My First Patient

by Timothy Guerriero

ItwasSpringof

2019.

I was in my junior year at UF taking a course called Introduction to Medical Professions II, a course that allows undergraduate studentstolearnaboutthevariousfields of medicine and shadow physicians at Shands Hospital. I followed my resident physician into the patient’s room where we were met by a seemingly healthy, jovial man in his early 60s, Mr. Seto. He had severe squamous cell carcinoma of thetongueandmouth.Hewasscheduled tohaveamandibularreconstructionwith afibularfreeflaplaterthatmorning.Ifelt sad for the patient for being inflicted by this disease but was excited at the same time about being able to watch the surgeonshealhisaffliction. Thesurgery was long and arduous and took several hours, but ultimately went smoothly. I distinctly remember how grateful the patient’s family was as my preceptor explainedthegoodnewstothem.

LittlehadIknownwouldIseethesame patient four years later during my third yearofmedicalschoolaspartofthecare team. I was on the second week of my internalmedicinerotationwhenIwalked into the room to find Mr. Seto, the same patient I had seen four years earlier for his mandibular reconstruction. I remembered him instantly. However, rather than speaking to the same healthy-appearing, jovial man that I had metfouryearsearlier,Iwasspeakingtoa cachectic, severely ill individual who was barely able to speak a single sentence. As I asked him what brought him in, he merely stated “it’s . leaking again .” as he pointed toward his abdomen. I was barely able to understand what he said but lifted his gown up to find a gastrostomy tube placed with gastric secretions covering his abdomen, slowly eating away at his epidermis. I asked him how long this has beengoingonfor, whichhereplied,“aweek.”Irealizedthis patientwasgoingtobefarmorecomplex than I initially anticipated and decided to tackle his unchanged G-tube dressings first. The nurses were busy, so I decided tochangethedressingsmyselfasIwould be able to collect additional history from Mr.Seto.Itwasstillincrediblydifficultfor me to understand him, but it got easier the longer I talked to him. During this, I learned that despite the attempts by the surgeons, his oral cancer had metastasized to several parts of his body includinghisesophagusandlarynxwhich endedupaffectinghisspeech.

Iwasdevastated.IperceivedMr.Setoto be my ‘first patient.’ I had scrubbed in, assisted with the procedure, and stood bytheattending’ssideasheexplainedto thefamilythatthesurgerywasasuccess.

I wondered how this could have happened, and whether the surgery failed. I later learned that he had a 40 pack-year smoking history. While he had quit smoking after his mandibular reconstruction, it was too little too late andthecancermetastasized.

I rounded on Mr. Seto every morning. This was my first time being able to followthesamepatientformultipledays at a time. As the weeks went by, I got to know him quite well. I learned that he lovedworkinginhisgardenandwasabig Nascarfan.Ilearnedabouthisfamily;he has a wife, kids, and grandchildren. Medical school ethics taught me: They are people first then patients. It wasn’t until taking care of Mr. Seto that I had actually felt this notion. I had been working in the healthcare environment for9monthsandwasbeginningtoforget that patients were not just patients, but ratherpeoplewhobecomeill.Iknewthis conceptintheorybutwasnotapplyingit to my practice. Having met him four yearspriorandgettingtoknowhisfamily and hobbies, I realized that this was an incrediblyhumanizingexperience.

As time went on Mr. Seto’s condition continued to deteriorate. The surgeons and gastroenterologists were unable to seal the tube. His metastatic disease was progressing rapidly in severity. TPN was initiatedashewasnolongerableto tolerate nutrition via the G tube. By the end of the week, he was on dialysis. My preceptorandIinformedthepatientthat his prognosis appeared to be extremely poor.MypreceptoraskedMr.Setotocall his family so he can inform them of the situation.Iquicklyrealizedthattherewas a significant chance of my ‘first patient’ dying before I had even finished medical school. I was overcome with emotion as the empathy and compassion I felt toward Mr. Seto overwhelmed me. I constantly thought about Mr. Seto, and how his condition affected those around him. I began to apply a similar sense of empathy and compassion toward my other patients. I began thinking about their emotions, fears and how their affliction affected their friends and family.

When I returned Monday morning, I was greeted by some of his family members who had flown in from various partsoftheUS.Tomysurprise,oneofhis daughters had recognized me from before.Onphysicalexam,Ifoundthathe was disconnected from his IVs, dehydrated, had fallen out of bed, developed a sacral decubitus ulcer, and his abdomen was soaked by gastric secretions from the leaky G tube. I was overcome with frustration that he was not being cared for appropriately. I had never felt anger that a patient was being uncared for until this time. I quickly found the nurse and helped apply dressings and reconnect his IVs. I stood there and made sure everything on my list was done as I texted my preceptor asking to increase his pain medications andorderanairbed.Onmywayout,the patient’sfamilythankedmeforbeing too attentive. I thought: I guess I have been extra attentive to Mr. Seto However, I realized that because I had begun to feel compassionate and empathetic toward this patient, I was being more thorough and ultimately providingbettercare.

I began applying the same values towardmyotherpatients.Iremembered: They are people first then patients. I realized that I must never lose touch of thesevaluesandthatImustfeel compassion and empathy for all my patients. Compassion can be defined as: a deep response to the suffering of another. Caring for Mr. Seto emphasized that medicine is both a science and an art. He taught me that compassion is a critical part of the art of healing. True healing must involve empathy and compassion, and I realized that I must keep these values for the rest of my career. Before he was discharged, his family divulged to my preceptor that “I was one of the providers to care for Mr. Seto at Halifax.” Upon further introspection, I realized that this patient hadfinallytaughtmethe art ofmedicine.

The Sixth Day

by Amelia Hartje

Scanning my eyes downthelaundry list of patients’ names androom numbers, I was filled with anticipation and anxiety as I was told that we were expected to makeroundsonthefortypatientsonour daily census. This was my first day as a third-year medical student starting on inpatient internal medicine, and I was terrified. My preceptor ran down the list with his fingers and then used his black pentoindicatewhichpatientshewanted me to “claim,” as if they were commodities. After reading the short blurb explaining each patient’s chief complaint,hestoppedatonepatientand said, “Oh this will be a good one for you to see; you’ll see this diagnosis all the time on inpatient.” After reviewing my patient’s chart, I learned that she was a 51-year-oldfemalewhopresentedtothe emergency room complaining of sharp abdominal pain in the midepigastric region as well as nausea, vomiting, and signs of dehydration. Due to the state of her dehydration, continuous vomiting, andabdominalpain,shewasadmittedto theinpatientfloor,whereshereceivedIV fluids,andmoretestswereordered. Walkingintothepatient’sroomhavinga generalsenseofwhat’sgoingon,I they are in the hospital. Upon initial observation, I notice an obese female who appears her stated age sitting up in bed in acute distress with a green vomiting bag in hand connected to multiple IV’s and monitoring systems. “I’m in a lot of pain and I can’t keep anything down,” my patient said. Using theCLCscriptinmyhead,Istartedasking the “focused problem” questions and learned that she rated the “sharp” pain an 8/10 and that she had a similar episode approximately 1.5 years ago, where she stayed in the hospital for 2.5 weeks with three days in the ICU. “I’m scared,”mypatientsaidasshelookedme intheeye,“Idon’twanttohavetogoto the ICU again.” I looked at her and said, “We are going to do everything in our power to try to prevent that from happening,” having no idea if we can preventthatfromhappening.

AfterIlefttheroom,Iwenttogocheck on my patient’s labs. She had a WBC of 14.5, calcium of 6.6, glucose of 330, lipase of 333, total cholesterol of 397, and triglyceride level of 7,534. I reported myfindingstomypreceptorincludingthe updated labs, and he said, “Just as I suspected, acute pancreatitis.” We kept her on IV fluids, nothing by mouth, morphine for pain, and anti-emetics. I came back the next morning to check on my patient to see if anything improved. She said her pain had decreased to a 6/10 but she was still vomiting most of the night. On the third day of her inpatientstay,Iwenttocheckonher,and instead of only talking about her symptoms, she started to confide in me. “I’masinglemom,andI’mreallyworried about my kids. I just want to go home to themandmakesurethey’reok.”Isaidin reply, “First, we have to make sure that you are ok before you can go and help them, but it’s normal to feel this way.” This was the first statement I made where I felt confident in what I said was true. She reluctantly nodded and started blaming herself for why she was in the hospitalinthefirstplace.“Iknowmydiet isn’t the best,” she said, “and I could exercisemore.”Althoughthese statements were true, now was not the time for her to start getting more depressedandanxiousabouthercurrent hospital stay. I tried to navigate the conversation away from her blaming herself and towards using this as motivationtoputherhealthfirstinorder to be there for her kids. She seemed receptive to my feedback and appreciativeofthetimeIspenttalkingto herlikeanotherhumanbeinginsteadofa labvalue.

On the sixth day of checking in on her and learning that she was still nauseous with a few vomiting episodes, my preceptorstartedtolosehispatienceand accuse other diagnoses that she had for why she was still in the hospital. “It’s all heranxiety;it’sallinherhead,”hesaid.I then rounded on my patient with my preceptor and could tell how overwhelmed he was with his growing patient list and how he was ready to discharge my patient no matter how she felt. On paper, my patient was getting better, but in person, she was still vomiting, unable to keep most food down, and not physically ready to be discharged.

When I went back to check on my patient before I headed home for the night,Icouldtellthatshewasaffectedby my preceptor’s reaction earlier that morning. “I don’t mean to be a burden, but I don’t think I’m ready to go home just yet.” I knew from what I had seen throughout the week and after my conversationswithher,mypatientwould notbeinthehospitalifshedidn’thaveto be. “I know you don’t,” I told her, again confident in my statement. I felt incredibly sad that my patient felt like a nuisance for trying to heal in a place designated to help those suffering. My experience led me to realize though that if the people assigned to help you are overcomebytheirownstrugglesandthe medicalsystemcontinuesinthedirection of putting profits over patients, it makes it much harder to fully invest one’s energy into helping those who need them. I hope in my future practice that I continuetolistentomypatients,evenon thesixthday,becauseIknowhow terrifyingitcanfeeltobeinthehospital, evenwhenyou’renotthepatient.

