Kyle Jackson

Before I began medical school one of my mentors told me, “You do not have to be the smartest to make it. You just have to persevere.” 

Lately, I have pondered this quote ad nauseum. At that point in my life, I had everything going on track: a good job, healthy dating life, and a future as a doctor. Sure, perseverance was a well-known concept, brutally beaten into me as a poor rural Arkansan boy who worked for everything he had. Yet, perseverance was a cliché that I had risen above. I had put myself through school, obtained a well-paying job, and then put myself through school again. Although things were tough, my wits were the tool to make my goals come to fruition. It actually felt easy.  Perseverance was simply pushing through the discomfort that rears its ugly head.

Medical school orientation finally came and surprisingly I became overcome with conjunctivitis in both eyes. Not the ideal way of making a first impression I assure you. The illness passed and I was seeing clearly again. Things seemed to finally be on the right track. I was even ranked #1 in my class. Then slowly, I began to notice a change in my bowel habits. I began to have daily bouts of diarrhea, abdominal cramping, and fatigue. What started as a once-daily occurrence progressed to multiple times a day with blood accompanying. “This must be a Clostridium difficile infection secondary to the antibiotics used to treat my eyes,” I thought. It would be easy, just push through the discomfort until this is diagnosed and treated. 

The insidious progression lasted months until my misfortune made a glorious crescendo. My father abruptly died of a heart attack. The stress tanked my health. I was a prisoner to the bathroom and essentially bedridden with extensive pain, bloody diarrhea, and fatigue. I was lucky enough to quickly see a gastroenterologist and get a colonoscopy which led to a diagnosis of Ulcerative Colitis, a type of inflammatory bowel disease that I would always have. There I was, completely and utterly broken, unable to come to terms with the loss of my health and the man I idolized the most. 

“The world breaks everyone and afterward many are strong at the broken places. But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially.”-Ernest Hemingway

These words lingered in my mind and seemed harshly relevant. For the first time in my short life, I wanted to give up, fly the white flag, and surrender. Life looked me in the eye, and I blinked. Born in those moments was the first true test of perseverance. The visage of who I was and the life I was expected to have? Gone. Few have known what it is like to mourn yourself. Now the choice was evident, a path clearly diverged. Do I give up and succumb to my illness or do I keep putting effort into school and a dream I had in a past life? There seemed to be only one true choice. 

Steroids helped tame the colitis but not fully. I still had significant symptoms and pain, but I was stronger. I was still proverbially chained to the restroom, but at least it did not feel like death. Like a reactionary counterforce, I became insanely focused and dedicated to what I could do. I pushed through and studied non-stop. If I could not leave my house due to illness and a new contagious virus (covid), so what? Studying would be how I persevere. This newfound tenacity was less a testament to what it meant to push through adversity, and more about simply regaining control. It was also a duty I had to my old man. It was a duty to the friends and family that supported me.

That is what I felt and believed for that next year, and it served me well. I returned to the top of the class, I fell in love with my now fiancée, and I had come to accept my situation. I was graciously granted testing accommodations for Step 1, turning a one-day test into two. The first day of testing went well enough, but as I returned home, life came around for round two. I received a text and call from one of my high school friends, notifying me that my best friend had just perished in a crop-dusting plane crash. His aircraft malfunctioned and crashed into the ground, killing him on impact. His body lay there, burning in the wreckage. Once again, I helplessly watched as a version of myself died. 

The next day I went and took the second part of Step 1. I was in utter despair, yet somehow managed to focus on the task at hand. I rushed to my hometown and said goodbye and mourned, and my illness continued to run rampant. That next month I had surgery to have my colon removed, trading suffering for freedom and an ileostomy bag. Throughout the following year, something slowly changed. The overt tenacity to push forward was lost, replaced by a desire to appreciate the here and now. Finally, a deeper understanding of the meaning of perseverance is beginning to emerge.

Everyone suffers and faces obstacles in life, and many have stories that put my humble one to shame. From storming the beaches of Normandy to simply making yourself get up in the morning, every day is riddled with deterrence. To persevere means nothing when you feel as though there is no other choice. When you must keep going because of obligation, duty, the need for control, or just to simply survive. Those honored for their achievements wave off the praise, there was no other option for them.  As for me, the world has broken me, and I feel stronger in the broken places. I see that there is always a choice.  The meaning of perseverance is to make the choice, no matter how simple, that progresses you towards your ideals in the face of adversity. When fate and circumstance give resistance and the choice to give up, diminishing your character, you scream “NO!” Duty, obligation, control, survival, love, hate, and regret are core tenants of perseverance but only in the sense that they influence the choice to push through the difficult times. Perseverance is a conscious decisionto transform your intangible character into a physical, unstoppable attribute. 

So, next time you are faced with an obstacle, be aware that your perseverance means something so much more than you even realize. When all is lost, your perseverance may be all you have left.

Kyle Jackson is a UAMS senior medical student from Lafe (Greene County). He is applying to Diagnostic Radiology for residency with his fiancée who is also a senior medical student. Before coming to medical school, Kyle was a CT/MRI technologist.

Conrad Murphy

“Hello?” I said. 

“Hey, guess what!” my wife shouted through the telephone. 

“What?” I said inquisitively, still punching keystrokes at work. 

