NO
APPARENT
DISTRESS
A Doctor’s Coming-of-Age on the
Front Lines of American Medicine
Rachel Pearson
W. W. NORTON & COMPANY
Independent Publishers Since 1923
New York London
For my father
NOTE
This is a work of nonfiction that includes some stories about people who have been my patients and the patients of my friends. Whether or not I was able to ask a particular patient for permission to use his or her story, I have changed details that might make that person identifiable. I have done the same with some of the health care professionals and medical students whose stories I tell.
We live in a time of hardening of hearts. Please don’t ask me why. I don’t know why God hardened the heart of the pharaoh. All I know is that right now, we are living in that time.
—Michael Thomas Jackson,
lay minister of St. Vincent’s House, 2015
Any man’s death diminishes me, because I am involved in mankind.
—John Donne,
Devotions upon Emergent Occasions, 1624
NO APPARENT DISTRESS
PROLOGUE
MR. ROSE HAS THIS PAIN. HE HAS THIS PAIN IN HIS STOMACH. . . man, right here in my stomach!. . .and it comes and it goes but it’s been there for four weeks, he guesses, though he’s not really sure because he was living with his sister and then her husband started using and wanted to put some of his own sorry-ass friends on the couch, excuse the French, Doc, but the things she goes through, it’s plain wrong—the pain? No, he doesn’t take anything for it. He tried everything. His sister gave him some Norco. He’s got this pain, and yeah, there’s a bad odor in his mouth. Well, he eats whatever, if he’s at his sister’s house he eats maybe a TV dinner, or if he’s with his cousin, sometimes they’ll barbecue. He doesn’t get to pick and choose, you see. Sometimes he doesn’t eat for a while. And the food is getting stuck in his throat, like right here. No, there’s nowhere he lives on a regular basis. He doesn’t have a telephone number. But he’s been eating less and less because . . . this pain.
I liked Mr. Rose right off, maybe in part because I met him before I learned the term “poor historian.” Later, when he showed up at the ER sweating and moaning, with his heart rhythm gone bad and his blood so thin it barely carried enough oxygen to keep him walking, the medical student who saw him there would say to me, “I wish you’d’ve been there when he came in, because you know his whole history. You’re like his primary care doctor. And it’s hard to get a story out of Mr. Rose . . . he’s such a poor historian.”
And when we finally knew about the cancer that had been fermenting in his belly all those weeks, when we saw the CT scan that showed a mass the size of two grapefruits in his belly and I realized it had been there and I never felt it . . . I would rack back through his story searching for the thing that would’ve told me how fast he was dying. And it was there: my mistake. The mistake for which I will never be forgiven, because the person who could’ve forgiven me was gone before I knew how to ask.
But I get ahead of myself. I, too, can be a poor historian.
CHAPTER 1
IN 1981, TWO DAYS AFTER MY OLDER BROTHER MATTHEW was born, my father sawed off the tip of his index finger. He was building an extension on to the Airstream trailer that my family was living in, in a clearing on a tract of land in the East Texas woods. Dad was working in a hurry, because my grandmother was on the way down from Arkansas to meet her first grandchild, and Dad wanted her to be comfortable. He must have been tired, too. He was running a two-by-eight into the table saw when the blade caught his fingertip and shredded it.
So Dad came hollering out of the sheet-metal workshop that still stands on that land. Blood streamed off his elbow. My mother had never seen him panic before, and she hasn’t since. She ran across the cleared field to hail my great-uncle Arnold, who wrapped Dad’s hand in a T-shirt and drove him down the dirt road that branches onto another dirt road that leads to Farm-to-Market Road 1097, and on to the hospital in Conroe. It was May, and wildflowers were still blooming along the way—eternal thanks to Lady Bird Johnson.
The doctors at the hospital patched Dad up, and he did not let the wound slow him down much. He finished the extension before my grandmother arrived. The finger healed.
By the time I was born two years later, it was clear that my brother was a bright child. My father would point down at us with his middle finger, keeping the sawed-short index finger bent in the way he still does, and say, “Reta, how are we ever going to send these kids to college?”
It was a question that had no answer—not in 1983. But it was important to my father, who did not graduate from college. He and my mother made a deal that he would support her through college if she stayed home for a few years while Matt and I were small. So I have early memories of coloring in the back of college classrooms and accompanying my mom’s ornithology class on a field trip. She eventually became a high school biology teacher, and Dad never wavered in his expectation that Matt and I would have college degrees.
All I can remember of that trailer is sunlight filtered through the tall pines and beaming in a back window, where it caught dust motes. The floor slanted a little bit.
Shortly after I was born, Dad built a sawmill. He cleared land, and sawed the pine trees into boards. He built us a house on the land he’d cleared, and Mom used her student loans to get a dishwasher. I grew up loving the sweet smell of pine sawdust and the enticing soft piles of it that built up near the sawmill—good to smell, but too itchy to jump in. Dad built us furniture. He built me a step stool, stilts, and a play kitchen with working cabinets. He built the table I am writing at now. He built the bunk bed that my brother and I shared in a room with rainbow curtains that my mother sewed. We would leap off the top bunk into refrigerator boxes that my dad brought home for us from his construction jobs.
