A History of the Present Illness

by Louise Aronson

  In the parking area, I imagined Perla’s K9 Safari camper truck with its trademark paint job: frolicking canines and squat, flat-topped trees on a background that was savanna tan on the bottom and the brilliant blue of African skies on top. Then I pictured Perla coming down off the hill toward the truck. She glanced at her watch and, instead of opening the tailgate, whistled that unique series of notes all her dogs knew. Standing alone on that flat stretch of rocky rubble a week later, I could almost hear the sound—the pitch rising, then retreating, then rising some more, like a complicated question.

  The dogs looked at Perla sideways, the whites of their eyes showing and their tails poised in midair, equally prepared to drop or wag, depending on her command. Having made good time that afternoon, she owed her pack and their owners another thirteen minutes, long enough for a jog down the pedestrian-only portion of the boulevard that runs through the park below the cliffs. Feigning indecision, she made the dogs wait an unnecessary second, their bodies tense and trembling.

  Moments like that one, she had said while telling me the story, reminded her why she loved dogs, their complete engagement and unrestrained joy in the face of life’s simple pleasures.

  Perla pointed past the gate at the pavement curving north down the hill. The chocolate labs, Silo and Seamus, barked, and a black-and-white collie named Bailey turned circles. The others sprinted forward with raised tails and lowered shoulders, and Perla ran with them, enjoying the stretch of her legs and the catch of cold air in her chest. She ducked under the gate. Beside her, Taco’s nails clicked on the blacktop. They passed the patch of giant cacti and the graffiti-tagged view bench that looked west toward Twin Peaks. At the curve, Perla heard her own panting, the swish and rustle of the wind in the eucalyptus, and just beyond the Esmeralda Street steps, an abrupt, high wail that stopped her mid-stride.

  She registered only color and motion at first, something bright red tumbling past the yellow grass and orange rock. Then, twenty yards down the road, the figure rolled off the cliff, and a second after it landed, she heard the thud of skull on asphalt.

  Some people would have run to the boy right then. They would have forgotten themselves and their usual responsibilities and just reacted. Perla noticed a plane buzzing overhead and the wind blowing strands of hair into her face. She said that even at a distance she could see that the body was small, with a red sweater and long blond hair.

  The dogs stopped running when she did. Now they sensed Perla’s tension and hovered close. She ran a hand along Taco’s trembling back and let the beagle crawl into the space between her feet. Just then, several people—an older man, two women pushing strollers, a teenager—hurried by, headed toward the body.

  Rasta stiffened.

  “No!” Perla snapped. “Come.” She tapped her left thigh twice with her hand. In slow motion, ears low and flat, the shepherd slouched forward and sat on her left side. She gave him a hunk of the cheese she kept in her zipped upper coat pocket for emergencies. The other dogs stared at her without blinking, licking their lips. She led them into the small clearing off the road beside the steps, made them sit, and gave each of them one of the small training treats from her lower pocket. A trickle of sweat rolled down her neck and into her shirt. Unless the kid needed CPR, she reasoned, little could be done until rescue arrived.

  Though she didn’t say so, it seems entirely plausible that Perla hoped an observer—and surely some of the people going by recognized her bush jacket with its dog-and-baobab-tree logo—might believe she was doing her part by keeping her pack out of the way. But then she came to her senses. She checked her watch; the human brain can survive only six minutes without oxygen.

  Perla told the dogs to stay and moved, faster than walking but slower than a jog, toward the crowd. People stood in two clusters, one around the boy, another a little farther away. She pushed through them without looking up. A heaviness slid into her shoulders and neck.

  The boy lay completely still but for the rise and fall of his chest. When she saw that he was breathing, she realized she was not and took a big gulp of air. Blood, already clotting, pooled around his left ear. A man Perla recognized knelt at the boy’s side, his eyes wide and mouth slightly open. She knew his yellow Happy Tails truck, that he walked large and small dogs separately, drank too much coffee, and didn’t do weekends, but she’d never bothered to learn his name. As she dropped to a crouch opposite him, he leaned forward toward the boy’s small ear.

  “It’s okay,” he said. “You’re okay. We’re getting help.”

