The truck had been making that sound for thirty miles. Not a loud sound—just a low, metallic wheezing that Bob Mercer heard over the engine and the radio and the silence he kept most of the time. He put it in the same mental category as the check engine light and the bald spot on the right front tire: things that needed fixing but probably would not, and when they did not get fixed, they would not fix themselves.

The road to Clay City was not a road so much as a suggestion that someone, once, had driven a tractor over it. The moon was a sliver and the hills were black, and Bob's truck was one of maybe three vehicles on this stretch of road that had a working headlight on the driver's side.

He was forty-one years old and he had been the only physician within fifty miles for six years. He had not had a day off in eighteen months. He had not slept through the night in longer than he cared to think about.

The clinic was a single-room building that had been a post office before the post office moved to Paintsville. Bob had bought it for twelve thousand dollars and spent eighteen thousand fixing it up. The X-ray machine was from 1968 and worked most of the time. The refrigerator that held the vaccines was the same one the previous tenant had used to store beer. The waiting room had two chairs, a magazine rack with issues of Country Life from 1994 and 1995, and a poster about smoking cessation that was peeling off the wall.

Ruth Ann was already there when he arrived, which meant she had been there since five in the evening, setting up for the morning. She was fifty-two, had been a nurse for thirty years, and had the kind of directness that came from having listened to men lie about their symptoms for three decades.

"You got the amoxicillin?" she asked without greeting.

"No. The distributor doesn't deliver to Clay City on Thursdays. And the one in Hazard is out. And the one in Pikeville says they can't ship until Monday."

Ruth Ann nodded. She had heard this conversation before. "Well, tell your patients to come back when you got something that kills bacteria. I ain't got the energy to explain to Mrs. Caldwell why her bronchitis ain't getting better."

Bob hung his coat on the hook by the door and went into the back. He filled a glass from the sink, drank it, filled it again. The water tasted like iron. He did not mention it because Ruth Ann would say the water tasted like iron every day and he would say he did not notice and they would both keep doing what they were doing.

The first patient was at eight. Hank Williams—no relation to the singer, though Hank liked to say his father had named him after him because his father used to listen to the radio and the singer used to sing about pain and Hank thought that was honest.

Hank came in with his left hand wrapped in a dirty rag. He had been working the mine at the bottom of Harts Creek when a support beam shifted and caught his hand between the timber and the rock. The rag was soaked through.

"Let me see it," Bob said.

Hank unwrapped the rag. His hand was swollen to twice its normal size, the skin purple and shiny, the fingers curled like claws. There was a cut on the palm, maybe three inches long, and it was oozing blood and something else that Bob did not want to think about.

"How long has it been like this?"

"Since yesterday afternoon. I figured it would settle."

"It's not going to settle, Hank. You've got an infection and it's spreading. I need to clean this out and I need to get you on antibiotics, and I need to get an X-ray to see if there's bone damage."

"The X-ray machine is broken," Ruth Ann said from the doorway. "It's been broken since Tuesday."

Bob closed his eyes for a second. When he opened them, Hank was watching him with the patient look that miners had—the look of a man who knew that asking for help was a weakness and needing help was a death sentence, and he was somewhere in between.

"I'll figure it out," Bob said.

He did figure it out. He cleaned the wound with iodine and saline and whiskey because the alcohol was all he had left. He packed it with gauze and wrapped it tight. He gave Hank a prescription for amoxicillin and told Ruth Ann to call the pharmacy in Ashland and see if they could overnight it. He told Hank to come back if the swelling got worse, which it would, and Bob knew it would, and Hank knew that Bob knew it would.

The second patient was Little Jimmy. He was eight years old and he had asthma, which in the mountains meant that every winter was a gamble and most of the time the house he lived in did not have windows that closed or a seal around the door or enough insulation to keep the damp out.

His mother, Ruth Ann's niece, brought him in because he had been wheezing since midnight and the inhaler was empty and the pharmacy was closed and Bob was the only doctor who would come out to their house at six in the morning.

Bob did not come out to their house. He asked them to bring him to the clinic, which meant a forty-minute ride over a road that would have made the EMTs refuse the call. But they came, and Jimmy was sitting on his mother's lap in the back seat, his little chest heaving, his lips a shade of blue that Bob had learned to recognise as "not immediately fatal but getting there."

Bob gave Jimmy two nebuliser treatments and a course of prednisone and told his mother to keep him warm and dry and fed and to bring him back if it got worse, which it would, and Bob knew it would.

