The second annual Bryson City Fireman’s Day was the first one I could actually enjoy. After suffering through a year of giggling and snide comments at my “victory” in the Miss Flame contest, I was eager to have a new contestant assume all the grief that came with the crown.
Downtown was packed. There were booths selling crafts and cookies and pies of all kinds. Kate and Scott had fun climbing into the big red fire engine, and we all enjoyed a caramel apple after the community lunch had been served. We ate and laughed and visited with friend after friend. After four years in this small mountain town, we finally felt we were not only an accepted part of the community but also a wanted part of the town’s life and times.
And my most vivid memory of that year’s Fireman’s Day was an incredible quilt. No, not the one Mrs. Fox made for Vanessa — the one representing new life — but the one at a crafter’s booth that Rick pointed out to me.
“Wow. Look there, Walt!” he exclaimed as he pointed to the back of the booth.
It was hanging on the back wall of the booth. Embroidered across this spectacularly detailed work of quilting and embroidery was a series of names — seven to be exact — including my and Rick’s names. On the top it said OUR DOCTORS; on the bottom it said PRICELESS GIFTS FROM THE GREAT PHYSICIAN.
The quilt was not for sale. But to Rick and me it was a priceless affirmation and blessing that God was indeed using us in the way he was crafting our lives and the lives of our patients into a remarkable and masterfully woven quilt.
part three
chapter twenty-four
THE GOLDEN HOUR
Bonnie walked quickly back to my dictation station.
“Louise called, Dr. Larimore. There’s a trauma case coming to the ER. She wants you there, stat. Mitch is on his way up.”
I dropped my pen and quickly left the office. My rapid walk escalated to a run as I heard the ambulance coming up the back of Hospital Hill.
I arrived at the ER as Billy was backing the rig up to the ER entrance. I ran to the back of the ambulance, where I was met by Louise. As soon as it stopped, we each grabbed a door and threw them open.
Our mouths fell open in astonishment. Don was in the back, sitting at the side of a bloodied patient. Draped across the patient’s feet, on the stretcher with him, was a whining, blood-covered golden retriever. It was Dan McGill and Samson!
“I’ll get another gurney!” Louise cried out as she spun around and raced inside.
“Some fool tourist was speeding through town on Main Street,” Don explained. “Hit Dan and Samson in the crosswalk. Someone said Samson tried to drag Dan out of the way — but it was too late.”
As Louise wheeled the gurney toward me, Don and I carefully transferred Samson. I could feel the broken ribs crackling under his chest wall as we lifted him. He whined in pain. I tried to comfort him with an “It’s OK, boy” as we turned and gently placed him on the stretcher. Louise quickly wheeled him into the ER.
Don turned to help Billy unload Dan, who was unconscious. His right arm and head were heavily bandaged with blood-soaked gauze, and an IV was running into his left arm.
“I think he has a broken arm and leg, Doc!” Don exclaimed as they unloaded the stretcher. “He’s unconscious, but his pupils are equal and reactive,” Don noted as we rushed Dan into the ER.
I did a quick exam, confirming Don’s findings. Although Dan was covered with deep abrasions, especially on his arms, the palpable fractures of his right humerus and femur were closed — in other words, the bones weren’t protruding through the skin. When I examined his right leg, Dan began to moan and to wake up and shake his head. I moved up the gurney so I could be next to him.
“Dan, this is Dr. Larimore. Can you hear me?”
His eyes began to focus on me. “Where am I?”
“You’re in the ER, Dan.”
“What happened?”
“I’m told you were hit by a car downtown.”
His eyes widened as he exclaimed, “Samson!” and tried to sit up. But as soon as he tried to push up with his right arm, he yelped in pain and collapsed back onto the pillow. “Where’s Samson?”
We both heard a bark from the next cubicle.
“He’s in the next cubicle, Dan.”
“How is he, Doc?”
“I’m not sure. I was tending to you first. I think you’ve got a broken arm and leg. We’ll need to get you X-rayed to see how bad the damage is. OK?”
“He’s fine!” I turned to see Dr. Mitchell as he entered the cubicle.
