Bryson City Tales

by Walt Larimore, MD

  I was so grateful for a friend so willing to brag a bit on me. It’s one thing for the DA from another town to sing your praises, but then to have those praises expanded and trumped by a well-respected native—well, could it get any better that that?

  So for the next twenty minutes I was in my element. I was prepared for all the questions and performed for the jury my role as professor. Photographs and charts, records and certifications were all expertly identified and explained. I could almost feel the jury in the palm of my hand. I was imagining that most of these folks and virtually the entire gallery would be leaving the courtroom to call the office for new patient appointments that afternoon—or, at the very latest, tomorrow morning. I was imagining the need to call the phone company at the first morning break of the trial just to have them install another phone line or two. I was even wondering if people might not travel from other towns just to see such an expert as myself.

  Then it was over—or so I thought. Mr. Buchanan, smiling at me, the jury, and then the judge, proclaimed, “No more questions, Your Honor.”

  The judge looked at Fred, who was still studying his mountain of papers. Mr. Moody didn’t move.

  “Mr. Moody!” exclaimed the judge. Fred looked up a bit. He seemed to be perplexed. Almost surprised.

  “Do you have any cross-examination, Mr. Moody?” queried the judge. Once again Fred raised himself up, shaking down his rather baggy pants. He picked up a folder of papers as he approached the witness-box. I saw a twinkle in his eye as our eyes momentarily locked. He placed the folder on the railing in front of the jury, reading something and slowly shaking his head from side to side.

  “Ladies and gentlemen of the jury,” he announced, “I must tell you that in all my years as an attorney and in all my years of law school and as a law clerk, I don’t think I’ve ever seen a more brilliant display of medical expertise and knowledge.” Now I really couldn’t believe what I was hearing. The DA already had me both looking and feeling pretty good. Now my friend Fred was putting some extremely sweet icing on the cake. I could begin to imagine the news headlines: “World-famous medical expert provides stellar testimony in Bryson City courtroom.”

  He went on. “Not only will I never be able to object to his qualifications as a medical expert in this court, I hope to never have to oppose his outstanding expertise or testimony ever again. To do so might well end my career.” He smiled at the jury and then at me as he turned to the gallery. Now my suspicious juices began to boil. Something suddenly seemed wrong. Really wrong.

  “Ladies and gentlemen of the jury, for an attorney to venture even one question after such complete and compelling testimony might seem both pretentious and egotistic. Nevertheless, I feel compelled, even at the risk of ridicule or embarrassment, to ask Dr. Larimore one small question—if you will allow me.” Now not only were my suspicions up, but so were the hairs on the back of my neck. I was beginning to feel nauseated.

  Mr. Moody slowly turned toward me. The twinkle was still in his eye, but now it looked more like the eye of a tiger. “Dr. Larimore, would you be so kind as to tell the jury just how many medical examiner’s cases you’ve performed in your long, illustrious, celebrated, acclaimed, and fabled career?”

  I thought I heard the audible hiss of air escaping from my rapidly deflating ego as I felt the blood rushing from my head to my feet. As Mr. Moody, head down, reading his sheaf of papers, slowly walked back to the defense table, I replied, “This is my first case.”

  He jerked to a stop, and his folder dropped to the floor, slapping the hardwood with a sound that caused those eyes not yet glued to him to so glue. A bunch of loose papers—all amazingly white, with no writing or typing or drawing or marking of any kind on them—flew in all directions around his feet. The eyes of the young attorneys and the spectators were wide with trepidation. Gasps echoed throughout the room.

  As the gasps and the papers quietly settled down, Fred slowly turned toward me with the most amazing look of shock I had ever seen. Even to this day I still don’t know how he did it, but his face was white and his hands were trembling. He knew this was my first case. Yet no one in sight, except me, knew that he knew. He pulled a handkerchief out of his pocket, wiping his forehead as he approached the jury.

  “Ladies and gentlemen, I must offer you my most sincere apology. As you know, my client’s life is on the line. Yet, even so, I have made one of the most grievous mistakes of my career. I have, without objection, allowed our esteemed district attorney to qualify to you, as a supposed expert, an extremely young man with no experience as a coroner or a medical examiner. He has, it appears, never, ever, been part of a coroner’s case. He, it appears, has never, ever, investigated a petty crime—much less a capital crime.”

