“My money’s on a drug or a poison,” Rick said.
When I walked back into the ICU, I found Martha at her husband’s bedside. Jimmy was asleep. “They’ve sedated him,” she commented.
I nodded as I pulled up a chair. “Until we know what’s going on, it’s probably best to let the ventilator do the work.”
I took some time to explain my thoughts about Jimmy’s case and the differential diagnosis that Dr. Pyeritz and I had discussed. When I finished, Martha’s head dropped. I presumed she was considering all I had told her.
Finally she looked up, her eyes filled with tears. “I’m prayin’ that Jesus will heal my Jimmy,” she whispered.
I reached out and took her hands in mine. “Will you do me a favor, Martha?”
She nodded as a tear spilled out of her eye and down her cheek.
“Will you pray for wisdom for Jimmy’s doctor?”
She smiled and nodded.
After dinner, Betty called from the lab. “I’ve got some lab results you might find interesting. Do you want to hear about ’em?”
“You bet!”
“I had the sheriff run some blood over to Sylva. They just called and told me the initial drug and poison screen is normal. But they’ve got some more testing to do. In the meantime, I’ve just run a full SMA test, and there’s one stunning result. His phosphate level is so low the machine almost can’t read it.”
“Hypophosphatemia!” I couldn’t believe it. Why hadn’t I considered it? “That’s it, Betty! That’s it!”
“You think that’s his problem?”
“I’m almost positive. But I need some additional lab work. Would you draw a parathyroid level for me?”
“When I saw the phosphate level, Walt, I asked Sylva to run a parathyroid hormone level. They’re working on it now. I’m also running a test on his muscle enzymes, if that’s OK.”
“You bet it is, Betty. Thanks. I’m heading that way.”
I hung up the phone, explained to Barb what was going on, and walked across the street to the hospital.
I had never seen a case of a severely low level of phosphate in the blood, but I had studied the condition in medical school and residency. Phosphate is one of those chemicals contained in every cell in the body. It is essential in order for the lining of the cells to work correctly, critical for energy storage in every cell, and indispensable for transporting chemicals inside the cells. An especially important function of phosphate is to produce a chemical called ATP, which provides energy for nearly every single cell function. In addition, phosphate is necessary for the oxygen-rich red blood cells, when they are in the microscopic capillaries, to release oxygen for the body tissues to use.
Normally, mild to moderate reduction in the phosphate level isn’t even noticed. But when the levels get severely low, the entire body can be affected. And one of the first symptoms is muscle weakness. It can involve any muscle group, alone or in combination, ranging from the eye muscles, to the arm or leg muscles, to the swallowing or intestinal muscles — all the way to the heart muscle. Hypophosphatemia can also cause the muscles of the body to dissolve, a condition we call rhabdomyolysis — which is why Betty was running the muscle enzyme tests.
And, most important, respiratory insufficiency or failure can be caused by severe hypophosphatemia. Worse yet, it can be accompanied by impaired heart function leading to life-threatening ventricular arrhythmias and rapidly impaired neurological function, which can lead to seizures, coma, or a paralysis similar to Guillain- Barré syndrome. I knew I needed to act quickly to keep a bad situation from getting worse.
In the nurses’ station, I quickly explained the situation to the head nurse, who headed to our small hospital pharmacy to retrieve the potentially lifesaving vials of potassium phosphate. I also wanted the nurses to be prepared with medications to treat any cardiac rhythm problems or seizures. Louise went to work gathering the necessary supplies that would be available at Jimmy’s bedside.
I walked over to Jimmy’s room. He was our only ICU patient that evening. Martha was sitting at her husband’s side, and I pulled a chair close to hers. “I’ve got good news. The Lord has answered your prayers. He gave wisdom to the head of our lab, and I think I know what’s going on.”
“Is it bad?”
“It’s fixable. I think we’ll be able to get Jimmy out of the woods.”
