Prison Medicine 1

************
medical        *
************
I hate to complain or maybe I hate to be obvious in my complaints. I actually enjoy moaning and groaning to myself and I do a fair bit of that.

Anyway, I had been miserable since Christmas day with nausea that had only remitted when I lay down and stopped any eye movements. I have also had a lot more pain in my left chest requiring more opiates which in themselves cause nausea. I tried upping my dose of Ondansetron (Zofran), an antinausea medicine, but can't tell if it really works. I tried pot 2 days ago but can't tell that it made much difference either and who wants to be stoned and sick?

However, I have another round of Chemo tomorrow and yesterday I couldn't imagine making a three hour car trip, going to the lab, having my Oncology appointment and then being infused for 8 hours followed by a 3 hour trip back. I will take the R.V. Jerry, my next door neighbor, goes with me and can at least drive and let me lie down in the back if need be.

On the day prior to chemo, I am supposed to take massive doses of Dexamethasone (Decadron), a steroid. I cheated and started 12 hours early by taking a dose at dinnertime last night  and my nausea is almost gone. I hadn't eaten for 2 days until last night when I got down some soup. This morning I had a couple of eggs and toast. I don't feel great, but able to do some writing.
-----------------------------------------
A notice about blog direction. One of the initial goals of the blog was to let my children know who I really was in addition to a contemplation of my history. I began working in prisons in 1987 when my boys  turned 12 and 9. I think they have a good recollection of my life and activities from that point.

Given that I'm not feeling so great, I'm going to free myself from strict chronology. Since 1987, my jobs have been:
1987 -- 1994   Medical Director Eastern Region Maryland Department of Corrections
1994 -- 1997   Residency in Psychiatry University of New Mexico School of Medicine
1997 -- 1998   Attending Psychiatrist Atascadero State Hospital (for criminally insane) California
1998 -- 2002   Psychiatrist, Ely State Prison, Maximum Facility and Death Row, Ely NV
2001 -- 2007   Private Practice of Psychiatry Las Vegas NV
2007 -- 2010   Staff Psychiatrist California Men's Colony (medium security prison) San Luis Obispo CA
2010 -- 2011   Geriatric Psychiatry San Luis Obispo County CA

I'm going to feel free to talk about prison medicine and psychiatry in general after discussing moving from Smith Island and starting my first job in a prison.
-----------------------------------------------------
Moving Off of the Island
In June 1987, Brian, my older son, completed the sixth grade in the one-room Ewell school. The following year he would have attended school in Crisfield, a 12 mile trip over open water from the island. The boat ride would have tacked another two hours onto his school day, eliminating opportunities for extra-curricular activities. So, I decided against remaining on the island and began looking to move to the mainland.

I was 44 years-old and had little in the way of savings. The boys were 11 and 9. My sources of income remained a day a week in the emergency room in Crisfield and whatever amount of time I wanted to devote to Island medical work. My living expenses would increase on the mainland because I had been living rent free on the island.

In choosing a place to live, I looked at the few towns within 45 minutes of Crisfield and chose Pocomoke City. The school system had a good reputation and there appeared to be opportunities for private practice within the town itself. I went ahead and made the move over about 30 days. It was laborious. Pack a few boxes. Load them onto a truck. Take them to the dock. Unload them onto a boat. Unload off the boat in Crisfield and put them in the van. Drive the van to the rental house. Cart the boxes from the van to the house. For the larger furniture and remaining boxes, I hired a waterman's boat for an evening after he had finished crab scraping during the day.

I had just begun serious search for more work when the night nurse at the Crisfield hospital encouraged me to apply for the newly advertised job of medical director of the new State Prison being constructed in Westover, Maryland.  She had recently been hired as the Director of Nursing for the facility by Correctional Medical Services (CMS), a private company that had the contract for providing the health care services in the new prison. This company had contracts in several states, but the new Eastern Shore Prison at Westover would be the first work done in Maryland. The company was keen to make a good showing  in hopes of acquiring the contract for the entire state in the upcoming bidding the following year.

I was interviewed at the prison by the regional manager, Philip Nichols, who had worked for the company for many years. He talked as if the job was mine if I wanted it. (Apparently there was not a long line of physicians fighting for the opportunity.) The offer seemed generous. The company paid a very small salary of $7200 per year together with excellent medical benefits. The medical director was responsible for taking call or paying other physicians to provide it. The stipend for this was $60 per day. The salary and the call  worked out to almost $30,000 a year...close to what I had been living on for several years. In addition, there was a contract which would reimburse me $40 per hour for each hour spent within the facility. There were 80 hours a week of available physician time. I could work as much as many of those as I chose and offer the remaining hours to another physician.

When I put all of this together, it looked like about $100K a year and the ability to live in rural Maryand, 5 minutes from the boat ramp on the Pocomoke River, about 30 minutes from Crisfield and about 45 minutes from the Ocean beach on Assateague Island. This was very exciting.

The final hoop in hiring was a face-to-face meeting with the Medical Director of CMS, Larry Levy, M.D. at Graterford Prison in Pennsylvania. It was a long drive, about 4 hours with several stretches of heavy traffic around Wilmington and Philadelphia. I was so worried about the health of my chevy van with its 150,000 miles on the odometer, that I rented a car for the trip.

I had never been in a prison before. I had done some work in jails, but this was different. It looked like a James Cagney movie. There was a concrete wall that seemed about 20 feet high and formed the perimeter. When I walked through the gate, it was disconcerting to see 2 plaques commemorating the lives of two correctional officers who had been killed there in the line of duty.

I had also missed something in translation about the interview there. I believed that I was talking to an administrator for the company, but instead I was being interviewed by Dr. Levy. He was both very smart and very smooth, a combination I had not seen in a physician since my days with the Public Health Service when talking with folks who managed to get grants and contracts from the Federal Government. I was definitely the country cousin talking to the city slicker.

I got the job and started work almost immediately.

Most towns or cities are not keen on having a prison constructed nearby. However, Somerset County was the poorest in Maryland and only too happy to participate in a non-polluting growth industry that guaranteed hundreds of new jobs for the area.

The prison was named Eastern Correctional Institution or ECI. It was located a little south of Princess Anne which is the Somerset county seat. ECI was less than 10 miles from my house in Pocomoke City, a drive of about 15 minutes portal to portal. I started work before the prison accepted its first inmates. This gave me an opportunity to get oriented to some of the culture in the prison.

Eastern Correctional Institution. Built as twin prisons, essentially mirror images with different administrations, East and West.

Somewhere a study had been done about optimal prison size. In deference to that study, rather than build a single prison, ECI was built as two prisons, one the mirror of the other. The only common areas were the infirmary and the Mental Health unit. Generally, these were both accessed through the eastern portion, ECI-East which was completed first. Work was still proceeding on the west ECI-W and would not be finished for 8 to 12 months.

Cleanup was going on throughout the east buildings and grounds in an attempt to find any tools or pieces of metal that had been left on-site by workers and which could be fashioned into "shanks" or knives by inmates. For me, the time before inmates arrived was an opportunity to read as much as possible about prison medical care (there wasn't a great deal) and to concentrate on hiring Physician Assistants who would conduct most of the sick call encounters.

What was apparent in 1987 was that a major reform was under way in American jails and prisons. Just 15 years prior, the American Medical Association (AMA) had surveyed jails and found

• 25% had no medical facilities whatsoever
• 65.5% had first aid as the only medical care available
• 28% had no regular sick call
• 11.5% did not have a physician on call

The National Commission on Correctional Health Care (NCCHC)  was founded in the 1970's by the American Medical Association after surveys of health care provided in prisons demonstrated disorganization and a lack of standards. The NCCHC had developed a set of standards that apply specifically to prisons. Correction Medical Services utilized these standards as their bible in developing prison health care systems. One of my tasks in the few weeks before prisoners arrived was to look at the rules and regulations for prisons in Maryland, to match them up against the NCCHC standards, and to write policies and procedures that would keep the prison (ECI) in conformance with both sets of guidelines.

A Prison Inmate's Right to Health Care
Prisoners are the only persons in the United States who have a "right" to health care as determined by the courts. A nice review of the law in this area is found in an article in the Journal of Correctional Health Care in 2008 by William Rold.

 http://www.realcostofprisons.org/materials/30_years_after_estelle.pdf

The two most significant legal cases are Spicer v. Williamson which establishes the obligation of the prison administration to provide medical services and Estelle v. Gamble which establishes three components of health care that must be accorded the prisoner.