“That you, Dr. Mitchell?” Dan cried out. I instantly knew Dan’s hearing was intact.
Mitch walked up opposite me and took Dan’s left hand. “It’s me, friend. I took a quick look at Samson. He’s got some broken ribs and a collapsed lung, so he’ll need a chest tube. And his left front leg is broken. He’s gonna need surgery.”
“Oh no!” Dan exclaimed. “Is he going to make it, Doc?”
Samson barked again as I heard Carroll Stevenson rolling the portable X-ray machine into the ER.
“We’ll do everything we can, Dan,” Mitch said, reassuringly. But as is the case with any major trauma, the first hour is what we call “the golden hour” — it’s the most critical time. We’ll just have to see.
Mitch checked Dan’s X-rays as I placed Samson’s chest tube. He was just as compliant a patient with his chest tube as Tommy had been with his. Of course, the morphine that Mitch had asked Louise to give Samson through his IV helped a great deal.
When Mitch had suggested I place Samson’s chest tube, I wanted to exclaim, “But Mitch, I’m not a vet!” But I knew it would be for naught. In my four years in Bryson City, I had delivered a calf; sown up pig-gored dogs; reviewed ultrasound images of pregnant cats, dogs, and cattle; artificially impregnated fertile cows on Mitch’s farm; and removed a trapped bovine placenta. This was just another step in my unofficial veterinary training.
Once the tube was in place and connected to suction, Samson’s collapsed lung immediately inflated and his breathing normalized. I couldn’t help but smile as I looked down on him — a human oxygen mask covering his nose. He took a deep breath and then fell asleep.
“Here’s the X-ray,” Carroll called as I heard him snap the films onto the view box. “Look’s like a bad fracture, Doc.”
Mitch and I met at the view box. I was expecting to see Dan’s X-ray but was obviously looking at Samson’s.
“His forefoot is even more busted up than Dan’s,” Carroll explained as he placed Dan’s X-rays next to the dog’s.
Indeed, the middle of Samson’s humerus was broken into over a dozen small pieces. At least the ball-and-socket joint appeared normal. I turned my attention to Dan’s X-rays. His humerus was also broken in mid-shaft, but there were only three or four major pieces. His femur X-ray showed a mid-shaft spiral fracture.
“What do you think the plan should be?” I asked Mitch.
He looked at the X-rays for a few more moments and then answered decisively. “Let’s admit them both to a semiprivate room. One bed for Dan and one for Samson. We’ll observe them for the next few hours, and if everything’s stable, we’ll take them to the OR this evening.”
“Them!” I exclaimed.
“Yep,” Mitch replied, as he turned back to the view box. “We’ll need to place pins in the bones and then cast them up. Dan should heal as good as new. And we’ll do the best we can on Samson. But my guess is he’ll do fine too.”
“We’re going to take a dog to the OR?”
Mitch cocked his head at me and then asked the question I’d frequently heard in my first year of practice but hadn’t heard for nearly a year now. “You stupid?” His ear-to-ear smile indicated that the question was in jest this time. “Seriously, Walt, why not?” he asked.
I thought for a second. “Good question, I guess. Why not?” Then I smiled as an idea dawned on me. “Mitch, we can’t take him to the OR.”
“Why not?” he asked again.
“Samson can’t si
gn a consent.”
Mitch laughed. “He doesn’t have to.”
Now it was my turn to ask again, “Why not?”
Mitch smiled at Carroll, his eyes gleaming. “Tell him, Carroll.”
The radiology technician explained, “Doc, since Samson’s underage, Dan, as his legal guardian, can sign his consent.”
I chuckled to myself as I thought, Obviously, these boys have done this a time or two.
The next week was remarkable indeed.
Dog and owner did well in surgery — despite the jokes about having to shave Samson’s hair. Samson’s surgery took the longest, because his bones had to be carefully pieced around a rod that Mitch placed in the bone. Mitch took bone from Samson’s pelvic girdle to use as a bone transplant. It was grueling surgery.
