 is Dr. David Cheetamire who's a palliative care physician at Theta-Karen Appleton in Nina, Wisconsin. He's on the faculty as a clinical professor of medicine and bioethics at the Medical College of Wisconsin. He enjoys being on the front line of medicine in the hospital. He was a visiting scholar here at the McLean Center in 1986-87. He has written or co-authored more than 125 papers and eight books focusing on the doctor-patient relationship and medical ethics. One of his books is a poetry book called House Calls, Rounds, and Healings, a poetry casebook. Dr. Cheetamire has an interest in the medical care of poor people and part of his medical training occurred in Liberia, West Africa. In 1992 he completed a short sabbatical at Tupacity Hospital in the western Navajo Reservation in Arizona. In the late 1990s he's worked on a project to improve the skill levels of physicians working at primary care clinics in the former Soviet Republic of Georgia. He has his own office practice for many years at the County Hospital in Milwaukee and he made House calls to see patients throughout the city. He also served for a time as the medical director of Family House Medical Clinic. Family House is a health ministry founded by Mrs. Cordelia Taylor to provide care for African Americans in the central city of Milwaukee. He is currently a palliative care consultant in several hospitals and is a hospitals medical director. Today Dr. Cheetamire will speak on the topic of quote the chart. Dr. Cheetamire. Thanks so much and thanks for bearing with one more talk. The chart entry November 13th, 1990. Dear Dr. Siegler, thank you for incorporating these notes from me into the chart. I know of your interest in expertise in medical ethics. As a retired English professor here at the U of C I thought you might be interested in putting these musings into my chart as a sort of literary addendum to my standard power of attorney for health care. As you know my diabetes has not been kind to me although you always have. Thank you for all you've done for me. Please file these pages in the chart. Anywhere will do. When I was a boy I lived near Sacksville on the Pine River. My father and mother were teachers. The Pine is a good natural trout stream. It sources north of the Mill Pond over there while grows and it flows west and south and grows deeper and colder at each fork. By the time it reaches the Wolf River it is full of big native wisel brown trout that hide underneath logs and undercut banks. I fished or walked along the Pine almost every day as a boy. I loved helping my father work on the stream. We put in rocks to deflect the current so it would move more swiftly where it would scour the bottom and it would get deeper on the bends where that silt deposits. We built shells of thick wooden planks for bank cover and we braced half logs against the shore. All of these changes created new habitat for the fish. Then during the Hexagina Hatch in mid-June when the giant mayflies rise by the millions I would be surrounded by the trout. And when I caught them on hand tied flies and I slipped them back into the water I blessed them and I pointed them back toward the deep banks. Live long and prosper. Live down deep and cold. Live forever. I grew up staying outside all day. I learned the sounds and smells of nature. I know a spring paper s voice, how it s different from a leopard frock and a bull frock. I know the tricks played by butterflies, how the visorite looks like a monarch, how eyes on the wings distract the predators. I've seen giant sucropia moths flying against the dawn sky in the dawn when only the planets are out. All the stars have disappeared. In my childhood I heard the night hawks boom as they swoop down on insects. Whipper-wills lulled me to sleep. Cedar waxwings trilled and their crusted heads swiveled as they watched me approach. I heard rustles in the bullrushes and the crackle of leaves from a thousand little wild feet, mostly mice and moles and voles. I tell you these things, just so you'd know what inspired me to spend my life writing. Mine was a rich childhood and my parents loved me more than I had any right to expect. I was more than lucky. My father took me with him on outings of all sorts and taught me how to plant trees. My mother read to me and played the piano for me and fed me well. What more could a small boy want? Things tasted sweeter back then. I remember one of my favorite recipes. Grandma's hot fudge sauce, one cup sugar, one square chocolate, one quarter cup butter, one quarter cup milk. Melted in a saucepan, bring to boil for one minute. You can also use that as frosting for chocolate cake. Hospital admission, August 1, 1976. John Catherwood, patient clothing and property list. One black belt, one pants gray, one shirt green, one pair socks black, one pair socks white, one pair shoes black, one t-shirt gray, one underwear gray, one black watch and bag with belongings. $6.04 in pants pocket. All belongings kept with the patient. Signed Melissa Smith RN. I checked the above list and acknowledged it to be correct. Signed John Catherwood. August 2, 1976. Dietician. Assessment. Patient currently screened at low nutritional risk with usual good appetite, stable weight. Estimated caloric needs, 1,800 calories a day. Patient receptive to the review of decreased sodium and cholesterol foods. Patient currently