A Country Doctor Writes:

Brenda Norwood was a single mother, doing her best. Her new boyfriend was not necessarily helping her deal with Sadie, and Sadie was a handful.

Sadie was the most sullen teenager I had ever run into. Her hair was orange, her eye makeup looked like something in a late night movie, and she wore a dog collar around her neck. She seemed to despise her mother.

For a brief while I thought I might be able to reach Sadie, but I was mistaken. Her attitude in general, and mostly toward her mother was so terrible that I did something I had never done before: I asked her to leave the room.

Brenda and I talked for a while alone. I gave her some suggestions about what she could do, counselors she might want to call, even the psychiatric hospital’s outreach telephone number and the youth crisis stabilization hotline.

Sadie was physically healthy, and as I wasn’t able to do much for her or her mother, I saw neither one of them for a while. Then one day I heard from Autumn what was happening with Sadie. I swear, Autumn knows more about what is going on in this community than anyone else, even when it comes to the small minority that she isn’t somehow related to!

Word was, Sadie was pregnant, and the father was Mickey Leblanc, a nineteen year old with a similar background history. We were surprised to hear that they were getting married soon after the pregnancy became public knowledge.

Imagine my surprise when Sadie and Mickey brought their newborn son to see me. I must say I didn’t quite know what to expect. There was Mickey, now working as a painter, wearing his work overalls, calm and completely focused on what his son and young wife were doing; Sadie, a pretty strawberry blonde with earnest, kind eyes and a soothing voice, was completely focused on the most beautiful baby boy, a calm, contented little soul, whose entire being seemed to be one with his mother.

Without missing a nuance of our conversation, Sadie did everything automatically for her baby as if she had done it all her life. She was in charge, and Mickey was in quiet attention, ready with a cloth or a hand when needed.

The other day I saw little Sam for his four-year-old well child visit. As usual, Sadie and Mickey were both there; Mickey in paint splattered overalls as usual.

Sam counted fingers, wrote down numbers, named colors and copied shapes for me. He walked toe-heel along the floor tiles and he hopped on one leg.

“This is the five year old stuff we’re doing at age four,” I pointed out. Sadie and Mickey both beamed.

“Sam is a great kid, you know that,” I said. “And I’ve told you this before: You two are doing a great job with him.” Still vividly remembering Sadie in her dog collar, I added: “He’s smart enough that if he gets bored or sees the adults around him not measuring up, he could turn into a real handful for you.”

They both smiled knowingly.

Herbert Beal took me by surprise yesterday morning with his question. He is a 70-year-old oxygen-dependent frail man with severe emphysema and a newly diagnosed 5.9 cm asymptomatic abdominal aortic aneurysm.

The vascular surgeons at our tertiary hospital couldn’t help him, so he was referred on to Massachusetts General Hospital in Boston. They felt his aneurysm could be stented, and his local pulmonologist thought he would tolerate that procedure, but probably not an open repair with a graft.

Thursday morning I got a call from Mass. General. They wanted him to have a cardiac evaluation before the operation next week. The chief of our local cardiology group agreed to see him at 11 am Friday.

Late Thursday afternoon Mr. Beal called because he had a cold and was raising colored sputum. I agreed to see him as a “double book” Friday morning on his way to the cardiologist in town.

In the exam room was Herbert Beal and his wife, who had never come with him to an appointment before. He had rales and rhonchi in both lungs, and deserved an antibiotic, especially with surgery next week. I also offered him a flu shot and made sure they knew how to get to the cardiology clinic.

As I was about to leave the room, Mr. Beal cleared his throat and asked:

“Doctor, what would you do?”

I looked at him again, and he continued: “Would you have the surgery?”

His wife spoke softly: “Herbert and I have talked about this – I understand that death from emphysema can be very uncomfortable, and death from an aneurysm is usually quick…”

I thought for a moment before answering:

“This is a high risk situation. As long as the aneurysm can be stented, your lung doctor thinks you’ll be OK with the surgery, and you’ll soon hear what the cardiologist thinks. If stenting doesn’t work, an open repair would be very risky.”

I paused and thought again.

“We don’t know how long you’ve had this aneurysm, and we don’t know how fast it will grow. If I were in your situation, I’m not sure I’d have the procedure.”

They thanked me and went on to his cardiology appointment.

Just as I was about to leave the clinic last night I got the cardiology report – OK for the stenting, very high risk for an open repair, just as expected. I called the Nurse Practitioner I had talked to before at Mass. General.

“Oh, really”, she said. “I heard from his pulmonologist yesterday, and he told me Mr. Beal had decided against the surgery. I guess we’re still on then – I’ll email the surgeon.”

What a terrible choice to be faced with…

Ted Hall was in for a blood pressure check and flu shot today. He is a secure, big-boned man with a hint of a southern drawl. A retired military man with a son who is a decorated war hero, he has seen a lot, and seems to take everything in stride.

