In the summer of 1981 Warren Silverman, M.D. moved to Ocracoke. It had been four decades since Ocracoke had a resident doctor. Dr. Silverman’s wife, Jean, a nurse, accompanied him. They practiced from their home until the island’s new Health Center was completed the following year. Dr. Silverman also made house calls. In 2017 Dr. Silverman visited the island, and stopped by to say hello. He regaled us with stories of his time at Ocracoke.
At my request, he sent me the following story about his very first patient, island native, Maltby Bragg (1904-1985):
I wasn’t sure what time it was, but it was early. A few hours ago I had come across the Swan Quarter ferry. Only the second time, but it was a time of significance, for it brought me to my new home. It had been exhaustingly late. A mad rush to catch the darn thing, the last one out from the mainland, and now, a knock. No, a bit of a pounding on the door, somehow not to impress urgency or anger, but persistence. I got up in this strange room in this old new house to me. The room was filled with morning light reflected on the slat board white-washed wall. I reached for something to wear. No worry about the details or wardrobe, for almost everything I had were the white daily uniform, white pants of an intern, I had worn each day at Duke. Not quite starched as once they were, but white, nonetheless with the appearance of hygiene. And a green scrub top, the other half of the simple uniform that marked me as house staff for three years. I put it on, the V-neck loose shift for my upper half. Did this non-descript green color exude calm or proficiency to rank it as the choice for inexperienced doctors? Hard to say, and frankly, had never questioned the clothes that had been given to me. No shoes. It was home, and as I would soon find, the lack of shoes offered the advantage of keeping the amount of sand out of the house, and ultimately the bed, down to a minimum. It would come to be my trademark, the bare-foot doctor of Ocracoke
I went down the stairs to the pounding door. It was at the main door, not the screen door outside the porch, so in fact two doors were breached. I could see him out there, the man who would later be known to me as Maltby, Maltby Bragg. I pulled the door open and he looked hard at me. The pause lasted long enough for his questions to be answered. Well, most of them.
“Are you the doc?”
“Uh…yea”, I replied. Surprised in fact, since I had not told anyone I was going to arrive or I had arrived on the island, trying to slip quietly into the village in the dead of night. Or had I mentioned it to one of the ferry hands at 11 last night. Didn’t think so.
“You gotta take care of this”, he thrust forth a gnarled and wrapped hand, an old tee shirt wrapped around the palm, mid-section of it. He was wearing an old plaid flannel shirt, in spite of the early morning heat, and a pair of dirty jeans. You could see the sun had been his master and worn him down and fed him at the same time.
I un-wrapped it. As the cloth came about I could see it was bloodied, dried blood of something that had happened hours earlier’
“I cut it on my boat last night, pulling nets, must have been something in there, but never saw it”
The hand was dirty, but the wound was straight and with sharp edges. He had washed it, in a rudimentary way, but you could see the effort had been made.
“Hmmm”, looking at him as he stared down into the damaged hand.
“I don’t think I can help you today, as much as I would like to. I just arrived last night and don’t have any of my stuff here. I have nothing to sew it up with. Nothing is set up and all the supplies are coming later.”
He looked oddly at me as if to wonder if I was really the doctor or not.
“Well, you gotta do something ‘cause I ain’t going to leave the island for this thing. Don’t have time and I figure you can do something to close it up. “
He meant it; I could tell, and was not being turned away. And, I, my first patient in my new home, would I be able to so easily turn him away? I looked back at the hand and stared a second. I thought a bit. In the trunk of my ‘70 Lemans, the Upjohn guy had filled me up with samples of Erythromycin and all kinds of other stuff. What else did I have?
My black bag. That vestigial remnant of the old days of medicine, we had to get as medical students, but never really would have to use. I had my basic tools in there. Stethoscope, otoscope and ophthalmoscope, a tuning fork and a percussion hammer. But, having looked in there occasionally, I remembered. There was a small package that contained a 4-0 Silk suture, still wrapped in its sterile, but expired package from when I had been a second-year medical student over 5 years ago. It was all I had, short of asking around the neighborhood for a sewing needle and thread.
I looked at him. “Do you have a pair of needle-nosed pliers?”
“And a tweezers”
“OK, go home and put them in a pot and boil them for 10 minutes. Drain the water, but don’t touch them. Bring them back with some whisky or vodka and we will sew you up. I don’t have anything to numb you, but if you can take it, we’ll get you fixed up.”
“You got it”, he said. He turned around and started wandering away. He had a limp, something to suggest he had hurt his leg sometime in the past. I waited until he was out of the yard and on his way. It was only then that I looked down at my arm and noticed it was covered with dozens of tiny moving specks. And with the specks I noticed a familiar feeling…. The feeling of being bit by mosquitoes. My arms were covered by flying hungry beasts at 6 am on a soon-to-be hot summer day.
