new revelation. There is always a person, a loved one, a family member behind each diagnosis. That is what keeps me studying. Medical knowledge is interesting, yes, but I learn it because someday that knowledge will save someone’s life or offer them comfort through understanding.

During our first week of medical school we wrote our class oath. We promised to uphold many things: appreciation for our families, respect for our colleagues, care of ourselves. At different points throughout my first year, each of 20

these elements has come to hold a deeper meaning. But the piece I continue to hold dearest to my heart is our promise to our patients: “To recognize our shared humanity and treat those in our care with respect and understanding. To see them as a whole person and care for them beyond their diagnosis. To treat them with the same dignity and respect we would treat our own friends and family.” My first year challenged me in many ways. It pushed me out of my comfort zone and occasionally made me question if I have what it takes. But now, standing on the other side, looking forward to the next three years, I am filled with gratitude and excitement because this is just the beginning.

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Title: Rebirth ______________________________________________ DR. SUSAN KAIB is a Career and Professional Advisor and chapter advisor for the Gold Humanism Honor Society at the University of Arizona, College of Medicine- Phoenix. She is a fellow of the American Board of Family Medicine. After graduating from Arizona State University with a Bachelor of Science degree in Chemistry, she worked as a neonatal biochemist for three years. She earned her medical degree from the University of Arizona, Tucson and completed her residency at Phoenix Baptist Hospital. Prior to joining the College of Medicine-Phoenix, she was in private practice in Phoenix.

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Rebirth

Cancer Lucky you came To bring meaning each day, Yield to its power, forfeit dreams, Alive!

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Title: After the Fire The Bush Fire in June 2020 burned 195,000 acres in the Tonto National Forest, making it the fifth largest fire in Arizona history. This photo, taken along highway 87 between Phoenix and Payson, shows the utter charring of desert landscape the fire left behind. ______________________________________________ DR. STEVE LIEBERMAN is an amateur photographer who enjoys shooting landscapes, architecture, and wildlife. He likes to present unfamiliar images of nature.

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Title: Flying Across the COVID19 Pandemic On March 16, 2020, my father passed away in Maryland while I was across the country, in the middle of my Transitions block at UACOM-P. Whether it was from COVID19 or not, I am uncertain. However, during my flight both to and from Maryland, I had time to reflect on the situation. I remember being stunned by the sudden rush of emotions from both this pandemic and my father’s death. This is further amplified by my experience of seeing the stark difference in the partially-filled flight on the way to Maryland and the practically-empty flight one week later on the way back to Arizona. Given the current events, I feel fortunate to have seen him for the last time before his cremation. In the same vein, I am thankful for this reflective opportunity to share my feelings during this disheartening time.

This 55-word story was originally published in the “Stories-in-Medicine” COVID-19 Reflections Collection, available from: www.tinyurl.com/storiesinmedicine _____________________________________________ JULIE TRAN is part of the class of 2022 at UA COM-P 26

Flying Across the COVID19 Pandemic

Flying 2,271 miles across the pandemic From Arizona to Maryland A partially-crowded and noisy flight My purpose?

Visiting my father for the very last time Who now lays still and pleasantly serene 15 scattered passengers on the flight back home A quiet plane for nostalgic memories I will always miss and love you, Dad. Always.

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Title: Reflecting on Mortality Studying medicine tends to highlight the tenuousness of human existence. Our bodies seem like fragile machines that can fail endlessly, especially when one’s studies highlight the myriad of diseases that can kill us. And yet, life continues on (for now) and is perhaps more beautiful for its improbability. _____________________________________________ MICHELLE ARNOLD is a third year medical student at the University of Arizona College of Medicine-Phoenix. She obtained her undergraduate degrees from Arizona State University in Biochemistry and Spanish and a Master’s from the same university in Biomedical and Health Ethics. She plans to pursue a career in Obstetrics and Gynecology.

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Reflection on Mortality Humans weren’t made to last – Our spines weighed down by the weight of our hands Reaching out for sustenance.

Holding on tightly until, loving, loved, losing, and lost, Gnarled fingers lose their strength.

Humans weren’t made to last – Hearts and viscera perform on a narrow tightrope, An endless balancing act before they fall; We too fail and fall and are failed, And yet we count our victories on the way down.

Life wasn’t made to last – Endless helical copies, each so delicately strung Subsequent generations become unrecognizable – Incomprehensible and ever changing In an effort to stave off the inevitable.

Life wasn’t made to last – This world too shall burn out, swallowed In the dying cry of a star.

In the meantime, our sparks burst into bright Dancing flames until we too are ash and stardust.

