For a week, each November morning at the Grand Canyon dawned clear and cold. The night let go of its secrets as sunlight flared up over the rim and promised a bright, pleasant day. By noon, though, clotted clouds crowded out the blue—dark clouds that clumped and rose in seething masses, as if annoyed by so many humans enjoying the views. These were not the usual thunderheads that wandered over the chasms, dropping dizzying shadows and scattered downpours. These storms besieged the sky, throwing hard rain like weapons and hurling endless spears of lightning into the earth. Tourists ran for shelter, and even old regulars who had lived at the canyon for years felt apprehensive.

New signs were posted, warning about the dangers of lightning and the need to take cover.

“Here we go again,” muttered Dr. Abigail Wilmore, her eyes widening as thunder exploded and shook the clinic.

Abby was about to examine a man with one of the worst diabetic foot ulcers she would ever see. Herman White, sixty years old going on seventy-five and a resident of his car for the last year, scuttled in just before the cloudburst, asking if a physician could look at his foot because it was draining more yellow fluid and pus than usual. While Abby felt some days that she had seen nearly everything, she also knew that the human body still had the capacity to astound her.

“I think my sugars are pretty good,” said Herman, pulling off a stained linty sock. “I can tell because I’ve got more energy.”

“You don’t have a glucose meter?” Abby asked, rapidly typing into her laptop, trying to document his medical history before examining him. “When you use insulin, it’s really important to know your sugars. A low blood sugar—you know, hypoglycemia—can kill you.”

Thunder crashed, and they both paused, staring at the frosted window where rain streamed like a waterfall down the glass.

Herman rubbed at his cheeks, bright with rosacea, and gave her a doleful smile. Pale hair straggled around his seamy face, the thin strands a washed-out gray, almost colorless. “I can’t win, right? If my sugars are too high, diabetes will kill me. If my sugars go too low, insulin will kill me. High. Low. Up. Down. Who can take that kind of pressure? So I just threw out my glucose meter, and I’ve been happier ever since. I was always out of batteries, anyway.”

Dolores Diaz tapped at the door and stuck in her head, handing Abby a paper slip. She looks weary, Abby thought. The clinic nurse was one of Abby’s favorite people, calm and competent. But they had been swamped this year with high patient volumes, and there was talk of hiring a second nurse, or at least an assistant.

“Well, something is working right,” Abby admitted, glancing at the lab slip, a little surprised. “Your A1c is seven-point-two, which is pretty good.” She would have guessed eight, or even higher. “So your diabetes is fairly well controlled.”

“I think it’s the walking I’m doing.” He nodded, then thumped his mounded belly. “Believe it or not, I’ve lost some weight.”

Abby compressed her lips. Walking was probably the worst thing he could do for a foot ulcer. Putting down her laptop, she picked up his brawny foot. His legs were thick, crusted and flaked with dry skin, like the bark of an old tree. She raised his foot higher and winced involuntarily at the yawning wound, a deep cavity burrowing into his sole at the base of his toes. The dark red crater consumed nearly a third of his foot. There was a dense white rind at the perimeter, and a dank polluted odor seeped up to her nose.

“It’s pretty bad, huh,” he said apologetically, craning to look.

“Mr. White.” Abby paused. “How much have you been walking on this? How much does it hurt?”

He laughed, a short grunt. “Not walking that much. Do I look like someone in good shape? But I used to not walk at all. And it doesn’t hurt, because I’m basically numb from the knees down. It’s like walking on wads of cotton instead of feet.”

“Well, I applaud your efforts, and I’m sure that’s helped your sugars.” Abby peered into the ragged depths of his foot, seeing only moist red tissue but knowing that buried somewhere in there, the bones were exposed and infected. She gently lowered his leg. “When was the last time you saw a doctor for this?”

He sighed. “Almost a year. I went to the wound clinic for months back in Chicago, but nothing worked. They wanted to amputate, and I just panicked and left. I’ve been on the road ever since. I get odd little jobs, just enough to get by.” He was passing through, no medical insurance, and he planned to leave the canyon that day as soon as the rain let up, to head for the sunny warmth of Phoenix and Tucson.

