![[Matters of Fidelity Cover.jpg]] --- (c) Lon Setnik - 2025 To Cynthia. I tattooed you on my finger because you’re always with me. --- ## Preface _The medical information in this book is fictional. The conflicting values that the characters struggle with are challenges that I have faced as a partner, parent, child, educator, and physician._ Everyone clings to something. A memory, a goal, a person, a story about who they are. What happens when that story fails them? Amira — brilliant, grieving, terrified to let go — builds an entire world to keep from admitting what she’s lost. Pierre has spent his career teaching others to face uncertainty, to care fiercely and think clearly under pressure, blind to how tightly he grips his own ideals. Marcus, chasing the next title, the next credential, buries doubts before they ever reach the surface. Sara, trying to rewrite her body’s betrayals, builds a fragile identity out of movement and strangers’ admiration. As their lives cross and tangle, from Boston to Paris to Morocco, their stories unfold under the influence of a new kind of medical learning: simulation. In simulation, plastic patients bleed, families weep, and doctors rehearse choices that might mean life or death. Simulationists strive to recreate a world just faithful enough to teach, without risking real lives. Matters of Fidelity is an intimate novel about ambition, love, and the dangerous ways we stay loyal to the stories that make us whole — even when those stories are carefully constructed lies. --- _There is a shadow over something that used to be a light_ _I was a window into something you didn't like_ _So you blamed it on me_ _And you thought it made you free_ _But that's not how it works, my love_  - Sasami “I was a window” _Sasami_ 2019, Domino Recording Co Ltd. --- # Sunday, April 17  ## Chapter 1: Amira - Marrakesh “Benti, my daughter, close your eyes, now tip your head back, here comes the summer rain, warm on your head.” Mariam’s head weights my hand and her soapy tangle of hair arranges into a silken tapestry as the cascade of warm water pours from the bowl and aligns each strand in its flow into the tub. Each splash kisses her forehead, rolls back over her scalp, and drops to join with the rest, ready again to caress her with gentle cascades.  Giving a four-year-old child a bath is a glory I hope to remember forever. My gentle hands support her head, which falls into my palm in the weight of trust a child places in her mother. I cleanse her beautiful lean body, starting at the top and moving down, the cloth meandering across her skin. The bond of parent and child strengthen with each cupful of rinse. She hates it when the soapy water gets in her eyes and gets terrified of water in her face. Not surprising, since it has only been a few months since I tore at the dirt and rocks that were suffocating her, and I saved her from the collapsed wall that trapped her near lifeless body.  God’s wrath shook our city with power I’ve never felt before or since. I fell to the ground and crawled across the newly slanted tiles to pull her unconscious body from the rubble. The historic benefits of our riad, tucked in the maze of the old city, became its curse during those fateful moments. Many lives were lost to the collapse of our ancient stone buildings. But I dug and dug until I saved Mariam, sweet Mariam. She is the only remaining link between me and her father, taken too quickly as well. Mariam, conceived in the few weeks between marriage and diagnosis, Ali’s jet of painful bloody urine was the first sign that something was wrong. We thought a kidney stone, what else would it be? But, when we saw the fear in the ultrasonographer’s face, we knew it wasn’t a simple but painful grain. Instead, a monster had lurked in his kidney, it had grown silently until exploding in a jet of blood, flowing down his ureter to change our lives in a moment, and take his in weeks. While waiting for a visit with the urologist, a piece of the tumor, which had silently invaded then snaked into his vena cava, broke free and lodged in his pulmonary artery.  We were eating a simple couscous, me and Ali. We had been sitting in our dining area on uneven chairs perched on ancient tiles. One moment we were eating quietly, then I looked up and saw fear, pale skin, breathing rapidly, then, collapse. My compressions could not force blood through the bulky tumor that blocked flow through his lungs. His face became a dusky plethora in my hands. I will never forget the purple in his cheeks when I kissed him for a final time, before he was taken from me on a squeaky wheeled cart to be prepared for burial. So, when I picked myself up from the dusty floor of the kitchen, I only had one thought: I could not lose Mariam, I would not lose Mariam. When I entered her  dimly illuminated room, I had realized the light was not from a bulb, but from the hole in the wall. Stones had jarred and dropped from their resting spot, they had been buried in our thousand-year-old walls. Unfortunately, when the wall broke, the dirt and debris had caved inward onto her crib. I clawed and tore at the pile, finding her not breathing, I had pulled the dirt from her mouth and kissed her, filling her lungs with air, pushing on her chest to restart her heart. I pushed and breathed as I had done for Ali, but this time I hadn’t stopped until I was successful.  Those moments flood back to me every time I bath her, when I see her scars, when I speak her name and she no longer hears me, no longer looks at me, no longer coos and talks. But, I know she is still in there, and I can get her back. Children are resilient patients, I have seen over and over their miraculous recoveries. But, here in Marrakech,  her chances are slim. She cannot get the occupational, physical and speech therapy that will help her re-learn her basic abilities.  This is my purpose now. I must get her to America. I will do anything. I must get her to those most amazing healthcare centers of the world: New England General Hospital or Boston Hospital for Sick Children. They will be able to help her live the best life she can live. And, while I love Morocco, I know our healthcare is likely to let her down, like it did for Ali.  So each morning I transfer her with quiet whispers to my mother’s guard and care while I ready for work. I pack my lunch, wrap a scarf loosely over my head, and tell my mother what Mariam will want to do today. What parks they might stroll to, what she might want to look at in the square. Mariam only talks with her eyes now, subtle movements that I have learned to read. Slowly, I alone have learned to understand her new way of being. Today is unusual, but it is not the first time I am going to work on a Sunday evening. I do the same ritual, but instead of getting ready for the day, I get her ready for the night, and hand her off to my mother.  Many days I cry, pausing on the landing in the dark after the click of the latch on the door. I cry for having to leave her, I cry for the gap between the life she should have had and the life she has. I mourn her lost future, her lost possibilities. I cry because I have to work, her only chance is for me to earn both notoriety and money. Her only chance is my growing fame. I call upon the strength of family, and with their will and God’s graces, I will take another step towards the future I know I can achieve. I descend the stairs into the center of the courtyard, which provides a quiet haven for my transition from home to work. As I exit the building, I latch the heavy wooden door separating our building from the chaos of the workers rebuilding our broken neighborhood. I speak to myself, to reassure myself that leaving her is the right thing, as I do each weekday. “She deserves better, deep breath, you are doing the right thing.” ## Chapter 2: Marcus - Boston “You deserve better, deep breath, you are doing the right thing.” I can explain the $740 upgrade to first class to Sara. For me, it will be a game changer. At six foot two, I’ve never slept for a moment on a plane. The economy class recline is a joke told by cruel engineers. The flight from Boston to Paris is about 6 hours, but for a few hundred dollars I can transform the next week of my life, by letting me sleep even 3 hours tonight.  For my first international presentation, to be able to lie down during the red-eye from Boston’s Logan Airport to Charles De Gaul in Paris, will transform my entire trip. I deserve to sleep. For the last 20 years, first internship, residency, then two fellowships at Harvard Hospitals, I have taken countless overnight calls. As an attending anesthesiologist at New England General Hospital, I have endured endless sleepless nights. And for what?  Still I’m an associate professor, I have been passed over time and time again. Each of my research programs has resulted in negative results. I have 15 papers that I first-authored, yet none has been cited widely or gained any traction. Artificial intelligence was a field, like cold-fusion, where the positive results were always five years away.  Being up at 3 am because you are saving a life is a mixed blessing. It’s hard to describe the rush of resuscitating a trauma patient. The intense focus of putting your earned wisdom and experience into practice as, for example, a young victim of a motor-vehicle accident, is rushed to the OR. When we hear the call, we prep the room. Then within moments, the team rushes up from the ER, squeezing bags of blood, trying to replace what is being lost. The patient’s body fighting desperately to hold on. Often, they are nearly gone when they arrive. The surgeons scrub, back through the door, then dance with the nurses as they don sterile gloves and gowns in a simple duet choreography. The best do not waste a single movement, and are immediately at the patient’s bedside to wrap a betadine plastic and cut the neck, the chest, or the abdomen to enter the compartment where the patient is bleeding to death.  However, they cannot cut until the patient is asleep and paralyzed. First comes my job, the intubation. I put the patient to sleep with a cocktail of medications. Sedatives and paralytics work in tandem to create unconsciousness in perfect timing with muscle relaxation. Then I can perform the life-threatening procedure that I have done tens of thousands of times. I transfer the act of breathing from the patient, to the ventilator machine through a tube in the trachea.  Every mouth guards access to the trachea, but each proposes the same problem to solve. I have to see the vocal cords at the larynx, however I have to see it through the mouth. The axis of the larynx points up to the top of the head, yet the axis of the mouth points straight back towards the external auditory canals, the entrance to the ears. These two axis must be aligned for me to be able to see the vocal cords, where the tube must pass for me to breathe for the patient. I have about 6 minutes in a healthy person to pass this tube or brain damage will occur from low oxygen, which is continuously used whether the patient is breathing or not. And in shock, it takes a frighteningly short period of time for the body to use all of its oxygen.  The soundscape of medicine is not well designed, beeps and boops creating meaningless and distracting warnings in a useless cacophonies. Monitors noises were created to fight for our attention. However, this was not done in a planned system where the urgency of the sound is related. Like the cars of Boston, beeping is not related to urgency. But, the oxygen sensor is an exception. The pitch of the oxygen monitor drops from an enthusiastic tone when things are going well and drifts to a low threatening pitch when things are going poorly. As the tone drops, my stress increases. In these dying trauma patients, the tone seems to drop with every pulse.  After the intubation, I turn my attention to rush blood into the body via intravenous lines. I add special monitors, inserted into the arteries to continuously measure the blood pressure with every heart beat. I increase the number and size of IV’s, inserting them into the veins of the neck and chest, as big around as your middle finger, capable of putting a liter of blood and fluid into the body in minutes. I monitor and maintain the internal or core body temperature. Blood clots best at normal body temperature, but all of our fluids and interventions can accidentally cool the patient, so I work to avoiding the circle of death in trauma of dropping temperature, bleeding, and disruption of the clotting system. While the surgeon heroically locates the locations of bleeding and applies pressure, I monitor and replace calcium, potassium and clotting factors. I also maintain anesthesia gases so the patient doesn’t experience or remember the torture that is happening to them as the team drapes their bowel on their pelvis to hunt for holes and bleeders. I treat and prevent pain, but treating pain drops the blood pressure, so I titrate medications to support and maintain the blood pressure.  Meanwhile, I continuously scan the machines for signals of how I am balancing all of the patient’s competing needs. Sometimes, the signals don’t add up. What is wrong, why isn’t the patient responding as expected? Is the machine off? Is a sensor disconnected? Or is the patient not doing what they should because of an undiagnosed medical condition? The human body is so resilient that we can go a lifetime without being aware of a faulty valve or a hole in the heart, defects that only make themselves known in the extremes of the operating theater. Doing this all at 3 AM leads to a morning of exhaustion, where I collapse and still cannot sleep. I sit alone many mornings in the quiet of my kitchen. I beeping of the OR echoes in my brain: I re-live the shouting, the blood pulsing out onto the floor as we compress the chest, her life ending literally in our hands. Was there anything else we could have done? I don’t think so, but who’s to know? Uncertainty rots me, I can feel it growing like a tumor in my soul.  Many sleepless nights have also resulted from the dashed hopes as Sara and I tried to conceive. First, we tried enthusiastically and naturally.  Our intercourses started passionately, then drifted to hopeful, and finally our couplings became purposeful. Now, after years without success, sex equals a combination of need and failure, finally sadly sex has become a task on the calendar. I had a job to do and somehow, like the patient dying on the OR table, with the most basic job of saving or creating life, or creating a research career, I haven’t been able to be successful.  A confusingly infertile anesthesiologist doesn’t need more reasons to sleep poorly, but now money was becoming a problem. While trying to advance my career in academics, the cost of living in our brownstone doubled in a few short years. Adding to that, Sara and I have spent tens of thousands of dollars at the best fertility clinics in the city, so in the world. We have missed work for appointments, and she had to cut down to part-time at her architectural firm for the hormone treatments and appointments. So, the unreimbursed $740 first-class upgrade was going to be hard to explain. So be it. After these years, I deserve it. ## Chapter 3: Sara - Boston You can only appreciate a perfect sunny Boston day after 5 straight days of April rain. The sidewalks have been pressure-washed by the showers, and as the sun rises, the morning mist burns off by 9 am. A buzzing energy infects the shoppers, tourists, students and families that pour out to celebrate the end of the winter. By the end of April, the transition to spring burst through by way of budding trees unfurling their leaves, and it seems in a day, the drab colorless Boston winter turns to spring. The city has been bricks and glass, granite and sticks since November, and after months of hibernation, boom! Flowers, leaves, petals, pollen, color! After our weekly exercise along the Charles, Jaimie and I walk, haltingly, to Suzzie's on Newbury Street. We used to run 9-minute miles for over an hour, completing a loop along the Cambridge and Boston sides of the Charles. It would always amaze me that in an hour, you could propel your own body through MIT, Harvard, Boston University, and the Back Bay, spending the whole time along this gorgeous river, while sailboats danced. You can enjoy views of both sides of the city, seeing everything from the Museum of Science to the Harvard Boathouse to Fenway Park. Now that she has Joey, we walk, usually about 3 miles. The Harvard and Longfellow bridges make a perfect 3 mile loop, we can meet near the Longfellow at her place, then walk the loop, end up back at Newbury Street for breakfast. Jaimie used to listen to me, and I used to spend all of my time venting about my fertility challenges. I no longer have that outlet. Her brain is overwhelmed by the constant transformation of Joey, from helpless infant to active toddler. Since she put her teaching career on pause to raise him, I think she no longer has the break room to share her stories. When I see her, we meet at the Museum of Science parking lot, she nearly tumbles out and I'm hit by a tidal wave of stories about what Joey is doing now. His first steps, his blowing bubbles, his eating, his every new ability and activity. It feels like I'm her only outlet to mark the amazement of the totally normal development of a human. For me though, my heart dries out like the leaves at the end of October, frozen by sadness every time I see them. My smile tries desperately to cover up the pain. Jaimie got married and conceived within weeks of the wedding. Joey was born 11 months after the wedding, and here I am, six years after mine, childless. Despite nearly a hundred thousand dollars, multiple rounds of IVF, Marcus and I still have no baby. I want to be there for her, I want to hear, but instead my head feels clogged, like the sadness is pollen, blocking my ears causing my eyes to water, nearly invisible, but landing everywhere, transforming and muting colors of her joy. Our usual Sunday breakfast at Suzzie's on Newbury Street used to be the highlight of my week, especially on those crisp spring or fall mornings that make it worthwhile to live in Boston. Only through suffering the dark rain of November and December, where it seems for months you don't see the sun. The sun's low angle is unable to penetrate the centuries of unplanned architecture of Boston. Suzzie's is known for eggs Benedict. I used to savor each bite, changing the order from week to week, my gluttony justified by our thousand calorie run. Now, I pick at my plate while she talks about the slides they discovered at the playground by Chinatown. She describes the strange feeling of being white, with a child who has Asian features, at the Chinatown playground. Does she belong? "Is this her child, or is she a nanny?" she thinks people wonder. "I mean, it's great to see him run around with kids who look like him, but I spend the whole time focused on making sure people know I'm the mom. I can't relax." So now, I take my runs alone. My runs have stretched out, now to 10 miles at a time. I don't share this with Jaimie. I don't share much. She spent 5 years listening to me pour my heart out. Each time we would meet, I could see the anticipation in her eyes, until I got close enough and she could see my sadness. After years, it was too much to keep talking about. I was almost happy when she got engaged, and as the wedding got closer and closer it dominated the conversation. Then, nearly right away, she was pregnant. She couldn't help it, she couldn't help her overwhelming joy. I tried to share it with her, and I hope she thinks I do. My runs are a form of meditation. My brain starts to think, and I pull it back to my breath, my feet, my heart. Running is about staying out of the red zone, how do you control your speed so that you are below your limit. How do you stay in touch with your body so that you are on the edge of exhaustion? How do you focus so that every rise, unnoticeable in a car but immediately punishing on a run, doesn't push you over your threshold? I run to feel that, I'll never win a race, but the gravitational pull of attention to my breath. It's the only time I don't think about what I don't have. It seems less and less likely that I'll ever get pregnant. We hardly ever have sex anymore. Maybe it's being married for so long, but I think that for both of us, what used to be pleasure is now painful. What used to be a way of us loving more, has become a reminder of what we can never seem to be together. This winter of emotion seems to never end. And while Jamie has lost her social spaces due to her being a stay-at-home mom for now, I've lost mine with Marcus's job and travel. Since he's always gone, and the couples we used to go out with have, one by one, gotten their families going, now we don't have anyone at our time of life we can share this lack of journey with. Being a mom might be isolating, but not being a mom is worse. “Sometimes I stop at the Elliot bridge. I look at the Boathouses. I watch the scullers silently sweep their oars through the water, and I cry.” I don't say it, though. I smile with my mouth and nod my head trying to be there with her, for her. It's doubly hard today because of my mixed feelings. Marcus is heading out tonight for his program in Morocco on the red eye. In so many ways, I still love him and miss him when he's gone, yet, there's so much tension and stress when he's home. It's hardly worth it to have him around. I can't say that either, not now, not with my sister. But if I can't say it with her, who can I talk to? Okay, I'm back now, smiling at Joey, hoping my eyebrows don't give away all the emotions I'm hiding. ## Chapter 4: Pierre - Paris "Papa, it's me. Sorry it feels cold, we warmed the water up. Don't grab me, papa. Close your eyes, feel the warmth of the wet towel, I’m cleaning your hair. I love you, papa.” I look away to not see his naked body as Anné washes him. My father deserves privacy from his child, yet he needs to be bathed - and it takes two pairs of hands. So, I help.  Bathing my father is a memory I hope to not resurface. He deserves so much more, he deserves to be released of this. He is trapped by his disease. He is stiff, not speaking. He looks off into the distance, mumbling, probably seeing things that are not there. He is slowly withering—he is a stick figure now, barely eating and drinking, urinating a few times a day, barely moving his bowels once a week, and having no other existence except whatever images are locked in his brain. His reality is his own, he is trapped, and his only relief is the sedation of medications that comes in the evenings. I turn him on his left side and remember rolling the mannequin earlier today at work. They are practically the same now—stiff, solid, expressionless, silent. They do not register the movement.  Neither is alive, yet they represent some version of life. The mannequin comes alive during simulations, it is animated by the software, by the voices of the AI characters we insert into them behind the scenes.  Somehow, the medical students I work with come to see the mannequin as real. Yet the doctors couldn't see my father in his human body as a real human being, and were unable to let him die with grace.  I love my father enough to let him die. I wish I could turn my father off with a power switch, like the blinking green light on the side of the plastic body I clicked before leaving the simulation center today. I love my students enough to let them experience the pain of learning, of fighting with the challenges we all face. One of my greatest forms of pleasure is watching these young medical students grow into the professionals they will become. I need to pack for my flight to Marrakech in the morning. I'll be presenting at the 2026 Sommet Nord-Africain de Simulation en Santé, the annual Simulation in Healthcare Summit for North Africa. This year, it takes place in Marrakech, I'm heading there alone, to build bridges, and see emerging programs that are being built and developed in the francophone countries of North Africa.  I'll be presenting on “Using AI characters to teach communication skills,” and hopefully introducing this idea to new colleagues in Morocco, Tunisia, Senegal, Mali, Cameroon, and possibly others. I'm excited and anxious to try to bring this technique to countries that have different cultures and communication models in their healthcare systems.  I understand it can be quite difficult to translate these ideas across cultures. Well, there's no way to know how it will land without trying. I pack my travel blazer, my shining new shoes and matching belt, and some short sleeve button down shirts for the heat. Where is my passport? And a hat, sunglasses, what else. Let me find my international travel checklist. "Pierre, come now! Pierre, Pierre! S'il tu-plais! Maintenant!" Anné is shouting, she never shouts. I run to the other room, Anné has papa on his side, he is vomiting. I rush over with a towel from the kitchen and put it under papa's head to catch the mucus and bile. Papa is retching over and over, his neck veins are popping out with the strain. He is so thin, but he is grabbing Anné with such force, I can see his nails biting into her forearm. She is bleeding and she does not even notice. It is as if her arm is not even hers, somehow, she has disconnected it from her so that she can focus on caring for papa. She is such a wonderful caregiver. She is trying to clear his mouth, he has practically no control. He is turning gray. He is sweating so much. She looks me in the eyes, "Should we call SAM? Should we have an ambulance? He is turning blue!" Her eyes are tearing. "No, we cannot. He does not want to go to the hospital. He wants to die here, at home." I softly reply. I barely can mouth the words. I feel so selfish, packing for a trip when he is like this. He could pass any day, and I wouldn't be there. But, I have been saying that for 3 years. I have not been traveling, I have only been running, working and home. I have not been dating, I have not been out with friends, I have come home every night to care for him. My love has become constrained to this little apartment. I have arranged 24-hour care for the next two days and tomorrow night. I leave in the morning, present tomorrow afternoon and Tuesday morning, and come home Tuesday night. This is as short as I can make this trip. I need this trip. I need to get away. I am looking away, at the wall. I am not looking at Papa. I can tell he is struggling by the tremors in his body and the tears in Anné's eyes, but I cannot bring myself to look at him. Slowly, he recovers. His breathing slows and calms, he swallows, he relaxes ever so slightly. I wipe his face, a mixture of mucus, bile, and his and Anné's tears. Mine never come this night. I have none left. How long can this keep up? When they are calm, I clean him up. I tell Anné to go outside for a few minutes. I take the plastic bag, and slowly walk over to my long-suffering father. I pull down his shorts and remove his diaper. I wash him with wipes and apply ointment to protect his skin. I replace his diaper myself, and get fresh pajamas. I unbutton his thread-bare shirt and replace it with an unmatched pajama top. I pull the blanket over his trembling frame, kiss his head, and walk back to my room. I open the doors to the balcony, and breathe some Parisian air. I set my alarm for 5:30 to have time to run then be at the session tomorrow morning before I head directly to the airport for an evening flight to Marrakesh. I won't have time to come back home before I head to the airport. Papa doesn't wake until after 8 most days. “Good night, papa. I will be away for the next few days, but you will be in great hands. I love you!” ## Chapter 5: Amira - Marrakesh I nearly step on a king cobra. The hoarse scream of a ghaita, a double reed flute played by a snake charmer, interrupts my lost train of thought. I easily step back, not afraid of the snakes. I know they’ve been cruelly maimed by the “charmer.” These characters are nothing more than a fraud with access to a dangerous looking snake with broken fangs. The charmer puts on a costume and plays the same three phrases of a “song” for 10 hours a day. The tourists support this scene enough for the modest lifestyle of the player and for paying off the local inspectors. It has been repeated for generations, all-day every day, for hundreds of years. This act has come to define Morocco to the west through travel articles and movies. As I hurry through Jeema El-Fna square, I keep my head down. The tourists create any number of frustrations for those of us trying to live here. People from Spain, France, Russia, Italy, Germany, and even a few Americans crowd the square anchoring the ancient walled city of Marrakesh. I navigate these fools with their floppy hats, even after dark and safari quick-dry khaki shirts and zip-off pants. They hold their bags in front to prevent pick-pockets and sip plastic water bottles like they are trying to walk across the Sahara.  Bees swarm piles of candied nuts that were baking all day in the sun. The bees serve to keep unmonitored kids from reaching up and taking for themselves, while they try to grab their own tiny bites of sugar. The vendors also cannot be trusted while they rob jet lagged and overwhelmed sunburned vacationers. The tourists buy for ten times the local price, and the vendors have to deal with their repeated questions. In some ways, they both are getting what they need. Every now and then someone gets stung, but usually the relationship is mutually beneficial held in check by a skeptical truce.  To the north, the souk serves as a break from the chaos of the square this time of day. As the city goes to bed, most vendor stalls remain open. A few cafe’s still keep their metal doors up, revealing a pile of now day-old croissants and pastries, the smell of espresso wafting from small paper cups. So many cups are crushed outside on the ground. Other shops are repairing motorbikes, selling kitchen wares, or turning leather goods. Most stalls, however, await their shop owners return again in the morning, with metal grates pulled down tight.  I can hurry through this maze. I glance back, ensuring that no one follows me, not that anyone could. I take a slightly different path each time, there are nearly infinite possible routes. Sometimes I stop in a shop and pretend to look at the wares, try on a scarf, and pass through out the back to another alley. I have memorized the turns through a lifetime. Although I could never give someone directions, I instinctively know the way. A series of turns takes me deeper into the labyrinth, finally I duck under a low arch, head down a gently downward sloping cobbled foot path that ends in a brand-new arched and darkly stained wooden door without any visible markings, knob or opening mechanism.  I reach below the scarf tied below my neck and into my cardigan. I pull out my dark brown ID badge, also blank except for my picture, and tap it about chest height on the left side of the door. A latch releases. The door swings inward a few inches and stops with a solid “clunk.” A small keypad is revealed. I type in my 12 digit passcode. I look directly at the camera mounted over a screen above the keypad. My unsmiling face looks back at me. Red brackets appear beside me, flash, then turn green. The door releases.  I take a deep breath and step reflexively over the threshold. I go from the dark of the evening into an impossibly bright entrance. ## Chapter 6: Sara - Boston Leaving Suzzie’s, I stop at the bodega and grab stuff for dinner. I’m going to treat myself to a new recipe, Sichuan Tofu Eggplant. I got two great Japanese eggplants at the farmer’s market yesterday. I grab a baby bok choi and a block of tofu, some almond milk for the morning, and checking my recipe, I throw some green onions into the grocery basket. At the check out, I put everything in my purse, the green onions in my pockets are a little silly, but it feels good to keep one less bag out of the oceans. I turn the corner and head into our building, I’ll check the mail then head upstairs to relax. I put the key in the lock and open our mailbox. Two days of junk are crammed behind the aluminum door. There are two more plastic mail-order delivery bags, more orders for Marcus, who knows what crap he has gotten this time. Probably another stupid car charger for his car or something. Flyers and envelopes and coupon mailers slide out and fall onto the floor at my feet. I lean over to pick it up and my phone falls out of my purse onto the floor. The crash echoes around the empty mail room. I bend over and pick up both the mail and my phone. One envelope catches my eye.  > From: Solutions Fertility Clinic > 1109 Commonwealth Ave > Boston, MA > To: Dr. Sara Stein and Dr. Marcus Stein > 27 Woodlawn Court > Allston, MA 02134 All my memories come rushing back, along with a bill for probably another several thousand dollars. My head falls, I spin with feelings of my body letting me, us, down. The repeated hopes, the repeated failures, the prayers, the tears. The sitting alone on the toilet, unable to look at the stick, knowing that the single blue line would again yell “Negative!” Marcus knocking on the bathroom door again, asking if I’m ok. The lying “Yeah, I’m ok.” I jam the bill into the coupon flyer, wrap it up, and walk the four flights to our condo door. I turn the key in the lock, and swing open the door.  Somehow, the view through our living room, with the evening spring sun reflecting off both the Charles river and the glass of the still empty building that has gone up to block so much of our view, manages not to lighten our home but to darken it.  I kick off my shoes and my feet stick, skin on polished gray slate, to our foyer floor. My naked feet landing echos in the emptiness of this lifeless space.  I turn on all the lights as bright as they can go. I walk out to the balcony, open the door, and let in the noise of the streets of Boston. The sound of traffic, tires, voices, and even the music from passing cars starts to add life to my surroundings. I go to the kitchen and fill a pitcher with water, I add a few drops of plant food, I grab the sprayer, and proceed to top off the plants.  The Boston Ferns by the door are dried and wilting, I pour most of the pitcher into their pots, some runs out onto the floor. The Jade looks good. Some Peace Lillies are on the sideboard, I give them some water. I spray the Aloe, although it’s not dry, I can’t help myself. How can it live in bone-dry conditions? I’m not hungry but open the fridge. Some of Marcus’s IPA’s are on the door, I don’t really like IPA, too hoppy for me, but I pop a can open, sit down, and turn on the Red Sox. I can practically hear the noise from Fenway, I could walk over and just go to the game. But, the announcers are relaxing, the team is struggling, and we have another bill on the table I don’t want to think about.  It seems ridiculous, we are two professionals with advanced degrees and great jobs and hearty paychecks. Yet, between our student loans, our housing, parking, cars, and the medical bills, we need to be careful. I feel like we need to be careful anyways, I’m not sure that Marcus realizes how tight things are. Infertility is not a medical condition, it’s a convenience, even when you work for a hospital. Come to think of it, fertility is also a medical condition, even when you work for a hospital. I’m pretty sure those rules weren’t made by men. I open the bank account on my phone, grab my finances clipboard off the coffee table, and record my breakfast with Jaimie. I like to keep track of my spending. It keeps me accountable. I’ll ask Marcus when I talk to him before he gets on the plane what he ordered, so I make two lines for “Online order:” He’s going right from work to the airport. But, I’m sure he’ll call before he gets on the plane. He always calls to say good night when he travels. Well, almost always. Less frequently recently, come to think of it. The Red Sox are losing 10-2 in the bottom of the eight inning. I turn it off. I pick up my library book, and enter into a different world. Within moments I am transported to another time, another place, another world. It’s a world that could exist, but for some minor differences in the rules of our universe. It’s nice to be in another world for a while. ## Chapter 7: Marcus - Boston I open the glossy plastic case with a click, pop out the buds, and put them in my ears. A single long squeeze of the stem and everyone just goes away. Another click and I start Gnossienne no.1 by Erik Satie played by Alexandre Tharaud, a prelude to Gymnopédie. Cascading rhythms of piano paired with the magical noise-canceling technology take over my brain. This combination overwhelms the chaotic noise of all of these people anxiously chatting while they get ready to board our plane. It is not that the world becomes silent, the world becomes manageable. In the operating room, my patients are asleep. The gentle clicking of surgical instruments, the slight chatter of the surgeons, the light background music, all fades into a single soundscape. Rarely is the magical scene interrupted by an alarm, almost always an early warning, some light perturbation of normal that needs just a tiny titration to bring the patient’s numbers back into range. If the blood pressure drops a little low from the combination of anesthesia, surgical intervention, pain medication, or any number of factors, I correct it. Usually a small squirt of phenylephrine, 30 micrograms pushed slowly in the IV, recycle the blood pressure, and it’s back into normal. If not, I have any number of tools, a little fluid, a little less anesthesia, or adding or subtracting any number of medications, and things will be fixed.  Behind the curtain, I conductor orchestra of one. I scan the machines and monitors, the drips and vital signs, and make tiny adjustments. I do it silently. I don’t tell anyone what I am doing. I am like infrastructure, only noticed when something is going wrong, which almost never happens to my patients. But out in the world, I have no control. People talk in public on speakerphone, they watch videos on iPads, kids cry and harried parents yell at rowdy kids while teens pull away into their own world.  I pace Boston’s Logan Airport, Terminal E. The international terminal is a mixture of pragmatic boring construction with tiled floors that easily clean up from the messes of humanity, and pockets of consumerism, with nods to the stories Massachusetts likes to tell itself about its place in history. This combination, plus the thousands of people traversing the space in various states of pre-flight anxiety and post-flight fatigue, creates a chaotic buzz. I hate it with a passion.   I turn up the volume on my music. I put Satie on repeat. I sit with my back to the terminal, facing a wall, open my laptop, and do the off-hours work of a modern professional: I clean my email inbox.  I only touch an email once. My choices include: delete, archive, block, reply, or if unable to do any of these, I create an action item in my “Done” application, designed to store all of those pieces of projects that make up my life. What’s the next step? If I can’t do it now, I put it in “Done.” What I cannot have, is an inbox acting as a to do list. Each application has its own function and place. Suddenly, I look around, and everyone is gone. I check my watch, boarding closes in 10 minutes. Perfect. Who wants to be on a plane longer than necessary. I have business class, so I’ll have room for my bag overhead. No problem. I get in line, music still filling my ears, and step up to the yellow footprints painted on the floor. I step exactly on each one, take off my glasses and look at the camera. A single flash, the screen blinks green, the flimsy plastic gate opens, and I’m walking down the walk way to the plane. I step into the door, duck my head, show my phone to the attendant, put my bag in the bin overhead, and drop into the second seat on the right. Perfect timing. The attendant walks by with a tray of glasses of champagne, “Yes, please.” And I do yet another thing I’ve never done on a plane before: I click on my belt and extend my legs, they don’t even touch the end of their tunnel when out straight. Incredible. I take a sip and let the bubbles tingle my throat. I close my eyes and let the waves of piano wash over me. I should look at the schedule of presenters and edit my slides again. Instead, I close my eyes and relax. I recline the seat, just a little.  A tap on the shoulder brings me back. “Monsieur … desolé … Doctor Sands, parlez-vous français? Or, do you prefer English?” “English, please.”  Her dark hair is in a perfect bun, her blue jacket and skirt are accented by a white collar shirt and a red tie. Her makeup is impeccable. She looks as French as someone can. Her blue eyes are locked on mine. This stare is uncomfortable in how long it lasts. I fumble to remove my ear buds. The champagne is making me slightly dizzy for some reason. “What would you like to order for dinner?” “Yes, of course, I’m sorry. I’ll have the sole. And, for breakfast. I’ll have coffee, black, a croissant, and fruit and yogurt.” “Would you like me to wake you?” “Excuse me?” “For your breakfast. If you are sleeping. Would you like to stay sleeping or would you like me to wake you?” “Wake me, please. Thank you.” “And can I take your glass now? Would you like another champagne once we resume service?” “Yes, please. Another glass would be perfect.” I smile. Our eyes remain locked. Did she ever blink that whole time? Did I? ## Chapter 8: Amira - Marrakesh It takes a few moments for my eyes to adjust, but I can walk straight ahead while the space comes into focus.  Most of the riads in this neighborhood have been converted from their former lives as homes for wealthy merchants to small, family run Bed and Breakfasts. They give tourists the feeling of staying in an “authentic” part of the city. Of course, the authenticity is maintained largely for and by the tourists, so can it still be authentic under those conditions? Does anyone even care? Well, our riad is not a B&B serving mint tea, it has been converted into a research lab. As is typical, the central open core contains a small fountain cascading down to a shallow rectangular pool. The pool is both a calming water feature, and a natural air-conditioner. Live trees provide green, pointing up through tiled surrounds into the upper 3 floors. Above me, the former concubine has been transformed into our offices, while the first floor houses our research space.  Although the lab is empty on this Sunday evening, the lights come on full strength with motion detection. I head up the blue and white tiled stairs to my office, also an unmarked wooden door accessed by a three-part security sequence: key card, security code, face identification. This three step method is high security made of a sequence of something you have, something you know, and a form of physical verification. Even if someone were able to take your card, and get you to enter your code, they would need your cooperation for the camera to recognize you. All of my colleagues have an alternative passcode we use if we were under threat. What we are working on is worth many hundreds of billions, if not more.  