SCOPE Volume IV: 2014

20 20 13 -scope-14

UT Southwestern’s Humanities Journal

SCOPE 2013-2014 • Volume IV Editors in Chief Alexandra Quintanilla Emily Rosenfeld Tyler Ellis Smith Faculty Advisors Lynne Kirk, M.D. John Sadler, M.D. Jim Wagner, M.D.

Junior Editors Heidi Kim Shelly Xie

Contributors Anonymous

Bethany Johnston

Lewis Chang

Nate Milburn

Nancy Guo

Evan Ross

Rosy Hao

Shelly Xie

Amy Ho

Andy Yu

Front Cover Art by Lewis Chang 2

Letter from the Editors 2013-2014 Greetings!

Welcome to the fourth issue of SCOPE, the medical humanities journal of UT Southwestern. We are proud to announce that this is the first issue of SCOPE to be made available online in a pdf format for your reading pleasure. Additionally, SCOPE will soon become incorporated into the Medical Humanities Interest Group, where we will continue to publish the wonderful pieces of our contributors annually.

This issue proudly boasts pieces from the visual arts, poetry, and short fiction/nonfiction compositions.

As a medical humanities journal based in a medical school, you will find many of the topics in this issue set in medicine and science. We hope that you will appreciate the struggle many students experience in maintaining humanity and empathy in light of such difficult training. Far too often, doctors are considered uncaring, a quality that many feel is engendered in our training and practice. Students often express the sentiment that they feel like a shadow of their former selves: uncaring, and cold. The pieces enclosed, and this journal itself, are made in attempt to express, regain, and improve upon our compassion and humanity that brought each of us into this remarkable field of study.

The editors would like to thank our faculty reviewers and authors for their time and effort in producing this journal. It has been a joy to work with you and produce this issue, which we sincerely hope our readers will enjoy. We hope that this journal will inspire our readers and authors to explore their humanity, and maybe even submit a piece for publication next year!

Editors in Chief Alexandra Quintanilla Emily Rosenfeld Tyler Ellis Smith 3

Table of Contents 2013-2014 • Volume IV Skull– Lateral ……………………………………………… Page 6

By Lewis Chang Spinal Muscular Atrophy …………………………………… Page 7

By Bethany Johnston Internal Medicine …………………………………………… Page 8

By Nan Guo Skull– Inferior ……………………………………………… Page 10

By Lewis Chang For the Wrong Reasons ……………………………………… Page 11

By Anonymous Hands …………………………………………………….. Page 17

By Lewis Chang Neglected: A Story of Schistosomiasis Infection in Ghana ……….. Page 18

By Shelly Xie On Becoming a Doctor ………………………………………. Page 21

By Amy Ho Skull– Interior ……………………………………………… Page 24

By Lewis Chang 4

Eye and Larynx …………………………………………… Page 25

By Lewis Chang Shadow Play ………………………………………………. Page 26

By Rosy Hao Skull– Anterior …………………………………………… Page 28

By Lewis Chang Sirens ……………………………………………………. Page 29

By Nathalie White Third Year Reflections ………………………………………. Page 30

By Andy Yu Woman in Pose …………………………………………….. Page 35

By Nate Milburn No One Dies Alone ………………………………………… Page 36

By Evan Ross Contributor Bios …………………………………………… Page 38

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Skull– Lateral by Lewis Chang 6

Spinal Muscular Atrophy

By Bethany Johnston The silent heirloom fest’ring in the boughs By lots wrought pestilence upon the leaf And though, forbearing since, must here endow Disease in birth which rails and spoils with grief.

What voice coerced the spine to bend aside, The legs to sleep in dreams and not obey?

Yet you, sweet child, are not so warped as I, Who foiled, not suff ’ring, turns, rebukes the day.

This giddy smile humiliates my frown.

Affliction gives your cheer more charm than mine.

How did this supple hand to me come down?

Like Briony I ponder life and line: Do you inherit this which lifts your face, Or did your soul float from some other place?

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Internal Medicine

By Nan Guo For one month this spring, I rotated through Dermatology. Perhaps because the specialty is visible and tactile in such an intimate way, the stark reality of what we sometimes do to our patients – not just for our patients – became very apparent to me.

One memory that has stayed with me involved an elderly gentleman from a nursing home. Thin, frail, and unsteady, he arrived with a past medical history significant for skin cancer, status post a Mohs surgery that resulted in the partial resection of his jaw. Per protocol, he was here for a routine skin check. I talked with him then started to examine him, head to toe. His hair was thin, light, and fine like that of a baby. His face and ears were speckled with small hypopigmented scars, an attestation to a lifetime of cancerous and precancerous lesions, removed by cryotherapy or biopsy. But what was most striking was the left side of his face, where the angle of his jaw was removed. The skin sagged over a wide concavity, as if that area of his head had been punched in, like in some silly cartoon. He wasn’t just physically fragile from age and wear. He was emotionally fragile. To all questions, he replied with a timid “okay”, as if he were a child, and as if agreeing was the right answer. “Sir, is it okay if we biopsy this small area? We’re afraid that it might be a small basal cell.” “Oh, okay.” We finished the exam, and we finished the small biopsy that we had decided to perform. Then, as the clinic was about to close, we simply said, “You’re all set now. You can go whenever you’re ready.”

And we left him to slowly change back into his clothes and leave the clinic, all alone.

