What Does it Take to Become a Physician?

By Arne Vainio, M.D.

News From Indian Country

Tomorrow I talk to the first year medical school students. I never really know for certain what I will tell them. I get to do this every year and usually in October. I generally start by showing “Walking into the Unknown” and use that as a launching point for further discussion. I vividly remember being a first year medical student and sitting in the front row, second seat from the right. When I first started medical school, I wasn’t even certain what each of the four years of schooling consisted of and much of it came as a surprise to me. It seemed all the other med students had a pre-existing knowledge of what was coming next and I didn’t want to show my ignorance by asking questions about things that seemed obvious to everyone else.

It occurs to me that other students may have some of the same questions and it doesn’t seem like there’s always an easy place to get answers. This is a general overview of what it takes to become a physician:

School through high school, then four years of college. The high school and college classes should have a heavy focus on writing, math and the sciences because they are preparation for the MCAT. This is the Medical College Admission Test and the scores from this test are sent to all the medical schools applied to. The MCAT is a one day standardized test and there are four sections overall. The test is very secure and the testing center needs photo ID, takes a digital photo, takes fingerprints and only allows pencils and scratch paper they supply. The scores from the test are one of the major criteria for being accepted into medical school. College transcripts are also important as is any previous experience related to medicine in some way. Another important part of the application is the personal statement. This is a written statement by the applicant and it tells their story and why they should be considered for admission. Reference letters are another part of the application and strong letters are important.

Most students will apply to multiple medical schools to increase their chances of an interview. Schools can easily have over a thousand applications for a relatively few seats each year and they review the applications carefully. Being invited for an interview is a major step in the right direction. Some schools have multiple interviewers at the same time and some do the interviews one on one. My interviews were one on one.

This is the opportunity to sell yourself as a future physician and this can be a difficult process for some students, especially if they come from a background where humility is a virtue.

Once in medical school, the overall structure is four years, with the first two years almost entirely in the classroom. The courses are grueling and the credit load is usually 30 credits or more. At the end of the second year of medical school is the first USMLE (United States Medical Licensing Exam) board exam and passing this is necessary to go on to the 3rd and 4th years of medical school. The 3rd and 4th years are doing required medical rotations in the hospitals and also in exploring specialty rotations. There is some classroom time, but much of the time is actually spent learning medicine from a practical standpoint. At the end of the 4th year is the second USMLE examination and passing this is necessary to go on to residency after graduating from medical school.

Applying to a residency program is a difficult process and it starts sometime in the 4th year of medical school. Residency is a minimum of 3 years and can be several more depending on specialties chosen. Residency programs applied to will want medical school transcripts, USMLE scores, a personal statement, letters of recommendation, medical school performance evaluations and a resume.

Residency is actually working in the hospitals and the intern is a first year resident. Usually a 3rd or 4th year resident will be in charge of the team overall. Shifts can be 24 hours long and 80-hour workweeks are not uncommon in residency. Residents get paid, but mostly just enough to live on.

On my very first day as a resident in Seattle, I was on a surgery rotation and at the end of the day; a quick game of rock, paper and scissors decided I was the resident to stay in the hospital. We had 33 patients on our service and I was constantly running up the stairwell from the Emergency Room to the post surgical ward on the sixth floor of the hospital. I took the stairs because waiting for the elevator simply took too long and there was too much work to do. I was wearing four pagers and all of them were going off constantly. I remember running up the stairs to the sixth floor to assess a post-operative patient with shortness of breath and my Emergency Room pager went off. I was totally overwhelmed, it was 3:30 AM and I remember thinking I know why people jump out of windows.

Residency includes lots of clinic work and I saw patients at the Seattle Indian Health Board. I loved working there and I quickly developed strong ties to my patients and everyone I worked with. The second and 3rd years of residency bring more responsibility and are not as grueling as the first year. At the end of residency is the third and final USMLE exam. Passing that exam means it’s time to apply for a Physician’s license in the state of choice.

Being a new physician is just like starting over and each step of the way felt the same way to me. As I was finishing my residency, I started to get calls and letters from recruiters. It was flattering to think so many places wanted me to work for them and the Seattle Indian Health Board very much wanted me to stay on as a physician. As tempting as that was, I had made a promise to an elder to come back to Minnesota and work for my people. I did that just a bit over eighteen years ago and I’ve been working on the Fond du Lac reservation ever since.

I’ve never looked back and I’ve never wished for anything else. Every single day I work with the smartest, most compassionate and caring people I’ve ever known. I come home almost every day knowing I changed something for almost every person who walked through our doors.

I get to teach medical students and I get to guide students aiming for medical school in the right direction. Right now I’m working with five students who want to get into medical school. All of them are sincere and are looking at medicine for all the right reasons. I have had students come to spend time with me just long enough to get a letter of recommendation and I can spot those students from a mile away.

What will I tell the first year medical school class tomorrow?

Medicine has always been a calling and true happiness comes from a life of service. Watch out for those who want to do what you do, they won’t always announce themselves.

Out of tragedy springs hope. As physicians, we are often the lighthouses in a sea of tragedy. We are trusted because we walk in the footsteps of those who came before us and others will one day walk in ours.

Leave a clear trail.

Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota and he can be contacted at a-vainio@hotmail.com.

The Gift of Silence

By Arne Vainio, M.D.

News From Indian Country

My wife Ivy and I traveled to Grand Portage for a memorial service for a friend of ours. We had known Ernest for years and he died a few months ago. We had to go to another town first and we didn’t get to our hotel until after midnight.

The big room in the community center was full when we got there and someone was setting up a slide show and there were photos of him fishing and snowshoeing and being outdoors.

This was a community event and a potluck and there was lots of food. We stopped at the store and picked up some bakery things as we felt we had to bring something. Afterward we moved to a quieter room so people could tell stories about Ernest. I learned he had a sister who first met him when she was twenty-five. She had been taken from her family when she was a baby and was raised by a white family and she was totally unaware of her Ojibwe heritage. She grew up only knowing she was different. She sought out and found her family and Ernest patiently taught her and now she lives her Ojibwe culture.

He had a good sense of humor. One of the women who remembered him worked in the bank and Ernest came in to cash a check and he told her, “I’ve got a few secrets, you know.” He cashed his check and they talked about the weather and some other small talk and he told her, “Yeah, I’ve got some secrets, but I’m not going to share them with you.”

“Why not?” She asked.

He answered, “Because you’re a teller.”

Ivy stood up. She used to work at a University and she curated an art show and it was a big event for twelve years under her direction. Ernest’s partner Marcie was the featured artist one year and that’s when we became friends. Ernest worked with leather and his work was sought after. He made a pair of moccasins and delivered them to a family during a Christmas Eve snowstorm when no other traffic was moving.

Ivy’s cousin talked of living in Detroit and never knowing what was going on in Grand Portage. His family started coming to Grand Portage every summer. They met Marcie and Ernest and they would catch them up on what was going on culturally and politically and Ernest was going to take Jason fishing. Something always got in the way and when it finally seemed like the right plans were in place, Ernest got sick and died before they could go. “I know I will see him again and we’ll fish together one day.”

I didn’t stand up and say anything because I couldn’t think of anything in particular that would tell a story that would mean anything to anybody. Ernest was my friend and we were always happy to see each other. It was usually in the summer when we traveled to Grand Portage for the Rendezvous Days powwow. We would always stop in and visit. He would usually be working on something and I would watch him carefully sewing or cutting. He would make it a point to show me how he worked and he would do that in silence and it felt good to stand next to him.

