VOICES
FALL 2020 · VOL 10, ISSUE 1
a literary journal SITES.DUKE.EDU/VOICES
VOICES about us
Voices is a literary magazine of the Duke University School of Medicine. We publish varied forms of creative expression from the medical community, and welcome submissions from patients, students, healthcare providers, employees, families, and friends. Our goal is to publish a range of unique voices in the healthcare system. We hope that as you read through the pieces published in this issue, you will be inspired to submit something as well. All submissions can be sent to dukemedvoices@gmail.com or online at sites.duke.edu/voices.
letter from the editors 2020 will certainly be a year seared into our collective memory. Initial newsreels of Australian bush fires quickly escalated to panic over one of the largest viral pandemics since the 1918 influenza outbreak, and then into an impassioned civil rights movement that will impact not only those who marched. At moments like these, it is ever more important that we raise our voices to be heard. Our role here at Voices is to broadcast those voices to the rest of our community and beyond. We do not profess to know the experiences of others, but we want to make sure those experiences are known to the world. To this purpose, we sponsored a COVID-19 writing contest under the guidance of the Trent Center for Bioethics Humanities & History of Medicine. The first place winner, Ms. F. Hayden Mulligan’s “The COVID-19 Chronicles,” is published here in its entirety. The second and third place winners will be published in future issues. From this contest and other submissions from the ongoing pandemic period, we anticipate that we will soon publish a COVID-19 special issue, detailing the experiences of those in the healthcare system. At the same time, we welcome pieces related to race and medicine, and hope to further explore the topic in future issues. In this issue, we have also included pieces that recall a time of a different normal. We hope we will one day return to a time without masked facial expressions and reminisce our current tribulations through rose-colored glasses. However, in the same breath, we also wish to see a more equitable future molded and improved by this pandemic. Until then, as always, we would love to hear your thoughts and ideas at dukemedvoices@gmail.com. Your co-editors-in-chief, Rui Dai and Norah Karlovich
table of contents
Letter From the Editors Rui Dai, Norah Karlovich 2
Reflections on AA Megha Gupta 4-5 Wee Woo Wagon Kelsey Graywill 5 Meeting in Moments
Seth Flynn
6
Two Weeks in Palliative Care Lindsey Chew 6 The COVID-19 Chronicles F. Hayden Mulligan, PA-C 7-9 Voices COVID-19 Writing Contest Winner
Old Man Medicine Jenna S. Hynes, MD 9-10 Extracurriculars Danielle Ellis, MD 11-12 The Family Secret Dana Creighton 13-14 Austin Ayer Seth Flynn Emily Hatheway Kira Panzer Isabelle Byers Devon DiPalma Megha Gupta
MS2 MS2 MS2 MS2 MS3 MS3 MS3
Jeffrey Baker MD, PhD Marjorie Miller MA Nikki Vangsnes
associate editors
Rosa Yang MS3 Sarah Hodges MS4 Shan McBurney-Lin MS4 Thao Nguyen MS4 Zachary Smothers MS4 Sam Hofacker, MD PGY1
faculty & staff editors Sneha Mantri MD Brian Quaranta MD
special thanks
Bruce Hillman MD, Karen Jooste MD, Jennifer Lawson MD, and Francis Neelon MD BACKGROUND PHOTOGRAPHY CREDITS: COVER and CREDITS/CONTENTS: Qiang Miao, PhD student
Reflections on AA I find the monotone of the first speaker unbearable, the smell of coffee bitter, as I sit in the back of the room, straining to hear what she says. The coffee was the thing that led me to the room in the first place; after detaining a poor college student to ask frantically, “Where’s the chapel? Do you know where I could find the AA meeting?” I rushed into the building and toward some stairs (my subconscious told me it simply must be in the basement) before a blonde lady in khaki mom shorts and a “HELLO MY NAME IS” nametag blocked my path. “Excuse me, do you know where I might find the AA meeting?” I asked, shoving my car keys into my pants, assuming that at 8:10 pm on a Thursday there couldn’t be much else happening at the church. “No, this is a preschool meeting. But good luck.” I don’t really know what it was about that ‘good luck,’ but it didn’t feel like a true good luck in that she actually wished I would find the meeting but rather a good luck in that I-must-surely-be-a-mess-to-beasking-strangers-where-thismeeting-was-and-shouldn’t-Ibe-more-discreet? way. But perhaps I read into that. I stumbled around, clutching my notebook till my knuckles turned white hoping that some sign or something would guide me to the meeting. Instead, signs for the ESL classroom led me to another staircase, this one was without blond moms or chil4 · SITES.DUKE.EDU/VOICES
dren’s squeals echoing upwards. I took one hesitant step down, and then another as the faint aroma of coffee grew stronger. Following my nose, I landed in what had to be the right space, set up for an audience with two chairs comprising the stage. I planted myself in the seat furthest from the speaker, ten minutes late and avoiding the quick glances the participants flashed my way before returning their attention to what must have been a compelling story from the main speaker. But I can’t stand her voice. And my seat is too close to the coffee and it smells bitter, almost like the taste left in my mouth after the good luck and the I’m not judging you hands up that the college student gave me after I mentioned the AA meeting. I sit and strain and feel deeply uncomfortable anyways, crossing and uncrossing my legs, making efforts to take up as little space as possible for infiltrating this room that I truly did not belong in. The monotone woman ends her story: “That’ll be it.” All I can feel is sweet relief. Tension broke in me, and I feel more comfortable in the silence than in her speech that reminded me of all the reasons I felt I shouldn’t be there in this community that I’m sure had no need for my presence. I took a moment in the reprieve. It really was the thing. The church basement. The coffee no longer steaming. Tension building in the room again as we waited for someone to speak.
