State Fair Pig

Deliverance” takes place in Georgia. 

I am going to say that again. It takes place in Georgia.  There are dialogue references to the Chatahoochee River and to driving to Atlanta, and if you don't believe me, wait for the end credits where they describe where they filmed it. 

I know because I once rented the VHS tape specifically to check and be vindicated. Back when people rented VHS tapes. 

I’m hammering on this point because I did my internship and residency in West Virginia, which is a gorgeous state full of amazing people. I'll say that again too. Gorgeous.  It is one of the only areas east of the Grand Canyon that makes me catch my breath when I see the landscape. 

But the minute I told people in Florida where I was moving after med school, about 80% of them started singing “Dueling Banjos”. Every single one of them thought they were being witty. And original.  Then I would brace myself for follow up references to “Squealing like a pig!” accompanied by pelvic thrusts. 

People in almost every state in the union like to use West Virginia for a punching bag.  Although the slogan when you drive in on Route 64 is “Wild, Wonderful” it might as well say “Kick Me!”

I would redirect to Georgia and the Chatahoochee, and they would say “no!” and would keep repeating the opening line of “Dueling Banjos”, only doing it more loudly, the way you do when you don't speak the lingua franca but believe that if you say things  emphatically the point will  be conveyed nonetheless. 

Generally, the people shitting on WV have never been to the state  but will utter cultural insights with great authority, such as “there’s a lot of incest in West Virginia!’

This is probably stemming from some vague notion about “inbreeding” which is really a separate thing from “incest” and is pretty common in many areas where people don’t move in or out that frequently. This happens all over the place. It is also called the Founder Effect, meaning that the few families that settle a place tend to have a genetic dominance and that consequently many people may be a little related.  

It doesn’t mean everyone is banging their sister.

These self appointed anthropologists  would also believe they were the first to tell me the joke about how the toothbrush was invented in WV “see, anywhere else it would be called a TEETH  brush!” Because poverty and poor access to health care are always comedy gold. 

Well, fuck you guys. After four years in flat, crowded, tacky-ass Florida,  I had an almost biological need to be in these mountains and I was going to use my internship year to get me there. 

Let me explain how internship works. The year after you graduate from medical school, you go hang out at whatever hospital agrees to let you. It will pay you a very small amount of money in return for which you get to make yourself available to do the work of the hospital and also be the subject of psychological warfare. 

Your attending physician, the one with whom you are working most closely for the month, is theoretically helping you learn. However, if you are picturing something akin to an apprenticeship with a senior artisan, or a didactic setting with a loving instructor, you would in most cases be mistaken. 

You show up on the first day of your rotation with the attending, who may or may not have remembered that he agreed to take an intern. The chances are quite good that expectations will never be stated out loud, but that instead you will be expected to infer how to keep this particular instructor happy via nonverbal cues, or else by getting berated repeatedly and publicly so that you can identify which particular thing got you yelled at. Basically, like shocking a lab rat in order to mold behavior.

You will be quizzed in a Socratic manner (called “pimping”) in the middle of patient care and often in front of the patient. It may be something that is reasonable for you to know (“what is the first thing we should start for this patient who is having trouble breathing?” “Oxygen!”), or something that you would have no reason to know and will never have reason to use (“where should I ligate the arteries on the cervical cuff?” “I don’t fucking know I’m a family medicine resident!”). 

Socrates was ostensibly trying to educate. A great many of these guys just wanted to humiliate, usually the way they were humiliated at this phase of training. You would also be evaluated on the extremely moving target of  “showing an interest”. This could mean that you asked a lot of questions: unless, of course,  your attending hated being asked a lot of questions when she was trying to do something. This could mean that you stayed way after the work was done “in case you needed anything else”. Unless the attending preferred that you get away and stop bothering him. It could mean that you read up on the subject that the attending assigned, except that after you spent an hour of your evening engrossed in minutiae, the whole exchange would be forgotten and the brownie points never reaped because your instructor does not recall the discussion. After which you will be graded down as a result of “not showing an interest”. 

