July 3, 1968. It was a day 21-year-old Dennis Kuzmickas would never forget. It would also become a day he'd try for a long time not to remember.
A medic serving with the U.S. Marines, Kuzmickas trod next-to-last in a line of Marines from the Delta 1/7 1st Division. The men were cautiously weaving their way through the tombtones in a sandy Vietnamese graveyard in Quang Nam province, southwest of Da Nang. The graveyard was thick with mines, but their lieutenant regularly ordered them to walk this way rather than a safer route because he didn't want the Vietcong to think his men were chicken. The idea was to follow behind the point man, the first in line. If he got through safely, then the places he stepped would be safe.
As for the point man, perhaps he followed God.
Kuzmickas had already had one scrape with death in the graveyard. A week earlier, he took a step and saw the sand start to funnel away from his foot and the earth collapse into a pit, the signature of an anti-personnel mine the Vietcong were famous for. The mines were designed to blow sideways and rip off a leg or arm, but not to kill. Fortunately, Kuzmickas pulled back quickly enough to avoid triggering it.
After hearing about Kuzmickas's narrow escape, the lieutenant ordered his troops to return to blow up the mines. So there they were marching through the tombstones, the air hot and thick, hoping not to be six feet under soon themselves.
At the back of the line, Kuzmickas walked near a Vietcong prisoner. A thought flashed through his mind: "The Vietcong lay warning symbols near their mines. The prisoner will know them. Follow him."
But Kuzmickas took a wrong step.
A sharp crack pierced the air. Then everything went black. Kuzmickas entered a peculiar state of conscious unconsciousness. He had blacked out, but a voice in his head kept up a running commentary. "God, what the hell happened there?" the voice asked. "I bet I stepped on a landmine."
Then, far off in the distance, he heard a scream, "like the noise you hear in a tunnel from far away. It got nearer and nearer," louder and louder until he came to and realized he was the one screaming.
"Everything was covered with warm, sticky blood," he says. "I knew my leg was broken. Definitely." Next to him, machine gunner Tom Newstead was pulling dressings out of Kuzmickas's pack to stop his bleeding. The voice in Kuzmickas's head asked, "When's that helicopter gonna get here?"
As Kuzmickas would soon learn, bones in both his legs had been fractured, and large chunks of muscle blown off. His right pinky was gone, and infections would soon fester in his wounds. After being medivaced out of Vietnam, he returned home to the States and was medically retired. He had his wounds cleaned, his infections treated, and his left knee joint fused. He hobbled around on crutches for a year, then learned to walk with one stiff leg, to type despite missing a finger, even to ride a bike again. You learn to live with the disability, Kuzmickas says plainly, and not to make a big show out of it.
But what do you do with the memories? Stuff 'em.
In a brick office building in downtown Baltimore that serves as a health clinic, people slump in hard plastic chairs or pace the room. One man sleeps while sitting, his head cocked on his hand.
These men and women are homeless. They are waiting, on this sunny March morning, to see a nurse or doctor, or to speak to a drug and alcohol counselor or social worker at Health Care for the Homeless, a not-for-profit agency developed and supported by the Johns Hopkins Medical Institutions and several other medical and charitable organizations in the area.
Standing at one side of the room, Dennis Kuzmickas, 48, scans the crowd of faces. He wears tinted glasses that shade, but don't hide, the crinkles framing his eyes. The lines appear when he smiles, half-closing his eyes the way Lloyd Bridges does, as though to keep out cigarette smoke. A deep cleft creases his chin. He is dressed in a flannel shirt, wool pants, and sport coat. A badge pinned to his lapel says, "Dennis Kuzmickas, Student, J.H.U. School of Nursing."
Kuzmickas has followed a parabolic career path that started him as a medic on the battlefields of Vietnam, took him to engineering jobs throughout the world, and has returned him to a healer's role, this time in the trenches of urban Baltimore.
