Story Crafting Below the Surface

By Jolene McIlwain

Once upon a time, I could literally see inside people.

Before I tried and failed at my dream of becoming a published poet, before I wrote a novel, and a group of short stories (the former sits unpublished in a drawer and the latter was published last year as the story collection, SIDLE CREEK), and before I spent years teaching literary theory and analysis at two Pittsburgh universities, I worked as an X-ray technologist.

In high school, I had been a science-and-math girl who’d loved art but knew she couldn’t actually be an artist of any kind because “How are you going to make a living at that?” was the unsaid (and, well, sometimes loudly voiced) question.

But I had taken a few writing courses in high school, both taught by the local poet, Delbert Baker. He inspired us with his love of language, of the line breaks and enjambments, of the power of metaphor. He’d self-published his own books. They were on sale at our local bookstore. He was like a celebrity to me, and he LOVED my creative work. I actually enjoyed diagramming sentences and building my lexicon with weekly vocabulary tests as much as writing poems and stories. Before he retired, Delbert Baker told me—no, demanded—that I go for the arts, not the sciences. But I ignored his words for many years.

Growing up working class in the 80s—the Reagan and Bush Sr. years—I knew what was expected of me: find an occupation that would pay the bills, earn a retirement savings, and, of course, offer health insurance benefits.

Attending college was the plan, and as I debated between a few of the schools where I’d been accepted, I was confronted by a new reality: my parents had both lost their jobs, and I’d have to defer my college dreams until I could afford to pay for that on my own.

Instead of going for that four-year degree, I chose X-ray school. It cost $1800 for classes and $300 for books. I’d be finished in two years, and I’d start making good money! (At that time, good money was a whopping $5.75 an hour!).

Happily, I loved it. Taking these X-ray “pictures” brought out the artist in me, and learning about the physics involved with radiographic technology scratched the math-and-science itch.

And little did I know, the field of radiographic technology would help me in myriad ways with what is now my current occupation—writing.

As an X-ray tech I had to write a lot. We were responsible for compiling detailed histories of our patients, creating narratives that would support or enhance what the radiologist would see in the radiographs we’d shoot. It was one of my first lessons in a different kind of storytelling.

Also, I learned a new language: medical terminology and technical terminology specific to radiology. There were cool polysyllabic words with Latin roots like esophagogastroduodenoscopy and hysterosalpingogram—(the latter would show up in the piece of writing my future agent would read and find me through). These words added layers to my conversations. I loved that I was suddenly and fluently bilingual.

Just out of high school, in this world of X-ray technology, I was fascinated by how much we could learn from the body, with the help of these exposing rays. I studied kVp (kilovoltage peak) and mA  (milliamperes), and Marie Curie (the first woman to win the Nobel Prize for her research in “radiation phenomena”). I lived through countless busy days of bodies telling stories—sometimes subtly, sometimes overtly.

I learned of gaps in story, something techs like me, with the help of the radiologists, worked together to fill. The positioning of the body, the framing of the X-ray, made a real difference in diagnoses, in the overall story.

For example, the levels of fluid and air in the lungs could be best visualized when a patient was in an upright position—sitting, standing—as free air always rises and fluids will locate to the bases of the lungs.

When diagnosing a fractured patella, we’d set up what was named a “sunrise X-ray” with the leg bent and the beam angled so the kneecap, when radiographed, looked much like a sunrise over the mountain of the leg bones—showing the gap in the patellofemoral articulation through what was called a tangential view. It was the only position that could show this.

Sometimes X-rays in a series had to be specifically ordered so that the test—or the story—made sense. While doing upper and lower gastro-intestinal diagnostic X-rays, techs lined up the films on the lightboxes. (When I was a tech, we didn’t work in the digital mode so actual films that looked like large negatives had to be positioned on lengthy lightboxes—now doctors can flip through a series of digital shots on their computers). The same was true with procedures that showed the path of contrast from the kidneys, through the ureters, to the bladder, and out of the body. The order of these X-rays on the lightboxes was so important in making sense of the story. In a series of X-rays the radiologist would always seem to find the one or two shots that best showed the crux of the body’s story.

