Category: Essays & Poetry

As I walk down the hall of the ICU toward your room, I know I am about to encounter something new. Just two days ago you were rushed into the hospital with excruciating abdominal pain: a perforated bowel, likely an adverse effect from your chemotherapy for ovarian cancer. Just two days ago you shared your story with me despite your extreme pain. Our conversation did not hide the fear in your eyes;  fear of not knowing what would happen after your surgery.  I shared your fear, my instincts telling me that what lay on the other side of this surgery was something no one wished for.

“Will she be okay?,” I asked your surgeon anxiously throughout your surgery, “She is only in her forties and has a husband who loves her. I hope she will be okay.”

Even as I said these words, I knew deep down inside that your chances of a long-term survival were grim. In fact, the answers to my questions lay right in front of my eyes as I looked at your pale, lifeless organs that reminded me of something I might see in an anatomy lab and not in the operating room. When we opened your abdomen, tumors throughout your entire peritoneum stared back at us. Your bowel was worse. It was so badly damaged from the chemotherapy that your surgeon described it as “frozen bowel,” unable to move or function due to the toxic medication intended to help you survive.She is only in her forties, she still has a whole life to live, I kept thinking as each minute went by and your chances of survival dwindled even more. She is younger than my mother. It was this thought that would haunt me for days to come. 

Your surgeon, and then I, spoke with your dad. “I am so sorry that this has happened. Her surgeon did a good job and took the best care of your daughter that he could. I am here if you need anything, and I will be in every morning to check in on her and on you,” was all I could say.  

I had no words to describe my own feelings, as I was still processing them myself.  When we left your father, it was 4:00 AM and I could tell his world was flipped upside down. As we walked away to get ready for the next surgery, regret pierced my head. Did I make a mistake? Should I have stayed and sat there with him after the night he just had?  But if I did that, would there be anything that I could have said to make this situation better? Frankly, I am not sure what I could or should have done in that situation, but I still think about what I might have done differently. 

The next day you were awake and moderately aware of what happened the day before.  Now, the fear in your eyes was met with somnolence, anger, and frustration. “How are you feeling?” I asked, even though I was afraid I already knew the answer. You shared your frustration about not knowing what would happen next. You wanted answers, but I did not have them.  I felt bad I couldn’t help you in that moment. I knew you were hurting and I knew the reality of your condition was slowly sinking in. There is so much I wish I would have said to comfort you in this time, but I couldn’t find the right words to help. “I will make sure all your questions get answered, and if there is anything else I can do to help please let me know. I am here for you and as a medical student it is my job to be an advocate for you,” I explained. Then I left your room not knowing that was the last thing I would say to you before you were sedated, intubated, and transferred to the ICU. 

It all happened so quickly. One day I was talking to you and you were responding. The next thing I know I was standing next to you and I was still talking, but you couldn’t respond. It felt unusual for me to talk to someone whom I knew would not respond, but it felt necessary.  “Good morning,” I would begin, “It’s Grace the medical student, and I am here to check in to see how you are doing.” Clearly she is not doing well, I would think to myself. However, I continued, “I am going to perform a physical exam and I will walk you through what I am doing.” I listened to your heart and lungs. I examined your dressing that was covering the opening to your abdomen that was never closed. I looked at your ileostomy and documented my findings. At this moment I became haunted again by my recurrent thought: She is younger than my mother. Then, I looked at your face where I once saw fear, anger, and frustration, but now saw peace and tranquility. I held your hand and said out loud, “It was nice seeing you again this morning, I will see you again tomorrow.”

I looked at your father, who responded, “Thank you for coming to see her today. I am glad she is no longer in pain.”  I let him know I was here if he needed anything and the nurses were just outside the door. I left your room, just two days after meeting you thinking to myself, I hope to see her again tomorrow.  

The next morning you were gone. You passed quietly in your sleep with your father right next to you the entire time. You were younger than my mother, you still had so much life to live, and I continue to wonder if there was something more I could have said to comfort you in your last days. It is funny how much communication can change in just a few days. One day you and I were able to have a conversation, and the next day I find myself talking to someone who I knew was never going to talk back.  

_______________________________________________________________________

**Photograph taken by author, Grace Newell, with a black and white film camera then developed in a darkroom.

“To me the leaf reminds me of what we saw during her surgery. Something fragile and lifeless, yet something that was so beautiful that was part of something bigger than the damaged spots that lay on the dying leaf. Just like the tumors taking over her body when her beauty and strength overpowered what she was battling with.”

