DR. RICARD (RIC) PUUMALA, M.D., CONTRIBUTED THE NEXT FIVE STORIES

Dr. Ricard (Ric) Puumala, M.D., is a family physician in Cloquet, Minnesota. His is the second in three generations of physicians. His parents, Dr. Reino Puumala, M.D., and Dr. Marie Bepko, M.D., his physician wife, Barbara, and he, formed a truly “Family Practice,” sharing professional lives as well as personal. This unique group received, together, in 1972, the prestigious Diehl Award of the University of Minnesota Medical Alumni Association. Dr. Ric is a veteran of forty-five years of rural practice. In 1996, the Minnesota Academy of Family Physicians elected him Family Physician of the Year. He has served as county coroner and as preceptor/tutor for a series of medical students. He describes himself as a bird watcher, a gatherer of mushrooms, a fisherman and hunter. Let me introduce Dr. Puumala in his own words:

When to Have the Baby

Obstetrics is the most unpredictable part of medicine. How can women unrelated and unknown to each other manage to deliver so nearly at the same time? It was one of those nights in my career.

I delivered a baby about midnight. While that was going on, a multipara... doctor talk describing a woman who had had one or more previous babies... came into the hospital in active labor. Shortly thereafter, a second such patient joined the party. I delivered one lady, ran to the adjoining delivery room and caught the second, then returned to the first delivery room to cope with the afterbirth, then back to the second lady...

Meanwhile, on a gurney rattling in from the emergency room came another woman said to be in labor. Her baby, already arrived, pink and blinking at the bright lights of the obstetrical suite, lay placidly between her legs. I dragged on sterile gloves. A boy, the little guy shook a fist at me, winked, then peed on my arm when I picked him up.

I chided the lad’s mother: “That’s cutting it close.”

She said, “Oh, he was born about eight miles out, but I didn’t dare tell my husband for fear he might drive off the road.”

Our women are tough, their babies robust. All was well.

Sulo

Beginning in the last two decades of the nineteenth century, iron ore became the economic lifeblood of northern Minnesota. The Cuyuna Range. The mighty Mesabi Range, a mountain of iron one hundred miles long. Iron ore mined must travel east to the steel mills of Ohio and Pennsylvania. The Great Lakes seaway provided the passage; boats up to a fifth of a mile in length were the carriers.

The season for shipping iron ore has always been decided by winter ice in bays of the lakes and in the locks connecting them. Shipping season averaged seven to eight months of the year.

Men loaded the boats from shore; other men rode the ore carriers back and forth. Men who tolerate storms and cold and isolation—men such as Sulo.

Sulo worked on one of the ore freighters from first day of shipping until shut-down in December. A man built up a powerful thirst by then, because a drunk during the season could cost him his job. Finally, the lakes froze and the drinking light was lit.

By Christmas Eve, Sulo was beginning to see frightening things. He came to the emergency room of the hospital in our town for a shot “to make the visions go away.”

When Sulo bent over the examination table to receive his injection, I noticed the neck of a whiskey bottle projecting from a pocket of his Eisenhower jacket.

I said, “Sulo, you’ve come for a shot to help you quit drinking, but you have whiskey in your pocket. That doesn’t make sense.”

The man’s cheeks were rosy, his eyes bright blue. He said, “But Doc, your medicine might not work.”

I took the bottle from him and told him he couldn’t have it until after New Year’s Day. I brought it to my office and stashed it in the safe.

New Years Day happened to be a Sunday. Sulo arrived at the hospital and demanded the return of his whiskey. Hospital personnel, of course, knew nothing about his treasure, so he had to come to the office the next day. He left with the bottle clutched to his chest. I have wondered what those patients in the waiting room expected from me when I sat down to write their prescriptions.

I debated refusing to return his whiskey, but legislating good judgment has always escaped me. Besides, the liquor store was four blocks away; his own bottle merely represented money in the bank.

I next saw Sulo two years later, when I was summoned to his modest home to pronounce him dead. I waded through a forest of empty vodka bottles.

A doctor can be touchy when forced to admit that a patient is more on target than he. Sulo had been right. My medicine did not work.

Is That You, Doc?

Maurie died in Arkansas at the age of ninety-two. I’m not suggesting that the location was responsible. Still, one never knows what that fabled southern hospitality might do to a man. His family had told him eons before that he would “live until he turned nice,” an implied guarantee of immortality.

Maurie had been a railroad man. He retired well before his ill-fated journey to the south. He had been a foreman in the shop, performing whatever mysterious activities that implies. Since alcoholism was a job requirement, he did that, too. Whether through irritation over his management style or through jolly good humor, people played tricks on Maurie. Things like letting him sleep in his chair at work, hours past time to go home. Heck, it didn’t even qualify as overtime.

I first met Maurie when he came to the office convinced that he suffered from heart trouble. His pulse was rapid, at the precise rate occasioned by detoxifying alcohol. My evaluation disclosed a rousing case of gastritis. Alcohol does that, too.

For some reason, he and I got along amicably. I learned not to ask too many questions (adaptability is helpful in a broadly-based medical practice), instead told him what to do based on his needs. I ignored what he asked for, usually something illogical, illegal or “ill” producing.

The usual scenario was a phone call at 7 a.m. “Is that you, Doc? My stomach is acting up. I need to go to the hospital.” I would put him on a bland diet, keep alcohol out of reach, and after a few days he would be good for several months. We never discussed alcohol. Gradually the spells got further apart, then two years went by.

An early morning call again: “Is that you, Doc?”

I asked, “Where did you find the bottle, Maurie?”

