House Calls on Casco Bay

A Physician & His 4-Year-Old Partner

 

House calls are a throwback to the time when medicine was more art than science, and not all of my house calls have been resounding successes. On my very first house call in 1985 on Chebeague Island, I forgot to pack a thermometer. To make matters worse, I couldn’t stop searching for it in my black bag. The mother of the two-year-old I examined looked at me like I was a total imposter. I should have felt her daughter’s forehead and declared it felt a little warm.

But we’re getting ahead of ourselves. People want to know, what’s inside your black bag?

The first detailed description of a medical bag is found in Hippocrates’ writings nearly 2500 years ago. Hippocrates suggested that “Because the shortage of these things creates embarrassment and causes harm…for your trips, you will carry a simple and portable kit. The most appropriate is the one which follows a methodic layout because the physician cannot keep everything in mind.”1 I think Hippocrates advice was spot on, but do you think he carried a thermometer? I don’t think so.

When I was in my second year of medical school, I bought a doctor’s bag. It was retro black with leather handles and a lockable metal clasp. I still have it. Inside were compartments for tongue depressors, gauze pads, alcohol swabs, and Band-Aids. My otoscope, to peer into ears, and ophthalmoscope, to peer into eyes, fit snugly inside a cushioned pocket. In a Tupperware plastic container, I kept a needle driver and several packages of suture material to practice suture ties. One never knew when you might come across someone needing stitches, and there you go. A reflex hammer and a medieval pinwheel to assess for sensation comprised my neurologic tools. Over time, I added a glucometer to measure blood sugars, and a blood draw kit and test tubes to transport samples to the laboratory. Nestled on the top of my black bag was my sphygmomanometer—for blood pressures. My stethoscope, an economical Littman, was the last thing to be placed inside the doctor’s bag and the first to come out. I liked the feel of draping the stethoscope around my neck. The black doctor’s bag and stethoscope connected me to a time when a doctor’s tools to evaluate and treat patients could be carried in one hand.

And I used that black bag. In my third year of medical school, the black bag was indispensable for school sports physicals. That year, I added a package of sterile gloves—to check for hernias, and was relieved to find I’d packed an extra pair when I discovered head lice in a third grader. That year, I began my hospital training; physicals were a daily routine and rectal exams matter of fact. That’s when a tube of KY lubricant became indispensable.

In my early years of practicing medicine on the Casco Bay Islands in Maine, I made my share of house calls. During one particular 6 year stretch, I probably averaged about 150 each year. Some were routine, some hair-raising, some unnecessary, some critically important to ensure that my elderly island neighbors remained independent. It never ceased to amaze me how my frailest patients managed to thrive in fragile equilibrium if I stopped by regularly to make sure they were behaving themselves.

A physician’s advice is based on trust and confidence. That particular afternoon on Chebeague Island when I examined the two-year-old, it dissipated like an early morning fog. That same day, the mother caught a ferry to the mainland for a second doctor’s appointment because she was uneasy about my diagnosis: a viral respiratory infection. It was a valuable lesson: Be Prepared.

Entering a patient’s home or apartment is an invitation to their broader life. The door is the opening to the first act of a play. At a glance I can see what my patients are really eating, their preference in reading, even their connection to family and community by what’s hanging on the wall or cluttering the kitchen table. It doesn’t take a detective to recognize that a package of cigarettes or a half-empty bottle of vodka on the bedside table indicates a significant problem.

When I pass through the door, I instinctively register how sick the patient appears. The patient looks well, the patient looks sick, or, get this patient to the hospital. If my instinct tells me the patient belongs in the hospital, I gather physical exam evidence to confirm (or refute) my first impression. Sometimes the most significant challenge is to convince the patient that they need to be hospitalized. In those early years, not everyone said yes.

House calls can clarify a long-standing mystery. One elderly diabetic patient of mine had a non-healing ulcer on the bottom of her third toe. This is a severe problem in a diabetic. Week after week she’d come into the clinic, and I’d carefully clean the wound, change out her antibiotic, and redress it. But the ulcer wouldn’t heal. Her shoes fit well; the remainder of her foot was spotless. One day, she asked if I could drop by her house. She wasn’t feeling well, and when I arrived, she was in bed. I kicked a slipper under the bed and pricked my finger when I reached inside to place it back on the carpet. Cautiously reaching once more into the slipper, I felt the business end of a tack which had penetrated the bottom and scraped the third toe each time she put the slipper on. As a long-standing diabetic, she didn’t feel the repeated injury. Tack out, she recovered nicely over the next two weeks.

