Dice

It had to come to this.

Abortion is just one facet of the procreation die (singular for dice).

Infertility is another. And for many, mostly women, procreation does become a dicey endeavor.

So now, with a righteous Alabama Supreme Court opinion, this discussion might actually come into the open.

Us medical professionals have found living in the gray area of personhood profitable. Some, though truthfully, it was just a few practitioners, made money performing abortions. Some might have found some moral duty therein, even though the Hippocratic oath forbids abortion.

The line for abortion used to be “quickening”. Read The Cider House Rules, and you’ll learn the meaning of the question asked of the young pregnant woman, “Are you quick?”

For when the growing fetus’ movement was felt, and that was the line called “quickening”, an abortion was not considered proper. Before becoming quick, it was her decision, mainly.

The law didn’t enter into it in colonial times. There was community shame and derision and family pressure, but the law stayed out of this realm.

But in the mid 1800’s the medical profession lobbied state legislatures to make abortion illegal. You see, midwives, lay health providers did this procedure, since medical professionals were forbidden by oath. And doctors got paid to deliver babies. Maybe I’m cynical, but “follow the money” is good advice when considering what laws get passed.

So, most states outlawed abortion. Then the US Supreme Court handed down the Roe Decision. The line drawn by those justices was “viability”. When the fetus can survive outside of the mother, it is no longer her choice. Before, it is.

Viability comes at about 24 weeks of gestation.

Quickening comes usually about 16-20 weeks. These lines when the control of the decision shifts was very similar.

But now that Roe is no longer the law, and we’re back to state legislatures arbitrating, not only ending a pregnancy, but the decision to try to start one might move into the hands of lawmakers, not mothers, or families.

Because there are some real issues with infertility care that might make one cringe. Might make one consider passing legislation.

Say a woman is young and not ovulating. She and her partner want to conceive. The medical and pharmaceutical industries have wonderful drugs that can stimulate ovulation. They are inexpensive and convenient, though often unpleasant.

And now she gets pregnant. But she has a multiple.

The best chance for having a viable, healthy pregnancy is to deliver just one baby. The odds go down a bit with twins and drop off rapidly thereafter.

If she has five growing embryos, the odds are against any surviving. And the risk to the mother, should she choose to continue the pregnancy also goes up.

Selective reduction is the term used for this medical procedure. Some of the multiples are “reduced” so that some might survive.

A family wanted a baby. The doctor’s advice about the best odds for getting one might come down to sacrificing others.

Before Roe was overturned, the medical profession, mainly infertility specialists, had the freedom to discuss these very painful decisions with their patients. Not now. Especially under Idaho law. I’ll bet a lot of those OB Gyns fleeing our state practiced infertility care.

Where will Idaho infertility be treated?

And we haven’t even started talking about in vitro fertilization (IVF). That’s what got the Alabama Supreme Court going.

I could try to explain IVF in twenty words or less here, but let it just be said that technology may be miraculous. But with such power comes the need for wisdom.

Every medical and pharmaceutical intervention has odds of risk and cost or benefit. Do you want to roll the dice? If it’s an infertility gamble, you might have to leave Idaho.

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Help

I always tried to help my patients. That didn’t mean always giving them what they wanted. I was trained to look to the goal of health.

And then there is the law. It seems the doctor patient relationship is in the Idaho legislature’s crosshairs. No wonder so many physicians are finding this state unwelcoming.

We must accept that there is evil amongst us. And we must be vigilant and loving.

Parents and relatives are not always kind. I have not always been kind. Please forgive me for this.

Parents and relatives can be evil. We must be vigilant.

If you don’t think the Idaho legislature accepts this, then you should watch the incredible Idaho Senate floor debate of February 27th, 2024.

The Senate session starts with the Majority leader asking his colleagues to support removing the statute of limitations for incest. It turns out, Idaho code had not included that crime when it specified which crimes were exempt from limitations from prosecution through time. His very moving testimony described a prosecutor that came to him, told him of a case of incest where revelations expanded the perpetrators, but prosecution could not proceed because of this flaw in the law. His colleagues agreed and this bill passed unanimously.

So, Idaho Senators can understand that incest occurs and should be prosecuted. They know there is evil and are doing their best to help our state laws deal with it.

But then, the tables turn.

On that same day, in those same Senate Chambers a couple hours later a different bill came up. The Senate Majority leader was the sponsor for this one also.

This bill would prohibit any treatment, counseling, procedure on a minor patient (under 18) without the parents’ consent. Further, all medical records of the minor child would be available to the parents for their review. The exceptions to this would require a court order, or a law enforcement request to deny the parents’ access.

Here he argued that parents are the best stewards of a child’s wellbeing. Just a couple hours earlier he was arguing for removing the limitations on prosecuting incest.

So, parents or relatives who sexually abuse a child should not escape prosecution. But a child cannot confide confidentially to a health care provider. They must first go to law enforcement or the courts.

It seems we need to be teaching the Idaho laws in middle school, maybe grade school. Police are your friends, not doctors.

Health care providers, counsellors, teachers, ministers are “required reporters”. Idaho law has that clearly defined. If there has been an allegation or a suspicion of abuse, these professionals are required to report such to law enforcement, under penalty of prosecution. So, we have these crosshairs on us already.

But just imagine.

I am in an exam room with a 15-year-old who seems distressed. I discuss their situation with them. Their mother is in the waiting room. The teen shares their worries with me. I ask them, “Have you talked with your parents about this?” They shake their head. “Is there anything more I need to know?”

They look at me, wondering just whose side I am on. Wondering, who will I be talking to.

