No Apparent Distress

by Rachel Pearson

  Up at the doctor’s office, Matt gaped down at the cut. As used as he is to fish gore, seeing his own body cut open was different. The doctor had splayed open the wound so he and his nurse could clean it out, and Matt looked down to see his white bone glistening through layers of fat and bleeding muscle.

  “Wow,” Matt said. “That’s gross.”

  “I guess that’s pretty gross,” the nurse said, pouring pink antiseptic fluid into the wound. “Doctor, should I get the suture kit?”

  “Please do,” the doctor said. He shot a few injections of lidocaine into the wound along the edges of the skin, and began to sew.

  “I’ve seen a lot grosser,” the nurse said.

  “I’m sure you have,” Matt said. He was feeling a little woozy, watching the needle dip in and out of his hand.

  “Wanna hear about the grossest thing I ever saw?” the nurse said.

  “Well, sure,” Matt said.

  “It was a bar fight in Ketchikan. Two loggers. They started out punching each other, but at one point they got in real close and were kind of grappling. Then one logger leaned in and just clean bit the other guy’s ear off.”

  “My, my!” Matt said. “That is gross.”

  “Oh, that’s not the gross part,” the nurse said, dabbing blood away from the far edge of Matt’s wound as the doctor stitched toward it. “Wanna hear the really gross part?”

  “Sure I do,” Matt said.

  “Well. That one logger had bit off the other logger’s ear, and then he just spat it out onto the floor of the bar. When that ear hit the barroom floor, his dog ran right up and ate it. It was like the dog was trained to do it!”

  “Wow,” Matt said.

  “Isn’t that gross?”

  “Yes, ma’am,” Matt said. “That’s pretty gross.”

  When his hand was all sewn up, the doctor explained that Matt had cut into two of the tendons that work his fingers. They were still attached, but it was hard to tell if they would heal on their own or rupture where they’d been cut. “Honestly,” the doctor said, “you might want to go out to Anchorage and get an MRI, because you’ll be wanting a surgeon to reattach those tendons if they rupture.”

  “An MRI?” Matt asked. “How expensive is that?”

  “It’s about five thousand bucks.”

  “Plus the surgery.”

  “Yup, plus the surgery. You’d be needing a hand surgeon for this. Might have to go down to the lower forty-eight; I don’t think there’s a hand surgeon in Alaska right now.”

  “And what happens if I don’t do it?”

  “Well, tendons heal pretty slowly because they don’t get a lot of blood flow. So we won’t know for a few weeks at least if you’re out of the woods. If these tendons of yours happen to rupture, you could lose the use of your index finger and your thumb.”

  Matt was in a tight spot. This was in 2009, and he was uninsured. But he was also a fisherman, and wouldn’t be able to do his work without his hands. Even if he could’ve somehow paid for the MRI and surgery, taking time off work in the middle of the fishing season to get back and forth to Anchorage, and possibly down to Oregon or Washington for surgery, would be a disaster. He’d lose a good chunk of the income that he counts on to pay off his boat and get him through the year. Missed fishing days can’t be made up.

  There was no way to do it. So he paid the doctor for the stitches and went back to work. He tried to take it easy on his hand for the next few weeks, knowing that another little accident would mean losing his ability to work. The hand stayed sore for a long time, and the fingers never have moved quite like they used to. They get stiff when he works long days. But the tendons didn’t rupture, and so Matt can keep on fishing.

  CHAPTER 16

  AFTER RETURNING TO AUSTIN FROM MY FAMILY MEDICINE rotation, I spent a month on the neurosurgery team. One afternoon that first week on neurosurgery, I squeezed into a room so full of people that I could hardly edge in. At the center, a thin nineteen-year-old boy lay very still on his hospital bed. His mother sat with her hands on his chest, listening to the neurosurgeon.

  “I wish I had better news for you,” he was saying. “But the CT scan this morning shows what we were afraid of. The cancer is in his brain again.”

