For the last two days, I’ve posted on the controversial topic of homosexuality. On Sunday I posted What if your son asks, “Am I gay?” and What the Bible says about homosexuality. Yesterday I posted one of my most read blogs in some time, How I wish the homosexuality debate would go, and the Christian Medical Association’s Statement on Homosexuality. Today I want to share a story of how I applied the principles and truths of these first four blogs in caring for a dying patient way back in 1983.
This story was first published in my best-selling book, Bryson City Seasons. This book was one of three (including it’s prequel, Bryson City Tales, and its sequel, Bryson City Secrets) in which I describe the events from my first four years as a family physician in the small Smoky Mountains hamlet of Bryson City, NC.
My partner in practice, Rick Pyeritz, MD, and I were sharing a moment and a cup of coffee, the week before Christmas, when he said, “I want to talk to you about Evan.”
I cocked my head. “Evan?”
Rick explained, “Haven’t you met him? He’s an older man—I’d guess sixty or so—and he and his partner own the art and flower shop over in Dillsboro.”
I responded, “I bet Barb’s been there, but I don’t think I ever have.”
“Walt, it’s a great shop and I enjoy going over there.”
I was curious. “Who’s his partner? Do I know her?”
Rick took a sip of coffee. “I would guess not. Evan’s partner is actually a guy whose name is Richard.”
“A guy?” I asked.
“Yep.” Rick answered. “They live in Whittier and I think they are pretty well accepted in that area—although I’m not so sure they’d be well accepted in Swain County.”
I nodded and took a sip of coffee.
“Anyway,” Rick continued, “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. The lesions were symmetric on both legs. They look like purplish papules.”
“Gosh Rick, when I think of purplish papules, I think of lichen planus or lymphomatoid papulosis.”
“Me too!” Rick exclaimed. “But, these just look different. Can you think of any sort 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 1970’s. “Other than the sexually transmitted diseases, I don’t think I know of any.”
Rick nodded and continued, “Me neither. I told Evan that, but I also told him I thought a lesion should be biopsied for safety sake—just to be sure it’s not some sort of melanoma or something like that. He’s decided to come over here and let me do it.”
We were quiet a second—both developing in our minds what doctors call differential diagnoses. When a doctor sees a patient, the first two steps are to take a history and then perform an exam. With this information, the doctor comes up with 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 had been taught to always think of the worst possible diagnosis or 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. I knew Rick was thinking the same. For internal cancers to cause an unexpected loss of weight and fatigue, as well as have cutaneous signs, was not unusual.
“Rick, I think it’s a compliment that he’s willing to come over here. Seems like most folks in that area get their care in Sylva or Waynesville—many even travel to Asheville.”
“I agree, Walt. But, it seems like folks are more willing to stay here for their care. And, I think that’s good.”
I nodded and we finished our coffee and began seeing our patients.
The day before Christmas morning, 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 the 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.” Louise Thomas had run the ER and the local doctors for more years than most folks could remember. 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 102o, a productive cough, a low white blood cell count, shortness of breath and a low oxygen level. The RT is down here and I’ve got him on oxygen.” She paused for a moment and then continued, “The patient is an older white man and he is skin and bones. I think he needs to be in the ICU.”
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 that this probably represented 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 their disease process, when treatment and sometime cure was 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 patients. That OK?”
“Sounds good, Dr. Larimore. I’ll let you know if you need to get up here any quicker. And…” Louise paused.
“And, what?” I inquired.
“And, you can leave your smarty side down there in that office before you come up here to my ER!” Before I could respond, she hung up.
When I arrived at the hospital, I first went to the X-Ray suite. Carroll Stevens was there. He was a great radiology technician and headed the X-ray Department. Although Bryson City had no radiologist in town, a consulting radiologist from a nearby city came over three days a week to read X-ray studies and to perform procedures like upper GI series and barium enemas. In an emergency, a radiologist could be called to travel the twenty-five or thirty miles to come help us out.
Carroll found the patient’s films and put them on the viewing box. “Looks like an atypical pneumonia, Walt. But, by the look of the patient, I’d guess cancer.”
I nodded. Carroll was as good at reading films as most radiologists I knew. “Thanks, Carroll. Best go take a look at the patient.”
“He’s interesting, Doc, I’ll tell you that.”
Aren’t they all I thought to myself.
When I got to the nurses station, I was met by Peggy Ashley. Peggy had been at the hospital for many years. She led the choir at the Presbyterian Church when she wasn’t nursing at the hospital and was married to Joe, a Ranger at the National Park.
“Hi, Peggy!” I called out as I entered the nurse’s station.
“Hi, Dr. Larimore. Here to see the new admit in the ICU?”
“Yep.” Our “ICU” was really just a former four-bed ward that was converted to care for our sickest patients. It was the closest room to the nurse’s station—which was good for the patients and the nurses.