The next speaker feels more tolerable, speaking about “taking a moment for oneself.” To read. To meditate. To get in touch with God. And that’s where this second speaker and I differed too. But this is her life and her solutions and all I really want to do is support that. We then slip into silence while we wait for the next speaker. “Hi, I’m D--- and I’m an alcoholic.” A thunderous “HI D---” follows, shaking me out of whatever stupor I slipped into, reinforcing the feeling that I was really there. Doing the thing. And D--- mentions to us, to the world, that “sobriety isn’t heaven on Earth,” and all I can think is damn straight because sobriety is part of the real world and the real world is painful. Can I blame anyone for blunting it? I mean, there’s a reason “happy hour” exists. Someone else starts talking, with almost a manic quality, as though the words can’t get out fast enough—I’m fairly sure this is the definition of pressured speech. Someone coughs, just loud enough to distract me from the next speaker. I find release in this moment as well. A moment for myself, to space out, to think, because the other stuff about God and pain and healing and recovery feels tense again. “I’m an alcoholic and I wanna feel good.” Yeah man, don’t we all? “All I want to do is focus on how I’m treating others.” Well, FALL 2020 · VOL 10, ISSUE 1
that sucks, right? Because others probably aren’t very nice to you if they know, with their good lucks and I’m not judging you hands. “You can always start your day over.” That feels so comforting. Sometimes we really need the redo. Refresh. Renew. Stuff out of a shampoo commercial for dry hair, surely, but also for the desiccated moments in life too. “Recovery is a spiritual thing.” I mean, I feel that in the room. Everyone’s spirits being touched, moved, encouraged, uplifted. We are here because we care about recovery and want to be part of that process in community, as joint spirits. Throughout there were a lot of jokes about Carrboro. I still don’t know much about Carrboro, but I got the distinct sense that it couldn’t be much more than a hub for old white male Buddhist monks or farmers markets and new age shops. “I don’t wanna drink, I wanna live.” What does that mean? But heads all around nod vigorously. “Handcuffs are cold, I don’t want them anymore.” Ahh. Freedom. An unshackling from the thing. We let the tension grow to where I literally felt my own shoulders lift up to my ears hoping to whatever God these people believe in that someone cracks another joke about Carrboro so I can finally breathe in the coffee beans again. Someone mentions deer in Carrboro, and I manage a short and uncharacteristic “Ha!” using the opportunity to inhale deeply. 5 · SITES.DUKE.EDU/VOICES
The coffee’s aroma feels less overwhelming, harsh, unwelcoming as when I first sat in the metal folding chair. “Who am I to knock something that gives you power in your time of need.” This almost feels like it could mean two things, but this audience does not believe that drinking gives one power, so it can only mean the other—a community, a kinship of spirits, a place to be welcomed and find comfort. Another person mentions obsessions, compulsions, mania, and depression as part of their recovery. My inner psychiatrist is alerted, but mostly because she’s seen it. Rule out drug or substance abuse, isn’t that the rule? Substances control our brains, not the other way around. The next speaker mentions rednecks, and because I’m sitting directly behind him and see his red neck, I can’t help but smile to myself, looking down to avoid notice. My legs are uncrossed. Tension builds around AA as a spiritual discipline and the weaponization of organized religion. Someone else makes a joke, and the air clears once more. We turn to talking about improving ourselves and the world around us, and Redneck leads the talk. “Therein lies the benefit of repetition.” A teaching tool ingrained in us, something I see many people identify with, a part of re-education, re-learning. “The way you get something is the absence of a negative— peace, calm.” I felt that in this