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Title: Planet X This photo was taken in Yellowstone National Park at the Norris Geyser Basin.

Yellowstone contains countless “otherworldly” sights that undergo continuous revision by the geologic forces that make it one of the truly unique places on earth. _____________________________________________ DR. STEVE LIEBERMAN is an amateur photographer who enjoys shooting landscapes, architecture, and wildlife. He likes to present unfamiliar images of nature.

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Title: Reflective Pearls This piece was adapted from a writing exercise I completed for my third-year medical school coursework to utilize guided reflection during one of my clinical rotations. The practice of reflection has always been important to me, and utilizing journaling and introspection allowed me to find meaning in one of my more challenging rotations of medical school. _____________________________________________ ALYSON TUKAN is student in the Class of 2022 at the University of Arizona College of Medicine – Phoenix. She completed her undergraduate education at Trinity University in San Antonio, Texas with a double major in Neuroscience and Spanish. At UA COM-P, Alyson served as the Medical Student Government secretary and is a member of the Student Ambassadors and the Certificate of Distinction in Service and Community Health. She is passionate about volunteering, martial arts, yoga, running, hiking, and knitting.

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Ever since I was a young girl, I have kept a journal and still routinely record my thoughts, document life events, and process my feelings on paper. Utilizing the practice of reflection was especially important during my trauma surgery rotation, which concluded my lineup of clerkships for the first phase of my third year. Not only was I mentally and physically exhausted from rapid fire 12 weeks of previous rotations, but I was also starting this rotation with a sense of apprehension for both the trauma and surgery aspects. I needed an outlet to process the intensity of this rotation.

Looking back over my time on surgery, I have a collection of individual moments like beads strung together on a necklace that summarizes my surgery experience. Some of these beads are bright and sparkling, representing times when I was able to laugh, bond with my team, or experience joy in a patient encounter.

Other beads are dark and brooding from the times I felt sadness, witnessed death, or became intimately familiar with a patient’s daily struggles with dis-ease.

Of all of these beads, one of the surprising moments was a patient encounter with a young man who presented to the ED for evaluation of his fistulas. This gentleman had a chronic demyelinating condition that had already paralyzed his legs, and now his multiple abdominal fistulas were draining foul-smelling bowel contents requiring frequent dressing changes. Despite his difficult circumstances, he was one of the most pleasant patients we saw all day. His brilliant blue eyes took time to make contact with each member of the team as he earnestly thanked us for being involved in his care. This man reminded me to be grateful each and every day, and to express my gratitude to those around me.

Along the same lines of gratitude, I was moved by my trauma experiences to realize that health is fleeting, and the restoration of health is a miracle. We saw patients who had woken up in the morning perfectly healthy, only to end the day in the trauma bay undergoing extensive life-saving measures due to an accident that had changed their life in seconds. For one such patient, my role in the trauma was to squeeze the bags of blood products to help them infuse faster since the patient was in hemorrhagic shock.

“Squeeze – 2 – 3; Release – 2 – 3” became my mantra as I repeatedly pumped four units of blood while the patient was assessed and wheeled to the OR for an ex-lap. One morning on ICU rounds this patient had awoken, and I was nearly brought to tears thinking about how a nameless individual had donated their own blood so I could squeeze it through a plastic tube to help save this woman’s life. While the situation was devastating, it was also a reminder of the miraculous efforts of countless individuals that goes into each patient’s care.

Despite many difficult moments, like witnessing the trauma mentioned above, I had a lot of reasons to 33

smile on this rotation. My team’s chief was constantly making me laugh with his spontaneous dance moves as we prepped patients in the OR, or his dad jokes that helped lighten the team’s spirits. I also smiled when our attending bought us all breakfast and we sat as a team in the healing garden, bonding over bagels and coffee. This same team deeply inspired me, as well. They were all so committed to their specialty, and their passion for surgery was admirable. I strive to one day feel so deeply passionate about my chosen specialty that I am able to persevere through the long days with a smile as they do. They are also so incredibly smart, and it was motivating for me to keep putting in the hours of studying so one day I can be as knowledgeable as they are. They used their expertise to educate me as their student, and also to educate their patients.

Even though I don’t foresee a career in trauma surgery for myself, I have been able to identify the value in this rotation through the act of reflection. Rather than getting bogged down in the some of the difficulties I experienced on this rotation, I was able to highlight the ways in which each and every moment taught me a lesson. Through my trauma surgery experience, I have grown as a student, future doctor, and fellow human.