Spicer v. Williamson
Of course a right for one person involves obligations for others. If a prison inmate has a right to medical care, who has the obligation to pay for it? This was decided in 1926 in the case Spicer v.Williamson. The facts of the case are that Mr. Peter Camel, an armed robber (and no relation to Joe Camel), had shot a deputy sheriff in his attempt to flee from the crime scene. Camel was then seriously wounded in the return fire. The sheriff, Mr. Williamson, attempted to obtain medical care for Camel locally but was directed by a local physician to a surgeon, Dr. Spicer, of Goldsboro in a neighboring county.

Spicer performed the surgery and sent Sheriff Williamson a bill for his services. Williamson passed the bill on to the board of commissioners for Duplin County. The board refused to pay and claimed that they had not approved the use of medical care in another county and had not authorized the expenses incurred for the medical treatment. Spicer, Williamson, and the Board of Commissioners all obtained lawyers and took the case to the Supreme Court of North Carolina which found that

• Sheriff Williamson had the duty to arrange needed medical care for Mr. Camel
• Dr. Spicer was entitled to payment for his services to the Mr. Camel
• Duplin County was responsible for payment to Dr. Spicer

The bottom line is that this case established that the incarcerating authority has the duty to both arrange for medical care and to pay for that care.

Estelle v. Gamble and the Appearance of the Eight Amendment
Estelle v. Gamble is the linchpin for current attempts by prison inmates and their attorneys to affect their medical treatment in U.S. prisons. The eighth amendment simply states:


Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.

This is where the Republicans would complain about judicial activists. It is pretty clear to me that the intent of the cruel and unusual had to do with punishments and torture. However, a couple of hundred years later, it is frequently utilized by inmates to intimidate medical professionals who have failed to meet the entitled expectations for a particular kind of medical care. That's the bad side of it--it has encouraged lawsuits against health care providers based on the constitution rather than on malpractice. This takes the case to Federal courts and bypasses the state system.

This doesn't mean that I disagree with the bottom line dictated by the decision--just that I'm amazed at the pathway by which it was attained.

The facts in Estelle v. Gamble are that Estelle was injured while doing farm work in a Texas prison. He sued claiming that he was denied a work excuse and was punished for failing to go to work. (I wonder if his whole case would have gone away if he had been given a lay-in as he first requested. The following material about the implications of the case is paraphrased from William Rold's article from the Journal of Correctional Health Care in 2008. The URL is  http://www.realcostofprisons.org/materials/30_years_after_estelle.pdf )

 Estelle lost the suit, but in its decision the courts more clearly defined a prisoner's rights to health care:

1. Access to health care
2. The prison's obligation to provide medical attention ordered by medical authority
3. The right to an assessment by a medical professional

Access 

All institutions, of whatever size, must have the capacity to cope with emergencies and to provide for sick call. Access to specialists and to inpatient hospital treatment, where warranted by the patient’s condition, is also guaranteed by the Eighth Amendment

Provide Services Medically Ordered

Once a health care professional orders treatment for a serious condition, the courts will protect, as a matter of constitutional law, the patient’s right to receive that treatment without undue delay.  (There is a group of greedy physicians practicing medicine out there who see the state prisons as deep pockets and are very quick to order a variety of treatments that they would not be ordering for Medicaid patients seeking their services. It's really important for medical directors to be able to identify these physicians and avoid them at all costs because they immediately create the potential for lawsuits by their recommendations...see the order for Valium before court under Joseph A below.)

The Right to a Professional Judgment

The adjudication of constitutional claims is not the business of second guessing health care professionals. In enforcing the right to a professional medical judgment, the courts will not determine which of two equally efficacious treatment modalities should be chosen. Rather, the courts seek to “ensure that decisions concerning the nature and timing of medical care are made by medical personnel, using equipment designed for medical use, in locations conducive to medical functions, and for reasons that are purely medical.”

The Security Cost of Care Outside of Prison

During the first few weeks of my job as medical director of the prison, I met with the administrator of the Crisfield hospital to determine the hospital's interest in providing services to the prison. They clearly wished to do so. I was already on staff and had hospital privileges. I would be able to admit patients to the hospital and to utilize the emergency room as necessary for procedures, such as lumbar punctures for suspected meningitis.

It was critically important to be able to do routine postoperative care at the prison infirmary which was staffed with RNs 24 hours a day. The prison infirmary was a 15 minute ambulance ride from the hospital.

I was very surprised when I learned that when care was provided to a prisoner at an outside hospital, two correctional officers were required to be with the patient at all times.


Consider the security costs for a week of hospitalization--over and above the hospital's charges. 

• Three shifts a day 
• 2 officers on each shift, for seven days is 42 8 hour shifts per week
• This is 326 hours a week
• If COs make $25/hour, this works out to $8400 to provide the security for a single inmate for 1 week.

Getting patients back from hospitals in a timely fashion was exceedingly important.

We also established a working relationship with William Gill, M.D., to provide surgical services at the prison on an "as-needed" basis. He lived 5 minutes away and could round on complicated patients as necessary at the prison. For each day that he was able to see the inmate in the prison infirmary rather thatn the hospital, the institution saved more than $1000 in security costs.

Some Negative Attitudes Among Taxpayers 

It is common in crime movies and shows to allude to homosexual rape waiting for a suspect after conviction. I think it is horrible that anyone be raped but especially when under the "protection" of the prison warden. The prisoner gives up liberty and pursuit of happiness in prison but shouldn't be forced to give up life or made to fear for life and limb. That was not in the prison sentence.

Most inmates, I think the figure is 97%, will eventually be paroled and be living among us again. What is the ability of the paroled inmate to engage in meaningful work? Rehabilitation attempts have been abandoned in many states. I don't know the science, but is there evidence that all forms of rehabilitation do not work?

Some General Issues Among Workers In Prisons that Challenge Health Care Provision

Correctional Officers and Health Care Workers have to cooperate in order to render health care to inmates. The major impediment to that cooperation is the frequently impolite behavior within each group.

Correctional Officers are generally well-paid when measured against the educational level required for employment. However, there is a long history of a "good old boys" attitude that ignores bad behavior among their members and a view of health care workers as "bleeding heart" "do gooders" who are too ready to provide medical care that is not as readily available in the community. There is also some resentment about the more generous salaries paid to the better educated health care workers.

Health Care Workers tend to forget the dangers posed by the criminal and are more likely to blow off security principles that represent the bible for Correctional Staff. This is probably perceived as dismissive by Correctional Staff and unappreciative of the provision of personal safety for the health care workers.

It is my impression that things have changed quite a bit in more than 20 years. Correctional officers are better trained and there is less harassment of inmates and other staff. I'd say that the great majority of correctional officers are aware that their attitude can either contribute to the stress level or diminish it. Boorish behavior by prison staff increases the risk for everyone, not just the employee who is meting it out. Resentments smolder and accumulate and may lead to violence hours or days later.

The Inmate's Situation

Generally prisons are overcrowded with 2 men placed in a cell intended for a single man. A typical cell has a double bunk bed, a stainless steel toilet and sink combination, perhaps a table but more likely a travel chest that is used to store belongings and the top used to write on. Often, there is no chair in the cell  and one sits on the commode as a chair or on the bunk. One must get used to someone defecating less than 8 feet away. I found it amazing that in such cramped quarters, there is not more violence.

If you take the point of view of the inmate with respect health care needs, he is dependent upon the tier officer to respond to his yell for medical assistance. There has to be a correctional officer on the tier to hear this. Then the officer has to try to sort out the problem and make a decision about whether or not to call the medical department.

If the inmate has a problem that is not emergent, he is generally expected to complete a request for a sick call visit. He  has a box on the tier where this request can be dropped (to enable him to retain privacy from correctional staff). Then this request has to be picked up by the medical department and evaluated by (hopefully) an R.N. or a medical technician who may schedule a sick call visit for the inmate or decide that the problem is more urgent and should be seen the same day.

Some General Issues Among Inmates that Challenge Effective Health Care Provision

Physicians, in particular psychiatrists, are trained to take a patient's story at face value. It is quite simple, at least in California, to utilize the mental health system as a way of avoiding hard-time. Psychiatric diagnoses are primarily dependent upon what the patient says. There is vibrant communication system among inmates that identifies "stories that work" and weak providers who will not stand up to pressures brought by inmates.

