Bryson City Tales (41 page)

“Lotta blood in there,” Mitch commented. He was now situated next to Kim at the head of the bed, where he could see the whole operation. Front-row seat, we called it. Best seat in the house.

When Ray nodded that he was done with the prep, I threw the sterile drapes into place. Nancy expertly handed us the clasps to hold the drapes, not only onto each other, but also onto the patient.

The OR door cracked open, and Betty Carlson, the head of the hospital lab, with a mask held tentatively over her face, shouted, “Ray, her hematocrit is 16, white count 25,000 with a left shift, lytes are OK, and blood is O positive.”

The hematocrit is the percent of the blood that contains red blood cells. Normally forty percent of the blood is red blood cells. Susie had lost over half of her blood into her abdomen. A normal white blood cell count is ten to twelve thousand. An elevated number like this could mean infection, but most likely not in this case. We are created so that if we have a sudden stress or accident or bleed, the bone marrow will pour hundreds of thousands of white blood cells into the bloodstream. These cells are on the lookout for foreign invaders that they can attack and kill. So, like soldiers, some are on patrol in the blood vessels, while most await action in the barracks—the bone marrow. In Susie's case, they were called into action, along with the reserve oxygen-carrying red blood cells of the bone marrow—all engaged in the effort to save a life that was quickly ebbing.

“Thanks, Betty,” shouted Ray. “Kim, run in the next three units of blood as fast as you can. Walt, let's go.”

For a moment the world stopped.
Walt, let's go.
Usually it was Mitch speaking. Usually, Mitch would say, “Ray, let's go!” Here was Ray in Mitch's place, and me in Ray's.
Did they trust
me? They must
.
Wow! What a moment!
I felt fully a part of the team. No special ceremony. No certificate of advancement or completion. Just a silent confirmation that I was one of them. Goose bumps jumped up on my arms.

Nancy slapped a scalpel blade into Ray's hand, and in one clean motion he sliced from above Susie's belly button to her pubic bone, all the way to her peritoneum—the lining of the abdomen. Usually he would cut the skin first, then with a second scalpel, the fat. Then any skin or fat bleeders would be carefully and slowly coagulated. The rectus muscle, the big muscle in front of the abdominal cavity, would then be carefully separated down the middle—and then, and only then, could the glistening, nearly transparent peritoneum be seen. But in life-threatening situations when the abdominal cavity needed to be accessed suddenly, surgeons are trained to get in fast.

Instinctively, Ray and I used forceps to grab opposite sides of the peritoneum sac. Instead of being clear, it was an ugly blackish-purplish color, indicating to us a copious amount of blood beneath. In unison we lifted the sac away from the fragile bowel we knew lay below. Ray made a puncture wound in the sac. “Lots of irrigation, Nancy.”

As the dark blood practically erupted through the opening, we each inserted the index fingers of each of our hands and the four fingers each instantly moved toward a different quadrant of the abdomen, ripping the tissue-thin peritoneum open. Nancy, using her right hand, began to pour in a large container of warmed saline solution that she had prepared prior to the surgery, while with her left hand she inserted a large suction tube into the abdominal cavity. Ray and I were scooping out large blood clots with our hands.

As Nancy suctioned, I grabbed an abdominal wall retainer and inserted it into the wound—both to hold the edges of the wound open and to protect the now exposed bladder. I could feel the blown-up balloon of the catheter in the bladder. Ray called out, “Louie, the catheter is in good position.”

Louise called back, “We're getting clear urine, Dr. Cunningham. And don't call me Louie!”

I could hear Ray snicker as he used towels—called laps—to push the small intestines up into the upper abdomen and hold them in place. As I irrigated and suctioned, Ray quickly located the uterus. Around it was swirling a torrent of bright-red blood.

“Kim, she's well oxygenated,” Ray instinctively called to his nurse anesthetist. The bright-red color meant that Kim was delivering an adequate supply of oxygen to Susie's lungs. Ray lifted the uterus out of the pool of swirling blood with his left hand, a clamp in his right hand poised above the wound. The uterus, shiny and purplish, about the size of a pear, appeared a bit larger than normal. He looked at Susie's right fallopian tube—it was completely normal.

Ray quickly turned the uterus ninety degrees so that the left fallopian tube came up out of the expanding pool of swirling bright-red blood. There it was. A mass of purplish-reddish tissue in the middle of the tube—and from that mass spouted a geyser of blood that shot out of the wound and across Susie's legs.

A new life, conceived in the middle of the tube where egg and sperm had met, for some reason did not travel into the uterus to implant. For some reason it had become stuck in the tube. Maybe there was a scar in the tube from a previous infection. Maybe Susie was born with that fallopian tube being narrower than usual. But for whatever reason, the new life, stuck in the tube, had implanted there and had begun to grow. It may have been growing for four weeks, maybe eight weeks—rarely longer. But finally the tube could no longer hold the expanding life. The tube had ripped open, and the blood-rich pregnancy began to hemorrhage. The preborn child quickly died, but the hemorrhage continued—and, in Susie's case, intensified. Before she knew what had hit her, over half of her entire blood supply had drained into her abdomen, robbing the oxygen and blood pressure that her brain needed, and she fainted—all in all an uncommon but not rare presentation for a ruptured ectopic pregnancy.

