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W. Grant Thompson, M.D.
W. Grant Thompson, M.D.
This is a memory, not a memoir - a recollection of events fifty years ago with no written record. What appears here is strictly from my head. No doubt time and subsequent experiences have colored my memory. Time tends to blur the bad things - the mistakes I made - and accentuate the heroics which the reader will find to be rather small. I have practiced medicine since then as a trainee, a consultant and a professor, and my career for a time obscured the memories of general practice. The following is what I now have time to recall.June 1961 began my first experience with general practice, or what since became known as family medicine. While it was a defining period of my life, in my subsequent career as a specialist and medical educator it left me with great respect for this undervalued branch of medicine. Admiration for my physician colleagues in Tavistock is the paramount memory of that year. Seldom in the intervening years, in myriad medical settings have I encountered greater dedication to the wellbeing of their community than that exhibited by my four senior partners. Yet each found time to teach me the ropes and begin my badly-needed maturation as a doctor. However, this is about experiences seen through my mind's eye a half century later. Others may remember them differently. Certainly my patients should be forgiven for any misgivings about a very young-looking, blond youngster landed in their midst and entrusted with their most valuable asset - their health. While I had scary medical experiences with which I barely coped at first, I encountered no malice in Tavistock. It was not Eden, but somehow it brought out the best in people. I remember it with affection. Ottawa, Canada 10/4/2009
CHAPTER 1 - TAVISTOCK
In 1961, Tavistock had a population of one thousand, according to the signs carefully placed at of the four road entrances to the town. It is situated on the border of Perth and Oxford counties in the Province of Ontario. The town lies about 7 miles (metric measure came much later) from Stratford, where in 1961 the famous Stratford Shakespearean Festival was enjoying its early years. Shakespeare, Ontario is 4 miles north, and Woodstock 10 miles to the south. Waterloo County lies to the east and Kitchener-Waterloo was a 15 minute drive away. Sebastopol, just four corners two miles north recalls the famous light brigade of Crimean War fame. It was the original local village, but lost out to Tavistock when the London and Hamilton railroad was built. Neighboring towns of New Hamburg, Baden and Schindelsteddle evoke the early German settlers, but nobody seems to know the origin of Punkeydoodles Corner. The Scots settlers, perhaps smarting from the highland clearances, contributed little to the local nomenclature other than the highland names on their rural post boxes.
Tavistock is named after a town at the edge of Dartmoor in Devon, England and was incorporated in 1848 by settlers that arrived some twenty years before. It was, and is a farming centre, with farm machinery retailers, grocery store, hardware outlets and even two undertakers who served the surrounding farms. Our practice included farmlands that roll off to the horizon where they blend with practices served by doctors in neighboring towns and cities.
The land was productive and many farms and businesses prospered. There were wheat and cornfields surrounding the town. Some farmers matured heifers from Alberta for the butcheries and restaurants of Toronto that lay about 80 miles southeast.
The people were largely of German Lutheran or Scottish Presbyterian origin and their ancestors acquired properties that must have been distributed in blocks. The Scots settled south of the Perth-Oxford line, the east-west road that bisects Tavistock and the Germans occupied the north. In 1960 that demographic was largely intact, but time, sales and intermarriage had begun a mixing effect. There were also Mennonites, Methodists, Anglicans and those of the United Church, but Roman Catholics seemed scarce. Amish families lived in colonies on the fringes of our practice. Their women wore frugal black dresses, and the shirts, braces and beards of the men set them apart. I frequently encountered their black horse and buggy rigs travelling to market along the country roads. Religion played a major role in the life of the town justifying its many churches and the prohibition of alcohol consumption or sale within the town limits. Hence the Canadian Legion Hall commemorating and accommodating our world war veterans lay discreetly beyond the eastern town limit. Many of my new colleagues and acquaintances were strict abstainers. Not of that persuasion, I often sought relief with friends in Kitchener or Toronto.
Each church celebrated its festivals, but the town came together with an annual sauerkraut festival. Crokinole was played then, but the annual world championships became a Tavistock tradition later. The local park was the recreation hub and a travelling fair came to town in the autumn.
There was little about Tavistock to distinguish it from dozens of other Southern Ontario towns. A water tower proudly displayed the town's name, and grain elevators signified an important industry. There were single family homes that housed the locals and retired folk from the countryside. Along the main Woodstock Street the houses mainly dated from the early twentieth century and were much renovated and added to. The side streets contained more modern housing and resembled the suburbia of any contemporary Canadian municipality. There was no hospital, but two nursing homes lay not far in the country.
Tavistock had a downtown. There was a bank, and two furniture stores cum funeral parlors. A hardware store was stuffed with everything from kitchenware to outhouse furnishings. Two small grocery establishments sold prepackaged meat and there were two bakeries. Milk was delivered to the towns? homes before dawn each morning. There was either a Sears or Eaton's order office, I cannot remember which. Most citizens owned cars by the sixties and went to nearby cities to shop. The streets were wide and traffic on the Shakespeare to Woodstock road was heavy at times. In summer the town seemed especially quiet as many of the inhabitants worked on the farms.
A thousand people cannot support two undertakers, so each maintained furniture business. Apparently for one trained in coffin making, it's a short step to furniture manufacture, a fact I'm told led to Ontario's then-successful furniture factories. A small horse fountain stands at the main intersection where 5 roads meet.
The Tavistock clinic was a renowned local institution and still exists. It was one of the town's most important institutions. As befits a farming community there was also a veterinarian. The only other professionals in town worked in a bank that commanded a prominent position at the main intersection.
CHAPTER 2 - THE CLINIC
The clinic was a one-storey building in the middle of town across from the bank and horse trough. A reception area and waiting room was situated by the entrance, and several interview and examining rooms were in the back. The closest pharmacy was in Stratford, so we had a small dispensary, and a utility/supply room. A single toilet completed the layout.
There was a clinic manager, the wife of our senior partner, and usually a nurse was present as well. The senior partner began his Tavistock practice in the 1930s, and learned surgery by doing it. The others came later when more formal training was required, so only the senior performed surgery. Anesthesia was provided by the second partner who took extra training for this purpose. By the time I arrived, all major surgery was done in the hospital in Stratford, and occasionally Woodstock. Also, by then, Stratford had a fully trained surgeon and an internist who provided valuable consulting services. Nevertheless, I was transfixed by my senior colleague's tales of past kitchen table appendectomies and snowstorm-defying deliveries. 1961 was a time of rapid changes in the practice of medicine.
Nevertheless, our practice was very traditional. Believe it or not we made house calls at any hour, and regularly cared for our patients in hospital and nursing home. Ontario had no medicare then, and payment was in cash: $3 for an office call and $5 for a house call. A house call could be 25 miles in the country, so there was a small additional mileage charge. Many patients paid by IOUs some of which never materialized. Despite the local prosperity, not all farmers did well, and often paid in kind. I remember receiving a dozen eggs for a call once - without a clue what to do with them. My meals were all prepared by my landlady. There was an interim health care program at the time called OMSIP. This provincial initiative paid for all in-hospital costs, but fell victim to the law of unintended consequences. Tests and treatments such as simple x-rays were covered in, but not out of, hospital so admissions soared. Mandated by the federal government, a full medicare program soon followed but by that time I was gone.
The clinic did make appointments especially during the day, but at night there was as a drop-in clinic. This was especially busy during the summer months as our farmer patients declined to come in until sunset when they could no longer work the fields. We five doctors were busy constantly and seldom met in clinic for other than the briefest conversation. Nevertheless, my partners were most supportive and the relationship was a collaborative one. I use the term partner, but in truth I was an employee with a possibility of future partnership. I started with the princely sum of $600. per month with quarterly increments, and I dearly hope I earned it. Since I felt like a partner anyway, I shall continue to use the term.
