Bryson City Secrets: Even More Tales of a Small-Town Doctor in the Smoky Mountains

by Walt Larimore, MD

  Donnie nodded as he stared down at the floor. Then he whispered, “He don’t have a prayer, does he? That’s why yer takin’ ’im to the hospital.” Large tears dropped from his downcast eyes onto the floor.

  I was quiet for a moment, fighting the urge to rush out the door and over to the hospital to go to work on Tommy. But I fought the urge, knowing that the nurses would need a few minutes to get Tommy in a bed and get the procedure set up.

  And then I remembered my own fears before Kate’s surgery on her legs — which had been rendered spastic by her cerebral palsy. I remembered how it felt to be completely out of control and to turn my child’s fate over to the care of others. My own eyes began to get moist as I saw Donnie’s tears falling to the floor.

  “You a churchgoing man?” I asked.

  He shook his head. “Not very often. The pastor fusses at me.” I could see a small smile on his lips.

  “You think prayer makes a difference?”

  He slowly nodded. “I reckon I do, Doc.”

  “Me too. Mind if I say a prayer for your boy?”

  He shook his head as I slipped my arm over his shoulder.

  “Dear Lord, Donnie and I pause here to turn to you. We know Tommy’s mighty sick. And we’re both scared. Lord, I ask you to give me and the medical team wisdom. I ask that you guide my hands as I place the chest tube. I pray that the medications will work fast and well. I pray, Lord, that you’ll use the doctors and nurses, the medicines and technology, the family and friends, to guide Tommy safely back home to his mom and dad and brothers and sisters. I ask this in Jesus’ name.”

  I squeezed his shoulder as he began to weep softly, and I stood and quickly walked out of the room. I knew every minute counted.

  chapter ten

  TERROR

  Terror is part and parcel of the practice of medicine. No matter how many years of experience or how many seasons a doctor may experience, the throat-gripping horror of the prospect of losing a patient — especially a child — is inescapable.

  That morning, terror was part of what the team at the hospital experienced when Don and Billy rushed our young patient into ICU. Tommy was critically — perhaps fatally — ill, and they knew it. Vernel and Maxine, the nurses who met Tommy as he was rushed into the hospital, knew the Grim Reaper was following close behind, and they immediately leaped into action to keep “old man death” at bay — at least for today.

  Betty Carlson, the head of the pathology lab, began collecting the specimens and cultures she knew I was going to order. Radiologist Carroll Stevenson took the supine X-rays he figured I’d ask him to take. The respiratory therapist, Randy Simms, drew blood gasses, adjusted the oxygen equipment, and applied the respiratory monitoring equipment, while Nancy Cunningham tried to comfort Tommy and explain to him all that was happening to him so quickly.

  By the time I arrived, most of the commotion was settling down. When Tommy’s dad arrived, he had been sent to the admissions office to fill out paperwork. In the meantime, the hospital had sent word to Isabella, Tommy’s mom, and she was on her way to the hospital. I found Tommy alone, and he looked scared.

  I sat on the edge of the bed and took his hand in mine. I squeezed, and he squeezed back. I smiled down at him. “It’s scary in here, isn’t it, buddy?”

  He nodded.

  “Let me tell you a quick story,” I began. “About seven years ago, I had to have some surgery on my lung. You have pus around your lung, but I had air. It really hurt. I bet your chest hurts, doesn’t it?”

  “Only when I breathe,” Tommy responded. When we realized what he said, we both smiled. His smile was wiped away by a painful, chest-punishing spell of coughing. When it had subsided, I continued.

  “Well, the doctor had to put a chest tube in me. And, Tommy, I’ve got to tell you something. Looking at that tube and the big ole container it was connected to ’bout scared me to death.” As I said this, I pointed to the equipment that Vernel and Maxine had set up next to his bed.

  “But you wanna know something?”

  “What?”

  “Other than the small shot they gave me to numb the skin, I didn’t feel any pain at all. And I’ve got a trick that will keep you from feeling even that.”

  Tommy smiled, and then I explained, step-by-step, what I’d be doing. I could see his curiosity grow and his concern subside a bit. “Can I watch, Doc?” he asked.

