Dr. Oakley's colleague and nationally-recognized sex educator Manuel Alvarez-Casilla's grief stricken behavior is disruptive to the department and creates another dimension to the already complex issues. Almost Hell is a contemporary hybrid novel that intertwines factual information and accurate historical data through Dr. Oakley's geyser-like life as she attempts to solve the mountain state's medical predicament. At the same time, the catastrophes continue to mount. A genetic wake, designer babies, sexual lectures, psychotherapy sessions, Mountaineer football, and a dramatic courtroom scene contribute to the story line which takes place in wild and wonderful West Virginia.