I enter my room, drop my bag on my desk, and boot up the computer. I need to run through my presentation for tomorrow. We are going to do a soft launch at this local conference in order to get early feedback on our amazing prototype. It is a huge step for our lab. I need to get the balance right, enough awe to attract attention, but not so much that our ideas escape our control.  Showing our technology in public is a risk, but doing it at a tiny conference where only a few dozen international scholars will be presenting might work. The goal is not to make a splashy launch, but instead find an international partner. I need someone who recognizes the potential without holding the power to take the ideas. I need someone I can leverage, who needs me more than I need them. I must have them need me enough to take me, my mother, and my daughter, preferentially to the United States.  The slides contain embedded videos. I play through each video, confirming the color, volume, and zoom are all correct. The videos will cause incredulity and awe, they still do for me. But, it is the product that will be the key. With that, I drop the updated presentation onto a drive. I delete the entire folder from my desktop computer and empty the trash. I tap my badge and re-secure my desktop. I put the drive in my purse, and turn my gaze to the cabinet in the corner.  I stand and walk over to a vertical cabinet with dark wooden panels that match the walls, but it has a vertical metal handle running the whole span. It looks like a refrigerator with a locking keypad, because that’s what it is. I tap my badge and type my code, my face scans, and the seal on the door releases with a light puff. I pull back both doors, and there it is, one of the most complex machines ever seen. The intricacies of the motors and pulleys are masked by the sensitivity of covering, it is the key to our species domination of the world.  In front of me, I still pause and gaze in amazement with what we have created. Just then, I hear the sound of a badge tap, keys being entered on a keypad, and a face scan being completed. Who would be here on a Sunday night? No one should be here, but obviously it’s an employee, and clearly someone with authorized access. I can feel my mouth get dry, my pulse quicken, I have to pause to not slam the door to the fridge, to do it slowly and under control.  I shut the door on the arm, and push the lock button. A mist of cooled humidity briefly lingers in the air between me and the doors, then fades. No one can know what I am doing! Not only will our entire project be at risk, but my daughter’s life is at risk as well. If I cannot get an American partner for my project, I won’t be pulled to the US, and will be stuck here. Europe would also be ok. The thing I cannot risk, is the plan. I take off my shoes and pick them up by the heels in my right hand. Silently, I hope, I walk to my desk, pick my purse up, and crouch behind the cover of the desk. I slide out the chair, the wheels give light squeaks that I hope won’t leave my room, and I scoot under the desk. I have to think about options right now. The only evidence of what I’m about to do is on the secured drive in my purse. It would be more dangerous for me to be found hiding under the desk, than to be found at my desk doing some catching up. I sit in my chair, badge back into the computer, open my email, and pretend to work.  I breathe deeply and try to control my heart beat. What happens now is outside of my control. ## Chapter 9: Marcus - Boston to Paris I breathe deeply and try to control my heart beat. What happens now is outside of my control. The plane drops suddenly again. I have been torn from my brief but deep sleep by the feeling of falling, then hitting something hard. Of course, as I open my eyes, I realize the repeated falling and crashing is turbulence.  A therapist once told me my fear of flying is a lack of control of the situation. That was not money well spent. On the other hand, the hypnotherapist worked wonders. Her calm words and hypnosis techniques brought my brain to a state of non-sleep deep rest. She was shockingly able to talk my brain to a point of near anesthesia. In fact, I would call it ‘moderate sedation” if the process had been medication provided by an anesthesiologist.  Anesthesia depth is measured largely in the persons ability to respond to stimuli. In light sedation, often after a low dose of a combination of pain and anxiety medication, given for people to better tolerate things like dental work, the patient is able to respond and remains alert. Vital functions are maintained, the body keeps breathing, heart beating, blood pressure is maintained. Light sedation can safely be given by dentists in an office, with some special training and equipment. Moderate sedation is similar but higher doses of medications make it so often touch or pain is required for the patient to respond. Vital functions are maintained. Doctors need special training and equipment for moderate sedation. The risk goes up but the benefits are that patients can tolerate procedures like colonoscopies without too much pain or memory, and generally healthy patients can tolerate pretty strong medication doses to do pretty painful procedures.  Deep sedation allows procedures that are very painful or require significant muscle relaxation, such as reducing a dislocated hip or fractured and dislocated ankle without memory or experience of pain. Only specially trained doctors, physician assistants, or nurse practitioners are generally certified to provide deep sedation. During deep sedation, the patient will not usually respond even to painful stimuli, and breathing and other vital functions may need to be supported by the doctor. General anesthesia is the deepest form of sedation. During general anesthesia breathing stops, the blood pressure often drops, and vital functions must be taken over by the anesthesiologist.  Anesthesia was life-threatening when first invented, because the medication delivery of chemicals like Ether was unreliable.  While doctors could make patients unresponsive, they could not tell how deep the effect would be, and patients would reliably stop breathing and have their hearts stop. The early anesthesiologist was playing Russian Roulette with someone else’s life. If they did enough anesthesia, someone would die. Gradually, both medication and monitoring technology has improved. Now, like flying, unanticipated deaths during planned anesthesia is incredibly rare. Yet there is so much we do not understand about how the brain works. Attempts to monitor brain function by getting them deep enough to turn off memory creating centers, has improved but not eliminated one of the key risks of anesthesia. The goal is to ensure that patients have no memory of their surgery, when it fails it is called awareness during anesthesia.  Imagine coming out of the operating room and being able to recall parts of your surgery. Where you realize you can remember the surgeon holding your bowel in their hand and looking for injuries. You were unable to move or get help, you were laying there hearing them talk about you possibly dying. You were paralyzed from medications, the surgical team thought you were unconscious, and yet, you remember specifics. You were unable to control your destiny, you were trapped by the situation.  Awareness during anesthesia happens between 1:1000 and 1:10,000 times people have surgery. It is more common in emergency situations like trauma where the patient’s blood pressure is dangerously low and the anesthesia team is trying to balance survival with awareness. They can and should balance towards survival, but the impact on survivors is often its own form of trauma. My flight anxiety began after I experienced a near-fatal airplane accident. I was flying with my little brother. I had been at college when my grandmother had an accident. My mother went to visit her, and I came home from college to take my little brother, then only eight, to visit. When we were about to land at Newark airport, we hit severe turbulence, and had to abort the landing.  I was pointing out the incredible New York skyline to show my brother the magic of flight. The huge shipping yards of New Jersey were just coming into view. We were merely a few hundred feet above the runway, when the plane dropped suddenly from wind-sheer. The pilot suddenly turned the plane nearly on its side to abort the landing. I could see the tip of the wing just passing above the cranes unloading shipping containers. Everyone was screaming. The pilot never even had a chance to say anything, they were busy saving us all. After we finally came around, landed, and taxied to the gate, I watched the pilots come out to inspect the wings for damage. After that, I started having panic attacks when flying. I had no memory of the hypnotists words, even immediately after the session. But the words had clearly had caused a change in my brain function. And, when I listened back to the session while walking, I was unable to fall into hypnosis, but when I did it lying down, I would emerge without memory. The effect was strangely situational. I realized that she never even mentioned flying.  She talked about me “letting go of ideas that no longer served me.”   I listen to that file every time I fly. She emailed it to me in an attachment that I called “phobiaphix.mp4” and dropped into my music app.  The combination of two glasses of champagne, the lay flat seat, the mood lighting, and the noise canceling headphones playing my _phobiaphix_ on repeat had induced sleep for, my watch said, nearly two hours. I pull up the flight map and saw that we are nearly over Iceland, about half-way to Europe. The data helps calm me, as does looking out the window. I could see we were still at 39,000 feet, 560 knots, and despite the bumpy ups and downs, our altitude and speed were unchanged. We were not falling. I raised the shade and looked out the window, I could see the aurora borealis towards the North Pole. Giant green flowing curtains of light are the result of ions hitting the atmosphere and energizing elements. As those elements give up the extra energy to get back to their resting state, they release photons of various colors, which we see an interpret as light. I am slightly disappointed that I know the science behind the aurora. Magic has been slowly replaced with science, when we humans think we know how something works.  I open my phone again, restart _phobiaphix_ and within moments, my consciousness fades. ## Chapter 10: Sara - Boston Closing the book, I look up. It’s dinner time. I open the fridge, but the thought of cooking a whole dinner for myself seems, well, a little sad. I grab the baby carrots, cottage cheese, and “Everything But The Everything Bagel” spice jar, and head back to the couch. I grab a carrot, dip, shake, and crunch my way through half of the cottage cheese container while scrolling my phone. There was a charity half-marathon along the Charles River this morning, and my feed is full of people looking satisfied and accomplished, they are holding up their medallions and posting their times. _Under 2 hours for the first time🔥🔥🔥 _ Everyone looks so happy! The day was incredible for a race, not too hot and not too cold, blue sky, gentle breeze. Jealousy, not for their time, but for their happiness, crashes over me. These women look so hot! The smiles are what wins me over: these smiles front women of all shapes, ages, and sizes. Many of them in couples or pairs, often clutching one another. They cuddle like exhausted partners, uncaring for the sweat, salt, mess. It is pure, joyous love and happiness. Ugh. I close the app, and on my screen the photo widget has some unasked for memory staring back at me. It thinks, for unknown reasons, that this is a good time to show me a picture of me, crouched down, with Olivia, the 6-year old I met in Guatemala 10 years ago. She had been abandoned by her parents who were unable to feed her, and she was staying at the mission so she didn’t starve to death. We visited the mission when I was in school and we were touring with Architects Without Borders, looking for worthy projects. I am crouched next to her, her smile is infecting me, I am hugging her. I chuck my phone onto the coffee table, and look at the mess of sesame seeds and onion flakes not just on the table but on the carpet, on my pants, my sweater, probably on my face. I wipe my face, grab all the food, and carry it to the kitchen. I grab a sponge and wipe down the table. I grab the stick vacuum and clean the couch and carpet. I head to the bathroom. Starting back at me is someone I don’t recognize, someone ugly, sagging, and defeated. Olivia, what would you say? _You have everything, what’s wrong with you? _ I grab my wallet and leave my phone. I head out to the bookstore, my happy place. The carpets are worn orientals, the shelves are always in a state of near collapse. Used books fill every void at every angle. This place is the casino for me, I put a couple dollars in, and sometimes I win, sometimes I don’t. I cruise the sections: biography, no, travel, not now, self-help, hell no, fiction, maybe, wellness, hmmm. My eye lands on a tattered, thin spine called “Chi Running” from decades ago. The round yellow sticker says $1. I grab it, pay cash, and head back to my place. I catch the toe of my shoes on the carpet as I get off the elevator, and go sprawling. I’m five pages into Chi Running, and I’m already hooked. After 3 chapters, I feel like a whole world has opened up to me. I never considered the structure and angular momentum of the human body as a vehicle for running. I had always heard, “However you run naturally, that’s how your body is supposed to move.” But Chi Running is a new paradigm.  Normally, when I run, I bring my heel in front of my body, and hit the ground first with my heel. My momentum slows, my center of gravity pivots over my heel, and then transfers to my toe, then I push off. Thick, cushy, padded shoes make this possible, because each heel strike does not break my body. Landing with a straight knee, flexed hip and flexed abdominal muscles is hard work. It feels best running slightly down hill, because the ground is falling away from me, and my momentum carries me over the top of my foot easily. However, each heel strike actually serves to slow me down, so I have to pull myself forward with every step to keep my speed. What if there was a way to always be running downhill? This is the idea behind Chi Running. You can feel like you are running downhill even when you are running up hill if you are always falling forward and your feet stay behind your center of gravity. If your feet hit the ground pulling backwards, they never slow you down. The goal is to keep your momentum by tilting your pelvis forward, keeping your legs and arms behind your hips, and imagining that if you were running on sand, you would barely leave footprints by just brushing the ground with your feet. You make circles with your feet, limiting movement at your hips, and having your knees and ankles do the work. You should look from the side like the road-runner cartoon: still body with circular  movements of your legs below the knee. You land in the mid-foot and push off with the forefoot. You focus on deep abdominal breathing, and keep your pace below your red-line zone.  When I was a little girl visiting my grandmother’s house, she had a toy called “Shoot the Moon.” The toy was simple to try, difficult to master, and impossible to understand. The player tried to move a two inch metal sphere up a ramp, dropping it in the highest hole labelled “Moon.” The ramp consisted of two parallel thin metal poles. By pulling the poles apart enough to roll the ball but not enough for it to fall through, you could have the ball “fall” up the ramp, which was attached to a fret at the top. You could only win with the perfect combination of pulling the poles apart with enough speed to have the ball gain momentum up the ramp, and fluttering them enough to keep the ball from falling through while it kept rolling up to the top. On a family trip to Frank Lloyd Wright’s _Fallingwater_ in Pennsylvania, I fell in love with great design. I found that nature showed us the way, if we could only pay attention. The stacks of balconies don’t constrain the waterfall beneath them, they are at one with the landscape. The rocks jut out, anchored by a fundamentally solid core, allowing them to span open areas underneath them. The homes core counterbalances and gives strength to the seemingly un-supported balconies. The beauty of physics is harnessed and displayed through human and nature centered design. Since I was a grad student, I have loved to incorporate cantilevers into my designs.  The generation of forward momentum in Chi Running is created by a cantilever, anchored at the ankle and foot. With a strong core, the leaning body is embraced. Beautiful design is harnessing form for function.  I race through the book, skimming the whole paperback in one sitting. The black and white pictures harken back to a different time.  When I turn the last page, I look at my phone. It’s 11 PM and there are three texts from Marcus over the last few hours. _Boarding now! Got first class upgrade, will explain._ : 7:57 PM _OMG, ? this is the appetizer?_ : 9:09 PM  _Love you see you soon 🥱💤😴 _: 10:42 PM ## Chapter 11: Amira - Marrakesh I am clicking around on my email, when I hear footsteps and see someone walk past the frosted glass of my office door. They pause at the door. I can see their shape vaguely outlined by the backlight of the hallway.  They continue, and walk past the door, I hear their footsteps echoing down the hallway, then a door opens and closes. Silence again shrouds me. Or, instead of silence, my heart beats in my ear with an overwhelming  pounding that only became loud when the rest of the sounds disappeared.  What should I do? I need to take the project out of my refrigerator and pack it up without being noticed, but I don’t know who is out there or how long they will be here.  Thinking, thinking. _There are four offices to the left, the senior team. Being CEO of this organization, I had wanted my office to be visible, at the corner of the long and short hallways.  If my office had been next to the staircase, I would have had an easier time leaving. I could just wait and see if they leave. Or, I can do some actual work while I wait. My last option, is to see if I can get them to reveal themselves._ Since what we actually were doing here is known only to me, like the frosted glass on my door, I give the appearance of being open, while what is actually happening is hidden.  I open an email > To: Senior Team > Subject: Re: scheduling of holidays > Please let me know at your soonest convenience when you plan to take holiday this summer. I am hoping to plan to be here when you are not, to ensure your teams are covered.  > Thank you, > Amira I hit send, then wait. I watch the read receipts. There are  four recipients, Chief Operating Officer, Chief Medical Officer, Chief Technology Officer, and Chief People Officer. We are a small company but I believe in having employees have titles that will help them get future jobs, so we have an executive team.  Since it is Sunday night, now Monday morning, I expect no one to open their email. Instead, two people, CPO and CTO, immediately open the email. However, I get no response. Do they just have email on their phone, get alerts, and open them? Or, is one of the people in the offices on their email? Can I tell? I try to tell the difference, but cannot. Could the person in here with me be doing their work? Or, are they also hiding something? Is that why they did not open my door? They seemed to know I’m here, or that someone was in my office.  It is not unusual for me to come to work off hours. Once my daughter is in bed, my mother and I would be home alone. I love my mother, and am grateful she is with me. But, sometimes I just need some space. Coming to the office is a way to justify getting out of the house that does not raise questions. As a single woman, I do want to be back in a relationship. Being at work in the evening lets me safely explore finding a man without having to explain this to my mother. Being a single widowed woman in Morocco is difficult, I need to meet someone outside of work, and lost many of my social connections when I lost my husband and retreated into family and work for the last few years. My friends, so supportive at first with meals and visits, have slowly slipped away as I disappeared.  Now, as I focus more and more on leaving Morocco, I sometimes head to the cafes surrounding Jemaa el-Fnaa. I will climb the stairs to the rooftop, and get a coffee. I bring a book, but make eye contact with men without rings. I have met a few. My best chance was Mohammed. He was from Fez originally, now living in Toulouse, France. He was single, and straight, unlike so many of the men sitting alone in the cafes! We talked, casually and bumped into each other each night for the three days he was in Marrakesh. We exchanged WhatsApps, and even kept in contact for weeks after he left.  I am not the best at answering my messages. Between my mother, Miriam, and work, I have little time or energy for what is not in front of me today. How can I trade a moment of holding Miriam’s hand or bathing her hair, for a text message with a man who is in France?  It will take the exact right person to share my life. It would take a man strong enough to face the whole package: a widowed mother, a professional woman, a daughter with needs, and a mother-in-law who will never leave. When his messages became more impassioned, I delayed my responses.  How could I balance being the woman a Moroccan man will accept with one a man will find attractive? My head scarf signals my participation in the culture of Morocco, but I remain secular. When I was in a similar building relationship in the past, and I responded in kind to the advancing heat of his messages, I was told I was disgusting and he left. With Mohammed, I remained unsure, what were his expectations? How religious was he? If he was conservative, I would be viewed as unclean, if he was secular and I didn’t build the temperature at the right pace with him, he would think I wasn’t interested. So, one day, he stopped messaging. Did he find someone else? Did I break some boundary? What did he think was proper? I’ll never know.    So, I turned back once again to my work as the escape for me and Miriam. I know how to do great work. I can turn my attention to learning how to navigate the scientific community. For now, that’s all I allow myself to want.  I turn my attention back to the refrigerator. I hold my breath and listen, all that meets my ear is silence, even the pounding of my heart has quieted, the item hanging there could be my ticket to America - it could also be my ticket to jail.  A drop of red hangs from the tissue, not falling, uncertain, barely clinging with the surface tension of blood, a stronger bond than water.   The human arm came to me like a prophetic gift. My original lab was in the basement of the hospital, near the morgue and the pathologist. I was heading down the hall, when I heard an argument. Dr. XXXX and Dr. YYYY were shouting at each other. I had heard they were in a relationship, and it was messy. From what I could make out, they were arguing over the margins on a resection. A young woman, olive skin like me apparently, had a sarcoma on her upper arm. The solution was total resection, amputation at the shoulder. This was the only way to save her life. The arm went down to pathology, and the question was, did they get all of the tumor.  Apparently, they removed just the section that had tumor in it, and put the rest of the arm in the hallway by the morgue for disposal. As I was walking by, I thought, this is the perfect model for what we are creating. I will borrow it to map it, dissect it, and understand its structure and function. Then, I will return it for destruction. No one will know the difference. However, when I tried to return it, there were people in the hallway. I put it in my freezer, wrapped of course, and it lay there ever since. I’ve been trapped by it. Moving it secretly to our new lab. I know, if I’m ever found out, no one will believe my story. They will probably think I harvested it from a corpse. The patient is long gone, I don’t even know her name.  But, when we didn’t meet our goals for the conference, we didn’t have any thing to show. We are so close. I will just use it to show our potential. I will take charge of this situation, use my resources, and grow our fame. Once it’s out in public, it won’t be about what I’ve done — it will be about what’s next. We’re so close. Just months. The only thing between us and that future is tonight.  # Monday, April 18 ## Chapter 12: Sara - Boston I make the turn back to my street and refocus on my body. _Pelvis forward, pull with the feet, land in the mid-foot, breathe from the abdomen, elbows back._ My mind wanders, then I pull it back. _Breathe from the abdomen, keep the cadence up, pelvis forward, land in the mid-foot…_ I think about Marcus, wonder how his day in Paris is going. _Pelvis forward, land in the mid-foot…_  Running like this feels like how people who describe meditation say it makes them feel. Meditation never caught on for me, I couldn’t sit still. While I enjoyed the feeling of my brain being focused, I couldn’t handle the feeling of my body being in one position. If I sat, I was uncomfortable, if I lay down, I feel asleep.  My mind flows out, then I pull it back to the moment. I have to pay attention to my body all the time, but the feeling is not effortful, instead the feeling is pleasant and intentional. My focus moves through my mouth, chest, abdomen, pelvis, knees, ankles, and feet in waves. My self-control feels like landing a big fish, let it out, reel it in, let it out, reel it in. Eventually, I seem to gain the upper hand over the wandering, and instead of fighting, we are dancing. The energy flow is intoxicating.  I stop in front of my apartment, end the run on my watch, and look, incredulously, at my pace.  _ 8:15/mi_ Eight minutes and fifteen seconds per mile for 5.6 miles.  _Impossible! I have never beat 8:30!_  I check the route, I do the math, it is true. I have shaved over a minute and a half off my best time for the standard route I run. My last average was 8:42. This all came from a simple change in form?  I open my phone, point the camera at my watch, and start talking. I record my reaction, sweat and tears pouring down my face. _Hi everyone, I cannot believe what happened. I just shaved over 15 seconds per mile off my best time using Chi Running. I feel overwhelmed. You have to try this! I have no connection to the authors, I just have had my life changed by the process. Not only was this the fastest run of my life, at the age of 32, but it was the most fun I have ever had! I wasn’t thinking about pain, I was meditating. I hope you can get the book, or watch some YouTube videos. Like if you are a fan of Chi Running, let’s connect! My life is changed forever.❤️❤️❤️🔥🔥🔥😅😅😅_ I post the video to my feed and head upstairs. No Marcus, so no complaining about my clothes on the floor. I peel everything off, and jump in the shower.   ## Chapter 13: Pierre -  Paris Running the Seine in the morning is one of the great pleasures of living and working in Paris. The boulevards wide although mildly uneven sidewalks take me through the Place de Bastille then I hit the Seine in a mile - 8 minutes. I turn right at the Seine and drop down an ancient stone staircase to the level of the river, where I join the stream of young, fit, athletic people getting their fix before the day starts. The noise of the awakening city fades to the calm of the river in just a staircase. A mere 15 feet of elevation change removes the sounds of traffic and transforms my experience from dodging cars and bicycles in a dangerous city, to hearing only my footsteps and breathing. I focus on pulling with each step, my kick launching me forward, keeping my momentum. The warm glow of the morning street lights still mark the path as the sun lightens the sky. It only takes one glance, just a second, and then I’m magically transported again. Now, I’m lying on my side. I’m tracing my fingers over his sweaty shoulders, the sweat running in rivulets  off his shoulder, as we cuddle after us being together. I imagine a tattoo, half a sleeve, hidden to everyone but the lucky like me. And then he’s gone. My momentary crush, his run has taken him from my imagination as he fades into the crowd. I don’t know what it is, but it only takes a glance to get me aroused. I look around and notice where I am again. The sun is behind me, I am chasing my shadow along the cobbled path. For hundreds of years, lovers have stood on these banks, both real couples and imagined lovers.  I’m passing the Pont Neuf, where I turn right again, up Rue de Pont Neuf and angle left on Rue de Montmartre. Deep breath. My love rises. Then slowly fades. My love is stuck, caged. On the sidewalk, another body catches my eyes. Again it’s the muscular shoulders. This one is shorter, a caramel color like me, slightly lighter, , also muscular. Just look at the shoulders. He is walking a small dog, I vault the leash, _Pardon!_ I look back, lift my eyebrows slightly, is he interested? Maybe. Oh well, next time. Today, I’m on a schedule. I have to get to the course, then to the airport.  I approach half way on my run, but the middle section here is all up hill, and the hill gets progressively steeper as I got. My breathing quickens, I stop thinking. I focus on my breathing. Running up hill is a matter of staying out of threshold. I keep track of every step, how hard I push myself is the key to keeping running, to not crashing. If I push too hard, I will have to walk, but just under my threshold is what I am trying for. The final push up Sacre Coeur is a 200 stair ramp up to the overlook. A funicular was built in 1900 to take most of the 2 million tourists and pilgrims up to the white stone cathedral that offers a panoramic view of Paris. I don ’t take elevators, or funiculars, I run stairs. It’s not just me, there’s a whole cluster of runners crowding the stairs on this perfect spring morning. The stairs remain shaded until mid-morning, so this time of day it is breezy and cool here, several hundred feet above the rest of the city. The rest of the runners are too thin for me, but there are a few muscular men climbing the stairs two at a time in a brisk walk. One is my age, wearing spandex pants, he is doing laps. He looks like a twice-a-day gym rat, 3% body fat, can bench more than twice his weight. I like something in-between. Not too thin, not too thick, somewhere more functionally strong. Sometimes, if  there’s a really hot guy on these stairs, I’ll also do a couple laps, try to make eye contact, and once I even paused at the top and started a conversation. This led to two weeks of pure pleasure. That memory pulls at me, but with my heart rate 178, I can’t meet my imagination fully.  I head right, briefly glance over the view of one of the world’s greatest cities. Paris was preserved in during World War II by our inaction, I have mixed feelings. I am grateful for the city staying beautiful, and am ashamed at why the French did to preserve it. Being half Senegalese, I only feel slightly connected to the French of the 1940’s. While my mother’s parents did move here after World War II from the French countryside, my father didn’t emigrate until the 1970’s. They met at graduate school, both in finance. They shared a bond of being top students but not fully endorsed, he was not fully embraced because of his race, and she because of her gender.  From that past, they got me, a gay man, half-black, never fully embraced by myself or my culture. I more deeply developed the skill of making new friends than keeping old ones. I became most comfortable meeting new people, working a crowd, looking for connections, learning about them. I was less comfortable sharing about myself. This skillset, mastery of the cocktail party, led me to Emergency Medicine. I was a good student, so got through schools with high marks and ended up finding myself in medical school. The rotation that stuck most with me was Emergency Medicine. I liked pushing my skills, and I liked the challenge of building trust within seconds. I titrate my smile for the moment, just enough use of the eyebrows while they talk, extra eye contact, and anyone will tell you their deepest secrets within seconds. My first position had me using this talent on young people, I got to be nosey. _Do you have sex with men, women, both? How many partners in the last 3 months? How many pregnancies?_ These are typical questions you get to ask as a doctor seeing a young person with urinary symptoms. These are questions you won’t ask your siblings! It’s a rush to learn everyone’s secrets. However, my job also put me in a position of asking other intimate questions: _What’s most important to you while you die? Do you want me to insert a breathing tube to keep you alive, even if you might never come off the ventilator?_ I wanted to build these skills, to make them a reliable procedure, as reliable as putting a tube in the chest to drain fluid, or inserting a tube down the trachea to breathe for a patient.  Then, my father got sick, and I saw how other doctors struggled with these essential questions. I knew I had to make a difference, to help others be empowered to build these skills. The only way to build your running endurance is to run, and if you want to run hills better you have to run hills. The only way to be more comfortable asking these difficult questions, is to ask these difficult questions. But, like practicing running up Sacre Coeur as practice for running a race, medical simulation lets people rehearse the essential skills of being a physician, before talking to real patients. I turn down one of the steep roads falling to the east of Sacre Coeur, and wind my way back to the 11th Arrondissement, finishing strong on the downhill. My focus is back on my steps and my breathing. My attention has turned away from who I might meet on the streets of Paris, and back on my pacing and my breathing. ## Chapter 14: Marcus - Paris I awaken to the smell of coffee, pull off my sleep mask, and warm croissants are placed on my meal tray. The tray has been covered with a pristine white table cloth. The silverware is metal, the cup is china, a small pitcher of cream enriches the coffee and cools it, so I can immediately drink it. Man, that is great coffee. I do something I’ve never done before, push the service button, and the attendant returns with the carafe for a second cup. She looks like she just took a shower, got dressed, did her hair, and put on her makeup. She definitely doesn’t look like she’s getting off a seven-hour red-eye. _This is how flying is supposed to be._ I check my watch, I slept 4 hours. The upgrade was worth it. I depart Charles de Gaulle Airport just after dawn, and grab the Metro to Hotel de Ville. I decide to walk around the Île de la Cité that is frame by the Pont Neuf on one end and and the Notre Dame Cathedral on the other. Crossing the Pont Neuf, I look east over the Seine, a cluster of runners is enjoying the early morning light. The street lights remain lit, but the sun is warming the early morning air. I look at the panorama of Paris, and wonder if I can just see the Sacre Coeur Cathedral to the North, or is that just fog in the hills of the city? I spend the next few hours sitting in a café, nursing coffees, and just watching the beautiful people of Paris. Runners, dog-walkers, cycle commuters, children heading to work, shop owners, many other types of people navigate the narrow sidewalk in front the café. The shoes of Parisienne’s are somehow nicer than those you see in Boston: patent leather, pumps, clean sneakers, all precisely dodge a smear of dog mess on the sidewalk. Countless beauties prance past me, lightly on their feet: they are skirted and stockinged, groomed, tucked, appointed, and cared for. A very attractive, thin, red-head passes by, heading south, she is walking like she knows where she is going. I decide to walk in her direction. I am traveling in the same direction as her, as fast as her, but not really following her. Despite me being at least a foot taller than her, I have trouble keeping up. But, I do my best to keep her in my view. I feel so alive, the sights are new, the sounds are foreign, the smells are more dense and enticing. I lose her in the crowd, and continue to travel up hill, ending at a park. I enter, the manicured grounds back up to the Luxembourg Palace, where, shockingly, the sign says the French Senate meets. There does not appear to any security or restrictions. People are milling in the early spring air, flower are starting to emerge. The city is fresh and clean.  I stroll back down towards Chatalet, where I can grab the Metro to Orly. In my low-energy state, I meander with the crowd. I do some more following, imagining walking hand in hand with a Parisienne woman, with her carefree laugh and her scarf tied around her neck. Maybe I’ll run into the attendant from the flight, with her perfect bun after an all-night flight. My mind wanders as my feel flow over the ancient stones of the centre-ville.  Arriving at Chatalet, I head down the impeccable stairs to an unimaginably clean Metro station. This city knows how to present itself. Compared to Boston’s tardy, dirty, crumbling T, the Metro gives the impression that this country cares about itself.  A quick half-hour ride, and I’ve arrived at Orly. I  head to the Controle de Passporte, and realize that this is the first person I’ve talked to in hours, despite being in a city of millions. I feel simultaneously alone and invigorated. The people here are beautiful, cared for, and attractive, in a way the usual westerners are not. A family cluster of slovenly, pajama’d, frumpy Americans with purple hair wearing Micky Mouse shirts screams by, practically yelling as their form of normal communication. They ignorantly break every social norm in this groomed, fit, reserved and preserved nation. I don’t need to see their dark blue passports to know they are American, their flip-flops announce it.  As soon as I board the flight to Marrakesh, I realize I have entered Morocco. The flight is predominantly men in suites and women in head-scarfs. The languages erupt from every direction: English, French, Arabic, others in loud cascades, bouncing between families and friends. The magazines are worn, the seats are worn, and the lunch is cold chicken with olives and preserved lemons. It is flavorful, but not fancy. There is no business class, this plane is transportation only.  We pass over the Iberian peninsula, then the Mediterranean Sea glows blue-green outside my port-side window. As soon as we have left Spain, I can see Morocco, a mix of reddish desert and green patches of agriculture. We progress down the spine of this nation, huge mountains with snow caps are below, eventually we spiral down into a dusty sprawling city in the plains of central Morocco - Marrakesh. The plane hops on landing, the breaks squeal, and all of us bend at the waist, as if in forced simultaneous prayer. The doors open after the stairs are lowered, and I can see that we we are to be let out on the tarmac. As I step onto the staircase that descends from the plane, I am hit in the face by the force of the mid afternoon sun, as if a sauna door and not an airplane door and opened in front of me. I take my first steps down onto Moroccan ground; my first steps on African ground. This earth is firm, just like I’m used to. The air is also hot and dusty, a hairdryer in my face with tiny bits of sand in the wind. I need to take off my jacket. Deep breath in, and out. Here we go. ## Chapter 15: Sara - Boston I look at my phone, dripping all over it, through the open shower door. Likes are popping, like a bag of microwave popcorn, first every few seconds, then accelerating to be a near continuous sound. I’ve kept likes on as notifications, because they almost never happen, and always are a friend committed to supporting me. But, I don’t have that many friends. Like a bowl that has been overfilled, the popping is pushing the lid off of my expectations. Likes have become a continuous stream.  I hop out of the shower. I dry off, since I can’t seem to confirm notifications or enter the app, with my wet hands and phone. I dry myself and my phone off, and, still just wearing a towel on my head and nothing else, since the house is empty, I open the app. _What the hell?_ The counter on my post is updating every 10 seconds or so and increasing by the hundreds at first, then thousands. _Hi everyone, I cannot believe what happened. I just shaved over 15 seconds per mile off my best time using Chi Running. I feel overwhelmed. You have to try this! I have no connection to the authors, I just have had my life changed by the process. Not only was this the fastest run of my life, at the age of 32, but it was the most fun I have ever had! I wasn’t thinking about pain, I was meditating. I hope you can get the book, or watch some YouTube videos. Like if you are a fan of Chi Running, let’s connect! My life is changed forever.❤️❤️❤️🔥🔥🔥😅😅😅_ Likes: 157,902 Comments:  _Thanks for inspiring me. I thought I’d peaked. I’m trying today, wish me 🍀 🍀 🍀 🤩🤩🤩!_ _So 🔥🔥🔥 🔥🔥🔥 🔥🔥🔥_ _🧘🏃‍♀️_ _same thing happened to me I cut 30 seconds off my mile in my first half-marathon back_ And on, and on, scrolling page after page. I flip on my video, selfie oriented, and hit record. _Wow!!! Ok, everyone, I’m overwhelmed here. I can’t believe the support! I so much appreciate all of the kind words and all of the love!!! See you out on the road!!!_ My voice is cracking with emotion. I feel like a quarter million people got together and are cheering me on at the end of a race. I still remember the last mile of my first half-marathon. The streets were lined with supporters, I was coming in at a 9:15 average, with the normal people. Hundreds of family members, friends, and just excited people, were lining the streets and cheering me on. There was a small up-hill before the last flat section. My legs were cramping, I felt like throwing up, but the energy drove me faster and faster, and I ended up finishing the last quarter-mile at 8 minute pace!  I kept searching the crowds for Marcus. He was supposed to be there, to see me finish. But, it was after a call, and I later found out that he had been stuck late in a case. A twenty-something had been hit by a car on her bike, and he had stayed in the OR to run the emergency blood transfusion machine.  In the end, he hadn’t made it in time for my emotional finish. And, she hadn’t survived. I came home with a buzz, and he was lying on the couch, darkness on his face. That was my first experience with running distance, and with a “race.” I was hooked. There was a set of intoxicating feelings racing through my body. I was actually shivering with excitement. I’d been stuck for so long at a certain speed, in a certain place.  