I was blessed with an excellent team that taught me about medicine and how I want to be as a doctor. I will always wear this necklace of memories that will help me in my journey in medicine, no matter what specialty I choose.

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Title: Thank you Letter to a Donor _____________________________________________ ANONYMOUS

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Title: Ashes to Ashes Life must one day come to an end. Yet in death, there is life. As the phrase goes, "Ashes to Ashes, Dust to Dust." In honoring the lives of those who have donated their bodies for our learning, we acknowledge that with their death brings about a new generation of physicians who will hold in high regard this life cycle, and dedicate our own lives to protecting the integrity of others' - in birth, and in death.

In the era of the COVID-19 pandemic, where nearly all of our learning is virtual, we must adapt. Through the mental and spiritual resilience we find ways to admire the resilience of the human body, and appreciate the harmony in the new opportunities that arise from this period of adversity. Without the life cycle, without our gracious donors and their families, these opportunities would not exist, and we are forever grateful to them.

In death, there is life. In life, there is hope. "Ashes to Ashes, Dust to Dust." _____________________________________________ Isabel Strouse is a student in the Class of 2024 at the University of Arizona College of Medicine – Phoenix.

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Title: What You Knew (A Thank You Letter) It took me a semester of trying to decipher an unknown person’s life story alongside my classmates via AnatomyTV to realize what a selfless thing it is for our donors to give us their bodies knowing they’ll never meet the people they’re giving themselves away to. It is the ultimate act of vulnerability. _____________________________________________ Meher Rakkar is a student in the Class of 2024 at the University of Arizona College of Medicine – Phoenix.

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I wonder if you knew Whether you would consume me Or if it would be the other way around; Voracious as I admittedly am In my pursuit of knowledge.

You must have known That you, too, would be immortalized In my body of knowledge.

How I would turn to you to heal me When this foundation fractured.

I wonder if you knew As I traversed the rugae of your stomach In search of this sustenance, That you would feed thousands of us In the midst of a medical apocalypse.

You must have known When you pried open your heart's protective rib cage And allowed your selflessness to pour out; Liters more of it than any volume of blood That once coursed through your now flaccid vessels.

I wonder if you knew All the ways you defied our carefully curated expectations.

It was your most human habit; To scream out to the world through slackened cords "I will not be nailed down!"

You must have known That, if not me, then some other student Would need your support to decipher The etchings in the thirty-three vertebrae That once held your head high.

I wonder if you knew That I still did try.

Because it is also human nature To attempt to confine all observations Within a framework of reason.

You must have known That all knowledge begins as observation.

And so allowing yourself to be observed Meant allowing yourself to be known Humbly, vulnerably, and in all your courage.

I wonder if you knew Why we all do this.

Or that combing through cranial tracts Unraveling their projections in lobes, plexus and nuclei Still wouldn't provide me with that answer.

You must have known I would spend weeks making sense of what I saw Trying to reconcile your body with your life.

It would matter to me who you were In order to accept your gift.

I wonder if you knew That your every experience Was immortalized in your body.

Each single step taken changing forever The layers of muscles hiding in your feet

You must have known Because, despite that, it did not matter to you Who you were giving yourself away to.

And for that, you know far more than I. I still have learning to do.

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Title: Dear Donors, thank you. _____________________________________________ ERIK GARBER is a first-year medical student at the University of Arizona College of Medicine – Phoenix. Alongside his study of clinical anatomy, he created Zentangle pattern-drawings with the Art in Medicine program. A sample of these pattern-drawings are placed alongside the appreciation letter to reflect how anatomical relationships as well as social relationships create meaning in medicine.

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Title: High Tops to Short Coats:A Reflection On My First Year of Medical School

_____________________________________________ ALEXIS BAILEY graduated in 2017 with a degree in biology from William Woods University in Fulton, MO. During this time, she also rode dressage through the university’s equestrian program and obtained a minor in equestrian science. Following graduation, she completed two years as a postbaccalaureate fellow in the National Institute for Arthritis, Musculoskeletal, and Skin diseases in Bethesda, MD, where she worked in a lab studying the genetics of rare pediatric inflammatory diseases. Throughout her undergraduate and post-graduate time, she has been heavily involved in hospice volunteering. She is broadly interested in hospice and palliative medicine and geriatrics as well as biomedical research.

Outside of her academic interests, Alexis enjoys running her photography business, caring for her many houseplants, and spending time with her fiancé, cat Maya, and bunny Frankie.