My Patient

by Taha Hmissa

Growingup in Ithaca, a small town in upstate New York knownbest for being home of the prestigious Cornell University, I found myself always longing to leave. As a kid, I’ve always had a natural talent for buildingthings,usingmyhands,andonly looked forward to shop class in junior high. I certainly never dreamed of workinginconstructionwhenIwasakid, but it was a job that suited me and paid well enough to support an 18-year-old withachildontheway.Iknewthatonce I found out I was going to be a father, moreschoolingwasnotanoptionforme. I quickly joined the field of construction the day after I graduated high school because I made my mother a promise that she was still going to have a child with a high school diploma. For the next 3 decades of my life, I witnessed a field that changed tremendously with enforcements of regulations and safety requirements that made me question whether my own health was ever impacted as a construction worker. Nevertheless, I was proud to say I had a hand in building a large majority of the homes and office retail space in upstate New York during a hard-working career lasting just over 30 years. While I’m proud of the career I left behind, retiring at 52 was certainly not what I expected tooccur,either.

Over the last decade of my career, I transitioned to a pure supervisory role. My managers helped me save face and told my coworkers it was because they neededmeasasitesupervisor;however, everyone knew later in my career that I wasn’tquitetheworkerIwasonce.Iwas never an athletic guy and I certainly neverexercised,butIdidn’tthinkIwould tire so easily in my late-40s. Often, my guyswouldseemehavetotakeabreak and fall short of breath. Having never smokedadayinmylife,Ijustassumedit was the physicality of the job taking its toll on me. It wasn’t until I retired that I truly felt like my body was giving out on me. Persistent cough spells lasting minutes at a time followed by gasping breathsforairwerealltoofrequentofan occurrence. Although I knew something waswrong,IpusheditoffforyearsuntilI achieved the second greatest accomplishment of my life, becoming a grandfather.

Shortly after having my son, his mother andIwerenotabletoseeeyetoeyeand grewapart.Mygreatestregretinlifewas not spending enough time with my son. I’ve missed baseball games, birthday parties, and taking him to school on many mornings all so I could provide as best as possible. I was never a rich man, but I made sure my son always had enough to be comfortable. Fortunately, mysonwasabletodomanythingsthatI couldn’t. First and foremost, he received acollegedegree.Healsoworkedhardto make his relationship work with his wife, whom he met at college. His success as an engineer afforded him a lifestyle that allowed him to comfortably have a child inhislate20s.HemoveddowntoFlorida to be closer to his wife’s family and they extendedtheinvitetome.Ifiguredsince heistheonlyfamilymemberIspeakto;a change of scenery may not be a bad thing. Shortly after, my grandson came into this world. I knew that there was now another life to live for and that my healthshouldbeprioritized.

I still remember the deafening, ringing tone I heard from my ears and the sensation of my stomach dropping when the word “mesothelioma” came out of my doctor’s mouth. This was only a condition I had heard of on TV commercials and never expected to see anyone with it in person, let alone be diagnosed with it. When I received the diagnosis, I was devastated––I couldn't bear the thought of my life ending like this. I first thought of the new life I wished to have in Florida, finally being able to be a part of my grandson’s life. Afterhearingmanynumbersand

I figured it was best to just be present with my family. I’ve accepted that my time will come, just like everyone else. Althoughmyconditionworemedownto thepointwhereIlost40poundsandwas coughing up blood almost monthly, I knewtherewasstillmoreoflifetoenjoy. However, when lumps of tumor starting to poke out of my rib cage and raise my skin, I quickly felt that it would be difficulttoenjoylifeincomfort.Thepain of taking a simple breath would send a shockwave throughout all of my body thatwasunbearable.

On my 58th birthday, almost one year ago, I watched my grandson play soccer for the first time. It took all of my strength to ignore the constant chest pain I was having or the lack of sleep catchinguptomeasIwasunabletorest while I was chronically aching. Previous doctorshavetriedtomanagemypainby theguidelinestheyweretaught.Theydid notlistentomeasapersonandwentby what protocol told them to. When I told them that the pain of a t-shirt rubbing against the lumps of tumor protruding through my skin felt like an 18-wheeler crashingintomyribcage,theystatedthat anymorepainmedicationsissomethingI would have to see a pain specialist for. Painspecialistsrecommendedallsortsof surgicalinterventionsandlong-termpain pumps. I felt that undergoing surgery would probably be something I’d never wake up from and turned to a new doctortoseeiftherewashope.

Mynewfamilydoctoristhefirsthuman I’ve seen cry when I described the pain I went through on a daily basis. He was able to provide me with medication that allowed me to live a comfortable life. He trusts me enough to use these pain medications responsibly and aimed to relievemeofmyburden.Iamfinallyable to sleep and spend the remaining time I have with my grandson in comfort. He later introduced me to the idea of hospice, and it frightened me, however his explanation of what services may be provided to me to keep me in comfort were encouraging. For the first time in mylife,Ilookforwardtomymonthly visits with my doctor. He is not a doctor who looks back at my previous life choices and tries to pinpoint what may havecausedmycondition.Hefocuseson howIcanbeabletomaximizemyquality of life. It brings me joy to see how he is sharing his empathic qualities to his students and is helping create a generationofnewdoctorsthatwillfocus onthepatient.

Beginning a Difficult Journey by Jared Jones

I was the eagereyed, hopeful future surgeon walking into my first third-year rotation with the notoriously toughest surgeons at my campus.Ihadnoideawhattoexpectand held my reservations as to any prior judgement that was bestowed in my mind. As the day progressed, I continued to become more comfortable in working with and around my preceptors. Nearing the end of the day, our final case was with SJ. He is middle aged man with a long-standing history of Crohn’s disease in which he had previously been treated with an extensive bowel resection some 20+ years prior leaving him with an ileostomy. His complaint was that the past few weeks he has noticed some “painandslowingoftheflowthroughthe ileostomysite.”

I follow my preceptor into the pre-op holding area and see a pensive man surrounded by his wife and daughter. Theyalllookanxious,includingSJ,whois unsure what this process will hold. My preceptor explains to them what he believes is happening based on the imaging and the conservative steps surgically to be made today. SJ agrees to thisplan.AsthesurgeonandIgobackto prep, I rattle off my questions about his thoughts of potential outcomes and subsequent adverse events that may ensue.However,allIcanthinkofarethe anxiousfacesthatwerestoodwaiting with baited breath at what the surgeon wasgoingtosay,allwhiletheirfacesheld complete confidence in his plan. The surgery proceeded without issues and the minor dilation we enacted at the ileostomyorificewasthebestfirststepto resolving his issue. The next morning as I am rounding, I stop by to check in on SJ. His wife was patiently waiting at the bedside watching him as he slept. In an effortnottodisturbhimatthemoment,I spoke to SJ’s wife about how he was overnight and delve into deeper subjects onhispasthistoryandhowhehasended up in this predicament. Through the few minutesIspokewithher,Icouldfeelher anxiety lifting as she had a voice in that momenttoexpressherconcerns.Igently awaken SJ to do a brief physical exam including checking his ileostomy site while asking some questions. No issues werepresentonmyexamandIexplained I would return later with the surgeon. A few hours pass and we return to the roomasateam.Thesurgeonexplainshis procedureandrationaleandinformsSJif he can eat and have reasonable flow at the ileostomy, discharge is an option. Later in the day, we return and find SJ withgreatflowanddischargehimhome.

A brisk few days pass on the surgery service. As I log into the computer and check my preceptor’s list of patients, I notice a familiar name, SJ. How was SJ back in the hospital? We sent him home and he was doing fine, I thought to myself.AsIproceedthroughmyrounds,I stopbyhisroom,andtomysurpriseheis up at the early hour. I begin to inquire about what’s brought him back in. The soft-spokenSJexplainstheprogresswhile in the hospital but the weakness and the continued issues of blockage at the ileostomy he had at home again. I knew as the surgical team we were going to have to try again. We returned to the operating room again trying with our most conservative treatment of a more extensive dilation with the intent of keeping him a few extra inpatient hospital days to ensure a proper recovery.AsIroundedthenextfewdays, SJandIbegantobondwhilehewas awake in those early morning hours. I provided a reassuring smile and ensured he was comfortable while maintaining a jovial relationship with him for the times whenhiswifeordaughterweren’tthere. His symptoms resolved during the hospital stay and he was recovering well from the surgery so he was discharged. This was the first patient relationship I had built as a third-year medical student withoneofmypatients.Iwasabletosee the care and compassion I could build just over a few days and how this impactedbydesiretocontinuetosoothe the patients with whom I was on the treatmentteamwith.

Adaypassed,noSJ.Anotherday,noSJ. A week passed, no SJ. I was beginning to miss our comforting conversations of my experiencesstartingmyclinicalrotations. But I also understood, not seeing him back was for the best. Another week passes and my preceptor received a page from the ED: “Patient with an ileostomy complaining of bowel obstruction.” My heart was gutted as I knew the sweet and kind SJ was back at thehospital.

The outlook now entailed a more extensive open surgery since the prior twoyieldednopositivelong-termresults. My expectations were that the kind, caring family members of SJ would begin to turn on the surgery team as it now seemed he was in a perpetual cycle in and out of the hospital. However, his wasn’ttheresponsewereceived.Coming to speak with them in the pre-op, while mildly agitated, they were still extremely grateful for the efforts so far in trying to postpone the major open abdominal surgery. With a reassuring nod to his family, I ensured he would be in good hands. A small tear fell from his wife’s eye as she nodded in reciprocation as he wasbeingwheeledback.

