It was a weekend of being on call for the group.
I started early Saturday morning in the hospital. I rounded on patients in the hospital then I needed to cover the Saturday clinic from 830 to 1:00 in the afternoon. It was a fairly light obligation on rounds, so I started in the hospital at about 7 AM, still dark on this deep winter, New Year’s Saturday.
I first saw the two other patients I was covering for my partners. Read the chart, check the history, review the notes left by my partners, then talk with and examine the patient.
My third hospital patient was Mrs. Smith. I knew her since I had just become her doctor.
She was an elderly woman who had come to the hospital three days before. She was brought to the emergency room by worried children who were responding to her complaints of chest pain. On examination and questioning it seemed Mrs. Smith had experienced a heart attack in the day or two priors. She said she felt fine now and didn’t see the need to be in the hospital. Her daughters were worried. I had been called as the doctor on call for “unattended patients”. The hospital kept a schedule for the community primary care doctors to admit folks from the ER who didn’t have a local doctor. This woman did not go to doctors. She was my kind of patient.
I reviewed the tests and listened to her story that Thursday afternoon. I explained to her that we usually hospitalized people after a heart attack to observe them and treat any irregular heart rhythms or medical problems. I understood her wanting to return to the comfort of her home, but I felt it would be prudent to be in the hospital for a day or two.
“By the way Mrs. Smith, who is your regular doctor?” I always want people to have their preferred provider.
“Well, I guess you are now, honey.” She grinned at me.
“I’ll be glad to do that. Do you have any questions about me?”
“Oh no, you look like a fine young man.” She patted my hand and looked at her worried daughter with almost a giggle.
She had no serious problems from her heart attack so far. In fact, I’m sure her heart injury had occurred at least a day before and we just needed to care for her should any complications arise. It turned out she had diabetes but wasn’t taking any medicine nor hadn’t for quite a while. It just wasn’t something that worried her much. Her daughters rolled their eyes and shook their heads (tsk tsk) when I asked them.
“Oh, Mom doesn’t like doctors. She took medicine for a while I think, but then just stopped. She didn’t want to come to the hospital with this chest pain even. She sure did take to you though,” they both smiled.
“Well, we’ll see how she feels in a day or two when I bug her to take her medicine.”
“Oh, I’m sure she’ll listen to you.”
I smiled. No sense arguing. We’ll just wait-and-see.
On her second hospital day I had come by to see Mrs. Smith in the evening. She was her usual chipper self but a little bit more tired than the first day. Her pulse was a little weaker, but steady, and her blood pressure down a bit, but not short of breath or with any swollen ankles. So, it seemed like her heart attack had weakened her heart but not seriously at this point. Still, I needed to know some things from her.
“Good evening Mrs. Smith. How do you feel tonight?”
“Oh, just fine. A little tired.”
“Have you had any chest pain?”
“No, I’ve felt just fine.”
“Did you walk at all today?”
“Just to the bathroom.”
“Did that tire you out?”
“No.”
“Did you feel short of breath?”
“No.”
“Good.”
I was feeling her pulse as we talked. Steady. Regular, but a bit weak. Still, it was the end of the day.
“Mrs. Smith, all the tests confirm you have had a heart attack, but you seem to be doing OK. I expect you to go home in a day or two. Probably by Monday if all goes well.”
“Oh, I hope so.”
“You live alone, don’t you?”
“Yes. My daughter’s visit a lot. My husband died six years ago.”
“You like living at home, don’t you?”
“Oh yes. I love my little house and my yard.”
“Mrs. Smith, I don’t want to alarm you, but I need to ask you some questions. When you are here in the hospital we can do things to you in many ways, some things that you may or may not want done. We do our best to respect your wishes. Sometimes things happen and people can’t talk to us. But we could do things to treat them that may revive them or not. For instance, if your heart were to stop beating, we have ways to treat that that many restart it. It has to do with shocking the heart with electricity. Further, if you were to stop breathing, we can put a tube down into your throat and breathe for you with a machine. Now, are these things you would want us to do? Have you ever thought about this before?”
“Honey, you just do what you think is best.”
“I’d really like to do what you want. It’s very hard for me to know what you would like. We’ve only just met. I’d like you to think about this. If you like I could talk with you and your daughters about it.”
She looked fairly peaceful about the whole discussion. “That would be all right.”
“Why don’t we visit tomorrow morning. Do you think your daughter could be here Saturday morning?”
“I’ll ask her. I’ll call her tonight on the phone.”
“Well, tell her I’ll be here around 8:00 if she can make it. Otherwise, I’ll just talk with you. Sleep well. Tell the nurses if you have any pain or feel short of breath. Goodnight.”
So, I had cleared the decks and now this sunny January morning I hoped to discuss Mrs. Smith’s wishes with her and at least one of her daughters.
