Solstice 09

Dear Ones:
Another year gone by, another Solstice approaches. Life above the 48th parallel gives Solstice some bite. The sun comes up only briefly, 8a-4p, more or less, with an hour off for lunch, and never really gets very high in the sky. That it comes up at all is usually only a cruel rumor, since the skies are cloudy as nuclear winter, but there does seem to be a part of each day where flashlights are not strictly necessary. Come summer, we will be having a hard time finding enough darkness to sleep in, but that is a long way off. Meanwhile we hunker down, read deep into the pile of unread books at the bedside, watch those classic movies we never actually saw, though we thought we did, and try to find the rhythm of the seasons. Part of that rhythm is recalling old friends and old times, and getting this damn letter out.
The year for us has been dominated by figuring out where, at last, we will settle. We started with listing what we wanted…His List: Small scale, simple, low maintenance, good view of San Juans or ocean. Her List: O give me land, lots of land under starry skies above, but convenient access to Bellingham, Office Room, Sewing Room, guest quarters, and don’t fence me in with a high mortgage. At the end of our lease in the previous house, we still had not found suitable digs to buy, nor even any real common ground as to what. Our poor realtor missed out, not charging for couples therapy by the hour while we looked at houses. So, we moved into a rental log cabin this February, and partially unpacked, while contemplating whether or not to buy the new place. It has a beautiful view of Lake Samish, a narrow, dramatic mountain loch, with us perched 200 feet above it, and only a mile or so away. It has llamas in the front yard, two of them, quite sweet, as llamas go, and a 2600 foot mountain in our back yard, with a very scenic three hour hike to be had, just for the walking. We have availed ourselves of the walking 4 or 5 times. But, it is also ‘spensive, and has way more land than I ever want to try and maintain. The driveway is a long gravelly uphill, and ruts out quickly after a rain. So it needs dragging with a tractor intermittently, and the llama field needs to be bush-hogged, and lawns mowed etc. etc. etc. So after long contemplation, we started house hunting again. We wore out two different realtors, looking at everything conceivable in Bellingham and Anacortes. A couple of possibilities came and went, but it was always something… Catherine preferred Bellingham to Anacortes, for convenience and culture, which is certainly Bellingham’s strength. But we just could not find the right house there. A beauty came available in Anacortes, and Catherine pointed it out and arranged a viewing, and we started to talk. You, know, the BIG PICTURE talk. Ultimately, we agreed that cohabitation continued to suit us, and bid on and bought a 4-bedroom house with a San Juan Islands and sunset view, and will move in the first of the year. Such a deal! Really, it is a buyer’s market, for a change. We have only experienced selling in a buyer’s market before this. It will be nice to have a place of our own, after two years, two rental houses, and three moves. We have been giving tons of STUFF to Goodwill, whittling down down down, as we should have done before departing from Seaford. But it is so hard to part with STUFF. The outcome still hangs on the sale of our Delaware property, slated for the 21st of December, and then our closing on this house the week afterward. House closings are like Sicilian weddings. You bring swords and a pen, and hope only to use the pen. Nothing is for sure until each says “I do,” and the bank does, too. So we wait.
The kiddies are good, scattered far and wide. Michele is still in Columbus, with Eric the Pilot and Jack (4) and Lily (almost 3) the grandchildren, growing up like little weeds. We keep up on Facebook and i-Chat on our Macs. Eric is back flying after the “private jet” political and economic turbulence caused some downsizing in the administration at his company. We hope to attract them out here, as his company does have a base in Bellingham, and it would be great to have them live nearby, here in Paradise. They don’t know it yet, but they are Pacific NW types to the bone. We are working on their knowledge deficit…Plus, we offer free grandparental babysitting.
Nathanael graduated with his BS in Exercise Physiology from Salisbury University, and moved himself and boxer dog Kirby to San Diego with an old Seaford friend, Nate, and is working there at the YMCA, doing personal training, and pondering a masters degree for a next step. He was released completely from the Army, with no more Individual Ready Reserve obligation, so all that is behind him completely. That was a tense process, but he is pretty happy to be done. He is loving southern California. We visited him there this fall, in their neat apartment, and then enjoyed a drive back north in Hannah’s Mini-Cooper. Jeezum Crow, but California is a big state! I had never driven the length of the Central Valley, but it is quite impressive. Glad I got that off my list of things to do. Once was enough.
Hannah is currently deployed in the Persian Gulf, aboard the USS Grace Hopper, (DDG-70) an Arleigh Burke-class guided missile destroyer. The ship is named after Admiral Grace Hopper, the first female admiral, and computer whiz, who was the co-inventor of COBOL language, among many accomplishments. Hannah is finding shipboard life a bit dreary and frustrating, marked by lack of sleep, hard work, and constant crisis as a way of being. But she is running on the treadmill, which is apparently quite a trick on a pitching ship, and notching off the days until that assignment is done, and until her time in the Navy is done as well. She ran another hundred mile race in the Cuyamaca mountains east of San Diego, before reporting to Pearl Harbor, her homeport. She did well, finishing in about 29 hours, with Catherine, Uncle Dane, Michele, and Grandma Kathleen in support. Her second cousin Jennifer ran and finished the same race, a couple of hours ahead. Hannah really loves that community of ultra runners. Her graduation from the Naval Academy was great fun, as we were docked in the harbor at the Annapolis Yacht Club, and stayed on the boat for our hotel room. We had a plethora of family and friends gather, to mark her commissioning as a new Ensign, along with her wonderful Classmates and their families. And the new Commander in Chief gave the address, and shook each graduate’s hand, to add to the historicity of the moment.
Everett is deep in the thicket of senior year at St. John’s College, facing the great unknown of “What next?” I am sure we don’t know, just as he does not, but it will come to him, I am certain. He has much to juggle, between finishing classes, taking an alphabet soup of GREs, LSATs or whatever, and work. I remember being DOOMED at all times as a college senior, so I am full of empathy. He has been living in a nice apartment in Annapolis, working part time at the Naval Academy Library for spending money, and generally moving into adult life in sensible stepwise fashion. This next step will be a big leap into the dark, though. We are all curious to see where he lands, though no more so than he is himself.
Catherine has continued full time with Quilts of Valor Foundation, her nonprofit foundation dedicated to covering all those service members touched by war with heirloom-quality quilts. They have distributed 28,000 or so thus far. She is working hard on getting some celebrity participation in the project, perhaps the Obama girls and Michelle. Stay tuned, and again, any and all tax-deductible donations are appreciated. Check her out at www.qovf.org. She drove with fellow quilters across country this summer, collecting enough quilts in their cargo trailer, to cover the entire 1,300-member 3/8 Battalion of Marines at Camp Lejeune, NC, on their return from Afghanistan. That was a spectacular success, and brought good publicity, but the work is never done. I suspect another such trip is in her future, for another returning unit. I am voting for the 10th Mountain Division, the most over-utilized unit in the Army
As for me, I just work. It is a predictable sort of rhythm. I do a mix of nights and days, which is harder than just nights, as I used to do. But it is tolerable. The folks here are very nice, similar in many ways to my old crew. At least they haven’t heard all my tired old jokes (yet). And of course the patients are still just the same. We see the tired, the poor, the huddled masses yearning to renew their Percocet prescriptions. We see old Aunt Bertha, full to the gills with fluid from her congestive heart failure, after a salt overdose disguised as the Friday Night Shore Dinner Special, at the Royal Fork. No worries. A night on the breathing machine in the ICU, on a couple of IV drips and a tube in every orifice she came with, as well as a couple of new ones, and she’ll be right as rain. See you next month, Aunt Bertha. We still see pretend seizures outnumbering real ones about 8:1. No kidding, that is a real number. If I am seeing an adult having seizure activity, it is likely bullshit. Dramatic Fever, as I call it. Real seizures have usually stopped out in the field, and I never actually see them. But folks suffering from Dramatic Fever need Xanax®, and Dilaudid®, and Soma®, or another wonder drug from a host of other popular addictive substances, or they will surely seize again, right before my eyes. They even warn me that they are “getting ready to have another seizure,” just in case I wasn’t watching carefully. And when they do their Daytime Emmy-nominated performance, they just don’t want to hear from me that they are not actually having seizures.
“Are you saying I am a druggie?” they will ask, indignantly, while still trying to feign seizure activity. “Are you saying I am making this up?”
“Oh, no!” I will offer soothingly. “There is a reason this is happening, it is just not from a rhythmic electrical discharge in one part of your brain. The symptom is totally real, but the cause is not the same as Epilepsy. And once we can address the cause, I am sure we can get you better, too.” Now getting better was never the point, but they have a hard time admitting that, so I have them on the run at that moment, and they leave, drugless, and with a detox/mental health referral. I do wish they wouldn’t litter on the way out--we are up to our ankles in crumpled up mental health referrals out there…
I have been trying to tend to my own emotional needs more, since leaving the affect-controlled administrative world. You know, avoid all meetings, eat when hungry, drink when thirsty sleep when tired, have sex when…, oh, well, never mind. But in that self-actualization spirit, I was lonely for a dog of my own, ever since Tig’r died, so I acted on mad impulse and got a bulldog, now named Max. He is very sweet and loving, a Velcro dog, attached to my leg most of the time, or snoring at my feet. He has some breathing issues, and required soft palate reduction surgery, but is otherwise a cool dog. Catherine was away when this impulse hit, and on the theory that asking for forgiveness is better than asking for permission, I got him and brought him home. I didn’t realize he was defective, but he has a great personality. He has slowly won her over, but that was not my high point in the marital consideration continuum. However, it is good to be the leader of my little pack again, and now, only 3 months later, I am even an inside dog again, myself. Just can’t get back on the couch, not yet.
I have slowly worked my way back to running, and am trying to stay with it. I read a neat book called Born to Run, by Christopher McDougall, about how running is innate in human makeup and evolution, and concludes that you don’t stop running when you get old, you get old when you stop running. I am beginning to believe that. Catherine’s wonderful Uncle Albert turns 80 this February, and still runs 5 miles a day, 5 days a week. He is an inspiration to both of us. We both ran today, thinking of him. For comic relief, I have also been trying to learn to play the alto sax. I got an antique one from the 50s on eBay, without a stitch of residual lacquer on it, and then got a starter book and DVD. I have been re-acquainting myself with my old pal from Junior High Band, Doremi Fasolatido. Doremi won’t be my friend on Facebook, so I guess that should have been a clue…I tried to do lessons, but I was unable to keep to a regular schedule, between work and travel, so my music teacher fired me after only a month. A cell-phone breakup—I was crushed. But I am laboring a bit on my own, learning scales, and a simple Miles Davis tune. I am not as good as Lisa Simpson yet, not even close. Poor Tory howls and whines as soon as I blow a note. Not a jazz fan, apparently.
I have been reading a lot of history lately, an affectation of people in their mid-fifties, apparently. With Hannah’s departure to the Pacific on a destroyer, I read a bit on the history of destroyers in WWII. I had no sooner finished several books, including The Last Stand of the Tincan Sailors, and forwarded that to her, when she emailed me in a panic, to send info on the Midway and Leyte Gulf Battles. She had to do a presentation for the brass on the boat, and had no internet resources beyond email, and a lifeline to old Pops. Boy, was I ready for that. So I sent her chapters from a survivor’s book, the Wikipedia article, and some other material, just in time for the required Power Point presentation. The stories of the SS Samuel B. Roberts, the SS Hoel, Johnston and Heermann were so inspiring, that I was only too glad to share. So you see, I am some use, even if a bit bent and decrepit. Just ask the right question.
So what are we to make of our world, and its wobbly course? The political world seems more partisan and poisonous than ever. I can barely stand to peel an eye open when the TV is on. Health Care Reform and universal coverage are so clearly needed, and yet we cannot get that done, even with a super-majority of Dems. So I continue to see people who present to me because they know I must see them with or without insurance, even though they won’t or likely can’t fill the prescriptions I write. If it ain’t on the Wal*Mart four dollar list, fuggedaboudit. When there is no longer any possibility of an elective surgery for their problem, they have an emergency surgery, instead. Their bills mount up, but nobody gets paid, they just get buried in debt, or just plain buried. Meanwhile we endure “Granny Death Panel” distractions by the Angry White People Party, soon to be the third party in the US, lead by Sister Sarah, Brothers Glen and Rush, and the howling mad Teabaggers/Birthers/GrannyDeathers/SwiftBoaters/Whatevers. I wish them luck in proving just how small a minority they really are. I don’t think they ‘get it.’ I don’t ‘get it.’ Michael Steele clearly doesn’t ‘get it.’ (Somebody get that man a mirror.) But I just don’t understand the world, I guess. I missed altogether the “You Are Entitled to Rule the World By Virtue of Your Superior European DNA” orientation in school. Missed the memo, missed the lecture, never saw the notes. Where were my friends? Why was I not paying attention??
Meanwhile we are “surging” into Afghanistan, bringing high tech and high ideals into a fractured medieval world, which wishes to remain infinitely fractured and determinedly medieval. And we still don’t have a plan or target date to end our dependency on foreign oil. If we are on a war footing, as we claim to be, why are we not saving cans and plastic, planting victory gardens of solar panels and wind farms, and taxing the bejesus out of purchases of low mileage vehicles? Why, then, would we care what the piddly tribal Saudis or Iranians or Iraqis do, if we didn’t fund their craziness with our own money, and nobody else did, either? We could count on them to kill each other, and leave us the hell out of it. Why do we not yet have a plan for national service for all citizens, whether Peace Corps, Job Corps, America Corps, CCC or military, and get everyone into the American Dream as a contributor, instead of another piglet on the teat? I dunno.
I pause, breathless, to note the passing of a few notables. Michael Jackson departed as bizarrely as he lived, but man, he could sure dance and sing. Farrah Fawcett gave us some adolescent tachycardia, before becoming a domestic abuse and anal cancer spokesmodel. Going way back, Soupy Sales was an over-the-top, cutting edge entertainer, long before that was boring, and Walter Cronkite actually reported the news, while making us feel it would all work out, somehow. Darrell “Shifty” Powers, of the 506th Parachute Infantry Regiment, and featured in Band of Brothers has made the jump. Riccardo Cassin, mountaineer extraordinaire was both bold and old. Ed McMahon, sadly, no longer has a house in Avalon. So long to Teddy Kennedy, and Eunice Kennedy Shriver, and to Andrew Wyeth and John Updike. And from my distant past, and my TV debut (No kidding, same as George Clooney) Uncle Al Lewis, of Cincinnati’s own “Uncle Al Show.”
And so, friends old and new, far and near, pause now and take stock of all you have accomplished, gather close all who are dear to you, banish the ghosts of doubt and fear which haunt the winter darkness, set aside all anger and grudges, seek forgiveness and make amends for past transgressions, and begin anew with resolve and vigor, to be that person you wish you were, and to wish for more. And stop feeling sorry for yourself! That way lies paralysis, and madness…To paraphrase wise Uncle Dane, if you wonder where you are supposed to be, look at your feet. You are supposed to be where you are. You walked there, and you can walk on from that place, to the next place you ought to be. You do not control all that happens, or more accurately, you control very little of what happens, but you do control your feet, and the directions you take, the choices you make. I wish you clarity, and reward for steps in the right direction, and peace for you and all you cherish, and peace even for those we do not cherish, but should.