My standard response was to always encourage communication with their parents. But I outlined the limits of just what could be kept confidential. I tried to help.

With this law, those limits of confidentiality will now significantly shift.

I guess it comes down to just what you see as the role of government. Do our laws protect the weak and powerless from abuse or enforce the authority of the powerful?

I think it’s pretty clear which side of this scale the Idaho legislature is placing their thumb.

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Coroner Story: Disability

Earl is trying to talk me into seeing this as an accident. “See, he could have pulled the shotgun this way by the muzzle across the seat. With the truck canted over on the slope like that it would be about right to hit him in the temple.”

I use all my patience not to laugh. I like Earl. He’s a good detective. He’s been out here on this back road in the dark for hours, taking pictures, setting up lights. He wants this to be an accident. It just isn’t. I have got to tell him so, one way or another. Kindly.

The call had come around 2AM. Dead asleep, not on call for my group, no lady in labor, so I was sound, dead asleep. But I still keep the skill of waking briskly whenever needed. The nice dispatch lady asks me to go to a scene in the far north of the county. For once, I know the location as she describes it. I used to hunt up past there. “Plus” she says, “You’ll see all the lights.” What? “They got all the night lights set up to investigate the scene.”

Sure enough, when I got there about 45 minutes later, in the chill of a dark late winter night, the whole valley glowed from the generator driven work lights. Their hum, roar, mutter kept a constant crowd noise in this isolated spot.

As I pull up, between the Sherriff’s Department rigs, I see a dirty four-wheel drive truck kind of on its side, down below the road. The passenger side is up against a tree. It doesn’t look like a wreck or a rollover, just like the little truck is tired and leaning on its right two wheels to take a break.

There’s a body back behind the truck, up on the road. I can’t really see it because they’ve thrown a red tarp over it. But there’s a blood trail in the gravel I can see leading from right outside the driver’s door to the tarp.

The road is gravel here. The pavement ran out a quarter mile back. The truck is off the outside of a turn. The drop off is steep, as is the uphill cut bank. If that little tree hadn’t held, she could have tumbled a few times before she landed in the river below. But instead, she’s on two wheels, the uphill ones up in the air. I can’t imagine rocking out of this stuck spot.

Earl tells me the story. “Well Doc, it looks like he got off the road here and couldn’t get back up on. See the spin marks under the tires? Hell, that little tree is starting to bend a bit since we got here. These uphill tires are six inches higher than they were. See, we think he reached across the seat to get his shotgun after he got stuck and it went off right in his hand.”

Rushing the story, a bit. I’m groggy. It’s cold. The lights make your breath a cloud at their angle. My nose is dripping. Back up a bit. Keep getting the story.

“Earl, who called it in?”

“Well, we got his name. Seems he came by and saw this guy dead on the road and the shotgun by him. He was worried someone shot him and might still be around, so he drove on. Called it in from Potlatch.”

“What time?”

“That was around ten.” And I’m here at 3AM. And these guys much longer. I appreciate that.

“Did he know him? Did the guy who called it in know the guy?” I gesture toward the tarp.

“No.”

“Anybody else see him today?”

“Well,” Earl shifts, “Somebody said they saw him with a passenger go through Potlatch this afternoon.”

“Jesus, Earl, you think somebody was with him when this happened?” I’m not being real kind here. I should have done better. But Earl plugs on.

“Not really, no sign of it. Course, the ground is frozen, and we wouldn’t see any tracks.”

“Who is this guy?”

He gives me the name, struggling with the pronunciation.

“You guys know him?”

“Well, yeah. He’s been taken in a time or two, mostly for drunkenness. Last time he was wacko, doc. He had to go to the State Mental Hospital for a time. Seems he’s got some mental problems, plus he drinks.”

“Where does he live?”

Earl smiles. “Up here somewhere. No one knows, really. When we took him in before he wouldn’t tell us where he was staying. Some of the guys are pretty sure it’s up one of these logging roads. I figure he’s built himself a hooch out here in the woods and just comes to town now and again. He’s a real looney, doc.”

Earl smiles at that, knowing I love medical terminology.

“But get this, doc. Look at all these papers we found on his front seat.” He goes over to the back of one of the rigs and pulls out a plastic Ziplock with the papers. “These describe his diagnosis, what the VA is treating him for and all his disability forms. Seems he was working with this lawyer in town to get the disability he wanted. And right here on top is the notice that he got it. Dated just last week. So, the guy should have been as happy as a pig in shit.”

I look down at the frozen gravel, almost white in the glare.

 I know this story.

The disability dance so many do for so long, and then what does it mean? I have watched patients fight, so sure they were right to get “their disability”, like it was a possession kept from them. Then, when granted, this long sought determination, it gives so little. But the fight, at least was over. And their touchdown dance was as pitiful as their chronic pain. This long-sought determination of permanent disability granted that they would receive a measly $759 a month was not a real victory. It was a sentence. But that’s maybe another story. Why is this guy dead?

I keep asking Earl questions. I’m putting off going straight to the body.  “Any family? Is he from here?”

“No, family back east somewhere. We don’t got no next of kin. But we’re going to call his lawyer in the morning, see if he knows anybody to contact.”

I’m feeling tired. And it’s cold. But I’m trying to respect the work my colleagues have done. They have put a lot of information together. “Can I look at those papers?” I take the Ziplock, but then ask, “Any booze in the truck, any medications?”

“Look for yourself, doc. Brandon, open up the door for him, would you?”

The deputy who has been standing by us goes to the driver’s door and opens it upwards.

