Harpers Ferry: 3

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Hair is out. I found out that behind my beard and hair is Trek without the trumpet ears. Notice that my normally fat face has puffed up to become even more round. This is part of the Cushing's Syndrome,

a cluster of signs and symptoms that are caused by an excess of corticosteroids. When the syndrome is the result of a pituitary tumor that stimulates the adrenal gland to produce more cortisone, it is called Cushing's Disease.

http://en.wikipedia.org/wiki/Cushing's_syndrome

In my case, I have had the weight gain of 15 lbs since starting to use prednisone and decadron after October 11.  Although I'm gaining weight, I am also losing muscle mass, both from the prednisone and a substance, Tumor Necrosis Factor, that is being produced by the cancer.

In the past 48 hours I have had a craving for beef--the bloodier the better--with Tapatio Sauce. Apparently such cravings are not so unusual and I'm enjoying the indulgence.

My brother Kirk and his wife, Claudia, have been visiting and  a large contingent of Jasmine's family came up from Los Angeles to visit us for the day. Overall, it was a very pleasant Saturday.

Harpers Ferry: 3  


For the past few days, I have been wrestling around with memories from 1976. Mostly I have left that year buried in the ashes of its own destruction for 35 years without trying to do any kind of analysis. Even after sifting through all the dust, I'm not sure that I understand what happened to me over the course of those 12 months. If a patient came to me and told me the story now, I would suspect a manic episode.  It will take me a while to work through the various pieces of the story.

Charles Town, the county seat for Jefferson County, is about 7 miles west of Harpers Ferry as the crow flies.  The town is named after Charles Washington, the younger brother of George. When I first arrived in town in 1973 there were still some old slave quarters that were being used for housing.

Charles Town and Harpers Ferry were also  "apple country,"  a blue collar area with many small, surrounding farms and orchards. Jobs were scarce and the economy was difficult in the mid 70s.

This is the agricultural Eastern Panhandle of West Virginia, not the coal fields of the interior and western part of the state. The Charles Town jail and courthouse are linked to the abolitionist, John Brown, whose rebellion occurred in 1959 when he raided the federal arsenal at Harpers Ferry. http://en.wikipedia.org/wiki/Harpers_Ferry_Armory

Brown and his attackers were put down by a U.S. Army troop under General Robert E. Lee. Some believe that this was the first blow struck in the Civil War. Brown was captured and his execution took place a couple of months after the raid. I think his final statement in court is worth a read.

http://www.historyisaweapon.com/defcon1/johnbrown.html

The Medical Conscience of Charles Town

Poor, rural areas often have problems retaining their educated young who are likely to move away in search of  better economic prospects. Luckily for Jefferson County, there was a small group of dedicated mid-level medical  professionals who had come to assume positions of authority and responsibility as first-responders and as nurses. They were scattered among the several towns and villages of the county. In many cases they had grown up and attended high school together.

Ron Grubb and Nada Lind were the two with whom I had the most contact. Ron was a nurse who had spent time at the R A Cowley Trauma Center in Baltimore and he brought back these skills to Jefferson County. Nada was an ICU/CCU nurse who was interested in the big picture of health care delivery in addition to the QRS complexes of the Cardiac Monitors.

Sometimes over a beer we would laugh about the idea of founding a medical commune or cooperative. It just would have been fun to do medicine the way that it could be done in 1976.

Although the older physician medical staff was fossilizing and was less able to keep in touch with medical progress, this younger group of non-physicians was very solid. They had made their commitment to the community and intended to stay in their home towns to make things better. This cadre was distributed among the nursing staff of the hospital and formed a backbone for the system. I became aware of their effectiveness one day in early March.

Doctor, He Was Putting His Boots On


Mr. A and his wife, a nurse, had recently retired and moved into the area. When he got dressed on the morning in question, he felt a deep, excruciating pain in his abdomen as he put on his cowboy boot. He yelled for his wife who ran to find him lying on the floor and sweating profusely. She called the ambulance and he was rushed to the Charles Town Hospital emergency room. Recall there is no resident doctor in the emergency room. On this particular day, Dr. N our county's newly arrived Orthopedic Surgeon was the doctor on call for emergencies. Mrs. A saw the mismatch between her husband's needs and Dr. N's area of expertise.  One of the nurses in the emergency room pointed to me and Mrs. A approached.


