A Complicated Man

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  medical        *
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I'm continuing to have some right occipital headaches that radiate into the right eye. I am still taking the basic medications for gout. My exercise tolerance is one flight of stairs. It has been six days since I have had a dose of steroids. I am using one or two oxycontin (12 hour tabs) per day. Since I broke out in a rash a few days ago, I have not used any more ibuprofen. I am sleeping about 4 hours at a stretch and my energy is improving slowly day by day. On Thanksgiving day I was limited to moans and groans when I was actually out of bed. I feel capable of making phone calls this morning.

A Complicated Man

My father died on the day after his 67th birthday after a long illness. At the time, my sister Suzanne and brother-in-law Ed were staying with him as they waited for their new home to be completed. He had company and help. Up until two years before, he had been caring for his mother in his home. She suffered from Alzheimer's disease and did not recognize him as her son. "He's too fat to be Billy!" As his lung and heart disease progressed he was unable to keep up with her needs and he found a board and care home for her in Charlottesville where she had died year previous to his own death.

My mother was finally able to separate from my father in the early 1980's. In spite of her episodes of depression my mother was a very social person. Church was always important to her and she had an ongoing fascination with reported appearances of the Blessed Virgin in places like Medjugorje where she eventually visited.
http://www.medjugorje.com/medjugorje-messages/43-latest-25-message/1259-our-lady-of-medjugorjes-november-25-2011-message.html
Her separation from my father was liberation where she started down the path to a new kind of life  free to enjoy her family, friends, and church. She was acquiring a momentum of wisdom. I hope that I have time to say a bit more about my mother, but not today.

If you recall, I was on my way to visit my father's 90 year-old second cousin in Georgia when this lung cancer became manifest. I wanted to know about his life before marriage, alcohol, and combat. Perhaps that won't be possible after all.

Having provided brutal details of his flaws and having portrayed our household as dominated and controlled by his moods and drinking patterns, the word that comes to mind when I think of him is WORK. He generally stayed very busy. Maybe this was a diversion from thoughts about drinking. At some time during his last ten years he told me how tired he was of thinking about alcohol--it was there as his master from the time he awoke every morning. Maybe work was a strategy for keeping it at bay.

Easter 1970 or 1971. Clockwise left: Dana, Molly, Mom, Dad, Kirk, Sue, Kris

This Easter Sunday picture demonstrates a typical work outfit for my Dad. He seldom allowed himself to watch a football game or to relax indoors. He needed to be busy at all times. If he were busy, there was a good chance that you would be busy as well.

His pattern was was to become very involved in a particular project that consumed most of his energy outside of his government job. I've described the acquisition of hand carpentry tools and the construction of built-ins in 1951. It was likely that there would be at least one focused period a year that totally consumed his time and attention. For example, sometime in 1956 he decided that he wanted a trailer for camping and to haul materials that were too big to fit in a car or on the roof of a car.

The Great Camping Trip of 1957
It had started with his desire for a camping trailer that could be hauled behind the Dodge sedan. The Dodge would move the six people in the family and the trailer would move the "stuff" that the six people needed for camping in comfort. 


Fully finished trailers were too expensive. His alternative was to begin with the frame of an automobile. However, that frame was still attached to the automobile, a British Ford, that appeared in our backyard one Summer morning. I remember a professional football player who acquired the nickname "hacksaw" by cutting a car in half. He always reminded me of my Dad who made good use of several hacksaws as he removed more and more of the body of that Ford and took it down to the frame. For years afterwards, our power lawnmower would encounter a fossil from the hacksaw days and spit out a nut or bolt reminder.


Once the steel rails had been exposed, Dad framed in the body of the trailer, essentially a box with various attachments for tying down loads. The final bit was the welding of the tongue of the trailer, the connecting link that held the female portion of the trailer hitch. The welding was done by "Shorty" an old time mechanic from the "old days" of Prince Georges County. He was held in awe by all the local mechanics, a god of the garages who always wore an old, red leather baseball-style cap stained with years of accumulated lubricants.


In July 1957 we were ready to embark on a 2 week adventure, camping our way to the paternal grandparents home in Erie, Pennsylvania then swinging across the state of New York to attend my Great Grandfather's 80th birthday celebration in Kingston, New York, south to Yonkers for more fun with family, and finally, camping on the Beach near Rehobeth Delaware.


We packed up started out around supper time. The first 100 miles were uneventful but then the trailer broke down in a rainstorm in Chambersburg, Pennsylvania. The weld of the tongue had separated and our trailer was useless. 


One of my father's talents was the ability to carry almost anything on the roof of an automobile. He was up this particular challenge. He removed the bench seats from the back of the Dodge and replaced them with footlockers from the trailer. Pillows on top of the footlockers would be our new seats. There was no roof luggage rack, but a tarpaulin and additional footlockers were tied into place and then covered with a large tent and tied down again. Mom went through all the the clothing and separated necessary from desirable. Within a couple of hours we were repacked and ready to go. The additional equipment, clothing, and auto upholstery were stored within the trailer which would be parked in Chambersburg for the duration of the trip and dealt with later.


We made it to Erie and camped in the backyard of our grandparents. However, on the way across New York state, we ran into heavy rains. Somewhere around Cooperstown, we noticed that our car roof was gradually sinking under the weight of the load and the accumulated water. We had exceeded the capacity of the auto's roof  to support our load and maintain its original shape. Further attempts were made to lighten what was on the roof but throughout the remainder of the trip the sunken roof hid our Dad's head from view from the back seat of the car.


This vacation was one of the high water marks of my childhood. I had never before seen the ocean. There was almost no alcohol use during the trip. Our parents worked together and solved the problems that arose in an efficient and successful manner. Kirk was a year old and everyone seemed to be enjoying having the little guy with us. The caved-in roof was a source of amusement. The only irritable people on the trip were the three older children who managed to get too much sun and were sitting in tight quarters in the Dodge with fairly significant sunburn. Even that snippiness lasted less than a day.

Last Harsh Words
My last confrontation with my father was the summer before my last year of medical school, a few weeks after the house fire. My mother and my two youngest brothers were living with me and he had called looking for them or for information about them. I told him that I didn't have any information for him and suggested that he use the mail to contact her. Apparently he was concerned about the insurance investigation of the fire and he warned me that "her money is at risk as well."

Sometime within the following few months, my mother had made the decision to "try again" and my parents both became very busy with the details of having their house rebuilt. My mother's decision made it very easy for me to separate from their toxic dance. At that point I had determined that my best course of action was to hold each of them responsible for their current position. I was also pretty sure from that moment forward that I wanted some geographic buffer to cushion me from the twists and turns of their relationship. I also realized that to see my younger brothers and my mother, I would have to deal with my father as well.

His Medical Problems
In 1971 my Dad called me on a Saturday morning and told me that he was having abdominal pain and asked if I would come take a look. I told him that it might involve a rectal exam as a bit of forewarning. He was feeling so poorly that he agreed. When I examined him that morning there were still bowel sounds and some left lower quadrant tenderness. Checks for hernia and the rectal exam were negative. I told him that I would recheck him in a few hours.

When I saw him in the late afternoon, he was sicker. There were no longer bowel sounds and he had other symptoms of peritonitis. He needed a surgeon and the nearest connection I had was at Maryland General in Baltimore, about an hour away. Unfortunately, I was driving the International Scout II, hardly a smooth ride. Nevertheless, in spite of his peritonitis, he managed to maintain a reasonable facsimile of a conversation for the entire drive. He had ruptured some diverticuli and there was some fecal spilling in the peritoneal cavity. However, I don't believe that a colostomy was done. When he awoke the pain was such that he was no longer able to sustain a conversation. He looked very hard at me and laughed. The surgical residents who had examined his belly before surgery were impressed with his stoicism and the mess that they found at surgery.

A couple of years after that, he had his first myocardial infarction. He was about 53 and this put an end to  his Federal work life and he retired, only to find a low level state job where he managed to hang on long enough to obtain another small pension. As he recovered from his heart attack, I recommended that he see the internist Richard Fisher in Baltimore and he did so.

I am sitting here thinking about Montana which brings to mind horses and cowboys and roundups and it occurs that my father's medical needs and conditions were an important opportunity for us to normalize our relationship to the extent that it was possible. In previous posts I have outlined some of the trauma that I experienced at the hands of my father. But from a reasonably early age I recognized that his own suffering was much greater than mine.

Although I haven't laid out the groundwork for some of the following, I have always believed that my mother loved me to the extent to which it was possible for her to do so. Although there were times when I felt abandoned as a child, they were relatively infrequent and they occurred when my mother was being brutalized.

I didn't see any love coming my father's way from his family of origin and not much from my mother as well. He was the perpetual poor relative who was taken into his cousin's home as a rescued teen-ager. He was a latch-key child. His mother was an alcoholic who would leave the family for days at a time. My mother's family found Dad's parents to be mostly interested in night-clubs and strip joints, less interested in more sociable night spots where you could drink and dance with friends in a social atmosphere.