Someone was always on call, and he would respond to calls anywhere in our area, and in any weather. Thus our patients could count on 24-hour care, yet return to their own personal doctor among the partners during regular hours. How I wish now that I could find such a continuing care model for my family. Except for holidays, we worked one in five which meant every fifth weekend I was on call often with no other physician within miles. This thrust me into frequent late-night conundrums where I must rely on my own resources. Thank goodness for the phone (sometimes at a neighboring farm). I could call an off-duty partner or on more than one occasion a former mentor at the University of Toronto.
The clinic was our nerve centre. Even when on house calls, I sometimes stopped at the clinic to grab supplies I predicted might be needed, or to repair the wounds of a farming accident or an altercation at the Legion Hall. When on duty, our manager directed traffic and assigned daytime calls to the least busy among us which was often me. She ran a tight ship.
The Tavistock Clinic was an exemplary institution providing the best of medicine to a rural community despite the limitations of distance, time and resources. Today other towns should be so lucky! I am glad to see that the clinic still exists, although at a different site and with a new generation of doctors. It even has a website! I was glad to learn that they help train medical students. However, I doubt that they can provide the same level of service and caring as that 1960s team I lucked in with. I often muse about the transformations I would have been part of had I stayed.
CHAPTER 3 - MY PRACTICE
The reader may now be wondering how a city boy like me turned up in a small place like Tavistock. Well, it was a coming together of several circumstances. After high school I served as counselllor in a scout camp. One of my responsibilities was to care for the scouts' illnesses and injuries. When first aid was unable to help, I went with the patient to a solo doctor in neighboring Wheatley, a small Ontario town near Windsor that was not unlike Tavistock. The doctor's vocation so impressed me that I lost interest in the engineering program I was to enter that fall. In late August, to my parents' astonishment (and I think delight) I resolved to apply to medical school. My marks were good, I was from an underserviced area, and I so impressed the Dean's secretary that I became a last minute addition to Meds 6T0. Such a late conversion would be impossible today.
However, by the time I was ready to intern, my ambition was to be a surgeon. I contrived to serve on surgery wards early in my internship so I would have an advantage when applying to the Surgery program. No doubt I would have been accepted if it weren't for another last-minute conversion. I discovered I did not like surgery, nor was I impressed by the behavior of some of the haughty surgeons I served under. My future in limbo, I decided to return to the reason I went into practice in the first place. I poured over the opportunity notices in the interns' residence, got advice from friends and mentors and applied to the Tavistock clinic. My tenure there was a happy accident, not part of a long-term plan.
Now the reader must understand that in the 1960s, unlike now, medical education was largely knowledge based. Patient interviewing and physical examination were taught by specialists, but there was little practical application before internship. There were no family practice programs. Hence my generation of doctors entered general practice with an impressive fund of knowledge and a distressing lack of practical skills. These were left to the school of hard knocks. Fortunately, I had skilled and supportive partners who taught me much. Thus I, and I hope my patients, survived. There was a doctor shortage at the time, so communities were glad to have a doctor, even a naïve one like me.
Nevertheless, there were immediate challenges. Working in the clinic was relatively easy as there was always someone around to ask about a problem, and I had previous experience in hospital out patients and emergency rooms. Hospital and house calls were another matter. I cannot say for sure what the townspeople thought of this slim, blond youth (I was 26) whose large black bag seemed the only visible clue that he might be a doctor. But I knew from the expressions on their faces how family members felt as I appeared at the farm door to administer to their kin. They were too polite to roll their eyes, but the disappointment could nonetheless be palpable.
There were a few little triumphs as I learned the trade. Indeed my first encounter of the healing potential of a doctor/patient relationship occurred in such an instance. In the farms of that day, families cared for their elderly grandparents in the farmhouse. Children and their parents included such care amid the myriad duties of a working farm. While the old folk typically lived upstairs, they had honored places, and were invariably scrubbed up and dressed for the doctor's visit. On a visit to a farm with a German name near the Lutheran Church, I met such a grandmother. For reasons I describe above, plus my arrival in a Volkswagen convertible, the disappointment in the room when I entered was obvious. In the awkward initial silence I was struck with an inspiration.
"Wie gehten ihnen heute Frau Schmidt?" I blurted in my best high school German. The atmosphere was transformed.
"Ach, du schpricht Hochdeutsch!" My patient cried, with astonishment and delight.
Thence I could do no wrong with that patient, and my standing at least among the German community improved. I had learned a valuable lesson that day, a lesson I too often forgot in the hustle and bustle of my subsequent career, but it made me a better doctor than I was.
On another such occasion on a Scots farm, Grandma MacD--- lay upstairs severely constipated and in pain. The community nurse had been in, but there was little to be done. She had seen another doctor who said she was suffering from old age and little could be done. Another opinion was the family's wish; not the callow youth who rolled up their drive in his toy car. In the attic my octogenarian patient lay clean and dressed - a picture of loving care few nursing homes can match. I did a physical examination with careful attention to the abdomen as I had been so recently taught. A beloved surgeon mentor's wisdom then echoed in my ears.
"A doctor who fails to put his finger in it will put his foot in it."
This patient was severely constipated and I must do a rectal examination. The bedroom was tiny, and dimly-lit. The bed was too low for my lanky frame to access easilt. While my patient readily consented, I needed the help and consent of her medically unsophisticated family. With the farmer's wife we rearranged the room and bed and draped her with towels. To make an unpleasant story short, I discovered a cancer of my patient's rectum that was obstructing her intestines. Laboriously in that dim room I was able to partially disimpact the rectum giving her instant relief. By phone I arranged for her to be met at the hospital by the surgeon, who after suitable preparation surgically bypassed the obstruction and she lived for some time after that. I failed to realize it at the time, but it's probable she was the first person I substantially helped all by myself. It is sobering to reflect that she, then, was not much older than I am as I write this.
My regular duties in addition to the office practice and on call duties were to make regular rounds of the nursing homes and the Stratford hospital. We sometimes had patients in the Woodstock hospital so my rounds including the farmhouse visits often covered more than 50 miles and lasted most of the morning. Occasionally I assisted at surgery and applied plaster casts to broken limbs. I acquired increasing skill and confidence as my year progressed - attributes that helped me later on. As subsequent chapters will reveal, it also engaged me in a few of the great tragedies and comedies of life. Most significantly it began the development of a health care worldview that I pursue to this day.
CHAPTER 4 - MRS. KOCH'S BOARDING HOUSE
At the end of my internship, after the fond and in some cases final farewells to classmates I had laughed and learned with for 7 years, I became part of a medical diaspora that scattered throughout the continent. I packed my little shiny black Karmann Ghia convertable, my first love at the time, and said goodbye to Toronto. My luggage included my prized possessions, clothes, a record collection and a stack of medical tomes I would sorely need in general practice. (In the event, they were of less use than I expected.)
I arrived at the clinic in the early afternoon. My future employers/partners had scouted a little for a room. From their information the best, in fact the only, bet was a boarding house on North Woodstock Street that was owned by Mrs. Koch. After confirming the address, I set out nervously to my new home a short distance away. Mrs. Koch met me formally at the front door, and showed me to my room.
Mrs. Koch was about 80 years of age and all of five feet tall. She was bright as a dollar and welcoming. She dressed in the local folks' traditional black, and was clearly honored to be singled out as the new doctor's landlady. My room was the upper front bedroom and was well supplied with the furniture and bedding of a much earlier era. There was a door onto the porch roof, and a large window through which I could view the stately trees that lined the street. It was not busy despite its status as the main road north to Shakespeare.