"Doctor Sohr? We need your help. This doctor is an orthopedic man. Something terrible has happened to my husband. Will you please take care of him?"  I asked Dr. N if that would be okay and he was relieved. Then we got to work. Mr. A's blood pressure was dropping and there was no femoral artery pulse on the right side. He was complaining of severe back pain. An abdominal aneurysm was the likely diagnosis but the patient's immediate need was to be on an operating table with a vascular surgeon in attendance. That couldn't happen in Charles Town, so we needed to make it happen as soon as possible in Winchester, a 45 minute ambulance ride.


Our local ambulance crew was still on site. We notified Winchester Hospital that we were sending an unstable patient with presumed aortic aneurysm. We started three IV lines, obtained a blood sample, hung plasma, began pushing fluids to attempt to maintain his blood pressure, and dispatched  a nurse with the ambulance on route to Winchester. We ran the blood work that we had drawn before his departure and telephoned the results ahead to Winchester.


Mr. A was out of our ER and on the road in short order. A team of people had worked on him. Three IVs were begun simultaneously. We skipped an x-ray because it would delay his departure and not provide any information that would help his survival. He arrived alive in Winchester. His kidneys shut down temporarily but recovered. It was an aneurysm and the Aorta was repaired. The following Easter I received a card from Mrs. A that showed her husband with his cowboy boot. The couple was continuing to enjoy retirement.


Mr. A's life had been saved by three very sharp nurses who dropped everything to respond to that emergency. Given the limitations of our small hospital, we had handled this case well--our responsibility was to get Mr. A to where he needed to go as quickly and as efficiently as possible. We were able to accomplish that in a manner that promoted his chance for survival.


These young professionals seemed to like interacting with me and I was honored. I did a fair amount of first responder/EMT education for them and I also taught a class for them based on the book "Take Care of Yourself," by Vickery and Fries, a well-designed and well-written "owner's manual for the body." The book was divided into sections based upon medical/health related problems. Each problem was then addressed using a specific "recipe," called an algorithm, that worked its way through the problem, one decision at a time until a resolution occurred. If you thumb through modern medical textbooks, you will see that this algorithmic method has since become adopted in medical education as a standard method for conveying information.

I hired one of these nurses, Nada Lind, to work my practice with me. It was to be more of a partnership. She was smart and had excellent credibility with the hospital. It was a delightful collaboration.

In Charles Town, We Seldom  Met a Uterus Over 40; The Empty Abdomen Syndrome

In medical school I heard more than two or three surgical residents express the belief that a careful examination of any asymptomatic human being would reveal at least 3 "surgical" problems for possible correction. I took it to mean that a surgeon could always find work by taking a closer look at prospective patients.

In Charles Town, the medical staff was very heavily skewed toward surgeons. Yet another surgeon joined the staff within a month of my appointment. A heavy dose of "surgeon" applied to the residents of Jefferson County WV had greatly reduced the total number of intra-abdominal organs.  Stan and I joked that it was the "empty abdomen syndrome" from chronic surgical exposure.

Of course Stan was interested in doing surgery as well. His  first abdominal case was that of a woman in her thirties whose symptoms appeared to be classic gall-bladder disease. The x-ray study showed no evidence of any gallbladder activity and the patient was scheduled for surgery a few days later. The surgery went well until an attempt was made to find a gallbladder. There wasn't one. Our patient had congenital absence of the gallbladder.  (Warning: this link loads slowly: http://www.wjgnet.com/1007-9327/11/6228.pdf ). Was this yet another example of Providence whispering in our ear?


West Virginia, Economy, Ethel, and My Tax Pit


West Virginia is poor state. http://www.infoplease.com/ipa/A0104652.html

It was relatively disadvantaged in the 1970s and remains so today. This is the classical double whammy. There are more people in need of social services and there are fewer people in the upper tax brackets to generate the revenues needed for the services. Being an hour or so from D.C. made Harper's Ferry a reasonable distance for use as a bedroom community. This brought speculators and investors to the area and drove up real estate prices, making it even more difficult for the local youth to compete in the housing market.


