The Doctor's Black Bag: 51 Years as a General Physician in the Rural West

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Lovelock, Nevada, 1996

The snow was falling hard. I-80, the busy interstate highway that bypassed town, was closed because of the snow and ice conditions. At the hospital we were prepared for a quiet night, only the direst problems would cause anyone to come to the hospital on this beautiful but dangerous night.

The dire problem presented about 8:00 pm. Maria was sixteen and a half, pregnant and in labor. She had neglected any prenatal care. Her history showed her to be full term, well nourished, reeking of tobacco smoke from the cigarette she had puffed before coming through the door, and she was planning to have the baby at our hospital.

Lovelock was a town of about two thousand people at this time, located in an area called The Big Meadows by travelers along the Humboldt River, California, trail. The lush grass and water allowed the people, their oxen, and other livestock to rest and replenish in mid-1800s as they migrated west. The Central Pacific Railroad had established a depot in what was to become the town in 1868 as the great transcontinental railroad was being built.

The town had grown as a farming and mining center, with the railroad and US-40 highway bringing people and goods. In 1983 when I-80 had bypassed the downtown area and passenger train service ceased, the town dwindled.

A community hospital, outpatient clinic, and nursing home were still open and active. No physician was resident in the town, but three or four doctors would rotate coming to town and spend twenty-four to seventy-two hours seeing outpatients, nursing home patients, the few inpatients, and all emergencies that presented from town or off the freeway. This night, I was that doctor.

The hospital had been built in 1962 and had an old, now unused, delivery room, and a nursing staff not practiced in obstetrical procedures. Patients delivered here who could not go the fifty-one miles to Fallon or ninety miles to Reno in time to deliver. The hospital policy was to evaluate women in labor and if at all safely get them transported by ground or air to those towns with experienced obstetrical staffs. The weather precluded such transport tonight.

We checked our supplies, which were maintained for just such an emergency, and called in to duty the nurse in town who had some obstetrical experience.

Have you delivered many babies Dr. Schmidt? was her question.

Probably around 500 altogether, but that was years ago. I guess things haven’t changed too much.

We settled in to observe our expectant mother’s progress. An examination of her abdomen showed the baby to be in good position, head-first, with a heart rate in the appropriate hundred and forty beats per minute range, the head to be engaged in the pelvis, and the cervix opening nicely. Our biggest immediate problem was keeping the patient in bed. She kept hurrying to the nearest door, stepping out into the snowy night, and taking ferocious drags from her cigarettes.

I had plenty of time to review delivery procedures and experiences in my mind.

My medical school, University of Texas, Medical Branch, Galveston, didn’t have a large population of obstetrical patients. As senior students we were sent to the Robert B. Greene Hospital, in San Antonio, where a large number of women went to deliver their babies. For three weeks I lived at the hospital with fellow students. There we got to attend many deliveries. We were overseen by interns and obstetrical residents. We learned to examine the patients, judge their progress in labor, recognize signs of distress, and know when and how to assist in delivery. We were taught when not to use forceps, and we saw some of the disasters that can occur during pregnancy—a placenta implanted too near to the cervix that then bleeds (called a placenta previa), a placenta separated from the wall of the uterus, threatening the life of the mother and baby (called an abruptio placenta), the umbilical cord wrapped around a baby’s neck, hampering delivery, and on to a large litany of other pregnancy complications.

These memories and lessons paraded through my mind.

I recalled I had applied those lessons and developed experience during many deliveries in Columbus, Ohio, where I had served my internship at White Cross Hospital, now Riverside Methodist Hospital, I had delivered perhaps fifty babies in Keams Canyon at the USPHS Division of Indian Health. The Hopi and Navajo women had spoiled me, as they rarely complained of pain and almost always delivered their babies with ease. Why just about 100 miles south of Lovelock, I had delivered many babies of our Paiute–Shoshone–Washoe tribe clientele at the USPHS Division of Indian Health, Schurz, Nevada. No disasters had befallen me during a delivery and with that reassuring thought, I relaxed.

Maria’s labor progressed as expected for a first baby. She waited thirty minutes at a time before racing outside to smoke a cigarette.

Then her progress slowed, the head did not seem to be advancing and the cervix was not opening as rapidly as I expected. My worries kicked in again. I remembered Carla from my time in Jal, New Mexico, and began to worry. Would this lady need a C-section, which we could not provide?

Jal, New Mexico, 1960s

Carla was the daughter of the owner of one of the oil service companies. Her husband, a faithful and attentive husband, was employed by Carla’s father. It was a close-knit family and Carla’s sisters had children. Carla was anxious to join them in motherhood.