 Inside rooms where spirit is tethered to time
 Lie incubators — warm and full of gab, frisk with 
 Glimmer and giddy — defiant souls of lesser green grass
  
 Naive whetted scalpels and abandoned bellies
 Naive to Caesarean sutures, iron-bounded one too few
 Naive of dread towards strange fruit and hooded men — white
  
 She stands tall in the wilderness of trees born steel and nitrile stockings
 Majestic like high-jumping gazelles, where no heights are 
 Greater than post-partum hypertension or gestational diabetes
  
 Her father tells her that she is Brown Sugar in a white coat
 And that her smile creates 
 Rainbows out of raindrops sphering over horizons obscured
  
 Epidurals pierce through spine colored with
 Melanin and scar tissue left by ancestral lashes
 Nourishment — discovered amongst the juxtaposition of her mother’s tears and prayers
  
 Outgrowths of bantu knots and unwavering resolve 
 Reveal that she is standing on the precipice of her own presence
 Giving birth to a new era of woman

In the webcomic The Oatmeal, illustrator Matthew Inman tackles the backfire effect. He goes on to discuss how the part of one’s brain called amygdala “makes us biologically wired to react to threatening information the same way we’d react to being attacked by a predator.”¹ Inman’s comic was a popular statement in anticipation for the 2016 election and presently remains relevant due to its wry humor and ongoing significance on why people are so resistant to hearing contradictory facts. However, many political scientists found it hard to replicate as a large-scale peer-reviewed study could not reproduce the findings.² I felt myself backfiring from reading the backfire effect. This phenomenon is the epitome of how debates begin, of how medical ethics are handled, of how scientific research is initiated.  

The motivated reasoning and confirmation bias that Inman discusses in the backfire effect can be manipulated in medicine, similar to the “truthiness” model. Dr. Jeffrey Matthew from the University of Wisconsin adopts Stephen Colbert’s illustration of the “truthiness” model as “Truth that comes from the gut, not the book.”³ The backfire effect and the “truthiness” model are some of the reasons as to why trusting the knowledge that professors, peers, or anyone else impart is so difficult for me. From one angle, I could see the controversial information that was taught to me as something that is just testing the resistance in my amygdala.  

I observed the bleak reality of clinical based medicine as something that has been anecdotally passed down to form “truthiness” yet have no evidence-based methodology. For example, we were taught the five most common causes of postoperative fever with one of the causes being atelectasis (partial or complete collapse of lung). However, the relationship between atelectasis and postoperative fever is unsupported. This ongoing tug-of-war between what is factual and what is practiced is the foundation of curiosity in medicine. It’s why I was interested in this profession in the first place.  

I was looking for answers. I did not want to look for them in books. That is why I consider our clinical rotations, known as the Longitudinal Integrated Clerkship (LIC) a perfect program for students like myself. TCU & UNTHSC School of Medicine’s LIC incorporates multiple specialties in one longitudinal rotation for approximately 40 weeks. This type of integrated learning allows us to test controversial information such as indication for which diabetes medication to prescribe in the various specialties. These experiences allow us to decide upon our self if these “clinical pearls” are a part of the backfire phenomenon or a form of “truthiness”.  

Several patients one day presented with evidence-based urgency hypertension, something I had recently read about but had not yet seen in my patients. These patients had blood pressures well over 180/100 such as 191/106 and 185/103, whereas normal blood pressure is 140/90. Proper protocol from my notes would suggest “oral antihypertensive agents, including β-blockers, angiotensin-converting-enzyme (ACE) inhibitors, or calcium channel blockers.”⁴ Proper protocol in my clinic: perform the HPI for the patients concerns and not address the hypertension. Talk about backfire.  

I began to question if evidence-based medicine is preferential over clinical based medicine. I asked my internal medicine preceptor her thoughts on the difference between clinical based and evidence-based medicine in this scenario and she stated “What evidence-based medication does not always take into consideration are the social factors such as patient compliance and adherence along with socioeconomic disadvantages. When those factors arise, that is when clinical based medicine becomes preferential to evidence-based medicine.  

