Coroner Story: July 4th

For some reason I passed up the family invitation to the fireworks.  I usually love fireworks, but my hip was real sore, and I didn’t want the pain of sitting on a grassy hill despite the pleasure of explosions and showers of color.  So, I stayed home, and they were all gone.  The house was empty except for me and computer solitaire when this coroner call came.  Dispatch gave me the address and name and requested me to come to the scene.  The dispatcher wouldn’t elaborate but it sounded like there may be some question about the manner of death.

I recognized the guy’s name and checked the medical record.  I had admitted him to the hospital just a month earlier for a partner of mine. He had painless jaundice and unexplained weight loss.  Both my partner and I, when discussing it were sure he had pancreatic cancer. These are the hallmark symptoms taught in medical school. The abdominal CT had supported this with their usual vague description of a mass in the head of the pancreas. It looked like they had tried to obtain a biopsy, tissue diagnosis.  You cannot treat without a tissue diagnosis. 

This is one of the basic rules of medicine.  We cannot treat until we know exactly what we are treating. 

I recall an incident when that was almost accidental, but quite fortuitous.  I’m now wandering off the coroner work into the doctor work. But you should have figured out by now, that’s just how it was.

One pre-Christmas December I was called to see a man who came to the emergency room with a first-time seizure.  His CT scan was up on the reading room boxes in the radiology department when I got to the hospital. The radiologist in his darkened room gloomily pointed to the mass in the brain and said, “Most likely glioblastoma, could be an astrocytoma,” both brain cancers.  Then he looked at me and said, “Looks like a young man.  Not good news you’ll be giving him this Christmas.”  As he was packing up the films in their large manila envelope he added as an aside “It could be an abscess I suppose but I doubt it.”  Then he headed out to his $45,000 car.  He had just earned more in 10 minutes of reading that film than I would in the next two hours with this family. 

I’ve never given this news to a man of his age.  I didn’t know him. I’d met his wife and young children in the office for sports physicals or their colds and sprains.  They were a friendly and loving family, not unlike my own.  As I climbed the stairs to the third floor of our small hospital I practiced the words, the speech that I would need to give. 

But you really can’t practice. You just still your heart and empty your mind.  You try for stillness and calm in the face of the unknown.  The immense and deep unknown of death we all will face if we only pause to realize.

I entered the room where the wife sat quietly in a chair next to his bed.  He was groggy from the seizure medication he’d been given in the ER.  He looked not much older than me.  I introduced myself and then asked them to tell the story of the seizure.  The family was getting ready to go to a Christmas party when he felt the seizure start.  His right arm jerked and stiffened uncontrollably then it marched to his leg and then generalized to his whole body.  He remembered only a little of this, so his wife told most of the story softly and calmly. 

It was a classic description of what I had learned in medical school as a Jacksonian seizure.  This is usually indicative of a brain lesion, something that didn’t belong, a brain lesion like we had seen on his CT scan, the horrible growth that had been glowing in the radiologist’s darkened room.  I did a cursory physical examination and then softly closed the door to the hall.

“I’ve spoken with the radiologist about your CT scan.”  I remembered looking at his face.  He was calm, open and waiting, listening.  I also looked at his wife’s darkened face in the corner.  “There is a mass in your brain.  This is what has caused her seizure.  The radiologist feels it is most likely a brain tumor.”

At this point I paused.  He was looking at me with his head on the pillow.  “Well, I guess that’s it then, isn’t it?”  He said.  I looked to his wife.  I don’t know what my face said, but hers was melting into shock, grief, despair, anguish.  Tears rolled.  Sobs shook.  His face was stolid and still.  She got up and walked over to him to hold his head. She buried her tears in his shoulder and sobbed.  He looked up at me.  “I guess that’s it, huh?”  He repeated.

I spoke to him of a tissue diagnosis.  One always wants to know for certain I said. We would arrange for consultation, a neurosurgical evaluation for their recommendations. I expected they would recommend surgery, at least a biopsy. “But that’s pretty messy isn’t it?  I don’t know as I’d want all that.”  He said.

I cautioned against fatalism.  “There is the possibility of an abscess, a lingering small area of infection.  Or some other cause possibly.  But yes, it does look like a malignancy, cancer, at this point.”

We arranged for the consultation.  The family dealt with the news.  And two weeks later, in our regional hospital the surgeons prepared to cut out his brain cancer, saving as much of the important tissue as they could for this active vital husband, father and professor. 

But they found that it was an abscess.  It was a pocket of infection that was drained and after weeks and months of IV antibiotics he recovered fully.  So, we always, whenever possible, press for a tissue diagnosis.

Why am I digressing into these doctor stories? Why can’t I just stick to the coroner story line? My mind just blends them. It was the work I did.

I remembered another case that didn’t go so smoothly. An elderly woman with a hysterectomy years before came to me with episodes of vaginal bleeding. She was overweight. On pelvic examination I could feel no mass or see a source for the bleeding, but imaging studies showed a growth in her pelvis suggestive of a malignancy. The surgeon and I suspected an ovarian cancer that had infiltrated the vagina as the cause for intermittent vaginal bleeding. He opened her abdomen to prove the diagnosis. As he looked around, he saw abnormal tissue growths everywhere. He assumed it was cancer and did extensive dissection. Specimens were sent to pathology. The extensive surgery required a week in the ICU and months of healing for recovery. The pathology report four days after the surgery described the tissue as endometriosis.