The tilted cab is strewn with empty beer cans, Copenhagen tins, pop cans, candy bar wrappers, booze bottles and old papers. And mud; mud on the floor, mud on the pedals. It was like he couldn’t help but track it in. He lived in it when it wasn’t frozen. Or dust.

“Jesus.” I say again.

“Hate to find his hooch.” Brandon grins.

“Hell, it’s probably booby trapped, as crazy as this guy is.”

I look at the papers. Lots of government forms from VA hospitals with lots of diagnoses: Post traumatic stress disorder, attention deficit disorder, alcoholism, depression, personality disorder, chronic low back pain. There were the lists of drugs prescribed, but it looked like more miss than hit. I doubted any drug was going to cure what this guy suffered with.

“Where’s the gun?” I ask Earl.

He goes and gets it from his rig. Evidence. Pump action 12 gauge.

“Loaded?”

“We cleared it.”

“How many shells?”

“Four left.”

“Prints?”

Earl winces. “No.”

None? I look up startled.

“No but he was wearing gloves, doc. You’ll see.”

There’s still blood on the barrel and the pump handle. I’m standing in the road facing the driver’s side of the truck as it tips upward. At my feet is a bit of the blood and the trail leading back toward the tarp. I look up. There is a canopy of fir and spruce and cedar above, glaringly illuminated by the yammering lights. The cedar boughs hold bits of fat and blood smears that shine different in the tangent light. I scan. Bits of skull are across the cab and hood, as well as blood.

Not much of his head left, I guess.

No.

“Why did you move the body?”

“Had to get the lights in here, doc. Plus, he was kinda blocking the road.”

“Show me where he was lying.”

Earl and Brandon shuffle about, showing me with gestures where the body lay, where the gun was, what they had found.

“Let’s see him.”

We go back to the tarp. The light isn’t too good here. It’s crossways. I try to imagine their description of how he laid, and the gun.

“We gotta get him back into the light. I need to see what’s left of his head.”

Earl and Brandon and I drag him back toward where he was on the gravel by his rig. I put the vinyl gloves on in the cold so I can mess with his shredded head. I turn the shoulders so I can see his right temple. The skin left there is torn and ragged.

“Now show me how you think this happened.” I say to Earl.

He gets a hold of his eagerness and backs the story up to the beginning as he sees it.

“Well, we think he was actually headed out to town, see. There’s tracks up there on the cut bank where we think he turned around.” We all walk up beyond the glare about 40 yards to where there are fresh tire tracks in the uphill dirt. “So, as he’s headed out to town about nine or ten or so, he decides he’s forgot something, maybe and he turns around.”

“Any money on him?” I ask.

“Nine dollars.” Earl pauses. No robbery.

He continues. “Well, he’s drunk and can’t make this turn and drives off the downhill side here. He tries to drive out, but she won’t grab. So, he gets out to go get help. He thinks to grab his shotgun out a the front seat and it goes off as he’s pulling it toward himself.”

“And hit’s him right in the temple?” I ask, skeptical.

“Well, yeah.”

I exhale and shake my head. “Sorry Earl, that is a contact wound on his temple. He, or somebody, was holding that gun against his head when it went off. No powder burns, no distance from the muzzle to the skin. So, Earl, if no one else was here, and you don’t think this is a homicide….do you think it is?”

“No.”

“Then I’ve got a hard time seeing this as an accident. If he’s pulling the loaded shotgun toward him the shot would have gotten his arm, neck, the whole side of his face, and he’d have powder marks. But the blast hit him square in the right temple. Contact wound, or very near. The muzzle was less than an inch from his skin, maybe even up against it. Plus, look at all that spray.” I gesture toward the cedar branches with blood and brains above.

“I think he pulled the gun out, racked a slug in the chamber, put the butt on the ground, bent his head over the muzzle and pressed the trigger with his right finger.”

Earl and Brandon were quiet. “But why would he do that? When he just got all that money from disability and all? And his truck ain’t totaled. We could pull it up outa there easy enough. What’s the reason for suicide?”

I looked down at the frozen gravel. I thought of all the stories, the reasons, all the patients I have worked with as they struggled with their disabilities and whether they could get “Their Disability”. I had some idea, but I really didn’t know just how the brain, now gone from this dead man might have worked. And I kick frozen gravel.

“Earl, I’m not sure I know. I’ll talk to his lawyer in the morning. I know him. Maybe he’ll have an idea. But the scene says this was a suicide.”

I turn and walk back toward the Hilux, then turn back to them in the glaring, raging lights. “I’m gonna go. I’ll ask the funeral home to run his blood. I’ll talk to you guys in the morning.”

His lawyer was little help. “No way he’d kill himself now. We worked on this for two years getting him his disability. He should have been as happy as a pig in shit.”

“When did you last see him?”

“Thursday, four days ago. I gave him the final determination papers.”

“He seem okay then to you?”

“Yeah, he was fine. He was happy the judge had decided for him, and he would be getting regular money.”

“Thanks.”

Blood alcohol 280

Cause of Death: Shotgun Wound to the Head.

Manner of Death: Suicide

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Immigrants

The Idaho Republican Party is doing its best to keep all immigrants out. And I don’t mean the Border Wall, Shelby Park border fight. I mean you and me.

Well, maybe not me.

You see, I am a registered Idaho Democrat. And I can’t defect. Well, I could, but it would have consequences.

Let me explain.

I have been appointed to serve on a Board that requires partisan balance. The Redistricting Commission I served on back in 2021 required I be a Democrat. We had equal, bipartisan representation. Bring your gerrymandering gripes to me.