Over the next two weeks, SJ remained on our patient list as his hospital course was complicated with prolonged antibiotic regimens, postoperative bowel rest, and electrolyte abnormalities. Through that time, I ensured I left home a few minutes early to have some extra timetotalkwithSJ.Wecontinuedto build the bond as I wanted to make his hospitalstayjusta littlebitbetter.

My time on the surgery rotation was coming to an end and yet SJ was still sitting, waiting, and hoping his hospital course would come to a close soon. On myfinalday,Iwalkedintohaveourfinal chat. I thanked him for being so reassuringtomyinitialclinicalexperience and so positive about the entirety of the situation he was in. I thanked him for comforting me and expressed how unfortunate it was that we had to meet thisparticularway.SJgesturedformeto take a seat on the foot of his bed. He grasped my hand and said, “Thank you. Thankyouforspendingthetimewithme and my family. As a father myself, I can only imagine the pleasure your parents have to call you their son. You are going to make a wonderful physician.” Tears were rolling down his face as I knew this hospital course was one of the toughest battles he faced. I thanked him, received ahugfromhiswifeandexitedtheroom.I held those words as I walked down the hallway, holding back my own tears, as not only was I grateful for spending the extra time with SJ but also to be in a position to make an impact in the way I had. I knew from this experience that no matter what is happening in your life or how busy it is on your day, those few extra minutes to connect will mean the most.

The Balance: Advocacy & Compassion

by Khari King

Itwasapproximately 7:05amwhen I and the rest of the day team huddled in the nurse’s station receiving sign-out. Overnight, the pediatric emergency department received an 11-year-old female in status asthmaticus. With proper execution of thestatusasthmaticusprotocol,thenight team was able to drastically improve her conditionandshewas reportedly “looking pretty good” by morning rounds. When we walked into the room to meet and assess her, we notedminimalworkbreathing,saturating around 97% on high flow oxygen, diffuse but mild wheezing on auscultation. To a layman, she looked like a normal kid resting in bed; to a medical professional, shehadcheateddeath.

Around 10 AM, the patient’s mother, who spent the night at the hospital, notified the nurse that she wanted to take her child home now that she was feeling better. The nurse rushed back to the station to convey to the rest of the medical team how this “ghetto mom” couldn’t understand that her child was only appearing well due to the steroids, albuterol, and oxygen being provided to her. The mother, however, was adamant that the child was fine and she simply needed a refill of her albuterol inhaler beforeshetookthepatienthome.Outof concern for the wellbeing of the child, the attending physician decided to call DCF in an effort to overrule the desire of the mother to take the child home against medical advice. I remember feelingsotornasthephysicianmadethe call; I understood that the doctors and nurses believed a discharge was not in the child’s best interest, and even considered it to be child neglect. However, involving DCF was an overstep of parental authority in medical decision makinglikeIhadneverwitnessedbefore. Ultimately, DCF denied the physician’s request for required the patient to remain in the hospital as her condition was now stable and seemingly no longer life-threatening. The medical team was furious. They proceeded to tell the mother they would call the police if she tried to take her daughter home. As one would imagine, the mom did not take these statements and threats very well, and this conversation quickly turned combative.

When the doctors and nurses walked out,Istayedinthepatient’sroomtotalk to the mom alone. With a calmer voice and kinder words than had previously been hurled at her, I tried to explain the severityofthesituationtothemomand why the patient needed to stay in the hospital. It was during this conversation that the mom disclosed to me that she hassixotherkidswithnosupportsystem and needed to leave so she could take care of her other children. She felt like shehadnochoice.Thiswasaperspective ofthecasethatthedoctorsandstaffdid not know and maybe did not care to know. They just felt like she was an “ignorantmom”notdoingwhatwasbest for their child. Despite our conversation, the mother eventually collected the patient’s belongings and took her home. None of the medical team, including myself, was surprised when the patient’s sats dropped to 83% as soon as the little girl took the nasal cannula out of her nose.Mybiggestfearforthepatientwas that she would decompensate later that dayandenduprightbackinourcare.

This situation was difficult for me as someone who tries to always see both sides of an argument. I certainly understood the medical reason for why the patient needed to remain in the hospital; it was clear that the patient’s status improvement was due to the medications and care that were being provided for her in the hospital. However,partofmewantedtosidewith the mother as well. I believe this cognitive dissonance originated because the medical team did not try to understand the mom’s motivations or understanding. They just saw her as a senseless woman and later joked about herhavingmorekidsthanshecouldtake care of when they found out the real reason behind wanting to take the patient home. But in my time with her, I wasabletoseeherasahuman,makinga difficultdecision,wantingtodowhatwas best for her kids. This situation reminds me that while I will advocate for my patients, I will do it with humanity, empathy, and understanding. We are seeing our patients and their families in some of their most stressful moments, and we owe it to them to meet them with genuine care and respect. While advocating for our pediatric patients can sometimes require DCF involvement, I willalwaysremembertoinvestigatethe situation to the best of my ability and refrain from making character judgements without gathering all the information.

A Unique Fellowship by

Madeline Mickler

Dr.ViktorE. Frankl was an Austrian psychiatrist, and he wrote that there are three aspects of human existencethatareinevitable–pain,guilt, and death. Yet his books ask that we declare optimism in the face of this tragedy hecallsit“tragicoptimism.”

For a number of the patients I met in the hospital and clinic this past year, it was clear to see that they were encountering some or all of the parts of this triad. In the face of their tragedies, I witnessed a wide range of responses. Somecourageous,someoptimistic,some melancholy, terrified, depressed, angry, resigned, etc. Often it was a mix. But I saw that people have the ability to find meaning despite their tragedy and I strongly believe that the role of the medical person in this case is to help facilitate this in each patient. From my own personal experience of death and dying,itisultimatelytheresponsibilityof theindividualtofindtheoptimisminthe face of tragedy. And the optimism only can come from finding meaning, and no one else can do that task for you. But! I think this task is something facilitated by the heart and soul of a person and therefore the physician, by being loving and tender to the patient, may help create that freedom in the soul that enables a person to seek the meaning. AndI’veheardtheseconclusionsinsome patients: great deeds they did, people they loved, and trials which they had gone through with dignity and courage. Thesewonderfulthingsstoredupintheir lives like treasures, which cannot be lost anddonotfadeaway.

Oneday,Imetapatientintheclinic.I walked in the room, and he was sitting hunched forward with his hands on the bench and had the thousand-yard stare I had become very familiar with. I smiled and introduced myself; he scrunched a quick smile and then back to the weary gaze.Hewasonly67yearsoldbutlooked much older and had a strong New York accent.Hewasthinandhadwire-framed glasses over a weathered tan face with grey hair that flowed out from the sides of his head; he kind of looked like Doc Brown. I decided to do more of an open, no-agenda type interview since the visit didn’t include a specific, acute problem. He had worked for a record company for decades in New York City before moving toFloridawithhiswife.Hehadlivedabit on the wild side throughout his life; was very politically active and outspoken during the ‘70s and had led many demonstrations during college. The nature of his career included lots of drug use, and of course, rock and roll. He was basically healthy since birth: never significantly sick throughout his life and always active. Yoga was a big part of his lifeforseveraldecadeswhichwasoneof his favorite hobbies and accomplishments.

When he hit age 50, he was diagnosed with squamous cell carcinoma of the head and neck and received successful treatment for it. But a decade later, was diagnosed with scleroderma and then amyloidosis. His trips to Mayo Clinic ended with the conclusion that although symptoms could be targeted, there was nothing real that could be done for the diseases themselves. He explains to me now – “I am not interested in going back to Mayo I want to focus on living the bestlifeIcanforthetimeIhaveleftand that’sit.”Itisclearhehurts.Hewalkslike apersoninpainandhebreatheswithhis eyes open and closed randomly, like a person in pain. He has oxygen at home andmovesfromroomtoroomonaline. “Enough length,” he explains, “to make my big trip each day.” He means the trip from the living room to his office where hiscomputerissetupforZoomcallseach day.Hestillworksandisabletodosoas afree-floatingheadonZoom.He explains, “when you work like that, no one knows you look like a tired old bird and that you’re sick…there’s no context soit’snicetojustworkandnothavethat surrounding you. Plus, I work with a bunchofyoungkidsnowandIthinkthey think of me as some grandfather to them but it works out; it’s a nice relationship.Ilovemywork.”

Myeyesshiftdownatsomepoint,andI see Elvis Costello on the faded old gray t-shirthe’swearing.“ElvisCostello!”Isay. He looks down and smiles, “Oh yea, I’ve seen him too many times to count he’s justspectacular,Iwaskindaaroadie.”I’m excited.“YouknowoneyearIlistenedto his album with Burt Bacharach almost everyday?”Isaid.PaintedfromMemory, he says with a wide grin. “Yes!” And we dive into the world of music. We go through the songs in the album and talk about its genius and then we’re talking about other artists and we’re on the same exact musical wavelength as time soars past us; he throws out a favorite line and I counter with another line. We laugh and we just smile ear to ear we’re talking about Joni Mitchell and how he, if stranded on an island, would choose to take Court and Spark with him, and I said I might take Bruce Hornsby’s Hot House, and he almost jumpsupwithexcitementforthatalbum too and pretty soon in my smiling I notice my eyes feel a little wet and I feel that heaviness on my chest that is a dull type of devastation because I can hate the nature of that inevitable triad, “pain, guilt,anddeath.”Whenthepatientison the table, I am auscultating and I can’t help but look at him as he sits there and imagine his younger self, pain-free and doingyogaoratanElvisCostelloconcert. AsIpercusshisabdomenandpalpatehis posterior tibial pulses, I feel a sort of communion with my new friend; it’s bittersweet. He laughs as I am looking in his ear and I ask what is funny. He says, “You know I haven’t talked about music like that in a while, what a pleasant morning.” I wholeheartedly agree. The visit comes to end as I jot a note or two down. I notice he wipes a couple tears awayas he is sitting back on the bench, looking out the window. A bit later when he leaves the office, we both turn to meet again before he rounds the corner, and we shake hands to say goodbye. He is beaming and I feel a sort of love in my heart for this patient, that love that comes from fellowship with another humanbeing.