This is uterine tissue that has migrated out of the uterus and is growing in other parts of the abdomen. She had been on post menopausal estrogen replacement. All we had to do was stop her hormones and the endometrial tissue would dissolve. It did. But a timely tissue diagnosis during the surgery would have saved her from the four-hour operation and prolonged recovery. We don’t always get it right.

But this elderly dead man that is not the fireworks had gone to a specialist and the procedure for the diagnosis had been difficult and fruitless.  He had suffered two endoscopies and an attempted needle biopsy through his abdomen.  Neither could obtain tissue to prove the diagnosis.

The pancreas can be hard to reach.

However, given his condition and presumed diagnosis treatment had been started.  Chemotherapy poisons had begun, and their chemical insults were affecting him even more than the undiagnosed illness. 

He was an elderly bachelor and had lived at home, alone by himself outside of town. But now the effects of the chemotherapy had required him to be in a nursing home for a few days stretching into weeks because of his nausea and weakness. 

But he was still his own man.  He walked the halls and with permission of his physician went out of the care center on passes in his old pickup.  And now he was dead at his home 10 miles out of town. And I was going to look at him.

When I drove out there the sky was darkening. You could see the occasional skyrocket from the private backyard, illegal celebrations of this holiday. Impatient children cannot wait for the late darkness in these northern latitudes at this time of year.

There were two sheriffs’ cars in the driveway. The sheriff himself came up to me in the gravel. I didn’t usually run into him on these calls. He must have taken the holiday shift this year. “He’s out here in the back,” he said leading the way.  I followed and told him I knew the man and some of his medical history.

“Is it a suicide?”  I asked.

“Well, it looks like it, gunshot wound to the head, but we haven’t found the weapon.”

“Did he leave a note?”

“Well, maybe.  They say he was a man of few words and there’s a note by the front door that says Jimmy, that’s his nephew, is to get his .44 caliber pistol.  He has a lot of guns and I guess he wanted to make sure that this kid got that specific one.  I guess it was the kid’s favorite or something.”  He was standing over the crumpled body of the old man.  It lay parallel to the back concrete porch.  There was a sliding glass basement door behind us. The hills and timber rose to the north.  A barn stood 100 yards off to the east.  There was still some glow, but the sky was darkening by the minute; near time for the fireworks show to start.

“No weapon huh?”  I asked.  There was tall grass from the concrete porch down to a seasonal creek behind the house.  I assumed they’d looked hard before calling me.

“Not that we could find, but we haven’t moved his body yet.  We were waiting for you.” 

I stood over the head.  Entrance wound above the right temple; exit wound must be down below. He was lying on his left side facing north, his back to the house.  His cap and glasses were off in the tall grass a couple yards to the east.  I picked up the hat. There was a bullet hole on the left side of the crown.  “There’s your exit wound.”

“Yeah.”

“Well, let’s roll him over.”  I checked and he was cool with a little rigor.  “Who last saw him?”

“A neighbor drove by and saw him in the yard around one o’clock. He checked out of the care center this morning on a pass. His son came out and found him here about five o’clock.  That’s when we got the call.”

I bent to pull on his downside arm and roll him onto his back. He was a small, withered old man. My eyes moved over him, and I saw the revolver. It lay down by his ankles in the darkening wet grass.  The deputy and sheriff photographed and inspected the weapon.  38 caliber Smith & Wesson.  Two shells, both spent.

“That’s typical, one test shot then the real one.”

With him on his back we could see the exit wound.  It was large and gaping on the left side of his skull.  Instant. 

We three, the sheriff, the deputy and I, stood over the body and tried to make the scene come back together.  His cap and glasses had flown off to the east, but his right hand had been to his temple.  Was he facing the house?  How had he stood as he shot himself?  These sorts of questions were going through our heads.  We were trying to get an answer to the last minute of this man’s life, looking for the final diagnosis.  It made no sense that this man would die looking into his basement windows with those beautiful rolling hills calling for his last attention.

“Look, if he stood here and was looking out at the barn and the trees, maybe a little to the east and shot with his right hand, the hat would come off over there where it landed. Then he must have spun almost all the way around before he fell down.”

“Yeah,” the sheriff said.  “That must have been it.  I don’t think he was looking at the house.  He must have been facing northeast, up that way; looking at the hills, the trees, and the barn.  And then the gun fell right to his feet.  And he spun around as he fell.”  We were trying to come up with an understanding, even though we knew it didn’t really matter; making out all the details, so that it would make sense. There was nothing here we could treat, maybe, except ourselves.

“Can’t blame him really, what he’s gone through.  What he’s facing.”

“No.”  The sheriff, the deputy, and I looked at the ground.  It seemed we understood the cause.  We were just doing our little study of the details to make our jobs more meaningful.  Put some order or sense to what we knew.

I drove home wondering if we made any difference. There were more skyrockets in the blackened sky.

Cause of death: gunshot wound to the head

Manner of death: suicide

Posted in Uncategorized | Tagged | Leave a comment

Idaho Mother’s Day

Idaho laws are clear about being a mother in this state. So, on this Mother’s Day, let us be clear how we celebrate you.

It is simple.

We love you and cherish you. That is not in the laws, but maybe I am going out on a limb to state it is understood. Maybe we can all agree on that.

But any pregnancy you carry is clearly written in our laws. And such is the process of motherhood, isn’t it? There are women, and then there are mothers. Since we celebrate Mother’s Day in Idaho, any woman considering motherhood should know just what Idaho laws say to you.

The laws are multiple, confusing, contradictory, but ultimately clear if you believe our Idaho Supreme Court and Attorney General.

Let me summarize.