  Perla reached for the child’s wrist. He’d landed perpendicular to the road, with one leg caught beneath him and his arms flung to the sides. At his feet, a woman wearing a tapered navy skirt suit and bright purple five-toed running shoes pointed at the silver earpiece and microphone that curved over her cheek in front of her mouth. “Nine one one,” she said. Then she cocked her chin at the child. “How old do you think she is?”

  “He,” said a man carrying infant twins, one on his chest, one on his back.

  The boy’s pulse fluttered under Perla’s fingertips, rapid but regular. A tiny tuft of saliva hung from the corner of his mouth. She stared at the pretty face and delicate hands, at the low-riding jeans, red V-neck sweater, and unlaced high-tops.

  Sirens sounded from somewhere down the hill in the Mission. People exchanged quick, relieved smiles.

  The Happy Tails man said, “She’s a girl, definitely.”

  Perla moistened her lips with her tongue. “A boy,” she said. “A ten- or eleven-year-old boy.” His chest rose and fell. His heart raced. The scalp wound had slowed to an ooze, and there was no other visible bleeding.

  “A nine-year-old girl,” the cell phone woman said into her machine with authority.

  The man with twins looked at Perla and shook his head. She shrugged her shoulders. Up the hill, a dog barked a guttural warning. Without letting go of the boy, Perla leaned to one side until she could see that all her dogs were still on the shoulder where she’d left them.

  “There were two others,” the cell phone woman said into her mouthpiece. She tilted her head back and squinted up at the cliff path. “But I don’t see them now.”

  The boy moaned. He didn’t open his eyes or move.

  “Please,” whispered the Happy Tails man. “Hang in there.” He rested a hand on an edge of red sweater and slowly moved it up and down. Perla tracked the boy’s pulse. She watched the lift and descent of his torso, faster than before. She held his wrist two inches above the ground, then let go. His arm dropped like a doll’s.

  The sound of sirens came from several directions now, louder and closer.

  Perla squeezed the tip of the boy’s second finger; he didn’t retract his hand, but within seconds his blanched nail bed regained its pink tint. The engines were close. Close enough, she felt sure, that soon the paramedics would arrive in time to help the boy.

  Something shoved her shoulder from behind, and a man’s voice said, “Hey, what are you doing? Are you a nurse?”

  Perla shook her head. She let go of the boy’s wrist. At that exact moment, his eyes twitched and the tendons on his neck strained with inspiration. When he exhaled, the noise sounded like bubbles blown through a straw.

  “Oh my God,” said the Happy Tails man. He looked at Perla. “What’s happening?”

  Perla thought the boy was going into pulmonary edema. Or that his lungs were filling with blood. She didn’t construct a more elaborate differential diagnosis than that two-item list. Instead, she imagined that she had thrown balls to her dogs on the rocky flat beside the parking area rather than running with them down the road. Or that she’d driven to the beach at Fort Funston that afternoon, or to the Presidio, or to any one of the other two dozen dog parks spread throughout the city.

  “They’re here,” she heard the cell phone woman say. Everyone looked down the hill.

  Red flashing lights lit the asphalt from the fire engine and rescue truck arriving at the park’s lower gate. Two pa
ramedics, each with a fluorescent orange tackle box, scooted under the barrier and began jogging uphill carrying a stretcher between them. It would take them at least a minute, maybe two, to reach the boy.

  Now the boy breathed in again, making a gurgling sound. His skin looked ashen. Perla reached for his wrist and couldn’t find a pulse, but he took another gasping breath.

  “Hurry, hurry, hurry,” intoned the Happy Tails man, looking back and forth between the boy and the paramedics.

  Perla felt for a pulse in the boy’s neck. She thought she sensed a flutter beneath her fingertip, but she couldn’t be certain. She willed him to breathe again.

  “Jesus!” shouted the cell phone woman. “Goddamn dogs.”

  Halfway down the hill, terriers, Chihuahuas, and a shih tzu, some trailing leashes, yapped and lunged for the paramedics.

  “Oh God,” said the Happy Tails man. “I forgot.” But he neither stood nor called his dogs.

