Bryson City Tales — Shiitake Sam (Part 2)

This is from the twelfth chapter from my best-selling book, Bryson City Tales. I hope that you’ll enjoy going back to Bryson City with me each week, and that if you do, you’ll be sure to invite your friends to join us.

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“I’ll shave his leg, prep for a hematoma block, and get the plaster ready.” Louise, the ER nurse, was talking heresy—at least to a Duke-trained physician.

Hematoma blocks were injections of an anesthetic agent, such as lidocaine, through the skin and into the fracture itself. They were used before a closed reduction and casting—not before an ORIF (operative reduction and internal fixation), which would have been, in my opinion, the correct treatment. Sam could be kept comfortable until he sobered up and then taken to the operating room for the recommended and modern ORIF. I was befuddled at her brashness.

She went on, seemingly not noticing my deepening befud- dlement.

“After you get him numb, I’ll help you with the skintight cast.”

Now I was at the absolute height of bewilderment. “Skin- tight cast?” I stammered.

She stopped, straightened up to her full five-foot four-inch frame, and stared straight up into my eyes, now on a slumping six-foot two-inch frame. “Doctor, you do know how to put on a skintight cast, don’t you?”

How was I to say no? I had never even heard of such a thing. And what’s more, all of my training in casting, most of it from the fabulous cast technicians at Womack Army Hospital in Fort Bragg, North Carolina, had emphasized the use of proper padding to prevent the cast from pressing against the skin— which could cause sores or ulcers.

My bafflement must now have been unmistakable. “Dr. Mitchell is your backup,” she muttered as she turned to roll Sam and his gurney into the ER bay and I turned to the phone. Surely Mitch could help me make some sense of this.

“Hello,” the obviously sleepy voice rasped.

“Mitch, this is Walt. I’ve got Shitake Sam here in the ER. He’s got a displaced, closed, trimalleolar fracture of the ankle with normal vascular and neural function, but he’s pretty loaded up with moonshine. I was thinking of putting him in a splint and then to bed. Can I put him on the OR schedule for you in the morning for an ORIF?”

“Does he have any abrasions or lacerations?”

“No,” I responded slowly. “If he had, I wouldn’t have wanted to put him on the schedule.” In cases where there are cuts or scrapes we’ll try to put off surgery if we can, to reduce the risk of infection when we finally do operate.

“Well, son, why not go ahead and place him in a skintight cast? Then admit him to keep the leg elevated and have the nurses check his foot circulation and sensation every fifteen to twenty minutes, and we can discharge him as soon as he’s sober and feeling well enough.”

I couldn’t believe my ears. I would later learn that this early twentieth-century technique had been almost completely replaced by surgical procedures—at least outside of this county. I must have been stone-silent or muttering to myself. Either way, Mitch picked up on my response.

“Son,” he slowly queried, “you do know how to do a skintight cast, don’t you?”

“Well, sir, I’ve got to tell you, we always operated on these types of fractures.”

“Son, this ain’t Duke.”

This was something I was quickly coming to recognize! Dr. Mitchell continued. “I bet I’ve been using this skintight cast technique for nearly twenty-five years. A whole lot longer than most of your professors have practiced.”

Well, in fact, that wasn’t true. A number of my professors at Duke had been practicing their craft for nearly four decades, but bringing that up at this particular moment didn’t seem appropriate.

“Now let me tell you,” Dr. Mitchell barked, “no one, and I mean no one, likes to operate more than me. I love being in the OR, just love it! But for this type of fracture, I think this approach works just fine. What’s more, I’ve only ever had to remove one cast because of swelling. It just plain works. That’s just the way it is.”

Again I remained silent. “Walt, you’ve got lots of book knowledge—great training, great education—but I’m here to tell you, the folks in the ivory tower of academics don’t have a monopoly on medical knowledge. There’s still lots of good old- fashioned medicine that works just fine. And it can be a whole lot cheaper to boot!

“Tell you what, son. Get Louise to show you how to do it. If you have any problems, give me a call.” Before I could respond, he hung up.

I followed the fumes into Sam’s ER bay. Louise had shaved his now splintless leg from the ankle to the thigh.

“Louise, I don’t think he’s gonna need a hematoma block. Would you mind helping me with the cast?”

She smiled. I think it was the first smile I ever saw from Louise. It wouldn’t be the last.

“Why, I’d be delighted to teach you what little I know, Doctor.”

The humility seemed both false and a tad bit out-of-place. But for the next twenty minutes this experienced nurse guided a novice in the task of very carefully wrapping and shaping his first skintight cast.

Then we rolled Sam down to the four-bed intensive care unit, and I watched as the nurses deftly slung his casted leg from an orthopedic bed frame. His foot was practically pointing toward the ceiling.

I left Sam, his snores, and his skintight cast in the capable care of the floor nurses. They assured me that they were used to caring for this type of thing. I was just hoping his foot wouldn’t fall off, should his ankle swell and the foot lose circulation.

I could hear Gary Ayers on the morning news: “Last night, the town’s newest physician . . .”



© Copyright Walter L. Larimore, M.D. 2016. 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.

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