“My OB called and said that they have an opening if you want go for induction tonight instead of tomorrow! Do you want to do it?” My wife’s voice was reaching the top shelf of excitement, I could essentially hear her smiling through the speaker. 

“If you’re fine with it, let’s do it!” I said. 

“Yes, absolutely! We’re gonna have a baby tomorrow!” My wife hung up and I sent a few messages to my boss to notify them that we were going to the hospital tonight and my one week off was starting right away. I drove home a little quicker than I usually did after work. When I got home I found Sarah rummaging through the house even though we’ve had everything packed for weeks. Our phones were buzzing and ringing constantly with messages from friends and family excited about the arrival of our daughter hopefully a day from now. 

We were absolutely giddy on the drive up to the hospital, looking forward to the whole experience. After admission we settled down in our room and my wife started getting hooked up to multiple IVs as well as a bulky fetal monitor to make sure our daughter’s heart was beating in the appropriate range. I took my spot on the couch and we each did our best to get some sleep, although the traces of adrenaline and Sarah’s positioning weren’t allowing for many dreams to come. The morning came quickly and we had multiple visits from our nurses and multiple cervical exams. Induction was in full swing now and the contractions eased into rhythm. 

Throughout the early years of our relationship, I witnessed firsthand the strength of Sarah. She was an athlete all her life and played collegiate softball as well as balancing multiple jobs at the time. She is tough. She doesn’t let anything keep her down. One battle she faced in childhood was scoliosis. During one of our first dates she showed me an x-ray of her spine and we both laughed at how it curved like a swan’s neck down her back. She had corrective surgery and one of the quirks that she claimed afterward was that she would always have perfect posture, the titanium rods keeping her manners in check for the rest of her life. 

We knew that this may be a complication with the epidural, but her surgeon had explicitly told her that he left “room” during her surgery so that she could receive an epidural block in the future if she wished. That was our expectation coming onto the labor and delivery floor. My wife could handle the pain; there was no doubt in anyone’s mind for anyone who knew her. However, she wanted to enjoy the experience, not just to tolerate it. We wanted that incredible gift of modern medicine. She wanted her first thoughts of birth to be of welcoming her daughter into the world, not praying for the contractions to stop. 

We brought this concern to her obstetrician during previous visits, but it wasn’t in his wheelhouse, so to speak. A man in scrubs came in during the morning hours to meet with us about getting an epidural block as my wife’s contractions began to pick up due to the induction medication. We explained the situation to him, showed him x-rays, and he examined her back. After discussing it with him, he told us that Sarah wasn’t going to receive the epidural. I was sympathetic to his argument at first because he told us of the catastrophe that could occur if her titanium rods were to become infected. It would be the beginning of a horrendous medical experience with roads that were uncertain of where they ended up. I heard my wife’s voice at his response. It changed. At this point in the story I’m ashamed to say that I should have fought for her at this moment. I knew what she wanted. I was here to support her decisions, yet I was silent. I was less than a foot from her and also across the world from her. Nowhere near. Sensing the brokenness in my wife’s voice, the anesthetist finished his thought by saying, “Women have done this for thousands of years.”

There my wife was, between two men – one unwilling to step in for her, and one dismissing her. The anesthetist departed and the room fell silent aside from the occasional monitor beep nearby. My wife just looked down to her hands, wringing the hospital blanket in her lap. Tears fell on the fabric. Unfortunately, contractions don’t wait for the sentiment to pass. God told Eve that her pain in childbirth would increase. And increase it did. I became more and more useless as the morning drew on. I sat there holding Sarah’s hand, seeing the pain roll across her in bigger and bigger waves, the crests growing higher and troughs between them growing shorter. The movies I’d seen betrayed my expectation of the pain. Many of the women I’d seen on the television screen were yelling, throwing things across the room. I wished that it had been that way for my wife more than what her labor was like. 

This pain was different. I’d never seen it before in anyone. You knew the pain came because the breaths from her hospital bed ceased. They were cut off, suffocated out until the cycle coursed through. All you could see were clenched arms and my wife’s lip quivering as silent tears made their way down to her chin. The pain brought silence. Commanded it. At some point during the onslaught the charge nurse came in to check on us. Our delivery was the talk of the floor. It was a cruel joke to many of the nurses that Sarah was induced, told that she could have the epidural block, then that gift ripped out from under her while she was already well into induction. The nurse gave us the option of continuing in labor or to stop the induction and go home until the contractions became spontaneous. She warned us that the contractions during induction are stronger and worse than if they occur spontaneously. 

My wife looked at me through red eyes and told me that she didn’t want to go. She was too excited to see the baby; she didn’t want to get back in the car. She wasn’t leaving without our daughter buckled up in the car seat. So she continued and continued. I am vastly underqualified to explain what my wife and so many women have felt during this time. I can say, however, that there is no worse feeling as a man when your partner is so physically close and so obviously in distress, yet you are unable to provide any relief whatsoever. All I did was listen and console. 

After some time we got word that another anesthesiologist wanted to meet with Sarah. A couple more minutes went by and our door opened to a tall woman with a bright, multicolored scrub cap on. She introduced herself and told Sarah that she personally knew who was her spine surgeon and knew that he usually left enough space for the epidural. “I know that you were told that you weren’t going to be able to receive one, but we’re going to try.” 