And the Health and Welfare Board where I currently serve, requires that there be three members from the minority party, four from the majority. I’m in the minority.

So, you see, I can’t just switch party affiliation, willy nilly. I can’t try to immigrate to the party where my next idiotic legislative representatives will be chosen. No, I have to stay in this measly mess of insignificance. As an Idaho Democrat, I know my place.

But most Idaho Democrats can. And most Idaho Democrats in districts where it might make a difference just got the mailing I did.

The nondescript mass mailing came to my wife and me, both of us registered Idaho Democrats. My daughter got one too. The mailing told us how to register in the Republican Party so we might have some say in the upcoming primary election. They didn’t want to spell it out, but I will for you.

Do you insignificant Idaho Democrats want any say in who represents you in the Idaho legislature? Because, if you do, the Republican primary this May is where you will have a choice. You can support a moderate Republican, or a crazy Republican. Because your Democratic candidate ain’t got a chance come November.

That was how this county was represented for many years. I got my introduction to Idaho politics in the 1980’s and 90’s. Back then, before the Treasure Valley boomed, my county was a legislative district. When I first got elected to the legislature in 2010, I represented Latah County. But Boise boomed and we needed to combine with Benewah in 2012. Redistricting.

But Latah County had mostly Republican legislators back in the 80’s and 90’s. It was wise to vote for Republicans because they could get seniority, maybe become a committee chair, maybe get into majority leadership. You need to know that

Latah County voters have been playing this partisan game for years.

Back then, voters could go to the primary election and choose a Republican ballot. Heck, I really liked some of those Republicans. And I’d vote for them. In the general. I didn’t do the primary switch.

But now that option isn’t informal. Now, if you want to vote in the Republican primary you will need to be a registered Republican. Some idiot Federal Judge decided the Idaho Republican Party’s right of free association trumped the Idaho Constitution.

Yeah. If you want to vote in the Republican primary, you have to register. That’s a public record.

Wait a minute.

The Idaho Constitution says, Article 6, Section 1:

SECRET BALLOT GUARANTEED. 

All elections by the people must be by ballot. An absolutely secret ballot is hereby guaranteed, and it shall be the duty of the legislature to enact such laws as shall carry this section into effect.

How is it an absolutely secret ballot when my registering as a Republican is public record?

Oh, well. I won’t be registering Republican for this May’s primary.

Maybe I should. Then I would get kicked off the H&W Board and I’d have standing to sue the state for not following their own constitution.

Aw heck, I like where I am. I don’t want to be no immigrant.

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Numbers

Nobody roused a crowd talking about numbers. Images stir us. Just look at TikTok. But the numbers tell the truth. Maybe we just don’t want to know the truth.

The brouhaha about how Idaho’s budget committee (Joint Finance and Appropriations =JFAC) is deciding to spend taxpayers’ dollars needs a specific example for you to understand the folly.

It’s about numbers, not dead fetuses, or freedom, so you might not care. But that’s how this country has become the swamp it is. Us common folk don’t often pay attention to the numbers. Rich folk do. And so, they are rich. We all should do better.

Let’s drill down on the Medicaid “maintenance budget” that JFAC has just passed. I encourage you all to read the bill. You’ll have to get to page six to read the Medicaid budget. This bill has passed both the Idaho House and the Idaho Senate. All Republicans voted for it. All Democrats voted against. It awaits the governor’s signature.

Here’s the catch. That’s last years budget. They have not made any allowances for how Idaho or our relationship with the federal government has changed in the last twelve months. Theoretically, that bill with all the changes is to follow. That’s where our majority Republicans want to nitpick.

Then, the rubber will meet the road.

Last year’s regular Medicaid budget had a federal matching rate (FMAP) for regular Medicaid at 69.72%. This year’s will be at 67.59%.

I warned you about the numbers. They are going to get big.

That small change came about because Idaho became less poor. Idaho led the nation in median household income growth.

Medicaid is a partnership with the federal government to get people health insurance who don’t get it through their workplace. If the state is poor, the federal government forks up. If our incomes improve, the state is expected to pay more. Many states are at a 50/50 rate. We have been as high as 80/20. But our household incomes have risen in the last few years. So, we will need to fork over more if we want to keep this health insurance for our citizens.

Maybe we do, maybe we don’t.

Because when the next JFAC Medicaid bill comes to both houses it will include this FMAP change.

I’m sorry, but you must pay attention to the numbers, and the definitions.

I am NOT talking about the Medicaid Expansion population. That small group of Medicaid expense will never be more than a 10% match for the state. That’s why it was such a good deal.

But the regular Medicaid folks, the severely disabled and the children, and the pregnant women are the ones under regular Medicaid. They are the ones who will become more expensive. $68M more expensive.

Legislators are still butt hurt about Medicaid expansion. They throw numbers around with brazen ignorance and it can alarm you. I have seen my elected representative do this at town halls. But he is doing this to build an image. His numbers aren’t real. They aren’t the truth.

But when the real budget bill comes up for a vote on the floor of the Idaho House and Senate, will they know the numbers? Will they know the truth? I deeply regret to say, they will not. They do not understand the details of the budget. And few of us do.

But here’s the punchline in this numbers game. If the Idaho Republican legislative majority doesn’t approve the next Medicaid budget, with it’s $68M dollar bump for the regular Medicaid folks, Idaho will not be following our agreed upon partnership with the federal government. We will be in default.

