“Jim, you ever notice this rash before?” I asked.
“Oh yeah, Doc. Been there off and on most of my life.”
I took an ophthalmoscope off the wall and turned it on. The ophthalmoscope is designed to help a doctor look into the eye—especially at the retina. However, because its light is bright and because it magnifies the view manyfold, it can be an excellent tool for examining the skin.
“Yep,” I commented. “I thought so.”
“What is it, Doc?” asked a now worried Jim.
“Infection looks deep, Jim. I’m suspecting it and the hives are connected. Tell you what, if you’re willing to take a little pill four times a day for the next three months, I believe we might just whip this thing.”
“Don’t know if I can remember.”
“Don’t worry about it, Jim. You just have your lovely wife, Elaine, do the remembering for you.”
He smiled, “That she can do, Doc. That she can do.”
That wasn’t the last time that day I used the ophthalmoscope trick. In fact, the next patient was a little girl who had suffered an insect bite on her wrist while working in the garden the previous weekend. The girl’s severe pain caused her mom to bring the little one to the emergency department twice—each time for an injection for pain.
To the naked eye, the skin looked almost normal, except for a small red line. However, under ophthalmoscopic magnification I could see two tiny parallel rows of red raised lesions—almost like two dotted lines lying together like a railroad track. I knew instantly what it was—a classic case of “caterpillar dermatitis.” Once I knew what it was, treating the pain required merely removing the tiny toxin-containing stingers embedded in the little girl’s skin.
I had Gay get me a piece of ordinary Scotch tape. As the mom gently held her daughter’s arm in place, I stuck the tape to the lesions, rubbing the tape onto the skin. Then I carefully removed the tape, which had all of the little caterpillar hairs stuck to it. The pain relief for my little patient was almost immediate.
This is one of those treatments that always makes the doctor look wise—instantly. I, for one, was glad that the tape worked in this prickly situation.
One of the lifelong joys of family practice is that we family physicians can fill in our basic training with a day-to-day training that continues for the rest of our professional lives. For instance, one morning a six-year-old patient who had shingles came to the office for a follow-up. I had done the original exam and had made the diagnosis, even before the rash broke out. Today the mother and child were seeing Mitch for the follow-up. Apparently the mother had told him about my “hitting the nail on the head by using the Kleenex test.”
A few days earlier she’d brought in her child, who was complaining of having “funny-feeling skin” that felt like it was burning, even though there was no rash whatsoever. I had learned the Kleenex test from cardiologist E. Harvey Estes during my residency. All the doctor had to do was gently pull a tissue, hanging loosely from his or her fingers, over the affected skin. If the sensation was painful to the patient, it served to predict the characteristic shingles rash that would follow. Mitch had never heard of such a thing and continued to brag about my lesson all afternoon. I, of course, was elated to be the one who earned his praise.
Toward the end of the day he had a chance to return the favor. A lumberman came in for a last-minute visit to have his hand sewed together with Dr. Mitchell’s “cut glue.” I examined the man’s hands and fingers, which were thickly calloused from his daily labor. It was not unusual, he said, for these calluses to crack open at the beginning of autumn when the air became cooler and drier. Needless to say, these cracks, as they tried to scab and then were broken open again and again, resulted in a fair amount of pain. The problem was apparent, but I had no idea what he meant by the “cut glue” treatment.
I left the room to find the maestro. “Walt,” explained Mitch, “this is a fairly recent trick of mine. You just fill the cracks with Super Glue.”
“Super Glue?” I half-asked and half-repeated—with more than a trace of doubt in my voice.
“Yep. Although application of the glue will sting like the dickens for a few minutes, the stinging stops quickly and the wound seems to heal faster than on its own. Not only will the Super Glue hold the cracks shut, it’s the only ‘bandage’ I’ve found that will stick to a sweaty palm. Then you just have the patient use a file or a pumice stone every night to keep those calluses a bit thinner. That will prevent further cracking.”