After his stint in Vietnam, he completed a degree in civil engineering at the University of Connecticut in Storrs, and for the next 20 years worked as an itinerant engineer. He helped construct submarine pipelines, marine terminals, and naval equipment in Indonesia, Africa, Norway, and the Middle East. His expertise in modular construction brought companies knocking at his door.
Kusmickas's work in developing countries also took him out into villages where he met many people who were poor or otherwise disadvantaged. Often, he'd find he could help them in simple ways. In Borneo, he helped a family fish and harvest rice. At a boys orphanage in Indonesia, he organized sporting events. These efforts, he says, added a new dimension to his work. Although he loved the problem-solving aspects of engineering, he says that by the mid-1980s the puzzles had become less challenging. He began to look for ways to work more closely with people, especially needy people.
That sort of work answered a voice he'd heard deep down inside since his days as a medic in Vietnam. "I felt I owed a debt to the people I'd left behind," he says, "especially the civilians."
A religious man, Kuzmickas toyed with the idea of becoming a missionary. But nursing seemed to be a way to help people on many levels - - medically, socially, emotionally, and spiritually. By then nurses were starting to take on more responsibility, and the concept of nurse practitioners was taking hold. "I thought I could do more for people through nursing than by earning money in engineering," he says.
So, while still working as an engineer, Kuzmickas took basic science courses in the late '80s to prepare him for nursing school. A friend who is a nurse told him that Hopkins has one of the strongest nursing programs in the country - - particularly in the field of community health. So he applied and was accepted. Since enrolling he's spent virtually all his spare time doing community health work in a variety of agencies including Health Care for the Homeless, where he finds himself on this March morning.
"George Sanders!" he shouts in a voice loud enough to be heard above the din. "George Sanders!" (The names of the patients in this story have been changed.)
A short, bearded man ambles over, and Kuzmickas escorts him up to the second floor where the center's doctor, fellows, eight nurses and nurse practitioners, and 16 volunteer nurses and doctors see their patients. (The organization also has a dozen social workers, substance abuse counselors, and mental health workers, who see their clients on the first floor.)
Kuzmickas and fellow Nursing student Alison Griffin (BSN '95) began working at HCH last summer under a Kellogg grant. Once the grant ended, Kuzmickas stayed on, volunteering his time one morning a week. It's his job to interview patients, take their vital signs, change any dressings, and conduct simple tests before they see a nurse or doctor. As important as the technical tasks, he says, is to treat patients in an unassuming, non-threatening manner.
"So, why are you here today?" Kuzmickas asks Sanders gently. The two men sit facing each other in a tiny beige examining room. Sanders glances up at a poster on the wall that discusses the risks of sexually transmitted diseases. Another outlines the cycle of cocaine dependency, and a third the hazards that drugs and alcohol pose for pregnant women.
Sanders explains that a pre-screening test for a drug study revealed he has hepatitis C. He's never had any symptoms though, he says, and would like to enter the study, which pays its volunteers.
Kuzmickas pops a thermometer in Sanders's mouth, and explains that he could have been exposed to the virus without knowing it and had a barely noticeable case of the disease.
"I feel fine," says Sanders. "The only time I'm tired is when I ain't gettin' three meals a day. And I ain't been gettin' three meals a day sometime."
"Have you ever had a blood transfusion?" Kuzmickas asks.
"No."
"Have you ever used any intravenous drugs?"
"No, never. You know at this shelter they're not clean people. They handle the butter with their hands, and all. Maybe I got it that way."
"The only way to get this type of hepatitis is through blood, such as through a blood transfusion or IV drugs," says Kuzmickas. His tone is matter-of-fact.
"I've smoked drugs out of a pipe. That's it."
Kuzmickas flips through Sanders's medical file. "And when you smoked drugs, what kinds of drugs did you smoke?"
"Crack."
"When's the last time you had any?"
"Two days ago." He pauses, then adds quickly, "See, I did speedball one time." Sanders goes on to explain that about 18 months ago, he injected "boy and girl," a mixture of speed and cocaine. "It makes your head spin," he says.
