I began working for Mr. Johnson when I was thirteen years old. My friend Rob was his neighbor and had worked for him before, leaving for a more lucrative position mowing riding trails for the Kensington Saddle Club. Rob and I worked together the first few weekends, and he showed me where the pruning shears were kept and how Mr. Johnson liked the enormous garden hose coiled in long loops rather than in a tight circle. When Rob left, I got that first-day-on-the-job nervousness again, but Mr. Johnson was a kind man and easy to work for. He was about sixty, balding on top with grayish-blonde hair, and an old-time thick moustache. His wife was also friendly, though quiet, and prepared wonderful lunches for us.
Mr. Johnson took an active interest in the care of his place. It was a large piece of land, even in our area, hidden far from Donlea Road by thick woods. The house itself was of the midwestern farm style, and sat behind an old hedge. There were many birch and maple trees scattered among small, well-tended gardens. Across the drive was a small corral adjacent to the huge wooden barn, and a long shed containing the vast supply of tools and equipment. Behind the house was a giant, sloping lawn that curved gently against the thick oaks and weeping willows, like a soft green pond. Further off was an old pasture and the dark, silent lake where Rob and I fished for bass and big northern pike. All thiswas Mr. Johnson’s, cared for first by him and his son, then by him and Rob, now by him and me. It was really beautiful.
I settle into a routine pretty quickly. I would ride my bike over in the cool early morning, and get right to work trimming the hedge. Mr. Johnson would leave the trimmer out on the porch for me so I could start with this quiet chore while the house was still sleeping. I would glide the trimmer over the protruding, upstart leaves, with dew still stuck to them, cleaving them neatly. Afterward, Mr. Johnson would come out with a list and tell me where to begin. He might say, “Some branches fell down in the back pasture. What I want you to do is haul them way back in the woods, so they can’t be seen when the leaves turn brown.”
He always explained why he wanted things done a certain way. He would make sure I understood, then leave to tend to a chore of his own. Sometime mid-morning, when the grass had dried, I would begin cutting. Halfway through that first summer, he taught me how to operate the tractor. It was an enormous machine, an ancient International Harvester, with only a little of its faded red paint remaining. It had a large and intimidating mower deck underneath. Mr. Johnson had been using this to cut the big area of lawn beyond where I had cut with the hand mower. He showed me the levers for raising and lowering the deck, and how to adjust the choke to start the thing under various conditions.
“When she’s cold, you’ll have to choke ‘er all the way,” he yelled, over teh din, and “watch those belts there. You get a hand caught there and she’ll rip your arm out the socket.”
I climbed way up onto the little seat, which gave way with steel-spring tension, startling me a little. Mr. Johnson laughed, “She don’t have any shocks. That’s the only shock she got.”
My muscles tensed, and with nervous hands I put the tractor in gear and took my foot off the clutch. It lurched, then stalled, and I stomped back down on the clutch. “Easy, now,” said Mr. Johnson, and I eased out the clutch, slower this time. It lurched forward again, but caught, and I rolled ahead. “You got ‘er,” he yelled.
I rolled along toward the lawn with a proud smile. There was a strong gasoline smell, and the machine coughed out black smoke now and again. After I had finished mowing, I stopped to examine my work. I smelled the fresh-cut clippings, and, walking along, stained my tennis shoes green.
Arriving one Saturday in October, I found sitting in the drive a big, gasoline-powered roto-tiller. Mr. Johnson had rented it to mulch the dead plants in the vegetable garden. The air was cool by now, and the leaves had turned. I could taste the rich scent of autumn, the brooding power of this fleeting season. I first gathered the bulk of the plants for the compost heap. They had already begun to rot, and were wet with a pungent, organic smell. I also collected the dead, half-grown squash and eggplant that had already begun to decompose and mingle their soft flesh with the black earth. The tiller was a powerful machine, with menacing blades protruding from the front and wheels covered with dried mud in the back.
“This beast’ll pull itself,” instructed Mr. Johnson.
I stood behind the tiller and held the handles tightly, without fear. “Let her chew on that dirt awhile, then lean on her a bit. She’ll move ahead. Greener pastures.”
With awesome power, the blades tore through the soil, churning the mulch in its revolving course. I made my way slowly back and forth under the raw, gray sky.
