Slop Bucket Road

                     

Slop Bucket Road

The wife of my youth and I have never regretted my scholarship obligation to the State of Georgia for four years of primary medical practice in a rural area. A fraternity brother convinced me to be his associate in Clayton, Rabun County, Georgia. On settling in Rabun County, I found that some patients, usually the older ones, not only wanted house calls, they demanded them. Experienced doctors had managed to project their less than enthusiastic attitude about house calls as being inefficient, time consuming, and not well reimbursed by insurance, especially Medicare, the universal medical insurance for the elderly.

On a cold morning In January 1971, I had been practicing in Rabun County for four months. A telephone call at one A.M. disrupted a cozy winter night's sleep. On answering the call with a drowsy "Hello?", my ears were assaulted by an obviously elderly woman with a demanding voice.

         "Dr. King, I want you to git out here right now. I got chest pain, and something needs to be done. I live off Persimmon Road."

         "Who is speaking?"

         "My name is Zipporah Watson, and I want you to come right now. I been hurtin' for two days."

         "Ms. Watson, have I seen you as a patient?"

         I addressed her with the non-committal title "Ms." until discovering that she had never married.

         "No, you ain't."

         "Where on your chest are you hurting?"

         "Over on my right side. I'm hurtin', so come on right now."

         "Ms. Watson, I would be glad to see you at home, but new onset

chest pain is something that needs emergency room or hospital care. How old are you?

         "I'm 78, and I don't wanna go to no hospital. You come on right now and do something here."

         "Ms. Watson, before treatment, you need X-rays of your chest, a    cardiogram, and some laboratory work. Those things can't be done at home."

         She continued to talk in the same vein, trying to persuade me to make a futile home visit for a complicated problem on a new patient in the early morning. For ten minutes, both of us persisted with the same ineffectual and discursive negotiating.

She suddenly said,          "Now listen. I'm gonna call you first thing in the mornin', then you can meet me at the hospital. But I ain't gonna stay."

         She hung up before I could respond. I had no chance to determine the severity of her pain or whether she  had shortness of breath. I fully expected never to hear from her again, but at 6: 30 AM, she called. I tried to determine how much distress she was having, but she only said, "I'll make out. You jist meet me at the hospital."

         I arranged for ambulance transport, called the hospital for preliminary orders and studies, and met her an hour later.

         Zipporah was an elderly doll. She was slender with good posture. She was meticulously neat in her dress and hygiene. Despite her somewhat loose dentures, she spoke clearly. Her family history was significant for a total absense of chronic illnesses. She was the fourteenth child of her father, he too being a fourteenth child. Her grandfather had fought in the Civil War. She had never traveled beyond the two county area of Rabun County and Macon County, situated in North Carolina just across the north east Georgia state line.

         Fortunately, my first office was located immediately across the street from the small twenty-eight bed county hospital. Her evaluation took most of the day, with my returning to the hospital several times to review X-rays and other studies. She wanted no pain medicine, and her respiratory status was good.

I found her to have a blood clot in her right lung, but I was never to determine the origin of that clot, because she refused to be admitted to the hospital or to be referred out of town. A nephew who was in his seventh decade attended her all day stay. He convinced me that she would never consent to an adequate medical work up for the clot, and that she definitely would leave the hospital against medical advice if not discharged that afternoon. Optimal management would have entailed heparin injections for at least a week, while carefully monitoring her clotting mechanism. Both the treatment and monitoring requiring hospital observation. On discharge, she would be prescribed oral treatment with the anti-coagulant warfarin, a common brand name being Coumadin, literally a rat poison.

In addition to the blood clot, Miss Zipporah's many years of untreated high blood pressure had caused an enlarged heart with an irregular rhythm.

         "Miss Zipporah, you are a wonderful lady. I really like you. But if you go home, your conditions will cause me to be very concerned about you for several days. Do you want to make your doctor nervous?"

         "If I stay here, I'm gonna really make you nervous. I'm goin' home, and you can see me there."

         Further discussion was obviously useless. "Okay, Miss Zipporah. Where do you live?"

         "Off Persimmon Road, on Slop Bucket Road."

         I barely managed to keep a straight face by biting my cheek. The very name Slop Bucket Road suggested a considerably less than fashionable rural setting with rundown shacks, pig sties, and rusting derelict cars in the yards. This was not so. Most of the cabins and houses on the long road were neat and well maintained. My first trip to Slop Bucket Road set the pattern for numerous future Rabun County house calls. Typically, I scheduled several home visits for my on-call Saturdays, my office being closed on weekends. Early on, I insisted on no emergency calls to the patient's home. However, it seemed uncharitable to require a chronically ill patient, usually frail and elderly, be manhandled into a car or ambulance for a routine follow up evaluation at the office or hospital.

         Slop Bucket Road is an actual location in Rabun County, Georgia. Several years ago, the powers that be proposed to change the name. The residents made such a ruckus about the change that the idea was dropped.

         My house call equipment was definitely low tech: a few essential diagnostic instruments in my black bag, a note book, a prescription pad, and my brain. I always took along recordings of classical music to play during the drive. House calls were never boring for me, and Medicare paid more generous fees for house calls and nursing home visits than rumor had it.

         Almost any driving along the roads of Rabun County discloses sublime vistas of the world's oldest mountains. A trip to Miss Zipporah's cabin was always worth the travel time. During drives to house calls in the beautiful Appalachian Mountains of Georgia, I often commented to myself, "I actually get paid for this."

          In 1978, Miss Zipporah, now eighty-five years old, had been my patient for seven years. Sadly, I wrote on the face sheet of her record, "prognosis poor - six months". Even though she was by then on effective treatment for her hypertension, she had developed congestive heart failure, and her heart arrhythmia was significantly worse. Despite her failing health, her mind remained as  sharp as a scalpel. One never argued with Miss Zipporah, but she and I had many unresolved discussions about referring her to a cardiologist. She had resisted that advice for two years. For no clear reason to me, in 1978 she finally agreed to see a specialist in Gainesville, Georgia, sixty miles away.

         Following the benefits of a cardiac pacemaker, Miss Zipporah's health improved remarkably. I rarely insisted on having her come to the office for her checkups, usually seeing her at her neat four room cabin. She had become a pet of my office and of the hospital. On her hundredth birthday, my office staff overwhelmed her with a large surprise party held at the community room of a local bank. Shortly after that celebration, her pacemaker battery needed replacing, but her cardiologist felt she could benefit by upgrading her antiquated device. He was right: after her pacemaker was replaced, she had another year and a half of clear-minded joie de vivre, dying peacefully one night in her own bed, in her home on Slop Bucket Road. What a wonderful admixture of high tech medical care and appropriate no tech dying! After many similar experiences with other patients, my faith in high tech medical treatment tempered with methodical primary medical care  was considerably enhanced.

         By the time my four year scholarship obligation to practice in Rabun County ended, my wife and I felt that the beautiful hills of northeast Georgia were the next best location to Paradise. The wife of my youth, our two children, and I decided to make the mountains of Georgia our permanent home.

         George Collier King