THE SUMMER I TURNED ELEVEN, my family moved to Port Aransas, Texas, home to three thousand hardy souls. Port Aransas is on Mustang Island, a small barrier island about midway down the Texas coast between the Louisiana and Mexico borders. To be specific, we moved to the Mustang Island RV Resort, and took up a spot in our camper while my dad and my brother, who was thirteen then, built us a house on a property down the road.
The camper was cozy. It didn’t extend much beyond the bed of my dad’s pickup truck. There was a loft space that went above the cab of the pickup, and my brother and I slept there. Below, there was a tiny kitchen and a table that folded down into a bed, where my parents slept at night. There was also a miniature toilet, but we mostly just used the restroom at the RV park. We cooked outside on the grill a lot, and ate on the picnic table at our spot. My mom says this was one of the happiest years she can remember. So if you can imagine living in a tiny camper in an RV park in Texas with a thirteen-year-old and an eleven-year-old and two small dogs, I guess this tells you something about my family. We get along.
Some of the happiness was lost on me, though, because by the time we moved to Port Aransas I had grown into an awkward child. Everyone will tell you that they were awkward in junior high, but I was a special case. For one thing, God had graced me with a set of those teeth that drugstores sell around Halloween, labeled “farmer teeth” or “hick teeth.” One of my top teeth stuck out of the gum at a ninety-degree angle to the rest of my teeth. Two were twisted all the way around. My family got insured to the hilt by the time we moved to Port Aransas—Mom was teaching by then, and my dad got a job as an electrician at the University of Texas Marine Science Institute, which happens to be on Mustang Island. Consequently, I got braces.
The braces were the first hit on my junior high aw
kwardness regime. My wicked orthodontist prescribed a thing called a Haas device, that literally broke my upper palate so that all my teeth could fit in my head. Then he had me wrap two rubber bands around each brace. The rubber bands would pop off randomly and fly across the room. But luckily they started controlling my teeth.
I was largely left to my own devices when it came to fashion and grooming, with the sole exception being that I was not allowed to shave my legs. I don’t know where I would’ve done it, anyway, because there was no bathtub in the trailer park. I would roll out of my sleeping bag sometime after my mom had left to commute to work, perform my perfunctory ablutions in the trailer park bathroom, and bicycle off to school on my prized possession: an awesome purple Diamondback bike. The clothes that I chose for myself—purple high-tops, a T-shirt I loved with sparkly papayas all over it, a purple windsuit—made me look like a cross between a Florida retiree and a bowl of fruit. And then there were the glasses. We were not the kind of family that could buy new glasses every time their two myopic preteens broke theirs. Instead, my father used his natural ingenuity and his skills as an electrician to solder my glasses back together. Over the course of the year, the lump of solder at the bridge of my nose got bigger and bigger.
When I got ready for school, I would brush my hair. But I would brush only the parts I could see, next to my face. It didn’t occur to me to brush the back. And so gradually, over time, a huge rat’s nest built up in the back of my head. It would be an insult to dreadlocks to call this a dreadlock. It was just a plum-sized knot of tangled, splitting hair. I hid it pretty effectively in my ponytail. Dad had always done my hair when I was younger, but in Port Aransas he was at work by the time I woke up. My mother might’ve noticed it anyway and combed it out if she hadn’t been leaving at seven a.m. to commute to work, getting home around six p.m., and then cooking dinner before doing lesson plans and falling asleep. My parents’ lack of attention to my appearance fell somewhere between feminist resistance to social norms about girls’ appearance and benign neglect. So I grew up without any complexes about my body, but I certainly had a rat’s nest. Sometimes I would reach my hand back and touch it, and it seemed so large and intractable and awful that I would just pull my hand back and pretend that it didn’t exist.
Imagine me then: the double-banded braces, the soldered-together glasses, the hairy legs and knotted hair and trailer park grooming. I was not cool. Miraculously, though, I loved myself. In pictures from back then, I am grinning through my metal mouth, with my arms around the other awkward girls who took me into their fold.
One of those girls was Jennifer, whose family had a condo and a swimming pool on the island. Frankly, Jennifer’s parents forced her to hang out with me. They thought I had moxie, and that I would be a good influence on shy Jennifer. So Jennifer and I formed a solidarity based on board games and the music of Queen, and over Christmas break her parents invited me to go on their annual skiing trip.
The skiing trip was my first real introduction to how the other half lives. I wrote postcards home detailing all of this: They gave us peanuts on the airplane, but they were not honey roasted. They were salted. In the ski lodge, I paid two dollars for hot cocoa and they gave me extra marshmallows. My glasses broke so I’m wearing my sports glasses. I fell a fair distance down the mountain and broke both my legs. Just kidding! And one night, beside the crackling ski lodge fire, Jennifer’s mother sat down and combed the rat’s nest out of my hair.