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There is a picture of me kneeling in front of the Azure Window, once off the coast of Malta, eating a chocolate ice-cream cone. To me this photo will always embody the plight of being a middle-schooler. I am wearing high-top “Bathroom Wall” Converse and not-at-all-grungy cargo pants in my attempt to emulate the 2008 aesthetic of Avril Lavigne (a favorite of mine at the time). On top I’m wearing a plaid button-down and a straw cowboy hat, which my mom had bought me the previous day at a tourist shop because it reminded me of barrel racing and Shania Twain. My face looks content, but beneath my ridiculous outfit I was wondering if people liked me or who my teachers would be in seventh grade and if I was doing well enough in school. Would my mom be mad at me for kissing a boy on the soccer field or using swear words?

And how many songs can you fit on an iPod anyway—better yet, how will I pay for them?

I distinctly remember feeling extremely cool, much cooler than my parents seemed to acknowledge, and yet utterly insecure. A striking dichotomy of both child and adult formed the conflict of adolescence. Every day my understanding of “self” unfolded a little more: I was aware of my own knowledge and ignorance; I noticed that my teeth were kind of yellow and my thighs were big when I looked in the mirror; I was pretty sure I had opinions, but I wasn’t quite sure if they were my own or not. I was blissfully unaware of my misguided attempts to be grown-up and yet all too aware of my awkwardness, never connecting the two might be related. After all, I had kissed my first “boyfriend” that year, and I had also built a home for a stuffed camel in my locker.

Fast-forward and I am in the middle school of medical education. The simple, naïve pre-med years are 45

behind me, and ahead of me lies a more competent resident and attending physician. My undergraduate years are elementary school: my meals provided to me by a cafeteria, more naps than I ever deserved, and plenty of time to spend with friends (and horses). As an undergraduate student studying biology and equestrian science at William Woods University, I was aspirational about my future, but still basking in the glow of higher education with no realistic concept of what the future held. Now a newly-minted second-year medical student, I am once again struggling to find my place, yet this time within medicine and not the schoolyard. I feel grown up enough to be a respected member of the medical team and yet too young to make any meaningful contributions, buckled into the Dunning-Kruger roller coaster of I got this! and Wow, I do not got this. Every new concept, experience, and physical exam skill affirms my love for medicine as it simultaneously terrifies me. Will I ever be good at this?

During my fourth session shadowing my community family-medicine preceptor Dr. Heavens, I was tasked with taking a patient history (histor-ies, really, as it was a couple). Panicked, I told Dr. Heavens I was not ready, but he assured me the task was not that bad and also not optional. Ashley the medical assistant pushed a freebie hospice notepad and an old pen towards me, signaling it was time. I knocked on the door of exam room 2 to find a sweet woman in a wheelchair and her husband next to her, staring a bit blankly (I would later learn this was key to his diagnosis of Parkinson’s disease). I nervously introduced myself and began to work through the OPQRSTADA I had learned in doctoring, scribbling down medications I hadn’t yet heard of and details I figured would be important.

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Despite my obvious discomfort, the couple was very willing to answer my questions and indulge a young stranger about their medical history. I attempted to follow up on their answers to the health screening packets the clinic provided for their yearly physicals, but it soon became clear to me I wasn’t prepared for that task. I had no idea how often women should get mammograms or when they aged out of Pap smears.

Nevertheless, a few minutes into the encounter, facing no traumatic event thus far, it suddenly didn’t feel so scary. My friendly yet frightened face seemed to discourage them from asking too many questions: they’d wait for the doctor.

“I’ll be back in with Dr. Heavens soon,” and out the door I went, clammy and relieved. As exhilarating as medicine is, real patients are terrifying—with real problems and no script. I still feel guilty admitting to my anxiety and hesitancy given how badly I’ve wanted to practice medicine for the last many years, but my excitement is not yet a match for the colossal amount of information I’ve yet to learn. Yet as I left the room unscathed, I felt confident in my history taking, and reported back to Dr. Heavens with the information I found. I rattled off prescriptions needed, new symptoms, gone symptoms, life updates— “Great! Did you ask about Cologuard for them?” Well, no…

“Her last mammogram?” Um, no…

“How are we going to keep them from dying of cancer?” Dr. Heavens said with a light-hearted smile, his

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medical assistants looking a little too satisfied at my incompetence. Welp. So much for my stellar history taking skills and the small amount of security I just had in myself. There is a lot of learning ahead of me.skills and the small amount of security I just had in myself. There is a lot of learning ahead of me.

When I reflect back on the past year, I see all of the growth that’s happened before my eyes, like when you walk outside suddenly and the grass looks green for the first morning of the year despite watching it change a shade every day. A regular afternoon of volunteering at Gardner Home, an inpatient hospice and dementia facility, turned into that very day as I signed in, noticing a new volunteer, Hala, present.