By the time I had unpacked and arranged my things it was suppertime and I was summoned very respectfully to the dining room on the first floor. It was sparsely furnished with an old oak table, sideboard and stiff, upright chairs. Faded flowered wallpaper and old family photos lined the wall. The room was dimly lit with lamps that had knitted shades. The atmosphere was solemn yet friendly, and I and Mrs. Koch set about getting to know one another. She was the widow of a farmer upon whose savings she now lived. She had no children in the area and was, except for boarders, all alone. But habits remained from her years of farm life. She stored her vegetables in a cold pantry in the basement. She made her own sausages, and these became my dietary mainstay. She baked and preserved and I think she even made her own bread.
In all, the place seemed at least at that dinner to be no worse than the varied digs I occupied during my seven long years in Toronto. It seemed that Mrs. Koch and I would get along fine. After dinner she retired to wash up, and I went up to my room to prepare for my first day at work, determined to get a good night's sleep.
My mind was on the sudden removal from a structured urban environment to an unknown rural challenge. Would I measure up? Would I get along? What would I do for entertainment? The bathroom was like the rest of the house, old fashioned. The tub stood on flowery steel legs and a flowered plastic curtain was fully drawn around it. The floor was covered with linoleum tile. The ceiling was high and covered with metal squares with an ornate, but faded design. The tall, upright toilet responded to a pull on its chain with a very satisfying flush that must have drained half the town's water tower. There was a plain iron sink with no place to set anything down.
I brushed my teeth and pursued my thoughts when I became aware I was not alone. Whether it was a sixth sense or a faint sound of breathing I do not remember, but I do remember the upright hairs on the back of my neck. I turned around and saw nobody. I resumed brushing but more aware than before. The feeling persisted. Curious and little frightened, I cautiously peered behind the shower curtain. A young man in work clothes lay in the tub.
"Is he dead?" I thought.
No he was breathing. Was he drunk? In any event what was he doing in the house's main bathroom? Was this a flop house after all? Surely I cannot stay here? I then spent a restless night with a chair jammed against my door.
In the morning, giving the bathroom a miss, I descended the stairs. Mrs. Koch gave me breakfast as if nothing was awry. My bacon, egg and sausage was delicious, a far cry from my previously accustomed fare, but I enjoyed it not. Finishing and still perplexed, I could stand it no longer.
"Mrs. Koch," I cried into the kitchen, "There was a man sleeping in the bathtub last night."
"Oh, that's John, he was in your room before you came and had nowhere to go last night, so I let him stay here." She assured me he would be gone when I returned that night.
As I drove to the clinic that morning I weighed my options. There seemed few. Other accommodation would be far out in the country. I wondered if I should delay my start and seek another place to live. When, welcomed back at the clinic, I told my story there was incredulous laughter. The doctors and staff all knew Mrs. Koch and they assured me she ran a good clean house. Noting the dearth of alternatives, they persuaded me to stay at least for a while. I'm glad they did.
CHAPTER 5 - MY LIFE IN TOWN
I was single and unbetrothed. I felt never far from the curious, yet kindly gaze of the townspeople, and acquired no colleagues or friends my own age. I dated a nursing student from the Stratford hospital once, picking her up at her father's farm. I think it was an awkward experience for us both. We had little in common, and I fear she found me alien and maybe aloof. Perhaps it was my choice of movie - one directed by Ingmar Bergman - quite tame now, but not then.
I find it hard to imagine that tongues failed to wag. My colleagues invited me to their homes and I came to know them and their families better. I attended the Stratford festival, and some of the local events, but somehow, although welcome, I didn't fit. I missed my Toronto friends.
The upshot was my social life continued in Toronto where some friends remained. They included a few young women, one of which I eventually married - but that was two years in the future. I did have her visit me in Tavistock from where we attended the spring opening of the Stratford Shakespearean Festival presided over by the Premier of Ontario. Mrs. Koch prepared a room for her at the back of the house. I do believe Mrs. Koch was jealous because my friend detected a certain coolness.
In the winter, I sometimes skied at Collingwood with a high school and university friend who was working in Kitchener. On my spring vacation he and I drove my Karmann Ghia to Florida. For a week in the winter, I skied in Vermont with a former classmate doing his residency in Ottawa. I took a one-week endocrinology course in Montreal and that was about it for my time off.
That is not to say I did not meet people in Tavistock. My patients were loyal, friendly and gracious. The hospital staff members that I met were friendly and I enjoyed casual conversations with them. My great regret is that I acquired no lasting friend during my time there - the only period of my life for which that is true. I gradually lost track of my colleagues over the intervening years. The senior partner died, and another colleague took further training at another university and became an internist. I did visit another partner again in 2004, but in the meantime he had served a period as the federal Member of Parliament for Perth County and was no longer practicing.
I have often wondered what course my life would have taken if I had stayed with that clinic. I liked the work and the town, but the absence of friends denied me roots. Had I been married, or even engaged, my life there would have been quite different. Of course, I was aware that a life partner might not look forward to life as a general practitioner's wife in a small town - especially if she were one of the urban girls that I then knew. Had I stayed, my life would have certainly been different. Nevertheless, after I left for Montreal in July 1962 I never looked back - until now.
MY FIRST INJECTION
In 1961, the most worrisome infections in Tavistock were due to a bacteria called Haemolytic streptococci that was responsible for severe throat infections and scarlet fever. These very contagious diseases were prevalent and temporarily disabling. However, the real reason for concern was that following a Streptococcal infection, some patients developed rheumatic fever or nephritis that respectively might permanently damage the heart or kidneys. We rarely hear of these complications today, not because the organism has disappeared - much to the contrary - but rather because the initial infection can be so effectively treated with penicillin and similar antibiotics.
Still, H. Streptococcus bacteria were a less common a cause of sore throat than other, mainly viral causes. The standard of care then was to take a swab of the patient's throat for culture. If the test result 48-hours later was positive for streptococci, the patient returned for an antibiotic injection. The treatment chosen at the clinic was a long-acting penicillin analogue that could be given in a single injection. The precise dose was drawn up in a glass syringe through a metal needle that must be sterilized in the autoclave after each use. There were no disposable needles or syringes then.
One early summer evening when the farm work was interrupted by darkness a patient, whose culture two days before grew streptococcus, arrived at the clinic for his antibiotic injection. He was over six feet tall, very muscular, and had an outdoor-acquired ruddy complexion. He must have weighed over 200 pounds - remember we did not use metric then. After explaining the injection to him, I asked him to wait and retired to the utility room to draw the drug into the syringe.
While I hadn't given many injections (they were the nurses' job at the hospital), I recalled having a nurse instructor show us med students how to target the needle to the outer upper quadrant of a volunteer patient's buttock. That volunteer was leaned over the examining table for the demonstration and actually received no injection. I dutifully positioned my large patient in a similar fashion and sent the needle home.
I returned to the utility room to rinse and prepare for autoclave the syringe and needle. As the autoclave opened releasing a cloud of sizzling steam I heard a sickening thud! My stomach sank to my boots as I sprang for the examining room where I found my patient supine, lifeless, and complexionless on the floor. The duty nurse was at his side in an instant deploying a pillow and blanket while gently slapping his cheeks. What followed was the most gratifying moan I had ever heard, and he slowly came back to ruddy life.
"The bigger they are the harder they fall," grinned the senior partner.
I learned two more lessons that evening. First, never, never, never do any medical procedure on an upright patient. Second, it was then that I began to be aware of the frailty of the male of the species. I seldom had a woman faint in a medical encounter, but men drop like flies with the mere sight or thought of blood.
CHAPTER 6 - THE SHAKESPEARE AFFAIR
One dark Saturday night about midnight I received a call from the Ontario Provincial Police. They were in Shakespeare on a call concerning a domestic disturbance. Could I help them?"
What could I do?" I thought. To explain they said that a man barricaded himself in his front room and refused to come out. He was very anxious and agitated. I agreed to come as soon as I was dressed.
