No Apparent Distress: A Doctor’s Coming of Age on the Front Lines of American Medicine

Pearson goes home to Port Aransas for Thanksgiving. Her grandmother is visiting. The week before Pearson arrived, she’d had a miniature stroke but had been told by an Emergency Technician that there was no need for her to go to the hospital. She also had scoliosis and was hardly walking at all by Thanksgiving. She has a cough and Pearson listens to her lungs. On the right side, she hears nothing, which is unusual.

When Pearson returns at Christmas, her grandmother’s pain is worse and her mental state is erratic. They take her to a hospital in Springdale. Her right lung is filled with cancer, and it has spread to her brain and bones. She dies weeks later in hospice, and it is hard for Pearson not to think about the things that might have gone differently if she had known more. 

In January, it is time for the MUTA-GTA, “a gathering in which second-year students are taught to do breast and genital exams” (110). Pearson’s first patient is a woman. SPs in MUTA-GTA are trained to teach the students what to look for in order to alleviate what is, for many students, an awkward first experience. She instructs Pearson step by step during her breast exam. Then she coaches them through a vaginal and cervical exam.

Pearson begins doing speculum exams at St. Vincent’s. When she is finished with her first patient, the woman is crying. She assures Pearson that she didn’t hurt her, but Pearson isn’t sure she’s telling the truth. A senior student who is observing Pearson says that the real thing is never like the MUTA-GTA.

Pearson moves to Austin for her third year of school, to train in the downtown hospital. She prepares to start her rotation in three months of general surgery: “I’ll learn how to be a doctor in a place with real access to care” (117). She tells herself that she will never have a situation like Mr. Rose’s again, where she needs a CT scan but has no way to get one.

The first surgery Pearson assists in is the draining of an abscess from the buttock of a homeless man. She does nothing but observe the surgery of the man she calls Mr. Barnes.

Every fourth morning, Pearson is required to begin a 24-hour shift working with the trauma team. She carries a trauma pager, and when it goes off she has to report to the emergency room. An 84-year-old woman had been in a car crash and would be arriving any moment. A social worker comes in when they bring the accident victim and tells the workers that the family is outside. She relays that the family does not wish for the old woman to be resuscitated if she was already dying. The doctors try several interventions, but nothing works. The woman dies: “This was the first patient I had ever seen die. Guilt washed over me: I was only a medical student, but I was also a twenty-eight-year-old woman. I had loved my grandmothers. I knew better than to step away and let an elderly woman die” (123). She wishes she had gone to the woman’s side and held her hand.

She goes directly to the operating room to assist in a lumpectomy. The patient is no older than Pearson is. The surgery proceeds uneventfully. Pearson knows that even if they removed the cancer, it will likely return and the woman will eventually die of it. She wonders if the young woman would want to know this, or if the doctors would be obligated to tell her. 

On her next-to-last night of trauma call, a surgeon shows her an X-ray of a foot with osteomyelitis, a result of diabetes. She sees the patient’s chart—his name is Damien—before she meets him. Damien is only 21 and has already had an amputation. When they meet him, he begs them not to cut off his foot. Damien’s diabetes began when he was 8. Pearson begins talking with Damien often. He blames his illness on himself. He had run away when he was 18 and had not taken care of his insulin.

During the surgery, they manage to leave two toes and most of his foot. The next day he has a fever. His infection has returned, requiring another operation during which the surgeon amputates his foot entirely. Damien leaves the hospital a week late, but he has nowhere to go and no one to stay with.

Pearson begins a month-long rotation of family medicine in Alpine, Texas, where she stays in a large house with her friend Margaret. Pearson divides her time between the two doctors in town, Dr. Leucke and Dr. Billings. The pace is different than her time in the surgery ward. Dr. Leucke calls his patients by name, jokes with them, and usually kisses them on the head at the end of a visit. Pearson examines a man named Mr. Hausen who has given himself a hernia lifting a hay bale and has come in with his wife. After Pearson examines him, Mr. Hausen and his wife keep asking, “if it will work” (139), which makes Dr. Leucke blush.

On her second night, Dr. Leucke calls her while she is asleep because a woman is in labor and he needs help. On the way, she gets pulled over, but the doctor lets her go when she says she’s a doctor en route to the hospital. He asks Pearson to check the woman, and Pearson is too embarrassed to admit that she doesn’t know what to do. She gets so flustered that she puts her finger in the woman’s anus, a mistake that she does not realize until Dr. Leucke points it out. Then Dr. Leucke tells her to step back and get ready to “catch the baby like a football” (143). The baby is born successfully but had a cough, which could have been the onset of pneumonia as a result of Pearson’s contaminated glove. Pearson realizes the effect her mistake may have had on the infant: “I felt sick, like this tiny baby’s pneumonia was entirely my fault. I had caused it by trying to do what I was told instead of confessing to the fact that I had no idea what I was doing” (144). She commits to admitting her ignorance from then on, and never compromising a patient’s health out of her own insecurity.