“Hi, I’m Alexis,” I said cheerfully, excited to see another young face in the unit. It was her first day volunteering, so I walked her through my approach to visiting patients, assisting nurses, fetching snacks, new straws, mechanical stuffed dogs, and wipes. Three women slept soundly in the living room, covered with freshly heated blankets. With this downtime, I turned my attention to the nurses’ report, fresh off the press from the morning. I asked Hala if she was familiar with these kinds of reports. She shook her head, so I began taking her through the information patient by patient so that we could better understand who we were caring for. As I read through the information and explained things like CVA, MI, mets, malignancy, EOL, and more, Hala listened carefully. She soon looked up at me and said, “Wow, it’s so cool that you understand what this is saying.”

I did? I did… I do.

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Not long ago, this was a foreign language to me. When I first started volunteering with hospice as an undergraduate, I only knew a word or two. I would sit in on interdisciplinary rounds, drowning in acronyms like PRN, NPO, BID, MI, etc. As I read through the report with Hala, I realized I not only could make sense of the jargon but now I also understood on a much deeper level—from the misfolded proteins accumulating in patients’ brains to the changes in the blood brain barrier to the pharmacology of pain medicines that were used to palliate at the end of life. The emotional connection of patients that drew me to hospice and medicine as an undergraduate student was now augmented by the science and physiology I’d learned in just one year of medical school.

The opportunity to understand medicine emotionally and practically keeps me motivated to learn, even when it feels most difficult. “Do you think this new coronavirus will be a big deal?” I asked a friend back in January. She wasn’t sure, but at the time we both hoped it would remain relatively uneventful. The first day of cancelled classes felt a bit like a snow day—an exciting break from reality but surely life would resume quickly? I feel stupid for feeling that way now that the pandemic has escalated and I head into my third block of online medical school.

Finishing the year through Zoom was certainly not the way I had envisioned ending my first year of medical school, but alas given these unprecedented times we have all found a new reality. It’s a little junior high of me to be concerned about myself—to worry about how this will affect my CV or my preparation for STEP1. But 49

I’d be lying if I said those things didn’t worry me. Fortunately, over a decade of frontal lobe development since middle school has given me the ability to be both uncertain about my future while also recognizing that I am very fortunate to be healthy and safe in my home, relatively unaffected by COVID-19. The pandemic will freeze 2020 in my mind like any emotional memory and contribute to the future physician I become.

In the end, there is something reassuring about the middle school of medicine: I already survived once.

Maybe not the medicine part. But the middle school part, yes—despite every awkward encounter, wrong answer, embarrassing moment, and weird change, I survived middle school to reach high school, then college, then medical school. I sometimes find myself wishing I could fast-forward, to be an attending confident in my knowledge without any of the pain that comes with learning and growing. But I know that these in-between, adolescent times are crucial to the development of my own values, resilience, and viewpoints, as if I am nestled in a cocoon of experiences, protected by the institution of medical school but awaiting to emerge a full-blown physician.

Sitting in Malta eating my ice-cream cone, I had no idea I would someday be a 12-years-older version of that same girl in medical school: excited for the future but worried about who I am and who I am becoming.

Fortunately for everyone, I ditched the high-top Converse and straw hat for a short white coat and a stethoscope.

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Title: Connections A reflection of what it felt like to learn about the human body through a computer screen, always connected to an extension. Seemingly one degree away from the real thing, yet colorful and fascinating nonetheless.

A reflection on adaptation, and what it means to find different ways to complete the circuit when all else fails.

Virtual school is not a fun experience, and I experience burnout on a seemingly weekly basis. But it’s getting done, and I will come out of this stronger, more whole, more resilient.

More Connected. _____________________________________________ Daniel Oheb is a student in the Class of 2024 at the University of Arizona College of Medicine – Phoenix, and the founding editor of “Graphic Medicine Collections: The Intersection of Art & Stories at the UA COM-P found at https://www.uagraphicmedphx.com 52

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Title: A Patient of a Different Kind _____________________________________________ DR. SARA POUSTI is a first-year Psychiatry Resident at the University of Arizona College of Medicine-Phoenix. This piece was written during her time as a medical student at the UACOMP, and originally published as part of the "Stories in Medicine" blog that she co-founded, available from: www.tinyurl.com/storiesinmedicine

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By the door I go, for she’s about to walk into a failed code.

The way is paved for her, She’s moving too confidently, She’s moving not urgently.

My pace trying to match the rate in which her concern denatures to devastation.

She walks in, suddenly on her knees.