If you have a growing fetus in your womb, we Idahoans, by the laws we write, express our care for that fetus at your expense. The life you grow in your body is more valuable to this state than your health.

Maybe, if it comes down to the ultimate question, that your life will be lost for you to maintain your pregnancy, the state will allow you to save your life at the expense of the life growing inside you.

But if the condition of your pregnancy is a risk, or harm to your health, you are forbidden to terminate the condition of pregnancy, no matter the stage, no matter the circumstances.

I believe this strong prohibition has been written into Idaho law because so many conservative Republican legislators believe women kill their babies growing inside them for convenience, at their whim.

No legislator has considered or proposed a law to allow a woman carrying a malformed, doomed fetus to be terminated. If you, an Idaho woman find yourself in such a situation, Happy Idaho Mother’s Day.

You will be required to carry this fetus, this child to term and deliver it to die, maybe in your arms.

If your growing fetus was the result of a rape or incest, you may be allowed to terminate this process toward motherhood. But only if you have a police report on record that confirms these suspect allegations. Our legislators are sure women are always crying “rape” or “incest” for their convenience.

Such generous wiggle room in this motherhood process has been contested by my own State Senator. He’ll get reelected.

Happy Mother’s Day, Idaho women.

Senator Foreman didn’t send flowers or candy. He is just reminding you of your God given obligation. Women must bear fruit.

Men demand it. They claim God demands it.

Maybe He does.

But men, and a few women write the laws that rule over all of us in this representative democracy our founders designed as such a noble, flawed experiment.

It really comes down to if we believe in the rule of laws, written by men, whom we the people elect.

Such folly may fade, as the rule of Our Lord comes to bear.

Happy Mother’s Day, Idaho mothers.

Idaho mothers might have faith in the rule of law. Or they might have some religious or spiritual direction. And they may instill such in their children they have borne. I guess we can only have such faith on this Mother’s Day.

I do not know the burden or the gift of motherhood. I have watched it closely in my years.

I have seen and been close to good mothers.

I have witnessed and investigated bad mothers.

But that is just my judgement, good and bad. It is no better than yours.

But here on Mother’s Day it should be clear what we Idahoans think of mothers, and motherhood.

I have my perspective.

I hang my head in shame to think of what we, through our elected leaders are saying to our mothers.

Posted in Uncategorized | Tagged | Leave a comment

Wrongness

I have made a few mistakes in my life. God willing, I will live a few years to make more. When we make a mistake, it means we did something wrong. Admitting the mistake, accepting our wrong behavior, choice, maybe even thought, allows for us to learn to not make that mistake again. There will be so many others we can learn from.

Isn’t this life wonderful?

Idaho was and is becoming again a bastion for wrongness. We are a place where people can live free in their wrongness. We have the space; we have the tolerance to accept our neighbors’ crazy ideas.

I am OK with that. I love space, I love tolerance.

Except when it crosses a line.

This week a prosecutor in North Idaho decided it wasn’t crossing a line to yell racial slurs and profanities in a threatening way at guests in our fair state.

I’m not saying he was wrong to make that decision. Our legislators write laws carefully, thoughtfully to draw these lines that we can go right up to and not cross. The prosecutor must read these laws carefully and act on them.

I am saying the behavior in that beloved North Idaho city was wrong. But with no criminal charges, I guess those folks are left to figuring out their wrongness on their own.

The Idaho Senate responded quickly to this story. Within a week of this hitting the national press a resolution was introduced that: “denounces acts of racism and commits to eradicating the conditions that allow racial animus and undue prejudice to persist in Idaho.”

One Idaho Senator voted “NO” on this resolution. Senator Phil Hart, who represents Coeur D Alene, voted against the resolution, both in his debate, and on the floor of the Idaho Senate. But only when he was forced to.

He tried to skate out of the vote by leaving the chambers before the roll call. The Senate Pro Tem, Chuck Winder did a “call of the Senate” which requires all Senator to return to their seats.

How you vote should be of note to your constituents. Phil came back and voted “no”. He’ll probably get reelected up there in that North Idaho district where it doesn’t cross a legal line to shout racial slurs and sexual threats to visitors of dark skin.

My Senator, Dan Foreman (Viola) voted for the resolution. I must give him that credit. You need to know; he did beat me in a remote election. Then he got beat, and then he won again. It’s fun to be in an Idaho legislative district where a Democrat has more than a snowball’s chance.

His debate on the floor argued against the Senate passing the resolution. He argued that the state, the Senate should not apologize. The perpetrator, the person who committed the act should.

Boy, can I agree with that. More people need to apologize. This world would be a lot better if there were more apologies and less growling.

Wag more, bark less.

Senator Herndon (Way North Idaho) did cast doubt on the veracity of the claims. “We don’t know if this really happened.”

Well, we now do.

We know it happened. We know there were multiple vehicles, and one perpetrator admitted to his behavior.

But, according to the laws of the state of Idaho, he didn’t cross a line.

So, in the realm of the laws that our legislators write, maybe it didn’t happen.

No line our legislature has seen fit to craft was crossed.

I respect this freedom they have given us.

But if my fellow citizens think such freedom is any sort of sanction for their wrong behavior, then our representatives need to be looking at the lines drawn, not toothless resolutions.

Posted in Uncategorized | Tagged | Leave a comment

Consent

Blanche took Dennis to the doctor’s office for his sports physical.

She had mixed feelings about him playing football. She knew he really wanted to join the other guys in the effort. It is a little school, and they need all the bodies on the field they can get.

But he hasn’t got his full growth yet. She knew they’d put him in with the seniors, bigger, stronger boys. She worried he could get hurt.