Abby felt defeated. “I’m pretty sure it’s infected, and probably into the bones. I can give you some antibiotic pills, but I have to be honest—it won’t be enough. It takes IV antibiotics to reach the bones, sometimes for weeks. Or even months. I can give you the name of a low-cost clinic in Phoenix, and maybe you can get some emergency coverage. Although that’s tricky to arrange.”

He started to pull on his sock, but she stopped him, taking out clean gauze and elastic bandages, wrapping his foot.

“You don’t suppose I can avoid amputation?” he asked, dispirited now.

Abby shook her head and felt bad. He seemed nice, just overcome. His impulsive escape hadn’t worked. “Truthfully? I doubt it. It’s really severe. But don’t depend on my opinion—you need to consult with a wound expert. Maybe there’s more they can do. Have you tried hyperbaric oxygen?”

Herman stared at the floor and nodded. “Maybe you should give me the name of that clinic. But thanks for explaining everything.”

Abby touched his arm in sympathy and asked him to wait while she arranged his paperwork and wrote a note for the indigent health center in downtown Phoenix. Walking down the hall, she peeked into the small office where Pepper sat bent over a computer. She started to say something, then decided not to interrupt him and moved on to the front desk, where Priscilla and Marcus were preparing charts and finalizing bills.

Marcus grinned and waved his fingers at her, but he was on the phone. His canary-yellow polo shirt, stretched over his wide stomach, made a bright splash in the dreary afternoon. Abby turned reluctantly to Priscilla.

Priscilla looked like an urban secretary. She wore a frilly snug blouse, a deep V-neck that plunged down between her breasts, down past where one would usually find a bra. Abby tried to imagine what might be underneath. No bra at all? Stick-on cups? That was the point, she realized, to make someone—preferably a man—wonder. Abby made a mental note to ask Pepper later about his impression, for she knew Priscilla must have paraded herself under his nose at least a dozen times. Despite the fact that Abby and Dr. John Pepper had now lived together for over a year, Priscilla apparently still hoped that he would suddenly comprehend her virtues and fall under their spell.

“Can I help you, Dr. Wilmore?” Priscilla asked formally, sitting up very straight and wiggling her shoulders slightly in case Abby had missed her bounty. The waiting room stood empty; the storm had discouraged everyone. And while the lightning and thunder were waning, rain still pounded savagely on the roof.

“Sure,” said Abby. “That last patient, Herman White. I want to be certain he only gets charged the minimal fee. He doesn’t have any insurance.”

Priscilla’s tiny upturned nose crimped, as if smelling something sour, and she shot a severe look at Abby. “Dr. Wilmore, I’m sure you know I can’t make that decision. FirstMed’s new policy says all reduced charges must be cleared with them.”

Her petite fingers flew over the keyboard, flashing with silver nail-polish that matched her glittering eyelids. Something a twelve-year-old would wear, Abby thought.

Priscilla pointed a sparkly nail at the screen. “See? You spent quite a lot of time with him, including reviewing his meds and discussing his diabetes and his foot ulcer and him being homeless. It’s all right here. I don’t see how we could even begin to justify a lower charge. If anything, he should have a higher code. I don’t want to get in trouble for under-charging.”

Abby told herself to be tolerant. Priscilla notoriously followed the rules if they fit her agenda. Abby knew she was tired herself, and she felt sad for Mr. White. And now she finally admitted to herself that she was worried about Pepper’s mood. She wanted the workday to end, even though it was only three o’clock.

“I didn’t do a thing for him,” Abby explained. “All I did was tell him to see a specialist in Phoenix. That’s not worth a big medical bill.” She took a breath, braced for an irritating conflict she didn’t want. “Besides, I’m not asking you to make the decision. I’m making the decision. If I could, I wouldn’t charge him at all.”

