SENSE OF PLACE

by Bruce G. Pitts

After Yale I went to medical school at the University of Pennsylvania in Philadelphia. The U.S. Public Health Service paid for much of my medical education in exchange for the promise that, upon finishing my training, I would serve in a medically underserved community for two years. I completed a residency in internal medicine, spending most of my final year working in the intensive care unit, a sort of fellowship in high-tech critical care before such a thing existed. I had committed the first thirty years of my life accumulating the credentials I’d need to rapidly ascend the east coast’s academic medical hierarchy.

It was during the last year of this training in 1979 that a woman from the Public Health Service called to ask where I wanted to fulfill my two-year service obligation. I said, “Alaska.” She said, “Everybody wants to go to Alaska. You need seniority to get posted there. You don’t have any.” I looked out the window. It was a typically miserable winter day in Philadelphia—dark, starless, chilly, wet, sleety. The New England kid in me said to the PHS woman, “Where else is it cold and snowy?” She replied, “How about Minnesota?”

I’d never been there, but I remembered a photograph of Hubert Humphrey fishing on a lake when he was running for president. To myself I said, “Minnesota. Looks like Maine.” To her I said, “Sounds good.”

This decision, uttered without forethought during a 45-second conversation, set the stage for the rest of my life. As it turned out, western Minnesota looked nothing like Maine. It also turned out that Clay County, where Barnesville sits, was not medically underserved. It just looked that way to the federal government.

The feds based its assessment of medical need on the number of doctors living in a county.

There were plenty of doctors practicing in Clay County but most of them lived on the North Dakota side of the Red River where income taxes were lower. Carl Simison had been Barnesville’s doctor for over thirty-five years. He was a big man, burly and gruff, who did everything from delivering babies to removing gall bladders, taking X-rays and prescribing eyeglasses. He accepted no insurances. When he announced his intention to retire, the town’s leaders figured that they could qualify for Public Health Service assistance.

Carl was very kind to me when I arrived. I had no place to work. The new clinic hadn’t yet been built. The city set me up in the old jail between the police station and the municipal liquor store. I saw my patients in a cell, in their homes, or at the nearest hospital twenty-five miles away. When I wanted to talk to Carl, I crossed the street and waited with the others in his waiting room. On one occasion I wanted to ask Carl for his records on a patient I had hospitalized. I sat in his waiting room with the usual cadre of Barnesvillians. His walls were paper thin; we all listened as Carl chastised a young woman whose mouth he was sewing up.

“It’s pretty dumb to drink from a broken bottle,” he roared. The woman emerged with a line of sutures extending from the corner of her mouth to her chin. Carl stuck out his bloodied gloved hand to her and said, “That’ll be five bucks.” She reached into her purse and handed a fiver to Carl. He opened his wallet and shoved it in. As the young woman left, Carl said to the folks in the waiting room, “Lunch time.” They all got up and left. Most of them weren’t there to see a doctor in the first place. They were there for the show.

When we were alone, I asked Carl for his records on our mutual patients. He laughed out loud.

“The only records I’ve got are these.” He opened a file box filled with cards bearing countless slash marks for all of the babies he had delivered (over 3500 in all).

Pointing to his imposing brow he added, “All of my other records are up here.” I knew then that Carl was going to be a tough act to follow. My superb academic and clinical credentials were meaningless to the people of Barnesville. I grew up in a part of the country where the most important question was, “Where did you go to school?” and where inquiring about one’s religion was strictly taboo. Nobody in Barnesville cared where I went to school, but everybody I met asked me where I planned to attend church. They were not initially impressed by Carl’s replacement. Why wouldn’t I do obstetrics? Why couldn’t I prescribe eyeglasses? Why would the new clinic need to hire extra people just to take the X-rays and run lab tests? They were deeply offended when I asked them to make appointments to see me. “Nobody in this town needs an appointment system except Rube, and his makes sense.” Rube was the local barber who wrapped up his haircuts by declaring, “That’s good enough for the girls in this town.” He gave good haircuts.

My second-class status in Barnesville was readily apparent in the grocery store. There were two checkout lines, and they were always long in the early evening. I remember feeling flattered when a woman approached me to ask a medical question. I responded politely. She immediately crossed to the other line where the town’s chiropractor was holding court with a large group of locals seeking his medical advice. He routinely counseled against childhood vaccinations and espoused that spinal manipulation could cure cancer. The lady who had spoken to me waited her turn to compare my advice with his.