Of all the things we do in a day; all the things we pine over, worry about, or strive for…I believe these loving encounters with patients is what seems to really matter. Thinking back to Dr. Frankl’s philosophy, I know that if even little acts or expressions of compassion can be exchanged, it brings the human spirit to a place a little less vulnerable to despair. It is my privilege to be able to take care of patients and love them throughthisuniquefellowship.

More than a Patient

by Brittni Miller

The second day of my general surgery rotationwaspacked fullof patients and procedures. After a long day, I was just about to leave late in the evening when there was a page from the emergency room describing a young man in cardiac arrestthatneededanemergencysurgical consult. I was offered to leave since it was getting late, but a hurricane was quicklyapproachingourarea,soIwanted tolearnallthatIcouldwiththetimethat I had. Little did I know the impact this man would have on me and my medical career. When I walked down for the consult, I thought to myself how crazy it was that this man was only a few years older than me. How could he possibly be a victim of cardiac arrest? When the surgeon and I arrived at his room, chaos hadalreadyensued.

Once the patient was stabilized and intubated, the surgeon told me I would be placing his femoral catheter. I was ecstatic to take the lead on the procedure,butverynervousforapoor outcome. I had never seen a catheter placementbefore.Heguidedmethrough the procedure. I worked carefully, and successfully placed the catheter. I felt so proud of myself for completing my first procedure, while also thankful to this man for affording me the opportunity to learnanewskill.

The next morning when I rounded on him, he was rapidly decompensating. He had no kidney function, and the femoral catheter had blown. Another catheter wasplacedontheothersideofhisgroin, but it was only a matter of time before that one would blow too. A few days after his admission, the decision was made to start a central venous catheter. The surgeon instructed me that I would be performing this procedure, and I was even more nervous than the first time. I had never seen a catheter placed in the neck before, and there is little margin of error when directing a needle into the jugular vein. I kept my hands steady and focused on the instructions being delivered to me. After the successful completion of this procedure, I tore my gown off, and thought again to myself howthankfulIwastobeabletolearnoff ofthispatient.

I rounded on this patient in the ICU every morning and every evening. After his first week in the ICU, his parents began to come sit with him during the day.Wechattedabouthislifebeforethis horrific event. Learning his story made me realize this patient has a whole life outside of these walls, and although I have never seen him awake or communicating, he had two small children at home that had no idea what he was going through. His parents told me of how the patient’s brother died on a skiing trip 10 years ago, and how the patient never recovered. He struggled with depression and alcohol for majority of his adult years after that incident, and now here he was laying in the hospital bed,unconsciouslyfightingforhislife.

After the second week he was in the ICU, he was not turning the corner. His kidney function had not resumed, so he still required frequent hemodialysis. He wasonaventilator,withnumerous medications all looming over his hospital bed.Afterseveralfailedextubationtrials, the decision was made to give him a tracheostomy tube. This time, the procedure felt different. He was no longera“cardiacarrestinbed3.”Hewas a son, a father, a brother. He was Michael.

After three weeks in the ICU, there was little to no improvement. When I would round on him in the quiet mornings, I would note the beads of sweat dripping down his face. I noticed how much weight he had lost since his admission. A face that was once full of life, now pale and without adipose tissue. I began to wonder if he was going to make it throughthis.Hisfamilyhungphotosona bulletinboardinhisroom,illustratingthe life he had before he was confined to thesefourwalls.Ilookedatthephotoof him with his four-year-old daughter, which was attached to a drawing labeled “feel better daddy, I miss you.” I hoped witheverypartofmybodythathewould pullthroughforthislittlegirl.

A month after admission, his kidney function started to rise. He had finally startedturningthecorner.Hewasawake and able to move his extremities, although he was not alert or oriented. Many thought he had suffered brain damagefromtheincident,andmaybehe wouldneverbethesameMichaelhewas before. How terrible it would be for the familytomournthelossofamanwhois still alive. I continued to root for Michael’s success and I kept my hopes high.

Gradually day by day he improved. I bonded with the family over how far he had come. Eventually, he began to communicate and walk with assistance. Bythelastweekofmyrotation,wewere discharging him from our service. The family had gotten him a spot at a rehabilitation facility in town that would work with him further. I could not help but think what a miracle this has been. Although I only played a small role in his overall care, I was so proud to be part of the team that helped save his life. Every patienthasastoryoutsideofourhospital walls,andthisexperience illuminated the importance of understanding our patients as people, ratherthanjust“thepatientwithcardiac arrest.”

Caringforthispatientgavemea“why.”I found a love for critical care medicine through this experience, because although there are many poor outcomes in situations like his, recoveries like this make it worth it. This experience ignited apassioninmetowanttointerveneand do all that I can do for critically ill patients,justtohavetheopportunityfor another patient to improve like he did. Watching him recover every day for over amonthwasmorerewardingthanIcould have imagined. I enjoyed learning more abouthim,andamthankfulIwasableto careforhimontheworstdaysofhislife. He may not remember me in his story, butIwilltrulyneverforgethiminmine.

More than Meets the Eye

by Joseph B. Parker

I walk into our patient’sroominthe emergency department and see a young26-year-oldfemalesittingupinthe bed. She is drinking a soda and eating gummy bears. She smiles and waves at me and asks how my day is going. It struck me as surprising that someone with her diagnosis was still this upbeat and bright. She had come to the emergency room thinking she only had a cold with a cough and increasing fatigue, only to find out she had acute myeloid leukemia. I come in to gather her history aswegetreadytoadmither.Weprepare her for her bone marrow biopsy and for induction of chemotherapy. As medical students we learn so much from our patients,abouthowtotalkwithpatients, theirdiseaseprocess,andsomuchmore. However, I had no idea just how much I wouldlearnfromthisyounggirlwhohad just been diagnosed with this serious disease.

This26-year-oldfullofresiliencehadthe resultsofherbonemarrowbiopsyreturn that confirmed the diagnosis of acute myeloid leukemia. She was started on induction chemotherapy with daunorubicin and cytarabine. As she was receivingherchemotherapyIwouldgoin and check on her every day. Every morning when I walked in the room I heard, “there’s my buddy.” I would see how she was feeling and one day she disclosedtomethathermotherhadjust passed away last week. She further discussedwithmethatshewashopingto makeitoutofthehospitalintimeforher funeral next week. I was shocked. This girl who had just been handed this diagnosis and lost her closest family member still greeted everyday with a smile and always made sure she asked how I was doing. This patient’s resilience and selflessness left a lasting impression on me. She taught me that you never truly know what is fully going on in a patient’s life. As a physician, we can always make an effort to show our patients the utmost compassion and to be patient with them. As I moved forward in my medical school journey after this encounter I always kept her in mind.WheneverIhadadifficultpatientI always reminded myself that I do not know fully what this patient is going through. I always made sure to stop and maintain my patience, keep a calm demeanor no matter the situation, and aboveallexhibitempathy.

Everythinghappenedsofasttogivethis 26-year-old the best chance possible at life. As the days continue to pass by, we continue monitor her labs. We notice that her red blood cells and platelet levels are dropping due to the chemotherapy. We begin to discuss transfusion with the patient, and we find out she is unwilling to accept blood due toherreligion.Thiswasnotdocumented and was not discussed ahead of the induction chemotherapy. This posed a dilemma. The chemotherapy she is receiving will cause her to have pancytopenia. She would most likely not make it through the chemotherapy regimenwithoutthetransfusions.We discussed with her the risks and benefits of the transfusions, however, she opted to continue without them. We gave her alternative means to increase her red blood cell and platelet counts. However, this was not enough, and her numbers were continuing to drop. We sat down and talked with the patient, and we found out the reason that she did not wantthetransfusion.Shestatedthatshe, in fact, wanted the transfusion, but was fearful of what her community would thinkofher.Wediscussedwithherthatit is completely her decision and no one else’s. She eventually opts to undergo transfusionandthehospitalworkedwith her so her community would not find out.Thisexhibitedtometheimportance ofpatientautonomy.

It is of utmost importance for a patient to retain their autonomy in the hospital. This is yet another quality that this patient left a permanent imprint in my life that I carry with me with every patientinteraction.Ittaughtmetonever make assumptions. It was assumed since she did not have another member of her religious community with her, which is usuallythecase,thatshewasnotpartof this specific community that did not allow blood transfusions. However, this assumption should not have been made and should have been explicitly asked. It also taught me to always clearly explain everything to the patient and make it clear that any decision about their healthcare is nobody else’s choice but theirs, such as what was done with this patient. The original decision to not receive the blood transfusion was out of fear and not her own decision. However, after explaining autonomy to the patient shemadethedecisionthatshewanted.

NoweverypatientroomIwalkintoIsee this 26-year-old girl smiling. I take the lessons that she taught me into every patient interaction. I take with me the lessons of humanism in medicine that I learned from her, to always exhibit empathy,andthatitisimportanttolisten tothewholestorybehindeverypatient.I alwaysmakesuretonotonlyaskabouta patient’s symptoms or disease, but their personallifeaswell.ImakesureItake thetimetotrulygettoknowmypatients and to have the cognizance that they mightbegoingthroughmorethanmeets the eye. Additionally, for every patient’s autonomy I always remember this 26-year-old. For every patient I always make sure to ask if they would accept blood products and to never make assumptions about patients. I always keep in mind it is better to ask too many questions than not enough. I always make sure to take extra time to emphasize that what treatment plan we decideonistheirchoiceandIamhereto be their advocate. As I walked into that patient room in the emergency department to greet this 26-year-old, little did I know the profound effect she would have on me. She taught me so much more than just about acute myeloidleukemia.Shetaughtmehowto exemplify humanism in medicine and to emphasize patient autonomy above all. As I move on in my medical career I will always remember this patient and the lessons she taught me to give patients theexcellentcarethattheydeserve.