Every month you do something different in order to expose you to the full spectrum of medicine. And so that the specialists had an extra pair of hands to hold a retractor and look stuff up. We didn’t have Google back then so we were the google: internet minus “net” you might say. There were 6 “house staff” in all, which meant four family medicine residents and two interns. Greenbrier Valley Memorial Hospital was like a lot of rural hospitals, in that we weren’t so big as to merit a huge team of physicians in training,  but we were really more than a 6 person call team could handle on the regular. In 2003, regulations changed so that residents could not work more than 80 hours a week, but that was not the case in 2000. 

The experience of being on call meant that you would be the one doctor in the building overnight and that you would get paged for whatever medical needs were going unmet by the current load of inpatients.  The nurses did not understand that, although they would finish a night shift and be done, the residents on call still had their day job to do, and so our desire to sleep was often interpreted as “lazy” rather than “biological”. 

Possible reasons to page me at 3 am:

“The patient in 206 threw up”.  This is a complete sentence but does not give me useful information. I do not know the patient in 206 and you treat vomiting from being on antibiotics very differently than how you treat vomiting from an inferior wall heart attack. If I asked for clarifying information, it was very common to hear some other shrill voice in the background yelling “can’t she just order some phenergan?” LIke I was the asshole here. 

“This patient is agitated can you help de-escalate?” and then when I arrive to try and be the person in authority, the neutral third party who might be able to redirect Demented Angry Guy, they turn and point to me saying  “here’s a pretty little girl to see you!” thereby reducing me to either a granddaughter or a piece of ass, depending on the old crazy man in question.

Navigating code status with families who had bizarre and unformed religious beliefs about health care, which were nonetheless attached to them like barnacles. “His breathing is getting a lot worse. Do you know if he would want to be on a ventilator or did he just want to be kept comfortable?” “Only God can decide when he is going to live or die.” “Ok, of course, but right now God seems to be cutting off his air supply so if you want to interfere with that we need a ventilator…” “Do everything you can! Let nature take its course!” “Doing everything we can is the opposite of nature taking its course and I can go in either direction but I need a better understanding….” “Look, aren’t you a Christian?”

Nurses wanting me to sedate a demanding and aggravating patient but trying not to admit that’s what they were asking for,  and so instead saying things like “I feel like he would be a lot happier if he could rest”. 

You also saw people who needed to be admitted to the hospital, and wrote the initial orders that would get them out of the emergency department and into a bed upstairs. There were only two floors of the hospital,  which was why one of our colloquial expressions for “dead” was “transferred to the third floor”. 

Oh yes, and speaking of dead, if someone did make it to the third floor on your shift,  you were the one to pronounce them. The first time I was asked to do this, I was puzzled because I was more used to being  known for my vocabulary than my medical acumen. In other words, usually if I was asked to“pronounce” anything, it was in the context of “how do you say ‘puerile’?”. Once I put together that it was “dead” I was supposed to pronounce, I was saddened and horrified and also embarrassed that something this permanent was being conducted by a dork who graduated from med school a month ago. 

Several members of my family, my self included, tend to have a mental soundtrack going for every occasion. I would often soothe myself while bickering with a patient by internally muttering Eminem lyrics. It is very unusual for me to order Italian food without a silent round of tarantaella rattling around in my head. And when dealing with someone who is being bananas, I may be thinking Patsy Cline or Seal, depending. But definitely “Crazy”.

In this case, the gravitas of the occasion of pronouncing the now-deceased was accompanied by a frenetic mental round of the song the Munchkin coroner sings when asked to verify the status of the Wicked Witch of the East post-cyclone. . As I leaned over the cooling body, a cartoonish voice sang in my head. “Not only is she meeeerely dead, she’s really most sinceeerely dead!”  I am pretty sure it was only in my mind that the song occurred but I make no promises and by now the nurses were kind of used to me. 

In every house staff there is one resident who is known to be the “Shit Magnet”, in other words the new doctor who had the Four Horsemen in their wake. If there would be an outbreak of rotavirus that affected the whole floor, it would be on their shift. On the night three patients had a simultaneous heart attack, they would be on call.

I managed to dodge that bullet but after one night during which I had to pronounce a record 4 patients the nurses started calling me “The Angel of Darkness”. 

