Harpers Ferry: 2

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medical        *
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nothing to report.

Stan and Joan


In the Spring of 1975 I got a call from Stanford J Huber, M.D., who will remain Stan forever after in these posts. Definitely Stan the Man of medicine. I had met Stan when I was an intern and he was a Junior medical student. He had a book on Neurology about eye signs in coma and I strong armed him into letting me borrow it for the evening. There was a patient at South Baltimore that I wanted to test.

Stan had started a family early in life. He began a surgical residency and was getting along well but made a decision to run the Emergency Room at South Baltimore instead of finishing training. He was divorced when he called, but he had recently met Joan, a very sharp, tough-minded emergency room nurse. They had fallen in love. Her parents had a place up the road from us in Harpers Ferry and Stan and Joan had grown fond of spending time in the area.

He called me and asked if I were interested in some help in a General Practice. Well, of course I was.

So Stan and Joan came by for a visit and toured the medical office.  I didn't think that I knew Joan, but I did. She was that hard-headed bitch nurse from North Arundel General Hospital who had given me some shit about my language. However, things had changed since our previous meeting four years prior. I still cursed but she had moved from North Arundel General to South Baltimore General. Perhaps she had come under tutelage of Evelyn Wade, R.N, M.D. because the girl could now curse like a sailor.

One of the mistakes that you can make as a physician is thinking that you will be spending a lot of social time with your medical partner. Quite the opposite. One of you will be working while the other is relaxing. There will be few opportunities to get inebriated together and if you plan to do that, you'll need to hire outside help to cover you while you are incapacitated.

Stan is an educator. Our last year of partnership was 1978 when we broke up in Montana (we'll get there eventually) but he went on to become an anesthesiologist, a naval aircraft accident investigator, and finally the director of a fellowship for pain medicine at the University of West Virginia. At the time I met him, he was surgically competent and he taught me most of what I know about minor surgery.

An Example of Stan Teaching


I was very nervous. We were in Glendive MT and I was about to do my first C-Section. I was going to do it under local. It was the patient's choice and it was the best kind of case for a novice to do, because there wasn't any critical time period. Most of the C-sections done in that location  were under General Anesthesia and involved a midline incision rather than the more fashionable bikini incision or Pfannenstiel. 


The midline cut was preferred because it could be done faster. The hope was to get the baby out in less than 2 minutes after induction, before the anesthetic agent could sufficiently accumulate in the fetus to obtund the nervous system. The following link shows that midline is faster but there is no data to indicate that it is associated with a better outcome.


http://journals.lww.com/greenjournal/Fulltext/2010/06000/Comparison_of_Transverse_and_Vertical_Skin.7.aspx


So with crash induction anesthesia in a C-Section, you were up against the clock. With a spinal there was no theoretical time limit. I struggled a little with the skin incision (I'd never done one on my own) and had an even greater difficulty with the uterus, which is also cut in the midline to allow access to the baby and placenta. Finally, we got the baby out and finished the surgery.


Afterward, he debriefed me. "Eric, the incision in the uterus was too small, that's why you had difficulty getting the child out. Remember, the blood supply is coming in from the sides of the uterus--you can cut as long in the midline as you like without there being any big bleeding risk--it will just take a couple of extra minutes when you suture it closed again. Most of the problems that you run into in surgery will mean that you cut more, sometimes for better exposure, sometimes because you need a bigger opening which is where you were today."


Up and Running

Both Stan and I were babes in the woods when it came to the politics and paydays of rural American Medicine. Had we known more, we would have skipped ahead and avoided Charles Town.

We were on a short leash, Stan in particular because he had three children to support. We had to generate enough income to survive and I don't recall either of us mentioning what that income would have to be. In  order to generate business, we needed patients. We had no idea that it might take a few years to actually have a practice of the size that would support a good standard of living.

When you come to town in a rural area, medical relationships have been in place for years in many cases. The residents have seen doctors come and doctors go. They may feel a sense of risk when leaving behind the usual doctor and hooking up with a new one--the risk that they will soon be abandoned by the new guy and have to return to the previous physician but returning with the taint of disloyalty.

