Bryson City Tales (17 page)

“Why?” I queried.

“Because,” he replied, smiling, “I wanted to marry someone who would outlive me!”

“Are you gonna consummate this thing?” I asked.

“Of course!” he exclaimed. “But
not
until we're married!”

“But,” I protested, “you must be very, very careful. Too strenuous of a honeymoon could mean a heart attack or even death!”

He looked me straight in the eye and said, “Well, Doc, if she dies, she dies!”

I think I must have looked, for a moment, utterly bewildered. Then he smiled and began to laugh. I realized I'd been snookered. He confessed that he was actually marrying a “proper” woman, although she was twenty years his junior. I began to chuckle, both at myself and then with him. We both began to laugh and laugh until we had tears running down our faces. Helen barged in to shush us up. We continued to do some shushed-up giggling.

One of the many truisms of medicine is that the doctor-patient relationship is foundational to the healing process. I have found that this involves each party learning how to teach the other. Many of the pearls of wisdom and the practical tips I've gleaned over two decades were discovered by my patients and taught to me. Some have subsequently been evaluated scientifically—while others remain anecdotal observations only.

Delores Smith was one of those patients who taught me. This elderly woman suffered from recurrent nosebleeds that occasionally required a trip to the office for an anterior nasal pack or a cauterization. I had tried all of our standard treatments, but topical steroids, nasal saline, topical petroleum jelly, topical Neosporin, and room humidification didn't help at all. I was befuddled. Finally I decided to try a new trick that I had picked up at a medical conference.

“Delores, here's a prescription for an antibiotic ointment. You just take a dab and rub it on the inside of each nostril—once in the morning and once in the evening. Then you kind of give your nose a pinch to spread the ointment a bit. If you use this every day, and keep using a humidifier, I think this'll do the trick.”

I didn't see her for many months, and I was sure my therapy was the distinct reason she wasn't coming in with any more nosebleeds. She next appeared in the office for her annual exam that spring. During the exam I commented, “Delores, I see from your chart that you've not been in for any more nosebleeds. I guess the ointment I prescribed must have worked for you.”

“Well . . . ,” she started, then blushed, looking away. “A prescription ointment
did
do the trick.”

There was an uncomfortable pause in the conversation. “Was it the ointment I prescribed?” I asked.

Another pause—her eyes still turned away from mine. She shook her head no.

“Whose then?” I asked.

“Well, Doctor, it was a prescription from Canada.”

Trying not to act
too
defensive, I inquired, “What type of prescription?” Actually, I was a bit curious. A family doctor can never have too many tools in his black bag. Maybe I would learn about a new one today.

“Fortunately for me, Dr. Larimore, my sister Dianna, who lives in Nova Scotia, inherited the same family predisposition to these types of nosebleeds. Her general practitioner, an ancient man, explained to her that the rosiness of her ruddy Irish cheeks had just migrated into her nostrils. He explained that this seemed to happen in only the most sensitive and exquisite of the grand dames. My sister found this medical assessment charming—especially when this gentleman explained that even Queen Victoria herself suffered this malady.”

What a cunning old codger,
I thought to myself of my Canadian colleague.
Amaster of the bedside technique!

She continued, “He explained to her that as a woman matures . . .”

Matures! What a great expression!
My interest in and admiration for this fellow was increasing by the moment.

“. . . the skin can thin a bit—become a tad more fragile, dainty, and delicate. This can be true inside the nostril as well as among other parts.”

“So
what did he recommend?” I wasn't even remotely prepared for the answer.

“Premarin cream,” Delores stated matter-of-factly.

I couldn't contain my surprise. “Premarin
vaginal
cream?” This common preparation of topical estrogen was often prescribed to women after menopause to thicken the walls of the vagina if vaginal dryness or pain during intercourse was a problem.

Delores looked at me as though I was daft. “But of course! He said that the lining of a woman's private parts and the lining of her nostrils contained the same type of skin. Didn't you know that?”

“Well,” I stammered, “of course I knew that. I've just never heard of using this cream in the nose.”

“He told my sister that most doctors had never bothered to think this through, but that since the skin of both areas is the same, then the same treatment could be used for both. He told her he had been prescribing it for years.”