Everyone talked about the things he taught them and about his sense of humor and I didn’t have any of those stories. It wasn’t until we were on the long drive home with the mist over Lake Superior that I realized what he had given me. Ivy and I lead hectic lives and it seems like we’re always on a dead run heading somewhere with no breaks in between. There always seems to be someone or something pulling me in multiple directions and I’m always way behind in the things I need to do and I never seem to be able to lift that weight. I wake up behind in the morning and I go to bed with things unfinished and I don’t see that getting better any time soon.

Ernest knew that deep inside and he gave me something I didn’t even realize I needed. He gave me silence and he taught me in that silence. All of the fishing stories and his taking his sister back into his life and his sitting outside the art gallery working leather were in that silence. When I stood next to him I forgot the things I needed to do and those cares and stresses were a world away. All that mattered was friendship and the sounds of the powwow and the smell of the lake. For a brief moment I could let time slow down and simply stand next to a friend.

The Fond du Lac Ojibwe Language Camp starts in a couple of days at the Kiwenz Campground on Big Lake in Sawyer, Minnesota on June 14, 2018 and everyone is invited. I will be with families and friends and teachers I haven’t seen since last year. Some of them will be only memories as we have lost some of our teachers since the camp first started a decade ago.

I had the privilege of sitting and playing cards with them and laughing and eating and dancing with them and I will remember them. I also had the opportunity to sit in silence with them. We sat together and the empty spaces in the conversation were not empty at all. Those empty spaces were filled with love and respect and friendship and the comfort of being in each other’s presence.

Words are not always the best way to communicate and when you use them, make sure they matter. If someone is important to you, don’t wait to stand up at a memorial service.

Tell them now.

Come to the Language Camp. We’ll be waiting for you.

My stethoscope is broken. The upper part where the ear pieces go into the tubing separated and I can’t find any way to fix it.

Why don’t I just get a new one? Because my mother bought it for me when I graduated from medical school in 1994. The photo is at my medical school graduation party. The party was also for mine and Ivy’s engagement party. I proposed to her a few hours after I graduated from medical school. I wore that stethoscope around my neck every single day I was in the clinic or in the hospital in Seattle. I listened to newborn babies with it. I listened to lungs by the thousands and I learned to identify the wheezing of airways tightening up in a young boy who couldn’t stop coughing when he played outside. His grandmother thought he was trying to stay home from school and she didn’t believe him all those times he was in trouble. He was on the verge of having to repeat the third grade when his grandmother brought him into the Seattle Indian Health Board and he was on my schedule at the end of the day. His lungs sounded fine when I first listened to him and his grandmother glared at him when I told them that. I could see the resignation in his eyes as he pegged me for just another adult who didn’t believe him.

I had him and his grandmother come outside with me and I had him run in the parking lot until he started coughing. I listened to his lungs on the pavement between the yellow stripes of the parking lot and I heard wheezes everywhere in his lungs. I ordered an inhaler for him and the pharmacist showed him how to use it. I took him back outside and ran him again in the parking lot and he ran and he ran and he was laughing and jumping and he was an eight-year-old boy again. He hugged his grandmother with the forgiving innocence of the very young and she started to cry because she hadn’t believed him.

I used that stethoscope to pick up a bruit in a grandfather’s neck. This is the sound made by blood being forced through a vessel that has been narrowed by years of cholesterol and cigarettes. His granddaughter brought him in because he had an episode of weakness in his right arm and some difficulty talking a few weeks earlier and refused to go to the hospital. His weakness and speech were better the next day. I had him turn his head to give me better access to his carotid arteries and I had him hold his breath. I distinctly heard the “ssshhhooooossshhhoooossshhhoooossshhhoooo” of every heartbeat being forced through his narrow left carotid artery. I sent him for an ultrasound of his carotid arteries and this showed an almost complete blockage. I referred him to a vascular surgeon and he had a procedure to open the artery the next day. The surgeon told him he could have had a stroke at any time and that his deficits could have been permanent.

He and his granddaughter came to see me again, this time so I could refer them for smoking cessation classes together.

I used that stethoscope in the ICU when we withdrew care on a 29 year old mother of three with metastatic breast cancer. She foresaw this moment and had it in her written wishes to withdraw support if it came to the point where there was no turning back. Her cancer was widely metastatic when it was first diagnosed. She fell in the park when she was playing with her son and her chest pain didn’t get better after a few weeks. She was seen in the Emergency Room and a chest x-ray showed cancer in two of her ribs and multiple masses in her lungs and subsequent studies found it in her liver. She didn’t tolerate the treatments for it and they didn’t do much to slow her cancer down. I was the resident on call the night she died and her husband and I were alone with her in the room when her labored breathing finally slowed, then slowed, then stopped. I listened for a heartbeat for a long time and I didn’t want to look up at her husband. He was holding her hand and was on the other side of the bed from me. I finally looked up at him with the earpieces of the stethoscope still in my ears and I could see the moment he realized she was gone.

I learned the sound of a belly full of fluid due to liver failure with that stethoscope. Normally the amount of fluid in a person’s abdomen is about a half a can of soda, just enough to lubricate the intestines and other organs so they can slide and move against each other. When the liver fails, the proteins that hold fluid in the blood vessels are no longer made and the fluid leaks into tissues, but really leaks into the abdomen. He had so much fluid in his belly I could push on one side and listen to the fluid splash against the other side.

His liver never regained function.

I wore that stethoscope through the scariest times being a resident and the scariest times being a physician in practice, but also some of the most perfect moments. I listened to a ninety-year-old heart finally slow down with an IV drip in the ICU. His heart was beating too fast and he’d been having chest pain for an entire day and he was certain he was going to die. I was with him and his wife of 63 years when his heart started to slow down, then came into a normal rate and rhythm. He wouldn’t let go of my hands and all he could say was, “Thank you, Dr. Vainio, thank you.” He held my hands in both of his and he repeated that phrase again and again and I could hear his wife weeping in relief behind me.

By the time I was finished with residency, my stethoscope had been left in my hot in the summer and cold in the winter car over a thousand times and had been around my neck so long that the tubing was stiff and I was afraid it was going to break. My sister beaded it for me after I graduated from medical school and her beading had to be cut off to rebuild it with new tubing. I had it beaded again by someone else and she used regular thread and it didn’t hold up to the constant abuse and the beading started to come apart.

Mike O’Neil from the Red Lake reservation asked if he could bead it as a gift and he used strong thread and he used buckskin under the beading to make it stronger. It was beautifully done and I’ve been using it for over fifteen years like that.

Now it’s broken. The earpieces and the bell of the stethoscope are from the original stethoscope my mother bought for me when I graduated from medical school. The images of that stethoscope are on the cover for Walking into the Unknown and are on the Native Report Health Matters segment and are in many other places. Every community talk, every medical school lecture, every health care event, every high school presentation has been with that stethoscope around my neck. There is a big part of me that doesn’t want to cut that stethoscope and the beading Mike so painstakingly put on. I want to put it away in a display case so I can see it forever.

How many of us carry or wear things from a loved one who has passed on? I didn’t realize my mother was with me every day when I wore and used that stethoscope. She struggled to raise seven kids by herself after my father’s suicide and she struggled to buy me that stethoscope. The only way I can keep that is if I have the stethoscope cut to reuse the bell and as much as possible of the earpieces and this will sacrifice my old and trusted companion.

I need advice. What should I do and why?

Dr. Vainio poses with his mother after graduating Medical School, with the stethoscope she gifted him.

Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. Per Dr. Vainio, “…I feel my primary role is that of a teacher and hopefully I can do this in a series of articles. My goal is to address complicated medical issues in a way that makes sense, and to empower people to take part in their own health care. This will include what I see as a physician and how that relates to and touches me. Even though I am a physician, my story is not all that different from stories I see every day. My family history is the family history of Native families everywhere.”

"Dr. Vainio, I’m not so sure I want to live anymore."

