No Apparent Distress

by Rachel Pearson

  The county said that Mr. Klein would need to live in walking distance of the hospital if he didn’t have a car. But the hospital was on the mainland, and Mr. Klein was still living in the Salvation Army shelter. His brother came through and bought him a trailer near the hospital. And things began to happen.

  After moving to the mainland, Mr. Klein would call Jacob every two weeks or so to update him. He was scheduled to begin chemotherapy in July. He had scans done to look for the spread of cancer around his body. He even went into surgery, where they placed a feeding tube in his stomach to prepare him for the removal of the throat cancer. He would be unable to eat by mouth for quite a while.

  But the throat cancer was never removed. Because, in a final agonizing turn, the county said in July that Mr. Klein no longer qualified for indigent care because he owned the trailer. He was too wealthy.

  Mr. Klein kept calling Jacob for a while, once a month or so. After a time, the calls stopped. Jacob still has the number in his phone, but he doesn’t want to call it. Some part of him just doesn’t want to know.

  JACOB SAYS NOW THAT his experience with Mr. Klein helped prepare him to care for Vicki Blair, the woman with the large mass in her belly.

  Together, Jacob and I talked with Dr. Black, who volunteers at St. Vincent’s every Tuesday. She is a no-nonsense doctor with impeccable credentials and a great bedside manner. I knew she would be the right person to help Ms. Blair.

  The three of us knocked and entered Ms. Blair’s room, and sat down around her. She was sitting in a chair with her back to the wall, dressed in athletic pants and a T-shirt. Dr. Black introduced herself and me, and then said, “I understand you got this CT scan done at Shoreline. And that Jacob told you that the doctors there thought that it might look like cancer.” I felt Jacob tense up beside me.

  Ms. Blair nodded.

  “I am sorry,” Dr. Black said. “I know that’s not good news, and it can be really scary.”

  Ms. Blair nodded again.

  “I want you to understand, though, that we don’t yet know if it is cancer. There’s obviously something going on, but a CT scan doesn’t diagnose it.”

  “Well, what do you think it is then?” Ms. Blair asked.

  “I don’t know,” Dr. Black said. “It could be cancer. But it could also be a kind of growth that isn’t cancer, or isn’t dangerous.”

  “So are y’all going to figure that out?” Ms. Blair asked. Her eyebrows were raised, and she looked skeptical. Which was right, I figured, because she had already gotten the runaround from a hospital. Why would she think that a free clinic could help her?

  “We’re going to try,” Dr. Black said. “We need to do a biopsy, where we take a needle and look at a sample of the tissue inside you. So our next step is going to be figuring out how to get you that biopsy.”

  “Figuring it out?” Ms. Blair asked.

  Dr. Black nodded. I knew why she was hesitating to just say yes, we would do it. A lot of things had been done at St. Vincent’s that don’t happen in most primary care clinics—things like Mr. Klein’s throat biopsy—but this would be a new one for us. We had never tried to do a biopsy through the wall of someone’s abdomen. And I wasn’t confident that we could do it, or should. What if there was a complication? What if she bled? I knew that in a worst-case scenario we could send her to UTMB in an ambulance. But was it safe to try this at all, with the nearest operating room at least fifteen minutes away? I could imagine the look on a surgeon’s face, receiving a patient transported from St. Vincent’s by ambulance and asking, “What the hell are they doing over there?” I could imagine a UTMB administrator calculating the cost of treating Ms. Blair for complications caused by a biopsy at St. Vincent’s, and then picking up a telephone to start a cascade of decisions that would shut down the clinic. I could imagine our patients, then, having nowhere at all to go.

  Then I looked at Ms. Blair. She was only ten years older than me. She was a mother. She was loved in the world, and she was struggling to trust us. Getting her the biopsy she needed might be a step toward earning her trust, showing her that somebody in the world of medicine believes that her life matters. But if something went wrong . . .

  I looked around the room, from face to face. There was skeptical Vicki Blair with something growing in her belly, calm Dr. Black, and Jacob looking nervous but determined. And there I was, the person trying to keep this operation afloat.

  Nothing about this was going to be easy, or simple. We were in over our heads.