In 1983 I had the opportunity to spend a few weeks with my father. His  heart attack 9 years before had identified the coronary artery disease. He had developed angina that became increasingly severe and by 1981 his doctor recommended that he have coronary artery bypass surgery. I was in Billings at the time where a new team of Cardiovascular Surgeons had set up shop. The physician I knew was Timothy Dernbach who had been trained under Denton Cooley in Houston. Dernbach's team had come to town and created a new, model surgical program. It's not just about the surgery, it's about everything. Their results were very good.  I persuaded my father to come to Billings to have his bypass surgery. His cardiologist was Robert Zirpoli. My father was not impressed with Dr. Zirpoli's choice of clothes (too much Sears) and I tried to explain that Dr. Zirpoli's brain mattered more than the fit of his clothes. I happened to like Dr. Z's blissful ignorance of clothing.

(There is a wonderful movie, What God Has Made, that shows Denton Cooley as one of a small handful of Hopkins surgical residents that were willing to assist on a surgery of the heart. The movie also depicts the racism of the 1940s  in Baltimore.)

My parents had been separated for a year or more at the time of his scheduled bypass surgery and I received a call from Dad's girl friend the night before his scheduled surgery. She related that she had a really "bad feeling" about this particular surgery being done in Billings, Montana. She wanted to warn him off. I told her this was the last thing that he needed to hear from anyone. I expressed gratitude that she was in his life and that she cared about him, but I told her that I was going to have to pull rank--that I was a physician, that I knew the people doing the surgery, that I knew for a fact that they were as good as anybody, and that he would get some extra attention as my father. I  told her he was asleep and needed that sleep.

After several days of tests and at least one insurance biopsy, the fateful day for admission came. My dad was very curious about the procedure, particularly about the way in which the surgeons could suture arteries in a beating heart. I had told him, that they would use a bypass pump to take over the heart's work for a few minutes and that they would cool down and stop the heart while they did what was required. He nodded an understanding.

My dad and I were watching an NFL playoff game and we had agreed to leave for the hospital immediately thereafter. At the end of the game, we both stood up, but when I glanced at him, he appeared very distressed and he stumbled and sat back down. He put his hand over his chest and said, "I need a couple of minutes." I had never seen my father look so scared and so frail. This wasn't the giant who had chased me down Ray Road when I was 15.

Then we were good to go. He never complained. He ended up with two surgeries. After the bypass surgery, he became unstable because he was bleeding into the pericardium, a condition known as tamponade. The pericardium is a cellophane-like membrane that slips over the external surface of the heart. The pericardium does not distend, so when it fills with fluid, there is a corresponding loss of potential space within the heart. With enough fluid in the pericardium, there is a loss of pumping ability and the heart can no longer keep up with demand. The treatment is to drain the pericardium and that was the second operation that he had that day.

When I finally saw him in the recovery room, it was hard to recognize him because of the enormous amount of head and facial swelling. His recovery occurred on schedule. However, about 1 week after his surgery, I smelled cigarette smoke in the bathroom of his hospital room. He never did stop with the cigarettes. He came home from the hospital and stayed in our Billings home for a few weeks until he felt strong enough to head back east.

As he was about to leave he asked if he could buy Molly a gift. I told him that she had said something about wanting a kerosene heater in the basement of our rancher. I felt terrible when he said that he couldn't afford to do that. Would you be surprised if I told you that he settled on a wine rack?

My Dad in West Virginia
In 1977 as I was struggling in Glendive, my father had called and asked if he could help me get the West Virginia house on the market for sale. I agreed and he was helpful in providing a feast and party for friends and family who spent the day constructing a new deck on the portion of the house overlooking the lake and river.

Allowing my father to use the West Virginia house generated one of our favorite family stories.

The Blue Hornet.
My brother-in-law, Ed Rader, and Bill Sohr are going up to the West Virginia house in 1978. They are driving an American Motors Hornet that could have circled the world four or five times. There are only two gears that can be engaged, 2nd  (out of three on the steering column) and Reverse. On occasion, they have lost Second Gear as well, in which cases, Bill has scrambled under the car with a hammer and banged around on the transmission with success.


On this particular day, they have exited the mountain road from the A Frame and are on route 340 heading East toward Frederick when they suddenly lose Second Gear again. Bill gets out with the hammer and bangs around for 15 or 20 minutes without success. Bill then directs Ed to walk to the gas station they passed about a mile or so back. Ed is to call Dana and explain that they will need him to come pick them up at the gas station on Route 340.


Ed hoofs it back to the gas station and places the call to Dana. As he hangs up, Ed sees an odd sight. Rte 340 is a divided highway, two lanes on each side. In the leftmost of the West Bound Lanes is a blue American Motors Hornet traveling west with traffic but backwards. Bill has decided that even without a second gear, the reverse gear together with his expertise as a driver will permit him to get back to the gas station where smarter mechanical minds and more tools will increase the probability of success.


The hornet's right rear tail light begins to blink indicating a pending left turn. The hornet moves briskly into the left turn lane and then proceeds across the other traffic lanes and slides neatly into a parking place in the gas station.


His Last Year
During the last year of his life, I lived in Pocomoke City, about 150 miles from Baltimore. I worked as the medical director of a prison in Westover, Maryland. I was required to attend a day of meetings in Baltimore on the first Wednesday of the month. Afterwards, I would drive down to Beltsville and visit with him. He was often talkative and I kept hoping for something approaching an honest conversation, but that never happened.

The following story captures quite a bit about my father's naivete, optimism, and faith in his own ability to get the job done. It's probably my favorite.

Elbow Room or Much Ado about Nothing
If I am correct, "elbow room" was on Daniel Boone's mind as he headed west. For my father, elbow room meant heading down and I don't mean as far as hell.


Our family was  living in a two story 1200 square foot cracker box. The 4th child, Kirk, arrived in September 1956. Sue has the smallest bedroom. Geoff and I share the middle bedroom. Mom and Dad and Kirk share the remaining bedroom.


Dad has no money. He graduated from college in 1954 and started a management training program with the Navy Department. His paygrade was a GS-10 before he quit the Veteran's Administration to begin college. He was hired into the Navy Department at a GS-7.  In the Spring of 1957 he may have advanced to a point where he was better off as a college graduate than he was without college in 1951.


With no money for an addition to the home, he longed for an unfinished basement that he could convert to more space. However, there was no unfinished basement in our house. There was a crawl space of about 3 feet between the ground level and the floor joists of the first level of the home.


He decided that he needed to turn the crawl space into an unfinished basement. For Geoff and me this project would consume time and energy for the next two years. Artist that he was, my father visualized the crawl space as a unfinished basement that had been filled in. We merely had to remove the dirt, the "we" being Geoff and me.


Dad began digging about 15 feet from the side of the house. He dug a ramp down from this point to the foundation wall of the house which extended about 4 feet below the ground level to the footings. The ramp was about 4' wide, enough to handle a shallow wheelbarrow. The digging was tough Maryland clay. He had an acquaintance, George Daigle, with whom he was doing a project for the Boy Scouts of America. George was a big, strong guy in his late 20's who came by to help with the digging, saying that he needed the workout.


George was there one Saturday as my father had extended the ramp right up to the foundation. The depth was very close to 6 feet. My Dad almost always wore a hat, maybe to hide his hair loss. I could see the top of my Dad's hat bouncing around as he stood at the bottom of the hole.


Something happened that I cannot understand to this day. In my possession was something called an ashcan. It is a very powerful firecracker. Vandals used to light them and flush them down toilets in order to destroy the toilet.

Ashcans: Always illegal in Maryland but highly prized by teen-age boys.

Mr. Daigle's presence encouraged me to consider tossing one of these ashcans into the hole with my father. It was a terrible thought. This was a pretty powerful explosive and might have easily injured my father. Nevertheless, I found myself pulling it from my pocket and looking at it. Then I found a book of matches. The hat was still there bobbing around at the top of the hole. I lit the fuse and tossed it into the ramp.


I waited. The hat kept bobbing around and then KABOOM. The hat jumped up about a foot and my father was out of that hole in a heartbeat. He looked at me and I froze. Then he looked to the left at Mr. Daigle and he managed a faint smile. He either had to beat me to a pulp then and there or he had to let me go. He would lose face if he waited until Daigle was gone before blasting me--I would know that he had been afraid of Daigle. For some reason or another, he never said a word about this incident. A much better sport than I would have been under the circumstances.


Finally the ramp was clear all the way to the foundation of the house. Out came the masonry chisels and an entryway was carved out.