  It was my turn to smile. “Well, it will be hard to see most of it, because I’ll be working on your side just under your arm, but you watch all you want to.”

  “Cool!” was his considered response.

  I softly pinched Tommy’s skin just before sticking the needle on the syringe of lidocaine through the skin. As was usually the case when I used this technique — one Louise had taught me in the ER — the patient didn’t feel a thing.

  “Man!” Tommy commented. “I was watchin’ you, and I still didn’t feel nuthin’!”

  I smiled and then slowly advanced the needle, infiltrating the tissues with lidocaine as the needle advanced until I felt the softest of resistance give way — telling me I was through the chest wall and into the chest cavity. I injected another few cc’s of lidocaine and then aspirated a sick-looking, thick, yellow-green pus. I knew it was coming from the space around the lung, and it confirmed my diagnosis.

  “Man!” Tommy exclaimed. “That’s gross.”

  Vernel and Maxine joined me in laughter as I removed the needle and handed the syringe to Betty, who immediately injected the pus into a culture bottle. In forty-eight hours or less, we hoped to know both the name of the bacteria causing the problem and the best antibiotics to treat it.

  “Yep,” I concurred with my young patient, “that is gross. But, my young friend, as they say, you ain’t seen nuthin’ yet.”

  His eyes became as big as saucers.

  After prepping his side with the dark-brown Betadine antiseptic and draping the area with sterile drapes, I palpated the ribs, knowing that my incision and the course the tube would subsequently follow needed to go just above a rib — as an important nerve, artery, and vein ran just below each rib.

  A quick, small incision gave me room to insert a trocar, which is a sharpened and tapered rod of stainless steel, through the skin and into the chest cavity. As I advanced the trocar, I looked up at Tommy, who was watching my every move. “Tommy, you’ll feel pressure and poking, but you should feel no pain. OK?”

  He nodded as I slowly twisted and pushed the trocar. As it advanced, it dilated a tract for the tube. I felt the pressure give way as the trocar entered the chest cavity. I quickly removed it and inserted my finger through the wound and into Tommy’s chest cavity. I knew this might be uncomfortable for him, but also knew that what I was doing would only take a few seconds at the most. My finger swept between his lung and the inside of his chest cavity, breaking up the many fibrous connections between the two that could clog the suctioning action of the chest tube. Fortunately, Tommy felt no pain — probably because of the lidocaine I had infused into the space.

  I looked up at Tommy, who was trying to see what I was doing. His eyes were still as big as saucers.

  “Tommy, when I take my finger out, I’m going to slide this long tube into your chest. For a few seconds it may hurt like the dickens. So I’m going to ask you to take a deep breath, grit your teeth, and hold on to Miss Vernel’s hand, OK?”

  His eyes looked frightened, but he nodded in concurrence. Then he looked at Vernel and back at me as he shook his head. “No way!” he exclaimed.

  “No way what?” I asked.

  “No way I’m holdin’ hands with no girl!”

  The laugher that swept the room sliced through the tension like a hot knife through butter.

  “OK, tiger. I’ll count to three, and you hold your breath and grit your teeth — and you hold your own hands, OK?”

  He nodded.

  “One-two-three!” I quickly pulled out my finger and replaced it with the chest tube, which I quickly guided a
round and behind Tommy’s lung. I could see his eyes and pupils dilate with the discomfort I knew he was feeling, but the brave little boy didn’t make a sound.

  “Done!” I exclaimed.

  “Whew!” Tommy responded. “That weren’t easy!”

  I handed the end of the chest tube to Vernel, who immediately connected it to suction. As I began to suture and then tape the tube in place, the thick, greenish-yellow pus literally poured out of the little boy’s chest. He was amazed — as we all were.

  After the initial flow of pus was stemmed, I instilled a dilute solution of lidocaine into his chest cavity and gave it a minute to numb the lung lining. Then I irrigated the chest cavity with warmed saline solution to wash out as much pus as possible.

  As I did this, Tommy watched as Maxine began infusing his vein with the antibiotics that, along with the chest tube and the humble prayers of a weeping dad and mom and a young doctor, would save Tommy’s life.