Her pregnancy progressed uneventfully, and her labor proceeded smoothly for a while. Then the progress of the baby’s head in the birth canal became closer and slower as her labor increased in intensity. An x-ray of her abdomen showed the baby’s head was too large for the mother’s pelvis.

The surgical team was assembled. I performed a C-section and delivered a healthy baby. We repaired Carla’s uterus, and sutured her abdomen closed. We breathed a collective sigh of relief.

My joy did not last long. Carla began to have a high spiking fever. Peritonitis, an infection of the lining of the abdominal cavity, became apparent. Carla verged on death for days on end. The surgeon returned and twice we took her to the operating room and drained her abdomen of the masses of pus which had formed.

My wife left her own mothering duties and provided Carla special nursing care. I spent many hours with Carla at the hospital and on the telephone consulting with other physicians about her care.

About ten days after her delivery her condition began to improve, and she was discharged to home on the sixteenth day after delivery. I could finally begin to sleep some at night and start to relax.

The baby did well, and Carla appeared fully recovered from the ordeal. A year later, Carla, her husband, and the baby moved to Dallas. I was greatly relieved. The thought of seeing her through another pregnancy and delivery was too much for me to consider.

One fine day, Carla’s father came to my office to report that Carla was pregnant and planning to return to town so that I could deliver the baby! No amount of pleading or pointing out that she would be better off in Dallas with its wonderful medical facilities could dissuade Carla and her family from their plan.

Fortunately for my peace of mind, the second pregnancy and C-section delivery were a smooth success.

When she returned to town with her third pregnancy, we all agreed that our mutual good health would be served by a sterilization procedure after the delivery.

Enough was enough!

This worrisome tale left my mind when I rechecked Maria and found her much nearer to delivery and the need for surgical delivery faded. Maria’s pregnancy was surprising to me. Her family was known to me, to be close-knit, and strict. Somehow, she had found a way and time to get pregnant. Eggs sometime seem to have a strong desire to be fertilized as I well-remembered from the experiences of Vanessa and Lorraine from my time in Jal, New Mexico. Their eggs had really wanted to hatch.

Vanessa—Jal, New Mexico, 1960s

Vanessa was in my office, sobbing and in deep emotional pain. You tell me I’m pregnant. I feel like I’m pregnant, but I can’t be. My husband had a vasectomy and I haven’t been with anybody else. He’ll kill me! I can’t be pregnant, but an examination and test confirmed that she indeed was pregnant.

I listened some more. She cried some more. I talked some more, and finally she agreed to tell her husband and plead, beg, do whatever was necessary for him to come see me.

When I met with Harry, he was angry, upset, and disbelieving of his wife’s faithfulness. Look, I’ve only got one testicle and the doc assured me that I’d be sterile six weeks after he operated on me.

I reviewed what Harry had been told by the other doctor and learned Harry hadn’t had the postoperative checkup to be certain that he was sterile. I entreated him to have a test of his semen to find out if he was indeed sterile. He reluctantly agreed and several weeks later finally had the test done. His test showed that he was quite fertile and thoroughly capable of having sired his wife’s child.

The couple was relieved.

At his request I performed another vasectomy on Harry. At the time of the operation, the site of the previous severance of the cord could be seen to be neatly rejoined, which explained the continued fertility. I cut the cord and carefully sewed each end well away from the other with tissue and interposed to prevent another failure.

They happily welcomed the pretty baby girl that resulted from the pregnancy, even though she was quite unplanned.

At a Lea County Medical Society meeting some time later, I had the opportunity to tell this story to the physician who had performed the first vasectomy. I never tie off the cord. I just cut it, take out a piece and drop them back in the sac, he informed me.

Do you ever check for fertility afterwards? I inquired of him.

Nope, never had a failure till this one.

Physicians are presented with many chances to make errors and in the nature of life; all of us will make errors. However, following established practices (which he had not) developed over the years to ensure safety and accomplishment of an end is well worth doing.

Lorraine--- Jal, New Mexico, 1960s.

Lorraine Brooks was in my office. Elwood, I’ve got the worst danged indigestion. I keep burping up this icky stuff and sometimes I even vomit a little bit. It doesn’t make any difference if I eat, or what I eat.

Could you be pregnant? was my first question.

No, remember Dr. Huff in Kermit tied my tubes when he did the C-section with Becky? she asked, mentioning her youngest child. And I had a period just last month and I’m having one now.