Humanity of Medicine

by Alex Roetzheim

Internal medicine wasonlymy second rotationasamedical student. It was also my first real experience working in a hospital and I had no idea what to expect. I began working in a small hospital during a time whereCOVIDwasverymuchstillpresent in Florida. To make matters worse, my small hospital was centered in a community consisting of mostly older aged residents. Residents who checked off many of the morbidity and mortality risk factors for COVID. This combination createdaperfectstormformyhospital,a situation seen throughout hospitals acrosstheUS.

I could see the exhaustion on the doctors’ and nurses’ faces as I entered thehospitaltoroundonpatients.

Everyone seemed to be juggling multiple tasks and always appeared to be in a rush. I began to truly understand the amount of work needed to care for such an overwhelming number of sick patients. Tasks needed to be completed asfastaspossibletokeepthingsflowing. This is where one of the common problems in medicine became apparent to me. I realized how easy it was to get caughtupinthemanytasksofmedicine, dehumanizingpatientcare.Furthermore, patients and healthcare workers were required to wear layers of protective gowns,masks,ventilators,andotherPPE. This constant physical separation betweenhealthcareproviderandpatient made losing sight of humanity much easier.

One patient in particular, truly helped mestayontherightpathofpatientcare. Thispatientwasan85-year-oldladyIwill call Mrs. Jane. She was a small frail lady withahistoryofCOPD.Shewasadmitted to the hospital due to a severe bout of COPDexacerbationfromCOVID.Thefirst time I saw her, she was in poor shape. She had IVs, ventilators, and various otherwiresconnectedtoher.Nursesand Doctors moved rapidly around her, coming in and out of her room to give meds and record stats. In all the commotion I noticed no one was really talkingtoher.AsIapproachedhertosay hello, I saw she was shivering. Her face was full of fear and in a weak voice she told me she was cold. I ran to retrieve a warm blanket, happy to be able to help evenifonlyinaminorway.

I introduced myself to Mrs. Jane and askedherhowshewasdoing.Onceagain in a weak voice she told me she was scared and didn't want to die. In this moment I realized that a big part of medicine does not revolve around traditionalmedicine.Inthatmoment,the most important thing I could do was comfort my patient and make her feel at ease. I held her hand and told her she was in good hands and that the team would do everything they could to keep her safe. In busy times such as COVID, I understood how easy it is to get caught upinmanytasksofmedicalcare.This cycle can cloud providers' minds and makethemlosetouchwiththehumanity ofthepatient.

The next day Mrs. Jane’s condition finally stabilized. Her breathing was controlled,andshewasabletotalk.Once againtherewasn’tmuchmoreIcoulddo from a medicine standpoint so I decided tojusttalkwithher.Igaveheranupdate on her situation and answered any questionsshehadmakingsuretoremind herthatshewasingoodhandsandthatI would be coming every day to check in on her. As I promised, each day I visited her to talk, regardless of whether I had anything to add to her medical care. As the days went on I noticed how excited she was when I visited her. Her face would light up when I entered the room and she would always say how grateful she was to see me again. Our conversations often shifted away from medicineandwediscussedlifeandother everydaytopics.DuringthosemomentsI didn’t feel like a medical student talking to a patient, I felt like a regular person talking to a friend. These conversations helpedmeseethruthelayersofPPEand reminded me of the humanity within eachpatient.

TowardstheendofMrs.Jane’sstayshe thankedmeonceagainforalwayscoming to talk with her. She told me that she didn’thavemanypeopletotalktoinlife. Most of her family and friends had passed away and she didn’t have many visitors. Mrs. Jane expressed to me that talking with me was a highlight of her days and that it made her stay much moremanageable.

Several weeks later I was in my outpatient clinic when one of the nurses pulled me aside and told me a patient was looking for me. There was Mrs. Jane ready to say hello again, looking just as happy as she did during our past talks. I was surprised that she had remembered me and was glad to see her again. Months after my rotation was over, my internalmedicinepreceptortoldmeMrs. Jane would still ask about me during her outpatient visits. I saw the impact my seemingly simple conversations had on her.Simpleactsofkindnessand genuinely caring made a lasting impact onapatient.

During busy days, chatting about random topics may seem like a waste of valuable time. But to many patients, this may be the closest thing they get to normal life. The hospital setting can be very overwhelming and chaotic. Dealing with illness in this foreign environment alonecanseemlikeamonumentaltask.I saw first hand how taking time to sit downandtalkwithapatientcouldhavea tremendous impact on their overall healthcare experience. Mrs. Jane helped meavoidgettingcaughtupintherobotic cycle of task completion. She helped remind me of the importance of treating patientsashumans.

He/Him with Menopause

by Samantha Singer

When the next patient walked in for his routine healthmaintenance exam, he asked me if menopause could be causing his racing heartbeat. I was perplexed. He had opened an entirely newalgorithmfordifferentialinmyhead. This was a 50-year-old white trans-male presenting with the complaint of new onset heart palpitations. He said his mother went through menopause at 50 and that the possibility seemed very likely to him. After presenting to my preceptor, she told me that although he was most likely experiencing premature atrial contractions, that was certainly something to explore deeper. We educated him on the benign causes of heart palpitations like premature atrial contractions along with the possibility of menopausebeingthereasonforsomeof his other complaints such as hot flashes, insomnia, weight gain, and decreased concentration.

I found this experience to be a huge learning moment. Although he had transitioned into a trans-male, we, as healthproviders,mustnotforgetabout managementtohisbiologicalorgansand their functions/disorders like going throughmenopause.

We asked if he needed a referral to his gynecologist or if he wanted to alter his testosterone therapy, and he declined. He decided to not make any changes to his testosterone replacement therapy and would address these symptoms in thefutureiftheystarttodrasticallyaffect hisdailyactivities.However,heagreedto get an ECG, chest x-ray and to see a cardiologist for management of his heart palpitations.

I was able to follow him to his referred cardiologist appointment, and initially I wasabitworried.Hementionedthatmy preceptorwasoneoftheonlyphysicians helikedtoseeregularlybecauseshewas both accepting to his transition, and she kept herself up to date with the medical management of transgender people. So, whenweenteredthecardiologistoffice,I was hyper aware to the interactions he had with the staff and medical professionals. I then thought to myself how exhausting it must be to be in his shoes meeting others for the first time, especially in the medical field. Does he wonder if his care is adequate? Does he havetoworrythatthestaffwilltreathim differentlybecauseheisatrans-male?As if reading my mind, when he finished checking in with the receptionist, he sat down next to me and sighed in relief. “Well,shewaskind.Youshouldseesome of the looks I get from people once they seemychartandbiologicalsex.”

We had some time before he got called backintotheoffice,andsoIgottoheara bit about his story. He started his transition eleven years ago and was rejected by most of his family members because they refused to accept his transition. A few years after coming out, he lost both his dad and sisters to drug overdose. He and his aunt moved to SouthCarolinaforafreshstart;however, a year after their move, he became a full-time caregiver to his aunt because shewasinaboatingaccidentthatlefther disabled. They then moved to Florida, and he was in charge of finding both he andhisaunthomesalongwith forher.Thisexperiencemadehimrealize that he wanted to give back and become a social worker to help others in situations like his own. So now, he takes care of his aunt, is getting his masters degree, and is a full-time teacher at a local elementary school. When hurricane Ian hit, his aunt’s home completely floodedsoitwasuptohimtohelpmove her out and fix up her place. It was around then when the heart palpitations started.Tosayapersonhasbeenthrough alotisanunderstatement.

Whenthecardiologistcalledusback,he told us that his ECG showed a normal sinusrhythmandthathischestx-raywas clear. The cardiologist asked if he was under a lot of stress. We both laughed, and he answered yes with his full HPI. The cardiologist said out loud what I was thinking,“Itisclearthatyouhavealotof responsibilities in your life right now and it seems likely that it’s causing stress to your heart.” He then proceeded to explain PACs, what a supraventricular premature beat would present as, and how it can be caused by lifestyle risk factors such as smoking, alcohol, caffeine,andstress.

Due to the sporadic nature of PACs and theinconclusiveECG,thedecisionforthe patient to undergo ambulatory monitoring via a 24-hour Holter ECG was made. The cardiologist then proceeded with reassurance on the benign disorder and told him to avoid the common triggers if possible. The physician then offerediftherewasanythinghecoulddo to help reduce his stress regarding his mother and her hurricane destroyed home. The patient declined but shared hisappreciationfortheoffer.

Thislearningexperiencewasimmensely influential and helped me gain insight into the challenges that transgender individuals may face when seeking medical care. By acknowledging the uniqueness of each individual and showingrespectandactivelistening,one is helping to create a more inclusive and supportive environment for all patients. From the moment a patient enters the office,allinteractionsmatter,as highlighted from this person’s anxiety at the front desk of his cardiology appointment. The newfound understandingofthechallengesfacedby transgender individuals can help provide morecompassionateandeffectivecarein the future. The patient felt fortunate to have my preceptor as a primary care doctor who is accepting and proactive in staying up to date with inclusive medical treatment for transgender individuals. Thisshouldbethenorm.Experienceslike this can be invaluable in shaping one’s practice. This encounter has shown me how important it is to continue learning andgrowingasahealthcareprovider.

