Welcome to the latest edition of Rubor, now celebrating its fifth anniversary and publication! Our mission as ever is to provide an outlet for students, staff, and patients in the University of Utah Health Sciences to share their challenges and triumphs through art. Whether from the healthcare setting, the Wasatch Front or yet farther afield, this year’s submissions confirmed anew the wealth of thoughtful talent in our community.
Contemplations on life and death by medical students and experienced physicians alike demonstrate ever present learning and gratitude found in healthcare, such as in the essay The Storyteller and the poetry of Dance. Passion and sacrifice are beautifully rendered in Give Me Another Letter, the story of an immigrant and her son’s experiences with medical training abroad and in the United States. Leaving Earth altogether, Panacea heartbreakingly asks what cost you would accept to have you, or your child, cured of an otherwise incurable disease.
With visual art, our contributors demonstrate skill with myriad techniques from the Impressionistic anatomy of our watercolor cover, Acute Appendicitis, to the deliberate calligraphy of our closing image, The Precision of Medicine. Between these covers, L’essentiel lays bare the clinical encounter with computer generated imagery, Layered State suggests the beating heart of a community with pen and ink, and a book is painstakingly transformed into whimsical, ingenious sculpture with To Fly.
I’d like to express bountiful thanks to everyone who submitted their work, to the hardworking staff of Rubor, and to the School of Medicine’s Division of Medical Ethics and Humanities and other sponsors for making this edition possible. Here’s to more art and more understanding in the world!
“What’d you learn today?” Mama asked in Arabic.
“Ehhh, we just did some lower limb stuff. Nothing exciting. You want a quiz question?”
“Sure! But nothing too hard. It’s been a while since I’ve learned this stuff.”
I gave a halfhearted laugh. “Tell me, what is the name of the structure that the head of the femur inserts into?” I said, speaking clearly to ensure she understood the question.
“Hmm, I know this one.” A long pause. “Don’t tell me…actually, give me a hint. What’s the first letter?”
“A,” I said. “You got this! I know you know this!” “Hmm, okay, give me the second letter.”
“ACETABULUM!” she shouted.
The joy in her voice made my day.
Mama is the smartest person I know. In Egypt, where my family is from, all high school seniors are required to take a standardized exam, the scores from which determine the careers young people can pursue. Of the quarter million students who took the exam in 1983, Mama finished in the top hundred. Her score of 96.5% surpassed the national minimum score of 89% required to enter medical school. She enrolled in College of Medicine-Tanta University, a respected medical school nestled in the Gharbiya Governorate of the Nile Delta Valley.
As a medical student, her work ethic was unmatched. She was a “gunner” long before I knew the term. She quickly soared to the top of her
medical school class, granting her the freedom to pursue any specialty when the time came to choose. Her male classmates would whisper snide remarks to scare her away from competitive specialties they also wanted. “Don’t you think Ophthalmology would be hard for you, especially as a woman who wants a family?” they’d ask. My mother saw through their games, working hard to edge them out when it came time to begin residency.
She went on to correct countless cataracts and corneal abrasions as an ophthalmologist. She managed many difficult cases, the most memorable being a young boy from the countryside whose eye had been impaled by the horn of a water buffalo. Her attention to detail and compassion towards patients catapulted her to the top of the Egyptian medical community. In 1996 she landed an opportunity to pursue a PhD in the United States. As is the case today, an American education was one of the greatest honors an Egyptian professional could receive. The decision to leave was easy.
It took years for my parents to adjust to American culture, but they learned to navigate its currents in snowy Syracuse, New York. The PhD program kept my mother busy, testing her ability to be a mother and professional at the same time. I remember afternoons with my younger brother, Omar, spent spinning on laboratory chairs, trying to mimic the centrifuge reactions she was performing. Mama, hunched over a microscope, would periodically glance over at us, flash a smile, then resume her work.
After earning her PhD, Mama took a part time job at the Syracuse Eye Center while studying for the dreaded USMLE exams. She knew her stuff—she had been a practicing physician in Egypt, after all—but the adjustment to practicing medicine in English coupled with the speed of the exams made them more challenging. It took her three tries to pass Step 1, and she made easy work of Step 2, passing both the Clinical Skills and Clinical Knowledge portions on her first attempt. Step 3, however, proved a different monster. By 2013 she had failed the exam two times, and was slowly building herself back up emotionally to take it a third time.