I went back into the house and walked up the stairs. Jean was lying in bed, half awake. The light was shining through the window onto the white sheets. She had preceded me to the island to set up house. In fact, she had done most of the negotiating and meeting and greeting, as I was tied up with the last loose ends back in Durham. She was good, real good, and I admired her so. I am a controlling person. I know that, a fault of mine. Yet, inherently, for the first time in my life I knew my partner would do everything right. That she could do things better than I and even before I arrived, she would have the island know us, be ready for us; begin to love us, for she was infectious.
“Who was that?” she asked quietly.
“I don’t know how he figured out I was here, but that was our first patient. I got the feeling he cut himself fishing or something with a good gash on his hand. I told him I couldn’t do anything about it without supplies, but I guess I’m going to. Want to help me?”
She seemed a bit puzzled, but something stirred a sudden gust of energy and she was up in a flash. We set upon the task of trying to get ready for the return of the fisherman. Apprehensive, borne somewhat with not knowing the people or how the outsiders would be perceived or accepted. You see, this was a community with a history. A history dating back to the 1600s and even though in the state of North Carolina, cut off from the rest of the American population for all practical purposes until the US mail boat began sailing, when people started arriving from the outside they found a fishing village that spoke in an old Elizabethan English accent and with only a dozen or so last names between the 600-700 folk population.
We set out to find some supplies. I got my black bag, still in the trunk of my car. Leather, just a place to keep my tools, but never carried to a patient’s bed. Different from my father’s. His was about twice the size. When you pulled apart the two sides of the top, there were compartments on each side. One side held the hypodermics. Glass syringes having been previously sterilized in an autoclave at his office. Now in a holder to keep them from breaking. The outside glass clear, with red painted lines to measure off the dose. The plungers a thin long shaft of etched roughened glass, the two parts sliding together with precision, but with a slight grittiness when they were dry
The needles were steel. Thin, or not so thin by today’s standards, shafts of tubular steel on a squared steel base, terminated in a Luer twisting lock to intercourse with the syringe in medicinal harmony. These steel needles had also been autoclaved and I myself, as a child, had sharpened them at times, using a whetstone, to take the tiny barbs off the end and decrease the pain on insertion into flesh. Tiny little circles, holding the tip of the needle against the stone, trying to mimic the angle that was there already. Sometimes turning them over to straighten out the barb, possibly from hitting bone or just banging around.
In the other side of his bag in the upper chamber was his portable pharmacopeia. I used to look through the bottles while playing in the back of our family car as a tot. Some were bottles with the rubber top to draw out the drug. The big bottles of Morphine and Demerol. There were glass things, ampoules that you had to break at the neck to open. They scared me. Wouldn’t you cut your finger breaking the glass or get glass into the medicine? There was epinephrine otherwise known as adrenaline, atropine, and Benadryl. There were often other things. Paregoric, Compazine, Thorazine, the medications that made American medical practice a powerhouse of society. His was the generation that crossed over from cupping and bloodletting, leaches and smoke inhalation for asthma, to electrocardiograms, cardiac care units, X-rays and proctoscopes. Here I was, stepping back to his beginnings. I was going to sew up a man with no anesthesia, liquor for anesthesia, and silk that had long passed its expiration date for sterility. And I had my black bag. It’s funny, my dad used to carry his black bag in the car with us wherever we were. It was his identity, an extension of self. Then in the ‘60s, he took it out. You see, the addicts, heroin addicts, would break into the cars of doctors. Particularly ones with MD plates, and steal the bags for their Morphine. Having it there threatened our family safety.
When I would go with him on house calls, long drives into the farm country of New Jersey, we would enter a home. “Thank goodness you’re here. Mother has been having a real problem.” The black bag and the stethoscope around the neck, a white coat. The treatment had started, even before he set his bag down. Even before he put a stethoscope on the old woman laboring in her breathing in the soft feather bed. One could feel the tension lifting, seeing the black bag. Everyone in the house feeling that, no matter the outcome, the doctor was here to lift the responsibility of the inevitability of fate and its consequences from off their shoulders onto his. And then, with a shot or two, be carried out in the black bag waiting for the hand of god to follow.
I put the bag on the kitchen table and opened it. It was sparse, not nearly as rich with stories and the weight of humankind inside. No compartments. But along each side was a pocket. Normally flat against the wall, but you could slip things in there. I suspected I would find my prize, and I was not disappointed.