But she wasn’t going to say no to him, though she’d shared her worries. He seemed pretty confident about it.

Blanche looked around the waiting room. Dennis sat next to her, worried, she was sure about the “turn your head and cough” thing he’d heard from all the other boys at school. She smiled a little to herself about boys and privacy. She didn’t say it, but she wished they had all experienced childbirth.

As she was smiling to herself, she looked across the waiting room at a young girl by over by herself. Couldn’t be much older than Dennis, maybe a sophomore She had makeup on and looking at her cell phone. Blanche didn’t like the torn jeans, though she knew it was the new thing.

A lady came out to talk to the young girl with a clipboard in her hand. The lady knelt down in front and explained something in hushed tones as the girl listened. Blanche saw the expression on her face change. First the girl had interest, trying to understand, then she started frowning. Then she tucked her chin in and started shaking her head. Then she just got up in a huff and strutted out.

Blanche could tell she was mad or hurt. Probably both.

“Something got her shorts twisted up.” She mutters to Dennis, who doesn’t miss much.

“Mind your own business Grandma.” He muttered back to her. She appreciated the good advice from this growing boy, soon to be a man.

The clip board lady retreated, and peace and boredom settled on the bland room again.

Not much else to study. An old guy with the oxygen tubes in his nose, a younger woman with him.

Blanche turned to Dennis. “You want me to go in with you?”

Dennis kinda snorted. “No Gramma, I’ll be OK.”

Blanche knew he would.

It was fifteen minutes after the appointment time, so Blanche was getting antsy. Doc Hawthorne never ran late. But he had retired, and they’d scheduled this with some new one, a nurse practitioner.

But the next thing you know the clip board lady comes out again and comes up to them. “Dennis?” She says to the both of them, kinda in general.

Dennis answers, “Yeah, that’s me.”

She does the kneel thing again in front of Dennis. Blanche wished she could still kneel like that. “I need to get your parent’s or legal guardian’s permission to treat you for your visit today.”

Dennis nodded at Blanche. “She’s my gramma.”

Clip board lady looks at Blanche. “So, are you his legal guardian? Then just sign here.” She holds out the clipboard.

Blanche knows something about this, having struggled with Dennis’ mom’s legal issues in the past. “No ma’am, I don’t actually have guardianship over Dennis. His mother, my daughter is currently incarcerated. She has agreed to let me take care of him, but she wouldn’t sign no papers about it. She hates my guts since I turned her in.”

The clipboard lady seemed a little bored about the whole story. “Well, it’s Idaho law now that an unemancipated minor cannot receive care without the parent’s consent. We need consent to treat Dennis.”

“You have my consent.” Blanche offered.

“But you said you aren’t his guardian or have legal custody.”

Blanche looked back at the clipboard lady.

She rose. “Come on Dennis. I guess we gotta go to the courthouse. You might not be playing football this fall.”

Posted in Blanche and Dennis, Health Care, Idaho Politics, Policy | Tagged , | Comments Off on Consent

Coroner Story: Cooperation

No dead bodies in this story. Though I felt like one at times. But I’m not dead yet.

I got a call, a message to the clinic where I was a daily, struggling family doctor in our small town. The prosecuting attorney wants me to come visit him.

I quickly racked my brain about my recent coroner cases. None I thought might be under consideration for prosecution. Had I missed something? Big gulp. Maybe a big oops here. I let his office know I’d be up to visit this late afternoon, after my last patient.

The courthouse is up on a tall hill overlooking our town. It has 1970’s architecture, so it is low, not tall and imposing. But there is the hill.

Close to the end of the day for county workers, so there was a spot in the parking lot. I slid the rusty Hilux in between a couple 4WD pickups.

The Prosecuting Attorney’s office is on the main floor. The secretary asked me to wait so I sat down. It was past five, so she must be getting overtime, I thought. Or maybe she did four tens. Maybe they didn’t come in until 9AM so they weren’t due to be off the clock. My mind jumps around like this when I’m nervous.

There was a picture of a barn on the wall.

James came out to get me. Big smile and handshake. He was in his second term in this elected position. I had just been appointed three years back. Both he and I would be on the ballot this coming fall. We all need to know our places. He brought me into his office, and I sat down. So did he. Behind the big desk.

There was some chit chat, then he got down to it. “I’m your attorney. As a county elected official, I represent your interests. So, I need to speak with you about your job as coroner and its obligations, your duties.”

“Yes?” Finally. Somebody is going to explain just what the heck I should be doing. I felt some relief.

He adopted a lecturing tone that seemed pretty natural for him. “Idaho code requires that you cooperate with other investigating agencies as part of your duties.”

Maybe I rolled my eyes. I hope I didn’t. I could see where this was headed. “I haven’t been cooperative?”

James looked down and shifted his elbows onto the desk. His voice was now softer. “I have heard from our sheriff that you aren’t always eager to investigate deaths that are brought to your attention.” Here he paused.

“If this is about his idiotic call to me about the landslide down in Juliaetta, yeah, that was bullshit. He calls me out with no information, no instructions to bypass roadblocks, and then when I get down there, there are no dead bodies, nothing to investigate. He called me out on a late Sunday evening on a wild goose chase. What part of me going to that bullshit scene does he call noncooperative?”

James shifted a bit.

“Or is there some other dereliction I have committed? If you ask me, he’s the one not cooperating. He isn’t sending detectives to scenes of unexplained deaths. Did he mention the one out past Bovill? Look, he’s got the budget. He’s got the personnel and the resources to investigate and document, keep evidence. He’s the one should be leading on these, not me. I got squat.”