Cheers, wassail, salud, amor y dinero, and all that jazz,

Risk Factors Ch. One

Risk Factors--Chapter One



When Hendricks heard the solemn intonation of the State Police dispatcher, "There's been an untimely in Wade township a shooting can you come?” he thought "I've never seen a timely death yet." He would soon know that he was wrong this time. But he got the directions to the head of the trail where a State Trooper with an all terrain vehicle would meet him and bounce him the two additional miles to the spot. He knew what they'd find. There would be a former human being, now Medical Examiner's Case, with a story to tell, and a bunch of cold ambulance attendants and hunters milling around talking nervously about bad luck, and what ought to be done about it. Getting drunk on the contents of their side flasks was usually the first thing on that list. He called his answering service, to put the needs of the living on hold for a few hours, and bundled up for the ride. He wore his own hunting clothes, partly for their warmth, and partly to avoid standing out from the crowd in his more upscale ski clothing. With local hunters, he was always self conscious in a $250 Gore Tex parka. Instead he wore a wool felt overcoat with blaze orange shoulder patches, to avoid being mistaken for a one hundred seventy pound trophy. And yet he still stood out. All the old timers dressed for concealment, in dark green or red buffalo plaid, and were secure in the belief that they wouldn't be shot if they were invisible. Never mind that nearly every year, somewhere in the Northeast, a believer in the invisibility theory was either killed or wounded by an excitable hunter. The old timers' lore was not susceptible to mere facts, and despite his explanations for all the orange clothing, he knew they still sneered privately. He'd always be a flatlander, no matter what.
He drove as directed, listening absently to the chatter on the C.B. radio. All the homebound folk with police scanners had the word out immediately, and the speaker crackled with fading snatches of rumors of death. He found the turnout, and the promised State Trooper, who brightened up considerably when he saw Hendricks. It was Sergeant Blunt, who now had the end of his shift in sight. Blunt and he had had several such meetings, and enjoyed a certain grim comradeship.
"Hi, Doctor Hendricks, glad you could make it."
"Hello Detective Sergeant Blunt," he said mocking the Trooper's formality, "what have we got?"
"Hunter, Doc. Haven't I.D. ed him yet. No license, and no wallet"
"What does it look like?"
"Looks like someone shot a noise, and got scared off when they saw what they'd shot. We've got about ten minutes to go on this trail. Jump on."
Blunt stood up astride a knobby tired All Terrain Vehicle, and when Hendricks was barely settled behind him, he gunned it and took off, throwing up clods of frozen mud and white smoke.
Conversation became impossible, so Hendricks steeled himself for the coming sight. He was a regular country doctor most of the time, and did this job as a favor to the State's Chief Medical Examiner. Dr. Andre Robillard was a diminutive, hyperactive backslapper, who curried his regional examiners out of the ranks of local physicians. His office covered vast areas with a thinly spread collection of small town docs, all kept in place by the personal pleading and encouragement of the Chief. None had any special training, and Hendricks in particular didn't relish the moments before he arrived at the death scenes. His imagination had always been vivid, and yet the realities had always outdone even his worst fears. Plus, he knew his forensic skills were gleaned largely from watching TV, and he feared screwing things up worst of all. Generally, the detectives had it all pretty well in hand, and led him gently around the scenes, but it was he who had to move and examine the corpses first, and the officers usually hung back discreetly for that.
They passed a blue Caprice with black wall tires and too many radio antennae, parked next to a battered Comanche four wheel drive pickup nose up in deep brush, and then the trail widened out to a large clearing. They had arrived at last at the scene, and it was just as he'd predicted. A small knot of hunters stood casting furtive glances back at the body, and shifting nervously from one foot to the other, like a flock of winter flamingoes. The ambulance crew sat in their van with the engine running and the flasher on.
"Jesus," Hendricks thought, "they must really hate to walk, if they negotiated that van all the way up here."
Another detective in street clothes stood with the hunters and waited until Blunt swung the ATV around to where they were. Blunt hopped off and walked over to the group with a cowboy swagger and a hitch at his belt. Hendricks gathered up his numb legs and butt, straightened his aching back, and dismounted with considerably less bravado.
"This is Doc Hendricks", said Blunt. "Doc Hendricks, detective Lieutenant Dick Simmons".
The detective was impatient to get the formalities over with, and turned to walk to the body without a word. Hendricks had the distinct impression he had annoyed the man already, but he didn't know how. His presence was a legal nicety only, and mostly amounted to delay for all concerned, waiting for the doctor's arrival. Still, he had to sign his name to the death certificate, or order an autopsy, and he couldn't very well do that on someone else's say so.
He labored behind the detective' brisk walk, over frozen tussocks and through scattered birches and red softwood whips. They were in a clear area surrounded by much denser woods, with a logging road cutting through and up a steep hill to the right. The clearing must have been a turnout for log skidders, though the area could not have been logged for years. The detective paused, and Hendricks, absorbed in keeping his footing in the frozen wheel ruts and tangled saplings, nearly bumped into him. He saw a green wool felt hat just ahead, lying on the ground, and covered with a light dusting of snow. It looked as though it had been cut nearly in half with a dull scissors, right through the crown. He couldn't see any blood.
They walked around the area in a fifteen foot circle, and the body came into view. It was a middle aged man, in camouflage hunting clothes, lying face down with his gun slung over his shoulder. His right hand was still in his pants pocket, and he looked like a tin soldier that had been tipped over. He had obviously died instantly. His head was creased from back to front, the bald scalp thrown up in a pale furrow. There was very little blood on the ground.
"Yep, he's dead." Hendricks said softly. "What have you got so far, Detective?"
"He was apparently walking along this road toward his truck. that could be his you passed at the start of the clearing. It is registered to a Mountain Counties Development Co. no individual owner listed."
Hendricks let his notice of the company name's similarity to the county hospital drop without comment.
"I make it a deer rifle, fired from the trees over there, probably from about fifty to seventy five yards."
"Why did you pick that range?" Hendricks asked.
"The bullet hit going pretty flat. The ground rises sharply past that, and the shot would have been more downward from further out. But that's really your department."
"That seems pretty close to mistake him for a deer, don't you think?"
"I think any number of idiots out here at the crack of dawn could have shot from cover into these whips and bagged him, and then cut out when they found out he didn't have antlers."
"No idea who it is yet, huh?"
"We haven't moved him yet we just patted him down for a wallet, and didn't find anything."
"Anything else?"
"Just the hat."
The hat lay fifteen feet from the body, presumably thrown along the path of the bullet. Hendricks walked back and picked it up gingerly. There were no markings and no blood. He sighted back to the body and beyond, to where the trees thickened and the ground began to rise. The trees and brush were very dense in there, a natural place for a hunter's stand. It would also be very hard to find a shell or other clue in that brush, he thought. Maybe someone could have shot from that cover without a clear view, but the victim's path down the logging road would have carried him fairly close to the shooter's position before the road turned toward his truck. The shooter waited until he got another fifty yards away before he fired. Hendricks didn't buy the Detective's theory yet. He turned and looked the other way, further along the path of the shot, and saw nothing but smooth barked birches and saplings. He couldn't see a bullet hole, but he thought that someone might be able to find that bullet in a tree downrange, if the lines were preserved. He turned back to the detective.
"You guys are checking the trees for the bullet, right?"
The Detective just grimaced and said nothing. Hendricks replaced the hat in its original position walked back again and stood at the side of the body.
"Well, let's turn him over, and see who he is." He pulled some rubber gloves from his coat pocket kept handy for skinning rabbits, also and pulled them over his cold hands. He grabbed the victim's jacket to heave him over. He was quite stiff, and just as heavy, but he rolled over without complaint, and Hendricks froze at the sight of the face. It was O'Leary. The face was a dark mottled purple from dependent lividity, and the ample jowls were molded to the ground he died on, but it was nobody else but O'Leary.
"You don't need a wallet, Detective. I know this man. It is Doctor O'Leary.

