Bryson City Tales

by Walt Larimore, MD

  They nodded again.

  “I’ll have Mrs. Wilson get you to sign the permission forms, and then if you’ll wait in the waiting room, I’ll come get you as soon as we’re done.”

  With tears streaking down their cheeks, they turned to leave. Immediately I empathized with them. I remembered Barb and I shedding tears when we handed six-month-old Kate over to the neurologist for her CT scan—the scan that would confirm a diagnosis of cerebral palsy. I remember how alone and frightened we felt as we waited in the waiting room. If we had only known then what we know now about the power and peace that prayer can bring!

  “Folks,” I called after them, “before you leave, would you mind if I prayed for your daughter?” I had no idea how they’d respond. I didn’t even know if they believed in prayer, but I knew I did—and I knew that their child needed it, as did I. They looked at each other with wonder. Then the dad spoke. “We’d appreciate that, Doctor.”

  I walked to the girl’s bedside, and her parents stood across the bed from me. I bowed my head. “Dear Lord. Little Amber is so sick. I pray that you might guide my hands as I work. Grant me wisdom as I choose her therapy. Cause her to respond well. I pray that you’d give her mom and dad peace and that you’d bring their daughter home safely to them. Amen.”

  I looked up. The mother was softly crying, the dad looked devastated. Maxine was standing by the door, and, to my shock, Dr. Bacon was standing next to her. As the parents turned to leave, the mother began to sob. Her husband gently placed his arm around her shoulders and walked her down the hall.

  Harold Bacon, looking rather stern, stepped into the room. He took one look at the child, and his face visibly changed. “Walt, what’s going on?” he asked.

  “Dr. Bacon, Max called me to see this young lady when she couldn’t reach you. I think she’s septic, and she’s obviously severely dehydrated. The cleisis that Dr. Mathieson began isn’t working and she needs IV antibiotics. I had the parents sign for a cutdown and a spinal tap. I’d be glad to have you take over if you’d prefer. I know you’re covering for Dr. Mathieson.”

  “Son, this girl looks bad sick. Bad. I think we’ll be losing her if’n we don’t act mighty fast. I’ve told Mathieson to stop doing that blasted cleisis.”

  I stood there, not sure what he was telling me to do. A moment later, he did.

  “Go ahead, son. If you don’t mind, I’ll assist you.”

  I nodded gratefully. “Max, let’s get her bladder catheterized, and get me an ABG kit, stat—with extra syringes. I’ll need blood culture vials also.” I pulled up Amber’s gown and located the very weak pulse of her left femoral artery. Maxine returned with the kit. I unsheathed the needle and plunged it into the girl’s groin. She didn’t move. When the needle pierced the femoral artery, the blood began to fill the syringe—but much slower than normal. “Her blood pressure must be low,” I commented more to myself than anyone else.

  “Not very red, is it?” observed Dr. Bacon. “Max, let’s get O2 started. Forty percent, humidified, via ventimask.”

  “Yes, sir. I’ll call the RT.”

  I withdrew the syringe. I had drawn extra blood that I now inserted into the lab tubes and blood culture broth. The rest would be for the arterial blood gases that would measure her blood oxygen, CO2, and acidity. I handed the tubes to the lab tech who had joined us in the room. “Austin, I need the ABG, CBC, and SMA-7 results stat. OK?”

  “Yes, sir,” he responded, scurrying off to the lab as Maxine placed the oxygen mask on the child’s face and started the O2. Almost immediately Amber’s color improved. “Her respirations are better,” commented Dr. Bacon. “That’s good.”

  Amen! I thought. I pulled her legs apart and inserted a catheter into her bladder. Only a small amount of dark, concentrated urine appeared. “Max, blow up the catheter balloon and then let’s roll her over for the spinal.”

  Maxine expertly secured the urinary catheter and then rolled the child on her side, folding her into a fetal position. Dr. Bacon was opening the spinal kit atop a bedside tray. I found the anatomic marks that guided me to the L4-L5 interspace and marked it with my fingernail—making a small indention in the skin. Once again, Amber offered no resistance. I gloved and then prepped and draped her lower back. I raised a bleb of lidocaine just under the skin where I had made the indentation. The spinal needle passed easily into the spinal canal and the clear fluid began to drip out of the end.