“Well, quite frankly, Delores, it makes a bit of sense, I must admit. How did he say to use it?”

Her smile radiated as she became the professor, I the pupil. She was fairly gloating in the experience. “This is what he told my sister to do, and it's what I did too. I applied a BB-sized drop of the Premarin cream to the inside of each nostril with a Q-tip—twice a day for thirty days, then daily for thirty days, then three times a week for another month, and then one or two times per week until the weather began to get a bit warmer.”

“How long did it take to work?”

“I had no more nosebleeds after using the cream for just a few weeks.”

“Mind if I take a look?”

“Of course not.”

The inside of her nostrils looked nice and pink. None of the unsightly little spider veins I had seen last fall.

“Delores, your nasal mucosae look almost as beautiful as you do.”

She blushed.
I can pick up a thing or two,
I thought—
even
across international borders!

“Thanks for the teaching,” I said.

She looked at me, cocking her head as though in disbelief. I could almost read her mind:
A doctor—thanking
me
for teaching
him?

“Thank
you,
” Delores answered, “for being such an attentive pupil.” She smiled. So did I.

The office calls during my first year in practice continually gave me a chance both to teach and to be taught. Ray approached me in the hall one afternoon about a patient with a skin problem—chronic urticaria, which is doctor-talk for hives. Ray had done the extensive laboratory tests recommended by an Asheville dermatologist he had called—and the lab tests were entirely normal. The medications he'd prescribed had either caused side effects or had had no effect. He and the patient were frustrated, and he was considering sending the fellow off for further treatment. But before doing so, he asked for a second opinion.

I wasn't sure I had a single thing to offer, but I did see the patient and spent some time taking an elaborate history—just like a detective looking for the perpetrator. But none was found. For some reason, toward the end of the interview, I remembered Terry Kane, M.D., my chief while I was in training at Duke University, who used to say, “You can take all the history you want, but when all is said and done, you gotta take their clothes off and look!”

Although the young man was already clad in his briefs, and although his skin, hair, and nails appeared normal, I had him pull down first his briefs and then his socks. And there, underneath the socks that had never been removed before, at least in our office, was a rip-roaring case of tinea pedis and onychomycosis—doctor-talk for athlete's foot and athlete's toenails. Ray and I exchanged knowing glances. We both realized, instantly, that this was a likely cause for the hives, since a fungal infection of the skin can result in recurrent hives in a susceptible person.

“Jim, you ever notice this rash before?” I asked.

“Oh yeah, Doc. Been there off and on most of my life.”

I took an ophthalmoscope off the wall and turned it on. The ophthalmoscope is designed to help a doctor look into the eye—especially at the retina. However, because its light is bright and because it magnifies the view manyfold, it can be an excellent tool for examining the skin.

“Yep,” I commented. “I thought so.”

“What is it, Doc?” asked a now worried Jim.

“Infection looks deep, Jim. I'm suspecting it and the hives are connected. Tell you what, if you're willing to take a little pill four times a day for the next three months, I believe we might just whip this thing.”

“Don't know if I can remember.”

“Don't worry about it, Jim. You just have your lovely wife, Elaine, do the remembering for you.”

He smiled, “That she can do, Doc. That she can do.”

That wasn't the last time that day I used the ophthalmoscope trick. In fact, the next patient was a little girl who had suffered an insect bite on her wrist while working in the garden the previous weekend. The girl's severe pain caused her mom to bring the little one to the emergency department twice—each time for an injection for pain.

To the naked eye, the skin looked almost normal, except for a small red line. However, under ophthalmoscopic magnification I could see two tiny parallel rows of red raised lesions—almost like two dotted lines lying together like a railroad track. I knew instantly what it was—a classic case of “caterpillar dermatitis.” Once I knew what it was, treating the pain required merely removing the tiny toxin-containing stingers embedded in the little girl's skin.

I had Gay get me a piece of ordinary Scotch tape. As the mom gently held her daughter's arm in place, I stuck the tape to the lesions, rubbing the tape onto the skin. Then I carefully removed the tape, which had all of the little caterpillar hairs stuck to it. The pain relief for my little patient was almost immediate.

This is one of those treatments that always makes the doctor look wise—instantly. I, for one, was glad that the tape worked in this prickly situation.