Bryson City Tales (40 page)

The spring football practices had gone very well. Tony Plemmon's shoulder was fully healed, and the two-a-day football practices of August had come and gone. The local team was predicted to be number one in the state that fall. Even Boyce Dietz had come by the office for an appointment for a “preseason evaluation” and a refill of a prescription of the oral antacid, Tagamet— enough to last the season. Expectations for the fall were high indeed.

The tourists were gone for now—at least until the color season began in October. The air was still warm but would begin turning cool this month. I had finished my first year of practice—and what a year it had been. But the most memorable medical event of the year was yet to occur. It began, strangely enough, at the Bryson City Presbyterian Church.

Rick was in Pittsburgh visiting his brother and parents. Usually we would attend church together. Barb and I would teach the Sunday school class for sixth, seventh, and eighth graders while Rick, who was now playing the piano for the service, would rehearse.

The small church was covered with whitewashed clapboards. The steeple and steep roof, highlighted by a well-manicured lawn and overflowing flower gardens, had, to us, an almost New England look. There was an air of dignity and stability to the small building that most of the churches in the area seemed to lack.

We felt comfortable there from our very first visit, about a month after we had moved to Bryson City. We were greeted at the door by a couple and their three children. “Hi, we're the Claxtons. We're glad to meet you, welcome to our church. Is this your first visit?”

We immediately felt welcome. We sensed that we were neither an imposition nor outsiders. We conversed with the Claxtons for several minutes, liking them more and more.

“Since you all are new,” said Mark, “why don't you join us in our pew? We can show you the ropes.” This was indeed unique, and we accepted gladly. They escorted us to their pew, introducing us to several of their friends on the way. We had originally decided to visit the church primarily because Mitch and Ray attended there. But by the time the service began, we already felt at home. We already felt a part of the family. We continued to visit there throughout the year and eventually joined the church.

Presbyterian services had a prescribed liturgy. After the organ's call to worship, the ceremonial entry of the pastor and choir began. The members and any guests would be welcomed by Pastor Ken Hicks, who himself—as of this fall—was also completing his first year in “private practice.” After a few brief announcements, he began the service with prayer, followed by the singing of a hymn. It was during the third stanza of the first hymn that it happened.

A young woman in the first row of the choir suddenly sat down. The congregation and choir dutifully kept singing, and the choir director, Peggy Ashley, one of the nurses at the hospital, kept leading. A couple of women beside the stricken woman looked down, concerned, but kept on singing.

Suddenly the woman careened off the chair and fell hard to the floor. The choir stopped, but the substitute pianist, her back to the choir, just kept playing for a few more moments. Almost instinctively and to the accompaniment of the piano, I leaped from the pew to run up front, only to find myself following Mitch.

When we arrived at the front, Mitch positioned himself at one side and Peggy at the other. I knelt down to be available for whatever might happen. They quickly evaluated her. Mitch gently slapped her cheek. “Susie, Susie, you OK?” There was no response. He pulled on her eyelids. I heard him mutter, “Oh my!” as he noticed that the inside of her lower eyelid, instead of being pink, was nearly white.

“Her pulse is over 140 and thready, Mitch. Skin is cold and clammy,” Peggy calmly reported.

Mitch's hands quickly and instinctively went to the patient's abdomen. As he quickly palpated her tummy, he pushed his fingers deep into the flesh just above the pubic bone. Susie moaned.

“Heavens,” he blurted out. “It's a ruptured ectopic!”

My mind was racing. How could he diagnosis a ruptured ectopic pregnancy with his hands? I would have needed a positive pregnancy test and an ultrasound showing a mass in one of the fallopian tubes. Or, I quickly thought, a culdecentesis, a procedure in which a doctor would pass a very long, thin needle through the wall of the vagina and into the abdominal cavity to see if there was blood—which can come from a ruptured tubal pregnancy. While I was considering this, Mitch went into action.

“Gay,” he called to his wife and medical assistant, “get a coat or a blanket so we can keep her warm. And get her legs elevated. Let's keep what blood's left in her
heart and head. Then monitor her vitals, and let me know if there's a change!”