  “Harold, I’m not going to take the time to measure opening and closing pressure. The way this is dripping so slowly, I don’t suspect high pressure and I don’t think we have the time to wait.”

  “I agree, son,” he nodded. “It does look pretty clear.”

  “Yeah,” I agreed. “I’m sure glad it’s not milky or cloudy”— either of which could have indicated a severe case of meningitis. I let about a teaspoon of the fluid drip into each of three sterile plastic collection tubes, then removed the needle and placed a Band-Aid over the puncture wound.

  Dr. Bacon actually smiled at me. “You’re doing good, son. Two down and one to go.” I appreciated his encouragement and affirmation, but the fact was that we were still in pretty deep weeds, and the hardest procedure was yet to come.

  I turned my attention to the little girl’s ankle. I was thankful for my training at Duke, which gave me the education and experience I needed for these critical cases. I palpated her ankle’s anatomic landmarks and made a mark on the skin above the vein I prayed would be underneath. I prepped and draped the ankle—and then regloved with a new pair of sterile gloves. I anesthetized the skin with lidocaine and then quickly made a two- to three-centimeter incision through the skin. A curved, blunt mosquito clamp allowed me to dissect the subcutaneous tissue. Then, right where it should be, appeared the large vein I was looking for.

  “Hallelujah!” exclaimed Dr. Bacon, obviously as relieved as I was.

  I exhaled a sigh of relief and felt a tremendous pressure ease off my shoulders. Thank you, Lord! The vein was flat, indicating not much blood flow, but was large enough to receive a catheter that would begin the flow of lifesaving medicine and fluids into Amber’s body. I tied the catheter in place and started to close the wound. By now, Dr. Bacon had gloved and assisted me by snipping the sutures as I tied them off.

  “I really should be assisting you, Harold.”

  “Nope, Walt,” he reassured me. “This is just fine. Just fine.”

  As Maxine dressed the wound, we looked at the lab results. They were terrible. The white count was low, indicating severe sepsis as her system was running out of infection-fighting warriors. The electrolytes were grossly abnormal. I quickly calculated her fluid needs and wrote orders for frequent vital signs, fluid and electrolyte resuscitation, and large doses of three different IV antibiotics.

  As I was starting to jot a brief note in the progress notes, Austin brought us the initial spinal tap results. Dr. Bacon looked them over. “No red cells, no white cells, no bacteria, normal glucose and protein.”

  “Good,” I sighed. “No sign of meningitis.”

  I turned to Dr. Bacon. “Harold, since you’re covering for Dr. Mathieson and since you know these folks, how ’bout you give them the good news. OK?”

  He smiled and looked down at his feet.

  “I’ve got to finish the notes and then dictate. Don’t let me keep you.”

  He nodded and then proceeded toward the waiting room. I was finishing my dictation when Maxine stuck her head around the corner. “Thank you,” she whispered. “Good job!” She was beaming like a proud mother.

  I nodded. She had been a nurse for several decades. She had seen just about everything. Her compliments were given rarely and were sweet indeed for any young physician.

  One week later, little Amber skipped from the hospital lobby to her dad’s waiting car. Other than a sore thigh, which was still swollen, she was fine. We never knew the source of the sepsis, but many times we don’t. I was just delighted that she had done so well.

  Two weeks la
ter, Rick and I sat before the medical staff as they heard our case. After testifying, we were dismissed from the meeting. We walked back across the street to my house. Barb, Rick, and I waited. We were, of course, concerned—but at the same time we had a sense of peace. We knew that we were practicing good medicine. To us this whole mess felt like a witch-hunt instigated by men seeking to protect their practice and their ways—both of which they wrongly assumed were threatened by our being there. I wondered to myself, Would I, in the same circumstances, respond the same way? I hoped not!

  We found out later that several others were also called into the room as witnesses. The parents of the slapped child testified for over a half hour. Several of the nurses who did the home bilirubin therapy were called in for brief questioning.

  After a couple of hours, we heard a knock on the screen door. It was Ray. We stood as he entered the dining room.

  “Have a seat,” he gestured. We all sat down.

  He sighed. “Well, good news, folks. Bacon voted with us.”