This doctor explained in detail about the risks of the procedure and examined Sarah’s back. The male anesthetist came in as well at this time. “She actually has a great presentation,” the physician said to the man as she was pressing in the middle of Sarah’s back. The female anesthesiologist then started the procedure and placed the epidural without any difficulty. The pain increased shortly after the procedure, but after a few very long minutes and some adjustments, relief came. My wife laid back and we watched television until it was time to deliver. It took less than 30 minutes from when Sarah started pushing for our daughter to make it into the world. We had to wait on our OB to get there or she would’ve arrived earlier. I saw a beautiful enraptured gaze extending from my wife’s eyes to our baby girl’s. Her mind was fixated on our daughter, not her pain. 

We spent the next night almost sleepless, but still thankful. The next day we had a host of hospital visitors including a pediatrician, a lactation consultant, nurses, our obstetrician, and the anesthesiologist. She came in to check and make sure that Sarah was having no signs of infection or discomfort. It was an extremely gracious gesture and my wife’s eyes lit up when she walked through the door again. A lasting impact was made in a shorter time that most physicians have to make such a footprint in the lives of their patients. 

I don’t believe that there are any “bad guys” in this story. There are no villains here, but there is a lesson, and there is a heroine. At the end of the day it took a woman to understand and fully grasp the mind of my wife. It took a woman to act out in courage for a patient that wasn’t originally hers. It took a woman who was fully confident in her skills and her ability to comfort. We men were not players in this story. We failed to act and unfortunately I’m afraid this isn’t the only time this has occurred, not by a long shot. 

I understand that as a future physician, I will never be able to understand or grasp the depth of a woman’s pain during childbirth, or much of a woman’s experience altogether. There will be women in my care, however. What I learned from that female physician and from the male anesthetist is that it is because I will never fully understand that I must act with care and precision – not only to train well in the procedures I will face, but to connect meaningfully and sensitively with the body of diverse patients I will meet. We need more women to teach us, we need to listen to the experiences of our female patients and the instruction of our female attendings. The solution is not to shirk from the changing landscape of medicine, but to embrace it. To the anesthesiologist that acted and relieved my wife’s pain, I want you to know that my daughter will hear of your bravery. It’s my hope that she will be inspired and choose to live as you do. Quick to act, careful to listen, and persistent in the face of opposition. 

Conrad Murphy is a second-year medical student in the College of Medicine at UAMS. He lives in Conway with his wife Sarah and daughter Reuelle. They are expecting their second child in spring 2023.

Kristen Stringfellow

I just finished my second year of medical school, took Step 1, and started rotations alongside my classmates. I have wanted to be a doctor since I was five years old. I have taken all the right steps to get here. I have volunteered and shadowed, kept my grades up, and learned as much as I could whenever I could. I am living the dream that my five-year-old self couldn’t even fully imagine, yet some days, actually a lot of days, the dream and idea of being a doctor one day is the only thing that keeps me going. This is lonely. This is hard. We miss family events. We miss hanging out with each other and our friends. We work hard to make good impressions, make new networks and connections, but lose some of the very relationships that supported us to get to the point that we’re at. 

So many people see the good. They see prestigious opportunities, research publications, volunteer awards, and they’re proud. Few people see the really ugly sides – through the extreme pain, they support us through the loneliest days. They see the insecurities, the weaknesses, the loss of strength when we have been too strong for everyone else, when we just can’t handle the pressure, we’re putting on ourselves. These are the people who everyone should recognize. These are the people who keep us going, making the dream a reality. 

In medical school, there are so many seasons that nobody really talks about. There are times we are so excited to begin new classes, to learn from new surgeons, to participate in patient care. Then there are other times that you’re struggling through a class or studying for Step 1. In the last few months, while preparing for the biggest exam that I had taken to date, I found myself in more pain than I can communicate. This is not what people talk about. They don’t talk about missing siblings’ soccer games and dinners with your dad. They don’t talk about not being able to go with your friends or significant other to enjoy the hobbies that they enjoy. They don’t talk about the pure isolation that so many students experience. 

So, I am going to talk about it. I’m going to write about the pain and the hardships that my friends and I experienced. The pain and the hardships that our families experienced. When we’re in these phases where we can’t see the end, we can’t see the light at the end of the tunnel. We are so stressed that we don’t recognize ourselves when we look in the mirror. These are the things that I wanted to know before starting these seasons. I wanted to know that there would be joy after finishing these awful phases. I wanted to know that there was hope. I wanted to know that our families will forever support us, love us, and understand the sacrifice from their point of view too. In the lonely season, this isn’t what we know. This isn’t what we think about. 

To the lonely medical student, the one who feels that they don’t know themselves anymore, the one who feels like the dream isn’t what you thought it was, the one who is in a place where you can’t process your emotions whatsoever, you will be okay. You will get through this phase. You will get to the end of this phase and you will be so proud. You will be proud of yourself for what you accomplished. You will be so proud of your support system for their own sacrifices and ability to support you at your worst. You will get to the next phase and remember why you had this dream as a little kid. You’ll round on your first patient as a third-year student and almost cry tears of joy right then and there because this is it. This is what you dreamt of. This is what you worked for. This is what you have planned for your entire life. You finally can be proud of yourself. You finally can see why you put yourself through all of the pain and sacrifice and have joy in the experience again.