"Oh, and he's got a gun." the policeman added.
Upon arrival at the scene, a noisy crowd of 20 or 30 excited people were gathered on the front lawn, and two police cars were parked in front with their emergency lights flashing. The crowd hushed as I drove up in my little convertible, and then parted to show me the front door. It was a warm night and through the screen I could see a man in a plaid shirt sitting on the sofa.
"Are the policemen inside?" I asked naively, looking at the group around me.
"We're right here." sounded a voice behind me and two burly cops stepped forth.
"Is the man disarmed?" I asked.
"No, he needs to be tranquilized first." a policeman replied "and that's your job."
"Great!" I exclaimed. "And how am I to do that?"
With sweaty palm I advanced clutching my black bag through the curious throng to the screen door. It was unlocked. The police were "right behind" me. The man had what was probably a shotgun on his lap, but at the time it looked more like a cannon. I asked him how he was, and he replied he was fine.
"Will you come out?" I asked cautiously.
"No," he replied curtly.
"May I come in?" I ventured, wondering what next.
"Sure." he said, so I did.
Sitting opposite to him I asked him how he felt.
"Afraid and tired." He answered.
"May I give you an injection to make you feel better?"
"Would you please put your gun away first?" I asked, trying not to plead. He passed it to me, at which point the police entered.
I injected a tranquilizing drug, and he became docile and sleepy. "You'll have to admit him" opined a policeman - "he's been threatening his family." I reached for the phone as the crowd outside slipped away murmuring amongst themselves. The policemen retired to their cars to write their obligatory reports. My patient fell asleep and the erstwhile-threatened family prepared for bed. For the next two hours, I struggled with the red tape necessary to have him admitted to the regional mental institution. Later, the police switched off their flashers and drove quietly into the night secure in the belief that they had solved another case.
CHAPTER 7 - MY FIRST FEBRILE CHILD
I received a good medical education at the University of Toronto. But whereas the intellectual, theoretical and fact training was excellent, my experience fell short in certain practical areas. In no discipline was this shortcoming truer than in Paediatrics. My month there was spent on the heart ward. While I became proficient in managing infants with congenital heart disease (blue babies), and could start an intravenous line in a baby's head vein, the experience was woefully deficient in the recognition and management of common childhood ailments. To make a point of it, my pediatric experience was poor preparation for general practice.
I was soon tested. One Saturday morning at 2 AM my phone rang summoning me to see a child with a very high fever. I was instructed to take the Woodstock highway to such and such a road, turn right until I arrived at a certain concession and the stricken child would be in the second house to the right.
"...and we'll leave the light on doc."
Awakened from a dead sleep and new on the job, I neglected to get the farmer's phone number, and wrote nothing down. Rhyming off the causes of a high fever from memory, I groped myself out of the house and into the car.
"Now, let's see, down the Woodstock road? Could I remember the road, and the concession?" Apprehensively I turned into a likely looking road and followed it to a concession wondering how I could get in contact with the family if I was lost. It was very dark and the concession sign barely showed through the gloom. Mercifully the light on the destination farmhouse porch shone forth and I (and maybe the patient?) was saved.
Inside I was greeted by anxious but grateful parents. The tiny toddler, an only child, was indeed febrile - I recorded 104 degrees. There was nothing to see on physical examination. There were no other symptoms and the fever had been present all that day. I recommended cool washcloths and baby aspirin and gave them some of the latter from my black bag. But I could see that the parents were less than satisfied. They were frightened, and frankly so was I.
I stood with them in the darkened room some 15 miles from anywhere and pondered the options. Who could I phone? My partners were away. I could call my pediatric mentors, but they were heart specialists and were probably less able to advise in this situation than was I. I knew that many things could cause such a fever, some of them nasty (although unlikely in this instance). Moreover, high fever could cause seizures. I would not sleep if I went home. So I called the Woodstock hospital and admitted the child.
"What's the diagnosis?" the admitting nurse asked.
"High fever", I replied knowing that was not a diagnosis at all. There was a pause at the other end of the line.
"Admission instructions?" she finally barked".
I rattled off the orders. We hung up and I watched the parents prepare to take their child (now fast asleep) to hospital. Weary and full of self doubt I went home to bed.
Promptly at 8 o'clock my phone rang again. I had a premonition it concerned my young patient and picked up apprehensively.
"Your patient has the chicken pox! He'll infect the whole ward!" the charge nurse declared unkindly. "Now please have the parents pick him up as soon as possible."
Humiliated, I complied and reached for my textbook on infectious diseases.
CHAPTER 8 - THE SNAKEBITE
An urgent call came one sunny afternoon as I worked in clinic. Someone had been bitten by a snake. Our clinic manager insisted I drop everything and go see what could be done. Snakebite? In Perth County? I wasn't aware we had snakes other than the ubiquitous garter variety that were harmless - except to frogs. The call was from about ten miles out and I had plenty of time to anticipate what I was about to encounter. We had no anti-venom and I doubt there was any nearer than Toronto and probably not there. Ontario was not Ireland, but snakebites were certainly uncommon. I once heard that a copperhead was spotted near my hometown of Windsor, but that was considered a fluke. Timber rattlers are found in the forests around Georgian Bay, but they were reputed to be less dangerous than those found elsewhere. I recall campfire stories of these creatures crawling into camper-warmed sleeping bags. But, how could a poisonous snake suddenly turn up on a southern Ontario farm?
As I left the clinic I grabbed a tourniquet that could at least delay the venom's spread, but there seemed little else I could do before getting the victim to hospital. Even then the options seemed few. My imagination flourished and I thought he would probably be dead before I arrived.
Speeding up the long farm lane, I noted nothing amiss. There was no panic, no shouting, and the scene seemed inappropriately calm. The farmer met me on the porch. "You the doc?" he asked "Where's the victim?" I asked in reply.
"In the barn." he replied.
We traipsed to the barn. He wore long rubber boots with regulation plaid shirt, jeans and braces. I had only my street shoes, jacket and tie. Gingerly I picked my way through the droppings that adorn all farmyards while he strode ahead. As we entered we found several hands tending some enormous hogs, but no sign of anyone in distress. "Who has the snakebite?" I asked.
A tall youth with tussled hair and sprig of hay in his mouth stepped forward sheepishly. He was a picture of rural health. "Well doc, I was outside the barn collecting hay for the cows, when I felt an electric shock-like feeling in my right arm. It hurt bad and I wondered what it could be." He proffered a moderately swollen arm.
"How long ago did that happen?" I asked.
"'Early this morning as the sun was rise'n."
"And you called just now?!
"Well me and the others got to talkin' about what it could be, and someone suggested a snakebite. My arm started to swell and someone said maybe we should call the doc, so we called." He replied. "Did you see a snake?" inquired I, mystified.
"Were there any insects about?"
"Maybe, I didn't notice."
"Well, let me see your arm." It was indeed swollen but not disabled. There was a red spot behind the elbow that he could not readily see.
"I think you've had an insect sting - probably a bee or yellow jacket." I said. You'll have to wait a few days until the swelling resides. Cool compresses sometimes help but it's too late to do much good" "That's ok doc, I just wanted to make sure it wasn't a snake. Thanks a lot for coming out here. How much do I owe you?"
I drove slowly back to the office allowing time for my adrenalin charge to subside. The wonders of medical practice! It was a silly and inappropriate call, yet the young man was relieved and truly grateful for my visit. I learned yet another lesson on human nature. What's trivial to me may not be so in the mind of another person.