  There was a collective sigh of relief in the room. He continued, “Two of the doctors voted against you. But the decision of the majority of the medical staff is that you all’s actions were justified. There will be no disciplinary action of any kind. Nothing to blacken your record. Furthermore, there will be no report or complaint made to the state.”

  He was quiet for a moment, then continued. “When Bacon voted for you guys, Nordling grew pretty quiet. You know, he’s been renting office space from Bacon. Wouldn’t surprise me to see him leaving that situation. Mathieson blew up and just stormed out of the meeting.”

  He drew in a deep breath and then slowly let it out. “Walt, let me encourage you to try to avoid slapping patients in the future. OK?”

  I smiled and nodded.

  “Rick, if you want to do home therapy in the future, I’ll need you to coordinate that with me. OK?”

  Rick nodded.

  “This event has shaken up the medical community a bit. But I think the shaking was needed.” He looked at us. “Are you all going to be OK?”

  “I think so, Ray. Are you?” asked Rick.

  Ray nodded. “Gotta tell you two, you’re two of the best things that have happened here—especially for me. If you left, I wouldn’t be far behind. I’m glad you’re here.”

  The next week, Dr. Nordling’s office was empty. I never saw him again and was told that he had left town. Dr. Mathieson stayed in town, but also stayed away from us. For months he wouldn’t speak to me—and he’d speak to Ray only if he needed surgical backup and Mitch wasn’t available. He wouldn’t acknowledge Rick or me at medical staff meetings and would often turn and go the other way when he saw us in the hall.

  Later that spring I was walking down the hospital corridor. Ken Mathieson was walking toward me. He smiled and kept coming toward me. I froze as he walked up. “Walt, I saw Amber today in the office. She’s doing great. Her parents mentioned to me what you did for her that night. For some reason I’d always thought Dr. Bacon had saved her life. I didn’t know it was actually you.

  “Anyway, Mrs. Mathieson, who’s my office nurse, recommended that I properly thank you. So . . . ,” he paused and tried to swallow, gulping in the process as he glanced away from me, looking very uncomfortable. “So . . . thank you.” Then suddenly he turned on his heels and continued to walk down the hall. In stunned disbelief I watched him go. And then, I couldn’t believe what I was hearing. He was whistling!

  From that day on Dr. Mathieson treated Rick and me as colleagues. I have no idea what turned him around. Was it Mrs. Mathieson? Was it the fact that we started using lots of injectable penicillin? Was it something Amber’s mom and dad said about a prayer from a scared-to-death physician over a nearly dead little girl? I don’t know. But it was nice to have peace—at least for the time being—among our Bryson City medical staff members.

  chapter thirty-one

  THE INITIATION

  It just so happened that I was alone in the office that Thursday in July. Ray was shopping in Asheville with Nancy, Rick was on vacation, and Mitch was at his farm. I was covering a very busy afternoon. Helen was pulling patients back into the exam rooms as fast as she could, and I was seeing the folks as quickly as good manners and good medicine would allow.

  Because of our schedule, I wasn’t able to have Helen prep me for each case before I walked into each room—we were shakin’ and bakin’! So, you can imagine my surprise when I walked into the procedure room to find Mitch’s son-in-law, Cam, sitting alongside the exam table where a beagle was lying on a blood-soaked towel and breathing shallowly. Adog!

  “Doc,” Cam explained, “we tried to find Mitch, but we couldn’t. So we did the next best thang. We brung her up here to you.”

  My guess is this was a compliment, but I wasn’t real sure. “What happened?”

  “We were a huntin’ after some boar, and Queenie here got gored real bad. I need you to stitch her up if’n you would.”

  I stepped forward and took a look at the wound. It ran along the base of the dog’s ribs for about ten inches. It had a thick clot of blood overlying the wound. Helen had already set out a suture tray and a syringe of lidocaine anesthetic. “Cam, can you steady her head for me while I work?”

  “Be obliged.”

  I scrubbed the wound edges with Betadine and then draped the abdomen with sterile drapes. I numbed the wound edges with lidocaine. When I began to scrub the wound, Queenie stayed still. I assumed she either had a very high pain threshold or was adequately numbed. The wound penetrated the abdominal muscles but fortunately not the lining of the abdominal wall—the peritoneum. I’d be able to close this up.

  Helen entered the room, “Sorry to keep you waiting, Dr. Larimore. What suture do you want?”