You won’t be lonely forever. You will be surrounded by love, appreciative patients, and professionals that encourage and challenge you. You can do this. Every student before you did it, and every student after you will too. Love your people through their darker phases. Make sure they aren’t too lonely. Give what you can give, but know when it is okay to take too. Your support system only knows you need support when you communicate with them. Take the night off to have dinner with your siblings and parents. In the business of chasing the dream, don’t lose sight of who you are, the people who made you that way, and the people who continue to morph you into the doctor that you will one day be. 

To the lonely medical student, 

I see you and I am you and I am proud of you. Keep going. Keep working. Keep doing everything you can do to chase your dream. 

Love always, 

Student Doctor K. S.  

Kristen Stringfellow is a medical student at UAMS. She grew up in Arkansas and graduated from the University of Central Arkansas with a bachelor’s degree in Biology and Nutrition. She currently serves as the OB/GYN Interest Group President, Class of 2024 Honor Council Representative and Women’s Health Night Coordinator at 12th Street Health and Wellness clinic, a student-run clinic at UAMS. In her spare time, she loves to hang out with her two dogs, Poppy and Remy, travel with her husband and friends, and read. She is in a dual enrollment program at UAMS and will graduate with an M.D./ M.P.H. degree in May of 2024 with an honors in research and finance. Ms. Stringfellow has strong interests in Women’s Health, the OB/GYN field, and public health.

Lindsay Ripley

Most people know the word “adrenaline” better than the word “epinephrine,” but the substance is one and the same. The first word is of Latin origin, the second Greek. Akin to Mars, representing the bloodlust and barbarism of war to the Romans, as Ares embodied it for the Greeks. Each word loosely means “near the kidney” in its respective language, referencing the chemical’s manufacturer, the adrenal gland—a little pea that sits atop the larger bean of the kidney. The gland’s purpose was a mystery until very recently in the span of human history.

We tend to use the Greek term in medical contexts: “Do you want the lidocaine with epi or without?”; “Sweetie, do you have your EpiPen with you?” “The patient’s blood pressure is still low. We should add a pressor; do you want vasopressin, norepinephrine, or epinephrine?” 

The Latin word dominates when referencing the natural form secreted by our own glands. No one says “my epinephrine is pumping” to convey stress. The use of “adrenaline” in that capacity dates back to the 1920s—“a shot of adrenaline” was used as a metaphor for excitement or vigor. In the 1960s, the term gained popularity around high octane, thrill-seeking behavior.

I was born at 2 a.m. one month before my due date. Given my over eagerness, when my mom told my dad in bed the preceding evening that she thought the baby was coming, he said, “No honey, it’s too early,” and rolled over, his snores soon permeating the room. Later that night they were rushing down the hospital corridor as my scalp crowned. There wasn’t time for an epidural; instead, my mom cursed loudly through my mercifully brief delivery.

Amid the overnight sprint to the hospital, my father had asked his sister Sylvia, who was living with us at the time, to stay home with my three-year-old brother, Keith,. Still asleep, Sylvia had blearily consented. After waking in the morning, she got dressed and went to work as usual, not noticing anything amiss. Keith popped out of bed as only a small child does, selected a book from a haphazard stack in his room, and wandered the house seeking a willing reader. “Mommy? Daddy? Aunt Sylvia?” 

Back at the hospital, Dad called Sylvia to assure her that all had gone well with my delivery. Though he usually moved at a glacial pace, he jumped off the couch in a panic when he learned that Sylvia was at work, totally unaware of the night’s events. My dad floored it home, adrenaline pumping, to find Keith sitting on the stairs bawling, clutching an unopened book with tiny white fingers. 

When confronted with a scary or intense situation, the sympathetic nervous system and the fight or flight response activates. Some people don’t do either, hence the alternative term fight or flee or freeze response. I was fighting, my dad was fleeing, and my brother was freezing. Mom was still recovering from labor, her epinephrine spent. Keith claims I scarred him, though in the end my dad brought him to the hospital where his day quickly improved as nurses fawned over the “poor baby” and fed him cake.   

The concept of networks of nerves spanning the body dates back to Galen in the 2^nd century. Galen proposed that these networks allowed a sympathetic, or coordinated, bodily response. It wasn’t until the 19^th century that scientists developed realistic theories of the sympathetic nervous system and its actions, which led to knowledge of the counteracting parasympathetic nervous system. Rest and digest. Two sides of the same coin.

The string of sympathetic nerves that travels from the brain to the spinal cord, then in a “chain of little brains” out to the body’s organs, causes blood vessels to constrict, the heart to pump faster, pupils to dilate, and digestion to pause. In short, changes to prepare the body for a heightened, quickened physical response. Eustachius had discovered the adrenal glands in 1563, but we did not link the two together.