Comparable examples can be found in other fields of medicine after extended hospital stays, rounds of chemotherapy, or just an energy-sapping bout of pneumonia. Whether it is a result of the disease, the treatment, or the accompanying immobility, patients are often left to face extended periods of rehabilitation and/or scars to remind them everyday of what has happened. Worse, the debilitation and the scars remind them that they can no longer function as they once did, that they are no longer perfect. As physicians, we try to patch these patients back up with plastic surgery, supplements, or even just more pills. However, in the case of Dermatology in particular, completely scar-free procedures are impossible, and scar-minimizing procedures are often too expensive. Ironically, the fear of having to undergo the same treatments again may very well be what keeps the patients 8

coming back to us. In return, we as physicians decrease the risk of further disease but without absolute guarantees. Particularly for those patients without strong support networks, this vicious cycle results in a willing but heartbreakingly self-defeated relinquishment of patient autonomy.

I am not sure of how to break this cycle. The treatments we offer are generally necessary and good. For my patient, he likely would have ended up with an aggressively invasive – if not metastatic – cancer if he had foregone that initial surgery.

On the other hand, physicians are not gods. When clinics are overbooked, and the end of the workday is approaching, our most immediate thought is often to prioritize the necessities and then move on to the next patient. However, perhaps we can lessen the hurt and give those emotionally beaten patients a sense of dignity and control by spending that extra minute or two to talk with them about themselves.

Our patients need to know that their physical imperfections do not make them imperfect human beings, and we need to affirm their lives by showing them that they are important and worth our time.

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Skull– Inferior by Lewis Chang 10

For the Wrong Reasons In memory of H.H.

By Anonymous The old man begins taking his first assisted breaths, the whirr of the ventilators and the chatter of the operating room staff being drowned out by the cadence of the steady puffs. The surgeon stands sentinel in the corner, staring quietly as he removes his ring and badges.

It is a moment of fascination apart from formality. When the patient had given his consent for the surgery, he couldn't help but notice how calmly the old man and his wife accepted the risks. They had replied in unison to his queries, almost as if they transmitted thoughts between their white hairs to each other. He had wanted to see what made them so unafraid of death that they would throw themselves into his hands- to gain more than a fleeting connection, to ask them how.

The moment was long over. Time to begin the ritual.

He steps over to the scrub sink and whips the sponge over each of his fingers exactly fifteen times. Next his wrists and elbows, imagining that he can see the filth streaming from his body and puddling in the yawning metal below. His thoughts start to race and nearly come bubbling up from the drain but they’re halted by the white foam dripping placidly down the walls of the sink. Thank God for that. No need to scream obscenities to tune them out.

Returning to the table, he raises his hands in supplication as the circulator's music plays.

"Turn that shit up," he says mechanically.

He's never heard the song before. It sounds like every other club track he's heard: bass thumping and synth brassing. He gives enough of a fist bump to show that he is cool and the scrub tech grins and gowns him. Enrobed, the whine of the speakers fades and gives way to the pulse pounding in his ears and he almost feels the hot breath at the back of his neck again. The anesthesiologist glances over and the surgeon tosses his head carelessly in acknowledgement of him as he surveys the prepped abdomen.

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Noting the scowl on his face, the OR staff resume their banter, ignoring him.

They sense that he wants to be left alone during these cases. He wishes that he could tell them that it is all primal fear, that he wants them to talk him down.

Maybe they would get the hint this time around.

Amid the drone of the circulator's TIME OUT he receives the scalpel and draws a straight midline incision. Gently, he guides the knife deeper into the belly; his hands are steady. Exhale. Smooth sailing. There goes the sub Q and the Camper's and the Scarpa's andThere’s a bleeder. He tries stanching it away but the thin trickle of crimson reappears as if it had been meant to flow in perpetuity. Automatically he grabs the bovie and zaps it quiet but his wrist jerks imperceptibly and catches a bit of the furling skin. Christ, the smell. The same odor as when- but no, this situation had to be different. He had to be different. Had to be.

Finally the bowels are lying draped across the table, glistening and moving idly in disembodied bliss. He caresses past the ligament of Treitz and begins his search hand-over-hand.

Thwap. Thwap. Thwap.

Not a word has been uttered for the past half hour. Thwap. Thwap. The walls and his companions fall away and he is standing alone at the table, the room lights glaring harshly at the scene below. He suddenly tastes salt. Shit. He's unsure whether it's sweat or tears but it's still strikethrough‌ ...strike three, someone shrieked as the pitch smacked into the mitt behind him.

He was a scrawny thirteen-year-old again. Shortest among the other players, he was getting his second time at bat in the past two years, finally getting away from right field. He had spent hours in the cages, wobbling his uncoordinated elbows and wrists and feigning deafness to the jeers from his teammates as he swung helplessly at ball after ball.

It was Coach's decision to exhibit him this way and let him play- only when they were up 3-0 with bases loaded- because he was doing him a favor. Only from the goodness of his heart. And he has struck out, not even lifting his bat, paralyzed with anxiety. Tears streaming down his face, he had thrown his helmet and ran, past the dugout and all the way back to the locker room. He hid amid the abandoned duffel bags and moldy socks for several hours until he heard the familiar isolated heavy footsteps coming for him. The lights clacked on and Coach was looking at him hard.

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"You promised to be a man and swing."

He did not reply.

"You know what happens to liars. Be a man and maybe your parents will come to the next game. Nobody wants to see a faggot play."

He closed his eyes.

His lids pop open and he has found the rock hard mass. Confined.

