“They don’t really know,” Mr. Rose said, “but they think it’s coming from my kidney. Not my liver like that one doctor was saying.”
“From the kidney,” I repeated. And in that moment, sitting beside my first patient, a cold wave of recognition swept down through my body. Kidney cancer. The urine sample. It was cancer that caused his urine sample to be all wrong. That urine sample I had misunderstood, and then forgotten. I remembered it right then and fell silent, stunned by guilt.
“I’m so sorry,” I finally said. I could not begin to say everything I was sorry for.
“Well, you know,” he said, apparently trying to comfort me. “They’re going to do some kind of a test tomorrow.”
“A biopsy.”
“Tomorrow,” he said. “And it may turn out to be one of those real treatable kinds of cancers.”
“Right,” I said. But I didn’t believe it—not when it had already spread so far.
“I’m waiting to call my brother until I know if this is really serious or not,” he said.
I knew it was serious. But I held my silence, thinking that a second-year medical student should not interfere with the doctors on the hospital team. They will tell him when the time is right, I told myself.
We chatted for a while longer. When I stood up to leave, he said, “Well, now you know where I am. So you can come visit.”
But I never did. I never had the courage to go back, and soon it was too late. Three months later, I read his obituary in the Galveston County Daily News.
TWO YEARS LATER, after my third year of medical school, I would find myself telling this story to a group of first-year students. It was in an afternoon seminar on the medical humanities led by Dr. Susan McCammon.
There were around fifteen of us in the room. We had gathered to read and discuss a poem, but somehow the conversation turned—as it does—to patients. And I began telling the story of Mr. Rose: How I forgot that urine sample, and we couldn’t get him care, and he died. How he had asked me to be near him when he was in the hospital, but I felt so guilty about my mistake that I abandoned him. Telling the story, I was surprised to find myself crying. It is so rare, almost forbidden, to cry in front of other medical students.
“How do you wish it would have been different?” Susan asked me gently.
The answer to that question was so vast that I could hardly speak it: I wish Mr. Rose could have been insured. I wish he’d had a primary care doctor who caught his cancer early. I wish at least we could have gotten him the care he needed, even if it was too late to cure. I wish I had the power to do what I was supposed to do, and provide him with medical care. I wish my first patient, the first patient I loved, the first patient who trusted me, had lived. But how do you say all that when tears are still running down your face?
“I wish he could’ve gotten into the hospital sooner,” I said.
Susan nodded. “And what do you wish you would have done differently?” she asked.
“Well, I wish I wouldn’t have made a mistake,” I said.
“We make mistakes,” she said. “It happens to all of us.”
And then I thought a little more. “I wish I had gone back to see him,” I said. “Even though I made a mistake, and he was dying. I wish I had had the grace to stay by his side.”
CHAPTER 10
THE LUNGS ARE EASY TO LISTEN TO. HEALTHY BREATH sounds are regular whooshes, as if the air were a faraway electric train passing sixteen times per minute. Fluid makes crackles: little pops when the air passes through a skein of water. Areas of no sound could mean a bad infection, or a growth, or a collapsed lung—depending on what else is going on with the patient. There are sounds called wheezes, rales, and rhonchi. By the Thanksgiving of my second year of medical school, I had listened to a hundred pairs of lungs, and I could pick up these abnormalities.
So what made me think that the most abnormal finding of all—a whole lung that made no sound—was normal? Maybe it was the way my grandmother’s backbone, twisted to one side from scoliosis that was never treated, changed the landscape of her body. Or maybe it was just my own lack of experience.
