Showing posts with label mary fernando. Show all posts
Showing posts with label mary fernando. Show all posts

09 June 2019

How Long Does Grief Last?


In a few weeks it will be one year since Carol died. She was my dearest friend since childhood. I hesitate to write about Carol because using words to describe a friendship like ours is like trying to carve a sculpture from water. 

We met when we were seven years old and throughout our childhood we wandered our neighbourhood chatting and laughing. During our teens we talked intensely about every dream, every heartbreak and all the new feelings descending on us. As we became adults we discussed university - all our courses, all our insecurities and, eventually, our marriages. She shared her stories of students she taught in her lab and I shared stories of my patients.

When my children were born, she was the first one in the door. She spent countless hours with my children, wandering the woods, reading books and calling every birthday with her lovely rendition of Happy Birthday. My children were almost in their teens before they realized that their beloved Aunty Carol wasn’t related to them. 

Over our decades of friendship we never fought. We thought that was odd since we were both intensely passionate people. What we did do was to find the humour in every and all incidents in our lives - no matter how trivial or serious. The closest we came to fighting was when we had spirited discussions about who paid the restaurant tab. We discussed this intensely and decided it was not as serious as a squabble but also more serious than a quibble, so we named these squibbles. We found that so funny and even our restaurant tabs became hilarious.

Once as the tab arrived, I asked Carol if this was going to be another squibble. She said it was going to be an outright squabble. We were grinning ridiculously at each other and the waitress asked - as we were often asked - about our relationship. People were perplexed by this Viking Beauty and WOC with a mass of curls and how we were so impossibly close. Carol, completely deadpan, replied, "Twins." Then, without missing a beat when the waitress looked perplexed, Carol continued. She pointed at me and said, "The lipstick always throws people." I have no idea how funny the politely smiling waitress found this exchange but we chuckled about it all evening. 

Over the nine months from her breast cancer diagnosis to her death, I visited, spent as much time as I could at her home. When she had her mastectomy, I was there and stayed for her recovery. We chatted and talked as we always did about everything. When we found out that the breast cancer had spread to her bones, we continued talking about that too. All through that time, we found so many things funny. Including cancer. When she was in hospital I stayed in her room when she was frightened.

Near the end, I had left to go home and her sister called and said she was asking for me. I went immediately and spent the last conscious night of her life with her. She lay there so quietly when I walked into the room that I pulled up a chair and held her hand. She said, “Mary! I would know that tiny hand anywhere.” We hugged. And then she slept. As I watched her sleep, I marvelled how, with her brain full of cancer, she still knew my hand. Still loved me. 

Many people have wondered when I’ll stop grieving Carol’s death.

A friend recently sent me an article that looked at a study where “They collected data from 26,515 people over 14 years, and found a range of negative consequences experienced by those who had a close friend die. In the four years after a death, significantly adverse wellbeing was found in people both physically and psychologically.”



This reminded me of a question I asked my supervisor when I started practice. I was trying to understand a patient who appeared to still be in mourning 15 years after the death of his child. I asked  about the length of the normal mourning period. I was young, didn’t have children but that question, quite frankly, was incredibly stupid. My supervisor kindly answered that the normal mourning period for a child was a lifetime. 

But what about a friend? Not just any friend, but a friend who forged me, who made me who I am and when there is nothing, nothing at all I have ever done that Carol wasn’t a part of? That kind of friend. My supervisor was a wise and kind man. If he were alive today, I would call and ask. I long for that conversation. 

There is something else about Carol and me. 

I was never the person I wanted to be. I wanted to be carefree, bold and irrepressibly confident. What I am is hopelessly serious, full of thoughts when I want to just be easy going. Carol was bold enough to climb apple trees without fear as a child and throw a knapsack on her back and head to Europe on her own after high school. She was far more carefree than I could ever be. She was a brilliant research scientist and a talented teacher. Maybe more so because she treated the meticulous and painstaking work of molecular biology like an adventurous journey with pipettes and gene splicing.

But we were also similar.  We both were totally honest, so we talked about our insecurities, our painful embarrassing incidents with ease. We also deeply loved kindness and recoiled from cruelty so we talked endlessly about the treatment of animals, children and people of all ages.  