Then there are complicated house calls; these require a different approach, particularly to the outer islands of Casco Bay. In addition to my black bag, I depend on an emergency tackle box, filled with carefully selected medications and intravenous set-ups. Inside its stacked drawers is everything from A–Albuterol inhaler, an asthmatic medication, to Z—Zaroxylon—a potent diuretic that can quickly remove excess fluid from the lungs. The tackle box contains my “what if” medicines, including several drugs not routinely used outside the hospital setting. As in, what if I am an hour from the hospital and a patient’s asthma is life-threatening? IV methylprednisone, an albuterol inhaler, and subcutaneous epinephrine were the answer. What if an islander became psychotic? Haldol. Heart attack? Subcutaneous heparin, aspirin, morphine. Or falls into a diabetic coma? Insulin and IV fluids.

In my early years of practice, I missed seeing my 4-year-old daughter Kate, who was often asleep when I left for work and sleeping when I came home. The solution was to bring Kate with me on selected house-calls (My wife, Sandi, drew the line at including her younger sister Molly who was not yet 2). Clearing it first with my patients, I prepared Kate as best I could for what she might see or hear, trying not to worry her about the details. For instance, Mrs. Jones will be in bed, and she’ll look tired and won’t feel well. I figured this was more than enough information. On the day, we visited Mrs. Jones, she brightened at Kate’s arrival and sat up in bed as I adjusted a pillow behind her. I listened first to the right lung, then the left where Mrs. Jones was on the mend from pneumonia. Kate hung back, pressing the silky corner of her blankie to her mouth. Then she spied Mrs. Jones’ calico cat, who allowed her to stroke her back while I dressed the wound.

“Daddy, what’s that bad smell?” Kate asked.

Without looking up from my work, I whispered, “It’s the cat. Sometimes cats have gas Kate.” She lifted up the cat’s tail. “It’s not the cat, daddy,” she answered, casting a suspicious eye towards Mrs. Jones. A detective was born.

Next was Mr. MacKaye. I explained that he was old and might look a little scary. Sometimes when people are sick, they lose weight. His hand won’t seem quite right, but he always has chocolate chip cookies next to his sitting chair. I rang the bell, and Mr. MacKaye answered the door, cleanly shaven but swaying unsteadily to the side that had suffered a recent stroke.

I felt a tug at my pocket. “Daddy.”

We moved into the foyer. Mr. MacKaye was proud that this was the first day he’d gone without his walker. I complimented him on his progress but suggested that he stay with the walker a little longer. If he fell, he might break a hip.

“Daddy.”

Mr. MacKaye eased himself onto his recliner while I made a list of home adaptation equipment he required: a grab-bar for the shower, a toilet seat extension. Kate planted herself in front of us. Looking Mr. MacKaye up and down she declared, “You don’t look very sick.” As in, why are we here?

One crisp fall day, when the rose-hips had lost their bloom, Kate accompanied me on a house call to Cliff Island 6 miles down the bay. As we approached the house, I explained to her that this particular elderly woman, Yohanna, might be gruff, but she had a very friendly dog. “Oh, and her left eye is sick, so she wears a black patch.”
Kicking off my boots inside the house, I said, “Yohanna, I’ve brought a friend, my daughter Kate. Kate, this is Yohanna Von Tiling.” With a free hand, Kate patted Yohanna’s dog, Midnight, who lolled her tongue with pleasure.

The visit did not go well. Johanna’s recent surgery for a spinal tumor had left her with a weak arm and in constant pain. She didn’t want to go to the mainland to see a neurologist or obtain x-rays. She didn’t want to take the pain meds I offered. She didn’t want to use the diuretic I suggested for her lower leg swelling. In short, we disagreed on everything. I was exasperated but tried not to let on.

Finishing the house-call, Kate and I walked the lane towards the boat. Kate finally offered, “Yohanna looked scary, like a pirate. What was under the patch?” The words tumbled out in rapid fire. “Behind the patch, was her eyeball still there? Was she a pirate daddy? If she was a pirate, was she a good pirate or a bad pirate?

I asked her if she was scared and she said no, then yes.

I told Kate that Yohanna was having a bad day. “Sometimes, when people are in pain,” I explained, “it’s one hard day after another. They wish they felt better, but they don’t. It’s frustrating, but I do what I can for them. I’m sure Yohanna was pleased we made the trip. I saw her smile at the picture of the boat you drew.”

Kate considered this and grew quiet. At the dock, I picked Kate up and placed her onboard and zipped up her life preserver. As she settled into her seat, she suddenly asked, “Daddy, are you sure you’re giving that lady the right medicine?” “That’s… possible,” I answered, perhaps a little defensively.
But then, that wisp of a question was replaced by a certainty that only a 4-year-old can muster, “They don’t put a patch on your eye unless you’re really sick.” In another 10 minutes, she drifted off, her head slumping forward on the life-preserver as we headed for home.

~Thanks for reading!

If you enjoyed this check out Chapter 1 of Dr. Chuck’s book “Go By Boat” here

1. Gregory Tsoucalas, Antonis A. Kousoulis, Ioannis Tsoucalas, and George Androutsos. Scand J Prim Health Care. 2011 Dec; 29(4): 196–197.