The lumberman hated the actual cut-glue treatment but loved the result—his cracked fingers and palms were sealed and pain free.
Just down the street from Swain Surgical Associates was Super Swain Drug Store. After seeing the rest of my afternoon patients, I decided to walk down to make the acquaintance of the infamous “Doc John”—John Mattox, Registered Pharmacist. Doc John was one of the old-timers, able not only to bottle up the most recent prescription medications but also to take raw ingredients and compound them into pills or potions or ointments or poultices or extracts or teas or powders. You name it, he could mix it—whether for oral, rectal, or topical application. Doc John was a generalist in the best sense of the term. He did it all. Not only that, he was known far and wide for his home remedies. Uncommon was the patient I saw in the office who had not first tried one of “Doc John’s Tried-and-True Home Remedies.” What came to surprise me over the years was just how many of them actually worked.
I stepped into the store and was immediately swept up in feelings of nostalgia. The store looked almost identical to the Rexall Drug Store that my family frequented when I was growing up. I had precious memories of my dad occasionally taking me before school to the soda fountain for biscuits and bacon. I can remember us sharing a cup of coffee—mine mixed as café au lait—and my feeling very grown-up.
At the back of the store was Doc John—aging, balding, and laughing with a customer, a deep roaring laugh accompanied by an affectionate swat on the customer’s back. You could sense his joie de vivre and understand why his customers liked him so much.
As the customer turned to leave, Doc John turned to me. “How can I help you, son?”
“Hi. Are you John Mattox?”
He looked a bit suspicious. “Am,” he replied.
“I’m Walt Larimore. I just wanted to come by and meet you.”
He immediately broke into a wide grin, pumped my hand in a vigorous and prolonged handshake, and commented, “My, oh my. I imagined someone much older. They all say you look young, but I never dreamed. Come, sit over here. Got a moment?” He ushered me to one of the booths near the soda bar. “How about a milk shake—on the house?”
“Sure, I’d love one. Vanilla will be fine.”
“Malt?”
“No thanks.”
“Becky,” he hollered to his wife, who was behind the soda bar. “This here’s the new doc. Can you get him and me a vanilla shake, honey?”
He turned his attention back to me. “Doc, where’d you go to medical school?” Before I could answer, he continued. “Because I thought they taught you guys how not to write—you know, how to scribble.”
I looked at him—more than a little mystified.
“In fact,” he continued, “I heard that when you fellows graduate from medical school, they make you sign your name on a ledger. And if they can read your name, you fail! They don’t give you your diploma!” He began to laugh and laugh. I smiled. “Anyway, I figured you must have failed out—at least once—because I can actually read your handwriting on your prescriptions.” His laughter burst forth yet again.
As I headed for home that evening, I could feel my confidence in my skills beginning to increase. My “book” knowledge and my “practical” knowledge were now starting to work together. After supper Barb laughed as she came across an advertisement in a magazine. She read it to me. “If it creaks, cramps, cries, eats, stings, smarts, swells, twists, twinges, burps, burns, aches, sticks, twitches, crumbles, or hurts,
we’ve got just the doctor for you.”
She paused. I asked, “Is that it?”
She laughed again. “Nope. The answer is . . . the family physician.” She gave my arm a reassuring squeeze. My confidence soared even higher.
That evening I sat out back on my bench. My thoughts returned to Barb’s encouragement. I found myself musing about general family practice—my growing forte. To my way of thinking, general practice is both unique and difficult—not so much in terms of the breadth of expertise required but in the com plexity of providing medical care in the patients’ real world. The focus of family docs like me is to combine the science of medicine with the art of medicine—in the real-life context of the community in which our patients live. A general practitioner has to be ready at any moment to switch between different perspectives—biomedical, psychological, relational, and spiritual.