When in doubt, cut it out. A chance to cut is a chance to cure.

Looks like a little football. Would it veer to the left and stay airborne for only a few feet if he chucked it? Better not think of that.

The only way to heal is with cold, hard steel.

He's got the thing out now. The anesthesiologist, circulator, and scrub tech let out simultaneous low whistles and crowd around the slop pail where the footballshaped mass is resting. Obligatory jokes about quick weight loss results ensue. He starts stitching and the needle bites its way through the upper pole of the football.

"This is therapy," he says, hoping that someone will pick up on his true meaning, on how this is all as much for him as for the patient. No response.

After he throws the first knot down square, it’s as if he’s suddenly staring at his cross trainers, laces untied after getting fucked, back aching from bending over.

The shower room was dark and dripping in the quiet cold of the night.

"You'll thank me for this later in life. I'll call your folks since you had to stay behind. Practice lacing those shoes so your coordination gets better," the voice instructed.

He fumbled with the mud-stained bits of rope over and over until they form a perfect bow.

Next, it’s seven years later. He was getting ready to start college, boxes neatly packed up, stuffed animals thrown into the closet. A syringe is positioned over some vessel coursing over his swollen bicep, one which he learns later to call the cephalic vein. No one had a clue about his crutch, how heavily he leaned on it. He was the last one anyone suspected of being a druggie. Even when the kids of CEOs had dogs sniffing through their lockers, the principal had specifically exempted him 13

from the screens.

“You’d never have the guts to do something this bad.”

How right he was. He’d always snuck outside his house in pitch blackness, hands shaking as they spun the lighter striker. Thinking of baseball. Maybe today would be different. He had bought some black tar from one of the anonymous cliquesters, made sure it was witnessed. Fantasizing about the hardcore reputation in his destiny, he jabbed the needle downward as death metal screamed in the background.

And then he coded, was medically dead for the next ten minutes. Dead to his parents for good.

Snip. The suture is cut sharply leaving two short tails for the pathologist. A sudden premonition sinks in the surgeon’s gut, and looking around sharply he waits for his audience to react. Did anyone catch that? He’s sure they know, that they can see the piled-up hate at the opposite end of his eyes, but they hide it damn well. Everyone’s back at their stations now that the football isn’t in play anymore.

Good timing. A large branch of the patient’s arterial arcade has popped open, ejecting rivulets of blood down the plastic drapes onto the floor. He murmurs thanks to a God he no longer believes in and grabs a tie and hemostat. Swiftly, he lassoes the gaping red mouth shut.

If only it were his.

He is sucked back into his dreamtime. He’d managed to piece his grades together and was on the interview trail when he saw him again. It was unmistakably him.

Hanging around the seediest dive in town, waiting for easy pickings. His carotids still bounded whenever he thought about it. Through some freak of alcohol fueled memory Coach had recognized him, barreling across the room in drunken exultation.

He steeled his core and threw him flat on his face. Coach stared unblinking at him for a moment and burst out with laughter that shook the droplets of blood away from his nostrils and lips. Standing over him, he had felt for the knife he’d taken to carrying, but all he could imagine was a rejection letter from medical school. He stormed away before any of the bewildered onlookers could make a move. Got in his car and kept driving.

He’d burned a tally mark on his shoulder for each year Coach went unpunished.

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As he gains proximal control the old man moans imperceptibly and automatically the surgeon replies, "It hurts me as much as it's hurting you."

The scrub nurse jerks up at this and stares at him with a mix of horror and pity.

The surgeon averts his eyes but he feels her gaze on him and again he is lost in memory.

This time, he’s at his ex-girlfriend's apartment, naked before her.

Of all of them, she was the one who understood the best. He shudders.

The night he learned where he’d be going for residency. He’d been meaning to come clean to her for months but was delaying the revelation until this moment, when he could couch it with the most positive news he could think of. For months he had slowly been revealing parts of himself that nobody could fathom were buried inside.

Except her. Those little moments of recognition made him deliriously happy. He was awaiting this transcendence feverishly, the night of the big reveal.

He started by explaining the brown vertical stripes on his shoulders, reeling the timeline backwards. He spun her a story that left nothing to the imagination. He told her the most unadulterated truth he knew, even more secure in its immutability than in gravity. He was almost on his knees in confession and groveling. From that room he watched, calculating and cotton-mouthed as he awaited her response. She said nothing for several minutes. Then: "You're better now. You're successful."

He is sure his voice had cracked when he told her thanks.

The filth came washing back and invaded his body as he woodenly made love to her for the last time. He went home and never called her again.

The artery is subdued with a nice stick tie and he waits for that jolt of pride of the conqueror. He had learned to accept it as inevitable. His training had taught him that.

His hands are steady now. It wasn't the same feeling, he told himself. What he did for a living was creation, repair, a noble cause- whatever he felt was different. Had to be. Only happened to coincide and reuse some of those old Pavlovian circuits. As long as he remembered they existed as parallel entities he would be able to control them– and himself.

Was he off of the road to destruction, or did he merely swap it for a more cir15

cuitous route?

The moment is long over, his thoughts coming back to the stapler anastomosis and the techno music returning suddenly as if on cue. He closes the abdominal wall in layers, working quickly and efficiently. His fingers smooth out tumbles of the suture and twists of the flesh. One more tick mark in the register.

He mops up the last trickles of coagulated mess and gift wraps it with some gauze. He looks up and realizes he has completed the operation in record time.