Wrapping up his visit, I looked at his “Problem list”, the cover sheet on the left hand side of the chart that lists his allergies, chronic medical problems, social and family history. A couple of words under “Family History” caught my eye and rekindled my memory. I asked:

“How is Brittany doing?”

He beamed. Brittany was his youngest daughter. I had seen her only once, but I have carried the memory of that June afternoon in my heart for the last 23 years.

It was a stifling hot Thursday afternoon. I was relatively new in town and Brittany Hall was a High School senior, who usually saw a colleague of mine who was off that day. She had a rash on her legs, graduation was the next day, and I agreed to see her as a “double book”.

Entering Room 11, the same room where I saw her father today, I met a pretty, blonde girl with a flowery summer dress. She didn’t look like most girls from around here, and she carried herself differently. She seemed older and more mature than most eighteen year olds.

Brittany felt fine, and was just concerned about an unsightly bright red rash on both legs. It had been there for a couple of days. She wanted it gone, or at least less noticeable by graduation the next day.

The rash that covered both calves of her fair-skinned legs was petechial and didn’t fade when compressed. The rest of her exam was normal.

“These are broken blood vessels,” I explained to her. “We need to run some blood tests.”

Fifteen minutes later I knew for certain what I had already feared. Her white blood cell count was 28,000, all the same kind of cells – she had acute leukemia, and within twenty more minutes I had arranged for her to meet with the oncologist on call at the hospital twenty miles up the road.

As she left the office with Ted, who came to pick up his daughter, she said:

“And I thought I would just get a cream to put on my legs.” 

I never saw her again, but the reports from the Cancer Clinic kept trickling in. She went through chemotherapy, delayed long enough so she could attend her graduation, and then she left for college. Ted was my colleague’s patient, and I would see him occasionally. Dr. Walls left the area, and Ted became my patient a couple of years ago.

I know I had asked him once before about Brittany, and he had told me she was well, but that time we had not pursued the subject more. Today we lingered more with the story we shared.

“She’s 42 now, you know, a beautiful woman” he said, “and she is married and has two gorgeous, healthy children. The cancer doctors had warned her she might never had children, but she had no problems.”

“I’ll never forget that day she came in with the rash on her legs,” I said.

“Me neither,” he choked.

It warmed my heart to see Albert T. McCall the other day. Nobody knows what his real middle name is, but his nickname is “Twinkle”.

When he greeted me, I instantly saw his deep-set small blue eyes sparkle against his pale complexion, and I knew “Twinkle” was back!

It had been a long haul. Ethel, the love of his life, had died about a year and a half ago. They were high school sweethearts and always did everything together. When her health failed, he took over all the household duties and kept her comfortable at home into the end. At age 83 he lost her, and he became a different man.

Years ago the two of them were the square dance royal couple of our area, and for a decade they ran a dance hall in a retirement community in Florida every winter. He was the caller, and she took care of the business.

“Twinkle” had a thick New England accent, and a wicked sense of humor. Over the years he had developed another persona, “Uncle Al”, with an even thicker accent, wide suspenders, an oversized plad shirt and a silly hat. He told stories about growing up poor and mischievous in the thirties, and he wrote hilarious poetry, which he would always bring samples of to his office visits.

Before Medicare D came about, with rising medication expenses for himself and Ethel, he self-published a book of stories and poems. This endeavor brought in enough money to cover one or two years’ worth of medications. The following year, his children helped him produce a CD based on his book. At 83, he was on a roll, making public appearances to promote “Uncle Al”, always joking in his quiet, soft-spoken way. His deep-set baby-blue eyes did justice to his nickname, squinting and twinkling in his kind, pasty-white, round-cheeked face.

After Ethel passed away, “Twinkle” lost his nerve. He developed heart palpitations, spells of wheezing and hyperventilation, indigestion and poor sleep. Nothing I did seemed to work, and he was always leery of new medications. He even ended up in the Emergency Room a couple of times with no firm diagnosis.

Finally he agreed to an almost homeopathic dose of an antidepressant – the same one his wife had taken for a while.

I knew the instant I saw him that the medication had helped; the twinkle was back in his eyes, there was a faint grin across his round face. His shoulders were raised high instead of drooping, and I could almost imagine the hat and suspenders from the cover of his CD.

“Jeez, I feel good”, he exclaimed, his little eyes squinting at me.

“I’m glad the stuff worked”, I said.

“I don’t know what’s in it, but I feel like myself again!” he beamed.

After many unproductive visits with Albert T. McCall, I again enjoyed the company of “Twinkle” and “Uncle Al”.

I need to find that CD and put it in the car; it will make great listening when I go on house calls this fall.