Every year I was in the Idaho Senate, and on JFAC, and crafted the Health and Welfare budgets, I would watch the votes for the appropriations bills as they worked through. Medicaid might pass the House with a couple votes to spare. In the Senate it wasn’t as close.

This year, the “maintenance” budget has passed. The next budget bill with its bump will stick in their craw. And they will be voting us out of Medicaid.

And they can lie to you that they voted for it.

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Coroner Story: Another Gun

This call came right after dinner. Martha would wrangle the little girls to bed, I could go do the coroner business and keep being a doctor in the morning. I was chipper.

I didn’t have to go far. It was dark, still late winter but not snowy or icy. We were in a thaw that teases the trees and bushes about spring.

This is a small town, and this scene was just about two miles from my house. The roads were wet but no ice. It was just off the two-lane highway heading to the eastern county and four blocks or so off the north south highway. These are two lane roads, no interstates in this country. But they were highways, nonetheless.

Martha and I used to live over here when I was trying to get into medical school. This is some thirty years back. I didn’t know much about this house where I was going, though. We had known some neighbors, but not here.

This area was called “Swede Town” by the old timers. Frame houses 80 years old, some without foundations. Great for renting to students, back when such housing was affordable.

I wasn’t looking for the shiny thing when I decided I wanted to be a doctor. I truthfully, had no idea of the incredible income of physicians. A high school girl friend had a doctor as a dad, and they were sure better off than we were, but not lavish. Then I learned more in medical school, and still. Maybe shiny things draw us. Even when we don’t look to the shine.

I must have looked away from it. I chose the lowest paid specialty in the medical field, though I had all the credentials, scores, recommendations for the top paid ones. Sometimes that shiny thing repulses us. Sometimes it draws us to it.

Our old Swede Town house had wool carpets that got moths in them, and in the winter the walls dripped condensation behind the posters we put up. When it got real cold the electric wall heaters ran nonstop. We loved that place. Our first little baby was born into that hovel.

We liked the little home, and the rent was what we could afford. It was a happy time in our young married life.

This house looked like a rental too as I parked. I found a spot in the alley behind a patrol car. There were two, both city cops here in town. A patrolman was by the door. The house had a board porch, soft and rotting I could feel, and the paint was peeling. But with some work it could have been nice. It seemed to have a foundation.

“Detective Frye is inside.” I went in past the uniform at the door.

All the lights were on, and the unkempt home gritted under foot. The linoleum crackled, though the floor didn’t seem springy. I saw two uniforms in the main room and Detective Frye talking with them. He turned as I came in.

“Sorry to get you out this evening.” He smiled. He and I went way back.

“I wasn’t doing anything. What have we got?” We become four men, listening to one tell the tale.

“The deceased is in the basement.” He gives me the name and age. “Seventeen-year-old male.” I don’t know him, at least by his name. But neither could I remember the names of most the patients I had seen today in the clinic.

I think I decided to forget names early in this small-town practice so that uncontrollable reaction of recognition wouldn’t betray me in idle or stupid conversation. Maybe that’s just my excuse for bad memory.

My medical school board scores refute that. I can remember long lists of nerves, muscles, bones and body parts and I can tell you just how they are connected. But I can’t, or don’t remember the names of the patients I see. I need analysis.

“It seems there was some partying here tonight. There were four, maybe five people here. They have all corroborated the story. We’ve gotten their statements.”

“Four or five?”

“Yeah, it seems one person left before this went down. We have her name. We’re tracking her down.”

“You know these folks?”

His thin-lipped smile again. “Yeah.” And nods.

“So, this is a party house.”

He shifts. “Kinda. We haven’t gotten anybody out of here for selling, but we know these folks use. And we know the deceased from prior interactions.”

“What are they using?”

The smile again. “Lots, doc. Mainly meth, but marijuana and some heroin. Pills. You name it.”

My old neighborhood.

“What happened?”

He pauses. I appreciate when someone is trying to develop a narrative. It can’t always be done.

“Well, they were partying here. There were the three folks who live here, maybe about 6 o’clock. The deceased came in and they all described him as kind of jittery, anxious, high strung. They smoked some dope to try to mellow him out and he seemed to relax they said. Then the girl came in.” He gave me her name, but I didn’t know it, or remeber it either.

 “They were all talking and being friendly, but the kid started bugging the girl and she ran out.”

“Was she his girlfriend?”

“Not according to the three guys. We haven’t talked to her yet.”

The weak couch is behind us, dirty and saggy. The corner has a lamp and there is a low cheap coffee table strewn with life and death and garbage. There’s a dirty soft chair in the corner, and another chair, not very comfortable against a wall. I can kind of see the scene.

“So, what happened?”

Detective Frye winces. Like his narrative might be weakening. We all wait. “The guys say he seemed to snap. He grabs the gun…”

“What gun?”

“Oh yeah, I forgot to say. They all described that they, one of the guys, had a gun he kept on the coffee table there.” He gestures toward the strewn low table.

“So, he grabs the gun?”
“Yeah, he grabs the gun and runs down the hall.” He gestures again, to our right. “They all thought he was pulling his usual drama and kind of laughed about it. Then they heard the shot in the basement. And called us.”

“They didn’t go down there?”

Detective Frye nods, acknowledging he has pushed the narrative. “Yeah, one guy went down and looked at him and that’s when we got the call.”

“Let’s go look.”

He leads me down the hall and down the stairs. Few houses in Swede Town have basements. This one was small and dank, as might be expected. It’s wet outside, and the ground is not fully frozen. But there was no water to walk in down here, no pools, just the damp smell of wet concrete below grade.