James looked me in the eye. “This is all news to me. He said you weren’t cooperating, so I said I’d speak with you.”

I just shook my head. Not cooperating.

James did the big sigh and spread his hands wide. “I know you are busy. You run your practice and all. But maybe this would be better if you and him had a talk. Make some time and you sit down with him. It is indeed in the Idaho law that you should cooperate in your investigations. But relationships take time.” He beamed, the peacemaker.

I reflected. My spat with our sheriff down on the Potlatch River blow-out was the only time I had any direct contact with our fellow elected officer. The people put us here. “You’re probably right. I’ll meet with him.”

James beamed. “It would be best that way, since you outrank him and all.”

“What do you mean?”

James chuckled. “I guess you don’t read all the statutes about your duties. You are the only one who can arrest the sheriff. And if for some reason he is incapacitated, absconds, or is arrested, you become the acting sheriff.” He was goddam grinning at me.

“No way.”

“Yes way. It’s the law.”

He chatted me out. With his hand on my shoulder he offered, “I’ll have my clerk look up the sections of Idaho Code that pertain to your office and duties. You should be familiar with these statutes. We’ll get those to you. This will save you all the searching around.” He almost winked.

Did he know there was some ambiguity here? Did he know the depth of my ignorance? Probably both. I chatted on out. I had met the prosecuting attorney and left feeling a fool. But that is my nature. The Hilux awaited.

The folder of photocopied Idaho Code came to me in a couple days. I read the Articles and Sections and Chapters. Could they possibly make it more confusing? From my reading it seems nobody in an elected position wants me, the county coroner, to know how I’m supposed to do my job, at least in the twisted, arcane laws they write.

Maybe they think I should know my responsibilities since the people elected me. If so, I’m beginning to lose some faith in our democratic institutions, from the perspective of an appointed county coroner who has now learned I can arrest the sheriff. But the voters will decide soon. Maybe I am unfit. Would they know?

In the meantime, I asked to meet with our sheriff. I had said I would, so I did. It took some back and forth and I had to cancel a couple patient appointments, money out of my pocket. He’s on the taxpayer’s dime. But I guess he was pretty busy. He fit me in.

The sheriff’s office is in same the county courthouse as the prosecutors. I knew the place well, since I was also the doctor for the jail, which was in the basement below the courtrooms and the sheriff’s office. I had been there many times. Getting that job is another story. I’m sure our sheriff knew this since the county sent me a meager monthly check for my oversight. I was cheap. Maybe he saw that as a weakness. I’m jumping around in my mind as I nervously wait.

 I sat in the reception area as requested by the uniformed female deputy. She was attractive. My thoughts again bounced around to too many places as I took my seat. No magazines, some wanted posters on the far wall, it was before smart phones, so I just sat there and looked around. A few desks with just the pretty deputy right here in front of me. And then the door to the sheriff’s office behind. Walls covered with metal file drawers on all sides. Back in the far southern corner was a door to the detective’s room. I had been there once to talk with Earl. I didn’t see him, nor many coming and going. It was pretty quiet.

The sheriff came out to get me. He greeted me warmly with a handshake, but I could see a tall deputy in his office. I was invited to enter. The tall guy was the same asshole from the Juliaetta mudslide. He stood with his broad shoulders and erect posture at the east window. I went to introduce myself and shake his hand, but he dropped both hands to assume the position of attention and looked off into the not real distance. Like he wasn’t to be acknowledged.

“I just asked Deputy Dobbin to join us as an observer.” The sheriff offered. Observer?

“So, Coroner Hawthorne, what brings you to our humble office?”

Lob. “I thought it would be best if we met in person, not at a scene, to improve our sense of cooperation.” Lob with spin.

“Yes.” He folded his hands and looked down at his very big desk between us. “And how could we cooperate better?” Deputy Dobbin rested his attention pose a bit, though he didn’t assume parade rest.

No point further dancing. “Sheriff, you have all the resources, detectives and equipment and evidence security to investigate suspicious deaths. I got nothing. So, when a death is suspicious you should be assigning your resources. If you want just the coroner to be investigating suspicious deaths in this county, I’m afraid we could miss something. We are required to cooperate in Idaho Code. I am here to ask for your cooperation in death investigations.”

He smiled and shook his head. “You are suggesting I spend taxpayer money on cases that you should be investigating. How does that serve the public?”

I hope I didn’t roll my eyes, but I might have. “Deaths sometimes need investigation. I’m very comfortable with my role. But sometimes, having a sheriff’s detective involved really helps. Can’t you see that?”

He shook his small balding head again and smiled down at his huge desk. “I’m hearing here that you just don’t want to do your job.” Here he looked at me directly. Deputy Dobbin came to his full height off to the east.

So, cooperation might just be off the table I assumed at this point. “I’ll do my job, if you’ll just do yours.”

Deputy Dobbin interjected his commanding tone I had heard down in the canyon. “The Sheriff is clearly doing an excellent job.”

But I was looking at the small balding man behind the big desk. He was moving his fingers around in a circle on the clean desktop. “I serve the county taxpayers. If we spend their tax dollars on death investigations that are your responsibility, then we have less money to protect them from the bad guys. If you’d do your job, we’d all be better served.”

“Can you give me an example of when I should have investigated a death that I didn’t?”

Here he smiled and looked at me directly. “I’m not here to criticize your performance. And I don’t believe you are here to criticize mine either. You said cooperation was the goal. So, let’s cooperate. You do your job and I’ll do mine.”