This is where I had to start learning the difference between clinical based practice and academic based practice. I found several articles on UpToDate that both supported and contradicted the clinical based practice in measuring high blood pressure in the clinic. My realization from this search was exactly what Dr. Jeffrey Matthews touched on in his lecture: “evidence is elusive.” Proper protocol depends on what year of research does the physician base their protocol on, the type of medicine (clinical or evidence-based) the physician practices, and just the physician her/himself. Now that I have learned, seen, and practiced the difference, this is a lesson that will never be forgotten. 

By any circumstance, this narrative piece is not me passing judgement. This reflection is about me ultimately realizing how medicine is fluid with waves of preference in evidence-based medicine or clinical based medicine. As a naïve medical student, I supposed the two would be one. Oh, understanding that the two types of medicine are rarely unified backfired on me- and my amygdala, the emotional cortex that hosts our core beliefs!  

¹ Inman, Matthew. “You’Re Not Going to Believe What I’m about to Tell You .” Comic strip. The Oatmeal, 2016. https://theoatmeal.com/comics/believe. 

² Haglin, Kathryn. “The Limitations of the Backfire Effect.” Research & Politics 4, no. 3 (2017): 205316801771654. https://doi.org/10.1177/2053168017716547.  

³ Truth and Truthiness in Surgery . Truth and Truthiness in Surgery , 2016. https://youtu.be/swYKy_u3If0.  

⁴ “Emergent Hypertension.” USMLE-Rx. Accessed June 2, 2021. https://usmle-rx.scholarrx.com/rx-bricks/brick/CP_CAR0087.  

I named you “Babar.”  
A familiar fixture on my face so permanent 
Bloodied blisters bloomed where skin and plastic met. 
The soft space between lip and nose wrinkled from weeks of crusted snot and  
Surgical tape.  
 
Our initial introduction was a bitter omen 
For the month that lay ahead.  
And I, a nonconsenting participant, fought wildly 
Against the pain while attempts to unify us failed— 
Repeatedly.  
 
One 
Two, three,  
Four, five tries before soothing voices whispered “swallow.” 
You were there stroking my gag reflex as  
Blood and tears leaked down my sweat-stained face. 
 
Just you and me, Babar. My parents fled the room  
To escape the attack on my nasal cavity. 
But they would come to know you too. Our union, 
My elephant appendage, would be the center of the circus 
And a brazen burden on all.  
 
For weeks noxious green flowed freely through you— 
A fast track from stomach to the external world. 
Internal physiology exhibited for all to gawk, an intimate connection  
Requiring diligent hands to sustain filling demands. 
Clamp, empty, connect, repeat.  
 
I pleaded for water while you sucked me dry.  
An assault of daily depravity and cruel balance of power yet— 
I grew to love you. Together we weathered  
Surgeries, sepsis, starvation. 20 pounds we lost together 
Catheters, a central line, and drains. 
 
A comradery visible yet unfelt among observers 
For you both delivered and understood my pain.  
But then ice chips replaced cracked lips 
As food for blood was swapped for solids, 
And I was left abandoned in your wake.  
 
Freedom was redefined by your depleting grasp  
And I forgot how to receive.  
I dreamt of liberation, but fullness led to rejection.  
Offerings of cotton candy ice cream, confetti sprinkles, 
And stinging bile swirled in a bedpan.  
 
Days spent begging for relief replaced with hopes of emptiness— 
A mouthwatering sickness of conflicting desires.  
Was it the gift of life or hefty price for outsmarting death? 
A searing throat from eating then retching. Retching then eating. 
Fond memories of us now fleeting. 

She was my first real patient. Before the pandemic, I regularly saw her at my family medicine clerkship for routine follow-ups. Always accompanied by her adoring daughter and designated caretaker, they would teasingly call me “baby-doc” as I fumbled with my stethoscope.

Now, almost a year later, I was holding her small bowel between my gloved fingers under the bright lights of the OR. As I ran my hand down the loops of intestine, I felt crunching– “I think I feel pneumatosis intestinalis,” I said to the surgeon. He met my hand at its place on her bowel and felt. “The kid is good,” he said to the scrub nurse, “nice catch!” Oh the validation of a correct diagnosis. Though eager excitement quickly made way for dread. I knew what this meant. Her intestines were dying, she was at the end of the road.

We met again 7 days ago in the emergency room when I was on-call. Fear of coming to a hospital full of COVID left her in agony for months as she ignored early signs of her dying organs. Serendipity or fate, when she did finally come for help, I was there.

