My most popular books, at least based upon sales and letters, are the Bryson City series, made up of:
- Bryson City Tales: Stories of a Doctor’s First Year of Practice in the Smoky Mountains (read a chapter here)
- Bryson City Seasons: More Tales of a Doctors Practice in the Smoky Mountains (read a chapter here)
- Bryson City Secrets: Even More Tales of a Small-Town Doctor in the Smoky Mountains (read a chapter here)
In the second book in this series, Bryson City Seasons, I published an account of caring for my first patient with HIV/AIDS (even before that horrible disease was named). It was in December 1982 and occurred in Bryson City, North Carolina.
I’ve excerpted the story for you and hope it will be a Christmas blessing for you and yours:
The week before Christmas, I saw Ella Jo Shell for a routine office visit. Ella Jo and her husband, John, were the proprietors of the Hemlock Inn and had become a major source of referrals to our practice. Therefore, I wasn’t surprised when Ella Jo said, “Before you run off to your next patient, I need to tell you about Evan.”
I cocked my head. “Evan?”
“He’s become a good friend. He’s an older man—I’d guess sixty or so—and he and his partner own a shop in a nearby town.”
“I bet Barb’s been there, but I don’t think I ever have.” “Well, it’s a great shop. I like browsing around there.” “Who’s his partner? Do I know her?” Ella Jo smiled. “I would guess not. Evan’s partner is actually a guy whose name is Richard.”
“Yep. Where they live they’re pretty well accepted—although I’m not so sure they’d be well accepted over here in Swain County.”
Ella Jo continued. “Anyway, Evan is concerned about his health. He’s been losing some weight and has some funny-looking moles developing on his legs. He asked me to look at them. Walt, I’ve never seen anything like it. They look like purplish lumps. Can you think of any sorts of special rashes that occur in homosexuals?”
Frankly, I had never cared for a homosexual—at least none that I knew of—through all of my training in the 1970s.
“Other than the sexually transmitted diseases, I don’t think I know of any.”
I was quiet for a second, developing in my mind what doctors call differential diagnoses—a list of possible diagnoses. Usually I would try to think of the most common diagnosis or diagnoses that would fit the history and exam (and any tests that had been ordered).
But at the same time I’d been taught to always think of the worst possible diagnoses—so that I wouldn’t miss something bad in its earliest stages. In Evan’s case the worst diagnosis I could think of was some form of cancer. For internal cancers to cause fatigue and an unexpected loss of weight, as well as changes in the skin, was not unusual.
“Walt, I told Evan he should get a skin biopsy—for safety’s sake—just to be sure it’s not some sort of melanoma or something like that. Anyway, I told him about you and Rick. I think he’s will- ing to come over here for an evaluation, if you’re willing to see him.”
“Ella Jo, I think it’s a compliment that he’s willing to come over here. Seems like most folks from their town get their care in Sylva or Waynesville—many even travel to Asheville.”
“Yep. But it seems like folks are more willing to stay here for their care. And I think that’s good.”
I agreed. We finished our visit, and I asked her to wish her family a Merry Christmas from Barb and me.
The morning before Christmas, I was on call for our practice.
After I had finished seeing patients for the morning in the office, I was dictating charts when the phone rang. It was Louise from ER. I greeted her with, “Hi, Louie!” when I picked up the phone.
“Dr. Larimore, don’t you start with no ‘Hi, Louie’ to me. You need to learn to respect your elders!”
I grinned as she continued without a breath between sentences.
“In the meantime, I’ve got a patient here with a pretty bad pneumonia. He’s got a temperature of 102, a productive cough, a low white blood cell count, short- ness of breath, and a low oxygen level.”
She paused for a breath and then lowered her voice. “Dr. Larimore, he’s an older white man, and he’s all skin and bones. He looks cachectic, and I bet he’s got ’im a bad cancer. I’ll begin writin’ up some ICU admission orders for him.”
She sighed and then continued. “The respiratory therapist is down here, and I’ve got him on oxygen.”
As Louise paused to take a breath, I couldn’t resist the temptation. “Louise, why is the RT on oxygen? Is he sick also?”
Louise didn’t reply. I was sure she was trying to process what I was saying, so I struck while the striking was good.
“Oh my goodness. Is some plague sweeping over the hospital? The county? Oh dear, Louise! Should I come work at your side, risking life and limb? Or should I flee for my life to Franklin or parts asunder? And if I do come, do you and I need to be on prophylactic oxygen ourselves? And, Louise, what if the hospital runs out of oxygen? Then what? Oh dearie me!”