As you put in your time you establish your relationships and gradually convince a larger number of people that you intend to stay. In Charles Town the old guard were in fairly reasonable financial shape. They knew the ins and outs of the business and had a generation of experience and relationship with the community.

Nevertheless, Stan also drank the poisoned cup of $15,000 from the hospital and we began to add to our medical tools and supplies. I remember making a trip to a medical supply house with him where we were so high on life and the thought of being able to get a practice up and running. We were laughing about generating revenue and hit upon the scheme of obtaining high grade health insurance and beginning to do surgical procedures on one another to get some money rolling in.

Stan had some carpentry experience and took the lead in making some build-ins for the office and we established hours 7 days a week with afternoon sessions on Saturday and Sunday. One of the hospital nurses took pity on us and helped us line up a contract with the two local racetracks to provide on-site medical services during racing days.

Molly and I were getting up and running, too. On Easter Sunday 1975 we had a meal at the local, famous German restaurant, the one with the dark beer and...uh oh! Pregnancy!

The Race Tracks


Isn't it odd to think of a town of less 5000 population with two race tracks? Charles Town was about a one hour drive from D.C. and Baltimore. It was the logical destination for the on-track betting fans from these nearby, big cities. I never understood the necessity for two different race tracks. I was told that there were a maximum number of racing days during a year awarded to any track. By adding the second track, the town had doubled the number of racing days for the town as a whole. A separate organization managed each of the tracks. The employees generally worked for both organizations and moved from track to track following the work.

Frances, a long term chief nurse at the tracks, took a liking to us and helped us get a contract to provide doctor services from about 6 PM until the track closed in the late evening. This put Stan and me in contact with the horse-racing community including owners, trainers, and jockeys.

Jockeys


If you ever have the opportunity to attend a horse race, I would encourage you to find a position as close to the actual track as possible for at least one race. Press yourself toward the action as a group of 1000 lb animals thunders toward you at about 30 miles an hour. Listen to the distinct pounding of 10 animals and notice how small the  jockeys appear when compared to the bulk of the horse. Listen to the staccato of individual hoofs hitting turf. Then listen for the other sounds, the barrage of pings, thuds, and knocks as dirt clods and small stones are hurled backwards from the hoofs and bounce off of the jockeys' helmets.


It is hard to keep your weight under 120 lbs if you are a grown man, though you may be of short stature. Look at the athlete Michael Jordan at 19 and then again at 35--a wonderfully formed male athlete at both ages, no fat, no excess--but look at the thickness of  his form, the natural results of male hormones on physical development between youth and approaching middle age. Jockeys must fight this tendency to increased bulk on a daily basis.


Many jockeys have developed eating disorders in order to continue to compete. There is both restriction of calories and bulimia, most commonly induced vomiting after feeding--these are behaviors most conducive for attempting longer term control. Short term reductions are often managed with the use of diuretics to cause a dumping of water with its attendant weight from the body.


In Charles Town the use of Lasix, a diuretic intended to decrease bleeding in horses, was commonly used. So, it was easily available for jockey use as well. 


(Let me recommend http://www.thinkythings.org/horseracing/lasixinfo.html as an informative site for those who might want to explore an interesting, offbeat topic.)


There is often a party atmosphere surrounding the race track. Alcohol, cocaine, amphetamines (also useful for weight loss) are generally plentiful. Jockeys tend to be young men and their testosterone will push them toward meeting women. Lots of women swoon over athletes and jockeys are no exception.


So now imagine jockeys as your medical patient. You will be interacting with a starving, dehydrated individual in many cases. He may be using amphetamines today. In such a state, few jockeys are at their best. They are likely to have social baggage as well. Jealous husbands may be looking for them with guns.


You won't need very many jockeys in your practice to make your days seem much longer as a physician.