“Yes, sir,” Gay answered calmly, as she would have in the office.

He stood, like a commander in control as he continued his triage—a skill developed not only in his military service but also over years of practice. “Tina!” he bellowed at Tina Hicks, the pastor's wife and a choir member. “Call the rescue squad, stat. Tell them to get here, and now!”

He continued, “Nancy, Peg,” he called out to Nancy Cunningham and Peggy Ashley, “get to the hospital, now! Nancy, get the OR ready for a laparotomy. Peggy, let the lab know I'll need six units of universal blood ready when we get there, and then you and Nancy scrub. Kim, we'll crash her as soon as she's in the OR.”

Kim Hammrick shouted, “My car's out front. Let's go!” The three nurses turned to run out of the church, and members of the congregation, now crowded around the altar, separated to let them pass.

Although it seemed like only seconds since Tina had run from the sanctuary, I could begin to hear the siren of the ambulance heading toward the church—which was only about a half mile from the station. Mitch continued to look around, evaluating who was available, what skills they had, and what still needed to be done. Our eyes met.

“Walt and Ray,” he continued, almost without a pause. He seemed calmer now, almost in a groove—the instincts of experience, concern, and training all flowing together before our eyes. I hadn't even noticed Ray at my side. “Get up to the OR and get scrubbed now. Once Kim has Susie out, you guys'll have to get into the pelvis as fast as you can. Ray, clamp the bleeder, then fill her tank. I'll stay here and ride up with the ambulance.” We could hear the siren outside and the squealing of wheels.

As we turned to run from the church, the crowd again separated. I could hear Mitch instructing the pastor as we left, “Ken, get the folks back in their pews, and let's begin to pray for Susie. She needs our prayers.”

As we hightailed it to the car, two city policemen were running up the walk. Don and Billy were pulling their gurney out of the ambulance.

“Walt, my car's right here,” Ray instructed.

We jumped into Ray's car and took off for the hospital.

“My, he's good,” muttered Ray. “Gotta be a ruptured ectopic. Gotta be.”

“How could he know?”

“Young woman. In great health. Married about four months ago. No birth control. They want lots of kids. Faints in a church that is cool, not overheated. Just finished Sunday school. We had refreshments. She couldn't be dehydrated or hypoglycemic. Exam shows her conjunctiva to be pale, meaning she's got a mean anemia, and pressing on her lower abdomen caused a pain response. Blood irritates the peritoneum.”

We were quiet as Ray raced the car up Hospital Hill. We could hear the siren behind us.

“They probably just scooped and ran,” guessed Ray—describing an emergency approach in which paramedics scoop a critically ill patient onto the stretcher and then run to put them in the ambulance. “Bet Mitch will have an angiocath in her sub-clavian vein by the time they get to the hospital. Wouldn't be surprised if he's got her blood drawn for the lab and a liter of fluid in her by the time we see him.”

My mind was racing. The way Ray presented the case made sense, but I wasn't sure I would have reached the same conclusions had I been there alone. My thoughts frightened me. I probably would have interpreted this as a simple faint. I could hear myself trying to reassure the pastor and congregation,
Pastor Hicks, it's
probably just a vasovagal episode. Very common. Not dangerous.
Let's just give Susie a few minutes. I'm sure she'll be OK.

Would I have kneeled at her side, expecting her to awaken after five or ten minutes while an unrecognized hemorrhage drained her of her life? I could hear Gary Ayers on Monday morning: “New young doctor watches patient hemorrhage to death in front of his eyes while reassuring her pastor that she was medically stable.”

Ray screeched to a halt just outside the ER entrance. We ran inside, past a wide-eyed group of family members in the hospital waiting room. In the doctor's lounge we pulled our scrubs over our Sunday clothes, pulled on shoe and head covers and facial masks, and ran together to the OR. We turned on the faucets at the scrub sink, ripped open scrub sponges of Betadine antiseptic, and began our scrub. Through the window looking into the OR we could see Kim at the head of the OR bed, anesthesia machine ready, drawing up her anesthetics into several syringes. IV fluids were hanging and ready, and the monitors were turned on.