I paused to chuckle.
However, Louise apparently did not share my sense of humor. “Dr. Larimore, you ain’t funny one bit. This man’s sick, and you best be givin’ me some ICU orders.”
I agreed and gave Louise the admission orders. I wanted him cultured up and started on high-dose antibiotics.
“Does he have family?” She and I both knew this case probably did represent some sort of end-stage cancer.
“Not that I know of. Just a friend who brought him in.”
Loners were not at all unusual in the mountains, and loners who came to the doctor only after their disease process was pretty far along were very common.
You see, to most of the mountain people, the hospital was a scary place. They would tell me that they knew people—friends and neighbors—who would come to the hospital only to die.
The result was that, instead of coming in early in the disease process when treatment and sometimes a cure were at least possible, the locals would often wait to come in until it was too late for us to help them.
“I’ll be up to see him just as soon as I’m done with my patients. That okay?”
“Sounds good, Dr. Larimore. I’ll let you know if you need to get here any quicker. And . . .” Louise paused.
“And what?” I inquired.
“And you can leave your smarty-pants side down there in that office before you come here to my ER!” Before I could respond, she hung up.
hen I arrived at the hospital, I paused in the lobby to look at the Christmas decorations. The tree was actually a live tree from Greg Shuler’s Christmas tree farm. The lobby, strung with beautiful lights and freshly cut evergreen garland, smelled exhilarating— it looked like a scene from a Christmas card.
I thought for a moment of how hospitals were places of death, without a doubt, but also places of new birth and healing.
In a very real sense, the events most of us celebrated at Christmas—the birth of the Christ child—and then on Good Friday and Easter— Jesus’ death and burial—were represented in my day-to-day life in the hospital caring for patients.
No wonder, I thought, God calls himself the Great Physician. I suspected that today I’d have to tell an old man of his impending death. I had no idea of the birth that would occur.
I passed through the lobby and went first to the X-ray suite. Carroll, the radiology technician, was there. He found the patient’s films and put them on the viewing box.
“Looks like an atypical pneumonia, Walt.”
I nodded. Carroll was as good at reading films as any radiologist I knew.
“I went ahead and did tomograms of the hilum,” he commented.
I nodded again, as Carroll was thinking just what I was—this pneumonia was probably caused by a cancer.
The tomographic X-ray allowed us to look at the area between the lungs—in this case, for lumps of cancer.
Carroll replaced the plain films with the tomograms. “But I don’t see any cancer. Maybe it’s a small-cell carcinoma.”
I smiled to myself. Small-cell cancer of the lung was a name that described a deadly type of cancer—but in no way did the name imply that it didn’t form masses that could be seen.
“Thanks, Carroll. I’d best go take a look at the patient.”
“He’s interesting, Doc, I’ll tell you that.”
Aren’t they all? I wondered to myself.
“Hi, Peggy!” I called out as I entered the nurses’ station. Peggy had been at the hospital for many years. She led the choir at the Presbyterian church when she wasn’t working at the hospital. She was married to Joe Ashley, a longtime ranger at the national park.
“Hi, Dr. Larimore. Here to see the new admit in ICU?”
Our ICU was really just a former four-bed ward located close to the nurses’ station and converted into the place where we cared for our sickest patients.
“You gonna tell him what he’s got?”
“Guess I’d better figure out what it is first, don’t you think?”
Peggy smiled to herself. It wasn’t unusual for the nurses to know what was going on far before the doctors did, and in this case, Peggy, like Carroll, strongly suspected cancer.
She handed me the chart. The name on the front was Evan Thomas. Could this be the Evan that Ella Jo was talking about? I thought to myself.
As I entered the room, the patient looked worse than I could have imagined. He was fairly emaciated. The oxygen had normalized his color, but instantly I knew this was a very sick man.
Another man was sitting by Evan’s bedside. As I entered, he stood.
“Hi, I’m Dr. Larimore. I’m the doctor on call today.”
“I couldn’t be more delighted!” the man exclaimed. “My name’s Richard White. Evan and I know about you and your partner, Dr. Pyeritz. Ella Jo Shell often visits our shop and has told us so much about you both. We were hoping either you or he would be willing to care for us.”
“Richard, Evan, it’s good to meet you.”
I turned my attention to Evan, taking a complete history and then doing a complete physical. When I was through, I pulled up a chair. I always felt it was better to communicate face-to-face, and sitting with patients helped me accomplish that.
“Evan, I think you know you’ve got pneumonia.” He nodded. “But it’s not a typical pneumonia. It’s atypical. Given your weight loss and fatigue, I’ve gotta be honest with you.” I paused for a moment.