We chatted some more exploring her symptoms and I examined her abdomen but did not do a pelvic examination because of her menstrual status. We explored some dietary strategies and antacid use to try to improve her symptoms.

Two weeks later she was back in my office. I just know I have an ulcer, I just know it. I hurt up here in the top of my stomach and if I eat Mexican food it just kills me. I want to know if I have an ulcer and what can we do about it? Her abdomen was examined and she was found to be tender in the area where people with gastritis and gastric ulcers frequently are tender. The diagnostic test for ulcer disease at that time was an x-ray examination using swallowed barium. This was called an upper gastrointestinal (UGI) examination.

The examination was ordered and performed and was not diagnostic for an ulcer but suggested the possibility of gastritis, an inflammation of the lining of the stomach. The standard medications of the day were prescribed for her and follow-up in a month was arranged.

On the office visit a month later she was distraught. Well, I’m not as sick and nauseous as I was and I don’t burp as much, but I almost think I felt some movement in my lower belly. But you know I can’t be pregnant since I had my tubes tied and I’ve just had another period.

Examination of the lower abdomen now showed a round soft mass, consistent with a four-month pregnancy. A pelvic examination and pregnancy test now confirmed she was pregnant, despite the tubal ligation and the repeated menstrual flow.

We both worried about the effect of the radiation from the UGI examination on the baby. Her husband had me perform a vasectomy on him, despite my assurances that at the cesarean delivery I would do another tubal ligation; they wanted to be doubly sure that she did not have another pregnancy.

We agreed on a date and I performed the C-section and delivered a perfectly well-formed and healthy baby. A close inspection of the fallopian tubes showed that the left fallopian tube was resected and the edges were separated by interposed tissue. On the right side the previous surgically placed sutures were observed but the side of the fallopian tube next to the ovary had migrated enough to have attached itself to the tubal portion next to the uterus. This had provided the conduit for the eager egg and sperm to reach each other, fertilize, and produce the constellation of symptoms and consternation and the beautiful child that resulted. I removed the offending portions and sutured the ends well away from each other. That bit of surgery plus her husband’s vasectomy ended the likelihood of a repeat pregnancy. In later years with better and easier pregnancy tests, I tested many, many women who avowed they could not be pregnant, but I believe some eggs really want to hatch.

By 2:00 am we took Maria to the delivery room, covered her in sterile drapes, and put on our gowns and gloves. At 2:30 am I delivered a vigorous little boy. Of course, being a worrying sort of person, I had been thinking of the Fairfax family and the Brush baby again from my days in Jal, New Mexico.

Jal, New Mexico, 1960s

Mrs. Fairfax was pregnant and was seeing me for her prenatal care. This was her third pregnancy. I had delivered her second child, a son.

I sure hope this is a girl, Dr. Schmidt, she said at every visit. William and I just need to have a little girl and our family will be complete. Prenatal sex determination was not a part of 1960’s obstetrical practice, so we waited for delivery to know the sex of her child.

Her pregnancy was generally uneventful. Delivery proceeded smoothly and I delivered a baby girl one Friday evening. She cried spontaneously and vigorously moved all her limbs and she pooped. Her examination showed no abnormalities. Her heart was fine, her lungs filled well with air, her abdomen was soft, and she soon took a bottle.

Saturday morning on rounds she was fine, and the Fairfax family all beamed with happiness of having their first girl child. Discharge was planned for Sunday.

Late Saturday evening, I received a call from the nurse at the hospital. Dr. Schmidt, Mrs. Fairfax’s mother is here. She wants you to come and see the baby. She says while she was watching the baby through the nursery window, she saw the baby cry and says she turned black. I’ve looked at her and she looks fine, but the grandmother is insisting you see the baby. I reluctantly left my evening’s entertainment and went to the hospital.

Mrs. Fairfax’s mother was very agitated. That baby girl turned black. She was just as black as the Ace of Spades. You’ve got to do something.

I gowned and went into the nursery. The baby was asleep and looked fine. I awakened her as I ran my hands over her head and then carefully her heart and lungs with my stethoscope. Her abdomen was soft to the examination and the baby was now crying vigorously and looked fine.

The grandmother had observed me through the nursery window. What did you find? What’s wrong with her?" she wanted to know.

You saw me examine her and she was fine by everything I can tell. Did she look black to you when I examined her?

No, but she was black earlier. I know what I saw, was her rejoinder.

I puttered around the nursing and did some paperwork and observed the baby some more. No problems were noted. I said goodnight to Mrs. Fairfax and her mother and went home