With respect to psychiatric diagnoses, many inmates complain of depression and anxiety. A certain amount of sadness and anxiety is to be expected when dealing with prison time.

Joseph A

This was an inmate at ECI who had been found guilty of terrorist threats. In addition to his current prison term he was involved in another lawsuit. At the previous prison, his physicians prescribed Valium for him to take before he went to court. Our facility was based upon a dictum that "every inmate is equal," and "what is done for one inmate should be done for all." Absent a severe mental illness, it did not seem reasonable to provide "comfort medications" to inmates going to court. Besides, knowing inmates, some would blame provided medication, such as Valium, for memory lapses and an inability to think. Under such accusations, it would be very difficult to medically defend a policy of medicating.  We stopped the Valium and dealt with his multiple complaints and threats of lawsuits.

There is a riddle among people who work in prison. "How do you know when an inmate is lying?" The answer is "When he is moving his lips." 


Unfortunately, in dealing inmates for 15 years, I would have to say that there is a lot of truth in this. I've come up with my own way of looking at the phenomenon. As a child I lied any chance I got until ?how old? and told my share of lies to teen-age girls.

I am not sure how I would try to survive in prison. Low down on my list of a "moral crime" would be a lie to a health care provider to get something that I felt I needed, like a single cell, a bottom bunk, a cotton blanket, special shoes, a cane, a special diet, night-time snacks, etc. As a physician I look at the behavior as partially survival and don't take offense at the stories. However, you can't run a prison if everyone is an exception. There have to be criteria for exceptions.

This was the essence of most of my work as a medical director in Maryland--in addition to the usual obligations of the physician, I had to establish that there were verifiable data that collaborated the inmate's story. If the data was lacking, my job was to refuse the request in a compassionate fashion. If the inmate wanted to appeal, I informed him about the mechanism for doing so.

Special Problems In California

I've only worked in Calfornia prisons for about 3 years and in forensic hospitals for another 3 years in the State. It is the largest system in the country. Both the mental health hospital system and the prison system have been put under Federal managers in the past decade. Both somatic and mental health care policies and procedures are driven by law suits and lawyers' concerns. However, lawyers who are involved in the oversight are making big bucks and have a vested interest in continuing to find fault with the care.

In my mind's eye I look at the Old Man and the Sea an analogy for the California Prison Health Care System. In the old man and the sea, a fisherman catches an enormous fish and attaches it to his small boat and begins the laborious process of getting the boat home. He runs into sharks who are constantly tearing apart the catch. When he final reaches his port, the flesh of the fish is gone and the fisherman is left with a large skeleton. I imagine the sharks to be lawyers for the class action suits and the mechanisms put in place that are particularly expensive and have not been demonstrated scientifically to be effective. The fish is the California Prison Health Care Budget.

California has built a number of prisons that are in the Central Valley, far from population centers and from available medical specialties and far from places where prison staff might want to live.

California is confronting some of its problems, envisioning a prison hospital that will provide a more uniform level of service quality and reduce the security costs associated with transport for care. Hower, the California authorities recently decided to go with a "an automated" medical record system that will increasingly irritate users. Rather than having access to paper records that left quite a bit to be desired, a "paperless system" has been developed and provides merely an adobe image of the pages of various types of documents. However, the selected categories of the tabulations in the new record do not distinguish between various subtypes of documents and this makes it very difficult for professionals to find the materials that they need in real time. Have you ever gone to the library and used the fax archives of old newspapers and magazines? That is the closest analogy that I can think of to this highly touted automated system that has been implemented.


One can readily see that the search problems will increase as the size of the individual patient records within the system increases. (I know that I'm no longer an expert on implementation of modern distributed computer systems, but I cut my teeth on user interface problems in the 70's and 80's and I've developed commercial software. Clearly this system was designed by folks who did not construct a mock up using a few large medical record and observing professionals attempting to put the mock ups to use.) A consulting firm that had hands on experience with automated systems  looked at the California Health Care System record system plans a couple of years ago and specifically recommended that such a system not be implemented.

As usual, California seems bent on doing things its own way.

----------------------------------------------

Most of this post has provided background information of a general nature. The next post will be attempt to weave more first-person experiences into the narrative.

Happy New Year.

Smith Island 2

************
medical        *
************

Thur Dec 22  6 AM. The queasiness and soreness in my mouth have been gone today. Pain has been minimal. I'm hoping the chemo effects are past.

Round 1 had about 5 or 6 days of symptoms. Round 2 was longer at 7 or 8 days but combined with steroid withdrawal. It was the most intense and painful.

Round 3 has had the longest run of side-effects, 13 days with the most prominent symptom being nausea.

During this last round I have used long-acting opiates, oyxcontin 10 mg twice a day and added additional pain relief on top of that. On Monday I had a reprieve from pain and nausea and forgot a few doses of pain medication and had definite signs of opiate withdrawal.

Fri Dec 23  7 A.M. I got out yesterday. Drove the van to the post office. Went to a movie, George Clooney in The Descendants. I thought it was pretty mediocre and couldn't decide if it was a comedy or not. Pales in comparison to Up In The Air or Michael Clayton. But it was great to get out.

-------------------------------------------------------------------------

As you might imagine, I've had a lot of thoughts and dreams about my present situation. In a few dreams, I've gotten a reprieve with cures and a vanishing of tumor. My waking thoughts seldom go to tumor and personal death, but are more about the dying process itself. Here I am dealing with an entity, the tumor, that is my own cell line. Cells from this tumor are a closer match to my functioning cells than exist anywhere in the world. Right now this tumor is trying to occupy all of my intrathoracic space, the space that my lungs need in order to function properly. In addition, the tumor is releasing cells into my blood stream for colonization of distant sites in my body. It has successfully implanted in two of my vertebrae and in my shoulder. When I get a headache, and I've had a few recently, I wonder what is going on. Is it tumor in my brain? If it is, am I likely to want to do anything about it?

So, that is the medical battle that is going on. However, I am at a place in my life where I don't have to worry much about bills or being responsible for others. I have medical insurance that will enable me to get what I need without the fear of bankruptcy or loss of my home. I live in a very comfortable house and can see the ocean from where I am writing this.  But, I know that there are thousands of people struggling with terminal illness at this moment who are cold, hungry, and alone and too sick to properly care for themselves. I wonder what would happen if, instead of saying 'hello' I started saying 'may you die in peace.'  I guess that would raise eyebrows at least with strangers.

In the prison in San Luis Obispo, a chaplain started a program for lifers that involved "keeping watch" with other prisoners who were dying. In a previous post, I mentioned Viktor Frankl's book, Man's Search for Meaning. Most of us want to make some difference in the world and we can often fulfill that need by doing for family and loved ones. For those with a conscience, the life sentence may equate to a meaninglessness life--a more severe penalty in the long run than loss of freedom for life. I think it is interesting that there is a long waiting list to "keep watch" in the San Luis prison. I know that some of it may be brushing up the resume for the parole board, but I've met enough of them to believe that most of it is well meaning.

---------------------------------------------------------------------------

Smith Island 2

In 1986 or 1987 Tom Horton, a reporter for the Baltimore Sun interviewed me and included the material in his book "Island Out of Time."

I think that he did a good job of pulling the material together and describing much of my life there. He talked to me at length at a time that was contemporaneous with my leaving and is likely to be more accurate than my memory twenty-five years later, so I've elected to take his work and insert it at the end of this post. In the meanwhile, I'll just sketch out some thoughts and memories of almost four years on the island.

A Map of Ewell

A partial map of Ewell. The distance from one edge to the other, left to right, is less than 2000 feet.

The Children's Life
It was quite a change from Montana where there were no playmates in walking distance and a bus or ride to school was required. On the Island the boys could walk the three blocks to the school. Their interest in learning and overall intelligence was stimulating for their teacher as well. She was very impressed when Keith asked her where Zimbabwe was on a classroom map of Africa. The map in use was too old to have incorporated modern changes on that continent.

For Brian, there was a ready made group of children around age 8. For Keith there were only a couple of playmates which meant that he and I were playmates for much of the afternoon of Kindergarten. His mother had spent hours reading to him and teaching him phonics. One morning, it had all kicked in. I woke up and he was reading Green Eggs and Ham out loud and he's never stopped. We both love history and today we exchange boxes of books that we have completed.