"Okay, I'll write that down too," says Kuzmickas, as he slips a blood pressure cuff around the man's upper arm. He tells Sanders that he could have been infected by that single injection of speedball. Breaking the tension, he adds, "You've got good blood pressure."
After Sanders leaves to see a nurse, Kuzmickas says, "When people come to Health Care for the Homeless, many times they don't say right off why they've come. You don't find out till later." A patient might say at first that he has a sore tooth, for example, but over the course of a visit or a few visits reveal that what he really needs is treatment for a sexually transmitted disease. "Getting the information is like bridge playing, finessing," Kuzmickas says.
Many medical problems the homeless experience are not conditions most people would want to publicize. AIDS. Drug abuse. Scabies and other results of life on the streets and in shelters. Most people who visit Health Care for the Homeless end up being treated for high blood pressure, substance abuse, or dental and diabetic-related illnesses. Many have secondary problems, such as mental illness or AIDS, that compound their primary illness.
However, says Kuzmickas, "A large problem with the homeless is hopelessness. You can take care of their feet, treat their high blood pressure, feed them, but first you need to deal with their hopelessness."
Kuzmickas has discussed this topic with his mentor, nursing instructor Kathleen Becker, who helped found Health Care for the Homeless a decade ago. Like Becker, he says, he believes that often, when people become homeless, anger or sorrow initially drives them to try to improve their situation. But if they encounter one barrier after another that prevents them from getting a job or a place to live, hopelessness sets in. "They start to go with the flow," says Kuzmickas.
Overcoming homelessness and joblessness are difficult because they cannot be done little by little. "It's like a step-function," says Kuzmickas, still the engineer as he chooses a mathematical term to illustrate his point. "To be a part of society you have to have a place to live, clothing, money for transportation." These things are like steps, rather than points on a smooth curve, because "you either have an apartment or you don't. You need 100 percent of the rent." And to get to one of the top steps - - a job, for example - - you have to climb the bottom step. "You can't get a job if you look like a bum. And you'll look and smell like a bum if you don't have a place to sleep and a place to wash." If people have no hope, he says, they lack the impetus to attempt even that first step.
But how do you restore hope to people who live in such meager surroundings? "First you give them your trust," he says. "Let them know they're important. Treat them with respect. It's the best thing we do for people. It's called unconditional positive regard - - cast no judgment. That's a hallmark of nursing."
Since arriving at Hopkins two and a half years ago, Kuzmickas has thrown himself into the bachelor's program, working days that begin at 7 a.m. and end long past midnight. On a typical day, he'll attend classes in the morning and work at a clinical site in the afternoon. Then he bicycles home through the city streets to study in his tiny apartment, just a breath larger than a dorm room. Divorced, he lives alone. His two teenage children live with their mother in Maine. Despite his packed schedule, Kuzmickas also finds time to participate in the Hopkins Christian Fellowship, to play volleyball, and to continue one of his favorite pastimes, reading. At least twice a year he rereads Slaughterhouse Five, the tale of a World War II soldier who repeatedly relives his traumatic experience during the bombing of Dresden.
Over the past two years, Kuzmickas helped the Baltimore Health Department develop a questionnaire that identifies tuberculosis patients who are at high risk for stopping their medication. He also completed a nursing rotation at That Place, a health clinic at a Baltimore middle school that serves a population of underprivileged children.
Due to complete his nursing degree at Hopkins in May, he's been accepted to the School's advanced practice program and plans to enroll in the fall. Ultimately, he says he'd like to work in a clinic where he can provide health care to an underserved population.
Despite Kuzmickas's years of experience in a field outside nursing, "Dennis is actually fairly typical of Hopkins's nursing students," says Stella Shiber, associate dean of undergraduate programs. The School welcomes and prides itself on having a large group of students who have had experience in other disciplines. The average age of students entering last year's class was 30, and 36 of the applicants accepted for next year's class are returned Peace Corps volunteers.
