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They didn't tell me about this in medical school. And they sure didn't prepare me for this in my family medicine residency. Of course, like all well-trained family physicians, I knew how to provide for the majority of the medical needs of my patients in hospitals and nursing homes. Naturally I had been taught the basics of how to practice medicine in the office setting. But I was quickly discovering that physicians who headed into the rural counties of the Smoky Mountains in the third quarter of the twentieth century needed to know much more than these basics. I don't remember any school or residency lessons on the peculiar calls I would receive from national park rangers telling of a medical emergency in the Great Smoky Mountains National Park. "Wilderness medicine," at least when I first started practice, was not in my black bag.
I don't remember any preparation for the unique medical emergencies faced by the Swain County Rescue Squad. Search-and- rescue medicine wasn't in my repertoire either, nor were the river rescues I would be involved with on the county's four rivers--the Tuckasegee, the Nantahala, the Oconaluftee, and the Little Tennessee. And I know for certain that I had no training in caring for animals or livestock--but, sure enough, those calls were also to come to a family physician in the Smoky Mountains. Although my formal education had not prepared me for these types of medicine, when the need arose to learn and practice them, I felt up to the challenge. Although I was often perplexed by some of the unique aspects of practicing medicine in a rural--and, I first thought, somewhat backward--community, I didn't find the demands particularly distressing. My first murder case, however, was a different story.
I had just moved a month before, with my wife, Barb, and our nearly-three-year-old daughter, Kate, from my residency in family medicine at the Duke University Medical Center in Durham, North Carolina, to Swain County, in the heart of the Great Smoky Mountains. The county had only 8,000 residents, but occupied over 550 square miles. However, the federal government owned 86 percent of the land--and much of it was wilderness. Over 40 percent of the Great Smoky Mountains National Park is contained within the borders of Swain County, which is also home to the eastern band of the Cherokee Indians, to one of the more southern sections of the Appalachian Trail, and to the beginning of the Blue Ridge Parkway. The doctors in the county seat--the small town of Bryson City, North Carolina--rotated the on-call assignment. When we were on call, we were responsible for a twenty-four-hour period of time, from 7:00 A.M. to 7:00 A.M. We were on call for all of the patients in Swain County General Hospital's forty beds, the Mountain View Manor Nursing Home, the Bryson City and Swain County jails, and the hospital emergency room. We also provided surgical backup for the physicians in nearby Robbinsville, which had no hospital, and for the physicians at the Cherokee Indian Hospital, located about ten miles away in Cherokee, which had a hospital but no surgeons. While on call, we were also required to serve as the county coroner.
Since pathology-trained coroners lived only in the larger towns, the nonpathologist physicians in the rural villages often became certified as coroners. We were not expected to do autopsies--only pathologists were trained to perform these-- but we were expected to provide all of the nonautopsy responsibilities required of a medical examiner.
Having obtained my training and certification as a coroner while still in my family medicine residency, I knew the basics of determining the time and cause of death, gathering medical evidence, and filling out the copious triplicate forms from the state. Not sure that I was adequately prepared, but proud to be the holder of a fancy state-provided certificate of competence any-way, I thought I was ready to begin practice in Bryson City-- ready to join my colleagues as an inexperienced family physician as well as a neophyte medical examiner. It was not long after our arrival that I was required to put my new forensic skills to work. I had finished a fairly busy evening in the emergency room-- my first night on call in my first week of private practice in this tiny Smoky Mountain town--and, after seeing what I thought would be the evening's last patient, I crossed the street to our home, hoping for a quiet night and some much-needed sleep. Sometime between sleep and sunrise, the shrill ring of the phone snatched me from my slumber.
"Dr. Larimore," barked an official voice. "This is Deputy Rogers of the Swain County Sheriff's Department. We're at the site of an apparent homicide and need the coroner up here. I've been notified that you are the coroner on call. Is that correct, sir?" "Ten-four," I replied, in my most official coroner-type voice. "Then, sir, we need you up at the Watkins place. Stat, sir." "Ten-four." Boy, did I ever feel official and important as I placed the phone in its cradle.
I rolled over to inform Barb of the advent of my first coroner's case. She didn't even wake up. Nevertheless, I sat upright on the edge of the bed, beginning to feel the adrenaline rush of my first big professional adventure, when I suddenly moaned to myself and fell back into the bed. Where in the world is the Watkins place? I thought to myself. I hadn't a clue. But I knew who would--Millie the dispatcher.
I hadn't yet met Millie face-to-face, but already I felt I knew her after only a short time in town. Every doctor knew Millie, and she knew everything about every doctor--where they would be and what they would be doing at almost any time of any day. Equally important to me was that Millie knew where everyone's "place" was.
So I phoned dispatch. She answered quickly and barked, almost with a snarl, "Swain County Dispatch. What you want?"
"Millie, this is Dr. Larimore."