For me to have someone as wonderful as Carol love me so deeply, so loyally 
for so long, made me feel better. Somehow less serious. Less hopelessly awkward. 

Carol was beautiful. Tall and blond. She was also strong. Until the last few months of her life. This photo of her as a young student leaving the apartment now is so poignant - it is her leaving me.

This year has been tough. My father died. My mother is now ill. I so needed to talk with Carol - these were the first hardships that I haven’t been able to share with her. Also, my daughter won a prestigious award and got a cat. My son went to Australia and published some exciting papers. Carol would have been eager to hear all of this and we would have chatted endlessly - and then she would have called the children for more details.

I miss hearing about the adventures of her life - her story was cut off mid-sentence. I want to know what would have happened if her story went on till we were old and ornery.

This was one of our last texts:



If there was ever a testament to the calibre of Carol, this is it. With cancer in her bones, spreading to her brain, unable to breathe and this, this is what she worried about: not being there for me. Steel in her spine. Pure steel.

This is the story of Carol and me, but each death leaves people with stories cutoff in mid-sentence. While some friends wonder when I'll get over my grief - my longing for Carol - my children and husband don't wonder. They share memories - sometimes we cry, sometimes we laugh - but always we miss her. We expect nothing less. 

Since I can’t ask my supervisor, I’m going to call this one. 

I will miss Carol for my whole life. 

When I die, missing her will be one of the last thoughts I have.

12 May 2019

Epigenetics and Elephants


Most of the time I interview people and allow the things they ponder to guide my writing. This is not that article. This is about my late night pondering. Excuse the indulgence, but it’s been a a tough year and I’m prone to sleepless nights and thoughts.

Unable to sleep, I was ruminating on epigenetics and elephants. They may seem odd things to stay up at night about, but these are seriously important.


What epigenetics does is shake things up. DNA decides who we are but life turns our genes on and off - impacting everything from the architecture of our brain to the diseases we have. 

If you want to keep up at night too, just read about how this happens and how we can reverse the DNA changes that happened to your grandmother.

What actually jolted me out of a slide into a lovely slumber was a child. In a shopping cart. 

I was young - probably around 8 - and shopping with my mother. A child less than 2 in a cart passed by and she was sobbing. Her mother, her face clenched in that angry way that makes people truly ugly, slapped the child and said, “Cry again and I’ll give you something to cry about.’ As if that poor child didn’t have enough to cry about. I said to my mother, “Do something!” She said, “Shh.” Afterwards, my strong, well-educated mother told me that much as she would like to, it’s impossible to change how people parent.

There are many things that make us decide on our profession and making medicine my choice was about a series of decisions. All of them started at that moment. I was going to get an education that could help that child.


Choosing medicine would never have been something I did if I didn’t see a road to working with the damaged, the broken and, as I eventually did, stop the breaking and beating. I only went into medicine to work in mental illness.  

Let me tell you about mental illness and medicine and the place it has.  Many wonder why anyone would chose it. I have literally had people ask why I gave up medicine and chose to work with mental illness. Let me get this perfectly clear, I am a doctor who works with the mentally ill. As a doctor, I bring skills to the table because no brain tumour masquerading as depression gets past me. So, I am a doctor. Who works in one of the most important fields of medicine: with the mentally ill. I didn’t fall into it. I marched toward it, and went through medical training and 8 years of specialty training to have the privilege of working with patients that I wanted desperately to work for.

And that’s where epigenetic comes back in. Changing someone’s mental illness changes their genes. Leaving it does too. Those illnesses that all doctors battle, well I battle them too. In a different way, on a different battlefield, but it’s all medicine.

This all made me think of Dr. Fraser Mustard, who I had the honour of meeting numerous times. The last time I saw him was in his lovely home in Toronto, where his children lived in the apartment above him. After an illustrious career in medicine he had ended up pondering epigenetics and childhood trauma. He wrote about it brilliantly. He advocated for children. He was very old when i met him but this belief in helping children made him seem ageless. Children do that to you. In his apartment, so full of interesting things, was where I first thought of how he must stayed up at night worrying about children and that made it his life’s work at the end.



Sometimes, at the end of a career, you ponder the beginning. The thing that started it all. The work you have done and the value of it all.