"Students with some life experience bring with them a wealth of information," says Becker. "They also can apply that information. They're assertive and independent, and they question why something is happening. They take matters into their own hands."
These traits particularly hold true for Kuzmickas, who says that his stint in Vietnam changed him forever, inside and out. "I tend to challenge people a lot," he says. I don't ever want to be in a situation where I accept orders and don't know why. I don't trust authority. If there's an unknown, I don't put my blind faith in something."
In the classroom, say some of his instructors, that's made him a challenging student to teach. It's also allowed him to accomplish a great deal.
"I've seen him so outraged" at the plight of the less fortunate, says nurse Ridge Pilcher, clinic manager at Health Care for the Homeless. "But then he goes and does something to help." Last year, for example, when the agency ran out of toiletries, Kuzmickas wrote to Arm & Hammer. "We got a huge package of toothpaste," she says. "That's the type of thing he does."
Kuzmickas hasn't always challenged authority. When the call came in 1968, sending him to Vietnam as a Navy corpsman with a Marine division, he went with no regrets, he says. "I was gung ho. I thought, `Wow, great! We're going to free Vietnam from communism and all that.'"
But the two weeks that he spent there, brief though they were, completely dissolved his support of the United States' role.
"It was the worst experience of my life, he says in a choked voice, as tears start to come to his eyes. Getting injured was only part of the trauma - - perhaps the least of it. "I thought there would be logic, order, and honor in the war," he says. Instead, "There was no society anymore, no more rules. The civilians were the most brutalized of any population I've seen. They had no support, no government."
"My first patients were a grandmother and grandfather carrying a baby who were accidentally run over by a motor scooter. They were crushed from the pelvis on down. Picking up their legs was like picking up a pair of long johns. The baby ended up becoming part of the motor scooter. After the accident, every time traffic went by the baby got buried by dust. That's how it got buried."
American soldiers, he said, would test-fire their weapons by firing toward peasants in the field. Their bullets would throw up dirt and water and send workers scrambling.
Perhaps the most horrendous thing was how other soldiers became numb to the violence and threats, even to walking through a graveyard they knew was riddled with mines. "These people had been there so long they were like zombies," says Kuzmickas. "They were walking through a minefield like they were walking through the park."
A few months after his return to the States, Kuzmickas learned that Tom Newstead, the comrade who probably saved him from bleeding to death, had later been wounded and died of his injuries. "I never had a chance to thank him," Kuzmickas says.
Still nursing painful wounds and infections that had spread to his bones, Kuzmickas immediately re-enrolled at UConn in civil engineering. While other students held candlelight vigils and marches against the war, Kuzmickas focused all of his energies on just getting around the snowy campus with crutches as his infections drained. He did, however, return to the war zones around Saigon for a week in February, 1971 as a photographer for UConn's Connecticut Daily Campus.
"I can't tell you exactly why I did it," he says, hesitating. During the time he served in Vietnam, he had been afraid, he explains. This time, even though the visit was painful, "I had to prove to myself that I could be in a situation there and not be afraid. Also, I had to look into the faces of the civilians and see that they were people. Before, they had been things."
Soon after graduation, he got an engineering job in Bahrain, and continued to travel from one overseas job to the next. Life sped along. He married and had a son and a daughter. On the surface, life was good, but underneath, the unresolved pain of his Vietnam experience was encroaching on his life.
When painful memories started to haunt him, a drink would smooth over the rough spots - - for a while. Though he never lost his job, got in an accident, or hurt anyone, eventually, he says, "I was dulling my enthusiasm for life. I didn't want to do anything."
Instead of coping with the emotional pain left from Vietnam, he says, "I was denying it. I wasn't very mature. I drank a lot. I tried to do anything that was risky. I just wanted to test myself." Out on an off-shore oil field, while carrying heavy beams, he'd jump from an oil barge to a bobbing tugboat. One false step and he could have slipped and been lost in the high seas. Engineers certainly weren't expected to take on such tasks, says Kuzmickas. "I could have said, 'I can't do that,' but I did it because it gave me a thrill."