  CHAPTER 24

  AT THE END OF CLINIC, WE HUDDLED AROUND DR. BLACK—Jacob, a junior director named Jacqueline, two other doctors who were volunteering that night, and me. In a clinic without social workers, care coordination happened like this: Jacob suggested contacting the ob-gyn doctors to make a Casebook application. I printed out the forms for Ms. Blair to apply to the county indigent care program, and Jacqueline said maybe we could start with an endometrial biopsy—but we ruled that plan out because our patient was already having heavy bleeding and an endometrial biopsy could be risky. Dr. Black called a pathologist, while another student director looked at the CD Ms. Blair had brought to see whether we could see the images of her CT scan.

  “The pathologist would need to see the images,” Dr. Black said, “to know if it might be safe to do the biopsy in clinic.” In all likelihood, this biopsy would need to be guided by ultrasound.

  “I’m worried,” I told Dr. Black. “If something goes wrong with this, what do we do?”

  “We’ll talk to the experts,” Dr. Black said. “We won’t do this if it isn’t safe.”

  As the preparations went forward, some part of my mind still hesitated to think this was a great idea. Other students were excited, proud of the possibility that our little clinic might be able to offer such high-tech care. As much as we students wish the best for our patients, we also take some pride in caring for people with complex conditions—exactly the kind of patients who need more than we can really offer.

  And so it happened. A month later, I stood in the doorway of a clinic room while Dr. Black and an interventional radiologist prepared to do the biopsy. A pathologist was also standing by. The radiologist had seen the images, and decided that she could safely guide a small needle through Ms. Blair’s abdominal wall into the mass. With all the equipment in there—the ultrasound, the microscope, the bevy of white coats—our clinic room suddenly looked like an operating room. I felt a surge of pride. But then, as Ms. Blair came down the hall to the room with her face as calm and impassive as ever, I thought, Oh my god. What are we doing here?

  Jacqueline and Jacob assisted on the biopsy, and were there a week later to give Ms. Blair her results: The biopsy had shown abnormal cells, consistent with a cancer of the uterus. She needed to get the mass removed. So she had hit the St. Vincent’s wall: we were able to diagnose her with cancer, but unable to offer her the surgery she needed.

  Some providers believe that the St. Vincent’s wall is not one we should even approach: Why diagnose people if we can’t make sure they will get treatment? It’s too hard on the students, and not necessarily a great service to the patients. Susan McCammon believes otherwise: Sometimes doors open after a cancer diagnosis. Knowledge can be power; knowledge can be among the faint threads of support—like nonabandonment—that we offer to our unfunded patients.

  Ms. Blair took the news, Jacqueline said, stoically. Jacqueline gave Ms. Blair her phone number, and made her a weekly standing appointment at St. Vincent’s. This was beginning to be our cancer care routine: for patients with diagnosed cancers, we guarded weekly Tuesday appointments to make sure they could see the same providers and get any symptoms managed quickly as they emerged.

  In these weekly appointments, Jacqueline began working with Ms. Blair on putting together an application for insurance through the Affordable Care Act health exchange. Through her two part-time jobs, Ms. Blair made just barely enough money to qualify for subsidized insurance. But she was scraping by, and was not sure she
could cover the cost of insurance even with a subsidy. Jacqueline counseled her to look for a plan that would cover a high percentage of the cost of care. Jacqueline walked her through the terminology that she was encountering on the insurance exchange, learning alongside her. Ms. Blair called on her own best resource: her supportive family, who pooled enough money to get her the insurance. When it finally came through, a few months after the biopsy at St. Vincent’s, she immediately made an appointment at UTMB.

  Jacqueline never felt a breakthrough with Ms. Blair. She never felt that trust developed, or that they became close. Ms. Blair cried only once. Jacqueline screened her for depression, but she wasn’t depressed. She was just sad.

  The doctors who did the surgery updated us on the results. The mass was removed completely, but it wasn’t cancer. It was just a large growth in the uterus. And it undoubtedly needed to go, but it never would’ve threatened Ms. Blair’s life. Jacqueline puzzled back through the studies—the CT, the biopsy—to try to figure out what had happened, why our diagnosis was wrong. A pathologist said that maybe the biopsy needle just happened to hit a pocket of abnormal cells.