Evan reached out and took Richard’s hand. He looked fleetingly at his partner and then back to me. “Is it cancer?”
I nodded. “To tell you the truth, that’s my guess. We would need to do tests to be sure. But that’s what I suspect.”
“Is it treatable?”
“It depends on the type. But my guess is that it’s probably already widespread. So we’ll just have to see.”
“When can we start?”
“Well, let’s get the infection under control, and then we’ll talk about getting started.” I was quiet and let them absorb the information. When it was clear they didn’t have any more questions, I left the room.
The next morning was Christmas, and I made early-morning rounds—well before our children, Kate and Scott, would wake up to celebrate Christmas.
I found Evan alone but awake. I greeted him and sat on the bed. His breathing was labored and shallow.
“Evan, how are you feeling?”
“Not so good, Doc. Didn’t sleep well.”
“Seems you’re breathing harder than last night. I’d better get Carroll to take another X-ray.”
“He’s already been here—along with Betty the Vampire.”
I smiled at his reference to Betty Carlson, the director of our laboratory.
“Let me go take a look at it and let you know what I see, okay? Anything else I can do?”
“Doc, I’ve been told you’re a man of faith. I’ve also been told you’re a very good doctor. But I’ve got to tell you, I was worried about coming over here to see you.”
Evan didn’t answer for a moment. Then he looked deeply into my eyes. “Doc, lots of Bible-thumpers call people like me evil and nasty things. I was worried you might think the same.”
Now it was my turn to be quiet for a moment. I was trying to think about how to respond to this man’s honesty and transparency. It was an unnerving moment for me. But, cautiously, I continued.
“Evan, my faith teaches me that the most important thing in life is a personal relationship with God. Everything else pales in comparison to that. And I found that when I began that relationship with God, he was fully able and willing to guide me into doing and thinking the right things. So the real issue isn’t what I think or what you think, but what he thinks.”
Evan smiled, and I saw tears forming in his eyes. “When I was a kid, church was important to me. I really enjoyed going—but never did I enjoy it more than on Christmas Eve. But when I grew up I just grew away from it. Do you think your God would even want a relationship with me?”
For a moment I thought about the Bible verse “Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But do this with gentleness and respect.”
I was pleased Evan felt comfortable enough to ask. But I’d always been taught in medical school that it was unethical to discuss religion with patients.
However, Evan had asked—in essence, he had given me permission to share with him. So I decided to proceed—albeit carefully and very uncomfortably.
Spiritual discussions were simply not something I had been trained to provide in the medical environment, but I’d begun to carefully incorporate them into my practice during my first year in Bryson City.
Furthermore, a still, small whisper was encouraging me to harvest this opportunity to share an intimate part of myself with a very, very sick patient.
“Evan, I know God wants to have a relationship with you. My understanding of the Bible is that it tells us that God loves each of us. Actually, he loves us so much that he sent his only Son, Jesus, not just to be born in a manger but to live a perfect life for us as an example and then to die a torturous death for us—for all of our wrongdoing. Evan, if you’re willing to believe that, God’s willing to begin that relationship with you—today—but only if you want to.”
Evan looked out the window of the ICU. The daylight was just starting. For just a moment, I was concerned he might have been upset, but instead he turned back to me and whispered, “It would be a good day to start.”
I was quiet. The tears began to flow down his face, and he sniffled. I reached out and took his hand.
He gave my hand a squeeze and then looked back at me. “Doc, I’ve done a lot of wrong things. Guess you thumpers would call me a pretty bad sinner, huh?” He smiled as he wiped his tears with his free hand.
I smiled back at him. “Evan, that puts you and me in the same exact crowd.”
He cocked his head and looked at me. “Dr. Larimore, are you …? Are you like me?”
“You are?” he asked.
“Yes, but let me explain. The Bible explains that the sexually immoral and idolaters and adulterers and homosexuals will not inherit the kingdom of God. But, Evan, it also says in the same verse that the greedy and slanderers and swindlers won’t either.”
Evan was quiet in his thoughts, so I continued. “You’re a homosexual. And I’m greedy and a slanderer. I’ve been far more selfish than I should have been, and I’m certainly guilty of gossiping more than I should. So, according to the Bible, you and I are in the same exact crowd.”
Evan smiled and squeezed my hand. I felt an acute sense that God was gently leading my thoughts and words.
