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A Vulnerable Place

"I have to take it out," he says finally. "She can't push."

The doctor's eyes widen. And flash with sudden understanding. "No wonder," she says to me later, "he was so concerned about his fingernails."

"I . . . I don't mind," he adds quickly.

The doctor raises her eyebrows.

"She would have done it for us," he says.

"Have you ever thought about a nursing home?" asks the doctor gently, at last. That was one of the main purposes of our visit, to broach this subject.

"She said once that she never wanted to be carried out of this house on a stretcher," he says. There is a sing-song quality to the sentence, as if it had been repeated many times before.

"Do you know why she felt that way?" the doctor asks quietly after a moment.

"She didn't want the neighbors to see her carried out. I think she would have been ashamed."

For a second, I wonder if something as simple as a quiet, late-night transport would solve the problem. Then, in the next instant, if it is more shameful to be carried out alive than dead. She has to leave somehow, sometime.

"Do you think there's anyone left inside to be ashamed now?" the doctor asks, very gently. "I'm not trying to answer that, I'm just wondering what your thoughts are. . ."

He doesn't respond.

Finally he says, "My father always said that if we put her in a nursing home she wouldn't last long." His eyes look troubled.

Would that necessarily be such a bad thing? I see the question in the doctor's eyes, but she leaves it unspoken.

He sighs, his face dark and clouded. There is a strange unguardedness about him. He must be nearly 50, but somehow he seems too young, too innocent, to be carrying the burden of this question.

"I talked with your father's doctors in

Anchorage this morning," continues the doctor. "They aren't sure he'll ever walk again. They feel quite certain that he won't be able to come back here or to help with her care. We thought perhaps they could be placed in the same facility, in Anchorage; that way they could be together. She wouldn't have to be alone."

The son pauses for a long time, lost in thought. "It's been like this so long," he says at last. "Five years. I guess I just don't know any other way anymore." He speaks slowly, and there is a curious absence of undercurrent to his words. He does not seem to be saying either that five years is long enough or that having gone this far he feels he must keep going. I think he means just what he said—that he can no longer envision any other way of living.

"He won't walk again?" he asks suddenly, changing the subject back to his father. He glances up, then down again at the floor. His voice and face barely register grief; he rubs his shoulder and arches his back, as if adjusting to the addition of yet another weight to everything he has learned to carry.

"Maybe," the doctor says. "But come back, probably no."

Her final word hangs in the air for a moment before she continues, asking, "It's you and your brother who take care of her, right? Are there any other siblings?" These are relevant questions, as well as a break for him from the harder ones.

"I have two sisters who moved away." He speaks quickly now, seeming relieved, glad to talk about anything other than his mother. "And a brother in the village. My oldest brother died when I was eight. It was a big change; suddenly I was supposed to be the older brother. I'd always looked up to him, worshipped him—he was my hero. There was a shooting accident. He was hunting, he got shot."

His tone is matter-of-fact, but his eyes look lost and helpless. There's the same inability to defend his heart against tragedy, the same taking on of impossible responsibilities; wounds that he felt at eight seem to be replaying themselves decades later.

We discuss the things that are entailed in caring not just for his mother but also for

the house—carrying water from the village's central source, removing waste, stoking the fire, tending to her dog and her bird . . .

"There's a bird?" It isn't important, but I'm startled by this new piece of information.

He nods. "She flies around the house. I don't think she's in there now." He bends down and peers into the birdcage, which is indeed unoccupied. "She's probably in the kitchen—hiding most likely. She's very shy. She got outside once, by accident; she was terrified. Doesn't know how to catch bugs or look for seeds. And the wild birds, they scared her something awful. I didn't know what to do. Finally I took the cage outside and she flew right into it. She wouldn't come out for days."

He pauses. Seeming to not quite know what to do next, he goes looking for the bird. "Here she is," he calls from the kitchen.

I walk in and crouch beside him on the floor. "She's under the table," he says. And there she is, sitting on one of the chairs, a small brown sparrow. She cocks her head at me anxiously. "She's awfully shy," he repeats. I don't think I've ever heard that word applied to a bird before, but it seems to fit.

She flies up and settles for a moment on the windowsill, still eyeing me. She has landed expertly amid a cluster of china puppies arranged compactly on the sill. She chirps and flutters her wings. Then in a whir of soft brown feathers she is gone.

Iremember being told when I was little—or maybe reading somewhere—that when Eskimos got old and were unable to work, they'd walk out onto the ice and die. Was that true, I wonder, or just a myth? If it did happen, how different from the scene before me now. Once the responsibility—the duty, the honor—would have been hers. Now it is her son's. She can no longer go out onto the ice herself. Should he be expected to push her? I ponder these matters as the doctor, the health aide, and I walk back in silent single file along the boardwalk, leaving behind us questions raised but unresolved.

Dusk has fallen—the long and eerie subarctic twilight. I hear waves breaking on the shore. A gull cries mournfully into the wind.

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Transue, a 1996 graduate of Dartmouth Medical School, is now an internist in Seattle, Wash. The incident she relates here took place when she was a third-year DMS student, during her family medicine clerkship in Bethel, Alaska. It is a true story, though identifying details have been changed to protect patient confidentiality. Transue began writing patient narratives while she was a student as a way to process the emotions of practicing medicine. Many have appeared in Dartmouth Medicine, and a collection of her pieces was published by St. Martin's Press in 2004 as a book—On Call: A Doctor's Days and Nights in Residency. She has been invited to speak about her writing at the annual meeting of the Association of American Medical Colleges in October.

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