It was early in my residency in Seattle and Victor had lived as a fisherman all his life. He and Genevieve raised their children on the water and he knew the islands and he knew Puget Sound.

He knew the best places to fish and he knew what time of year was best for any given fish. He’d been close to pods of whales and he watched the sun rise and set from his boat.

I never met Genevieve and she died a couple of years before I came to Seattle. The first time I saw Victor was for an infection in his hand after cutting it on a rusty piece of metal when he was working on his boat. He was relatively quiet that first time and he didn’t seem to want to use any words that weren’t necessary. He listened carefully as I explained what the redness in his hand meant and the need to see me again after I started the antibiotic to make sure his infection cleared.

He did come back and his hand was better. “It was so swollen I could hardly bend it and now its fine. I’m glad I came in. This happened to me once before and it was a couple of months before it got better.” After that he only wanted to see me and for the most part, his life on the water kept him in good health.

Over several visits he opened up about what troubled him. He came home from fishing one day and found Genevieve on the floor. She’d had a stroke and he called an ambulance. She died after a couple of days in the hospital and never fully woke up. He told me how he stayed with her the entire time and how after she died he was lost and alone.

“Her funeral was awful. There were so many people there and all I could think was she would have been alive if I was home when she had her stroke. I knew her since we were kids and I never wanted anyone but her. We were married forty years and she was too young to die.”

The day he told me he wasn’t so sure he wanted to live anymore was after a couple of bad months fishing. He made his payments by what he brought in and he thought luck was against him. Normally the rainy weather on the sound didn’t bother him and he liked the way the cries of the water birds were kept close by the low clouds and he reveled in the view of the mountains through the breaks in the rain.

Now it was just clouds and gloom. “I always think about Genevieve and you’d think I would be better by now. It’s been almost three years since she died and when the clouds are out it seems like the sun will never shine again.”

I talked to him about antidepressants and he was reluctant to try them. “I don’t want to get hooked on pills. I need to pay attention when I’m on the water.”

He wouldn’t see a counselor and “I only want to talk to you.”

He started having trouble sleeping and he started to gain weight. “It’s because I’m so tired all the time. All I want to do is sit at home and eat.”

His lab results were normal and I talked to him again about depression. He finally agreed to start an antidepressant and I saw him back in a couple of weeks. “I feel about the same. I don’t know if these things are making any difference.” I discussed with him that often the person taking the medicine isn’t the one who notices a difference, but the people around them.

He smiled the first smile I’d seen in a long time. “I’ve been having more dreams. Lots of them have to do with fishing and my dad was in one of them. I think the fishing is going to get better.” He agreed to increase the dose and we set an appointment for another month out.

One month later and the room was brighter when I walked in. “The fishing is getting better and I’ve been getting up early again and I can’t wait to get out on the water. My dad has been coming to me in my dreams and it almost feels like we’re fishing together.” He didn’t want to change anything and agreed to see me again in three months.

Residency is a busy time and the next three months were filled with clinic and studying. I was doing a rotation in emergency medicine and the days flew by. Suddenly it was three months later and Victor was in my schedule.

He looked good and I told him as much. “Dr. Vainio, you know those dreams I was having? Genevieve was in one and only one of them. I was on the boat and she was with me, just like we used to be. The rain was coming down and we were trying to get back to shore and the boat was working hard. It seemed like that went on for a long time. Then the clouds broke and the sun started to shine through. Genevieve turned to me and she said, ‘Victor, I want you to be happy.’”

“Then she was gone.”

He went on to tell me that not long after that he stopped in at a small café and the woman there was running it by herself. She was there at 6:30 in the morning when he stopped in and she was there at 6:30 in the evening just before it closed. He said she never complained and she was nice to everyone who came through the door. “I never thought I would see anyone work as hard as Genevieve and there she was.”

I finished my emergency medicine rotation and then a medicine rotation and an orthopedics rotation and I was getting ready to start a rotation in obstetrics. I loved Seattle, but I wanted to get out of the city for just a day and I got up early and I drove. I got off the freeway and I drove along the sound as much as I could. The water sparkled and the sun was bright and it was a beautiful day to be just driving. I drove past some expensive restaurants and tourist destinations along the way and I wasn’t following any planned route.

I stopped for lunch at a small café with a gravel parking lot. There were mostly trucks parked in the lot and I could see this was a place where working people stopped. I walked in and Victor was behind the counter wearing a white apron.

“Dr. Vainio! I’ve been meaning to stop in and see you, but things have been pretty busy. It seems like this place never slows down and I don’t know when I’ll get a chance to get that way again.”

There was a woman in her mid-fifties taking orders from one of the booths and she walked over and stood next to Victor. She could see we knew each other and she looked at me, then looked up at him.

“Dr. Vainio, this is Elizabeth. I have never seen someone work as hard as she does and I’d put her up against any man in this place, including you. We were married about a month ago and it was a small ceremony. I still fish when I get a chance and we’ve been running this place together and I have to say I don’t mind working inside.”

She shook my hand and went back to clear a table. I ordered my lunch and Victor brought it to me at the counter.

“I stopped taking the antidepressant, Dr. Vainio. I didn’t figure I needed it anymore and I don’t know when I’ve been happier.

He slid the plate toward me. “It’s on the house. Do you believe in dreams, Dr. Vainio?”

Arne Vainio, M.D. is a physician at the Fond du Lac Reservation and he was awarded the Association of American Indian Physicians’ Physician of the Year Award. On the Fond du Lac Band's website, Doctor Vainio relays his, "primary role is that of a teacher" and he hopes to accomplish that "in a series of articles," with the goal of addressing "complicated medical issues in a way that makes sense, and to empower people to take part in their own health care."

(From News From Indian Country)

I Want You To Remember Me

By Arne Vainio, M.D.

News from Indian Country

I was looking for an old truck someone had told me about and I thought I had the right place. She slowly stepped out of the house into the hot summer sun. She was thin and pale and I didn’t recognize her until she spoke.

“I heard you’re going to medical school. I always thought there was more to you than you let on.”

As I was growing up I had worked lots of jobs that I liked, but they didn’t really lead anywhere. I was a skidder operator for years and worked dragging trees out of the woods so they could be loaded onto trucks and brought to the saw mills. I worked on a saw mill and I was used to hard and dangerous work with very little pay. There was no health insurance offered and going to see doctors was not anything anyone routinely did. I was in my late twenties and any thoughts of mortality were distant and didn’t apply to me.

I knew her, but she was much older than I was and I hadn’t seen her in a very long time. She knew my mother and she was easily a generation older than me. Her husband drank himself to death and I knew he was a mean drunk when he was alive.

When I made the decision to go to medical school, I was a professional firefighter and a paramedic and I loved what I did. Every time the truck or the ambulance went out, someone was in trouble and we had a chance to save another life. Most of the time we did.

I sometimes saw death and most of the time it came out of the blue.

She leaned against her cane and I could tell even that was an effort and she spoke in short sentences.

“I could tell you didn’t recognize me. I was getting sick and I couldn’t eat and I was constipated all the time. I tried drinking warm water and I ate prunes and that didn’t help. I went to see a doctor and he did some blood tests and said he didn’t see anything and I didn’t go back for a long time.”

I didn’t know what to say and we were both silent. She took a deep breath and went on. “I remember when you were a little kid. You used to read those science fiction books when everyone else would rather watch TV. Do you still read them?”

“I do.” I answered.

“I always liked that you did that.” She said. “I like to read and my husband and my kids thought it was such a waste of time. I always wanted to go to a tropical island somewhere and I wanted to swim in the ocean and watch the sunset from the beach.”

“Did you ever get to do that?” I asked.

“I never did.” She replied. “My husband never wanted to travel and said everything we needed was right here. Now I’ll never get to go.”