IT TOOK A YEAR OR SO for my family to build the house. We built it on afternoons and weekends, because Dad was working at the Marine Science Institute down the street. He kept that job for fifteen years, because it enabled us to have great insurance and he could benefit from the teacher retirement system. But he still says that it was a waste of his life in so many ways—digging ditches at age fifty, replacing light switches. He was a man who could design a house and build it from the ground up, who built a giant robot in his free time and then used it to make me a life-sized wooden velociraptor skeleton for my birthday. His creativity and his skills weren’t much called for at his money job. “I never want you to have to work like that, not for insurance,” he’s told me.
I’m safe in my profession, but Dad still wants my brother to go back to school, to have all the chances that Dad never did. Sometimes I argue the point with him—college no longer guarantees a good job. But mostly I let it drop. I study; I am grateful.
The house is on stilts—big salt-resistant creosote-soaked pilings that seep sticky black in the heat—so floodwaters from a hurricane could pass underneath. (God forbid.) On every level, the floor and roof are secured with dozens and dozens of hurricane ties: L-shaped bits of metal that take eight nails each. Hammering hurricane ties was my job, and I hated it. Matt turned from a pudgy kid into a strong and lanky teenager the year we were building, hanging from the house frame forty feet up as he helped with everything: the framing, the wiring, the cabinets, the painting, the roof. Our neighbor did the shingles. Mom hammered, kept the workers fed and supplied with sweet iced tea, and supported the family with her teaching job. I helped lay the flooring when we graduated from painted plywood floors to varnished pine. Matt still works construction in the off-season from commercial fishing; last year he texted me a picture of him siding a house in six-foot-deep snow in Alaska.
DAD’S QUESTION ABOUT how they would send us to college was answered by the government: Matt and I both got full scholarships to the University of Texas at Austin, under a program that no longer exists. It was the best school I could imagine, and the only school I applied to. It was perfect.
The first two summers of college, I went home and worked for Dad. Dad had a big project, renovating twenty-six tiny abandoned cottages in the middle of Port Aransas. So my brother and I drove home from Austin in the beat-up Ford F-250 we shared, and spent the summers ripping out old plumbing, patching plaster, and hanging drywall. We worked in the heat of a South Texas summer, and everything we did had to be repeated twenty-six times. I liked the work. Matt had done plenty of construction work before, but I had never had work that felt so solid: I would work all day, and see in the evening what I had done. I began to understand why my father loved carpentry, and to get a glimpse of how creative that work could be, if you had the skills.
I was unskilled, however, so most of what I did was grunt labor. I spent some afternoons sweating under heavy plastic rain gear while I power washed old paint off the concrete walls; tiny bits of concrete would blast back at me hard enough to have left bruises if it weren’t for the rain gear. I decided to call Dad on the cell phone. He was supervising from afar while he worked his electrician job.
“It’s like two hundred degrees under this rain gear,” I told Dad. “I could faint.”
“Bah,” he said. “Drink some Gatorade.” Like his own father before him, Dad has always believed that children are best utilized for manual labor, and that a significant benefit of hiring one’s children is that you don’t have to offer worker’s compensation or supply safety devices. He did keep the cooler full of Gatorade, though.
The cottages had been on the transient highway for years, and not everyone was happy that we were developing them. One man left behind a mountain of trash when he evacuated a cottage he’d been squatting in. Another expressed his displeasure by killing a possum and smearing its guts all over the freshly hung drywall. We hung it again.
Matt and I spent one week ripping out the old toilets and carrying them across the property for storage. Dad insisted that these were “valuable antique toilets,” built before water-conservation laws limited the number of gallons that could flow from a tank. He was going to sell these valuable toilets on eBay.
That week, I found that the bonds of civilization are strong but odd: Even though there had been no water running in the cottages for years, people had continued to shit in the dry toilets. Matt and I would flush them with bleach and water from the hose, then wrench off the bolts connecting the toilets to the floor. When we heav
ed them up, though, bleach water with traces of feces would splash out on my socks from the goose neck inside the toilets.
I called my dad on the cell phone. “Dad,” I said. “I think we should abandon the toilets.”
“Those are valuable antique toilets, Rach,” he said.
“There’s shit on my socks, Dad. Transient people’s shit is splashing all over my socks.”
“Use more bleach,” he said.
I would like to state for the record that the valuable antique toilets were never sold on eBay. They stayed in an unused unit until Dad realized that it would be too much trouble to sell them, and then they went into a Dumpster.
That summer, my father started a tradition of cornering me in the evenings to have long conversations about my future. It was a sort of collaborative pipe dreaming, with both of us reveling in the opportunities that were open for me. In those conversations I could feel how wrapped I was in his love, and also the weight of my own life and how much it meant to him. Usually, Dad would encourage me to take premed classes, and I would refuse. “You could just get the basics now, kiddo, in case one day you want to apply,” he’d say. “You never know. You’d be a great doctor.” But back then I wanted to be a writer.
One evening, our conversation turned to marriage. I was sitting on the countertop in our kitchen, and the lights were dim. Dad’s theories about my marriageability included suggesting that I shave my legs and stop being so particular. (I was twenty.) “What are you looking for?” he asked.
“Well, I guess I’d like to marry somebody like me,” I said. “With a good education.”
Dad quietly looked down. “Rachel, you never know,” he said. “One of those guys without a college degree might surprise you.”
No Apparent Distress Page 1