making good choices but states, I'm going to do better. Patient does admit to some hypoglycemic reactions late morning. Patient is aware of symptoms and how to respond with food. Signed Carol Ent. Registered dietician. August 3, 1976. Operative note. Pre-op diagnosis. Gain green at the distal part of the left foot. Post-op diagnosis. Same. Nature of operation left below the knee amputation. The patient was placed in the prone position under spinal anesthesia after being scrubbed. The legs were placed in the usual fashion, wrapping completely the part of the left leg to be amputated. A fish mouth incision was made with equal flaps approximately 10 to 15 centimeters below the knee. The skin was incised up the fascial plane and superficial saponous veins were divided and ligated. Muscle planes were incised and bleeders were ligated with 3L plane cat gut and part of the hemostasis The tibial vessels and nerves were divided and ligated with 2L chromic cat gut. Using a bone saw, the tibia and fibula bones were transected. Bone wax was used to stop local bleeding and the rough edges were smoothed by rasp. Further hemostasis was then accomplished with electrocautery and the stump was closed approximating the borders of the fascia with a cat gut over the bone ends. The skin was closed without tension in vertical mattress sutures with 3L silk. Two quarter inch penrose drains were left in subcutaneous tissue and a bulky dressing was applied. The patient tolerated the procedure well being awake all the time and the estimated blood loss was approximately 100 cc's. Transfer to the recovery room in satisfactory condition signed William DeVries M.D. Pathology note clinical diagnosis gangrene of the left foot. Final pathologic diagnosis left lower extremity gangrene gross examination. The specimen consists of a left lower extremity amputated below the knee. The site of transection of the fibula is 25 centimeters proximal to the malealus on the lateral aspect of the lower leg. 9 centimeters proximal to the lateral malealus is a 6 by 8 centimeter ulcer covered by a blackish eschar. On the anterior aspect of the leg is a 10 by 6 centimeter ulcer covered by a black eschar. On the dorsum of the foot involving all of the little toes is a 11 by centimeter area blackish discoloration of the skin and lesser aspects of the first four toes are black and mummified. Microscopic examination reveals coagulative necrosis of skin subcut tissue and skeletal muscle signed Beverly Crusher M.D. Primary Care Medical Note December 1, 1990 Letter from Dr. Mark Siegler to Dr. Ellen Rilke Assistant Professor of Medicine Section of Nephrology Dear Dr. Rilke I'm sending my patient Dr. John Catherwood back to you for evaluation for a possible dialysis. Let me briefly summarize his history. He's a 70 year old man who first presented to the hospital at age 50 back in 1970 with polydipsia, polyuria and polyphagia. He complained of blurred vision and was diagnosed with type 2 diabetes. He had no care of him at 1977. Unfortunately he had required a left below the knee amputation the year before I began seeing him due to diabetic foot ulcers and gangrene of the toes. After that, of course, he began taking his diabetic control much more seriously. He also quit smoking. He lives in Hyde Park and was a professor of English here at the University of Chicago. Recent labs November 30th and BUN are at dialysis level. His potassium is also elevated. He has developed some mild congestive heart failure. He has known coronary artery disease but has refused for their evaluation and is not a candidate for surgery. He does take cardiac meds. I think his fistula is ready for dialysis. Please consider enrolling him in our dialysis program as soon as possible. Thank you in advance for your care of Dr. Mark Siegler, professor of medicine and section of general internal medicine. John Catherwood note continued in 1940 at age 20 I fell in love with Catherine Young the woman I would marry. I found some old cards love letters and poems you wrote to each other. On Valentine's Day in 1940 I wrote on a blue card with blue ink. This card is symbolic of love. The blue, the outer covering may smear but underneath there is a deep surface which smears not and which endures. I chuckle at reading this now. We had our disagreements Catherine wrote me once I feel very badly that I didn't know you felt badly. Others saw the despair in your face and I missed it. You silenced your feelings and your hurt and my mind was silent to tell they were there. How can two people so close be close to each other in the desperate hours? I should have been able to see something was bothering you. You should have been able to tell me why is love blind and silent? Another time can true love leave and lovers drift apart can true love leave? Can there be a change of heart? Can love cope with changes time rearranges people places? Have I abused love? Am I confusing love? Am I so mistaken? Or is love shaped in daydreams, thoughts and hopes? When I enlisted in the Navy Air Force that was sent to Pensacola where I flew in training but never got to the war she wrote me this farewell poem sitting here with lonely thoughts of lovely you hours spent on white bond with black print Gilbert bond 25% cotton paper so tired sitting here I miss you so tonight that the black meshes with the white I wish the cotton