Modern suture materials are mad of a variety of substances. With time, more and more complex and synthetic. The early materials were the bailiwick of the tailor. Cotton, silk, wire, familiar things that we could understand. With the war, World War II, came nylon. Silk was wonderful material. Soft, yet very tough. If you tie a knot, it stays. If you place it down it lies flat. But the tiny fibers allow bacteria and debris to form, and the scar that results is inflamed and likely to be quite noticeable. Nylon monofilament, basically fishing line, was the more modern alternative leaving better results, but also more likely to untie itself, or remain rigid in its shape. Many other materials were to follow, but are of no matter for Maltby. For you see, what I had in my little black bad was silk, 2-0 silk to be exact. Suture material diameter, its degree of coarse or fine, is measured in numbers with the more zero’s the tinier the fiber. One would sew up an eyebrow on a child with 7-0. 2-0 usually has a large needle and is good to pull together skin edges that need some force to bring them together. It is usually too tough to break even if one pulls real hard. Today it was Maltby’s number. Sutures are also double wrapped and sealed for sterility. The sterilization process has an expiration date. But on this day there was only the blue seal left and the expiration, 6 years passed.
Nonetheless, I would not open it until we were ready to go, to avoid bacteria from gaining unfettered access. Access that they more easily had in my father’s medical bag with the hypodermics in their case.
Jean went to find some gauze. Maybe something in a first aid bag, or in her supplies, and where was our tube of bacitracin and some of our band-aids. Paper towels to make a surgical field, and soap and water to clean the wound.
It took about 45 minutes for him to return. This was North Carolina time, where the clocks run at about 1/3 the speed of those in the northeast.
I had been a brand-new intern, just starting on Long Ward at Duke. It was considered the “public ward” which meant that they were poor farmers, some white, mostly black, who had no money, no Medicare, Medicaid or any other anything. It had existed decades earlier in the north as “charity wards,” but had long disappeared, but here was Long Ward, the Public service ward for males. My first patient …. “How are you today?”
“What brings you in today?”
“Doc, I can’t understand a word you’re saying. You have ta slow down, you speakin’ too fast”
And he was right. It took me a couple of painful weeks to talk reallllll slllooooowwww, before anyone could understand me. So it made sense that this medical emergency was now almost an hour into it and that wound was no better off. So we sat there. It was a small kitchen table and soon to be surgical suite. It was early July and one could feel the humidity already. There was a window by the table. The items we had accumulated in our life together so far were all put away. The kitchen was clean, simple and ours. Sleep gone from Jean’s eyes, they looked around, so many things to see. The eyes of a girl at the beach, the eyes of a wife, a new bride explorer going off into the unknown with her husband, the eyes of a nurse about to care and nurture.
We heard the front door open.
“Ok, come on back here and we’ll fix you up. I felt the sweat on my brow beginning. There was no air conditioning in as yet, it was early in the morning, but it was July.
“Come on over here,” Jean in her southern Greensboro accent. She gave him some soap and told him to wash the area best he could. Normally, this is the part where we scrub the wound with Povidine Iodine a few times, followed by saline or peroxide, cleaning and scrubbing until all the debris is done and establishing a sterile field. Sterile gloves are used. Tools are placed in the sterile zone and sterile and non-sterile are segregated. She put paper towels on the table and told him to put his hand there, palm up. She had found some cotton balls in her make-up kit. I had her put them in a cup and we took his bottle of whisky, bourbon, and poured some in. Latex gloves….not today.
I went to the kitchen sink and washed my hands.
“This is gonna sting,” I said, looking over the array of items on the table and the man sitting with arm and hand extended…palm up in vulnerability.
Maltby didn’t look up from his palm. “Don’t worry ‘bout it.”
I took a cotton ball and squeezed out the extra booze. Even I could feel what was going to happen, but it was easy. I dabbed at first, trying to apply the alcohol to kill all the bacteria. Then seeing him sitting there with hardly the flinch, I took another and began to scrub. Some blood started flowing.
I set his hand down on the less than sterile field that Jean had prepared; some paper towels from a roll she had picked up at the Variety Store down in the village center. I had a chance to look at the wound. It was a laceration about 4 centimeters in length, or just shy of two inches. It was in the area of the thenar eminence, that fleshy part of the palm that sits just below the thumb, but above the wrist. Not too rough a cut, it had gone through the dermis and just into the muscle.
I asked, “Do you feel this”, as I stroked the skin lightly over the thumb.
I looked over at Jean. She was in her nurse’s role, one I had seen her perform so well, so many times. Often, in such situations, she would take the other hand of the guy being inflicted with whatever medical torture was happening that day, but she could tell that this man did not look to hold a woman’s hand at this moment. He was concentrating, in his own stoic way, to not care. But, she had to do something. She was standing behind him as he sat at the table, and she did the one thing she could to comfort, she put her hand on his shoulder. Perfect strangers, communicating without words, a sub-primal form of speaking. I could see in her eyes, she was anticipating feeling the pain, and I knew, if I could watch her face, there would be a grimace coming.
And I asked him to move the thumb, which he did with no signs of problem. There are some nerves that go through this area, important to the thumb, but he seemed to have missed them.
