Dr. Campbell in the MEDesign Lab

Short Story Chapter:

The One That Got Away

James Stewart Campbell, MD. 2012-13

It was a warm spring day and Doctor Jim looked longingly out the office window at the budding trees. He would much rather be way out in the mountains hunting herbs, but there wasn’t much money in that, so the office practice had to go on.
His next patient was new to the Mountain People’s Clinic, and Doc sized him up as he entered the room – a balding middle-aged guy of average build accompanied by a younger wife with long black hair. She did most of the talking and obviously wore the pants in the family.
His name was Walter Smith and his wife was Sharri – Sharri Smith.
“So what brings you to our humble clinic?” Asked Jim.
Sharri indicated to Walter to answer.
“I’ve got stomach pains, doc. It keeps me up at night. And sometimes I burp up a blood taste. Garlic or raw onions makes the pain much worse, especially late at night.”
“Ever pass foul black stools?” Doc asked in his best medspeak.
“Once,” replied Walter, “and come to think of it, doc Stroud over in Murphy said I was anemic and asked me the same thing. That was several months ago, though.”
“How about weight loss?”
“No problem there,” replied Walter, rubbing his apple-shaped belly.
Jim then checked the patient as Sharri looked on. Walter was slightly pale. His mouth and throat looked OK except for several missing and carious teeth. Heart and lungs were normal. The stomach was somewhat tender over the epigastric region. Liver and spleen were normal, and the four extremities had full pulses and no swelling was present.
Doc took out a sterile lancet and stabbed Walter’s finger, sucking up the blood in a capillary tube. The tube would be spun in the lab centrifuge to find the hematocrit – the percentage of red cells in the blood. Doc held the spun specimen up to the measurement chart – Hmmm, 38%. Low for a middle-aged male. Jim also checked Walter’s urine to rule out severe diabetes or kidney trouble. That was normal.
Walter’s diagnosis was not difficult. “You’ve got a bleeding stomach ulcer,” Doc stated categorically, “and we’ve got to start treating it before you need surgery.”
Now back in the 1970’s the acid-blocker drugs had not made it out of the lab, and the idea that stomach ulcers were caused by a bacterial infection was unheard of. Standard ulcer therapy consisted of large doses of milk and antacids around the clock supplemented by psychotherapy to unravel any “stress.” Surgical procedures were reserved for those whom this therapy failed – and it often failed.
Jim was anything but a standard practitioner, however. He knew some other basic remedies to try that just might save Walter from the knife.
“OK, now I want you to do three things to heal your stomach:
“First – dig up some Yellow Root. It grows down by the water. Do either of you know about it?”
Sharri said she did. She apparently knew a lot about herbs.
“Clean off the roots and chew a half-inch piece after each meal. Spit out the pulp. This will increase the healing secretions to your stomach lining.
“Second – get some strong cayenne pepper powder. Put it into ‘OO’-sized capsules and take two capsules twice a day. Can you do that?
“Third – Get your teeth repaired so those infected stumps aren’t poisoning your stomach.”
Sharri said she could get the capsules and pepper and would make them up for Walter.
“Great,” replied Doc, “let’s check you again in two months.”
The couple left the office holding hands.

Two months passed quickly in the rush of rural medical practice. When the Smiths returned it was obvious that the therapy was working. Walter had had no further black stools, his stomach pain was less, and he was tolerating the bitter Yellow Root and the cayenne capsules well, but his teeth were still in poor shape. His hematocrit was up to 44% - normal. Urinalysis was also normal, without even a trace of protein. The therapy did not seem to be injurious.
“Keep up the therapy for another three months,” said Jim. “I think you’re on the road to recovery. Just be sure to get to the dentist…”

Spring faded into summer and the Fourth of July came around with fireworks and festivities and the Hayesville parade. Doc caught sight of Walter as he marched past the square, proudly wearing his uniform from the Korean War.
“So Walter was a Korean War veteran,” thought Doc. “That may be the cause of the ulcer…” Stomach ulcer was a semi-psychiatric diagnosis back then, and men didn’t talk out their war experiences except to act macho. Those repressed memories of the horror of war could wreak all sorts of somatic problems – including ulcer. Jim put it in his mind to bring this up to Walter at the next office visit.

