Bryson City Tales (19 page)

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.

“On the appointed
day the reporter drove up to the house, walked past the Secret Service agents and up to the front porch. She knocked on the screen door. Miss Lillian greeted her and took her into the parlor, where they both sat down. Miss Lillian offered her no refreshments, which would be highly unusual, even rude, in that area of the South.

“The reporter tried to make small talk. Miss Lillian's response was to look at her wristwatch and say, ‘You have twenty-seven minutes.'

“The reporter began her interview with what was to Miss Lillian one of the most offensive questions she could be asked: ‘The president has been quoted as saying that his religious beliefs would compel him to never knowingly tell a lie. You raised the president from the time he was a baby. You saw him grow up. During that time did you know him to ever tell a lie?'

“Miss Lillian's cheeks flushed, but she remained cool on the outside. ‘When you say “lie,” asked Miss Lillian, ‘do you mean a white lie or a black lie?'

“It was the reporter's turn to flush. ‘What's the difference?' she asked indignantly. ‘Isn't a lie a lie? I mean, just what is a white lie?'

“Miss Lillian stared right at that reporter lady and said, ‘A white lie is like . . . ,' she thought for a moment and then continued on, ‘a white lie is like when I met you at the door and said, “‘It's so good to meet you.”'”

Louise threw her head back and laughed. I laughed with her. She had made her point.

From that moment on I began to feel comfortable around Louise. Maybe it was because I relaxed about not being the know-it-all that doctors are often led to believe they should strive to be. Perhaps I was becoming more accepting of the fact that as long as I was to practice medicine, I would need to continue to learn and be taught—by my patients and by my colleagues.

Louise and I developed a special relationship. Sure, it was a bit bumpy at the start—but, like a fine wine, it mellowed and matured into something very valuable to me. No lie. Not even a white one!

chapter sixteen

THE EPIPHANY

O
ne day during morning rounds the call came over the hospital intercom. “Dr. Larimore, stat to the ER.” I was in the EKG reading room, on the other end from the ER. I quickly ran the couple of hundred feet.

The patient appeared whiter than the sheets on which she lay, and she was gasping for breath with very rapid, shallow breaths. Even more ominous was a rapidly expanding pool of bright-red blood on the floor under her gurney—at least four or five feet in diameter. Worse yet, there were several waterfalls of blood actively dripping from the edge of the sheet covering the patient.

“Dr. Larimore, get over here!” Louise shouted. “She's hemorrhaging from the vagina.” I ran over as Louise continued her history. “She had a positive pregnancy test last week, and her last period was about three or four months ago,” yelled the ER nurse, who was cutting off the woman's clothes, while Betty, the lab director, was starting an IV and drawing blood for lab samples. Nancy Cunningham had run in to help us and was starting oxygen.

“Let's set up for an exam,
now!
” I ordered. “Louise, get the Gyn tray!” In moments the stirrups were set up and the patient pulled down to the end of the bed, flat on her back, legs spread—we call it the dorsal lithotomy position. I quickly gloved and turned my attention to the woman's perineum, which had blood coming from the vagina at a remarkable pace. “What's your name?” I asked her. She didn't answer but just stared at the ceiling. We were losing her.

Louise, who knew everyone in town, filled in some of the details. “Her name's Doreen, she's eighteen, been married about six months. Just out of Swain High last May. Works down at the plant.”

“Doreen, I'm going to do a quick exam. I'll be as gentle as I can. I suspect you're losing your baby. We'll do everything we can to help you.” In my heart I was thinking,
I don't want to lose you,
Doreen. Fight for me
.
Lord
, I prayed,
help Doreen. Help me!

I went to work, quickly inserting a sterile speculum, and discovered what I was expecting to discover. Doreen's cervix, the opening to her womb, was about three-quarters of an inch dilated, and hung up in it was a dark clot of material—what medical professionals usually called “the products of conception,” what I called a preborn child who was miscarrying. Around the tiny baby and placenta the uterus was hemorrhaging—and hemorrhaging big-time. The cure would be to remove the little body and placenta as quickly as possible.

“Ring forceps!” I asked Louise for an instrument I could use to gently extract the fragile mass. It came out intact and I examined it. All I could see was the placenta. This was not unusual, as the tiny preborn child could often pass without being noticed—or sometimes could be absorbed by the womb before the miscarriage.

“Nancy, let's give five units of Pitocin IM and add twenty units to the fullest IV bag and slow the flow of that bag to 125 cc's per hour.” The Pitocin, normally used to induce labor, would hopefully stimulate the uterus to contract, and the contraction of the muscles should then slow or even stop the bleeding.

“Walt,” Betty said, “I'll run the usual labs and get some blood set up. Looks like you'll need it.”

“Thanks, Betty,” I called out as she headed toward the lab.

I placed the mass in a formaldehyde container that Louise had opened. Then I quickly removed the speculum. Louise was working in tandem with me as though we had done this many times together. Obviously, for once I was doing what the older physicians would have done in the same circumstances. It felt good.

Louise squeezed some sterile K-Y Jelly onto my outstretched fingers. “Doreen, we've gotten the miscarriage out safely. Now I need to examine you on the inside. Can you take some deep breaths?” She still seemed dazed and incommunicado but did begin to breathe deeply. I did a rapid manual exam. I could feel no other products inside the uterus. Then with my inside fingers I lifted the uterus up toward the abdominal wall. With my outside fingers, I began to push and massage. “Doreen, this may be uncomfortable, but it will help the Pitocin stop the bleeding. Can you bear with me a moment?” She nodded. As I massaged the uterus I could feel it shrinking and hardening.
Thank you, Lord
, I prayed.

Nancy asked, “How about a second line?”

“Great idea. Will do. It needs to be a large bore needle and normal saline. We'll use that line to transfuse her.”

“Done.” Nancy had the IV inserted in seconds. This nurse was good, real good!

The uterus was continuing to contract, and very little blood was now flowing. “Vaginal pack,” I said.

“Yes, sir,” responded Louise. She turned to get one from a nearby cabinet. I slowly inserted the pack, which is a roll of narrow sterile gauze.
Whew,
I thought to myself,
I think we're going
to make it!

“Good job, Dr. Larimore,” Louise whispered. She fairly glowed.

“Hematocrit is ten,” announced Betty as she rushed back into the emergency room. “Blood is O negative. I'm cross matching for six units.”

Each transfusion of packed red blood cells would increase Doreen's hematocrit by about three points. A hematocrit of forty would be normal, but if we could transfuse her to twenty-five or thirty, she could build her blood count from there just by taking some oral iron.

“Betty, bet we won't need more than four or five units, but let's do get started as soon as the units are ready.”

“Yes, sir,” she said, and headed back to the lab.

I took off my gloves and went to stand at Doreen's side. I took her hand in mine. “You OK?”

She
turned her head away, tears now flowing freely. She shook her head no.

“Are you having any pain?”

“It just feels like menstrual cramps.”

“Doreen, I'm sorry we had to work so quickly. But we had to stop the bleeding. I'm expecting you to make a full recovery, but we'll need to give you some blood to replace all that you've lost. I'm hoping you'll be able to go home in a day or two.”