Federal law requires that all patients entering the hospital be asked if they want resuscitation. (Advance Directives is the government- speak term). But most of the time the admitting clerk just checks the box “patient unable to discuss” and fulfills the obligation. Mrs. Smith had now been in the hospital for three days with a heart attack and we didn’t know her wishes. Truthfully, she probably didn’t know what she wanted. She didn’t even know the possibilities. Doctors who perform CPR almost always check the Do Not Resuscitate box. But patients and family think such violent treatment is care.
It was a very pleasant and comfortable talk. One of Mrs. Smith’s daughters was there. Mrs. Smith had decided that if her heart stopped or she stopped breathing she wanted nothing done. “Mr. Smith has been gone for six years now and I’ve thought for a while now it was time to join him.” Her daughter was blinking back tears.
“Mrs. Smith, I appreciate what you want, and we will respect your wishes, but honestly, I’m not sure this is your time to die. You have had a heart attack, but I think you’ll make a full recovery. Still, it is best to know what you want should anything unexpected happen.”
She just smiled at me warmly and patted her daughter’s hand in comfort.
I had not checked her pulse or examined her in an attempt to use all my time with the discussion about her “Advanced Directives.” As I left the room I glanced at her bedside chart: blood pressure even lower and some weight gain; pulse still regular but a little higher. A little troubling. I checked with the nurse on my way out. She too frowned at the vital signs, concerned. I told her of the discussion, ordered a new medication and went to the morning clinic. I made sure I had written an order for “No Code” in her chart and told this to the nurse. Then I went across the street to see the morning patients.
Busy clinic as usual. At 11:00 there was a knock on the examining room door of the 10th little kid with a cold that day. My nurse said through crack of the door “Sheriff’s office, line one”. That was her code for a coroner’s call.
“I’ll be right out.”
The Sherriff’s dispatcher asked that I go to a rural Cemetery in the south of the county for a suicide. I had to leave and disappoint the last 15 people with colds. I wouldn’t be able to cure them today.
The directions were very good, but I was still nervous.
About getting lost. I always seem to get lost when looking for these out of the way deaths. And everybody acts like you know the same country they do. “Oh, you know, right past Mrs. Kannikiberg’s old house, where that divorcee is now living and she has all those boyfriends”. Trying to pin down the dispatcher to right and left, miles, yards, color of houses, etc. is painful. They act like I’m an idiot.
Suicide in the Cemetery. Reminded me of the 80-year-old guy who parked in front of the funeral home and shot himself, trying to be considerate, save the undertakers the trip. But they had to have the soiled pickup towed.
I’ll bet this guy wasn’t being considerate. I looked across the winter landscape. Not much snow, sunny, with a chill blustery wind out of the west. I’ll bet he went up on Cemetery Hill last night to look into the wind out of the west and eternity.
There was very little traffic and no ice on the road. I had a pleasant drive. As I wandered through the small town heading east, I saw the hill with the sheriff’s patrol cars on it. A couple well-established trees signified it wasn’t just another hilltop. I couldn’t see the headstones from this distance, but it had to be my objective, since there are only so many hills with sheriff’s patrol cars on them. The hill had a view over the little town and valley, I’m sure a comfort to the people attending funerals. Probably give a sense of perspective and peace.
Although I could see the top of the hill, finding the drive to get me up there took a while. After my first circle around it on dirt farm roads I took the first driveway that I had initially passed up. It was right by a trailer house, and I didn’t see the sharp left and the gate right afterwards.
As I crested the top of the hill, entering the cemetery, I noticed how the one deputy’s rig was running, a trail of steam out of the tailpipe torn to the east by the wind. They were seeking a warm refuge in the bitter breeze of the hilltop. I doubted they were contemplating the peaceful perspective, with their motor running, the radio conversations with dispatch and parked next to a cold car with a dead teenager in it.
As I parked, I saw the victim’s car. It was painted half black, half primer, a 1970s Pontiac with a peeling vinyl top. From here I could see the windows misted over and the back window frosted pink.
“So, Doc, you get some clues in your first sweep around the hill?” Both deputies grin. People always love it when other’s look dumb.
I didn’t answer.
“Yeah, we watched you from up here. If you went around again, we were going to come down for you.”
I still didn’t want to rise to their taunts. “So, what have you got?” I asked.
“19-year-old male, at least we think he is. Caretaker found him this morning. Opened up at 10 AM and drove up here. The car was running. He looked in the window and saw him dead and went down and called dispatch. He said he locked up the gate the night before at 8 like usual but didn’t come up here so he figured the kid must have drove up before that and then the caretaker locked him in. Says he didn’t hear anything. He lives down in that trailer at the bottom that you went by. They let him stay there for cheap for minding the cemetery.”
“Who is he?” I nod at the dark car.
“Well, we haven’t ID him, because we’re waiting for you, but the car is registered to David Rich. His mom called the sheriff’s office this morning saying he didn’t come in last night and an officer went to her home. We haven’t told her yet because we’re not sure he’s dead. (He grinned at me). We thought we’d wait for you to declare him dead. Then we can check his pockets.”