“Why is that?” I asked.

“I went back to the doctor.” She replied.” They took me to surgery to see what was causing my stomach problems. They found out I’m all full of cancer and there’s nothing they can do. They closed me back up and told me I have less than 6 months and they sent me back home. My kids are going to take turns staying with me for as long as I can stay here.”

“I’m so sorry to hear that.” I replied.

She took my hand and said, “I want you to feel my belly. All that cancer is inside there and I want you to know what it feels like so you never miss this.” She put my hand over her stomach and she pushed it down hard and she moved it to different parts of her abdomen and she kept pushing. I could feel multiple hard areas throughout her abdomen and I was worried her pushing so hard was going to hurt her. She could tell I was trying to hold back and she pushed my hand down harder and said, “I know you’re worried about hurting me and I want you to feel this deep inside. I’m an old woman and I don’t have anything left to pass on to anyone. My opportunity to leave something permanent is gone. I want to know the first time you ever recognized cancer was here. You’re going to feel this again and you’re going to have to tell someone what it is. You need to know what this feels like so you catch it earlier than they did with me. If you’re going to be a doctor, you can’t be afraid.”

I pushed deep into her belly and I knew where the major structures in her abdomen were. I followed along her large intestine, past her left kidney and up to her spleen in her left upper quadrant. I followed her transverse colon past her stomach and her pancreas and over to her liver in her right upper quadrant and her gall bladder under that. I followed her colon down past her right kidney and down to her appendix and over to the center of her abdomen by her umbilicus. All along I kept finding hard nodules and masses with softer, normal areas between. She winced occasionally as I palpated and she finally spoke again.

“You’re a reader. You know there’s a whole big world out there I will never see. All those beaches and sunsets will have to live in my imagination. I can picture them and I can smell the ocean and I can feel the breeze on my face if I just close my eyes. I know you get that and I know you can close your eyes and be by the ocean or on Mars or anyplace you’ve ever read about. You and I have that in common and you’re the only one who understands me.”

She was quiet again and then she spoke.

“I want you to be a good doctor. I want you to travel and I want you to dream. I want you to not listen when someone says you can’t do something or that something you desire doesn’t make sense. I want you to never miss anyone’s cancer.

Someday when you’re watching the sunset with the ocean breeze on your face I want you to close your eyes and remember me.”

Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. He can be contacted at a-vainio@hotmail.com.

They were late to the appointment and I almost wasn’t able to see them. A five year-old girl missing one of her top teeth and her mom, single and taking the day off for this appointment. She was in college getting her general requirements done and one day hoped to go into nursing. She worked at the casino and had been there for several years.

The girl had a cough for the last week and her mom thought it was getting worse. She was coughing off and on as I was getting the history from her mom, but she was also singing songs from one of the animated princess movies and she was dancing and doing pirouettes and wearing a billowing blue princess dress.

She had a beautiful singing voice.

I showed her the ophthalmoscope and let her look into my hand with it and showed her how it magnified my fingerprints. She turned her head so I could look in her ears and both of her eardrums were fine. I looked in her nose with the scope and could see some puffiness in her nasal passages and the back of her throat looked fine. I checked the lymph nodes in her neck and told her how they were part of her immune system and how they can get bigger when they are fighting an infection. I listened to her lungs in four different places on her back and told her how her lungs move air in and out and how they sounded normal without any wheezing or sounds to suggest pneumonia. I listened to her heart and told her as I was listening to each of the four valves how her heart beats over 100,000 times per day, every day and it never stops. I checked her abdomen and told her as I followed along her large intestine and palpated her left kidney, then her spleen and her stomach and her pancreas, then her liver and gall bladder and her right kidney and then her appendix, then her small intestine in the center of her abdomen and she listened to every word.

“You have a cold. Antibiotics will not help this and it just has to run its course. Cough syrups are fine and it’s OK to take medicines to help with fevers and achiness. Chicken soup and a mother’s love are what you need most and the chicken soup is optional. You have a beautiful singing voice and I don’t know when I’ve seen someone who could stand on their toes so gracefully. I’ve known you since you were born and I know that you’re bright and I know you’re a good reader. What do you want to be when you grow up?”

“I don’t know.”

“It’s not too early to start thinking about it. Those big movie studios that make the princess movies want you to buy dresses and clothes and they want you to buy dolls and all the things that go with them. They want you to want all those things. But they also want you to think that your greatest value as a girl is how you look. When you go to the mall, look around. Everything there is telling you that you need to be thin and you need to be pretty and you need to be giggly and superficial. The songs you listen to are telling you the same thing. Everything around us wants you to be a helpless princess and it wants you to be saved by a prince who rides in on a high-stepping horse. Almost all of the shows on TV are trying to tell you the same thing.

Right now you like to read and I know you understood when I was telling you how many times your heart beats. Someday, someone will try to tell you reading is hard and math is hard.

It isn’t. Math is rules and learning the rules isn’t hard. Science is mostly noticing the world around us and wanting to know how it works. All those things that want to turn you into a princess are meant to make it harder for you to do what you want to do.”

“But I like being a princess.”

“It’s OK to be a princess sometimes, but you need to be a doctor. You need to stay smart and you need to make sure your mom studies and makes it through college. Have you seen how hard she works at it? She needs you to believe in her.”

“Sometimes she cries when she isn’t ready for tests.”

“Everybody cries when they aren’t ready for tests. The important thing is that she’s working hard to make a better life for both of you. Good parents always want their kids to do better than they do and that’s why she works so hard in school. She wants to be a nurse so you can be a doctor.”

“Is that true, Mom?”

Her mother was crying. “It is true. I just want the best for you and I never thought about you being a doctor. I’m always proud of you and I would really be proud if you were a doctor.”

My pager went off and it was time for me to see another patient. I turned to the girl and said, “Remember, this cold is going to get better. You keep reading and getting good grades and I will do whatever I can to help you be a doctor. One day a frog is going to tell you if you kiss him, he’ll turn into a prince. He’s going to be very convincing and they always are. Do you know what you need to do?”

“What?”

“Leave him in the swamp. He’s just a frog.”

She was laughing and she started singing as she pirouetted toward the door. Her mother reached up and squeezed my arm as she walked past.

“Thank you, Dr. Vainio. It’s hard doing this alone and sometimes we barely get by. I’ve thought about dropping out and I have cried when I’m not ready for tests. But this is important and she needs to see me finish. Thanks again for talking to her. I think I needed to hear that as much as she did.”

(From News From Indian Country)

“Has it really been sixteen years?”

“It has.” She answered. “I still think about him every day.”

She was 78 now and I could tell seeing me brought back a flood of memories. When he was dying, I saw them almost every week and I hadn’t seen her since his funeral. I remembered the flower arrangements and the bulletin boards covered with photos flanking his casket. Those old pictures had been pulled out of albums and were curling in the corners and they showed me a side of him I never knew.

She was too heartbroken and too busy at the funeral to talk to and I didn’t see her again, but I thought of them off and on over the years. They were married for just over forty years when he died. He was a veteran and there were photos of him when he came back from the war. He was young and thin in them and there was no hint of the liver cancer that would eventually take him.

I started to see him when his legs began to swell and his skin turned yellow. His liver tests were elevated and a CT scan showed several large masses in his liver with spread to other organs in his belly. He was hoping for surgery, but his cancer had spread to too many places. Chemotherapy made him sick, but he wanted to stay alive long enough to watch his tenth grade granddaughter graduate and he was willing to do what he needed to do.

His hair fell out, but then began to come back and it was wavy and thick and gray. His liver tests seemed to get better for a while, then his jaundice and his swelling came back. He was following with the Oncologist, the cancer specialist and they changed his chemotherapy to a different regimen.