As each exam required months of preparation, Mama grew nervous that her age (midforties at the time) would make her an undesirable candidate for residency. Having been removed from clinical settings for over a decade, she pursued an internship in Chicago to make herself competitive. She shadowed family medicine and internal medicine doctors, splitting her time between the small suburb of La Grange and the city’s south side.
Around the same time, my father suffered a serious cerebellar stroke. He spent months in the hospital with Mama glued by his side, meticulously doublechecking all the medicine that went into his care. His rehabilitation plan was no small undertaking, requiring a strong support system to see it through. With my brother and I in college, the burden of his care mostly fell on her. I pleaded with Mama to allow me to take time off from school to help her care for him, but she insisted I stay. Nothing more important than education, she reminded me.
As the years passed and with my father’s condition gradually improving, Mama, then approaching 50, found herself in a difficult spot. Her heart longed to practice medicine again, but she knew my father’s dependence on her wouldn’t allow for it. She came to terms with her situation, spent every night in prayer, and eventually made peace with the fact that she would never practice medicine in America. Yet there was still one thing left to do: pass Step 3. She might not be able to practice, but she had every intention of proving to herself that she could pass that exam.
Mama studied hard during any free time she had. I’d often catch her buried in her heavily annotated copy of First Aid, eyes closed and whispering back the material to herself with a cup of tea in hand. She took the exam during the summer of 2014, a couple months after my college graduation. When the scores were finally posted, Omar and I were out watching Guardians of the Galaxy. When we returned, an echo of sobs resonated through the house. We found Mama curled on a couch in the family room, eyes swollen. She had failed the exam—by one point. One point. I’ll never forget the image of Omar holding Mama on the couch, trying to console her, as she hysterically proclaimed herself a failure. My heart hurt for the patients that would never experience her care. I grew bitter towards the medical system that made it so difficult for immigrants to succeed. And I was sad for Mama, the most selfless, loving, caring human being I’ve ever known. If anyone deserves to have happiness in this life, it’s her.
Life went on for Mama, but the memory of that exam still haunts her. Sometimes while on Facebook scrolling through her newsfeed, a post from one of her former medical school classmates will pop up. Many are respected doctors, some associate professors at large universities. Upon seeing their titles, my mom can’t help but wonder how successful she would have been had she never left Egypt.
In search of new opportunity, my parents relocated to Northern Virginia in the summer of 2016. While packing their belongings, Mama came across a crumpled edition of Egypt’s AlAhram national newspaper in the bottom of a coat closet. On the front page was an old photo of Mama dutifully half smiling. Her flowing black hair is pulled back tight. Her picture was the first of three rows of black and white photos of young people, each being recognized for a different academic achievement. The caption to Mama’s portrait read, in Arabic, “Heba Abdelmaksoud, top 1989 medical graduate of Egypt.” I asked Mama about the picture.
“Sometimes, whenever I am down, I like to look at this picture to remind myself of where I used to be,” she told me.
I wish my mother could see that she is anything but a failure. Failures don’t raise children who go on to become journalists or medical students. Even today, when I catch myself complaining about an upcoming exam, I think of Mama’s arduous journey. I understand that where I am today is a direct result of her foundation and example. Sometimes, when I smile at patients, and they smile back, I like to think it’s her essence they are smiling at.
Following most days at school, I make the short walk to my bus stop directly across the street from the Moran Eye Center. On one particular day, the wait for the bus was taking longer than usual. As I rummaged through my book bag for my headphones, I realized I had forgotten my daily call to Mama.
She picked up after the second ring. “One day, habibi, when you finish with school, I will be your first patient,” she said.
“I got you!” I replied. “You ready for today’s question? Which cranial nerve innervates the trapezius?”
“Spinal Accessory Nerve!” she exclaimed, without asking for a letter.
The dust of the earth
Raising spirit in your core
Bear the weight of God
Carry the marks of
A thousand years of curses
Cloak my tenderness
Light brown and speckled
Two deer poised to lick the salt
from a thousand meals
Red arch to the sky
For a moment exalted
Then plunge- spew your blood
Cascade of our blood
Cradle all humanity
In your four chambers
Ignored until you bloom big
One mass through the head
A thousand armies.