I smiled to myself as I gazed out over the valley. Ageneralist, I mused. Not what everyone in medicine wants to be, but certainly what I sense I’m called to be. And maybe I’m beginning to get there. I’m not yet the family doctor I want to be, but it’s coming. Slowly, ever so slowly, it’s coming.
chapter fifteen
WHITE LIES
One day after lunch I walked over to the hospital for afternoon rounds. I saw Louise coming down the hall. Ever since the case of the skintight cast, I had felt uncomfortable being around the ER nurse. I wasn’t sure why. Perhaps I was still wrestling with the fact that her clinical and practical experience so vastly outweighed mine. Perhaps it was the reality that she knew these people and their ways so much more intimately than I did. Although she was nice enough, around her I just felt uneducated. And what was even more painful, I felt unappreciated.
Louise was heading toward the ER with a syringe in her hand. I was trying to think of something to say, but she beat me to the punch.
“Dr. Larimore, you got a moment? I need a hand.” She continued on to the ER without comment. I followed like an obedient pup. As we walked toward the ER, I saw Louise place the syringe in her pocket. An elderly man was coming out of the ER, holding his paperwork and struggling into his plaid coat.
“Louise, the sugar worked like a charm. The hiccups are completely gone. You may never see me again in this place!” He smiled and turned to leave.
Louise smiled and glanced my way. “I’ll explain later.”
We entered the ER, and I could hear the whimpering of a child, which increased in volume as we approached the cubicle. We went in, and I saw a small woman with a four- or five-year-old boy.
“Mae Bell, Dr. Sales says it’s the strep throat and that some penicillin should clear it up pretty quickly.”
I suspected Dr. Sale was on call for the ER. For some reason, Louise always called him Dr. Sales.
Louise went on. “The best way to get the medicine into him is to put it into a muscle.” She paused and pointed to her hip. The mother’s eyes widened a bit as she recognized the “shotlike” gesture. “Is that OK?” asked Louise. The mother began to nod her head yes. Louise continued, “And the best way to get the medicine into the muscle is to have your little one lie down on his stomach. OK?”
The mother continued to nod. The young tot had no idea what was coming. The fully informed verbal consents often administered these days to the very young and their parents were just not a part of medical practice back then—certainly not in Bryson City.
“Henry . . .” Louise now directed her comments at the unsuspecting lad. “I want you to get up on the bed and lay on your tummy so that Miss Louise can check your backside.” Louise wasn’t just “checking his backside,” she was getting ready to give him a shot. Was this lying? I wondered, making a mental note to ask her about this later.
Henry was eyeing Louise with an impressive degree of distrust, especially since a white-coat-clad, doctor-looking type of guy was standing next to her. But he allowed his mom to help him up and lay on his tummy—glancing back over his shoulder with grave suspicion.
As Louise moved closer, she instructed, “Mae Bell, can you give Henry a little back massage while I look at his back? And Dr. Larimore, I want you to take Henry’s feet and turn them so that the toes are pointing toward each other and hold them there for a moment.”
I’m sure I looked at her with a furrowed brow. What in the world was she thinking? I had never seen such a thing. But obediently I gently grabbed Henry’s ankles and turned the toes so they were facing each other while his mom rubbed his back. Louise very quickly pulled down one corner of his pants, took an alcohol sponge from her pocket and rubbed it across the skin, gently pinched Henry’s unsuspecting upper buttock between her left thumb and index finger, and with her right hand reached into her pocket, single-handedly unsheathed the needle, and drove it into his flesh. Before he knew it, the syringe was empty and the deed done.
As we all released our grip, the full implication of the dirty deed traveled up Henry’s gluteal nerve and spinal column to the pain center of his young developing brain. This resulted in neural impulses that both instantly widened his eyes and tightened his perioral muscles, which caused his diaphragm to contract and draw in a full breath of air. His intercostal muscles then contracted with such force that the subsequent yell was heard clear out in the waiting room. The embrace of a loving mother muffled the crying as Louise and I stepped out of the cubicle.