Nothing at the base of the wound besides the top layer of muscle. It seems clean and not too deep. The skin edges were smooth, it must have been a sharp edge of some sort. Many such objects on a trawler, as I would later learn, some covered with some amazing things pulled from the deep.
I took one of the couple of packs of silk. I ripped it open, exposing the thin black thread. Wrapped around a piece of thicker paper, the silk was packaged in longitudinal loops which are designed to facilitate removal by a steady pull of the needle, and yes, there was that shiny semicircular metallic needle, barely larger than the thread. Some inventor had once figured how to insert the thread into the core of the needle so that there was no loop, no knot, as might be found in the seamstress’s needle-thread interface. The shape of the needle when I had first seen them, had reminded me of needles that I had seen as a teen, used to sew carpets, semicircular thin metal designed to come back to you if pushed away. A boomerang of sorts.
I took the pliers and, reaching down into the package, I found the needle and grabbed it. With a gentle tug the needle came and the black string followed.
Ok, how was this going to go? I had sewn people up before they had gotten the full effects of the local anesthesia, I had sewn up children with topical anesthesia whose main constituent was cocaine. I had even sewed up a person or two under hypnosis, who in fact, felt no pain, but I had never gone into untouched skin. The only thing I could compare it with were the old black and white westerns I had grown up with. Remember the cowboy who is shot, maybe it was a couple of John Wayne films or some others, and old Doc comes around and says he has to take the bullet out with only a shot of whiskey to numb up the pain. Well, today I was old Doc.
You hold the needle, which is semicircular so that the leading portion is perpendicular to the skin, a straight down plunge. I took it. With a swift movement, I puncture the skin and down. Maltby didn’t move, pull back or flinch. A slight twitch of the muscle in his hand, which he could not control was his body’s only response. Now changing angles, out through the base of the wound, I could see the gleam of the needle emerge between the muscle walls. Then grabbing the other side with the tweezers, I pushed forward about the same distance. It was smooth as silk, so to speak. The final movement takes the needle back up perpendicular to the skin with a sudden thrust, and out pops the point of a razor-sharp needle. I took hold of it and completed the act by pulling the entire needle out and all of the string until only about 2 inches was left on the other side. I was good at tying. Had scrubbed in hundreds of OR cases, and been asked to close many times. Instrument tie or manual tie, with fingers flashing about in difficult to see movements. Hours and hours of practice.
As students, we had been told to practice on the foot of a pig. Pigskin is quite close in consistency to human, and it would provide non-living flesh to make mistakes on. We tied knots on everything, any bar we could wrap a string around. I recall going home for thanksgiving and bringing home some silk to tie the turkey closed once the stuffing had been placed. With a bit of around, in, out, up and down the first knot was placed. A surgeon’s knot, with the thread being swung around twice instead of once to make it stay. And then a gentle pull to draw the edges of the skin together. Not too tight, for a knot placed too tight will strangle the blood supply to the tissue underneath and cause tissue death or necrosis. Or it can cause the edges to misalign with more scar formation. But also not too loose, for edges that leave a gap are filled with fibrin, which later becomes scar. The suture must also have entry points far enough away from the wound to keep from choking the underlying flesh. We call this “taking a good bite.” It is a complex task which eventually becomes routine. Now with silk one can get by with two or three knots, since, once tied it is likely to stay tied if one snugs things up. Were this nylon, or some of the other synthetics, it would be a matter of 6 knots or more, each in alternating direction, to avoid the suture untying itself. Silk is easier, more pleasant to work with, but it leaves more scar than the biologically inert nylon.
After a couple of knots, laying one upon the other, I lifted up the leading suture material and the tail, and with a snip, cut them both with ½ inch of a tail for each. Time for number two. Maltby was ready, Jean was ready, no reason to slow down.
I repeated the process until 4 sutures were placed, each sitting flat and lined up like miniature rungs of a ladder. The wound had come together nicely.
“O.K., it looks pretty good. Now don’t touch it and find some first aid ointment. Cover it with some of that and a band –aid. Keep it clean and dry and come back and see me in a week, sooner if it looks like it is infected, red, or has more pain.”
“How much I owe ya?”
I looked at jean. She shrugged.
“Well, I don’t even have a way to charge you yet, so this one is on the house. Benefits of being the first patient in this office. Anyway, I haven’t even thought of how much things cost yet, so don’t worry about it. Jean smiled.
“Well, thanks doc.” He got up, looked again at his hand with the little black lines on it, and walked out the door. I followed him out and so did jean. Screen door closed behind us, we stood on our porch. We watched him walk away. Suddenly, I realized something stirring on my arms. I raised my hand and saw an amazing sight, maybe 30- 40 mosquitoes all dancing on my arm. Jean looked at me. “Oh, I didn’t tell you about that; how about some breakfast.”