I took the coast road from Galveston to Port Aransas that Thanksgiving. I drove the twenty miles down Galveston Island to its narrow southern end, where the San Luis Pass separates it from the next barrier island. The day was bright and cool, and pelicans flew low over the water. After Galveston and Surfside, I turned toward Freeport to drive through the industrial towns: refineries, ports, and more refineries loom along the Texas coast. When I was a kid, I thought the refineries at night looked magical, like glittering fairy castles with tongues of colored flame at the top. From Freeport I jagged inland through Brazoria County with its lush oaks, then farther south through coastal plain—a remnant of the warm shallow sea that covered Texas in Paleozoic times. Trilobites were abundant here. Two hundred and fifty million years later, native people gathered oysters and conch on the shoals that start to crop up after you cross the Copano Bay. Today, you could go there in a flat-bottom boat to hunt stone crabs at low tide.
Soon I was in the little shrimping towns, then skipping from island to island along a long causeway to Port Aransas. The sun gleamed off the bay and I saw fishermen out wading. The last step to Port Aransas is a five-minute ferry ride across the ship channel.
Things in town looked the same that Thanksgiving: the fake shark head at Dolphin Docks, the souvenir shops, the boats huddled in the harbor and the empty beach. It was cool and windy. My stethoscope dangled from the rearview mirror. Thanksgiving is a family holiday for Port Aransas, without the crazy influx of summer tourists. The grocery store closes Wednesday night, then you’re on your own.
Port Aransas is a lot like Galveston, though much smaller, and the water is clearer. Habitat for birds and other wildlife in the surrounding bays and lagoons has been better protected. But if you look offshore from the beach at night, you can pick out the oil rigs from the tankers waiting to come into the ship channel by the way the oil rigs blink. Fish congregate around the rigs, which serve as a sort of artificial reef; anchor nearby and you might catch red snapper or even tuna. The health risks of living farther north on the Gulf Coast are well-known: The stretch of refineries along the Louisiana and Mississippi coasts form what’s called a “cancer belt” for nearby residents, who die earlier than average, and from strange cancers. In Port Aransas, and on down toward Brownsville, the risk of living on the industrial coast is not well documented. We had to evacuate once in junior high, when a tanker carrying a chemical gas caught fire in the ship channel. Cars backed up on the long road down the island, and when the wind changed, the chemical blew over us where we were waiting in that line. My eyes watered a little bit, but nothing serious happened. Refineries have blown up in Corpus Christi and Texas City. But in Port Aransas, we feel pretty safe from all that.
We live on the road that goes straight from the ferry through the middle of town to the beach. There are three stoplights in Port Aransas now—there used to be only two, and the third one was the subject of much debate in the local newspaper. You go through two stoplights on the way to our house, and then a stop sign next to the Mustang Island RV Resort, where we lived when we first moved here in the summer of 1994.
My grandma was visiting that Thanksgiving of my second year of medical school. She had been a healthy lady in her seventies, except for the scoliosis. But this time she wasn’t doing so well. She had a light but persistent cough that wouldn’t go away. Then one night, the week before I came in, she had what seemed like a TIA—a transient ischemic attack—which is basically a ministroke that clears up quickly. She smacked her lips five times at the dinner table and her cheek drooped. Then it stopped. My parents made a phone call, and a local guy from the EMS came up the stairs in his uniform. He’d been in the class behind me in Port Aransas High School, and he knew my family.
“You can take her into the hospital,” he said to my parents, “and they’ll run all these tests. They’ll scan her brain, and t
hen they’re going to tell you it was a TIA. There’s not any treatment she needs right now. So, it’s up to you.”
My family stayed home.
Grandma was also having a hard time going up and down the stairs, especially the outside stairs from our first story down past the pilings to the ground. It would take her thirty minutes and she hated it; she moaned the whole way, so it was a small miracle that my mom got her to the doctor at all for her persistent cough. The cough didn’t seem like much: soft but persistent, once or twice a minute, and grandma felt like she had something in her throat. She had a low fever that came and went, and the usual pain from her twisted back. When mom took her in for the cough, the doctor didn’t find anything.
We didn’t have a doctor in Port Aransas the first years we were here. You still have to cross the causeway for a hospital. I went to the ER over the causeway in Aransas Pass one night with a kidney infection, and they had one doctor running the whole emergency room. Which is just to say, these towns are small. My graduating class was thirty-five kids.