CHAPTER 9 - MORPHINE MAGIC
It seems my most memorable experiences in Tavistock occurred at night. Come to think, that was true in my subsequent hospital practice as well. There is something about the lonely, silent drama of a night call that imprints the memory. It is in such circumstances that one sometimes achieves the most gratifying results, through relieving pain, or (in my later years) stopping a bleed from the stomach, or sometimes simply reassuring a frightened and worried patient. At night the action is up to the doctor and to that person alone. Such responsibility in a lonely, remote country lane or an otherwise quiet emergency room is always a little scary, and adrenaline-charged.
Such an occasion was one very dark and very wet night when I was summoned to see a middle-aged man with severe abdominal pain. His wife said on the phone that he was in such agony that he could not talk on the phone. She then detailed the directions to their farmhouse and as was the custom she would leave the light on. As I drove through the rainy blackness, I wondered if it was an unwritten rule that all those farms not expecting the doctor conspired to leave their lights off. Whatever the case I was grateful. My destination's porch light served as an indispensible directional beacon.
As usual, the worried family surrounded me as I shook myself off at the door. In contrast to the porch, the living room was dimly lit with ancient lamps, so I could just make out my patient moaning on the bulky couch. Wife, older children and grandparents faded behind me as I approached him. I took a history and examined the writhing patient as well as I could on that low, plushly-upholstered couch. His head was at the end opposite to where it would be on an examining table, so I faced his abdomen backwards. He was a larg man and the examination was further hampered by layers of clothing that, when peeled away, revealed impenetrable long johns. Nevertheless, I could hear and feel enough to determine that my patient was having his first attack of biliary colic - a severe abdominal pain due to stones lodged in the gallbladder. What to do?
The hospital was far away, and the X-ray department would be closed. Any definitive action would in any case await subsidence of this attack. In the unlikely case that the attack would persist, or he became jaundiced, he might need emergency surgery, but certainly not yet. Come to think of it, jaundice would be hard to detect in that dim light. I checked his eyes but could see no yellow. Meanwhile, I could hear, rather sense, the wringing of hands behind me. I must do something to relieve his pain.
All I had for that purpose was morphine. In those days morphine came in tablets and in order to inject the drug nurses dissolved them in normal saline (physiological salt solution) on a heated teaspoon. I opened my bag and drew out the tablets and a syringe of sterile saline. I asked the patient's wife to fetch a teaspoon, candle and match. With a low rustle, my audience gathered closer around me. Thinking of it now, the scene reminded me of An Experiment on a Bird in an Air Pump I saw years later in the British National Gallery.
Eyes wide in the darkness, the family watched me inject the saline onto the spoon, add the morphine tablet and gently heat it over the lighted candle. Next I drew up the solution and prepared to inject. Then a small miracle occurred. My previously moaning and squirming patient was quiet, and with the fascinated audience around me fixed his eyes on that healing spoon.
With help, I rolled him over and I sent the solution as deep into his buttock as the needle allowed, but the action was an anticlimax. The healing part of my visit had already transpired - the pain was gone. The mere anticipation of something being done had been the principle treatment. Such is the power of certain healing rituals. No science can adequately explain this phenomenon - and in analogous ways I witnessed it often that year and since. The family offered me tea and a bite to eat, and then bid me a grateful goodbye. Soon, I was once again driving through the cold, dark night. Did my patient's pain coincidently improve before the injection, or was it the powerful placebo effect at work? I was a little chuffed, I confess - but I was by that time mature enough to know that it was the art of medicine that triumphed that night, not I.
CHAPTER 10 - MY FIRST PREGNANCY
I had excellent training in obstetrics during my internship and recall delivering over thirty babies during the Christmas - New Year period. At least the delivery room nurses let me believe that "I" delivered them. It was inevitable that I would eventually have a pregnant patient in my practice. She was a husky farm woman with blonde hair and sun-dried features whose physique made me believe she would have a healthy pregnancy and delivery. She consulted early in my stay, so I would be there for her delivery. I lined up one of my colleagues to help keep me out of trouble. Once the diagnosis was made, I placed her on a program of regular pre-natal visits with the prescribed regimen of diet, exercise, vitamins etc.
We had little in common; my very rural patient and I still a city boy. Nevertheless we got along fine. I discovered a mild iron deficient anaemia that responded well to treatment. There was no ultrasound then, so we exchanged friendly predictions on the subject of her baby's gender. We judged the baby would arrive in May.
One late afternoon in February I received a panicked call from this woman's husband. She had a massive hemorrhage and was weak and unsteady. I told him to get her into the Emergency department as fast as he could. Then, over the phone I shouted orders to the duty nurses there, called for my surgical colleague and set out on one of the longest seven mile drives of my life. It was dark early and snowing. There were no lights on those back roads and I picked my way through the gloom using the telephone poles as guides. When I at last entered the bright lights of Stratford, the evening traffic was in full swing slowing my progress and amplifying my anxiety.
What had gone wrong I agonized? She was in the second trimester and the baby would not be viable. What would I encounter at the hospital? Was there something I could have done to prevent this? By the time I arrived, I was convinced that whatever had happened was my fault.
Sure enough, there was a blood trail to the examining table and the table itself was frighteningly sanguine. My robust patient had transmogrified into a prostrate ghost. I rushed to start an intravenous and urgently attempted to revive her with saline and blood, when the surgeon mercifully arrived. After a quick assessment, he transported her to the operating room leaving me to talk to the poor, anguished husband. I believe at that moment that my grief was almost equal to his - but of course that was narcissism. He was shattered.
Together wrapped in our separate anguished thoughts we awaited to hear from the operating room. It wasn't long, but it seemed an eternity, before we got the news. Mother lost the baby, but the bleeding was stopped and the she would live to have other children. By then the baby's loss could be no surprise, but we feared for my patient's life. Had we lost her, her husband would experience unfathomable loss, and I would have thought I should quit medicine. Of course, it was just one of those tragic things and no one could have prevented it. All the same, it took a long time for me to regain my confidence. I hope her subsequent life was long and happy.
CHAPTER 11 - SLOW DEATH BY CANCER
Palliative care was unknown in 1961. Managing the slow, painful end of life of a cancer patient was a vocation for which I was ill-prepared, as many of us were in those days. Upon arrival in Tavistock, I fell heir to the care of an elderly man with advanced prostate cancer. It seemed nobody else was in charge. A urologist had operated upon him and found that his prostate cancer was too large to remove. However, he was what we called an itinerant surgeon from a larger neighboring city, who travelled to small towns and cities performing surgery that no local surgeon could perform. Even if he returned periodically to our hospital he would not expect to continue as the patient's doctor.
I struggled to do my best for this man but I fear I fell short. At that time, as now, there was great fear of narcotic addiction. In medical school we had it drummed into us by teacher after teacher to use such drugs sparingly and for short periods, lest the patient become addicted, or suffer miserable side effects. Moreover excessive drug could have dire consequences such as respiratory arrest. For short-term pain caused by accident that may have been good advice, but for a terminal and painfully ill man it was not.
Non-narcotic pain-killers available at that time were few, and for my patient, ineffective. I made use of the barbiturates and tranquilizers available at that time, but none were very helpful. I did use narcotics, but as my teachers recommended, very gingerly. The pain bore on relentlessly. I visited him almost every day. I sought help from my partners who offered little, and were content to leave his care to me since they seldom came to Woodstock. I contacted the surgeon, who made it clear to me that the case was out of his purview - as indeed it may have been. Only occasionally did I skip a visit, and I confess the motive may have been my own sense of frustration and inadequacy. I may have been too young to comfort him properly. His wife visited him regularly, but I could hardly face her.
He eventually and mercifully died, but how I wished subsequently I could have tended him with what we know now. Why the situation could not move me to overcome my inhibitions to give him all the narcotic he needed, I fail now to comprehend. We do much better with such patients now, and palliation is now a specialty. Perhaps the lesson is to eschew cant and rote learning when it does not fit the situation. I am haunted by the old physicians' aphorism:
CHAPTER 12 - MUMPS
Some tragedies are relative. It doesn't require death or disability to create one.