I was with her in the hospital room, where she laid helpless, vulnerable and scared. I was with her in the OR where she laid open, vulnerable and exposed. Balancing the duality of humanity and science, I held her daughter’s hand after each surgery and translated the surgeon’s medical jargon. I was the last person she talked to, giving soothing words as the anesthesiologist put her under, never to awaken again.

Her final days were spent unconscious and intubated in the ICU. Her daughter was by her side every day, for as many hours as COVID policy allowed. Between patients, I would go down and visit them. We would sit and I would listen to her daughter tell stories of her kind and quick-witted mother.

On the final day of my Surgery rotation, and what I would later discover would be her final day of life, I wrote her family a letter. Simply to share how grateful I was to have learned from their mother’s case, wishing them peace in the soon-to-be passing, and offering whatever soliloquy of comfort I could. It was a simple gesture, one that I figured would be met with a few moments of gratitude and then slip to the back of their consciousness and forgotten in grief. Months later, her daughter would reach out to me to share how impactful that simple gesture was for her family’s coping.

I chose medicine, because in no other field are you stretched to be both so technically proficient and emotionally vulnerable. The science of medicine is constantly infused with the raw emotion and heavy responsibility of having a human life in your hands. To have such privilege is a beautiful burden.

I walked into the patient’s room and saw my sister. At least, Mary* could have been my sister for her age and complexion seemed to match. As I opened my mouth to speak, her shaking hands, thick palpable nervousness, and a downwards stare portrayed an individual uncomfortable and unaccustomed to a physician’s office. I greeted her with a smile, stating my name, position, and purpose. Just as I had with the patients before her, my first question was to ask why she had come in. The words—“I’ve been feeling depressed”—were quickly and quietly spoken.

I witnessed Mary’s familiar face lower to the floor as her quiet, delicate nature came to light. I felt a reverence for her feelings of grief, a scene that might quickly be compromised due to my inexperience. It took a few moments, but she gradually warmed up to our discussion as I centered the interview around her journey to the office. We talked about her mother’s supportive and guiding influence which had led her to request the visit. We discussed the coping mechanisms she was trying, including an increased reliance on marijuana, which had proven unsuccessful in warding off feelings of self-doubt. I reassured her that the attending physician would provide excellent care, good enough that I would recommend him to my own sister. A vivid image of my sister passed through my mind. I could see her, or them. My conversation with Mary felt familiar.

Despite that I had never worked with a patient challenged by mental health concerns, my confidence in understanding Mary climbed as I completed her interview. Perhaps due to her semblance to my sister, I left the room with what I felt to be a complete picture of her condition. As I began my oral presentation to my preceptor, I boldly told him of her one-year history of feeling depressed. I described in detail her symptoms, including nausea and vomiting, which I proudly deduced had stemmed from her use of marijuana.

The seasoned physician listened patiently and then paused for a moment. “Did you ask Mary if she’s ever considered killing herself?” he asked. I stared back at him. I was tempted to try and rationalize why I had not, especially with all of the other important history items that I had obtained. “No,” I frankly replied back, somewhat embarrassed by overlooking what he knew was a key part of her history. Like an expanded balloon experiencing an air leak, I felt the common deflation of an overly confident medical student. I discreetly tried to cloak the puncture.

Why hadn’t I asked? Without meaning to, I thought about how my sister would never do something to hurt herself. Even with family, suicidal ideation can be a sensitive subject to address. I didn’t want to intensify my discussion with Mary, especially since she had already extended herself in discussing her drug use. Mary was vulnerable in coming alone to a new provider visit. I would need appropriate justification to ask a question like that. If she did struggle with suicidal thoughts, what would I have to do with that knowledge? 

As I contemplated these questions, the attending told me about selective serotonin reuptake inhibitors, or SSRIs. They are one of the most commonly prescribed antidepressants. Citalopram, or Celexa, works very well to treat patients who are experiencing depression. However, there is an FDA black box warning prominently displayed on the side of the medication. This warns of the possible increase in suicidal thoughts or actions in some young adults at the initiation of treatment. For these patients, prior suicidal ideation is further investigated with extreme precaution prior to prescribing the medication. If these thoughts are already present, alternatives are further considered. Completely unaware, I had left Mary’s room without a vitally important aspect of her history. Although the medication could improve how she was feeling, giving Mary this antidepressant could contribute to a negative and permanent change to her life.