The boys were never particularly interested in catching crabs but we spent many hours playing basketball and touch football. Very few fathers have failed to stop as many baskets as I, some of it my lack of ability but much of it the result of playing time.

Both of the boys acquired the Island dialect, Keith more so than Brian. It sounds illiterate to proper speaking folks, like a Caucasian analogy to Ebonics. I'm sure it made Molly cringe.

I was surprised at the level of pornographic materials that were in circulation on the Island...fairly hard core stuff with the portrayal of women as sexual objects. It wasn't the nudity as much as the profanity of the situations portrayed. My guess is that all Island children were exposed to some of it. I'd be very curious to know what the level of exposure to such material is for all children in our society. In a previous post I mentioned how erroneous information that I received had been incorporated into my own masturbation fantasies--that we may have a Lovemap from an early age. Rather than bullshit porn, it might be better for kids to see consensual sex such as Lady Chatterley's Lover. By attempting to keep our children from seeing "good" or "healthy" sex, we may be condemning them to the pornographers idea of sex. I'll take D.H. Lawrence any day.

Movement to the Island in 1983 corresponded to my acquisition of a VHS player. My sister was kind enough to send me about 50 movies on tape. I'm not sure if I have ever thanked her enough. These were a godsend when living in a place with poor television receptions. In a way it was a blessing for me as well. I found that when I felt overwhelmed or bummed out, joining the boys who were watching a movie was good therapy. I just shut up and enjoyed their enjoyment of each other, the movie, and the moment.

Cooking was not my forte. I had a few standards like Shepherd's pie, spaghetti, and stew in a crockpot. Breakfast was much easier with French toast, cereal, eggs, oatmeal, and pancakes. Lunch was generally peanut butter and jelly or cheese sandwiches. A lot of evening meals were done at Ma Willie's before clinic hours.

One of the advantages of a one-room schoolhouse is that a child can advance at his own pace. Brian had finished the sixth grade curriculum within a couple of years and was given some independent study. Keith had nearly maxed out at the end of third grade.

The Spring of 1987 was the last possible year that Brian could spend on the Island without having to travel to the mainland for school on a daily basis. Although the school boat was one of the most modern on the Island, the Tangier sound was still a formidable body of water and it worried me. The school day was extended by two hours for transportation alone and the strict boat schedule made extra-curricular activities almost impossible.

So, in April or May of 1987, I began looking for housing on the mainland. My plan was to continue to come to the Island two days a week, to continue working the day a week in the Emergency Room in Crisfield, and to find another job to boost income.

Some Interaction With the Islanders
When first arriving on the Island, I had trouble with the clothes dryer. This was most inconvenient when living in a house with multiple leaks in the roof. However, there were clothes lines in the back yard and Charlie's Store sold clothespins. So I was in luck and I began hanging out laundry. According to Reverend Z, this was quite a shock to the men--to see a male hanging clothes. So be it.

The camaraderie among Islanders is quite remarkable. It could best be found on stormy mornings when the boats were confined to port. The place to experience it was Charlie's General Store at about 6:30 A.M. when he opened. By that time, he had a fire going in the pot bellied stove off and the fishermen began showing up to drink their coffee and smoke cigarettes. It was common on the Island for coffee drinkers to add cheddar cheese instead of cream to their coffee. I wondered if it went back to times when their were no fresh dairy products.

Sitting around the stove, the banter and stories would begin--but so good natured it was hard for anyone to take offense.

Terry Laird and The New Light
One morning at about 3 A.M. I got a call from Terry Laird. A man on Tylerton was having severe chest pain. Would I come? Of course.


I got my cardiac bag and went down to Terry's boat, a couple of hundred feet away, near Ruke's store. He fired up his engine and we pulled backed into the Big Thoroughfare. We proceded a few hundred feet and made a left into the main channel (upper right corner of the satellite picture). 


Terry was a native of Tylerton and his mother still lived there. It was pitch black and there was no moon. We turned off of the main channel and headed south on the approach to Tylerton. The lights of the village grew closer when all of a sudden a shower of sparks and hisses began at the top of our fishing masts. We had jumped out of the navigation channel and were 50 or 100 feet east of it. Our masts were stuck in the power lines to the village. 


Terry was able to back out and slide over into the navigation channel. 


What happened? Terry had made that trip hundreds of time in his life. He navigated by heading for the last in a line of street lights in the village. Recently, an additional light had been added to the line. Terry was using the new light and had put us into the power poles.


The patient was suffering from unstable angina. We were able to get excellent helicopter air transport but the patient died within 48 hours.


Taking the Time to Save My Engine
One morning in the middle of a storm I went to check on my boat. It had sunk. However, the engine had been removed and was sitting on the county dock. Later that day, Later that day Joe Kitching told me that he noticed that my boat was taking on water and he had removed the engine to keep it from sinking with the boat. An outboard that sinks in salt water is likely to be ruined.


Mrs. Sneade
She was about 85 and very hard to please. She grumbled so much that she was cute. I was about 40 at the time when I said to her, "You may have this problem, but you are going to outlive me."


"I certainly hope so was her reply."


The Inebriated Teen
It was late one Saturday evening and someone called me from Charlie's store and said there was a drunk boy lying on the lawn. He was not from the island but had apparently come to visit friends and had missed the boat. He was barely responsive to pain and he smelled of alcohol. 


I had no idea of his blood alcohol. I called the State Police for the rescue helicopter. The dispatcher questioned a transport for alcohol intoxication, but I explained that we had no way of determining the severity of the child's condition and they sent the helicopter at once. I never received any feedback until three years later when I was working at the prison in Princess Ann. One of the guards told me that I had saved his grandson's life, or at least that's what they said in the ICU at the Salisbury hospital after he was admitted.


Personal Crabbing
Netting
I've tried a few methods of crabbing, including setting out pots, using chicken necks and strings to bring them to the surface where they can be netted, scraping the bottom with a net, and netting from a skiff. My favorite method is from the skiff.

In netting from a skiff, the crab net has two functions: it is used as a pole to move the boat about and it is used to net the crab itself. Crisfield, Md. advertises itself as the crab capital of the world, but even here you will be not able to purchase a ready made, suitable crab net for this purpose. You will need to make one.

To fish for crabs in this manner, you will be standing on the front of a small boat. You will use the net to move the boat to explore adjacent areas of the bottom or to move the boat toward a crab that you have spotted, in which case, you will want to position the boat so that you can use your net to strike at the prey.

You could decide to move the boat only using the bare end of the net, but generally this will be less efficient. By using the net itself against the bottom, you are in a better position to immediately bring the net to bear upon your prey.

In order to use the net part for pushing, it must be very heavy duty. The handle is a wooden pole up to 10 feet long, and generally the thickness of a closet pole, at least 1" in diameter. The net hoop itself is not one of those wimpy things you see in the store. Instead, it is a heavy galvanized double ring with a stem of several inches. A central channel is drilled into one end of the pole to receive the stem. Epoxy resin can be used to fill any space in the cavity. A screw clamp is often added for increased bracing around the end of the pole that holds the net hoop.

You won't find ready made string nets. You are best off weaving them yourself.

Net Weaving Shuttles. They are loaded with string.

To weave, a shuttle is indispensable. They are loaded up with string and can be passed through loops without having to pull a long string through the opening.

Now with the small boat and the crab net and a few bushel baskets, you are ready to set off. You may also want to keep a waterproof container on board. If you run across a soft shell crab, you will will want to be able to keep it moist.

On a perfect, day there will be very little breeze so that the surface is as undisturbed as possible. The more that the surface is rippled, the less likely you are to get a good view of the bottom. Sometimes you can squirt fish oil in the area you are working. It does cut down on rippling. (Oil on water actually works!)

You want to be in water as shallow as possible. It increases your visibility and gives you a better percentage of successful netting because the crab will have less ability to avoid you in the vertical plane.

Here is pretty good picture of a blue fin crab.

The predominant color of the animal is a greenish brown, exactly the color of the grass. The grass is not continuous, like a lawn. Instead there are multiple, interspersed "bald" spots where the mud of the bottom is exposed. The color of the bottom is generally a light brown. In addition, there will be sunlight that will "ripple" across the bottom in your field of vision and appear to cause motion.

So the crab is in a habitat where he is well disguised.  You spot him based upon shape, color, and movement. A clump of "bottom" is in the shape of a crab. You may see a flash of blue from the claws or the back swimming fin. You may see him swimming.