A few months into my tenure as a country doc, the same Mike who had introduced me to the town came to see me at the new clinic. He knew that business was slow. He gave me a few pointers. “Doc, you need to shed the necktie. Put on a flannel shirt and some nice boots. And come to the high school games. People like to show off that their town has a doctor.”

So I changed my sartorial habits and started attending boxing matches and Friday night football games. I remember the first time that a Barnesville Trojan went down on the gridiron under my watch. From the stands I waited to see if he would get up. He didn’t. I quickly realized that folks in the stands were not looking at him like I was. They were looking at me. I got the point. The crowd parted as I descended to the field. I made a spectacle of examining the young athlete, as if I could actually feel anything through thirty pounds of pads. I called for the standby ambulance crew to bring out a stretcher. We sped off to the clinic

“Is the medication helping?” I asked. I had given him a nitroglycerine tablet to place beneath his tongue.

“Ya. It is better.” with the siren blaring. The kid was fine. Business at the Barnesville Area Clinic took off the following Monday and was relentless thereafter.

I scanned the EKG that my nurse had taken before I arrived.

I was becoming familiar with the mid-western, agrarian values in which I was newly immersed. Anything I had done in the past, however glorious and entitling it may have been in the east, was of no value in Barnesville, Minnesota. What I did yesterday didn’t matter. The only thing that mattered was what I did today. As Mike explained to me, “Around here we earn our stripes every day.”

A short time later I was called back from lunch at the Wagon Wheel to see a man with chest pain. I found him sitting on my exam table, sweaty, breathless, pale. His name was Henry. He wore jeans, a gray thermal shirt, dirt-caked work boots.

“When did pain start?”

“While I was climbing onto the combine this morning. It just filled my chest and took my breath away.”

“This shows that you’re having a heart attack, Henry. A big one. We’re going to plug in an IV and get the ambulance to take you to St. Ansgars. I’ll follow you up there.” St. Ansgars was the closest hospital in Moorhead, Minnesota. Moorhead is home to the Prairie Home Cemetery, the place from which Garrison Keillor adopted the name for his radio program.

Henry shook his head. “Nope. Can’t do that. I gotta finish the harvest.”

“If we don’t get this taken care of, you may not live to finish the harvest. This is serious, Henry. It could kill you.”

Henry stared at me, saying nothing for a few long seconds. “Nope. I gotta go. Give me some of them little pills to put under my tongue. I’ll come back when the corn is done.”

I argued with Henry a while longer, but I knew it was a hopeless task. Henry was more afraid of missing harvest than he was of dying. It was partly about money. His wife and four kids relied on him to convert a year’s investment of labor and capital into the ready cash they needed to live. But I knew that Henry’s recalcitrance was about more than money. In the 1970s U.S. farm policy had encouraged farmers to assume debts that many were unable to meet. Henry wasn’t just afraid of losing a crop. He was afraid of losing the farm that his grandfather had homesteaded eight decades earlier. He was afraid of losing a way of life. To him this was a matter of pride, identity, and duty. He would surely rather die than break the chain of love, obligation, soil, and grain that made him a man.

I had not encountered this situation before moving to the Red River Valley. I understood the circumstances that might cause a person to choose death. My father fought in WW II as a very young man. My aged grandmother refused treatment when diagnosed with cancer. But I had never met a person who would rather die than miss work. East coasters don’t think that way. I had taken care of a lot of Philadelphians when they or their loved ones died. The rich ones commonly perceived death as a big surprise, an injustice, a rude insult, a crude joke, something to be avoided at all costs. Surely something can be done! Poor Philadelphians couldn’t escape death’s violent or drug-soaked presence in their squeezed neighborhoods. I gave bad news to both the rich and the poor, certain that I would provoke a strident emotional outburst. I didn’t know any Philadelphians who would show up for work if they thought it would kill them.

Henry left my office and finished his harvest. He came back to see me about two weeks later. He had survived his myocardial infarction. He and I spent the next few years managing his heart failure. The cardiologists of the time had little more to offer than I did.

