Bryson City Tales (14 page)

Fred's legacy lives on in those he taught—by word and deed—that success in life is not defined as just being excellent at what you do, but as doing the excellent in an excellent way, even when there is no obvious reward for doing so. Fred taught me early in my career that the difference between extraordinary and ordinary is the “extra.” And I was able, in the end, to get beyond the fact that this important lesson was learned at my expense!

I was new to this small town. But the town and its ways were certainly not new. I had so much yet to learn.

chapter twelve

SHITAKE SAM

S
am was one of the entrepreneurs in town. Oh, he would never use such a term. But when it came to trying new ideas, he was the man. His dad had farmed the end of a small hollow near Bryson City—mostly corn and burley leaf tobacco. In those days the tobacco brought in more money, but the corn was useful as a supplement crop and to feed the livestock during the cold, gray winters. However, the crops could only be grown on the valley floor and the more gentle slopes, which left a fair amount of steep forestland.

Now, the forest could be logged every few years, but that didn't provide for the year-to-year needs of the farm or the family. With tobacco prices dropping, and with an upsurge of out-of-towners demanding more exotic menus in the local inns and in the finer restaurants in Asheville, Sam took a hankering to learning how to grow mushrooms.

He had talked first to Mr. Lyday, the county agriculture agent, who didn't have a clue about mushrooms or how to grow them, or even if they
could
be grown in our part of the country. But a call to Raleigh resulted in a small bundle of information. Indeed, a particular brand of mushroom, the Shitake mushroom, loved a hot, humid summer and a cool to cold but damp winter. They did not do well in the direct sunlight, but it was said they would flourish in the relative shade of a forest floor. Furthermore, the ideal growth medium for this particular type of mushroom was a dying oak tree, and our oaks in the Great Smokies seemed to be one of the oaks they loved the most.

So Sam learned how to drill a one-inch hole all across the top of the oak logs, pack a plug of sphagnum moss into the hole, and sprinkle the mushroom spores on top. He ordered the spores all the way from Japan, and while waiting for them to arrive he rigged up a sprinkler system using the crystal-clear, ice-cold water flowing from one of the several small branches (or creeks) on the property.

It wasn't too many years before Sam's entire forested cove was covered with logs growing the newest cash crop of that century. Others in Swain County had smaller patches of Shitake, and before too long, trucks from Knoxville, Asheville, Waynesville, and even Sylva were dropping by Bryson City once a week to pick up the luscious, fresh Shitakes. Why, Sam even gave a talk at Rotary Club about his Shitakes—and that's where we first met.

Our second meeting was in the emergency room. I was there, sewing up a minor hand laceration, when the call came over the radio.

“Louise, this is Rescue One.”

Now since there was no Rescue Two, I was frequently amused by this type of call. I guess the Swain County Rescue Squad was just planning for the inevitable future growth.

“Go ahead, Rescue One,” Louise responded.

I threw and tied the last stitch, which was admired by its new owner, and then began dressing the wound while Louise learned about our next guest.

“Louise, this is Don. I've got Shitake Sam with me.”

I hadn't heard this nickname before but knew immediately to whom the paramedic was referring.

“He's busted up his ankle pretty bad. We've put an air splint on it. His vitals are OK. But he's already taken a fair amount of anesthesia.”

His anesthesia, I suspected, was crystal clear, drunk from a Mason jar, and nearly 150 proof. I suspected we'd smell Sam well before we saw him.

“Ten-four, Rescue One. What's your twenty?”

“We'll be there in ten, Louie.”

“Louie” was their nickname for Louise. I could call her Louise but never Louie—at least not yet. Only a few of the locals could call her Louie and get away with it.

“Doc!” Louise exclaimed. “What you doing making a dressing here? Don't you know that's my job?!”

She continued to fuss as she completely redressed my patient's wound. I thought I'd done a pretty good job, but I was continuing to learn my proper place in the scheme of things. And dressing wounds was
not
the doctor's place.