Using your net you push the boat toward the crab and then position the boat so that you can take a whack. Generally the crab backs up before launching himself in some direction, so it's nice to aim the net directly behind him as you make your move. If the crab begins to swim away, you can make an estimate of where he will be and try to get the net there. It's hours of fun for me.

I did it whenever I could, when low tide fit into my schedule and when it wasn't too breezy. I would give away or sell my crabs. At night, after a day of netting, it wasn't unusual for me to close eyes and to have the sense that I was still crabbing, to see in my mind's eye the rippling of sunlight over the bottom and the sense of rocking in the boat.

Netting  kept my weight down and was good exercise for core muscles. There was a lot of torquing of the hips and spine in order to move and position the boat.

Scraping
One of the problems with netting is that weather conditions have to be ideal. If I really needed a crabbing fix, I would sometimes crab scrape.

Scraping was the primary method of catching crabs on the Island during the summer.

Crab scrape showing handle, rectangular scrape and trailing net

The young girl is holding a new crab scrape. The material is often galvanized rebar. The struts are the handle. The girl's end would be attached to a rope that was tied off somewhere on the boat. The scrape is   thrown overboard and trails the boat. The speed of the boat is maintained to keep the scrape on the bottom rather than bouncing up and down. The leading edge of the rectangular portion will pull up the bottom grass which will be caught in the rectangular mouth and flow into the net. Gradually the bag will fill up with grass and become heavier. It is then pulled into the boat for "processing."

The term "lick" is used for once cycle, i.e. from tossing the empty scrape to completion of sorting and tossing the scrape again. (I went one day with Rukie Dize as he scraped. These bags end up weighing a hundred pounds and must be maneuvered on board and dumped out. I pulled in perhaps one out of six licks that day and went home exhausted and slept for eight hours.)

After dumping the scrape net on the sideboard of the boat, the material is sorted for hard shell crabs, softshell crabs, peelers (crabs likely to molt soon), and other material of interest, such as fish and shrimp.

It was all fun and I miss it.

-------------------------------------------------------------------
I warned you I was going to cheat. Here it is.

The italicized text that follows is copied verbatim from  An Island Out of Time  by Tom Horton, Paperback Edition W.W.Norton & Co. 


Pages 221-224 is a section subtitled "Island Doctor.  Eric Sohr"


I think it's a great book and recommend highly as a study of one our interesting subpopulations.

• The day in 1983 I first went to see the island, the captain bringing me over asked, did I need help getting aboard. Before I could answer, he said, "Because if you do, doc, we don't need you here." The accents there were very strange, and I remember thinking how dirty the place seemed—at the time there was an open dump, and half a mile of rusted cars lining the one main road. So many of the docks and shanties seemed just patched together, and the waterfront was full of junk.

I was recently separated, a single father of two boys, four and seven, and looking to get off the treadmill of a family practice in Montana. I had three choices: a fellowship at the University of Missouri; moving to Saudi Arabia and making an enormous amount of money; and Smith Island, where I was not sure I could survive financially. Years before, I practiced in a town on the Eastern Shore mainland. I didn't like the town, but I became absolutely addicted to crabbing. The day I first visited the island, I listened to the men in Tylerton's church, talking about all the ways there were to catch a crab. I was impressed. The job would include a house, rent-free, and my utilities paid. For making house calls I acquired a skiff and a bicycle. I arranged to work a weekly, twenty-four-hour emergency room shift in Crisfield's little hospital to make ends meet, and that was how I became the island's first doctor in fourteen years. When there was slow time in the E.R., I sometimes passed it by weaving crab nets as the islanders taught me.

The island was a good place to be a single parent. The boys were always in a crowd of kids. I felt like I had a hundred sets of grandparents. The people were so affectionate and polite. There was just a gentleness to them. In nearly four years there, I got very little business from fights. The islanders were very good at not taking offense. They have worked out non-violent ways of living better than most.

It seemed resident doctors had served the island, periodically, for at least a century. Other times, there had been nurses; also, in modern times, a number of dentists and doctors and nurses from the western shore—including the National Institutes of Health, Johns Hopkins, and Georgetown University—had volunteered time there. Most recently, several of the local volunteer firemen and women have trained as Emergency Medical Technicians.

I was struck by how motivated to work the islanders were. If injured, their first question was always how they might get back to work in spite of it. Both men and women were that way. I don't think I have ever seen such a strong work ethic except among cowboys I treated in the West. Islanders had a heritage of taking care of problems on their own. They would talk about old-timers like the man who got blood poisoning after a crab bit him. With red streaks shooting up his arm, he decided to "walk it off." For two days and nights, in agony, he paced back and forth in his house, sometimes putting a jacket or blanket over his head to try and blot out the pain. A young woman with no health insurance said she had treated herself for what must have been quite severe burns from a kitchen accident that scalded all over her thighs. It was not unusual for men to do minor surgery on themselves—for infection around fingernails, for example; and I recall a housewife setting her own dislocated elbow.

I was very impressed by the physical strength of the men, from pulling scrapes and pots and tongs all their lives. One crab scraper in his late seventies came to me with a bicep muscle that had ripped completely loose on one end. Soon after, he was back on the water, pulling in scrapes that, moving through the water, were like lifting 100-pound weights.

For all that, I would not say islanders were an unusually healthy population. Diabetes and heart disease seemed to run in some families with extraordinary frequency, and there was more obesity than on the mainland. Some of it was lifestyle and diet. I gained ten pounds a year, every year I lived there. They ate lots of seafood, but mostly deep fried; and they put sugar in everything, even lasagna. Also, though they worked hard, aerobic activity in such a confined place was easily avoided. Smoking was rampant, especially among men. It is that way on the whole Delmarva Peninsula, which has one of the nation's highest rates of lung cancer deaths.

Some of their problems likely were genetic. A western shore doctor to whom I showed photos from the island remarked that just from some of the faces, he could tell there was inbreeding. He acted as if he had already decided they were somehow inferior. To my knowledge, no one has ever done a careful study of the island's genetic situation. On Tangier Island, a similar population to Smith, a study in the 1960s identified a rare genetic abnormality that causes elevated cholesterol, enlarged liver, spleen, and tonsils. It is known as Tangier Disease, and only a few dozen cases have been documented worldwide.

Of course the gene pool is less diverse for Smith Island than most of mainland America. On the other hand, it is scarcely as if people are going around marrying their first cousins. This stuff about the islanders all being descended from the same families who founded the place a few centuries ago is over-

 stated. You find out, when you start talking to them, that quite a few people, in just the last few generations, came from other places, often through marriage. Several of the kids there, some of them now grown and married, were adopted from the mainland. There is a branch of the Smiths that is unrelated to the other Smiths. The family was established on the island around the turn of the century when a Smith from Manhattan, to get away from an abusive home situation, found work on an oyster dredge boat and settled here. It's said there were some marriages that brought Native American blood over here several decades back. At any rate, you quickly grow to see through the faces; and what you see are some of the most interesting and beautiful people you will ever meet.

Other medical conditions are what you would expect from people in the occupations they follow there: bone spurs from standing so much on boat decks; eye trauma and precancerous skin growths from constant exposure to the sun's glare. A gynecologist on the mainland said it was not uncommon to see women with hernias and other problems aggravated by the heavy lifting they do, horsing bushels and boxes of seafood on and off boats and into crab steamers.

I never expected my practice would be a normal one. My first emergency house call I set off on a bike, down a wet, slick road, with my emergency defibrillator dangling from the handlebars. I had not been there a month when a woman came over from church with asthma. I was working on her when the State Police Medevac helicopter landed, and this trooper comes running in with an emergency medical pack and a gun in his shoulder holster. We tried, but she kept arresting and died in the office. Afterward an islander remarked it was a shame she couldn't have gone en route, on the 'copter. I asked why. Been a little closer to the Home Office, he said.

Three days a week, I made house calls, a day for each town. For Tylerton, I went down in my little skiff. A third of the population there was over sixty, and medically, the most important place to see older people is in the home. I would find a reason to peek in the refrigerator, to see if they were eating right; use the bathroom, to look in the medicine cabinet to make sure they were taking their medications—with so many same last names on the island, it could be a problem making sure the right person got a prescription.