Martha bowed her head and began to sob. I simply sat and silently shared her joy.
chapter twenty-six
A BITTER PILL
That evening, Barb and I were having dinner at the Fryemont Inn. Sam Tanager was babysitting Scott and Kate, and Rick was joining us for what was sure to be another fabulous meal from Katherine Collins’s kitchen.
Katherine was known across western North Carolina for her warm hospitality, sparkling smile, quick wit, easy laugh, attention to detail, and green thumb. But most of all she was known for some of the best cooking in our region — having won several culinary awards and recognitions.
For Katherine, summer was her busiest time of year — aside from leaf season. The inn she now owned and operated was originally built by Captain Amos Frye and his wife, Lillian. The Fryes were married in 1895, and Lillian became the first woman attorney in North Carolina. Lillian both practiced law and ran the inn until her death in 1957. Katherine’s father, W. B., owned and ran the inn until he retired, and then he sold it to Katherine — who ran it alongside her husband, Jim. The couple had divorced just about the time we arrived in Bryson City, and now Katherine ran the inn by herself.
Soon after Rick joined me in Bryson City, he and Katherine had started seeing each other. At first, they tried to keep their relationship a quiet and discreet secret — but there’s really no such thing as a quiet or discreet relationship or secret in a small town, at least not for very long. Rick and Katherine enjoyed being with each other, and we deeply enjoyed our time with them. In fact, Barb and I were half suspicious that Rick and Katherine might have a special announcement for us just about any day. And did they ever!
Over dinner I explained to Rick some of the additional facts I had learned about Jimmy and his case of bad breathing. “It turns out Jimmy had been having a lot of indigestion.”
“What’s that got to do with anything?” Rick asked.
“Simple. He had been taking handfuls of antacids for the previous three weeks. The acid in his stomach had caused him to develop a small ulcer, and without knowing it he had been self-medicating that ulcer with antacids containing large amounts of calcium. That caused his parathyroid gland to begin dumping phosphate from his kidneys. And it turns out the antacids, combined with the onslaught of beer and ice cream, caused his phosphate level to suddenly bottom out. That caused his muscles, including his chest wall muscles and his diaphragm, to stop working. Good thing his friends knew CPR.”
“Well,” Barb commented, “you’ve got to admit, this has been one strange year. You guys have had to take care of so many things you were never trained to do — from veterinary care to surgery to dealing with evil spirits. Maybe you should write a book!”
Rick laughed, “No way, Barb!”
“Why not?” she asked.
“No one would ever believe any of these stories.”
Barb smiled and nodded. “You’re probably right, Rick. By the way, where’s Katherine? She hasn’t come out from the kitchen to see us.”
“I don’t know,” Rick responded. “She’s been acting mighty strange lately. I’ve been wondering if something’s wrong.”
“Probably just busy with meal preparation,” I suggested — not knowing how wrong I was.
Late that night, Barb and I were in bed reading when we heard a gentle tapping on our bedroom window. We looked at each other, perplexed.
“Who could that be?” she asked.
The only other time this had happened was Christmas Eve the year before. It had snowed heavily that day, and we were excitedly preparing for the first white Christmas of our lives. Ray and Nancy Cunni
ngham, along with local dentist Michael Ham-rick and his wife, Kim — one of our hospital’s two nurse anesthetists — were tapping on our bedroom window. They invited us to go cross-country skiing with them across the Rec Park under the bright light of a nearly full moon. We declined — we didn’t have skis, and I don’t think Barb would have left the sleeping children alone.
“You don’t think it’s the Cunninghams and Hamricks, do you?” Barb asked.
I shrugged my shoulders as I got out of bed and walked over to the window. I pulled the curtain open, not knowing what to expect. To my surprise, there was Rick.
He smiled. His voice carried through the window. “Saw your lights were still on. Mind if I come in for a moment?”
I motioned to the back door and closed the curtain. I quickly put on my robe and walked to the back door to let my friend in.
“What’s up, partner?” I asked.
