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Coal Miners' Doctor

Forty years ago, a freshly-minted M.D. learned about life and death -- and how to drink home-brewed beer and (almost) eat squirrel's brains -- while practicing medicine in the hills of eastern Kentucky.

BY Rita Mariotii

AS FAR BACK AS I could remember I had planned on a nursing career -- until, at age 13, I was walking along south Broad Street in Philadelphia, passing large brownstone buildings in which lived many of the doctors who worked at two local hospitals. How elegant and rich these homes appeared! Why settle for nursing when I could be a doctor and live in similar grandeur? I thought. My family's poverty never entered my mind. It seemed a simple and definitive plan for a student with good grades. My parents and teachers would surely be thrilled by my resolution. They were, but they were mature enough to realize that attaining this goal was almost an impossibility for a female, let alone one with no money.
   My instructors at school kindly -- but strongly -- discouraged my ambitions, but my parents always supported them. Years later I learned how they agonized over making the dream a reality. No one in my family had ever been to college. My parents' simple plan was to pool my brother's, sister's, and father's salaries to allocate money for my education. My time would be spent studying so I could obtain
   scholarships. Remarkably, it worked -- not without problems, but it worked. I graduated from Penn in 1952 and went on to earn my medical degree at the Medical College of Pennsylvania.
   But I did not become the prosperous South Philadelphia physician I imagined in my youth. As an intern in the late 1950s I exhibited the same air of confidence and egotism as my colleagues. We made brilliant diagnoses thanks to our proximity to book learning -- and horrendous mistakes from lack of experience. We basically knew nothing about the real world. During the waning months of my internship, a sobering reality hit me: I was not ready to go into practice on my own. A medical journal promised experience, adventure, and an attractive stipend of $12,000 a year, compared to the $1,200 I earned as an intern, working for a chain of hospitals in eastern Kentucky owned and operated by the coal miners union that provided free medical care to miners plagued by chronic lung disease. Besides the stipend, the union promised pleasant working and living conditions for its medical staff, culled from all parts of the country.
   I signed on and entered a very different universe. Practicing in the hills of Kentucky introduced me to unbelievable poverty, and to a commitment to patient care that never reaped great financial benefits. Medicine became a passion and a way of life that put other desires on hold.
   The red brick hospital in Liggett County, Kentucky, one-tenth the size of the city hospitals of my training years, was bright and clean against a blue sky molding itself over the leek-green, tree-covered mountains. In the early morning, fog settled between the mountains like mounds of cotton balls muffling what few sounds emerged from the small town below. I loved this change from city life and enjoyed breathing cool air free of industrial fumes.
   As I opened the hospital door my crisp, starched white coat almost softened from the emerging heat. Hospital odors were subdued by the smell of the fresh paint and untrodden rugs of the new hospital. My new importance impressed me. The Miners Hospital nurses stood when I entered the room, they opened the door for me, carried my charts, and reviewed the status of each patient as we made ward rounds. My smile made people think I was pleasant and easy going, but it actually represented joy and amusement at my elevation from lowly medical student and intern.
   I had difficulty bonding with my first patient.
   Mary Holcomb's 350 pounds strained the small hospital bed; her fleshy arms pressed against the metal side-rails that confined them within the bed limits. She lay flat on her back, snoring heavily around the oxygen and feeding tubes that filled her mouth and nose, whose secretions crusted around the plastic invaders. She had been in these tight quarters for six months, since a stroke sent her into comatose vegetation. Three nurses acted as pulleys to shift her so that I could examine her lungs and under-surfaces. She frequently lay in watery puddles of excreta, the smell of which caused our nostrils to twitch and our stomachs to reverse gears. Remarkably, she never developed pneumonia or bed sores. Most of her medical care revolved around balancing her tube feedings to insure stools that were neither too liquid nor so firm as to require physical extraction. My inexperience and confusion about my role in this patient's care caused me increasing agitation and dislike of the poor creature. Helpless frustration unfortunately overwhelms logic and humane responses, and my daily visits became increasingly difficult. She was still alive when I left the area a year later.