The island can be a hard place to stay when you get old; but I have never seen a place where it is harder on old people to have to leave. "They throb with this island, like the bay with tide," a former preacher said. I don't think it is strange that all three churches say special prayers every Sunday for "all those in the nursing homes."

They valued a doctor, and were good about paying their bills—the most honest people I ever treated as far as expecting to pay for services and not expecting to get anything for free. They didn't have enormous expectations; just expected you to be straight with them. A far bigger concern for me was tourists in the summer. You became an E.R. for strangers, and that made me nervous, because unlike the islanders, they could be litigious. I don't think I ever made more than $20,000 a year from the island practice. The mainland E.R. shift and some small savings allowed me to survive.

I have a personal interest in alcoholism, so I was attuned to alcohol abuse on the island. Even so, it seemed of major proportions. At least five young men in a decade had died, essentially, from drinking, even if that was not what the death certificate usually said. Some of it may have been genetic. One part of the island called me out so much on Saturday nights with alcohol-induced panic attacks that I doubled my usual fee of $20 a visit in those cases, and after that the calls stopped.

Maybe the drinking also had to do with the fact that people were seeing their whole culture implode, their way of life dwindle as the seafood declined and the population dropped. They have gone from subsistence to consumerism on the island awfully fast, in little more than a generation. People's time wasn't as free any more, they said.

I had guaranteed to stay a year, and I stayed almost four. I moved because my oldest was getting near the age when he would leave the island every day for school on the mainland—not a school that impressed me, either. I still miss the nature of the place, the way the reality of work was so apparent. You saw your dad and mom working right around you; watched your whole community harvesting a living as you rode across the Sound to school. Your surroundings were so connected to your whole being. And I remember the people, how beautiful their voices were—they loved to sing. And of course the crabbing, which I came for, was just superb.


----------------------------------------------
Merry Christmas!

Smith Island 1

*************
medical          *
*************

It's Monday Dec 12  at 10 AM...It's a little more than 48 hours since my 3rd round of chemotherapy. Based on past experiences, significant side-effects are more likely today and tomorrow. The initial changes I note are warmness in my palms and soles with numbness and tingling in finger tips and heels. In the past this has been followed by severe aching in the hips and things and darting, stabbing pains in the little joints of the fingers particularly. So far, aching in hips and the beginning of the sharp little pains that are occurring tens of times a minute.

I've felt a significant increase in shortness of breath (medical term is dyspnea) since noon yesterday. When I noticed this in my prior two rounds of therapy and I was concerned that I had lost some large amount of lung tissue I got a CT scan to rule out a pulmonary embolus a couple of weeks ago. Now it is pretty clear to me that it is a side-effect and just something I'll have to accept and adjust how fast I try to do things.

My CT scans on 12/6 showed two more areas of bone involvement, Lumbar vertebra 1 and my right scapula. I was started on the drug Zometa to reduce the risk of bone fractures. The remainder of my chemo combination was continued. Carboplatin, Paclitaxel, and Avastin.

It's Tuesday Dec 13 at 1 A.M. The shortness of breath has been severe for most of the day. I feel breathless getting into and out of the car. Late yesterday afternoon, the generalized achiness and joint pains became much more prominent. I crawled into bed around 8 PM but couldn't sleep past midnight.

I'm planning to try to fly to D.C. on a red-eye from Oakland on Friday morning. There are some people I want to see. I was thinking of calling my journey Cher's Ultimate Final Good-Bye Concert.

It's still Tuesday but about 6 P.M. Shortly after noon the joint pains were back in spades. I took some more Advil and Oxycodone, got a nap and woke up feeling able  to do some errands, like check tire pressures on the RV, get diesel fuel, and replace the fish-eye mirror on the passenger-side RV mirror that was too small to clearly show my blind spots.

Thurs 6 P.M:  Wednesday was much worse than Tuesday. There were  muscle and joint pains for most of the day and I went to bed exhausted at 8 PM. I was up again at 1 A.M. and took an oxycodone and went right back to sleep for another 4 hours. When I awoke again I was so miserable, I knew that there was no chance that I could travel today. That realization was a relief--I could remain within a few minutes of my home and comfortable bed and not be concerned about feeling super sick in a plane over Iowa.

I don't know that it is possible to completely quash denial of this illness prior to death. It seems my thoughts and plans about making a trip to the East Coast were a part of my denial. I do know that there was a strong, rewarding sense of relief that I would not have to test myself today.

Peace an Old-Fashioned  Fat Cat
I'm sitting here at my dining room table. Jasmine is cooking and the television is on and dialed into some woman named Spelling talking about selling her mansion--a lot of noise to me. So, I've put on earphones and I'm listening to Fats Domino's early hits. Next to me is a 16 year-old tabby named, Peace, who has been a recipient of Jasmine's love since her 5th or 6th week of existence.

Peace weighs a little over 20 lbs.

Peace: December 15, 2011

Both Peace and Archie have anxiety disorders. (Do you think being around psychiatrists makes animals crazy?) If Archie is kenneled, he will pace incessantly to the point that his foot pads break down and begin oozing blood. From an early age, Peace could not tolerate being around strangers and she would swat seriously at anyone who attempted to reach out to touch her. You can imagine that our dysfunctional family was not one of the favorites with vets.

In the winter of 2008-2009, peace began to lose weight and to become weak in her hips and back legs to the point that she was unable to jump up on chairs. She was also drinking and urinating more--classic symptoms of diabetes. We began Peace on insulin in January 2009. However, she has not had a single blood test since that time. Jasmine is treating her the way in which diabetics were traditionally treated in the 1950s and 1960s, with urine sugars instead of blood sugars.

In general, the kidney filters everything in the serum into the kidney tubules. Then the kidney works to pull   back all of the good stuff in the filtrate, such as the salts and sugar (glucose), while letting the waste products, the urea, exit into the bladder for final excretion. However, above a certain level of glucose in the bloodstream, the kidney will be overwhelmed and will be unable to recover all of the glucose which will "spill over" into the urine.

Unlike our era, in the 50's and 60's, blood sugar testing required one's appearance at a laboratory for blood draw and hours for doing the test itself.  However, there were testing strips that could be used to measure  immediately the concentration of sugar spilled in the urine. Jasmine began to use these for Peace in 2009 which means that Jasmine has been routinely collecting urine samples from her cat for the past 3 years. Of course, she has to be aware enough to know when the cat is heading for the litter box. Peace is calm enough to allow Jasmine to put a collection bottle between the urethra and the kitty litter and get a fresh urine on a daily basis. Pretty amazing, huh?

Peace has also developed heart failure. She can get exhausted while eating and require a time out for several minutes where she lays down next to her plate before gathering enough strength to finish the meal. She can also become overwhelmed while walking from her perch in the bedroom to the litter box. I noticed that Jasmine has placed a little box midway between the two sites where Peace can lay down and catch her breath. I call it the step-down unit.

Peace in her "Step Down" Unit

However, in her old age, Peace has turned the psychiatric corner. She has become comfortable around strangers and allows others to stroke her. She purrs almost constantly, much more than during her youth. As sick as she is with her heart failure and diabetes, she appears to be enjoying her life and getting the loved old age that Jasmine envisioned for her.

This devotion to an animal is not something I could have imagined a few years ago and it is easy for me to view it as pathology given the extent of human need in the world. However, the care of animals is an opportunity for us humans to express love and that makes us feel good. It is interesting that neither Jasmine nor I would consider expensive surgery or chemotherapy for our animals. It's not so much about preventing death as seeing the animal enjoy its life. That's sort of where I am right now.

Finally, it is Sunday morning, more than a week after Round 3 of chemotherapy. There is so much I don't understand about the symptoms (and for the most part, I don't have any burning desire to better understand). This round was easier than the last where I was withdrawing from steroids but I'm still feeling very weak with a headache and some nausea this morning. On this round of chemo I was more aggressive with the pain medications, making sure that I was taking oxycontin about every 12 hours as the long-acting opiate source and then adding Ibuprofen and oxycodone on top of that.

Overall, it has become harder to write. Words don't flow well and many can't be reached. It's a far cry from last week when I was on my bicycle for a couple of days.

Olivia
No one in the next generation in our family has shown any particular interest in the practice of medicine, but I got a nice note from my niece, Olivia, a spunky, smart first year student at James Madison U.