Chapter Two

O'Leary! It was O'Leary. The poetic justice, the very impossibility of the fact made Hendricks look and look again at the dead face. A horror mixed with an almost smug mirth held him transfixed there, squatting in the frozen mud and staring as though something about the scene would change if he waited long enough. Everything had changed, but nothing was changing now. In that instant, Hendricks became convinced that this was no accident, but a premeditated murder. And there would have been quite a line of people waiting for the chance to do this buzzard in. Even Hendricks had fantasized causing a bad end for O'Leary after a few particularly bitter committee meetings. Enjoying a moment's fantasy of revenge is a long way from committing a murder, but it was just too much to ask of coincidence to believe that this death at this time was an anxious hunter's mistake.
Detective Simmons broke his heated reverie with a question -"What are you looking for?"
Hendricks flushed and looked up, aware suddenly that sixty silent seconds had passed, and he tried to stand. His knees were quite stiff, and unequal to the task, so he sagged over on his right hand, and let O'Leary flop back into the wheel rut. Now he was completely embarrassed, and scrambled stiffly to attention next to the corpse, unable to meet the Detective's eye. "Sorry."
"Sorry. I'm a bit shocked. I know him well, and I didn't expect to find him here."
"Neither did he" Simmons said dryly. "We still need his wallet and whatever else, if it's not too much trouble." Hendricks turned back so the task of rolling his bulky associate onto his side, and then feeling in various pockets for whatever they held. He first felt inside the clothing over the abdomen and noted a fleeting warmth, evidence that the death had likely occurred in the last 4 8 hours. Even a minute later it was imperceptible. Hendricks wished he'd thought of it when he first turned the body. He continued on grimly. The shirt pockets gave up a hunting license in a transparent carrier clipped into the cello wrap of a pack of Marlboros. The inside jacket pocket gave up a silver side flask, carried to fortify one against the chill. This one was empty. The opposite jacket inside pocket yielded a small plastic compass, and the outer coat pockets only a plastic shell case, nearly full of .30 06 silver tipped ammunition, and a red cotton bandanna, thoroughly used as a handkerchief. There were all handed gingerly over to the lieutenant, who bagged them unceremoniously and handed them off to the uniformed trooper.
Next came the job of examining and unloading the rifle. Hendricks rolled O'Leary the rest of the way onto his back, and pulled his hand out of his pants pocket. A key ring fell onto the ground. The arm was stiff, the fingers more so, indicating again that some hours had passed since the time of death. The rifle sling came off the shoulder without problem, and Hendricks unlocked the bolt to take the firing pin down from full ready before handing it off the Simmons. It was a Browning A Bolt rifle, a finely made and espensive gun, but showing evidence of having been carried in the woods for years. Simmons worked the bolt immediately and ejected a silver tipped round into his gloved hand. He opened the magazine trap from below, dumped the remaining 5 cartridges, then closed the bolt and replaced the safety. He handed the rifle off to Blunt, and returned his attention to the dead man.
"Can you fix a time of death?" Hendricks dreaded the question, since he hated to commit verbally and then be found wrong later. He also feared misleading a serious criminal investigation. Cases of little old recluses dead of natural causes didn't ask for much accuracy, but in murder cases, alibis hung and fell on just theses facts. However, he had surprised even himself at the depth of his observation already, and the logic of his conclusion.
"I'd say about 6 hours, with outside limits of 4 and 9.
The Detective didn't speak, so he continued. "The body shows early fixed dependent lividity in the face, and we'll see the rest at the mortuary. The belly was very minimally warm, and would be expected to hold heat against the ground for a time. The rest of the body is quite cold. the fingers how early rigor mortis, and the longer joints less, but consistent with that time frame in cold weather like this. We will draw some samples and take a core temperature at the mortuary to confirm it, but that's about the size of it."
The Detective still said nothing. His face remained unchanged, leaving Hendricks convinced he was unconvinced and angry. Hendricks struggled to fill in the long blanks in the conversation.
"This will clearly be an Medical Examiner's case I'm sure Andre Robillard will want to do an autopsy, so when you're done with the scene, we can move him to Bittner's funeral Home, so I can complete the preliminary exam."
"Put him back the way he was for a bit. We'll get a few more pictures and then bag him. I've got about all I'll need. Simmons turned away and strode over to the hat. Blunt handed him a 3x5 accordion front camera, and he took several exposures from the hat along the line of the body toward the rise. He circled the scene and did the same in the other direction, and then he motioned to the ambulance crew to take over. He bent over and collected the hat, and headed back toward the cars.
Hendricks followed, to get a look at the truck. The Detective had already been through it, but Hendricks, felt obligated to check it all out himself, since medical details might suggest themselves. The truck was cold, and reeked of cigarettes. The ashtray was full, and the floor full of fine ash mixed with powered mud. Hendricks noted only Marlboro butts. The interior was empty except for some gun oil wrapped in a rag, and a loose crow bar and jack under the seat. The glove box was absent its door, and empty. He pulled the sun visors down and found nothing more, and he flipped the seat forward, to reveal only dirt and the plastic rings from a few spent six packs; a scan of the back of the truck was similarly unrevealing. He went over to Simmons, who was packing the camera away in an aluminum case and putting the rifle and the bags into the trunk.
"Do you want more pictures at the mortuary, detective? Hendricks asked. A record of the lividity might be helpful."
"No, thanks, I've got enough. Blunt can go with you. I'm going to get back to the office.
"OK, I won't be long. I'll call you if anything new turns up."
"Don't get your hopes up, doc. This is a cold one. No weapon, no other physical evidence, and no bullets. Unless the one who did it had friends with him, or brags about this, we'll never figure it out. I suggest you rule it accidental, and get on with real life."
I don't know, Detective Simmons, but I know a lot of people around here won't be sorry he is dead. And I'd say that people will wonder how we really could believe that such a popular guy could have had a hunting accident. You know better than I do that more than one local feud has ended in a "hunting accident". I think this may be the case here."
Simmons face drew taut, and he faced Hendricks squarely, his hands on his hips. "You can speculate all you want. All the local yokels will, too, but so what? Murder cases turn on evidence, and we don't have any. So short of asking around at local hangouts, and hoping that alcohol loosens a worried tongue somewhere, we are stuck with an open homicide. What makes you say anyone would want him dead, anyway?"
Hendricks hardly knew where to start.
"Let's just say that that man was the richest doctor in five counties, and controlled Mountain Countries Hospital completely. He made and broke administrators, other doctors, and he broke a lot more than he made."
"If you have any evidence to give, Doctor, you'd better do it. If you know someone with motive, means, and no alibi, I guess its my job to hear it. But I haven't got time for overactive imaginations. I can't go to a prosecutor with any of that shit, and I don't care what John Q. Public thinks about it."
"Right. Just the facts, ma'am," said Hendricks, but his Dragnet imitation didn't raise even a look from the detective. Hendricks decided Summons wasn't a very happy individual generally, and today wasn't even particularly a bad day.
"What a pain it would be to have to deal with him on a regular basis." he thought. Simmons shot him a look as though he'd read that thought, and then pulled his long legs into the car. He turned the key and said, "Thanks for your help doctor. I'll be speaking to Robillard tomorrow. Sergeant Blunt can take it from here." He slammed the door shut and put the car into reverse, backed out around the Comanche and popped the Chevy into drive while rolling backward. The car jolted into drive like a horse under a sudden lash, and then trundled down the frozen dirt road with a whine and crunch of over taxed automatic transmission and oversized studded tires.
Blunt sauntered up behind Hendricks smirking, trying not to laugh out loud.
"How'd you like Dick Simmons? Helluva guy, Helluva detective. They don't call him Dick for nothing."
"Wow! What'd I do? Either he is a major league jerk, or I'm the dumbest thing he's ever met."
"No no don't flatter yourself. You just entered his field of vision, and that's enough to piss him off. He's that way all the time, near as I can tell. He has given up making any distinction between the good guys and the bad guys. Everybody is a liar and a fool, usually in the way of his solving his cases. Either they're criminals, and lying about it, or just incompetents who will surely fuck everything up. You are clearly in the latter category to him, but don't worry. He doesn't think much of Robillard, or me either."
"I guess they don't call you Blunt for nothing, either."
Blunt smiled a sly smile, and ambled back to the ATV.
"C'mon Doc, we've got to get you back to someplace warm.''
"To the funeral Home, then, Sergeant. Just the place."
The ambulance crew had completed the task of zipping O'Leary into the stiff plastic body bag, and were wobbling over the uneven ground with his bulk strapped to an aluminum stretcher. They shouted over to Hendricks "Which funeral parlor Doc?"
"Bittner's!" shouted Hendricks, and they waved their understanding.
Blunt was again astride the clamorous ATV, and Hendricks mounted behind him. His lower back objected immediately but it was too late to consider riding back in the ambulance. That prospect didn't appeal much anyway, so they departed as they had arrived, in a swirl of white smoke and metallic noise. They soon reached the cruiser and Hendricks' car. Blunt paused to allow Hendricks to dismount, and ran the ATV onto a smowmobile trailer tilted up behind the cruiser. It tipped to horizontal as he drove up, and Blunt jumped off and briskly began securing the trailer and strapping down the ATV. Let's get a coffee, Doc. The crew will be 15 minutes yet. They have got to call in."
"OK, Sergeant. I'll follow you into town."