  The DA was quiet. Where was the objection? My reputation was going down like the Hindenburg. I needed help—and fast!

  “So, ladies and gentlemen, please forgive my certification of this man as an expert. I can’t take that back now. But now we all know the truth. He’s never done this before! And this is a mistake I will never make again. But, ladies and gentlemen, please, I implore you, don’t hold my inexperience and poor judgment against the man I represent.”

  By now I was resigned to my fate. A shrewd country lawyer—experienced in the substance of law and the art of the theater, had trumped both my inexperience and the DA’s bravado. “I have no further questions, Your Honor.”

  My admiration for my friend soared as he walked back to his chair. I had observed an Oscar-level performance—the demonstration of a remarkable skill. Here was a simple man, pulling out every trick he could in order to do the best job he could for his client. He would continue applying his various and copious skills for the rest of the week—and I dropped by on several occasions to sit in the back of the courtroom and observe his expertise. He would be paid very little for his work—apart from the immense admiration of the young attorneys and one young physician, who were blessed to have seen both his amazing performance and his consummate skill.

  Fred’s legacy lives on in those he taught—by word and deed—that success in life is not defined as just being excellent at what you do, but as doing the excellent in an excellent way, even when there is no obvious reward for doing so. Fred taught me early in my career that the difference between extraordinary and ordinary is the “extra.” And I was able, in the end, to get beyond the fact that this important lesson was learned at my expense!

  I was new to this small town. But the town and its ways were certainly not new. I had so much yet to learn.

  chapter twelve

  SHITAKE SAM

  Sam was one of the entrepreneurs in town. Oh, he would never use such a term. But when it came to trying new ideas, he was the man. His dad had farmed the end of a small hollow near Bryson City—mostly corn and burley leaf tobacco. In those days the tobacco brought in more money, but the corn was useful as a supplement crop and to feed the livestock during the cold, gray winters. However, the crops could only be grown on the valley floor and the more gentle slopes, which left a fair amount of steep forestland.

  Now, the forest could be logged every few years, but that didn’t provide for the year-to-year needs of the farm or the family. With tobacco prices dropping, and with an upsurge of out-of-towners demanding more exotic menus in the local inns and in the finer restaurants in Asheville, Sam took a hankering to learning how to grow mushrooms.

  He had talked first to Mr. Lyday, the county agriculture agent, who didn’t have a clue about mushrooms or how to grow them, or even if they could be grown in our part of the country. But a call to Raleigh resulted in a small bundle of information. Indeed, a particular brand of mushroom, the Shitake mushroom, loved a hot, humid summer and a cool to cold but damp winter. They did not do well in the direct sunlight, but it was said they would flourish in the relative shade of a forest floor. Furthermore, the ideal growth medium for this particular type of mushroom was a dying oak tree, and our oaks in the Great Smokies seemed to be one of the
oaks they loved the most.

  So Sam learned how to drill a one-inch hole all across the top of the oak logs, pack a plug of sphagnum moss into the hole, and sprinkle the mushroom spores on top. He ordered the spores all the way from Japan, and while waiting for them to arrive he rigged up a sprinkler system using the crystal-clear, ice-cold water flowing from one of the several small branches (or creeks) on the property.

  It wasn’t too many years before Sam’s entire forested cove was covered with logs growing the newest cash crop of that century. Others in Swain County had smaller patches of Shitake, and before too long, trucks from Knoxville, Asheville, Waynesville, and even Sylva were dropping by Bryson City once a week to pick up the luscious, fresh Shitakes. Why, Sam even gave a talk at Rotary Club about his Shitakes—and that’s where we first met.

  Our second meeting was in the emergency room. I was there, sewing up a minor hand laceration, when the call came over the radio.

  “Louise, this is Rescue One.”

  Now since there was no Rescue Two, I was frequently amused by this type of call. I guess the Swain County Rescue Squad was just planning for the inevitable future growth.

  “Go ahead, Rescue One,” Louise responded.

  I threw and tied the last stitch, which was admired by its new owner, and then began dressing the wound while Louise learned about our next guest.

  “Louise, this is Don. I’ve got Shitake Sam with me.”