There was a bathroom down here. The original builder must have seen some value in excavating so far down. For the deceased young man was sitting on a toilet seat, lid down, in a dank well-lit bathroom, now splattered with his brains and blood.

A large caliber shiny revolver laid on the concrete floor.

He was reclining back toward the toilet tank, his arms relaxed by his sides, like he might be at peace, except the top of his head was gone.

I looked closely at what was left. It looked like he might have had curly blond hair, since the front of his scalp remained. The eyes might have been blue, though the lids were half down. Around his mouth there were short, linear lacerations radiating outward.

I turned to Detective Frye. “How do you read this?”

He shrugs. “He came down here and shot himself.”

“Can you see that he put the gun in his mouth?”

He leans in and looks closely. “Yeah, I can see it. There’s that hole back there in the back.”

“Can you see the stippling around the entrance wound? That’s from the powder from a near contact wound.”

He looks at me and looks onto the open mouth again.

“See the splits on his lips? That means he closed his mouth around the barrel and when it fired, they were blown outwards.”

He looks again and nods.

Might as well share what I have learned. It’s not shiny or bright, this business of investigating death. The revolver sure was, there on the cement.

“You can clear that.”

The detective has his vinyl gloves but looks up. “I’ll have to go get an evidence bag.”

I shrug.

A patrol officer had followed us down. He moves behind and points to a defect in the lousy tile above the toilet. “I think I can get the slug out of here. See, I think it’s imbedded.”

Detective Frye tells him to do his best, then heads up to do his business. I stand upright.

“I’m not sure what that slug will tell you. I can call it. We’ll get blood for tox, but I don’t see the need for an autopsy. I’m going to go now.”

The shiny revolver lays on the damp floor, splattered with just a bit of blood.

“Yeah, doc, you can go.”

Cause of Death: Gunshot wound to the head.

Manner of Death: Suicide

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Borders

Dale found this service both meaningful and convenient.

The militia had discussed the southern border problem for weeks but had finally come to this compromise. The whole militia could have loaded up and gone down to Texas where they would be welcome. But they all had jobs.

Except Fred, the Captain, who was on social security.

And Donnie, with his disability. They were both gung-ho to take the trip south.

Both Justis and Junior seemed to be living off of some settlement, and they didn’t seem eager.

But Dale had to work. So, he’d said he couldn’t go to Texas.

So, they set up this outpost on the southern Idaho border to protect our country from the invasion.

They had their tactical gear and rations. Though Dale’s wife, Betty had pointed out to him the cost of all that gear equaled a car monthly payment, maybe more.

The wind was cold. The sun slanted west. Again, he wasn’t at the barricade, but up on look out. He thought back to when they had been protecting the unborn. That had gotten dramatic. He wasn’t sure of any unborn children saved, but at least they’d made a stand.

But this border thing was a bit harder for him to understand. He really didn’t want foreigners moving into his neighborhood. But Paco and his wife sure seemed to be reasonable folks. Paco did concrete work and she made tamales. They were good neighbors, though their kids were wild. Dale smiled as he thought of their antics.

But he had seen on the videos how there were tens of thousands coming across bringing fentanyl to poison his neighbors. And they were bringing in sex slaves, children to be defiled. He felt a righteous purpose. This righteousness brought him peace. Lord, he needed peace.

He scanned the southern horizon. They had been warned to look for vans, since the unlawful immigrants are often piled together. It was chilly, but he was warm. The low sun and the peace left him time to think.

He thought of his next job. A dairy south of him needed another water line. He could rent the trencher and knew how to make the connections, but working down in that trench was beyond his girth. His last employee was violated and now serving a rider.

The dairy seemed to have lots of Spanish speaking workers. He wondered if any of them were part of this invading horde. He also wondered if any of them knew how to glue PVC.

He shook his head to clear it. Too many thoughts can distract you. But he saw nothing in the distance.

He thought again about the pipes and the trencher and some young skinny guy he could teach down in the ditch.

His radio crackled. “Red Leader to Blue outpost.”

He toggled. “Copy”

“You see the white van from the south?”

Dale looked as far as he could, but the wind brought tears to his eyes. He held his hand up to block it and sure enough, a white van was coming north across Idaho’s border. “Roger. I see it.”

There was a long pause from Red Leader. Then, “We will intercept. Must protect the border.”

Dale dropped below the ridge and got out his binoculars. He could see the militiamen move the barricades out onto the road and shoulder their arms, like in the drills.

The van slowed and stopped. They were interrogated. The road militia stood with arms ready, but after the questioning, the barricades were removed, and the van passed.

Dale asked. “No illegals?”

Red Leader was chipper. “No, just some Mormon fundamentalists coming back from Mexico. They’re OK.”

Dale felt good about his duty.

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Coroner Story: A Gun

I was starting one of my usual working days, seeing patients as a family physician. 

I got a call from the sheriff’s office early in the morning.  I was interrupted from seeing a physical to come out and talk to a deputy on the phone.  He was at the scene of a suicide in the northern part of our county.  We discussed the case.  It was an elderly man who had shot himself in his yard.  He had left a note.  His wife had found him, shot in the neck and head with a shotgun.  The deputy described the scene and the circumstances to me.  The man was suffering from some condition with chronic pain. He had seen his physician in Spokane the day before.  He had been denied his usual pain medication for reasons that were unclear.  This was quite upsetting to the man, according to his wife, and he returned home despondent.  The next morning, he shot himself after leaving the note.  His death was pretty clearly a suicide and the sheriff’s deputies felt comfortable handling the investigation. They didn’t think I needed to come to the scene, and I was thankful.