Encased. A well-placed foot will
bring you to your knees
Hollow near the heart
An inverted atmosphere
Outside safely in
Yellow and black bile
Into you flows all that ills.
Aquifer of the soul
Atmosphere in flux
A crimson courier
End of each deep breath
I was once afraid of Death.
Before we’d met.
But, now, we know each other well.
We’ve walked together.
We have danced.
And, no, Death has not always led.
And when we arm wrestled
Sometimes, you let me win…
At least for a while.
I thought we had an understanding.
And, then, you
entered my childhood home.
I saw you meet and strike,
And walk away
With the man who cradled me when I was born.
I have been angry.
I have been sad.
Some days each step
Seems more than I could bear.
Until I remembered–
I remembered, Papi, what you used to say.
In my childhood ear,
“Live each day
With the wonder of your first.
Live each day
As if it were your last.”
filled with Life.
Shall we dance?
“…The dead have more claims on you than what you might want to admit or even what you might know about and then claims can be very strong indeed. Very strong indeed.”
— Cormac McCarthy, No Country For Old Men
He looked through the window at the waiting day and in the young light of the morning it was gray and the ground was frozen and the world moved slowly. A light snow began to fall. Days like this were treacherous and the benign gray tinge to the world gave no warning of the bitterness awaiting one brave enough to walk outside. If he were smart, he would turn around and crawl back into bed. He heard a car labor to start down the street and ventured out the door.
He stood there in the cold and the snowfall for a long while. The cold resonated with him. It seemed to understand him. The physical discomfort it caused matched the unease in his heart. Sparse snowflakes drifted reluctantly to the frozen ground, as though they would rather remain in the clouds. He understood their reluctance to do what one was made to do. So he stood there, in the presence of something that understood, something that allowed him to bring mind, body, and heart into one again. A rare experience these days, and he stood.
He then began to run and the sound of feet hitting pavement was all he heard. Later he heard his labored breath as the cold air began to sting his lungs. Often he wondered why he ran, wondered if he was running towards something or away from something yet unknown. He would then reason that time passes to reveal what is yet unseen. So he would cease to wonder and continue to run, for on cold mornings such as this, that took energy enough.
He ran for two miles, returned home, showered and dressed for the funeral. As he walked through the stained oak doors and into the chapel, he noticed the empty seats and the dirge of an aged organ. He was aware of the sweet smell of flowers, juxtaposed sharply with the acrid air of candle smoke and loss. He felt out of place, it wasn’t customary for someone in his position to attend a funeral like this.
He had only cried once, three days after he had heard the news, at the thought of forgetting the sound of her voice. It is details like these that tether the lost to the living. To forget them is to lose them in the ethereal labyrinth of neuron and synapse and things spiritual. He was not ready for that. Despite these thoughts and the regret and the longing he would not cry again. He had made himself numb and he had expectations to live up to.
He sat and watched the candles and the smoke as it rose, floating lazily to the vaulted ceiling blown by the breeze let in by the old building. He watched as people continued to file in. He watched as the reverend spoke. He rose as the casket was carried away and he stayed in the cemetery until everyone else had left.
As he made his way across the frozen ground made uneven with memories rendered permanent in stone, he saw a fallen sparrow, speckled brown with a white breast darkened by the weather. In its beak was a piece of string, frayed and dirty. He crouched to examine the bird and felt forlorn at the thought of this its unfinished nest and its struggle to make a life for itself alone. He couldn’t help but wonder why this bird had not made its way to warmer climes. But then again, sometimes it does seem easier to take the hard road to failure, marching to the beat of one’s stubborn drum, than to allow oneself a chance to succeed while falling in line.
He picked up the sparrow with unused tissues from his pocket and made his way back to the gravesite where two men in navy blue jumpsuits were lowering the coffin. Ignoring their stares, he placed the sparrow on the casket of the woman. She had always admired birds, they had many conversations about them and he imagined her house still stood surrounded by birdfeeders, without seed or sugar water, waiting for the ice to thaw. He reasoned that this sparrow deserved as sophisticated a burial as any creature did dying in the pursuit of its dreams. He grabbed a handful of soil and sprinkled it on the casket as it was lowered and left the cemetery.
