No Apparent Distress

by Rachel Pearson

  I thought of Dr. Leucke kissing his patients on the head, giving out his cell phone number, living across the state from his family. I was, frankly, afraid to become like these Alpine doctors, who had given up so much to practice family medicine. He loves his patients, I thought, but is it possible to do right by them this way? The dark lay thick over the desert all around me, and I lay awake for a long time.

  CHAPTER 15

  THE PROBLEMS OF RURAL MEDICINE FELT PERSONAL TO ME, not only because of my upbringing and my training in Alpine but also because of my brother, Matt.

  Matt grew up to be a fisherman, as we all knew he would. He started deckhanding in Port Aransas at fourteen years old, and moved to Alaska when he finished his undergraduate philosophy degree. His first job there was on a cod-fishing boat in the Bering Sea. He would stand on the deck and gaff cod after cod as they rose shining and struggling from the water, hooked by the long-liner, before they were pulled into a machine called the crucifier and then shuttled down into the freezing hold. On one trip, so much ice fog froze in the high rigging of the ship that it threatened to capsize them, and the whole crew had to spend three days with picks and jackhammers breaking ice. Capsizing meant death, and that’s the way most people die in the Bering Sea—all together, when the ship goes down. The work can tear your body down, rip your digits off, or lame you, but death is generally a group affair.

  Matt tells a story of a crew that got caught in the cabin of a capsizing boat because they put on their survival suits—bright orange jumpsuits that float and keep you warm—in the cabin, and couldn’t get out when the vessel immersed. He tells another story of a crew that died from the poison fumes in a cabin when the boat flipped over, burning. Whole crews of thirty that just disappeared in the waves and fog. I would wait for Matt’s monthly phone calls while I worked summer internships in my latter years in Austin, trying not to think about those stories.

  Nowadays, Matt runs a salmon troller that docks in Craig, Alaska. Craig is a thirty-minute floatplane ride from Ketchikan on Prince of Wales Island. The area is basically a flooded mountain range, where towering firs grow right down to the edge of the water. Seen from above, Craig is small and bright on the island, home to fourteen hundred Alaskans and more tourists in the summer, plus plenty of bears and eagles. Like West Texas, Alaska feels freer because it is wild. One of the freedoms you might have in this part of the world is to start a fish-processing plant on a semiremote island, and then call the town that springs up around it after your first name: Craig.

  If you go out to visit Matt, he’ll just wait on his boat until he sees the floatplane go over, then walk down to the dock to be there, grinning through his wild beard, as your plane touches down gently by the harbor. Matt’s boat, the Viking Rover, is a small operation that he can actually run entirely by himself. The Viking Rover is a troller, not a trawler. (A troller is a small boat that catches fish on lines, often by hand; a trawler is a larger operation that uses nets.) Matt’s boat is also his home. It is stocked not only with gaffs and lures and survival suits but also with fast-cooking Irish oatmeal, tobacco, a shotgun, a pair of gray fleece slippers, and piles of books. The last time I went to visit Matt, he was reading a book about the colonization of British North America. In his bunk, there was a Dave Eggers novel, Anne Applebaum’s Gulag, and a book by William Barrett called Irrational Man: A Study in Existential Philosophy. Matt would anchor nights in a pretty cove near a bed of kelp where sea otters like to nap, and sit up a while after twelve hours of hard fishing, reading about the clash of civilizations and spitting tobacco overboard out the window. The Viking Rover is, in my opinion, damn cozy.

  Matt sleeps lightly when the boat is anchored. He’s attuned to boat noises, and the littlest sound can wake him: a rope rubbing, a change in the wind direction, even the sudden silence of a lull. He’ll go out after the salmon for five days at a time, so he spends most nights during the fishing season anchored in some cove near wherever he’s fishing. The Viking Rover has an anchor alarm that sounds a soft beep if the anchor starts dragging across the seabed—as it might do if the wind kicks up at three a.m.—and Matt will spring up out of his bunk at the beep, throw on a pair of shorts, and hustle out onto the deck to haul up and reposition the anchor while the Viking Rover rolls and bucks. If Matt didn’t wake up, he’d risk losing the boat if she ran into rocks or into another boat anchored nearby.