  He paused as a shudder ran through the room. The boy’s mother shook her head slowly, lowered her eyes. “We can do surgery, but to get to the lesion we will have to cut through brain tissue. So, just like before, you know the risks. There’s a chance of dying in surgery. And afterward, we can’t predict what brain damage there might be. You might not be able to move your hands anymore, or understand language. We just don’t know.”

  A stern-faced man spoke up: “And if we don’t do the surgery?”

  The doctor paused again. “Well, forgoing the surgery in this case would mean that Elias would likely pass away.”

  “How long?”

  “Not long, I think. It’s impossible to know for sure, but maybe in a day, maybe a few days. The tumor is bleeding and pressing on his brain, and so he would likely lose consciousness fairly soon. The choice is up to Elias.” The doctor’s voice lowered. “Son, you’ve already been through so much. Do you want to do this surgery?”

  Everyone turned to look at the boy. His face was still. Slowly, he nodded. His mother leaned close to hear him whisper, “Yes.”

  We left the room and began preparing to operate.

  ONE DAY ELIAS WAS A NORMAL PERSON. He had graduated from high school and was living at home, taking college classes part-time while he worked to save money. He went fishing with his buddies, teased his little sister. Then he started coughing, and it didn’t go away. Finally, he coughed up blood and was frightened enough to go to the doctor. Then, quite quickly, he became a different person: a young man dying of one of the most brutal cancers that we know.

  Testicular choriocarcinoma affects young men, often in their twenties. The cancer starts in the testicle, then spreads so aggressively that it’s rarely caught before it has moved through the bloodstream to the lungs, the liver, the brain. Elias coughed up blood because the cancer was in his lungs.

  Here is the terrible part. Choriocarcinoma comes from germ cells—primordial cells in the testicle that could turn into many other kinds of cells. In this case, they turn into placental tissue. This means that the cancer does what placentas do: it burrows into tissue like a placenta would burrow into the wall of the uterus, and then it starts building blood vessels. When a placenta builds blood vessels, that means that the fetus inside can get nutrients from its mother’s bloodstream. But when choriocarcinoma builds blood vessels, it just means that this cancer bleeds. So every time a new lesion popped up in Elias’s body, it would burrow in—into his brain, into his lung—and begin to bleed ferociously.

  To the neurosurgery team, this meant that Elias needed a brain scan any time his symptoms changed. If his right pupil dilated, or his head flopped back because his neck had grown weak, or his lip slumped, it could be a sign that a new lesion was bleeding into his brain, putting pressure on his brain and brain stem. These lesions needed to be dealt with quickly, because brain bleeds can kill a person quickly.

  By the time I met Elias, he had been through two rounds of chemotherapy and had been admitted to our hospital for emergency brain surgery. The first brain bleed damaged his cortex, and the surgery further damaged his brain. Quite simply, to get to a tumor in the brain quickly, you have to cut through healthy brain tissue. The outcomes are often poor. Patients who survive can be left severely disabled from the combined effects of brain cancer and brain surgery.

  We were actually trying to get Elias transferred to another hospital where he could get whole-brain radiation in the hopes of stopping the brain metastasis. But he had popped another bleed before he’d even recovered from his first brain surgery enough for transfer, so we were going in again.

  ON MY NEUROSURGERY ROTATION, I would bicycle to the hospital around 4:45 a.m. I’d page one of the doctors and round with him, going from room to
room to see all the patients on our service. We rounded quickly, and behind every door we opened there was some new horror. We would often start with the young woman who appeared perfectly healthy but could remember nothing. She had had a brain infection that had required multiple surgeries, and was still in the hospital in part because there was nowhere else to send her. Every morning, we would shake her awake and ask her her name.

  “I . . . I’m not sure,” she would say. She seemed embarrassed.

  “It’s Nan,” the doctor would say. “Your name is Nan.”