room. No censorship of anyone. All souls welcomed, enveloped by the aroma of coffee, encased in chipped mugs with fading graphics. The absence of the negative. “I felt hugely relieved after a drinking dream because I wasn’t terrified.” The relief, the release of tension, feels familiar, a sensation I tune into throughout the meeting. The jokes, the coughs, the brief human moments throughout the entire experience, give me the space I need in a space where I didn’t think I should be. I am no recovering alcoholic, or even there to support a loved one. I am simply an interloping student assigned to attend and reflect on an AA meeting. What would they do if they knew I disrupted the anonymity of this healing space? But the point of the space is not to out those who feel uncomfortable. AA is about finding a community to help one heal. Before attending, I knew the burdens of caring for someone with an addiction, but now, I’m no longer terrified of the thing—healing and recovery from the social stigma and emotional burden that consume people as much as alcoholism once did. Someone makes another mention of Carrboro. The laughter is a little lighter this time. There’s less tension to be relieved, the negative more absent in this basement room, in this church, with the coffee, doing the thing. Megha Gupta is a 3rd year medical student at Duke University School of Medicine. FALL 2020 · VOL 10, ISSUE 1
CREDIT: KELSEY GRAYWILL
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FALL 2020 · VOL 10, ISSUE 1
Meeting in Moments
Two Weeks in Palliative Care
Today, you know me. You gush about your trip to the McAdenville Christmas lights, a lifelong tradition, with vibrancy and joy illuminating your eyes like a twinkling kaleidoscope of bulbs. You were there at the first lighting 63 years ago and you haven’t missed a year since. We decorate the small tree in your room together while you softly sing along to holiday songs by Brenda Lee, Elvis Presley, Loretta Lynn. You know every word. You invite me to lunch because it’s vegetable soup day Creamy - never chunky - your favorite. Today, I am a stranger.
He could only express so much. or nod. or shake his head sometimes yes, others no. He wanted to live. What gives us dignity? we all strive to be something in our lives. At the end of the day, will we hold onto the fire? Small gestures impact. I know. Now, I know.
You eye me with distrust as I introduce myself, the Hospice volunteer. Lindsey Chew is a 3rd year MD/PhD You decide that I am your cousin and your mood softens. student at the Duke University School We make plans to plant okra on your family farm and joke about how your dad’s Hyde County accent sounds of Medicine. like he “talks with rocks in his mouth.” With a giggle and a grin, you take me to the corner of your room and proudly showcase the little house you built for your cat, Maisie, and her precious litter of kittens using wood pallets and some spare whitewash a cardboard box filled with Ensure.
Seth Flynn is a 2nd year medical student at the Duke University School of Medicine.
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FALL 2020 · VOL 10, ISSUE 2
The COVID-19 Chronicles
03/10/20: After finishing with my 10 am patient, I found Hannah, our practice medical director, frozen in her chair. She looked up at me with fear in her eyes. “Italy’s morgues are full. People are being forced to keep their dead at home.” My mouth dropped open as my mind struggled to piece together an image of a reality that awful. When it couldn’t, it rationalized why it wouldn’t get that bad. Italy doesn’t have as many hospitals per capita, so maybe that’s a reason? With forewarning we have more time to prepare... right? 03/14/20: My inbox is flooded daily with COVID emails from Duke, each bolded, unread message a tiny siren reminding me we’re under siege. Everyday there’s a change in guidelines. Eventually they blur together. Our days are full of scattered anxiety surges we just ride out, like this morning when Hannah came back from seeing a patient she was confident had COVID. Her voice crumpled to a whisper, “I hope this isn’t the last time I see her,” she said as she turned her face away, a tear rolling down her cheek. Moments like these shake the ground we stand on, which is so unsteady to begin with, like an earthquake when you’re already standing in quicksand. 03/15/20: There’s talk of opening drive-thru testing centers. It’s still taking five days to get the test results, back and we’re only testing people with fever and cough. I’m worried the testing criteria are too restrictive, 8 · SITES.DUKE.EDU/VOICES
but I know we’re trying not to run out of PPE and tests. A local Target employee just tested positive so we’re bracing ourselves for a boom. We echo each other’s fears, finding comfort in our shared burden, but knowing all we can do is mentally prepare for it to worsen. 03/16/20: I was ok this morning. The fear comes in waves. By 5 pm, the tide rolled back in with my first COVID test. I felt claustrophobic in my hazmat suit, sweating in the exam room for 15 minutes while the flu test ran. When every second of exposure increases your chances of contracting a deadly virus, the time oozes by like molasses. Flu was negative, so I tested her for COVID while she coughed all over me. While removing my PPE, the edge of my face shield hit my shirt. I immediately changed into workout clothes I found in my car, and our nurse manager sprayed my entire body down in Lysol. Overreaction? Probably. Would I do it differently? Nope. 03/17/20: Schools closed today. 03/18/20: More young people are being affected than anticipated. Another thread of comfort lost as my fabric of hopeful denial disintegrates. I texted Keifer today and explained I couldn’t see him. As hard as it is to get through this alone, I feel grateful for the solitude because it means I don’t have any loved ones to potentially infect at home. Other doctors are undressing in their garages, scrubbing their skin raw in the shower