  He gets up for good around five a.m., hauls up the anchor, turns on the radio, and motors out to start trolling. The cabin is heated by a diesel stove, so Matt nudges the kettle over onto the hottest part of the stovetop to heat water for his morning coffee. When he gets close to a fishing spot, he puts the boat on autopilot and goes out to the aft deck—the back of the boat, also called the cockpit—to set the fishing gear.

  The Viking Rover is a power troller. It’s a thirty-six-foot boat with a central mast and two high outriggers, which are poles that form a V-shape on either side of the mast when not in use. When engaged, the outriggers drop down parallel to the boat to hold the gear out from the sides of the boat, so that four long cable lines can run down toward the bottom at once. Each cable has a heavy steel sinker at the bottom, about the size of a honeydew melon. These sinkers sit in holders on the back of the boat when the gear is up. To set the gear, you lift up a sinker out of its holder so that it dangles over the side. Then, you engage the power winch so the sinker slowly trundles down. There are spacers set about every ten feet all along the cable, and as the sinker goes down you clip a leader onto each spacer. The leaders are basically heavy strands of fishing line with lures tied to the end. So Matt clips around fifteen lures to a cable as it trundles down, flipping his arm back to make sure the hooks dangle free out into the water, then sets the brake on the winch and moves to the next cable. Once all four cables are set, he heads back into the cabin for coffee and the boat moves slowly along, dragging the lures. There are springs on the outriggers that bounce and tighten when a fish comes on, so Matt has some idea of how the catch is going.

  Matt’ll troll along for anywhere from twenty minutes to an hour, depending on what kind of action he sees in the springs. When it’s time to haul gear, he heads back to the cockpit again and engages the winch in reverse to start hauling up a cable. Back there in the cockpit, he can see the bright flashes of free lures or the shine of a salmon as the hooks come up. When there’s a fish on, he stops the winch and grabs a gaff. He pulls the fish up close to the boat with one gloved hand, and then smacks it quickly over the head with the club end of the gaff. This stuns or kills the fish. Then he gaffs it through the head and hauls it up onto the boat, where he slits the gill rakers with a small knife so the fish bleeds out. Matt explains that this is a quick way for the fish to die: instead of asphyxiating in the air and suffering, they die fast. Matt cares about fish more than anyone I’ve ever known—he thinks they’re neat animals, and beautiful, and he loves them—so I trust him on this point.

  I like helping out on the boat, but the one thing I can’t do is club the fish. The first time I tried, it took me three swings to hit the right spot. “That’s what you’re looking for,” Matt said. “That little shudder that means they’re dying.” But my poor fish had been hit about the shoulders twice before it shuddered, and dangled around in the air while I struggled to get it into position at the side of the boat. I tried again on the next fish, but that time I held the gaff too loosely and it went flying behind me toward the center of the boat.

  “Whoa,” Matt said, as the gaff whizzed past him.

  “I don’t think I want to slug the fish,” I said.

  “Okay, no problem,” Matt said. “But you know, it is a really decent way for them to go, all things considered.”

  “I don’t mind that they get clubbed,” I said. “I’d just rather they get clubbed once by somebody who will do it right the first time, instead of getting knocked around and hurt by me.”

  “Right on,” Matt said. “I understand.”

  The truth is, I had had
enough of that kind of thing—hurting other living beings in my process of learning—in medical school. Since I wasn’t going to be a career deckhand, there was no point in my hurting any fish so that I could learn to do it right. So after that, I stuck to setting gear, manning the wheel to avoid logs and big bunches of kelp while Matt was in the cockpit, and cleaning fish.