Chris and John Crawford: Harpers Ferry Artist
Just inside the front door of my current home are two drawings by John Crawford. They are done in a style that emulates the 19th century printing methods, like a Currier and Ives reproduction. He called it "dot-to-dot," constructing a scene from individual ink points. Here is an example:

Copyright John Crawford Harpers Ferry WV 1983

I met John Crawford and his 5 year-old son, Chris, in the Summer of 1976. We were closing down the office for the day. Stan was going to the race track to do the shift and I was heading over to the hospital to do rounds, when they walked into our office. John said, "My son came home a few minutes ago and said that he was bitten by a snake. Would you take a look at it?"


There was a wound on the left forearm that consisted of two puncture sites. Stan and I left the room to confer. We both thought it a snakebite. I was hoping Stan would volunteer and let me do the track for him while he did this case. Instead, Stan just packed his bags for the track and told me to give him a call if I needed to talk about anything.


I took  John and Chris over to the emergency room at the hospital. I took the trauma textbook with me.  Whether Chris was admitted or not, he was going to need an IV. We had a very experienced nurse, Joyce, who worked the evening shift and was expert at pediatric infusions. I asked Joyce to get the IV started and began reading the chapter on snakebite in the textbook. The expert who wrote that chapter was at Hopkins in Baltimore.  It was Dr. B.


In more than 40 years of practice, I found that it was generally possible to speak to well-known physician experts about any case at hand. In any teaching hospital, the chief resident of a department is generally the next expert who will leave the department to establish a new practice. In fact, the chief resident in any department is often the most knowledgeable and current physician in the field. Over the years I have contacted infectious disease specialists on tens of occasions, orthopedic surgeons several times, etc. As a physician, another physician will talk to you about a medical case and they are often pleased to be of assistance. The ability to get such help in emergent situations is one of the most beautiful things about the practice of medicine--the idea that knowledge should be shared for the benefit of our patients.


Within a few minutes, I had reached the operator at Hopkins. When I told her that it was an emergency, she asked for a number and said she would get back to me. Within a few minutes, Dr. B called. At the time of his call, we had Chris relaxed in the Emergency Room with his dad. An IV was running and we were going to get Dr. B's help with the initial decision-making...the most important question being whether this was a case that we needed to ship ASAP and if so, in which direction? To Baltimore, about 80 minutes away to the East, or Winchester, VA 45 minutes West.


When Dr. B called, we had established that we had two doses of general antivenin for snakebite. The emergency nurse called the hospital in Martinsburg and they had an additional three doses. Dr. B estimated that we had sufficient material on hand to begin treatment on site if we were also able to monitor coagulation studies.


So, we admitted Chris to the hospital and began the treatment vigil, the first case I'd seen of poisonous snake bite.


Antivenin was prepared from the serum of horses who had recovered from snakebites of various kinds. So, antivenin was general purpose against most or all of the American pit vipers. In the case of Chris, the snake would have almost certainly been the water moccasin. Because antivenin is a horse product, allergic reactions are common. They can occur immediately in persons who are allergic to horse. They will occur late in most others as the body develops an allergy to horse serum following the use of antivenin, the name of the condition being "serum sickness."


To eliminate serious early allergic reactions, a very low test dose is used. If the patient is tolerant, then the full treatment begins.


The goal of treatment is to provide enough antivenin to "lock-up" all the circulating snake venom. One cannot know how much antivenin will be required. You have to give enough to do the job, but you don't want to give too much because this will increase the downstream problem managing the allergic reaction that you will be expecting over the next week or so.


To determine the end point, you follow the skin changes in the area of the bite as you administer the antivenin. The venom will cause a remarkable change in skin color, at least in Caucasians. The skin that is being directly affected by venom turns a greyish white and has a dead-like appearance. This region of "death" migrates up the limb toward the body. Every 15 minutes or so, a mark is made on the skin at the boundary between dead-looking skin and normal-looking skin. You are keeping track of the migration of venom. When the migration stops, you have neutralized the venom.


In the case of Chris, we used 3 ampules of antivenin over a few hour period and things were turned around a little after midnight. Stan came by after the track and we discussed the case over a cup of coffee. 


It felt like a wonderful day's work. Chris did develop a mild serum sickness that resolved quickly at the end of a week and there were no ill effects.