In the late 1800s, various clinicians described a syndrome in which otherwise healthy people had recurrent paroxysms of headache, palpitations, sweating, anxiety—symptoms mimicking overactivity of the sympathetic nervous system. Autopsies in many of these patients revealed masses on the adrenal glands, labeled pheochromocytomas. Charles Mayo, a surgeon, set out in 1926 to treat an affected patient by severing her sympathetic nerves. Digging around in her abdomen to do so, he found a large tumor on her left adrenal gland. Mayo made a game time decision—instead of severing the nerves, he focused on excising this mass, becoming the first surgeon to remove a pheochromocytoma from a living patient. Her symptoms resolved.  

Scientists realized the adrenal gland played a significant role in the sympathetic nervous system. A barrier to understanding the function of the glands was that, excepting the sympathetic nerves providing input, they didn’t seem to be connected to anything. How could these isolated glands be causing effects in other parts of the body? It turns out that adrenaline, produced in the adrenal medulla and released in response to stimulation from the sympathetic nervous system, was the first discovered hormone—a chemical secreted directly into the blood that affects distant organs. 

While the nerves of the sympathetic nervous system do directly innervate some sites where their actions take effect, perhaps their most important function is to stimulate the adrenals to secrete epinephrine, washing the body with excitement and regulating its overall response to arousing stimuli. Pheochromocytomas are tumors that make epinephrine.

I spent my first night outside the womb in the neonatal intensive care unit. My mom complains about how she couldn’t hold or even touch me. She could only put hands into the incubator through gloves built into its side, a layer between us, as if I were in quarantine for a highly transmittable disease. Or an alien—a creature of unknown origins and potentially dangerous. Something not fit for this world.

I was fine and was released home after a couple days. There weren’t any more health scares until my toddler years. One day someone innocently handed me a jar of peanut butter and a spoon without a second thought. I lugged my prize out to the back deck, plopped down in a sunny spot, and dug into the jar as large as my head. The sensation that hit me was new: the smell, the taste, the stickiness. But the distinction went further. Red welts popped up all over my body, my tongue and eyes swelled, and I struggled for breath. My already scarred brother, now five or six, watched in horror. Initially paralyzed as he had been back on those stairs when he thought he’d been abandoned, but quickly running, screaming for help. 

 I don’t know if I remember the moment, or if I can just viscerally feel that sensation from other times it has usurped my body. I am sucking air through a straw and don’t know how long I can keep it up. I am dizzy and my vision is fading; if I stand up, I will pass out. My whole body burns as if I’ve fallen into a pile of fire ants. My lips have blown up three sizes and my eyes are mere slits. Tears fill the only space they have left and stream down my face. My stomach is revolting, rejecting the poison, trying to expel it by any means possible. I do remember my nanny holding me upside down over the sink, frantically washing my mouth out from the faucet, shaking me, trying to get it all out. 

This is anaphylaxis, a process triggered by an antigen that is perceived as foreign and harmful. Anaphylaxis affects the respiratory system: the bronchioles constrict and the airway narrows; the cardiovascular system: the blood vessels dilate, causing hypotension and decreased delivery of oxygen to the brain; the skin and mucous membranes: hives erupt diffusely, the eyelids, tongue, and lips swell; the GI system: abdominal cramping, vomiting, diarrhea. The airway compromise can be fatal. But there is an antidote: epinephrine. 

As it does in a physiologic, sympathetic response, epinephrine attaches to different adrenergic receptors—there are two main subsets, alpha and beta—each triggering different downstream effects. It narrows the dilated blood vessels again, bringing the blood pressure up to a normal or high range. It tells the heart to beat stronger and faster, contributing further to a bump in blood pressure. By binding to another receptor in the smooth muscle of the lung, epinephrine causes bronchodilation—the shrunken airways open up. Both blood and air are again delivered to the body. 

The first craze for using epinephrine was to decrease bleeding in surgical procedures, particularly in delicate but highly vascular areas like the nose and the eyes—the constriction of blood vessels means less bleeding. Formulations of epinephrine plus lidocaine (a local anesthetic) were created to numb up the skin in minor procedures; the vasoconstriction also means less lidocaine gets carried away from the injection site, decreasing its systemic effects and increasing its local ones. Had there been time, my mom would have gotten epinephrine as part of her epidural. 

On a larger scale, obstetricians injected epinephrine into the hemorrhaging uterus damaged by the placenta tearing from its wall; gastroenterologists injected epinephrine into ulcers hemorrhaging into the intestines. Boxing cut men started applying epinephrine to the tips of cotton swabs they’d press on fighter’s faces between rounds to quell bleeding and avoid the ref calling the match. These uses remain common today.

Shortly after the peanut butter debacle, the same thing happened with fried catfish. No one seemed to realize I also had severe allergies to antigens besides peanuts. We had gotten EpiPens by the time I ate fish, however, so I ended up with a puncture wound in the thigh. EpiPen is the brand name practically synonymous with epinephrine autoinjectors. The whole device is the length of a new pencil, but much thicker; grasping an EpiPen is similar to holding a dumbbell. When the tip hits a surface with sufficient force, a 1.5 cm needle emerges, delivering the epinephrine. I had to carry my EpiPen with me everywhere as a precaution. Other precautions included things like not cleaning the cafeteria tables after lunch like all the other kids and eating in the school nurse’s office when fish sticks were served. 