Doc had a lot of patients coming through his door, and in the press he forgot all about Walter until one day in late August when he was enjoying a milkshake at the soda fountain in Ray’s Drugstore. At a nearby table two women were gossiping about Mr. Smith’s nervous breakdown and how the ambulance crew had to tie him down for the trip to Broughton Hospital in Morganton. Not wanting to compromise medical privacy, Jim pretended not to hear. He paid for the shake and quickly returned to the clinic.
There were several patients waiting, but Jim first shut his office door and called the local ambulance service for details. Sure enough, neighbors had called the crew to the Smith’s house on Qualla Road two nights earlier. They found Walter in a state of severe combative dementia, yelling incomprehensively and threatening all who came near. He was obviously a danger to himself and others and thus was involuntarily committed to the nearest state mental unit – Broughton Hospital.
“What the heck?” thought Jim as he hung up the phone. Composing himself, he went to the door and welcomed the first patient of the afternoon. He had a feeling he would see Walter soon at the office.

Sure enough, Walter and his wife came in about two weeks later. They said tests done at Broughton showed that Walter had bad insulin-dependent diabetes. As soon as the doctors there got his severe hyperglycemia and metabolic acidosis under control, he became coherent, sane, and “his old self” again. The Smiths had come to see Doc for an insulin prescription to control the diabetes.
Now Jim didn’t like to miss a common diagnosis. “Hmm,” he mused, “if Walter had such intense diabetes, why were the urine sugar and ketone tests negative just a few months ago? Such diabetes should come on over a half-year or more.” He would have liked more information, but Doc was on his own. Fax machines were a new invention - there was only one machine in town at the lawyer’s office. And phoning for the lab results at Broughton might be a bureaucratic nightmare. He would have to use his basic country doctor skills to manage this case.
Jim started as usual by asking what happened. Sharri did most of the talking and told the same story as the ambulance service had previously. She had to mind the house and pets, so she had not gone to the hospital with her husband, or even visited him there. The ambulance service had brought him back home. Doc stopped her lengthy report and requested quiet while he performed a mini-mental exam on Walter: “Count backwards from 100… OK, but slow. Repeat a sentence… fair. What is the day, date, and year…OK, but Doc caught Sharri coaching Walter. Please, no prompting. Conclusion: mental functioning was slow and slightly inaccurate, but there were no signs of dementia. Could be a result of the recent diabetic crisis.
Neurological exam was also pretty normal, right down to the pupil reactions and Babinski reflexes. There was some unsteadiness during the Rhomberg balance test, and Walter’s gait was marginally slow and shuffling, but again Doc passed that off to some neuropathy from the diabetes. Physical exam was all normal except for slight stomach tenderness. “Hmm, how’s that ulcer problem doing?” Doc remembered to ask.
“Much better, doc.” replied Walter. “I’ve been able to cut down on antacids now that I’m out of that hell-hole hospital and can chew my Yellow Root. I kinda like that stuff. And those Cayenne capsules seem to work and don’t burn my stomach anymore.”
“No problem making ‘em,” Sharri injected. “Walt made me a capsule filler by drilling a block of wood.”
Doc wrote the prescription for porcine insulin Lente. With the long acting Lente, Walter might keep his diabetes under control with just one shot a day. Then he taught them the practical way to monitor diabetes at the time:
“Start with 20 units of the insulin injected into a fatty area each morning. Monitor your urine twice a day by peeing on a piece of Dextrotape (sugar-detecting tape that came on a small roll). If the sugars stay high, or if you feel sick, check your urine with a KetoStick to detect any problem with ketoacidosis. If you have sugar in your urine, go up 5 units of insulin a day until the urine sugars show trace to none. Continue that dose, but try lowering it by 5 units a day from time to time to reduce the chance of low blood sugar. Low blood sugar is more dangerous than high.
“Keep restaurant sugar packets nearby everywhere you go – even in bed. If low sugar symptoms start, such as difficulty thinking, visions dimming or narrowing, lack of coordination, tremor, or a panicky feeling, pour a packet on your tongue like a Goody Powder…”
Sharri seemed to be taking this all in. “Walter should be OK, he’s in good hands,” Doc thought as she helped her husband off the exam table. “Call me if you’re having trouble with the insulin. And come back to see me in about a month for a re-check.”

No calls came from the Smiths, and Jim assumed all was going well. So it came as a surprise when his office assistant mentioned that Walter had been admitted to Broughton again. His neighbors had called the ambulance due to the ruckus next door, and the crew had to strap him down to the stretcher he was so agitated.
Doc checked the appointment book – it was two weeks since the Smith’s visit. Had Walter’s diabetes gone haywire despite the home monitoring? Or maybe the insulin had not been refrigerated. At least Walter was in good allopathic hands in Broughton. Jim would sort it all out when Walter got back home.

