By Donald Kollisch, M.D. (email)
The old farmer was trying to be the best patient he could. The doctor was trying to be the best caregiver he could. The message, in this short story by a DMS faculty member, is that treating the disease isn't all there is to medicine.
Like a sponge," Elwin was thinking, sitting in his father's old chair. "The doctor said my lungs are filled up like a sponge, that they need to wring out." He pictured a large sponge—the kind his father used to use to wipe down the horses after a full day's work—knobby and heavy and dripping in his hands. Elwin held the image in his mind as he tried to clear his laboring lungs. Some sections were softer and more supple; others were stiff and scarred. Water was stuck in the stiffer cavities so he wasn't able to squeeze it out. That was what made his breathing fast and shallow —the way it had been ever since he'd come in from moving the John Deere into the barn. Now he was sitting at the kitchen table in a sweat.
He heard Doris on the phone saying, "Doctor, I'm bringing Elwin in again. He can't breathe—the valve must be stuck again. I'm bringing him straight to the hospital. Can you get them ready? Jesus, Doctor, it's awful bad this time."
She had found him wheezing in the kitchen and had fixed him with a glare. "You stupid son of a bitch, you've done it again, haven't you? Gone and cut hay when the boys were out just to prove you could do it, just to prove something. Sweet Jesus, when are you going to learn?"
As she half-carried him out to the pickup, he remembered how light baby Johnny had been when they'd had to rush him to the hospital for the meningitis. Now, 50 years later, as Doris was carrying him to the same place, he made himself as light as he could so as not to be too hard on her.
The nurses met them at the emergency room ramp with a wheelchair and had an intravenous tube into him in seconds. They gave him a shot of the water medicine right away, too, just like the last time. Elwin pictured his lungs compacting like a cider press as he pushed out each hard breath. He pushed the fluid down through himself and out the tube that they'd slid into his long, curved penis, which hadn't seemed to shrink with age like the rest of him. His urine, almost colorless, collected in a plastic bag hooked to the side rail as they wheeled him to the x-ray machine and then hooked him up to the EKG machine.
"Yup, Elwin, it's the same thing," the doctor said as he scanned the results. "Looks like it's that valve again. I can hear the murmur louder than hell. Any pain this time? I know you go and work on that damn tractor and strain your heart. The valve is too tight and then the heart works too hard and can't push the blood through hard enough, and your lungs fill right up with fluid, and here you are again." He told Elwin about the sponge again, and Elwin did all he could to help squeeze.
Then there was an echo test. Elwin could see his heart pumping on the screen like a cartoon in yellow and green, with thumps and whistles coming out of the speaker. Polly, the echo technician, was daughter to Doris's niece and said that it looked to her like the valve was just as tight as before but no tighter, and that the heart muscle was somewhat weak but still pumping. But she was only the technician, she added. The heart specialist would have to look the next day at the tape she'd produced of the test to make the verdict official.
Elwin knew all the hospital staff by now. He tried to help each one to make their jobs less unpleasant; he knew that the nurses and aides were the important ones, the ones who—if they liked him—could get him home to his John Deere faster. He was always ready for his pills, ready when they came to change the bed, ready for the walks down the hallway. He pictured his insides and made sure his bowels worked after the change of shift so the night nurse would leave happy. Then Janice, the day nurse, would be cheerful and humming as she helped him into the bathroom and wiped his bottom —just as, he figured, she wiped her son's bottom and hummed before leaving for work.
When his hand slipped and he spilled the water in the blue plastic pitcher that sat by his bed, he got Doris to clean it up so the aides wouldn't hold it against him and tell the doctor that he was still weak and needed to stay in the hospital longer. Doris was used to this and murmured, "You silly old man," as she mopped up.
The doctor sat down on the bed the day Elwin was discharged, as he had done at least twice a year for a decade, and went over everything again. "No salt, Elwin. Doris, there is to be no salt for him. You can't make that bacon, he can't have your soup, and you have to tell Johnny not to bring over that smoked ham at the start of hunting season." It was a familiar litany, and Elwin and Doris nodded their understanding. "The nurse will take your catheter out before you go. Remember to take the pills just as I told you."
"Yes, doctor, of course. No salt, no straining, no riding the John Deere by myself anymore. We'll see you in the office next week with that old appointment I've got, you figure?"
"Well, yes, keep that appointment, but there's more this time, something else to talk about." The doctor fingered his graying beard and hesitated. He looked first at Elwin, then at Doris, and then his eyes settled on the clock on the wall. "On that echo test, your valve is getting tighter—getting to be what they call 'critical.' I'm not sure we can keep going from one crisis to the next any more. I think maybe we're going to need to do something. Maybe send you down to the Hitchcock for one of the heart surgeons to take a look at you. Maybe replace the valve."