He also had recurrent nightmares. In one dream, the military told him he had to go back to Vietnam. "I didn't want to go back and I felt ashamed that I didn't want to go," he says. Some dreams were so real that afterward he had to check his calendar to figure out what he'd really been doing during the time he dreamt about. He did not discuss these dreams with his wife or friends. "I put it away," he says.
Though he sank very low, he says he never gave up entirely. "I thought, `I don't know anything, but I know there is a God. I know he loves me, and I'll build from that.'"
Little by little, he began to build himself back up. He stopped drinking through Alcoholics Anonymous. After a trying divorce, he finally sought counseling and was diagnosed with post-traumatic stress disorder (PTSD), an illness once known as "shell shock." It results from traumatic, often violent, experiences that scar the mind and can lead to nightmares, flashbacks, depression, and difficulty completing simple daily tasks. Many people don't experience symptoms until years after the traumatic event. As he began to acknowledge and talk about his experiences, says Kuzmickas, he realized that he didn't have to hide his feelings. "Memories have their place." By bringing them out in the open, he says, "they shouldn't have to control your life" - - to drive you to drink or become apathetic.
"The experience I had in Vietnam was a real eye-opener," he adds. "I wouldn't trade it. But I wouldn't want to go back again." So as the 20th anniversary of the official end of the war neared this past spring, Kuzmickas said he would not commemorate the event.
Kuzmickas isn't done reconciling with his past. Though his physical wounds have long healed, he still has some raw emotional ones. During a taxi ride one day recently from the TB Clinic to Health Care for the Homeless, Kuzmickas tries to address the memories he's still grappling with - - memories of atrocities he witnessed in Vietnam. "I admit it, I feel ashamed not saying things," he says. "There are things I can't talk about." He shifts his weight self-consciously on the vinyl seat. "I just had the feeling I should have done something. But I didn't know what to do. I was in shock."
Is the nursing work he is doing now in some part making up for that? "I think so," he replies quietly.
"How ya' doin' today?" Kuzmickas asks a patient one day recently at Health Care for the Homeless.
"Just all right," replies Pete Kennedy, a young man in a blue baseball cap. "If I could hang a job, I'd do better but I ain't hangin' no jobs." He smiles sadly. Every other tooth is blackened like piano keys.
Kuzmickas talks to him about Break the Cycle, a job training program housed in the same building as the clinic. As he places the blood pressure cuff on Kennedy's arm, he asks him where he is living and why he's here.
It turns out that Kennedy is seeking help for a sore knee. But Kuzmickas focuses on his blood pressure.
"The bottom number is the diastolic pressure," he explains patiently. "Yours is 86. It's getting close to what's called `the break.'"
"What's a good one?" Kennedy asks.
"Try to keep the top number below 140 and the bottom number below 90," answers Kuzmickas. "You can easily lower your blood pressure 10 points by not adding salt to your food. I know that's hard, especially when you're eating on the street. A lot of genetics go with this, things you're born with. But a lot of things we can try to prevent."
Later, in the waiting area, Kennedy says he thinks his knee pain is the result of all the running he did in the service. "I served in Germany and all over the world," he says. "I got out just before I'd have to go to that other place, what's it called... Iraq."
Kuzmickas has met several veterans in his work with the homeless. "Sometimes I feel I have a closer relationship with them," he says. "I can empathize with these people. There's a stronger bond. We've gone through the same adjustment and denial.
"I could have been there myself," he continues, but with the help of his family, friends, and his faith in God, he pulled through. People who lack that support need the help of strangers.
Teaching a homeless man how to prevent high blood pressure "is secondary," says Kuzmickas. "The primary thing is the fact that you're concerned and taking the time to teach him, not to criticize him, and to say, `I think you're important enough that I'm going to give you information to make your life better.' Hopefully, he'll walk away thinking, 'Since that person cares enough, maybe I am worth something.'"
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