I wasn’t really taking care of his cancer, but they liked that I explained everything to them in a way they could understand. They were both too respectful of the Oncologist to really ask him questions and they felt if they had to ask him to explain something again, it would mean they thought he wasn’t telling them the truth.

As his liver continued to fail, the complications increased. He started to get confused and had to start a medicine to get rid of ammonia and the medicine made him have diarrhea. Once he was in a store and he didn’t make it to the bathroom and he never went back to that store again.

His belly started to swell and it made it hard for him to breathe. He had the fluid drained off by the Radiologist and it came back a couple of weeks later. Clotting factors are made in the liver and he got a nosebleed that wouldn’t stop and had to have a nasal packing done in the emergency room. That was a painful procedure and he told me he never wanted to do that again.

His back started to hurt and a scan showed his cancer had spread to his spine. He had to take narcotic pain medicines and the resulting constipation was so severe he had to be seen in the emergency room several times for enemas.

All the while, they continued to see me and I followed him when he was in the hospital. They were both happy to see me and he was in the hospital the last morning I saw him. He was feeling hopeful to go home and it was coming up on Halloween. He told me one year he dressed up as a scarecrow and sat on the swing on the porch and jumped up when trick or treaters rang the doorbell. “I found more candy on the porch than I gave out that year.”

He felt sick to his stomach later that morning and he collapsed in his hospital room. A code was called and they couldn’t resuscitate him. An autopsy found he had a massive bleed into his stomach and went into cardiac arrest due to the loss of so much blood. She was with him when he died.

Now it was sixteen years later and she was in the hospital for a COPD exacerbation. I could tell seeing me brought all of that and his last day back to her vividly. “That was a long and difficult journey we were on together, Dr. Vainio.”

“It was.” I said. “I’ve thought about you over the years and often thought I might run into you somewhere.”

She didn’t say anything for a while and then she spoke softly. “I’ve avoided you. I just couldn’t talk about him and I didn’t want to relive any of those days. I don’t know why I thought that, because I relive them all the time anyway.”

“Does seeing me now hurt as much as you thought it would?” I asked.

“It does.” She replied. “I was seventeen when we were married and everyone said he was too wild for me. He was at first and he ended up in jail a couple of times for fighting when he went into town. The police never sided with him and always assumed he was the one starting those fights. One of them was over me. One of the men in town called me a squaw and he tore right into him. He finally settled down and he was a good man and he was a great father.”

“I liked him a lot and I really respected him.” I told her.

“He really respected you, too and he was so proud that you became a doctor. He was proud that you treated him like he was worthy of your respect. Not everyone treated him that way. He grew up during hard times.”

“You grew up during those times, too.” I answered.

“That was a long time ago, Dr. Vainio. Those times were bad for us. People said some awful things and thought they were funny. I keep hoping people will see each other for who they are and not as something undeserving as they were led to believe. You saw him as a good and worthy man and he was all that and more to me. He was my medicine and he was what kept me on this earth. My children and my grandchildren have lives of their own and I’m an old woman. Maybe not this time, but one of these times I will make that journey to join him. I’m ready for that and I’m not afraid.”

“I don’t think this is that time.” I replied. “I expect the antibiotic and the steroids we started will have you feeling better in a few days.”

“I suspect you’re right.” She said. “When my time does come, I want you to know I appreciate all you’ve done and I don’t want you to feel bad for me. Promise you’ll remember me when I didn’t need a walker and remember me as the young woman in those photographs.”

“I promise.” I replied.

“Can I ask you one more thing?” She asked.

“Yes.” I answered.

“Remind everyone to love those who are connected to them and to respect everyone. It’s easy to judge others if you don’t understand them. Ask them to visit someone who’s alone. Bring them a meal. Most importantly, sit and eat it with them. Tell each other your stories. This big world can be a lonely place if you’re just waiting for it to end.”

I was shopping for tractor parts when a young Native American man came up to me. “Are you the doctor on Native Report?” He asked.

“I am.” I replied.

“I watch it all the time and I want you to know it really helped me.”

“Thank you.” I said. “I’m glad it helped.”

“I’ve never met anyone on TV and I didn’t know if I should come up and talk to you. I got kind of nervous.” He said.

He went on. “I’m not from here. I grew up in Illinois and I had to leave the city I was in. All my friends were using and it was hard to stay away from them. I went to treatment close to here and I’ve been clean for 9 months. I like waking up hearing the birds sing. Before I never paid any attention to that and all I wanted was meth or heroin. I didn’t even know there were different kinds of birds, they were just birds to me.”

“How did you end up here?” I asked him.

“No real reason. I wanted to see Lake Superior and that was good enough for me. Some of the people in treatment are court ordered to be there and are just serving their time, but quite a few of them are really trying and it felt good to be with them. I’ve wanted to quit for a long time and I never thought I would be able to. Every time I tried to quit at home, someone would bring me something and there wasn’t anything else it seemed like I could do.”

“What are you doing now?” I asked him.

“My sponsor does roofing and I’ve been working with him. It’s hot work and it’s hard work, but I like earning my money and seeing what I’ve done. I’ve never been good at anything before and I like what I’m doing and I’ve been told I do nice work. I’ve never had a reason to get up at 6 o’clock in the morning and that’s when I’ve been hearing the birds outside my bedroom window. I leave it open and they wake me up. They sing to me in the morning. Do you think that’s weird?”

“I don’t.” I answered. “One of my elders told me to pay attention to everything in the natural world. That includes the birds and the clouds and how the wind moves the trees. He told me all of those things are trying to tell you something and you need to look and listen to find out what that is.”

“Do you do that?” He asked.

“I do.” I replied. “I go outside every morning and I listen to the world. I have to get up early to do that and it starts my day out the way it should be. I put tobacco out for the spirits that watch over us and I think about the people I know who have died. I put coffee out for them in the morning and I give them the first drink.”

“How do you do that?” He asked.

“I spill it on the ground. A good friend of mine was dying and he asked me to spill some spring water I collected on the ground at his funeral. Ever since then I put coffee out for him every morning.”

“I didn’t grow up traditional.” He said. “My grandparents were in boarding school and they moved to the city to work after they finished school. They really didn’t have any traditional ways and my dad left when I was in kindergarten. Sometimes I think I’d look for him, but I don’t know what I would say. My mom struggled to raise me and my brother and we both ended up using drugs.”

“Where is your brother?” I asked.

“I don’t know.” He answered. “He used to call once in a while and he came over for Thanksgiving a few years ago and my mom got mad because he brought drugs with him. She didn’t know I was already using. I haven’t heard from him since.”

“Do you talk to your mom?” I asked.

“Not very often. She’s happy I went to treatment, but I think she wants to wait and see if I stay clean. My brother was put in treatment and he started using again the day he got out. I think she’s afraid that will happen to me.”

“Is that a valid fear?” I asked.

“I want to think it isn’t,” he answered, “but it would be easy to start using again. I was in treatment with someone who’s been in lots of times and he always thinks he can just use a little bit without getting started again. I need to stay with clean people like my sponsor. I know I’d never make it without that support. What did you mean when you said you put tobacco out?”

“Tobacco is central to all of our ceremonies,” I told him. “We offer it to the spirits when we say our prayers and I put it on clean ground for them every morning so they can help us live in a good way. Sometimes it gets smoked and sometimes it can be burned in a clean fire.”

“I smoke,” he said. “Can I count that?”

“It’s not the same thing.” I told him. “When you’re smoking just to smoke, you’re abusing a gift and something sacred. Tobacco is a powerful medicine and when people abuse it in non-traditional ways it can do a lot of damage and lead to some tragic health problems like heart disease, strokes and cancers.”