Elwin tried to think about how to help this along. He wanted to get home. "You know me, doctor —I don't want anything special, anything drastic. Just give me medicine and get me home. You know me, doctor." The argument didn't sound, even to Elwin's own ears, quite strong enough to change the doctor's mind, but the doctor sighed and nodded and signed the order sheet in the chart. "Okay, Elwin, to home with you, but we'll talk again next week. And you be thinking about letting them give you that new valve."
At the doctor's office the next week, Elwin greeted the nurse cheerfully: "Feeling great, Gayle. Doc sure patched me up this time." As she wrote "Feeling great" in his chart, Elwin was already rolling up his sleeve because he knew she'd want to take his blood pressure, too. He'd been through this many times before.
"Sorry to be running late," the doctor mumbled as he brushed into the examining room. "Nurse says you're doing good."
Elwin, as he always did, tried to make it easier. "Like I told Gayle," he spoke up, "I'm feeling fine. Doris is taking care of me just like you said, and Johnny's not letting me mow until you give the word." He watched the doctor carefully to make sure he was shaping his case well. "But last cutting's done anyway, and we're getting ready to get to Florida next month, same as usual, get out of the cold. So could you fix me up with some prescriptions, do you think, the way you always do?"
The doctor hesitated, tapped his fingers, and motioned for Elwin to loosen his shirt. He listened to Elwin's breathing on the back of his chest. His beard brushed Elwin's cheek when he listened in front. "I guess, Elwin, I guess. You really don't want to go down to the Hitch, do you?" Elwin looked up at him and shook his head.
"I worry about you down in Florida," the doctor continued, "where they don't know you. I worry that Doris'll bring you to a hospital all worried, the way she gets. And a doctor who doesn't know her and you, doesn't know how these things go with you, will open you right up, and . . . Jesus, Elwin, this isn't a walk in the woods, this surgery, if you know what I mean." Elwin glanced at the door. "A heart attack, a stroke, anything can happen on the table once your valve gets this bad. Can't I send you down to the Hitchcock so that one of the guys I know can take a look at you?"
Elwin shook his head, with a small grin on his farmer's weathered face, and took the prescriptions the doctor offered him. "I'll see you first thing in the spring, Doc, don't you worry."
Before leaving for Florida, Elwin climbed up onto the John Deere in the shed and sat there for the afternoon, listening to the swallows swooping to and from their nests in the eaves and to the cats chasing mice in the hayloft.
The months of the winter went so fast they were a blur. Afterwards, Elwin barely remembered arriving at the trailer park in central Florida. He didn't remember climbing onto the mower to help the park's owners trim the front yard. He didn't remember the pain and breathlessness, the ambulance ride to the unfamiliar hospital, or the tall, stern doctor with the Southern accent telling Doris that surgery was Elwin's only chance. He didn't remember waking up in an intensive care unit with a breathing tube in his throat, unable to move his right arm and leg, unable to ask the nurses what the matter was and how he could help.
The doctor had told Doris that Elwin was lucky to have survived the operation at all, but that his new valve was working fine. He'd reminded her that the stroke was something they had spoken of as a possible complication when she had signed the papers at the beginning, and that Elwin's rehabilitation back up at home would tell the story about how much strength and ability to speak he'd be able to regain.
The first thing Elwin remembered was looking at Doris with tears in his eyes as she tucked a blanket around him in the back seat of Johnny's car for the trip north. "I'm so sorry, my dear old bag of bones, but there isn't anything you can do to help—I know you want to."
On the ride back home he began to understand. They stopped at their own little hospital as soon as they reached Vermont. The doctor had agreed to meet them there and was waiting for them. His voice cracked when he saw Elwin slumped in the wheelchair, and he carefully unwrapped the blanket to examine him. He took in the flaccid arm, the droop in the face, the pain and fear in Elwin's eyes, and he gently grasped Elwin's arm. "I knew for all of these years how much you've helped me help you, Elwin," he said. "You thought I didn't know, but I did. And now your job is to get as strong as you can. Doris can't take care of you alone, at least for a while, so I've got to put you into the county nursing home to help you recover. They're good down there. You know that . . . I'll keep you here at the hospital for a couple of days to make the arrangements, and then send you down."
Elwin knew then how he could help. After Janice, the day nurse, got him settled in a bed and after Doris left him, he pictured himself on the John Deere, cutting wide swaths in a dense hayfield, the fallen grass lying thick and green and pungent behind him. He reached into the pocket of his barn jacket and pulled out a small hourglass and placed it on the hood of the tractor, where he could watch the sand running down with each pass that he made across the field.
And when the last grain ran through, he closed his eyes, the tractor stopped, and he slept.
The author is an associate professor of community and family medicine at Dartmouth Medical School. He has taught at DMS since 1983 and practiced family medicine at DHMC since 1995; he previously practiced in northern New Hampshire. This story is fictional, though some aspects are loosely based on a real patient.