However, the post-op recovery was uneventful for Dan and Samson. Both patients enjoyed the hospital food. Eloise wouldn’t hear of feeding Samson dog food. “We don’t serve dog food in my hospital!” the registered dietician was overheard explaining to the hospital administrator. So Samson’s food, once he began eating, was catered on the usual hospital tray.
Both Dan and Samson were lovingly attended by the nursing and physical therapy staff. The day they were discharged from the hospital, each patient was in his own wheelchair. Pete Lawson from the Smoky Mountain Times wanted to take a picture and run an article about the duet; however, hospital administrator Earl Douthit, appropriately concerned about community perception and the unpredictable response if health or government regulation folks were to catch wind of this unconventional practice, convinced Pete to exercise journalistic caution and not record the event in our local paper.
Even the usually gossipy radio deejay at WBHN, Gary Ayers, was careful to keep the news off the airways. But the well-tuned gossip wires in town kept interested locals up-to-date on Samson’s and Dan’s day-to-day recovery. By now, I was well aware that nothing of significance could be kept secret in Bryson City. Even the most private and painful of secrets were likely to be revealed and discussed in harsh, condescending whispers.
It was two months before Dan and his dog could get out and walk together again, and another six months before their stamina and strength would allow them to walk the length of Main or Everett Streets. But they finally did.
I just wish I could have been there to see it for myself.
chapter twenty-five
BEER AND BREATHING
When I arrived at the ER later that week, the patient was sitting up and obviously alert. A stocky lad, he appeared to be in his midtwenties, and he was wearing a Swain County High School football cap. A nasotracheal tube was taped to the side of his face and connected to a ventilator at the head of the bed. I could see the ventilator effortlessly performing its lifesaving chore, connected by a flexible tube to the breathing tube that had been inserted down his nostril, through his vocal cords, and into his trachea.
With each successive deflation of the air chamber, the patient’s chest slowly expanded. The patient ever so gently nodded his head, acknowledging my entrance. I knew the tube in his nostril was uncomfortable, explaining why his head movement would be minimal.
Sitting at the patient’s left hand was Randy, one of the respiratory therapists, who was adjusting a small plastic clamp on the patient’s right pointer finger. The clamp had a bright-red light that shone onto the pad of the finger and was connected by a wire to a pulse oximeter. This machine allows the blood level of oxygen to be continuously and painlessly monitored.
An intravenous line was running fluid into his right arm, and his right hand was firmly grasped by an obviously anxious young woman. She stood up when I entered the cubicle.
“Hi, Dr. Larimore. I’m Martha Jenkins.” She pointed to the man whose hand she still held. “I’m Jimmy’s wife. And I’m not really sure what’s going on.”
Randy was taping the finger clamp to Jimmy’s finger as he explained, “None of us do, Doc.” After attaching the last piece of tape, he stood and faced me.
“Jimmy here was at the Rec Park playin’ softball with a bunch of fellas. They’d all been drinkin’ beer from an ice-cold keg they had up there. When the game was over, a bunch of ’em went to Na-ber’s Drive-In for some food and was downin’ some of those big ole banana splits.” Randy looked across the gurney. “Martha, why don’t you take it from there?”
“Doc,” Martha began, “Jimmy started sayin’ he felt weak all over. We just reckoned it was from all the beer he had been drinkin’. But then he started gittin’ real short of breath. Couldn’t hardly catch his breath. I knew something was wrong when he started turnin’ blue. Someone called 911. Jimmy was bent over and really strugglin’ to breathe. I just knew he was gonna die. Then I could hear the siren comin’ up the road. When they pulled into Na-ber’s, Jimmy quit breathin’ and fell over on the ground.”
“Don and Billy found him unconscious, Doc,” Randy continued, “but with a heartbeat and a pulse. They applied bag and mask ventilation with 100 percent O2 and pretty soon he perked up. So they put him in the ambulance and started to transport him up here. But his breathin’ pooped out, and Don had to bag and mask him until they arrived up here. He just couldn’t maintain his oxygen, so I intubated him, and he’s been fine ever since.”
The curtain behind us parted and in walked Louise, lab work in hand. I looked at the paperwork. The complete blood count, electrolytes, and urinalysis were normal. Even the patient’s blood alcohol wasn’t terribly high. “Carroll did a chest X-ray, which he says is normal,” Louise commented.