One day in late winter I visited a young man on a farm who was suffering severe abdominal pain. He had a high fever and was shivering in an adequately heated room. He seemed delirious at times and taking a history was difficult. He had been sick for several days and his cheeks were swollen. The fever was disabling and he had no appetite. The pain was severe and penetrated to his back at the level of the last rib. Upon questioning, he admitted his testicles were painful. There was nothing to find on abdominal examination. His parotid glands were indeed enlarged and tender as were both his testicles. The man was very ill and dehydrated. Hospital admission was required.
Mumps was about in the community and I suspected this was an unusual adult case of that childhood infectious disease. I was wiser after several months of practice, and so admitted him under isolation conditions, and ordered intravenous fluid replacement, pain killers and among other tests, a serum amylase and lipase. Mumps can sometimes affect the pancreas, and the pancreatic amylase is elevated in the blood when the pancreas is inflamed, such as in pancreatitis.
By the time I finished my rounds and got to the hospital, the tests were back and his serum amylase was sky high - I've forgotten what units of measurement we were using then. (Inflamed parotid glands release amylase as well, but the very high level in this man, the abnormal lipase result, the abdominal findings and history convinced me that pancreatitis was present.) Therefore, the clinical findings virtually clinched the diagnosis of mumps affecting the parotid salivary glands, the pancreas and the testes. He was very ill and required hospital treatment for several days before making an apparently complete recovery. Despite the severity of the illness, my patient then could look forward to complete healing of his parotids and pancreas, but not perhaps of his testes. At that time it was believed that mumps affecting the testes in adults frequently caused infertility, although now it is claimed that this effect is rarely permanent.
In the city, mumps seldom affects adults who develop immunity through acquisition of the virus or at least contact with it from other children at school. In relatively isolated country schools such exposure is less likely. It seems that my young man had escaped infection as a child and paid the penalty of a particularly severe infection in early manhood. The mumps vaccine became available a decade later, and mumps is seldom seen today.
My patient recovered in several days and appeared to have no after affects. His previously swollen glands subsided without obvious physical changes. However, I was faced with a dilemma. In the light of what we knew then, there was a chance he would be unable to sire children. He was single and unattached. Should I tell him of the risk? Would I disturb him too much, or provoke decisions that might adversely affect him? Not to tell him seemed equally unappealing, but these were days long before notions of full disclosure and malpractice defense became the norm.
In the end I elected to tell him, but gently, that inability to have children was a possibility that was very unlikely. As the evidence accumulated over the intervening years, it seems that advice should be appropriate today. I hope that he had no dark worries later on, and had lots of children.
CHAPTER 13 - A SCREAMING TODDLER
I have already indicated that my pediatric training ill-prepared me for the front lines of treating children. But experience matters too, as I was reminded one afternoon when visiting a distant farmhouse in response to a couple's worry about their child's violent crying spells. I arrived to find the child, a two year old toddler, playing on the floor. The parents explained that although the child was quiet now he would occasionally erupt into a fit of screaming that frightened and unnerved them. For some periods the screaming seemed to occur in short intervals starting and finishing abruptly. They reported that he was otherwise well and was eating normally. There was nothing they could think of that could have provoked the crying spells.
I examined the child. His temperature was normal. His ears and throat were not inflamed. The chest sounded normal, and the abdomen seemed soft and only a little tender to the touch. He seemed healthy and giggled when I tickled his tummy.
I explained to the parents that I could detect nothing wrong, ignoring the disbelief in their eyes. I was in the process of arranging a return visit when the child suddenly lay on his back, drew his legs up to his abdomen and screamed blue murder. Now I was unnerved! I reexamined him as best he could, but to no avail. Then a few minutes later the attack suddenly stopped leaving everyone breathless.
The clinic was operating so I phoned my senior partner.
"Sounds like an intussusception" he said matter-of-factly. You better admit him and I'll visit him there this evening."
"Why didn't I think of that?" I complained to myself for the umpteenth time that year and made the necessary arrangements including an order for a plain X-ray of the abdomen.
Later, the hospital reported continuing attacks. I accompanied the senior partner there after our evening clinic. My colleague was not a trained surgeon, but a graduate of the school of hard knocks. He necessarily learned on the job. After examining the child and peering at the unrevealing X-ray, he became convinced of the diagnosis and called the operating room. In those days abdominal radiology was primitive and not of much help in such cases. Treatment of intussusceptions is now often non-operative, but then, after a period of observation, surgery was deemed necessary to reduce the telescoping intestine lest gangrene occur. I scrubbed in as assistant surgeon.
Sure enough, as my colleague opened the abdomen, a segment of my tiny patient's intestine had folded onto itself and its dusky blue colour indicated that the blood supply was compromised. The intussusception was easily reduced, and I believe my colleague used a stitch or two to anchor the accordioning gut. The bluish intestine quickly regained its reassuring pinkness. Recovery was rapid and the child was soon home with his relieved and grateful patients.
I reckon that about now he would be contemplating retirement.
CHAPTER 14 - THE VET
As befits any self-respecting farming town, we had a veterinarian. He was not the city vet you know with a pet hospital and cute and groomed clientele. No, rather he was in the mold of James Herriot. No Pekinese for him, rather calving Herefords or limping Clydesdales. He was seldom seen about town, but was apparently much beloved by his farmer clients, despite his eighty plus years.
One day the clinic received a farmer very ill with wheezing, fever, and hives rapidly developing on his skin. He was excited and angry and blurted he had received an overdose of a vaccine. An intravenous was started and he was given antihistamines and a hydrocortisone shot. He would need admission to hospital for observation and corticosteroid therapy. The story gradually came out as he was treated.
Cattle need protection against brucellosis, a bovine infection that could potentially ruin a farm. The brucellosis antiserum that was available at that time was produced in horse serum. Injected into susceptible animals, the horse-generated antibodies would inactivate the organism. When a herd is to be vaccinated, the farmer's job is to maneuver each cow into position so the vet can inject antiserum into the animal's behind. On this occasion, the farmer somehow maneuvered himself between a waiting cow and the elderly vet who was automatically loading and discharging his mammoth syringe. As a result, the farmer received one whole cow's dose of anti-brucellosis horse serum from which he promptly developed serum sickness. I was not there long enough to learn if the vet was rehired by that farm the next year, but the story certainly had a long life.
CHAPTER 15 - THE TOWN POLICEMAN
Tavistock was a bucolic, peaceable place and crime seemed remote. The only infractions seemed to emanate from the Legion Hall where veterans and wannabe veterans refought the Second World War on Saturday nights. True, some trucks raced through town at Indie speeds on the way to somewhere else, and people tended to park where they pleased, but the town was far from lawless. Nevertheless, the council apparently felt that the Ontario Provincial Police did not have the town's concerns at heart and that our growing community needed its own law enforcement service.
So, a policeman was hired, and outfitted with a shiny black police car. He apparently lost no time transferring "POLICE" in large white letters to the car's front doors, and attaching a large siren festooned with colored lights that when flashing could strike terror in the heart of a miscreant miles away. He turned out in a new police uniform, and his hat in navy parlance had plenty of scrambled egg (brass). He appeared, or wanted to appear ready for action.
However, to everyone's amusement, whenever trouble did arise he contrived to be somewhere else. His offhand "Don't forget to call the coroner" when I set out for the farm where someone had reputedly killed himself was a case in point.
One Saturday evening when, for some reason, we were still at work in the clinic our police officer arrested a man in town for being drunk and disorderly. Upon depositing him in the town's only cell beneath the town hall, he asked one of my colleagues to check him out. Other than a small laceration on his scalp which my colleague repaired, there seemed no damage. However, he was barely conscious, so admission to the Stratford hospital was arranged. A couple of hours later, our policeman appeared at the clinic looking chastened and forlorn.