paper were my sheets and that the bond was with my lovely you all meshed together we'd be except for Gilbert and lonely. In 1947 I married Catherine I was 27 the girl in the red jacket and I lived in an old gray shingled house she stamped snow off her boots on the doorstep inside I cooked supper anticipating our love is like a January thaw for each other unexpected warmth in the winter ice cracks and pops like cubes and soda glass melting down together becoming one then our cold hearts warmed by the living water surrounding us. We dissolved completely in our poured out. We had our first child at next Christmas I led a pretty quiet life eventually teaching English here at the U of C by 1955 we had four children I remember 1955 was the year that the Ed Sullivan show won the Emmy and Ernest Borgman won the best actor award President was Dwight D. Eisenhower Dr. Jonas Salk had just discovered the polio vaccine although we still feared polio with much justification several of our friends were stricken with it and McDonald's opened its first restaurant in April I was 35 then and in my prime teaching was going well I was writing a lot lecturing every semester as I write this I am 70 years old I've had diabetes for more than 20 years probably even 25 maybe 30 now that I think of it I was first diagnosed in 1970 and I was getting ill even in the late 60's I was 30 pounds overweight I smoked a pack of cigarettes a day I quit smoking in 1977 after my amputation and after Dr. Seger told me that I had to quit I was developing heart disease Catherine, Bill, Amy, Sue and Mike my dear wife, my beloved children I've been meaning to talk with you about my death every time you think about the words just walk away from me how can I tell you how helpless I feel my disease has robbed me of my leg and in a way my sense of self it will surely kill me but I want you each to know that I'm ready to die even though I would prefer much prefer to live even though I'm completing a power of attorney naming Catherine as my agent I want you to know that I will still try dialysis to help me with my kidney failure I will if you can forgive the pun be taking my own sweet time to die of this disease January 3rd, 1991 renal clinic intern soap note subjective the patient complains of some shortness of breath he says this is worse with exertion even usual activities such as brushing his teeth taking a shower making a meal he denies any chest pain objective temperature 97 1 pulse 100 respirations 18 blood pressure 140 over 90 weight 78 kilograms heart S1S2 positive 3rd heart sound lungs crackles extremities 2 plus edema fistula loud brewery lab creatinine 10.5 today potassium 5.9 impression renal disease plan will discuss with staff Dr. Wilka signed William Riggs intern attending patient seen an exam concur with exam arterial venous fistula and the arm has matured I did discuss the risks of dialysis with the patient will plan to start dialysis tomorrow January 4th signed Ellen Wilka MD Dr. Mark Siegler January 4th 1991 dialysis unit notes type of dialysis maintenance patient type outpatient schedule Monday, Wednesday, Friday start time 0700 stop time 100 duration 3 hours by Jan Jankowski R.N. by Thomas Wilson tech dialyzer CA211AB machine B19 patient dry weight 72 kilograms pre dialysis checklist complete post dialysis checklist complete dialysis flow sheet complete correct dialyzer yes sterility yes machine prime yes heparin volume 400 pre dialysis BUN 90 post dialysis BUN 36 pre dialysis creatinine 10.5 post dialysis creatinine 2.2 post dialysis weight 73 kilograms patient develop mild chest pain during dialysis which resolved with one nitroglycerin heptivax, fluvax, pneumovax given hand films ordered serum albumin, HIV, hep B, ferritin aluminum BTH phosphorus ordered sign Jan Jankowski R.N. John Catherwood note continued I want my most recent poem to Catherine to be the way I end my chart note valentine if I say I love you more than the birds of the air will you say you love me too you deserve better than a retired academic an old english professor who never wrote a blockbuster here from the upstairs window where I perched like a one legged bird I wish you a happy valentine's day and give thanks most of all for you my beloved Catherine so much more than I deserve signed John Catherwood final chart note by Dr. Mark Siegler dated January 5th 1991 Dr. John Catherwood died at home last night of an apparent cardiac cause his wife called to let us know this morning she says he did not feel well after dialysis and in the late evening developed chest pain shortness of breath and diaphoresis and in few minutes became unresponsive he had previously requested a dnr order and had discussed all of this with her so the paramedics were not called and autopsy was not performed epilogue John Catherwood walked into the stream he would fish the pine river at night down near that deep hole under the bridge his favorite fly was already tied on his back cast was strong smooth and easy fireflies rose and fell all around him illuminating the banks on both sides his waiters tightened around both of his legs he could feel the water flowing swiftly by but he was easily able to keep his footing he heard a whipper well up up above the willows on that oak ridge it didn't seem possible that he was back here but it didn't pay to think about it the fish were rising