“Evan, the Bible describes many names for Jesus. My favorite is that he was known as a friend of sinners. All he requires from us, if we want to have a personal relationship with him—if we want to be his friend—is for us simply to admit that we’ve missed the mark, that we’ve sinned and done wrong.”
“I guess I would qualify.”
“Me too, Evan.” I paused to let him think for a moment.
“I think I’d like to be his friend. That would be nice—especially on Christmas Day,” Evan whispered between labored breaths. “How do I start?”
Dear Lord, I thought, what do I say now?
Then I had an over-shadowing and extremely comforting sense that God had been at work in Evan’s life for a long time.
Evan’s spiritual journey and awakening had, in point of fact, started long before today. I wasn’t exactly sure who had been involved in his life up to this point, but I was sure God now had a small part for me to play in Evan’s story.
“Actually, Evan, it’s pretty easy. You just talk to God—what we thumpers call prayer.”
We smiled, and I continued. “Just let God know you’re ready—invite him into a relationship with you, into your heart, and he’ll come in. First you have to realize that you’ve done wrong. Then you have to be willing to trust him with your life and your choices.”
Evan nodded and closed his eyes. “Lord,” he whispered, “I begin.”
It was the shortest and sweetest prayer I had ever heard.
He looked up at me and smiled.
We were both silent—sitting together after a conversation we had begun as doctor and patient and con- cluded as spiritual brothers.
“Evan, the Bible says that when we admit to God our wrongdoing—just agree with him that we’ve missed the mark— he will instantly and eternally forgive our sins. And based on that forgiveness, he’s willing to become your friend and your Lord and to reserve a room for you in heaven.”
The tears were still flowing down his cheeks. He nodded.
“The Bible also says that when we receive Jesus, when we believe in his name, he gives us the right to become children of God, not like when we’re born physically but when we’re born spiritually—of God.”
Evan nodded, tears still running down his cheeks.
“So, my friend, if you’re a child of God and I’m a child of God, then what does that make us?”
He thought a moment and then smiled. “Brothers?” he whispered.
I smiled and nodded.
“I’ve never had a hug from a brother,” he said quietly.
I slowly pulled him up and felt his arms encircle my shoulders.
He was very, very weak, but his hug was very, very real. After we hugged, I eased him back down.
“Would you like to see a pastor today to talk a bit more about this?”
He smiled, nodded, and squeezed my hand.
We were quiet for a moment as I thought about our extraordinary encounter. I hadn’t been trained to incorporate spirituality into my medical practice, and despite my initial discomfort, my time with Evan had seemed so spontaneous and sincere. Once Evan gave me permission to share all of who I was as his physician, it had seemed natural.
“Evan, I need to go check that X-ray, okay?”
I went to the X-ray reading room, and on my way back to ICU, I saw one of the RTs running toward the unit. I walked quickly into ICU and arrived just in time to see Evan surrounded by nurses and in the process of being intubated by the RT.
“He just had a respiratory arrest. BP has bottomed out. Bradycardia. Okay to get him on a ventilator?”
I nodded my assent and went to work.
But from there, things went downhill fairly quickly.
Evan’s pneumonia quickly evolved into ARDS—a severe form of respiratory disease that is very difficult to treat—and then he went into kidney and liver failure. He died late that afternoon.
The autopsy report confirmed the pneumonia but blamed it on a bacterium I’d never treated before—Pneumocystis carinii.
The report also confirmed multi-organ failure and a form of cancer—Kaposi’s sarcoma—but said the cancer was confined only to his skin.
I could only assume, with what I knew then, that this unusual infection had overwhelmed his immune system and caused his death.
I called Richard’s shop to give him the results, but the number had been disconnected.
I then called Richard’s home—but, once again, the number had been disconnected.
Ella Jo told me she heard that Richard had closed the shop soon after Evan’s death and left the area. I was never able to find him, but I wondered if he didn’t know, even then, that Evan’s death had in some way been related to their relationship.
For Evan had not died of cancer. Nor would such a mild bacterium have overwhelmed an intact immune system.
I now know he died of a disease that was then unnamed—HIV/AIDS.
So Evan was my first patient with this horrible disease.
But he was also the first patient with whom I shared my personal faith so forthrightly—and the first to so openly ask me to do so.
Looking back over a long career in family medicine, Evan’s case and his decision to give his life to Christ represented one of the high points.
But what his autopsy did not show, and could not show, was that Evan died a new man—spiritually.
He had become a friend of God. He had been born as a son of God on the day we celebrated the birth of the Son of God.
And his life truly began the morning of the day it ended.
I know I’ll see him again one day. I hope he’ll give me—his brother in the Lord—another hug.