"Did you get your prisoner safely to the hospital?" inquired my colleague.
"There were no beds." he said.
"There were when I called." declared the doctor and a quick phone call disclosed that there was indeed a bed, and the nurses were still expecting the man. The clinic staff and waiting patients had by this time drifted into the reception area of the clinic to see what was up.
"Where did you take him?" My colleague was losing patience.
"To the Woodstock Hospital." That was ten miles in another direction.
"That was the wrong hospital, now please take him to Stratford now." ordered the doctor as he turned to get on with his work.
"But you don't understand." stammered the cop whose cap and badge and uniform and indeed his whole spiffy uniform seemed to shrink as he spoke. "I stopped for a coffee coming back from Woodstock, and when I returned to the car the b-------- was gone."
"Our small crowd watched him curiously for a moment as he stood miserably, cap in hand, in the doorway, then spontaneous peals of laughter rocked that solemn clinic. For days after, the town buzzed with speculation about the erstwhile felon's fate, and of a curative and redeeming drive in the cool night air.
CHAPTER 16 - THE LEGION HALL
In the early 1960s, Ontario was still a prohibition state. It was forbidden to have alcoholic drinks with a restaurant meal or anywhere on Sunday. There were taverns, but women could not enter unescorted and then only through a separate door labeled Ladies and Escorts. Newspapers carried stories of people arrested for having a beer in their back yard, or of having an opened beer carton in the trunk of their car. Liquor stores then, as now were owned by the government, but the service was terrible, the store hours were inconvenient and no bottles could be displayed. One could only order from a list of brands, and upon handing over money a bottle appeared discreetly covered in a brown paper bag. It was necessary for customers to sign their name on their order form. I think ‘Mickey Mouse’ bought the most booze in those days.
The landscape was patrolled by a quasi military force known as the Womens’ Canadian Temperance Union (WCTU) and some protestant denominations insisted that their parishioners sign The Pledge never to let demon rum pass their lips. Even in this repressive climate, some jurisdictions declared themselves dry, and Tavistock with its predominantly protestant churches was one such jurisdiction.
However, amid this cultural movement Canada fought two world wars. Every community lost friends and family, and surviving veterans were specially honored. If they could die for their country, than surely they could drink for it as well. This was not the reason for the Royal Canadian Legion, but it became a powerful motivating and recruiting force so few towns dry or otherwise lacked a Royal Canadian Legion Hall.
In Tavistock, the “Legion” was located discretely just beyond the town limits on the back road to Stratford. It was high on our clinic’s radar, because apparently the “war veterans” celebrated Saturday nights with replays of old battles. As a result, the physician on call could expect to be called at least once on a weekend to repair the human damage. Anesthesia was no problem as most of the casualties arrived well-sedated, although the occasional tough guy would threaten to trash the place.
Some of my colleagues were dry and regarded such antics with a cold eye. However, I was a veteran of Toronto St. Michael’s hospital emergency department, and was accustomed to lacerated faces, and broken limbs. What was remarkable was that such goings on were tolerated by the provincial police and beyond the long arm of the WCTU. The public cut our veterans a lot of slack back then.
CHAPTER 17 - A FARM ACCIDENT
A country general practice in 1961 embraced the full spectrum of comic and tragic scenes against a vast panorama of humanity. Many incidents I encountered were indeed sad, but even some of these had a comic side. I think if it were not possible to tease out the humorous side of even the grimmest experiences, life could be melancholy indeed. Nevertheless, some experiences permit no mirth.
One such event occurred on a sunny early autumn afternoon. I was summoned to a farm to find a young man in shock. He was white as ash but for blood spattered up his middle. The other farm hands told a frightful tale. He was manning a harvesting machine which consisted of a series of small buckets moving up a crane-like structure on a continuous chain. I was too occupied to learn the contraption’s name or purpose, but I do remember looking at it, ominous against the azure sky, and thinking it resembled a ditch-digging device. When leaning over the moving buckets to shut it off, one apparently caught the young man’s overalls in the crotch and emasculated him.
There was little to be done there. A farm boy helped me by applying pressure over the wounds, while I gave him a pain-relieving injection. I briskly ordered his co-workers to lay him in the truck and rush him to the Stratford hospital emergency. I followed the truck and supervised his removal into the accident room where I quickly set up an intravenous with the largest needle I could find, and rapidly ran in two litres of normal saline. A nurse took a blood sample for an urgent cross match with instructions to fetch the blood to be transfused as soon as it was ready. Fresh bandages helped me staunch the bleeding, but he had already lost much blood. I asked the nurse to call the surgeon “stat!”, and then set about trying to stop the bleeding. It was a mess with genital parts mingled with torn clothing. I am not very squeamish, but the mere thought of the wound nauseated me. Eventually that wonderful nurse helped me clean it up.
The surgeon arrived and we rushed him into the operating room where the bleeding points were cauterized and he was patched up as well as our resources permitted. He would need highly specialized care in a Toronto Urology unit.
When our patient left for what then passed for the intensive care ward, the surgeon and I shared a coffee. He was an experienced, vigorous man with young children, but even he shuddered at our patient’s prospects. We talked long that otherwise bright day about what it means to share one’s life with someone and to have children. No clouds were in the sky but a dark cloud had just passed through our lives. A person never appreciates more what he has or might have than when he or she contemplates losing it.
A few weeks later, I was in Toronto to visit friends and resolved to visit my patient. I found him in the Urology ward his colour restored, attached to a urine bag and nestled in white linen. The intravenous line was gone and he was eating. He had had more operations and told me that they were restoring his bladder. I guess I was looking for a happy ending, but none was to be found. Nonetheless, he was cheerful and comfortable at that moment and assured me he was getting the best of care. How could he be cheerful I thought? Was there denial, or was I witnessing the elasticity and resilience of a youthful character?
I never saw him again as I left the practice not long after. Nevertheless, often since he has been on my mind.
CHAPTER 18 - THE FALL
"We found him at the bottom of the stairs." said the frightened farmwife. As usual I encountered a difficult problem late at night during a long week-end. My partners were away and I was in a darkened farmhouse. The fallen man's wife denied that he had had previous fainting spells, epilepsy, diabetes, strokes or any other disorder that might explain the fall, and no, he had not been drinking alcohol. The fall seemed unexplained.
I examined the man carefully. He was semi conscious. The heart was normal and the pulse slow and regular, but I thought he had a slightly dilated pupil and signs in his lower extremities of a central nervous system disorder. He moaned a little but did not seem to be in pain. To add to my worries there was a large bump on his head where he had probably hit the floor at the bottom of the stairs. I reckoned he may have had a stroke and then fell, or he might have simply fallen and hit his head. Thinking it through, I suspected the latter, and that he had a hemorrhage with a developing clot outside the brain's casing known as a subdural hematoma.
One of the hardest tasks when facing a possibly life-threatening situation with limited resources, is to know when and how to sound an alarm. I knew that if I left him there I would not sleep the rest of the night. I thought of admitting him to our local hospital, but there would be limited resources for such a case. If I called an ambulance and shipped him off to Toronto, his fate would be in unknown hands, and the sleep-deprived emergency physicians would not thank me if there was nothing wrong. ...for that was the real problem; I was unsure whether he was brain damaged or not.
I watched him for a while and he seemed to become a little more conscious, but still drifted off, occasionally moaning. Finally, I could stand the suspense no longer and asked to use the phone. I recalled the number of the Toronto Hospital, but not that of any doctors. Reluctantly, after hearing our plight, the operator gave me the number of my former teacher, a neurologist who was very well known in Canada for his research work. He was a major figure with a daunting personality and I was amazed at my own temerity in calling him at such an hour, now nearly 1 a.m.