Then it was time to keep digging. Each wheelbarrow was rolled up the ramp and the dirt was discarded on the empty lot next door. As summer came, Geoff and I were assigned a quota of dirt to remove on a daily basis. It was cool in the summer under the house. It was also a good place to smoke cigarettes that I had snitched from my parents. 


As the digging progressed, there were a number of obstacles left to overcome. The first problem was running into the groundwater that accumulated in our basement. This required the installation of a sump pump and running power to it.


The second problem was the center support for the I Beam of the house. It was masonry and quite large. My father decided to install steel jacks to replace the masonry pillar. He dug footings for two jacks and installed them 8 feet from the exterior walls of the house. He locked the top of the jacks into the steel I Beam and then he gradually increased the a amount of weight on the jacks by about a quarter turn every week until the I Beam was lifted off of the masonry pillar. At that point, he removed the masonry pillar leaving the steel beam of the house resting on the exterior masonry and the steel jacks.


The house footings and foundatons were engineered for a crawl space, not a basement. A wall interior to the footings would be required. This would need its own footings and  a concrete slab floor. A great deal of work remained to be done and my father was running out of steam and had come to the part where money had to be invested. He decided that the project should be put on hold. He put a plywood cover over the opening in the foundation and filled in the ramp space that extended into the side yard.


Fortune smiled on my father at work with a promotion or two and my mother received word that there was a final child on the way. My parents were able to obtain a home equity loan to add on about 400 square feet to the back of the first floor.


If you knew my mother you would know that she would be on top of this project, making sure that the builder provided every nail promised in the contract.  Mom enjoyed rough and tumble business scuffles. The IRS found her so outrageous that they audited her several times. She loved that challenge. 


However, this time the builder had the trump card. When she complained that the Better Business Bureau might be interested in the progress of the bonus room, the contractor pointed out that several county agencies might be very interested in what was going on underneath the main house. I wasn't there for that conversation, but I think I can guess at the expression on my mother's face.


The basement issue was finally solved when my parents decided to sell that house. Fresh dirt was purchased and shoveled into the basement. The passageway through the foundation was permanently repaired and the house was sold.

Glendive MT: 1977-1978

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medical     *
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Chemo was last Friday. It has been a week

Side-effects began Monday with long bone pain.

Dr. Neal, the Stanford Oncologist, recommended that I try Oxycontin to see if I could sleep through the night. So for the last few nights I took Oxycontin, Doxepin 10 mg, Prazosin 1 mg to help with an expected decrease in urinary stream from the doxepin, and finally 100 mg of Seconal (secobarbital). I used that for a couple of days.

I slept about 7 hours...a really good stretch for me. Although it is more like "coming to" rather than waking up." Usually I'm fully awake when I step out of bed.

Seconal was first manufactured in 1928. In the 1960's I'm sure that it was no more than $.10 a capsule. According to my local Rite-Aid pharmacy, the retail price for 30 capsules is now $500, that's more than $15.00 per capsule. My copay was $45.

Another recent example of anti-market behavior is the colchicine that I have been using. Colchicine is an ages old remedy for Gout. It has been in use since 1500 B.C. It was a very inexpensive drug until the FDA decided that there was not sufficient proof of effectiveness. We can now thank the FDA that dsthe cost a single pill which I take daily has increased from .09 to 4.85.

A few years ago, my Colchicine would cost $2.70 a month. Currently it is costing my insurer (which means us) about $150 per month.

http://en.wikipedia.org/wiki/Colchicine

My wife, Jasmine, just informed me that she had never seen the movie "Conehead." She was looking directly at me. I wonder what that meant?

Most of this current post was written before chemo side-effects kicked in. It has not been possible for me to get anything done since. Yesterday was especially bad, I was in bed for most of the day and when I did get up it was to moan. Why would moaning be helpful?

We were supposed to visit friends for Thanksgiving. I couldn't imagine leaving the house. In a burst of enthusiasm 2 weeks ago, I purchased plane tickets for a trip East the week before Christmas. I was going to call it Cher's Absolutely Final Good-bye Tour. I was hoping to see some folks like my Aunt Ginny and cousin Patsy who have been so supportive.

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Glendive Montana 1977

I had never lived in the West. My only previous exposure as an adult was a trip across the country where I had spent a week camping around Reno.  I loved the lack of humidity, the clarity of vision, the open skies, and the general feel of things--the expansiveness.

On my initial drive from Denver to Glendive, I could see John Deere dealers with inventory appearing on distant hills. They were so far away but so clear that hey looked like child's toys. It seemed you could see everything in the West, even down to the last century of abandoned farm equipment lying about the ranch. In the East, there is such a profusion of vegetation that the past gets buried pretty quickly.

I know that the refrigerator that my father irresponsibly rolled down into a small Maryland creek in an adjacent lot is still there (or at least some of it remains) but it will be overgrown by ground cover. In the West it would likely continue to be exposed and to have less rust.

Even though the West has a less of a past than the East Coast with respect to English speaking settlers, more of the past is visible in the West, particularly unwanted items, trash heaps, abandoned mines and tailings, etc.

Most striking on my initial drive to Glendive was the isolation. There were only a handful of hamlets visible on the interstate for 200 miles. There were few cars on the road and a striking absence of people or other evidence of human activity. It was hard to compare that with the 200 miles from Baltimore to New York City and the wall to wall people.

I spent about 20 uncomfortable months in Glendive. I have time to tell that part of the story but I don't have the time to do justice to the severe beauty of the area or to the strength of the men and women who are there producing our cattle and wheat for us. Allow me to just touch upon some of the challenges that they face and overcome on a daily basis.

Geographic isolation. In Glendive in 1977, a woman was 200 miles West or 250 miles East of an obstetrician. General practitioners did most obstetrics. Specialty services were available in Billings or Bismarck as were the nearest airports. Generally we used the Bismarck Airport since tickets from the East Coast were a little cheaper there. The town of Dickinson, North Dakota was about midway between Glendive and Bismarck. With no MacDonalds in Glendive, all trips to the Bismarck airport required a stop at the Dickinson MacDonalds for a cheeseburger fix...generally 20 or 30 to be distributed to family and close friends.

Isolation by weather. Shortly after I arrived I cared for a woman whose 35 year-old husband had frozen to death trying to make it from stuck pickup to his front door. In the winter, you do not pass people who are broken down on the road. Being stranded in the elements can be a death sentence. In my second week there,  a body was brought in to town by snowmobile, the only effective means of transportation from an isolated ranch. -40 F is a relatively common night time low.

Need for preparation. You don't leave town in your car without safety equipment. Warm blankets, bedroll, water, candle, matches, flares, chocolate or other dense food, additional coat, hat, mittens, bucket, toilet paper.

Childbirth. There was no obstetrical anesthesia in Glendive. It was all natural childbirth. Unlike the weeping and gnashing of teeth seen in the inner city hospital, the farming and ranching women came to the hospital eager to welcome the next member of their family. Eight and nine pound babies were probably the most common. I've read about the Chinese women back in the fields after delivering in the morning. Those women in Glendive are cut from the same cloth.

The Elderly. This was not West Virginia. Most of the population had retained their mobility and teeth. They lived a very active old age. Despite an environment that included ice covered streets and sidewalks for much of the winter, I didn't see much in the way of broken hips. There were many social functions for the aging couples including dances and parties--much more activity than I had seen in West Virginia.

General Optimism. People seemed to believe that things were going to get better. Granted the state was in a good position with respect to the increasing need for energy and the increase in coal-train traffic from West to East. Four to six of these 100 car monsters came through Glendive each day carrying low-sulfur western coal to power plants in the East.

February 1977
There was quite a bit for me to learn in Glendive. I was entering a long-established medical practice that had been manned by several itinerant Irish physicians during the previous ten years. I had my first exposure to a medical student trained under the British system while I was an intern in Baltimore. He did a meticulously thorough physical examination that would have put most Americans to shame. Likewise, in Glendive I was frequently impressed by the details in the record.

The practice in Glendive had been successful for many years. This was the first opportunity that I had to see and participate in a successful family practice.

What doesn't work in a new practice is being too conservative. A previous post discussed the notion of uncertainty of diagnosis and that by increasing the patient's tolerance for temporary uncertainty, one can reduce the cost of care.

This backfired on me with one of my first cases. A two year-old boy had been wrestling with his sister and had been thrown to the floor. He cried about his shoulder for about 20 minutes. It was Stan's patient, and I agreed to meet the family in the emergency room. By this time the child was quiet and playing with his trucks and using his injured arm to move them. I could not elicit any tenderness over the shoulder or collar bone and I didn't think that an x-ray was warranted. The family seemed okay with that decision, but I got a call from the father the next day. The boy had begun crying the next morning and they had taken him to another physician who ordered the x-ray and determined that there was a greenstick type of fracture of the collar bone. The father was angry and said, "That was a very hasty diagnosis, Doctor." Then he hung up without discussion.