Hendricks was left to himself in the relative silence of his car to think about what he had to do now. He felt a bit queasy about the rest of exam. A dead naked O'Leary was not on his list of sights he'd like to see, but it was to be his fate apparently. That same feeling of mirth and horror babbled back into his consciousness, and he turned his thoughts from the nitty-gritty of today to speculation about murderer and motive. He had surprised himself at the firmness of his conviction that this was murder. Probably his own desire to see O'Leary come to a bad end played into that, but also he couldn't believe that in his last few moments, O'Leary had not been close enough to the shooter to be seen clearly, even in poor light. Hendricks was suspicious generally of coincidence, especially in the politically charged world of Mountain Counties Hospital. He remembered countless confrontations between various staff members and O'Leary, some only stopping short of fisticuffs because of cooler heads intervening. When he thought of the level of civilization as expressed in those staff meetings, he could only shake his head sadly. Pure, naked aggression was the norm, and recourse to civil restraint more commonly a play for positional superiority rather than a sincere bid for peace. It was pathetic, but it had only been worse before his arrival. He and his partner Bill Morgan had been injected into a very closed, traditional community, lured by recruiting promises from an aggressive young hospital administrator. The staff was far less enthusiastic about the arrival of two well trained young Internists from the big city than Hendricks had been led to believe. The truth was more that they regarded them as a direct threat, as over credentialed young upstarts who would steal patients from their practices. Times were not good generally, so the threat was real. They all made a comfortable living on a high volume of patients, and despite a high level of unpaid bills. The well insured patients came at a premium, and were the more likely to turn away from their general practitioner to see a fancier board certified internist. The poor were, as they say, always with them. The result was that after a stilted welcome reception, the staff had settled into an uncomfortable silence, and referrals to Hendricks and his partner were slow in coming. The only exceptions were the ophthalmologist, who had a monopoly, and the youngest of the three surgeons on staff, Peter Klein who was similarly new and insecure in his position. He had made an immediate effort to be friendly and helpful, even if the point was plainly to solicit goodwill and referrals from the new doctors. The man was sincerely friendly, however so Hendricks didn't mind. He was the best surgeon on the staff anyway, so referring cases was easy. The elder chief surgeon, Dr. Martin, was very old fashioned and autocratic, and still expected nurses to stand when he arrived on the ward. He had not bothered to do more than grunt in Hendricks' general direction, even including at the reception party, so it was easy not to send referrals his way, even when the opportunity arose. His surgical skills were as old fashioned as he was anyway, so Hendricks avoided the whole dilemma. The third surgeon, Dr. Pope, was engaged in maintaining his lock on the Chief's spot, since the Chief was in his late 60's and sure to retire or die sometime soon. Pope made as few waves as possible did competent surgery, and referred all complexities out of town to the regional medical center. Keeping tough cases in town made waves if they did badly, so sick patients endured long ambulance rides over terrible snowy roads to do their dying in the medical center. Referring patients to Hendricks also made waves with the Family Practitioners, so that never happened, even though Pope was outwardly friendly. He was never wanting for work, though by comparison to Dr. Klein, who seemed a bit desperate for cases. Klein tended to keep the complex trauma cases at Mountain Counties, which suited Hendricks fine, since he enjoyed the challenge of caring for sick patients in the intensive care unit. They had a good collaborative relationship in the ICU, and had salvaged some badly injured patients, without resorting to a "Miracle Center" transfer. That made waves, for sure. The patient's families were happy not to be traveling, and the administrator was ecstatic at the increased billings, but the older surgeons and family practitioners were clearly jealous, and vocal in their "concern" if anyone went sour.
Those quality review meetings were the grimmest, most bitter scenes Hendricks could imagine, and he hated that aspect of small town practice worst of all. There was no escaping the politics, and no way not to appear to be choosing sides.
The brake lights of the Trooper's cruiser unexpectedly close brought Hendricks back to the task at hand. Blunt shot him a look in the rearview mirror to see if Hendricks was still awake. Hendricks smiled wanly, and turned into the gravel lot in front of Mabel's.
"Don't make me write you up for following at an unsafe distance, Doc. Jeezum! I thought you were going to nail my trailer. We'd be doing paperwork till tomorrow night."
"Sorry. I'm just a bit preoccupied. Coffee will cheer me up."
They stepped into the smoky entrance of Mabel's Kozy Kitchen Restaurant, and the thin afternoon crowd fell silent.
"Hey, Doc, Jack," a thin man in the front booth piped up. How are you boys?
Not bad, Marcel, the trooper answered. Silence fell again. The man with Marcel Gagnon was a town selectman, Walter Brubaker. Marcel ran the branch bank in town, and was the soul of propriety, always friendly, but revealing nothing. Brubaker was a politician, when he wasn't running his law practice, and never hesitated to ask hard questions in public places.
"What happened in the woods today, doc?"
Hendricks looked at Blunt and back to Brubaker. "Well, Walter I can't say much yet. A man was shot, apparently an accident, but his next of kin haven't been notified yet. I'll know more in a little while." More silence followed. Mabel rescued the moment with a smoke husky "What'll you have boys?" and Hendricks gratefully blurted "Two coffees, one black for me."
"And a regular for me, Mabel" said Blunt. Hendricks laid two dollars on the counter and scooped up the coffees, and they bustled out before more questions could follow.
" See you later, gentlemen, and lady," said Hendricks as he retreated. "Bad idea, Blunt." he said as they got out into the fresh air. "They know more than that from the CB I'm sure, so they're real disappointed to miss out on the scoop first hand".
"Too bad." said Blunt, who seemed to enjoy the superiority of the privileged information. "Too bad."
The ambulance flashed by just then at well over the speed limit, so they got back into their cars and followed to the funeral parlor.
Hendricks watched the oncoming traffic first watching the ambulance, then spotting the state trooper's car a second later. Each one braked suddenly, and slowed rapidly to the limit. The speed gun mounted on the dash flickered red at each car's approach. Blunt could have made a week's quotas right there. "He must have fun catching these clumsy fools." thought Hendricks. He could imagine all the cursing and heart pounding going on in each car until it rolled out of sight and out of danger of a confrontation with the trooper. The ambulance arrived at last the basement side door of a large Victorian house, set apart by open land from the surrounding houses. Mr. Bittner himself had unlocked the side door and awaited their arrival. Blunt cradled his coffee and went straight inside to wait, while Hendricks lingered to chat with George Bittner.
"Hi Doc!" George said.
"Bad way to spend your Saturday."
"I'm on call anyhow," said Hendricks.
"What's the story today, Doc?"
"This is Doctor O'Leary." said Hendricks, to Bittner's obvious surprise.
"Oh no, Doc. What happened?"
"Hunting accident, apparently. At least that's what the investigating officer thinks. It's going to be an M.E. case, so I just need to look him over more thoroughly before the State Medical Examiner office comes to pick him up."
"We'll do the transfer, Doc. We have a standing contract. Let's get him in, so you can get home."
They went in behind the litter, into the part of the funeral home not seen by grieving families. The ambulance attendants were used to seeing it, but still fell into a hush as they maneuvered past the parked hearse and lawn equipment and then past stainless steel carts of mortuary equipment and onto the lift.
The lift was too small for anything more than the litter, so they all tramped up the stairs silently while George Bittner sent it groaning upward with its doleful cargo. He opened the outer door, and the attendants slid the litter out of the lift, and into a cold, bright tiled room. Bittner had a steel embalming table waiting, and another pale corpse lying on the other table. The attendants resumed grumbling about the weight of their load, and the length of time spent on this call, and briskly slid the body bag onto the empty table. Bittner began unzipping it, and the attendants fell silent again, pausing for a last look before departing.
"That be all, doc?" the driver asked.
"Thanks boys." Hendricks said. " Sorry to keep you waiting so long."
"No problem Doc. Take it easy."
And then they left, loading the empty litter onto the lift, sending it downward again and clattering off down the stairs after it. George Bittner followed them out. Hendricks looked around at the other corpse, an elderly lady he also knew, dead of breast cancer after a prolonged struggle. Both breasts were absent replaced by white "S" shaped scars, and the ribs protruded through sagging skin and wasted flesh. George would have a job getting her presentable for a wake, he thought. Bittner returned and they completed the unzipping of the bag, rolled O'Leary out onto the table, and then began the task of undressing him. The boots were tough, but came off with a malodorous flourish. The pants gave less trouble, and gave up no more secrets from the pockets. The jacket and overshirt were no problem either, but the underwear had to be cut off with shears. The socks went rapidly into a plastic bag, where they could give no more offense. Bittner placed a rubber block under the shattered head, and at last he was ready for the exam. Blunt drifted in only mildly interested. He was on overtime in a warm place, and in no hurry. The body was purple over most of the front surface, despite lying on its back for the past half hour or more. To Hendricks it was no longer O'Leary, but a body to be viewed, described, sampled, and then written about. And however vicious and powerful he had once been, he was just a dead body now, and a rather unimpressive specimen at that. His purple features bore his usual impatient snarl, but made worse by black eyes and puffy purple lids, half closed over cloudy blue eyes. The wound was glancing only, and had grazed the skull, but had not entered completely. It had only depressed a furrow and gouged out the outer table of bone. It was pale, and nearly bloodless, suggesting his death had been instantaneous, without much persistence of heartbeat or blood pressure after the bullet struck.