Peggy walked over to me and whispered, “You gonna tell him what he’s got?”
I whispered back, “Guess I better figure out what that is first, don’t you think?”
Peggy smiled. It was not unusual for the nurses to know what was going on far before the doctors did. She handed me the chart. The name of the front was Evan Thomas. Could this be the Evan that Rick 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 visitor exclaimed. “My name’s Richard White.” He pointed to the man in the bed. “Evan and I know your partner—he often visits our shop in Dillsboro. We were hoping either you or he would be willing to care for us.”
I now knew this was the couple Rick had been telling me about. I tried not to show any surprise. “Richard, Evan, it’s good to meet you.” I then turned my attention to Evan, taking a complete history and then doing a complete physical. When I was done, I pulled up a chair. I always felt it was better to communicate face-to-face, and sitting with patients helped me accomplish that. I was never pleased to be around doctors who felt they had to stand over the patient—which always seemed to be to be a power thing.
“Evan,” I began, “I think you know you’ve got pneumonia.”
“But, it’s not a typical pneumonia. It’s atypical. Given your weight loss and fatigue, I’ve got to 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?” Evan asked.
“It depends on the type,” I replied. “But, my guess is that it’s probably already widespread. So, we’ll just have to see.”
He looked straight into my eyes. “When can we start?”
I explained, “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, I made early morning rounds—well before Kate and Scott would wake up and we would celebrate Christmas. I found Evan alone but awake. I greeted him and sat on the bed. He 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 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. OK?”
He nodded, but I sensed there was something on his mind. “Anything else I can do?” I asked.
He looked away, out the window, at the darkness surrounding the hospital, and then back at me. “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.”
“Why’s that?” I asked.
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 a moment. I was trying to think about how I might respond to this man’s honesty and transparency.
“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 his eyes begin to mist. “Doc,” he began, “When I was a kid, church was important to me. I really enjoyed going—but, never more than on Christmas Eve. But, when I grew up I just grew away from it. I don’t think your God would ever want a relationship with me. In fact, I think he might just be punishing me a bit.”
For a moment I thought about the Bible verse that says, 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 that Evan felt comfortable enough to open up with me about what was on his heart. But, I had always been taught 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.
“Evan, this much I know for sure. I know God would want to have a relationship with you. The Bible clearly says that God loves each of us. In fact, He loves us so much that He sent his 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, He’s willing to begin that relationship with you—today—but only if you want to.”
Evan looked away, out the window of the ICU. The darkness was starting to abate a bit as the daylight was just beginning. He whispered, “It would be a good day to start.”
I was quiet. Still looking out the window, 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?”
I answered, “I am.”
“You are?” he asked.
“Yes, I am,” I repeated. “But let me explain. Evan, the Bible explains that the sexually immoral and idolaters and adulterers and homosexual will not inherit the kingdom of God. But, Evan, it also says in the same verse that the greedy and the slanderer and the gossip and the swindler will not inherit the kingdom of God either.”
Evan was quiet in his thoughts, so I continued. “Evan, 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 continued, “Evan, the Bible has a lot of 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 to simply admit that we’ve missed the mark—that we’ve sinned and done wrong.”
Evan nodded and commented, “I guess I would qualify.”
I smiled. “Me too, Evan.”
Evan turned to look out the window once again. The sun must have just peaked over the horizon, for day was quickly getting brighter. I paused to let him think a moment as the tears continued to run down his cheeks. Evan whispered, between labored breaths, “I think I’d like to be his friend. That would be nice—especially on Christmas day.”
Then he turned and looked me in the eye. “Doc, how do I start?”
I took a deep breath and then explained, “Actually, Evan, it’s pretty easy. You just talk to God—what us thumpers call prayer. Let him 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.”
Then, he opened his eyes, smiled at me and squeezed my hand.
I smiled back. It was the shortest and sweetest prayer I had ever heard. “Evan, the Bible says that when we admit to God our wrongdoing—just agree with him that we’ve missed the mark—that he will instantly and eternally forgive our sins. And, based upon 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.
I asked him, “Would you like to see a pastor today to talk a little bit more about this?”
He smiled, nodded and squeezed my hand one last time.
“Evan, I best go check that X-Ray. OK?”
I let go of his hand, stood and left to go to the X-ray reading room.
On my way back to the ICU I saw one of the RT’s running toward the unit. I walked quickly into the ICU and arrived just in time to see Evan surrounded by nurses and being intubated by the RT.
“What happened?” I exclaimed.
“Doctor Larimore, he just had a respiratory arrest. BP has bottomed out. Bradycardia. OK 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 same afternoon.
THE AUTOPSY REPORT confirmed the pneumonia—but blamed it on a bacterium I had 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.
Evan had not died of cancer.
I now know he had 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 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 actually began the morning of the day it ended.
I know I’ll see him again one day. I hope he’ll give me a hug.