Priscilla’s penciled eyebrows flew up as she recited the medical company’s dogma. “Dr. Wilmore, FirstMed is not a charity. Maybe if I cleared it with Dr. Pepper we could—”

“Don’t worry about it, Priscilla,” Marcus chipped in, beaming widely at the two women. He had hung up and was typing away. “Just let me do the bill, and you can stay out of it. We can use the 99201 code for a simple new visit, then give him the thirty-percent discount for a cash patient. And I can set up a payment plan for him if he can’t afford it all at once. Does that help enough, Dr. Wilmore?”

Priscilla whirled on him. “Marcus Limerick, you should mind your own business! I’m having a private discussion with the doctor.”

“I just thought I’d pitch in,” Marcus said happily, completing the form and hitting Print. “I mean, I really appreciate all the help you’ve given me, Priscilla, orienting me in this job all week. It’s time I did my share. It’s so nice when we work together like this.”

Priscilla fumed while Abby smothered a smile and thanked them both. As she turned away, she heard Priscilla fire back at him in a severe whisper, “If you really want my help, you should ask me about your clothes. For your information, that yellow shirt does not go with those burgundy pants. Not at all. This is a professional office, and you should dress like it.”

Marcus chuckled heartily. “I know, right? My colors are always a mess—maybe I should get tested for colorblindness.”

“It’s not funny,” Priscilla hissed, as the door swung shut.

Abby gave the papers to Herman White, recommending that he wait in the lobby until the rain slackened. Then she stepped into the cramped closet they called their doctors’ office, where Pepper sat with his chin in his hand, reading a medical article on the computer.

“Anything new?” she asked, scrunching in next to him.

He shook his head and smiled, reaching over to grip the back of her neck underneath her twist of hair. It was the one affectionate gesture he allowed himself at work, and she cherished it every time.

“Just more copycat drugs we don’t need, at higher prices.” He tilted his head to listen to the rain outside the window, which had suddenly diminished and barely dripped now. “I can hold down the fort, if you want to leave early. I doubt we’ll see many more patients today.”

“I want to run home, but I’ll be back. I meant to bring those cookies I baked last night. Everyone looks tired today—including you, by the way—and there’s nothing better for morale than a fresh batch of chocolate-chip cookies.” She looked pointedly at him without meaning to.

“Morale?” His eyes narrowed, went frosty blue.

Abby shrugged. “Marcus and Priscilla are, um, adjusting. Sniping at each other. Although Marcus doesn’t snipe—he just gets nicer and makes fun of himself, which infuriates Priscilla. And Dolores is overworked.”

“And me?” he said cautiously. “I got the feeling you meant something about me.”

Abby shrugged again. Quit shrugging, she told herself. “No. Not really.”

“That’s convincing.”

This was not the place to have this conversation. “You’re fine. Maybe sometimes a little distant.” She smiled. “You know how you are.”

Pepper shook his head, dismissive. “That’s silly—everything’s fine. Go get your cookies. I promise to eat a dozen and be the happiest man alive.”

“Ha. You’d better watch your waistline,” Abby teased. Pepper was tall and thin, and he could truthfully stand to gain some weight.

He laughed and looked like himself again, amused, a little unruly with his ruffled hair and short brown beard. “Hurry up with those cookies. Now I’m hungry.”

Abby pulled on her jacket and tramped briskly through the trees. Although the rain had stopped, large cold drops plopped on her head from the branches, and she tugged up her hood. The temperature had dropped, and her breath puffed out in faint clouds. She wondered how much longer these storms would persist, raging along the rim every afternoon. It wasn’t the usual time of year for thunderheads, but the weather had been unsettled since autumn began: first frantic winds that ripped old trees from the ground, then record-breaking heat that parched the forest and sparked fires, and now these odd violent storms, attacking them day after day.

She made up a cheerful box of cookies, lined with a bright red napkin. So domestic, she thought—even Marcus and Priscilla couldn’t resist feeling better when they saw that. Then she rolled her eyes at herself. As if anyone could accuse her of being domestic—most days, if she had any energy left by the time she finished work, she took a walk and contemplated the geology stacked below her, the complicated bands left behind over millions of years. Hundreds of millions. Or she might go running, which she was just starting up again.

