“Well,” Clem countered, “you shore did a good job deliverin’ Walter, eh?”
I tried to look like I was irritated, but Clem looked so innocent that it was hard to pull it off.
“OK, Clem. What do you need?”
“Come on with me.” He turned to walk to the barn, and I followed. Over each stall was a name: Daisy, Buttercup, Doris, Walter — and others. We walked up to Doris’s stall, leaned against the wall of the stall, and peered in. Doris was facing the far wall, contentedly eating from her hayrack. At her side a newborn calf was suckling. Both mother and child looked healthy and content.
“So what’s the problem, Clem? Mom and baby look fine.”
Clem opened the gate and entered the stall. He lifted up Doris’s tail, and then I saw it — an umbilical cord hanging out of her introitus. “She’s got the placenta trapped in her uterus, Doc.”
“Clem, you know how to remove a trapped placenta, don’t you?”
Clem smiled and held up his bandaged hand. “Didn’t want to chance gettin’ this hand or her uterus infected. And you and I both know it’s easiest to remove a placenta on the first attempt. So I wanted you to give it a go. Thought it’d be best for all involved.” He looked down at a pail of water on the floor. “Got ya some soap and Betadine water ready.”
I smiled and stripped off my shirt and tie. “Clem, I’m gonna talk to the chamber of commerce about recruiting a vet to town.”
“We’ve done without one for decades. You human docs don’t do too bad a job.”
I entered the stall and scrubbed my hands and then my right arm.
“OK, Clem, hold her tail.” I looked at Doris, who was contentedly chewing. “And Doris, remember that there’s a law somewhere that says you can’t kick the doctor. You hear?” Doris kept chewing. “Remember the word ‘steak,’ Doris!” I threatened.
Clem held up the tail, and I grabbed the umbilical cord with my left hand and pulled it taut. Sliding my right hand up the umbilical cord, using it as a guide, I found the correct horn of the uterus. I knew a cow had two uterine cavities, which are called horns, and that the placenta had to be in one of them. The umbilical cord would lead me to the prize.
I found myself considering what I might find. The simplest problem would be a placenta separated from the uterus and just caught at the cervix. Next in difficulty would be an undetached placenta, which could usually be peeled away rather easily from the lining of the uterus — at least in humans. The worst would be a placenta that had grown into the wall of the uterus. This last option would require a veterinarian surgeon, for sure.
As my arm slid deeper and deeper, my fingers finally felt the edge of the placenta.
“The placenta is still attached, Clem.”
I felt around the edge of the placenta and found an edge that had lifted free of the uterus. Slipping two fingers under the edge, I slowly advanced my fingers as the placenta ever so gently separated from the wall of the uterus. I held my breath, as I did when I performed this same procedure in human moms. The placenta is very fragile and can be easily torn. If a fragment is left behind, it can lead to continued bleeding or, worse yet, postpartum infection and even death.
Slowly but surely the placenta completely separated. I curled my hand behind it and gently pulled it out. Doris let out a contented bellow as I breathed a sigh of relief.
“Where do you want the placenta, Clem?”
“Just drop it on the ground.”
“The ground?”
“Yep. Doris here will eat it once we’re gone. It’s full of iron and protein, and it’s good for her.”
I grimaced at that thought as I washed my slimy, bloody arm in the bucket of water and put on my shirt. Clem closed the stall gate behind us, and we walked over to the stall of my namesake.
“She’s grown into a fine cow,” Clem commented.
She didn’t even turn to us but just kept eating. Then I noticed a movement behind her and realized that a small calf was suckling on her udder.
“Walter’s a mom?” I exclaimed.
“Heaven’s yes.” Clem replied. “In fact, this here’s her second calf. First little calf we named Kate, and this one’s named Scott.”
I laughed out loud. The Larimore family names were being replicated in a solitary mountain cove.
As we turned from the stall, I heard Walter’s son softly make a sound that was something between a bleat and a moo. Clem laughed and slapped me on the back. “He’s jest sayin’ good-bye, Doc. And as fur as I know, them’s his first words.”