Naturally, you don't want this to happen to you very many times in a county with a population of about 8000. It was my error. I was not established in the community. No one knew anything about me. It would look like a hasty diagnosis rather than an attempt to reduce x-ray exposure in children.

About phones: I had another case that was crucially instructive to me and no doubt saved me hundreds of hours of heart-ache in later years of practice. One early afternoon, a 30 year-old man came to see me for flu-like symptoms. He had a productive cough with discolored sputum. Given the sputum, he was probably a candidate for an antibiotic in 1977 and that's how I treated him.

A few hours later I was sitting down to eat dinner when I got a call from the patient's wife who complained that her husband wasn't feeling better yet. The complaining call from the spouse who didn't come to the medical encounter made me angry. After establishing that he wasn't worse, I told her that it was unreasonable to expect things to happen so quickly. My irritability with their expectations must have come through and she hung up on me. That "hang-up" led to hours of rumination. I finally came  to the conclusion that I should never answer a phone call that I am not prepared to take. The answering machine can hold the fort while I'm putting my emotional house in order. A offhand remark during a phone call can produce a mess that  requires hours of undoing.

To Work:
The first month was slow but steady. Both Brendan and Stan sent me overflow patients. Without a hospital practice to speak of, I made rounds with Stan every day.

I tried to attend all deliveries of the partners and I was busy studying Eastman's Obstestrics book at every opportunity. I was somewhere between nervous and terrified. I borrowed two different types of obstetrical  forceps from the hospital and practiced with them at home. I was fortunate that I could count on Brendan or Stan to bail me out if I got into trouble with a particular delivery. As the person with the most surgical skill, Stan was the C-section man. Just as I had learned minor surgery from Stan in West Virginia, Brendan was in the process of learning abdominal surgery from Stan.

I remember a little bit of a tiff over one of those cases where Brendan had decided that a patient needed an appendectomy. Stan was out of town but was expected back in a couple of hours. There was no need to do an emergency surgery. Brendan asked me to scrub in on the case and it turned out to be a straightforward appendectomy. When Stan returned, he confronted Brendan about the surgery. Although the case went well, what if it hadn't? Neither Brendan nor I were surgeons. What would we have done if the patient had Crohn's Disease or some unusual form of abdominal pain? Stan's point was that the surgeon needed enough skill to get the belly closed safely no matter what the findings. I don't think Brendan bought into that argument.

Molly:
Molly made a decision to come to Montana sometime in mid-February. The West Virginia office was closed and gone--shipped out to Montana. What was left was our home on the mountain which she began to pack up. She was hoping to be able to come sometime in March or early April.

So, I could no longer stay with Stan and Joan...I needed to find a place. In typical Western tradition of banking, I managed to purchase a house in Glendive with $1 down. It was that first house built in Glendive in 1882, the one for the first Railroad Superintendent.

Original Home Built for First Railroad Superintentdent 1882. Glendive MT

It was a very peaceful place. It had been through a variety of uses during the years, even as a nursing facility. It was reasonably cozy with good size windows and nice lighting. The basement was crudely dug out and unfinished. There were two very large rooms on the first floor, actually too large for a comfortable living room or dining room, with a kitchen-bathroom-utility room addition to the rear. There was a small sun room off of the living room. An old carriage house at the back of the property had been converted to a 1 car garage and a workshop. There were three bedrooms and a bath on the second floor. Shortly after purchase, I remember several times just sitting in the house for a couple of hours trying to experience it's presence. I really liked its feel.

When first built, the big brick house sat naked on the plains. In the interrim, the town had grown up around it and it was now in the middle of a mature neighborhood on the South Side of Glendive.

The Falling Out:
Brendan and Stan were unable to manage their success. I wasn't privy to all of their dealings and once they began feuding, the source of most of my information was Stan.

Brendan was wealthy but heavily invested and not very liquid. Stan was trying to get on his feet--he had only been there for about a year. He was in a new marriage and had 3 children from his previous one. It could be that Brendan wanted Stan to borrow more money, I don't know. I suspect that both were having cash flow problems.

Brendan worked all the time. As he worked, he required x-ray and laboratory support. This meant that there were supplies to buy and technicians to pay by the hour, especially for any overtime work. Given that he had his own lab and x-ray, it became more common for Brendan to see after-hours emergencies in his office and to use his own equipment rather than seeing a patient in the hospital and having the work done there.

Stan was not a workaholic. He worked hard and long, but liked to come home at some time in the early evening and have a drink, put his feet up, eat a relaxed supper and hang out with Joan. Stan wanted a life and medicine.

You can see that the problem they are going to have is the allocation of expenses for their lab and x-ray departments. What will be the formula that they will use to determine a fair share of expenses? I don't know what they proposed or counter-proposed, but they could not reach an agreement.

This is hearsay: In March of 1977 Brendan and Stan are getting their lunch in the hospital cafeteria. It is packed. From one side of the room, Brendan is alleged to have said, "Stan, you're a fucking liar."

This put me in an awkward position to say the least. I am in a strange country dependent upon two physicians who have guaranteed my income but cannot talk to one another. I have closed my previous practice. I have bought a house. My wife and child are getting ready to come to join me in this new practice..

Was I paranoid? No. As they began to feud, they no longer referred patients to me--they were hunkering down in their own survival mode and were determined to stack money against the future. My workload for the second month was less than for the first. This would not be a sustainable practice. In a place like D.C. or Baltimore, I could hunt around for more work, but not in Glendive, Montana where the nearest city was 200 miles away.

The next step in the drama was the evacuation of Stan and Joan from Brendan's rental house. I don't know the whole story but they called me one day and said they had nowhere to go. So, they came to live with me.

Things were becoming very complicated very quickly.

How I Became A Communist:
It was at this point that Eric Sohr, M.D. became the local face of socialized medicine, a turncoat physician. I needed to guarantee an income, so I went to the Feds and I negotiated a salaried position with the Rural Health Initiative. This made me a Federal physician. The Rural Health Initiative used Stan's practice and the Glendive Community Hospital as a means for providing the funding. This infuriated the local physicians who saw it as unfair competition.

For the next year and a half, I was a social outcast. With one exception, members of the medical staff did not speak to me beyond a nod of recognition should we meet in the hallway of the hospital.  My only professional contact in town became Stan and then, a few months later, some newly arriving Public Health Service Doctors. It was very uncomfortable.

As I recall, the RHI gave me a contract for $48K a year. However, they wanted me to transition off of the payroll into a fee-for-service practice. They made it possible  for me to acquire an escalating percentage of my accounts receivables based upon time in service. In other words, after 3 months of work, I was entitled to 25% of the accounts receivables. After 1 year of work, I would own 100% of the accounts receivables. It was their hope that after 1 year, the collections from the Accounts Receivables would provide a reasonable standard of living and that I would stay in town.

They did not think through the contract very well, because as they wrote it, there was nothing to prevent me from  taking the accounts with me and leaving town. That certainly wasn't their intent but it was quickly becoming mine. The last hospital had gotten the best of me. Maybe I could even the score with  this RHI organization.

The Efficiency of Practice:
Big city hospitals allow for nursing specialization. That is not possible in rural areas. Glendive Community Hospital was a 20 bed medical center. There were two cardiac monitoring beds. The same nurses who were watching cardiac monitors one evening might be assisting with  obstetrics the next evening. I was very impressed to see the nurses appear to adapt these different roles so effectively.

My medical office was next to the nursing home which was next to the hospital. I could get from one place to another within 5 minutes. It was also a five minute drive or a 20 minute walk to my house.

I remember admitting a child from the office for croup late one afternoon. Within 30 minutes the lab and x-ray were done and the child was in a bed receiving some vaporized medication, and I was on my way home to supper. A few years later, while practicing in Billings, I fondly recalled that case as it took me two hours to achieve something similar in big city hospital for the child of my clinic nurse. There were definite advantages to small town and small hospital practice.

Stan and Joan, Ginger and Shiva:
Stan and Joan were fun to be with. They were still honeymooners. Sometime during the first few weeks, I saw them occasionally shake hands in the morning as they sat down to breakfast.  I found out that when they had intercourse on one evening, a handshake was their tradition the following morning. It was cute.

In the meanwhile, Stan was determined to do some hunting and acquired an English setter for pointing birds. This was Ginger. Unfortunately, Ginger was terrified of guns and would sometimes stop along the trail to savor the cow pies that seemed to be everywhere on the range. I recall an incident where Stan was using a fishing rod with a bird wing tied to the end of the line in an attempt to get Ginger to point toward the wing. Instead, Ginger seemed to cower in front of the bird wing. Joan told me later that she had made the mistake of chastising Ginger for bringing her a dead bird. She never told Stan the truth.

Evan Shiva seemed to enjoy watching Ginger's education.