The same hands that pounded on her daughter’s heart are now tightly wrapped around her side, trying to lift her to a chair, a chair that a nurse placed nearby.

She screams into my neck— A sound I’ve blocked but my body still feels, Even now, feels the vibration of a sound so wretchedly animal, yet so specifically human.

A sound that was patented for this moment, otherwise never to be summoned.

She speaks two languages, yet cannot find a single word for this.

My gloves are filled with perspiration as I clench my fists, so that she doesn’t feel a tremble.

“Time of death—“ The raw, unfiltered cry of a mother’s worst nightmare fills the room and spares no one. Even the seasoned ones.

Everyone clears the room for respect.

I follow suit but my heart is on it’s knees, next to her chair, beside her bed.

I look back to this mother and with such authority I want to say, “We have a new patient in this room, someone needs to stay."

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Title: Sick or Not Sick _____________________________________________ DR. RICHARD CUNNINGHAM wrote this piece at the end of his fourth year of medical school. He is currently an Emergency Medicine resident at Maricopa Medical Center. He graduated from The Ohio State University College of Medicine. Professionally, he is interested in airway management, critical care, ultrasound, and global health. Outside of medicine, he enjoys lifting weights, mountain biking, camping, learning languages, and reading.

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“Sick or not sick?” This is the question that preoccupied me throughout my emergency medicine sub-internships. Simple in concept, yet vexing in interpretation, save for the extremes at each end of the spectrum. On my away rotation, I am easing into the rhythm of an evening shift and browsing the board for a new patient. One pops up whose triage vitals are all highlighted in red: febrile, tachypneic, tachycardic, hypotensive, hypoxic… this patient is sick, is my immediate impression.

Eager to discover what the chief complaint of “SOB” would reveal, I head over to the room while the nurse is placing the young mid-20’s female on monitors. This patient is sick, I think to myself again as I lay my eyes on her for the first time: cachectic, chest heaving in and out with each breath, and a glazed-over look in her bulging eyes, betraying a mixture of confusion and panic. I ask her what brings her in and receive a myriad of complaints: “I can’t breathe,” “My back hurts,” “I feel weak….” This patient is sick. The history is difficult to draw out. The answers I get are either tangential and confused or single words uttered between labored gasps for air. “Let’s give her some oxygen and fluids,” I tell the nurse, feeling confident for stating the obvious. I note petechiae on her legs and my mind (freshly indoctrinated by the study of USMLE questions) zones in on meningococcemia. Sepsis, no matter the cause, seems to stand out for sure. I ask her if she has ever used drugs and she says no. I note a strange rash on her forearms forming random knots over her skin; maybe there is some autoimmune phenomenon going on?

I quickly finish my exam and present to the attending. After stumbling over the multitude of symptoms and findings, I get straight to the point. “This patient is sick,” I bluntly conclude. We go in together, and the attending examines those peculiar bumps over the antecubital fossae and asks if she has ever used drugs.

Her mother, silent up to this point, interjects: “Honey, when was the last time you used?” “Tuesday,” she replies, hesitant to make eye contact with us as she does. Track marks, of course, I realize, admonishing myself for my naivety. Endocarditis, likely fulminant, jumps to the top of the differential.

After leaving, I apologize to the attending and swear that the patient denied drug use to me. She calmly responds that she believes me and it is likely the patient was understandably afraid that she would be treated differently if we knew she was a drug-user. The attending tells me that she has never seen such a late-stage presentation of this disease process, and I am lucky for getting to see it as a medical student.

While she is correct, I am indeed fortunate for encountering such a sick patient and witnessing such a late-stage (what I fear to be end-stage) presentation, it is obvious that the opposite is true for the patient herself.

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What struck me as most disturbing was her initial denial of drug use. She was afraid of admitting it to us, likely for fear of being treated as “just another drug addict.” At this thought my mind jumps to a few weeks prior; another patient with a history of IV drug use expressed gratitude to me and my attending for “treating her like a human being” after draining an abscess. Looking back, I can’t help but wonder if at one point she was not treated like a human being by a healthcare professional. I then imagine our current patient having a similar unpleasant interaction that led to her hesitancy to seek out help for her illness, despite weeks of progressive and debilitating symptoms.

The chest x-ray comes back showing diffuse bilateral opacities. The patient is started on PPV and IV antibiotics and is eventually sent upstairs to the ICU. While we have done what we could, the situation looks grim. The next day, I come in early for the morning shift and look up the patient to check on her status; that dreaded warning that I am entering the chart of a deceased patient flickers onto the screen.

