The wilderness still lurks in the back canyons and forests of the Okanogan Valley. Only a narrow strip of land along the river has been domesticated with apple orchards, wheat and cattle. A few small towns dot the riverbanks. The people of these towns are still people of the frontier. A mystique of strength, self-reliance and just plain ruggedness permeates their lives. I was spending a few months in this remote rural Washington state community as part of my residency training in family medicine.

As I looked at the screw sticking out of the bottom of Jimmy's foot, I knew that injury and disease also lurked in the Okanogan's shadows. Jimmy, age 3, had been running around in a pasture barefoot when he stepped on a forgotten construction screw. The X-rays showed it to be embedded about an inch, but luckily it had not struck bone. I tugged at the screw gently. Jimmy winced. The screw did not budge. I was going to have to unscrew it to get it out.

Jimmy looked at me with a huge pout on his lower lip. He wondered what I was going to do. I wondered what I was going to do. General anesthesia or a large dose of narcotics would be dangerous. Local infiltration of anesthetic would be painful. I sent the nurse to get a screwdriver. "Take it out," he said.

I sat on the examining table next to Jimmy. He was wearing a scaled-down version of the overalls most of the local farmers wore. "You know, Jimmy," I said, "I am going to have to take the screw out of your foot. It's going to hurt, and there is nothing I can do about that." He frowned but nodded his head. "But I want you to be in control of how much it hurts. Can you count to five?"

"One, two, three, four, five," he muttered.

"That's good. Now as I take the screw out, I want you to tell me how much it hurts. 'One' means it hurts a little, 'two' means it hurts a little more. 'Three' means that it hurts a lot. 'Four' means it hurts a whole lot more, but not so much that you can't take it. 'Five' means it hurts too much. If you say 'five,' I'll stop. Do you understand?" Again, a nod and a frown. Jimmy's mother sat by silently.

The nurse then returned with the screwdriver. "Here we go," I said gently. "Remember, if the pain gets to a 'five,' I'll stop." I inserted the screwdriver into the notch on the head of the screw and slowly, steadily started to turn.

"Three!" Jimmy yelled. "Threeee! . . . Four . . . Four . . . Four!" His voice was shrill and tears flowed from his eyes, yet he held his foot rock steady. His mother looked like she was in shock. I broke out in a cold sweat. I continued to turn the screw.

"If you want me to stop, say 'five,' " I said through clenched teeth. The screw was starting to loosen.

"Four!" he cried. "Four, four, four, fou--" The screw fell onto the table. Instantly his mother was up and had gathered him into her arms. Over her shoulder Jimmy stared at me fiercely. He rubbed his dirty wet cheeks with his fist.

"I didn't say 'five,' " he said.

"No, you didn't say 'five.' " I looked out the window for a moment to compose myself. A drop of sweat trickled down between my shoulder blades. I stared through the summer haze up the Okanogan River to the little town of Omak and wondered, how is it that even the children are strong?

From "Last Day in Omak," published in "Patients and Doctors: Life-Changing Stories from Primary Care," copyright 1999. Reprinted by permission of the University of Wisconsin Press.