I’d been stuck with Marcus. We spent so much time being sad together about not being able to conceive. I was stuck with his frustrations with healthcare, and with him not being able to advance and get promoted. His constant state of exhaustion was combing with the other ingredients to turn into a soup of anger at his hospital.  I was stuck in a liminal space, not ready to enter a growth track at work, with the fading hope of having children. I was stuck at my previous pace. If I ran too many miles, my feet hurt. If I ran less, I got slower. I hadn’t found anything that made me faster. I tried hills but got a stress fracture in my 5th metatarsal last fall. I had to take two months off. I tried intervals but my hamstrings hurt for two days. I tried lifting weights, but didn’t know how to do it right, and people kept telling me I was going to get hurt. So, after the “First Month Free,” I quit the gym. I hit post on my video. I turned off notifications on the app, and go to pick out some clothes. ## Chapter 16: Pierre - Paris Deep breath in, and out. Here we go. As we start our simulation day, I do some deep breathing to help me stay calm. I find the day invigorating, and possibly frustrating. I love these kids, and when the learners buy in, and see this for what it is, a learning experience like no other. Simulation allows them to do the things they will need to do on patients, without needing to practice on patients. But, when they don’t participate, and they don’t buy in, I find myself so incredibly frustrated. Don’t they know, that this is their chance to learn?  When I was 17 years-old, I crashed my mother’s car. She picked me up at the police station. She didn’t say anything, except, “What did you learn today?” She didn’t protect me from the pain of learning, she leaned into it. I now drive carefully. But for my students, my love for them turns to frustration when they don’t engage with the learning.  Sure, the AI characters are cartoonish, and the facial expressions on the mannequins are ghastly. But AI is bringing so much to life with conversational training. We spend countless hours designing the characters and situations to meet the exact needs of the learners. We script the AI generated characters to have real backstories, on what a patient or nurse would say or do in this situation. We have created something amazing! But, students now-a-days, only focus on what is fake, instead of all the parts that are real. When I was training, computer based-learning systems were truly awful. Although the designers had good intentions, if you didn’t do exactly what the system wanted, in the order it wanted, you were marked wrong. You spent more time learning how to use the system and follow the “rules” of the game, you spent very little time learning the task at hand.  While video games were developed that had realistic first-person shooter gameplay, and gamers spent thousands of dollars transitioning from the plastic guns of “Duck Hunt” to the sophisticated, intoxicating gameplay of modern driving and first-person shooter simulators, healthcare was stuck in the 1980’s.  We had 8-bit graphics, branching logic responses that mandated certain answers, and third-grade-level cartoons to interact with. But now, Artificial Intelligence is opening an entire new world of conversational training! Not only can learners speak their questions, but they get real responses from a character played by AI. They can even interact with multiple characters at once, all are played by AI. The students I’m working with are experiencing the future of emergency communication training.  The simulation is about to start. I do my best to get them ready. I hug each student before the day starts. They know how much I love them! This is my chance to expand my love star just a little bit, to open it from the collapsed state that it has become.  “Today we will be experiencing a simulation session designed to help you grow as trainees in Emergency Medicine. My role is to be the facilitator, moving us through the agenda and the cases. Your role is to be the learner, engaging thoughtfully, participating as if this were real, and sharing your perspectives. While this is a simulation of the real world, this is your chance to learn with direct observation and coaching, with feedback, before you put your skills to work on real patients. We hope you can participate fully.” I continue with the briefing. “The first case today is one that I hold dearly, because it will be an opportunity to explore the challenges we face when we receive a patient in distress. We MUST  balance learning about the patient’s goals of care with treating their life-threatening problems. The learning objectives here are simple but profound: 1) perform the necessary resuscitation steps in a variety of patient emergency presentations, 2) determine the patient’s pre-existing wishes regarding aggressiveness of resuscitation, and 3) translating their wishes and goals of care into an action plan that supports their wishes during the emergency. What questions do you have before the simulation begins?” Watching these trainees, I cannot believe what I am seeing. Once again, they ignore the patient’s wishes, and proceed with intubation. I watch with horror as they talk to the actor playing the patient’s wife.  “We must place a breathing tube, or he will die. Is that what you want?” The nurse character, prompted to gently advocate for the patient’s wishes but quickly resign to the authority of the doctor, speaks up. “But doctor, it looks like they might not want a breathing tube.” Then, they all go ahead and place the breathing tube. They appear happy with their performance. Unfortunately, this is the opposite of what that patient wanted. The patient has a terminal illness, and they have just removed the possibility of him dying with dignity. I need to end this to get to the debrief. “Ok, this scenario is over.” Moving out of the simulated hospital room to the debrief room, I listen to them. They are happy, actually gleeful, about what they did. They think they did a good job? They may have placed a breathing tube, but that wasn’t the purpose. The purpose was for them to realize that **not** placing a breathing tube was the key to this case. That supporting a dying patient and his family was what the case called for. “We are going to spend the next 20 minutes talking through your actions. I could see what you did, but I don’t know why you did it. My role will be to help you grow as trainees by exploring the drivers to your actions.” “I’d like to start with your reactions. How are you feeling right now after this case?” “Energized!” “Confused.” “Annoyed.” “Excited.” “It sounds like you’re feeling overall good about what you have done. There might be some confusion about the right course of action. I have a particular point of view to share, let’s talk more about what were the best actions. But first, to clear up any confusion, this was a case about a patient near death from breathing problems, who had pre-existing wishes describing that he would not want a breathing tube.” “I’d like to talk about the importance of determining the patient’s resuscitation wishes before proceeding with placing the breathing tube, before the intubation. I saw you see the dropping oxygen level, tell the wife that he would die without a breathing tube, and proceed to intubation. I did not see you stop to determine the patient’s wishes. I think this removed the possibility of the patient with a terminal illness dying with his dignity, and in the manner that he had already chosen. Help me understand what was going on for you then.” Their responses make my blood boil. They chime in with their thoughts: “We didn’t have time to determine what he wanted.” and, “The wife should have told us!” “When facing death, he should have a chance to change his mind about what he wants, and she is his proxy, so we had to ask her!” I cannot even repeat those ideas, I cannot reflectively listen, because naming them would give them validity. So, I have my response,  “No, no, no. This is not the time for her to make decisions. She is facing a crisis! Who can make decisions during those times. Your job is to do the hard work of supporting her in what he has wanted, not putting the burden on her. He has already decided, how cruel and unfair of you to ask her to decide again! I hope you never do that to a real patient.” “But, don’t patients have the right to change their mind?” they ask. “Of course, this is all about the patient. But how you ask is the key. You said, “We must place a breathing tube, or he will die. Is that what you want?” What a terrible choice you put on her. Never do that again!” And, here’s the response. Always an ego in the way of learning. “This case was so unrealistic. No one would have their oxygen fall that fast in real life. And, I would have more people. I would have the team to help me set up the intubation, so I would be able to talk to the wife. Also, this stupid plastic mannequin is designed for intubation, it doesn’t look real. I don’t feel that it is a human when I am in the room, I feel like I’m caring for a fake patient. Of course, I’m going to intubate, it is a Barbie doll. This is totally unrealistic. It lacks the key fidelity of caring for a human.” “So, you will blame the computer and the mannequin for your decisions. Well, I hope you take more accountability in real life.”   The students file out, looking despondent. My heart drops as well. I have accidentally poisoned the learning, and how do they know that I love them when I tell them what to do? Will they see my passion for what it is? My passion comes from not only how much I love them and want them to succeed, but also because I hope that if my father is brought to the ER again, they will check his wishes before placing a tube.  I turn to the AI recorder of the debriefing. We have the computer provide a transcription of what the students did, but also the debriefing. We are researching this project. We will show that AI is as good a technique for learning as using standardized patients. I receive the transcript. I read it again, incredulous at the results. It shows that the learners became hardened in their responses, instead of softening. We are researching the ability for AI-based communication training to help people move off of their preconceived positions when it comes to these values disagreements. The transcript shows the opposite. If this keeps up, I’ll never be able to get the next round of support from my program director. Publication will be stopped in its tracks. And all of this work will be for nothing. More importantly, simulation won’t be supported. Yet, I know this works! I just need to find the right way to prove it. But, we don’t keep any recordings of the debriefings. We only keep the transcripts. I can just make some quick minor edits before handing these over to the rest of the team. I can augment what the learners said, so that we can continue our work.  ## Chapter 17: Marcus - Marrakesh I am in Morocco! I decide to keep my sport jacket on, I have a tee shirt underneath, and that somehow feels too informal for a Harvard speaker at an international conference. I push through the airport, and immediately notice that I am the outsider. I am taller than almost anyone, several inches, and my pale face and bald, uncovered head, and lack of beard make me stand out. Many of the people in the airport appear to be multi-generational travelers, with several children, parents, and grandparents. Additionally, many of the women wear head coverings of one sort or another. Few are totally covered in black burkas, many have a scarf tied, and a few young women are wearing western clothes. The tourists, however, seem to stand out.  The tourists seem to largely be European. Many have backpacks on their shoulders, and smaller backpacks on their front. These front packs are hugged like babies, I sense their unease. The packs are dusty and well worn. Some travelers have business suits and patent leather shoes, almost all men. One thing is for certain, I am an outsider. I negotiate the entry process, it involves a good old fashioned handing over of the passport. The person, he is dressed in a police uniform, looks at my passport, then at me, then speaks perfect English.  “How long are you staying?” “Four days.” I reply. Just the facts. “What is the nature of your travel?” “I am speaking at a conference, a scientific conference.” “What is the conference about?” “Healthcare simulation: learning to be a doctor, or nurse, or other healthcare professional, through practicing on mannequins. I specialize in the debriefing, the learning conversation that comes after a practice session. While I do pay significant attention to the …” I continue until he cuts me off. “Here, in Marrakesh?” He interrupts “Yes.” “And then you go back, to where, America?” “Yes.” “Not through Paris?” What does he want? “Well, yes, through Paris, but only for a few hours. I was only there for…” Thump.  He interrupts again. The passport is stamped, handed back to me, and he waves his hand behind him, gesturing me to enter the country. The exit from Passport Control takes me into a high end perfume and facial products store. I am blasted again, this time not from the heat of the country at 3 PM, but from the blinding lights sounds and smells of capitalism. I actually cannot see an exit to the store, I wander a little, pick up some Kiel shaving cream, look at the price, 340 Durhams, is that a good price? I cannot remember.  I realize what has happened, I have been turned, through entering my default mode, into a consumer. The disorientation of the transition caused me to lose who and where I was. I put the shaving cream down, and scan the walls again. I see a gap, unclear on first glance, but now a path out has emerged from this new vantage point. I head towards the exit, and again am disoriented as I emerge into a large marble-floored space which is now clearly the airport terminal.  I scan the signs hanging from the ceilings. Infographics matched to English Arabic, and French point to Taxi. I follow the arrows. I head outside back into the heat and fine a line of men waiting by their cars. I am directed into the first car, it is old and creaky, but the driver is engaged and wants to talk. He discusses the history of Morocco and their love for the King and the stability he provides the country. He is clearly proud of Morocco and how it represents a different form of Muslim nation. He feels Morocco welcomes diverse people to come and enjoy the history and beauty of the country.  The King has kept Morocco in wonderful freedom compared to Libya, Algeria, and the other countries flipped into chaos during the Arab Spring.  When he learns my last name, Stein, he asks,  “Jewish?” I pause my reply, just a moment. “Yes,” with uncertainty. My uncertainty is on many levels. How much should I disclose, what would it mean to him, are there any risks?  “I must bring you to the Jewish Cemetery and Jewish Quarter! Did you know, during the Nazi time, we have many many Jews come to Morocco and Marrakesh for safety. They leave in the 1970’s, but we maintain the history. And we now have many Israeli tourists who come, isn’t that amazing?” “Thank you! I am hoping to just go to my riad today, but will have two days after the conference to explore the city. So, I will be sure to check it out. Would you be wiling to take me straight to Jemaa el Fnaa, then I can walk to the riad from there?” “Of course, of course, whatever you want. I will take you straight there!” I watch on my maps application, as we meander the city, heading east from the airport, but instead of going straight to the square, we bear south first, then to the east of the old city, then back, weaving up and down through the streets instead of the obvious straight approach, finally, we are at the edge of the square. He clearly milked me for extra fare. Oh well, this is tourism. What choice do you have? The price of this 45 minute ride, with sightseeing and geopolitical and historic commentary, was only $20 anyways. I give a nice tip, 250 Durhams, given the fixed ten to one conversion. At least that is easy to manage.  I open the taxi door and am immediately overcome by noise. A conductorless symphony of battling ghaitas erupts from the square. I see packs of people surrounding snake charmers, and all types of vendors, stalls, and performers. I am brought back to the Hitchcock movie from the 1950’s with James Stewart, “The Man Who Knew Too Much,” and who was in it with him? Doris Day, that’s right. This looks _exactly_ the same as in that movie. Has nothing changed in the last 70 years? ## Chapter 18: Amira - Marrakesh It is in my backpack as I cross Jemaa El-Fnaa square.  Last night, I had to wait for over an hour before I left the offices. I waited until the other person, never known, walked past me again, and I heard the light clicks, then heavy thunk of the door at the entrance as it closed and locked. Once again, I had been left alone in the offices. I waited another ten minutes to see if I was wrong, but I heard nothing. So, I went back over to the industrial refrigerator in my office, and unlocked it. The doors swung open. Humidity in the air immediately condensed into swirling fog, a cloud obscuring my view. My glasses became frosted with condensation.  I took off the frames and wiped the glass on my shirt, although what I was looking at was obscured by mist and the blurriness of my 38 year-old modern eyes. I am near-sighted by the computer work, I could only make out the shape of an arm, hanging by the shoulder. I wrapped it in three layers of thermal resistant sheets, a type of mylar on bubble-wrap. Finally, I placed it all in two layers of sealed 25 liter zip-lock, interspersed with ice. The whole thing was put in the insulated backpack, cooling in the left side of the refrigerator.  Our company name, “PeauRéelle” boldly crossed the outside of the backpack. The pack is black and the words are embroidered in a khaki or olive or tan, depending on the light.   I hoisted the pack on my back, it carried well on my frame. It’s not too heavy, but I can feel its presence. Backing away from the refrigerator, as I got ready to close the door, I heard a thud from outside my room.  I stopped.  _Don’t tell me someone else is here!_ I thought. I waited, and held my breath. I didn’t hear any other noises. No footsteps. No creaks on the three hundred-year-old stairs. No beeping of the access process. No sighs. No breathing. No talking. No walking. The noise must have come from outside. I closed the refrigerator door and grabbed my purse from my desk. I put my computer to sleep with a tap of my badge, and took one last look around. Nothing looked disturbed. I headed downstairs and paused at the exit. I listened for a few seconds. Nothing. I opened the door, and was met by the darkness of the evening, and the quiet of a nearly empty souk. I pulled my head scarf in front of my face, and walked a circuitous route back to my home. I avoided touristy areas. I didn’t run into anyone. I crept up the stairs to my apartment, and opened the door.  I was met by silence there as well. Miriam was asleep, Zhara as well. I had a cup of tea, checking on my backpack to ensure it was cold and sealed, and went to bed.  I slept in. I didn’t have to head to the conference until the afternoon. So, in the morning, I lingered with Miriam and Zhara. I watched them light one another. Miriam laughed while Zhara got her dressed. Zhara laughed while Miriam squirms and tries to avoid the clothes. When I dress Miriam, it is with purpose. I need to get her ready, I need to leave on time. She needs to be in a certain state before I feel comfortable leaving the house. The weights of my needs blanket the interaction. Grandmother and child have no such urgency. Neither is going anywhere on a schedule. Neither has a plan that is at risk. They bring the carefree nature of permanent vacation, of timelessness. They exist together in another plane. I love seeing the two of them together. My heart is lifted knowing they are there for each other. I am now ready to face the day. I bring my pack into the bathroom for one last check before I am ready to depart for the conference. Then, when I have triple examined, and inspected under the bright lights of the dressing area, I know this is the moment that the whole company has been working towards. PeauReélle is ready to see the light of day. Or, I should say, we are ready to open the shutters to our secret work, so that I may partner with people who have the money and resources and exposure to bring us to the next level. The next level will bring me, with Zhara and most importantly, with Miriam, to the US.  There, in that land which is still running with milk and honey of venture capital, we will be able to bring PeauReélle to the next stage of its existence.  We will be able to both get my daughter the care she needs, and get this magical company beyond the confines of this monarchy. Then, what we are really capable of, will come to the world, and change so many industries. I am not naive. I know that healthcare simulation, while important to the world, is a tiny fraction of the world’s desire for more realistic mannequins. The real money will be, like most new technologies, when our product is used to please man’s oldest desires.  Many simulation companies have created more realistic models of silicone cast on plastic endoskeleton. They weight and feel so much more life-like than their predecessor generations of mannequins.  Starting with basic CPR mannequins that many people around the world have used for basic rescue training, Resusci Anne in the 1960’s was a plastic model of a breast-less white woman that merely helped people learn where to put their hands to perform compressions and how to seal their mouth to perform mouth-to-mouth. In the 1980’s, started to combine with microcomputers, to provide basic heart and lung sounds, and to allow more procedural training. In the Silicon Valley, Dr. David Gaba was combining the magic of computers with the early mannequins to train anesthesia providers. In Florida, the METI mannequin was being developed, and Laerdal in Norway also was creating more advanced versions of their human patient simulator. These were tethered by cords, and were run behind the scenes by a team. They were best used for anesthesia, where patients don’t move, and the patient physiology can be reproduced by the impact on vital signs. Anesthesia teams were trained to detect changes in heart rate, blood pressure, and oxygen.  Along with other technological improvements, these trainings have contributed to a massive decrease in the risk of patients undergoing anesthesia, and have opened up many new treatments because patients who are chronically ill can now undergo anesthesia with increased safety. However, these early simulators did not have any speech, eye movement, or facial expression.  Not much has changed since then. Mannequins have become untethered, just as computers now communicate via WiFi, Bluetooth, and other similar technologies, mannequins have become battery powered and untethered. But, many challenges remain.  There is still no patient expressions to reproduce human emotion, they cannot sweat, shiver, bruise, or die in a convincing way. Despite this, simulation has become a core curriculum of most of healthcare training. The technological advances have come not in mannequin realism, but in learning processes. Advances in briefing conversations, the learning conversation before the simulation, have led to more engagement by the participants, despite the “uncanny valley” that simulation is currently trapped in. Participants must get beyond the sometimes disorienting or off-putting simulators, to still have learning conversations. And, simulationists have started incorporating hybrid technologies. For obstetrical training, a model pelvis can be strapped to a real person, so the trainee can experience helping the mother through the birth process, while also learning specific maneuvers to deliver complex and dangerous presentations. Learners can strap augmented reality glasses over their faces, to add other team members, or change the  appearance of the patient. These remain cumbersome and early. The technology is simultaneously magical and fake. Participants get dizzy from visual delays, and it can be argued that a cartoon overlay on a plastic mannequin distracts as much as it enhances. Since 2020, with the international movements towards representation gaining momentum, mannequins have become more diverse by age, skin tone, ability, and the other variations of humanity. But, simulation remarkably continues to lack the feeling of caring for a human.  That is where PeauReélle comes in. Our hyper-realistic skin will help bridge the gap between current and future. When combined with miniaturized actuators coming to the current generation of robots, our skin appears to look like a resting human that can come alive and sweat, become cool, have dropping oxygen, and have so many of the other features that human learners expect of human patients. Currently, silicone skin is the most realistic that is made, but ours leapfrogs the realism, with the layers necessary for the function and realism of skin. We bleed, we wrinkle… But, I am getting ahead of myself. My pitch comes out naturally, because I am so passionate about this company. And, I know, simulation is not the only use for this technology. When it reaches the West, it will be used for sex. Then, the real dollars will role in. But, this is not why we exist. We exist for the betterment of the world, not for the pleasure of sick men who cannot maintain a loving wife. I reach the far corner of the square when my mind stops roaming. A candied nut vendor is selling. I watch him for a moment. This is what I need to do! I need to pick out my best customers, attract them, and finish the sale. I take a few steps in, trying to blend with the crowd of tourists. I am watching how he pulls them in with his promise of meeting their unmet needs.  In this case, they have just gotten to the square after hours of uncomfortable travel. They are seeing their first taste of true Moroccan tourist culture. It feels like they are joining a place without time, and eating a local flavor is one of the best ways to enjoy and to become a part of a locality. He offers sesame coated candied peanuts. This profile combines things they love, sugar and peanuts, with a local flavor, sesame seeds. They are priced too high for locals but cheaply for tourists.  Then the vendor asks where they are from, he speaks enough of their language, and this makes him appear safe. Then, he makes them feel like they are getting a deal, with two-for-one sales “Because it’s the afternoon.” Little do they know, the same peanuts are for purchase at twenty percent the cost further in the souk. By that time, they will have forgotten, or no longer worry about the scam. “Oh god, I’m so sorry!” A man, American by the looks and sound of it, right off the plane, still wearing his suit jacket, has turned around and crashed into me. He spilled his candy nuts right on me. He reaches out to brush them off my shirt. “No, don’t touch me please.” I say in my slightly accented English. “It is ok. I will clean them off. Please, I’m going anyways.” I head away from the stand, annoyed at being distracted. I keep moving towards the stand of taxis, while I pick candied nuts out of my outfit. They have melted in the afternoon sun, and are slightly sticky, but don’t seem to leave too much of a residue. Luckily, I don’t need to go home and change. ## Chapter 19: Marcus - Marrakesh “Oh god, I’m so sorry!” I blurt out. A woman, Moroccan by the looks and sound of it, stands too closely to me. I spill my candy nuts right on her. Was she picking my pocket? Now, that seems unlikely. Ugh, these thoughts just creep into my mind. I know I sound like a scared American. But, you can never be too careful in these countries. I try to get her to back up by reaching out to clean off the nuts. “No, don’t touch me please.” She says in slightly accented English. “It is ok. I will clean them off. Please, I’m going anyways.” As she turns and walks away, I see her carrying a relatively awkward backpack. It is black, appears insulated, and says PeauReélle in glimmering needlework calligraphy across the back.  I don’t think that is the type of person who would be picking my pocket. She seems like a professional woman, although what do I know. I have been here for mere minutes. I still have most of my overpriced nuts. The saltiness of the peanuts is coated in a crunchy candy shell and rolled in sesame. The collision of flavors explodes in my mouth. I don’t need the whole bag, but can’t stop eating. It’s the combination of jet lag and the novelty of the moment. I stroll around the square, inspecting the corners. I thoughtlessly dip my hands in the paper bag while I become entranced by a snake charmer. The music rises and falls repeatedly. I think they are playing about five tunes. I can tell they don’t fear the snakes, they have probably been de-toothed.  “Damn, what is that?” Suddenly, a sharp pain on my left index finger. I look down and see a hornet on my finger, it is actively stinging me. I shake it and shake it, finally it flies off. I put my finger in my mouth reflexively. I am not allergic, but it hurts a ton. Ok, enough of this. I pour the peanuts onto the ground and walk away, crumpling the paper bag. I open my map app and type in my hotel name. The Happy Traveler Riad is just to the north, a few turns into the souk. It looks like I go through that gate. As soon as I pass the gate, I am lost. The transition from wide open square to ancient maze is immediate and total. I turn around to look back and see the square, outlined through onion shape of the gate. Outside is almost impossibly bright, the souk is dark, the square is open, the souk is claustrophobic. While there is chaotic noise in the square, sound is directed up and out. In the souk, the noise echoes around the stone floor, walls, and wooden ceiling. Each vendor has pushed their wares as deeply into the path as possible, which is just wide enough to handle a donkey cart.  The traffic flows like sludge moves through pipes, stopping sometimes for clogs to release. Motorbikes, carts, people, bicycles, even the rare car, pushes through the amorphous mass of people traveling different speeds and in different directions.  My maps app gave me walking directions, straight ahead for two blocks, turn left, go one block, then right for one block, then left into the “street”, and at the terminus of a dead-end alley sits The Happy Traveler Riad. However, once I try to navigate that myself, I realize that it is impossible to determine what is a block. Which of the numerous gates and doorways leads to an alley, versus which is a road, versus which is a store, I don’t know. None of the “roads” are marked. The traffic seems to be the same no matter the direction of travel.  At the same time, many languages come from many types of people. Northern European tourists stick out by their worn backpacks, their blond hair, their fitness, and their shoes; their shoes are different than what I’m used to in the US. But, there are men and woman dressed in full Muslim garb, as well as many wearing Western clothes. I see a Boston Celtics hat, bright green with the shamrock. “Yay, Go Celtics!” I give a thumbs up. I am met with a big smile. The man runs up to me. He is selling from a leather store, or at least he was standing in front of a leather store looking at the crowd.  “You are a fan of the Celtics?” “Yes, I’m from Boaston.” I exaggerate my accent. “Ahh, I used to live in Boston. I left in 2016 to come home to be with my family. I loved America.” His English is pristine, lightly accented.  I hear German being spoken with vendors, and English, and Spanish, and Italian, and French. That sounds like Arabic, from maybe local tourists, or teenagers. Are they working? Or, are they shopping? Other languages I do not recognize break through, is that Berber? I don’t know. I look around, give a smile back to the Celtics hat, and head back to into the flow.  I walk further, then realize that I am definitely deeper than two blocks. I must have missed my turn. I head back. I peer down every alley, gate, and open doorway. I cannot tell where to turn. I open my maps app, the walking directions no longer show me where I think I am. I zoom in as far as possible. My location is moving from street to street, even though I am standing still. I find myself sucking on my fingertip while I walk. Am I controlling my pain or self-soothing my anxiety about being lost. I head back towards what I think is the gate I came in, maybe I’ll start again. Then, there it is, Celtics hat, bright green against the mostly black and dark brown of the leather shop. I walk back to him. “Can you help me? I don’t seem to know where to turn for my riad.” “Of course, my Boston brother! Where are you going?” “The Happy Traveler Riad” “No problem! Let me find you a guide. Mohammed!” An apparent 10-year-old boy comes up to us, with a smile. “Hello sir, I take you where you want to go. 10 Durhams.” Not a question. A series of statements. “Ok!” I respond “You pay me now, and I take you.” “Ok.” I open my wallet and hand over a 10 Durham note. “Thank you. Where are you going?” “The Happy Traveler Riad.” “No problem! I know it well. Follow me.” I struggle to keep Mohammed in sight. His size and comfort allow him to weave through the mess, while I get stuck behind all types of obstacles. I also am patient, he pushes his way through the obstacles. My foreignness makes me anxious about pushing people, plus, I wouldn’t push my way through a crowd at a concert, or at the Esplanade on the 4th of July. I would say “Excuse me,” there doesn’t appear to be any of that here. “Go through that store, and you will be on your street! Happy Traveler at the end of the street!” Mohammed points to the left at a men’s clothing store, it contains suits, shoes, belts, and fabric. Several men in tailored blue suits of their own, shined shoes, looking dapper and formal, loiter in front, waiting for customers. “Uh, ok? Thank you, Mohammed?” I look his way, but I see no sign of him. He is already gone. I walk into the store, three men approach me. “Looking for a suit, sir? We have amazing suits, wool, we tailor custom to your size. It will be done in one hour, 4,000 Durhams, but if that is too, much we can talk.” “No thank you, I’m just passing through.” I respond. The suits are nice. The cost is a little high. I remind myself of what I read in the guidebook. That you should barter down to close to 10% of the advertised cost in the souk. I don’t know if I could do that, but $40 for a tailored suit might be worth it! “No problem! Let us know if you change your mind.” He smiles. I wander through the back of the store, looking for an exit. There isn’t one. I walk back out to the front. “How do I get through?” I say. “What do you mean?” Responds the tallest of the blue suits. “The boy told me if I went through here, I would be at my riad.” “What boy?” He answers, with a big smile. “Mohammed.” I grunt, frustrated now.. “Everyone here is Mohammed, I am Mohammed, he is Mohammed. Sorry, I don’t know who you’re talking about.” “Nevermind, thank you for your time.” I open my maps app, I am no where near The Happy Traveler. The riad is due north of the gate I entered, I am on the east side of the souk now. What the hell? Well, from this direction, I can see that there is a mosque just west of the riad. If I can find my way there, I can find my riad. So, I head south by my compass. After a short while, I see a sign on a wall pointing into an alley, _Mosque Mouassine_ that’s what I’m looking for. I follow the sign, right then another to the left, another sign for the mosque. I must be getting closer. I go another block, and find myself at another clothing store. I go into the store, he’s there. Mohammed, the boy, is talking to Mohammed, the man. It’s the same store I was in. I came from the opposite direction somehow. They smile at me. It is still a store with no exit. It is still not the way to my riad. The signs led me here. “Looking for a suit, sir? We have amazing suits, wool, we tailor custom to your size. It will be done in one hour, 4,000 Durhams, but if that is too, much we can talk.” “What are you talking about? I just talked to you! That boy led me here, even though I paid him to take me to my riad.” Now I’m pissed. “You must have me confused with another boy.”  He smiles with a huge smile at me. “But, I can take you where you want to go. 10 Durhams.” The street signs lie to me, the people lie to me, it’s all a trap to get me into a store! I head back the way I came, and now just follow my compass. I keep heading west. Finally, I see the minaret of the Mosque peak out over the tops of the stores. I am nearly there. I break into an open area. The Mosque is a block of quiet and peace, nestled into the zoo of the souk. I suddenly appreciate any religion for the space it gives you, in this case, it is peace from the cacophony. It is almost like a city park. I see a sign for my riad, and walk down an alley, there it is. A dark wooden door is closed. I can still hear the swell of voices, horns, donkeys, motorbikes, echoing down the alley. I turn the handle. A creak, and the door opens inward. I step over the threshold. The floor is tiled blue and white. I step through, the door closes, and I am hit by silence. The quiet is actually overwhelming. A small pool sits in the middle of the courtyard, a “U” of five small trees surrounds the pool. I step inward. ## Chapter 20: Pierre -  Paris “D’Accord. Merci. Ok, thank you. Let’s take 15 minutes to talk about how today’s program went. What worked, what could we improve. We can start with everyone’s reactions. How are you all doing right now?” I’m leading our team’s debrief after an afternoon of running simulations for the medical students. To me, we still struggle with engagement and realism. The goal of today’s session was to help them tackle a problem in emergencies: how do we simultaneously treat the patient in front of us with a life-threatening problem, and also determine their wishes for any limitations on their care?  “For me, I still struggle with how to give the trainees a patient that they could theoretically intubate, but one that is real enough that they believe they are a human. The mannequin can have the procedure done, but they lack the humanity. If we use a human simulation actor, un acteur de santé simulé, the trainees cannot perform the procedure, if they decide to.  If we use AI, the learners revolt against the fake computer patient.” “It remains an impossible conundrum. We simply need mannequins that have more fidelity. They need the physical fidelity of the procedure, the mouth and jaw need to feel right. The head needs to be weighted, and the neck needs to have the right amount of resistance to movement. We also need to conceptual fidelity of the case, so that the tension is real. That’s where my father’s story comes in. Using that IS real. Finally, we need the emotional fidelity, they need to feel that they are caring for another human.” “This is where we are let down. If the character is an AI, it lacks the emotional fidelity to have them feel that their decisions actually matter. Put those together, and you have a model with the key characteristics of a human yet one that can withstand procedures. I am thinking lacking this is what leads to the trainees pulling back from engagement. It’s just not real enough for them with the mannequin or the AI, we need something between. We lack the fidelity of a dying patient.” I have told this before, I’m almost tired of listening to myself talk “Pierre, it’s the same complaint every time.” Says my colleague, Jacques. “The fidelity is good enough, the learners get a lot out of these sessions, especially your debriefs. That’s when they learn. Let me look at the transcripts from today. See here, they have learned, they have grown. This is ideal! I can’t wait to bring all the data together and show the growth.” “Then why even have the simulation. Why not just have the debriefing” I say, probably too forceful for the moment. “You know as well as I do, many times the simulation is just an excuse for a great debriefing.” This statement is Jacques classic line, his excuse for all imperfections in simulation.  I just see it differently, I think the learners are _always_ learning, and sometimes we unintentionally teach them to _not_ pay attention to the patient when we use these terrible plastic dolls. They are learning about the relationship with us as their supportive faculty. They are learning how much we love them. And for their sake, we need better physical models. I pack up my briefcase, and nod goodbye. I need to leave for my flight. I’ll be presenting at the 2026 Sommet Nord-Africain de Simulation en Santé, the annual Simulation in Healthcare Summit for North Africa. This year, it takes place in Marrakech, I’m heading there alone, to build bridges, and see emerging programs that are being built and developed in the francophone countries of North Africa. I’ll be presenting on our project “AI Based Communication Training in Healthcare,” and hopefully introducing it to new colleagues in Morocco, Tunisia, Senegal, Mali, Cameroon, and possibly others.    I’m excited and anxious to bring this technique to countries that have more hierarchy in their healthcare systems. I understand it can be quite difficult to translate these values dilemmas across cultures.  Well, there’s no way to know how it will land without trying. I grab my travel blazer, my shining new shoes and matching belt, and some short sleeve button down shirts for the heat. Where is my passport? And a hat, sunglasses, what else. I review my international travel checklist, and head for the bathroom to freshen up for the trip. I want to land in pristine condition.  I cross my right hand over, and again, tuck behind, then pull through the end of my bright red tie for the third time. I pinch the knot in an effort to get the dimple just right. Red tie, blue jacket, white shirt: the colors of France proudly frame me. My bald head is freshly shaved, the gray in my beard makes me feel earned, not old. I come to represent, and to present to this culture, the methods of education that I hold so dearly. I check my briefcase one more time for my charge cable, my projector connector, my clicker, my notebook. Yes, yes, yes, it is all there. I am ready. The conference arranged my flights and hotel in a sign of confidence in my ideas and my ability to share them eloquently. I won’t be paid, but I will be opening a whole continent up to a set of ideas and values that changed my life, and I will be the one to help change theirs. The satisfaction of teaching others is an intoxicant. When people line up after I present, they shake my hand, tell me how I’ve helped them, it is unbeatable. This feeling is hard to describe to those who haven’t experienced it. Learning is not just the transmission of ideas, when it occurs between people, it is a social transaction. Learning in this format takes place in the space between two people, not within one person.   