Hey Uncle Eric,

Just wanted to let you know, I've been reading your blog a lot lately. It's amazing how you can remember all of these stories, did you ever keep a journal before your blog? Reading back over your blog, i feel as though you're lucky to be writing all of this down. At first your posts about your present condition and all the medical terms you used seemed like a distant universe only physicians were allowed to go, but ever since my health class here at JMU has covered a lot on chronic diseases, i'm starting to understand more. It's all so interesting, I don't know if i'd pursue it as a career though, even though neurology has always been quite engaging... All the biology and chemistry classes seem so stressful though, kudos to you for going through with all of it. It takes passion to get through all those years of schooling..but according to your posts, it's beyond rewarding..
...
Anyway, sorry for typing so much, the words just kept flowing out, and i'd be wrong to ignore them.

Have a nice dinner, (6:40 p.m. your time) much love,
Liv

It would be gratifying for a healthier member of our family, such as Liv, to look at the medical profession as a possible career.

Smith Island 1

In October 1983 my destination was Smith Island. It was very nearly the 350th anniversary of a permanent English settlement there. Rather than carving out a life in a wilderness, I would be trying to balance a life of medical work and time with my children.  They were five and seven. Within a few years the need to establish personal independence would take precedence over the needs of childhood. The things of value that I had to give them required my presence and my time while they were still young. Later would be too late.

Looking back I see my two sons in very stable relationships with two strong and emotionally healthy women partners. No lies or speculations proclaimed as certainties were told them regarding the origin of man.  Since my sons' middle names are Gregor and Darwin, you can guess that my own belief system is post enlightenment. The ten commandments were not drilled into their heads. The golden rule seemed more than adequate.

Maryland was settled by Catholics who landed at St Mary's City on the Potomac in 1634.
http://en.wikipedia.org/wiki/St._Mary's_City,_Maryland

That same year, a group of Protestant dissenters left St. Mary's and sailed east, settling on an island in the Middle of the Chesapeake Bay--an Island  discovered by (and named for) none other than John Smith of Pocahontas fame.
http://en.wikipedia.org/wiki/Smith_Island,_Maryland

The first settlement on the Island appears to have been at Rogue's Point, on the Western edge closest to the future shipping lanes. The name Rogue is assumed to be a reference to piracy.

Distance from Washington D.C. to Smith Island: 83 miles by crow

I  promised the Islanders that I would stay at least one year. I hoped it would be more.

I moved the household from Billings, MT to D.C. with a large rental truck and towed the 1961 Mercedes behind the truck. I left in the early evening in October after stopping at the Worden clinic and to pick up the Liquid Nitrogen Tank. It was raining and I had the satisfaction of dumping the remaining nitrogen into a mud puddle and watching it freeze.

Farmers and ranchers are exposed to heavy doses of sunlight over their lifespan. They frequently develop skin lesions called "actinic keratoses" which are pre-cancerous. One of the treatments is freezing of the lesion with liquid nitrogen. Given that the predominant occupation on Smith Island was fishing, I expected to see a fairly large number of actinic keratoses there as well.

Many farmers and ranchers have liquid nitrogen tanks for storing semen for artificial insemination. I remember taking a rancher back to the treatment room in Worden to sew up a cut. He saw the nitrogen tank and said "What in the hell are you guys doing back here?" I couldn't tell if he was serious but I was very careful to explain that we actually applied the liquid nitrogen to the skin.

In general, I love to drive almost any vehicle, but I could not get comfortable with that moving truck.  I managed to pin myself into a dirt parking lot at a restaurant in Miles City and this required over an hour for extrication.

I took I 94 across North Dakota. At Jamestown and Fargo I noticed a fellow hitch-hiking. He was about my age wearing what I would call now a "Rasta" style hat. I saw him again around Minneapolis and I finally picked him up in Madison.

It was a stroke of luck for me. He had been a truck driver for a good portion of his life and after a hundred miles, he asked me if I wanted him to drive.  I was happy to let him do so. For the next few hours I dozed off and on and listened to his stories about his wife who was 30 years his senior and living in the Caribbean. He was working as a merchant seaman. I was particularly grateful for his help around Chicago where he demonstrated his expertise at navigating through narrowed road construction lanes bordered with concrete slabs.

He drove about 500 miles with only a few breaks and by the time our paths diverged, I was feeling refreshed and I was within a few hours of Washington, D.C.

I got to my father's house and stored furniture Molly wanted to keep for her own place. The next day I was supposed to have the moving truck in Crisfield to meet the boat that would take it to the Island. There was a miscommunication with Molly. I hadn't realized that I would have the children while caught up with the physical acts of moving.

Nevertheless, it turned out to be an adventure and what's not to like about fast food if you are five and seven. The boys and I made the three hour drive to Crisfield. They were fearless even as we took the moving truck over the Chesapeake Bay Bridge and were buffeted by moderate winds.We spent the night in a motel and the following morning, we met Rev. Zollinhofter (Rev Z from now on) for breakfast. He was accompanied by the owner of an old landing craft that would carry the van to the Island.

It was a bleak day. The sky was overcast with occasional drizzle and there was a substantial breeze. There was very little for the boys to do as the boat captain maneuvered the loading in Crisfield. It was a cold ninety minutes to make the crossing over the Tangier Sound  to the village of Ewell, the largest of the three communities on the Island. Finally, the moving truck was unloaded from the barge and was parked in front of the clinic. I had 3 days in which to get everything off and get the truck back to the D.C. area.

Of course the boys were hungry again and I took them to Ruke's Grocery Store.

Ruke's Grocery Store: Ewell, Smith Island

The gravel road in front of the store accesses the county boat dock which is about 100 feet to the right. The county dock is the major hub for ferry launches, excursion boats, and freight delivery. When we arrived in 1983 the structure was smaller. The right most part of the building was a screened-in deck constructed by Reverend Z and a friend in 1984. Since Z was married to Jan, the grand-daughter of Ruke's owner, there was some complaining about the preacher using his time and carpentry skills to benefit his own family.

The grocery part of Ruke's looked very much like a corner store at the beach or a convenience store with respect to the stock. Canned goods tended to be present in smaller quantities, to be crammed into all available space, and to be expensive. Much more of the sales space was devoted to milk, bread, and eggs--the perishable, everyday items.  Grocery shopping at Ruke's was primarily limited to a particular ingredient for a planned dish but it was also a major source of credit for Islanders who were living hand to mouth.

If you popped into Ruke's after 6 PM you would have found four or more elderly watermen playing dominoes at one of the tables. Two or three younger men would be sitting at the counter waiting for food, generally cheese steak subs and fries. The conversations were often general. Someone playing dominoes might be having a cross conversation with someone at the food counter. The Islanders are great for kidding one another and telling stories. The "tall tale" is the specialty of the region and in Crisfield there is a dedicated "Liar's Bench." Ruke's Grocery store was the only place you could get prepared food in the evening. It was also the place to go to find the 6 oz Coca Colas, the ones I remembered from childhood and hadn't seen in years. The six oz glass bottle coke could have been an icon for the island.

Ma Willie was the proprietor of Ruke's. She was a widow when I met her and she ran the store with her daughters Chart (Charlotte) and Mary. Mary's daughter, Jan, the preacher's wife, spent time working in the store as well. "Ruke" was Chart's husband's name. I don't know why or how his name became attached to the store.

Ma Willie
She had a limp and walked from her home to the store twice a day. She opened the store in the morning and with one of her daughters began preparing lunches for the school children. During crabbing season, the women would be working out in the shanties fishing up the soft shell crabs or picking the hard shells. It was often easier to have Ruke's prepare and deliver the school lunches leaving the mothers to continue working. Softshell crabs are quite perishable. They needed to be packed in ice and awaiting the 4 P.M. ferry if they were going to make it to Fish markets on the East Coast, including the Fulton Market in New York.


If I had to find a single adjective to describe Smith Islanders as a group, it would be guileless.  They could be quite cunning when it came to besting the sea for a catch, but there was a remarkable simplicity and gentleness in their treatment of other human beings. Throughout the region Islanders were known to be "good people" who could be trusted. If I had to find a noun to associate with the Island, it would be food. They love to eat and they relate to others by giving food. (The most notable historical act of giving food was feeding the British fleet that passed through on the way to sack Washington in the War of 1812.)


After I left the Island, Willie had a series of small strokes that left her paralyzed on the right side and unable to speak. After a time she was no longer able to recognize family and required full nursing care, so she was placed in a nursing home in Crisfield. The family was very much aware that Willie wanted no extraordinary measures to prolong her life in this situation. It had been discussed on several occasions.