and still keeping a distance. 03/19/20: A provider at a nearby Duke Primary Care office just tested positive. We share patients so we’ve likely been exposed already. Another COVID tentacle worms its way into our office orbit, tightening the noose. We watch cases increase while supplies dwindle nationally, and all the CDC has to contribute is: “In a crisis, healthcare workers could use bandanas or scarves over their faces while treating patients, despite the fact that neither are proven to be effective.” For the first time in this pandemic, my sadness and anxiety gave way to fury. Medical professionals are dutiful people. When called to the frontlines, we WILL be there. But there is a SIGNIFICANT difference between our voluntary sacrifice and forced martyrdom. We are in this position because we have no national leadership. While we fight this pandemic, we dress ourselves in trash bags instead of armor because our unprepared government was too busy encouraging people to inject Lysol and drink fishbowl cleaner to appropriately outfit its frontline. You don’t send an army to battle with crocheted hats instead of helmets or pool noodles instead of guns. We’ve been abandoned to confront this nightmare alone. 03/20/20: Tonight, my older brother expressed his anxiety about food scarcity and the economy. I listened quietly, feeling both irritated and guilty for being irritated. He worries about
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the economy; every day I worry if today is the day I get COVID or pass it to a patient. I know he’s scared, but I don’t have the emotional bandwidth to support him. I have to ration my emotional energy like he’s rationing toilet paper. 03/22/20: We just started televisits. The billing is a mess, and the rules are unclear about who qualifies. Working through this pandemic is like trying to walk with vertigo - you can hardly take a step forward without feeling like you’re going to topple over. The effort to stay upright all day is so exhausting I get home and just go straight to bed. I keep hoping hedonic adaptation will kick in and I’ll adjust to this new norm, but nothing stays the same long enough. 03/23/20: Laura whacked me across the face with a news update before I managed to sit down at my desk. She called her friend, a CT surgical resident in NYC, who said their heads of transplant and general surgery had both been placed on vents and an ED nurse had just been escalated to ECMO. Apparently, the hospital has developed an ethics committee to weigh the life contributions people have made to determine their worthiness for a vent because there aren’t enough to meet the demand. I deflated into my chair. I can’t imagine what it’s like inside those walls for my NYC brothers and sisters, their families, and the patients dying alone in isolation. Those shoved into the position to choose who lives and dies will do the best they can and then carry the burden of that responsibility forever. Their 9 · SITES.DUKE.EDU/VOICES
decisions are inevitably going to be dictated to them from “higher up” based on a set of criteria they may not agree with but are forced to execute. They will have to look a patient in the face and tell them that because of their higher likelihood of dying and estimated longer need for resources than someone else, they have been sentenced to death. In a few short weeks I could find myself deployed to a COVID unit in the hospital, involuntarily forced to play God. I don’t want that burden. I didn’t sign up for that. But it would be my duty if I found myself there. I keep praying that doesn’t happen, but then I feel ashamed. If it isn’t me, it’s someone else, and as a medical community, we carry this together. I took a blank Advanced Directive form from my office to fill out at home. 03/24/20: I just need a hug! I’m physically isolated from everyone and emotionally isolated from non-medical people. Thank God for my work family. I started a tradition at lunch a couple weeks ago where everyone has to share three things they’re grateful for to help us cling to positivity. Sometimes it takes a while, but we all consistently say our families, our job, and each other. Day after day, we face a firing squad hoping to avoid impact, and if we are hit, that it isn’t anything vital. It’s probably time to call Mom. Before the conversation started, I apologized to her and then told her what I wanted if I died. It’s grim, and as a 30- year-old, a bit unsettling, but it’s enough of a possibility that to not have the