When I lecture, I must first start with being a trusted source. A trusted source is a professional. I dress the part, I embody the part, I show up as the audience expects me to. I am impeccably rehearsed, my timings are perfect. I know when I will pause, I know when I will make eye contact, I know when I will click the next slide so that my words are aligned with the words on the slides.  I will not be telling facts, I will be telling a story. This story will have three parts, the audience is also the characters. I will be telling their story as teachers, then I will explode their world, and I will end with them being new learning leaders. This form of learning is called “transformative.” After my talk they will no longer see the world the same way. They will no longer teach by telling, they will teach by allowing their learners to learn. They will come to see their learners as predictable emotion-driven beings, not fact-driven automatons.  In healthcare, it does not matter what you know, it matters what you can do. Yet, we select for the best test takers, and we teach our students how to produce facts with our Socratic questioning and standardized multiple-choice testing. AI based learning is a whole new paradigm. Simulation provides opportunities to practice the skills your patient needs, before you get to the patient. And, AI, is the perfect fake patient. If only we could wrap it in a real patient. The patients deserve for you to be ready for the moments and situations that you face together. Need to deliver bad news? There’s a procedure for that situation. As a teacher, you can outline the procedure, students can learn how to answer it right on a test by reading or by listening to lecture. But, as any patient knows, the difference between knowing and doing is enormous. The actualization of knowledge depends on so many elements: context, emotional state, situational awareness, hierarchy, fatigue, hunger, and more.  Simulation can reproduce those challenges.  We can put the student in positions that allow them to practice the important skills. We can use an actor, so the learners can practice saying “You have cancer.” They can get feedback from an expert, they can get coaching, and they can get better. We can narrow the bell-curve of performance for those skills, so patients get more reliable experiences. We can create testing situations with “Standardized Patients,” so each learner can pass a test showing that not only do they know what the steps of delivering bad news are, but that they can actually do it. We can observe for, and grade the students, on demonstration of empathy, on active listening, on sitting down, and of offering open ended questions to ensure the patient understands what was communicated.  However, learning in the healthcare setting is complicated. Our medical students have been selected for being perfect, and our patients deserve perfect errorless care. So, physicians and medical students have been trained to have self-images of perfect performance. When there is a gap between their self-perceived performance and actual performance, the ego protects the student from receiving feedback that is anything but perfect. They often blame the technology that delivered the learning experience. So, here is a challenge, how do we make a realistic enough simulator, with the benefits of both AI characters, procedural safety of mannequins, and realism of a human? The answer to that conundrum is what I will looking for in francophone Africa.  I have given this presentation with our preliminary data nearly twenty times across France and Europe. It is clear, perfected, funny, poignant, and transformative. I will be the one to change their world by introducing our AI driven communication training. And, what will they have for me? ## Chapter 21: Sara - Boston I hit “post” on my video, and close the app. I need some space. Scanning my messages, I see an alert from my “monthly” app that tracks my periods. _You’re late!_ drops down like an ominous curtain.   I should have turned that off a long time ago, but never got around to it. I think I didn’t want to even go into the app, the memories were just too painful, so I usually just swipe away the notification. _Hmmmmm. I should have had my period by now, but I don’t have any symptoms at all._ I get a little shot of acid into my stomach, up my esophagus, and into the back of my throat. I turn around and walk back into the bathroom. I sit on the toilet, and reach down into the cabinet under the sink. There are two tests left.  I open the first box, take out the stick, and manage to dribble a little bit on the test area. I set my timer for 1 minute, and sit waiting, with my pants down. _What the actual fuck is happening today._ I concentrate on my breathing. My timer goes off and I wait. I don’t want to look. I have had so much pain in this journey. Okay, so I’m a few days late. This happens. Why put myself through another negative.  I throw the wand into the trash and leave the room. I finish getting dressed for work. I have to be at work, today is an in-office day, and I’m already late.  With transportation in Boston, the one thing you can count on is that it will take longer than expected. A survey recently showed that the only reliably transportation in Boston is the ferry system. Unfortunately, I can’t go by sea from Allston to our offices near Tufts on the Medford/Somerville line. When traffic is low - practically never but between midnight and 5 am, the highways are the best way to go all the way around, even though it is 10 miles. But, almost every other time, going straight is best, but a painful 5 mile crawl.  I put on my jacket, step out the door, and go back inside. I race back into the bathroom and pull the test out of the trash. I look at the test. There is definitely a negative in the control. I really think the test result area is a plus sign and not a minus sign. I sit back onto the toilet, fully clothed, and nearly fall off the cheap plastic seat, buckling slightly under my load. I catch my balance. I reach under the toilet and grab the other test. I check the expiration date: June 1st. Today is still April, it’s a valid test. I look in the trash at the box. That one was June 1st as well. I grab the other test, and sit, straining to pee. But, I can’t seem to squeeze out another drop. I put down my bag and run to the kitchen. I gulp two large classes of water. I have an instant coffee, that will make me pee. I microwave a mug of hot water, put in some almond milk, and stir in the instant coffee.  I go back to the bathroom. I sit. Nothing. When I want to hold it, I have to pee, when I have to pee, nothing comes out. Ugh. I check my phone. What? I see my video:  _Wow!!! Ok, everyone, I’m overwhelmed here._ I scroll down. There are 1.4 million likes, and 125,776 comments.  _❤️‍🔥❤️‍🔥❤️‍🔥#ChiMILF 🔥🔥🔥 Still got it, lady!!! DM me_ Is the top comment, and it scrolls off the screen with too many to count, many saying the same thing. Scroll back up, and I watch the whole video. I realize, I thought I was just filming my face, straight out of the shower, with a towel wrapped around my head. It was such a quick reaction to what was happening. But in the reflection of the mirror is my back, and my upper torso, a bit from the side. And, after the first moments, the side of my left breast is fully outlined. Actually, my breast is not outlined, it is a full side-boob shot, nipple out, with “just out of the shower and a little cold” being advertised to the whole fucking internet. Especially with the last several years of infertility, my body has been letting me down. Yet here, a little shot of my boob, and the world is going crazy. It’s a small breast, but perky-ish? I mean, I think I’m cute enough, but I never considered myself sexy. I don’t dress up. I don’t advertise. I run in tank tops, sports bras, and baggy shorts. If my tummy shows, it’s because it’s hot out and I hate the heat. A video call comes in. It’s Jamie. I have my camera off, I want to see her, but can’t look at myself right now. I usually answer with my camera off. I hate looking at myself in these things. “What the hell is happening?” Jamie yells “What do you mean?” I shout into my phone. “You are blowing up! Do you even know what is happening to you?” “I don’t know. I mean, I know, but I don’t know why! Listen, Jamie, I’m late.” I realize what I’m saying. “What?” “For work. I’m late for work. I have to go, like 15 minutes ago. This is crazy, but I’ll call you tonight, ok?” I don’t want to talk about the test right now. Too much to process. “Ok! Love you!!! You crazy bitch!” She screams. “Love you too!!! Thanks for calling!” I sit on the toilet again. I pee. I set my timer for 2 minutes this time. I wait. ## Chapter 22: Amira - Marrakesh I open my bag, and pull out the arm, I put it on the table. The arm is still wrapped, soon I will allow the world to see our creation for the first time. First, I connect my computer to the monitor installed behind me in the display booth. Light is shining on PeauReélle for the first time. This is a soft launch.  We have been working for three years on creating a real human skin. The skin, the result of growing tissue cultures, is like the cultured meat that is now being sold. In the US, cultured chicken, salmon, and in other countries, beef, is being sold to consumers for ingestion. That seems more controversial than what I am doing. I am merely creating a human tissue for performing procedures. At first, we will just be doing venous access procedures, placing intravenous catheters into arms, necks, and groins. These skins will initially be hairless, olive-skinned, neutral. But, in the future, we will have darker and lighter skins, different hair densities, different thicknesses. Eventually, we will be able to scaffold these onto other structures, like cultured tracheas.   PeauReélle is human meat, coming from my own human cells to avoid any feelings of theft of DNA or data. I scraped a few skin cells into a dish 10 years ago, then took a tiny punch biopsy. Since then, a PhD later, we had a proof of concept. Then, with the help of our wonderful King and his sovereign investment fund, a spinoff into PeauReélle was born.  Since then, we have been working in secret. Indeed, everyone at our company knows what we are working on, but no one knows how far we have come. So, when six months ago, I learned of this conference coming to Marrakesh, just blocks from our home, I just knew this is where I needed to open the windows and bring eyes to our invention.  It was a race to get something to be able to show. Many in the company didn’t think we would make it. But, as the leader, I had to make hard choices. I had to go ahead, and do anything required to make this work. I turn on our presentation, and the digital slideshow shows our team, our name, and our first product. The arm. I unfurl the wrap around the arm. A blood pressure cuff is alternating between inflation at 60 mm of mercury, then 140 mm of mercury, then releasing. This is the unit of measure of blood pressure, mmHg. Fake blood is inflating the veins just as it would in a real arm, by being pulsed into it via a pump. Then, as the cuff inflates, the pump cuts off, and the veins pressurize as the cuff doesn’t allow blood out of the arm. We hold that pressurization for up to one hour. Then we release the cuff, allow the “blood” to drain, then do it all again. The cuff inflates to 60 mmHg, the pump starts, fills the arteries, then the cuff inflates to 140, holds the blood in the arm, and the veins inflate. I ready my booth by flipping the cloth sign over the front of the booth, and I await visitors. I check my face in the mirror. I have the perfect combination of mild western makeup with a head scarf. I have a bright blue tailored suit, custom made, fitting perfectly. My body, round in the right places, not waif like those Americans seem to want, is both maternal and professional. Anyone at this conference will know I am in charge. They will see me not as a young model hired to promote vaporware, but as a serious researcher demonstrating her life’s work. The arm is cut at the mid-humerus. The elbow is present, as is the veins of the back of the hand, wrist, forearm, the antecubital fossa (the crease of the elbow), and the basilic vein. These are the most important veins of the arm. The basilic is cannulated by ultrasound for long-term IV’s. This model is perfect for routine and emergency intravenous access training.  Since I have come here alone, only I know the reality of this prototype. Only I know how difficult it was to obtain. Only I can speak to this product, what it will do to change the world, and how this is just the very beginning of a whole set of new industries built on human tissue grown in a lab. As long as I don’t run into anyone from PeauReélle, this will go perfectly. I have made sure everyone on the team has important tasks to do today, and actually the whole week. If I do run into someone I know, well, I am the boss, I can do what I want. ## Chapter 23: Marcus - Marrakes This place is ridiculous. Music is playing, people are dancing. I thought this was a conference, not a rave. The cookies and afternoon treats were put out right as I arrived into the foyer, checked into the conference as a speaker, and walked past into the main conference hall.  I’m thinking I’m going to do a pass through the vendors. I don’t really know what I’m looking for, but I need an opportunity, something unique. I need something that no one in the US has seen, or knows about. I need a connection that will help me find a new path, a new partnership. I need something that I can leverage for the next phase of my career, so I can get out of my rut. There’s no future just in simulation the way it is.  I need a leapfrogging either technology, opportunity, or partnership.  And, I’ve got something no one else at this conference has. I am from Harvard.  “The further you are from Cambridge, the more important Harvard is.” Goes the saying. Well, we a pretty frigging far from Cambridge right now. I noticed that several dozen booths are set up around the outside of the courtyard. The booths were exhibiting all types of simulation-based technologies. Right now, virtual reality glasses for training specific procedures are a big seller, apparently.  New, expensive, so called “high-fidelity” simulators are always for sale. High-fidelity, in simulation technology, means computerized mannequins. But, they aren’t high-fidelity for many parts of caring for patients, especially the human aspects. They are high-fidelity in that they can have vital signs that display to a monitor, they can be “shocked” or defibrillated, they can have CPR done to them, they have lungs that take a breathing tube. So, for much of anesthesia training, they are high-fidelity. But, if you are talking about communicating with patients, performing a psychiatric or neurological exam, or many other parts of medical care, they sure aren’t high-fidelity. But, they are expensive, so simulation technology companies love to sell them. There is another part of simulation training, so called task trainers. A catalog called “Limbs and Things” sells all kinds of simulated body parts. Any body part that can have a procedure done to it, think arms, legs, male and female genitals, has associated task trainers. These are often considered “low fidelity,” because they are not representative of the whole patient. However, they can be really high-fidelity for their purpose. For example, there are a whole bunch of joint reduction trainers, think shoulder dislocation, elbow dislocation, that don’t look like real arms, but require the real maneuvers, to reduce them. And they can be used over and over for the same procedure.  The next booth has a VR simulator. In this case, it appears to be only virtual reality. Some combine VR glasses with a physical mannequin, so called augmented reality. This allows you to have one trainer and layer over it with what the participant sees to change the situation. For example, you can have a mannequin that is layered over with signs of a burn. This booth does not have any physical mannequin or task trainer, so I assume that it is purely virtual reality. “Can I try your VR simulator?” I say to the young man and woman, barely old enough to be out of college, that are standing at the edge of the booth looking for customers. “Absolutely! Please, step over here, sir. Where are you coming from?”   “Harvard, Boston, United States. I’m an anesthesiologist.” “Perfect, wonderful. You are exactly who this is meant for. I’m going to put this screen on your head. There, can you see the patient?” “Yes.” I am getting used to the screens on my eyes. I’m suddenly in a cartoon operating room. “Can you see the anesthesia machine?” She asks. “Yes.”  “Great. Now hold these controllers in your hands. Perfect. Now reach over to the anesthesia machine, and adjust the machine. What machine are you used to? Ok, I’ll program this to have that machine. We have most machines in our system. Great. There you go. Now, look, the patient is starting to desaturate. Their oxygen is dropping, so go ahead and increase the oxygen concentration, and the do a recruitment maneuver for the lungs.” “I’m titrating up the oxygen flow to 50%, and I’m going to do a breath hold.” That is pretty cool, they swapped out the anesthesia machine for the one that I am used to. The knobs and buttons are all familiar, if a little cartoonish. I open the APL valve, give a breath hold, and the patient’s oxygen comes back up. “Ok, are you ready for a scenario? This is a scenario intended for first year anesthesia residents. The goal is to manage a rare emergency.” “I’m ready.” I say. I teach most of the possible emergencies in simulation to our first year residents. Since I’ve been doing this for a decade now, I’ve actually experienced most emergencies. “Ok, I’m starting the scenario.” I see scrolling words rolling up the screen, simultaneously I hear them spoken, like at the start of Star Wars. A video of an anesthesiologist, an almond skinned woman wearing scrubs, face covered with a mask, is displayed on the screen behind the words. “You will be caring for Mrs. Alami, she is a 60 year old woman with moderate asthma. You are giving another anesthesiologist a lunch break. The patient is undergoing a laparoscopic partial colectomy, part of their colon is being removed, after a polyp was found on a screening colonoscopy. Her induction of anesthesia was uncomplicated. The intubation was easy.  She was given pre-surgical antibiotics without complication. She has been stable. The surgeon has asked for me to hold her breath a few times as he explores up under her diaphragm. What questions do you have?” She asks me. “None, sounds good.” I reply, I’m ready. “Ok, you are running the patient now.” I look over the patient’s vital signs, everything looks normal. The curtain is up, I cannot see the surgery. I look over the curtain, and see a surgeon operating laparoscopically. A camera is inserted through a port in the patient’s abdominal wall and another port holds an instrument.  I do my scan. Patient, circuit, machine, vitals. I notice her oxygen has drifted down a little again. _I’m going to bump up her oxygen again._ I increase her oxygen to 60 % of the gas flow. Still plenty of anesthetic being delivered at this rate to maintain anesthesia.  Suddenly, the machine starts to beep with a warning. **OXYGEN SUPPLY FAILURE** _So that’s the scenario. Oxygen failure. Hah, I teach this!_ I say. Something we train for is hospital-wide oxygen failure. It is a rare situation, but happens sometimes during construction, or other situations where say a truck hits the main oxygen tanks.  You can run anesthesia without oxygen, you switch to an anesthetic that goes into the intravenous, so called total intravenous anesthesia - TIVA. And most patients, since they normally breathe room air, can just be ventilated with room air. But, this patient was requiring increasing oxygen during her case. So she will need oxygen from another source until the surgeon can gain control of the situation. I turn to the machine, and flip the switch to oxygenate from the tank stored connected to the back of the anesthesia machine. This lets the machine be mobile, or be used independent of wall oxygen. When I flip the switch, the alert should stop, as oxygen starts flowing from the backup tank. I unhook the machine from the wall oxygen. This is a step that many new residents forget, it is important to ensure that you don’t use the wall oxygen until it has been tested, so that the patient doesn’t get contaminated gases. **Total hospital oxygen failure. Please go to backup tanks. All spare oxygen tanks should be brought to the operating rooms, intensive care unit, and emergency departments. Repeat, this is a total hospital oxygen failure.** Is broadcast overhead in the simulation. But, I look at the patient, and her oxygen level, which we typically keep in the mid 90% range, has drifted down now to 84%. This is starting to get dangerous. I unhook her from the ventilator and give a few manual breaths. Her oxygen continues to drop, and the **OXYGEN SUPPLY FAILURE** warning continues to flash. I put her back on the ventilator. I spin the anesthesia machine around and look at the back. The tank is empty. Now I need to get a new tank and hook it up to the anesthesia machine.  I look at the circulator nurse, the nurse who is not sterile and helps by getting things for the surgical team. “I need a new oxygen tank.” I say to him, as calmly as possible. I’m aware a crowd has gathered. Probably here to watch the American crush it. The patient’s oxygen is now below 80%. There is no extra time. If I don’t get them oxygen soon, they will die of low oxygen. People cannot live for long with low oxygen in their blood, and below 80%, things start happening physiologically in most people in most situations. If I don’t fix this soon, the patient, will die.  I’ll be damned if I let a patient die, and fail the scenario, in public.  _Come on, get me that tank! Now!_ I think to myself.  I’m not going to come all this way to embarrass myself. It’s hard enough being embarrassed with my lack of promotion, I can’t get my wife pregnant, I can’t even take her out to nice dinners anymore. I am NOT going to fail here, too! ## Chapter 24: Pierre - Marrakesh My first time at a conference in Morocco and I **love** it. The vibe is so different than in the US or Europe. At 4 pm, just after my arrival from the airport, a huge table was covered with little pastries and cakes, including baklava, my favorite. While the serving was happening, I was watching and waiting for them to be done setting out the snacks.  All of a sudden, music started playing. People were singing and waving Moroccan flags. The place was teeming with young adults, maybe medical students. Everyone was bouncing. A dancing circle opened up, some of the elders were dragged in, and the young people were forcing them to dance.  This is like a wedding! So much wonderful energy. People are pushing behind me, I’m moved out towards the dance floor. I find myself doing my best moves in the circle.  _What is even happening! I don’t even usually dance at weddings. I will dance at the occasional rave, but that’s only if my date is younger, insists, and has a pill for me._ I turn my back on the music and dancing, and push out to grab a baklava, since I’m hungry from the flight. I didn’t want to eat the beef hot-dog in a croissant that was served on the flight. But, all of the food that was just put out is already gone. I cannot believe it! I don’t think it has even been 5 minutes. There is a small macaron, slightly crumbled, on the side. I grab it and pop it into my mouth. Lesson learned, eat first, then dance. The simulation conferences in the US are so over-run by commercialism. They are glitz and glitter. There are thousands and thousands of people.  And in Europe, it’s the seriousness of academia that dominates. Everyone is trying to prove their value through the quality of their research. So, in Europe, we get ahead by promotion. In the US, they get ahead by money. But, here, where the field is being invented, inclusiveness seems to dominate.  The goal here seems to be to show the value of simulation in a developing healthcare system. Demoing new technology is the promotion space’s highest feature. The goal is to introduce the politicians and decision makers to simulation, and to get them to invest in this technology, and the people behind it. I casually stroll through the expositions. Newborn mannequins that offer procedural practice for newborn emergencies are incredible. A new one, that I haven’t seen before, packs all of the hardware of a modern simulator into a tiny package. I pick it up, it feels realistic in weight. However, it doesn’t move, and its skin looks realistic but feels like plastic jelly.  I ask to try it. I haven’t placed a breathing tube on a newborn in several years, so I take my time and practice a few times. This is so close to the right fidelity for the procedures! The surfaces look shiny, like moisture. The epiglottis flops if your blade falls back, just like a newborn’s airway anatomy. Incredible! Visibly this is amazing, tactile, not so good. It is cold, hard, and a realistic skin away from being nearly perfect. _Sir, what do you think?_ The vendor asks me. _I think it’s really well done. The skin though, it is still plastic, it still lacks the tactile softness of a newborn._ I reply.  I continue, _And, there is no spontaneous movement, other than breathing. I pay a lot of attention to how a newborn moves. So, if the skin were better, and the newborn movement was realistic, and responsive, then you would have perfection. For example, when a newborn pinks up, it starts moving more, it starts fighting a little. That’s a sign that you are making progress in your resuscitation, no?_ _Thank you for your kind words. We are working on all of those limitations. But, right now, we think it is very useful. Especially for new learners. Can I scan your badge?_ A music video plays on the TV above the mannequin. The video shows a team working on training around this mannequin. Everyone ends with giving each other high fives. This is the promise of a great simulator, and great simulation. The participants experience fidelity close enough to their real life that the simulation gets out of the way, and they are just in it. They forget it is a simulation, and just do what they would do, and learn from the experience instead of fighting it. _D’Accord, voici._ Of course, here it is. I hand him my badge. I’ll spend the next two months canceling spam emails I get from this conference. I hope it’s worth it! _Merci!_ The vendor smiles. Everyone speaks English, French, and Arabic, at least. It makes it easy for me when I fall into French, by habit. I move to the next booths. I just see some plastic arms and legs, penises and vaginas, for nursing students to practice placing intravenous catheters, and urinary catheters. _I wish penises looked like that._ Haha, must be the travel.  The next vendor is a single woman, well put together. She stands behind a single table, with a video showing a slideshow.  The slideshow is of a high-tech lab. People working in white bunny suits, they call them, scientific isolation suits. This is a Moroccan company. I can tell because all of the pictures in the slideshow have the moroccan flag, red with the green five-pointed star, hanging in the back. Also, pictures of the king are in the background of many of these. They must be professional photos, since a pro knows to put the king’s picture in the background, how to get the angles so it almost looks like he’s a part of the team. Or maybe he’s the benefactor, looking over their shoulders, ensuring the work is happening. I walk up to the model, it is a human arm. No, it is not a model, it is a real arm. I’m confused. It is so realistic, is it some type of cyborg? It’s not moving at all, but I can see the plump veins showing under the skin. _Bonjour, çava. Je m’appelle Pierre._ Hi, how are you? My name is Pierre. I introduce myself. ## Chapter 25: Marcus - Marrakesh If I don’t replace the oxygen source with a fresh tank, Mrs. Alami, who came to the operating room today totally healthy, who trusted her life in my hands while the surgeon did his work, will die. _Coming right up._ He responds. He returns with a new tank. I “carry” it with the hand controllers to the back of the machine. Using the controllers I unhook the oxygen tank, and open the plastic seal on the new tank. I am careful to not drop the O-ring, a little piece of plastic that allows the new tank to seal to the machine without leaking. I pop the O-ring on the pin, and slide the tank into the holder. I connect the regulator, screw it down tight, and release the valve. I can see the oxygen pressurize the regulator.  I go around to the patient side, I turn up the oxygen to 100%. I continue total intravenous anesthesia. I provide rescue breaths with the bag. I watch the patient’s oxygen level continue to drop.  The oxygen is now down to 60%. The beeping on the anesthesia machine is calibrated by pitch to the patient’s oxygen. When the oxygen is normal, the pitch is nice and high, like a chime, reminding us “everything is ok!” But when the oxygen drops, the pitch drops. And, like an ominous sound track to a horror movie, the low pitch is a source of continuous panic.  Because the oxygen we are measuring is in the patient’s finger tip, it can take about 20-30 seconds, sometimes even longer, for the oxygenated blood to reach the monitor. So, even when the problem seems to be corrected there can be an anxious delay between the problem being fixed and the oxygen monitor catching up and telling us “everything is ok” again. Suddenly, the pitch increases. I watch as, breath by breath, the oxygen starts to come back up. 67%, 72%, 79%, 84%, 86%, 92%, 98%, 99% The chime is back. The rest of the scene becomes normalized again.  The surgeon says to me, _Everything ok over there?_ _We just had an oxygen failure, but she’s better now._ _I have a while left in this surgery, how long can I operate for?_ I turn and look at the machine. I still have the flow of oxygen going wide open. At this rate, I won’t have long to support the patient. I was supposed to put her on low-flow once I got her stabilized. I turn the flow down. **That concludes our scenario** _Wow. That was actually almost good!_ I say to the young man and woman, after I wiggle out of the controllers and remove the goggle setup. _I found it pretty clumsy with the controllers to do the little tasks necessary to switch over the tanks. But, I can see the future potential. If the equipment was real, in my hand, but the scenario was virtual. And if the characters were AI, not scripted, but real characters. That would be something. Someday, this might actually work for training!_ They ask to scan my badge so they can be in touch after the conference. _No thank you, I’m just looking._  I walk down the aisle looking at all kinds of other types of trainers. I seem to have entered an area of limbs and things. I walk through vendors with plastic crap that doesn’t look anything like what it is supposed to represent. Then, a booth catches my eye.  **PeauReélle** it says in big letters across the cloth hanging from the table. On the table is a human arm. _Oh, my god. That is a human arm. Disgusting. How did they get that here?_ I mutter under my breath. _Oh, is that a mannequin? Amazing! This is it!_  This is what I’ve been looking for, the new frontier, something that has never been seen in the US before, something that I can bring back, that I can use for not only improving our teaching, but for getting that advancement. The research, I can already see the series of papers we will write, comparing old trainers to these. There is a darker skinned, very well dressed man, about 50, short hair. He is put together sharply, but listens well, has an air of respect for himself, and for the woman he is talking to. She is younger than he is, olive skinned, head scarf. She is also dressed very well, tailored blue suit. She appears maternal, and gorgeous. She holds herself with a quiet confidence. They are taking turns talking. It looks like an in-depth conversation. Well, I want a part of this. My phone rings. I silence it. I step forward, confidently. _Hi,  I’m Marcus Stein, anesthesia, from Harvard, Boston, United States. This arm is incredible._ ## Chapter 26: Sara - Boston While I wait, I try to call Marcus. The phone rings and rings, no answer. Oh well, maybe he’s not on the network. Or he’s busy. My timer goes off, it’s definitely a big blue plus symbol. _+_ The control is a blue minus sign. _-_ I’m spinning. I should try Marcus again. What time is it there?  Wait, no. I can’t call him again. This trip is so important to him. He’s probably doing something important. What’s the rush, maybe it won’t even stick. I don’t want to add to his stress. Or, maybe, I just need to be with this news for a little on my own anyways.  In a fog, I walk downstairs. I get to my car. I sit for a few minutes in the drivers seat. I start to head to work, and somehow find myself going east on Storrow Drive. Where am I even going? Well, there’s no use now in turning around. I am swept along in the flow of traffic. Stop, go fast, narrow turns at 40 miles per hour in bumper-to-bumper.  Storrow Drive in rush hour is classic Boston driving, with lanes seeming to appear and disappear with no purpose or rhythm. The road splits, you can go left under a short tunnel or stay straight, and both end in the same place. I stop at the sweep of the Arthur Fiedler Memorial Footbridge. A bunch of people are running over the bridge to get to the river.  I look left, dozens of people are running. They are all shapes and sizes. One thing they have in common, is that nearly every one of them has poor form. They slow down with each footstep, then need to accelerate again. I see them land on their heels, like I used to. A few ultra fit people, probably college runners or recent graduates with a history of collegiate running, glide by. The difference is striking.  The experts don’t move their heads practically at all. Their breathing is controlled. Their kicks vault them forward, their feet land in cadence with their movement, not slowing their momentum down, but keeping their momentum. They run like spinning a basketball, just tapping the ground to keep themselves going.  _Beeeeeeep!!!_ The space in front of my car has opened up, I was lost, watching the runners. Now, everyone needs to let me know. I accelerate into the open space in my lane, but a car has swerved, right in front of me. I hit the brakes. I hear squealing behind me. A car slams to a stop, inches from my bumper. I accelerate again. I hate driving in Boston. Another half-hour of this crazy, stressful, fight or flight for every inch of travel, and I pull into the driveway of our little office building. As I creep through the lot, I see that every space is taken.  I perform an unglamorous seven-point turn, and head out of the lot. I circle the neighborhood. Eventually, I cram into a spot-ish, and park. I’m almost up against the car in front of me, and my rear bumper is encroaching a few inches into the driveway behind me. Oh well. I’m taking my chances with a parking ticket.  I leave my car, grab my purse, and glance at my watch. _10:20 AM. Ugh. I head into the office. I **hate** being late._ Miranda looks up when I come through the door. “Yo! What is up?” “I know, it’s crazy. I don’t understand it.” My face falls. “You don’t understand it? You put your boob on the internet!” She’s chewing her pen tip, and gum, that comes off pretty uncaring. “I know, I mean, I didn’t know. But, my first post was blowing up without that. It was the Chi Running. That was the whole point of it.” “Well, it doesn’t matter what the point was. Your nipple was the point.” She’s now matter of fact.  “Oh god, really?” My heart sinks. “Yes, really. Hashtag ChiMILF is famous.” How can she say that with no emotion in her eyes? “Fuck. Miranda, I’m at work. Don’t say “Hashtag ChiMILF.” That’s gross.” Can I turn around now and leave? “Gross or not, that’s you!” I walk into our open floor plan office, six desks, each with large dual-monitor set-ups for us to plug our laptops into. Everyone stops talking. Then they all look down. They pretend to work. But everyone’s fingers are just sitting, not moving, on their keyboards. I realize, once again, that besides Miranda, our admin, I’m the only woman in this little company. Obviously, everyone has seen the video.  _Gross, gross, gross. All of these fucking men have seen my nipple._ I sit down, open my laptop, and pretend to work. Just like them. ## Chapter 27: Amira - Marrakesh “Bonjour, çava. Je m’appelle Pierre.” A smile breaks on my face. Here we go. A smartly dressed man, short hair, handsome, great smile, a professional, probably a physician, is approaching. He is practically wearing the French flag with his red tie, white shirt, and bright blue suit, walks up and introduces himself. He’s not American, I can tell, the blue is too bright, Americans always wear a darker blue. And, these days, Americans don’t tend to advertise their nationality when they travel abroad, especially in muslim countries. “Hello, Pierre. It is so nice to meet you. Tell me, what’s holding you back in your simulation teaching?” “Well, great question. Like so many of us, the learners, as soon as they start to get stressed, they blame the simulator. Students now are unable physiologically to endure the pain of learning, so they turn their ego on what is not real.” Pierre immediately explains to me his biggest obstacle. I have heard this so many times before. But, it is his journey I am interested in. I smile, keep quiet, don’t react.   He continues “I work in communication training through simulation. I cannot get enough real human actors, it is too expensive, the training, and they go off on their own agendas. So, I have turned to AI characters. Which, in some ways is amazing, but they are portrayed by these ridiculous cartoons. It is like a Disney movie is trying to teach the students how to talk to people. So, what I am looking for, is something that is realistic, that has high social and emotional fidelity to caring for another human. But, I need that to be programmable, to run an AI character.” This _is_ the problem. I have the response. “So it sounds like you need more realism for your mannequins, they need to be able to portray the human experience, no?” “Yes, that’s it exactly. So, tell me about your arm?” As a perfect saleswoman, I now know just what he needs, and he has asked me for my pitch. I am not selling to him, I am helping him solve his problem. Let me tell him about this arm! I am excited to say it for the first time. “You are right, this is my arm. Look, the skin, exactly the same tone. Why? Because, as you see in the pictures, this is lab grown skin and tissue, based on my cell lines. This is our company, PeauReélle. “Real Skin,” as you know, is the translation. Because, that is what we create. Real, human, skin.” I wait, I watch a series of emotions cross his face: confusion, revulsion, acceptance, understanding. “So, if what you are lacking, is reality, we provide reality. Give me a cell sample, just a skin scraping is all we need, If I had yours, for example, the skin would be darker than mine. And name a tissue type, and I will grow it for you in the lab. I will provide you a plastic skeleton, moves naturally, and a human tissue, mapped for the correct size, shape, and age person.” I continue to meet him, to map a partnership. “But, so far, we have not had any use in communication training. This is an area of interested for us. I was hoping I would be meeting people like you, people who would push the boundaries.” Suddenly, another man is there. He literally elbows Pierre out of the way. “Hi,  I’m Marcus Stein, anesthesia, from Harvard, Boston, United States. This arm is incredible.” “Pardon, Pierre.” I turn to the new man, I smile, “Hello, my name is Amira, this is my company.” I remember taking Miriam to the zoo once, we watched a display of carnivorous plants. We held our breath as = two flies tickled the edges of a, would you call it a mouth? The plant kept the jaws open, just waiting. If one fly triggered the closure first, it would lock out the other. But, patiently, the plant waited for both to enter, then closed the doors behind. “And my name is Pierre, I am an emergency physician, from Paris. We were just getting to know each other, and what do you do with simulation?” “Well, I specialize in team training. But, we are working on bringing actuators to mannequins, so they move naturally. But we have been held back because the skin is so shitty on these mannequins. I mean fake, pardon my French.” He smiles awkwardly. “What do you work on, Pierre?” This man, Marcus, turns is attention to immediately challenge Pierre. He has forgotten about the arm already. I intercept the conversation. “Pierre uses AI to teach communication, he was just saying how the big problem he has is the lack of realism, and how he needs basically a programmable patient head.” I turn to Pierre, he nods in agreement. “So, this is my company. I use human skin cultures to create realistic human-based skin and tissue, they can overlay any plastic. This arm for example, is a perfect intravenous trainer” I continue, adding one plus one plus one, to get infinity. “So, you Pierre, have AI based characters to naturally play roles. And you, Marcus, say you have robot actuators to make simulators move naturally, and I seem to have the perfect way to unite our technologies, the skin that will make it all real. Together, we could create a human character driven by AI, moving with robotics, and overlayed with real skin. Gentlemen, I think we have just created the next generation of realistic simulators.” # Tuesday, April 19 ## Chapter 28: Marcus - Marrakesh I toss the covers off. Goddammit. I’m awake. I peel my eyes open to look at my phone. 2:37 AM. Where am I? I feel for my beside table. There’s a lamp, I find the on switch, and am blinded by an unpleasant blue-white LED, I look around. _I’m in the hotel, I the riad, in Marrakesh._ This moment, of transition from sleep to wake, is a hard one for me. I’ve spent so many nights on call, trying to sleep in a hospital, that I never really know where I am during this transition. How long have I been asleep for? I look at my watch. It keeps track of my sleep. But, it assumes that I’ll go back to bed like a normal human. But, I know better. It’s 8:37 PM in Boston, and my body thinks that I just had a four-hour nap before work. So, I’ll be up now the rest of the night. Or, better said, I’ll be entering a fight with being awake. Do I want to just submit, pour some coffee, and be up? _Not really._ Do I want to fight with sleep for the next four hours until breakfast is served downstairs? _Not really._ Dammit.  Today is the day I’m presenting,  I’ll try to go back to sleep. I put my earbuds in, and put on a boring podcast. There’s nothing like two dudes blabbing on about robotics to put someone to sleep. I hit play.  _Am I asleep?_ It doesn’t feel like it. I come to the end of the hour-long episode, _was I awake?_ I think so. _What was that podcast about?_ I’m not sure. Anyways, I’m up again now. _Should I call Sara?