I didn’t know it would be the last time I’d see Walter and her little brood of Larimore namesakes.
chapter fourteen
LIVE AND LEARN
One of the reasons they call my profession “the practice of medicine” is that a doctor’s education never ends. The wise young doctor will learn from continuing medical education courses, colleagues, experience, and, of course, his or her patients.
In Swain County my education continued virtually every day, courtesy of the five more experienced docs in town, as well as of the “granny midwives” who still inhabited the hills in those days. I would see some of their patients after a home delivery and some for the latter part of the pregnancy and then attend their delivery in the hospital; others I would see only when problems defeated the midwives’ tried-and-true home therapies.
A young lady from neighboring Graham County came into the office one afternoon with a bloody towel tied around her thigh. Bonnie told me that Jenny was twenty-eight weeks pregnant and had been sent to the office by granny midwife Elizabeth Stillwell for sutures. Jenny had been crossing a barbed wire fence when she slipped and severely cut her inner thigh near the groin. The exam of her abdomen showed that the baby was in a good position — head down — and the baby’s heartbeat and movements were normal. The baby seemed to be the right size — about two and a half pounds — for his or her gestational age. I donned some gloves and turned my attention to my patient’s bandages and wound.
When I removed the towel, a spurt of arterial blood shot across the room and would have hit Bonnie in the middle of her chest had she not jumped out of the way.
“Mosquito clamp, Bonnie! Quick now!” I cried as I applied compression to the artery.
Bonnie quickly pulled a small clamp out of a container of sterile instruments. I gently rolled back the leading edge of the towel until the spurting vessel came into view and quickly clamped it off. This allowed me to examine the wound, which was much worse than I expected. It was about three to four inches long and nearly an inch deep, going through the subcutaneous fat and penetrating into the sinewy lining of the muscle of the inner thigh called the fascia. Fortunately, the large femoral artery, vein, and nerve were spared. I would be able to repair this in the office.
As I was examining the cut, I noticed that Jenny’s panties were stained with an apparently fresh whitish-yellow stain. It was a stain I quickly recognized — one that was fairly common in pregnant women — a vaginal yeast infection. I made a mental note of this and then re-gloved to numb the cut with lidocaine.
After Bonnie cleaned the wound with Betadine cleansing solution, I talked with Jenny. She was a pretty eighteen-year-old woman who had dropped out of school to marry her beau — who was working as a lumberman and had done so since he was sixteen years old. This was their first child. They couldn’t afford medical care for the pregnancy, so they were being cared for by “Granny Stillwell,” who also planned to attend the birth in their home.
“Jenny, while I was numbing your cut, I noticed that you have a vaginal discharge. It looks like it might be a yeast infection. Have you been having any discharge or itching down there?”
The yeast infections that can plague a woman — not just externally but internally as well — are particularly frequent in hot, humid environments. We’d often see them during the hot months of a Smoky Mountain summer. But when a pregnancy is added to the recipe, the problem can increase in frequency and intensity. The reason is
simple: normally, the vaginal membranes house a balance of a “good” bacterium called Lactobacillus acidophilus and the yeast Candida albicans. If the bacteria die off, however, from antibiotics or the influence of changing hormones, the yeast can overgrow and wreak havoc. The itching and irritation can be vicious.
“I’ve been havin’ trouble with the yeast since my condition began,” Jenny commented.
I assumed that the condition was her pregnancy.
Jenny continued. “But Granny Stillwell has been havin’ me keep it under control with yogurt douches. I haven’t been doin’ ’em for a week or two, though. Now the itchin’s a startin’ up again, so I need to restart the douches.”
In my residency I had been taught that the oral ingestion of “active culture” yogurt could prevent vaginal yeast infections. I had never heard of using yogurt as a douche to treat the acute symptoms of the infection. Of course, our modern vaginal medic-inals are now quickly curative, but they were simply not available prior to the last quarter of the last century. The country doctor and midwife were left to utilize natural remedies. Therefore, I was very curious to learn more about this treatment.
“Do the douches work?”