“Well, uh, behind the wood pile in the garage.”

That turned out to be the last time he drank.

Eventually Maurie graduated to genuine heart disease: A myocardial infarction, an acute attack due to plugged up coronary arteries. Later, his aorta ballooned out, an aneurism. He had it repaired. Bloody sputum led to a diagnosis of lung cancer. Tobacco and alcohol are such regular companions. Removal of part of one lung resulted in a cure. His luck held.

Maurie owned eighty wooded acres outside of town. Deer, beavers in a pond on the place, even a house weasel to keep the mice down, were Maurie’s late-life companions. He became profoundly deaf. He often invited me to hunt on his acreage. I could expect to shout at him, straightening out his medications, curbing a generosity that led him to give away far too many of his belongings.

His wife, Sylvia, gradually slipped into the dim world of dementia. Maurie did a great job of caring for her, kept her clean, fed and medicated. She died eventually after a severe fall.

In the end, Maurie became “nice”—and died. I really miss him. Some mornings I awake with a start, convinced that the phone has rung and that I will pick up the receiver to hear once again, “Is that you, Doc?”

There Must Be an Alternative!

Colon cancer is the second or third most common malignancy to plague humanity. Because it is silent during its early, most curative stages, we doctors all too often discover the disease after it has spread beyond the bowel. It is a very lethal kind of tumor.

Fortunately, access to the large bowel is readily available. Today, colonoscopy is the gold standard in checking for colon cancer. Instruments have been invented that can be threaded the entire length of the large bowel, allowing direct visualization. Polyps, those precursors to cancer, and cancer itself can be located and biopsied to establish a diagnosis. Simple, noninvasive in terms of surgery, and accurate. The result is joy and gratitude among patients and physicians alike!

Wait a bit. Maybe joy overstates a patient’s response. There is that “prep,” twenty gallons of foul-tasting laxative solution to drink. Okay, maybe not quite twenty gallons. Lots, though. Flavored with some artificial fruit that never grew on a tree.

Put the stuff in the same column as an A-bomb.

Next, “Smilin’ Doc GI-Guy” hauls out a fifteen-foot-long tube the size of a plumber’s snake and... not really fifteen feet? Long enough. I guess you get the picture. Enough to make a patient long for the good old days before colonoscopy was invented. Only problem, a few with long memories recall what a barium enema was like.

Sigh.

A radiologist is a specialist whose role in the panoply of medicine is to read x-rays. An x-ray film is actually the negative. Everything is reversed; black means transparent and white means you can’t see through that part. Bone, for instance. It takes getting used to, like recognizing Aunt Tillie from the negative of her photograph. Another thing radiologists do is to perform “contrast studies.” There are many kinds of these, but right now we are focused on examination of the large bowel. A barium enema. A huge can-full of liquid barium is pumped into the patient’s colon. Why barium? Because it stops x-rays, more of that white-on-the-x-ray-film, you-can’t-see-through-it factor. It nicely outlines features inside the bowel in the process.

This sounds benign. Still, where one happens to be, standing (beside the x-ray table), or lying (on the x-ray table), has a lot to do with your perspective.

In our neck of northern Minnesota, there was a fine radiologist by the name of Dr. Al Balmer. He would arrive at our hospital for a morning’s work. A series of completely anonymous human bodies, clad in large bibs, enshrouded in white sheets, lay lined up on a fleet of gurneys in the hallway outside the x-ray suite. So often the requested procedure was clearly detailed in the patient’s chart, but the reasons for requesting it a blank page or one covered with illegible scrawls. Doctors are notoriously poor scribblers. Dr. Al would again be confronted with the frustration of having no patient history.

As he maneuvered a bucket of milky-white barium mix into place, he would conduct an impromptu interview with the patient. Take the case of Mrs. McElhenny. The lady was in her eighties and had been known to wield a mean cane when aroused.

“Good morning,” genial Dr. Al booms.

No response.

“She’s kind of deaf,” a nurse volunteers.

“What seems to be your problem?” Dr. Al roars.

The lady tightens her lips over store-bought choppers. The nurse turns her onto her side, while he does what a doctor planning a barium enema has to do.

“It helps me to know why we are performing this,” Dr. Al explains.

A frown from the lady. Grim.

Barium mixture flows.

“You don’t have much to say,” the doctor says.

The bucket of barium is now nearly empty, the lady beginning to squirm.

Mrs. McElhenny pipes up, “I’ll talk! I’ll talk!”

Office Humor

A young matron came into my office for a prenatal exam. She had reached the fourth month of her pregnancy. She pointed to her breasts, enlarged by the hormones of her condition.

“Look, I’ve finally got something to brag about!”

—————

Elsa was one of those slender ladies whose rib cage reminds one of a xylophone. The nurse had pinned a note to her chart: Breast exam. As is my custom, I still asked her the reason for her visit.

She chirped, “I came to get my fried eggs checked.”

I puzzled through her answer—ah.

Later the same day, a second lady with a similar build arrived. Another breast examination. I knew her to have a good sense of humor and asked her if she had come to have her fried eggs checked. She chortled and said, “No, it’s for my spaniel ears. They’re real handy, roll them up and drop them in.”

She was right.

—————

“I’ve been having a cough,” Mrs. Anderson explained. She demonstrated. I asked her to remove her blouse so that I could listen to her chest with my stethoscope. No unusual breath sounds. The straps to her bra were quite wide and I unhooked them so I could better listen. When I had finished, I refastened them for her.

She jerked around and looked up at me. “That’s the first time a man ever did that!”

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