Around noon, Mrs. Johnson rang the bell by the back door. Her father, who lived nearby, would sometimes join us for lunch. He was old and somewhat feeble, but still pretty sharp. Though not appearing overweight, he was bulky, and I remember thinking he must have been very strong at one time. He had bushy eyebrows and was very friendly. When Mr. Johnson and I came in that day, he was sitting at the kitchen table, talking with his daughter. The kitchen was warm and thick with the smell of beef stew.
“It’s nippy out there today, huh fellas,” said the old man. “I don’t believe it’s getting any warmer.”
“That’s right, Pop,” said Mr. Johnson. He looked at me with a smile. “We’ll be pruning back the rose bushes this afternoon and covering them for the winter.” He had warned me a few weeks before about this particularly tedious chore. “You’d better dig out the iodine, Sally. The kid may need it before this day is over.”
The stew was hot and delicious. We ate it with warm bread and big cups of cold milk. Suddenly, Mrs. Johnsons father began coughing violently, struggling to inhale. I was sitting closest, just on his left, and watched not knowing what to do. He wasn’t completely choking, but obviously suffering. He coughed out chunks of food and spit. Swaying forward, he inhaled deeply, easier now, his face bent over his plate. Something clear, tears or saliva, fell from his face. Mr Johnson helped walk him to the bathroom to clean up. I was sweating.
“Growing old,” muttered Mr. Johnson. “Growing old is hell.”
After a couple of years, I left Mr. Johnson’s to work as a busboy in town. Now, years later, I am struck with the clarity of these reflections. At the time, these things just happened. They seem to mean more now, to give some twist to logic, some sort of insight. Now just four weeks away from graduating from medical school, I am still trying to understand these things.
During the first two years of medical school, the students never even touched a patient. In June of our third year, we took the National Boards exam, and started in the hospital soon after. We had had an introductory course in clinical medicine where we practiced the physical exam on patients who had varying degrees of tolerance for fumbling students. My first real assignment was internal medicine at the nearby Veteran’s Administration Hospital.
The medicine rotation at the VA was notorious for breaking the spirit of many a medical student. We all knew beforehand what we were getting into: 80-to-100 hour work weeks, on call overnight every fourth night, and a team of only one resident, one intern, and one student to take care of up to thirty patients. Menial labor-intensive tasks, known as scut, performed at other hospitals by paid employees done here by the team. These things trickle down, of course, and the intern and the student typically started all the IVs and drew blood in the middle of the night. Patients came to the VA because they had served their country and had no insurance. The VA was considered a step above the county hospital, or maybe half a step. Our patients, coming from the west side of Chicago, were mostly poor as hell. Regular health maintenance was not a priority in their tough lives, and the bloated, poorly-funded federal system did not particularly encourages a change. Admitting a patient with a tumor like a softball sticking out of the side of his neck was never a surprise.
We met that first morning, the eight students, outside the designated conference room. Our short coats were clean and white, and the men wore their favorite ties. We showed each other our stethoscopes and made nervous jokes about bringing in a toothbrush for whoever was scheduled to be on call that night. One of the high-ranking attendings gave us a brief pep talk, then the chief resident took us to meet our teams. One by one we were swallowed up into the tiny residents’ rooms where the teams were meeting for teaching rounds. My attending was Dr. Patel, an older man from India. He had a rough, expansive face and shiny eyes. He alternated between being very serious and very jolly. He would sit with his palms on his thighs, then lean way back in his chair with an enormous laugh when something amused him. The senior resident was a Czech called Theo. He was stern at first, but relaxed some after a few weeks. The intern was short, with a young-looking face and a loud mouth. His name was Mike, and he had just graduated from my school. “You live around here?” He boomed, “We’re on call tonight.” He turned out to be a really great guy.
After rounds, Mike showed me around the ward. He showed me the bandages and syringes kept in the locked supply room, and how to use the computer. Patients walked up and down the hallway pushing IV poles and talking loudly. Others crowded around the nurses’ station, laughing or complaining about something. There were stuperous patients sitting in wheelchairs along the walls with bags of urine strapped to their armrests. There were a few small patient rooms along the hallway, but most stayed in the big room at the end of the hall. This room had sixteen beds and four televisions. The odor was terrific. It varied in character, but was always there. Sometimes the strong, feculent odor of waste or the acrid smell of urine dominated. Other times it was just the unwashed, diseased flesh or the sharp chemical smell of disinfectant. The antibacterial soap was also distinctive, and lingered, so that if I smelled my hands at home the whole yard would come rushing into my mind.