The face showed fixed purple lividity, from blood pooled by gravity and then clotted into place. Early in the process, the purple color could be removed by pressing in the skin and blanching it. But with further time and cooling, the purple color remained after pressing, and gave a clue to the length of time that had passed since blood stopped circulating. The color also outlined where the weight of the body was in contact with the earth, since those areas remained pale, as had the chin and upper abdomen. The purple did not completely conceal the numerous red veins about the nose, which had told of hard drinking, at least in distant past, if not recently. Hendricks' gaze swept then over the frowning jowls, now sagging in the warmer air, revealing teeth stained and broken like old crockery. The chest was mottled, and sagging, a hulk of muscle gone decidedly to seed, and with more of the telltale varicose veins as on the face. The belly was protuberant, pale along the flanks and bulging slackly. His penis was shriveled to a wrinkled purple button under the bulge of his paunch, and his scrotum was swollen and dark. The legs were surprisingly well muscled in contrast to the rest of his flabby bulk. Hendricks made an effort to roll him halfway up to examine the back and Bittner hastened to help flop him over. It was a trick on that slanting, slick steel table not to drop him off. The back was pale, covered with blackheads and old cysts, but revealed nothing else. They rolled him back on his back.
"Ok, George. I've got a couple of samples to take, and we'll get out of your way. Do you have a 60 cc syringe with a long needle, and a smaller syringe with a needle?"
"Sure, Doc, I'll get them right off."
"Jack, I'll need two sample kits, for alcohol and toxicology screens in duplicate." Blunt produced the desired boxes as if by sleight of hand.
"Way ahead of you, Doc". Bittner returned with syringes and needles, and Hendricks went to work.
He palpated the chest on the left for the space between the fifth and sixth ribs, where they joined the breastbone. He inserted a three inch needle under the skin, and then advanced the needle straight in, almost to the hub, while drawing a vacuum on the plunger. he was rewarded with 40 ccs of strawberry red fluid, the serum left in the heart after the blood had clotted in the ventricle.
He withdrew the needle, and injected the fluid into the four tubes. He labeled each with a code number from the outside of the box, initialed each and sealed each with a coded sticker. The tubes were sealed into a foam lined cardboard box, and handed over to the trooper, who detached and returned a receipt back to Hendricks.
He turned next to his least favorite task of all, the collection of eye fluid for determination of time of death. The concentration of potassium salt rose steadily in the eye fluid as time passed after death, and was relatively temperature independent, and so was useful in cases where the person had died outside. He took the small syringe fitted with a slender needle, and pulled the outside corner of the eye backward toward the ear. He place the needle tip against the globe, and advanced it with a palpable 'pop' through the tough white sclera, again drawing a vacuum, and got 1cc of clear straw colored fluid. This he injected into a sterile tube, and again sealed, signed and transferred the tube to Blunt. It was done.
"Don't wash off the face or scalp, George, but you can hose the rest of him down. He soiled himself a bit at the end there but don't they all. I need to talk to Dr. Robillard now if I can use your phone."
"Sure, doc. Use my office desk."
Hendricks stepped into the carpeted hall and into the bland decor of the public areas of the converted Victorian house. He came to a heavy oak door marked "OFFICE" in bronze letters, and entered a bright corner room. It was getting dark, and he wanted to get this over with. A dark cherry wood desk covered with orderly piles of bills and invoices filled the corner, with the chair facing back inward toward the door. Ignoring the view of darkening rounded mountain tops set against a gaudy fuchsia and orange sky, he sat and dialed the Medical Examiner's answering service, and waited only a few minutes for the return call. While he waited he scanned the bills for caskets and supplies, and wondered idly about the markup, and the baser aspects of the funeral industry. George was a good sort, through so he put those thoughts aside, and resisted the impulse to riffle through the piles for more detail. The phone rang once, and Hendricks picked it up quickly.
"Hi Paul". It was Robillard himself. Twenty years in the department, fifteen as chief, and he still took every third weekend on call. "What's up?"
"Hi Andre." Hendricks said. I have a real problem case for you. Doctor James O'Leary was killed by a gun shot to the back of the head this morning, and I think you're going to want to have a look at him yourself."
"Sounds like it, Paul. What do you know so far?"
"Well, not much, really. He was hunting apparently and was shot from behind across the top of his head by someone only 50 or 60 yards away. The Detective is convinced it's an accident, or at least that he'll never prove otherwise, but I'm not sure. It seems to me the shooter was close enough to see what he was shooting even at 7 or 8 in the morning, and anyway, O'Leary didn't have too many friends."
"Well, that's too bad, too bad. Sorry you had to go out on a case involving a friend."
"He was no friend, but thanks. It was a shock to do a scene investigation on someone I know well.
"Yeah, life in small towns in small states can be hard sometimes. No one can be anonymous up here."
"You got that right. Any bottle of wine I buy is an open subject in town. They know every movie I ever rented, and whether I ever make it to church."
"I know it only too well. I grew up in Warren Township, you know. Now that I live in the capital, I won't don't miss life being that small town ever again. Anyway, was there any physical evidence?"
"Not much, No shell, no bullet, and no other obvious evidence at the scene. The detective was quite pessimistic about finding the shooter."
"Well, they generally know their territory pretty well. Who was the investigating officer?"
"Lt. Dick Simmons."
"Oh. Sorry again. Was he any trouble to you? I hate for him to badger my regional examiners, and make them want to stop doing cases. It's hard enough to recruit you guys as it is."
"Oh, he isn't too bad, said Hendricks, lying politely. "I guess he does know his business."
"Well, don't let him buffalo you. You have legitimate jurisdiction over the medical aspects of the scene, and your input is very important to these cases. You've done some good work for us before, like that suicide case where you found the medicine bottle they'd missed. Keep a sharp eye out, and write it all down. Maybe he heard about that case, and has a chip on his shoulder toward you."
"I doubt it, Andre. He's just in a hurry, and I'm probably in his way as much as anything."
"Not at all, Paul. It's a team effort. He's not the whole case, no matter how much be thinks he is."
"Well thanks for your encouragement, Andre. I need to discuss a few details with you, for my report." He shifted in his chair and hunted around for a pen and paper. A plastic pseudo quill in a marble base came to hand, and a memo pad with the Bittner letterhead sat next to it.
"Now, I figured the time of death as about 7 AM, about seven hours before my arrival at 2:00. There was early fixed lividity, and the belly had a faint trace of warmth left to it. The fingers were mildly stiff, and the arms a bit less, but there was definitely early rigor.
"Did you get a core temperature, Paul?"
"Oh shit, no I forgot. I don't even know if Mr. Bittner has a thermometer, and I don't have one with me."
"Never mind Paul You've got enough data to fix the time pretty close. I'm going to need some eye fluid.
"Already done, Chief. I got some heart blood for toxicology, as well."
"What drugs are you thinking of Paul?"
"Alcohol mostly, but you might consider a generic screen. You never know what might turn up."
"I don't know, Paul. I've got a budget to deal with over here. If you don't have any specific questions, I'll leave it alcohol for now."
"Ok Chief. That's probably the only thing involved, anyway."
Hendricks realized the improbability of his search for illegal drugs, and flushed at his own eagerness to find dirt where none existed. He really hated O'Leary after all, and looked for scandal. He'd better watch his own motives, never mind the shooter's. Robillard's encouraging voice brought him back to business.
"You go ahead and write it up as six to seven hours, and leave it open. I'll do the death certificate here after the autopsy, and I'll let you know what we find. Let me give you a case number for your report. Let's see #1990 196. Be sure to bill for all your time today Paul."
"Thanks, Andre. I appreciate your help."
"No, no, the thanks are all mine to give. I'm sorry the state can't afford to pay you fellows what you're really worth, but the legislators don't see paying doctors more as a big priority. Keep up the great work!"
He rang off, and Hendricks hung up, folded the memo paper up small and stuck it into his shirt pocket. He returned the pen to its holder, and went back to the embalming room.
George Bittner had O'Leary cleaned up, and back in the zipper bag. "Can you help me get him onto the litter, Doc?"
"Sure, George. Hendricks went to the foot of the table and got a grip. He heaved at the stiff plastic and slid him onto a wheeled cart and then Bittner threw a garbage bag with the clothing onto the feet. He strapped the chest down with an auto safety belt, and bound the clothes and feet with another.
They loaded O'Leary onto the lift, and started downstairs after it.
"Okay Doc. Thanks again. Let me show you out, and you can get back to your family."
"Hey when are you coming in about that blood pressure, George? I can see already you're working too hard, and you've gotta do something about it."
"I know, I know, Doc. I'll get in there, but I hate the thought of taking meds."
"Me too, but then there are worse thoughts, as you know." He glanced back at O'Leary.
"Okay Doc I get it. See you next week, perhaps."
"I hope so. This Medical Examiner job is even less fun when you know the party involved. See you soon."
Bittner closed the outer door behind them, and left them in the gathering dark and cold.
"Okay Sergeant, I'm all set. I'll send Simmons a copy of my report, and he'll take it from there. I should hear a preliminary from the Chief Medical Examiner office in a couple of days. If you all have any questions, you know where to find me."
"Take care Doc. It's been a pleasure, as always."
Hendricks drove off to his house, and to supper being kept warm for him by his long suffering and tolerant wife. He hoped that Blunt's family showed the same understanding.