My mind was swimming. This scene didn’t make any sense at all.
“Here are his blood gasses. The first one is on room air and the second on the machine.” Randy handed me the first readout. His initial oxygen level was dangerously low and his carbon dioxide levels minimally high. The values on the second sheet were normal. Instantly this told me the patient had what doctors call hypoxemic respiratory failure — an oxygen level of less than 60 mm Hg and a normal or low carbon dioxide level. This type of respiratory failure is the most common, and it’s usually associated with acute diseases of the lung.
I took a medical history from Martha, which Jimmy confirmed with his eyes and head nods. There was no history of respiratory disease, pneumonia, TB, bronchitis, or asthma. He had no history of allergies or hives — no recent cough, fever, weakness, or shortness of breath. His blood count was normal, meaning this wasn’t caused by a severe anemia. Jimmy wasn’t even a smoker. He had been healthy his whole life.
A quick exam gave me no clues. His lungs were clear. His heart and abdomen were completely normal. Neurologically, he was fine, although on testing his muscle strength, he was weak in both arms and legs. I assumed this was from the stress of this entire event. Furthermore, there were no signs of chest wall trauma or abnormalities. His neck and trachea showed no signs of swelling or trauma.
As I looked at his chest X-ray, which was indeed completely normal, I thought to myself, What could cause sudden respiratory failure in this young man?
Respiratory failure can arise from an abnormality in any of the components of the respiratory system, including the airways; the air sacks, which are called alveoli; the central nervous system; the peripheral nervous system; the respiratory muscles and diaphragm; and the chest wall. Other possibilities include poor circulation due to heart disease or blood loss or septic shock from bacterial disease. Yet the patient had no sign of any problems in any of these systems or organs.
Or did he?
Suddenly it dawned on me. He did have a sign of one of these problems! But to get to the bottom of this, I needed to do more investigating — and quickly.
After discussing my findings and concerns with Martha, I finished Jimmy’s intensive care orders. I ordered additional lab work and then walked across the street to Rick’s home for a consult.
“So what’s up?” Rick asked.
“If you don’t mind, I’d like to get your ideas on a patient I just admitted to ICU.”
/> I sat down and presented the case as Rick carefully listened. When I finished, he looked out the window for a moment, obviously turning the facts over in his mind. He took a deep breath and then, almost to himself, commented, “Well, in a case like this I’d think about poor breathing and muscle weakness. When I think of poor breathing, at least in acute respiratory failure, drug intoxication and poisoning come to mind. When I think of muscle weakness, all sorts of things come to mind — myasthenia gravis, polio, a primary muscle disorder, Guillain-Barré syndrome, a metabolic disorder, polymyositis, hypothyroid myxedema, and tetanus.”
He was quiet for a moment and then looked at me. “Given the particulars of what you tell me, the top of my differential diagnosis would be drug abuse, poisoning, a muscle disorder, or a metabolic disorder.”
“Not Guillain-Barré?”
“Actually, it wouldn’t top my list. I think of the first symptoms of Guillain-Barré as including varying degrees of weakness or tingling sensations in the legs, and then in many instances the weakness and abnormal sensations spread to the arms and upper body. When these symptoms increase in intensity, the muscles get weak, and this can go on to almost total paralysis. And it sounds like his wife didn’t give any history like this, did she?”
“She really didn’t. And his chest wall weakness is much more pronounced than his arm and leg weakness. I’ve asked Betty to run his blood and urine for a drug screen. But I’ll tell you the truth, I didn’t think of any poisoning.”
“It might be worth sending off some blood to check for this,” Rick commented.
I nodded. “What muscle disorders would you be thinking of?”
Rick thought for a moment. “Actually, I wouldn’t think a primary muscle disorder would present this way. Maybe a weird metabolic disorder?”
“That’s what I’m thinking, Rick. I don’t know why, but I’m wondering about some sort of calcium problem.”
Bryson City Secrets: Even More Tales of a Small-Town Doctor in the Smoky Mountains Page 18