  “Oh, thank you!” she would say. “Nan.” And then she’d go back to sleep. Outside in the hallway, the doctor told me she probably wasn’t going to get any better. Behind another door, there was the man who went hiking and dove head first into a shallow pool, arriving at our emergency room unconscious with a massive bleed pushing his brain stem down against the base of his skull. There was the woman who was pushed from a moving car by her partner; she had been in the hospital for three weeks, and her head was still so swollen that her eyes were pressed shut and her face was unrecognizable. There was the thirty-eight-year-old mother who had a bad headache and then suddenly keeled over on her kitchen floor from an aneurysm. There was the junior high school teacher who cracked his skull on a sidewalk, the jogger who was hit by a truck. We would shrug on yellow gowns and gloves to see the brain cancer people, wraith thin, in isolation because their immune systems were trashed by the medicine. Our patients had big areas of their heads shaved where we’d cut into their brains, and thick black stitches arched across their skulls. Some were on ventilators in the ICU. Some were breathing on their own, but you had to rub their sternums hard or dig your fingernail into their nail beds to make sure they were responsive to the only stimulus they could still react to: pain.

  Rounds made me face the consequences of our work. In the operating room I could focus on the problem at hand, follow each step, and even have a sense of accomplishment: We found the source of the bleeding! We sucked out the tumor! On rounds, I had to peel up the eyelids of the patients, gaze into their pupils, and think, We did this.

  Many of our patients were young, especially the trauma patients. And many, especially those who hung on in states of semiconsciousness, were alone. There would be family at first, but gradually the rooms would empty, leaving these wounded people locked alone in whatever minds they retained. I would pass by their rooms sometime before dawn, rake my knuckles across their sternums until they startled, and then leave them alone again.

  Eventually, they were all alone, except for Elias and the jogger. The jogger was my mother’s age, but she had no children. She had gone out jogging on a Saturday morning and been hit by a truck. Her face split open at the eyebrow—a job for plastic surgery—and her brain smashed against the front of her skull. We had temporarily taken a bit of her skull off to relieve the pressure on her swollen brain, then stapled her skull back together when the swelling reduced.

  I remember her husband in the emergency room right after the accident, sitting at her bedside and petting her arm, whispering to her. He was in his fifties, his kind face contorted with fear. I looked back at him as we rushed her toward the operating room. He had one hand over his eyes and he was watching us through the cracks in his fingers, like a child who could not believe what was happening.

  The jogger survived her surgery, but she would never be the same. This time it wasn’t so much the surgery’s fault as the fault of her injury—she was badly concussed, and it was hard to say how fully she would recover. She could put words together coherently, but she couldn’t remember where she was. Her husband would sit beside her bed and read her stories, or just gently hold her. He slept in her room, and would wake up to talk with us each morning when we rounded.

  One afternoon I went in to check on the jogger’s stitches, and her husband and I talked for a while as I used a soft brush to clean the dried blood from around them.

  “Can you do the stitches on her face, too?” he asked. “She’s always been pretty. I think she’ll feel better if those are cleaned up a bit.”

  “Sure,” I said. It was late afternoon and we were done with surgeries for the day. Golden light slanted in through the room. It was quiet in there, away from the beeping monitors of the nursing station. I took my time.

  When I was done, the jogger did look better. The dried blood had made her face look freshly wounded, but now she just had the clean line of stitches and some swelling. Her husband smiled into her face. “That looks so much better!” he said. “Here, honey, look at this mirror. Look how pretty you are!” And he walked her gently over to the mirror by the sink, smiling into her reflection. The thick black stitches made a rectangle on the shaved left side of her head, and another jagged line of smaller stitches went from the middle of her forehead down through her eyebrow to her cheekbone. They stood close beside each other, with their fingers laced together.

  “I’m pretty?” she asked him.

  “You’re beautiful,” he said.

  ELIAS’S SECOND SURGERY WENT SMOOTHLY. I headed down to the operating room along with the neurosurgeon and the nurse practitioner. We all scrubbed, washing our hands and arms for five minutes with strong antiseptic soap, and nudged through the swinging door of the OR backward, with our clean hands before us. The scrub nurse got us gowned and gloved, and the doctor requested Mozart.