When he arrived home, he collapsed on the couch in a broken heap, a movement he would scold himself for undertaking were he to do it in public. Tonight however, his apartment was empty and quiet and still. Unsure how to feel, he felt nothing. Unsure what to think, he thought not. Unsure what to do, he did what most creatures of habit do and clicked on the television. He continued searching through the channels knowing he would find nothing to watch. Of all the emotions he expected to feel after a funeral, apathy was not one of them.
Maybe he didn’t need to grieve. After all, he had only known her over the course of several months; each interaction packed into 15-minute appointments and brief phone calls. Does someone really need to grieve for someone they knew for such a small amount of time?
Not two days later he would begin to feel empty and he would realize that it’s not the amount of time spent with someone that fetters a part of your soul to theirs, it was the quality of the relationship shared, the part removed callously by loss. That was the only way to explain the hollowness that now filled his morning runs, and his hours in the clinic.
Eventually, he would learn to embrace the loss he felt. He gave it place and time and purpose. That emptiness gave way to hope, and hope to determination. Regret and self-doubt gave way to motivation. Her memory followed him and pushed him, it lived in each patient he saw. Her death justified with each patient that went home. He kept that frayed piece of string with him in his pocket.
I know there’s something wrong this time.
Yes, I realize I am in my prime.
But so was she! And her! And him!
Just before they lost a limb…
It’s my lower left intercostal space,
Something feels quite out of place.
Yes, that’s the main symptom, more or less the only sign.
But I just know that it portends a precipitous decline.
No, it started just this morning
which is precisely why it’s so concerning.
The chronic rarely swiftly kill
Only acute conditions fit that bill.
I’ve drawn up a differential:
Acute lymphoma has potential;
It could be genetic, hemolytic.
You know, I think my grandma was arthritic…
Feel free to palpate, percuss, and auscultate.
Please, do your own search of Up-To-Date.
I think you’ll find that it’s no use,
This illness is just far too abstruse.
Fatal? Yes. Of that I’m sure.
I learned in class that there’s no cure.
No, it’s not easy to admit,
But I think this really might be it.
Such a shame we won’t be hanging out again.
But enough of me, how have you been?
I heard your sneeze when you came in,
And I must say, the prognosis may be grim…
A drop hitting water
Spreads like eternity
An affect that continues
Like emotion pouring out of me
Wondering where are we going?
Open air expands
Beyond my capacity
That changes every part me
What am I to receive?
Anger burns reason
Necrosis of humanity
Taste every morning
Like the sun coursing out to the sea
It feels like reciprocity…
Fall senescing into amber
Brown honey and gold
Melts into tomorrow
Transformed by the snow
Reflection assembles pain
Turning loss into possibility
An electromagnetic expanse
Capable of metamorphosis
Life is evolving.
Change like an isomer
Love as a commodity
History as we want it to be
Amidst a sea of white coats and one girl’s secret smile,
Emerged a secret hope that many years of fear had compiled.
To prove my worth, the penitence for the debt I could not pay.
It is an apology that came too late, to a man who would not stay.
Another for a woman whose mind had long been broken,
And all the years I lost while these words had gone unspoken,
Six lost souls wandered aimlessly, one after the other,
My brother was our father and I sister served as mother.
Later, betrayed in the night by a false friend and misplaced trust,
The character of a man was revealed in the weakness of his lust.
So at last when I began walking this sanctuary of healing rooms,
I was fighting an invisible disease praying not to be consumed.
And in these halls I found others, more lost souls, sick and afraid.
Our mutual struggle united us against the diseases that were laid.
Through dark waters I pressed onward, led forth by their shining lights,
As I shared my own to guide them on this journey of shared plights,
All the memories that surfaced of ships lost, the tales of grief and strife,
Paled to the realization that even in illness can still be precious life.
Now at last as I set anchor and emerge from this white sea,
I find that those I fought to heal, were also healing me.
“The art of storytelling is reaching its end because the epic side of truth, wisdom, is dying out.”
“Not only a man’s knowledge or wisdom, but above all his real life—and this is the stuff that stories are made of—first assumes transmissible form at the moment of his death… Death is the sanction of everything that the storyteller can tell. He has borrowed his authority from death.”
— Walter Benjamin, The Storyteller: Reflections on the Works of Nikolai Leskov
Our initiation to healthcare involves a confrontation with death. When we meet our cadaver, we encounter a death that defies nature – one that is removed from temporality. With embalming, his moment of death is both preserved and made tactile – it is engaging and it is patient – it is open and it is raw. In death, our cadaver shares with us things that even his unconscious chose not to reveal to him in life. His body is an expression of the utmost vulnerability.