Years later, while studying story craft, I’d see that this work in X-ray inadvertently led me to re-see how stories can be manipulated for the best reading, how to pair down to the most important scenes, sentences, words and much more.

For example, POV is such an important decision in both lines of work. I wrote briefly about this for The Journal of Compressed Creative Arts a few years back. Precise language is so necessary in both as well. Backstory—well, doctors and readers need to know what led up to the inciting incident, whether it was what happened just before stroke symptoms began, or just before a character decides to run their car off a cliff.

Both jobs required markers to sometimes lead the radiologist/reader into the right direction. In X-ray, we had tiny metal beads, wires, arrows, and left and right leaded markers to show the doctors more specifically where the point of pain existed, where the masses or scars or moles were located. Markers in writing might present as several beads of powerful motifs and repeated images, transitions aimed to smooth time jumps, and details selected to orient the reader in time and place.

In radiology, we were exacting. We didn’t want our X-rays to be misread. That could lead to improper care, delayed healing, or even death.

Also, in our patient histories, and during our procedures, we were required to note body language, sounds, scents, touch. Anything we could add that would make a more vivid story was helpful to the radiologist: How is the patient reacting to the questions? Is the patient light-headed, pale, sweating, chatty? We paid close attention to the number of respirations, crying, tensing jaws, clasped hands.

As an X-ray tech, I learned that “showing, not telling” should be used in most cases.

Accuracy in description—and not allowing readers to make assumptions—was paramount in X-ray as is the case in effective storytelling. We could not include, in our patient histories, any assumptions about the patient (i.e. “the patient is intoxicated”), but we could write that the patient was staggering or slurring her speech. This had to do with making the wrong diagnoses as well as a host of other reasons, not the least of which was that it was not up to us to judge the patient. Once I had a patient I’d believed was terribly drunk who was instead suffering from dangerously low blood sugar. (I also learned from a senior tech that sweet breath from high acetone levels could smell like alcohol.)

Many years later when I was working as a university instructor, a doctor in the ER thought my dad was drunk when he was actually experiencing a brain bleed. He’d fallen in our dog’s outdoor run, had dog feces and dirt on him. If he’d come into the ER without us, I wonder how he would have been treated? The importance of detailed, clear descriptions of patients made all the difference and this is equally true for writing characters.

Another big connection between writing and radiology is based on the Rule of 2s, which is often taught to X-ray technologists and other medical students. I returned to these rules of X-ray often as I thought about storytelling because, after all, the body tells its story, with the help of X-ray, that will glean an understanding of the diagnosis of the patient. According to the latest list of rules, there are at least ten “Rule of Two” considerations—some lists have twenty.

Here are some that specifically apply to story crafting (to read more about them, go to a sample chapter from Otto Chan’s book, ABC of Emergency Radiology):

Two Views: One view is too few.”

Many bone fractures go undiagnosed with only an AP (anterior/posterior) view or only a lateral view (side view). Sometimes, in fact, a third or fourth view, called an oblique or tangential view, is the one that finally “tells the story.” So, when in doubt on the page, when I’m really stuck (or even if I’m not), I’ll often write a story in another character’s POV.

The writer/teacher I had in my junior year of college, Cecilia Rodriguez-Milanes, instructed us to write a very short story—maybe from a childhood memory. When she returned our work, her new assignment was: Write this story in another POV. Each week, she asked us to change the POV. I wrote the “same” story in at least five POVs and it quickly taught me that when I thought I was finished with a story—when I thought I knew everything I could know about my characters, their actions, etc.—I had much more to learn and these extra POV shots showed me what I was missing.

Two Joints:

When X-raying a long bone, like the femur, we always made sure to include joints above and below the injury to get the full picture. This could illuminate additional issues or important details, as frequently, the information around the big event is just as revealing as the event itself. In our drafts of stories and novels, we tend to worry a lot about writing that pivotal scene, that inciting incident, that huge conflict or climax, and we oftentimes neglect the scenes that surround those. This can, and often does, lead to melodramatic writing, or worse, incomplete writing that falls flat. It’s these parts—on either side of a fracture—that illustrate how the characters react, revealing more about their world views, their limitations or their strengths.