Error Reduction in the Emergency Department
Adoption of Error Reduction Techniques From Other Industries to
Emergency Department Procedures

     The practice of Emergency Medicine is a complex, variable and difficult job. Efforts have been made to analyze it according to standard industrial models, and with varying success. It is at the most complex end of the spectrum of systems humans operate, and therefore most error-prone. And unfortunately, errors do not result in unacceptable widgets being produced, they result in bad outcomes, including death, for our patients. No one argues that error reduction is not a noble goal. Many argue that systems this complex defy analysis by these industrial methods. However, in our current recognition of the appalling toll that errors cause, nihilism and objections to proposals to reduce errors are correctly viewed as self-interested resistance, and non-productive push-back. Analysis of similarly complex and life-or-death-dealing systems, such as operating room anesthesia, commercial airline operations, and U.S. Naval aircraft carrier operations, have shown that the analysis can be very fruitful in identifying risk points and areas for improvement.
     Emergency Medicine in a standard hospital setting is a complex system, in some ways linear, but in many ways functioning with multiple parallel processes interacting at various points, with various workers responsible for the processes, and with multiple outcomes possible, depending on the inputs from these parallel processes. It is also a high-risk, high variability endeavor, with multiple points at which error can be introduced, and with death and serious injury always lurking as a possible result of error. Strictly linear processes are amenable to the familiar Quality Control (QC) methods of auto manufacturing and similar assembly line processes, even if they are complex. Non-linear, complex, tightly coupled processes are not so transparent, nor as amenable to QC procedures, partly because the processes cannot all stop while awaiting a result or outcome of one particular step, and partly because the processes necessarily proceed based upon incomplete or even erroneous information, incomplete knowledge of the individual facts at hand, and even incomplete knowledge within the field in general about any specific problem encountered. Further, the process is necessarily time-limited and time-pressured. One source of time limitation is the urgency of the disease and the need to intervene. Another is the substantial risk, if a possibly urgent symptom is not investigated rapidly and the potential life-threatening diagnosis rapidly ruled out or ruled in. A third source is the need to process large numbers of people, most of whom have readily identifiable and non-threatening problems, and yet to sort out of these the ones who seem trivial at first blush, but actually harbor life-or-health-threatening problems not yet identified. And finally, there is just the simple pressure of patients wanting to ‘get in and out’, and who value their convenience and time over anyone else’s life-threatening disease, and are not the least shy in expressing their displeasure at having to wait.
Against this backdrop, it is not surprising that Emergency Departments are among the highest risk departments in most hospitals, in terms of claims filed and complaints lodged with the hospital, and in terms of payouts on malpractice settlements. It is also not surprising that pressure to limit these losses is becoming intense. What is surprising is how resistant to change the enterprise can be. Changes proposed from outside the ED are generally met with resistance based on maintenance of tradition, territoriality, and internal perception of ‘unique’ knowledge of the system which makes the proposed change ‘impossible’, or at least ‘impractical’. Proposals for changes from within the system meet internal barriers of hierarchy, in which doctors remain responsible for “medical care”, nurses for “nursing care”, and operations personnel for supplies, structural features, and support staff. The overall operations may not even be under one person’s or even one department’s control, although the department leadership is generally held responsible for outcomes, even in the absence of operational control. It is not that people want their system to fail, but they see their portion of the system as capable and functional, and see failures primarily elsewhere in the system. Almost all of the systems involved have evolved over time. The processes within them have been fixed by convenience at the time they began, or by limitations of architecture, or by limitations or personal preferences of staff, or by general industry practices based on limitations of knowledge at the time. They are also driven by consumer (patient and family) demands. Change comes mostly from analysis and reaction after failure. Such analysis traditionally has sought to assign fault, and often results in changes of personnel. Only recently has an emphasis on systematic cause of failure come to the fore. Changes which do occur are focused on the failure, and rarely encompass any more than is necessary to address the particular circumstance of the failure. The reaction of the department to the failure typically results in policy or procedure changes, which are promulgated at the time of the analysis, disseminated to the staff, placed in a manual, and gradually forgotten. The entire process or processes are rarely examined in full detail, and are generally not subject to radical re-alignment, barring some disastrous error, or other severe stress. Some changes do persist, and contribute to the evolution of the system, but after a few years and a few cycles of personnel turnover, there is rarely even institutional memory of why processes are done the way they are done.
     An analysis of how to do things better needs to proceed from an understanding of how we do things now. This alone can be a daunting undertaking. A typical ED receives patients in many ways. A patient may arrive by ambulance, with some assessment already accomplished, and some advance notice of their arrival and possible urgency. (or no notice at all) A patient may arrive at the triage window, and state a complaint either urgent or non-urgent. The complaint may have no bearing on why the patient is actually there, since all patients know that a complaint of “chest pain” will reduce waiting time, even if the real concern is something completely unrelated. A patient may only become a patient when they slip in the hall visiting another patient, and are brought through the back door by nurses on the floor. Patients stagger through the ambulance entrance after being stabbed or shot, and patients are occasionally born unexpectedly to other patients who only had abdominal pain as a complaint. Patients also become ED patients when the admissions staff has no bed available for an urgent direct admission, and they are redirected to the ED and “held” pending bed availability. This list is not all-inclusive.
     The next step in the process is supposed to be a sorting process, called “triage”, from military parlance. This is an example of practice from another area which was incorporated into general practice of Emergency Medicine, although its evolution subsequently has rendered it unrecognizable to a military practitioner of triage. The concept comes from military mass-casualty situations, in which battle casualties must be rapidly assessed and categorized into groups, in order to use resources efficiently to save the most salvageable, and to avoid wasting time and resources on unsalvageable cases. Triage involves almost no treatment, except momentary airway interventions or application of pressure to bleeding, which can salvage a soldier with a minimum of time. Triage also involves harsh choices, such as assigning a hopelessly wounded soldier to a category of comfort care only, so that minimal further time and resource is devoted to a vain effort. It also categorizes painful but non life-threatening injuries for deferred care, after the most urgent but salvageable cases are treated. This process, done correctly, preserves the maximum of life and limb under limited resources. It also translates poorly into the civilian world. First and foremost, the term applies to mass casualties. There is no need for sorting if only one patient presents. Nevertheless, in the ED the “process” is applied mechanically, more for administrative and record keeping purposes. Secondly, patients who are still alive, (and their significant others) generally expect that all possible interventions will be employed until the patient is actually dead, regardless of the apparent futility. Our ability to assess futility accurately is notoriously poor, so their expectation is actually not unreasonable. In the field, a gunshot wound through the chest with low blood pressure and with more than an hour of transport time to stabilizing care is for all practical purposes a dead patient, and with high reliability. A similar patient in an ED is already at the next level of care, if not definitive care. The use of the “unsalvageable” category does not work, except in the extremes of mass casualty rarely encountered on the civilian side. Third, individual patients among the “walking wounded” have almost no understanding of priorities of problems currently being managed, nor do they care. They are concerned with their own problem, and how fast it can be assessed and treated.
     Overlaid on this transplant from military practice is the need to gather demographics and medical information on the patient. True triage would bring the salvageable, urgent cases immediately to care without further delay, and to a certain extent, the civilian version functions in this way. However, in typical practice, “triage” has evolved to mean “record initial complaint, divert the obviously endangered to the back, and gather demographics and medical history on the remainder.” It has also devolved from a multiply-parallel process to a linear one, resulting in the complete undoing of its basic function. If the triage nurse is in the middle of an assessment, the assessment of the next to present will typically wait until the first patient is finished. Even if multiple nurses are available, the process becomes multiple linear parallel processes, limited at the front end. No matter how many personnel are available, such a structure will overload when the numbers of people presenting exceed the number of staff available to assess them individually. And the above process only encompasses the 80% or so of patients who arrive at triage. Other processes occur for ambulance cases and other portals of entry to the system.
     The stream of patients divides at this point in the process, between those who are deemed acute and are brought to the treatment area, and those assessed as stable enough to wait. Here there is variability in that if there are spaces in the treatment area, and no particular backlog in triage, non urgent cases may be brought back directly. Likewise, the assessment of what is urgent and what can wait is somewhat variable, depending on how full the treatment area is, and how urgent are the patients already being treated. A laceration of the hand with a blood-soaked bandage might be brought back immediately under normal circumstances, or wait an hour or more in the public waiting area under others. A patient who begins yelling and behaving in an inappropriately angry way might well be brought back out of triage sequence just to avoid a confrontation. In theory, the triage personnel assess the waiting patients periodically for deterioration of their condition, and might upgrade their category if appropriate, for more immediate treatment. In practice, their ability to do this is variable, with variability existing due to the numbers of patients and staff, and also variability due to the nurses’ individual skills and experience.
     Once in “the back”, a patient has vital signs re-assessed and recorded, and the remainder of a complete nursing assessment is gathered and recorded. This process might take five minutes and might take twenty-five, depending on complexity and also nurse variability. During that time, the physician might or might not even be aware that a new patient is in the back, and would generally have no idea of the nature of the problem unless a nurse requests that the doctor come immediately. This is generally done for serious problems, such as chest pain, but again, variability exists between nurses, based on skill and experience, and also occurs based on the other demands on the physician’s time at that particular moment. For example, if the physician is scrubbed and finishing a suturing procedure, the nurses might not interrupt for anything short of a “code”, even though in terms of acuity, a stable suturing procedure can be safely, though not conveniently interrupted. Variability also occurs based on physician openness to being interrupted, and on their individual tendencies to encourage or discourage verbal consultation by the nurses.
     Once the preliminary matters are accomplished, the physician portion of the encounter begins, with a history and physical. The physician usually carries a clipboard with the initial complaint and some aspects of the patient’s past medical history, medicines and medical allergies, as well as most recent vital signs. She does a fairly focused and problem-limited assessment generally, and then writes orders on the chart, or enters them in a computer in some cases. Most typically, however, written orders, either hand written or from checklists of common orders, are handed off to a secretary, who enters them into the computer, and then gives the nursing related orders to the nurse. There might or might not have been a conversation between the doctor and nurse about these orders, depending on the availability of each at the appropriate time. The doctor might have an opportunity to record the salient portions of the history and physical on the record at that point, but the need to deal with other urgencies may not allow that. Some doctors are themselves linear in their function, and insist on completing a task before taking on another. Some take on multiple tasks, and some have difficulties keeping all of them moving at once. Most of this variability is individual.
Orders awaiting nurse action are typically flagged, or placed in a rack awaiting nurse availability to accomplish. There may be a linear structure of one nurse generally assigned to one patient, (so-called ‘Primary Nursing’) or there may be teams, or sectors, or just any available nurse models in operation. Variability occurs here at multiple levels, with prioritization of orders dependent on a physician notifying the nurse personally, or consistent use of a flagging system, and dependent of course on the amount of work and the urgency of the other cases currently in the system. Such orders might include blood draws and establishment of intravenous access (IV), obtaining a 12-lead EKG, obtaining of specimens of urine or stool or sputum, initiation of oxygen, continuous electrocardiographic monitoring, and administration of various medications. Some of these tasks will be carried out by the nurse, some by technicians or nurse’s aides, and some by specialized technicians such as phlebotomists, respiratory therapists, and radiologic technologists. Some can be accomplished in any order, and some require prioritization, due to one task interfering with another, or being dependent on the prior accomplishment of another, or due to the particular needs of the patient. The physician may have specific desires as regards these priorities, and may communicate these desires, but the accomplishment depends frequently on the availability of staff, and the decisions ultimately made by the nurses and techs. Some of these orders and procedures are routine and predictable for various problems, and can be initiated on a protocol, or standing order. Some cannot, and must await individual physician or nursing assessment and individual order. Some orders, which could and should be done as standing orders, are not, due to nursing discomfort at initiating “orders”. And all such orders are dependent on the support for, or resistance to nursing initiation of orders, by the individual physician.  A single physician insisting on physician prerogative and questioning nurse initiated orders as they occur can scuttle the entire process.
     The next phase of care is the accumulation of data and the observation of the patient’s course after the initiation of initial therapy. Here the physician has relatively little contact with the patient, although she might check on progress intermittently, time permitting. The nurses are responsible for checking on progress, and reporting back to the physician. There is a large amount of variability here. Nurses may or may not see their role as gatherers and reporters of significant information. They may or may not check on patients, and update the physician. They may expect that the physician finds all the results and reacts to them, without any input from the nurse. When lab results become available, and are grossly abnormal (Panic Values), these results are usually brought to the physician’s attention, and reaction to individual results might generally take the form of an order for additional therapy, or more testing. These orders might be written, discussed verbally with the nurse, or both. Abnormal results not of that level of concern might or might not be brought to attention, as multiple results are released at once. They may be available on a computer, but not brought to notice until the physician specifically queries the system for the results. Variability in these results reaching attention occurs here quite commonly, and with a high potential for error resulting. Variability in nursing practice as regards periodic updates to the physician also occurs, with significant information going unreported, or alternatively being buried unrecognized in a mass of trivial information, and mechanically reported without adequate prioritization.
     Finally, after accumulation of data is complete, and therapeutic trials initiated and results assessed, the time for disposition has come. The physician must review all the data, confer with the nurse, perhaps reassess the patient, and then determine that the patient must be admitted, or transferred to a higher level of care, or can safely be discharged. The physician must then contact an admitting physician, or make a plan for outpatient care. She must then put in an order for admission, or write instructions for after care and follow up, along with prescriptions, work excuses, orders for medical devices, and orders for follow up appointments or testing. These are all reviewed with the patient and family, either by the physician and nurse, or at least by the nurse. Normal practice is to verify understanding by the patient or caregivers, and to document this understanding. At that point the visit is concluded, either by transfer to the floor, or by discharge. There remains only a substantial amount of paperwork to document all aspects of the encounter, and a reassessment of all other tasks then pending, along with the status of the next presenting patient. That there should be error in the above outlined processes should surprise no one. That it ever occurs as intended and without error is the more dubious proposition.
     A similarly complex system which provides useful parallels is the U.S.Navy’s carrier operations. In that example, highly complex operations requiring much precision, with high risk for fatal error, are carried out under difficult and variable conditions by a staff with rigid hierarchy and high turnover rate, but to a very high degree of reliability. Each of these features bears similarity to ED function, and each would be expected to add a degree of uncertainty and dysfunctionality, and yet the Navy carries out thousands of launches and landings per ship, with millions of individual component actions carried out in sequence, by tens of thousands of individuals, and all at vanishingly low error rates we could only envy in the medical world. Several methods of error reduction employed by the Navy have immediate application to the ED, but the Navy is by no means the complete example. Civilian aviation has parallels as well, with millions of operations yearly, and a very low fatal error rate, despite the constant possibility of error leading to mass casualties, rather than resulting in a single fatality, as in medicine. And manufacturing industries have lessons to teach us also, in examples of work teams, automation, and information sharing. A variety of possible strategies can be culled from all these sources, and applied to Emergency Medicine, with the expectation that we can reduce error and injury substantially. Given the record so far, we cannot afford to remain complacent.