  I hadn’t heard this nickname before but knew immediately to whom the paramedic was referring.

  “He’s busted up his ankle pretty bad. We’ve put an air splint on it. His vitals are OK. But he’s already taken a fair amount of anesthesia.”

  His anesthesia, I suspected, was crystal clear, drunk from a Mason jar, and nearly 150 proof. I suspected we’d smell Sam well before we saw him.

  “Ten-four, Rescue One. What’s your twenty?”

  “We’ll be there in ten, Louie.”

  “Louie” was their nickname for Louise. I could call her Louise but never Louie—at least not yet. Only a few of the locals could call her Louie and get away with it.

  “Doc!” Louise exclaimed. “What you doing making a dressing here? Don’t you know that’s my job?!”

  She continued to fuss as she completely redressed my patient’s wound. I thought I’d done a pretty good job, but I was continuing to learn my proper place in the scheme of things. And dressing wounds was not the doctor’s place.

  While Louise wrapped and fussed, I finished my paperwork and wrote a proper prescription for a pain reliever and an antibiotic. At Duke I would have seen my patient back in twelve to fourteen days to remove the stitches. However, here he’d see Louise for the suture remove. I’d learned that this was just the way it was in Bryson City.

  I heard the beeping of the ambulance as it backed up to the emergency room entrance, and in a few moments Don and Billy walked in with Sam and his stretcher in tow.

  After quickly transferring Sam onto the emergency room gurney, Don turned to me. “You may not remember me, Doc. Don Grissom. Billy and I met you up at Clem’s place,” and he quickly thrust out his hand to grasp mine. His hand was rough, calloused, huge, and strong. It enveloped mine, yet almost gently gave it one pump.

  “Sure, I remember you,” I said. “Good to see you.” I remembered that night only too well.

  The smell of Sam’s alcohol-induced “anesthesia” and the deep snores indicating its effectiveness inundated the emergency room.

  “Doc, his pulses and sensation in his feet are fine,” Louise reported. “I’m gonna take him on over to Carroll in X ray.”

  In most ERs the doctor does a history and an exam. But the scheme of things here was that those were part of the nurse’s duties. The doctors in town—in order to preserve their sanity and to try to spend some time at home when on call—leaned quite heavily, as they did in those days in many small rural ERs, on the eyes, the ears, the skills, and the experience of the ER nurse. In a few minutes, Sam, his snores and smell, and his X rays were back.

  “A trimalleolar fracture,” Louise announced confidently. “I’ll get him ready to cast.”

  Before I could catch myself, I blurted out, “Cast? Are you crazy?”

  Sam and his gurney ground to an immediate halt.

  Louise, looking half-incredulous and half-incensed, cocked her head and said, “Dr. Larimore, I am not crazy, and I’d suggest that you never speak to me in that tone again.”

  I could feel the blood rising in my face. “I’m sorry, Louise,” I apologized. “But at Duke . . .” She didn’t even let me finish my statement. I was going to tell her about the studies showing how well these fractures do with an operative technique called ORIF (Open Reduction and Internal Fixation), which means that we surgically open the fracture site, wash out the blood, and then use wires or screws or other hardware to hold the bones together while they heal. I wanted to tell her how I was experienced in assisting the orthopedic surgeons in doing this operation and how quickly we could expect Shitake Sam to be back on his feet. In fact, with the newfangled fiberglass cast, he could even be tending his mushrooms soon. But I wasn’t able to finish my lecture.

  “Young man,” she almost snarled, “you’re not at Duke, you’re in my ER. I’d recommend you not forget it!”

  I stood aside, chastised and befuddled. I’d been around a lot of strong-willed ER nurses, but never one like Louise.

  “I’ll shave his leg, prep for a hematoma block, and get the plaster ready.”

  Now she was talking heresy—at least to a Duke-trained physician. Hematoma blocks were injections of an anesthetic agent, such as lidocaine, through the skin and into the fracture itself. They were used before a closed reduction and casting—not before an ORIF, which would have been, in my opinion, the correct treatment. Sam could be kept comfortable until he sobered up and then taken to the operating room for the recommended and modern ORIF. I was befuddled at her brashness.

  She went on, seemingly not noticing my deepening befuddlement.