But affectionately.

My first month was spent learning internal medicine with an oncologist. I know I’m supposed to say things about “triumph of the human spirit”  and “inspirational to see how people face adversity”. I can’t, because it wasn’t. If there were a pithy expression which conjured “colossally depressing efforts to provide complicated medical information to undereducated people who have to decide between driving a two hour round trip every day for 8 weeks of radiation or just staying home and having something amputated” I would say that, because it was more on the money.  July was a long month.

Toward the end of July, people around me started talking about “Fair Week”, in a manner that sounded less “Rogers and Hammerstein”  and more “Pinocchio Gets Dragged Off to Donkey Island”. “You’ll be working Fair Week?” Side eye. Heh heh.  “Oh, honey, you want to be sure you at least stay away from working the FULL MOON  on Fair Week.” Conspiratory shuffle up.  “Now, has anyone told you about Fair Week or were they just going to let you be surprised?”

Since August was going to put me in working in the emergency department, I knew I should explore these hints as I would be on the front line, or, as inpatient people would say “being the wall”. The job of the “wall” is to keep people from getting admitted for bullshit that they could handle at home. Example: if someone who has a seizure and has a known seizure problem and did not take their meds for two days, they do not need to be “admitted for a work-up.” Be the wall!

I also knew I should be diplomatic. Despite my own indignation about the cultural integrity of West Virginia, I knew that the odds were good I would come off the wrong way just by being me.

Once, during med school, I was at the rodeo in Davie, Florida. Fort Lauderdale is spring break and titty bars, but its neighbor 5 minutes away is country. There is a hitching post outside the McDonald’s.  As part of  the opening rodeo ceremony, the emcee was delivering a patriotic monologue about “old Glory” over a swelling background of “America the Beautiful”.

For reasons that are unclear even to me, I thought the performance was intentionally ironic. A wink at old-timey values, an affectionate parody. Why I would assume that about people spending Saturday night at a rodeo and eating boiled peanuts while wearing shirts with the Stars and Stripes on them is anyone’s guess. But that’s what I thought. Or, at the very least, I thought that the rest of the folks in the stand were also noticing the ridiculousness of the performance and were in on the joke. 

I started braying like the jackass I was and nudging people around me as if to share our communal disdain. “Get a load of this clown, huh? Bwah hah hah!”

My more savvy Georgia born friend saved me from mob execution  by hugging me and patting my shoulder to make it appear that my shoulders were shaking because I was sobbing with patriotic fervor and not because I’m a disrespectful asshole. 

A few months later I would get a fortune cookie which would deliver the eerily on-point message, “Not everyone has the same sense of humor as you do.  You think you are breaking the ice, but you are actually alienating people.” Damn, Confucious.

20 years later, my daughter would echo this tendency to ride roughshod over other people’s icons when I brought her to a Golden Gloves where I was the ring doctor. While everyone is getting seated, they play assorted jock rock wind-up-the-crowd music, but the last minutes before they start the bouts, they cue  up the theme from “Rocky” . This really gets the eye of the tiger happening for the fighters, and I am certain many get chills.  My 17 year old, however, started weeping with open and red faced hilarity, which was awkward because she was literally ringside with me and in full view of both the fighters and the fans. Fortunately, she read my mom face early enough to dial it back to the occasional smirk.

Lesson learned: whatever else I gleaned  about what was clearly the Local Big Deal,  I knew it was going to be important to present as respectful  and not as the jeering buffoon I showed myself to be in Davie. As with many underdog cultures, they may have a sense of humor about themselves, but they are the home team so it’s allowed.  So when they repeatedly dangled the Fair Week bait, I bit and asked for details and tried to keep my tone curious rather than sniggering. 

As it turns out the WV State Fair is held every August in Lewisburg. The fair grounds are situated on the main drag through town, literally right on it. When you get to the spot, Rt 219 splits and now you have Rt 219 one way going south to the right, with the fairgrounds stretching several blocks to your left. If you need to go north from there you need to go down the hill into the neighboring town of Ronceverte and turn around by the Kroger. You can imagine what kind of a bottleneck this would create during Fair Week so even for practical purposes the locals kind of dreaded it. 