  Perla watched as a pale pink bubble formed between the boy’s lips. He looked as if he were wearing lavender lipstick. He looked like a girl.

  “Can you imagine being the parent who gets this call?” asked the man with twins. “Can you just imagine?”

  The paramedics dropped to their knees. One began assessing the boy, and the other threw open his tackle box. Perla stepped out of the way. She couldn’t imagine receiving the call about the child, but she could imagine making it. She walked to the edge of the asphalt and retched into the dirt.

  No one who knew Perla as I did would call her thoughtless or irresponsible, though she was one of those people who had been slow to find her place in the world. K9 Safari, a year and a half old when the boy fell, was only the latest of her independent ventures. In the decade since she and I had worked together, she had also run a catering business, done a two-year stint in real estate, and worked as a personal trainer. But Perla said K9 Safari was her best job yet, her favorite by far, and the most successful. She had a twenty-dog wait list and bookings for holidays more than six months away. And it was true that she excelled at her work. In the aftermath of the boy’s fall, when she wouldn’t have minded if her dogs acted up, making it necessary for her to escort them back to the truck, they remained in an orderly pack on the shoulder of the road, sniffing the air and throwing sidelong glances downhill toward the growing group of worried humans.

  You can see San Francisco General Hospital—where I work and where Dylan Hunter was taken by the paramedics—from the cliff where the three young friends were walking the afternoon of the fall, and you can see Bernal Hill from certain parts of the hospital. Not from the pediatric ICU, where Dylan spent ten days, or from the wards, where he spent another three weeks before being transferred to a long-term rehabilitation facility. But you can see much of the hill from my office, its eastern slopes jutting like an island of primordial wilderness above the neighborhood’s expanse of intersecting freeways and tightly packed houses. If I stand to the far left of my windows and look up and to the right, I can even see the stretch of asphalt where Perla waited with Dylan after the fall. I look at the hill often these days, noting the greening of the grass with the winter rains and the different hues of the rocks as the light changes throughout the day. I would like to tell Perla that I now see those colors and changes and the opportunities they represent when I look at Bernal Hill, but she and I are no longer in touch.

  * * *

  Fourteen years and five months before the boy’s fall, in the third week of June, Perla and I both arrived in San Francisco (me from Baltimore, she from Chicago) to begin the family medicine residency at SF General. Looking at Perla then, you couldn’t have guessed that she’d already had second thoughts about being a doctor.

  That first morning, a low, wet fog hung over the city from San Bruno Mountain to the Golden Gate. As we gathered on the steps outside the hospital’s main entrance, water dripped from rusted pipes along the cement façade, and people passed wearing the sort of clothing I hadn’t expected to need in California—knit watch caps and leather gloves, long coats and colorful woolen scarves. The residency director, Dr. Ernest Westphall, told us to line up for the official class photograph, and then the ten of us—five women and five men, all bright-eyed and vaguely self-conscious—jockeyed for the front-and-center positions while pretending not to care where we stood, until at last we’d assembled in two uneven rows. We had stethoscopes draped casually, almost elegantly, around our necks and pagers clipped to our belts. Each of us wore a pressed white coat with his or her surname embroidered in red script across the left side of the chest, after which were written the same two letters, M and D, as if being a doctor is a singular experience. When Westphall said “code blue” instead of “cheese,” one short second before the shutter clicked and the flash exploded, most of us tried to smile.

  We all got a copy of that photograph. Mine hangs above my office desk so our new recruits—I replaced Westphall five years ago as residency director—can see that I began just like them. (Of course, that isn’t what they see; they notice only the dated clothes and our pockets stuffed with books, the contents of which they now carry in slim chrome or black handheld devices weighing less than the most benign pocket manual of yore.) Still, it’s a great pre-digital-age photo, the sort of flawed, overly revealing glimpse of life that would be deleted these days, inadvertently constructing an artificially polished historical record. Four of us married within the group, and with the exception of Perla—I was the only one who remained close to her—we’ve all stayed in touch; you don’t go through what we went through without forming intense bonds. We helped mold and define one another, both as doctors and as people. So it matters that the photograph exists. It’s a reality check that we can hold up against our memories, a glimpse of what we were like untainted by all that followed.