By ten in the morning, Bob had seen four patients, run out of iodine, broken the blood pressure cuff, and had a cup of coffee that was cold and tasted like the pot had been burning it since the previous afternoon.

Ruth Ann came into the back room while he was washing his hands. "There's a man at the house," she said. "Says he's a miner. Says his chest hurts. Says he can't breathe."

Bob dried his hands on a towel that had not been changed since yesterday. "Is he in the waiting room?"

"He's in the truck. I told him to come in and he said he'd wait till you were done with your coffee."

Bob looked at the coffee. He looked at Ruth Ann. He looked at the X-ray machine that worked most of the time.

He walked out to the waiting room and found the man in the last chair. He was maybe fifty, maybe sixty, hard to tell with the coal dust. His face was the colour of the hills on a winter morning—grey and tired and covered in something that was not quite dirt and not quite ash.

"Name's Earl," he said. His voice was a rasp, like gravel in a tin can. "I've been working the seam at Blackstone for twenty-three years. I can't breathe right. Not anymore."

Bob sat down across from him. "Let me listen."

He put his stethoscope on Earl's back and asked him to breathe in. The lungs sounded like someone crumpling paper. Bob asked him to breathe out. The sound was worse.

"Coal dust," Bob said. "It's in your lungs. You've got pneumoconiosis. Black lung."

Earl nodded. "I know what it is, Doctor. I been knowing it for five years. I want to know if there's anything you can do."

Bob removed the stethoscope. There was nothing to do. There was never anything to do with black lung. You could give them inhalers and steroids and oxygen if they could afford it, but you could not take the dust out of their lungs. You could not un-breathe what they had already breathed.

"No," Bob said. "I can't fix it. I can make you more comfortable, but I can't fix it."

Earl nodded again. He did not look surprised. He looked like a man who had known the answer and had come anyway, because coming was what you did. You went to the doctor even when there was nothing to be done, because going was the only thing left.

"Alright," Earl said. "Alright then."

He stood up, slowly, the way men in their fifties stood up when their knees had been damaged by twenty years of crawling through tunnels that were too low and too narrow and too dark. He thanked Bob with the quiet gratitude of a man who was not used to thanking anyone and did not know how to do it well.

Bob watched him walk to his truck and drive away, the truck making the same sound Bob's truck made, the sound of something held together by rust and hope.

At noon, Bob sat down at his desk and opened his lunch—a sandwich he had made the night before, the bread slightly stale, the peanut butter slightly hardened. He ate it standing up, because sitting down meant starting a conversation and he did not have the energy for conversations.

Ruth Ann came in with a stack of unpaid bills and set them on the desk. "Three of these have been unpaid for six months. One for a year. The man who owes for the appendectomy moved to Kentucky. I don't think he's coming back."

Bob ate another bite. "Put it on the tab."

"The tab is already bigger than the revenue."

"I know."

Silence. The kind of silence that came from two people who had stopped trying to fix things and had moved on to simply enduring them.

"Bob," Ruth Ann said. "You need to eat something that isn't peanut butter."

"I know."

" You need to sleep more than four hours a night."

"I know."

"You need to leave this town and go somewhere where the air doesn't taste like coal and the patients don't all die."

Bob looked at her. He wanted to say something—something honest, something that would not sound like a platitude or a lie. But he did not have the words, and even if he did, they would not have helped.

Instead, he said: "There's a man at the house who says his chest hurts."

Ruth Ann nodded. She had heard him say it before. She would hear him say it again tomorrow.

"Alright," she said. "Send him in."

Bob picked up his stethoscope and walked to the examining room, where the air was cold and the paper on the table was torn and the walls were bare except for the anatomical chart that had been there before he arrived and would probably be there after he left.

He heard the door open. He heard a man's voice, rough and tired and saying something Bob could not quite make out.

"Come in," Bob said. "Tell me what's wrong."

And he listened, the way he always listened, to the next person who had come to him with something broken, knowing that he could not fix it, knowing that he would try anyway, knowing that tomorrow he would drive his truck over the same road, past the same hills, to the same clinic, and do it all again.

Because that was what he did. That was who he was. Not a hero. Not a healer. Just a man with a stethoscope and a truck with a broken headlight and a clinic that smelled like iodine and regret.

And in the morning, he would do it all again.

Objective Tension Mapping Encoding v2.0 (OTMES v2) [DR]-1974-[Appalachia]-[Occupational Disease]-4ACT-[1480]W-NO-SUP-PER-1PL-LIM