While dejected, I cannot say I am surprised. I review the bulky vegetations revealed by her echocardiogram and the cannonball septic emboli found on the CT of her chest. This patient was sick, and now this patient is dead.

Compassion comes easily to a bright-eyed, fourth-year medical student on his or her emergency medicine sub-I’s. The patient with a history of IV drug use requiring an I&D is easy to treat as a human being, not only because she is indeed a human, but also because I am a green and eager physician-in-training who is excited by the opportunity to perform the simplest of procedures. But in a field with arguably the highest rate of burnout in medicine, I fear that one day my compassion will falter.

After all, the odds are stacked against me.

If there is a silver lining to this story it is imparted in the following lesson: treating patients with dignity saves lives. If this patient had not feared the stigma associated with drug use and anticipated reprisal from those on whom she depended for life-saving treatment, she might have come in at the onset of symptoms, not weeks after the fact. We might have saved her.

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Title: Encounter I stumbled onto a YouTube video during the pandemic that I wish I had never watched. It featured a praying mantis laying-in-wait at a hummingbird feeder. The video begins with five seconds of beautiful mantis stillness. An unsuspecting hummingbird, shimmering in jade green and ruby red, hovers into position for a feeding of sugar water. The mantis abruptly grabs the bird from the air and positions the head close to its mantis mouth. . . I will stop there.

Weeks later, I found the subject of this photo quietly positioning itself on a pumpkin. The scene reminded me of the video. I was as fascinated as I was sickened by what I might see if I observed long enough. ____________________________________________ DR. JONATHAN CARTSONIS earned his medical degree at the University of Arizona-Tucson and completed his residency in Family Medicine. He has worked in many different settings, including the federally funded clinics Avondale Family Health Center and Health Care for the Homeless. He currently cares for patients at the Estrella Women’s Jail in Phoenix. He is faculty at UA College of Medicine-Phoenix where he is highly involved in the Pathway Scholars Program and is Director of the Rural Health Professions Program.

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Title: PB&J When everything seems lost, and no answers given for why, the only thing one can do is to find solace in giving of oneself. ____________________________________________ DR. DAVID BEYDA is a published writer with 3 books and national awards for essays. He started writing in high school and found his place of calm while writing. He writes using a fountain pen and a typewriter.is a published writer with 3 books and national awards for essays. He started writing in high school and found his place of calm while writing. He writes using a fountain pen and a typewriter.

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Martha Clements, a pale, simple person with bright, deep-set hazel eyes, was frail. She was a modest dresser, looking homely at best. Her pinched lips and thinning hair did nothing to give her any semblance of beauty to even a marginal level of being attractive. She covered herself up with a turtleneck sweater, a pleated skirt, leggings, and no makeup. She had always been an introvert, with a lack of self-esteem and a conformist. She was cursed with a fear of being touched or recognized. Being an atheist, she had a spiritual quest that was elusive. She often had pathological religious visions and delusions, causing her mental uneasiness. The devil was close by. Brought up by an abusive father and an alcoholic mother, she had little chance in life becoming her own person. She had no hobbies, no friends, except for her books.

Martha had a Master of Library Science. She found herself intrigued by the rare book antiquities one year while working as a librarian in a Jesuit university. She got a Certificate of Proficiency in Rare Books, giving her an open the door to a few sought-after spots in the rare book sections of private and public libraries.

Despite her degrees, she could not find a job in a library and was hired as a rare-book expert and consultant at the Alcuin Rare Books store.

Bro. Julius Verhelst, fifty years old and a Benedictine monk for thirty years, was still struggling with following his road of faith. The road was full of potholes, cracks, and bumps, and yet, he took that one even though, right next to it was a newly paved one, just recently opened, and shiny new. He started slowly, easing onto the road, hitting the first pothole, and thinking, thinking for just a moment,

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that he best turn around. But he didn’t. The road was passable if done so with caution and patience. The road had no turns, a road that was straight and what seemed without end. That road one would think was his life, but not so. That road was his mind as he traveled through his character of what he was and who he wanted to be. The “what” was the broken, potholed, bumpy character of a man lost. The “who” was found at the end of that potholed, bumpy road, a humble servant to a God who he wasn’t sure existed.

And that is where he was now at the St. Aurius Abbey in California. He wore his cassock, missing the dress of contemporary men. The loose-fitting ankle-length garment was rough and uncomfortable, especially since no undergarments were worn. His bardocuclullus, his hooded cloak, was also uncomfortable. He often wore his cilice, a hair-cloth shirt, for penance as well.