  In the snapshot, I’m standing in the center of the front row, wearing a red bow tie I still own and resting my arm on Josette Rivera’s shoulder. She’s pressing her hip comfortably into my thigh, both of us elated to have a familiar presence in our new city, three thousand miles from the medical school where we weren’t particularly close despite being the only two Pinoy in the class. Josette looks like a child playing dress-up, clogs poking out from below a pantsuit that doesn’t quite fit. Beside her, Nam Tran pulls a face. At thirty-one, he’s the oldest in the group, but he has no intention of growing up. He’s had to do that already in his life, first at a detention center in Hong Kong, then in a housing project in Lowell, Massachusetts. Behind him, Darius Shah, homeschooled through age thirteen, then Harvard cubed—B.S. ’91, Ph.D. ’95, M.D. ’98—just twenty-two years old, stares at the camera as if daring it to challenge his right to be there. Diminutive Tea Tores, next on the upper step, has a wide, beautiful smile and plans to start a free clinic in the Central Valley for the children of farm laborers like her immigrant parents. Lamar Johnson, to her right, has an M.P.H. as well as an M.D. and muscles straining the sleeves of his shirt. Beside him, Sumita Banerjee has close-cropped hair, piercings the length of both ears, and a key ring hanging out of her pants. She’s looking down at Althea Bukowski, who appears flushed, excitement and anxiety radiating from her moist blue eyes and bright orange lips. Only Marcus Rosenberg, standing beside Althea’s half-turned back, isn’t smiling. Finally, there is Perla, completing the front row. She’s wearing a pale yellow blouse tucked into a black pencil skirt and a necklace made of tiny Lego blocks in primary colors. Unlike the rest of us, she looks intelligent and calm, mature and prepared. In other words, unlike the rest of us, she looks like a doctor.

  The four patient-care wings at the General were distinguished only by signs labeled A, B, C, and D, as if the administration couldn’t be bothered to provide more specific or interesting designations. I had trouble finding the lab, the stairs, my patients. The hallways all looked the same, especially at night: speckled off-white linoleum, fluorescent track lighting, stained, dingy walls that might once have been colored in a drab, subdued palette. In addition to my deficits
in navigational skills, my new job also seemed to have exposed interpersonal inadequacies. My resident—a pediatrician, as I had started on the pediatrics service—hated me. Ditto, apparently, my patients and their parents, or so it seemed on those rare occasions when I managed to locate them. (I had no idea then that this generalized antipathy had little to do with me. My patients had spent enough time in the hospital to know that nurses provided comfort while doctors caused pain. My resident—one week remaining in his three-year training stint—was what I soon learned to call toxic, a phenomenon for which we now have jargon in the form of the words burn out, words evoked with increasing frequency by my exhausted, angry, dysphoric residents, who brandish them in order to secure time off for yoga and navel-gazing instead of just sucking it up as we did.) During that long first day of my internship, I worried that I wouldn’t make it through my shift, much less the year.

  Eighteen hours after our class photo was taken, I sat pen in hand over an open chart at a nurses’ station thinking about the word green. Up until that night, if I thought of green at all in reference to myself, it was the noun I considered: the communal central greens of the East Coast towns and universities I’d unknowingly given up by moving to drought-plagued California; green, the slang term for money, which I hoped to have more of now that I’d finally be receiving a paycheck; and the green paint in the bathroom of my new apartment, made by combining my leftover yellow (bedroom) and blue (kitchen). By contrast, as an adjective, green had always seemed to refer to others, such as the patients at the refugee clinic where I’d volunteered during high school: the newly arrived Hmong elder we found squatting atop the handicapped toilet, his first pair of tennis shoes leaving footprints on the seat, or the Sudanese woman who burned herself and her two daughters after starting a fire in the living room of her new American home in order to cook dinner. And then suddenly, at the start of my internship, a practicing doctor for less than twenty-four hours, there I was, trying to access data from a computer in a hallway on the toddler-to-teen ward of a San Francisco hospital, living the adjective: “not in condition for a particular use; deficient in training, knowledge, or experience; not fully qualified for a particular function.”