“My grandfather had a stroke,” he replied. “He was really angry about that and he died in a nursing home. He smoked, but I don’t think I can quit right now. Everyone in treatment smokes and we take smoke breaks when we’re roofing.”

“People quit smoking all the time.” I told him. ”It might be hard right now when you’re still fighting other addictions, but you can do this. You’ve already proven yourself to be strong and you know the people you work with respect you. From what I know of you in just this short time, I see a life of promise.”

“Do you really think so?” he asked.

“Absolutely.” I answered. I took out a pill bottle I carry with me and I opened it. “This is traditional tobacco, asemaa, and I make it in the winter. Making it is a slow process and it takes weeks staying up late at night making enough to get me through the year.”

I took some asemaa out of the bottle and I put it in his hand. “I’m giving you this as a sign of respect. You have changed your life and the path you were on was not the path that was meant for you. You need to share your strengths with others and you need to accept the strengths others offer you. Your strengths are not the same and you will need all of them combined to help each other.”

He was silent as I put the cap back on and handed the bottle to him. Tears welled up and he grasped the bottle and held it to his chest.

“I’m not used to having people believe in me, Dr. Vainio. It feels like a big responsibility.”

“It is a big responsibility, Daniel. Remember to look and listen to the world around you. These things are trying to tell you something.”

This had been a complicated operation and the incision was long. The sutures needed to come out and this was going to take some time. After any surgical procedure, the sutures need to stay in long enough to allow the incision to heal and stick, but not so long that they become a wick for bacteria and a risk for infection.

I was working with a first year medical student. Being in the clinic allows them to actually see their education put into practice. The first two years of medical school are mostly classroom and sometimes it seems like hands on care is a long time in the future. Most of the time they observe and even though they have worked hard to get into medical school, everything is new and medicine is a complicated field. All medical students sit in the classroom with valedictorians and salutatorians from all over and the competition to get into medical school is fierce.

I was looking at his incision and I asked him. “Today is your chance to teach a medical student how to be a doctor. Is it OK if she takes out your sutures?”

“That’s fine by me. I’ve never had a chance to be a teacher before.” He answered.

I showed her how the knots in the sutures were tied and she put her gloves on. She held the suture scissors in one hand and the forceps in the other. I could see she was a little shaky and uncertain and I could also tell she was excited to be carrying out a procedure. She cut the sutures carefully and the nurse painted tincture of benzoin along the edges of the incision to make the steristrips stick. After every other suture came out, the steristrips would go on and stick to the benzoin. These could take over a week to come off and they were strong and reinforced strips of tape made to hold the incision together as it continued to heal.

The end result was beautiful and she was rightfully proud of her work.

We walked into the next room and as soon as we walked in I asked her, “What do you hear?”

The room was quiet and we listened carefully and there was an easily audible and rhythmic sound of a buzz and a click,“dzzzzt-click, dzzzt-click, dzzzt-click….”

“What is that?” I asked.

“I don’t know.” She answered. “His watch?”

“It’s an artificial heart valve.” I answered. “Let’s listen to it for a bit.” Not all valves are this audible and I asked him how that valve changed his life.

“I was tired all the time before and it was getting worse. Dr. Vainio sent me for an echocardiogram and my aortic valve wasn’t working. He sent me to a Cardiologist. I had my valve replaced and I’ve never felt better. I hear it all the time, but it reminds me what I have to be thankful for.”

We saw a patient with alcoholic liver failure. Her liver couldn’t make the protein that helps keep fluid in her blood vessels and watery fluid was leaking into all of her tissues. Her ankles were huge and swollen and a week or so earlier she had nine liters of fluid drained from her abdomen. That’s the equivalent of four and a half of those big two liter bottles of soda. Normally there is the equivalent of less than half a can of soda in the abdomen so the internal organs can slide against each other. She was short of breath for the last couple of days and I ordered a chest x-ray and we looked at it with the patient. It showed a huge amount of fluid around her right lung and I called the Radiologist at the hospital and sent her there. She had a liter and a half drained from around her lung and her breathing was better and she was sent home.

We saw a prenatal patient at 14 weeks of pregnancy. She wasn’t sure she was feeling her baby move yet and she was worried. That first movement is called quickening and with a first pregnancy is normally felt at 16 to 18 weeks. I let the student find the fetal heart tones with the Doppler. She put the gel on the probe of the Doppler and carefully moved it around the mother’s abdomen. At first she was listening too far up and I had her move the probe farther down. We heard a heartbeat with a rate in the 70s per minute and the medical student kept the probe there and listened.

“Is that the baby?” I asked.

“I don’t know. How could I tell?” She asked. I had her feel the mother’s pulse and her pulse beat was in exact rhythm with the Doppler. I had her move the Doppler even farther down and there were heart tones with a rate of 140. Babies normally run rates of 120-160. Both the medical student and the mother knew this rate was much faster and they looked at me.

“That’s your baby and the heart rate is perfect.” I explained. This was the first time the mother could hear her baby and she started to cry. “I was so worried. I’m not really showing that much yet and I wasn’t feeling the baby move. I was starting to wonder if I was even pregnant!”

I ordered an ultrasound at the hospital and when we left the room the medical student had tears in her eyes. “That was so cool! I’ve never had a chance to listen to a baby! Thank you for letting me do that!”

We saw a woman for a follow up of a hospitalization for pneumonia. That was six weeks earlier and she was feeling much better. She was here for a follow up chest x-ray to make sure her pneumonia was resolved and to make sure there wasn’t something else in her lungs that was hidden by her pneumonia when she was in the hospital. Her chest was clear with just a few crackles in her right lower lung. I had the medical student listen.

“What do you hear?” I asked.

She listened for a long time. “Nothing. I can hear her breathing, but I don’t hear anything else.”

I had her roll a little bit of her hair between her fingers and told her that crackling sound was what she should listen for. She listened again. “Nothing. I just hear her breathi…No, wait! I hear it!”

I ordered a chest x-ray and we looked at it with the patient. “Your pneumonia is gone and I don’t see anything else it might have been hiding. Your diaphragms are flatter than they should be and this is usually caused by smoking. How long have you been smoking?”

“Over forty years.” She answered. “I stopped six weeks ago when I was in the hospital and I’m going to do my best to quit for good this time.”

I offered and she accepted help with smoking cessation and I set her up for low dose CT scan of her chest to screen for lung cancer. She thanked both of us as she left.

At the end of the day, the medical student waited until I was done charting and watched me go through a long list of refills and watched me send out lab letters and go through hospital reports.

“Dr. Vainio, thank you for such a great day! I have never been so excited about anything and I want to go into family practice!”

“I’m glad to hear it.” I answered. “We need more Native American doctors and we need more medical students. Your people need you and they already look up to you. You’re breaking barriers and you’re defying stereotypes. I see all the makings of a great physician in you and I will do everything I can to help you. Traditional healers have always spent long times away from their families during their training and their families didn’t fully know what sort of commitment that training meant. It’s no different now. This is a sacred path you are on and sometimes it will feel like you’re alone. I want you to know I will always believe in you and I’m looking forward to the day you become a physician. We need you.”

These future doctors are our children and our grandchildren, our nieces and nephews and members of our communities. Becoming a physician is a commitment to a life of service and I can see them getting ready for it.

I still don’t know how things aligned to open my path to medical school, but I do know others went out of their way to make it happen. Go to www.aaip.org online.

We are the Association of American Indian Physicians. We’re ready to teach our students.

We’re ready to pay it forward.

Arne Vainio, M.D is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. He can be contacted at a-vainio@hotmail.com.

He was nearing death. This moment was inevitable and he hadn’t eaten anything in the past ten days. Three days ago he started refusing water and he was intermittently awake at any time of the night or day. He had fought his cancer for as long as he could and decided to stop chemotherapy when it was making him too sick to be present for his family.