The act of dissection on a human cadaver seems to obliterate both ritual and nature’s course. Now, a new ritual and ceremony must evolve in their place. How do we imbue the now segmented, dissected human body with the sacred? How do we preserve human life and memory while systematically taking the human body apart? As we look inside of our cadaver and recognize the body’s container-like capacity, the organs so neatly displayed, how do we remember that it is in fact a human being?
This is the Storyteller – a gifted teacher, his insides silently speaking for him.
When Walter Benjamin talks about the death of the storyteller, it is due to a lack of shared experiences in modernity. Anatomy lab provides an opportunity to resurrect the storyteller and create a new ritual. Medical students gather around the Storyteller, carefully taking his body apart while learning how to listen to the stories it tells. His body becomes the storyteller and only those of us who have seen inside of him can carry on his tales.
Everyone dies with memories, says Benjamin, however, “these [memories] do not always find an heir”. For our Storyteller, we become his heir. It is now our responsibility as medical students to carry his bodily memories with us and let them inform our practice. For me, the Storyteller presents life itself – preserved, static, and tactile in its last waking moment.
That she Trusts,
is The Gift.
and grace emerging,
despite the odds
and without a warrant,
out of the dust.
Do you see this space right here?
It’s not very big,
But there’s room enough for you
Should you need it
Should you want it
It may not look like much,
But it’s all I have
And with you there,
It could become so much more
I promise I’ll keep it.
I’ll save it.
Just in case.
She was late
And didn’t see
B: bilateral breath sounds.
The black ice
C: palpable radials, DPs b/l.
As she ran
D: GCS 8.
To catch the bus
E: clothes off, 2 warm blankets on
That Monday morning
Maybe there is something I can do
To tap into
To drain the stream of restless visions
Out of view
To leave you finally, at ease
Not in pieces
But in peace
I looked out over the tarmac from the launch platform. There were a lot of people. I found my parents down there, waving up at me. My mom was wearing a black dress, and from that distance I couldn’t tell for sure whether she was crying, but I know she was. I could almost make out a handkerchief. My dad stood next to her in a black suit, with his arm around her. I liked to imagine that he was being strong and stoic, but I’m sure he was crying as well. I couldn’t see my brother or sister. They were probably with Grandma and Grandpa.
A nurse walked over to me and turned my wheelchair toward the door. I looked back one more time and waved at my parents, but then I was moving, and I couldn’t see them anymore. There were six other young people in wheelchairs being pushed by nurses ahead of me, and five more behind me. Some of those kids looked really sick. Lots of tubes and masks and wires and tanks. I wasn’t sure whether we were a triumphant parade or a funeral procession.
My nurse wheeled me through a narrow hallway that ended with an elevator. The elevator took us up two additional floors to a circular room with twelve pods arranged like the numbers on a clock. My nurse helped me stand up and climb into pod number 7.
Three months ago my doctors had told my parents that I was rejecting my kidney transplant. I had only had it for a year. Soon I would have to be on dialysis again. I remember sobbing when they told me that. I didn’t want to go through that hell again. The swelling and the nausea and the somnolence. The itching. The shortness of breath. Trips to the emergency room for peritonitis from my dialysis catheter. Nights in the intensive care unit for hyperkalemia and pericarditis. Generally feeling like a zombie. I got my new kidney from my dad, and my mom wasn’t a match. Neither were my siblings. My chances of getting a new kidney in the near future weren’t great. Not that I was a great transplant candidate anyways. I had the heart of a 75-year-old, I was slowly going blind, and I couldn’t even swallow food safely without aspirating.
I told my parents there was no way I was going to go through kidney failure again. I told them I loved them, but I was sixteen-years-old and they couldn’t make me. I’d rather die. They cried a lot. I don’t know whether I actually had the legal right to decline treatment as a sixteen-year-old, but my parents knew I had been through a lot, and they wanted to respect my wishes. That’s when the doctors told them about Panacea.