Being a country doctor in southern Appalachia was an isolated job in those days before the Internet. Hayesville was famous for being “two hours from anywhere,” and it was hard to get to professional meetings, especially with his obstetric practice. Babies could come at any time. So Jim was dependent on medical literature for the latest information. He had subscribed to the New England Journal of Medicine when he had started the clinic, but found it too esoteric for a country practice. Nevertheless he tried to slog through each volume in his spare time. To keep up as best as possible, he kept the unread issues in a basket near the toilet, and would “multi-task” each morning during his sit. He’d pull the oldest issue from the bottom of the stack and try to find information useful to his patients. He was months behind when he opened the January 10th edition to page 73 and read the abstract. It was a major article titled “The Neurotoxicity of the Rat Poison Vacor.” It is a good thing Doc was on the toilet or he probably would have soiled his pants! Vacor poisoning, the abstract said, is known to cause diabetes mellitus, and acute encephalopathy was a typical feature. Jim composed himself and read on: Vacor destroyed the pancreatic B-islet cells, causing permanent diabetes, damaged the nerve cells throughout the body, and could cause a temporary toxic encephalopathy – sudden violent dementia. “Oh my God!” thought Doc, “Walter is being poisoned!”

Jim’s mind raced. If Walter was being poisoned, who was doing it, and why? Could he be inadvertently poisoning himself by somehow ingesting Vacor? Not washing his hands after handing the stuff? That seemed improbable because it apparently took a gram or more of the poison to bring on the toxic dementia. That would require a quarter teaspoon or more. Or maybe he had a bad neighbor, but both episodes of dementia had occurred in the evening. No, it was far more likely that his younger, controlling wife was giving him the toxin at night. The cayenne capsules that Doc had prescribed could easily be packed with a gram or two of poison. When the first dose landed him in Broughton but failed to kill him, she had tried again. Jim shuddered to think that his therapy had likely been used for evil. He had an urgent duty to warn his patient of his suspicions. Should he call Walter? What if Sharri answered? What would he say that would not arouse her suspicion? Instead, he first looked at the appointment book. Walter had a scheduled appointment in two days. Doc figured the best thing was to confront both of them together at that meeting. He was curious to see the look on Sharri’s face when he brought up the subject of Vacor poisoning. What would she do? Jim tore out the journal article and put it in Walter’s chart, ready for the confrontation.
The day of the appointment came, and Walter showed up right on time – alone. He was in worse shape than before, using a cane for balance as he shuffled across the office floor. That second dose of Vacor must have done more damage to his nervous system. Disappointed that Sharri had not come, Doc confronted Walter with the evidence, stating that it was highly likely that someone had been poisoning him, most likely his wife.
“With your permission, I think we should both go to the sheriff and let him investigate what happened.”
Walter hesitated. His thinking was slow and his words muffled. “No, doc,” he said. “Sharri moved out about a week ago. Took all her things while I was over in Murphy. The neighbors say some guy helped her pack and she drove off in his car. I think they went to Tennessee.”
“But she was very likely trying to murder you. She certainly damaged your health badly. You will be diabetic the rest of your life now.” Doc protested. “And she may do this to someone else.”
“No. I don’t want anything to do with her anymore. I’m glad she’s gone out of my life and it will only be more trouble for me if I do anything. She was weird, doc. Had a strange altar in the basement. Used to make up my treatment capsules down there too. She’ll lay a spell on me if I do anything to her. I think she was some kind of witch. Let that other guy worry about it now.”
Despite Jim’s protestations, Walter was firm. He was not going to investigate what had happened. And he definitely was not going to the sheriff. So Doc checked his diabetes with a urine test, wrote the prescription for more insulin, and told Walter to return in two weeks for a recheck.

Doctor Jim was now in a quandary. Without Walter’s permission, he could not go to the sheriff without breaking medical privacy. And the evidence he had was only circumstantial and highly technical. What would the authorities do, anyway? They had no firm evidence either. Walter would deny everything, and Sharri had probably cleaned up the basement before she left, taking any remainder of the Vacor with her. Doc sighed, closed up the file folder, put it in the cabinet, and went on to the next patient of the day.

Walter never came back to the Mountain People’s Clinic. Jim last spotted him shuffling along in the Fourth of July parade the next year, dressed in his old uniform. He still appeared to be in poor health. The damage to his nervous system was probably permanent. Vacor was eventually removed from the US market by the Environmental Protection Agency and is no longer available. And as far as Doc knew, Sharri was never seen in Hayesville again. She was indeed the one that got away.


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