_ maybe. I ask my phone, “What time is it in Boston?” “It is 9:45 PM in Boston, Massachusetts.” The voice is robotic, but somehow friendly, and something I’ve become used to talking to over the last few years. She, or it, is not a friend, really. And it is shocking how the functionality hasn’t improved in the last 10 years. It can still just answer basic questions about time, weather, my calendar, etc.  Sara will be just going to bed now. She would want to talk, but I am afraid of waking the other guests. Talking out loud before 4 am in here is a bad idea. Oh, Sara. _Do I miss her?_ I do miss her. But, I don’t miss the feeling of tension that has crept into our relationship. There is a certain freedom of being here. I feel like I cleaned my glasses, or took a shower. It’s a lightening, because our failed efforts to have a child seem to have created a constant strain between us. She wanted to keep trying, and I wanted to adopt. She didn’t think adopting was worth it. And we just stopped talking about the next steps, because we were stuck. Thinking of Sara does make me think of how sex was, when we were first together. We lived in that shitty apartment, it was barely heated, and we had to cuddle for warmth. We would just look at each other, and run to the other room with glee. I would trace her body with my fingers and, _deep breath._ _Is internet porn legal in Morocco? Could I be arrested for watching porn? Could I be arrested for Googling “Is internet porn legal in Morocco?” Do I want the robots to know that is a question I am asking?_ I should have asked that in Boston, on a private search engine. I put my phone in _Private_ mode, not that I know what that does. I open my search window and type “What search engines keep my data private in Morocco?” Sometimes, sex with myself helps me sleep. I take the risk. I think about Sara, I imagine that she is the woman in the video, and I am the man. Does that make this ok? Of course, both of the people in the video appear to be fitter, stronger, more virile versions of us. They also last longer, have more fun, and always end at the same time. They don’t have any of the baggage that we have.  Sex is just pleasure for pornstars, or that’s how they act. Of course, in reality, sex is just a job for them. Or is it? Crap, I’m losing my excitement. This happens to me sometimes. I lose excitement in the middle, my mind wanders, I overthink sex, like I overthink everything. I think of Sara again, and those early days. I get some more lotion. I’m excited again. I try to be in my imagination again. This feels real, this feels like I’m in the video. When it’s over, I turn off the lights, and try to go back to sleep. I go back into the ring with sleep, my long-standing enemy. We wrestle and brawl, me and sleep, for the next several hours, until 6 am local time, when I finally throw off the covers, get up, and take a shower. I heat water in the kettle, and pour an instant coffee stick into a paper mug. They don’t have tiny plastic cups of half-and-half here, instead there are tiny sticks of coffee and sticks of milk, ultra-pasteurized to be able to sit out unrefrigerated. I find it hard to trust ultra-pasteurized dairy. Oh well, here goes nothing. I pour in two sticks of coffee, I love it strong, and two sticks of milk, and the hot water. _Your hours of sleep and your cups of coffee should equal eight in any day!”_ This is a saying we used to have in residency. Now that I’m older, any more than three cups of coffee and I won’t sleep well the next night. But, today, I don’t care. I need the stimulation, I can’t be sleepy the day of my presentation. My watch says, “You slept 5 hours and 17 minutes. Your sleep was restless and non-restorative. Consistent sleep hours are important to fitness and health. Try to get a better night sleep tonight.” _Thanks asshole. I could have told you that I slept like crap. Last night I was on a plane and I just did a time change, of course I didn’t sleep well._ I wish these digital “friends” were getting smarter, but they seem stuck in some moment where there is so much promise but they constantly seem to let me down. AI is the current promise, will it be better? I’m not sure. I should ask Pierre what he thinks, sounds like he’s all in on AI. I finish my coffee, take a look in the mirror. Not bad for someone who has slept nine hours in two nights. But, I know myself. Today, I’ll be slightly unhinged. I’ll have to be careful, I won’t have much frontal lobe function, I’ll say things that I know are true, but normally wouldn’t let out. I grab my laptop and head down for breakfast. My watch says 6:59 AM. I’ll look over my presentation again and get some more coffee. I head down to the breakfast. I see a few people who might be going to the conference. They might be doctors or healthcare professionals. They might also be well dressed tourists, or even business people. Certainly no one I know. I open my email.  The first message is my credit card bill. Damn. How is that always so much bigger than it should be? I open the credit card application. All of these companies are just sucking from my account every month. It feels like black flies in New Hampshire on a spring hike. They are impossible to avoid. $20 per month for each content company, $35 for each news paper, hundreds and thousands for my medical journals and professional fees. But, this is what it takes to be alive now, right? I’ve tried to cancel a bunch of things, but then there’s something we want to watch or read, and I find myself signing up again.  I’m a doctor, and Sara’s an architect, we should be able to afford to watch TV shows, right? I won’t be able to pay this until my next pay period. Which is fine, I’ll be able to clear all the charges so I won’t be keeping a balance. But, it’s surprising to note that despite our two incomes-no kids status, we cannot pay our credit card with cash at hand. If I could be promoted, then my income would go up, probably just enough where we could really start to save. Well, I know what I have to do. I have to find a great partner here. ## Chapter 29: Pierre - Marrakesh Well, this was unexpected.  I do my best not to wake him, as I get up and head to the bathroom.  I was hanging out in the hotel lobby after the day at the conference with a whole group of Moroccan medical students.  I had found it strangely relaxing to be socializing without alcohol. I do love the way wine tastes, and the whole process of choosing, opening, tasting, smelling, the ritual of wine. But I no longer love what it does to my sleep. But, in France, it is impossible to socialize without wine. In Morocco, wine will not be central to public socialization. Wine can be found, if you look hard enough. However, we were just hanging out in a hotel lobby, so wine was not the center of the experience.  The conversation was the center of the experience. The cross cultural exchange, the cross generational exchange.  One student, Youssef, stood out for his outspokenness, “I cannot be happy in a country where the students cannot choose their specialty. It is as if we must emigrate to have choice. We test, all the stakes are in this one test, then we are left to choose the specialty slots that are left. Many of us get no position in Morocco. Then we have to go abroad, to France. No offense, Pierre, but I want to train here in Morocco! My family is here in Morocco, my community is here. I want to be a surgeon, and I want to practice here. If I don’t ace the test, the door is closed.”  “You can come to France for the DFMS, no?” I reply, referring to the program that allows Moroccans to train after medical school in a specialty in France. “True, but, that also is limiting. I cannot then stay in France. I hate all of these doors closing based on one stupid written test. Medicine is not practiced by written tests. I mean, if this were an OSCE, a standardized set of patients that we had to care for across a valid list of conditions, that would at least have face validity. This is just a memorization game and a test taking competition. Can I not be a great physician if I have test anxiety?” Youssef is animated, charismatic, and there is this glimmer in his eye. He is making trouble and knows it, and he is making a safe amount of trouble in this kingdom. It is ok to challenge the test and its structure. Different to challenge the King. “You can only do so much to change the world, no? At times, you need to accept the world the way it is and do your best within the reality.” I respond with earned wisdom. “Spoken like an old man!” he holds my eye, and laughs while he puts me down. I love medical students, and I listened intently to their unique struggles. This was one of the best ways to learn about what is really happening in a medical system. The students still have their sense of righteousness intact. Us olds have our sense of justice immure by the numerous battles lost.  Although I know they too will experience learning what cannot be accomplished, what cannot be changed in a system, they don’t yet know what they cannot do. So, as I listened, I heard my previous self echoing in their  speech. I too, had thought I would change the world by being a doctor. Now I realize that the most I can accomplish on any given day is a temporary patch on a flawed human experience.  But, I also am not an old man. I’m in pretty good shape. I am sure I can beat him in my weekly 10 kilometer run around Paris, through the hills, despite him being half my age. We exchanged ideas about right and wrong, ideas about the role of a doctor and patient, and I watched them struggle with many of the conflicts a doctor faces: how to allow a patient autonomy of bad choices, how to relinquish decision-making control to a family when you disagree with them, how to experience and tolerate poor outcomes that you feel responsible for, and many others.  As I listened, the group got smaller and smaller. Finally, it was just myself and Youssef. And, as he talked, I began to notice that his eye contact became more prolonged. In the pauses in our conversation, he would not be looking away, but instead looking directly at me. I was initially uncertain the implications. I wanted to be careful, to be cautious of misunderstanding cross cultural non-verbals. But, I felt old enough to recognize a certain way of looking. He was also careful not to commit through any specific action. I suspect there must have been a certain bravery or even refutation of the world that he exists in for him to have been so bold.  “So, are you going to invite me upstairs?” he said, his voice low, leaning in, but his posture as steady, as if he were discussing more about test validity theory. “I have to think about that.” Was my reply.  The reality of the situation is that I am taking an unknown risk. It is one thing to cross a busy street on my runs through Paris, it is quite another to do it without looking first. And, I know enough to know he was being beyond bold with his comment. Instead, he was being either reckless or purposefully defiant. And for me, I am so attracted to the youthful enthusiasm. I love these students so much! I love all of my students so much. I want them to have the lives that they should have. I want to help them grow, become full fledged humans. I love being a part of that. How do I separate the types of love? And, when it has been so long since I have felt a love given back to me, how can I resist that bucket being filled? I give and give all day long. I give to my father. I pour love into his skeletal body every evening. And, with his still face, his Parkinsonian mask hides any emotion. His Parkinson’s brain hides any speech. He is unable to direct love back to me. He is unable to respond with even a glimmer of recognition.  And with my patients, I am unable to spend the time, to develop the relationships, that show my love. Working in a city, if I know a patient from a previous visit, it means that patient has serious social and medical problems, and usually both. It is so rare that I can really build a deep and reciprocal relationship in the Salle D’Urgence, the emergency room. I have to be able to gain trust, and move to the next patient.  Finally, my students know I care for them, but how can they care for me? They are too busy building their own identities as professionals, as physicians, to notice the now old man looking at them so longingly. They laugh and flirt with each other, and when I walk over, they think it means the case is about to begin, and they walk back to their seats. It has been so long since anyone has made me feel young and shown me love and pleasure. How could I resist that chance last night? Well, now that it has happened, I can tell you all of the ways I _should_ have resisted. Did I do it because of loving him? Did I do it because of needing love myself? Did I do it because I have become so aware of death, watching my mother and now my father die, life is so short, eat dessert first? But, this wasn’t another man my age. Ugh, what have I done?  Maybe I just need to go back to Paris, right now, to leave this country and never come back. There is a chance, small, as it is, and I looked this up in the middle of the night, that I could go to jail for being with another man in Morocco. There is a bigger chance that my career, or his, could be immediately cut off.  “What are you doing?” He asks. Oh, I’ve woken him.  “I’m sorry, I’m nervous. Article 489 I Googled it. Three years in prison.” I reply, looking down at my phone. My face is lit by the white-blue light of the search engine on my browser. He looks at me with compassion. “You’re not the first foreigner to wake up in the middle of the night worried about Article 489. I don’t live in fear. Just don’t blab about this and it will ok. Don’t be reckless.” As a Moroccan, Youssef has even more on the line than I do. But, he’s a grownup. He opened the door, I walked through it. Should I have? But, now we are both on the other side.  ## Chapter 30: Marcus - Marrakesh Presentation day. This is my opportunity to show myself to this whole region of the world.  I get up eventually, peeling myself from the sheets after the restless night. There is a little caddy of coffee stuff. I fumble with filling the electric kettle under the sink, then realize I might not want to drink the water. How long would I have to boil it for in order for it to be safe? Will the kettle even do that? I pour out the water and fill the kettle, this time from the bottled water in the room. I said it to boil and jump in the shower. When I'm out, the kettle is off, but the water is hot. I opened up a little tube of Nescafé instant coffee and drop it into a cup, tiny for western coffee drinkers. Do people not get dehydrated here. I'm looking for any kind of creamer, and eventually realize that the milk actually comes in little plastic tubes, the same size and shape as Nescafe instant coffee containers. So I pour in a couple of milks and add the hot water. Hmmmmm, this coffee is surprisingly good! It tastes nothing like that crappy instant café that comes in plastic bottles in the American grocery stores. Now that I have my system down, I make a 2nd cup. I have to make up for a rough night of sleep, the time change. Come to think of it, actually two rough nights of sleep in a row. Now that my eyeballs are functioning, and my brain seems awake I take to my personal grooming. Since I've been balding, I think from the stress of residency in your early attending, I've been cutting my hair high and tight to hide it a little bit. I really like to have a fresh haircut when I'm doing a presentation. It makes me feel professional.  I take out my hair trimmer, plug it into the wall, and set it to the shortest setting. I hit the power button and the thing jumps out of my hand. It's going so fast, it sounds like the engine is on double speed. I turn it off, and look at it for a minute. What the heck is going on? I grabbed my phone and start searching the internet. It turns out, the alternating current in the United States runs at 120 volts at 60 hertz, that means 60 switches back-and-forth per second at that certain voltage. Morocco uses 220 volts at 50 hertz.  An electric motor responds to the volts and hertz and uses the energy to create a set of actions, it only knows the alternating current it sees unless it has a system for converting it. Well, mine doesn't seem to, so here are my real choices. According to the internet, “If you plug a U.S. device into a Moroccan outlet without a proper voltage converter or dual-voltage support, it can overheat or be damaged — especially devices like trimmers, hair dryers, or other resistive/heating appliances.” Dang.  I can go into my presentation with longer hair than I like and feel uncomfortable and shabby, or I can cut my hair with what feels like a double speed trimmer. I decide to go for it. I go fast, start with the right side and work my way around the back of my head. I'm about halfway through when I realize that my trimmer is scalding hot and I think maybe I burned the back of my head. I stopped and look in the mirror. Crap I can't see the back of my head in the mirror. I get my phone out and try taking pictures of the back of my head, which is shockingly difficult to do. This is ridiculous. On my third try, I get a picture of the back of my head. It shows that my hair is cut on the right hand side, but there's a red mark smack in the middle. It looks not too bad, there's no blisters. I don't think this razor is waterproof, so I wait for a few minutes until it cools enough to touch it, turn it on again and make a few more cut passes. I keep this up, but it takes about an hour just to cut my hair. I look again with another picture of the back of my head and it doesn't look like I've done any permanent damage.  OK. Lesson learned, I need a different method for cutting my hair while I'm in Morocco. Next time, I'll have to just get a haircut the day before I come. I put on a nice shirt, my blue blazer, khakis, and my brown, shiny shoes. I don't think I need a tie, it doesn't seem like most people were wearing them here. I put on my lanyard for the conference, I hope that if anyone else is going to the conference, I might be able to make their acquaintance. This would be a great way of building out my network in Morocco and North Africa. I head down to breakfast to see what they have. It's still in the early side, so most of the tables are open. I sit down and almost immediately one of them many staff members hanging around comes over to take a coffee order. That's nice! I order a cappuccino and go to check out the food choices. There's a whole wall of baked goods: little brown buns, croissants, pain au chocolates, sliced bread, pita bread. I grab a croissant, “When in Rome!” Next, heating pans with eggs, potatoes, and chicken sausage. No pork here. I take some of each, yes, yes and yes please. I keep moving. Here is a gorgeous spread of cheese, dried fruit, fresh fruit, yogurt, olives. I grab some olives. Fun! Finally, there is a big pot of some tomato like soup. It looks pretty thin and light, some lentils and herbs, fantastic smelling! I pour a bowl. I realize I cannot balance the bowl on my overfilled plate. I head back to my seat, drop my plate and go back for the soup. My bowl is gone, it must have been cleared by the staff.  I fill another bowl, and go back to the bread section, and grab a little whole wheat looking roll. Perfect for dipping into the soup. I head back to my seat, and right as I sit down, my cappuccino is delivered. Look at this breakfast! I could get used to this country. ## Chapter 31: Pierre - Marrakesh I wake again, and I’m alone. Good, I’m glad he got out so we didn’t have any awkward moment where we had to say goodbye. Would it be “Au revoir” or “À bientôt,” “Until I see you again” or “see you soon”? I hope he made it out without being seen, anyways. After my shower, I feel more awake. I get dressed again, meticulously, the white of my shirt shows off the contrast between my skin and my rapidly graying hair. At least I still have my hairline. I head down to breakfast, I first take a pass around the breakfast to make sure Youssef is not here. He is not. Then, I can relax. They have a full American and European breakfast laid out with little Moroccan touches. I grab a croissant and head to a seat.  Oh, here is Marcus! Look at that spread he has. Typical American, eating too much. “May I join you?” I drop by his table. “Of course, that would be great! I need something to help me wake up, the jet lag is hitting me, I didn’t sleep much on the plane and then last night was restless for me.” He replied. I wonder how much coffee he has had. He’s even more talkative than yesterday. “So, is this your first time in Morocco? How are you finding it?” I make some smalltalk. “Oh, I’ve been loving it! So much fun and adventure. I even got lost in the souk. I guess that’s a right of passage.” He seems genuinely excited to be here. “Yes, yes. Everyone has to get lost in the souk, at least once. Are you good at getting back and forth to the riad now?” Once you have the pattern, it usually isn’t too bad. “Yeah, I can find it easily now. But it’s still fun to wander around a little, and I find I’m expanding my circle of confidence each time I go out. It’s nice of them to put so many of us speakers together in this riad. That way we can get to know each other. It’s great to have you speaking such clear English and French, it helps my transition to have people around who speak French in case there’s an interaction in English that isn’t going well. I’ve had a few of those. But, everyone here is so multilingual, I really haven’t had much difficulty at all. In the US, it’s hard to find anyone who speaks a second language, here it seems like everyone speaks five languages!” He shares his thoughts openly, very American. “So, the project of Amira is amazing, no?” I transition to our shared goal. “There is no doubt, it will revolutionize simulation. That arm was shocking, just shocking. I’m still having a hard time believing it wasn’t a real human arm.” I am finding it hard to talk to him while he eats that enormous spread. He is moving from bite of this to dip of that, vacuuming the items on his plate like a starving dog. I still have my croissant and my coffee, just one sip and one bite so far. “Yes, for me as well. I had thought if it was a tissue cultured-based arm it would be less, how would you say it, variable. It would be more consistent. One of the great things about humans is their imperfections. You know, Madonna’s mole and all that. They even had a few freckles on the arm. That was what I found to be so _franchement,_ eh, frankly, difficult to believe. It was such a mature product to show for the first time at a small conference like this. I guess because it is close to home, and as she said, they just finished this production. It makes sense, how she said, that they put more energy into their first creation. Once they do many copies, they will be more consistent, less human. This was like seeing a prototype vehicle at a car show. It is all custom touches. You would never do that for a mass-production car.” The concept does make more sense to me when I say it  out loud. Last night I was having some doubts. I take another bite, and another sip. He continues his unsystematic cleanup of the various plates and bowls in front of him. “Ok, when I first saw you two talking in front of her booth, I knew I needed to understand what that arm was. Then, as we talked, I could really see a plan coming together. I am so excited about using AI to coach learners, as you are doing, and if they have amazing models, they can get so good so fast. I think this is really the future of medical education. But, when I got back to the hotel, I started to get confused. How could this be real? How could someone be creating human tissue cultures? But, then I opened up the New York Times, you know this newspaper?” He paused. “Uh, _Oui_ of course.” “And they had this article about a company in Seattle that is selling cultured salmon for human eating. They are growing raw salmon meat, for sushi, in a lab. And it looks _exactly_ like raw salmon. It has the layers, the texture, and the interviews were that it is uncanny, it is just like regular salmon. I was thinking back to medical school, and we saw this picture of the Vacanti mouse, the mouse with the ear grown on its back. That was made at New England General Hospital, where I am. It is a great source of pride. And they are creating custom neo-tracheas for kids with tracheomalacia, then they cover the matrix with mucus membrane cells from the children’s own stem cells, and, voila, a brand-new custom trachea. So, this makes sense to me. And I do believe now, that the missing piece in this model is the lack of movement. So, I can bring our micro-actuators and create a hand that moves. I can tell you, the combination will be amazing. When I did it to our mannequins, everyone was shocked. But, it actually brought the learners more into the uncanny valley, not less. Instead of being amazed, they were disgusted. This, however, will just be a moving arm.” He is obviously convinced, and I have to say, it is contagious, his excitement. “Well, I for one just want the learners to stop saying, ‘It’s not real.’ I hate having that conversation so much. I want them to say, ‘It is SO real.’” I push back my plate, the conversation pauses.  “I’m going look over my slides for a few minutes. But, let’s try to connect at lunch.” I say. He’s already looking at his phone. ## Chapter 32: Sara - Boston I didn’t talk to Marcus at all yesterday.  By the time I got home from work, it was midnight in Marrakesh. So, I try him again after breakfast. I had gone to bed last night with my running stuff on, it helps reduce the barrier to running in the morning. No excuses, I’m even already dressed. I decide I’m going to try to refocus the attention on the Chi part of #ChiMILF. All publicity is good publicity, right? People will soon forget all about that second post, and many people pulled into the attention by the algorithms that rule our lives will never see it. I can overwhelm it with daily posts, including (clothed) video posts, and keep feeding the dragon of the attention economy. That’s what they say, right? The secret to sustaining attention is daily activity.   I sit on the couch wearing shorts and a tank-top. I am glowing fluorescent yellow. So much has happened since Marcus left, my head is spinning. I need to update him, but where should I start. I open a video call. He picks up, but his camera is off. “Hey, I’m at the lunch. I’m stepping out now.” He says quietly into the phone. I turn off my camera and start slow, “Hi Marcus! Sorry we didn’t connect yesterday. How’s it going over there?”  “It’s absolutely amazing. I mean, somehow I found it. You know, I came here looking for something that would help me move forward, move up in the organization, to finally get some traction on the research side. I came looking for a differentiator. And, oh boy, I found it! There’s a woman here with an amazing human tissue technology. It is going to change so much about how we research, how we teach, how we train, the uses are endless. And, she thinks it’s going to be for simulation training. Well, I’m sure that’s going to be a part of it. But, once I get a piece of this technology, the heights are endless. And there are basically no other Americans here. This is it baby!” I listen to him going on and on. He starts to explain how realistic it is, it’s not a mannequin, it’s actual cultured human tissue. He’s talking about mice growing ears on their backs in the past, but this is totally different. They can grow a whole arm. He’s obviously really excited, and I’m excited for him. It’s been so long since he had anything to be excited about. But, it’s not his technology. I don’t know why he’s making it sound like it’s his.  And, for what it’s worth, I have some big news to share with him, too. But, he never asks how I’m doing, he never asks what’s going on for me. Finally, after minutes of him pouring his excitement over me through the phone, he finishes. “Sorry babe, I have to go back in, we are meeting about trying to make a research and publication team. We have to do it quietly. And, I have to do it right now. If anyone else gets this, it all will just go up for me in a puff of smoke. I cannot loose this! I love you, I’ll try to call you at your lunch. I’m setting an alarm for 7 pm, that should be 1 pm for you, I think. Love you!”  “Love you, too, Marcus.” I whisper. The call ends, he hung up. When I look down a few moments later, I notice the phone is still in my hand. The phone sits in my hand but it doesn’t feel like my own hand that is holding it, my hand feels distant, unattached. I need to clear my head. I pull my shoes on, tie my laces, and I can feel that I’ve tied them too tightly. I untie them, wiggle my toes back and forth and push my arch up, the laces loosen. I retie them. Better.  I have a few berries and a half-glass of water, pee, and close the door behind me. But, before I go downstairs, I decide to create a before and after video this morning. I go back inside.  “Hi everyone, I’m getting ready for my run today. I’m going to just have a light breakfast, some blueberries, and a little water. This helps give me just the energy I need. Today’s plan is just two miles, but focused speed intervals, and I’m going to need my stomach pretty empty because I’m hoping to get to the edge of emptying it from the intervals. Haha! I’ll see you in the middle of the run, and when I get back.” Watch the video. My face is glowing yellow from below due to the tank. But, I look good! And, everything is appropriately covered.  If I do a separate video before, during, and after, I’ll start to push the nipple down my feed. Then, in a few days, when I have millions of followers at this pace, I can just delete it. New followers will know me as the cute enough 30 something Chi runner named #ChiMILF, but won’t know why. Of course, what the originators of that tag don’t know, is that the day I became a famous MILF was also the day I became a mother. I shut the door, head out, and make my way to the riverside, where the long stretches of uninterrupted sidewalks give plenty of space for training. On the way, I do some leg kicks to warm up my hamstrings and some butt kicks to warm up my quads. I start slow with the intervals, 20 seconds on sprint at about 80 percent effort and 20 seconds walking for three minutes. It’s actually kind of hard to both go fast and pay enough attention to my body to keep it in the Chi Running posture.  I turn on my camera and hit record. “Hi everyone, I’m along the Charles, you can see MIT behind me, and I’m doing Chi intervals. I am finding I have to focus extra on my pelvis, arms, and breathing. My sprint has a different style usually. I typically pump my arms more, and Chi wants me to rest my arms, so I’m having to figure out where to get my power from. I also usually end up breathing from my chest, and I’m trying to figure out how to breathe deeply from my abdomen. So, now I’m going to ramp up to 100% effort for 20 seconds on and 40 seconds off. We will see how it goes!”  I turn off my video, and lean over. It’s good content, but I’m back lit by the sun. I delete, and turn on the camera again to start recording. “Hi everyone, I’m along the Charles, you can see MIT on my left...” I reproduce the video nearly perfectly. “Now I’m going to ramp up to 100% effort for 20 seconds on and 40 seconds off. We will see how it goes! Thanks for being on the journey with me, please like if you want me to keep posting!” I add the last part to keep the energy going on my feed. I’ve seen plenty of people do that. It’s not selling out, it’s how the platform works. I watch that recording. Ok, it’s better. I post it. I start to sprint again, going for 100%. But, I realize that I cooled off and it’s hard to get up to speed. I modulate down to 80% and do another three minutes of 20 seconds on 20 seconds off. Now I’m warm.  I do my 100% intervals for five minutes. The last few, I’m slowing down. This is good. I’m pushing myself. I finish on a full effort sprint until I feel like I’ll barf. It turns out to be 35 seconds or so at 5:22 per mile. I felt like I was gliding on ice. Despite my heart rate pounding out of my chest, I’ve never run that fast in my life. My head and torso was isolated, not bouncing at all. I felt like my legs were just doing their thing. That was incredible. Sweat pours down my face, into my eyes. I turn on my camera again, I hold it up. By now, the sun is brighter. The skyline of Cambridge is amazing in the background. I had sprinted and jogged almost to the basketball arena, and back. Wow, I made up a lot of ground. I’m pretty much back to where I recorded from.  I hit record. “Wow everyone, that was amazing! My last sprint, I felt it! I was sprinting effortlessly. Well, that’s not really what it was. I was not wasting any energy, all of my energy was put into moving me forward. My head wasn’t bobbing, my arms weren’t flexing, my chest wasn’t throwing off my balance with huge breaths. It was all so, what’s the word, synchronized. It was so efficient feeling. I’ve never had that before. It only lasted 35 seconds. But, like some things, it’s not how long it lasts that’s most important, but how it feels. OMG, I can’t believe I just said that! Haha. Well, like if you want more.”  I walk back to my apartment watching the video, I watch it six times. Do I hit “post” and lean into #ChiMILF? Why the fuck not! I’m going for it.  Before I hit post, I check my others. It’s only 7 o’clock in the morning, but I already have hundreds of thousands of likes. My follower count is at 2.3 million. This last post is going to be like when I tried a Gu -those gross little gel packets - for the first time as I was running that half-marathon.. The sugar boost immediately powered me to speeds I didn’t know I had.  ## Chapter 33: Amira - Marrakesh Conference day today is turning out to be different than my initial plan. After I found some partners at the conference last night, I put the arm back, so I didn’t need to bring it back today. Instead, I keep the videos of our offices rolling on the TV, and have some handouts describing our product. I don’t get much attention, which was fine with me. The conference had already served its purpose.  But, I do have a few interesting conversations. When curious people come to my booth, I open with the same question, “What gets in the way of your students learning the necessary skills?” Jonah, from South Africa, talks about challenges with getting time with the students. “The school is locked into the old model of classroom time.” I hear this a bunch from people all over the world. “I need to break the previous model of education. If simulation skills training is going to be effective, we need enough time and resources with the students. But, instead, they have to leave my effective training for more boring classroom time.” He finishes with an exacerbated look on his face. Myriam, from Morocco says it best, “Classroom time, lecture time, is a representation of power in schools. And, your power and influence at an organization is linked to how long I have been there. If I have been somewhere for a long time I gain political influence, and I might have lots of research in my field to give me influence in the school as well. That is how people advance in academia. Then, I argue with the deans that the thing that I teach is important, and I go in front of the students to tell them what I know.”  “But, wisdom and skills cannot be told.” Myriam said that one line and perfectly summarizes the problem with classroom lecture format teaching. I write it down in my notes app. The amazing and interesting conundrum for these educators, it seems, is that as a scientist, there is data showing the low value of passively hearing about a topic. Basically, if the goal is building knowledge and skills in the students, lecture time is one of the least effective ways to do it. Yet, this model persists because it is how things have been done. Ironically, medical and nursing schools are scientific organizations, nominally, but their educational models often don’t follow scientifically derived principles of teaching and learning.  So, that is a barrier that my product won’t help with. Instead, I find myself in coaching sessions as a change agent. “You shouldn’t argue with the deans about what is important from your standpoint. You need to ask them what problems they have and how you can help solve them. What would you hear them say that you could leverage for influence?” I ask Jonah. “Well, we do have a problem where the medical students show up on their rotations and are expected to place IV’s, but they aren’t really good at that yet. It seems like the hospitals think we are supposed to teach the students, but we think they are supposed to learn at the hospital. And, in the end, the students are frustrated and the patients don’t get what they need.” Jonah has says the magic words I’m hoping to hear, to give me an opening. “Ahhh, so if you could solve that problem for the dean, what would you need?” I reply, building the case for my technology without telling him anything! “I would need trained faculty, time with the students, and a good model they can practice on. When I was in school, we used to practice on each other, but that isn’t really allowed anymore. The plastic mannequins out there are ok, but they just don’t have the feeling of human tissue. I played with putting a tube in a steak and having them put an IV into that, but some of the students were freaked out.” All the current challenges of skill development through simulation are being laid right out for me. “That is why PeauReéle exists! We can bridge that gap. We can provide something actually real, cultured human tissue, reusable, in variable skin tones and ages.” I reply to his challenges. “I have to be honest, that is the most disgusting and possibly unethical thing I have heard in a long time! I can’t believe this is allowed. Oh gross, cultured human tissue. No thank you.” He looks like he smells carrion. He backs away awkwardly, and backs right into someone looking at my video. A short “Sorry” was all he could muster at the person he had backed into. He continues walking away, apparently lost in thought. If you are going to push the boundaries you are going to make some enemies. I am not afraid of some people’s reactions. What I need is a product that is good enough to overcome the first reaction. And, I may need a way to introduce the concepts more slowly. Maybe, instead of trying next time with the whole arm, I should bring some skin layers for suturing. Those should be ready to show in just a few months.  The PeauReéle project is in a really good place. Jonah aside, he can be a late adopter if he wants, what I need are early adopters right now. I need people willing to push some boundaries, willing to consider new ways, willing to fight with me to overturn the status quo. If we are doing something incredible, we will inevitably create some enemies.  The question right now for me is: are Pierre and Marcus willing to do what it takes to bring this project to fruition? That idea is on my mind as the afternoon food is being served.  I pack up. I’ve done enough for today at the booth, now I need to keep working with Pierre and Marcus, I have to, what is the saying? “Strike while the iron is hot.” ## Chapter 34: Marcus - Marrakesh I stand up and brush the crumbs carefully from my blazer and pants. Damnit, there is a grease stain on my right leg above my pocket. I hope my blazer covers it when I stand. I look down, it does, mostly. I don’t think a quick wash in the sink will help, so I try not to think about it as I make my way to the conference center. That was a fascinating conversation I just had with Pierre. I replay it in my mind. Somehow Pierre learned a lot about me, but what did I learn about him?  Was my initial excitement to join forces with Amira and Pierre misguided? How can I have confidence that they have the expertise and ability to move a project like this forward? How does a successful team form across these boundaries? And, in any collaboration, there are winners and losers. Some benefit more than others. I always seem to do the work and others reap the benefits. Well, the whole reason for this project is to get the benefits, so I need to think about that moving forward. I arrive at the conference and sign in. The event is being held at a medical school. The building is clean but not fancy, a central stadium-seating style lecture hall surrounded by eight or ten classrooms. The furniture is hard plastic, the walls are painted cinder block. The whole appearance reminds me of my elementary school. In the US, at least in Boston, medical schools are so much fancier. We have comfy chairs, smart boards, video projectors, decorated walls, sound insulation, and the trappings of modern American educational system spending.  Of course, in the US, medical schools cost hundreds of thousands of dollars. Where does that money go? What is it for? Is it just for comfortable chairs for the students? There also doesn’t seem to be the intermingling of research and learning. I don’t see much in the way of multi-hundred million dollar glass and steel and tile and wood research buildings. The intermingling of research grants, for-profit drug and device development, and medical student learning does not seem to have developed yet here in Morocco. But, that does not mean that the content is no good, I should check out some of the presentations. I look at the presenters list for the 10 am slot, and see an interesting topic, “Facteurs humaine dans le simulation de santé” looks like human factors in simulation. Human factors, the study of how humans interact with the environment, is a growing part of what medical simulation is used for. When I was first in medical school, we were told that the problems in healthcare were due to poor training of people, that if we could just get the doctors and nurses to be better trained, patients would get what they need. Now, the thinking is that problems come from the intersection of humans and their environment, and that there can be critical challenges working with the variety of technologies that we face. Often those technologies use very different design languages.  Once, I had a patient who need a shock to get them back from cardiac arrest. Their heart had stopped because of a heart rhythm abnormality. The faster that the electricity is delivered, the more likely they are to recover. Deliver the shock right away, and the likelihood approaches 100%, but every minute that passes reduces the odds of recovery by something like 6-10%. I called for the defibrillator. The unit that they brought was a new device, the organization had switched vendors. I had a brief training on the new defibrillator a month before, but in the stress of the moment my reflexes took over. I put my thumb on the round red button in the upper left hand corner of the device. In the moment of pushing the necessary button to deliver the shock, I said “clear,” and pushed the button. Nothing happened. I looked at the device, and then realized my “error.” The new device had a round red button in the upper left hand corner marked, with a circle with a vertical line through it. The old device had a round red button in the upper left hand corner marked with a lightening bolt. The new device red button was for power on/off, the old device red button was for delivering the shock. Was this my error? Or, was this a problem with the interaction between humans and technology during a stressful moment? I would love to learn more about human factors and how simulation can help us improve or at least learn to deal with the issues around them. So, I migrate to one of the side classrooms. The presentation was just starting. I walk in and sit down by the door. All of a sudden, I heard my name, “… Dr. Marcus Stein from Harvard and New England General Hospital...” I look up, confused. I realized that everyone is looking at me, so I wave and smile.  