Now I’m writing another book. It isn’t a departure from any of my other work. It is about the lost, the damaged and the suffering. I can’t change course because I simply don’t want to. It is what we see, truly see, that decides our course in life.

There is an African Zulu greeting: “I see you.” It is a haunting saying. When I was young, I visited many zoos around the world because my biologist father would meet other biologists and talk about the conservation efforts they were making at their zoos. I understand the conservation part. I do. But I really didn’t give a damn then, or even now. I hated zoos. Seeing the animals, really seeing them, in cages that were far too small or chained up - because that was the way zoos were then - I could see that the cages and chains around the elephant legs were truly like beatings. They diminished these animals, and their suffering was evident to anyone who bothered to look. In East Africa, where we spent many months on various trips, I saw wild animals on the plains. My first sight of elephants, not in chains but walking and taking such tender care of each other, made me fall in love. For the wildness of them. For the beauty of them. For the tenderness. I saw them.

Medicine or writing or elephants - it is all about seeing. All of it will keep you up at night if you let it. And these days I do.

And that child, being beaten in a shopping cart for all the world to see but not intervene. That too. That always. It shaped my life. I wish I could have told that tiny darling that. 











22 April 2019

DNA Testing for Crimes by Twins


Science is on the verge of distinguishing between identical twins. Consider cases of crimes where DNA material leads not to one person, but two: identical twins. Until now, no one could say with certainty which twin might be guilty. Here's why.

Each twin comes from the same egg, split into two, creating two eggs with identical DNA. Old DNA testing was unable to distinguish between identical twins, but there are two fascinating options on the horizon that might just help.

The first difference between identical twins begins immediately. Although each is endowed with the same DNA - “When a fertilized egg starts dividing, there’s a small chance each new cell will gain a new mutation. When the cells separate into twin embryos, one gets some of the mutant cells and the other gets the rest. Unique mutations will end up in cells throughout each twin’s body.”

“Such a test would be difficult, then — but it would also be definitive. Just a single mutation, confirmed by multiple analyses, would be enough to implicate one twin and exonerate the other.”

“It’s not something that’s going to happen every day in every laboratory,” said Dr. Krawczak (a geneticist who now teaches at Kiel University in Germany). “But once people become aware of this, there may be a lot of cold cases that come back to life.”

However, this testing is in its infancy and is both expensive and time consuming.

The next set of DNA changes are called epigenetic changes and happen during embryonic development and continues for the rest of our lives.

Dia Rahman, a PhD student in Public Health at University of Waterloo has a special interest in social impacts on health and, therefore, is fascinated with epigenetics. “We are born with our DNA but what is impacted by the environment is the dance between active and inactive genes,” Dia says. “That is what is impacted by our upbringing and experiences. That is epigenetics.”

“A common analogy used to describe the epigenome is to consider genes as instruments in the “symphony” of life. But they don’t play themselves. They need musicians. Epigenetics would be the musicians that help express (or silence) the performance of our genes. Exercise, sleep, trauma, aging, stress, disease, and diet have all shown significant effects on the epigenome.”

Detecting epigenetic changes is faster and cheaper than looking for mutations. Graham Williams at the University of Huddersfield, UK, has found that epigenetic changes alter the melting point of DNA. “When the team heated up the twins’ DNA samples, they found the melting points were different – allowing them to tell the twins apart genetically. The test was also much quicker than whole genome sequencing, says Williams. “It can be done in just a few hours.”

So, essentially, we are born with our DNA - an entwined gift from our mother and father. This is not immutable. Some of our DNA can be altered by mutations. Parts of our DNA is also turned off and on by how our life impacts us. As our DNA testing improves, we can distinguish between identical twins.

Perhaps the most important part of all this has nothing to do with crime. It show that our DNA we once thought never changed is actually impacted by the life we live. And that is fascinating.

10 February 2019

The New Playground of Criminals: Sexting and Phishing.


Amanda Todd was in grade seven when an on-line stranger convinced her to expose her breasts. Then he attempted to blackmail her, saying he would send Amanda’s naked image to family and friends if she didn't provide him with more nudes. She refused. He sent her nudes and, from that point on, she was ridiculed and bullied. 