"A machine, a real Tin Man," remarks the circulator as she helps him break scrub and liberate the old man from the table. "We need to get you a heart one of these days."

The OR staff are quiet with their eyes averted. He grins, teeth bared in defiance. He is glad the mask is covering the savagery beneath. Better to leave them unsatisfied.

There was always the next performance.

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Hands by Lewis Chang 17

Neglected: A Story of Schistosomiasis Infection in Ghana, Scenes 1-5

By Shelly Xie EDITOR’S NOTE: these scenes are stills from a larger performance piece. To view the entire work, please visit http://m.youtube.com/watch?v=lo1cRLdqKq4

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On Becoming a Doctor: Excellent Medical Student, Terrible Clinician

By Amy Ho You enter medical school wanting to help others, but exit wanting to help yourself There is a saying that you enter medical school wanting to help people, but exit it wanting to help yourself. It may be a cynical view, but a realistic one. The criteria to being a good medical student are far different from being a good doctor. Medical education may be breeding a legion of self-serving, grade-grubbing, SOAP-note spewing machines rather than the “empathetic”, “compassionate” and “caring” physicians of admission essays yore.

I was no different. My first two years of medical school, I was largely a disinterested student; I didn’t care for basic sciences, research or pathology. Like many others, my knowledge waxed and waned with the test schedule, and after Step 1, I entered my clinical years an acceptably successful medical student.

Excellent student, terrible clinician Third year (MS3) begins a reign of terror lead by the constant gauntlet of heavily-weighted rotation grades, standardized exams (NBME Shelfs) and the looming threat of residency applications and ‘Match’, when, after 20 years of schooling, some pie-in-the-sky computer would tell me if I was good enough or not to be a doctor, and subsequently determine my life for the next three to seven years.

Grades were a priori to make myself the most competitive residency candidate possible. I studied and worked hard. Each patient became an opportunity for me to impress on notes, rapid-fire oral presentations and predict nuanced ‘pimp’ questions.

I learned to charm patients just enough that they’d acknowledge my “care” to the attending during rounds; I interrogated my patients just enough to write the excellent notes I knew I’d be evaluated on; I “learned” about my patients by memorizing their daily lab values to proudly recite on rounds.

Patients weren’t people with problems but stepping stones to rack up points with the attending. Once rounds were over, patients became time-sucks from shelf 21

studying time, an exam worth 30% of every rotation grade. Real humans do not follow textbook presentations, but exams do; the warm body in front of me only detracted from my evaluation by cold scantron. By my attendings’ clinical comments, I was an “excellent medical student”, but I knew I was a terrible clinician, rehearsed only in the games of academia, not medicine.

How I learned to stop worrying about the ‘Match’ and love patient care My shift in paradigm came with a shift in career path. My worst fear as a fledgling surgeon was not ‘matching’ for a residency spot. My worst fear as a fledgling emergency physician was killing a patient. Suddenly playing doctor became very real, and in the middle of my OBGyn rotation, I started to care not about textbook presentations but real-world ones. I didn’t care for OBGyn and volunteered to cover the peripartum critical care unit, a similar environment to emergency medicine (EM).

My first day on the unit, I saw a patient roll in as I was in the middle of practice questions on the computer. I glanced up but returned to my test preparation, justifying my delay in evaluating the patient because the resident was still in surgery.

Half an hour later, the resident came to evaluate the patient and I followed - the patient was obtunded, hypotensive and sitting in a growing pool of her own blood. It would not have taken a MD to realize that this patient required immediate medical attention, and I kicked myself for not evaluating her sooner. I may have been a pretend doctor, but it finally struck me that I was a pretend doctor on very real patients.

For the rest of my time in the unit, I made it a point to personally round every hour, on the hour, on every patient. I didn’t always write notes for these hourly rounds – getting credit was no longer important to me – patient care was. While they initially questioned my obsessive rounding, the residents quickly came to trust my dedication and leave me to my own in the unit, knowing I’d alert them if necessary.

At my institution, hell hath no fury like an OBGyn resident unnecessarily interrupted, so I spent my time reading on appropriate treatment courses for the different conditions I saw in the unit. After I rounded, I’d give the resident a list of orders to put in; the nurses began to treat me as the main provider in the unit. I got to be the first person to make critical medical decisions, sending patients to the OR STAT, activating mass transfusion protocols, calling codes, and truly impacting patients’ treatment courses. I pulled long hours and hardly studied in the traditional sense with prep books and practice questions, but I was constantly reading on my patients. I aced that Shelf exam and got the best evaluations of the year, from some of the notoriously toughest residents in the hospital. I had learned to stop worrying about the ‘Match’ and love patient care.

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Not “just” a student After that revelation, I fought to earn more responsibility and trust on each rotation; I learned more, gained competence and became more satisfied in my chosen career in medicine. On emergency medicine, the specialty that started it all for me, I learned more medicine in one month than I did in my entire third year. It was a pass/fail course with no motivation by grading, but I was terrified I would be the first person to evaluate a patient and not recognize a critical condition. That hemorrhaging patient from day one on the peripartum critical care unit still haunted me.

People can decompensate quickly and unpredictably – at any moment, you may go from being “just” a student, to being the only medical provider in the room.

At the end of that rotation, I aced Step 2. Behind each question I’d see faces of patients with that exact presentation; behind each answer choice, I’d see the clinical consequence of making the wrong decision. Finally, I understood what it meant to be both an excellent medical student, and (at my level of training) an excellent clinician.