He wasn’t dismissing me, but almost. So, I took what I expected was my last shot. “Sheriff, you have the resources for good investigations. I don’t. If a death needs that level of investigation, I would appreciate you authorizing those resources. I don’t want to be left out on my own. I’m afraid we could be doing the citizens a disservice.”

He was standing and coming around the big desk. Again, I was shocked that he was shorter than me. He was smiling, like he had won this duel. “I’m sure you will do your job, just as I have sworn to do mine.”

I left the office knowing this was not going to work out. I felt like a weak pissant to his authority. Welcome to this democratic institution. I knew I had failed to persuade.

Our cooperation was dead.

Manner of Death: ineptitude

Cause of Death: weakness

Posted in Uncategorized | Tagged | Comments Off on Coroner Story: Cooperation

EMTALA

The Emergency Medical Treatment and Active Labor Act (EMTALA) has been in the news recently. The Biden Administration has sued Idaho over our restrictive antiabortion laws, claiming the Federal Act trumps the states restrictions. Oral arguments were heard before the US Supreme Court this week.

So, let’s step back a bit and try to understand just what EMTALA says.

The law was passed by Congress and signed by President Reagan back in 1986. There were many stories at the time in the press and professional testimony telling stories of patient “dumping” between hospitals.

A patient with no health insurance might show up at an emergency room. Let’s say the ER is in a private hospital.

If the city had a public hospital, like LA County Hospital or Cook County Hospital in Chicago, the private ER would just send the patient down the road to the public hospital without offering any treatment. That is, they performed a “wallet biopsy” and determined they wouldn’t get paid, so sent the patient off to a publicly supported facility.

There were also cases of pregnant women in active labor being shunted off. Tragic outcomes were reported.

Congress acted. Not to fix our messy health care system, just to make such dumping cases sanctionable.

Congress put the Centers for Medicare and Medicaid in charge of enforcing these rules.

EMTALA violations are investigated, and fines are levied. Every year 3-4% of US hospitals are fined. Private, for-profit hospitals have twice the incidence of violations as do nonprofit hospitals. Fines average about $34K per incident.

So, dumping still occurs, I guess, but it just doesn’t stir the outrage it used to.

EMTALA prohibits the transfer of patients based on their ability to pay. It also required patients receive stabilizing treatment before transfer. Indeed, the emphasis on “stabilizing treatment” in the law is at the crux of the Biden Administration lawsuit against Idaho’s antiabortion laws.

I am not a great fan of the Federal EMTALA law. I think it responded to outrageous behavior with bureaucratic hand slaps. Indeed, the cost of healthcare went up after EMTALA. More cost shifting onto insured patients occurred when hospitals were required to provide uncompensated care.

 But it was enacted to put a band aid on our bleeding health care system. Uninsured patients were being treated inhumanely. So, dumping them gets a fine.

Instead, we should have made sure all had health insurance.

Back when EMTALA was passed about 17.6% of the population was uninsured. In 2022, we have gotten down to 7.9%. EMTALA didn’t give anybody health insurance. It just brought civil penalties, fines to violators.

The public and Congressional moral outrage at hospitals denying care based on the patient’s inability to pay lead to EMTALA. But we still have uninsured. We still have the most complicated, mind boggling health care system in the world. Maybe you think it’s what makes America great. I don’t.

Whether the US Supreme Court will decide Idaho’s antiabortion laws violate EMTALA has almost stood the purpose of the law on its head.

Idaho is arguing our laws, to DENY CARE take precedence over the Federal requirement to provide care.

Specifically, in Idaho, if a pregnant woman comes to an emergency room and is unstable due to conditions of pregnancy, she cannot be treated with an abortion, that is, delivery of the fetus that likely will not survive, unless it is to save her life. If she is bleeding, infected, unstable, and the recommended treatment to save organs, her reproductive future, she cannot receive this treatment in Idaho. She must be transferred to a state where such treatment is legal. Six such transfers have occurred since our laws went into effect.  Idaho is dumping our unstable pregnant women on other states.

Little wonder that doctors who treat pregnant patients look at Idaho with trepidation. Such a determination puts them very close to, if not over the line of “do no harm”.

Posted in Uncategorized | Tagged , | Comments Off on EMTALA

Pit Toilet

My wife and I just finished a 5000-mile trip across this country in our 1985 Volkswagen Adventurewagen. We saw a lot of farm country and small towns, since we avoided most interstates. We camped in a lot of nice little parks that most people fly over.

We always commented about the toilets.

It was a bit early for most parks to turn the water on. We had 2” of snow in Mobridge, South Dakota. It was freezing in Rosebud, Montana.

But the pit toilets were open for use. We had a shovel but didn’t have to resort to that.

The pit toilet at Far West, where Custer left the steamboat for the Little Big Horn was inspirational. It was very clean and had a poster on the wall. “Let gratitude wash over your experience.”

In Ohio, a sign above the toilet forbade trash disposal, as many do. “It is extremely difficult to remove.” The half dozen plastic bottles below told me something.

Pit toilet ethics are worth consideration.

Pit toilets have a specific construction that is best enabled when the door is closed and the seat on the throne is closed. Most toilets have such a sign inside. It seems only respectful to follow such advice. Most people do.

Pit toilets are the alternative to flush when water or septic doesn’t suit.

 I remember when my favorite road stop on the Salmon River switched out their flush toilets for pit ones a few years back.

Flushing is what we are used to. We all love it. But this site was just above a treasured river. Septic drains downhill. Pit toilets get pumped. I came to appreciate this choice.