Despite the crowding, these several weeks in the same house were almost therapeutic--united again in a foreign land. As spring came we were enjoying music, cooking outdoors, and sight-seeing this new country.

Obstetrics:
I came to like obstetrics. The relationship between doctor and patient seemed to go to another level of permanent bonding. I became very conservative in my treatments. Enemas were a common standing order for women in labor at the time. The idea was to empty to bowels before the baby came so that you were less likely to be dealing with a baby and feces in the same field. I didn't think enemas worked, so I stopped them on my patients.

I was also a minimalist about doing vaginal exams as the delivery date approached. It was important to know that the baby was coming head first--so important that in our rural hospital we routinely did very low dose x-rays to demonstrate head position. A child coming butt first or legs first would likely need a C-section or a trip to Billings for more specialist care. One would not want to begin to attend the woman in labor and discover an abnormal presentation that late in the game. However, I saw no advantage in doing weekly vaginal exams to determine the condition of the cervix until the patient became overdue or a candidate for an induced delivery. I tried to keep my hands out of there.

I restricted my Obstetrics to low-risk and only took women who were committed to Lamaze training. After a few months I became interested in birth without violence and began using LeBoyer's method for those who were interested.
http://childbirth.me.uk/laboyer.php
Generally the child was born without tears and demonstrated persistent curiosity. It was a very satisfying experience for all.

However, it was possible for me to be comfortable because of Stan's presence and ability to do the C-Sections.

Community Medicine:
Connie, the office nurse,d and I put together a teaching program for hypertension and identified patients whose blood pressures were not under control. We obtained some educational movies and combined these with a blood pressure clinic to serve the patients who were not responding fully. This went surprisingly well. Patients responded very positively to increased education about their condition. It was fairly easy to get them to take on a more active role in the management of their hypertension by asking them to track their pressures on a routine basis.

I also had the opportunity to sponsor a nurse practitioner from the University of North Dakota. One of our local nurses had the opportunity to return to school and qualify. Even though I left town, a new Nurse Practitioner went to work in rural Montana providing primary care services where none had previously existed.

Our Family:
The original reason for the move was the work opportunity, to be able to do a family practice in a supportive community. This is a picture from early winter 1976 in West Virginia that seems to capture some of our tension and depressed mood. Molly has been losing weight and though 5'7" or 5'8" is almost certainly less than 100 lbs here, all due to depression and loss of appetite. At this point it was not clear whether we would separate with the move.

Fall or Winter 1976 Molly, Eric, Brian. Pulling up stakes in West Virginia.

It is comforting now to be able to look back and see that things worked out. Whatever slips, bumps, and bruises along the way, Brian and Keith have selected great partners and appear to have the skills necessary for re-affirming their relationships. Things have turned out better than alright.

Brian with Ginger and Shiva. Glendive 1977

When Molly and I rejoined in Glendive in 1977, the major component of our relationship was uncertainty. We put our physical relationship on hold for the time being and we began to work on our day to day interaction. No matter where we were in Glendive, we were always within 5 minutes of home. I was home for lunch every day and had the chance to play with Brian several times a day. My salary was more than enough for simple comforts and we were able to explore some of the surrounding countryside and the "badlands" nearby. Having Stan and Joan in the house was probably a moderating influence and kept us from trying to explore our core issues before we were ready to do so.

Sometime in late Spring or early Summer, Stan and Joan bought a beautiful old house in Rustler's Gulch. I forget the name of the street, but there was a common belief that the original cattle and sheep kings of Glendive had been quick to scoop up the strays on the prairie. Those that made the early fortunes in the cattle business built houses there.

When Stan and Joan left, we had the house to ourselves and more opportunities for conversations about the future. What was clearest about the future was the necessity to avoid a second child which would impose upon us the need for managing another infancy and increase the degree of difficulty in finding satisfying life paths for each of us.

Molly and I went to a Christmas dance in 1977 that turned out to be quite a party. We were both well over our limits of alcohol and were driven home. Rather than go immediately to bed individually we ended up going to bed together. A few weeks later, when Molly decided that she really better get a diaphragm, she learned that it was too late.

I was really surprised. Some part of me wanted to wonder if this unexpected pregnancy was a way of prolonging the relationship, but I knew her better than that. She really did not want a second child at this point.

Having learned the hard way with Brian, we knew that help was required for to prepare for the new baby. Molly's sister, Debbie, agreed to come to stay for awhile. She came and stayed for a few years. Molly is more like a mother than a big sister to Debbie. They both have the Boyle sense of humor. They worked on crafts projects together, did things to beautify our environment, and certainly made my life much easier.

I particularly liked hanging out in the rail yards with Brian on my back. All of the utility cars had dates of creation. I got a kick out of finding cars that had been born in 1912 and 1914 and were still in use. As the pregnancy grew, I remember this 1000 mile vacation trip from Glendive to Lake Mary Ronan. It required two cars. Debbie and Debbie's friend Pam came along. Kristin was there with her friend, Shannon. My brother Kirk was hitch-hiking around the West and he came as well. We rented a large cabin on the lake and had a great deal of rain that forced us inside to play meaningless card games. It was a very relaxing vacation.

My Mother
In 1977 my mother visited us in Glendive. To fully discuss that visit, I have to set the scene. I know that what I am going to say will upset some family members, but it does provide some insight into the nature of her depression.

You will recall that my mother had several experiences that made it more likely that she would suffer major depression. She had early life losses: her mother at age 9, a little sister at age 7, a big sister at 13. She had experienced the transition from comfortable middle class to poverty. She had lost her home as a teenager and was living in a bedroom with sister, Virginia, four years her junior. They were eating meals with another family. In her twenties, my Mom became deaf. Several surgeries at Johns Hopkins in the 1940s were only partially successful and eventually failed.

My mother's academic credentials were a business high school with preparation for being a good secretary. Despite such lack of credentials, my mother read the Wall Street Journal until her 80s. When she died she had saved $500,000. If I had used her to make my financial decisions, I am certain that I would be much better off today.

However, a good business sense and the ability to save is not protection from depression.

In 1968 my father's alcoholism had escalated. Though primarily a binge drinker with 4 to 6 episodes a year, there was more and more intermittent use of alcohol outside of the binges. By 1968, he was dealing with a grown daughter, Suzanne, who was 22. Suzanne was not about to let her drunken father leave the house in a car with the two boys who were now 12 and 9. She might take them into her car and head out somewhere or openly confront him and tell him that she would call the police if he attempted to leave in an auto with the children.

Sometime in March 1968, my father decided to destroy Suzanne's furniture and clothes. He tossed everything into the backyard and built a bonfire. Poof!

The only effective way of dealing with such behavior is through law enforcement. It's crime to destroy the property of another. Alcoholics generally have to be forced into treatment and the law is a reasonable stick. Of course, given the dysfunction of our family, that wasn't done. So a few weeks later, when he was angry at my mother, he decided to burn her clothes in the fireplace in the recreation room. The same can of gasoline that might have been helpful for the bonfire in the backyard was employed in the recreation room with disastrous results.

I was on call with Russ Hicks at the Baltimore City Hospital when I got the call from Mr. Carragher. He told me that he had heard of the fire on the police scanner. When he went by, there was a gasoline can in plain site that he had taken. I called Geoff who was in dental school in Baltimore and we went to our parents' house in Beltsville. The fire company was just leaving. A neighbor had taken in my father who was about to go to sleep. Much of the house was still standing. However, sometime in the next few hours, the house reignited and finished the burn. The fire company responded again. By the next morning, everything was down. It was all a pile of rubble.

Sally and I were living with 1 year-old Kristin in a basement apartment in Laurel, just a few miles from my parents' house. We took in my mother, and my brothers, Kirk, and Dana. My mother was as if paralyzed. She was unable to monitor the activities of the two young boys who were no doubt acting out their own grief as well. For example, the kids insisted on entering and exiting the apartment via windows rather than doors as Mom just sat there.

For the next month, my mother went to the rubble field on a daily basis searching for meaningful connections with her past, such as her grandmother's tea pot and photographs that had survived the heat. About two weeks after the fire, I was home when I got a call from my mother. She said that she was at the firehouse and that a strange car was following her. She wanted me to come and pick her up, which I did. My mother was suffering from a psychosis as a part of her depression. It was the first time that I saw it. However, from then on, when she had a severe depression, my mother was more likely than not to suffer psychosis as well. Often this took the form of a religious delusions, "I am the devil," or "I am the savior." Sometimes, I would just get a call out of the blue. When the ground war started in the first Gulf War, I got a call. "Eric, the retribution has begun." click.

To follow up on the house fire and the separation from my father, they were back together before the end of the year and their marriage outlasted mine to Sally by quite a number of years. Why do abused women have such difficulty letting go of the toxic spouse?