conversation seemed irresponsible. Mom took it like a champ. I was proud of her. I asked Hannah if she would advise my mom on my medical care if the time came, apologizing for being morbid. She’s apparently preparing too. We don’t talk about these things at the office, but it’s comforting to know I’m not overreacting. We all have to acknowledge that we could die in the next few months. I spent the rest of the evening writing an email for my mom to reference: Cremate me and scatter me in Maine. No funeral or black clothing. Make it a life celebration and let my brother name it something cheeky. Play Amazing Grace. Supply lots of alcohol. Use my life insurance to go on a trip somewhere you couldn’t afford on your own. 03/25/20: I’m not sleeping. My jaw is sore from grinding my teeth through the nightmares of trailers filled with black body bags. I asked the other providers if they were having trouble sleeping. Apparently, we’re all having nightmares. 03/26/20: During lunch, we watched the Facebook video of Atlanta residents on their balconies applauding hospital workers at shift change. We all cried. 03/27/20: I’m trying to sleep, but there’s a group gathered at the courtyard firepit, which is supposed to be closed, loudly socializing and not six feet apart. I know it’s only 8:30pm, but I need every ounce of sleep I can get. And frankly, I resent them. Every day, I get up and put myself in danger. The only job they
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have is to socially distance and they can’t be bothered. It’s a slap in the face. 03/28/20: Today, I Zoomed with my cousins. I craved connection, but found myself unable to engage. I felt more isolated after that call that I did beforehand. 04/04/20: I’ve stopped caring what I put in my body. I ate Cookout twice last week and slept all weekend. I’m so tired. 04/06/20: I texted Nikki today. The ICUs are all full in the Boston hospital where she works and they’re using 7 of 10, ECMO units. 04/07/20: Hannah called. Jasmine from our office tested positive and now five others are out for testing. Apparently the COVID test has a 40% false negative rate. Might as well just flip a coin. How many cases have we missed? 04/18/20: I just feel helpless. I’m worried I’m mismanaging patients with coughs because we have to funnel them through the COVID screening but they could have any number of issues, from allergies to a pulmonary embolism. 04/20/20: I dream of hugs, dates, coffee shops, CrossFit, bookstores, and walking into a grocery store without panic. I miss actually seeing someone smile, the luxury of not being an immediate threat to my loved ones, and not worrying I’m toting a miasma of deadly illness between exam rooms. I miss proximity without danger. 04/23/20: Every day I’m seeing and experiencing more people lashing out at healthcare workers. A patient said to me yesterday, “You doctors are on 10 · SITES.DUKE.EDU/VOICES
thin ice during this crisis. People aren’t happy with you.” What? We are risking ourselves and our families to fulfill our duty to our communities. How are we getting blamed for this pandemic or the state of the economy? There were protests in Raleigh to end social distancing. A courageous nurse practitioner was there to counter-protest and was harassed about her weight, threatened and verbally abused. “Old people are going to die anyway” is not a valid reason to end social distancing, and if people had any idea what they were talking about, they’d realize COVID isn’t just affecting the elderly population. I’m disgusted and disappointed. 04/26/20: Hannah suddenly felt unwell this morning at work. Her voice shook when she said, “I don’t feel well.” She called employee health, scheduled a COVID test, and went home. I’ve been praying for her all day. 04/28/20: Hannah’s ok. Just a GI bug, thank God. 05/04/20: Murder hornets? You’ve got to be kidding me. It’s like apocalypse roulette. 05/07/20: 74 days have passed since two white men chased and fatally shot 25-yearold Ahmaud Arbery in Georgia. It took 74 days, despite video evidence, for the two killers to be arrested for murdering an unarmed black man. My heart is broken. My body is exhausted. And there’s still more than one sickness to battle. F. Hayden Mulligan, PA-C is a family medicine physician assistant at Duke Primary Care Mebane. This piece entitled was the winner of the Voices COVID-19 Writing Contest.