I didn’t use my EpiPen again for over a decade. Then came the only time I’ve had to inject myself. I was a college student on summer vacation, staying with a well-to-do family in Madrid. The children ate separately from the adults, served by the nanny. Often the parents were out at an event until the morning hours. If they were home, they’d eat dinner at 9 or 10. More on the kids’ schedule, I joined the clan for dinner one night at a reasonable hour and took a bite of what I assumed was a chicken nugget. Wrong. It was a fish stick. 

One chew. Two chews. I spit it out. Embarrassed at my idiocy and the vulnerability of my body, I quickly retreated to my basement suite. 

I could feel my face swell. Self-control out the window, my nails tore at my flaming skin, forming superficial lacerations. I started to wheeze. I had not spat the bite out soon enough. Frantically, releasing my own adrenaline, just not enough of it, I rummaged through my never fully unpacked suitcase and found the stick I’d been coached to always have at hand. Cap off, I plopped the device on the white comforter next to me, pondering the next step. 

I was scared to use it. A rush to the bathroom with diarrhea interrupted my weighing of pros and cons. I threw up in a trash can while I sat on the toilet. Spots appeared in my vision. As I tried to stand, I slipped onto the floor, barely conscious. The choice was obvious. I half crawled and half dragged myself over the tile back to the bedroom, reached up to grab the pen, and plunged epinephrine into the lateral portion of my already bare right thigh. Almost immediately, my throat opened, and my blood pressure normalized.

I read a ton of adventure books as a kid, and always wondered what would become of me if I were trapped on an island, like The Swiss Family Robinson, or Tom Hanks in Cast Away. I’d either die from eating fish or die from starvation—surely one can’t live on coconuts alone. Sometimes this fear, among other worries and anxieties, led to me staying home. I’d gone to Spain, but I didn’t tell anyone what happened. I quivered when I read a news story of a girl who had died from her throat closing after a bee sting, despite carrying two EpiPens and using them both. I can safely assume I’m allergic to bees, but I’ve never actually been stung. If I’m enjoying myself in a gorgeous botanical garden or strolling through a peaceful meadow and I near bees I get out. When planning a trip with a friend, I vetoed Thailand as a vacation destination citing my discomfort with the cuisine, which I pictured as a filet of fish topped with crumbled peanuts.

Psychologist Kenneth Carter wrote a book called Buzz!: Inside the Minds of Thrill-Seekers, Daredevils, and Adrenaline Junkies. In it he postulates there are two types of people: low sensation seekers and high sensation seekers. Carter labels himself the former and constantly references his fascination and puzzlement of the latter. Why would anyone find risky or unfamiliar experiences enjoyable? Two people can have totally different reactions to the same stimulus, one finding an experience exhilarating, the other plagued with anxiety. 

It turns out these people we label as adrenaline addicts or even chaos junkies have lower levels of epinephrine release in response to stimuli. Are people who jump out of planes and off bridges seeking a level of arousal that others might attain simply by watching a horror movie from the safety of their own couch? A lot of thrill seekers claim to dislike being adrenaline-charged. One base jumper stated “I don’t like the way it feels. I don’t like being scared.” Rather, the point of these activities may be to attain a flow state, a hyper focus, a control of one’s emotions. Another labeled thrill seeker said of running with the bulls “It’s not a disregard for life, but an addiction to life and trying to intensify moments instead of dull them out.” Do these people who skirt death so flippantly have a greater appreciation for life?

According to Optimal Arousal Theory, we all seek a sweet spot where we are neither bored and lethargic, nor stressed and panicking. A Goldilocks Zone in the center of a bell curve, either extreme of which feels unpleasant and likely leads to poor performance. Exactly where that spot is and how to get there is different for everyone. Without an instruction manual for oneself, finding that spot is a matter of trial and error. Carter says the world needs both high and low sensation seekers, and that these people need each other. Low sensation seekers are the anchor for the ship that needs to stay still; high sensation seekers are the tugboat for the barge that needs to be coaxed along.

I learned a lot about myself during my internal medicine residency, essentially three years of being shuffled around between hospitals and clinics, different subspecialties, with decreasing levels of supervision over time. I didn’t want to be an intensive care doctor—the constant pressure and high stress, having to insert a central line into a giant vein in the neck or a tube into the airway in critically ill patients freaked me out. When I had to stay overnight in the hospital, I lay awake on top of the sheets in the call room, sweating through my scrubs and waiting for my pager to go off to let me know that someone was dying. I pounded coffee the mornings after my sleepless nights to keep up that arousal that made me miserable, but that I needed to wrap up patient care before I could leave. The anxiety didn’t stop at the hospital’s doors; at home I’d often wake to hallucinations of my pager shrilly wailing.

I also knew from practicing as a primary care doctor a few days a month, seeing relatively well and often hypochondriacally inclined patients in clinic, that I didn’t want that either. One patient after another. All day. Everyday. Prescribing blood pressure medications and talking about diet and mood. I’d be bored out of my mind. 

After residency I chose to work as a hospitalist, a general doctor who cares only for hospitalized patients. Those who are sick enough to be in the hospital, not so sick that they require intensive care. Optimally ill? That sympathetic response, the epinephrine, is necessary for more than just aggressive or frightened responses. It’s important for small arousals, a series of which most people “need” each day. Unless epinephrine and the sympathetic response activate when we stand up, squeezing the vessels down on a fixed volume of blood, gravity will overpower us. The blood will pool in our legs, draining the life force from those vital organs at higher altitude. We will become dizzy, fall, pass out. Even lying down, being sedentary, for too long can trigger this. Thank God there are doctors unlike me who enjoy the extremes.