Home by Samantha Snow

My parents immigrated from Russia two years before I was born anddidnot speak a word of English until I started kindergarten. Growingupinanareawith great cultural diversity, my parents and ourextendedfamilywereabletofitright inwithotherRussianfamilieswhichkept usspeakingRussian,watchingRussianTV and preserved the culture at home. I did notrealizewhatablessingthiswaswhile constantly being pulled out of class to attend additional English classes, but I haveneverfeltsomuchgratitudeformy upbringing and cultural roots as I have thisyearinmedicalschool.

My earliest memories of healthcare consistofvisitstotheoncologistwithmy grandma. As soon as I was old enough, I served as the amateur translator when her or my mom did not understand something in English which gave me my first glimpse into language barriers in healthcare and inspired my love for language. The ability to effectively communicate thoughts, fears, beliefs, and uncertainties lifts so much of what burdens us and can itself be medicinal. Thediversityoflivinginameltingpot unfortunately also creates inequality and barriers to access in healthcare. Having seen the impact this can have on health outcomes and medical decisions inspired me to major in Spanish to broaden my ability to connect with, communicate, and care for more people. The most rewarding parts of my clinical experiences has been developing trust andconnectingwithmypatients,hearing their stories and seeing how therapeutic communication can be. There is no greater privilege than that trust between physicians and their patients. It is the art ofmedicinetoknowourpatientsdeeply, toknowtheirfearsandtohealthemwith intangibletherapies.

When I started my OB/GYN rotation, I quickly learned that there was a significantRussianpopulationinthearea. Iwasfinallyabletousemyknowledgeof the language to connect with my patients. The day I met Lena was the most memorable of my medical school experience to date. As soon as I walked intotheroom,hervoiceremindedmeof my mom’s and I immediately spent the first few minutes learning that she grew up in Belarus just like my mom’s side of thefamily.Ilearnedthatherparentshad passedawayafewyearsagoandthatshe had recently moved to Palm Coast with herhusband.Theybothworkedtwojobs and had two young children at home so she always came to her OB visits alone. I imagined everything my mom must have experienced having us in a foreign country, barely knowing the language and could not imagine how alone she must have felt. I had the privilege of seeing her for her weekly third trimester visits. She always came alone, and we always spoke Russian the entirely of the visit and truly got to know each other. We both lit up when we saw each other, and she always thanked me and my preceptor for allowing us the chance to voice her questions and concerns in her nativelanguage.Thisbroughtmebackto being a child at the doctor’s appointments with my grandma, using my incredibly limited knowledge and understandingofanythingpertainingto medicine to help my family make life or deathdecisions.

When I walked into her room in labor and delivery, I felt sad that she did not have anyone with her, but she insisted that she’s done it before and she can do it again and that she did not need her husband seeing this. This feisty strength and independence reminded me of the tough Russian women in my family and made me admire and reflect on everything they experienced immigrating to this country so I could have the life I have. As her labor progressed, the fetal monitors started showing some concerning signs and she was growing exhausted and scared. It was close to 1am, her husband was asleep at home with their kids and I felt that I was the closest thing she had to family in that moment. I wanted to comfort her as I wish someone had for my grandma navigating her cancer treatments in a foreignlanguage.Iwantedtobringsome familiarity, a sense of safety, peace and home to Lena navigating something as frightening, emotional, and uncertain as childbirth. I stayed by her side, spoke to thenursesaboutanythingshewantedto makehermorecomfortableandcoached her through her delivery in her native language. As I was helping deliver her beautiful and healthy baby girl, I realized Ineveraskedwhatshewasnamingher.I was overwhelmed with emotion when she coincidentally said the same name my dad used to call me as a nickname when I was a kid. The next morning, I camebacktocheckonherandthewhole family was there with Russian snacks waiting for me. I finally got to meet her husband and kids that I have heard so much about, and he was equally as excited to meet the Russian medical student she had been telling him about the last few weeks and thanked me so muchfortakingcareofhiswife.

Getting to know this family and being therefortheminsuchanemotionaltime is something that will stay with me forever.Ittrulymademeunderstandhow important it is to take the time to listen to and connect with people. We all want tofeelheard,understood,cared about and to belong. I felt so grateful to be able to combine my culture and upbringing with my passion for helping people. There is so much diversity in this country yet so much division and hate. I believethatseeingourpatientsasasum of all their life experiences instead of as isolated medical conditions is what makes a great physician. Taking the time to understand their culture, values and beliefsisessentialtounderstandingtheir needs and developing the connection andthetrustnecessarytoheal.

My First Delivery

by Taylor Spiletic

How has it already beenalmost a year ofclinicalrotations?

I feel like just yesterday I was starting with Dr. Parsons in his family medicine clinic. I learned so much about medicine in such a short time. Having donesomuchthispastyearrangingfrom suturing in surgery, to caring for patients in the ICU, to seeing a patient put on ECMO in an attempt to save his life, to seeing acutely manic and schizophrenic patients, there was still one more thing on my list I felt like I needed to experience as a medical student. I wanted to deliver a baby on my last rotationforobstetricsandgynecology.

This is the one rotation I felt like I had learned nothing from my first- or second-year studies to prepare for it clinically. I mean yes, we learned about endometriosisandgynecologicalcancers, but a mom in active labor? I had no idea what to expect. I wish the rest of this story was going to be about how great myfirstdeliverywent,butitwasfarfrom that.

Dr. Bagwell told me we have one in triage. I saw her first at the same time the nurses were doing her vitals and checking for fetal heart rate. Momma is anexperiencedG7P5015.G7P5015isnot the name of a robot, but a shorthand thattellsphysiciansthemothersbirthing history.Shehasbeenpregnant7times,5 babies were born at term, 0 were preterm, 1 was an abortion, and 5 are living.Hercurrentbabyis27weeksand5 days. She comes in because she has not feltbabymoveforafewdays.Herblood pressure comes back 152/88. I asked if she has had any headaches, “Yes my head has been hurting for the past 3 days.”Ithennoticedthenurseseemedto get a little nervous as she was having trouble finding the fetal heart rate on doppler.Oneoftheothernursessaidshe wasgoingtogetDr.Bagwell.Istayedwith mom asking her a couple more questions, but more importantly I wanted to be there for support because she had no family with her. This was my first day, so I did not know a lot, but I knew not finding a fetal heart rate was not a good sign. As I asked her questions about her other children trying to keep herascomfortableaspossible,allIcould think about was the possibility that Dr. Bagwell may not be able to find a heart rate. The next couple of minutes that I was waiting for Dr. Bagwell to run over, felt like a lifetime. I was in a position where I wanted to reassure mom, but I knewIcouldn’tinthecasethatherbaby boy is not okay. I think I was seeking reassurancemyself.Ididmybesttohide my uncertainty and be there for mom whilewewaited.

Dr. Bagwell comes in with the ultrasoundandlistenstomeasItellhera briefpatienthistory.InoticeDr.Bagwell’s attitude change very quickly and a tear cometohereye.InthismomentIalready knewwhatwascomingnext.Iwassickto my stomach, and despite all the noise in the typical hospital room, I felt like I could all the sudden hear a needle drop. She asked mom if baby had a name yet, and mom said “JJ.” Dr. Bagwell empathetically said “I am really sorry to tell you mom, but JJ did not make it, the most important thing for you to know is thatthiswasnotyourfault.”Iwantedto cry, but I held back my tears. Mom had no emotion, understandably, I think she wasinshock.Wewaitedwiththepatient for a second ultrasound technician to comeand confirm the fetal demise. Mom did not have anyone to come and give her support, so I wanted to be there in any waypossible.Thesecondultrasoundwas no different, and the fetal demise was confirmed.Dr.Bagwelltoldmomitwould be best to deliver the baby today for her own health so we would induce her labor. At this point I had no idea what to expect. The uneasiness I had when I first sawthispatientintriageneverleft.

After we left the room Dr. Bagwell told me this is the worst part of obstetrics. Her emotions were a reflection as if she just lost one of her own children. The patient was started on misoprostol and oxytocin. I checked on mom over the nextfewhoursandthenDr.BagwellandI deliveredJJ.

Being my first delivery, I really had no idea what to expect. Dr. Bagwell told me shewashopingthebabywouldcomeout all in one piece, otherwise if baby breaks apart it can be very challenging to get everything out. This then is not only more traumatic for mom, but it puts her at risk of hemorrhage or DIC. Luckily when we started delivery, JJ was in occiput posterior positioning and he cameoutonlyafteracoupleofpushesby mom. JJ came out complete and the placenta was delivered shortly after. JJ’s head was full of hair, but all his bones, specifically his skull looked very soft and seemed mushy. One of the nurses asked meifIwasokay,Itoldheryes,whilethe inside of me was screaming no. For the purpose of looking more presentable we swaddled JJ and then gave him to mom. Mom was in tears and we stayed there for support. I was at a loss of words and wanted to help, but I have never felt so helpless.

We were able to get some family on facetime to be there for her too. I could not stop thinking about the mental trauma she will experience from this. Thankfully she does have 5 healthy childrenathome,whichIdothinkmakes this easier than it being her first born. I went home for the night and told her I wouldseeherinthemorning.Ireflected a lot that night and was still processing myownemotions.

ThefollowingmorningwhenIwalkedin mom was looking over JJ’s crib. I asked her how she was doing, and she said “okay.” I told her that it was okay to grieve and to feel all the emotions she was feeling. I knew her getting back to herfamilywouldalsobegoodforher.Dr. Bagwell and I talked with her about postpartum depression, eclampsia, and contraceptive. She was really interested in contraceptive and opted for Depot. Shewasdischargedhomethatday.