In 1975 I cared for Ethel and her family of eight. They were managing a dairy operation  and barely scratching out a living. The farm owner was paying them about $400 per month. That broke down to $50 per family member per month. This tiny amount made them ineligible for medical assistance!


Ethel was a very old 35. She had suffered from rheumatic fever as a child and was left with significant heart valve damage. She was constantly breathless. She was also toothless (as many were) and the hardness of her life was readily apparent in the wrinkles and weariness  embedded in her face. She was 35 going on 60.


There was no way that Ethel could afford medical services for her family. There were free immunization programs for the children through the health department, but anything else had to be paid for.  I could not imagine taking money from her. So, she paid "in kind." Occasionally her family had surpluses of milk, cottage cheese, and eggs and she would bring them to me in lieu of money when she had them.


There were a couple of problems with this arrangement. Frequently, I would not have any immediate need for eggs, milk, or cottage cheese. In kind payments also create tax problems. The law required me to estimate the value of what I received and to report this as income. My solution was the creation of a tax pit, about 50 feet from the back door of our home. I dug a shallow hole. Rather than go through the "estimate of value" nonsense, I estimated that the government was entitled to a third of what I received. I tossed that into the tax pit to square things with the IRS.


She's Done Laid Down with a Man

Molly and I had become close to Ethel's family. Their farm was next to the Shenandoah River and we passed close by on every trip in and out of town. Ethel's children treated my daughter Kristin as if  she were a celebrity. They said "she looks like a movie star." They were fascinated by her blondish hair and healthy teeth. Kris was an accomplished social animal from birth and she enjoyed having opportunities for interactions with Ethel's children and the barnyard animals. It also gave Kris and me things to talk about--like how hard life could be for some people.


In the Spring of 1976, Ethel's 15 year old daughter became pregnant. If you were to guess which women would be most likely to be living under the Poverty Level at age 35, you'll find that early teen pregnancy and keeping the baby is far and away the best predictor of downstream penury.


Ethel had seen this movie before. Not only was she living it, but other versions of it were all around. She came to see me in tears. She didn't want her daughter's life destroyed before it began. She asked me about options for her daughter. She was leaning toward abortion. Although I can't recall the details of our talk, I know that we would have discussed her daughter's right to make a choice in the matter--that abortion could not be imposed upon the child.


I  offered to front the money to Ethel and she told me to make arrangements, which I did. However, a few days later, Ethel called and said that the family had changed its mind. They had gone to the preacher who convinced them to keep the baby. "Dr. Sohr, she's done laid down with a man and she needs to accept the consequences."  It sounded like Baby As Punishment.


Molly and Brian


My recollection of Brian's newborn period is very shaky. I don't believe that we made sufficient arrangements for the kind of help that Molly would need in trying to manage the newborn care and the attempt to breastfeed Brian. He seemed always to be awake or to be sleeping poorly. I think both of them were exhausted for most of the first few weeks.

I was busy trying to sort out the new reality of the medical practice and didn't have sufficient appreciation for Molly's disappointment or the degree of difficulty of tasks confronting her. In addition to Brian's care, she was still managing the accounts for the medical practice.

Looking back, I believe that she suffered a post-partum depression. At the time I thought it was just a general unhappiness with things.

We  also made a medical decision about Brian's feet. The orthopedic surgeon recommended that we correct the problem at as early an age as possible.

Metatarsus Adductus. The Forefeet are rotated toward the midline.

Treatment involved casting of both feet and legs. I believe that this was started in March and for the next few months, Brian was constantly banging his casts against his crib, the floor, whatever was in the neighborhood. The imposition of such intrusive medical treatments added a further level of complexity to the mix of our family difficulties.

Changes in the Practice


The practice had to change. Instead of two physicians offering care, it was down to one. The contract at the track was no longer viable because there were times that I would need to cover the emergency room on a racing day. I also dropped the week-end office hours.