Later that afternoon, we got very busy with admissions. I watched Mike start an IV on a new patient. “You’ll do the next one,” he said. “See one, do one, teach one.”
The next one needed to be done pretty soon. Mike took me into the supply room and began putting stuff into my hands. “You’ll need this, and this. And this.” My arms were full with tubing, catheters, gauze pads.
“You’ll also need this,” he said, stuffing a tourniquette into my pocket. “Don’t lose it. This is the VA and I doubt you’ll be able to find another one. Go ahead and get set up. I’ll be in a minute.”
I introduced myself to the patient, and set all the things down on the bedside tray. I connected the tubing and laid out a chux pad to protect the bedding from blood. I opened the catheter and gauze as I had seen Mike do. He came in and rearranged a few things.
“The key to this and all procedures is to have everything positioned right before you begin. Okay, go ahead. Wait, don’t forget gloves.”
I wrapped the tourniquette around his arm. I was nervous and dropped the catheter, contaminating it. As if expecting this, Mike pulled another from his pocket and handed it to me without a word.
“He’s got great veins,” said Mike. He pointed to a big blue-green bulge. “Try that one.”
I wiped it down with alcohol, making it shine and stick out even more.
“Little pinch,” I said.
I plunged the catheter in, pushing firmly and looking for a return of blood. I pushed further, but still nothing. “Pull back and try again,” said Mike patiently.
This time a drop of blood appeared in the plastic window. “In a little more,” he said. “You got it.”
We finally went to sleep that night around three. It was still dark, though very late when the PA when off.
“May I have your attention please. Code blue, six north. Code blue, six north.”
Mike was already reaching for the door while I tried to shake off my sleepy confusion from the top bunk. “That’s us,” he said as light flooded the room. I jumped down; everything was rushing. My mouth was sticky, my hands suddenly cold and damp. I fumbled for my glasses and darted after Mike, the hallway like some weird flourescent tunnel. As we approached the dark ward, I could see the end of the hall light pouring out of the room on the left, and nurses hurrying about. There was a crowd around the bed in the corner, and the other patients lay with wide eyes under their covers. The dying man lay naked, jerking rhythmically with each thrust made upon his chest. At his head, a resident was holding a mask over his face, squeezing a bag with a hissing sound. Another resident, a tall man, stood with his arms crossed, calling out orders.
“Epinephrine, please. Someone get a gas – try that left arm.” He laughed. “No, the other left arm.”
Everyone seemed busy, precise. A nurse was placing EKG leads on the man’s chest while another was carefully writing on a clipboard. There was a strange, earthy smell in the room.
“Let’s shock him,” said the resident. “200 joules, please.”
A nurse made an adjustment on the machine on the crash cart. The resident took the paddles and untangled the wires. “Hold CPR,” he said. He placed the paddles on the man’s chest. “Clear.” Everyone backed away. He pushed a button on one of the paddles and the naked man jerked violently and was still. Someone placed his fingers deeply into the man’s neck. “Nothing,” he said. “Resume CPR.”
I stood outside the circle, watching. Someone had to get by me, and I backed away from the scene. An older man, I never knew what his position there was, leaned close and said passionately, “You got to get in there. You got to grab all you can.”
He walked over and whispered something to the tall resident, who looked over at me. The older man motioned to me, and I squeezed my way up to the bedside. The resident who had been doing compressions was sweaty.
“Ready to switch?”
I moved as through water. Stepping up, I bent over the man and placed my hands on his chest. I began rocking down and up firmly. His ribs gave way like a spring, and I could feel cracking somewhere inside.
“A little faster,” someone said gently. “Watch the monitor and get a nice, even rhythm.”
All my muscles were taut and I was soaked with sweat. It dropped on the inside of my glasses. After awhile, I heard, “I’m gonna call it.” I felt a hand on my arm and I stopped. The man lay still on the bed, and someone moved to cover him. As we silently left the room. I could see out the window the pale light of morning and moving over the city.
A few days later, Mike and I were going over a list of things to do. We had our feet up on the desk when Theo came in. “What are you doing?” he asked.
“Stomping out disease and saving lives,” replied Mike.