This was my reminder that medicine does not always have good outcomes. More importantly though, were the interactionswehadwiththispatientand the ways we delivered the bad news. Dr. Bagwell did it in such a compassionate waythatIcanonlyaspiretobelikewhen I am a practicing physician. This experience flooded me with mixed emotions. At the same time, it made me gain tremendous respect for pregnant mothers and everything they go though. Despite the bad outcome, I think it is important for us to realize we made the best situation possible out of it. I cannot imagine the difference in care mom would have experienced if a physician came in and had no compassion or empathy. JJ would have been delivered and mom would be okay, but the toll on mom’s mental health would be so much worse. I am glad Dr. Bagwell walked me through this experience and showed me howtohandlebadnewssuchasthis.

A Hand to Hold by Nicholas Thomas

As a medical student, I had witnessed many patientswhoweregravelyillandinneed ofurgentmedicalcare.However,nothing couldhavepreparedmefortheprofound momentwhenIhelpedcarefor,Mr.O,a 76-year-old patient with stage 4 lymphoma in the intensive care unit (ICU). It was an experience that will stay withmefortherestofmylife.

Mr.OwasadmittedtotheICUfromthe emergency department with initial complaints of shortness of breath. It was discovered that he had both a malignant pleural and peritoneal effusion, leading to a significantly protuberant abdomen that made breathing laborious. He was visibly in unbearable pain and required supplemental oxygen. The first thing his wifesaidtouswhenweenteredhisroom fortheconsultwasthatshewantedusto do everything in our power to save her husband. She wanted all measures taken to prevent his death, but the patient himselfseemeduneasyasshespoke.

HewasadmittedtotheICUandstarted on fluids and medications to keep his vital signs as stable as possible, with a plantoperformaparacentesistooffload some of the fluid and help his breathing. Once we “tapped his belly” fluid began rapidly pouring out in the collection canister and I noted the immediate look of relief on Mr. O’s face. There was complete silence in the room, even the fluid had a blissfully silent laminar flow. Mrs.Owasaskedtoexittheroomduring the procedure. Mr. O transitioned in and out of sleep and this was likely the first time he felt comfortable in a long while. After we collected nearly 3 liters of fluid from his abdomen, I stood next to the monitor and watched Mr. O’s heart rate begin to rapidly increase. The doctor asked, “how do you feel?” and while he could barely get the words out, Mr. O said tearfully, “I am tired of living like this, I don’t want any more procedures, but I am afraid to leave my wife.” He became increasingly anxious as the doctor began asking more questions on his wishes for his care. He was weak and haddifficultymoving,buthereachedout and asked me, “can you please hold my hand?” It was a poignant moment, and my stomach sank as I realized that this manknewhewasenteringhisfinaldays.

Since he had full decision-making capacity,werespectedhiswishes,andhe asked us to relay the information to his wife. I stood by the doctor as he relayed Mr. O’s wishes to his wife. Once she heardthewords"lethimlivehisfinal days in peace," I watched as she fainted her eyes quickly rolled to the backofherhead,andshefelltothefloor nearly hitting her head in what seemed to be slow motion to me. I stood still in fear, as the rapid response team was called to assess Mrs. O. She quickly revived and but was visibly distraught. Sheaskedfortimetotalktoherhusband and daughter to make sure this is truly what he wanted. Through the glass window of Mr. O’s room, I watched her scurry in and embrace her husband as if it were the last time she would see him. A little while after the family spoke, Mrs. O came over to the nurses’ station and told us they were ready to sign the DNR and proceed with palliative care. A few momentslater,hospicearrivedattheICU todiscussnextstepswiththepatientand hisfamily.

Theydecidedhewouldbedischargedto home hospice. The doctor I was with cautioned me that his lungs were not strong enough to be off oxygen and that he would likely expire soon after it was removed. As this was one of my first experiences in the ICU, it was a sobering reminderoftherealitiesofmedicineand end-of-lifecare.

Thiswasatoughtimeforme,andIhad been following this patient for over a week I could only imagine how it felt for his daughter or his wife of 44 years. AswedidallwecouldforMr.Oatthe beginningofhistimeintheICU,wewere so hopeful that our interventions would work. He had moments where he began to improve but quickly deteriorated and continuedtoworsenthroughouthisstay. Throughout his time there, I often witnessedMr.Ospaceoutasheseemed to be thinking deeply about something. NowthatIreflectonmytimewithMr.O, Irealizethiswasafirst-handdepictionof one’s life flashing before their eyes. His communication was limited, but his expressionsspokevolumes.

Mr. O was more than just a patient in room X with stage 4 lymphoma. That message holds true for all patients. We mustrememberthatpatientsarenotjust medical cases, but individuals with unique experiences, values, and emotions. Taking the time to listen to their concerns and understanding their perspectives can make a significant difference in the quality of care they receive. This experience with Mr. O was eye-opening. It was a reminder that we must also respect the wishes of our patients and provide them with the care they need, even if it means letting go. It was also a lesson in the importance of communication, both with our patients and their families, and with our colleagues.

I am grateful for this humbling moment inmymedicaleducation.Nomatterhow

Volusia County Medical Society

Welcomes 2023 New Members:

RossWheeler,MD–SkinDermatologyandCosmeticSvcs.

JayaBadhwarKumar,MD–FloridaRetinaInstitute

DennisWen,MD–SportsMedicineHalifaxHealth

RebeccaPeck,MD–FamilyMedicine

LindsayLucas,MD–TheOrthopedicClinic

BenjaminPeck,MD–FamilyMedicine

William“Champ”Douglas,MD–FamilyMedicine

HughColeman,DO–GeneralMedicine

MariaNovoaVillavicencio,MD–HalifaxOB/GYN

PaulGraham,MD–OrmondDermatology much we may wish to cure our patients, therecomesatimewhenwemustaccept the inevitable and provide comfort and care in their final days. It also reminded me of the importance of empathy and compassion, and the vital role that medical professionals play in helping patients and their families navigate the difficultjourneytowardstheendoflife. Offeringahandtoholdmayseemlikea small gesture, but its value cannot be overstated. It allowed me to meet Mr. O where he needed me most. This is the true essence of patient-centered care, showing him that, whether this was our firstor30thencounteroftheday right then, in that exact moment, he was the onlypersonthatmattered.

ZophiaMartinez,DO–RadiologyImagingAssociates

TravisFuchs,MD–RadiologyImagingAssociates

JonathanFriedman,MD–RadiologyImagingAssociates

BoydHatton,MD–RadiologyImagingAssociates

JesseGreenblum,MD–HalifaxHealthOB/GYN

JulieDegele,MD–FamilyMedicineHalifaxHealth

LarissaRaymond,MD–FamilyMedicineHalifaxHealth

Dr.ClaudiaLagoToro,MD–BreastCancerSurgicalOncology

MiriamStaub,MD–Psychiatry/BehavioralHealthFHCP

Vitamins B & K and Our Intestinal Biome Andria Klioze, MD

As many of you know, my last 20 years of work have been about helping patients not only lowering weight, but reversing disease. Our intestinal biome and its health has everything to do with our personal health and the health of our patients. Every year, I try to focus not only on educating on the pathophysiology of disease as it’s currently discussed in the literature, but also on an overarching theme, and this year it's the biome.

I have decided to make 2023 “The Year of the Biome - Our Newly Discovered 'extra organ’.” The nature of the biome, how to maximize its impact on our health, the details of its functions and interactions with our body, are profound and the knowledge around it is growing rapidly.

There are many important details on how this biome is impacted not only by nutrients, but also by sleep, exercise, spirituality, and the community you keep. This month I will focus on the vitamins our biome makes and how these vitamins impact us and our patients. In our Shield of Life “Heal Program" we have 9 core videos every participant receives explaining the pathophysiology of disease which is constantly changing. Now our Shield of Life company is developing a learning management system (LMS) to break these key lectures down into more specific learning bites.

Our video number 9, for example, is on the biome: “Understanding the Intestinal Biome, the Bacteria in Your Gut, and How They Can Help You Make the B and K vitamins.”

After reviewing many complex scientific articles on how B an K vitamins are created by a healthy biome and their impact on our health, I decided to summarize them in an article our monthly coaching group of clients reviewed and would now like to share it with you to help you understand the level of education and guidance our participants receive. If any of you have seen my husband's, Dr. Scott Klioze, more sophisticated educational videos on YouTube, please forgive my much simpler graphics, as I'm not an engineer!

In order to begin this discussion, we must first understand the makeup of our intestinal tract. The picture or cartoon below depicts one wall of our intestine and the bacteria in our intestine, the biome.

Here you see the tight junctions and the two mucosal layers (inner and outer layers) which are vital to the health of our intestinal wall and body. If there is a breakdown of the mucosal layers and tight junction between intestinal cells (epithelium), you can get “leaky gut” or intestinal permeability leading to many diseases.

Some of these include autoimmune, inflammatory bowel, diabetes, obesity, cancer and cardiovascular diseases, etc. As you know from our previous review, Lecture 3: Grain and Free Radicals, free radicals can disrupt cell walls and cell wall function.

Keeping the intestinal barrier in check depends on a healthy diet, adequate sleep and exercise, and avoiding free radicals including diets high in glucose, fructose, saturated fats and chemicals; but, a big part is maintaining adequate vitamin D levels!

Vitamin D activates vitamin D receptors (VDR) that activate reactions inducing the formation of many of these tight junctions and help maintain a strong mucosal barrier.

Now that we understand a healthy intestinal wall depends on a healthy lifestyle, avoiding free radicals and maintaining healthy vitamin D levels, we can next address our intestinal or gut biome, the bacteria in our intestines.

Ahealthy gut biome is a diverse biome made up of a variety of bacteria and other organisms. Often it is referred to as a “rainforest” as it has many players including bacteria, eukaryotic and archaea, but also protozoa, fungi and viruses. We will focus on the bacteria.Ahealthy diverse biome is primarily made up of bacteroidetes, and firmicutes and, on a smaller scale, by actinobacteria, proteobacteria and verrucomicrobia. They all work symbiotically with the human body and have been noted to affect our circadian rhythm, help make neurotransmitters, endocrine hormones, stabilize the immune system to control inflammation, infection, prevent cancer, and also make vitamins.