I look up at the presenter, gesturing at my seat. I guess they know me already? I hate being late, and I did not expect this attention.  The presentation continues, and I quickly realize that it is fully in French. I have some choices, since I don’t speak French, but a lot of the words are the same. I could, possibly quite rudely, get up and walk out of the room and find an English presentation. I can sit there and get what I can from the presentation. I decide it is worse to leave than to stay. “Facteurs humaine” is a close translation and easy to pick up, hopefully I can learn something.  My mind wanders in and out of attention. When I hear things I think I can understand, I snap back, but sometimes I drift. Towards the end, I can see people wrapping up, and I can tell by the gesticulations that the denouement of the session is close at hand. I’m not sure what I am learning, but there are cool pictures about the evolution of the cockpits of airplanes and the evolution of anesthesia machines. There are also some interesting recordings of the soundscapes of intensive care units and emergency rooms, I think we are asked to pick up the emergency alarm within different sounds. Suddenly, I realize that the presentation has stopped and the presenter is looking at me. I look around, every eye in the room is looking at me. I do not know what has just happened. Have I been asked a question? Have I been requested to comment? I sit up and run my fingers over my scalp anxiously. Time slows, I feel the irregularity of my hair trim. Eyes blink, waiting for my response. “Je suiz deso-lai. Je ne parler pas france, fran-sai.” I stammer, feeling myself blushing. The waiting continues. Noticing my awkward linguistic incompetence, like the attendant on the plane, the presenter immediately switches to near-perfect English.  “Professor Stein, dow do you teach the Harvard medical students human factors?” He continues to look at me, a half-smile on his face. My mind races. I am not a professor, I am an associate professor, the lowest level. I teach residents, part of the Harvard system, and have an appointment at Harvard, but don’t work with medical students. I don’t know much about human factors, and it is not a part of any active teaching I do. I haven’t been able to get promoted, all of my research has been a failure. I don’t speak French, I have a stain on my pants, I burned myself cutting my hair this morning. My wife and I haven’t talked for two days. I can’t seem to even have a baby, over 8 billion people on this planet were born of conception, but I cannot even do that right. I stand and look around the room. “Could I please answer in English?” I ask?  “Yes, of course, we will all understand,” she replies. “Well, I do things very similarly to here. I am not a pilot, so I don’t use the flying metaphor. But, right now, cars are becoming more and more difficult to use. Buttons are being replaced by touchscreens, Tesla’s even have the gear shifter on their touch screen. So, I show pictures of drivers seats, and we talk about things like that. So, very similar to the excellent presentation that you have done.” I make this up, on the spot. I must have actually absorbed some during her presentation. I sit back down. I don’t think I appeared flustered. I smile and nod and look around the room. So many wide eyes and smiles are looking at me. I did well, I complemented the presenter, I appear to have earned some respect. I did not disclose the mis-information they had about me. And, Professor Stein, it does have a nice ring to it.  ## Chapter 35: Pierre - Marrakesh “When my father was first experiencing the neurocognitive decline that was eventually diagnosed as Parkinson’s Disease, we went to several neurologists for diagnosis and treatment. Each time, I found myself wondering, will this doctor be nice, kind, thoughtful, supportive? Or, will they be rude,  and dismissive, with poor listening skills? Who here has felt uncertainty about the communication qualities of the physicians they go to, or they bring their family members to?” I like to start my presentations with a cold open, a story to prompt thinking and emotional engagement. And, this is my true life! This is why I am pushing the boundaries in this field. Of course, nearly every hand goes up in the audience. The hands that don’t go up appear to be from people on their phones. Oh well, you can’t win over everyone. “Today’s patients need consistent communication skills from their physicians. Our current educational system, which starts with learners with varying skill sets and applies inconsistent and ad hoc case experience, sometimes conflicting advice from supervisors, unclear communication strategies, and already overworked and burned out clinical faculty, creates a milieu of inputs that results in a wide bell curve of abilities upon graduation. This gap leads to a set of physicians, many of whom are unprepared for their jobs, and ends up causing unhappy patients and unhappy physicians.” I start by naming just some of the problems with communication education in healthcare right now. And here is the hook, “What medicine needs right now is a consistency of the learning process for communication. Medicine needs a coach that doesn’t see skin tone or gender, that is free of bias, that provides clear feedback, that is free of the emotional entanglement of humans. That coach is Large Language Models, or LLMs, a form of generative artificial intelligence. With AI coaching, how I will refer to this technology, the computer is given a rubric to grade the conversational skills. AI can consistently both play the role of a patient, family, or healthcare teammate, and can observe, grade, and give advice for improvement. AI does this from a platform that is acceptable for the learners, one that they are used to working with already, a computer.” “Right now, we are collecting data on the effectiveness of this strategy. I can tell you from early results, this works. The learners like it and the faculty likes it. AI provides a cost-effective approach to coaching communication that frees up the supervisor to see patients, allows the school to have a consistent grading system, and lets the learners know how they are doing and what changes they must make to get better. AI coaching solves key challenges in healthcare education.” I go on.  Now, I go through the data. I start with the data about the poor current results in communication skills. Then, I move to the data we are generating about AI coaching. I leave out some results that are less than convincing, which is any changes in actual patient care. This skill transfer gap is a problem across all of simulation. I don’t need to emphasize that here. These are early times with the technology, and we need to learn how to use it before we are going to see actual real world changes. For now, I emphasize how much students enjoy working with the AI coach.  I pause. I look out at the audience, and I see Amira and Marcus there as well. They are sitting together. They are leaned over and talking, I see nodding and agreement. Their heads are close together, their eyes lit by the screen of a phone. They are whispering, looking down, then up at each other, then down again. The glimmering from their eyes makes it look like they are on a date at the movies. Their heads are really close together. I realize I have stopped talking. I look down at the slide in front of me, where am I again? I see which slide I am on. There is a picture, I used AI to create this, but they definitely cannot tell. There is a diverse group of students with papers and books in front of them, talking and smiling. I am almost at the end. “Next, here are some quotes from our learners. As you can see, they find this to be useful, fun, and engaging. ‘I really liked working with the avatars.’ And, ‘This seems almost like a real patient. It let me practice without people watching.’ The first step is acceptance, and I think we have shown beyond acceptance.”  I am running out of time. The next slide presents unflattering data, the data on transition to practice. Unfortunately, we have not been able to show that this actually makes learners better when they hit the wards. I pause for a moment. Do I delve into this now? Or, better to skip it and get to questions and answers. Why undermine my presentation with negative data at this phase. I rapidly double tap the clicker, jump over that slide and end with my contact information on the screen with a QR code to reach me on email. Finally, I bring my talk to a close. “And that is the current state of AI coaching in medical education. I left some time for questions, what questions do you have?” A member of the audience bursts up, “Hello, I am Ibrahim Bako, Professor of Surgery, from Cameroon. In the back of my mind is a quote from my favorite medical education textbook, _Understanding by Design_ by Wiggins and McTighe. It goes something like this, “Beware the urge to protect your learner from the pain of learning.” In general, I avoid any learning experience that my learners like too much. I expect that their enjoyment means they aren’t really learning very much. For example, does this really get them ready for the messy social dynamics of talking to real patients? Do you have any comments about this?” He gives a big smile with his mouth, but his eyes are not glimmering.  “First, how do we know our learners are ready to be with real people? Modern students are more used to texting than talking. I believe this to be a preparatory technology. There is no doubt that working with a computer avatar is different than working with a human. This helps ease that transition. Also, what if this technology could be embedded in a hyper-realistic model? There are converging technologies right now. VisionPro by Apple creates super-realistic 3D avatars and Google’s Project Starline gives us a 3-D television-like projection that we talk to. What if the AI model was in those? Walking robots from Tesla, Honda, and Walt Disney have human-like movements. Finally, most importantly, what if our simulation mannequins had real faces, crafted from real human tissue cultures and expressions controlled by micro-actuators. These disparate technologies exist today. They will be combined by people pushing the boundaries. However, those humannequins, and I just invented that word, will need personalities and stories to generate the interaction with the students. They will also will need the skills to then coach the learners. The underlying AI technology is what I am working on.”  After the presentation ends, there is a small group of individual questions. Then Marcus and Amira come up to me. “So that is the name of our company, Humannequin?” Her eyes glint in the sunlight. The corners of her eyes squish in the unmistakable reality of a true smile.  “I love it! Perfect! We did some Googling and could not find anything named that already, except a hardcore rock song!” Marcus chips in enthusiastically, laughing with a little snort. Then he looks down at his phone again. “Sorry, Sara is texting. She wants to talk. I’m going to step away.” He pauses and looks at Amira. He does not step away. Instead, he stays - with us. With her? _I don’t think it really means anything, does it?_ “You know, it literally appeared in my brain as I was talking. I cannot believe it doesn’t already exist. We will have to look more, and trademark it in our countries right now.” I haven’t felt this excited about something at work in so long. The last time I felt like this, the perfect match between what I had for skills, knowledge, and personality and what the world wanted from me, was when I was selected into Emergency Medicine for my training.  Of course, the actuality of that job has become quite different over time than how I imagined it would be. My intense smile starts to fall, just a little. “Beware the urge to protect your learners from the pain of learning” rings in my mind for a moment. What might _I_ be about to learn, what am I protecting myself from? ## Chapter 36: Sara - Boston I am sitting in my car in traffic. I am waiting for a call back from Marcus. Nothing makes you question your life choices like Boston traffic.  Although I have what might be considered a “reverse commute,” I leave the city each morning and drive back in during the evening, there is no road without traffic during rush hours. Everything is in gridlock, nearly every day, nearly the whole time from 7 am to 6 pm. When the Red Sox, Celtics, or Bruins are playing, the evening gets even worse, through 7:30 pm.  But here I am on Storrow Drive, looking directly into the sun, waiting for the car in front of me to creep up another 5 feet. Then I need to keep close to their bumper, or the car beside me will jump in.  I didn’t like how that last conversation with Marcus ended. So, I’m going to try again. Unfortunately, I don’t have a lot of faith in our ability to talk about difficult things right now. But, I also don’t want it to get worse. I think he should know about what is happening, at least. So much has changed since he left town! I tap my fingers on the steering wheel. I ask my phone to play my favorite music. Marcus calls my playlist “Sad Lesbian Music.” He wasn’t wrong. I love the haunting sounds of the current popular woman singer songwriters, Adrianne Lenker, Phoebe Bridgers, Boy Genius, Mitski.  _Night Shift_ by Lucy Dacus comes on. “You’ve got a 9 to 5, so I’ll take the night shift / And I’ll never see you again if I can help it.”  I don’t need this song to make my shit worse right now. I turn off the music and switch to sports talk. The Red Sox early season is in full swing. Every year, the sports talk stations sell us hope during spring training. We buy it, born from success in 2004 and 2007, when we actually won the World Series. But lately, the seasons have started out mediocre and tailed off into disappointment. A true Red Sox fan is more comfortable with disappointment than winning. That’s what we are used to, that’s what we grew up with. But, I have enough disappointment waiting for Marcus to call back, I switch to NPR news. Even worse! I turn off the radio, and sit in silence.  Is this even worse? I think it’s worse. I try my sister, “Hey do you have a few minutes? I’m stuck in traffic, surprise!” Jaimie answers on the fourth ring, I was about to hang up. “Yeah, just a minute though, I’m getting the little monster ready. What’s up?” “I just need to process. What is happening? My numbers this morning are up to 5 million followers. It’s exponential growth. What do I do?” Jaimie has a good head on her, very balanced and thoughtful. She’s a planner.  She jumps right in without a second for thought. “What do you mean? You run with it! People don’t get this type of chance twice! Here’s Joey, talk to him for a minute. Wait, I’m putting video on, he likes it more.” Joey is on my screen. He waves from his stroller, his little throne. He’s got his sun hat on and holding his bottle like a scepter, like a little king on his throne.  “Joey, I can’t look at you, I have to keep driving, ok? I love you though, auntie Sara loves you so much, you little dragon.” I sneak a glance down as he waves back. “Baba, Sala.” He says into the phone. “Wait, did you just say my name? I’m Sara, that’s right, Joey!” I look down, then the car behind me beeps. I take my foot off the brake and creep ahead. All of a sudden my car beeps loudly and jerks to a stop. My head whips up, I’m inches from the back of the white truck that must have snuck in front of me while I was looking down. Damn, damn, damn. That’s why I don’t do video in the car. Then, I see the stickers on the back windows: Bright white on the black of the windows are “F #@& Cancer” and “Save the Tata’s” with a pink ribbon.  When I was growing up, you might see a political bumper sticker, or even clubs that people belonged to. But you would never see vulgar stickers the way you see now. I look around, there’s a pickup next to me with a guy urinating on, what is that, the Chevy symbol?  I realize that today branding is about being more eye catching than the other guys. It’s about having a word that no-one else has, and owning that word in the minds of the population. The social norms around politeness are gone. I’ve been given a gift. #ChiMILF is mine, and I have to run with it, pun intended. I creep through the traffic, and pull into work. I’m ten minutes late again by the time I park. I gather my bags, lunch, computer, papers, sketches, and take a big sigh. I pause at the door, can I face these fuckers again? And, there is Miranda, same as yesterday, same as tomorrow. She looks up from her desk. “Nice job, ChiMILF! You go girl.”  “Come on Miranda, can I just be Sara here? Or, Mrs. Stein, please?” I try bargaining. “No way. You gotta own it. ChiMILF it is. I can make you a custom email address if you want.” She twirls her hair.  I drop my head and walk past, into the open format work area. Once again, the typing stops. All I can see are eyebrows, capped by balding or already bald foreheads and downturned eyes. No one can even make eye contact with me. These guys are so weak. I wonder how many times they looked at the clip of my nipple. I wonder if they have looked at my more recent posts. Before I know what I’m doing, I clear my throat. “I want to make an announcement. As of now, I am resigning my position. It has been wonderful to work with you all. I sincerely hope our paths cross in the future. Mr. Holmes, I’ll send you an update of where I am at with my projects, and agree to smooth the transition to whoever is taking over for me. I can do that work from home. No need to pay me the next two weeks. As the only woman working here, I know you will not question this process. It would be a mistake to try to force me to come to the office for the next two weeks.” I make direct eye contact with Mr. Holmes, the owner. He looks down. “Take care, everybody!”  I turn around, and head out the main door. “Thanks for all your advice Miranda. Now, here’s mine. Go work at a business owned by a woman. Stay in touch!” My heart is pounding, my mouth is dry. I did it! What did I do? I go out to the car. I try my sister again. No answer. I try Marcus again, he doesn’t pick up. Well, here we go. A door to somewhere has closed, and another has opened. I open my camera and start the video recording, “Hola everyone. I have something to share. You are the first to know. A few days ago, I was named “#ChiMILF” and at first I was mad. I felt my privacy was invaded. But, there’s a part to this story that no one knows. Which is, I am pregnant. I am poised to be a mother for the first time, after so much trying. I don’t know how this happened, honestly. The whole story is long and complicated. But, I was never able to conceive before this week. Now, I tested positive twice. And, I’m so excited. I am #ChiMILF. I think I can embrace my identity. Being a mom _is_ sexy. This society is so fucked up in what it considers hot. But, I’m here with you. I’m a mid-thirty something who runs 8:15 miles on her best day and is 20 pounds over what society thinks I should be. But you know what, that’s reality. So, if you are in, DM me - let’s run together! #ChiMILF merch is coming! We are going to have T-shirts, no, not T-shirts, crop top tanks in ALL sizes, laptop stickers, bumper stickers, let me know in the comments what else you want! I’m opening my store soon. Will post updates!” I hit the button to end the recording. I post it without re-watching. My heart is pounding out of my chest. _What the hell did I just do?_  I don’t know, but it feels like the most true thing I have done in years.  ## Chapter 37: Amira - Marrakesh “Today went so very well!” I tell Miriam about the meeting I had with Pierre and Marcus. “Two wonderful men came to the booth today and are excited to work with me. We are planning on combining our work to bring maman’s project to life.  Our body, Marcus’s muscles and bones, and Pierre’s computer mind. We met yesterday, then again today. We have a real plan coming together about how to bring our project to life!” Cultured human-derived tissue will be animated by the actuators and controls from the people at New England General Hospital in Boston, and will be given a personality that is real and responsive by the AI communications experts from Paris. Miriam’s eyes have glazed over. This is too much for her to comprehend as a young child. But, I hope it helps to see me excited by my work.  As a working mother, I don’t just want to get her to Boston, but I want to model being a professional woman. Except for her and mima, already in bed I presume, I don’t have anyone close to share with. I need somewhere to share my successes. I cannot bring them to work yet. I am not sure they would understand how far I have stretched the boundaries. Clearly PeauReélle has made great strides in developing human-derived tissue, but we aren’t yet ready for full disclosure of our technology. So, it is a stretch to have shown this much in public. But, how long can and should I wait? Won’t we be better off for moving forward in public, for flying in front of the plane, so that the partnerships and technologies to really bring this to life are in place when our technology matures? Didn’t Steve Jobs show the iPhone live on stage when it was really a mockup, then they spent the next several months scrambling to bring it to fruition? This is exactly what happened, and exactly like what I’m doing.  I think this is called leadership.  “Oh Miriam, we are so close to our dream. Now, close your eyes, and I’ll tuck you in bed. I’m speaking only English now to you so you get used to it. Have dreams of the new life we will have as soon as we make the trip to Boston. The city is full of glass, it is quiet and organized. The cars don’t beep their horns at all hours, and there are no donkeys in the alleys or snake charmers in the squares. Yes, it is scary for me to think about such a big change, but we will soon get used to our new lives and we will have such great doctors, physical and occupational therapists, and you will get better, so much better!” “Mima! Are you still awake?” I ask gently to the air. No response, she must already be in bed. After tucking in Miriam, I head to my kitchen. I pull sprigs of fresh mint from the refrigerator and breathe deeply before I put them into the bottom of a glass. The arm is wrapped in the fridge, so I close the door quickly. I don’t want to think about that now, I want to think about the future. The water boils and I hear the click of the automatic kettle turning off. I pour water over the mint, and the leaves immediately change first from dark green to a brighter green, then start to blacken on the edges. A bouquet releases, mist holds the smell of mint and rises from my cup like a genie from a lamp, there to grant me wishes of relaxation. I drop in a lump of sugar, which dissolves in swirls while adding sweetness and viscosity to the bottom of the cup.  I wrap my hands around the glass and feel the energy transfer. The anxious shivers that had been coursing through my body exchange and seem to fade as I feel myself warming from what I grasp. Why does stress make you feel cold? It should make you hot, I would think.  I hold the cup to my lips and sip, tentatively, bringing cooling air with the near-boiling tea to make it possible to drink. The temperature is on the edge of what I can tolerate, any hotter and I’ll burn myself. But, this is where the best flavor is. Life, as well, requires us to be on the edge of what we can tolerate. The maximum sweetness and flavors of the tea comes from the first hottest sip. I let the liquid swirl through my mouth, evaporating up through my nasal passages, letting taste and smell and feel combine to create the miracle of mint tea.  Three simple ingredients — water, sugar, and mint — transform one another into something far greater than the sum of their parts. Sugar alone is overwhelming. Mint is bitter. Water quenches but lacks taste. But, combine them, and a transformation occurs. Mint tea is a main character in the lives of us Moroccans. Mint tea celebrates with us, it is there when we mourn, it soothes meetings of new people, and reminisces with families and old friends. It helps us transition from rest to wake in the afternoon, and calms the energy of the day in the evening. It is a balm on our soul’s wounds, and a boost in our moments of uncertainty. This cup heals me from the day and endorses my actions. I get to the bottom, the syrup is thickest, the flavors are strongest. I chew some leaves, coated in a sweet slurry, then dump them into the sink. I rinse the glass, which I hold up to the single bulb in the middle of the kitchen ceiling and gently turn it. The pattern of gold-leafing around the outside acting as a kaleidoscope. As I turn the glass in my hand, the light diffracts. I settle on the position that lets me see the bulb clearly, distorted by the glass and haloed by the gold. If I turn the glass in any direction, the light does not shine through. Even a single atom of gold can block the light. So many things might stop my plan, but if I aim just right, I can make it work. We have three simple ingredients - skin, moving structures, and personalities - these will come together in a revolutionary technology. Harvard will have to bring me on. And, despite the currents moving against us in international politics, we will get to move to the US for Miriam’s treatment. It will be a change for mami, for Zhara, but she will adjust. The whole change and project will be worth it to see Miriam return to her previous state of living. What will tomorrow bring? I do not know. But, tonight, I have done what I can to get us on the right path.  ## Chapter 38: Marcus - Marrakesh This conference knows how to have fun! We, the presenters, hop into a bunch of vans and headed to a fantastic restaurant overlooking the minaret of the Koutoubia Mosque on the edge of Jemaa El Fna square. The sun is setting in the late spring evening light. It is the perfect temperature, coolish but not cold. A gentle breeze keeps any bugs away but still allows the candles to burn without blowing out. As the sun sets, the candles become brighter, lighting our faces and the Moroccan plates that they drop ceremoniously on our round tables for ten people.  Most of the conversation is in French, but the people next to me are kind enough to speak in English. After we eat, a total of three dining courses then dessert is served on a long table. Various baclava-type dishes intoxicate us with honey glazes, chocolate, sugar, etc. We move seats around with some regularity. Finally, I end up talking to someone I saw at the conference but had not yet met. Her name is Fatima, and she is so incredibly outgoing. She is in western clothing, very touchy, very loud. Not just with me, with everyone. I would like to think that she finds me special, but I notice she is the same with everyone: men, women, no matter.  Some of the women in Morocco have been more reserved. Not Fatima! She’s practically yelling in my ear the whole time. This is almost a little too close for my comfort, but she is really fun and pulls me onto the floor when a local DJ comes to play music for us.  She is singing along and bouncing up and down on the floor, I look around and all the Moroccans that came with us are singing along as well. What’s playing seems to be an electronic dance Moroccan hybrid. I don’t understand any of the lyrics, which I think are in Arabic. But, it sounds like “I’ll kiss you” is the chorus. I don’t feel great about singing that here with Fatima. So I just dance. I do my best to keep up. After the song, she’s grabbing me and we are spinning, I start to feel a little sick so I pantomime that to Fatima, and I head over to a seat. I don’t think “I’ll kiss you” is the likely lyric, but what do I know, so I pull out my phone and ask it “What song is this?” The phone returns something that makes more sense: El Kass Hlou by El Mehdi. I plug that into my search engine, it translates as “The Sweet Glass,” that makes more sense.   Fatima bats at my hand, “Why are you on your phone? Look, this beautiful view, this beautiful night, this beautiful music.” “I missed some calls from my wife.” I want to get that I’m trying to connect with my wife into the conversation right now. I text Sara, “Hi honey, I can talk! I’m at dinner but the music stopped for a few minutes. Love you, miss you.” I’m hoping that I’m not misreading Fatima being friendly and fun with something more forward.  “So, you are working with Amira, huh?” She says, breaking a moment of silence in the set while the DJ takes a break.  “We started to connect on a project, yeah. Why do you ask?” I reply. Fatima asked with a slight hint of something in her voice. Maybe I was making it up, but she seemed a little bit concerned. “What she is doing, I’m not sure it is legal, or ethical.” Fatima drops on me. She holds my eye contact when she says it. She usually talks with a boldness, almost an aggressiveness. But now, she is quiet and firm.  “What exactly do you mean?” If Fatima knows something, I should find out. She has seemed well connected, laying her hand on the shoulders of many of the deans and dignitaries.  She pauses for a moment, and looks at the ground. “I’m not sure what I should say. I want you to have your work. But, I wouldn’t trust her. Previously, she did some, how do you say it, sketchy things when she was in graduate school. She didn’t play by the normal rules. But, in the end, she got her PhD, and now has her own company. People were saying she got special treatment because her family died in the earthquake and the school just wanted her to be able to graduate. But, I heard now that she is working with dead people.” I jump in, a little too quickly to defend her. “Not dead people, human cultures. Her tissue cultures are derived from people, but no, she’s not working with the dead. She told me her husband died, but her daughter and mother are still alive. I think that’s what she said. And, oh yeah, he needed some procedure to save his life but the doctors didn’t know how to do it. She said that they had only trained on plastic simulators, and they couldn’t do the procedure. I think it was a chest tube. So, she is designing better simulator mannequins for procedural training. That’s how she explained it to me. I saw the arm that she created. It’s incredible. I’ve never seen anything like it. We need trainers like that in America as well. Anyways, I think it’s all above board.” I need this to work so badly. Sure, it’s a risk whenever you partner with people. But, her technology plus mine, it’s my ticket to promotion, to get out of this cycle that I’m stuck in.  “So, what are you going to do with her?” Fatima seems genuinely interested, or concerned, I’m not sure. Then she ends the sentence with one upturned eyebrow. What’s she getting at? It’s not like Amira and I are in a relationship. We are planning to be business partners. “We are going to work together to combine her tissue models with my micro-actuators and Pierre’s AI people to make the ultimate real human simulator. It’s going to fix so many of the problems with reality, so the students stop complaining about the fidelity of the mannequins, and finally give them the perfect replica human to learn on.” Why am I telling her this? I seem to be putting the cart way in front of the horse, we don’t even know how any of this will work, or if at all. The music pops on again, “Ok, whatever, let’s go dance again!” Fatima seems not too concerned, so I feel her pull my hand back out there again. As I am drawn up from my seat, I leave my phone back on the table accidentally.  As I’m dancing, I look back and see the screen on my phone light with Sara’s beautiful smile. It’s a picture that Jaimie took of her after the first half-marathon they ran together. Sara’s pouring sweat, but the radiance of her smile is what I love to remember. I haven’t seen that positive energy pour from Sara in a long time.   I keep dancing. I wouldn’t have been able to talk to her anyways with how loud it is now. I take a deep breath, let go, and put my hands into Fatimas, try so hard to not be self-conscious, and I give over to the music. # Wednesday, April 20 ## Chapter 39: Pierre - Marrakesh I got to the airport almost three hours early. Even though it is only a 4 hour flight to Paris, you can never be too careful with international travel. On arrival, I walk right through customs and passport control, I receive my stamp, and am to the gate area with two and a half hours to spare. The first risk has been averted. I find a nice quiet cafe at the end of the terminal and sit by myself at a small round table, I have the only chair at the table. I order an espresso and a croissant, it is surprisingly good for an airport.  I scroll my phone looking at the news. America remains crazy. France, which has been having its own challenges with immigration, right-wing politicians rising with populism, and class issues, seems stable compared to what the US is going through.  I look up and see Marcus, I look down. I’m hoping for just a quiet morning before my flight. I look up again and he is walking away. He seems to doing laps in his blazer with a backpack on. The third time he passes to the end of the terminal, he sees me, waves, and comes over. He grabs a chair from a nearby table and sits down next to me. “Pierre, good morning. I’m so happy I ran into you. I get so anxious waiting for a flight - I just walk laps until boarding. I was expecting a backlog at customs, but I guess it’s easy to leave this country, just not easy to get in. Listen, I wanted to talk to you about a conversation I had last night.” He sits down. Typical American, Marcus doesn’t seek permission to join me, or even ask how I’m doing. He just jumps right into a conversation expecting me to follow his lead.  “Good morning, Marcus. And how are you today?” I respond, slowing the interaction down, I need to warm up to him today. I haven’t slept well in a couple of nights, and am both dreading going back to my dad and anxious to see how he is doing. “So,” he jumps in hesitantly, which is different than his normal bravado. “I met this woman Fatima last night, and she had some very interesting things to say about Amira.” He ignores my pleasantries and any signals I am giving off. “She asked me if we trusted her. She asked if we knew she was working with dead people. I found myself defending her, but now I’m not sure. How do we even know we can trust her? How do we know it is safe to work with her, or with anyone from Morocco?”  Ugh, the American fear of the rest of the world! How are they simultaneously the world leaders and scared to get outside of their own borders? “I don’t think we should be afraid of working with her just because she’s from Morocco. We have seen her technology, it is world leading! For us though, it is normal, even expected, to get, what is the expression, cold feet.” This grown man is so emotionally needy. “Yeah, well, you cannot be too careful. I mean, I need this so much, I could end up blinded to a risky situation. It just seems everything hasn’t worked out for me for the last seven years. I had all of these plans, and my actuators were supposed to revolutionize much of what we do. They were supposed to be in our operating room tables so that the table could ensure we didn’t cause nerve injuries. The actuators were going to work like a bed of nails to distribute the weight more evenly. And since they can go up and down, the table could ensure that no part of the body has pressure on it for more than a few minutes at a time. A challenge in the operating room is that sometimes we position patients in a way that they accidentally have pressure on a nerve, and since the patient is under anesthesia, that nerve can become paralyzed. Like if you are asleep on your arm and you wake up with a dead arm. But in the operating room the patient doesn’t shift around at all. So if the bed can shift microscopically where the pressure is, no area will have pressure on it for too long. I created the technology, but haven’t been able to market it.” He’s really opening up now. “Why do you need to market something you have invented?” I chime in. “My chair keeps pressuring me to find a way to monetize. It’s not enough at Harvard to invent, you have to make money off your invention. At least the hospital has to make money, not that I would see any of it. But, that’s how I can get promoted. Anyways, that’s why I have this dead end technology. And if I could use it for this purpose, we could sell it to Laerdal or another one of the big simulation mannequin companies for royalties. Then, I could advance, and my job would be secure, and I wouldn’t have to work so many hours clinically. Sorry, I don’t mean to drop this all on your lap. I haven’t had too many people to talk to about it because while everyone at work is in the same boat, we are also competing with each other.” That’s a tricky position for him to be in. And, I wonder what else hasn’t worked out for him. “I can relate in some ways. Although I don’t need promotion, I do really want this to work. I get so frustrated when the students complain about the fidelity of the mannequin. I see it getting in the way of their learning. Their ego finds this flaw in our simulation, and the ego has to be open for the possibility of learning to take place. So, if we could get rid of how fake the mannequins are we could overcome this barrier to learning. And the students would finally be able to learn what we need them to learn. We would be able to coach them, so they could be the consistently great communicators our patients deserve. For me, I am going for it. I know there is always risk in partnerships, but I don’t think the risk is in Amira. I think the risk is just in the inventing something new. You never know how it is going to work. Yes, it seems like a perfect match for us. But a lot can happen on the road to invention.” I feel this to be true. I do realize the risk, but want to go for it. The success will be worth it. “I guess you’re right. I’m just getting cold feet. And, I’ve never done anything like this. But, you’re reminding me of this saying I heard on a podcast recently. ‘Never take a job you’re qualified for.’ They said. ‘That’s where the growth is.’” He seems, mildly reluctantly, to be in. Good, I don’t want to be forcing him. He needs to be committed. “Here’s the thing,” he continues, “I’m not going to stay  an associate professor. I’m going to find my way up the chain. This is finally something marketable, something that can be monetized. I watched my dad, floundering as associate professor, doing the nights and weekends. Taking the call. He was a surgeon. All the professors were on their boats and he was doing the fucking work. Well, he didn’t seem to mind. He felt he had a good life, had provided for us. He was planning on just 8 more years of work when he died of a heart attack at 55 years old. He walked into the kitchen at 9:30 at night after a full day operating, grabbed his chest, and was dead. He never got to relax. Well, that’s not happening to me. I’m going to ride this bull, and make it work.” We sit quietly for a few minutes. This determination is a side of him I hadn’t seen, it’s respectable. I tell my story. “For me, I have watched my father go to appointment after appointment with first primary care then specialists. They said he was just getting old, then they called it depression. He couldn’t get moving. He lost years of his active life. He had worked hard as well. He had emigrated from Senegal, he had worked his way up, made a wonderful life. But then, he was stuck in his kitchen, unable to move. It wasn’t until the final neurologist sat and listened to him, heard the whole story, paid close attention to the path and the exam, that his Parkinson’s disease was diagnosed. By then, years had gone by, he was reconditioned, and he _was_ depressed. He had lost faith in the doctors. His retirement was also stolen, although differently than your father’s of course. Which is why I need this to work. I will also make this work. So we can finally teach communication the right way to emerging doctors. When we create the realistic mannequin, with your actuators, Amira’s skins, and my personalities, the students will finally get to learn consistently. And future patients won’t have to deal with doctors who don’t know how to listen. If I can’t make this work, it feels like my father’s suffering will have been wasted.”  He is looking down at his phone, not really listening. Ironic. But, he looks up at me with fatigue and sadness in his eyes I have not seen before. “I’m so excited to work with you and Amira. I can’t wait to be on an international collaboration. This will really help! I’m also exhausted. The travel is long for just a few days. Next time, I’ll bring Sara and we will do a whole vacation. I haven’t been able to talk to Sara, with the time change.” He pulls out his phone. “No new messages.” He frowns at me. He shows me the screen. He sighs and flips open his socials and starts scrolling. “Wait, what is going on? Look, she has millions of followers, and she has posted all these videos. What is this?” He is sitting up, practically yelling at the phone. I lean over. I hear a woman’s voice coming from the phone, there is a pretty woman sitting in a car, “Hola everyone. I have something to share. You are the first to know. A few days ago, I was named ‘#ChiMILF’ and at first I was mad. I felt my privacy was invaded. But, there’s a part to this story that no one knows. Which is, I am pregnant. I am poised to be a mother for the first time, after so much trying. I don’t know how this happened, honestly. The whole story is long and complicated. But, I was never able to conceive before this week. Now, I tested positive twice. And, I’m so excited. I am #ChiMILF. I think I can embrace my identity. Being a mom _is_ sexy. This society is so fucked up in what it considers hot. But, I’m here with you. I’m a mid-thirty something who runs 8:15 miles on her best day and is 20 pounds over what society thinks I should be. But you know what, that’s reality. So, if you are in, DM me - let’s run together! #ChiMILF merch is coming! We are going to have T-shirts, no, not T-shirts, crop top tanks in ALL sizes, laptop stickers, bumper stickers, let me know in the comments what else you want! I’m opening my store soon. Will post updates!”  I watch his eyes grow huge with surprise, then hurt, the difficulty is clear. I think he is just finding out about this pregnancy. Is that possible? I don’t understand what is happening, but it looks very painful. He places a call.  