The academics of medicine often makes us forget the “59 yo AA M with pmh CHF dx 2010 (EF 20% by TTE 8/2013) p/w SOB x 2d” is a real person, with real vulnerabilities and real fears. We are not “just” students, but trainees and members of the medical profession. Grades and exams do not define us, but are simply checks on clinical competence. Trite as it may be, remember what you wrote about in your admissions essay – why you embarked on this journey in the first place. We came to medical school not to become excellent medical students, but to become excellent doctors; all else, the grades, the ‘Match’, the exams, will follow.

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Skull– Interior by Lewis Chang 24

Eye and Larynx by Lewis Chang 25

Shadow Play

By Rosy Hao She’s sitting on the couch. Fraying the tissue in her hands as she folds and refolds it, she scrunches up her nose so she won’t cry for the fifth consecutive session.

“I don’t like to think of myself as a victim,” she says defiantly.

But she’s instantly in that room, remembering the flowering purple that claimed her skin.

Remembering the knife that pressed on her neck as she lay crumpled in the living room she and her sisters used to dance in.

Fall back. She’s nine years old. Her sister is hanging upside down in the toy closet with the help of a yellow nylon jump rope, screaming and begging to be let down. And despite all of her parents’ coaching about protecting her siblings and taking care of them, she knows the best thing she can possibly do is nothing.

Spin around. They’re at Magic Kingdom. Their dad has bought them hot chocolate, and they watch the fireworks go up over Cinderella’s castle. Her mom squeezes her hand. She thinks, “I love my family.”

Take a step. She feels the cool tile on her feet. Her mother’s on top of her sister, pinching and slapping every surface area available. Her sister is crying so hard that she’s starting to retch. The next day, there will be purple dots on her upper eyelid—little bruises forming, capillaries broken from the exertion of a breaking heart. And no one will ask her about it.

Reach up. Her dad has driven forty minutes to tutor her in physics because she got a 62 on the last test. He painstakingly explains potential energy, kinetics, velocity, acceleration. She makes an 88 on the next one.

Side sweep. His hands are in her mother’s hair, dragging her to the red carpet. She ushered everyone else upstairs, knowing that their combined crying and screaming and begging will do nothing to stop their parents’ fighting. She stands guard at the staircase, trying to gauge when it’s done. When it’s safe.

Still for a moment.

“I can tell you’re loved.”

She looks at him warily, this boy who claims he can read people, read her. “I can tell your 26

parents really care about you. That’s something that I don’t quite have.” She quietly agrees, but thinks that sometimes, her parents care about her too much.

Jump forward. She is tugging down on her sleeves, hiding the bruises from the beating the night before. “We want you to remember what you did every time you sit down. We want you to feel the pain you’ve caused.” Her friends ask what happened. “I fell off my bike.” They are satisfied.

Leap high. Her mother is talking about the first date she had with her dad. Her mother talks about how they went to an amusement park. How on the bus ride home, she was starting to fall asleep, and this boy-growing-into-a-man took off his jacket, rolled it up into a makeshift pillow and put it under her bobbing head.

“At that moment, I knew this was a man who would take care of me, my family. He was thoughtful and unselfish. You need to find someone like him.”

Hold the position— Did you make this?

“No, my mom made it. Every now and then she makes me a lot of food, so I don’t have to cook,” she says.

I wish I had your mom.

“No, you really wouldn’t,” her friend blurts.

She glares at him, her eyes spitting out: how dare you remind me.

These are so sweet! The figs taste like honey.

“Thank you. My dad grows them in his garden.”

He’s so talented—working so hard, having the time to grow these, raising such accomplished children. I want to learn his secret.

She bites her lip.

—and smile.

Her therapist leans forward, placing her file on the desk. “Why?” Because it means I’m defenseless. Because it means I’m vulnerable. Because it’s easier if I don’t think about it. Because I don’t want anyone’s pity. Because I can’t stand it.

Tears drip off her chin. She tucks herself into a ball, hides her face in the worn-down tissue square, and relives every moment she felt the nagging intangibility that she wasn’t normal.

Wait for the applause.

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Skull– Anterior by Lewis Chang 28

Sirens

By Nathalie White The sirens, the sirens, They came early today.

The sirens, the sirens, Signal help is on its way.

The sirens, the sirens, Hint humanity still has hope.

The sirens, the sirens, Puts my medical study into scope.

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Third Year Reflections

By Andy Yu Internal Medicine

TIA observation.

Nursing home waiting list after PEG tube placement.

ACS rule out.

Within my first days on the VA wards I quickly learned that these are not considered “sexy” admissions. In fact, they are pretty run-of-the-mill. Maybe even– boring? As a newly-minted third year student I still had an eager excitement for every new case, but I could read between the lines when my resident said, “Sorry Andy, can you take this one today? We’ll get you a cool one next time.”

With those words, my expectations were preemptively set a little lower, my eager excitement tempered a little bit. But then I met the patients.

I met the patients. I sat in the room with them and listened. And they told me about themselves. Without the pressure of a half-dozen other patients to manage, I had the time to really hear them. And that’s when I learned that “TIA observation” doesn’t encompass a man’s life, his modest ranch outside of town, his herd of cattle that he and his son still tend to though they are now well into their 60’s and 70’s, and his fresh bread rolls that he bakes every morning.

I learned that “nursing home placement” was a man with a rich history in Dallas.