Old Man
My alarm went off, jarring me too early from sleep. As I struggled to open my eyes, my boyfriend rolled over to face me and stated, very matter of fact, that he had shingles. Eyes now wide open, I sat upright in bed and told him that was ridiculous. “You’re not a 60-year-old man,” I informed him. “You do not have shingles.” At this, I hopped out of bed, put on my short white coat, and headed to the hospital for another day of learning on the wards. But as the day wore on, I began to wonder. Maybe he was right. Maybe it wasn’t such a crazy theory. We had taken a road trip the weekend prior and while driving, he had mentioned that his forehead was bothering him and was tender to touch. I had decided that it must be related to his sinuses, clearly an infection or bad allergies from the change in season. As the weekend went on, the right side of his scalp started burning. Sunburn, obviously. We had spent too much time outdoors during our weekend adventures. At the time, these things had seemed unrelated, but back at home, out of the sun and under the dull, dirty yellow glare of hospital lights, things looked different. Sure enough, a few hours later, I received his text. “I have shingles.” This time with more certainty. “The
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Medicine
doctor agrees with me.” The doctor. The real doctor, he meant; a doctor who was not his girlfriend, one who had, in fact, finished medical school. Sheepishly, I apologized for my dismissal of his symptoms. I apologized for disregarding his theory. I apologized repeatedly because I felt like a terrible girlfriend and a terrible clinician. He started Valtrex that day, but by the next morning a red, painful rash appeared on his forehead. The focus of the rash was a monstrous blister in his eyebrow, aptly and hatefully nicknamed “Herpesaurus.” This new friend was accompanied by swelling and intense, unrelenting, burning pain. I had never seen my boyfriend so miserable; for three days, he barely moved from our sofa. He called his mother, who told him that his dejected face with protruding swollen forehead reminded her of Quasimodo, the Hunchback of Notre Dame. Thankfully, after a few unhappy days, his rash started to recede and the pain improved. Once he was feeling better, we agreed that my diagnostic skills could use some work. Fast-forward a few years; I was nearing the end of medical school and this man, fully recovered from his bout of shingles, was now my husband. This time, he complained about pain in his foot, specifically his big toe. He’s an athletic guy, goes to the gym, walks to and from work every day, and plays in the occasional softball game. It’s probably musculoskeletal, I told 11 · SITES.DUKE.EDU/VOICES
him. Maybe you ran on it wrong. Stress fracture? Tendinitis? Plantar fasciitis? “I think it’s gout,” he said. “My father has gout.” I scoffed. “Only old men get gout.” He went back to the real doctor who examined his foot, ran some labs, and confirmed it was gout. Podagra: gout in its most quintessential form. Again, I apologized. Again, I felt like a bad wife. And I was really starting to doubt my clinical skills. My husband has since traded seafood, red meat, and alcohol for daily allopurinol. Despite his best efforts, that nagging pain occasionally returns. We call it the “goat toe” – a play on his grumpy attitude and hobbling gait during an attack – and it has joined us on trips around the world, including our honeymoon. Unknowingly, my supportive but very non-medical partner taught me a few important lessons. The first: listen to your patients. He knew he had shingles long before I came to this conclusion on my own. The second: keep an open mind. I assumed that shingles and gout were out of the question because my husband didn’t fit the stereotypes. The third: providing medical care for the people you love is tricky. Twice, I misdiagnosed my husband’s ailments. If he had come into the Emergency Department with the same complaints, I would have been embarrassed to miss the diagnoses, yet I missed them on the person I know best. Our close personal relationship made it
difficult for me to objectively evaluate his symptoms. Perhaps subconsciously, I didn’t want to admit that there could be anything wrong or that we might one day get old. For him, I’m a better wife than doctor. Now that he is feeling better and has forgiven me for my faulty diagnoses, my husband prefers that I avoid giving him any further medical advice. As a gynecologist, I am happy to oblige. Jenna S. Hynes, MD is an Obstetrics & Gynecology resident at the Duke University Medical Center.
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Extracurriculars If harsh words fall but no patient is around to hear them, do they make a sound? Nights on the Trauma service are like a box of chocolates – you never know who you’re going to get. This particular night, the page comes in like this: “red trauma: multiple gunshot wounds no loss of consciousness eta 10 min.” There’s not a lot of “who” in that. This isn’t really a trauma center, so everyone’s kind of excited. Well, not everyone. Kind of anxious, too. Jittery. It’s 1 am. In the Emergency Department, gowns and masks and hats are on. ED Cowboy stands at the head of the bed, Surgery Senior stands to the side. Alongside them are the throngs of people without obvious purpose that always seem to show up just in time for that evening’s episode of “drama in the trauma bay.” Everyone’s done this a thousand times. Well, maybe not everyone. “Trauma’s here.” So much for who. While the EMT is giving report, we do the only thing we can before running through the ABC’s of trauma care – unstrap Guy. He’s yelling so loudly that we can’t hear the EMT. Guess he has good reason to yell. A: Airway. “What’s your name, sir?” ED Cowboy yells. Guy says something incoherent back about being in pain. “Airway’s intact.” 12 · SITES.DUKE.EDU/VOICES
His name in the computer is “Disaster” since no one knows it. Probably best to stick with Guy. B: Breathing. Surgery Senior wastes no time. “Bilateral breath sounds.” Guy’s blood pressure starts dropping during C, D, and E. What had been deafeningly loud yelling has given way to perhaps more deafening silence, but now quieter doesn’t seem so good. He’s not protecting his airway very well, his blood pressure is dropping, and his feet are cold. It doesn’t take the diagnostic prowess of a fourth-year medical student to discern that he’s bleeding into his increasingly distended belly. And his blood pressure keeps dropping. ED Cowboy gets ready to intubate and like it was scripted that way, Guy’s heart stops. “Starting chest compressions.” Got a pulse back. Boss Surgeon finally steps up to the table. She’s short and it’s loud, so she has to yell. “IF WE’RE GOING TO MAKE IT TO THE OR, WE NEED TO CROSS-CLAMP. EVERYONE WHO IS NOT ACTIVELY RUNNING THIS TRAUMA NEEDS TO STEP BACK. WE NEED A THORACOTOMY KIT.” This is the second ED thoracotomy in 2 weeks. Boss Surgeon says it’s her second one in 10 years. The likelihood of surviving an ED thoracotomy after gunshot wound? 4.3%.