I had a conversation with daughter, Chart, about Willie's condition. There was no realistic hope of improvement. There was no evidence of quality of life. She was unable to recognize, much less communicate with her family. She had stopped eating. The nursing home wanted to put in a feeding tube. I pointed out to Chart that her mother's wishes were for nothing heroic--that a feeding tube would only prolong the current existence--and we already knew that Willie wanted to die rather than be artificially maintained.


It was several months before I spoke with Chart again. She told me that her Mom had just died. I was so surprised. Chart started crying. "I know we talked about it doctor Sohr, but the nursing home just kept after me. They said 'Are you going to let your mother starve to death?' Chart had been pressured by the professionals to permit a feeding tube.


We have come to the point in our country where some professionals have taken on the seamier aspects of businesses and can look at a dying human being as an income stream. For shame!


The First Week on the Island
The first day had been eventful and the evening was busy as well. There were actually Islanders wanting medical care. I had to turn them away until the following day when I would have had the opportunity to find some of my basic equipment. I had to rip my way through boxes to find linen to make beds for the boys. In the meanwhile, several men came by to offer their much appreciated services moving furniture and boxes. Reverend Z was in and out several times.

Finally it was time to put the boys to bed.  My bedtime story-telling repertoire consisted of three tales known by heart and complete with voices, expressions, and certain sound effects. I didn't read to them before bed any more, because that required light. A recitation allowed me to turn down the lights to a bare minimum and to increase the drama. I had read "The Uses of Enchantment" by Bruno Bettelheim and I gravitated toward the old fairy tales.

The kids picked a story and I told it. On this day they were both exhausted and were asleep quickly. Then I was alone with my thoughts and entered what quickly became my favorite part of the day, the first hour or two after the children have gone to sleep. I'm sure that billions of women know exactly what I am describing. From the moment of awakening, the demands of others take precedence and provide the framework of the day. As the primary caregiver I can make some modifications and change a few things here and there, but I am on a fixed track, maybe even a treadmill. However, as soon as the children are asleep, the chains and weight of responsibility are lifted. I could sit there with a cup of coffee and relax in the peacefulness of this new place. It was a delicious feeling and I would experience this almost nightly for the next several months.

Within a few days the van had been unpacked and returned to the rental company. I constructed some shelving downstairs in the clinic to store books. I went through the existing patient charts and decided to keep files by birthdate. I looked at the existing equipment and decided that I couldn't trust the sterilizer that in the clinic. I had accumulated a number of surgical instruments in my practice with Stan. Later that week, I found that the Crisfield Hospital accomodated my request for help by sterilizing my equipment for the first few months.

The "doctor's house" was not in very good condition. There were several leaks in the roof and it was difficult to find dry areas for stationing the beds during rains. However, it would not be possible to just repair the roof. The plans for the doctor' house included opening up one side of the roof and placing five 4' glass windows to form a long wall that would given unobstructed views of the harbor and the Big Thoroughfare. A new roof would have to wait upon completion of the addition. When it was done, there would be a million-dollar view, but that was in the future. At the time we arrived, we had no way of knowing that we would be living in a construction zone with a leaky roof for the next year.

In order to work away from the Island, I needed child care help. Thelma Goodman was recommended to me and she agreed to watch the boys and to feed them while I worked away in Crisfield. My first stint at the hospital turned out to be a very rainy time and I returned to the Island to find all of the bedclothes wet, with numerous buckets on the floor to catch drips. The boys had renamed Thelma Goodman as Thelma Badman. The clothes dryer was not working properly but one of the islanders who did electrical work came by and got it running so that I could get clothes and bedding dried.

The Island practice would be much different than Montana. I would no longer be doing obstetrics or the immediate care of the newborn. Most of the women had established relationships for their routine gynecological needs such as Pap Smears. There was no x-ray machine on site and there would be few opportunities for routine orthopedics.

Smith Island Economics
The economy of Smith Island is almost entirely cash. After seeing a waterman for a visit, the patient would generally reach into his right front pocket or into a wallet and say, "Thanks, Doc! Let's settle up." Then I would be paid in cash. Seldom was a receipt wanted. The right front pants pocket was generally the Islander's bank.

Even boat purchases were commonly straight up cash rather than mortgaged. When an Islander lost a boat due to a fire or sinking, it was common for the community to come together and purchase a boat that could be utilized to continue fishing.

A lot of charity was personal and straightforward. As an example, I had a patient with kidney disease who was being treated at a Johns Hopkins clinic on a monthly basis. It was common for neighbors and friends to come to the parents in the days prior to the appointment with what was called "a piece of money," cash that could be used for travel or medical expenses.

Many Islanders are wary of mainland banks. In 1985 there was a hurricane, Gloria, that for a few days appeared to be aiming for the mouth of the Chesapeake. Evacuation from the Island was recommended and there was plenty of time to do it. A number of widows left carrying suitcases that they refused to let others handle. It was suspected that this was a parade of thousands of dollars from hiding places all over Smith Island.
http://www.hurricanes-blizzards-noreasters.com/HURRICANE-GLORIA.html

Smith Island is actually a cluster of islands, gradually sloped hilltops that are barely peeking above the surface of the Chesapeake. There are hundreds of square miles of shallows that surround the Island. Throughout the shallows are a number of "guts"--deeper cuts that permit navigation.

These shallows are among the world's most productive habitats for the blue fin crab. In order to increase in size, the crab must shed its hard shell (called molting) and remain vulnerable to eels, birds, and other crabs for several hours while a new shell is formed and hardens. I can imagine myself in the naked crab's place, hunkering down and helpless on the bottom hoping to survive undetected for the next few hours. It seems similar to my father's story about being in a foxhole and being under bombardment by mortar fire. To attain adult size and the ability to reproduce, the female molts several times, ten is the average number that I recall.

Since the Islanders are self-employed fishermen, they don't get paid if they don't work.  The most common question for me in clinic was "Doc, what do I need to do to work tomorrow?"

I established general clinic hours beginning at 6:30 PM in the evening. It was first come, first served and the clinic continued until everyone was seen. I was generally finished before 9 P.M. The boys got a kick out of sneaking down the circular staircase and hiding in the laundry room and eavesdropping on the conversations in the waiting room.

McCready Memorial Hospital 

McCready Memorial Hospital, Crisfield Maryland

It is hard to imagine a more beautiful location than the hospital in Crisfield. I was surprised that the structure was not purchased by a group of plastic surgeons for the care of the wealthy from Baltimore and Washington.

The buildings were on a peninsula with greenery and water all about. It was possible to reach the hospital by land, sea, or air. There was a dock capable of handling boats of almost any size and families from Smith and Tangier Islands were able to bring their boats to within a stone's throw of the emergency room.  I saw two or three obstetrical cases arrive in this fashion in the four years that I worked there. There was also a heliport to handle emergency evacuations to Salisbury and Baltimore, and there was a connection by road to Crisfield proper.

The evening nurse, Vesta, was originally from Smith Island. She spoiled me terribly and brought me supper whenever she worked in the emergency room. I generally slept in an unoccupied hospital room and spent blocks of time doing programming work, reading medicine, and working on another piece of computer software for patient records.  Somewhere during the first year on the Island I learned how to make crabnets and I would occasionally bring a net or two to the hospital to complete.

Despite the apparently poor hourly rate for work in the Emergency Room

• I estimated that the 24 hour shift really involved less than 8 hours actual medical work during that 24 hours 
• I generally managed to get a few hours of sleep during shift
• I wasn't responsible for any of the admissions to the hospital although I tried to help out and do the history and physical for the attending doctor
• there were always beds and I wasn't trying to turn away patients
• I seldom felt overwhelmed--generally I was pretty comfortable with the pace of work
• Salisbury, Maryland with a tertiary facility was less than 45 minutes away by ambulance

When factoring in all of my requirements and the actual burdens of the job, the hospital employment worked out well.

Settling In
The first few months were time of settling in. On my first Sunday on the Island, Doris Spriggs sent me a traditional Smith Island dinner, stewed chicken with onions, potatoes, carrots, turnips, and dumplings--all  in the same pot, with a large slice of Smith Island Cake for dessert.

Since then, this cake has been named the "State Cake" for Maryland.

Smith Island Cake: More traditional is yellow cake.