How we treat each other is reflected in these ethics.

I remember reading about the Mormon Trail. These westward travelers left firewood for the next party and had their latrines downstream from their camp. It was in their ethics, their values. They got less typhoid. I appreciate such values.

It might seem a frivolous writer’s obscure segue to come around to the Idaho legislature about now, discussing pit toilets and septic systems. But permit me.

We elect these folks to do the duty of taking care of issues for all of us.

I am here arguing that the Idaho Legislature has left the seat up on a mess they have made. The smell is evident.

Idaho Republican legislators have acknowledged that their abortion statutes are a mess. Idaho House Health and Welfare Committee Chairman Vander Woude said, “OK, now we have to take a really close look at the definitions.”

But they didn’t.

Vander Woude cancelled the public hearing of the joint Senate and House Health and Welfare committees to hear from medical providers about how their mess was affecting health care for Idaho citizens.

The Idaho legislature left the seat up as they walked out of our pit toilet. What does that say to you? I find myself disgusted by such behavior.

When you walk into the pit toilet and the lid is left up, you might find yourself muttering curses against the last guy before you.

But in this case, the last guy has an excuse. He was told to leave the lid up.

It turns out our Idaho State Attorney General directed his fellow Idaho Republican colleagues to walk away from solving this stinky problem. He wants to make a name for himself as he argues his case before the US Supreme Court.

This has indeed become very stinky.

It should not be so.

If folks, our Idaho Attorney General and our elected legislators would have just lowered the lid on their mess, this pit toilet we share might be less unpleasant.

But they chose not to. They left the lid up.

Think about the pit toilet of Idaho politics. And let gratitude help you vote.

Posted in Uncategorized | Tagged | Comments Off on Pit Toilet

Medical School

I attended a town hall meeting with two of my elected legislative representatives a while back. Only two of the three who represent me were in attendance. The absent was my State Senator, Dan Foreman.

He beat me in 2016 (Trump-Hillary), then lost in 2018, probably because he couldn’t control his temper. But he bounced back. Maybe he’s figured out public interactions don’t suit him. That’s just Idaho Republican politics.

Instead, I want to talk about another of my representatives.

Representative Brandon Mitchell voiced an interesting idea. It’s an old, tired, worn idea that might have some credibility, given Idaho’s recent explosive growth. But I doubt he has much understanding of the history of this idea.

He suggested it might be time for Idaho to be considering establishing its own medical school. This is a guy who represents a district where there are currently 80 medical students residing. All are tax-paying voters, I presume.

Idaho shares in a consortium with the University of Washington School of Medicine. That consortium is called WWAMI, which stands for the participating states: Washington, Wyoming, Alaska, Montana, and Idaho. The states shell out cash to UWSOM to make medical school seats available for their residents. Applicants must prove their Idaho residency, then get charged in state tuition for their four years of training. Idaho taxpayers shell out the difference between tuition and the full cost of the education.

This program started back in the 1970’s. Full disclosure, I am a graduate of this program, back in the stone age. We puked and bled our patients.

But Representative Mitchell’s idea might possibly serve Idaho if we had any kind of sticking power.

But it would definitely not serve his district. Maybe he’s seeing the bigger picture. I don’t really know. He doesn’t respond to my emails.

I just drove across South Dakota. It has less population than Idaho and its own very decentralized medical school. It proudly claims to produce doctors for their rural needs. I googled the heck out of their budget documents but could not find what South Dakota taxpayers fork over to fund this program.

They must be happy with it.

Wyoming wasn’t. They had a medical school for a while but dropped it to become the second “W” in the WWAMI program. It was too expensive, and they weren’t getting the product they needed. States should be critical about how they spend their money and pay attention to what they get for the dollar. Wyoming was and joined WWAMI.

Idaho should be critical too. But what do you count?

Idaho’s current yearly funding for WWAMI is about $7.5M. That supports 40 Idaho medical students a year. These students also pay their share of their tuition coming to $55K a year per.

For South Dakota medical students it’s only $32K a year.

You can see that the numbers are piling up here. And we haven’t even discussed the cost of a cadaver lab.

Facilities are the capital costs. But, if you build them, maybe they will come.

Remember, Idaho already has a private, for-profit medical school subsidized by Idaho taxpayers because of a cheap, 60-year lease agreement made by our previous governor.

Idaho College of Medicine is down in Meridian, churning out Doctors of Osteopathy. Their tuition is significantly less than UWSOM. They seem to be doing great. Why isn’t this the model we should be following? Capitalism solves all public needs through the invisible hand, right?

Only WWAMI graduates are required to come back to Idaho, under current law. Doesn’t that solve our shortage? Unless we keep driving them away, maybe.

Will Idaho doctors be from UWSOM taxpayer supported, or ICOM, the free market variety?

These are twisted concepts that require vision.

Representative Mitchell’s idea to build an Idaho medical school will send 80 of his voters to Boise. And all the funding that goes along with them.

Who is he working for? Not his district.

Posted in Uncategorized | Tagged , | Comments Off on Medical School

Who Pays?

I can understand that the Idaho Republican Party and our Attorney General Raul Labrador like their closed Republican primary election. I just wish they didn’t expect all of us Idaho taxpayers to pay for this “good old boys” clubhouse they have built.

You know us taxpayers paid the construction costs, don’t you?

First, we paid their lawyers.

Back in 2011, the Idaho Republican Party sued the State of Idaho. There was infighting then, as there is now amongst the R Party about whether their primary should be “open” to all who want to vote, or do they have to show “club membership”, i.e., be a registered Republican. 

