CHRISTMAS FIRSTS (PART 1)
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.” “A guy?”
“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 willing 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, shortness 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.
When 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 was there. He found the patient’s films and put them on the viewing box. “Looks like 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?”
“Yep.” 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.”
“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.
TO BE CONTINUED
PAST STORIES FROM BRYSON CITY SEASONS
- Dead Man Standing (Part 1), (Part 2), (Part 3)
- Eyes Wide Open (Part 1), (Part 2)
- Auspicious Accidents (Part 1), (Part 2)
- Answered Prayers (Part 1), (Part 2), (Part 3), (Part 4)
- Rotary Luncheon
- Death by Emotion (Part 1), (Part 2), (Part 3), (Part 4)
- The Invitation (Part 1), (Part 2)
- Barbecue and Bacon (Part 1), (Part 2)
- A Touchy Subject
- Family Time (Part 1), (Part 2)
- Chicken Pops(Part 1), (Part 2)
- Swain County Football (Part 1), (Part 2)
- Hospital Politics (Part 1), (Part 2), (Part 3)
- The Bobcat Attacks (Part 1), (Part 2)
- Dungeons and Apples
- A Tale of Two Surgeons (Part 1), (Part 2), (Part 3)
- Tanned Feets (Part 1), (Part 2), (Part 3)
- Wise Counsel (Part 1), (Part 2)
- An Anniversary to Remember (Part 1), (Part 2)
- Mrs. Black Fox (Part 1), (Part 2)
- The Littlest Cherokee (Part 1), (Part 2)
- Christmas Firsts (Part 1), (Part 2)
PAST STORIES FROM BRYSON CITY TALES
- The Murder (Part 1); (Part 2); (Part 3)
- The Arrival (Part 1); (Part 2)
- The Hemlock Inn (Part 1); (Part 2)
- The Grand Tour (Part 1); (Part 2)
- The Interview (Part 1); (Part 2); (Part 3)
- Settling In (Part 1); (Part 2)
- First-Day Jitters (Part 1); (Part 2)
- Emergency (Part 1); (Part 2)
- The Delivery (Part 1); (Part 2)
- The “Expert” (Part 1); (Part 2)
- The Trial (Part 1); (Part 2)
- Shiitake Sam (Part 1); (Part 2)
- Wet Behind the Ears (Part 1); (Part 2); (Part 3)
- Lessons in Daily Practice (Part 1) — Anal Angina; (Part 2); (Part 3); (Part 4)
- White Lies
- The Epiphany (Part 1); (Part 2)
- Becoming Part of the Team (Part 1); (Part 2)
- Monuments (Part 1); (Part 2)
- My First Home Victory (Part 1); (Part 2)
- Fisher of Men (Part 1); (Part 2)
- Fly-Fishing (Part 1); (Part 2)
- Something Fishy (Part 1); (Part 2)
- A Good Day at the Office
- An Evening to Remember
- Another New Doc Comes to Town
- ‘Twas the Night Before Christmas (Part 1); (Part 2)
- A Surprising Gift
- The New Year (Part 1); (Part 2)
- The Home Birth (Part1); (Part 2); (Part 3)
- The Showdown (Part1); (Part 2); (Part 3)
- The Initiation (Part 1); (Part 2); (Part 3)
- Home at Last (Part 1); (Part 2); (Part 3)
© Copyright WLL, INC. 2017. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.