  It was two weeks before Tommy was well enough to go home, but when he did, he was holding the hands of an eternally grateful mother and father. I knew the joy that was in their hearts. I was thankful for our modern medicines and healing techniques. I was grateful for a well-equipped hospital and its caring and competent staff. But most of all I was gratified to have in my black bag the power of prayer and the guidance of the Great Physician himself.

  That evening, while sitting on the park bench behind my house and thinking back through the rush of the day’s events, I came to the conclusion that terror will likely always be part of the practice of medicine.

  Now, of course, most folks don’t know this fact simply because doctors are taught to never visibly manifest the actual terror they feel inside. But it is unavoidable that terror will raise its ugly head from time to time — and never more predictably than with those cases that have the potential to end in death or some other horrible outcome.

  And terror is what I felt when I first saw Tommy and perceived how close he was to death’s door. Sadly, I knew it would not be the last time I would wrestle with such feelings. Such is the fate of those called into the healing professions. It serves to motivate us and impel us into action. And as we age and mature, it will hopefully become a sensation that is quelled by the Great Physician himself, whose command to those of us called to join him in his ministry of caring and healing is a simple yet profound “Do not be afraid, for I will be with you always.”

  The fear I felt when I saw Tommy and when I inserted the chest tube indicated that I wasn’t very accomplished at the “do not be afraid” thing just yet. But I was hopeful that fending off fear would become a characteristic of my future life — professional and personal. Sitting on the bench that night, I bowed my head to pray just that.

  chapter eleven

  A THREEFOLD CORD

  Later that week, Rick dropped by the house after dinner one evening.

  “Anyone home?” he called.

  “It’s Uncle Rick!” the kids exclaimed as they ran from the living room through the kitchen and into his arms. After hugs all around, Rick and his diminutive minions paraded into the living room.

  “Where’s Barb?” Rick asked.

  “And howdy to you too!” I responded.

  “Hey, Walt,” Rick laughed as he plopped onto the couch. The kids settled back onto the floor where they were playing — toys scattered all about. Whenever I had a day off, it was characteristic of Rick to drop by to fill me in and to consult on the day’s events at the office and hospital.

  “Barb’s down at church. Tina Hicks has her involved in a women’s Bible study.”

  “She like it?”

  “Tina or the Bible study?” I asked.

  Rick laughed.

  “I think she likes both.”

  “What are they studying?”

  “It’s a study on what the Bible says about suffering and pain.”

  “Is it about how to avoid pain and suffering — because if it is, I wanna sign up.”

  I laughed. “I wish!”

  Rick smiled. “What’s she learning?”

  “Actually, Barb says she’s been surprised to learn how much the Bible has to say about how suffering is part of the human condition. She’s been sharing her lessons with me, and we’ve been shocked to learn that followers of Jesus are actually called to suffer. Even though we’ve studied the Bible together for a long time, I’ve gotta tell ya, this was new ground for us.”

  “Where does the Bible talk about Christians and suffering?” Rick asked.

  I put down the paper I was reading and reached over to pick up the Bible sitting by my chair. I flipped through it until I found what I was looking for. “Listen to this: ‘Consider it pure joy, my brothers, whenever you face trials of many kinds, because you know that the testing of your faith develops perseverance. Perseverance must finish its work so that you may be mature and complete, not lacking anything.’ What Barb and I found interesting is that the verse doesn’t say ‘if you face trials’ but ‘whenever you face trials.’ ”

  “That’s some heavy stuff, I’d say!” Rick exclaimed. “Maybe you and I should go through that Bible study.”

  I nodded as I turned the pages to another verse. “Here’s another one: ‘In this you greatly rejoice, though now for a little while you may have had to suffer grief in all kinds of trials. These have come so that your faith — of greater worth than gold, which perishes even though refined by fire — may be proved genuine and may result in praise, glory and honor when Jesus Christ is revealed.’ ”

  “So do you think God causes trials and suffering?”