“Shore ’nuff, they do — if’n I use ’em. Granny Stillwell gave me some starter to use to make my own yogurt. I make up a batch and then put six tablespoons of yogurt into a small douche bag of warm water. I just do that douche twice a day, whenever the yeast is bothersome. I think it’s time to start it up again.”
I smiled to myself. The therapy had probably been used for decades in these hills. And, by Jenny’s account, it worked — and worked well! Furthermore, it made perfect sense physiologically.
It turned out this treatment would become one of my most popular “mountain medicine” tips over the next two decades. In fact, I published the tip in a medical journal nearly a decade later and was pleased to come across studies later in my career that confirmed the treatment’s effectiveness. However, like any therapy, there are cautions and possible adverse reactions or side effects of which the prescriber must be aware — one of which I learned about the hard way.
Mildred Mingus called one night while I was on call. She was a patient of Kenneth Mathieson, D.O., who had retired to Swain County after years of private practice in Pitt County, North Carolina. His initial plan was to spend his newfound free time being a lay leader in the Seventh Day Adventist church, but even though he was in his late sixties, he found retirement to be less fulfilling than he had hoped. Not long after his arrival, he reinstated himself into the practice of medicine.
His patient was complaining of symptoms that sounded like a classic vaginal yeast infection. She wanted me to call in a prescription for a medicinal cream, but the drugstore was closed. I explained to the patient that I could phone in the prescription to the hospital emergency room and that Louise would gladly dispense a twenty-four-hour supply — enough to last until her doctor could call in a prescription the next day. However, I told her I had recently learned of a natural remedy she might want to try. She was interested, so I gladly shared the yogurt douche treatment with her.
I added that if the symptoms worsened in any way, the problem should be evaluated at her doctor’s office.
The next day, Bonnie took the call of one very distressed and very angry Mrs. Mingus. It turns out that instead of plain yogurt she had used yogurt containing strawberries. The yogurt itself would have worked just fine, as it was active-culture yogurt. So what was her complaint? Simply that the strawberries had clogged up the nozzle of her douche bag, and she had a dickens of a time cleaning it out!
Oh well. In family medicine the doctor must live and learn. I made a mental note to always prescribe plain or vanilla yogurt from that day forward.
chapter fifteen
HORNET’S NEST
I enjoyed my office and the exam rooms in our new office building. Each one had windows that looked out over the recreational park and up Deep Creek Valley toward the heart of Great Smoky Mountains National Park. Day by day, the fantastic, ever-changing views that I observed would provide me great pleasure, satisfaction, and often even inspiration.
The walk to the office that morning had been cool, which was not atypical at the end of April. The characteristic, low-lying smoky clouds — the ones from which the national park received its name — filled Deep Creek Valley at the dawn of what would turn out to be a beautiful, crisp, clear day.
About mid-morning, while taking a phone call in my office, I noticed a crew mowing and trimming at the edge of the park, just down the hill and across the road. The crew wore bright-orange jumpsuits with “Swain County Jail” stenciled across the back. There were two deputies, each carrying a shotgun, standing guard as the crew — both adults and adolescents — worked. All of a sudden, several of the crew members bolted and began to run in different directions. My first thought was that I was witnessing an attempted escape, and I half expected to see the deputies fire warning shots — but the crew and one of the deputies were running together. And they weren’t just sprinting; they were hopping and jumping and slapping their heads and bodies. Then I realized the men must have encountered a nest of hornets or yellow jackets.
The sprinting stopped as they turned to brush the stinging insects off each other, and I could see them laughing and joking with each other as cigarettes were pulled out and a hastily convened smoke break commenced.
Then, all of a sudden, one of the young men collapsed. I could see the crew and deputies gather around him. One of the deputies put his ear to the young man’s mouth. Then I saw him quickly give the boy a deep breath, mouth-to-mouth, and begin chest compressions. As I began to figure out what was happening — the prisoner had probably suffered anaphylactic shock from the stings — I realized I needed to get Patty or Dean to call the ambulance while Bonnie and I had to get out to the scene with our resuscitation kit.