In addition to pheochromocytomas, those tumors that secrete epinephrine, all kinds of masses can grow on the adrenal glands. Most are meaningless. They do nothing but sit there, perhaps enlarging sluggishly, never reaching notable size nor causing an adverse effect. A minority are functioning masses, secreting hormones; this can be epinephrine, or it can be other products of the adrenals: cortisol or aldosterone. And a small but important percentage of adrenal tumors represent malignancy. A cancer that can spread and kill. 

On autopsy, pathologists find a mass on the adrenal gland in 5-10% of patients. As our methods for performing non-invasive imaging have leapt forward exponentially over the past decades, we are detecting more and more of these in living patients. The adrenal glands have become the characteristic home of the annoying, the vexing, the troublesome incidentaloma, a term coined in 1982 to describe this surging diagnostic conundrum. Not long after, in 1986, a New England Journal of Medicine article first used the term “cascade effect” in reference to evolving medical technology and its downstream effects. 

Physicians can identify pheochromocytomas, as well as other hormonally active adrenal masses, by testing blood and urine for certain metabolites. The only way to know for sure if a mass is cancer is to cut it out, stain slices of it, and peer at them under a microscope. Chasing every mass will end in a lot of unnecessary surgeries. Even if we just perform blood tests on every patient, the healthcare system will incur a lot of unnecessary costs, the patient will be sapped of time and resources, and we may find other abnormalities of little or undetermined significance that snowball into further testing. Like giving a mouse a cookie.

What if we hadn’t done the scan that revealed the mass in the first place? Studies have shown that patients with incidentalomas have a decreased quality of life. Perhaps due to a constant low level of induced anxiety. All of this—whether to do an initial test, whether to order additional testing to follow up an unexpected abnormality—is a series of risk-benefit analyses in search of the optimal testing threshold. Physicians need to be able to tolerate a certain amount of risk and uncertainty. I find unanticipated masses, nodules, anatomical variations all the time that don’t warrant further testing in the hospital. Many do warrant testing in clinic, follow up in six months or a year, a visit to a subspecialist. I can’t guarantee this will happen; I have to let my patients out into the world.

I’ve seen Tarantino’s Pulp Fiction probably a dozen times. The film is number two of Tarantino’s planned ten films for his career (he’s now finished nine), notorious for fascination with blood and gore. Pulp Fiction is also the break into the resurgence of John Travolta’s career. Travolta plays Vincent Vega, an enforcer for a drug kingpin. Vincent is always cool as a cucumber, barely blinking an eye when he’s shot at five times, or when he accidentally blows the head off a guy sitting in the backseat of his car. He manages instead to focus on the important things in life, such as how to order a quarter pounder with cheese from McDonald’s in Europe given they use the metric system, or if a milkshake can really be worth five dollars. 

The only time Vincent gets riled up, shows some real fear and emotion, is when he finds his boss’s wife unconscious and foaming at the mouth. Uma Thurman’s character Mia has OD’ed from greedily snorting Vincent’s heroin that she mistook for cocaine. Vincent can’t let Mia die. After all, his boss has a reputation for throwing people who displease him out of windows. Vincent freaks out, calls his drug dealer Lance for help, then speeds his red Malibu convertible fully onto Lance’s front lawn, crashing into the trash bins. Lance, who has been interrupted eating a generic version of Fruity Pebbles and watching a black and white movie, emerges in his tattered robe and reluctantly helps drag Mia into the house. There is screaming. There is panic. “Get the shot!” Lance yells at his wife. “Fuck you!” she retorts. She must use that phrase on him a dozen times a day.  

Eventually the gang gets it together and manages to find the vial of adrenaline, fill the syringe, and get past arguments of “I ain’t giving her the shot!”. Vincent Vega stabs Mia Wallace directly in the heart, through a target he’s drawn in red marker. I learned the shot was filmed in reverse—Tarantino didn’t think Travolta would be able to stab Thurman full force and make it look real. So he filmed Travolta pulling the needle rapidly away from Thurman’s breast then flipped it. After Travolta stabs (or unstabs?) Thurman, she pops up, gasps for air, and flails about like a mad woman. Her vitality has been regained; she needs a while to recover from the rush.

Let’s indulge Hollywood and ignore the medical fact that adrenaline is not the treatment for heroin overdose. Plus, you would never stab someone directly in the heart, as any perforation in the myocardium would cause a leak. What the scene gets right is that people are stabbed with epinephrine needles, as I did to myself, and the drug can revive the dead. Or at least we cling to it as though it does.

The first miracle act that epinephrine performed was to restart the heart of a dog that had been stopped 15 minutes earlier. In 1901, the LA Times advertised that “adrenaline can be made to revivify the heart of the dead child.”  There was a rash of administering it to famous people, Thomas Edison and FDR included, around the time of death to stave off one’s maker. Usually unsuccessfully. Today, epinephrine is the go-to drug in Code Blue situations—trying to revive a patient in cardiopulmonary arrest, i.e. dead. No matter why the heart has stopped—a fatal arrhythmia, a lack of oxygen, a serious derangement in the blood’s acid or electrolyte levels—a milligram of epinephrine is administered every 3-5 minutes. Until the heart restarts, or the code and the time of death are called.