I went to visit him before that time and he was thin and weak and his voice was soft. I had to sit close to him and wasn’t sure if he was always aware of my presence. He reached for my hand and held it and it seemed like he was back asleep. He opened his eyes and he smiled at me. “I see spirits all around me now. They come and they talk to me and they tell me things. You keep doing what you’re doing and thank you for coming to see me.”

I wanted to see him again and it was weeks before Ivy and I could make that long drive. He died before we could get there and the funeral home had already come to get him. We sat with his wife and his family and she told us, “He was talking when he was asleep and when he would wake up he would tell me who he was talking to. Some were people he knew when he was a young man. One of them had your last name and he killed himself a long time ago and he wasn’t very old.”

My father committed suicide when I was four years old. He was forty-two when he died.

I don’t need reminders to think about my father and his suicide and I’ve been thinking about him often since then. George Earth and his mother and father were living in a shack in the summer of 1957. His mother mostly stayed in the shack and cooked and picked berries and gathered what she could. George and his father ran chainsaws and cut and limbed trees all day. The summers were hot and the mosquitos were vicious and the dust from the skidders dragging trees out of the woods hung thick in the air. They didn’t have ear protection or safety glasses or insect spray and the chain saw smoke kept them in an acrid, choking cloud. In the winter they froze as they cut and they ran for the shack when they got too cold. They didn’t get paid by the hour, they were paid “by the stick” and the trees they cut were counted and kept track of and they each earned less than forty dollars a week.

George introduced my parents to each other. My father was running a tavern called the Good Luck and he was good to George and his family. Sometime after my parents were married, George’s mom was walking along the side of the road and someone ran over her and killed her. Her death wasn’t investigated because she was Ojibwe. No one offered to look into it and George and his father knew better than to ask. The bar business wasn’t good and my father committed suicide that same summer.

George and his father left after that and I didn’t see him again until almost forty years later. As soon as we met we were family again. George came to stay with us as often as he could and we talked on the phone all the time. Sometimes I would call him when I was looking at the stars and listening to the wind and the sounds of the night. Every time I traveled to the ocean, I would call him when my feet were in the water and I would hold my phone out so he could listen to the ocean birds and hear the crashing of the waves and we would put asemaa out together at those times.

I wanted George to travel with me to conferences so he could be with professionals to learn from them, but more importantly, to teach them. He had a gift for humor and a gift for humility, but he was also a vast wealth of traditional knowledge and he could see right to the heart of most matters. He started to get short of breath and he was diagnosed with idiopathic pulmonary fibrosis. This is a condition with no cure and no known cause and it causes progressive scarring of the lungs and he eventually had a hard time breathing at all. He passed his dance regalia to me at a traditional powwow and I danced as he sat at one of the drums. The last time I saw him he brought me a guitar he used to play in his youth. He was so short of breath he didn’t even get out of the passenger side of the van. He had me take the guitar case from the back seat and open it on the ground next to him. I flipped the rusty metal buckles on the cardboard case and inside was an old guitar with strings that didn’t match. It was clear it hadn’t been played in a very long time. “I played everything from Merle Haggard to Johnny Cash on that guitar back when I was drinking and it sure made a lot of people happy.”

Our phone conversations changed and I think George was seeing spirits in his final days. I had collected spring water at sunrise on Easter Sunday and my mother used to do that when I was growing up. We drank it as regular water and she cooked with it, but she saved some to use when we were sick. I told George how I collected that water and he said, “I want you to spill some of that water on the ground at my funeral. Will you do that for me?”

I didn’t want to talk about that and I didn’t want him talking like that, but he made me promise and I did that when he died.

Every morning I go outside and I offer my asemaa to the four directions, to the water and to the earth and to the sky. I thank the spirits who watch over us and protect us. I bring my coffee with me and I offer the first drink of coffee to them and I spill some on the ground.

I think of George and I say good morning to him. I think of Leonard and my brother Kelly and my aunt Emma and my mother and my grandparents and my sister Shelly and all of my teachers who have gone before me. We come into this world through a doorway and travel this circle and hopefully make it through all four stages of life before we cross that threshold again. We are told the very young and the very old hold hands across that doorway. No one spends more time closer to it than doctors and nurses and all those who care for those most vulnerable. We see birth and we see death and we see everything in between.

Someday we will all make that journey and what we give of ourselves will be what remains.

I do not see spirits.

Someday, I will.

Arne Vainio, M.D. is an enrolled member of the Mille Lacs Band of Ojibwe and is a family practice physician on the Fond du Lac reservation in Cloquet, Minnesota. Contact info: a-vainio@hotmail.com.

I was in my residency training in Seattle and it was the first day of my surgery rotation. The surgery team was rounding at 6 AM and we were dividing up the patients on the service.

I was a brand new physician and uncertain of myself and constantly afraid of doing something wrong. The chief resident was in charge and there were three other surgery residents on the team. We covered rounds fast and we went from room to room to take care of post-surgical issues, draining wounds, cutting dead tissue from infected sores, managing pain, managing low blood pressures and patient fluid status and all the other issues that come up after surgery. We had over thirty patients on the service and there were new patients coming in through the Emergency Room and by referrals and there were patients to discharge to home or to nursing homes to continue their recovery once they were past the acute phase.

The team stopped in front of a room and the chief resident told the team, “Mr. Jensen is eighty years old and he has five fractured vertebrae from jumping out of an airplane. That was over a month ago and we can’t get him out of the hospital. He’s mad at everyone and all he wants is pain medicines and no one can talk to him. He won’t eat, he won’t get out of bed to work with physical therapy and what he was thinking when he jumped out of that airplane is anyone’s guess. He was too old to be doing something like that.”

We went into the room as a team of six and the chief resident asked him loudly, “Mr. Jensen, how are you doing today?”

“My back is broken. How the hell do you think I’m doing? I hurt constantly and I can’t walk and that physical therapist is trying to kill me. Get the hell out of my room!”

We walked out of the room and into the hallway. The chief resident looked at the assignment list and said, “Dr. Vainio, he’s your patient and you need to get him out of the hospital. No one has been able to talk with him. There isn’t anything surgical we can do to fix him, but he needs to be eating and he needs to start walking. Good luck.”

We finished rounding and I had other patients assigned to me and spent most of the morning discharging patients to home or to nursing homes, getting discharge medicine lists right, writing prescriptions and dictating discharge summaries. It was late afternoon when I got back to Mr. Jensen’s room. I knocked on the door and there was no answer. I opened it slowly and he was lying in bed glaring at me. “What the hell do you want now?”

I pulled a chair close to his bed and held out my hand. “I’m Dr. Vainio and I’ll be the doctor mostly working with you.” He looked at my hand, but didn’t shake it. “I’ve seen plenty of doctors and another one isn’t going to make any difference.”

“Fair enough,” I said loudly. “Is there anything I can do for you?”

“You can make my back stop hurting. I know everyone thinks I was crazy for jumping out of an airplane, but I did it and now I hurt all the time. You can’t change that, can you?”

“I can’t. Is there anything else I can do?”

“You can get me new batteries for my hearing aids.”

I put an order in his chart to get his batteries and the next day I went back to see him after morning rounds were done.

“How are you doing today, Mr. Jensen?”

“My name is Bill and you don’t have to yell anymore. My hearing aids are working fine. What did you say your name was again?”

“Dr. Vainio. What do we need to do to get you to eat? You need to eat so you can heal.”

“I get sick to my stomach and start burping when I eat anything. I haven’t had a good bowel movement since I’ve been here because it hurts my back when I try to have one. The nurses ask me about it, but it’s none of their damn business.”