I spent the rest of the day being a family physician.  Later that afternoon, in a clinic we have in a smaller, rural town, I visited with a young high school student. He described vague abdominal complaints to me.  While I was talking with him it seemed like there may be more to the story.

I found him likable, but he had deficits. He was on a regular seizure medication for epilepsy and his features were a bit dysmorphic. That means, “funny looking”.

I asked him if his parents were with him, and he allowed me to invite his mother into the room.  A prolonged discussion ensued. 

He was not doing well in school. 

He had medical problems, but they were stable.

I could see how he might be labeled by his fellow students as not bright.  He spoke slowly; his speech was sometimes slurred.  However, in my discussions with him he seemed to have insight and be cheerful. 

But he was not doing well in school. 

His mother said he didn’t study or apply himself.  When I asked the student what he would change about school if he could he said, “I wish they’d ask me to do more things.”

“What do you mean by that, more schoolwork, or more activities with your fellow students?”  I asked.

“Both,” he said. “They think I’m dumb but I’m not.”

I looked at his mother.  She looked at her son.  She asked, “What do you do when they ask you to do more?”

“I don’t do it,” he said looking at the floor. I could see this conversation had been done before.

“What does he like to do?”  I asked the mother.

She paused for a moment and the two discussed this. It sounded like he likes to play computer games, listen to music, and play sports.  He really does not like to read or do schoolwork.

The mother has tried to encourage responsible behavior by getting him a job mowing lawns.  But she described continually nagging him to get this done. He doesn’t do it on his own.  The two talked with each other in a warm and open fashion, but it was obvious there had been some conflict, maybe even a lot of conflicts.

I asked the mother if she had tried withdrawing privileges.  She said she had tried but it never really worked.  I asked her how hard she had tried.  She seemed puzzled.  “Have you taken all the things that he likes to do away from him?”

“Well, I’ve tried, but that doesn’t really work,” she replied.

“How long did you do it for?”

“Oh, a day or two, and it works a little bit, but then he slips back into not doing his homework.”

I looked at the mother, and then I looked at the boy.  “What we are talking about here is learning discipline. Do you know what discipline is?”

I looked at the young man. “Discipline isn’t spanking or punishment. It’s what we all need to learn to be happy in this life. It’s the duty we feel and the obligation we fulfill to do the tasks we need to do, when they should be done.”

I turned to the mom. “You’re going to have to do it for longer.  He’s going to have to understand that you mean it.”  As I looked at the boy, he looked at me and actually grinned.  I smiled too.  It seemed like he knew this was coming, and he was somewhat relieved by this discussion.

I outlined the plan to both of them. Everything except the bed, his clothes and a lamp were to be taken out of his room. No extra activities until his grades were at a certain level (C’s-B’s, whatever was an agreed, realistic goal). As he achieved these marks the privileges are reinstated. I warned this usually takes a couple weeks. It will not be without conflict or anger. The two seemed quite comfortable and warm with each other, even loving.

I wasn’t sure if the mother had the fortitude to pursue this.  I had never met this family before. This is what I call, as a physician, shooting from the hip.  You try to get a sense of the family and advise as appropriate.

I had a good sense about the meeting. Maybe even a little elation, like I might have actually helped somebody in the allotted fifteen-minute time slot. But then, who really knows. They go home and I see the next patient.

Later that night I got another call from sheriff’s dispatch. Another suicide. It seems they come in bunches.  This one was in the eastern part of our county; out past that rural clinic I had been in this afternoon. A 16-year-old boy had shot himself. 

Usually, I ask the dispatcher the name, so if I know the person I’m not surprised at the scene. A little preparation helps the mind be clear for observation.  I forgot to ask this time.  Then, as I was driving through the night to the small town, a worry came over me.  A deep sense of dread weighed down that this might be the kid I saw today.  I wondered if I had misread the family and things had gone very wrong.

I drove through the small town where the clinic was. The old brick high school on the hill looked down on me darkly. I didn’t get lost this time on the rural county roads and I approached the location where the dispatch had told me the suicide had occurred.  The deputies’ cars were parked off the rural lane and their lights were circling red and blue in the dark.  I approached Brandon, the deputy in charge of the scene and asked him first thing, “Do you have the name of this kid?”

He scowled and admitted he didn’t. He’d forgotten. He got on the radio to call dispatch to get the name. 

As we waited for the reply he launched in: “Let me tell you the story, Doc,” he said.

Then he turned and started to lead me back into the brush with his flashlight to look at the body.  He’s walking ahead with his flashlight, talking, leading. I follow. “It sounds like the parents weren’t happy with this kid’s school performance.  It sounds like they came down on him pretty hard tonight, and he got pretty upset. They were giving him grief, I guess around dinner, about schoolwork, and saying he couldn’t see his girlfriend anymore. He grabbed a gun and ran out of the house.”

I step over branches and brush, following downhill, listening.

“The way the parents talked he was a hot head and had stormed off like this before, so they didn’t run after him. When he didn’t come back for half an hour his little brother went looking for him.  He found him out here in the brush.  There’s a note by him, and there’s a gun. He’s just back here in the brush down off the bank.”

By now, I’m reeling.  I’m following a bobbing flashlight into the black and enclosing brush. As we step over twigs, and they snap and crunch I tell the deputy he has to stop.  I can’t look at this kid until I know his name. I bend over and put my hands on my knees to steady myself. I say out loud, to the ground and the dark warm air, “If this is the kid I saw this afternoon this family will never forgive me.”  And I wonder if I could either.