John became a good friend. Somehow, atheist that he was, he convinced the Boys Scouts of America to allow him to function as a "den mother" for the local cub scouts who had no women volunteers. I asked him how he could square the Boy Scouts of America with his lack of interest in mainstream religions. He just smiled and said, "I just talk a lot about peace and love."


John was also a practical joker. For the 1976 Bicentennial Celebration, John made a large paper-mache model of a female superhero torso dressed in the vertical red and white stripes. Bursting through the skin tight shirt were two enormous pointed breasts.


Out of Money

Within a few months Stan and I realized that we had made a bad bargain with the hospital. We had taken their money and set up a practice. By being on the medical staff, we committed ourselves to the provision of emergency room services for about 1 week a month. We sent a steady stream of patients from our office to the hospital for x-rays and laboratory tests, both important sources of revenue for the hospital but with no commercial value for the ordering physician.

We were feeding the hospital quite a bit in revenue. Our expectation had been that the emergency room would be a significant source of money for the practice. Indeed our accounts receivables were growing rapidly from our work in the emergency room, but unfortunately, most was never collected.

Stan and I were totally committed. We had 7 day a week office hours, we were covering the emergency room for several days a month, we had a 4 hour gig each day at one of the tracks. Our practice grew but with a greater proportion of working poor.

A particularly galling experience was with the Apple Growers of the region, including the famous Byrd family of Virginia. The growers used migrant worker help but there was no workman's compensation program for the payment of claims for job injuries. Believe me, people do fall out of apple trees and become injured in many other ways. However, when you treated these injuries in the emergency room, you had to understand that you were doing it for free.

By the summer of 1975, we knew that Molly was pregnant and expecting around Christmas and that we were in a practice that promised very hard sledding for a few years. Both couples took a day off that summer to look at an established practice in Berkeley, West Virginia, where the family physician had recently died. We went through the practice and spoke to the administrators at the local hospital who were anxious to recruit us.

However, Molly had looked very carefully at the bookkeeping and the accounts receivables. When the hospital administrator assured us that the deceased physician had made a very good living, Molly simply said. "Well, I looked at his accounts receivables. If he had collected them, he would have owned the town." Imagine being the administrator plastering on the bullshit to our group and hearing this simple statement from a beautiful, smiling young woman.

Waiting for the Lump


Well, our partnership was done for. We were going broke too quickly to recover. Stan began looking around for another practice opportunity. He was hooked. He loved the work--just needed to make a living.

He called Molly's pregnancy, "the lump."  "I can stay until the lump arrives and then we'll leave." He kept his promise by a day or two and then he headed to Glendive Montana to join another doctor refugee from South Baltimore General Hospital, Dr. OK.

I never felt so close to Molly as during this period of time. She was pregnant. Most of our days were spent in close proximity, she and Joan working the office. We had lunch together daily and got into the LaMaze training, etc.

On December 23 I was on call for the emergency room. Molly and I were making the bed in the office when her water broke. I called Stan and told him we were going on to the hospital in Hagerstown and he took the emergency room.

The labor was particularly intense and painful. We practiced our training but we had been up all day and now all night. We were both exhausted by daybreak. The lying-in room was ugly. Some of the nurses were not helpful and gave the message that lack or progress with cervical dilation was somehow under Molly's control. I remember being so awfully tired that I was relieved to be asked to leave Molly's side by the obstetrician who reviewed the case with me. That break of ten or fifteen minutes 36 years ago is right up there with my favorite fortunate occurrences.

Finally Brian did come. He had a problem with a rather severe Metatarsus Adductus, but was otherwise totally healthy. Molly was fine. I went home. I'll never forget the sunshine on the Western mountains as I drove back to Harpers Ferry. I was no longer tired. I got home and went right down to my workshop and continued some project that I had. All was right in the world. We had a son. We had started our family.

But a lot of things were going to change. Stan was done. I would immediately have to shoulder more work. Joan was gone. Molly now had Brian as well. In addition, Stan and I had decided not renew our office lease. We had rented a three bedroom rancher within a few doors of the hospital and I needed to move the office. 1976 was coming and it would not be for the better.