The Idaho law back then required open primaries.

But then the Idaho Republican Party sued itself, oops, I mean the State of Idaho about whether it could have a closed primary or not. The Idaho Republican Central Committee passed its rule for closed primaries back in 2007, but it didn’t have enough control in the statehouse to get the law changed, so they filed a federal lawsuit. They won in Federal Court.

Whether that was the right or wrong decision is worth a few other columns, but it was the court’s decision.

And the Idaho Legislative Republicans then voted to pay the Idaho Republican Party lawyers’ $300,000 legal fees. Straight out of the Idaho taxpayers’ pockets straight into the Idaho Republican lawyers’ pockets. How does that make you feel? I get a greasy feeling, like after a week of camping without a shower when I think about it.

That was the first payment.

Now we taxpayers pay yearly rent to the Idaho Republican Party for them to keep a private clubhouse on the public dole. We buy with our tax dollars the voting machines they get to use in their club’s closed primary election. All of us taxpayers pay the salaries of the State and county officials who run and monitor the Private Republican Party elections with our tax dollars. We keep a taxpayer funded public list of their club members.

There’s a public list of Idaho Democrats too. I’m amazed Dorothy Moon hasn’t called for expelling all us Idaho Democrats yet.

Private clubs like the Idaho Republican Party aren’t and shouldn’t be illegal. Heck, they often do good for their communities. I’m sure the Rotarians and the Lions clubs are great organizations. I don’t mind paying for my lunch or contributing to their plate when I attend one of their meetings. But my tax dollars shouldn’t be siphoned into their coffers. The Idaho Republican Party has its hand in the Idaho taxpayer’s pocket.

 Maybe this is okay with you out there because you’re an Idaho Republican. You think the amount of good you’re doing for the State of Idaho is worth the cost. But your private clubhouse must be built on principles. I believe it is. You have a noble, high-minded if not wacky platform. I don’t see anywhere in there where you support public funding of private clubs.

Let’s step back and look broadly. It’s only fair.

Every expense the state or county lays out for the Idaho Republican closed primary is also laid out, in a much smaller proportion, for the other political parties. Us half dozen Idaho Democrats get to vote in our publicly funded primary.

But we don’t require club membership. We allow anybody to choose a Democratic Primary ballot, even if you are unaffiliated with any party. We are not a private club, just a small public one.

This is why primary elections in Idaho should include everybody. Because we all pay for it. Even people who don’t vote pay for it.

But the Idaho Republican Party is getting away with keeping their primary private, “closed” in their terms, and still getting public support to run their elections.

If this sleazy behavior makes you feel dirty, there’s an initiative soon to be on the ballot I need to tell you about.

Posted in Uncategorized | Tagged | Comments Off on Who Pays?

Mature

When I’m feeling old, I try to consider that I am mature. That means I have aged, not become decrepit. Maybe wisdom comes with maturity. Perspective is everything.

Idaho needs some maturity. We have aged as a state, and recently we have grown. We have not matured.

I first began considering this as I watched the legislative oversight committee on Child Protection. You can see their hearing online. It’s worth watching.

The committee, and their citizen partners were very frustrated with how care is being provided for our foster children. One Senator even asked for heads to roll.

They may. But is that a mature response? Sometimes it is the right one. But I like to consider systems.

I have asked for the funding and enrollment history for foster care from the Department of Health and Welfare. Even though I am a Board member, I have not received it. I will continue to study this. But I need some more information to really understand the problem. I hope I get it. If not, I can see why heads should roll. That’s the reaction I feel when frustrated.

Then I got informed of another very interesting study with lots of good information. The Idaho legislature directed their stellar Office of Performance Evaluations to look into Idaho death investigations and coroners.

This is close to my heart.

I was a county coroner for 15 years. I saw the poor performance we were doing investigating deaths in Idaho, me included.

But we are the wild west out here, aren’t we? I didn’t wear a Stetson or ride up on my bay mare at a death scene, but I often felt like it.

Frontier justice might satisfy frontier times, but it doesn’t serve a mature state. It’s time we decide if we have passed puberty.

The report, and many other good reports from OPE are available online. You have broadband, don’t you?

The short story about death investigations here in Idaho is that we are dismal. We do the least autopsies of child deaths of any state. This state that claims to revere the life of the child (maybe only the unborn?) doesn’t seem to want to know why the child has died.

We were the last state in the union to establish a Child Fatality Review panel. It was only put in force by Governor Otter’s executive order. And since it was an executive order, the panel cannot subpoena records. They can politely ask county coroners for their reports, but refusal is allowed.

Did the county coroner do their job? Do you, the electorate even care? If a child dies, shouldn’t the cause of death be a concern for the state?

It sure is if it’s in an Idaho woman’s womb.

Idaho has not grown into the maturity of seeing the whole system.

Children dying is worth protection.

Our state has the most restrictive abortion laws in the nation. Our legislators are very proud of this.

They should be ashamed that they do not care to protect the lives of children out of the womb.

As I said, I was a county coroner. Children in my county were killed. Children in my county died. It was a tragedy. I did my best to investigate. But I was on my own.

Investigating is the first step to understanding.

The Idaho legislature seems to be very preoccupied with protecting children from books in libraries. But they seem to have no concern for children who die.

Unless they are inside a woman’s uterus.

A mature response to this would not be a flurry of laws or resolutions. We see enough of this from our immature legislators.

Instead, we need to understand the systems and change them. That would be a mature response.

Posted in Uncategorized | Tagged , | Comments Off on Mature