The people working in the ED didn’t kind of dread it. They really dreaded it. Just as the hospital wasn’t big enough to merit more than 6 house staff, it wasn’t big enough to accommodate the huge expansion both in terms of volume and in terms of crazy. The nurses were also easy to draw out on what specific concerns they looked forward to that would change the clinical flavor for the month. . 

“Well you’ll be seeing a lot of animal bites and STDs”, remarked one nurse when pressed. 

I’m sorry, what? Did you mean that to be one sentence?  Like…do you mean animal bites comma STD’s or do you mean that they are somehow a package deal?

The taciturn nurse shrugged. “Well, the carnies ain't too particular.”

Ah. 

The more chatty staff might share a longer narrative:

“Well, we always get one every year where Papaw loads up the grandbabies in the fifth wheel, gets down here 5 hours to camp by the Fair and then goes and has the Big One and now we have all these grandbabies and no Papaw. Makes social services crazy, they always come from Huntington or somewhere and it’s awful trying to get them back home.”

An unexpected short hand was revealed in the phrase “call maintenance!” Anywhere else in the hospital that would mean a ceiling fan was making a buzzing noise or a lightbulb was out. In the ED, it meant someone had been injured so strangely that the usual medical implements would not suffice and that we would require the use of a power saw or a large pliers. 

You always knew it was going to be something good when you heard them call maintenance.

I had worked in a whole bunch of ED’s during med school and was thus used to the parlance of  motor vehicle accidents (School bus vs. Chevy; muscle car vs pickup. You get the idea). In Greenbrier Valley, the MVAs had a different cast of characters:

“ Room 4: 17 year old Mennonite vs dairy cow! We need a CT scan..”

When I pushed for more details,  the attending physician said with a complete straight face, “Dairy cows are just mean cows.”s Res ipsa loquitur. Dr. Bookhout was not prone to seeing the humor in things; he was the same guy who, when I had to borrow a Japanese colleague’s white coat, had fixed me with a stern look and said “YOU’RE not Dr. Onishi.”

No fun. 

But the beautiful union of animal bites, MVAs and the carny world came to me through a med student, Jacey. 

I will say up front that she was and probably still is a better person than I am and so she was bringing more  professionalism to the Emergency Department in general, and her current patient in particular, than I was failing to bring to the entire month of rotation. I was a horrible role model for a physician in training but fortunately for both of us,  it probably never occurred to her to see me as a role model. 

She came over and asked me if I would check the sutures she had just completed. As she was starting to present, the nurse looked up from her clipboard and chimed in “oh yes, the State Fair Pig.”

I’m sorry, the what now?

“Calvin Swine!” she elaborated, which was similar to “dairy cows are just mean cows” in that it gave me no new information but lent to the overall sideways quality of the conversation. 

Jacey, like the dutiful student that she was, presented the specifics of the matter. 

As the University of Richmond has a Spider mascot and Iowa has Herky the Hawk, the West Virginia Fair has Calvin Swine. In this particular case, the persona of Calvin was inhabited by a high school boy. Picture a nonspecific mammalian costume for the parts below the neck (and probably some kind of suit, I never got a good look) and for the upstairs part, a big old pig head which the kid would wear over his natal noggin. 

Because of the shape and position of the part around his eyes, it was generally assumed to be best practice if he had an escort so he could navigate around the fairgrounds and be festive without walking over any small children or disturbing the livestock. This sacred mantle was given to a teenage girl.  She would walk next to him either coaching him on directions or holding his hand. This was particularly important when it came to crossing the street. 

Remember how the main drag of Lewisburg went right next to the Fair? They were preparing to go to the far side of the southbound lane.

The girl paused to flirt with a state trooper. 

The pig kept going. 

SooooooIEEEEEEEEE!

At this point in Jacey’s presentation, I was laughing hard enough that I could barely collect enough air to hog-call while pounding the nursing desk. I say “barely enough” but I managed, oh indeed I did. And at volume. If there were hogs anywhere in the vicinity of the Greenbrier Valley Hospital Emergency entrance, they would have come a-runnin. Several times. I apparently had not learned my rodeo lesson well enough, because I’m still basically an asshole.