While Louise wrapped and fussed, I finished my paperwork and wrote a proper prescription for a pain reliever and an antibiotic. At Duke I would have seen my patient back in twelve to fourteen days to remove the stitches. However, here he'd see Louise for the suture remove. I'd learned that this was just the way it was in Bryson City.

I heard the beeping of the ambulance as it backed up to the emergency room entrance, and in a few moments Don and Billy walked in with Sam and his stretcher in tow.

After quickly transferring Sam onto the emergency room gurney, Don turned to me. “You may not remember me, Doc. Don Grissom. Billy and I met you up at Clem's place,” and he quickly thrust out his hand to grasp mine. His hand was rough, calloused, huge, and strong. It enveloped mine, yet almost gently gave it one pump.

“Sure, I remember you,” I said. “Good to see you.” I remembered that night only
too
well.

The smell of Sam's alcohol-induced “anesthesia” and the deep snores indicating its effectiveness inundated the emergency room.

“Doc, his pulses and sensation in his feet are fine,” Louise reported. “I'm gonna take him on over to Carroll in X ray.”

In most ERs the doctor does a history and an exam. But the scheme of things here was that those were part of the nurse's duties. The doctors in town—in order to preserve their sanity and to try to spend some time at home when on call—leaned quite heavily, as they did in those days in many small rural ERs, on the eyes, the ears, the skills, and the experience of the ER nurse. In a few minutes, Sam, his snores and smell, and his X rays were back.

“A trimalleolar fracture,” Louise announced confidently. “I'll get him ready to cast.”

Before I could catch myself, I blurted out, “Cast? Are you crazy?”

Sam and his gurney ground to an immediate halt.

Louise, looking half-incredulous and half-incensed, cocked her head and said, “Dr. Larimore, I am
not
crazy, and I'd suggest that you
never
speak to me in that tone again.”

I could feel the blood rising in my face. “I'm sorry, Louise,” I apologized. “But at Duke . . .” She didn't even let me finish my statement. I was going to tell her about the studies showing how well these fractures do with an operative technique called ORIF (Open Reduction and Internal Fixation), which means that we surgically open the fracture site, wash out the blood, and then use wires or screws or other hardware to hold the bones together while they heal. I wanted to tell her how I was experienced in assisting the orthopedic surgeons in doing this operation and how quickly we could expect Shitake Sam to be back on his feet. In fact, with the newfangled fiberglass cast, he could even be tending his mushrooms soon. But I wasn't able to finish my lecture.

“Young man,” she almost snarled,
“you're
not
at Duke, you're in
my
ER. I'd recommend you
not
forget it!”

I stood aside, chastised and befuddled. I'd been around a lot of strong-willed ER nurses, but never one like Louise.

“I'll shave his leg, prep for a hematoma block, and get the plaster ready.”

Now she 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, 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 befuddlement.

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

Now I was at the absolute height of bewilderment. “Skintight 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. 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 . . .”

chapter thirteen

WET BEHIND THE EARS

A
few days later Dr. Mitchell and I were discussing several of the patients I had seen in the office the day before—as well as looking at some of the plans for the new office building. I was growing to appreciate Mitch's wisdom, experience, and common sense. Suddenly Helen came in to tell me, “Walt, your first patient is ready and in the procedure room.”

“Whatcha doing, Walt?” inquired Mitch.

“I don't know,” I answered. I looked up to the nurse. “Helen,
what
am I doing?”

“Well, I'm no doctor . . . ,” she began, with her usual and somewhat sarcastic disclaimer, “but it looks like a small nonin-fected sebaceous cyst.” She paused for a second and then inquired, “You gonna use the iodine?”

At first I thought she was discussing the substance I would use to clean the skin prior to making an incision to remove the cyst. I thought,
Doctors haven't used iodine for operative prep for
years. Most doctors use Betadine.
My mind quickly reviewed our protocols at the hospital.
Dr. Mitchell uses Betadine in the OR.
Wouldn't he use the same thing here in the office?
So I decided to question her question—not necessarily a wise decision.