As though it had a zipper, Guy’s chest is open and we’re staring at his frantically beating heart through the gaping space between his ribs. The aorta is clamped. Praise the Lord. Quite the scene: Boss Surgeon, Surgery Senior, Surgery Junior, Respiratory Therapist, and Guy of course, racing through the hallway like the Jamaican bobsled team carrying two weeks’ worth of groceries. Everyone is scrubbed quickly. The time-out is short since no one knows Guy’s name anyway. Better say a little prayer, not even sure whom for. On her way out of the OR, Surgery Junior raises her eyebrows. “Danielle, get ready with the sucker. There’s going to be a lot of blood.” She wasn’t wrong. Liter after liter of blood pours out faster than we can yell “towel” at Scrub Tech. 2 am ticks to 3 as 6 units of transfused blood swelled to 30. White Queen Surgeon rolls in – seems like Boss Surgeon needed some help. You can tell her hair used to be blond, but she’s the sort of woman who might as well have been born with white hair, full of wisdom and secrets. With furrowed eyebrows on her kind face, she asks “What happened to this gentleman, anybody know?” Wish she hadn’t asked. The operating room erupts into a choir of speculative sensation, like TMZ covering the Rapture. Does it even matter? There’s no way anyone could FALL 2020 · VOL 10, ISSUE 1
know the whole story. Not sure anyone really wants the whole story anyway, probably just the “good” parts. Guy’s family has made it to the hospital and congregates in his room in the ICU with the White Queen. She tells them that he has required another 10 units of blood since arriving to the Unit. 5:30 am. The daytime team has crept in and brought the morning with them. In the solace of the work room, it was time for Signout. Guy is the only one without a Signout note. Partially because his name is still “Disaster” in the computer. Partially because no one is sure how Guy’s story will unfold today. The White Queen interrupts Signout to inform us that Guy’s family has decided to stop. No need to sign him out. As the night team heads out, Plastics pipes up. She’s on the day team. It’s fairly apparent that she much prefers her Plastic Surgery world to the ICU. She lets out a nasal, high-pitched, “Oh my gosh y’all he lives in the neighborhood next to mine! Isn’t that scary?” Ortho turns around in his chair, already faithfully attending to the morning’s tasks, one of which is filling out Guy’s death packet. “I don’t think you need to be worried about that. He probably has different extracurriculars than you do, if you know what I mean. I’m sure he wasn’t just sitting on his front porch reading his Bible.” 13 · SITES.DUKE.EDU/VOICES
Why people out there like Guy can’t have the same extracurriculars as the people in here, in the work room isn’t clear at first, but then it makes sense – they just can’t. Because if they do, then the people in the work room aren’t safe anymore. People like Guy couldn’t possibly read their bibles, of course, because anyone with their nose in a bible, covered in the love of Christ, would have been impervious to the kinds of things that shatter lives, things like bullets. No one in the room knew Guy’s story, but they had already etched his narrative into their minds in ink as permanent as the Philippians 4:13 tattoo on Guy’s chest. Guy’s story, at least the one written for him in the work room, was a story that no one here – not Ortho, Plastics, Surgery Senior, or Boss Surgeon – would ever or could ever be a main character. Well, maybe not everyone. Ortho’s words hit hard. Because there’s always a chance that someone in the room isn’t all that different from Guy. Someone whose name sounds more like “I” than “Guy,” who came in as a “red trauma with multiple gunshot wounds” many years earlier at a different hospital. Only now, years later, someone with remarkably similar extracurriculars to Ortho and Plastics and Surgery Senior, someone who huddles in hospital work rooms writing other people’s stories.
But it’s not often obvious when someone in the room with you – especially someone sitting in the next seat over, or standing at your side over the operating table, getting ready for the river of blood about to erupt – someone with very similar extracurriculars, is also kind of like Guy. In our best attempts to get as far away from Disaster as possible, I wonder how many times we have made someone else in the work room – one of our very own – wish they had a different story. Danielle Ellis, MD is an alumna of the Theology, Medicine, and Culture program at the Duke Divinity School, and currently a 1st year General Surgery resident at Massachusetts General Hospital.