A man who grew up brawling rough and tumble in the streets of Oak Cliff. A man who, in his twenties, got out of his 90-day jail sentence early with a combination of “good behavior” and a blood donation– then asked the pretty girl at the blood bank if she’d go with him to the movies.

I learned that “ACS rule out” was a delightful old African American gentleman.

Surrounded by a loving wife, a daughter, grandchildren, and great-grandchildren, he enjoyed their company around his bedside late into the night. At first I was intimidated by his big family. But as we slipped into an easy conversation, and as I handed his toddling great-granddaughter a fascinating new toy (my penlight), I felt myself gaining the trust of the family. When he called me “a fine young man” at the end of the history and physical, I felt a swell of pride and satisfaction. I felt truly invested in taking care of him.

I am well aware that, as I write this, I am still a wide-eyed and fresh-faced third year medical student. I know that many of my attitudes and mindsets may change as 30

my career advances and my experience grows. And without a doubt, I do hope to get exposure to a lot of cool cases throughout my medical training so I can learn how to manage the rare and the complex. But I also hope I will always remember that behind every “run-of-the-mill” case, there is a unique patient, an interesting story.

I hope I can always remember that there is no such thing as a boring patient.

Neurology

Ms. X The first day of my neurology clerkship. My first brain death exam. An aneurysm in Ms. X's brain ruptured catastrophically last week and despite her doctors' and surgeons' best efforts, she remains comatose. The pressure inside her skull pounds with a deadly force and remains recalcitrant to all reduction attempts. Her brain has almost certainly been squeezed to death over the last few days and now we must confirm it.

I enter her room. She lies limp on the bed. Her mouth is wedged open by a breathing tube, lips and tongue motionless and awkwardly splayed around it. Her chest rises and falls, but it is clear that the breaths are blown in by a machine. No living lungs ever inhaled like that, so jerky and robotic.

I touch her foot– still warm. We call her and shout her name, dig our knuckles into her sternum and eyebrows, but there is not even the slightest flicker of response.

We hold her eyelids open. The eyes that stare back are cold and lifeless. They respond neither to bright light nor touch nor icy water poured in the ear. We turn her head from side to side and they stay fixed straight ahead. When we let go, her eyelids stay eerily open. We suction her throat, but she has no gag or cough. With a grim finality, our team washes up and leaves the room.

Ms.X has told us enough. She will not be coming back.

It feels odd. I've known since starting medical school– with a sense of dread– that I would be involved in determining death. I've feared this moment, worried that I would not be able to handle it. But then it happens, and it almost doesn’t feel real.

Maybe it is because I never knew her in life. Maybe because for me she has always been mute and unresponsive in an ICU bed. But in that moment, Ms. W's brain-dead body does not frighten me. I feel sorry that we can’t save her but I also felt a strange sense of relief. She is not suffering. Her organs will save the lives of others. And with her help, I learn a crucial aspect of the nature of medicine.

Ms. E Ms. E suffered a ruptured brain aneurysm last week and she is doing remarkably well. She needs no breathing tube to sustain her. She wakes up, speaks to us, and 31

sits in her chair to eat her meals. Her husband, daughter, and neighbors dutifully stand watch in shifts as she slowly recuperates from her brush with fate.

But something is not quite right with Ms. E. Although she opens her eyes and answers all my questions, when I pay attention to her perfectly fluent speech, I realize that the content is riddled with inaccuracies. As we check on her, she has a different story every day. Today we are in Hawaii, yesterday in Waco. Sometimes we are in a hospital, sometimes her home, many times in a place I am not familiar with. Our team members have alternately been doctors, chefs, or Lowe's home improvement staff.

And nearly every day she continues to ask us, “Are we going to check on the rats in the hall?”

Is Ms. E confused and disoriented after a traumatic bleed? Yes, but maybe there is something more. Given the ease and certainty with which she creates these elaborate stories, along with the location of the brain injury, she could be truly confabulating. When she tells us about a conversation she had with a visitor who was never there, is that reality for her? Where do these false stories come from? Do they seem as true to her as my world to me? Is she trying to mask feelings of confusion and disorientation or does she truly believe her imagined explanations?

I wonder about all these questions– how it feels to be a person with a frontal lobe injury–but I am left to speculate on my own time because, according to the neurologist, Ms. E is stable for discharge.

Ms. L Ms. L does not have classical locked-in syndrome from a brainstem stroke, but when I first meet her, she is locked-in just the same. She is intubated in the ICU for severe, refractory, "brittle" myasthenia gravis. She cannot open her eyes, she cannot swallow her saliva, her head flops unrestrained on a completely flaccid neck. She cannot lift her arms, but her fingers still have strength. Remarkably, although she makes no facial or head movements at all, when I speak to her, she writes complete sentences on a pad by her hand.

Her handwriting is impeccable.

She is scared, paralyzed, and helpless in her own body, yet her mind is completely intact. What could that possibly feel like? To have perfect vision but be unable to open your eyes. To hear, feel, and smell the world but be unable to move or interact. How terrible and terrifying.

That first day, I hold open her eyelids so she can see me. Her eyes seem to have an expression of gratitude. She tells me the breathing tube feels like it is choking her. I ask the nurse to let her have some of her sedative. Sleep soon comes to relieve her from her cruel imprisonment. It is the one act of kindness in my power 32

that day.