A new thought smacked her. Could that be what was bothering Pepper? Could he be having doubts? Maybe she had grown too solitary, too limited, without realizing it—absorbed by her own routines. Maybe he craved something more, something different. They had discussed their concerns about having children, but neither felt ready to create that intense commitment. Had something changed?

Abby sat down, still in her rain jacket, the box of cookies in her lap. She reviewed their recent moments, his touch on her neck, his laugh, and she scolded herself for being silly and high-maintenance; they just needed to talk. She grabbed a notepad and drew a quick little stick-figure cartoon of Pepper frowning at her cookies, a word bubble over his head saying, “Feed me cookies or else,” which she propped on the kitchen table. Then she slid a plastic bag over the box—because the sky was drizzling now, a morose gray fizz—pulled up her hood, and marched back to the clinic.

Drawing near, she saw the ambulance angled into the back entry, left empty with the doors flung open, a crumpled wet towel on the pavement. She broke into a jog. How long had she been gone?

Pepper, Dolores, paramedics, and rangers all crowded the treatment room, where a hectic resuscitation was underway.

Pepper braced the paddles against the man’s bare chest and called out “Clear!” Everyone stepped back. The body jerked, but nothing twitched on the monitor. Abby stood in the background; there was nothing she could do. The patient was young and muscular, with thick blond hair and a spray of acne across his cheeks, still in his khaki hiking shorts. He was already intubated, and someone resumed chest compressions while Pepper ordered drugs and adjusted the oxygen and Dolores filled syringes. It went on and on. Abby read Pepper’s grim, unhappy face; she knew he felt up against the wall, nothing helping, nothing happening. The energy in the room begin to flag, and people exchanged glances, starting to wonder when. The mute heart in question remained silent, inert, done.

A ranger stood beside Abby and filled her in. The patient had staggered into the Kolb Studio just below the rim, wet and bedraggled, gasping. He told staff that he had just finished hiking down to the river on the South Kaibab Trail, then back up the Bright Angel, a brutal trip covering more than fifteen miles and forty-five hundred feet down, then forty-five hundred feet back up in elevation. It was a route that no one recommended, even though elite runners and hikers tackled it regularly. And although he was an accomplished hiker who had done it before, today he leaned against the wall of Kolb Studio, complained of palpitations and chest pain, and collapsed. His heart was galloping in ventricular tachycardia when the rangers got there. After being shocked, it quivered into ventricular fibrillation; and after they shocked him again, it stood still in no rhythm at all.

Pepper finally stopped, told everyone to quit. They had tried for an hour. The young man’s heart never thumped or bumped, not even once. The desolate process of locating his family began.

Marcus peered into the room and motioned for Abby. “There’s a patient who’s been waiting,” he said quietly, his eyes flicking toward the inert form on the table. “Can you see her?”

Dolores was cleaning up the body, biting her lip as she removed the cardiac leads and IV lines, wiped off blood and adhesive. Pepper thanked everyone for their efforts and went into the little office. His eyes met Abby’s briefly, arctic.

“Of course,” Abby said to Marcus. “What’s going on?”

“She’s pregnant, and her urine burns.” Marcus looked somber, but as they stepped away he carried on with the plethora of information he had somehow managed to extract from the patient within seconds. “It’s a boy. They were going to name him Nathan, but now the father thinks that’s a sissy name and wants to name him Robert. Only she once knew a Robert that she couldn’t stand, he was such a bully, so she refuses to call her baby that. Anyway, she’s collecting a urine sample, and she’ll be ready in a few minutes. And everything with the pregnancy has been perfect so far, and she’s hardly felt sick at all, right from the start.”

Abby nodded appreciatively. She picked up her forgotten box of cookies, which sat on the counter although she didn’t remember putting it there. Then she went to the office, where Pepper was staring at his computer, and put the box beside him.

“I saw him last spring,” Pepper said, shaking his head, “just for a rash. He was totally healthy, twenty-nine years old. No meds, no scary family history, nothing. No drug abuse. His dream was to hike in the Himalayas.”

Abby stood behind him, hugged him, and kissed the top of his head, something she had never done before at work. He reached up and wrapped his long fingers around her wrist.