His role at the abbey was that of “cartulary.” The keeper of the monastic records. He had been at that role for the past thirty years and didn’t expect to be anything other than a cartulary. And not that he would want to unless he could become the librarian for the abbey. He loved books and spent as many hours as he could in the library, absorbing everything he could. He had questions looking for answers that were not being revealed. He had recently put down a deposit, taken from his trust fund, at the Alcuin Rare Bookstore, for a rare four volume collection of 15th century bibles with answers hoping to be found in them.

The Alcuin Rare Books bookstore closed without warning. She had hoped to buy the store one day. A sign on

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the front door said, “No one buys, therefore no business, therefore we closed.” Martha looked at the sign, read it, and turned away. Today was payday. Today was pay the rent day. Today was buy the groceries for the week. Today was the day that her life ended. Her studio was less than modest and fit only for the cockroaches that lived there, never having to pay rent. The landlord was not accommodating, demanding the rent because it was due with no exceptions. By 10 am that morning, he evicted Martha from her studio. Carrying her small suitcase, she entered the street, looking left then right, chose left and started to walk.

The weather had sucked the life out of her, her face wrinkled, dry, and leathery, with eyes faded from the chameleon hazel color. No name. She may have had one, but no one knew what it was other than the one given to her by those who saw her often at the homeless shelters: “Miss Stinky pants.” She was like an apparition, sometimes appearing and leaving the same way. This emaciated, frail, stunted woman, droopy-eyed, with pinched lips and sunken eyes, was grotesque to some and invisible to others. She was indifferent, a ne’er-do-well sort of person who had craved alcohol and a compulsion for wandering, dissatisfied with life. She was against society and herself. In her past, she had a made-up faith that protected her from the demons that she knew were after her. She felt them and even saw them, their long arms reaching out for her, beckoning her to join them. She sought refuge from them, turning to prayer. As an atheist, that didn’t work so well.

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An association of spirit, or as some call it a “divine coincidence,” found Bro. Julius and Martha coming together. She was seeking something that was missing, he was seeking something worthy of his conviction as a monk.

She walked up to the large doors that welcomed all who came to the abbey. She was not sure how and why she was there now. A path had been placed in her mind, which she followed, like a lost dog who knew where its home was, and with no directions, found its way back to a home remembered. She knocked and stood back.

Bro. Julius answered and was struck with what he saw, his heart opening up to the realization that this was the moment that his conviction of virtue was being tested.

She didn’t say a word, nor did she look at him. A dirty and torn piece of cloth covered her head.

“We're serving dinner now, and there is an open bed for you.” Bro. Julius said, hoping she would come in.

She raised her head and let her head covering fall back. Her slant-eyed look, daring him to continue, made him quiet. She smelled pasty. Bro. Julius breathed through his mouth, trying not to show emotion. Her hand was out, her fingers curled in a pretzel-like twist, seeking alms.

“Can I get you something to eat? A peanut butter and jelly sandwich, at least? Come in, and I’ll make it for

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you while you take a shower and put on some clean clothes.”

She didn’t reply.

“All right, I’ll bring you the sandwich then,” he said, turned, and left the door open.

Returning just a few minutes later, she was gone, the peanut butter and jelly sandwich in his hands. He closed the soul a failure, and a wave of anger began to tornado down his mind as he went back to his small room and knelt.

“Abba. What is the meaning of hurt and abandonment? What is the purpose of loneliness? How do you choose some to live well and others to live as they die every day?” he prayed, his voice filled with anger. He became silent, not wanting to say more, as he sat on his wooden chair and waited until vespers.

Light from the eastern sun was breaking through the low-lying clouds. Bro. Julius had tried hard to pray and chant with the other brothers during vespers but could only think of her. The early morning prayers over, he walked to the front door and opened it. There lying at the doorstep was a woman covered by a tattered sheet, her head hidden. Kneeling, he touched her. No movement. Cold. Stiff. She had died many hours before, outside the door.

Waiting for a peanut butter and jelly sandwich.

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She was buried later that day in a potter’s field. No name, just the date of death crudely engraved on a metal disc no larger than a saucer, that marked the patch of dirt that was her resting place. Bro. Julius was the only one other than the local jail gang there who were the burial crew for the unidentified, the poor, and the unclaimed. He said a brief prayer as they lowered her into the earth, throwing dirt on her simple pressboard casket covered in blue felt. Placing his hand in his pocket, he felt the sandwich. Taking it out, he placed the peanut butter and jelly sandwich on her grave, turned, and walked away.

“The bitterest tears shed over graves are for words left unsaid and for deeds left undone.”

--Harriet Beecher Stowe

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