While I was in West Virginia, I had picked up my mother on a few occasions when she was depressed and beginning to espouse paranoid ideas. I would bring her back to our house in West Virginia and let her be--place no expectations on her. She liked to be around us and she used the time to decompress and to regain her bearings. After a few days, she would be more herself and able to return home.

In addition to developing the propensity for having psychotic episodes with her depression, my mother began hanging out with a group of Catholics in the 1970s who were into prayer and healing. When my mother came to visit in Glendive in 1977 she was very much caught up in healing and had begun to believe that God had given her some "power" that could be used to combat illness.

Well, her belief would be heavily tested.

Shortly before her visit, I was working in my office when I saw a child with a high fever who appeared very toxic and had a seizure. The workup included a lumbar puncture to make sure that we were not missing a meningitis, but we still had no diagnosis until 12 hours later when the child began stooling. He had been in a day care center (the one caring for Brian). It turned out that we were on the cusp of a Shigella outbreak that would ravage Glendive for the next month.

Everyone in the Sohr household was affected, including Grandma, who was probably sicker than anyone.  The symptoms included bloody diarrhea and a sensation that you were never quite finished with the bowel movement.

Westward Ho! 1977

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medical        *
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2nd round of chemotherapy was done Friday. Had no problems but we made the mistake of trying to eat supper on the way home. We left the clinic at 5:30 PM and ran into San Jose traffic. We stopped for dinner but it was Friday evening. We had a terrible meal at Outback and wandered around Salinas trying to get back onto Route 101. We lost about 90 minutes in doing so. It didn't seem significant then, but was.

Jim is great company. He is a remarkably wiry, fit man in his mid-fifties. His major hobby is cleaning a stretch of beach in Santa Barbara where he went to college. He drags objects out of the sand and surf and moves them to a pick-up point for trash and junk. Some of the objects are large...like shipping containers that he cuts down before moving.

I love driving and did both ways using Jim as backup. I started having some intestinal griping about 15 miles before home. I thought that I had made it safely, but as I exited the car in my driveway, what I had supposed was gas  turned out to be something more substantial and made the next hour more interesting than it should have been. I'll come directly home next time.
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My ex-wife Molly and husband Jerry came to Morro Bay for a two day visit. It was an amazing time. There were some tears, a lot of laughter, good wine, good food, and very good company. They are very tight, both high powered CPA ass-kicking auditors who had interesting careers with the General Accounting Office, an arm of Congress. Both have now retired and spend a lot of their time traveling the world.

Here is photo of Molly and me battling to see who can keep the resentments left from our physical union of more than 14 years. This occurred at Sebastian's General Store in San Simeon...the best french dip ever in my opinion. Notice the sign that the kind people at Sebastian's have posted for parents who might decide to leave a child unattended. "All kids left alone will be given Espresso & a Kitty." The result of the contest was we both lost and therefore won.

Molly and Eric battling for supreme control of all resentments from 14 years of marriage.

Leaving West Virginia
In December 1976 I notified my patients and the hospital that I would be closing the practice and moving on. I then attempted to exchange more than $50,000 in accounts receivables incurred in emergency room work for my debt of $15,000 that had been borrowed from the hospital. The hospital declined the offer and asked when I intended to repay the $15,000. I told them as soon as I was able.

The Poison Cup and Accounts Receivables

By fronting me $15,000 at little or no interest, the hospital lost the use of that money until such time as I would repay it, but it was a sweetheart deal for the hospital.
In return:

• the hospital was able to reduce its cost for providing week-end outside medical coverage of its emergency room--this put immediate money in the hospital pocket by expense reduction.
• the hospital had yet another physician in the community who would feed the hospital a constant stream of laboratory and x-ray diagnostic work.
• a new physician offered the community another possibility for care that might eat into the traffic of the locals to out of town medical services.

A significant problem for Stan and me had been a kind of competition with the hospital. When a patient went to the emergency room for a problem, there would be two bills. The hospital would bill for the use of space and supplies, and the physician would bill for the doctor services. If you were a patient and had to choose which of those two bills to pay, chances are you would pay the hospital first. The hospital had a variety of collection resources including lawyers' threats that could be directed at patients in arrears.

When Stan left town in 1975 Molly and I were still physically present to manage collections. Stan's account were pretty much collected over the next 12 months.  After Molly and I left, less than a few hundred dollars in accounts receivables were ever collected.

Winter 1976 through 1977
This was the coldest winter weather in Maryland and West Virginia since the founding of the republic. Readings of zero and below began in early January and continued for about 6 weeks. Nearby Shepherdstown lost its municipal pipe system that had been put in the ground 150 years before. These were wooden water mains where the expansion of freezing water split the pipes longitudinally.

The following clip is from: http://www.erh.noaa.gov/lwx/Historic_Events/md-winter.html

January 1977: The Bicentennial Winter was the coldest seen on the East Coast since before the founding of the republic. In Maryland, the snow began on January 4, just as the Carter Administration was moving into town. New storms dropped a few more inches every few days to put a fresh coating on the streets that were just clearing from the previous storm and give a clean look to the piles of dirty snow that were accumulating along roadways and in parking lots. The Tidal Potomac (salt water) froze solid enough that people could skate across it near the Memorial Bridge. The average temperature for the month of January was 25.4� F which was the coldest since 1856 when the temperature averaged 21.4� F in Washington. The normal January average temperature for Washington is 34.6� F. Baltimore averaged only 22.9� F , again almost 10 degrees colder than normal. The prolonged cold wave caused oil and natural gas shortages. President Carter asked people to turn thermostats down to conserve energy. Maryland did not see heavy snow like the Great Lake region did that winter. The cold winds blowing across the warm lakes brought 68 inches of snow to Buffalo, NY. Washington recorded 10 inches of snow in January and Baltimore had 8.5 inches, but none fell the rest of the winter ending it 9 inches below normal in Baltimore. The cold wave penetrated into the South. On January 19, snowflakes fell in Miami, Florida!

The plumbing in the house at Harpers' Ferry was much less protected and remained frozen for several weeks. Bruce Waxman and his sons helped us with designing a work around using a large, clean trash can as a water reservoir to give us enough to cook, drink, and flush the toilet occasionally. The office water system was unaffected and we used that as necessary for showering.

In the meanwhile, we were packing up both the office and the house while our relationship was in limbo. I knew that I needed a job and that I was going to Montana to start on February 1, 1977. Molly had not decided whether she wanted to go West with me.

On the morning of January 17, 1977 I set-off for Glendive, MT by way of my brother Geoff's place in Denver. I packed our International Scout II with initial clothing and personal items I would need for a couple of months and set out with our dog, Shiva.

Shiva
What a dog! I ran across her while I was doing insurance physicals after returning from an extended camping vacation in 1972. We were living with Charles Eby while I was being processed for a Federal job with the National Center for Health Services Research. 


One day in December I had to visit a client in Upper Marlborough. It was a large, newly constructed home in an affluent neighborhood. It was a cold day and there was a puppy tied to a tree in the front yard. She was shivering and whimpering. The family was inside watching T.V. The examination was for the male head of household. While sitting at the kitchen table completing the insurance form and waiting for the patient to provide me with a urine sample, some of the family were standing around the kitchen exercising a fairly normal curiosity about having a doctor in the home.


I asked about the dog in the front yard. Well, the dog wasn't working out very well. When the children petted the dog she would nip them. They were planning on taking her back to the shelter where they would probably euthanize her.  I asked if they would let me have the dog and they were very happy to be done with her.


Overtaxed in my knowledge of Hindu mythology, I named the dog Shiva as I untied her and put her into my car. Shiva was actually the god of destruction, not the goddess as I thought. Charles and Molly were very kind to never point this out to me.


Once back at Charles' house, it was easy enough to identify the dog's problem. She was hypersensitive to prolonged touching and patting and would grab your hand in her teeth after a stroke or two. However, by taking an old undershirt and tying a couple of knots, she would let you pat her while she gnawed away on the cloth--no problem at all. After a few weeks, she didn't need a mechanical teething cloth of any kind and never had further issues.


Shiva was a vegetable thief and she raided gardens in the area. She could dig up potatoes and bring them home for us, although she wasn't interested in them for her own food. She stole tomatoes, some of which she ate, others of which she put on the front steps. She loved salads but would never eat onions or mushrooms. She especially liked corn on the cob and had her own method for managing to eat this delicacy without the use of hands and doing a reasonably good job of cleaning the cob.


She was very smart, was housebroken immediately, and fit in well with the family.


There was a very embarrassing moment with her in the Spring of 1973. I maintained my VW beetle on a regular basis and was changing oil one Saturday morning when I heard a car crash a hundred yards up the road on Ednor Avenue. It was a semi-wooded area and I couldn't see much, so I trotted through the trees up to the road way. It was a two car collision, with two passengers in each car. It was a rear-ending at a stop sign. The struck car had been pushed into the intersection in the arc of a left turn. The passenger from that car was lying on the ground, complaining of neck pain. The passenger of the striking car had struck the windshield and sustained cuts on the face and left arm. He was leaning out of the opened door and there was minimal bleeding from the wounds.