Grandma was a farmer’s daughter in rural Arkansas, and then a secretary and a farmer’s wife. They either didn’t catch her scoliosis until it was too late to treat it, or couldn’t afford the treatment—back braces, surgeries that had a slim chance of succeeding if done after puberty. Treatments have improved since the 1940s, but scoliosis is still common.
She was tall like me, and she was beautiful. After high school, she went to Lincoln for secretarial school, cooking for a family there in exchange for room and board. Her aunts told her she was an old maid at twenty, but then she met my grandfather at a sing: all the Ozark families would come together in a church to sing. They’d call all the women up to sing a hymn, then everybody related to so-and-so, then all the mothers, the fathers, the oldest children. Grandma had a beautiful voice that she did not pass along, but both my mother and I have her middle name: Great-grandmother Ora Mae, Grandma Lena Mae, my mother Reta Mae, and me. It’s an old-fashioned name now, Southern and rural. I’ll give it to my daughter, if I have one.
As Grandma got up into her seventies, her spine twisted into a bent S, humped up, and ached. She walked with a cane, and would threaten to whack us with it but never did. (She also threatened to whack George W. Bush, Saddam Hussein, and preachers who spend too much time trying to raise money during a sermon.) But by Thanksgiving she was hardly walking at all. I would rub capsaicin cream on her back for the pain, and slept beside her some nights for company.
They say you shouldn’t treat your family, and I know that’s right. In Grandma’s case, it went like this: After the cough didn’t go away, her pain was so bad that she didn’t want to leave the house again to go to the doctor. My mother was afraid of pneumonia, so she asked me to listen to grandma’s lungs. I pulled up her shirt in the back. On her left side, there was the regular whooshing of breath, clear all over with no fluid. On the right side, I heard nothing. Her back sounded dull on the right side wherever I tapped, instead of hollow like a normal lung field. Her spine was twisted over that direction; I thought maybe I just couldn’t hear through the bone and muscles. I didn’t listen in the front, too shy to ask my grandmother to pull her shirt up over her breasts.
“I don’t hear any fluid,” I said to my mother in the kitchen. “I don’t think she’s got pneumonia.”
We baked four pies—apple, cherry, and two pecan—and my grandmother came out to sit in the recliner for Thanksgiving dinner.
WHEN I CAME BACK three weeks later for Christmas, everything was worse. The pain was worse, and she seemed confused. Even getting across the hall to the bathroom was an ordeal. She was repeating weird sentences—“Holy moly macaroni rack”—and for the first time in my life I saw her get really angry.
One night when I was lying in the bedroom with her, she asked me if I thought she was dying. I don’t know why she asked her granddaughter this. Maybe because I was in medical school, or maybe she was just confused and it was late.
“Oh, Grandma, you’re not that old,” I said. “You could live for a long time.”
“Oh, Lord,” she replied. “I hope not.”
AFTER CHRISTMAS WE CANCELED her flight back to Arkansas. Mom rented a car, and she and my brother drove Grandma to Springdale. She suffered on the way, and they went straight to the hospital; my uncles and cousins met them there.
It wasn’t scoliosis that had prevented me from hearing air moving on her right side. I might have figured that out if I had listened in the front. I might have thought twice if I knew more, if I wasn’t just a student, or if I loved my grandmother less and could have thought clearly through what was right in front of me.
Her whole lung was obliterated by cancer. It was in her brain—that drooping lip, those weird phrases she was repeating—and her bones—that pain.
When I think about it now, there are so many things that complicate this story. I think about that small-town EMS guy who cared about my family, who couldn’t have had the medical training to know that what seemed like a TIA was actually from cancer working its way into her brain. I think about how her scoliosis was never treated, so the pain seemed almost normal. Her body was marked by that untreated disease, twisted and bent, and it confused me. And then there’s me: a second-year medical student, too inexperienced to even know how little I knew.