There are no blood or guts nor dismemberment, no bloated body to see on this dark brushy hillside, but it’s the closest I’d ever come to throwing up or passing out on a coroner call.

This one might not be all right.

I have come to find that most deaths are forgiven. Homicide, suicide, accident. In some way the sense of it fills in and I can come to peace.

The families do or they don’t, and it wears them down, but peace and forgiveness heal. Maybe not this one for me.

 It’s taking forever for dispatch to come up with the name. I stand up and wait for the name over the radio. Brandon is walking on in the dark, leading the way, unaware of my hesitation. He’s talking away into the radio.

I steady myself and follow.

Down the bank I can see the flashlight beam on the shoes. I’m dizzy and cannot brace myself, but I can see the shoes.

They are not the shoes I looked at on the kid in the office today. 

The name that finally comes through the radio is not the name I heard today. 

It’s not the same kid. So, my guilt is assuaged. And I can now recover the distance. The faint I feel fades.

I climb down the bank to look at the face. It is misshapen now with the top of the skull gone and the bones of the face left with little to hold them up.

The buzzing in my head recedes. I can look at the suicide note to his girlfriend and find myself smirking at the misspellings. Distance lets you smirk.

But it’s still a dead kid. Another dead kid.

I look up at the deputy. I can’t see his face since he holds the flashlight. “Kinda makes you not want to lay down the law on your kids, huh?” I say.

“You got that right Doc. I was riding my daughter about her homework tonight before I came on shift. And soon as I heard this one, I called her on the cell and said, ‘You know honey, it’s OK how you’re doing in school’.”

I thought about the kid this afternoon and his mom.

Was this the horror she thought she was avoiding?  Or did she know she could not forgive herself if this happened.

We cannot prevent the tantrum.

A gun makes a tantrum fatal. And our sense of self can be so confused that we feel responsible for the cause or the cure.

And then there’s the gun.

Cause of death: Rifle shot to the head.

Manner of death: Suicide

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Coroner Poem#7

Apartments full of sleeping students

Draped with white sheets of snow

Over the old apple orchard knoll

Where he shot himself some years ago.

He sat on an old apple tree stump.

Facing south, there was no sun only cloud.

The revolver shiny a few feet from his hand

Now open to the gray overcast shroud.

The clouded-over eyes no longer looking,

Faced upward. The mouth open, teeth dull,

Blood puddled in brown clots on the mud,

Next to the hole on the right side of his skull.

Assume a student, his life unknown pain

Escaping, he thought, days and nights of misery.

With a brief pull of the easy shiny trigger

Died where we left not one apple tree.

Asphalted over his last bloody bed, the mud where he lay.

Awaits my quiet early tread on this sleepy snowy day.

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Idiots

Are we, or are they? Maybe they just think we are.

Megan Blanksma is no idiot. But her posture of protecting us from government intrusion makes me think she might think us so. Shame on her.

She wants to change how immunizations are recorded here in Idaho to “protect privacy”. She should set her sights on Google or Amazon, not the Immunization Registry.

I wish Representative Blanksma could have been with me in the ER on the weekends in Grangeville. I can’t tell you how many times folks showed up with a scratch or a cut from the rusty nail wanting a tetanus shot.

“I don’t need no stitches, doc, just the tetanus.”

When was your last shot?

“Heck, I don’t know. It’s been years.”

We will look it up. The nurse starts logging in.

“That shot keeps it from getting infected, don’t it?”

Well, no. Tetanus is a rare complication from an anaerobic wound. Last year in this country about seven people died from tetanus. But wound infections are much more common, and the tetanus shot does not keep you from getting a wound infection.

The nurse finds that his last shot was three years ago, recorded in the state registry.

It looks like you don’t need a shot, you are well protected from tetanus. But make sure you wash that wound, soak it, let us know if it gets red or painful. You don’t need another tetanus shot for another seven years. Though there is some evidence you only need them every thirty years. You’ll be fine.

The current immunization registry guidelines are that people can “opt out” at their request. If they don’t opt out, their immunization data is recorded in a protected data base. Identified health care providers can access the information.

Do you think your shopping data is protected? Are you an idiot?

When you Google 18 cubic foot refrigerators then log in to Fox News and see ads for 18 CF refrigerators, do you think this is just a coincidence? Then you’re an idiot.

It’s all about information. For some reason, our state does not have the capability to find people we have improperly disenrolled from Medicaid. But our DMV knows if you have car insurance. Why doesn’t Representative Blanksma go after that data base?

I think it’s because she knows an avid base when she sees one. Antivaxxers are at the head of any Trump rally. So why not combine the universal desire for privacy with the antivaxxer sentiment? It’s a win-win. But that’s just because she thinks we are idiots.

I don’t believe we are.

Opt in and opt out is a crucial pivot point.

Most of us don’t think about our retirement.

Nor about keeping up to date on our immunizations.

Good evidence shows that employees enrolled (opted in) into a retirement plan, with no cost to themselves, have more savings in the long run. When the retirement benefit is structured so they must “opt in”, some choose not to. Maybe they are suspicious of their employers’ motives, who knows. But the opt in, opt out pivot point is powerful.

Please, look in your wallet. Do you have a smudged immunization card?

Maybe you think this service of keeping track of immunizations is best done by the private sector. Make sure you give them your credit card information and email address.

Yes, you are an idiot.

Representative Blanksma described being shocked when she found out that her children’s immunizations were recorded in the state registry when she had “opted out” from that process years back. I can appreciate that affront.

But dismantling a good system is an idiotic response.

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