We returned to Mary’s room and learned that my preceptor’s inquiry was especially important in our visit. I observed the connection that he made with Mary, gathering key information and using her responses to create a treatment plan. We discussed our options and decided to prescribe Mary a different medication. Although the conversation was difficult and personal for Mary, my preceptor’s kind but direct questioning inspired me to better obtain a more complete medical history out of each of my patients. 

Someday I may encounter a sister, brother, friend or neighbor sitting in the corner of my examination room. In spite of the familiarity, I need to work towards gaining an unbiased and more complete understanding of the information which could impact their health. Like with Mary, I look forward to understanding who my future patients are, and how best to treat them, through asking the right questions. This will probably not be the last time I walk into a room, and see my sister.  

*The patient’s name has been changed to ensure privacy.

Maybe it is the fact that the clinic I have been placed in as a first-year medical student is primarily patients aged 65 and up, or maybe it is the tremendous amount of death we have all faced this year amidst the COVID-19 pandemic, but lately I’ve been pondering what it means to experience death in the field of medicine.

Recently, I had a discussion about death with my clinical skills preceptor, Dr. Ashley Huddleston. She started her career in emergency medicine, constantly in the face of death. She oftentimes only knew these patients as “ill” or “dying” as opposed to in primary care, where patients are seen in all facets of life. Dr. Huddleston has since changed fields of medicine to wound care and hyperbaric medicine: rehabilitation. Now, she gets to watch as her patients experience life. She gets to form relationships with them, often seeing them weekly. Yet, interestingly, she stated that this now makes death more difficult to swallow when it does come. These long-term relationships in outpatient medical care become so pronounced, as opposed to the sometimes unfamiliar nature of relationships in inpatient care. These humans are no longer strangers, but companions.  

I cannot predict how I will face death as a medical professional or even as a human. But I do know I want it to be as intimate and raw as the day I had first experienced a healthcare-related loss. I was interning at an outpatient addiction treatment center that summer. It was unexpected. It was angering. It was reality. Here is an excerpt of my writing based on that day:

“A typical Monday morning as an intern at an intensive outpatient addiction treatment center is brimming with positive energy and new beginnings. Pulling up to the office, I would see the clients chatting and laughing on the front porch. Their communal cigarette smoke mingled with the sweet scent of gardenias in the summer air. Inside the center, which resembles a quaint pink cottage, the therapist, the medical director, and a pot of freshly brewed coffee would joyfully greet me. Monday mornings felt like sobriety was at our clients’ fingertips – until it wasn’t. 

On July 5th, Monday morning felt dark. The porch was empty and humorless. Its usual inhabitants sat confused and quiet inside the group therapy room. The staff’s office doors remained shut. No one there to greet me. No freshly brewed coffee. Minutes felt like hours as we waited. Eyes scanned the room to see who was there and who was not. With heads bowed, the staff entered and took their seats. The silence was finally broken: ‘Joe; had overdosed and passed away. Joe, the one who everyone in the program looked up to, who was thought to be the last person this would happen to. Addiction had won, and its triumph rang loud in the silence of the room.

I have regularly come back to that somber July Fifth when Joe lost his fight. That day, 

there was a sense of quiet perseverance. Reflecting back, I realize how difficult it was to retain such fortitude amidst tragedy. Nonetheless, each one of us left holding our heads a little higher — the patients, the therapists, the physicians, and me. The patients persisted in their fight for sobriety. The therapists and physicians persisted in their inclination to treat those suffering. I, aching for that same inclination, persisted in my pursuit of medicine. In that vulnerable moment, gripping each other’s shaking hands and wiping our weeping eyes, we were able to bridge the gap between patient, intern, and provider. There was a genuine camaraderie that day which left us all at ease.”

This memory is frozen solid within me. And it was what pushed me closer to medicine. In fact, without this experience, as tragic as it was, I do not believe I would be where I am today. It is not that it motivated me, it is that it matured me. It revealed to me the realities of medicine, while erasing the previously glorified view I had of medicine as simply healing. 

Will this experience prepare me for future confrontations with death? Possibly. I just hope whenever death comes, I am surrounded by people in the most humanely raw way possible. No hierarchical labels of physician, resident, student, or patient — just fresh human emotions, compassion, and perseverance.