No one answers.  He looks at his watch. It is 8 am here in Morocco, 2 am in Boston.  He does not say anything more. He picks up his stuff, still looking at his phone, I hear the clip running again. He starts walking away. Should I follow him?  I’ll give him space. ## Chapter 40: Sara - Boston I am up early, before my alarm clock even. I have a new energy. It is 5:45 am and today is the first day of my new life. I tossed and turned all night with anxiety of my decision, but today I feel like a page has turned. I head to the kitchen to make coffee. I decide to celebrate with a cappuccino. I get out the scale, measure the beans, grind them fresh, and tamp them down. I lock in the handle and push start. The machine makes horrible noises and a concentrated essence of coffee emerges by way of pressure and hot water. A smell erupts from the cup. I feel like I’ve never smelled coffee before today. Everything is sharper and clearer than yesterday.  I steam the milk and pour it over. The milk drops in with a glop at the end. I never learned latte art. Maybe with my new free time! I have so many ideas though, I have to figure out how to monetize #ChiMILF. My mind starts racing and I lift the cup to my lips.  I never noticed how sweet the steamed milk is when it is aerated. I lick my lips. The hot coffee hits me next, nearly burning me, insulated as it is by the blanket of foam.  I spit it out into the sink. Wait, can I drink coffee? I’m pregnant. I’m pregnant? I’m pregnant! Can I drink coffee? Should I drink milk? Maybe I should switch to oat milk. That would be weird, since I’m going to be making milk. But, I saw a post last week about veganism during pregnancy and all of the benefits. I can’t remember though, is coffee good for you or bad for you during pregnancy?  I put it into my search engine. I get an AI overview, “The American College of Obstetrics and Gynecology says to limit your caffeine intake to 200 mg or less per day, the equivalent of 1-2 cups.” Thank goodness. I grab my cappuccino and sip again. Wait, those AI things hallucinate all of the time. I let myself swallow this sip, but start to do my own research.  A half hour has gone by, I still haven’t finished my cup. I’m onto milk, it’s reported benefits. I also find a whole subculture of women who are pretty clear about the problems with dairy in pregnancy. I will need extra protein and calcium, which milk has plenty of, but I’m pretty skeptical of the claims about the health benefits of dairy. All of these studies, if you trace them back, are from big dairy, I bet.  I feel absolutely dizzy from reading online arguments about nutrition. I grab the cup and drain it. Screw it. A billion people probably drink coffee with milk during pregnancy and are fine. I even heard French women drink a little wine during pregnancy, and French people are no more fucked up than the rest of us. Not that I’ve ever been to France. Maybe someday! I glance at my watch. Marcus should be landing soon in Paris. Then he has a two-hour layover. There should be plenty of time to talk. I have to catch him up! He’s going to loose his shit when I tell him I’m pregnant.  I send a message: _Hey, I’m up, give me a call when you land 🥳_ I throw on my shirt, shorts, and tie my shoes. I head outside for a run. Just two miles today, yesterday was a rest day, today is intervals. I set my watch, it holds a whole training routine. It tells me how much time to spend running, and what the goals are. Today is high intensity intervals, one of the best ways to get your speed to improve. I’m excited to see how I can implement Chi Running during interval training. I don’t know if Chi sprinting is possible, but it will be a great concept to post about. The first mile is for warming my body up. I do some jogging, chi style, then some leg kids, jump squats, and heel kicks. After about 11 minutes, my timer goes off, and I sprint for 20 seconds, jog for 20 seconds, and repeat that on and off for the rest of the run.  By the sixth repeat, I’m starting to feel in the moment. I’ve gotten so tired that I no longer am trying to do all of the parts of Chi Running, I’m just floating. All of a sudden I see a woman pushing a stroller with what looks like a premature baby, it is so tiny. I cannot believe it is out! Maybe it’s just a newborn. I thought I remembered how big Joey was when he was born, but he was a “chunky monkey” from day one. But this one barely seems to have any cheeks and its hands are blueish and the size of spiders. It looks so vulnerable and fragile. I realize that I’ve slowed down to a walk even though it is still time for me to be sprinting. I push myself to start again, then my timer goes off. The interval is over. I finish on the Esplanade, with the sun now risen over the Boston skyline. I feel the sun on my face. It is the golden hour, so even though the sun is directly in my face, I look pretty good with these golden highlights.  “Hi everyone, today’s update is about intervals and chi running. I just had my first day running intervals. I found it quite difficult actually, it was hard to push myself to the edge and also keep my form. Since the key to intervals is getting to a certain level of exercise output, it isn’t about the actual speed that you are running at, I don’t have a statistical update for you. What I noticed was that the first few intervals I was really struggling. I had to keep reminding myself of my form.” I feel a little disappointed in telling the world how #ChiMILF had difficulty, but I think being open is more important right now than being perfect. I am getting attention because I’m being real.  “Then, I started to let go a little. As I got more and more fatigued, it was harder for me to keep paying attention to my form. Strangely, what happened, was that the less I tried to stay Chi, the more I fell into a type of running trance. I started gliding. I could feel my feet moving at exactly the right speed to keep my momentum moving forward. When I would come up for air, so to speak, when I would start paying attention, things would start to fall apart from a form standpoint. It was really interesting that the more I paid attention to my form, the less I was in the moment and letting my body do what it knows how to do. So there it is. I leave you today with a paradox. Trying makes it harder to be present and let your body …” Just then my screen is taken over, “Incoming video call from Marcus” flashes on my screen.  Crap, that take is ruined!   Wait, I pull myself back. I need to talk to Marcus. I click “Join.” “Hi honey! Oh my god, I miss you so much. So much has happened. I have to catch you up. Are you in Paris? What’s going on? How was your trip?” I ask a stream of questions at once, because there is too much to know right now. He is looking at me a little strangely. I don’t know how to interpret this look. “Hi Sara, so much is happening here as well. I am in Paris, just landed, still on the plane, so I’ll try to be a little quiet. I have my ear bud in so we have privacy. You start, sounds like you’ve got some news to share?”  ## Chapter 41: Amira - Marrakesh I slide into my office chair and turn on my computer.  Usually, my first day back after the weekend or from being away, I will open my calendar, look at my meetings for the day, then my meetings for the week. I will ensure each meeting has an agenda, that the people invited match the needs, and determine the key question to be answered or decisions to be made. I refresh my memory based on the previous  minutes, and start to outline a plan.  Today, I open my computer and just sit, staring at my desktop. I am organized. There are no extra documents on my desktop, which, like my actual desk, helps me focus by not being cluttered. The work of today isn’t in a document. Today, I need a strategy, and a process for moving us forward. I need to be able to hold hands with my senior team as we take a bold step in partnership.  I need to accelerate the development of the project, but transform it from one being done in secret to one being done in the light. And, I have to lead this transformation while not disclosing the arm that I brought to the conference.   The first meeting on my calendar is “Senior Team Updates.” Now I remember having booked that to reconvene after the conference. I was so naive, imagining what would happen. And, here it happened. I found partners. I can only imagine what would happen if my senior team found out. Would my board fire me? Probably. But, sure this is an important job. More than that, though, I would probably be charged with ethical and possibly criminal violations. In this country, there are no second chances. No eager investors lining up to fund your next lie. If you’re exposed, it’s over. If I mis-step it is all over, not just for the project, but for me. If you are found to be a fraud, you will not be given another scientific project to lead. You also will not be given the advantage of the position again. I will need to change careers completely, and will not have the resources to travel with Miriam. All I have worked for, to get her out of here, will be lost. I could be fired. This thought has me stuck, wobbling on the edge. I need to do this right.  My mind starts to wander. I remember the trip we all took. The whole family had piled onto a flight to London, then through Heathrow with its chaos on to Toronto. We wanted to take Miriam up the CN tower, she was just a toddler, maybe 18 months old.  It was a relatively quiet early morning on a weekday, we had risen at 3 am as a family thanks to the time difference, and had been on the first elevator of the day. Ali went to the restroom, and Miriam and I explored the lower level. We came around the turn, she wobbled along, then came to the edge of the glass floor on the lower level, and just stepped right out onto it. She crouched down, confused by what she was seeing. Then, she immediately became used to this new reality, apparently no stranger than any other reality she had seen. She walked on. But, I couldn’t seem to take the step out onto the glass. I was stuck. She wobbled ahead, and I stood there, looking down through the glass. I remember her black pants holding a diaper covered by a black shirt. But, her shoes were silver with sparkles. She got almost to the far end, then lost her balance and dropped on her butt. She twisted and looked at me. She reached back and beckoned me, palm up, opening and closing her tiny hand with the opposite gesture of waving good bye. I continued to be paralyzed by the view. I could not believe that the glass would hold me. I could not get myself to step out.  I held my hand to the wall and leaned forward. I could not bring myself to rest my shoe on the glass. I knew I would fall the 30 stories to the ground. I could see tiny people lining up to buy tickets under my feet. I could imagine the glass breaking down on their heads, and me falling, falling, falling… Miriam got back to her feet and unsteadily traversed the whole glass panel. She was heading out the far end, now leaving my view around the continuous circle.  Ali found me, standing there, alone. “Where is Miriam?” He asked with wide eyes. There was no anger there, just confusion. I pointed across the glass. “I couldn’t do it! I didn’t know, should I run around the entire circle? Can you go find her? Please, Ali!”  Then I see him, with contempt for my weakness. How could I leave our daughter alone? I would do anything for her, but I couldn’t face my fear? Ali bolted across the glass, and within a few seconds he was coming back around the corner holding her hand. He didn’t even look at me as they walked past.  I eventually found them at the bottom of the tower, looking at flowers.  I will never again stand frozen while Miriam is at risk. I cannot let my fear overcome what needs to be done.  I lift my hand and look at my palm. I open and close my fingers, like Miriam had. I hover my hand over my mouse. Then I move my mouse to the agenda. I hover again. I open the agenda and start to type.  I know exactly what needs to be done.  I am the one to do it. # Wednesday, July 27 ## Chapter 42: Marcus - Boston A giant honey bee has landed on my left arm. I am at a Jurassic Park like place, giant ferns with psychedelic colors are over my head. It is hot and steamy, and I am lying on my right side. Something has happened and a branch has knocked me to the ground. Is this the Montreal Biodome?  After I took the Step 1 exams at the end of second year of medical school, we had a week off and Sara and I took a cheap northeast road trip. We walked and walked around Montreal for two straight days, then decided we would take the public transportation to the Biodome. Those days were so fun. We didn’t have much money, we stayed in the cheapest crappy hotels, but we were free of this constant pressure. I feel the buzzing on my wrist from the bee again. Buzz, pause, buzz, pause. I look at it and I see it trying to take off, but it is stuck to me for some reason.  I open my eyes and realize that my watch alarm is going off. It is black in the room. Why is it so hot? Sara’s arm is over my shoulder, I peel it off. Even though we are only wearing a sheet, we are stuck together by the heat and humidity. The AC must be off. It is midsummer in Boston. Actually, the power looks out completely. No lights anywhere, probably a brownout. Anyways, it is 5:00 AM, my alarm is going off, I have to get ready for my meeting with Amira and Pierre.  I sit up, and try to see Sara in the darkness. I can hear her, but if I make anything out of her it is just barely an outline. My mind is playing with me, I think I see her lying on her side with a tiny baby bump. But, I know this is just an illusion. There is no way that she is showing yet, at least not noticeably in this light. Maybe the tiniest little tummy has grown, but it is more like a normal human lower belly than a pregnant abdomen at this point.  Since I cannot see anything, I wait and listen. What I hear is almost a purring. She sounds so calm and at peace. Since she quit her job and became an influencer, she has been working harder than ever before.  I wish I could support her better, but she’s been up late every night learning everything she can about content creation. I don’t know anything about what she’s doing. And I go to bed by 9 or 9:30 to be up for my early calls.  With their jobs and the time zones and my job, we have found that meeting at 5:30 AM EST allows them to meet during their lunch hour Monday, Wednesday, and Thursday. Amira doesn’t work Fridays, and Pierre can meet most days when he is teaching and only works clinically on Tuesdays. I can meet almost every day at this hour, unless I’m on call. This is how we have managed to make so much progress in the three months or so since we met in Morocco. And, I’ve changed my goals a little. Sure, academic promotion is amazing, but what if I could be free of the chains of academic medicine completely? As we have gone along, I’ve realized there might be a huge financial payback at the end of this journey. A hyper-realistic human simulator is incredibly valuable. I would keep working as an anesthesiologist, but not full time. I could move out of academics to the private sector and keep developing the technology. Sara, the kid and I could be free of our money tensions.  I would do anything to get back to that sweaty but free smile I see on the front of my phone when she calls. I want to be able to play catch in the evenings, go to dance recitals, and even some elementary school graduations, always on a weekday morning.  I’ve seen how my partners argue with the department chair on being able to get a morning off here or there. But, mornings in the operating room is where hospitals make their money. And they depend on the anesthesiologists to staff the cases so the surgeons can cut, sew, transplant, and most importantly to NEG, to send enormous bills for hundreds of thousands of dollars. A small European company made a realistic premature infant mannequin and they were recently purchased by Laerdal, one of the industry giants in healthcare simulation.  I don’t know how much they were purchased for, but I’m guessing it was millions and millions of dollars. And the market for that technology is pretty narrow, neonatal intensive care units. This technology is much more generalizable.  By working off hours, from home, on my home email, I am not using any of the hospital’s resources for this project. I’ll be damned if I’m giving the intellectual property rights over to NEG, as we call New England General Hospital. Sure, I take the meetings at work when I’m on call and nothing is going on, but when that happens, I don’t even use the hospital WiFi. I’m careful to do it over cellular, which works surprisingly well on WhatsApp. I have been keeping the meeting minutes including how we met, what time, etc. to make sure if they ever were to come after me, I show how I didn’t use any of their resources. I turn on my phone light and head to the bathroom. I wash off in the shower really quickly, since the AC is out, a quick shower will cool me off. Then I check the power in the kitchen. It’s out, too. I look outside, it looks like this whole area of the city is out. I find the headlight I keep in my backpack and put it on.    I grab a match from over by the candles, and turn on the gas range to heat some water for a cup of coffee. I like hot coffee, even in the summer. I make a cup of the top-end instant coffee that we keep around for these types of “emergencies.” The milk is still cold in the fridge, so the power can’t have been out for too long.  I light a few candles, and set up my laptop for the meeting. I tether it to my phone by plugging in my phone, which will use the cell phone service to access the internet despite the power being out. Wait, is the internet on? That’s a good question. I open my phone and check my email. The email loads, so I think the network is working.  I sit back, sip my coffee, and take a few minutes of calm before 5:30 comes.  This project has moved from interesting to critical. And, we have so much momentum.  We have come so far, at least in what we have created on paper.  Can we create the technology that lives up to our imagination?  Pierre and Amira seem to think we can. I wish I was so sure. ## Chapter 43: Pierre - Paris Teaching ends at 11:30, so I’ve got to get done right on time so I can make it to the meeting with Amira and Marcus.  I look at the medical students coming back from the simulation. They don’t look upset. This is really the first time that they look ready to learn after that particular case.  This is the same case I have been running for years. The situation is exactly the same, the challenge remains how to both resuscitate the patient and figure out their goals of care at the same time. The difference this time, is that we co-created our learning goals with a shared set of objectives. In Morocco, I had gone to a session called, “Are your learners ready for this sim?” It was put on by a wonderful man, Mohammed, who was from Libya originally but is now working as an anesthesiologist in norther France. He talked about how learners can reject our case if we haven’t prepared them for the case properly.  I always thought, these students are training in Emergency Medicine. They have to be ready for anything, anytime, anywhere. But, he convinced me that part of what they might be rejecting is not the ideas I’m trying to teach, but the method of teaching. If they do not yet have the sophistication to grow in the scenario I have given them, they might feel embarrassed and ashamed by the case, instead of having learning activated by the case.  So, I made a subtle change to the course. We still have three and a half hours and the same overall approach. But now, up front, I tell them the objectives very explicitly.  I said, “We need to be ready to handle this challenge. We need to be able to start a resuscitation immediately, but we need to know the patient’s goals of resuscitation in order to know how to care for them. Let’s figure out what we might want to be able to do at the end of the day to make progress towards having the skills to do that in the real world.” I look back at the board and see what we wrote this morning. I stood up at the board, and transcribed what they said: “Compassionately incorporate family into the resuscitation”   “Communicate what is happening quickly and directly to the family” “Determine the goals of care while implementing basic comfort and care interventions” “Put a team member in charge of reading the medical record for goals of care while others focus on the patient” “Ask the patient what they would want, if they are able to communicate” So, after they have all sat down, I start my debrief. “I’d like to take our remaining time to reflect on progress that we made towards our co-created objectives. Let’s look at the board together. Read through those, and please, when you are ready, let me know what you have learned today.” I look proudly across the group of five students. They are men and women, light and dark skinned, lots of tattoos, all in the mid-twenties or so. They are so easy to love. I feel a little bolt of juice injected into my bloodstream by something. I really do love these kids. And, that Jonah, he is really cute. I sigh.  Jonah starts, “I’ll be honest, I don’t think the strategy of asking the patient usually works. When they are gasping for breath, they can’t make good decisions. I think I’ll ask the family, but I think in a lot of cases that isn’t the best strategy.” André chips in, “Yeah, it just doesn’t seem realistic to put a team member in charge of figuring out goals of care. I mean it works here, but there are five of us. When it’s just us, how are we going to do that?” Nour jumps into the conversation, “I agree, I mean having five of us, it really changes the dynamic. I’ll never have five doctors and no nurses. It was just an unrealistic scenario. I still don’t know how I would both manage the patient dying of difficulty breathing and figure out their code status. I guess maybe I could put them on a non-invasive ventilator in some circumstances, but not always.” I breathe deeply. Now they are complaining about the lack of realism from a participant standpoint. I cannot win. I rub my forehead, and respond. “Here’s the thing, this is your chance to learn, to try, to see how hard it is and how important it is. If you are going to complain about the fact that five of you are here, talk to the school. I don’t make the rules. They send you here five at a time, what am I supposed to do? Just because it’s not perfect, it doesn’t mean you are incapable of learning something, does it?” As that last sentence rolls out of my mouth, I immediately regret it. Yasmina responds, “No Doctor Diop. We can learn. We are always learning. I believe that I have learned that what you want us to do will take more work and practice.” She rescued me. I nod, feeling suddenly foolish. “I am sorry to have to end there. I have a meeting at 11:30 and I believe you are now off for lunch then you will be back at 12:00 for the afternoon session with Doctor Masson. She will expect you here promptly.”  Doctor Masson will have them running ACLS like machines. She does a great job with the cookbook algorithms. I focus more on the mental challenges of becoming a physician.  It’s easy to teach people a recipe to bake by, much harder to create a path for them to learn how to become chefs.   ## Chapter 44: Amira - Marrakesh “Hi Marcus and Pierre, welcome back and thanks for joining us on time. We have a lot to catch up on. I am thinking today we should review where we are at with our parts of the project, and then decide next steps to keep moving us forward with more our momentum.” I start the meeting with balance of optimism and leadership. As CEO, this is a skill I have honed over the years. “Hi Amira, good to see you. I’m happy to report some progress on my end. I can start unless Pierre wants to.” Marcus goes first. “That’s fine Marcus, go ahead.” Pierre consents, we are used to the American needing his voice early in the meeting. “Ok, so I have done some prototyping. Of course, I don’t have human cultured skin to work with but I was looking at options and I got some pig skin from the butcher to use. Of course, pig skin is thicker than human skin and has more fat with less support structures, but it is a good metaphor given where we are at in the process. I am happy to report that the actuators will move the skin without any difficulties. Our original use for the actuators, providing narrow places of pressure that were constantly supporting and releasing in order to prevent pressure on any one spot from being there for too long, is quite different than how faces move to create expressions, but the overall theme is correct and functional. I believe we will be able to recreate some elements of facial expressions quite successfully. Since the actuators push a proboscis or almost a tiny finger, and we had originally designed for this finger to go up and down, we need more degrees of freedom to get the expressions to work well.” I let Marcus keep going, here we are seeing the realities of combining our technologies with some of the keenest details yet. “For example, let’s talk about the similarities and differences between surprise and pity, both of which we would want to convey. With surprise, the whole upper face opens. The eyebrows raise, the forehead wrinkles, and the eyelids open. These actions would be well re-created with a single upward movement of a series of actuators that push up on the eyebrow, we would want also to be able to pull up the upper lids. However, pity involves the raising of the central eyebrows without the lateral eyebrows, the forehead scrunches in the middle, and the eyes soften, with a bit of pinching in the areas lateral to the eyes. In my mind, this means our actuators need to both be able to push in multiple directions, and pull from multiple points. This will be possible, but it will require some complex manufacturing, combing pushing forces with some type of pulling forces. Anyways, I view that as a good news and bad news situation. I created a mockup using pig skin, actuators, and a glass eye.”  Marcus switches to sharing video. “Ok, watch this. I’ll show you first surprise, then pity. Granted, this is early stuff, but I have found a local 3-D printer where some college kids work where they are printing stuff like this. I’ve drafted a mockup of a contract for them to create a prototype for us. Anyways, watch the video, it’s definitely coming along.”  The video shows skin with an eyeball in the middle, stationary. I see the skin lift up and in, and lift up straight, and lift up and out from the center of the eyeball. I start to feel sick to my stomach. Not only is it against much of what I believe in to recreate a human face at this level, but to do it with pig skin is quite disturbing given my upbringing. This is an abomination on an abomination. Marcus continues, “So, what I need is agreement that this is the right path for my part. Pierre, how would an AI use this?” Pierre enters the conversation, “From my standpoint, the AI is great at identifying the emotion that the character would portray. It is simple to then have it call for a certain set of actions simultaneously with the words it would use. For example, what if the AI wanted to portray surprise and then sadness? If they were told out of the blue that their loved one was possibly dying, then they are put in the position of making a decision about their life and death situation, the AI would need to direct the non-verbal gestures that a human would exhibit. I know that AI characters currently do this using a digital avatar. I have not heard of it being done with a physical avatar, but I don’t see any reason why it can’t be. In fact, I can guarantee it can be done, and I will find out how by the time we meet again. I agree, you are on the right track.”  Every fiber in my body is rejecting this entire project. Pig skin, human faces, re-creation of human beings, AI and its moral dilemmas, how did we get here? I put a similar mask on my face. I lean forward, pull the corners of my mouth up and out, scrunch my eyes, monitor my pitch, “This is incredible. I cannot believe what fantastic progress we are making. Marcus, you are on track and doing things I never could have imagined. Pierre, your wisdom of what AI is capable of is phenomenal. We are going to change the world. I am in, are you?” The meeting ends, and I go directly to the bathroom. I look in the mirror. I mechanically cycle through expressions: surprise, pity, horror, love. They come one after another. I have been hiding my real feelings for so long, it comes without any effort now  I put a handful of paper towels in the sink and put the water on high. After the sink fills, I plunge my face into the sink. I scrub and scrub.  Finally, I lift up and look again. It is the same; my face is still a mask. I pull and twist, seeing if I can find the real emotion, seeing if I can free what is trapped inside. My face is red and puffy, tears are falling down my cheeks. At least now my real sadness is showing.  The door to the bathroom opens, so I plunge my face down again into the water, and rub at it, then emerge. “Some allergies, so sorry.” I say and don’t even make eye contact or look to see who it is. My mask is back on. I walk out, head down, blotting at the corners of my eyes. ## Chapter 45: Sara - Boston Marcus is almost ready to leave the house when I get up. I shoot down the hall to the front door to say goodbye. “Have a great day, honey! Love you.” He pauses at the front door, and closes it behind him while still facing me. Usually he is in a huge rush to get out the door, but today he takes an extra moment. “I can’t believe what is happening. The last few months have been such a whirlwind for us. I’m so proud of you, baby. I just want to let you know, I’m proud of you and with you no matter what happens.” I’m standing there, stunned. He kisses me right on the lips. He isn’t the type of person to give out comments and statements like that or to frequently show that type of affection. I know he loves me, but he just doesn’t say it directly like that too often. Tears well up in my eyes, but they don’t flow. I give a huge smile, wrap my arms around him, and just hold him for a minute.  “Okay, I really have to go now, I’m going to be a little late, but it was worth it. See you tonight, love you!” The door closes, and the quiet of the apartment feels comforting and not vacant today. I turn and head back to the kitchen. All of the clocks are flashing and it’s super warm in the apartment, so I guess the power went off again this morning. We’ve been having a ton of rolling brownouts lately with the extreme heat, but hopefully with this morning’s thunderstorms, it will be a little cooler today. Either way, I have to get another video made and posted. My numbers have taken a dip lately. I am not sure if it’s the algorithm punishing me, but all I have read is that the secret to maintaining your followers is about consistency in posting. I have been a Monday, Wednesday, Friday, Saturday poster since my second week. That seems like a good rhythm to keep people engaged. Instead of coffee, I have a small mocha smoothie and a couple of tums. That combination seems to give me a little energy to run, yet doesn’t cause the massive acid reflux I’ve been experiencing lately. I know the baby isn’t pushing up on my stomach yet, but boy have things changed in my digestive tract. I never had awful vomiting, but I have had a lot of nausea. And the morning, while the time when I have the worst of the nausea, is the coolest time to run. I put on my lime green tank with #ChiMILF across the back in hot pink and the hot pink booty shorts with just a little #ChiMILF in reflective print on the left thigh. They have a sleeve for a cellphone on the right thigh, and a small pocket on the low back for a pair of keys and some energy bars or something like that.  I designed these so the panel would stretch through thirty weeks, maybe all the way. Right now it’s folded over twice, hugging me tight — for now. I have to say, these look hot. I think they should keep me feeling tight until this thing is over, but who’s to say how I’ll feel at 38 weeks about flaunting my tummy.  They also have a sleeve on the left that matches the cellphone sleeve. The sleeve perfectly holds a legal-sized pepper-spray and whistle combination that we sell. I drop one in to have on hand. Not that I feel like I need it, but it’s good to have just in case. And, part of the just in case is that I might meet someone who wants to buy them. I check myself in the mirror. Yup! I bend over and tie my shoes and get a squirt of acid up into my throat.  Ugh, what the hell! Should I wait until this settles down? Naw, maybe running will help? I stand up and feel a little dizzy. I sit down again. I should probably drink more before I head out into this heat. After drinking, I try again. Less dizzy standing up this time. Hopefully that extra water doesn’t come back in the form of more acid reflux. How many Tums can you take in one morning anyways? Should I ask Marcus? No, I’ll just make it work. I think two is the max at a time. I open the door to outside. Even though it is only 8:30 in the morning, it is really hot. I was hoping the early thunderstorm would have cooled things off, but instead it seems to have created a Finnish sauna effect. Someone poured water onto the hot rocks, well the sidewalks, of Boston. Today is Wednesday, which means for training that it’s the last long run before the weekend. I’m scheduled for 6 miles. I don’t think I’m overdoing it. I read an article last year in the Boston Globe about a woman who ran a marathon at 38 weeks pregnant. I know it can be done.  I start with a walk to the Esplanade along the river. There is less shade there but you are away from the cars and traffic. By the time I’m at the Charles, I’m soaked with sweat. But, I’m pretty warmed up, so I just start heading west along the river.  I’m focused on my body, my breathing, my contact, my posture. I am right where I need to be, in the moment of the run. This meditation is why I’m #ChiMILF. As my mind wanders to the business, I pull it back to my feet, my ankles, my knees, my hips, my abdomen, my lungs, my shoulders, my mouth, my nose. I let my mind sweep up from the ground to check over and over how I’m doing.  And, before I know it, I have gone 3 miles and it’s my turn around location. This feels fantastic. I’m one with the running, I’m in the flow or the zone or whatever your want to call it. My music of choice, EDM, or electronic dance music, is thumping in my ears. I get a sound track that is EDM tracked to my tempo goal. The music pulses, my feet glide, my breathing is controlled. Bang! I’m pulled out of it by a woman who stepped right in front of me waving her arms. I do a little half-step, twist to the left, and fly off the sidewalk onto the grass of someone’s front yard trying to not knock the woman over. I pull out one of my ear buds, “I’m so sorry!” I yell. “No I’m sorry! I just wanted to say Hi. Are you ok? Here, let me help you get up.” She comes over and puts her hand out. She looks absolutely crushed by what happened.  “It’s ok! I’m ok! I was just in the zone, you know. So, I didn’t see you there. I guess I was just lost in the moment, not paying attention to where I was going. Hi, I’m Sara,” I say, brushing the dirt off my knees. She looks like she wants to hug me. Weird. Her eyebrows have pity in them. She starts to cry. She is talking to me through the sobs, “I didn’t want to hurt you. I’m just a huge fan. I just wanted to tell you I was a fan, that’s all. And now you’re hurt. It’s all my fault.” It’s not pity for me, it’s self-pity that she’s experiencing. Oh well.  “Honestly, I … I think I’m okay.” I say. I actually feel fine, I just kind of rolled onto my side. “Yes you are, look, your leg is bleeding.” Her sobs are slowing down. I look down, blood is running down the inside of my leg. It’s probably just a scrape. I rub at my thigh. Then, I realize I’m bleeding down the other leg as well. I start to feel dizzy.  Baby, Marcus, baby.  Oh no.  I sit down, hard.  ## Chapter 46: Marcus - Boston I race out of the hospital to meet Sara. My heart is pounding and deep breaths aren’t helping. Goddamnit, why does she push herself so hard?  I race around the parking garage, tires squealing on each turn even though it doesn’t feel like I’m speeding. These garages are so annoying. I pull up behind the car in front of me, they are struggling to reach the badge reader. “Come on, come ON!” I talk to myself, windows up to not make a scene. Then I see them drop their badge and open their car door. “Oh what the hell.” I turn around, no one behind me. I back up about 20 feet and pull into the other gate. I tap my badge, the gate lifts, and I pull out onto Longwood Avenue and weave down to the Riverway, which is flowing well at this time of day given it is still rush hour in the morning. Then I hit Storrow Drive and come to a halt.    “Damnit, Damnit, Damnit!” I pound on the steering wheel. I can hear the fear in her voice when she called telling me what happened. She was blaming herself, “I shouldn’t have been running. Oh, why do I do this to myself?”  I try some positive self-talk. “Okay, okay, it’s just some bleeding. Many women have some bleeding during the first part of their pregnancy. She’s early still, we don’t know that anything is wrong. Let’s get an ultrasound, then we will have the data we need. What’s her blood type again? Will she need Rhogam?” Medical thoughts crowd my head.  I realize I’m turning her into a patient as a way of coping. I have to be careful, get this out of my system before I pick her up. She’s not my patient, she’s my wife. This is my child, unborn as it is. “Fuuuuuuuuuuck. Move damnit.”  I swerve into a tiny opening between cars to advance another ten feet. The person behind me lays down on their horn and beeps at me, not happy with my move.  I put my left hand out the window and raise my middle finger with the Boston wave. Finally, after I don’t know how many angry people and horns blaring, I make it to Waltham where I find Sara sitting on the grass. She isn’t crying, which is good. I pull the car over and put it into park on the side of the street. I don’t care if this is a spot or not, people can go around me. I jump out of the door, and race over to her. She looks up and sees me at the last moment.  “Hi honey, I’m so sorry.” She bursts out crying again.  “Oh Sara, you have nothing to be sorry about. I am so sorry you are going through this, we are going through this. What do you want to do? Do you want to go home first and clean up? Or, should we go right to Dr. Harrison’s or the ER?” She’s sobbing onto my shoulder. At 19 weeks pregnant, there really isn’t anything to do for an episode of bleeding. There are not any procedures that can halt a miscarriage if it is happening, it is a totally helpless feeling and I hate that sensation.  “I called Dr. Harrison while I was waiting, I got to talk to her actually. She looked up my ultrasound results from last week and there weren’t any problems with my placenta, so she said it’s probably just a little, hold on I wrote it down,” she scrolls her phone, “subchorionic hemorrhage. She said those are common and generally harmless. She said my blood type is A+, so I don’t need that medication. So, I could go home and take it easy, no heavy lifting, no vigorous exercise, call if a big gush of fluid or blood or cramping. I started feeling movement over the last week, so if anything changes there I should call right away.” She looks up at me with a lift of one eyebrow. “And, no sex for the rest of the pregnancy.” “Okay, wait, what? Oh, I get it. Hah hah.” Amazing that she’s able to joke right now.  I take her hand and we walk back to the car together.  The drive back to our apartment is quiet, but not tense. We are just together. But, my mind is wandering, as usual. An awful memory from training bubbles up: a new mother was flown into our ICU. She had a rare and life threatening problem after delivery called, somewhat ironically, HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets. Her small blood vessels started to develop tiny clots in them, why? No one knows. Her HELLP had progressed to chew up the red blood cells and platelets and then her liver crapped out. It can be a vicious cycle of clotting and bleeding that spirals out of control. And it happened fast, she was only two days after delivery. I remember her swollen body being pulled over from the helicopter stretcher, it looked like she had been thrown out of a car. She was covered in bruises, tubes from every spot in her body were oozing and draining blood. They were infusing her with blood, plasma, and platelets as well as multiple drips to keep her blood pressure up. She was clearly dying, but she was also a brand-new mother. She deserved to live, unlike so many of the elderly patients with dementia or people with clearly terminal cancer that we were keeping “alive.” She needed to live. She needed to feed her brand-new daughter, to watch her grow, to love her. We gave her everything we had.  Immediately after arrival, we were pouring in blood products. But we were spraying gasoline to put out a fire. Adding more platelets, loaded with foreign proteins from another donor, made her immune system lash out. It started destroying the very blood we hoped would save her. Finally her heart just stopped. Plugged by clots, starved of oxygen. Then everything else — lungs, brain, kidneys — followed. A cascade of dying. We started compressions. With each press on her sternum, between the breasts swollen with milk they had never gotten to let down, blood would spray out of the tubes draining under her armpits, draining the bleeding around her lungs. Blood was pouring out of her breathing tube, her urinary catheter, and even where the IV’s were secured in her arms. It was futile, but we kept at it anyways. When the attending finally called the code, none of us knew what to do. We all just stood around, no one even silenced the monitor. We just stared at her bloated form, blurred through our tears. Then we realized the next pain we had to endure, telling her partner that the love of their life and the mother of their two-day old child, had died. I still remember her wife’s shocked face, disconnected from the arm rhythmically rocking the baby in her carseat. I looked at Sara, but saw the bloated form of the dead mother sitting next to me. The mother was sitting up, wearing Sara’s running gear, melting into the seat. I had put a white towel down under Sara, and I could see blood pooling on it. I try to shake the image, but the puddle of blood is all I can see. The last few months had seemed unreal. From Sara’s unexpected fame, to her pregnancy, then my trip and partnership with the Moroccans and Pierre. In January, when I was planning the year ahead, I could never have imagined any of it. This feels like one of our simulations. I’m in a story on the edge of credibility — designed for what learning, exactly? ## Chapter 47: Sara - Boston A quiet afternoon at home with Marcus is what I need. Let’s just sit on the couch and watch the Red Sox. They have a day/night double header after the game was rained out last night. The team is good enough to be entertaining, but they will break our hearts again by teasing us in August with some wins, then will drop off with their annual “September Slide.” In some strange way, the emotional roller coaster is reassuring to a Red Sox fan. Sure, when they won the World Series in 2004 we were excited, but we get uncomfortable when the team is consistently good.  