  I clean fish like a true medical student: carefully, precisely, and slow as hell. The cleaning matters a lot on a salmon boat, because the fish get graded number 1 or number 2 back at port, and number 2s—which have damage to the muscular fillets on the side of the fish, or leftover gore around the head—are worth less money. Matt says that a fast fish cleaner can do two salmon in a minute, ripping out gills, guts, and blood vessels, and tossing them to the gulls behind the boat. I probably average about one salmon every four minutes. I get distracted by the anatomy, wondering why this salmon has such a big liver or puzzling over markings on the scales. I notice the wounds that the salmon have survived: big gashes to the belly or the side, where their intestines have adhered to the sidewall just like human intestines do after a wound. Some fish have lost whole fins, and I ran my hands over the atrophied muscles that must’ve moved that fin. It’s just like in people, I thought: When a nerve is cut or a limb is lost, the corresponding muscles waste away. And just like humans, the salmon were able to survive and heal from some pretty massive injuries. It was humbling to me as a medical student to be reminded how capable the body is of healing itself—even in salmon, which obviously have no access to medical care.

  Once I get the haul cleaned, I pack them in ice down in the hold of the boat, or in big ice-slush totes on deck.

  One reason Matt likes the salmon trolling is that there’s practically zero by-kill. Any fish that we can’t keep, Matt releases from the hook. Sometimes the lowest hooks will pull up bright-orange rockfish, which are doomed by the sudden change in pressure as they are hauled to the surface. Their eyes bulge and their air bladders swell so that they can’t swim back down. As Matt pulls them off the hook and tosses them out, he says, “Eagle’s gonna get lucky.” And sure enough, a big bird will swoop down to carry away the poor rockfish, which no doubt regrets ever eating that shiny lure.

  When a salmon shakes out the hook at the last minute, Matt shrugs and says, “Fish wins.” When one salmon shook the hook out so hard that it flew back and embedded in Matt’s rain gear, he said, “I’m hooked.” Then, after a pause, he added, “This was probably the most resounding fish win of the day.”

  Matt truly wants to wake up every day and kill two hundred salmon, but he also respects the fish. He has little patience for the environmentalists who only care about mammals—What about fish? Fish are so important and so neat. Nobody cares about fish just because they don’t have cute furry faces—or who want to preserve wilderness completely free of human access. People need to get to wilderness, he believes, and you shouldn’t have to be rich enough to hire an eco tour to be able to use it. Matt cares about conservation that will keep wilderness wild, but open, and he supports fisheries management that will keep fish populations strong but also allow men and women like him to earn a living trolling. And don’t even ask him about farmed salmon. Salmon farms raising Atlantic salmon on the Pacific coast have loosed a whole new, non-native species on the ecosystem Matt loves.

  Our friend Margaret tells a story of going fishing for white bass with Matt on the Llano River in Texas. They fished all day, and they caught quite a few, but Matt found excuses to let every single fish go. He would pick them up and marvel at them for a minute, then say how this fish was really pretty but probably too small to keep. He’d place it back in the water and watch it swim away. Later in the day, Margaret pulled in a nice-size bass, but Matt said, “This is a nice fish, but really we’re not going to catch enough at this point to have a mess.” So he gently unhooked the big bass and watched it swim away. You might think it’s a paradox for a man who kills fish for a living to love them so much. But if you knew Matt, you’d understand.

  I ALSO SEE THE Viking Rover with the eye of a medical student. The hydraulic-powered winches are relentless, and would rip off a finger if Matt got caught in them. The cables that hang down around the sides of the boats are hazards for tripping and busting open your head. Gaffs and knives and hooks are everywhere. And what about the big diesel engine that rumbles in the belly of the ship, separated from the cabin by just a few planks and a plastic-coated carpet? Matt hauls up these planks to go work on the engine, which is old-timey enough that he can fix it with wrenches instead of having to call in a technician with a computer. But the engine will burn him if he goes in when it’s too hot, or could spill fumes into the cabin if something gets misrouted. The larger danger of commercial fishing is obvious: it’s the sea itself. But I see all the little things that could maim my brother or even kill him in an accident, especially if he’s out on the Viking Rover alone. The little things can really get you in isolated places: food poisoning that makes you pass out so the boat rides up on rocks, small cuts that get infected, dehydration.