Slowly but surely, with daily blood cleansing treatments, Ms. L begins to improve. The change is so gradual it's sometimes frustrating, but her strength unmistakably begins to return. She starts to gives me a thumbs-up when I see her in the morning. Her eyes can finally start looking up and down. She begins to hold her eyelids open without assistance and her neck muscles allow her to start shaking her head.

One afternoon I find her sitting up in bed, head held high, reading the newspaper with her glasses on. § The last day of my rotation is here and it's finally time to take the breathing tube out of Ms. L's windpipe. We're all very excited with her progress.

"Do you know how much money we had to pay her to get better on the last day of your rotation?” my attending jokes.

As I enter the room, her family members are all smiles.

"Hello," Ms. L says.

"Ms. L!" I start. "This is the first time I've heard your voice!"

"Yes," she replies. "I have a voice. I have a voice."

Surgery

Heading into the final rotation of my third year, I hoped that I would be able to manage the workload of my surgery clerkship– at least better than I might at the beginning of the year. And sure enough, my experience with the hospital, electronic medical record system, and early morning rounds was tremendously useful. But nothing could really have prepared me for the crush of terribly sick patients that I encountered on a daily basis during two months of surgery.

I have seen more pain, dismemberment, and poor prognoses during this rotation than on any other thus far. Some of the patients will be seared into my memory for quite some time: the 20 year-old girl who was ejected from her car during a highway speed crash after a night out and died the night of her birthday, the surgeons beating her heart in their hands again and again.

The young, homeless paraplegic man who arrived in the ER with gaping sacral decubitus ulcers teeming with maggots.

The cachectic corpse-like old man whose brother insisted we go to the operating room despite obvious massive bowel ischemia– on opening the abdomen, dark patchy purple intestines poured out; he died a few short hours later.

The young woman with 95% total body surface area burns after somebody had doused her with gasoline and lit her on fire.

More than the hours, the workload, or the lack of sleep, it was the sheer magni33

tude of human suffering that fills the halls of Parkland Hospital that was most challenging for me during this clerkship.

Faced with this deluge of misery, it is no wonder to me that young physiciansin-training often emotionally detach from the plight of their patients. While most of the patient-physician encounters I witnessed were medically very professional, I was struck by how easily the residents could move from one life-changing illness to another without a break in their stride. Surgeries, rounds, wound care, and floor work dominated our days - hand-holding and listening to feelings did not. This armor is no doubt a necessary survival technique in order to carry on and care for the many patients in need. By the end of this rotation, I saw how I too could easily lose sympathy for patients when faced with the workload of surgery residents.

One of the issues I worried about even before entering medical school was that the experience would change me– that I would become callous to suffering or cynical about life. I had read and heard in many places that so many empathetic young students emerge from their training grumpy and mean. More and more though, I am beginning to see that one’s attitude towards patients (like so many things in life) is an active choice, not simply something that happens. The balance between paralyzing empathy and emotional detachment is a tricky one when it comes to caring for the ill, and one that requires constant conscientiousness. While it may be easy to criticize trainees for their loss of idealism in medicine, it is a much more difficult thing to actually go through the harrowing growth process and continue to retain the appropriate dignity for people in what is oftentimes the most undignified of situations.

Ultimately, within the midst of all the chaos and pain of the hospital, I did consistently find examples of truly honest doctoring by both residents and attendings. I saw doctors who were patient, spoke kindly, and thought carefully about the best medical therapies they had to offer– even when faced with poor options and having worked non-stop all day and night. I saw lives dramatically saved and suffering eased. And at the end of the day, I saw doctors doing their job. I still have a way to go, but I know that with the right attitude and the right role models, I too will soon be able to call myself a competent, caring physician.

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Woman in Pose by Nate Milburn 35

No One Dies Alone

By Evan Ross The pager rang at 7:02 in the afternoon. It was the first time it had done so in my presence, and for a moment I couldn’t believe it was ringing. Surely it was someone’s phone here by the pool or a friend’s by the grill. Surely this wasn’t my pager.

I reached down, popped it out of its holder and lifted it up, squinting to see the numbers on the screen through the glare of the Texas sun. Five digits glowed back at me. I picked up my phone, hand not entirely as steady as I would have liked, and I punched in the phone number for the hospital’s Medical ICU. This was happening.

A nurse’s voice came on the other end of the line. I told her who I was and why I was calling. She put me on hold. All I could hear was poolside revelry, splashes and laughter. Then another nurse’s voice on the line: “We have a patient,” she said, “we’ve withdrawn care, but his mother won’t come to see him. He has a friend in town, but he won’t come either.”

“You called the right guy,” I said, hoping that was the truth.

23 minutes later I walked into the MICU, the smell of disinfectant and plastic a sharp contrast to the grilling and chlorine and freshly cut grass I had left behind. In the room I saw a man sitting up in bed, eyes wide open. I had not expected him to be awake, and it took me a split second to wrap my mind around it. He was going to die, but he wasn’t dead yet; he was going to die, but for now he was wide awake.

I spoke briefly with his nurse, the woman who had called me. She gave me the briefest of back-stories: a mass in his neck was constricting his airway. He had declined surgery and wanted no more interventions. What little comfort we could bring him was all we had to offer. I nodded, as if to show that I understood, as if I could possibly understand.

The man was sitting up in bed, his body rocking back and forth as if he were in a trance, his eyes fixed on the middle distance and an oxygen mask tight to his face.