Henry was my first introduction to the calm acceptance of death’s reality among my new neighbors. They didn’t greet fatal diagnoses with the screams, howls, and paroxysms to which my Eastern sensibilities had been accustomed. Instead, they responded with silence, serious deliberation, perhaps a few soundless sniffles, and finally, “Alright then. Thanks, doc.” Intense sadness. Deep disappointment. No histrionics. No visible fear.

I mentioned this phenomenon to a friendly Barnesvillian after I had been in town long enough to have observed it several times.

She surprised me by quoting Francis Bacon (1561-1626): “Death is a friend of ours; and he that is not ready to entertain him is not at home.” She added, “Death here is personal, small, inevitable, attended by the neighbors who will gather together to harvest your field if you can’t. We are a quiet people. In death we just get quieter.”

Later that winter the town was snowed in by a blizzard. The roads weren’t open. There was no way to get to a hospital. Marcella, the town’s 24-7 police dispatcher, called to tell me that a baby had died at a home across town. She said that the plow was on its way to clear a path for me to drive there. When I arrived, two young parents were holding the lifeless body of an infant across their laps. The parents had found their baby dead in its crib early that morning. The child was beyond resuscitating. They asked me to take him to Mr. Dobmeier. Like many small town morticians, Don Dobmeier also ran the local furniture store. This probably had something to do with building both coffins and cabinetry in the old days. Dobmeier told me to bring the baby to his house. In the winter the ground was frozen too hard to bury the dead. He stacked coffins in his garage until the spring thaw.

The plow led the way as I drove the dead baby to Dobmeier’s house. It was a bumpy ride. The baby lay wrapped in a blanket on my front seat. I had to reach over to keep his stiff little body from bouncing to the floor. This death was personal, small, far too soon, attended by parents and by neighbors who plowed a path, pronounced a death, and gave a lifeless child a home for the winter.

I remember a woman who saw me repeatedly because of vague symptoms of fatigue, sleeplessness, anxiety, and migrating pains. I couldn’t figure out what was wrong with her, so I did what the good folks of Barnesville had taught me to do when confused about a patient: I made a house-call. I had learned this lesson in the early days of my country practice, before I had an office and the only place I could see patients was in their homes. It quickly became apparent that house calls were better than all of the social workers in the world in figuring out why patients weren’t getting better.

On this occasion a little girl answered the door, a dirty child in a torn dress. The house reeked of cigarette smoke. The floor was covered with trash. My patient lay on a beat-up sofa. A man sat in a recliner with a cigarette in one hand and a beer bottle in the other. He ordered the child to bring him another beer and offered me one. I declined. He gave me a dirty look. When the child brought him his beer, he slapped her across the face. “You didn’t open it, you little slut.” She took the bottle back to the kitchen to open it, a tear marking a white track down her dusty cheek. It was nine in the morning. The child wasn’t in school. It didn’t take long to figure out why my patient wasn’t getting better.

One summer morning I was awakened by a call from Marcella. She said, “Doc, the anhydrous storage tank north of town sprung a leak and a big cloud of the stuff is covering I-94. A bunch of people drove into it. The rescue team is on the way. They need you there.”

Anhydrous ammonia is a substance that farmers inject into soil to enrich its nitrogen content. Upon contact with water, it turns into ammonium hydroxide, a caustic substance that dissolves living flesh. People exposed to anhydrous ammonia experience immediate distress in their watery tissues—eyes, mouths, and throats. Their airways can swell and close off so suddenly that breathing is impossible. On that bright summer morning, over twenty motorists were blinded and struggling for air. Our small town made up for its scarce medical resources by rallying in force to save lives. The clinic staff tended to the less severely wounded, flooding their eyes with water, giving them oxygen, calling their families, holding their hands. The volunteer ambulance and fire crews transported the critically wounded to hospitals twentyfive miles away, calling ahead to secure the care they’d need. I rode up with the two victims most likely to require tracheostomies to open their airways. The rescuers suffered from the anhydrous, too. Our eyes watered, and our throats stung. Everybody survived, but some were scarred for life. One of the victims was an opera student on her way to Minneapolis for an audition. The anhydrous withered her vocal cords. She never sang again.