Redundancy
Redundancy is a concept not unknown in medicine, and it is employed to advantage in error reduction already. It is not employed systematically however. There are two modes of redundancy, namely procedural redundancy, and physical redundancy. Both can be employed to good effect. Procedural redundancy is the use of two people to accomplish a task, utilizing two sets of eyes and experience bases to cross check a safety critical procedure. Physical redundancy is the acquisition of two pieces of equipment or items of supply, so that in the anticipated failure of one, a second is immediately available. Depending on criticality and likelihood of failure, more than single layer physical redundancy might be required.
     An apt military example of procedural redundancy has been termed “stressing the survivors.” Under normal circumstances, multiple personnel have overlapping areas of responsibility, but none is at maximum capacity under normal operating conditions. There is a sufficient surplus of personnel that part of the duty of each is to observe the ongoing functions around them for which they are partly responsible, and to provide safety crosschecks and input as abnormal events are observed. If there are losses, or if the system is saturated and maximally stressed, the surviving personnel will have to step up to maximum capacity function, and some of the redundancy will necessarily be lost, or assumed by assets outside the immediate unit. The assumption, however, is that there is an expected “inefficiency” built into the routine staffing level, which allows procedural redundancy, and to a certain extent, physical redundancy of staff.
     Procedural redundancy in health care is employed currently in certain medications. By long and oft-quoted tradition, doses of insulin are drawn up by a nurse, and a second nurse is required to check that the syringe contains the written dose of insulin, before it can be given to the patient. This is a perfectly rational and useful example of increased safety achieved by procedural redundancy. Its origin is lost in the mists of time, but the behavior is embedded in nursing training nationwide, and is reproduced broadly in both hospital policies and procedures, as well as in actual practice. At the same time, the same nurse is free to draw up other, more frighteningly lethal medications on a scribbled order or verbal order from the physician, and inject these medications intravenously without ever a thought of cross checking. Thrombolytics, various cardiac medicines, antibiotics, chemotherapy agents, and a host of others are not subject to the same institutionalized scrutiny. Individual nurses do cross-check meds on an ad hoc basis, but this is driven by their familiarity with the med, their comfort with the ordering physician, the time pressure, etc. Interestingly, doses of potent narcotics can be drawn up and administered without cross check, but any instance of a partial dose being given and the wastage of the remainder requires cross checking, a practice driven not by patient safety, but by control of potential narcotic diversion. The systematic use of this cross checking could reduce one of the commonest identified sources of significant error, medication errors. Barriers to its employment include the necessary demand on staff time, which of necessity reduces availability for other tasks. This demand will ultimately require more staff, and therefore more salary expenses. A cost-benefit analysis will likely show that this is nevertheless cost effective, because it could impact the single largest source of error in the ED. At the physician level, redundancy is harder to achieve. In single coverage, there is no one available to double check decisions, nor is the practice warmly viewed in the field. Doctors are expected to know what to do, and though they do consult one another, as a generalist consults a specialist, constant cross checking within the same level of care tends to be viewed as weakness, or lack of knowledge. An area of redundancy that is not exploited in medicine is the practice of cross checking by any level in the work team. A technician questioning a doctor’s order, pointing out to Nurse B that Nurse A was just in the room giving potentially the same medication might or might not be warmly received. The Navy uses this technique to great advantage, by allowing flight operations to be suspended by anyone on the flight deck, if a safety issue is noted. While the person might be criticized if wrong, he is never punished, and is rewarded when correct. Here hierarchy gives way to safety, and medicine could use the lesson. In fairness, the most functional work teams in medicine do use this paradigm, and the most functional team leaders are often the least rigid in terms of role, but the practice is not standardized nor even well recognized.
Physical redundancy is also well known in medicine, but underutilized. In critical areas, such as the OR, ER and ICU, certain obviously critical devices have designated backup devices already present. Most of these are kept in reserve by established procedure, and many of these procedures represent the result of retrospective analysis of actual failures in the past. Prospectively, not many hospitals have taken the step of analyzing each procedure in each area, asking the question of where is the designated backup if (X) fails. Furthermore, expecting staff to find a manual to identify the backup plan at the time of a failure is designing failure into the system. The location of each backup needs to be posted on each device house-wide, so that at the time of failure, a manual does not have to be located and consulted. In many cases, the result of any specific equipment failure may not immediately be safety critical, but will impact the organization elsewhere if a backup is taken from another department, or cannot be obtained at all for a prolonged period. This may result in an unanticipated safety issue elsewhere. Physical redundancy may also be as simple as insisting that an array of endotracheal tubes already be available and assembled for use prior to intubation, in case the primary tube is dropped, or is too large, or the balloon is violated on insertion. A systematic evaluation of each department’s procedures with prospective failure analysis is required to see where safety gains can be made. Much of the redundancy already exists in terms of equipment and supplies, but the benefit is not available due to faulty procedures. These barriers can be reduced.

Checklists
Aviation provides several additional techniques which can be employed to advantage in the ED. One well understood technique is the use of checklists. Each airplane type has multiple procedures specific to its operation, and its operation is a complex, sequential task, with high potential for failure if procedures are omitted. Each aircraft has associated with it a series of checklists applicable for various phases of operation, both routine and emergency. Starting a simple single engine piston plane requires twenty or more procedures, and pilots are completely accustomed to use of a printed list to avoid errors of omission. No matter that the pilot has 10,000 hours in the type, and 3,000 takeoff and landing cycles under her belt, she still uses the checklist. Emergencies have multiple complex procedures for solving problems while continuing to navigate and aviate, and pilots, ideally with the help of redundant copilots, run these checklists to investigate and isolate the failure, while determining where and when to land. In Emergency Medicine, by contrast, we rarely use printed checklists. Much of physician training involves memorizing lists of things to check and sequences of actions to carry out, and we are expected (and expect of ourselves) that we can produce these lists instantly on demand, without omission, and without reference to printed material. This is of course a crazy and unrealistic expectation, and the cause of innumerable errors of omission, but yet the attitude persists. Pilots live in a world of high regimentation along with high authority. The pilot is responsible for the safety of the flight, and may violate FAA rules and regs if dictated by safety needs, but pilots also comply with a degree of regulation in routine operation which physicians never face. They do so because of their culture, but they do so also because they are employed by airlines, or are officers in the armed forces, and because they are required to do so. Doctors are historically independent, although becoming less and less so. Nevertheless, their culture is anti-regulation, and resistant to admitting that errors of omission are the inevitable result of faulty human memory. An FAA of medicine is a far-fetched notion, but that level of regulation may come to medicine if medicine does not reduce error to acceptable levels independently. In ED processes, checklists could be very beneficial in preventing discharges before all ordered tests are returned and reviewed, or without ordered meds or treatments. The entire list of tasks at the end of the encounter can readily be assembled and reviewed each time, to ensure completeness, and to ensure that prescribed treatments do not conflict with known allergies, etc. Likewise, on intake, and depending on presenting complaint, a checklist containing standardized procedures can ensure that oxygen is started if appropriate, that monitoring is placed as soon as the patient is in the bed, that vitals are obtained and stable, that the call bell is available and the rails up as appropriate. This list is carried out ad hoc by the nurses currently, and errors of omission are a constant and unassailable presence in the ED. The proliferation of pathways or protocols which are disease specific represent another use of checklists. These have been developed piecemeal to deal with documented omissions in the care of the most common diagnoses. They do have the potential to increase the percent of patients who receive standard meds in certain diagnoses, such as aspirin and beta blockers in unstable angina and MI. They have unfortunately met with resistance from physicians, who deride them as cookbook medicine. Another example which can be helpful is standardized order sets, based on presenting complaint. Abdominal pain, for example, will almost always require a list of labs including urinalysis, blood count, basic chemistries, and a pregnancy test in females of appropriate age. The nurse in triage can initiate this sequence immediately, preventing delay in care by “rounding up the usual suspects” at the earliest possible time, and preventing omission of one or another step, preventing missed diagnoses, or at least further delay, while the omitted lab is obtained later. Multiple other complaints are amenable to this technique, and yet physicians continue to object that it eliminates their professional judgment. In truth, it will result in too many labs being done when trivial pathology with the same complaint could have been managed without lab at all. And to the extent that the physician is available to see patients as rapidly as they present, they are free to exert their judgment up front. But to the extent there is a waiting period before evaluation, the time, staff and ED bed congestion costs must be weighed against the occasional overuse of lab testing. A rigorous analysis has not been published, but the balance is likely in favor of standing orders.
Another aviation model is the concept of the “sterile cockpit”. FAA records are replete with examples of distracted flight crews carrying on unrelated conversations during critical phases of flight, particularly takeoffs and landings, and failing to note warning lights or sounds in time to avoid disaster. Similarly, “crew resource management” (CRM) procedures dictate that there be clear understanding between the pilots of who is flying the plane and who is jiggling the loose wire under the radio. Documented civil aviation crashes have occurred as both pilots became absorbed in a non-critical warning light, and neither flew the plane. In the ED, as in the cockpit, there is a culture of gallows humor which is part coping mechanism and part machismo. It is not unusual to have resuscitation situations, which are often futile exercises in any case, be remembered more for the witty repartee than for the outcome. Even without this phenomenon, there is constant, often loud chatter going on which may relevant to the tasks at hand, but which obscures the flow of information up and down the chain. There is variability in how effective team leaders are at recognizing the problem, and how they cope with it. Formal training in trauma codes includes assessment of and reduction of distractions, but the concept of sterile cockpit could be employed in many other areas. Avoidance of “task saturation”, with everyone in a code paying attention to one task to the detriment of their assigned task is likewise a learned behavior, reinforced by training, and seldom achieved individually without training.