“Mom say he was depressed? She worried about him?”
“Well, she says he just broke up with a girl. But the girl didn’t see him last night, the mom says anyway. But she must be kinda suspicious since she’s called all over this morning looking for him. He’s just moved back in with his mom. He had some troubles recently, I guess. Lost his job. Didn’t graduate from high school last year and his girlfriend is just 16 so that actually is illegal if they are having sex, you know.” (Another grin)
“He shoot himself?”
“Boy did he.”
We’ve walked up to the driver side window now. The car is parked facing west, into the biting wind. It is a big 1970s two door muscle car.
The wind draws tears to my eyes and drops from my nose.
I can see him through the window. Not much of his face left. Top of the head gone and the face split. He’s got a jacket on. It is remarkably clean, unlike the rest of the car. Splatter goes along the line of force.
A rifle with a banana clip is between his legs now with the muzzle on his chest. One hand is on the rifle and the other lying by his left side.
“Look here Doc, we think he may have got off a second round. There are two dents in the roof back here from bullets. That’s a semi-automatic and sometimes they jerk enough with the first shot to discharge a second round.”
Two small pimples protrude the roofs peeling vinyl. I’ll bet this occupied their conversation before I became a more available distraction.
“Could be,” I said. “Is the door locked?”
“Don’t know. Caretaker said he heard the radio, and the car was running when he came up but it don’t sound like it’s on now. Probably ran out of gas and now the battery’s gone dead. Here Doc. I’ll clear that gun for you.”
I stand back and the deputy opens the big door. It creaks loudly. “Bet he had a hard time sneaking in at night with that door” I offer.
“I’m not sure he had to Doc. His mom was a real terror. We know her pretty well. She’s out all the time. We think she’s into meth but haven’t pinned anything on her. I bet she wasn’t even home last night to know if he was home or not.”
The deputy is removing the rifle, a cheap imitation AK-47 with a wooden stock. The boy’s arm is stiff on the stock. I can see the majority of the mess is in the back seat and on the headliner. Blood pooled on the floor of the back and brain bits; skull bits sprayed all over. Front seat pretty clean except for his premorbid mess; the empty cigarette packs and candy wrappers and old cassette tapes.
As we are manipulating his stiff, near-frozen body to get to the wallet we see the note in the front seat next to him. A little blood is on it. Block print. Miss-spelled words. He says sorry to his girlfriend. Not a word to Mom. His wallet is bloody and the deputy with the latex gloves gets the driver’s license out.
“Yup, that’s him. See Doc, the key’s still on. Musta run out of gas and the battery finally went dead like we said. When you think he did this?”
“Oh, last night I guess, before midnight. Car cooled down fast in this wind. Probably got down below 20 last night. He’s pretty cold and stiff already.” Lots of this job is just being observant.
My beeper goes off. It is the phone number for the hospital. “Well, I got to go. Call the funeral home to come get him”.
“Autopsy?” The deputy asks me. They always want an autopsy.
“Nope. You guys going to talk to the mom? Somebody gonna talk to the girlfriend?”
“We’ll take care of it, Doc.”
I drive down the hill. The caretaker is on his trailer porch watching me as I go through the gate. He’s frowning at me. Could be just the sun and cold wind. Then again, he could think I’m a real loser too and worthy of his contempt. Death seems to bring out judgments in people.
As I’m heading down the hill and into the little town, I bet to myself the beep I got at the cemetery is about a lab test result on Mrs. Smith. Or maybe she’s having problems. I worry a bit. The drive back I’m not as relaxed. I get a bit more worried when I get the second beep, just 10 minutes later. I speed up a bit but there’s only so much you can do in an old Toyota pickup. As I crest the hill and coast down toward town doing the legal 55 miles an hour, I notice an old green Datsun 210 coming up the hill toward me. As I watch it starts to drift into my lane just 100 yards ahead. I drift to the right, onto the shoulder and slow down, gripping the wheel tighter, ready for a swerve. At 50 yards I see the driver is bent over doing something, not watching the road. He drifts all the way to my shoulder then finally corrects back into his lane just 10 yards from me, never slowing.
I am stopped as he passes. This casual little green bullet of death speeds on oblivious. I felt the nausea of visceral fear. My perspective on death expanded and contracted suddenly on the clear sunny lonely highway of the New Year.
When I get to the hospital, they tell me Mrs. Smith died about noon. They coded her, doing CPR for 10 minutes until the nurse I spoke to this morning called from the nurses break room where she was having her lunch that Mrs. Smith was a “no code”. They found my note in the chart and stopped pressing on her chest after the futile ten minutes of trauma, the indignity I had tried to save her from. The family was in the room with her now.
“Were they here with her when she coded?”
“No, they had gone out to lunch.”
Cause of death: gunshot wound to the head.
manner of death: suicide
Cause of death: myocardial infarction
manner of death: natural