  Matt is attentive to such things. In fact, if you ever want to feel safe in a dangerous place, I recommend being the little sister of a commercial fisherman. My first night on the boat, he oriented me to the fire extinguishers (there are five), showed me my survival suit, told me the difference between smoke flares and parachute flares, and taught me how to use the emergency radio. He also taught me enough about running the boat that I could get out of a tight spot alone if I needed to. Just before I rowed the dinghy out to a nearby kelp bed to look at some otters, Matt told me a story about a guy who died when his dinghy blew past his boat and out into a current. He was pushed out to sea, and eventually drowned. So Matt made me wear a giant, bright red coat with a built-in life jacket and an emergency beacon as I rowed about one hundred yards to look at the otters.

  On the boat, I began to realize that the stories these fishermen tell about deaths at sea serve a purpose. I wouldn’t put on my survival suit inside the cabin; I would be sure to keep one eye on the Viking Rover during my dinghy trip. Those stories could save my life. They reminded me of the stories surgeons tell at their weekly morbidity and mortality conferences, when the whole department reviews the details of cases in which patients died or were hurt. Sometimes, M&M conferences lead surgeons to change some aspect of the system—­for example, to move recovery beds closer to the nurses’ station, or to increase the number of bags of type O negative blood kept in the emergency room. But even when deaths lead to no such change, talking about mistakes—knowing the story—could prevent another surgeon from making the same error. I wish that more doctors spoke openly about our errors, and that our shame did not prevent us from doing so.

  Thinking back over medical school, I could only remember two times outside of M&M when doctors described making mistakes. The first was a lighthearted story from an old neurologist telling how he accidentally hit an artery when trying to draw blood for the first time. He almost fainted when blood went squirting across the room.

  The second story was more frightening; indeed, it was intended to frighten us. A surgeon who was leading a small classroom session one day got angry when we second-years couldn’t list the criteria for judging liver failure. She was a transplant surgeon, and had a fearsome intellect. “I can’t believe you students,” she said, stalking back and forth at the front of the classroom. “This is pathetic. If you don’t learn your stuff, you’re going to kill people.” Then she told about a death on the operating table.

  A mother was donating her kidney to her young daughter, who had renal failure after a bad infection. Mother and daughter were brought into operating rooms side by side, so the transplant team could move the healthy kidney immediately into the girl’s body. The girl was anesthetized and her kidneys were removed. A surgery resident was told to give her a medication so she wouldn’t reject her mother’s kidney. The resident made a mistake: he pushed the medication, which was a protein, directly into the girl’s IV.
She went into anaphylactic shock, and died right there on the table.

  In the adjacent operating room, the team had already cut the ureter on her mother’s kidney.

  “That resident should’ve known,” the surgeon said. “It was basic knowledge that you get in these preclinical courses. He should’ve known, but he didn’t, and he killed that little girl. He has to live with that for the rest of his life.”

  The classroom had grown very quiet.

  These are the kinds of error stories you hear as a medical student: the ones that suggest that your stupidity, laziness, or failure to study will make you kill people. They are terrifying and they do serve a purpose. People’s lives are in our hands.

  I wonder, though, about all the other errors—the ones that don’t lead to deaths, but to delays, frustrations, and unnecessary procedures. The small errors—or the ones that can seem small—like forgetting to report the results of a urine sample. Stories about that kind of error need not be designed to terrify us, but rather to help us learn from the mistakes of those who have gone before. After hearing the stories told by these fishermen, I began to realize that I could benefit a lot from hearing more such stories from the doctors training me.

  When I think about the mistakes I made at St. Vincent’s, I often feel all alone with them. Perhaps talking about them could not only help other students like me feel less ashamed but could prevent them from making the same mistakes that I did. Perhaps, I thought, the medical system could learn something from these fishermen, too.

  THERE IS A DOCTOR IN CRAIG, who is good enough that everybody on the dock says they’re lucky to have him. “If you get him,” a fisherman named John told me, “you know you’re in good hands.”

  One year, he sewed up a nasty, infected cut on my brother’s hand. Matt slashed his palm down through fat and muscle to the bone with a fillet knife. He wasn’t far from Craig, so he wrapped the hand in a T-shirt and motored into town.