  “Helen, how about a 3–0 chromic for the fascia and sub-q and a 2–0 nylon for the skin?”

  “Nylon for the skin?” Helen asked. Oh, how I wish I had inquired as to why she was questioning my decision, but unfortunately I did not.

  “Yep, nylon will do just fine.”

  I closed the layers quickly and then carefully closed the skin—ever aware that my boss would see my handiwork. After the wound was dressed and an antibiotic shot administered, Queenie seemed to perk up a bit.

  “She should be as good as new. You can take the dressing off tomorrow and have Mitch take the stitches out in ten to twelve days. If there’s any infection or swelling, please let us know.”

  “Thanks, Doc,” replied Cam, as he picked up Queenie to leave.

  Friday afternoon I was standing and writing a note when Mitch walked up to me. He stopped and looked up at me. “You stupid?” he asked.

  That question still surprised me, even after nearly a year of practice with him. Fortunately, I was hearing it less often. Nevertheless it was still a shock to hear such an abrupt interpretation of my deficiencies. So my stunned response was the same as usual. “What?” I replied.

  “You stupid?” he repeated.

  My mouth, per usual, dropped half-open. Then I smiled to myself. “Well, given my registering Independent in this town, I guess you could officially call me stupid.”

  He looked astonished. “Follow me,” he instructed.

  He led the way to the procedure room, and I followed like a heeling puppy. Inside the room I experienced a sudden déjà vu.

  There on the procedure table was Queenie, her side looking like it did twenty-four hours ago—before I sutured the wound. It was opened up and covered with a huge clot.

  Mitch lectured, “When Helen asked you if you were sure you wanted nylon suture, you shoulda thought twice. Who in the world would sew an animal with nylon—especially a wound within reach of her teeth? If the wound is on top of her head, then nylon’s an option. But her abdomen . . .”

  He paused, but the silent completion to the phrase rang across the room, You stupid?

  “Son, you have to use steel suture in an animal like this.”

  Steel suture?” I was incredul
ous. I had never heard of or “seen such a thing.

  “Yep, we keep it in the office for cases just like this. Well, let’s get started. Before I die, I want to get you educated a bit. You may have graduated from Duke, but you’ve still got a lot to learn.”

  So I assisted my mentor—the master, the surgical sculptor, the medical maestro—as he worked. I had to admit that, even after nearly a year in his office, he was still a joy to watch. And, quite frankly, next to him I often did feel, if not stupid—well, a bit inept at least. But as I watched and then began to learn how to throw stitches with the easily bent and knotted steel suture, I smiled. I knew that once again I was learning—and learning a lot. I think I knew that I was at least somewhat less stupid than the year before, and hopefully I would be even less stupid the next year. At least that was my goal.

  Delivering a calf locked in breech and sewing up a boar-gored beagle would be unusual events in the life of any first-year doctor. But for me, these events did shed light for me on the value of these animals. I was also coming to appreciate the value of hunting and fishing to the people of this area—the bond between these men and nature. Entering into this bond with new friends opened doors for meaningful connections with them that would otherwise have been impossible.

  I had some of my most meaningful experiences while fishing. I was coming to especially value my fishing buddies and experiences, which took me far away from the pressures of medicine and were, in their own way, healing and refreshing. One such experience occurred on my first fishing trip with Greg Shuler, the Christmas tree farmer.

  Greg came to pick me up at 5:00 A.M. in his old ramshackle truck.We were headed to Graham County to look for a very special fish—the steelhead trout. We stopped in Robbinsville at a café already packed with men—hunters and fishermen—drinking strong black coffee and smoking. Greg was not a man of many words, but I liked him. As we ate scrambled eggs with country-smoked bacon and ham surrounded by grits and biscuits smothered in butter, he shared a bit of his family’s history. His great-grandfather had come into the county on a wagon and set up a farm west of the small settlement of Almond. His grandfather and father had been born on that farm. His voice slowed measurably as he told of the government coming in and taking over the farm. They clear-cut the land around the barn and home place, as the men took those buildings apart, board by board. The lumber and all of their belongings were loaded onto a flatcar and hauled over to Bryson to be reassembled on what would become the new home site—the place where we had purchased our Christmas tree. Then the valley was flooded to become Lake Fontana.