“Actually, it is their business. If you don’t have a bowel movement, everything backs up. When you eat, it causes a reflex that makes your intestines move stuff out of the way. If your gut is really full and your stomach can’t empty that way, it tries to come back up your esophagus and makes you want to throw up.”

“So how do we fix that?”

“An enema to start and you should be on a regular bowel program with some fiber and a laxative.”

“I don’t want to be on more medicines. I wasn’t constipated before I came here and something here caused it. Is it the hospital food?”

“It isn’t the food. The most likely cause is the narcotic pain medicine you’re getting for your back pain. Those medicines cause lots of constipation.”

“My back is going to hurt worse if I stop those medicines. It’s the only thing that gets me through.”

“Your back likely will hurt, but those medicines don’t help as much as you think they do after the first few days. Most of the time people get dependent on them if they take them for too long and it’s really hard to stop taking them.”

The next day he was sitting on the side of his bed eating lunch when I came in. “That enema really helped and these hospital peas and carrots never tasted so good! My back hurts worse, but I’m trying to use less of the pain medicine. Physical therapy really hurt today, but I’m going to try to walk out of here if I can.”

The next day he took a few steps and made daily progress and a few days later I came into his room. I was really starting to enjoy our visits and he pointed to the chair when I walked in. “Sit down, Dr. Vainio. Where are you from?”

“Minnesota. Out in the woods up north.”

“Everybody thinks I’m crazy for jumping out of an airplane at my age. Do you think that?”

“I don’t, Bill. I hope when I’m eighty that I can even consider doing something like that. You’re the only one I’ve ever seen do that and I respect you for it.”

“Well, that will be the only time. My brother Randy and I were twins and he was born a couple of minutes after I was. He had polio when we were kids and it left him in a wheelchair. When we were in high school, I played football and he couldn’t. When I went into World War II, he stayed behind and I could read in his letters what he lost by not being able to do the things I did. He always wished he could have jumped from an airplane and he asked me to describe it to him again and again and no one was prouder of me the day I became a Major. He was diagnosed with colon cancer and it was too far along when they found it. The day he died, he asked me to tell him one last time how it felt to jump from an airplane. I did that jump on our birthday and I tried to see it from my brother’s eyes. Now I see that was the thinking of a foolish old man.”

“I see it differently than that, Bill. I see it as the promise of a warrior to a brother who always looked up to him. I see it as strength and courage and love. There isn’t anything anyone can do to fix your fractures and they have to heal on their own. I have no doubt you’ll have the strength you need to get past this and I admire you for what you’ve done for your country and for your brother.”

“Thank you, Dr. Vainio. I think I’m about as ready as I’ll ever be to leave the hospital. I’ve taken a few steps and I know I’ll be able to walk again. Randy never had that chance and I’ll walk for both of us. I’ll be thinking of you when I do.”

“I’ll be thinking of you, Major Jensen. Is it proper if I salute you?”

“Normally, the correct etiquette for a civilian is to hold your hand over your heart, but a salute from you would be fine by me. Can you help me up?”

I helped him slowly rise out of his chair. I could tell it hurt for him to stand and I knew he was standing for a brother who never could. He stood tall with his feet together and his hands at his side and I hoped my salute was a proper one.

I helped him back into his chair and went to get started on his paperwork.

One of our teachers, James Vukelich, posts the Ojibwe Word of the Day on Facebook every Thursday and I try to never miss it. These are beautiful lessons in what the words in our language mean, where those words came from and how our ancestors could see the best place to put some of our most important lessons so they wouldn’t be lost is in the language itself.

Gwayakwaadiziwin means honesty, but it means much more than that. It means to live a life so others can see your honesty and integrity and virtue. It means following through with what you say you will do.

The next day I was off work and I was thinking about living my life in that way and I didn’t take the first drink of my coffee. Instead, I remembered when George Earth was dying and he asked me to pour some of the spring water I collected on the ground at his funeral. Since then I make it a point to spill some of my coffee on the ground in the mornings before I take the first sip and I offer it to George and all of my relatives who have passed on. I offered my asemaa to the four directions and to the spirits in the water and to the earth and to the sky. It felt good to start my day in that way and I had lots of things to do and I silently vowed to do everything with integrity.

I had to go to the bank and the wait was long for some reason. I went to the store and I got into the line right after someone who had a full cart and she cut in front of me, even though she could see I only had three items. I needed to bring the rest of the liquid nitrogen I used for my mad science demonstration back to the welding supply place. I forgot to put it in my car and I had to drive back home to get it. I had to go to the tool supply place because I needed a new chain for my saw and I didn’t have the right part numbers, so I couldn’t pick it up. I ordered an antenna for my wife’s car from the internet and it didn’t pull in any radio stations and I had to go to the post office to send it back and I was third in line.

My hope was to work on one of my old cars and I hadn’t been able to do that for a long time. I finally got back home and realized I drove over 45 miles a couple of days before to pick up an engine stand and I didn’t bring part of it home. I had to drop everything and get into my rusty old truck and try to drive 45 miles again and get there before they closed.

I was trying to hurry and I came to a traffic light that is never green. This was a light that normally takes forever to turn green once it turns red and I was sure I was going to make the light and…

A pickup truck pulled out from a side road right in front of me and I had to slam on the brakes to slow down and I was sure he was going to make me miss that light. I could have let this pass, but instead I laid on the horn and stopped in front of him as he was pulling out from the side road. He stopped and I was able to go around him, but not until I got a good look at him. I was expecting a younger person who would maybe give me the finger or shake a fist at me and I wanted whoever it was to know they didn’t even look before pulling out in front of me and that this could have caused a serious accident. I thought maybe this was a beginning driver who might learn something from such a close call.

What I didn’t expect was an old man who was at least 90 years old. The skin on his face was thin and wrinkly. His eyes were blue and his hair was white and his head had a steady side to side tremor. He was alone in the truck and I could tell he was used to being alone. He didn’t look at me with anger or apology and he didn’t look at me at all. Instead, he threw his hands into the air and I could see him start crying. His hands were in the air in a gesture of giving up, of complete surrender and he slammed on his brakes and I went around him and I made it through the light and I left him behind.

Who else left him behind? His wife? His brothers and sisters? All of his friends from work? He most likely outlived all of them.

His vision and his hearing and reflexes were not what they used to be and I sensed he was isolated and alone and his long life had allowed those things most important to him grow old and die or to simply fade away.

In my hurry, I could see I was the straw that broke the camel’s back for him and I couldn’t stop thinking about him on my 45 mile drive. I thought about him as a young man, strong and with his entire future ahead of him. I thought of him finding love and raising children who inevitably found lives far away and only saw him occasionally and had a hard time talking to him on the phone. I saw a 90 year old man holding on to the last of his independence.

I saw the fragility of that independence and no doubt he had been seeing signs of it for a long time. Now his hearing and vision loss almost caused an accident and he would be too well aware he was the cause of it.

I picked up the rest of the engine stand with about five minutes to spare before they closed. I noticed my own strength as I picked up the steel frame and lifted it over the side of the truck and thought about what it would mean to have that strength taken away from me.

On the way home there was a rock outcropping on the top of a hill. I stopped my truck on the side of the road and I climbed until I was overlooking a small valley. I put my asemaa out for that old man. I had never seen him before and had no reason to think I would ever see him again. He would never know I climbed this hill for him and maybe he wouldn’t even see it as important.

I saw it as important. A light breeze picked up and it took my asemaa and it carried it out over the valley. I asked forgiveness from those who had gone on before me. I asked forgiveness from the old man.

On the first day of my new way of life, gwayakwaadiziwin, I didn’t live up to the lessons our old ones put into our language. My brief moment of anger had a lasting effect on someone else.

A moment of kindness would have lasted forever.