I turned my attention to the neck pain fellow who was fully conscious. He was lying flat on his back, nose front and center, holding onto his head with both hands. This seemed like the best possible position at the time. He was able to speak. He denied a head injury or pain in his chest abdomen or elsewhere. I told him that he was doing exactly the right thing to maintain his neck in that position. I then brought the driver over and positioned him behind the injured man and explained he could assist the victim in maintaining this position by merely placing a hand on each side of the head  from the rear. I explained to them that there should be no twisting of the back or attempt to roll over or get up and that the EMTs would take the necessary steps to immobilize him completely in a few minutes.


Then I went back to the second vehicle as several other motorists and neighbors began to arrive on the scene. The injured passenger was spun around in his seat about 45 degrees with the door open. Immediately below him in the street was a small pool of blood. Positioned next to the pool of blood was a small black dog doing her best to lick that blood off the street. Embarrassed, I shooed her away and was beginning to assess the bleeding man when the ambulance came. The bleeder also had some likelihood of neck injury, and I asked the ambulance crew to consider moving that patient to a spinal safe position before attending to the man on the ground who was already in a safe position.


Then I went back to the house with my cannibal dog who had begun to taste the good life.


Shiva was also an accomplished dermatologist. As we began making a move to our new home in Harper's Ferry, Shiva broke out in a rash that looked like eczema. She was itching fiercely and was scratching herself raw. I got prescriptions for Thorazine for itch and Prednisone to decrease inflammation and gave her a dose of each. Molly and I went out to the movies and when we returned we found that Shiva had gotten into the medications, opened the bottles, took no Thorazine but all of the prednisone. The rash was gone in 48 hours and never recurred.


Shiva and I headed West. She was having trouble with her anal glands. She ended up marking the front of my warm blue sweater and I smelled terrible for the next two days. I had brought some rubber gloves and lubricant to try to express the glands if necessary. Several people beeped their horns when they saw me off to the side of the road with my index finger up Shiva's butt trying to milk her anal glands.

The only scary part of the trip was an ice-storm that stayed with me across Missouri during the night. Four wheel drive was absolutely useless and I was too scared to pull over because of the lack of visibility and my fear of being blasted from behind. The storm didn't seem to affect the speed of the eighteen wheelers that kept screaming past me for several hours. It was just turning first light when I reached Kansas City and had my first look at Arrowhead Stadium.

We had travelled more than 1000 miles. I was no longer tired and we just rolled the next 600 miles across Kansas and into Colorado. Maybe we napped for an hour and then on to Denver--the miracle of the Interstate Highway System where having an auto is the ticket for use.

 When I arrived at Geoff's house, the only thing that I noticed was some problems with my balance, the sensation that I was still moving. I had driven pretty much straight through in 36 hours.

I hadn't spent much time with Geoff since the camping trip in 1972 when Molly and I visited him at Ft Polk, Louisiana where he was doing his military service as a dentist. Following that he had settled in Denver and started his own practice in the suburb of Littleton. He had become very busy and was expanding his practice. In his free time, he was renovating parts of his home, including the construction of a massive masonry fireplace and chimney. We spent some time together drinking and playing a new game for us, "Mastermind." It was a relaxing few days. I did some shopping in Denver for some better winter gear, both clothing and essentials for the Scout, including a basic survival kit and a plug-in block heater that would give me a chance of starting the car at 40 below in the mornings.

On Sunday night I took off for Montana. At about 4 A.M. I pulled off the empty interstate at Douglas, Wyoming and got out of the truck to take a leak and I was standing there, with one hand holding my spiritual steering wheel (at the time) and the other hand pulling aside my coat so that I wouldn't spray it. I looked up and fell into the sky. I had never seen stars like this, so bright and magnificent. I was awestruck, one of the truly mind-bending moments in my life. This was exciting!

It was early light as we wound through the Caspar oilfields and soon after I could see the Bighorn mountains in the distance for the next couple of hours. I got to Hardin MT sometime around late morning and turned northeast to hit I 94 and then east the final 160 miles to Glendive, Montana and the home of Stan and Joan where I would be staying temporarily until my situation was clarified.

I still was not 100% certain that Molly would decide to come west. The office had been packed up and was being shipped to Glendive and was to arrive in the next two days. I would spend the week sorting things out and setting up my own space  adjacent to Stan's and Brendan O'Keeffe. Brendan was a year or two behind Stan, but had opted out of further training after an internship at South Baltimore General.

Glendive had a long history of successful recruitment of Irish Nationals to provide medical services to the community. The Irish doctors had been trained under the British system, they spoke good English, and there was a large contingent of American Irish in Glendive. It had worked out well. So, Brendan had always intended to go to Glendive. It was a relatively prosperous town and partially booming as the local energy economy revived in response to the Arab oil embargo and the soaring prices of energy. By working hard, and he certainly did, he expected to be able to buy his parents a house in Ireland with his earnings the first year.

Although younger than us, there was no doubt that Brendan was the senior partner. He worked night and day and partied hard. He had been there a few years and was accumulating properties. He owned the house that Stan and Joan were renting. Brendan had recently purchased a five or six unit hotel adjacent to the hospital. It was fondly called Brendan's whorehouse by some in the community.

Brendan was quite the character. He was short and a little thick in the body but very strong. He had dark hair, heavy brows, a twinkling eye, and a charming brogue. He was quick on his feet and witty and on our first meeting he told me that "when my mother carried me, she went into false labor on Fool's day." We both loved medicine. We were both relatively high energy, but he more so than me.

Glendive Community Hospital
The technological miracle of the 19th century for the United States was the development of the transcontinental railroads. The western portions of the major U.S. East West highways are all located alongside the rail lines built before 1900. For example, in Northern Montana,  Rt 2 is the major roadway, called the high line. It parallels the rail bed of the original Great Northern Railway. Interstate 90/94 is the Southern Montana East West route and tracks the original rail bed of the Northern Pacific Railroad.

The history of Western railroads includes the need to scale the Rockies and the Sierra Nevada using a variety of techniques including switchbacks and tunnels. In winter, temperatures of -40F are not so unusual. It is estimated that the winter outdoor gear worn by the men working on these steel monsters weighed an average of 80 lbs. in 1890. There was no thinsulate at the time.

Most of the larger towns in Montana developed from railroad stations and depots. Even Custer's actual mission at the time of the Battle of Little Bighorn was to find a suitable path across parts of Montana for the Northern Pacific Railroad.

In 1882 a house was built for the first railway superintendent in Glendive, Montana. A roundhouse and significant rail storage and repair facilities were established here. When the railroad created a benevolent society in the late 19th century, one of the four hospitals was established at Glendive. It was intended primarily for the treatment of railroad employees in an organization that was a forerunner of an employer established HMO.

In 1965 the railroad decided to get out of the business of providing medical care and sold the hospital to the City of Glendive. The old hospital became a nursing home after a new medical facility was built adjacent.

Most of the doctors in Glendive had been "railroad doctors" with the Northern Pacific Railroad and established private, fee-for-service practices upon the departure of the railroad from the hospital.

The Rural Health Initiative
Eastern Montana is a big place and doctors were scarce and were generally to be found as near as possible to modern types of facilities that could support them in the practice of medicine--that is they were most likely to be found in offices near hospitals. In Montana it is not unusual to drive more than 100 miles each way to see a physician, some part of that mileage over dirt roads winding in and out of large ranches and farms.

Sometime in the 1970s, grant funds were provided for the improvement of access to health care for Eastern Montana citizens. It was called a Rural Health Initiative (RHI) .  Office space for the agency had been rented in Glendive. An administrator for the program had come to town. He was in his late 30's or early 40's,  appeared to be well-paid, was living in a big house, was driving a large Chevrolet Suburban, and he became very visible by speaking to various citizens groups about health care. At the time that I arrived in town, the RHI had hired an excellent dietitian and had gotten behind the WIC program for the provision of food for pregnant mothers and infant children.

However, one of the missions of the RHI was to provide primary care services to particularly remote areas. The only physician that they had provided was an orthopedic surgeon, not a good fit for primary care. The orthopedic surgeon had believed that the older ex-Northern Pacific physicians were hostile and he left as soon as he found a better position.

The same evening that I arrived in town, I went to a special meeting of the medical staff where I was introduced as a new physician practicing with O'Keeffe and Huber. I remember that most of the meeting was a discussion of this "communist" entity, the Rural Health Initiative.