   If Mary was not capable of returning my dislike, another patient, Zeke Bailey, did his best to make up for it. He hated me passionately.
   "That damned woman doctor is trying to kill me," he shouted to everyone who would listen. "She keeps taking my oxygen away. How can I breathe without it?"
   Zeke's lung capacity was limited by fibrosis from chronic black-lung disease, the result of years of working in the coal mines. With my fresh medical training, however, I knew that his metabolic condition was being compromised by continuous oxygen flow. I tried to save his life by doing what I knew was right, and merely succeeded in losing Zeke to the care of another physician when he insisted I be taken off his case.
   The chronicity of so many of the hospital-bound patients made the excitement of the emergency room a welcome change, but we residents rotated this service not so much for variety but out of necessity. We were the only medical facility in a 50-mile radius, so all medical problems, emergencies, injuries, and coal-mine disasters became our struggle. It did not take long for me to realize how little medical school had taught me about life and death and most conditions in between.
   Patients from Liggett County were surprised and hesitant in the presence of a female physician. It was the first such encounter for most of them. The quiet, reserved demeanor of these people could be traced to Welsh and English heritage. Their dialect was full of old English idioms which gave it a Chaucerian flavor. In fact, one of our physicians later traced much of the phraseology to Chaucer's writings. Not that these people read such literature, but their isolation kept the language traits passing from one generation to another.
   My first emergency-room patient was a miner, covered with a thick layer of coal dust that made the whites of his eyes and teeth prominent. We got used to them leaving a residue of black powder on seats when they stood up. There was always a fallout on your hand after a welcoming handshake. My black-powdered friend quietly informed me he had been bitten by a copperhead snake. The beating of my heart echoed through the empty memory chambers of my brain. Whoever treated a snake bite in Philadelphia? Fortunately, the patient and nurse were skilled in such treatment. When bitten, the miner had placed a tourniquet around his lower leg and suctioned the wound. My efficient nurse led me to the snake-venom antisera, assuring me that a successful cure was available for this common emergency.
   In the adjoining room a pale, thin girl lay on the gurney. She appeared much younger than the 12 years registered on the chart. Her mother wore the typical look of a miner's wife: Non-smiling, thin gray lips; worry lines pressed deep into colorless cheeks; expressionless eyes staring from under straight, prematurely graying hair. Two smaller children hung on her loose-fitting, black-and-white checkered dress, and wiped their noses on shabby, frayed coat sleeves. The mother's tender caress as she stroked the face of the sick child, Peggy, belied her outward appearance of disinterest.
   Peggy's eyes were sunken. Suddenly, she raised her head from the stretcher, her arm groping in the air in an agitated, pleading way. Then it came. A projectile tide of vomit missing the emesis basin that the attentive nurse had produced when she understood the reason for the child's flapping arm. Floating in this bilious mess were three large, fat, roundworms. Seeing the six by one-half inch creatures caused me to draw back uncontrollably and run from the emergency room. When the nurse got everything cleaned, she ushered me back into the room and quietly suggested we proceed with arrangements to admit the child. Peggy was well known to the emergency room staff. She and her family had been treated many times for recurrent Ascaris worm infestations. Her case, however, had been resistant to treatment, and she gradually worsened. A few days after being admitted to the hospital she went into a coma as the worms entered her central nervous system.
   It was not difficult to understand why worms were such a problem in eastern Kentucky. Patients lived in one- or two-room shacks, which frequently housed six to eight children, plus parents. An outhouse was some distance away, and it was not unusual for the children to defecate around the house rather than walk to it. Winter or summer, the children went bare-foot. Refuse was carried in and about the house. With no running water, hand washing was not readily available. Such lack of cleanliness ensured constant reproduction of worm ova carried by the oral-fecal route.
   That evening I walked across the hospital grounds toward my apartment wanting to put the events of the day behind me. The cool October breeze was refreshing. The tree in front of the apartment complex had a few remaining apples hanging heavily on tired branches. I picked a nice red one, bit into it, and a tiny white worm wiggled a defiant dance.
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