“Mind if I talk to you and Barb for a moment?” He seemed more serious than normal, as though he was worried about something.
“Not at all, Rick. Come on back.”
Barb beamed as we walked into the bedroom. “Hey, Rick. To what do we owe this honor?”
Rick sat on the bed at Barb’s feet, and I went around and got up on my side of the bed.
“Normally, I wouldn’t bother you so late. But I just need to let you guys know something.”
Barb closed her book and leaned forward as she pulled the duvet up to her neck. “What?”
Rick looked down for a moment and then looked back at Barb. I could see there was a mist in his eyes. “Katherine has called it off.”
“Called what off?” I asked, knowing perfectly well what he was referring to.
“Us,” Rick replied. “She doesn’t want to see me anymore.” Rick smiled sadly. “Well, she said she wouldn’t mind seeing me as a customer or as a friend. But she doesn’t want a romantic relationship right now. She knew I was falling head over heels for her. And I would have liked to believe she felt the same way.”
I could sense Rick’s deep hurt and was glad he felt comfortable enough to talk with us about something that was obviously a very bitter pill for him to swallow.
“Barb,” Rick continued, “I’d marry her in a minute. But her divorce with Jim has been so ugly, and she says she needs more time and space to heal.”
“Oh, Rick!” Barb moaned as she reached out to take his hand. “I’m so sorry.”
“Me too,” I added.
When Rick hurt, we hurt — especially Barb. They were like brother and sister. We talked for a long time, but we had no special advice to give. When Rick left and we turned off the light to go to sleep, I began praying for my practice partner — that God would bring his soul mate into his life.
I was only just beginning to understand the power of prayer — to heal, to instruct, to comfort, and, perhaps most of all, to prepare.
chapter twenty-seven
AZAR
A couple of weeks later, I was finishing my last few charts at the end of the day when Rick walked up to my dictation station.
“Hey, partner.”
“Hi, Rick,” I responded as I continued my chart work without looking up.
“I’ll be over at the Fryemont Inn this evening.”
I put down my pen and turned toward my partner, curiosity on my face.
“Yep. It’s my last meal with Katherine. Believe it or not, she’s sold the inn.”
“Sold the inn!” I couldn’t believe my ears.
“Yep. To a couple from Atlanta — George and Sue Brown. They absolutely love the inn and are actually taking over as the new proprietors tomorrow. Apparently it happened really quickly.”
“I’d say so.”
“Anyway, Katherine and I are just going to talk. She’s moving to Sylva and will run a family business over there.”
“Wow! That’s a big change, Rick.”
Rick smiled sadly and nodded. “I’m coming to understand that big changes are just part of life.”
“True enough, partner.”
“Anyway, I need to check out a patient to you.”
I was on call for our practice that evening, and, as was our habit, the one who was off duty would let the on-call doctor know of any patients in the hospital or any potential problems that could arise.
Rick continued. “It’s little Danny Hammond.”
I had first seen this adorable little boy almost a year earlier in the emergency room. He had been playing football with friends. While throwing the ball, he and his friends heard a horrible snap, and then Danny had collapsed in the yard in terrible pain.
The X-ray showed a clean fracture of the humerus not far below the shoulder. But to my dismay, the fracture was surrounded by a black space where the whitish color of bone and bone marrow should have appeared. I knew immediately that Danny had either a bone cyst or bone cancer, which had weakened the bone, leading to the fracture from an action as benign as throwing a football.
With my encouragement, Danny’s mom and dad took him to the Duke Cancer Center for evaluation. A biopsy confirmed the diagnosis of a type of cancer called osteocarcinoma. We all had hoped and prayed that the amputation of his arm would have brought a cure. And for nearly eight months there had been no sign of any recurrence.
Then I saw him in the ER for an episode of acute, severe chest pain. A chest X-ray revealed multiple tumors in Danny’s ribs — with one of the ribs being fractured from the relentless erosion of the cancer. Further X-rays showed that the tumor had spread to little Danny’s spine and skull.