I was glad the lights in the shuttle were dim. My nurse gave me some special goggles to wear during hibernation. Images of lions hunting gazelles, children walking into a cathedral, and a decades-old football game flashed before my eyes. Who knew we would get an inflight movie? The nurse put an oxygen mask on me, and I suddenly felt very relaxed. It occurred to me that as a child I had at different times wanted to be a firefighter, cowboy, policeman, doctor, even veterinarian, but I had never really wanted to be an astronaut.
Panacea was colonized in 2031. It’s a planet in another galaxy. The government was looking for a hospitable alternative planet to Earth, in the inevitable event that we Earthlings depleted all our natural resources and cooked the planet with our carbon dioxide emissions. Panacea was similarly positioned to Earth with respect to its star, and it had a comparable atmosphere. The miraculous thing about Panacea was that people become healthier there. Not just healthier – they were cured.
This discovery was made by Jorgen Ericksen, a Danish physician who had traveled along with the crew to study the effects of deep space travel on healthy humans. Ericksen had a limp from his childhood and walked with a cane. Dr. Ericksen was astonished to find, on his second day on Panacea, that he was able walk without his cane. He made the completely irrational postulation that something about Panacea’s atmosphere had caused his body to heal itself. He began to interview the military crew, and found a similar pattern. One soldier reported that his frequent migraines had gone away. Another told about his post-traumatic nightmares ending as soon as they landed. And another hesitantly admitted that he was having erections again. Dr. Ericksen was pretty sure he was going to win the Nobel prize for Medicine, and he did, in 2037, although it seemed more like dumb luck than the work of a genius. Kind of like giving a Nobel prize to Columbus for happening upon the West Indies. No one had actually worked out how Panacea cured people.
Four years after this initial discovery a military base had been built on Panacea, and medical trials were underway. Wealthy adults with terminal diseases were able to fund their own travel to this exotic sanatorium, and the reports consistently showed miraculous healings, patient after patient. But those healings only persisted as long as the person lived on Panacea. It was another five years before the government approved trials for pediatric patients. At that time the waiting list was longer than the six months many terminal kids had to live. But I was the first patient with my disease to apply, and one of my doctors had some connections and was able to get approval for a voyage in three months.
And now I’m here, in this hibernation pod, getting ready to travel to another galaxy. It sounds ridiculous. But I’m hoping when I get there my kidneys will start working again, my corneas will get clear, and all the muscles in my wasted body, including my heart, will be repaired. I won’t have to take medications around the clock, and I’ll have energy to be the active teenager I’ve always wanted to be. Who knows, though? I’m the first patient with this condition to travel to Panacea, so there are no guarantees. Most of the people who have gone have had emphysema, strokes, heart failure and cancer. Lots and lots of cancer.
I don’t know what is on the other side of this journey. I am looking forward to being healthy, to being whole, but I am terrified of the unknown. I’m not talking about the unknown dangers of space, like being hit by a meteor or getting sucked into a black hole. I’m referring to the general unknown layout of the rest of my life. Most kids grow up knowing the basic path their life will take. High school, then college (or not), probably get married somewhere in there, find a tolerable career, have children, some kind of mid-life crisis, eventual retirement with sunny beaches and golf, grandchildren. You know, nothing crazy. There will surely be some surprises, but most people end up leading pretty predictably ordinary lives.
My life, on the other hand, has heretofore sucked, and now I’m getting a second chance. But even though I probably have many years of healthy living ahead of me now, I can’t help but feel that my life is being cut short. I will never see my family again. I won’t get to go to senior prom. No summer job as a lifeguard. College parties are out. College in general isn’t going to happen. Maybe I’ll find a sweet girl miraculously cured of her leukemia, and we’ll settle down in this distant space colony. I don’t know whether the military performs weddings up there yet. I really don’t know anything about what it was like up there. There might be some jobs up there, but I imagine most of them involve menial labor. Definitely not going to be a lawyer. Slim chance I’ll play professional basketball. Maybe they’ll let me live like an independently wealthy person.
A voice came over the speakers. “Prepare for departure in five minutes.” Although whatever they were misting us within our oxygen masks had a wonderful calming effect, this announcement made my heart start racing, and I suddenly felt short of breath. I’m not ready to die! I thought. I felt like I was drowning. Don’t be ridiculous, I told myself. Stop panicking. You’re not going to die. You’re going to live!
The nurse closed the lid on my pod. My eyes filled with tears. Did I mention I’ll never see my family again?