She went straight into hospice. My mother never left her side. I drove up for the last few days, with Charlie. We slept overnight in my car at a Walmart parking lot in Oklahoma; Charlie would pop up from time to time to growl at the semitrucks that rumbled past on the highway.
We made it to Springdale the next morning. Grandma was in a residential hospice facility. She squeezed my hand when I got there, but her last words had already been spoken. Over the next few days, I would sit in the room with her and my parents and family, and step out sometimes to study or talk with cousins.
Sometimes, I would lay my face on her chest to listen to her breathing. Her breath was regular for days, and then it grew ragged. There was no sound of breathing on the right, where the cancer had choked out her whole lung—just the thrill of her heart. I felt like I was already a different person then: a medical person, who would experience this death in a different way.
One afternoon in the hospice facility, my uncle asked me what exactly was happening with her body, since she wasn’t taking food or water. I knew how to answer that question.
“When people who are dying stop eating and drinking,” I said, “their body doesn’t want food. The gut kind of shuts down. Everything shuts down gradually. Pretty soon she’ll stop making urine, and then her heart will slow down and she’ll pass away.”
She died after dozens of visitors, with us all around her telling stories and praying.
After she passed away, a nurse came into the room. She listened to my grandmother’s heart, and listened to her lungs. Everything was quiet.
CHAPTER 11
JANUARY ON GALVESTON ISLAND BRINGS QUIET BEACHES, migratory white pelicans, and the MUTA-GTA: male urogenital teaching assistants/gynecological teaching assistants. The MUTA-GTA (pronounced “moota gouda”) is a gathering in which second-year students are taught to do breast and genital exams. For a few students, the MUTA-GTA is the first time they’ve touched the real live genitals of another human being. For many, it’s the first time they put a finger into a man’s anus. For all, it’s quite an experience.
My group gathered in the standardized patient lab—a medical theater designed to look like a clinic—in the afternoon. The MUTA-GTA is a bit different from other SP experiences. For this most sensitive exam, the patients actually teach as you go. They’re paid well, and they want to make sure student doctors learn to do these exams right.
After a brief introduction from our professor—the kind of doctor who is so precise and so socially awkward that you can’t help but trust him—we went in groups of three into the patient rooms. My group consisted of two guys, and me.
“Now, y’all wash your hands!” the woma
n awaiting us called out. “I don’t want y’all even coming anywhere near me till y’all wash your hands!” So we washed our hands, one after the other, and then gathered around the end of the exam table in a huddle. Our patient was sitting on the table, dressed in a gown with a sheet over her legs. We introduced ourselves.
“All right, now I know they’ve told y’all what to do, but I’m just gonna walk you through it. Okay?”
Okay.
“So, we’re going to start with the breasts. Now don’t go asking me to lay down. You just want me to start off sitting right here and taking the gown down so you can look at the breasts.”
“Um, yes ma’am,” I said.
“Now you ask me if it’s okay to untie my gown in the back.”
“Is it okay if I untie your gown in the back?”
“Go ahead,” she said.
I untied her gown, and then she lowered it so she was naked from head to waist.
“All right now. You want me to hold my hands up behind my head like this, with my elbows out, and you just look at the breasts. What are y’all looking for?”
“Um, abnormalities,” the student to my left said.
“Okay, like what? Don’t just tell me ‘abnormalities.’ ”
We started listing them: differences in size or shape. Scars. Dimpling of the skin. Retracted nipples. Redness.
“Good, now do y’all see anything like that?” We did not.
“So, you just say that my breasts look ‘normal.’ Don’t go saying they look ‘great,’ or ‘awesome,’ or anything like that. Say ‘normal.’ ”
“Your breasts look normal,” one of the guys said, blushing deeply.
“Okay, now you’re ready to do the breast exam. So, pull out my footrest.”
One of the guys pulled out the footrest at the end of the bed, and our patient laid down on her back. “Now, you want to make sure I am as covered as possible at all times, right? So don’t go leaving me with both of my breasts hanging out. Use your drape! Who’s going first?”
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