  We looked quickly at Elias’s brain scans, which a nurse had pulled up on the computer screen in the OR. This new tumor was on the opposite side from the first one, so we would have to drill a new hole instead of going in through the same place we did for his last surgery.

  “I think his family is pushing him,” the nurse practitioner said.

  “Yes,” the doctor said. “I wouldn’t choose this.”

  “They know he’s dying?” the nurse practitioner asked.

  “They’ve been told,” the doctor said, “but I don’t think they believe it.”

  Elias was anesthetized by the time we finished reviewing the scans. A little huddle of people was around him—the anesthesiologist at his head, gently pushing a tube down his throat and then moving away so we could get to his skull. It was already shaved, so the doctor began quickly—cutting through the skin with a scalpel, then drilling burr holes. There was no role for me in this surgery. Since we had to move quickly, I would only slow things down. I stood beside the nurse practitioner and watched. The doctor used a tiny rotating saw to connect one hole to the next, and we lifted away a rectangular portion of Elias’s scalp. Underneath this was the dura mater—the thick outer layer of meningeal tissue that surrounded his brain. It was cloudy, like wax paper. Moving quickly, the surgeon cut through it and exposed the brain. The brain looked pink and perfect, shiny like candy. The tumor was deep inside. We cut down toward it, through the matter that held his memory of all language, his ability to kick a soccer ball smoothly across a lighted field at night, the shape of his mother’s face. We found the bleeding tumor, and sucked it out through a tube.

  I know it’s awful to say it like that, because you probably want to imagine neurosurgery as this perfect science. You want it to be precise and technical, guided by benevolent machines. Sometimes it is like that. But the tube that sucked up the bloody mass in Elias’s brain made the same sound you hear at the dentist when they suck saliva from the back of your mouth.

  I LEFT THE HOSPITAL in a hurry after Elias’s surgery. I pedaled hard uphill past the university and onto Manor Road, trying to shuck that hospital feeling. I wanted to leave Elias behind, to let him wake up with a freshly mutilated brain surrounded by his family, to let my mind let them alone. I breathed in the still-hot October air, and yanked up the leg of my scrubs when it caught on the gearshift. My scrubs ripped at the ankle. I breathed out and stood up to pedal harder. I was twenty-eight and alive, and I was going on a date.

  I went home and changed into normal clothes, then biked back out to the Long Branch Inn. It was a blind date in the sense that all Internet dates are bl
ind dates, so when I walked in from the sunny sidewalk I stood blinking a moment in the dim bar, unsure of whom I was looking for. A man stood up, and I walked to him, smiling.

  I don’t remember what we talked about that night, but I remember thanking god that he was funny. I described my neurosurgery rotation in the vaguest outlines; his mother was a nurse so he understood about how people want to leave those things behind sometimes. And, in his presence, I did. I was no longer the medical student on the neurosurgery service, but a live woman! We went outside and ate tacos that he had brought. When we got on our bicycles to go home, we realized that we lived just a few blocks away from each other.

  I felt like a human again, that night. I was out of the hospital. I had a crush.

  THAT HUMAN FEELING DIDN’T LAST LONG, though. In the morning, I discovered that Elias couldn’t talk anymore. He couldn’t move much of his body. He could understand language, and he could communicate by holding up one finger. His family was still all around him, reading, talking, praying. They wanted us to continue our efforts. They believed in miracles from God, and would hear no talk of gentling him toward death. The possibility of whole-brain radiation, if we could get him out of our hospital, sounded like hope to them, a pathway toward some miracle. I stood quietly beside the surgeon and realized what we had done to this nineteen-year-old boy who, we knew, was surely dying of his cancer.

  If the neurosurgery team was Cerberus, the three-headed hound of Greek mythology that you pass on your way into hell, then I was the weakest head that month. I couldn’t do much. I just sat quietly, attached to some complex devil but only watching as my patients—too desperate to refuse our knives, longing too badly to stay in any kind of world—passed by.