I am lying back with my head on the arm rest, my feet on a pillow on Marcus’s lap.  “It just kicked! That is the weirdest feeling.”  His phone buzzes. He is tapping out a reply.  “Marcus, did you hear me?” What the hell? This is huge. It means everything is ok! I’ve been holding my breath for the last three hours, since we decided to go home and rest instead of going in to see the doctor. He looks up, for a moment. “Is that the first movement you’ve felt since you fell?” We both know what this means. “Well, maybe. Sometimes I can’t tell if I feel it or not. Like, sometimes maybe it’s just gas, but that was definitely a kick.” There is no way to tell someone what it feels like to have an independent body growing inside yours. And now I know, it is still there and kicking! “Back, back, back, back, against the wall, and it’s off the top of the Monster. Aguillara slides into second with a double.” Yay, the Sox have a man on second base in the first inning. Maybe this will be a fun game to watch. I grew up with my mom as a huge sports fan. She took us to games all the time. We sat in the bleachers, getting soaked by beer, watching fights break out. One time, a guy behind us was asking everyone if they wanted to buy any cocaine. My mom was so tough, she turned around and told him to shut the fuck up. For me, watching a game is not just a great way to have a relaxing evening. But it brings my mom back, I feel like she’s still with me. Who wants to doom scroll the news? Nowadays, we all need a healthy distraction from the real world.  The socials used to provide that for me. Well, I’m not sure how healthy it really was. But for now, it is my job, and definitely not a healthy distraction. I look over and Marcus is back to tapping away, so I scroll the feeds and check my stats. The follower counts are pretty steady, but my watch numbers are down. I didn’t post today, and I probably won’t tomorrow either. I try not to break the chain, to stay consistent, but you have got to put your priorities in the right order.  Today’s scare has properly placed those numbers, though. What seemed important yesterday seems trivial today. Who cares about watch numbers and followers? Being enslaved by an invisible algorithm is so chaotic. I’m not happy to have the distance a health scare provides, but I do accept the lesson. “Who are you texting anyways?” Marcus isn’t usually a texter. “Amira. She is angry with her mom and it’s hard for her to vent about family with people in Morocco.” He doesn’t even look up. Well, that’s interesting. I don’t think of Marcus as being a listening post, and I’m his wife. “She lives with her mom, right?” He has told me a little about Amira. “Yeah, since her husband died from renal cell carcinoma. Her mom moved in to help her raise Miriam, her daughter. Then, when her daughter got injured in the earthquake, her mom became indispensable.”  “Ugh, I had forgotten about her husband dying. I can’t imagine.” Going through even this alone would be brutal.  “Yeah, it happened when she was pregnant. And, I don’t think Amira has many friends. She’s the CEO of her company. It’s lonely at the top as they say.” Marcus explains. That’s a lot of detail about someone from Marcus. For one, he doesn’t usually pay attention to other people’s social situation. The fact that he even knows about her life is unusual. I remember one time he went on a four-hour bike ride with a friend of his who had just been divorced. I asked him how things were going for Jeremy, and he said, “Honestly, we didn’t talk that much.” He has been distant and distracted since he picked me up. Today, of all days, I thought he might be paying attention.  At first, he was so caring and loving. Then, when we got in the car, he was looking at me really weirdly, like I was a ghost.  Sometimes I feel like he goes away for a while. I don’t think it’s seizures, he just kind of floats away into his own head.  He told me once that is what he likes about being an anesthesiologist. Much of his day is spent alone, behind the curtain, deeply focused on the numbers in front of him. He’s a tinkerer, he loves making micro-adjustments to see what will happen.  When he was a little kid, he apparently used to play flight simulators for hours. He wouldn’t practice landing very often. He would just tap keys to keep the plane at a constant height and direction. One time, when we were visiting his parents, he pulled up his old program on the video console.  He got lost in it. I was watching over his shoulder, and after a couple of minutes, I was so bored. But, he was happy as a clam.  Not me. I need to be with people. That’s part of why I want a child. I love the idea of spending all day with another human, watching him or her, or them, grow. Especially if I’m going to be working by myself, like I am now. Sometimes I spend the day with Jaimie and Joey, just hanging out, watching Joey be a kid. Children aren’t weighted down by the world. They don’t yet know what they can’t do. I wish I could be like that. I always feel pressure to achieve. Even the running, that used to be a way to stay in shape, has become something with another goal. Now it is my job.  I have to run. I have create a story, then record it, edit it, and post it. I have to thread the needle of selling without making it feel like I’m just selling. I have to do these things because I quit being an architect. And, I don’t want to be like Jaimie, dependent on her husband for every paycheck.  I’m not saying she doesn’t pull her weight, she does everything around the house and with Joey. It’s just that I’ve seen too many women in that position who end up without their husband and without a way to live a stable life on their own.  Come to think of it, Amira has her own career and is making it without her husband. Respect. ## Chapter 48: Amira - Marrakesh “Well, Pierre, I guess we should get started. I tried Marcus but he hasn’t answered. I hope everything is ok for him. How are you doing today?” My rule is a meeting starts no later than five minutes after the start, if you aren’t there, that’s your problem. “Hello Amira, thanks for asking. Honestly, I haven’t been able to make much progress since our last meeting. I had a run of shifts and teaching, and have not had any time for anything else. Between that and my dad, it feels like I have been working all the time.” Pierre responds, looking spent. “Let’s look at our action items from last meeting. I’ll pull up the notes, let me share our screen. By the way, is the AI scribe on? Ok, see here. Marcus was going to look into potential sources of initial funding. I understand there are multiple ways to get initial funding for projects like this. He was going to compare grants, private funding, and public private partnerships. We will have to wait for him to report back on that. I was going to create some videos of the different facial tissue types, so you can start planning how the expressions will come across. Pierre, you were going to do a literature review. Have you made any progress on that?”  “Ok, I did find some literature that might be helpful. I started looking Ito different forms of simulation and the strengths and weaknesses of each. What I mean by different forms includes simple task trainers, hybrid simulation where humans wear task trainers, so called ‘high-fidelity’ simulators where whole mannequins are used with lungs and hearts and vital signs that can respond to actions or be programmed, virtual reality, computer-based avatars, and human actors. The newest kid on the block is augmented reality, where some type of virtual reality is overlaid on other modalities. There is really very little comparison of the different modalities in research, but there are some best practice recommendations.” Pierre appears to have done some work after all.  “So what have you found for research?” I think it will be important to know what is out there for us to make our best argument for why this technology matters.  Pierre looks a little defensive. “This is just a preliminary scan, but the level of research is quite limited. For example, in 2025 there was a randomized trial of trainees on using a task trainer versus a ‘high-fidelity’ simulator to learn placing a tube in a patient’s esophagus to stop major bleeding. They actually found the task trainer was better. They believe this was because fewer distractions and more focus on the specifics of learning the job. When the learners  were immersed in a full simulation, there was more for them to pay attention to besides just learning the task. The concept is called “extraneous cognitive load,” meaning anything your brain has to pay attention to that is not doing the task or learning the task is a distraction to the learning process.” “Well, that implies that the fidelity is not that important?” This would be a big problem because it explicitly contradicts the goals of our entire project. “Yes and no. I think a question is ‘when does fidelity matter and when does it distract?’ Maybe the ‘high-fidelity’ trainer distracts because it actually isn’t high-fidelity. It’s still just a plastic doll. It can demonstrate fidelity for the clinical problem in certain circumstances, but if you are trying to reproduce emotions, or certain physical attributes, then you need different tools, or even real humans.” He is starting to get more nuanced.  He continues, “In some ways, those mannequins can be lower fidelity for the task at hand, and they can be weird to work with. There is this idea called the ‘uncanny valley.’ As models or graphics approach real humans, they get really creepy. In fact, it’s less strange to work with a version that is very unrealistic, a cartoon is better than a CGI that is not perfect. The technology has to cross the valley to get to realistic, or our human brains get distracted by the yuck factor. For example, did you ever come across the American horror movie called ‘Child’s Play?’” He pauses. “No, I don’t think I have ever heard of that movie.” Being raised in a conservative household often makes me feel like I missed a bunch of references. It is true that American movies were often released overseas, often later, or pirated and watched. But, not in my household, not with my parents. I’m picking up that this is not a movie I would have liked. Not because it’s scary. Because it hits too close. The idea of something almost human, animated and dangerous? That’s not horror to me. That’s grief with a face. ‘“Child’s Play” was made in the late eighty’s and it was about a doll that came to life, was re-animated, and was trying to murder everyone. I think a lot of the creepiness was due to the doll being almost human. Sometimes I see a Chucky like character to the simulation mannequins. Their eyes open and close and they speak, but they have no facial expressions, which is disorienting. It works for anesthesiologists whose patients are all asleep and expressionless. But in the ER, most of our patients are awake and for me, it is very much a turn off. That’s why our mannequin, if it can do this better, has a real chance of being a game changer.” Pierre wants perfection, Marcus will probably be ok with good enough.  “Ok, what I am hearing is that we need to cross this uncanny valley in order to make a, what is the word, frogleaping, technology. But, there is a risk. We might end up with a Chucky if we don’t get far enough.”  I think back to washing Miriam’s hair. I would give anything for her to re-animate, for her to move from trapped and silent in her human body to being awake and conversant. I take a deep breath, and move the meeting forward.  “Wait, here is Marcus. Hello Marcus, thanks for joining. I missed you earlier.” ## Chapter 49: Pierre - Paris Now we need to catch up Marcus. I hate when meetings have this start-stop pattern. Best to just finish and move on. I’m probably just overtired, makes me grumpy. Amira starts, “Hi Marcus, I’m sorry you were late. I missed you. Let’s catch you up.”  Marcus, “Okay, thanks. Sorry to have missed the start. I had an emergency here, but things are better now.”  I’ll hang back and let Amira run this. “So, Pierre was just letting us know that we need to avoid what is called the ‘uncanny valley’ and not make a ‘Chucky’ like mannequin that reminds people of a re-animated horror movie where dolls try to kill everyone.”  “That sounds like a good idea to me as well!” Marcus winks a little. Amira continues, “Also, Pierre was saying that there really isn’t much research for what technologies work best in what contexts when it comes to simulation-based learning. Pierre, you mentioned some expert opinions.” I jump in here, “Yes, going way back to 2007, Peter Dieckmann, David Gaba and others wrote an article about the concepts of when different realities matter. This was followed by Jenny Rudolph, Robert Simon and Dan Raemer, who wrote an editorial called ‘Which reality matters.’ Together, this dyad of papers lays theoretical groundwork for when does reality matter, and if so, which types of reality.” Amira jumps in, “What do you mean, which types of reality?” I continue, “Well, maybe that came out wrong. Which types of fidelity matter. Fidelity, as they define it, is the way the model reproduces the real world. Is it physical fidelity, social/emotional fidelity, or conceptual fidelity - ie. does the case ‘make sense.’ Reality is defined by the people experiencing the situation, in this case, the learners. For a long time we've been asking learners to accept a certain lack of fidelity for the sake of learning. But if we get to a place where the mannequin is real human tissue, does this matter anymore?” Here's where Marcus jumps in again, “Amira, this is what I love about your arm. It was just real. They didn't have to be any ‘suspension of disbelief.’ Somehow, you had made the real thing.” I add in, now excitedly, “That's what people say about conversing with an AI, they can't distinguish it from a human. It just is real, so we might get beyond a point of fidelity. So a real person behind a real mannequin, does this debate even matter anymore? If participants can't distinguish between an actor and a mannequin, those lines go away.” Marcus, “You are making me excited. I can’t believe I’m saying this, but I’m in love. I haven’t felt this way in years. I want to see you again. Can we make plans?” I jump in, “I have to step away for a minute.” The conversation has gotten inappropriate, I don’t want to be present for it. They have forgotten I exist, I mute myself and turn off my camera. But, I keep listening. No recognition of what I just said, Amira just leans in.  “I want to see you as well. It would mean so much for us to be together. I know how much progress we could make in person. But, the way things are in the US right now, it is too risky for me to travel there without a permanent plan, a sponsor, and all that. I can’t afford to get stuck at the border, or worse, in some cell. We need everything in place for us to be together.  Would you be willing to come to Morocco again?” Marcus continues, talking only to Amira. “Of course, Amira. I would love to come see you again. This might be sound crazy, but I have vacation in about 5 weeks, right after Labor Day, and I didn’t have any plans. I used my week of CME going to the conference last time. I didn’t take any vacation over the summer so I got an extra week in September since we don’t have any kids I thought that was a great trade.” I had noticed some flirtation on previous calls, but I’m not sure what is happening here. They do not even notice I am gone. This is beyond flirtation, I know flirtation when I see it. I thought something had approached a line in Marrakesh, the little stares and glances were adding up to an attraction.  But now, I’m wondering if that line is being crossed. I am feeling like a third wheel now in the way this conversation is rolling. But, can I do anything? Well, I want this project to move forward. The closer they are, the more energy they will put into the project.  This building relationship would be good for me as well. I am somewhat concerned because Americans are quite uptight about extra-marital concerns, much more so than us French. On the other hand, I don’t want things to get messy. But, they are adults.  If this all burns down, it won’t be because of me, it will be because of them. ## Chapter 50: Sara - Boston What did I just hear? I definitely didn’t hear what I thought I just heard. I got some cramps and had to run to the bathroom. It can be shockingly hard to tell what organ these feelings are coming from. Do I need to pee? Do I need to poop? Is that the baby moving? Am I having a complication? They can all feel about the same: I get a vaguely uncomfortable sensation coming from down there, it builds, shifts, I try to pee to see if that helps, it releases. Did peeing help? I don’t know, but it feels better now. That’s a typical cycle for my body to go through. But, right now, I’m extra sensitive to anything. Any feeling I get opens the door to the horrible question, “Am I about to loose this baby?” So, with that heaviness binding me, encircling me like a girdle, I got some cramps. I ran to the bathroom. Marcus apparently joined a call from the guest room/office. I can hear through the other door that connects the rooms.  But, it sounded like I was hearing phrases like “love” and “see you again.” It didn’t sound like meetings I’m used to. What the actual fuck is happening to my life? Normally, I would flush, then get up and leave. That’s my way. No reason to see what comes out of me. But, I don’t want to make a noise, so I stand. I bend over to pick up my pants, happy that I can still do this with the growing tummy, and turn around.  The toilet is full of blood. I blink. I stare. The water is red. Deep red, with clots.  I crumple.  I text Jaimie, “I need you. Can you talk?”   “Give me 5, I’ll call you.” She replies I check my watch, it’s 2:35 pm, she’s probably picking up Joey. The meeting probably lasts till 3. I need to move, I need to get out of there. I head outside and start walking, I’m literally spinning, I don’t know where this feeling is coming from. Am I losing blood? Am I spinning from Marcus? How can both of these be happening at the same time as all of this craziness with the rest of my life? Did I even hear what I thought I heard? Could it mean something else? Please, please, please call Jaimie.  Deep breath, deep breath, deep breath.  I tell Jaimie what happened today, the whole thing. Tears wet my face, but I only ugly cried at the beginning. Jaimie is such a good listener, she doesn’t try to tell me I’m crazy, but she does make me think about if I heard what I think I heard. Was there anything else lately?    “No, really. Jaimie, he’s always been distant and distracted. He’s a guy. He works a lot. I haven’t noticed anything! This is out of the blue.” I go on and on with this train of thought. “Well, I don’t want to tell you what to do but I think it’s possible that you didn’t hear right or you heard right but you didn’t get the context. I mean, could the words you heard mean anything else? Could he love working with them and say something like that? I’m _not_ trying to gaslight you! I just don’t want you to jump off a bridge that doesn’t actually exist.” Jaimie is putting doubt into my mind.  Fuck, everyone does this to women, even other women. We are told we don’t know what we know. We are made to doubt ourselves. But, maybe she’s right! Damn, another cramp. I look right. I’m in front of “Bee and Bonnet.” This is one of our local coffee shops, they are super nice and I go there a fair amount, or I used to when I was an architect and I just wanted another place to work. “Jaimie, I’m going to call you back. I have to use the bathroom.” I hang up. “Hi, can I use your bathroom?” I’m holding my baby bump. “Bathroom is for paying customers.” She looks at me with glazed eyes, tattoos on her neck and arms, piercing on lips and nasal septum, huge false lashes and strong makeup.     “Fuck me, I’ve gotten a hundred coffees here. I’ll have a flat white, decaf. I really need the bathroom.”  “What kind of milk? Cow, Oat, Almond, Soy?” She responds flat and soul-less. “Cow please.” I courtesy and keep walking to the bathroom. “Hey, you haven’t paid.”  I keep walking. The door is locked.  I come back. I tap my phone. No tip. “What’s the code?”  “One-Seven-Seven-Four” She replies. I bet she doesn’t even know the meaning of 1774 in Boston. This country is doomed. “Hey, what’s your name?” She calls after me. “Amira” I respond. I don’t know why I say that, but I don’t want to be Sara right now, that’s for sure. I sit alone on that toilet for a long time. The cramps come in waves. More blood on the toilet.  Alone in the Bee and Bonnet, that’s how this is going to go? With Marcus on a call with someone else telling them he loves them? After all we went through? All the pain and disappointment. All the heart ache? And, it’s all my fault. It was my fault for running. It was my fault for not paying attention. I could have had a baby, and now it’s gone and I’m alone.  I flush and stand up. I wash the tears off my face in the bathroom sink. I wipe with my shirt. The good news is that everyone knows, literally everyone. I mean hundreds of thousands of my closest online “friends.” My whole brand is about this pregnancy. My job, my future.  This is the worst day of my life. I leave the bathroom and push the little door with the bell to head out onto the street.  “Hey Amira, your flat white.” ## Chapter 51: Marcus - Boston I hadn’t noticed how much I’d missed Amira until I joined the meeting. She brings a managerial focus that is fantastic! I just love how precise, in control, and on target she stays. I have to say, it’s really attractive. She speaks like five languages, she cares for her daughter, she runs a company. It’s impressive to say the least. And she does it with this little sly smile, this bit of an edge, this bit of spice. It’s intense, maybe a little too intense at times, if I’m being honest. But, she gets stuff done, no arguing with that! What an incredible woman! With what she has been through, to persevere, to keep going and be able to organize and create. Deep breath. Okay, what do I have to do to be able to travel the week after Labor Day? Usually, everyone at work is back by then, getting their kids into school and situated, and ready to take shifts. It’s honestly the perfect time to take off.  I had that week open, wasn’t sure what I was going to do. But, honestly, I need a break from Sara. I’m not sure this whole influencer thing is good for us. She is constantly checking her stats, checking her likes, her followers. It’s so self-absorbed! She has to make her videos in the best light, which means timing everything around her. And, now she’s talking about getting some fillers and lip enhancement. I don’t know how to tell her this, but that’s a real turnoff for me. For me, the realness is what makes people attractive. I get grossed out by the modern idea of everyone trying to look the same, pouty lips and narrow noses and perfect chins. Where’s the variety? Like Amira’s mole. It’s well situated to be just so. I always had a thing for Jewel’s snaggle tooth and Madonna’s mole.  Maybe I just need some time away, a little time to re-calibrate. In 5 weeks, wait Labor Day is late this year, September 5th actually, so she will be, well about 20 weeks pregnant. 20 weeks is a good time to be away. It’s about half-way. Not too close to the end, things are pretty settled then.  So, what do I need to do to make this happen. I’ll let Sara know that I’m going to Morocco for another conference. I’ll let work know I can’t take call that week, like I said, it should be fine. Let’s see how tickets look, okay not too expensive. Six weeks ahead can be the cheapest time for tickets, I read that somewhere. So, I should book soon. Usually this isn’t a touristy time of the year, so maybe hotels will be cheap as well. Well, you only live once and you can’t take it with you, so I should just go for it! I’ll book everything now, then talk to Sara, and still have the 24 hour free cancelation in place. Okay, done and done! Whew, exciting! Morocco, here I come. Distance makes the heart grow fonder, isn’t that what they say? Where is Sara, anyways? “Honey, are you there?” I call to the main room, no answer. I go to the kitchen and heat up a cup of hot water. I look in the cabinet. Ahhh, mint tea. Just like being in Morocco.  I drop in the bag and steep it. I like it strongly mint, with a good serving of sugar. So calming, sweet, and powerful. Just then, the door opens, Sara. “Hi honey, where have you been?” Oh no, she looks pale, and sick. She’s holding her belly. She slides down the door after it closes behind her. “I’m bleeding again.” She says it almost too quietly for me to hear. She’s looking at the door, not at me. Tears are rolling down her cheeks. She starts having dry heaves. “Come on, Sara. We are going to the ER. I’ll take you to New England General. We have to figure out what’s going on. And you look so pale, have you lost a lot of blood?” I hook my arm under hers and she barely helps me. What happened? Where was she? Why wasn’t she home?  Back out into rush hour traffic, I hate this fucking city! You have to fight and fight for every inch. Get out of the way! This is an emergency! Can’t you see what is happening here? She’s sitting quietly, head resting against the seat belt. She’s looking away, out the window. What’s going through her mind? I’m going to let her process. We get to the ER, dozens of people are waiting. We check in, tell the nurse what is happening, and there is a doctor sitting there, checking people in. “I’ll get an ultrasound ordered right now. And some lab work, we will check your blood counts and blood type.” “A-positive.” I reply. The doctor looks up, she’s confused, “Excuse me?” “Her blood type is A positive. Her doctor told us when we called her. I’m an anesthesiologist, here. I work here.” I reply. “Oh, okay. Well, we always recheck just to be sure. And nice to meet you, Doctor, is it Stein? I’m Lauren Jones, let me know if you need anything. Sorry about the wait. We will get you back as soon as we can. But we can do the ultrasound and labs while you are waiting for a room that way whoever sees you will have everything they need to let you know what’s going on. We should get a urine, so if you have to pee, Sara, collect a sample please, okay? Let me know if anything changes!”  A line is already forming behind us, so we step over and find a nook in the waiting room. Sara didn’t say anything that whole time. She just held her hands on her belly and looked down. After 45 minutes, Sara’s name is called. We have labs drawn, then back to the waiting room. But, someone has taken our corner, so we go to the only two seats open next to each other in the middle of the room. A family with three children is struggling to wait. They are all coughing, noses running. The youngest, around a year I think, is crying and mom is giving it a bottle. I get up and get us masks. Sara uses the bathroom and carries her own urine in a paper towel across the waiting room of about 30 people. Gross. Eventually, Sara is called again. A nice gentleman has a wheelchair to take us to Ultrasound. We sit in a quiet internal waiting area. The tech asks Sara if she has a full bladder, she needs a full bladder to get the ultrasound. What the hell? They told us out front to give a urine sample.  The tech tells Sara to drink water and let her know when her bladder is full. There is a water dispenser with tiny shot-glass sized paper cups. I make at least 5 trips to refill. Finally, Sara says she has to pee again, and we call the tech. No one comes. Sara really has to pee now, it’s uncomfortable. Eventually, the tech comes back and takes us to a room. Sara pulls her pants and underwear down to just above her pubis. Is she shaving now? When did that start? I look away. The tech has the screen away from us. He is totally stoic. He scans back and forth, back and forth. He pushes buttons. I try to see but his body is in the way. I’m sitting holding Sara’s hand. He has no expression on his face. “The doctor will review the images and will have results in about an hour.” “Are we going to a room now?” I ask. “I don’t know, let me bring you back out front and we can ask at the desk.” He replies - continued expressionless demeanor. “Unfortunately, we still don’t have a room for you. If you’ll take a seat we will call you when we do.” The nurse out front tells us. We take a seat again. This time next to an elderly couple. She is holding his hand, he keeps saying the same thing over and over. “My neck hurts. Are we at the hospital? What happened? Did I fall?” She patiently answers, it must be a dozen times.  We wait, again. ## Chapter 52: Amira - Marrakesh What just happened? Did I really invite Marcus to come visit? But, I’m not ready! The prototype is not ready! Why did I do it?  So much to do, so much to prepare. And, how can I get ready for him to take the next step, for us to take the next step? That thinking is for tomorrow. Right now, it’s bedtime. Miriam needs me to be present with her. I close the lid to the laptop. I look down the hall to Miriam. “I’m coming just now honey, finishing some work right now.” I take a few moments for myself. I boil water in the kettle, pour it over some mint leaves, and drop in a sugar cube. I inhale deeply. The smell is overwhelming. It is sweet actually. How can a smell be minty and sweet? There is so much mystery in the world. I take a sip. And another. One more, then I’ll be ready.  “Mother, do you want any tea? No? Ok, let me know if you do later.” I head down the hallway to Miriam’s room, the light is off and she should be nearly sleeping now. It is past her bedtime. I’ve kept her up with my meeting, and my delays. I’ll get her changed, and read to her, even though it is late. She never wants to miss bedtime stories. “Miriam, I need to get you ready for tomorrow. Now lay your head back. There you go. Keep your eyes closed. It’s bedtime now. I’m going to get you into your nightshirt. Oh you have gotten so stiff, now give me your hand, give me your hand, Miriam. Please! Help just a little!” I hope beyond hope that physical therapy can still help her, that occupational therapy can still help her, that mainstreaming in classrooms is still possible. “It is possible, isn’t it mother? That she can get better? That with enough help, enough therapy, she can, maybe not be normal again, but be better?”  I look at mother, those eyes, so much wisdom behind them. She doesn’t need to say anything, I know it’s a long shot, but it’s our only shot. “Tonight, I will read Goodnight Moon. This is one of the most old-fashioned but classic American bedtime stories.” I turn the book towards her. “Okay now, I begin. Settle down — In the great green room there was a telephone and a red balloon and a picture of the cow jumping over the moon ... ” I linger on the first pages. “Look honey, the cow is jumping over the moon in this little picture. Can you see? Can you see? Tell me you can see, goddammit, tell me, tell me!” I am shaking her. What is happening? I am losing control. Not me, I won’t lose control. My self control is all I have.  “Mother, are you there? Mother? Where are you?”  I don’t hear or see her anywhere. I hope she didn’t see my outburst. I feel my cheeks flush. Is it embarrassment at my behavior? Anger at my situation? Shame at my promises? I cannot tell, I just know that I need to pull it together. And soon. When Marcus gets here, he needs to see me as a partner, to want me to return with him. He must need me to return with him. How can I get there? How can I become undeniable, unavoidable, inescapable? I know things have been hard in his marriage, and his work. He must see me as a way out of his traps. Not just me, but what I have, what I represent.  “Zahra, are you there? Talk to me Zahra. I need your advice.” ## Chapter 53: Pierre - Paris I’m off the call and almost ready to head home. I took the meeting from the simulation center after my evening shift in the ER. I still need to pick up, clean up, and get this place turned over for tomorrow.  Simulation programs are places where everyone chips in, I’m no exception. I often empty the trash, pick up the chairs, do whatever it takes to make us ready.  Healthcare does not optimize for education. We get by on getting by. It is a tragic truth that being an educator in healthcare is usually less money, less status, and more hours. The joke I tell my mentees, “If you want to make less money around here, go into education!” Actually, it’s no joke.  It’s not just healthcare, of course. Academia rewards us in other ways that are non-financial. I have many interesting experiences.  Even this connection with Amira and Marcus, so fun and interesting! I don’t know what the hell they are up to, but it _is_ interesting.  Tomorrow, we will be running cases in the operating room. I take a stretcher and start pushing it to the OR. “Manny, I need to get you ready for tomorrow. Now lay your head back. There you go. Keep your eyes closed. It’s bedtime now. I’m going to get you into your gown. Oh you have gotten so stiff, now give me your hand, give me your hand, Manny. Please! Help just a little!” That was wasted energy. Of course Manny cannot help. But, I often find myself talking to the mannequins.  When I talk to the students, I don’t call them dummies, or mannequins. I call them by names, human names. This one is usually Manny. I want the learners to treat them as people. But, of course, they are not live people. I think that the more I treat them as real, the more the students will be able to buy-in.  Once we have PeauRealle up and running, we won’t have this problem with those mannequins. But, there are lots of low-cost plastic mannequins out there that will last for decades. So, this problem will linger. Well, I won’t solve it tonight.  Now, I need to get him intubated. I’ll open his mouth, and with my left hand holding the handle, I place the laryngoscope into his mouth, then advance it back into his pharynx. There is his epiglottis, lifting, and now his vocal cords are visible.  I take my eyes off for a moment to grab the endotracheal tube that will connect the ventilator to his lungs, when I look back, the vocal cords are gone.  “Damn, must have slipped. I’ll do it again.” I pull out the laryngoscope and go to re-insert it. But, now his teeth are clenched closed. I cannot open his mouth easily. There is a setting that does this, we have one that clamps his jaws, another to inflate his tongue, others to close his vocal cords, there are many ways we can make Manny impossible to place a breathing tube in. But, Manny is off, so how could those settings be enacted right now? “Hello? Is someone playing with the mannequin right now?” No answer. I didn’t think anyone else was in here. Let me try again, maybe I just slipped, or was stressed. I lubricate the tip of the tube so it will pass the cords, rubber on rubber doesn’t slide well. Now his mouth opens easily, I visualize his tongue, his uvula, epiglottis, and finally cords. I pass the tube easily. I turn on the anesthesia machine, the bellows deliver a breath, the chest inflates, and a breath returns to the machine. So, the ventilator is attached, and Manny is ready for the OR tomorrow.  I turn off the anesthesia machine but leave Manny intubated. Doing this to a patient, and they would asphyxiate in about 6 minutes. Brain death would occur rapidly. This used to be a major cause of death in the operating room: malfunctioning equipment, misplaced tubes, disconnected oxygen, lack of effective ventilation, these and many other errors could lead to asphyxiation under anesthesia. Now, modern monitoring has made these outcomes exceedingly rare.  Silence now, no breathing, no sound but my own.   Still, it feels strange to leave someone intubated with the ventilator off. Like I’m setting Manny up for a horrible end. But, Manny isn’t real, right? He’s a mannequin. I take a few steps to the door of the OR. I look back one more time. Manny lies still, like a body waiting for the coroner. I turn off the lights. I grab dinner around the corner from the hospital, a poulet rôti avec pommes de terre. Hearty and satisfying, the chicken and potatoes warms me inside and gives me just enough energy to get home. I am wiping my fingers when I come through the door. It has been such a long day. “Papa, I’m home.” No response as usual. Maria is not here today, another care taker I don’t know, Mamadou is his name. I introduce myself. He speaks a hardened French, western African I believe, the consonants are stronger than mine. But, he seems nice enough. He goes back to scrolling on his phone.    “I’ll change then come help with Papa.” I get into something comfortable. Well, at least not scrubs. I guess scrubs are the most comfortable, but they feel wrong to wear at home. When I come back, I reach down, and immediately realize something is wrong.  He’s stiff and cold. “He’s so cold.”  I look at Mamadou, he freezes. He looks carefully at Papa. There is no breathing, no movement. His warm chestnut skin is pale, taut, and bluish. There is no doubt, he is dead. Mamadou grabs his phone and his jacket. “Desole, Monsieur.” And runs out the door. Silence now. No breathing, no sounds but my own. I press my fingers to his neck. No pulse. No breathing. “Oh, Papa. It is over. I am so sorry, Papa. Close your eyes. Be at peace.”  His shirt has food on it, as does his chin. I go get a fresh shirt and a towel. I wipe the food from his chin. I try to open his mouth, but it is shut tight. I cannot pry it open. I pull his shirt off, but the sleeve catches on his hand. “Now give me your hand, give me your hand, Papa. Please! Help just a little!” Finally, the shirt is off. I go to the refrigerator where the number to call is posted. I pick up my phone, staring at it. I am unable to punch in the numbers. # Monday, August 15 ## Chapter 54: Sara - Boston “It has been almost three weeks since I have posted anything. I know many of you have been worried about me, and thank you for all the support. I would like to give an update without going into too much detail.” I take a deep breath. “The last three weeks have been very difficult for our family. I had a medical emergency and have not been able to run. But, now, I am recovering. So, today, I am back. I am going to take a run. It probably won’t be far or fast, but it is the best I can do under the circumstances.” I’m not as weak as I was. By now, I’ve walked out to the Esplanade, it’s mid-summer so I’m out early to avoid the worst of the heat. Luckily, the sea air is cooling the city with an offshore breeze so far today.  “As you can see, I’m wearing my #ChiMILFStrong Singlet in honor of today. Some of you have been able to be mothers, and some of you are probably in my group. Those that have not wanted to or been able to have children. Yet. But, I am still pregnant — after a big scare. And, now I am back. I’ll be honest, you might see me walking, you might see me jogging, but you might see me running. I’m committed. #ChiMILFStrong is my identity, it is what got me here, and I am who I am. There are no guarantees in life. But, if you see the finish line, you should try to cross strong, and give it all you’ve got. And, that’s what I’m doing! I’ll come back at the end of the run to let you know how it went.” I start to jog, holding the phone in selfie position in front of me. I go through my mantra. “Breathe from the belly” I tip my hips forward, loose ankles, brush my feet on the ground and take off. Despite being 17 weeks along, I don’t have much of a baby-bump. With all the stress, running, and how I’ve been watching what I eat, I actually have lost weight this pregnancy. I’m not scrawny like the cross country women, but, I’m fit. I’m jogging into the sun, towards the breeze, towards the salty smell coming off the harbor. I was so grateful when my doctor said I could start running again. They didn’t put me on bed rest, exactly, but I was limited to “gentle, short walks.” I felt so sluggish, really. In many ways I was trapped between two things I wanted.  I had the desperation of the pregnancy — a miracle after all we had been through, up against the pressure of my career and passion. #ChiMILF had turned into so much more than just my career. I was now being recognized for doing good in the world. Women would stop me and thank me, they would give me hugs. A few times people even cried when we were talking. I represented something to them, something about acceptance.  It feels so fucking good to help people accept themselves. And I was the face of that. To be recognized on the street, not for something I did wrong, not for being a scammer like Anna Sorkin. It was more like being Michelle Obama. Honestly, who is going to give that up? I feel the pavement under my feet. Someone waves to me, I wave back and smile. I focus on my form, the meters melting under my feet.  My mind falls back to Marcus. Will I have to leave if he’s falling for someone else? With all I have done to be self-actualized, to be self-sufficient, to become a mom. Could it actually be that when I get there I’m alone and getting child support?  I get a cramp and come up short. “Fuck, fuck, fuck, fuck, fuck.” I hate having to stop. But, I have to listen to my body, to practice what I preach. I realize that I’m crying.  Luckily, I find that I’m in the middle of the Bill Russell Bridge. There is a bump out where you can stand and look towards Winthrop. I put my back to the crowd of pedestrians and commuters, and let the tears drop down into the Mystic River, the world doesn’t even register my presence.  Screw that! I’m not going down without a fight. I turn around, my back to the bars of the railing. I lean back, my body over the harbor. I scream up into the sky. “Buckle-up, I’m just getting started!”  I pivot forward and look at the people passing. People are zipping by on electric scooters, headphones and helmets on. They are speed-walking with ear buds, they are running to work with tiny packs. No one notices my primal scream. Just another fucking crazy person on a bridge.  I turn around and head back the way I came. I feel the downhill of the bridge pull me — gravity plus Chi Running giving me wings. The wind and sun are at my back now, I can feel the world pushing me forward. I have the momentum.  I focus on my form, and every time my brain starts to pull itself back towards my anxieties, I wrestle it back to my mantra.  I pull up out front of the apartment without pausing. My heart rate is a pounding 170, my breathing is ragged. I try holding my arms above my head to help open my chest, and I throw up on the ground in front of the entrance.  The bile still stinging my throat, I realize this is gold, exactly what the world wants to see. I hit record.