During my second year in Barnesville I received an invitation to return to a prestigious academic position in Philadelphia. Just a few months earlier, it would have been an answer to my dreams. But Barnesville had changed me. I remember the moment when I decided to stay in the Valley. I had received a call from the hospital in Moorhead that one of my patients had gone into shock. I hopped into my red Bronco and headed west along dark roads, bouncing over pillow drifts and hoping that the storm wouldn’t get worse. Halfway along my journey on I-94, it started to snow in earnest, as it does sometimes in a Minnesota autumn. While lost in whiteout and barely able to see the highway ahead of me, I caught sight of something out of the corner of my eye, something ethereal that floated in and out of my vision. I realized that my truck was being ghosted by a group of snow geese. There must have been ten or fifteen of them. They flew next to me for several miles before silently disappearing into the white haze. Magical. Beautiful. Something that would never happen in Philadelphia. I felt like I had been visited by a supernatural force determined to influence my choices.

I spent a third year in Barnesville to finish what I had started, but I knew that I wasn’t cut out to be a country doc. My training was too specialized. I had a baby son, and taking calls every night wasn’t sustainable. I had started to make a life in the Valley. I recruited a new doctor to Barnesville and moved to Fargo where I could do what I was trained to do. And being on call only once a week looked mighty attractive.

The Fargo Clinic (then MeritCare, now Sanford Health) was the right choice. It was a large, multispecialty group practice, physically connected to the hospital where its doctors cared for their patients—the Mayo model. For nearly forty years, I got to do things that I would never have been able to do in Philadelphia’s more rigid medical culture. Fargo was small enough that pretty much everybody had to wear more than one hat if anything up to Fargo in an ambulance.”

“What happened,” I asked.

“Well, he was gored by a bull.”

“How is he?” I inquired.

After a pause Maurice replied, “Dad or the bull?” was going to get done. This suited both my wide variety of interests and my short attention span.

Over the years, in a variety of roles, I came to know the many faces of the Red River Valley. I taught advanced cardiac life support and advanced trauma life support in Crookston. I gave lectures in Mayville and Wahpeton. I learned a lot about Grand Forks as associate dean of the University of North Dakota’s medical school. I worked on clinic and hospital mergers up and down the Valley while Chief Medical Officer at Sanford Health. I married into a family that farms near Lidgerwood and Sisseton—and wound up taking care of not only members of my wife’s family, but also members of her ex-husband’s family. Such acceptance and candor would never happen in Philadelphia.

My wife’s family came to represent to me the things that I respect and adore most about the Valley. They were kind, hardworking, and tough as nails. Her uncle, Ray, and his son, Maurice, farmed near Lidgerwood. Ray was pretty old when, on a memorable Saturday, Maurice called me in Fargo and said, “Dad is on his way

“Your dad!”

“Oh, I think he’ll be OK. I told him that you’d meet him in the emergency room.”

“Of course I will. I’m on my way now.” But I was curious. “How is the bull?”

“The bull’s not so good. Dad was so angry about being gored that he went to the barn to get the sledgehammer and hit him over the head with it. The bull’s dead.”

Some years later Maurice was run over by a massive four-wheeldrive tractor. It crushed his pelvis.

Maurice was transported to Fargo, then flown to Minneapolis. Doctors offered little hope of his survival. Maurice is in his late eighties now, still plowing and combining. To this day he’ll laugh and say, “Ya, we’re pretty hard to kill in this family.”

I have always been struck by the sheer danger of the farming life, and more struck by how philosophical and accepting farmers are about the risks they face every day. Shortly after I moved to Fargo, a Barnesville teenager lost his arms in an auger attached to the tractor he was driving for his father. He died. Nobody got sued.

I am an old man now. It has often been said that one of the Valley’s greatest exports is its kids, and my kids are no exception. They were well educated in Fargo’s public schools. They went to good colleges. They have enjoyed successful careers, one on the east coast, one on the west. When I talk with their mentors, colleagues, and clients, their comments echo what I have long associated with the ethos of the Red River Valley. Our kids are humble. They are hard working.

They are exceedingly competent. They are good to work with. They earn their stripes every day. They never showboat. They never take their positions for granted. They never behave as if they are entitled or privileged. In Valley words, “they get ‘er done.” These characteristics may be taken for granted in the Valley, but they are exceptional on the coasts. They stand out. The Valley grows great crops. The Valley grows great people. l

BRUCE PITTS was a doctor in Fargo for over thirty years at the Fargo Clinic/MeritCare/Sanford. He is married to Ryn Pitts, father to P. Casey Pitts, and step-father to Amber Olig. Together, they summer on Pelican Lake. His wife still farms in South Dakota.