After making a heartbreaking video, Amanda took her own life at fifteen.

Research looking at 110,000 children, all younger than 18 and some as young as 11, found that one in four young people had received sexts, and one in seven reported sending them. 


This is the new back alley rife with predator crime: the internet.

Darren Laur spent 30 years of his life as an inner city policeman. He retired three years ago, got certified in Open Source Intelligence and now specializes in online investigations.

“To date we have saved 186 youth who were considering suicide and self-harm in response to bullying and a full third of these were because of sexting,” says Darren in a voice that marries authority and empathy in equal measure. “We have the resources to do these investigations and put a package together to bring to law enforcement.”



As a policeman he wants to do what he has always done - he wants to put the bad guys away. He also wants to continue the work he did in the inner city - to help people by steering them in the right direction. Through his company - White Hatters - he does outreach for teens. His research shows that 1/4 of teens have sent nudes by the age of 16, and the youngest one was in grade 4. 79% of them were pressured into sending these nudes - often in the context of relationship building.

So, while explaining the dangers of sexting, Darren also recognizes a painful truth: preaching abstinence will only work for some. Just like with sex education with young people, an abstinence-only message is not as useful as giving a more robust message of safe sex and protection. With sexting that is the message he offers. Safe sexting.

If you are going to sext- because young people will - Daren teaches harm reduction. Sexting should be done without your face, or anything that can identify you like tattoos, clothing, background. This way,  if it goes public it is not evident it is you and there is deniability. He also teaches how to scrub any metadata that identifies the individual.


Darren explains that safe internet interaction applies to a far wider area than sexting. Those of us on the internet might want to be aware of another internet crime: Phishing. 

This is the use of a phishing link on twitter, email or texts, where a simple click can open you up to identity theft and fraud. Fraudsters will use social engineering to assess our likes and dislikes and use them to fool us into clicking links.

“According to Symantec’s 2018 Internet Security Threat Report (ISTR), a whopping 54.6% of all email is spam. Even more to the point, their data show that the average user receives 16 malicious spam emails per month”

“There were two bits of very bad news for consumers in the recent annual survey of identity-based fraud. First, there were 16.7 million victims in 2017, easily the most ever, fuelled in part by a series of high-profile data breaches. But even worse, criminals are migrating to more sophisticated, multistep frauds, with the rates of new account fraud and noncredit credit card fraud soaring. Why should you care? Those are the crimes with the most potential to hurt your credit score.”



Darren explains, “We can strengthen internet security, but the weakest link is always the human link.”

Every day, I join many others in clicking sites on searches, opening emails and texts and clicking interesting URLs on Twitter - oh, a cute dog video! Click. Click. 

 I agree with Daren. I’m a weak link. Wandering around like Bambi in the wild west of the internet. 



 I’m grateful that we have Darren Laur and investigators like him to educate us and – if we become a victim of identity theft or a number of other crimes – we have someone to fish us out.

Pun intended. 



13 January 2019

Nurse burnout: Maitre d' or Sentinel?


“The hospital doesn’t have Splenda.” was a response on a Patient-satisfaction survey. “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
That happened.

Surveys used to assess nurses also ask questions like, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” 

Hospitals with high patient-satisfaction scores get more money, so nurses are under pressure to do everything they can to make patients happy.


Also in the news: “Forty-nine percent of registered nurses under 30 and 40 percent of registered nurses over 30 experience burnout, according to one study — a sobering statistic for healthcare providers who want to improve patient care.”

These two things are related.

“Nurses are not waitresses or waiters,” says Nurse Smith, who has been a floor nurse and is now a nurse educator. “I see nurses as sentinels. A sentinel stands guard and is constantly on alert.

 “When a nurse walks into a patient’s room, there are a hundred things going through their mind. They are looking at monitors, carefully selecting which ones are important given the patient’s disease and treatment. They need to understand not just the physiology but the pathophysiology of the disease so that they can assess the patient and monitor their progress or decline.

“If an elderly demented patient starts to act a little wonky, is it just the waxing and waning of their dementia? Could it be some form of a hypoxia, perhaps a stroke? They need to have the assessment abilities to know if this could be a serious issue, when to call in the doctor and which tests could help clarify what is happening with the patient.

