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