As I was about to turn to leave my office, I saw one of the crew point to our building. The next thing I knew, two of the crew had grabbed the boy under his arms and were dragging him, on his back, toward the office. I could see he had no shoes on his feet, and I grimaced as they dragged him across the asphalt road and up the hill toward our office.
I ran to the nurses’ station. “Bonnie, there’s a code coming in!” I could see that Rick was gloved and in the middle of an outpatient surgery in our procedure room with Patty and Sandra, an EMT student from the local technical college. “Let’s set up in an exam room, stat!”
I stepped to the corner and yelled in the direction of the front office, “Dean, get the back door open. Now! Bonnie, call 911 and get Don and Billy up here ASAP!”
As Dean opened the back door, the crew dragged the victim into the office and over to my exam room, as directed. His battered feet left two tiny trails of blood down the hall.
I was proud of the team as we worked together.
Dean stripped off the boy’s shirt and applied electrodes as the cardiac monitor sprang to life. He did have a heartbeat — albeit very slow. Bonnie brought in our resuscitation kit, a portable cart with a wide array of equipment and medications to use in a cardiac emergency.
Sandra had come into the room, while Rick and Patty continued to care for their surgical patient. I instructed the EMT student to insert a large-bore IV line in the boy’s right arm as I checked his breathing. Then Dean escorted the prisoners and deputies to the waiting room. I felt a terror begin to fill my chest when I could detect no respirations! I grabbed an ambu-bag from the resuscitation cart and began breathing for the boy — what we call “bagging the patient.”
“Sandra,” I called out, “we need to get some epi in him, stat!” I was referring to epinephrine, commonly called adrenaline, which is an emergency and lifesaving treatment for a severe allergic reaction. I was sure the victim had had an anaphylactic reaction. With the right treatment, we could save his life.
“No blood pressure!” Bonnie exclaimed. As I continued bagging, I could see the patient’s chest ris
e with each compression of the ambu-bag.
“Here, Bonnie, take over bagging him, OK?”
Bonnie took over as I once again pulled out my stethoscope. Both lungs had good breath sounds. The heart rate was slow, but there was no arrhythmia. As I listened, I felt for his radial pulse, which was present but weak and thready. That told me he had enough cardiac function to pump blood. But he needed the medicine, and he needed it now.
At that moment, the EMT student turned from the resuscitation kit to the patient, with a small syringe in hand. She inserted the needle into the IV line and injected the clear solution. I noted the second hand on the clock as I waited for the medication to take effect. I knew it was likely to see some response in less than a minute, but what happened next shocked us all.
In just seconds, the patient’s eyes opened and nearly bugged out. I could feel his pulse surge as the beeping of the cardiac monitor almost immediately increased from a heart rate in the forties to a rate over 160 beats per minute — and it was getting faster as each second went by. Before I could comprehend what was happening, he became conscious, threw off the ambu-bag that Bonnie was using to breathe for him, and sat straight up. His face was sweaty and flushed. He coughed a couple of times and then leaned forward, suddenly grasping his chest.
“My heart! My heart!” was all he could exclaim, before he fell backward, apparently unconscious once again.
What just happened!? I thought to myself. Usually the response to the epinephrine is rapid — but never like this!
“Pressure is 210 over 130!” Bonnie exclaimed as the cardiac monitor raced up to 180 beats per minute. “And respirations are 42 per minute!”
“What did you give him?” I bellowed to Sandra.
“Epi, just like you asked.”
“How much?”
“3 cc’s.”
Instantly I knew what had happened. And so did the student! I could see the shock on her face as she gasped and then clasped her hand to her mouth. The normal dose of epinephrine should have been 0.3 to 0.5 cc’s. The patient had received 6 to 10 times more adrenaline than he needed, and I had no antidote for the overdose. But I knew that if his heart could survive the onslaught for just another moment or two, the effect of the overdose would quickly pass.
Bryson City Secrets: Even More Tales of a Small-Town Doctor in the Smoky Mountains Page 10