“Sometimes this job just sucks,” he said.

She leaned against him and read the chart over his shoulder. “What do you think happened?”

“Probably something genetic. Some heart defect, you know. Cardiomegaly, aberrant coronary arteries, who knows. A fatal arrhythmia syndrome. Something that’s already there, then gets triggered by extreme exertion. We’ll have to see what the autopsy shows.”

Abby straightened and nudged the box toward him. “It won’t help, but have a cookie. I’m going to see that last patient.”

He opened the lid, and a fragrance of brown sugar and chocolate filled the room. “Let’s hope these things don’t come in threes. We just lost that other guy last month, another sudden death. I mean, he was a little bit older, but he’d been healthy too. And he was only forty.” Pepper bit into a cookie, chewed, and allowed himself a little smile. “This might actually help. It’s really good.”

The patient Abby saw was seven months pregnant, and her urinalysis confirmed a bladder infection. Abby listened to her gravid belly and found the chirpy little heartbeat, then let the mom-to-be listen; they shared a grin. Abby sent her out with antibiotics and a careful list of precautions, because an escalating urine infection could be dangerous to a pregnancy. By the time Abby emerged, Pepper had shared the cookies with everyone and the box was empty, except for crumbs and the two cookies he had set aside for her.

Hearing that tiny tapping fetal pulse was the most positive moment of Abby’s afternoon.

Needless to say, they did not talk about anyone’s mood that night. She and Pepper spooned together on the back deck, watching while the clouds tore themselves apart and a half moon fought through, flooding the rim with weak milky light. Tiny stars prickled the night, cold and distant.

They still needed to talk about serious stuff, but not now. Abby took a lighter direction. “Are you and Marcus really going to start watching that new series Friday night?”

Pepper poked her playfully in the ribs, making her squeak. “You mean you’re not going to watch it with us?”

“Vampires vs. Zombies? I don’t think so,” she scoffed.

He pulled her hair aside and lightly bit her neck. “Where’s your sense of adventure?”

“Stop it,” she said, turning to him, trying not to laugh. “I can see the sexy appeal of a handsome vampire—maybe—but zombies? Disgusting.”

He drew her close, and she forgot why she had been concerned.

The Journey Itself follows the path of a young woman physician, Dr. Abby Wilmore, who works at the Grand Canyon Clinic on the South Rim. She has taken significant strides in re-making herself after overcoming an anxiety disorder, and she feels good about her progress. Abby cares deeply about her patients and always tries to serve them well, despite the endless distractions of insurance problems, personnel issues, and the increasing moodiness of her physician partner, Dr. John Pepper, who is also becoming her life partner. A series of unexpected cardiac deaths complicates his skeptical outlook, as he seeks to understand the causes and prevent future cases. Abby’s situation deteriorates when a new female friend suddenly disappears, assumed to be a suicide, and Abby berates herself for missing the woman’s depression.

Eventually, Pepper admits that his mood is tied to family problems; he asks Abby to help him out by letting his teenage niece move in with them while the niece’s parents try to patch up their rocky marriage. Abby’s and Pepper’s experiences in fostering this troubled teen, as well as their investigation into the disturbing cardiac deaths, let them explore what is meaningful to each of them. Pepper’s niece makes an unexpected alliance with a tough female farrier, who shoes the canyon mules and faces sexual discrimination on a daily basis from male wranglers, while Abby discovers that her friend’s disappearance was probably not suicide but a different sinister fate.

All this is set against the stunning backdrop of the Grand Canyon, during an unusual season of violent weather, and an array of challenging medical cases, ranging from uranium poisoning to illicit drug sales. The characters tackle their personal pasts and individual demons as they try to grow and help one another move forward. The Journey Itself shows all of them attempting to discover what puts value into their lives and how their own decisions affect others.

I wrote this novel to show the complex, demanding tasks of physicians in their everyday professional and personal lives, and to explore the meaning of a life fully lived. The adventures, the medical exploits, the quirky secondary characters, and the remarkable geology of the setting are the frosting on the cake of our amazing and complicated existence.