“They also need to assess when patients need more time. And it is not always the loudest patient. It may be the very ill patient whose blood pressure is dropping and a good nurse needs to attend to them.”

 The name of the game is not patient satisfaction - it’s patient safety.

So, surveys asking patients if the nurse came when they were called are completely inappropriate. The nurse must be given the clinical respect to make decisions about which patient needs attending to urgently and which patient can wait. What matters is did the patient get better? Did that nurse monitor and save lives of the very ill first? Even if some patients had to wait for ice chips. 

Nurse Jonathon - a nurse with over a decade of experience in the emergency room, critical care and in management - explains that numerous issues contribute to burnout in nurses.

“There are often too few nurses per patient and that is not safe,” says Nurse Jonathon. He points out that in an emergency room there could be a number of patients that should be admitted to the ICU but are waiting for a bed. These patients require constant care but there may be six to 9 other patients, or more, that the nurse needs to watch over and care for.

‘We are the ones who monitor patients,” says Nurse Jonathan, “No one else but your nurse monitors you 24/7. Everything from heart rates to breathing to blood pressure. We constantly assess patients.

“Most nurses have a passion for excellence and we want to get everything right. If something happens to our patient, we can’t stop. We must move on and take care of the next patient. We can’t stop for a second. These are peoples’ lives.

“Hospitals don't help staff to cope with these feelings. A debriefing would help. To understand what happened.”

Nurse Smith explains, “As the patient goes through their journey in hospital, it’s the goal of the nurse to help them advance every shift - to get home or at least get better. At the change of shift, it’s like a relay race - you pass the baton to the next nurse who continues the journey.”

Handing off your patients and doing so safely is one thing. But what if you are handing over too many patients for the next nurse to handle? Worry. Because all good sentinels watch and keep those they stand guard over safe. 

Many surveys demand nurses do a job that has no resemblance to the job they were trained to do. Nurses feel the pressure to do certain things to get good scores on these surveys. Ultimately though, nurses want to do their real job. The one they were trained to do. They want to keep watch over patients to keep them safe, to intervene when they need to and to have enough time to do this job well. They were trained as no one else is to do their job.

Letting nurses do their job, having enough nurses to do the work safely and having an opportunity to debrief from stress would go a long way to reducing burnout. Oh, and holding the Splenda comments.

Note: The real names of the nurses were not used. Both practice in the United States.

09 December 2018

Part Two: Physician Burn Out and Suicide – The Road She Forged.


Dr. Mamta Gautam developed complications in her pregnancy and, after delivering twins in 1991, she was in a coma for days. She was soon forced to return to work with an open abdominal wound. She realized then and there that, “Medicine doesn't care about the health of their healthcare workers.”
What Dr. Gautam did with this knowledge was to carve out a new way to do medicine. A psychiatrist by training, she became the “Doctor’s Doctor” and, in the 1990’s, began work with individuals and organizations to address burnout and suicide before it was on anyones radar.
A pioneer in the field of Physician Health, Dr. Gautam founded the University Of Ottawa Faculty Of Medicine Wellness Program, the first in the world to deal with physician health issues. She is now an international expert in physician health and leadership. 

So, when I was searching for answers on how to help reduce burnout and suicides in physicians, I reached out to her to find solutions.

Dr. Gautam said, “Before I answer, I want to talk about complexity theory.”

At this point, I had my pen poised. When interviewing people, I always wait for what Virginia Wolfe eloquently asked of them: “…to hand you after an hour’s discourse a nugget of pure truth to wrap up between the pages of your notebooks and keep on the mantelpiece forever.” I was a little disappointed to be sidelined by a theory I hadn't heard of, rather than an actual solution to the serious problem we were discussing.

Luckily, my disappointment was short-lived because that theory, and how it applies not just to medicine but all professions, actually was a nugget of pure truth. So, here it is for you to wrap and put on your mantelpiece. Forever. Whatever your profession.
  • Dr. Gautam explained that some problems are Simple and can be solved by following simple instructions, like baking a cake. There are instructions, and if they are followed, we have a cake.
  • Some problems are Complicated but can be solved by following more detailed instructions and require expertise, like sending a man to the moon. With the right expertise, we can again have a solution that we can replicate.
  • Some problems are so Complex that their solution cannot be boiled down to a list of steps and and expertise doesn't always help, like parenting. If you add people in, we have different outcomes depending on the person (in this case both the child and the parent). So, we are better off with guiding principles, rather than strict recommendations and rules. 