  So Jacqueline was left wondering if the whole thing had been worth it: the months of worry, telling a woman that she had cancer, and the effort that Ms. Blair’s family had to make to pay for her insurance. After the surgery, Ms. Blair never again contacted St. Vincent’s, Jacqueline, or Jacob.

  One day, Jacqueline came up to me in the library on campus, and asked if we could talk.

  “For sure,” I said. We went out to a sunny bench outside the library. We could see nurses and medical students having lunch behind the hospital, and junior students rushing back and forth with their backpacks. The big clock next to us was still stuck at the time that Hurricane Ike had flooded through the campus five years before. Almost as soon as Jacqueline started talking, she began to cry. It was about Ms. Blair.

  “I gave her my phone number,” she said, “and I really want to call her, but I don’t know if that’s okay.”

  “Just to call her to check in on her?” I asked.

  “Yeah.” Jacqueline knew that the surgery had been successful, and that Ms. Blair wouldn’t need further treatment, but she had no way of knowing if Ms. Blair herself was okay. And did she think it had been worth it, after all?

  Students never entirely know what boundaries we are crossing in caring for patients at St. Vincent’s. The fact of giving out your phone number could mean that boundaries were being violated—the fragile lines that, in some cases, help us medical providers keep some notion of having “normal lives.”

  On the other hand, I had given my number to a couple of patients, and I knew that the doctors I admired most—Dr. Beach and Dr. McCammon—had done the same. Jacqueline was afraid of turning into Dr. Beach, so exquisitely dedicated to his patients that he seemed unable to pull away from the medical school, from St. Vincent’s, from us students. And yet she also knew she would, someday, become a doctor like that.

  “Well, sure, I think that’s okay,” I said. “That’s good medicine.”

  ONE DAY, JACQUELINE went in to do a pap smear on a patient whom two second-year students were seeing. When Jacqueline inserted the speculum and the woman’s cervix popped into view, there was a bloody growth dangling from it. Jacqueline closed her eyes for one moment and reopened them: the growth was still there. It was as if Jacqueline could see already the months that lay ahead, the pain, the fear. The woman was alive and dying in that moment, rushing more quickly toward some precipice that, for this silent moment, only Jacqueline knew was there.

  The woman’s name was Gloria, and she had come in because she was postmenopausal, but had started bleeding. Jacqueline removed the speculum, apologized briefly to Gloria, and went to get the doctor.

  Later, Jacqueline would wonder why she gave her phone number to Gloria, why she drove Gloria into Houston for an appointment at MD Anderson, why Gloria became the patient she worried over so much. Why this one, and not them all?

  “I guess it’s because she reminds me of my grandmother,” Jacqueline said. Then she corrected herself. “I mean, my nanny.” Gloria would ask after Jacqueline’s family, call her tender nicknames in Spanish. “She thinks I’m the best,” Jacqueline said, “even though we’ve had these really difficult encounters. I’ve felt like I was failing her from very early on, and through all that she calls me cielo and princesa.”

  JACQUELINE WAS RAISED in South Texas, and Gloria was raised in El Salvador.

  Jacqueline’s grandparents emigrated from Cuba, and hers was a family of doctors. Her father’s father was an ophthalmologist in Cuba, then repeated residency in Detroit to become an American general practitioner. Jacqueline’s own father became an oncologist. Her mother once refused to move to Port Arthur because “it smells.” Jacqueline had a nanny, whom she loved. There is a Catholic shrine in the entryway to their house, and Jacqueline’s mother often tells her to pray. Her father says that she will need God as a physician. Once you stop living in the world of black and white, and live all the time in the gray areas, he has told her, you need God.

  Gloria had a husband and a chauffeur in El Salvador. But after she and her husband both lost their jobs, Gloria promised a coyote three thousand dollars to bring her north. She worked for a while in a shrimp factory in Virginia, saving enough money to pay off the coyote and to bring her daughter north. The daughter married an American citizen and doesn’t involve herself much with Gloria, certainly not enough to help pay for Gloria’s sons, her brothers, to come north. As for Gloria’s husband, well, Quien sabe? So Gloria moved to Galveston, to live with a nephew and work in a hotel kitchen. She wore high yellow gloves that made the skin of her hands crack. And one day she arrived at St. Vincent’s, and Jacqueline met her.