He looked at us. “I hope you don’t get sick.”
“We are pacing ourselves,” I said.
“Well, Mr. Stewart is asking about you. He says he needs a CBC checked and you’re the only one who can do it.”
I reached for my tourniquette.
“Oh, we are getting an admission, you may want to pick him up. He’s got a head and neck CA. Dehydration, calcium of 17.”
“Otherwise healthy,” added Mike sarcastically.
Cancers of the head and neck are killers, and Mr. Stevenson’s was teh size of a grapefruit. I learned about him mostly from his chart, as he wasn’t able to speak when he came to us. He had been diagnosed about a year and a half ago and treated with chemotherapy, but had stayed away from the follow-up clinic after that. We later learned from his family that his right cheek had slowly swollen up, and he had become thin and weak. But he refused to come back. “I ain’t gonna take that,” he’d said. “Bringin’ everything back up and runnin’ off from behind. Just leave me be.”
The oncology consult service regarded a calcium of 17 as a therapeutic challenge. They tried a variety of drugs, but if it went down any, it soon came right back up. We put a tube down his nose to feed him. His sister wanted that, but consented when we asked to make him DNR. We saw him every morning on rounds, looked at his chart. What were we going to do? Sometimes his eyes were open and tears rolled down his face. I wondered if his tears were a physiologic response to his being unable to close his eyes, or if he was crying. Was he thinking? Was he feeling?
We were on call July Fourth. Late that evening, after helping take care of our new admissions, I was sitting in the residents’ room. I knew the routine, and had earned a few minutes’ rest. Maria, one of the nurses, came in and told me that Mr. Stevenson’s IV was out. It had taken me an hour to start his last one, as the chemotherapy had fibrosed all of his veins. Walking into his room, I saw the IV catheter with a piece of wet tape stuck to it hanging from the pole beside his bed. His roommate was reading the newspaper by a bedside lamp, casting a shadow into the corner. I looked down at Mr. Stevenson. His eyes were open, blank, and his skin was very pale. I felt his wrist for a pulse. It was faint, distant and very slow. There was a thick and pungent smell. I moved the IV pole out of the way and adjusted his pillow.
Mr. Stevenson’s roommate looked over at me. He was old, with sallow rough skin. I had seen him before, but he was on another service. His cheeks were drawn, and his IV bag was wrapped in brown cellophane. Another cancer patient. I wondered where it was.
“You can see the fireworks,” he said, looking out the window.
“Yeah,” I replied. “Happy Independence Day.” He knew what was going on, I could tell. I sat down. He put down his paper.
“We used to get the big ones, when we’d go on leave to Hong Kong. We’d send ’em right off down the street.” He paused and looked at me. His face was impassive, and he held still the newspaper in his lap.
“We used to get them in Wisconsin,” I said. “Me and my friends would have wars with the roman candles. Nobody ever got hit, of course, you never new where those things were going when they fired. Actually, I did get hit once, on the sleeve. My mom was pretty mad. It was one of those Izod shirts – remember those?”
“With the alligator?”
“Yeah. She’d got it at Marshall Fields and all. She was pretty bent out of shape.”
There was a sudden gasping sound from the next bed. I got up and stood over Mr. Stevenson. His eyes were open, not looking at anything. There was spit running from the corner of his mouth. His chest did not move. I placed my stethoscope over his heart. Slowly, yes, and softly, but it was still beating. I stepped back. He inhaled violently, and began slowly breathing again. I sat back down.
“We used to take the streetcar down to Marshall Fields,” said the old man. “That was the easiest way to get around in those days.”
The dark smell seemed to fill the room.
“When did that stop running?” I asked.
“1940. Of course the buses were running extensively by then.”
I looked over at Mr. Stevenson. He was still. I got up, listened again. There was a faint, distant beat, a long pause, then another. I kept listening. Dumt. Dumt. Then, nothing. I put my stethoscope in my pocket. The old man was looking out the window.
“I’m gonna do that when I get outta here,” he said. “Go shopping for some new clothes.”
“What’s wrong with what you have on?” I asked, indicating his VA issue maroon polyester pyjamas.
He looked at me and smiled weakl. His face still held a stoic expression. He looked out the widow again.
“It’s finished,” he said. “The fireworks are over.”
“Yeah,” I said. “They’re over.”