He did not seem to see me come in, so I took his hand and introduced myself. I told him I was there if he needed anything. A few seconds later he stopped rocking, his head swiveled towards me, his eyes found mine, and for a moment I knew that he saw me. Then his gaze slipped past me, his focus somewhere beyond. I felt him squeeze my hand as he resumed his back and forth, back and forth, back and forth. That was 36

the last time he showed any sign of being aware of what was happening in the room.

All through the night as he fought to breathe I could see the skin tighten against his neck and chest. He may have decided against surgery and declined further interventions, but this was not a man who was going out without a struggle. At one point he grimaced at the wall and reached for his oxygen mask. His hands were not strong but he succeeded in pulling the mask off of his face. He shook his head as if to clear out the cobwebs, never once ceasing his slow oscillation. Moments later he took my hand and pulled himself forward, making as if to get out of the bed and walk away.

Then he stopped and lay back, putting his hands behind his head as if he didn’t have a care in the world. I couldn’t help but smile.

His condition predictably deteriorated as the night wore on, but it didn’t strike me as a particularly violent process. His vital signs didn’t seem to be falling so much as gliding slowly downwards like a bird tracing a lazy circle above the earth. He was dying, yes, but it was clear that he had decided it would be on his terms.

My partner in the program had agreed to arrive at midnight to take over the vigil and maintain it until 6:00 a.m., so I darted home for a few hours of sleep. When I came back I found the man on his back, fatigue having robbed him of his rhythm.

His eyes now watched the ceiling, and his mouth was open wider than it was when I had left. His breathing was louder now, more difficult and less steady. He seemed to forget to breathe for seconds at a time then pant to make up the difference.

As the sun began to rise outside, I noticed that his breathing had become much quieter. I somehow knew that it was time. I squeezed his hand as I listened to his last breath. I waited for him to gasp, to remember to breathe once more as he had a thousand times before, but he never did. I watched his pulse flutter in his neck, the beats of his heart arrive further and further apart until another beat didn’t come. The monitor beeped. It was over.

I don’t know what he was seeing when he stared at the wall, and I’m not certain he was completely aware of my presence. I can’t explain what his rocking motion was about or why his family couldn’t come to attend his final moments. I don’t know the etiology of the mass in his neck, and I can’t say why he refused further care. I don’t know much about that night, but I do know that this was why I decided to come to medical school in the first place. I know that this vigil’s end is where me being a doctor begins.

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CONTRIBUTORS 2013-2014 • Volume IV Anonymous thanks you for reading.

Lewis Chang is a third year medical student currently doing pediatric emergency medicine research at Children's Medical Center. From Austin, he's been sketching for fun since elementary school, and primarily works in traditional pencil and paper medium. This series of skull drawings were done in his first year as a study aid in preparation for the Anatomy lab practical.

Nan Guo is currently an inbetweener doing a research fellowship between her MS3 and MS4 years. She learned quickly during 3rd year that she could basically write whatever she wanted - however she wanted - for these reflections essays, and the only person she needed to impress was herself. Thus, she started to write these essays as notes-to-self. The purpose of this particular piece is to remember the importance of preserving patient dignity and self-worth, along with the incredible heartbreak that can result otherwise.

Rosy Hao is a 23 year old girl becoming a woman becoming a girl. You will find her wearing knee socks, eating soup, and watching NBC comedies. She likes books with strong female characters, by strong female characters. Her first favorite poet was E. E. Cummings.

Amy Ho is a fourth year medical student at UTSW going to University of Chicago for emergency medicine residency. Healthcare policy and patient advocacy was what drew her to medicine in the first place and actually being part of the 'house of medicine' showed her that medicine as a culture is not at all what the rest of the world would expect it to be. In part, she thinks this contributes to some of the problems pervasive in healthcare today - physicians aren't necessarily the most active in looking for and implementing change. She writes on issues that she thinks are important for the medical community to consider as a way to gradually shift us towards progress.

Bethany Johnston wrote this sonnet after her experiences at Camp John Marc a couple years ago after meeting a young boy with Spinal Muscular Atrophy. She chose 38

to write in sonnet form simply because she loves the rhythm it provides and how story-like it sounds when read aloud.

Nate Milburn, MD/MBA class of 2017, had never taken an organized art class his entire life until Dr. Teotia's "Classical Figure Drawing,� where he produced this piece. After realizing that this work would likely be the pinnacle of his art career, he retired from all artist endeavors shortly after its creation.

Evan Ross wrote this essay during his second year of medical school about one of his experiences with the Parkland chapter of a nationwide No One Dies Alone volunteer program. The program has as its goal to provide company to those who are dying but do not have friends or family available to sit with them in their final hours.

Evan matched into General Surgery in Austin, Texas.

Nathalie White grew up in Sunnyvale, TX, and graduated from Dallas Baptist University. The sirens from an ambulance weigh heavy on her heart when she hears them. Sirens are sounded multiple times a day in the medical district, and she listens to them, actually hearing them and letting herself feel what they mean. This short poem tries to express that feeling.

Shelly Xie is a medical student in the Class of 2017. She created this sand animation piece to shine a light on the struggles of those who battle with schistosomiasis on a daily basis. The goal is to expand public knowledge of the disease and encourage people to take action toward eliminating the disease.

Andy Yu will be starting his Pediatric residency training this summer at Children's Medical Center / UT Southwestern in Dallas, Texas. In composing his MS3 end-ofclerkship essays, Andy appreciated the therapeutic effects of reflective writing, especially in the setting of his first true encounters with illness. He plans to continue documenting his experiences in medical learning for years to come.

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