Nancy was scrubbed and preparing the OR equipment. Peggy and Louise were quickly bringing Nancy equipment and sponges. As we scrubbed, Nancy and Peggy completed the instrument count, a procedure that was carried out before any surgery. This count of each piece of equipment and sponge would also be performed after the surgery, as a way of ensuring that nothing was left inside the patient that should have been removed.

Just then there was a crash as the doors of the OR suite flew open. Don and Billy raced Susie toward the OR. Mitch was nowhere to be seen, but a nearly empty bag of IV fluid was sitting on Susie's chest. Louise and Peggy met the team at the door.

“Thanks, guys. Great job. We'll take her from here,” Peggy barked as she and Louise rolled Susie into the OR and began to transfer her to the table. As Ray and I finished scrubbing, they would cut off her remaining clothes, insert a catheter into her bladder, and cover her with warming blankets. In the meantime, Kim would start additional IV lines and fluids and begin the blood transfusions. She would also begin to administer an IV agent to paralyze Susie. After Susie was immobilized, which would take only seconds, Kim would have to place a tube in her trachea to ventilate her. Kim would have only a few moments to complete the intubation. If Kim experienced delay or failure, Susie's brain cells would begin to die from loss of oxygen.

“What are her vitals, Billy?” asked Ray, finishing his scrub.

“Doc, she's afebrile. Actually a bit cool at 97 degrees axil-lary. We put some blankets on her. Pulse 140 when we scooped, but Mitch got the central line in, and by the time we were here, he had a liter in her and the pulse was 120. Respirations 24 and shallow. BP 60 palpable. Glad she wasn't in the national park or too far out when this happened.”

“Me, too,” said Ray.

“She was on her way out, huh, Doc?” Don's statement was half question and half statement.

“I suspect she'd have bled to death in just a little bit.”

“She gonna make it, Doc?” asked Billy.

“I reckon she will, Billy. I reckon she will. In no small part due to you all's response time. Good thing you all were at the station and not at church.”

“Yep, we're usually up at Franklin Grove Baptist Church.

Would've added at least ten to fifteen minutes—and the pastor hates it when we get called out during the sermon. He always thinks we do it on purpose.” Billy laughed.

“Well, that extra time was definitely not something we had. Thanks, Billy.”

“You both break a leg. We're outta here. Heard on the way up there's been a little fender bender on the four-lane. May be hauling some more business for you in a bit. Keep you guys outta trouble.” Billy smiled as he turned to go. I suspected we'd see him soon enough.

Ray and I finished washing off the soap and quickly backed into the OR, our hands held up and in front of us, water dripping from our hands down our arms and off our elbows. As the OR doors closed behind us, we saw Mitch, now donned in scrubs and mask, enter behind us.

“You gonna scrub, Mitch?” asked Ray as he quickly dried his hands. Nancy was already helping me gown. The answer surprised me.

“Naw. Just thought I'd watch you boys work together,”
he bantered. “Besides, I'm off this weekend. You're on surgical call, Walt's on ER call. I'd probably just be in you all's way.”

Ray looked at me and I at him. He had been planning to be first assistant and I the second. Now we had suddenly been bumped up to first class. No words were actually spoken, but a thousand unspoken words crossed the space between us. This was a pretty high compliment in the face of a highly public and life-threatening emergency. This kind of life-saving surgery was Mitch's forte, his pièce de résistance, his reason for being and practicing. Something was up.

Mitch went on. “Once you guys clamp that bleeder, the show's really over. Besides, Gay and I have lunch reservations up at the Frye-Randolph house. The Adamses are cooking up something special for us and serving us at the private table under the gazebo. Gay will kill me if I miss that. Now you two get to it!” he barked.

While Nancy helped us with our gloves and Peggy and Louise tied our gowns from the back, Kim had started two more IV lines and was running in fluid and three units of packed red blood cells. “OK to put her to sleep?”

“You bet, let's move!” roared Ray.

We positioned ourselves across from each other. Ray quickly scrubbed the abdomen with Betadine. Normally he would take four or five minutes to do this. Today, less than ten seconds. I quickly prepared the drapes. “Boy, she's distended,” he said, almost to himself.