Squeal like a pig indeed. 

Ultimately Jacey threw enough shade at me that I settled down and got the specific mechanism of injury. 

Our young Calvin, before the shocked eyes of his teenage escort and the trooper in question, was taken down by an off duty paramedic in what was fortunately a small car and not the pickup that would more commonly have been found coming in and out of fair country. (State Fair Pig vs Camry!).

This sent me into another explosion of giggles while I imagined the thought process of a man going home from his shift as a first responder and suddenly finding a 6 foot tall pig across his windshield. Jacey soldiered on without pausing. 

“It seems the pig head is what saved him.” she intoned between my sobs of laughter.  “I guess it acts enough like a football helmet that it protected him from severe damage despite his being drug about 10 yards down the road.” Yes, she was local and so the past tense of “drag” was “drug” “ He just needed some sutures to his face and got a little banged up.”

At this point she paused and fixed me with a stern stare. 

“I need you to check those sutures for me.” Hands on hips. “But I am not letting you go in there until you get a hold of yourself.” 

I will never be anyone’s straight man but I did manage to put something resembling a scholarly medical look on my face. At that time in my life I was the doctor who everyone told “you look like you are in high school are you really a doctor?” so I probably was not fooling anyone but it was the only face I had to work with. 

I was doing fine until we went into the room and found the nurse adjusting the boy’s pillow as she presented his lunch on a tray (it was pork chops and I’m not making that up). Right at the moment of my entry she asked him in a kind, maternal tone, “will they be able to get a replacement for you, honey?”

Trying to keep things moving, I chimed in, “you mean like a stunt pig?” and then had to run out of the room before Jacey gave me a traumatic injury of my own. 

The last thing I heard before getting back to the nursing station was the boy responding in good spirit, “Ma’am, I was the stunt pig!”

Before my retreat, I had time to observe that Jacey had actually done a very neat job with the sutures. The mantra of suturing is “approximate, don't strangulate”, which is a cute, medicalese way of saying “pull the sides of the wound together but don’t make them too tight or the wound will bunch.” In Jacey’s particular case, she had approximated the laceration edges and not strangulated me, so you could argue that she had gone a level above. 

I would think of Calvin years later when a close friend and I had a girls’ weekend in Montreal. An ardent foodie, her choice for dinner was at a place called Au Pied du Cochon, although turns out the signature dish is not the pied but the tete. It is served roasted with, of all things, a lobster in its mouth, and I could think of nothing less appealing but it’s a dish for two and I couldn’t crush a friend’s dreams. 

There is an implied rebuke when served the head of something on a dish. Hard to remain in denial about what you are eating. You can talk yourself into a certain dissociation when gnawing on a piece of thigh meat or even a rib, but when the thing seems to be looking at you (and it always seems to be looking at you) you feel you need to cowboy up and look back. Stare it down. 

There is a scene in Through the Looking Glass where Alice is at a party in her honor, which the Red Queen is sabotaging by continuing to introduce her to the food, which then takes umbrage because “It’s very poor manners to eat something you have been introduced to!” Alice tries to derail this process as the pudding approaches, but the Queen jumps in and quickly blurts, “Alice. Pudding. Pudding, Alice.” I can still picture the dour expression on the pudding in the illustration. 

No one introduced us but I felt guilty anyhow. I thought of Calvin, and I figured that if I was going to eat this thing, I could at least make a gesture on its behalf, some kind of restorative justice. Let the pig go down swinging. Or at least, let him not die unavenged.

“Waiter?” I called. He returned, looking sexy and efficient as Montreal waiters tend to. “I was wondering…..

He looked expectant. “Yes, madame?”

“Did you happen to get the license plate of the car that hit him?”

My friend rolled her eyes and dug in. Before she took the first bite, she paused, stared back at me and whispered, “Squeeeeal.”

As I watched her hack away like the Pennsylvania gal she is, I idly counted the lacerations she was making. And idly wondered what kind of suture I would use to repair them.