Feedback Loops
Much of medicine is carried out in sequential input-output cycles. An order is placed, a lab is drawn, and a result reported. This result raises other possibilities to be investigated, or requires a therapeutic intervention. The doctor responds with the appropriate test order or med order. All of this depends on results reaching the ordering physician, and efficiency and safety dictate that they reach her as rapidly as possible, and as soon as available. This is the phenomenon of “feedback loops”. The sheer bulk of this information provides one problem, since a typical order set might contain 20-30 expected results, and require positive action to review each of them for relevance. Results are already prioritized by reporting abnormals in a highlighted format, and reporting defined “critical values” by direct verbal report to the ordering physician. However, the presence of a “normal” result in the setting of a suspected diagnosis incompatible with this result is not a scenario captured by such a protocol. For example, if a man with suspected kidney stone has a “normal” urine, when blood is expected in the urine, the routine normal report without urgency may not alert the physician to the fact that an abdominal aneurysm is actually the cause of the pain, and that the patient is about to expire without surgical intervention. Likewise, an abnormal result which is reported into a computer database, requiring physician action to access and review it may transmit the needed information, but information resident in a database is not the same as information in the possession of the doctor. This extra step can result in delay or omission, and does lead to error. In manufacturing and in aviation, critical results which determine the next action in a sequence are commonly presented in formats which “force” review and response. Alarms may sound which must be addressed before the next sequence can be initiated. Orders for an action might require that the precipitating data be included in the order. In medicine, this occurs with some regularity, but not with uniformity. Many lab results require urgent action, but because the result is separated in time from the order, the positive feedback portion of the loop is lost. A positive Pap smear reported two weeks later, by mail, in a stack of 50 negatives, has caused numerous preventable cases of cancer to go on unchecked. An abnormal potassium level, not highlighted in a list of twenty normal results reported routinely two hours later, could be the source of both severe injury and legal controversy. And as electronic data transmission has taken hold in the industry, many of the old reliable systems of paper-based notification systems have been dropped, but without adequate systems to replace them. In our institution, lab results formerly came as printed reports, with ranges of normal and abnormal included with each result. The physician got a piece of paper thrust into her hand, or placed on a chart for review, and presented by the secretaries. She reviewed, initialed, and responded to the results. Results not reviewed or not initialed were re-presented, and very few results were missed. That system did not capture results which were simply not reported, and these misses relied on the physician noticing that a desired result was still not available for review, and either tracking it down, or tasking someone with the chore. Currently, results are released into a database which the physician must affirmatively access to find results. If a result is not yet available, the physician must access the system again later to get it. If a result among many is reported earlier than others, it does not reach the physician until the physician seeks it. If there is a missed order, or a failure to enter the report, the physician must still note the absence of the desired result, and initiate an investigation to determine if the order was missed, or the blood not drawn, or just not run, or perhaps just not reported. The net effect is that the electronic medical record (EMR) is actually less functional in terms of feedback loops than was the paper system it replaced. Feedback loops can be designed into EMR products, but the problem must be understood by the programmers, and the effects on safety and functionality must be assessed by the caregivers. And the goal of forced feedback loops must be understood as a design priority in the first place. Currently the assumption is that the physician is responsible ultimately for results of orders, but it is clear that designing systems which require repetitive human action instead of utilizing the power of repetitive machine action is the same as intentionally designing failure and error into the system.
     Another feedback loop-related technique, which comes from aviation and military practice is “readback”. On a ship’s bridge, a command to steer a set course at a certain speed is repeated back to the commander by the helmsman. Ahead full, 2-7zero degrees AYE! A clearance from the Air Traffic Controller is read back verbatim to the issuing controller by the pilot. This serves the dual function of confirming that the order was even received/heard by the receiver, and that it was understood. These practices are so routine in aviation and military practice, they barely provoke any notice. In medicine, however, despite the historical love of hierarchy and chain of command, the practice has not taken hold. It has much to recommend it, but will require training and enculturation. With the new JCAHO standards comes the mandate that verbal phone orders must now be read back to the ordering physician. Physicians have grumbled and resisted, but the practice is unassailably correct, and will prevent many errors in exchange for a minimal expenditure of time. In the ED, particularly in code situations, but essentially always, verbal communications are complex and burdened with jargon. Many drugs have similar names, and numbers and letters are frequently mis-heard. Multiple patients with similar sounding names come and go in rooms with numbers. Errors are frequent, and many would be caught by adopting this practice. Here the cost will be training, and enlisting buy-in by the participants, since the cost in practice would be negligible.
Still another feedback loop which is not employed widely is the affirmative requirement for reporting results of interventions. If a respiratory treatment is ordered and delivered, the therapist is the only one then in possession of the information about what was the effect on the patient. She can complete the order and depart, or seek out the physician and report on effect, so that additional therapy can be ordered if needed, or the fact of improvement communicated. Likewise a nurse giving pain med can just carry out the order, or can reassess and report in twenty minutes. The cycle of input-output can be compressed, and more care delivered much more efficiently in this way. But this does require the training and expectation that an order presumes and requires a return report on effect. And the extra work for the nurses will require buy-in, so that they see benefits in terms of increased power and influence in patient care, as well as improved turnover of beds and operational efficiency. ED nurses don’t generally like long dwell times in their beds, when more patients are waiting in the waiting room. They do like to make a difference in their patient’s course and care.

Automation
The notion that automation can be the salvation for medicine in terms of the flow and speed of data is attractive, but the holy grail remains a distant vision. As noted above, automation can worsen rather than improve some situations. On the other hand, as these early problems are understood and designed out of future versions, the utility should improve. However, the potential in terms of error reduction is enormous. Just the elimination of handwritten notes and orders will be an enormous victory. Pulldown lists of available meds at available doses will speed drug ordering from manageable formularies. Drug orders will be entirely legible, and transmitted instantly to the pharmacy. Inventories can be maintained simultaneously, preventing shortfalls of supply. Med lists can be scanned and reproduced immediately, and updated by exception, rather than re-writing each individually. Allergies and incompatibilities can be picked up and flagged, and pre-screened alternatives suggested. On the other hand, the industry must be aware of new types of errors introduced by new technology. Excessively rigid menus may not allow legitimate but unusual uses of meds. Rapid reproduction of erroneous or outdated medication lists, and transmission to other sites of care can preserve errors on the original list, and place many copies of the error into the system. And of course, all databases are subject to human error during data input.

Human Factors
Human beings function best when they are well rested, focused on the task at hand, motivated, and properly trained. This happy confluence seldom occurs, and if it does, it does not persist for long. Error occurs even under optimal conditions, but the rate of error rises drastically as fatigue sets in, and error also rises as each of the other factors vary. A famous incident of resident fatigue during an on-call period of 36 hours leading to a young woman’s death has resulted in much discussion and even state regulation. The typical reactive response of the regulatory agencies has been followed by steady erosion of the changes, to the point that there is very little difference beyond official posture a decade later. In principle, everyone knows that doing complex tasks for 24 hours in a row results in reliably poor performance. In practice, the expense of hiring more staff to enable shorter shifts and prolong rest time has created resistance. The tradition in the ED is built around twelve hour shifts for both physician and RN staff in many locations. Multiple studies show that by the end of a twelve hour shift, the ability of a worker to remain focused on task is generally very poor, and error rates rise, as output speed declines. The “change of shift” phenomenon is observable every day, as throughput times rise, and patients wait longer, coincident with the outgoing shift’s unavoidable slowdown. A study of errors by time of day/relation to shift change would be interesting. A study of errors in a stable system before and after the adoption of a change from 12 to 8 hour shifts might also be very enlightening. What is clear, however, is that systems currently in wide use take almost no account of error probability, and are driven instead by the desire of the staff for time off, and by HR concerns and staffing costs. Other industries, more highly regulated than medicine, such as over-the-road trucking and commercial aviation, require strict adherence to limited work schedules, and mandatory rest periods before a new shift can begin. These measures are costly, but survive in these industries because error is costly and not tolerated to the extent it is in medicine.

Conclusion
The call for reduction of errors in health care has arisen as a relatively sudden outcry, prompted by the Institute of Medicine’s report "To Err is Human." Responses range from defensiveness, to an open dialog within the medical community, to politically driven regulatory responses. Medicine has much housecleaning to do, and nothing to gain from a posture of defensiveness. On the other hand, the health care industry does not operate in isolation, and as resistant as it might be to suggestions from outsiders, insiders can well afford to look to the outside world of other industries for examples of systematic error prevention which can be imported and adapted to medical use. The above examples amount to a catalog of the obvious, examples of “low hanging fruit.” Some are almost cost-free. Some will require commitment of substantial money and time. These demands will play out in our world of diminishing resources and rising costs, particularly for health care. But the IOM makes it clear that error is expensive, both in money and in lives lost or forever altered for the worse. It is also clear that error is inefficient. Some of the expenses required for systematic correction will be offset by reductions in error, and some will not. Some will just have to be borne as a cost of a system which no longer accepts routine error as normal.



References:

To Err is Human—Building a Safer Health System, Kohn, Corrigan and Donaldson, eds., Committee on Quality of Health Care in America, Institute of Medicine, National academy Press, 1999.
Dement WC. The perils of drowsy driving. N Engl J Med 1997; 337: 783-784.
Jones MA. Medical negligence. London: Sweet and Maxwell, 1991.
Leape, Brennan, Laird, Lawthers, Localio, Barnes, Hebert, Newhouse, Weiler, and Hiatt. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II, NEJM, Volume 324:377-384 February 7, 1991 Number 6.
Lowenstein, "Where Have All the Giants Gone?: Reconciling Medical Education and the Traditions of Patient Care with Limitations on Resident Work Hours"
Perspectives in Biology and Medicine - Volume 46, Number 2, Spring 2003, pp. 273-282
The Johns Hopkins University Press.
McCall TB. The impact of long working hours on resident physicians. N Eng J Med 1988; 318: 775-778
Nebeker et al., High Rates of Adverse Drug Events in a Highly Computerized Hospital, Arch Intern Med 2005;165:1111-1116.
Pierce, Promoting Patient Safety by Preventing Medical Error, JAMA 1999;281:1174-1174.
Powers MJ, Harris NH, Lockhart-Mirams A (editors). Medical negligence. 2nd ed. London: Butterworths, 1994.
Rochlin, La Porte, Roberts, The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea., Naval War College Review in 1987, reprinted in 1998.
Rosen et al., Physicians' Views of Interventions to Reduce Medical Errors: Does Evidence of Effectiveness Matter? Acad Med 2005;80:189-192.
Schenkel, Promoting Patient Safety and Preventing Medical Error in Emergency Departments., Acad Emerg Med 2000;7:1204-1222.
Sexton, Thomas, Helmreich, Error, stress, and teamwork in medicine and aviation: cross sectional surveys, BMJ 2000;320:745-749 ( 18 March )
Shojania et al. Safe but Sound: Patient Safety Meets Evidence-Based MedicineJAMA.2002; 288: 508-513.