Sorting Out the Office
My medical office from West Virginia arrived on Wednesday. The moving van had jackknifed at Bozeman and there was some miscellaneous damage to various items. The remainder of the week was spent setting up exam rooms, making a bookcase for my medical library in the consultation office, and getting a temporary Montana license. There was a local physician, Dr. M, who was quite proud of being one of the members of the medical board. He was able to examine my credentials and sign off on the license application, thereby saving me a plane ride to the state capital, Helena.

After meeting with Dr. M, Stan pulled me aside and told me one of the most bizarre stories that I'll do my best to relate here.

The Unfortunate Dr. Collins
If  this story is to be believed, Dr. Collins, an Irish National, is renting space from Dr. M., who is very careful with his money. There is an ongoing and slowly escalating discussion over some weeks about the exact allocation of utilities, particularly the "fair share" of the electric bill.


Both Dr. Collins and Dr. M are fond of an occasional snort that leads to several more snorts. On this evening after many snorts, the two begin to feud. Dr. M tells Dr. Collins that as a member of the State Board of Medical Examiners, he can have Collins locked out of the hospital. Collins leaves the drinking establishment and heads to the hospital on foot to see if it is true. 


In his state of inebriation, Collins goes to the high school instead of the hospital and determines very quickly that he has indeed been locked out. Using his cowboy boot he smashes out a window to gain rightful access to his place in the hospital. Once inside he discovers his mistake and leaves.


The Glendive Police notice the chronically overworked and apparently inebriated Dr. Collins staggering down the sidewalk and kindly take him into their cruiser and drive him home.


Sometime before daybreak, the police find that a window has been shattered at the school and the door is unlocked and opened. When they investigate they discover a cowboy boot. They look at each other and remember that Dr. Collins was wearing only one boot when they picked him up and took him home a few hours before. 


Dr. Collins, breaking and entering.


Nuts and Bolts of the Operation
The medical office space was in the third building of the complex. The nursing home was immediately adjacent and a long corridor was used as a natural pathway to the hospital, the first building. This pathway made it possible to go from hospital to office without concern about the weather.

Stan had found nurses for my practice. They were sisters, Connie and Bev, who wanted to share the job and child care. They were both incredibly efficient, knowledgeable, hard-working, resourceful and dependable. Connie was particularly interested in community health practices and internal medicine. They were natives, knew the people of the Glendive and were important sources of information about living conditions, social situations, health of relatives, etc.  They were a good team and a great hire.

There were thousands of existing medical records. My pet medical record system would have to go by the wayside to a large extent. I would begin to organize a problem list and stack it in front of the existing medical records as I used them.

I also started the EBook with a list of illnesses and diseases with particular attention to chronic illnesses.

There was a common waiting room and a single front office that handled all of the billing for the practice of our three individual offices. There were two full-time people employed answering phones, making appointments, posting charges, taking messages, and sending out bills.

The time frame for practice was restricted to posted office hours, generally 9-12 and 2-5. There were no weekend or evening hours posted. Anything done after hours was done in the hospital emergency room. Patients seemed glad enough to be able to get in for appointments and made the time to do so despite long distances of travels to the outlying farms and ranches.

Physician dress was actually more formal in the wild west than in West Virginia where I frequently wore casual pants and flannel shirts to work. O'Keeffe was the senior physician and he wore three piece suits with expensive shirts and ties. He wore shoes with heels that increased his height a bit. Stan and I wore three piece suits.

In my first week in Glendive I had a couple of meetings with O'Keeffe including a time that he cooked some steak and cabbage for me while we drank too many beers. He was a very sharp guy--street smart, and money smart. He was charismatic and a showman. For example, one day we were walking back from lunch at the hospital cafeteria and engaged in some low-key topic. As soon as the door opened to the medical offices, his demeanor changed immediately--body up straight, serious expression, and a determined, rapid-paced walk through the waiting room into his office suite.

He had a natural way with people and gained their confidence easily. He had a very good command of  occupational worries and stresses, like some of the nuttiness seen in farmers when rains delay spring planting. He understood life's timing and the timing of life's problems. Early pregnancy occurs in young girls. That anxiety that you see in the suddenly anxious 15 year-old girl may be reflecting some fear of that. The 50 year old male who may be concerned about declining interest in sex or worries about maintaining erections.

He had a respectful earthiness. He might ask about the diminution of urinary stream that occurs with a growing prostate with "Can you still piss over a fence?"

In cowboy movies, it was common to see a coiled rope hanging from the saddle. Brendan drove a cream colored Volvo with a coiled extension cord wrapped around the driver side mirror. The electrical cord let him more easily utilize electrical outlets for plugging in his block heater.

On the Sunday before I was to begin practice, Brendan, Stan and I sat down for a meeting. We went over their agreement with me about the guaranteed salary for a limited period of time. They both stated that they intended to send me overflow patients to get my workload up to an acceptable level quickly. In this way, the contract would expire as soon as possible and we would all be on equal footing. Well, not quite equal footing. They were in the process of complicating their practice in a fatal manner.

The Lab and X-Ray Acquisition
Brendan and Stan had made a decision to add a clinical laboratory and an x-ray capability to their medical practice. This would require a significant investment in capital equipment, supplies, and labor costs to pay for technicians. They hired the best in town.

Brendan was working all the time. He seldom handled any problem over the phone, but insisted that the patient come to him in the Emergency Room. This is not my style, but there is a certain logic to this method. The physician always sees the patient before making a decision. The hospital has lab and x-ray services available if necessary. There is a fee for providing an emergency service due to the physician. So Brendan has made the decision that "I will be available. I will do the work. I expect to paid for it."

Brendan slept in until about 8 A.M. on Sundays and then did nursing home work for most of the day. The man had energy. He told me that he really only relaxed when he traveled. He took a couple of weeks off a year and got out of the country and did heavy duty R&R in places like Tokyo or the Caribbean. He believed Glendive living was so restrictive that he might as well be working as much as possible.

Brendan and Stan told me that I was expected to use the new office lab and x-ray services and that they would be the responsible physicians for billing of those particular services. Lab and x-ray income and expenses would accrue to their practices.

The single radiologist in Eastern Montana commuted by air to 4 other hospitals and might only be available 1 day a week to do film readings. By the time he looked at the film, the case would usually have resolved in some fashion. The attending doctor suspecting pneumonia would have taken the x-ray and made some immediate decision without the benefit of the radiologist's thinking.

One of the most egregious examples was pelvimetry done on women with a delay in labor. Supposedly  a set of measurements of the pelvis could be compared with baby head size and an assessment of the advisability of C-section could be estimated. If the lady was in labor on Monday afternoon, she was likely to have gone on to have the baby and to have been discharged before the radiologist ever saw the film. The radiology charge for the reading of the pelvimetry after the fact is a joke since there is no value in it. Any value expired sometime before the birth of the child.

I didn't see a problem with Stan and Brendan charging fees for real-time services. If I ordered an x-ray, one of them would take a look at it and write a report and give me a call. It was a better immediate service than I would get from the hospital radiologist.

No one had promised me that I would be given an opportunity to be a full partner. They had given me a chance to start a practice with a very generous offer. If they saw an opportunity to increase their revenue by further investments in their practices, that was up to them. I needed a job. I needed to do medicine. I was ready to get going.

The Handling of the Emergency Room
Like Charles Town, there was no full-time emergency room physician for the Glendive Community Hospital. There was an alphabetical list of the doctors in town on the board in the emergency room. As each case came to the ER, the next name on the list was called. If that doctor was unavailable, then the next one was called.  The only rule was that at least one doctor had to be in town. Other than that, there was no rule that said you couldn't leave town whenever you wanted. If you didn't answer your phone, the next doctor would get the call.

The Medical Politics
At that time, despite their youth, Brendan and Stan had the best medical reputations in town. Stan had more surgical training than any other of the local physicians. The nurses had evaluated his work and let the community know that he was very good. Brendan was the sharpest at diagnosis in the town. They were both becoming ever more busy.

Brendan was wrapping up most of the obstetrics  and doing a great deal of the general practice. He was always available and if he showed up to see your sick child at 11 P.M. in the emergency room when you were 200 miles from a pediatrician, you wouldn't quibble about the fact that he was coming from some night spot down town. The point was that he was coming in the middle of the night. And he would be charming.

The established doctors, all previously employed by the Railroad, were now in competition with younger, energetic and recently trained physicians in an era of more rapidly increasing medical knowledge. They were not happy to see me joining a thriving practice. Their own patients would feel increasing pressure to  utilize the newer physicians. The local physicians were also unhappy about the RHI association with the hospital. A commitment to providing more primary care physicians threatened the established physicians with more unwanted competition.

The hospital was certainly upset to see O'Keeffe and Huber getting into the lab and x-ray business and costing the hospital this part of expected business. Nevertheless their volume of patients was responsible for many admissions to the hospital. The willingness to see patients after hours in the hospital emergency room brought significant additional revenues to the hospital.

And this is where things stood on the day that I started practice in Glendive, Montana on Feb 1 1977.