The primary ones are the B and K vitamins. For our biome to be productive, it must be healthy and it requires nutrients, vitamins, elements and a healthy gastrointestinal tract.

The microbiome produces micronutrients like the B and K vitamins, but also requires them for survival. Currently, research shows that the majority of our B and K vitamins comes from our diet, but our gut biome makes a large number of them as well. The foods that have most B and K vitamins include: broccoli, Brussel sprouts, cabbage, kale, spinach, liver, seafood, poultry, eggs, seeds etc.

Our gut biome not only makes vitamins, but helps regulate the absorption of vitamins and minerals from our diet. Interestingly, our biome helps regulate the absorption of certain vitamins such asA, B, C, D, E and K; and minerals such as calcium, iron, zinc, magnesium and phosphorus. Yes, the biome makes the B and K vitamins, but it also helps regulate the absorption of the exact levels we need. Now you can see why it is so important to eat your vegetables, as they are full of these vital nutrients that help us, but also help the gut bacteria do their job. In addition to the vitamins and minerals we mentioned above, the gut bacteria need fiber, and vegetables have a lot of fiber! Diets higher in protein lead to microbial by-products that can slow down gastric emptying, therefore inducing constipation. Have you ever been constipated after eating a high protein diet?

Often, when processed foods are lacking in important vitamins and minerals, the industry modifies the food item by “fortifying" it with x minerals, vitamins etc. So, yes, you’re getting the vitamins and minerals, mostly chemical, but why settle when you can get them naturally from vegetables?

Another very important point, for a healthy diet with appropriate vitamins and minerals, is that certain vitamins (A, B2, D, E & beta-carotene) help increase the abundance of the biome while others help maintain its biodiversity (A, B2, B3, C, K) and quality (vitamin D). VitaminsAand D help with the immune response via supporting the mucosal lining which provides intestinal and biome health. Vitamin B2 and E help produce more bacteria that generate short chain fatty acids. Remember we mentioned them in lecture 9? Short chain fatty acids are post-biotic or the “poop” of the bacteria. Post-biotics act as an anti-inflammatory agent to the body and organs. I know, “gross”, but we do depend on a “healthy” biome, therefore we must choose wisely to stay healthy.

So, does this mean you need to run to the store and buy all these supplements? No!This is why over the 20 years of working with patients, I have seen crazy and really amazing changes in people's bodies and their body's ability to overcome disease by just eating more vegetables and taking certain extra vitamins and minerals.

If you have been following our Shield of Life program for a while, you can see that part of the reason your body is transforming, is because the foundation of our “Healthy Food Choices” nutritional platform is providing you with these vitamins and minerals your body has perhaps not only been missing, but maybe even craving! We want to empower you with the understanding of how your body works, so you will resist putting bad fuel in your engines, but strive to always make correct choices.

Below I will summarize just what the B and K vitamins do for you: There are eight B vitamins (B, thiamine, B2, riboflavin, B3, nicotinic acid, B5, pantothenic acid, B6, pyridoxine, B7, biotin, B9, folate, and B12, cobalamin).They are water soluble and are produced by the microbiome. Currently it is felt we need more than what the biome produces, especially in patients with inflammatory bowel disease, diabetes and other metabolic diseases, but this could be the current state of our unhealthy bodies and biome.

Vitamin B1 -Thiamine is a key vitamin in the generation of cellular energy from glucose. Many bacteria make thiamine and its exact role is not know, but it is felt to be involved in intestinal immunity.

Vitamin B2 - Riboflavin helps in the redox reaction to reduce free radicals: it's an anti-oxidant. It also promotes healthier bacteria, where in its absence there are more pro-inflammatory bacteria in the biome. It also promotes healthy intestinal mucosal and when there is a deficiency, the intestinal lining is inflamed.

Vitamin B3 - Nicotinic acid like Vitamin B2 is a very important cofactor in decreasing free radicals. Many of the bacteria that make up the biome have the ability to make vitamin B3.This is also very important in maintaining a healthy intestine and decreasing inflammation in the bowel mucosa. Patients with inflammatory bowel disease have lower vitamin B3 levels and treatment with vitamin B3 have shown improvement in acute intestinal cell inflammation.

Vitamin B5 - Pantothenic acid is important in metabolic pathways that help generate cellular energy, neurotransmitter formation, and breakdown of fatty acids. Several bacteria make pantothenic acid, but several require it to make vitamin B6.

Vitamin B6 - Pyridoxine is important cofactor in making amino acids which are the building blocks of proteins. It is also needed to breakdown proteins. There are many intestinal bacteria that make vitamin B6. As we have seen with many of the B vitamins, a deficiency in vitamin B6 is associated with irritable bowel disease. It is felt that an abundance of pyridoxine induces the activation of anti-inflammatory cytokines, whereas a deficiency causes pro-inflammatory cytokine activation.

Vitamin B7 - Biotin is a coenzyme for glucose breakdown, cellular interaction, epigenetic regulation, and genetic expression. It may be involved in anti-inflammatory activities. Many bacteria make biotin, but there are bacteria that decrease it.

Vitamin B9 - Folate primarily comes from diet, but some comes from gut microbiome. It is involved in cell growth and DNAactivation. When vitamin B9 is deficient, it affects cell survival and proliferation. It is also associated with maintaining the intestinal lining, providing nutrients needed for brain activity, decreasing cytotoxicity of natural killer cells and decreasing lymphocyte growth. Many bacteria in the biome make folate, but when it is deficient, it jeopardizes the integrity of the intestinal lining and has been related to a higher risk of intestinal cancers.

Vitamin 12 - Cobalamin is important in DNA and RNA synthesis, and is involved in the breakdown of protein and fat. It is very important to the central nervous system and the formation of red blood cells. A large majority of the biome requires vitamin B12, but not as many make it. For this reason, a deficiency in vitamin B12 effects the growth of the biome.

Other key vitamins that are made by our biome:

Vitamin K1- can activate clotting the cascade and has effects on bone health. It can stop cancer cells from proliferating, but vitamin K2 is more potent for this.

Vitamin K2 - has anti-cancer properties. It induces cancer cell death (apoptosis) and can stop cancer cells form proliferating. Cancers noted to be affected are liver, colon, bile duct (cholangiocarcinoma), ovarian, pancreatic, lung and bone (leukemia). It is also noted to decrease osteoporosis, and liver cirrhosis.

Vitamin K3 - has anti-inflammatory and anti-cancer effects, but due to its toxicity to liver and disruption of red blood cells in carrying oxygen, it is not used.

In general the B vitamins should not be taken in isolation other than vitamin B12. I hope this sheds some light on the power of the biome and of a healthy diet.

In conclusion, we have reviewed the importance of our intestinal biome, the bacteria in our intestine, and the vitamins B and K that our microbiota produces. We have discussed how the vitamins and minerals from our diet are necessary for our gut bacteria to thrive and produce these vitamins, but also for our body to absorb the exact levels of vitamins and minerals we need. We have also discussed how these vitamins have several roles in maintaining a healthy intestinal lining, decreasing inflammation, decreasing free radicals, and aiding in DNAand RNAsynthesis. Finally, we have also discussed how vitamin K1, K2 and K3 have anti-inflammatory and anti-cancer properties.

It is important to remember that in order to maintain a healthy intestinal wall and microbiome, we must maintain a healthy lifestyle, a diet high in vegetables, avoid free radicals and maintain healthy vitamin D levels. In addition, we must also be mindful of the vitamins and minerals our microbiome needs to thrive and make the vitamins we need to maintain a healthy body.

1. Akimbekov NS, Digel I, Sherelkhan DK, Lutfor AB, Razzaque MS. Vitamin D and the Host-Gut Microbiome: A Brief Overview. Acta Histochem Cytochem. 2020 Jun 26;53(3):33-42. doi: 10.1267/ahc.20011. Epub 2020 Jun 16. PMID: 32624628; PMCID: PMC7322162.

2. Sun J, Zhang YG. Vitamin D Receptor Influences Intestinal Barriers in Health and Disease. Cells. 2022 Mar 27;11(7):1129. doi: 10.3390/cells11071129. PMID: 35406694; PMCID: PMC8997406.

3. Gut microbiome–micronutrient interaction:The key to controlling the bioavailability of minerals and vitamins? Journal article·2022·Barone, D'Amico, Brigidi,Turroni

4. LA Frame, E Costa, SA. Jackson. Current explorations of nutrition and the gut microbiome: a comprehensive evaluation of the review literature. Nutr Rev, 78 (2020), pp. 798-812, 10.1093/nutrit/nuz106

5. Hossain KS, Amarasena S, Mayengbam S. B Vitamins and Their Roles in Gut Health. Microorganisms. 2022 Jun 7;10(6):1168. doi: 10.3390/microorganisms10061168. PMID: 35744686; PMCID: PMC9227236.

6. Xv F, Chen J, Duan L, Li S. Research progress on the anticancer effects of vitamin K2. Oncol Lett. 2018 Jun;15(6):8926-8934. doi: 10.3892/ol.2018.8502. Epub 2018Apr 16. PMID: 29805627; PMCID: PMC5958717.

Volusia County Medical Society Educational Foundation

Each year, the Educational Foundation proudly partners with Daytona State College to provide a medical track student with a Scholarship. This year we announce the Scholarship was awarded to O’Liyah Wilson. Best wishes to you on your way to becoming a CRNA!

Volusia County Medical Society Educational Foundation is a tax exempt 501(c)3 and your contribution matters! Send a check to PO Box 9595, Daytona Beach, FL 32120. Together we can make a difference!

Are you a Volusia County physician that is not a Member yet? Join us!

www.vcms.org