Pearson next assists Dr. Billings during a C-section delivery. It is an urgent procedure, but successful: “The baby girl began to cry. A minute later, I was crying too. Some things in medicine really are miraculous; there’s no other word” (147).

A week later she goes with Dr. Leucke to a small border town called Candelaria. They set up a makeshift clinic inside a church and begin to see patients. Pearson conducts pap smears for many women in the chapel. By the afternoon, they have already given out all of their antibiotics, but there is still one more family with two feverish kids. Dr. Leucke says they both have strep throat. He tries to comfort the mother, but tells her that she needs to try to make the trip to Ojinaga, a town with a hospital. Pearson is conflicted because the clinic they set up is cheap: “It was not the best medicine, and I felt that these people, who were so poor, really needed the best. What if the presence of the monthly free clinic kept them from going into Presidio or Ojinaga, where they could get better care?” (151). The same argument could be applied to St. Vincent’s.

She watches Dr. Leucke with admiration, but also thinks: “He loves his patients, but is it possible to do right by them this way?”(152). 

The situation of her brother, Matt, makes the issues of rural medicine personal for Pearson. Matt became a fisherman and works in Alaska. He is a salmon troller and works and lives on a boat called the Viking Rover. Pearson worries because the work is dangerous, and Matt has limited access to medical care in rural Alaska. Once he cut his hand badly and it had been laid open to the bone. After a doctor sewed his hand up, he told Matt that he should get an MRI to tell if his tendons would be able to heal on their own. The MRI would cost $5000, and that was on top of whatever surgery might then be required. Matt decided to gamble and not get the MRI. The doctor stitched him up and the tendons healed. Matt returned to fishing, but Pearson knows that he beat the odds. He could just as easily have ruptured his tendons and ended his career.

Pearson next spends a month on the neurosurgery team at Austin. She is present when a doctor tells a 19-year-old boy named Elias and his parents that cancer has returned to the boy’s brain. The chances of surgery succeeding are not guaranteed, but if they do not operate, Elias could die within a day. Elias had graduated from high school and been healthy. One day he began coughing up blood and went to the doctor. He had testicular choriocarcinoma, “one of the most brutal cancers we know” (165). The cancer was already in his testicles, liver, lungs, and brain. When Pearson met Elias, he had already been through two rounds of chemotherapy.

Pearson describes her rounds in neurosurgery as a new horror behind every door. The many varieties of brain trauma are disconcerting and heartbreaking, and many of the patients are young.

Elias’s surgery goes smoothly and Pearson leaves quickly, “trying to shuck that hospital feeling” (170). She is going on a date and is trying to remind herself that she is only 28 and that there is more to life than brain surgeries and the heartbreaking stories of patients. It is a blind date that was set up on the Internet, and she has fun: “I was no longer the medical student on the neurosurgery service, but a live woman!” (170). She says that she feels like a human again.

In the morning, Elias can’t talk. Brain surgery often requires surgeons to cut through healthy brain tissue to get to the malignant areas, causing unavoidable damage. The rest of the month is difficult for Pearson, and she looks forward to seeing the man she is now dating: “Like my patients, I wanted desperately to be in this world. His heart beat fast against me when we kissed, and when I touched him I felt like I was flinging myself toward life, life, any kind of life” (171).

The following week, Dr. Ijimo calls Pearson at three in the morning for an emergency craniotomy. She assists as the doctor removes a bleeding tumor from the brain. Pearson recognizes the fresh cuts on the skull and realizes that it is Elias. His parents insisted on the new procedure while he had been unconscious. Elias survives the surgery, and Pearson dreads checking on him that afternoon in the ICU.

Six months later, Elias returns to the hospital with his lungs full of blood. It’s unclear whether he can understand anything that anyone says. Pearson and a nurse practitioner agree that his family needs to let him die and feel that Elias continues to consent—if he indeed understands them—out of a fear of letting his family down: “His family wanted us to be heroes, and we tried too long to play that role. It was easier for us at the time to put the blame on his parents for clinging to his life. But the fact is, we kept on doing the surgeries, even though we knew each one would leave him more devastated.” (173). Pearson knows that at a certain point the doctors could have refused.