With physician burnout and suicides, prevention is best thought of in terms of guiding principles, at the level of the individual physician, the culture of medicine, and the healthcare system.
One key principle is the need for community. For some this may be implemented by re-creating the doctors’ lounge. This where we can gather and talk about the day; the hard parts, the best parts and the funny parts. It is the ability to break out of the isolation and connect. For all of us, no matter what profession we are in, the trauma of our day can haunt us. For physicians, this might be the patients who died despite our best effort, the metallic smell of the blood that covered the patient, the room and us in surgery as we struggled to save a trauma patient, the young baby who fought valiantly and the breathless sobs of her parents after she died. Those traumas we need to talk about. 

The next part - and the crux of the matter: doctors are human. They should not be so tough that their hearts aren't wrenched when patients suffer. We can and should viscerally feel the often soundless sobs of the families that mourn. That is who we are, and that is the best of us. So, there must be an end to the ‘tough doctor’ and a new opening for the human doctor.

This is a principle for all healthcare workers and for all professions. We have many ideals that we strive towards, never being able to truly fulfil them but always keeping them in mind as we move through life. Many are worthy ideals. However, the ideal of the very strong, very together, never broken and beaten down person is an ideal that many of us hold dear. That person, that ideal, is actually a Trojan horse: if we let it into our lives, it will become stuffed full of all that will defeat us. It will be filled to the brim with the guilt of not living up to this ideal and the feelings of vulnerability that we stuff in it because we are terrified that the feelings are not worthy of the person we should be. It will be filled with the trauma we face, the small and large wounds we suffer but do not speak about. So, it is time to find another ideal and recognize the Trojan horse for what it is. We need to be human, striving to be strong when we need to be and allowing ourselves to be vulnerable, weepy and sad, infuriated and needy too. Because our empathy, our compassion, that makes us vulnerable, is actually the true iron in our spine. Wholly and wonderfully complexly human.

So, how to recreate community where we are allowed to be fully human?

Dr. Gautam said, “There is not one answer. If people accept the need for community and allow each person to be human, how they create that community depends on where they are and what they need.” 

So, Dr. Gautam asks for solutions to this, from each of us. The principle matters, the execution of the solution, like all good answers to difficult problems, is written on water and open to life. 

She sees this article, and others like it, as an opportunity to ask each person what they need and how to carve out this solution. It is a beginning of a conversation we all need to have.

28 October 2018

Hell hath no fury...


Imagine being so ill that you cannot even get out of bed. Or being too sick to spend time with your family and friends. Now imagine being too frightened and ashamed to tell anyone you are ill. Being so humiliated by your disease, that you can’t even tell your own doctor that you are ill.

One out of five people, 20% worldwide, have a mental illness. Many often go through this scenario. Some bravely ask for help. Some hide in the shadows. Some hide in alcohol or drugs.

When I was a young, inexperienced doctor, I was certain that the unfair stigma of mental illness would and should be eradicated in my lifetime. I felt that mental and physical illness were both simply illnesses to be treated. Now, after treating mental illness for decades, I know that I was correct. 

The suffering of those with mental illness is real, and as varied, as patients suffering from anything from a broken leg to heart disease. Just as there is nothing shameful in having cancer, there is nothing shameful about having a mental illness.

Where I might have been a tad optimistic was in my hope that all the stigma of mental illness would be eradicated in my lifetime. However, since I am not dead yet there is, indeed, time. I have seen a lifting of the stigma of mental illness, a willingness to talk about it and reach out and get help. 

What we still need to do is reach into the dark corners, the places where this stigma grows, and open the curtains and let the light disinfect the place. 

The one prevailing myth that needs some attention is that the mentally ill are dangerous. This comes from articles about murders or violent crime, where mental illness is brought up as a possible cause. Also, from the books where murderers are often mentally ill: yes, I mean novels about crime.