  “After you get him numb, I’ll help you with the skintight cast.”

  Now I was at the absolute height of bewilderment. “Skintight cast?” I stammered.

  She stopped, straightened up to her full five-foot four-inch frame, and stared straight up into my eyes, now on a slumping six-foot two-inch frame. “Doctor, you do know how to put on a skintight cast, don’t you?”

  How was I to say no? I had never even heard of such a thing. And what’s more, all of my training in casting, most of it from the fabulous cast technicians at Womack Army Hospital in Fort Bragg, North Carolina, had emphasized the use of proper padding to prevent the cast from pressing against the skin—which could cause sores or ulcers.

  My bafflement must now have been unmistakable. “Dr. Mitchell is your backup,” she muttered as she turned to roll Sam and his gurney into the ER bay and I turned to the phone. Surely Mitch could help me make some sense of this.

  “Hello,” the obviously sleepy voice rasped.

  “Mitch, this is Walt. I’ve got Shitake Sam here in the ER. He’s got a displaced, closed, trimalleolar fracture of the ankle with normal vascular and neural function, but he’s pretty loaded up with moonshine. I was thinking of putting him in a splint and then to bed. Can I put him on the OR schedule for you in the morning for an ORIF?”

  “Does he have any abrasions or lacerations?”

  “No,” I responded slowly. “If he had, I wouldn’t have wanted to put him on the schedule.” In cases where there are cuts or scrapes we’ll try to put off surgery if we can, to reduce the risk of infection when we finally do operate.

  “Well, son, why not go ahead and place him in a skintight cast? Then admit him to keep the leg elevated and have the nurses check his foot circulation and sensation every fifteen to twenty minutes, and we can discharge him as soon as he’s sober and feeling well enough.”

  I couldn’t believe my ears. I would later learn that this early twentieth-century technique had been almost co
mpletely replaced by surgical procedures—at least outside of this county. I must have been stone-silent or muttering to myself. Either way, Mitch picked up on my response.

  “Son,” he slowly queried, “you do know how to do a skintight cast, don’t you?”

  “Well, sir, I’ve got to tell you, we always operated on these types of fractures.”

  “Son, this ain’t Duke.”

  This was something I was quickly coming to recognize! Dr. Mitchell continued. “I bet I’ve been using this skintight cast technique for nearly twenty-five years. A whole lot longer than most of your professors have practiced.”

  Well, in fact, that wasn’t true. A number of my professors at Duke had been practicing their craft for nearly four decades, but bringing that up at this particular moment didn’t seem appropriate.

  “Now let me tell you,” Dr. Mitchell barked, “no one, and I mean no one, likes to operate more than me. I love being in the OR, just love it! But for this type of fracture, I think this approach works just fine. What’s more, I’ve only ever had to remove one cast because of swelling. It just plain works. That’s just the way it is.”

  Again I remained silent. “Walt, you’ve got lots of book knowledge—great training, great education—but I’m here to tell you, the folks in the ivory tower of academics don’t have a monopoly on medical knowledge. There’s still lots of good old-fashioned medicine that works just fine. And it can be a whole lot cheaper to boot!

  “Tell you what, son. Get Louise to show you how to do it. If you have any problems, give me a call.” Before I could respond, he hung up.

  I followed the fumes into Sam’s ER bay. Louise had shaved his now splintless leg from the ankle to the thigh.

  “Louise, I don’t think he’s gonna need a hematoma block. Would you mind helping me with the cast?”

  She smiled. I think it was the first smile I ever saw from Louise. It wouldn’t be the last.

  “Why, I’d be delighted to teach you what little I know, Doctor.”

  The humility seemed both false and a tad bit out-of-place. But for the next twenty minutes this experienced nurse guided a novice in the task of very carefully wrapping and shaping his first skintight cast. We rolled Sam down to the four-bed intensive care unit, and I watched as the nurses deftly slung his casted leg from an orthopedic bed frame. His foot was practically pointing toward the ceiling. I left Sam, his snores, and his skintight cast in the capable care of the floor nurses. They assured me that they were used to caring for this type of thing. I was just hoping his foot wouldn’t fall off, should his ankle swell and the foot lose circulation. I could hear Gary Ayers on the morning news: “Last night, the town’s newest physician . . .”