  “I don’t know the answer to that, Rick. I mean, I know God allows trials. Remember the story of Job, where God let Satan put Job through various trials. And God allowed that. But does God cause suffering? I guess I’ll have to study on that some more — or let Tina and Barb share the answer with us when they learn it.”

  Rick smiled.

  “But I’m convinced of this — God can and will use the trials we go through in such a way that they will eventually turn out for good. To me that’s heavy stuff that’s actually pretty good news.”

  “I think I agree,” Rick commented. “Speaking of heavy stuff that turns out good, I about got my pants scared off this afternoon.”

  “How’s that?”

  “Louise called me to the ER. Brian Kelly had brought in one of his kids.”

  “Brian Kelly the builder?”

  “Yep.”

  “He’s the guy whose wife broke her arm in several places when their family was camping, and you had to set and cast it, right?”

  “One and the same. Turns out Brian came to the ER carrying his little boy. The kid couldn’t even walk.”

  “Trauma?”

  “Nope. Had a cold and a low-grade fever — no big deal — other than he just started getting weaker and weaker. First he couldn’t stand and then he couldn’t even sit up. His pop rushed him to ER. His cranial nerves were fine and his reflexes all intact, but he had almost no muscle strength — and all of his muscles were tender to the touch.”

  My mind was swirling with possibilities. This was a very atypical case, whatever it was. “Guillain-Barré syndrome? Polymyositis?” I asked, thinking of the disorders where viruses can attack and disable the neurological system.

  “At first I thought that. In fact, I did a septic workup and a spinal tap and admitted him to ICU. I started broad-spectrum antibiotics, and then I got some shocking lab results.”

  “White blood cell abnormality? Meningitis?” I guessed.

  “Nope. Not that simple. His CPK was over 10,000!”

  “Whoa!” I exclaimed. The CPK is an enzyme that escapes from muscle or brain tissue when it is damaged. Normal levels are far less than 100. This result represented over a hundredfold increase. “Did you recheck the value?”

  “The lab did. It was accurate.”

  I shook my head in astonishment. A doctor can tell which tissue is damaged by asking the lab to run what are called isoen
zymes. The CPK-BB comes from brain tissue, the CPK-MB comes from heart tissue, and the CPK-MM comes from skeletal muscle tissue. “I hope it wasn’t BB or MB,” I muttered.

  “Nope. That was one piece of good news. It was 100 percent MM.”

  “Rhabdomyolysis,” I commented, thinking of the group of disorders that results in the dissolution of muscle tissue. “I’ve never seen a case in a child.”

  “Me either, Walt.”

  “Any evidence of trauma, poisoning, snakebite, or anything like that?”

  “Nope. Just the sudden onset this morning of fever, chills, dry hacking cough, and runny nose. His mom and sister had the flu last week, which should have given me a clue. But I had no idea what I was dealing with and began to worry I might lose this kid. Walt, I’ve gotta admit — it was terrifying.”

  I nodded, understanding completely what he had been feeling.

  Rick continued. “I immediately began running IV fluids mixed with sodium bicarbonate to prevent all the protein from his muscles from blocking up his kidneys. Then I called Tom Dill, the pediatrician in Sylva, but he wasn’t available. So I talked to an infectious disease specialist in Asheville. And I’ll tell ya this — am I ever glad I did!”

  “What’d he say?”

  “He said they’ve been having a peak in their influenza cases over there, and they had seen a couple of cases that sounded identical to mine. He explained that the most common viral illnesses to cause rhabdomyolysis are influenza A and B. He said they think the virus actually attacks the muscle directly and that the virus also makes some sort of muscle-specific, muscle-melting toxin.”

  “I never knew that.”

  “Me either, partner. But I sure was relieved to hear it. Then he told me there were other viruses, like the Epstein-Barr virus, the herpes viruses, and the chicken pox virus that can also do this.”

  I shook my head. “Wow, that’s amazing! So what’d he say to do? Transfer the kid? Or what?”

  “Nope. He said that as long as the CPK levels drop over the next twelve to thirty-six hours, and as long as the kidneys and electrolytes stay stable, we could watch him here. In the meantime, I need to keep his urine output strong and the urine alkaline.”