As I dialed his number my heart was racing, and it nearly stopped when his familiar voice answered sleepily. I don't think he thought me one of his brightest students, and I remember the condescending way he rebuked us when one of us did or said something stupid, which was rather often. To my relief, he remembered who I was, and to my undying gratitude he was sympathetic and concerned when I explained the situation to him. When I related my admittedly tentative findings, he was unhesitant. You must get him to a neuro ward pronto, he said, and asked me to get an ambulance to take the patient to London which was nearer to us than Toronto and had one of the best neurosurgical services in North America. When I expressed doubt about the competence of my neurological exam, he said gently, "Once you think of a subdural, you must act on it. Prompt surgery could be lifesaving."
These were the words I needed to hear. I called for an ambulance delegating the farmer’s wife to give directions, instructed other family members to place him in warm clothes and called the London Hospital's Neurosurgeon in chief, who told me where to send him and not to give him medication. He wanted an intravenous started, but, of course, that was not possible. He was kindly to me despite his lofty position and I since have learned that his students and staff loved him. I asked for writing materials and prepared a detailed history of what I knew about the patient and his current state.
As the ambulance carried the patient and his wife into the night and out of my care, I reflected on how helpful those specialists were to my patient and me that night. My memory is too dim to relate what happened to my patient subsequently, although I know he did survive. Years later, I had trainees of my own. Some would often complain about the mundane nature of some of the cases referred to us by general practitioners. Why send us such a stupid case they would say, with youthful impatience to get onto something more important? Don’t the GPs know anything? Then, recalling that lonely night and the help that I had making that tough decision, I would remind my charges that if the frontline doctors could handle such cases, there would be no need for us specialists. Few specialists nowadays have experience in general practice – a pity!
CHAPTER 19 - MY LANDLADY
My landlady (Mrs. K.) and I became fast friends, but despite my entreaties she always called me Doctor, and treated me with a deference that did not suit our respective ages. Nevertheless, she was reluctant to talk of her past. That she had been a hard-working farm wife needed no saying as she still commanded her household at eighty years of age. Her husband's death many years previously prompted her to move into town to retire on their savings. She mentioned a child or two at times, but they were someplace away, maybe far away, and she would say no more. Did they call her, write letters, produce grandchildren, send money? I never knew.
Her cooking was wholesome farm fare and she often had a great pie for dessert. She kept the house tidy, and did my laundry. There seldom seemed to be other tenants and we two normally ate breakfast and supper alone. I foraged for lunch elsewhere, but I cannot recall where. I suspect that then, as later, I often failed to stop for lunch at all - a practice I would never commend to a patient.
Mrs. K. dressed neatly, but always in black. Sometimes she had a lacy collar, but that seemed her only frivolity. She had thick-heeled black shoes, and her snow-white hair was neat in a bun. No necklaces, broaches or hairpins were visible. She retained her wedding band.
That spring, a federal general election was in the offing. The town and surrounding countryside was the site of a straight fight between Liberals and Conservatives. Our constituency was Perth, and the incumbent was a Conservative. Indeed it seemed the Tories had a lock on Perth. A few days ahead, I asked Mrs. K. if I could drive her to the polling booth on election morning. She said yes, and I thought little more about it.
On the appointed morning, I was surprised to see a new Mrs. K. sweep in for breakfast. She had but on her best bonnet and dress, and was elegantly adorned with bracelets, necklaces and the other feminine accoutrements of which I, having no sister, was only dimly aware. Her shoes seemed brand new and there was bounce in her step. I didn't recall that she dressed this well for church.
She settled in my small convertible and we paraded down North Woodstock Street to the hall where the ballots awaited. What a sight we must have been - a youngster voting only for the second time, and an elegant elder citizen - proceeding slowly and regally in an open car to the polls. We were certainly noticed by the scrutineers, poll officers and other hangers on as I opened her door and escorted her in to cast her ballot. There to take in the scene, many of her friends chatted and murmured approval.
She knew and spoke to everyone, and enjoyed the attention. Then, our ballots cast, we returned just as regally the few hundred yards back home. She was coy about for whom she had voted, but needed say nothing to convince me she had enjoyed it all immensely.
I mentioned earlier that my girlfriend stayed overnight in another room so we could go that evening to the Stratford Festival’s spring opening. She signaled that she had her doubts about the girl and my friend said, not half seriously, that she was jealous. So, when the time came to leave I feared she might be very sad. I think she was, but we exchanged fond goodbyes and never saw one another again. It was a long time before I looked back.
CHAPTER 20 - CONCLUSION
Late in the autumn, I received confirmation that I was appointed junior resident at the Montreal General Hospital beginning July 1, 1961. I remember well the dismay on my colleagues faces when I informed them late one evening after clinic. I briefly flattered myself that they would greatly miss me, but soon realized that they had misunderstood. Believing my departure to be imminent, they feared their holiday plans were awry. I assured them that I would stay until June as my contract stated.
From then it was understood that I was temporary. That changed little in practical terms, but it altered my relationship with the clinic and the community. I was a welcome visitor, but not of the family. I doubt that could be avoided, given my dislike of secrets. Nevertheless, my remaining time was rewarding, and I left with more wistful regret than I expected.
June inevitably arrived. My belongings overfilled the capacity of the now fully paid-for Karmann Ghia. I had the clothes and personal things that I arrived with, but had added a new turntable and record collection. There was also a tuner I had assembled from a kit, and fastened in the passenger seat was my New York-purchased high fidelity speaker equipped with the latest in woofers and tweeters.
There were fond goodbyes at the clinic. I visited the bank to purchase a $2000. Canada Savings Bond, and made a slow, nostalgic drive to the house to collect the remainder of my things. After my farewell with Mrs. Koch, I set out down Woodstock Street for the last time bound for Montreal and a very different life.
That is my reversed telescopic view of a unique experience long ago. Perhaps the lens is rose tinted and I have no doubt that I err in details which time and telling embellished or suppressed. It was a medical rite of passage.
The experience gave me confidence to be a doctor, and taught me things about life and human nature that are not obvious in the pressure cooker of a modern teaching hospital. Importantly, I gained great respect for the discipline of General Practice - the heart of any successful health care system. Specialists know a lot about a little, and are exposed only to a small slice of a person’s personality, character and general health. General practitioners (the change to “family doctor” was unfortunate) know a little about a lot for they must deal with the whole person and all his infirmities. When functioning properly, a general practitioner has the complete medical record and provides ongoing care with strategic advice from specialists. This is the most difficult task in medicine and needs nurturing, respect and support. The decline in applications for “family medicine” training should concern us all, especially us aging specialists who now need their services.
That is not to denigrate specialists. I was one myself, but the specialist has two masters; the patient of course, but also the doctor who must continue to care for the patient and all his medical problems when the specialist’s work is done. I valued my generalist colleagues in Tavistock. I appreciated their help when confronted with difficult problems. I learned also that they had no time for long clinical notes and that the most important parts of a specialist’s report are his diagnosis; his recommended treatment; and who is responsible for what.
Why didn’t I stay? The reasons are many and interacting. I was young, single and eager for new experiences. Social life was difficult in the transparency that characterizes a small town; I was an outsider and knew few of the locals well. Had I had been married then, things might have been different. Too, I was frustrated by my lack of knowledge in many areas, and resolved to learn a lot about a little so I could treat patients with more confidence. I don’t see it quite that way now.
Whatever the case, I regret not a moment of it. It is unfortunate that today, aspiring specialists cannot now gain such experience; such is the rigidity of our government-funded and specialty society-directed post graduate programs. I therefore salute my erstwhile colleagues, and hope that my patients of long ago in that small town lived happy lives.
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