The new hospital  in Charles Town opened in 1975. The new building increased the traffic through the emergency room. When I had call duty, I spent more than half of my day in the emergency room. Again, there were lots of charges for services, but very little in the way of collections.

Our Social Network


There were several younger couples in our neighborhood with whom we spent our scarce amount of free time. Prior to beginning the medical practice, alcohol and pot would have been common materials at hand during our dinners or parties. I was never able to imagine myself making medical decisions within several hours of smoking pot. So, after the fall of 1974, I never had the time to be able to use pot.

I felt differently about alcohol and didn't believe that there was a problem with beer. From 1974 until 1980, I drank many more days than not-- generally three beers a night beginning with supper. The only days I would not drink were days when I was on call for the emergency room.

The Patients

Pauline
She was fun. Eighty-six and spunky. Fifty-five years my senior and still flirting. Her daughters brought her to a monthly visit. She laughed a lot.


At eighty-three she had given up the wild life. She stopped smoking and drinking and started to go to Church.


She developed atrial fibrillation and then congestive heart failure because the heart was beating too fast to fill properly. We started a little digitalis and she responded beautifully.


On some visits, we ran a rhythm strip to see how her heart was behaving. She believed that the machine was pumping life into her heart and began to insist on a rhythm strip on each visit. Or did she like me taking off her bra to put the electrodes across her chest?

The Good Reverend

He was the Episcopalian minister for the town. His congregation included the chief of the medical staff and the hospital administrator. He was very much criticized. He had been a successful businessman before entering the seminary. He believed that he was in town for all people of whatever faith. His congregation was unhappy about sharing him with others. He was also divorced and had a young female housekeeper.


Early one morning, perhaps 6:30 or 7:00 A.M. he brought Charlie, one of the town alcoholics, to my office. I knew Charlie very well. I had treated him perhaps a dozen times in the emergency room for problems related to his drinking. When he wasn't drinking, Charlie did work. He had a super muscle car. The good reverend didn't know it, but I had already confiscated a pair of Charlie's tires and was holding them for ransom in a storage room in the clinic. He wasn't getting those tires back until he paid something on his bill.


The good reverend had spent the night with Charlie, trying to find an Alcohol Treatment Facility. I said, "Guess what, Father? There aren't any in the Eastern Panhandle that are open 24 hours a day."


As Charlie snored in my waiting room, the good reverend told me about passing out twice in the previous six months while exercising. He had been to the chief of the medical staff who told him that there was nothing that could be done except to use some Nitroglycerin. I listened to the reverend's chest. He had very loud aortic, systolic murmur.


I sent him to my friend, Richard Fisher, in Baltimore. Within six weeks, the good reverend returned with a new Aortic valve. Thanks to Charlie.


The good reverend and I laughed about it over a drink and agreed that the reappearance of Christ on earth might well take the form of a drunken Charlie seeking help in an emergency room.


William G


On this particular Sunday, there were three admissions to the intensive care unit. One of them was William G, who was in his early 70s. He had suffered a myocardial infarction, his third within 18 months. 


During the previous year, Mr. G had updated his will and spent several months traveling the country visiting old friends and family. His wife told us that he had been even busier in the previous few weeks contacting people by phone. She believed that he knew he was going to die.


For the first few days, he appeared to do well but then began deteriorating. He arrested at 2 A.M. one morning. When I arrived the code was already in progress. It had been initiated immediately with early success and then re-arrest. We continued resuscitation attempts for another 45 minutes and then pronounced him dead.


 I called his wife and asked her to come to the hospital


"He's dead, isn't he?"


I would have preferred to have told her face to face, but I couldn't lie to her. I then asked her about funeral arrangements. She told me to check his wallet, that she and he had both donated their bodies to medical science.


In his wallet I found the card and I called the number in Philadelphia. The phone rang about 10 times.


"Hello?" It sounded like a young man's voice just awakened from sleep.


"Yes, I'm a doctor in West Virginia. Is this the Anatomical Board for Pennsylvania?"


"Just a minute, please..."


It sounded like the respondent had covered the mouthpiece and shouted to a sleeping roommate. "Jack, it's one of those calls again."