In one of my stories in SIDLE CREEK entitled “The Less Said,” I included a few major scenes, but I found in revision that the real story takes place in the pivotal scenes on either side of the tragic events, or societal fracture. In another story, “Seed to Full,” the story takes place after a stillborn comes into a couple’s world—nothing of this birth, the pregnancy, is really revealed. The depth of story is found in the aftermath of this couple’s fracture.   

Two Occasions:

Our radiologists always asked for previous X-rays, if any were available. For comparison.

Comparing the before and after of a story’s world is often required in order to help the reader understand the true impact of the story world’s equilibrium. Just as seeing a patient’s abnormal lung doesn’t tell us as much until we see their healthy lung from a few days or weeks before, in comparison, seeing a character in crisis means more when we can imagine them in their normal state.

In an X-ray, vessels, ureters, some soft tissues, etc. are difficult to visualize unless a material is added (by I.V. injections or by drinking, for example) that is denser than the tissues around it, blocking or limiting X-rays from passing through. On an X-ray, the contrast material appears bright white against mostly gray and black gradients. Similarly in writing, one of the best ways to see things clearly is to show their opposites or juxtapose them. Gabriela Pereira, founder of DIY/MFA and writing coach, outlines effective ways of using contrast in our stories. 

Two Sides/Two Visits:

Sometimes, a fracture won’t show up in the growth plate area of a child’s extremity. However, if they return weeks later to be X-rayed again, the new growth around that same site will reveal that there was, in fact, a fracture. Or, if a child comes in to be X-rayed for an injury and there’s a history of old fractures to the same bones or others, the fractures could be related, and a skeletal survey will be ordered to rule out bone diseases, or in some cases, parental abuse.

The writer Charles D’Ambrosio, in a lecture I once attended, spoke of this idea of the first mention not revealing enough in a story. He called this: “Einmal is keinmal,” meaning, “once is never.” Even better, something repeated twice, something Russian Folklorist, Vladimir Propp, called “trebling” or showing up three times is very satisfying for readers. (Read more about it here.) 

Repeating X-rays helps the radiologist form an accurate narrative for the diagnosis.

Repeating an image, idea, or object makes the greatest impact on a reader, and this is why I am the biggest fan of the strategic use of numerous types of repetition to drive a point home. Repetition in the form of phrases, like the anaphora in Charles Dickens’s A Tale of Two Cities, makes the writing memorable:

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.”

Another example is motif repetition in The Great Gatsby, a green light that appears at important points in the narrative, indicating that we should pay close attention.

Those years working as a radiologic technologist allowed me to view what’s not readily visible to the naked eye and proved that details make the story, whether you’re trying to understand a patient—or a character—inside and out. I may no longer yell out, “Hold your breath!” and zap people with radiation to see deeply inside them in my current work. But I hope that by using what I learned in those dark buzzing rooms—where scatter radiation bounced off walls, where the X-rays I took assisted in large and small ways with diagnosing and even healing people—I can work hard to hold my reader’s attention, zap them with a story that might just take their breath away, and help them deeply “see” my characters and their trials and triumphs with X-ray vision.

Jolene McIlwain

Jolene McIlwain has taught literary theory/analysis at Duquesne and Chatham universities. Her stories appear widely and have been nominated for Best American Short Stories, Pushcart Prize, Best of the Net, and anthologized in Best Small Fictions. Her short story collection, Sidle Creek(Melville House)set in the Appalachian plateau of western PA—where she was born, raised, and currently lives—received a starred review from Publishers Weekly and was selected as one of NPR’s and Library Journal’s Best Books of 2023.


2 responses to “Story Crafting Below the Surface”

  1. This is so good and I enjoyed walking down memory lane in the Xray world. The essay read like it could easily be a graduation speech; both uplifting and encouraging with direction.