The last time I ran a code was in my third year of residency at Harborview, the county hospital where I trained. Just after 8 am, I was walking around the fifth floor with my two interns, reviewing test results and seeing patients before going to 9 am conference/donut-and-coffee-time. The hems of my scrub pants were still damp from the Seattle rain outside. As our trio was about to enter a patient room, the overhead speaker made the clicking sound it always made before coming on, followed by several infuriating seconds of static. I paused midstep and cocked my head to the side, waiting for the announcement. “Code Blue. Main hospital. Third floor. Room 217. Code Blue…”

I shot my interns a look intended to say “You know what this means. Go on without me” then took three strides to the stairwell across the hall. As I descended the two flights, one of multiple pagers clipped to my waist went off. The code pager. I emerged from the stairwell to find nearly a dozen people gathered in and around room 217. There were nurses, techs, a respiratory therapist. Lots of essential things were happening, but there was no coordinated effort. 

I was the first senior resident to arrive; the responsibility of running the code was mine. My heart thumped in my ears. My eyes flitted around to take in the scene. One deep breath in and out; as any good resident knows, the first thing you do at a code is take your own pulse. What’s the worst that can happen? Technically the guy’s already dead. Yet my own pulse was racing.

Beta blockers are the common term for antagonists of the beta-adrenergic receptors in the heart. Clinically, their main purpose is in patients with heart failure, to decrease the amount of work that goes into pumping, granting the ailing heart a longer life span. Beta-blockers are an open secret among musicians and snipers, who use them to slow down their heart rates and keep their hands from shaking in high pressure situations. Others pop them for public speaking. While epinephrine itself is a common banned drug in sports due to its ability to activate the body, beta blockers are also banned for athletes for whom they might provide an advantage, like archers and biathletes. I wanted a beta blocker in that moment to counteract my rush of adrenaline and slow down my heart, whose pounding fueled my anxiety and drained my confidence. 

While I had too much epinephrine pumping through my veins, putting me outside my optimal performance zone and certainly out of my comfort zone, maybe the same substance would help the patient. In a subset of situations, it has shown some ability to restart the heart. But this is rare. Additionally, research has failed to show any improvement in neurologic outcomes in these patients who have missed out on vital minutes of oxygen delivery to their brains. The American Heart Association’s statement underlying the rationale for administering epinephrine in resuscitation efforts boils down to one line: “It is reasonable.” Which sounds like another way of saying, “Well, crap, I don’t know, why not?” 

With a deep breath, I pushed through the crowd to get into the patient’s room, introduced myself as the Code Leader, and gathered what information I could. The dead man had been found unresponsive on morning rounds. He was in his seventies, with a sick heart. He was thin, slightly disheveled, and his only movement was that caused by the compressions on his chest that had already begun. While I summarized the case and gave orders, the nurses and techs performed CPR, my co-residents arrived and placed a central line, put an ultrasound probe over his heart to get a look at what we were dealing with. The anesthesiologist intubated the patient and the respiratory therapist delivered breaths by manually squeezing a bag. 

We gave epi two or three times. Then the nurse with her finger on the patient’s groin felt the femoral pulse she was looking for. Another nurse checked a blood pressure. Adequate. The man, now alive again, proved it further by turning his head and groaning. Things had certainly changed since he’d last been conscious. Nurses whisked him upstairs to the ICU. Later that morning another Code Blue rang out over the speakers. New room. Same patient. Same result. The third attempt at resuscitating him after I’d gone home that night was unsuccessful. Probably for the best; I hope he found that sweet spot of arousal, his Goldilocks Zone, while he was alive.

Lately I’ve thought about what a kid said to me in carpool one day on our way to ballet practice after elementary school: “Why don’t you just eat a peanut and then EpiPen yourself?” I couldn’t think of an answer but deemed the question imbecilic. What a stupid idea! One answer that occurs to me now is that I have no desire to eat a peanut. So why take any risk? I’m not even interested in volunteering for peanut allergy desensitization, a growing but still fairly new practice. But for some reason I really want to try sushi. And smoked salmon. And lobster bisque, crab nachos, caviar. I have a running list in my mind of all the foods I would try a bite of in quick succession before stabbing myself with the EpiPen. Of course, I’d have a back-up syringe and a doctor friend at hand. I call the concept Seafood Day. Can I afford to take that risk? 

Can I afford not to? Near the middle of the runtime of Pulp Fiction, though near the end of its events in chronological order, Vincent—who has survived being shot at five times, prevented his boss’s wife from dying, escaped the law when he shoots a guy’s head off in broad daylight on the street, and foiled armed robbers at a diner—is shot and killed. Shot and killed with his own gun that he left on the counter, as he emerges from a bathroom in his typical languid fashion. 

Lindsay Ripley, M.D., is a physician in internal medicine at a county hospital in Texas. Her publications have appeared in D magazine, Journal of Graduate Medical Education, The Smart Set, and multiple medical blogs. Dr. Ripley currently is pursuing an MFA in creative nonfiction at Antioch University in Los Angeles.