The pediatric oncologists at Duke had tried the strongest chemotherapy that was available. It caused little Danny to become bald and to lose weight and muscle strength — but not his incredible sense of humor or his astounding spiritual faith.
All the boys in his class at Bryson City Elementary School had shaved their heads in support and solidarity for their classmate. And for his first office visit after losing his hair, we all wore bald headpieces, which made Danny laugh and laugh — especially when he saw Rick with his bald head and thick beard.
Danny and his family were active members of a small country church. Their church was an important part of their life, and their pastor, Harold Shook, was an important source of encouragement to Danny and the family as they fought for his life — along with the best medical care and prayers I could offer. Danny’s mom, Myrtle, believed with all her heart that God was going to heal Danny, with either our therapy or the Lord’s direct intervention.
Sadly, his cancer outpaced our medicines, and the Lord apparently said no to the family’s prayers for a miraculous healing. Nevertheless, as Danny became increasingly weak and emaciated physically, his emotional and spiritual energy seemed to surge.
Danny ran out of the physical stamina to continue school, so I recommended to Danny’s family that they allow hospice to provide home care. Initially, Myrtle and her family resisted my recommendation, but when the administration of the medications for pain and nausea became more complicated, the family relented.
I would regularly make a home visit to see Danny — at least once a week, as well as whenever something urgent would come up. One particular evening, I had stopped by the house. Danny’s dad had taken his sisters into town. Myrtle had met me at the door.
“Evenin’, Doc.”
“Evening, Myrtle.”
I could see that her eyes were puffy and suspected she had been crying.
“Come on in. Danny’s been sleepin’ most of the day. Can I offer you a soft drink or a cup of coffee?”
Myrtle was ever the gracious host, and her graciousness again bubbled up, even from the depths of her grief.
“A cup of coffee would be very nice, thank you.”
I closed the front door and followed her to the kitchen. She motioned to the kitchen table. I set my black bag on the table and sat down.
Myrtle poured two cups of coffee. “Cream or sugar?” she asked.
“Both.”
After doctorin
g the coffee, she delivered my cup and sat down.
“Myrtle,” I began, “you look sad.”
She looked down at her coffee and nodded.
“What are you thinking?”
Myrtle thought for a moment as she stared at her coffee. “Doc, I’m just upset about my Danny.”
I nodded to myself. “I can’t even imagine how difficult it is to care for a young child on his deathbed. The closest Barb and I came was before Kate’s surgery. The anesthesiologist wasn’t sure Kate would survive the anesthesia. So while she was in surgery we prayed and prayed, not knowing if we’d get her back or not.”
Myrtle looked up at me. “So God answered your prayers.”
I nodded. “He did.”
“You must have great faith. Pastor Shook says that if we have enough faith and pray with enough persistence, the Lord will answer our prayers. He told us God wants Danny to be healed, and that if we ask him to heal Danny, he will.”
Myrtle took a sip of coffee and then continued. “He says all we gotta do is ask him in God’s holy name and with belief and with persistence. He says that if we just say the word — if we just declare it and profess it — and claim God’s great promise to heal Danny’s stripes, he’ll do it.”
I took a sip of coffee, trying to formulate a response. I was not a pastor, and I had no theological education, but what she was being taught just didn’t line up with the Bible I read every morning. I sensed a soft, quiet voice encouraging me to share a thought.
“Myrtle, the God I know is a God who loves us more than we could ever imagine. He’s a just and sovereign God, and, most of all, he’s good. But I know for a fact that he doesn’t answer our every prayer with a yes. Sometimes he says no, and sometimes he says wait.”
“Doc, our pastor says Danny’s cancer came from the sickness of sin. And he says me and my husband gotta confess our sins. He says the only thing keepin’ God from healin’ Danny is either our failure to admit and confess all of our sins or our lack of faith to claim God’s healin’ for Danny.”
Bryson City Secrets: Even More Tales of a Small-Town Doctor in the Smoky Mountains Page 19