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The Family Secret My brother Brian is 8 years older than me. He would have been sixteen in 1981 when Mom first denied it. While peeling potatoes in the kitchen, she stopped, turned to him and said, “You may have noticed that I’m awkward sometimes when I move, but really I’m just clumsy.” Brian had observed that some of our cousins developed slightly uncoordinated, clunky movements. He had also noticed the same in mom. Brian had found out about the family disease accidentally and was the first among us to find out that our family would be next. He was going to the bathroom late one evening, and as he passed my parents’ bedroom, he overheard their strained and pressured dialogue. Mom was clearly distraught as she sobbed, “What are we going to do?” Dad replied that they would just figure it out as they went. That was Brian’s secret to carry, but not for long. Mom had consulted multiple specialists since she first suspected that she may have been at risk too. For ten years their consensus was that she had likely escaped her siblings’ fate. But after a pair of visits over two years, doctors finally detected the gradual fine-motor deficiencies that were indicators of the disease. Dad called a family meeting and explained to all four of us kids that Mom had been diagnosed with the family disease: a form of cerebellar degeneration with a dominant pattern of inheritance. Unbeknownst to me, all four of Mom’s 14 · SITES.DUKE.EDU/VOICES
siblings had already died from the disease. Although I had never met my cousin Mike, I remember vividly that he died at age 31 while I was in the fifth grade. I recall standing in the lunch line in my elementary school cafeteria while considering the tragedy of his death, but as I had no personal connection to anyone in Mike’s immediate family, I went on with my day as usual. I’m certain now that Mom must have played out the worst-case scenario in her mind. Mike started presenting symptoms as early as twelve, and cousins Susie and Betsy were symptomatic in their early teen years, before I was born. My two oldest brothers had already escaped their teen years unscathed. Surely it’d strike one of the two youngest, my brother or me, first. Mom’s siblings had succumbed, one after the other, to the family disease. Having watched their friends disappear over the years, she knew that her close friends would eventually wander away as her disease progressed. Preferring the driver’s seat to a passive role, she cut ties with each and every friend she had. As Mom’s symptoms progressed, she very consciously and systematically limited her social interactions, no longer attending church or social events and severing ties with all of her friends and extended family. Her decision to detach from her connections affected all of us. As much as she felt she was protecting herself from further pain, she was exposing the rest
of our family to more of it. Imposing isolation from the comfort and support of family and friends over the next ten years would negatively impact us all. We didn’t talk about or acknowledge her ongoing absences. We had all bought into keeping her painful secret. Initially, the doctors that Mom saw advocated for her to continue living her life without factoring in the possibility of an eventual diagnosis. How could they even suggest a mechanism for coping with the potential illness lurking in her DNA? With no alternative, the doctors decided to give her hope in the form of a Hail Mary pass, but she was nowhere near in position to receive it. Mom was mortified when she finally had enough data to discern the risk that she had passed on to all of us. Initially feeling guilt for having put her own children at risk, she was eventually silenced by her shame. Although we were both affected by the disease in our third decade, the diagnosis was a blessing to me and a curse to her. Only now can I begin to comprehend how my mom’s diagnosis and mine can hardly be compared. I had a fulfilling childhood and was relatively unscathed by my mom’s struggle with her condition. Every summer Dad would take the four kids on family vacations all over the country. He would take me across the state to play in AAU basketball tournaments, and I went on to earn a scholarship to play basketball in college. I was only twenty when Mom died, FALL 2020 · VOL 10, ISSUE 1
but I had already learned how to soldier on despite the circumstances. I went on to get a master’s degree in exercise physiology, worked in community health as a research coordinator for twenty years, and built meaningful connections to others along the way. By the time I received a positive diagnosis, I was firmly living my life with no intention of changing trajectory. Unlike Mom, I grew up with an awareness of the malady that ran in our family, and I factored in the possibility of my own diagnosis. For thirty years I continuously thought about, but suppressed talking about, the way Mom was devastated by this condition. Our stories, similar and yet so different, exemplify how easily the mind attaches itself to the narrative it creates. Our thought patterns each aligned to reinforce our appointed stories, even in the face of contradictory or inconsistent facts. We took in and digested new information only as it related to our past experiences and current narratives. From a young age, I very consciously chose a story that was inverse to hers. For years, her path was blazed subconsciously by fear. Mine would be marked by decisions that put myself in the best possible position to continue traveling after a bump in the road. I relied on living just as I had so far, not allowing fear to drive my decisions as my mother did. When the moment came to confront my diagnosis head on, I was in a much better place. Dana Creighton grew up learning how to shroud her pain in silence. 15 ¡ SITES.DUKE.EDU/VOICES
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