“Thank you for the help, Dr. Larimore,” said the nurse as she resheathed the needle and jotted a note on the patient’s chart.
“Louise, two questions,” I said. “One, what’s this about sugar and hiccups? Two, what’s the deal about the toes?”
Louise smiled and then slyly asked, “Why, Dr. Larimore, didn’t they teach these things to you all at the big Duke University?”
“Don’t believe so, Louise. We were too busy learning how to save lives.”
My hint of humor was obviously not received well as Louise glared at me over her spectacles. “Actually, Louise, I wasn’t taught either technique. What’s the deal?”
“What were you taught to do if someone comes into the ER with a bad case of hiccups that had been going on for hours or days?” Louise quizzed me.
“We usually used intravenous Thorazine. That seemed to work pretty well—at least in the two or three cases I’ve seen.”
“We’ve used Thorazine here, but I can’t even remember the last time. The sugar seems to work just fine. It’s sure a lot cheaper. Just like with Shitake Sam when he broke his ankle, we try to do things the least expensive way we can. Many of these folks don’t have no medical insurance. ’Nother thing ’bout the sugar is that it has none of the side effects that meds like Thorazine can have.”
“How do you administer it?”
She looked confused. “The Thorazine?”
I chuckled. “No, no. The sugar.”
“Oh, well, it’s real simple. Just take a heaping tablespoon of granulated sugar—I get it from the staff lounge—and have the patient swallow it down.”
“That’s it?”
“Yep, that’s it. Usually works in ten to fifteen minutes.”
“How does it work?”
“Dr. Larimore, I don’t have a clue,” she answered bluntly. “I just know it does.”
“OK. So what’s the deal with the toes?”
Louise perked up. “I do know how that one works. Let me show you. Dr. Larimore, stand facing the counter.”
I did, but asked, “Louise, you’re not going to give me a shot, are you?”
She laughed, “No sir. No shot. Just a demonstration. Here, I’ll do it with you.”
She stood and faced the counter beside me. “Now turn your toes in so they’re pointing toward each other,” she instructed.
We both turned our toes in. It’s a good thing no one’s watching this! I thought.
“Now,” she continued, “try to tighten up your buttock muscles.”
I tried, but my gluteal muscles just wouldn’t contract—at least not very much.
“Wow,”
I commented. “That’s really great!”
“You see, pointing those old toes pigeonlike keeps the buttocks from tightening up. You can do this standing or lying down. By preventing the tightening of the gluteal muscles, you can relieve some of the pain for the patient. That’s just the way it is.”
By now there was no more whimpering from the cubicle. Mae Bell and Henry appeared from behind the curtain—no worse for wear. As they left the ER, I turned to Louise.
“Louise, just one more quick question. You really lied to that little boy, didn’t you?”
“Say what?”
“You told him you were just going to check his backside—when you knew all along you were going to give him a shot. Isn’t that lying?”
“Well, Dr. Larimore, I’ve learned that misleading statements made for the benefit of the patient or the family are sometimes appropriate. They’re just white lies.”
I furrowed my brow. “Louise, isn’t a lie a lie? I mean, is there really any difference between a white lie and a lie? Aren’t they both really just the same thing?”
She paused to rub her chin and then explained, “Not really, Dr. Larimore. One intends to deceive and one intends, in a caring way, to help.”
“But,” I persisted, “both of them are still lies. How can a lie help a situation?”
Louise smiled kindly, if perhaps a bit condescendingly. “Dr. Larimore, after President Carter was elected, I heard a story ’bout his momma, who had a home in Plains, Georgia. She hated to do press interviews. She resented the way the reporters mischaracterized her son and what he stood for—especially his spiritual beliefs.
“So after her son’s election, his staff persuaded her to do an interview with a well-known national magazine. Miss Lillian did not want to do the interview, but she agreed—as long as it was done in her home on her home turf and the interview was limited to thirty minutes or less.”
I was wondering where this was going but continued to listen.
Bryson City Tales Page 13