  THE BLOODY GROWTH in Gloria’s vagina was cancer. It was cervical cancer, which is generally among the better cancers to be diagnosed with at St. Vincent’s. A federal law called the Breast and Cervical Cancer Prevention and Treatment Act of 2000 guarantees funding for both screening and treatment for these cancers to women living at or below 250 percent of the federal poverty level. This means that St. Vincent’s patients can get mammograms for free, and when one of our pap smears is abnormal, we can refer the patient for treatment. Unfortunately, however, that program doesn’t cover undocumented women like Gloria.

  Worldwide, cervical cancer is the third most common cancer in women. But in the United States, it is the fourteenth most common. Cervical cancer is both preventable—with pap smears, condoms, education, and the HPV vaccine—and treatable. And the United States has done a fairly good job of funding prevention and treatment. As recently as the 1940s, cervical cancer was a top killer of women of reproductive age; the reduction in cervical cancer deaths is a major victory.

  However, certain groups within the United States are still quite vulnerable to dying of cervical cancer. Latina women are diagnosed with cervical cancer at twice the rate of white women. Foreign-born Latinas are even more vulnerable. The Texas border is a cervical cancer hot spot with the highest rates in the nation. There are also racial disparities there: In some counties on the Texas border, Latina women are twice as likely to die of cervical cancer than white women living in the same county. Black women are not as likely as Latinas to be diagnosed with the disease, but black women who are diagnosed with cervical cancer are more likely to die of it than white or Latina patients.*Disparities like this—in a preventable, treatable disease—often reflect disparities in access to care. Even though screening and treatment can be funded, women without regular primary care are unlikely to be screened.

  So in a sense, it was unsurprising that we found cervical cancer in Gloria. As a foreign-born, uninsured Latina woman living in poverty in Texas, she was among the people most likely to be diagnosed with this disease. Yet even though undocumented women like Gloria are the most likely to get cervical cancer, they are deliberately excluded from the programs that fund treatment.

  So, we started car
ing for Gloria’s cancer at St. Vincent’s. This meant moving piecemeal through the steps of diagnosis and staging while we tried to find charity care for Gloria. Jacqueline made sure to be present at each of Gloria’s appointments—the cervical biopsy, then the endometrial biopsy. If Jacqueline wasn’t the student in charge, she would translate. Gloria took to hugging her, holding one of Jacqueline’s hands in her own, and saying que Dios te bendiga—may God bless you. Meanwhile, Gloria was rejected by three hospitals in the Houston area, starting with UTMB. Every time she was rejected, Jacqueline gave her the bad news.

  Jacqueline is no longer a practicing Catholic, but sometimes after these encounters she would call her father. “It will work out, Jacqueline,” he said. “This is why you should go to church.”

  If it doesn’t work out, Jacqueline thought, I’m going to need to pray to somebody.

  As the rejections kept rolling in, Jacqueline and Gloria began cooking up more elaborate plans to get Gloria the cancer care she needed. Somehow, Jacqueline convinced St. Vincent’s House to fund three thousand dollars for a CT scan to find out if Gloria had cancer in the rest of her body. One of the doctors got on Jacqueline’s case for dedicating so much to this one patient. “Do you think she’s trying to play you?” he asked.

  For what? Jacqueline thought.

  When the scan came back negative, showing that the cancer hadn’t spread, the same doctor asked Jacqueline why, then, they had needed it. Jacqueline was just silently grateful to see that the cancer had not invaded Gloria’s organs.

  This took time, and in some ways it felt like we were stalling—killing time while we scratched around for someone to offer surgery and chemo. If Gloria could have been admitted to a hospital, all of these things—the biopsy, the scan, beginning treatment—could have been done in a day or two. But at St. Vincent’s, weeks turned into a month, then two months. The cancer was growing. Over the course of a workday, blood seeped through Gloria’s underwear.