The Anatomical Board had either shut down or changed its phone number. I imagined hundreds of wrinkled, yellowed, aging cards bearing the old phone number and inhabiting wallets of true friends of medical science. 


Jack came to the phone and gave me a Philadelphia number. It was for a private ambulance company that offered to come to our hospital and remove William G for about $500.


Mrs.G said she couldn't afford to pay for that trip. I called back.They were willing to bargain with me. The would do the transport in return for the Social Security death benefit payment.


Instead of agreeing, I called the University of West Virginia in Morgantown and asked if they were willing to take the body. They were happy to have Mr. G and to pay the freight. Mrs. G agreed.


The Slide

Sometime in the summer of 1976 I worked three consecutive days on call for the emergency room and did not manage to sleep more than a few minutes out of 72 hours. The return in terms of money was not there. We were managing to pay-off Stan for the Accounts Receivables that he had left behind, but we were not making a dent in the money that we owed the hospital.

Kristin's mother had hired yet another lawyer to hassle me about child support. I was accused of failing to find a practice that paid more money. The child support had been an ongoing issue with Sally. In 1970 she had taken Kris to Europe for an extended vacation with an old boy friend. I was given an address for sending child support payments. I never received other information about Kris's whereabouts and I wasn't told when she and Sally arrived back in the U.S. some months later.

A friend of mine in Baltimore who knew my situation, tipped me off that Kris and Sally were living in a northern Baltimore suburb. I drove to the neighborhood and staked it out one morning and saw them. I approached Sally and she said she wouldn't talk to me without her lawyer present. So I made arrangements to meet with them.

Her lawyer was a heavy hitter, by the name of Cal Bregel. While I was sitting in his office, he took a phone call and took pleasure in dropping the name of John Unitas. There seemed no recourse at the time. If I wanted to see my daughter, I needed to make a deal and I did so in 1971. However, the demands in 1976 had escalated and my Maryland lawyer had been happy to take a retainer the prior year but was unwilling to put in the time when he needed to file responses to Sally's attorney. I've seen that story with lawyers a few times in my life. You may have more to fear from your own attorney than from the adversary. Lawyers should be reported for abandonment for ducking their responsibilities. When something similar happened to me in 1997 the threat to report that attorney to the Bar resolved my issue in one minute.

By the end of summer 1976, my thinking was different. I had more energy. I needed less sleep. My mind seemed to be working more efficiently although I was irritable at times. My eating habits changed. I no longer ate sweets, and I lost about 25 lbs and I was delighted with my new body image. My interest in sex went through the roof.

I was able to drink more in social situations without any apparent increase in effect. I began hanging out with one of the nurses, a young divorcee. Before long we were sleeping together when I was on call at the hospital. I was oblivious to anyone's feelings and totally insensitive to Molly's current difficulty in dealing with her own issues, much less with my increasingly open infidelity. I was so absorbed in myself that I was incapable of empathy for someone that I loved.

Nevertheless, I could see that my situation was not sustainable and that my life was dissolving.

Sometime in the fall of 1976, Stan and Joan returned from Montana for a visit. Stan and I talked about the existing prospects in West Virginia as opposed to those in Montana. I had been at it for two years in West Virginia. It still wasn't clear that there was a reasonable living there. Stan said that he and his new partner had discussed taking on another physician. They were willing to guarantee me an income of $50K for the first year or until my income had reached that point. "There is plenty of work there. But you will have to learn obstetrics. We'll help you with that. What do you think?"

The decision was pretty easy. My life was becoming increasingly complicated and a source of pain to others. The easiest way to stop some of the things I was doing was to move away. I didn't know much about "geographic moves" at the time--the fact that my real problem, Eric Sohr, would be traveling with me.

One evening in December I was on call for the emergency room. It was a warm night with a light rain. I found myself walking barefoot down the sidewalk at about 2 A.M. with an abnormal fear about being arrested so that I would not be able to leave the town. There was no rational basis for that belief, it was a psychotic thought. Looking back, it seems to fit pretty well with a manic episode. http://en.wikipedia.org/wiki/Mania

The Lump: Brian and Eric. Harper's Ferry 1976.