In a flash Ray passed the jaws of his clamp in front and behind the tube, right next to the uterus, and closed the jaws. Immediately the bleeding stopped. I could hear an audible sigh from behind his mask. “Thank God,” he whispered. I echoed his relief. I continued to irrigate and suction, and in a moment the blood in the pelvis was gone.

“Ha, I knew it. Boys, I knew it. Couldn't be anything else,” bragged our senior observer from the head of the table. “I think she'll be fine. While you boys are moppin' up, I'm gonna go join my beautiful bride for lunch.”

As he turned to leave, he commented, “Kim, Peg, Nancy . . . ,” he paused for effect. “Well done!”

He began to move, then stopped in his tracks and turned to Louise, who was sitting on a stool by the wall. “Oh, and
Louie
. . . ,” he snorted, “good to see you.” He began to laugh.

“That's
not
funny, Dr. Mitchell. You can just go ahead and leave
my
hospital right
now. You go ahead and get out of here. These young boys don't need your poor example. You've been here
far
too long not to know better. You're about to get me irritated and mad. So get on out of here, you hear?”

Mitch was just laughing, his eyes sparkling behind his surgical mask as he looked back over at me and winked. “Louise, I'm leaving. But there's not a lot I have to teach these young university-trained docs anyway.” Then he was gone.

We closed Susie up. By the time she was in the recovery room, her hematocrit was over thirty, and her vital signs were normal. Her left fallopian tube was resting comfortably in a small container of formaldehyde. The pathologist would in a day or two confirm the ruptured tubal pregnancy. Susie would recover—and go on to have several more children.

As I walked back to our house, I decided to take a detour to look at the new office building. It was coming along nicely. The Norwegian spruce we had planted after Christmas was doing well, with plenty of new growth. The view from the office up the Deep Creek Valley was magnificent. I couldn't wait to move in.

I made my way back to our little house by the hospital and went around back to sit on our bench. I was looking out over the Smoky Mountains. I could just begin to see the change in the colors of the leaves—or was it only my imagination? Nevertheless, before long the hills would be ablaze again, as they were one year ago, as they had been for countless falls and would be for the falls of the future. I took a deep breath. The clean, crisp air was cool in my lungs—the mountains and the seasons appearing to me as they had to my professional predecessors for over a century.

After that day I was no longer the same. My initiation into this small town was complete. I felt fully on board with the medical team and was beginning to feel a welcome part of this small, closed mountain community. I also felt an intense admiration for a group of aging but skilled physicians who had taught me so many lessons that could never be learned from a textbook.

My life now bore the thumbprint of the folks of Bryson City. Their pleasures and tragedies, their wisdom and faith, their traditions and stubbornness, their loyalties and wounds, their preferences and prejudices—all had shaped the man, the husband, the father, and the physician that I was becoming.

I now knew why they called it the
practice
of medicine. And I was coming to understand that my skills in medicine, in faith, and in life itself would never be mastered. I'd just have to keep practicing and practicing and practicing . . .

Read an Excerpt from
B
RYSON
C
ITY
S
EASONS

chapter one

DEAD MAN STANDING

I
t was one of those swelteringly hot summer afternoons the Smoky Mountains are known for—sticky and unyielding. Not even the heavy, sultry air was moving.

“You didn't tell me about this!” my bride of nine years complained.

“About what?”

“About this heat! If I had known it was going to be this hot in the mountains, I might have just stayed in Durham and let you come up here by yourself!”

Barb turned to smile at me—one of those “you know I'm kidding” smiles I had grown to love. She turned back to face the mountains. “At least I would have asked the hospital to put an air conditioner in the house!”

We were sitting on the park bench we had placed in our backyard when we moved to Bryson City, North Carolina, over a year ago. It looked out over an exquisite view across the rolling hills of Swain County Recreational Park, then up and into Deep Creek Valley, and finally all the way to the distant mountain ridges—deep in the Great Smoky Mountains National Park—that separated North Carolina from Tennessee.

The view was mesmerizing, and we had now seen it through each of the four seasons—my first four as a family physician—since finishing my family medicine residency at Duke University Medical Center the year before.

“I didn't know it would be this hot,” I commented. “But then, there were so very many things I didn't know, weren't there?”

Barb threw her head back and laughed. My, how I loved her laughter!

“True enough!”

We both silently reflected on our first year of medical practice. I had left residency so full of myself. Indeed, I had been very well trained—at least for the technical aspects of practicing medicine. But when it came to small-town politics and jealousies, the art of medicine, the heartbreak of making mistakes and misdiagnoses—all piled on top of the difficulty of raising a young daughter with cerebral palsy, dealing with one strong-willed, colicky little boy, and transitioning a big-city girl into a rural doctor's wife—well, the task was not only daunting but had been totally unexpected.

Barb turned to look at our house for a moment. She was listening for the children. Kate and Scott were both lying down for a nap. We had the windows in our air-conditioner-less house open—both to capture any passing breeze that might come our way and to hear the children if they were to awaken.

Rick Pyeritz, M.D., my medical partner for nearly a year and also a classmate in our family medicine residency at the Duke University Medical Center, was on call this day for our practice and for the emergency room. In this small hamlet, the on-call doctor was truly on call—for the hospital, the emergency room, the sheriff and police departments, the national park, the coroner's office, the local tourist resorts and attractions, and the area nursing home. But the fact that one of us would cover all the venues in which medical emergencies might occur made it very nice for the other six physicians in town who weren't on call.