If there is a disinfectant for myth, it is fact. 

Since the U.S. has one of the highest incarceration rates in the world, with 666 citizens in jail per 100,000 of the population, we can assume that most of the dangerous people do end up in jail. However, if all those who are mentally ill were dangerous, that would mean that 20% of the population, more like 20,000 per 100,000 population, would be in prison. 

How about an analysis of those who are in prison? Large scale reviews have shown that, in the prison population, less than 4% have psychotic illnesses. 

The myths of mental illness and murder arise most frequently with the worst offenders: mass murderers. Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century, has found that only one in five are psychotic or delusional. This means that 4 out of 5 mass murderers are people who are clinically sane. 

Even analyses of those who are mentally ill and commit crimes shows that only 7.5 percent were directly related to symptoms of mental illness. 

So, is there NO connection between mental illness and crime, particularly violent crime? The answer is that there is a very small connection, and one that is present largely in those who are not treated and who also abuse alcohol/drugs.

Those who are depressed are three times as likely to commit a violent crime. However, 60% of people who kill themselves have a mood disorder and suicide is the tenth leading cause of death in the US overall, and the second leading cause of death of 15- 34 year olds. Since there are twice as many suicides as homicides, the most likely violence done by depressed people is to themselves, not to others. 

With schizophrenia, the risk of committing a violent crime was 3-5 times greater, but this was found largely in those not on medication. This research on violence and mental illness also showed that those who are mentally ill are more likely to be victims of violence than perpetrators.

For a final look at mental illness and murder, I present the full quote from the title of this article: “Hell hath no fury like a woman scorned.” Most of us would say that scorn is a good motivation for murder and that Shakespeare was insightful for writing this. However, Shakespeare didn't write it -  it was written by the playwright William Congreve. Further, this isn’t even what was written - the actual line is ‘“Heaven has no rage like love to hatred turned / Nor hell a fury like a woman scorned.”

Common, widespread ideas can be wrong - like the origin of this “Shakespeare” phrase and the idea that those with mental illness are inherently violent. Certainty is meaningless unless it can be backed by facts, and in this case the facts do not support the certainty that most people feel.

Sometimes our first impression is wrong. Even with things we feel that we know, such as Shakespeare or mental illness.

14 October 2018

The High Passion of a Woman: Men Are Victims Too


“I’m embarrassed. I’m supposed to be the man of the house, and these things don't happen to a man.”

I’ll call him James because he doesn't want his real name to be used. However, James wants his story to be told: it is a story about a woman he was living with.

“She was charming. Sexy. Everyone wanted to be friends with her. My parents loved her, but her own mother was a nightmare. I felt sorry for her.”

The escalations were small, each a little more violent. Each incident was followed by abject apology. At first, her abuse was just verbal, then it became physical. She was a mean drunk. She would put away a litre of wine and then scream, throw things and hit and kick. Once she drove her car into James.

Out of his depth, he determined to leave, but each time, piteous tears and wretched apologies reopened his heart. One day at work, for example, he found a note from her with a little cartoon that said “Every child deserves love, especially when they don't deserve it.” His heart broke for her; it would be quite a long time before he recognised manipulation.

At first, James felt he could put his own needs on hold, compensate for her terrible mother and lend her some of his strength. He soon realized that the violent escalations were too much for him: “The constant dripping of water creates a gorge.”

One day he watched a T.V. show with a woman talking about her husband’s abuse. She said he had a dead look in his eyes when he would start abusing her. Afterwards, he would promise never to do it again.

“I understood that,” said James. “A dead look would come into her eyes and I would think that this was going to be one of those nights… Like the girl on the parapet, I'm convinced a kind of self-deluding madness overtakes the perpetrator. Like in a Russian novel, they can't change their behaviour no matter how mutually destructive their actions are… The language of perpetrators indicate they're at the mercy of outside forces– this or that event 'made' them do it.”

The next time she turned physically violent, James called the police. “She was in such a rage that she took it out on the cops. They warned her that this was a warning and there would be consequences.”

James found that there was no place in domestic abuse shelters for men. He started to spend time away from home. Eventually, she departed.

Looking back on this relationship, and one with a similarly needy and violent woman in college, James said, “I felt I was bigger, tougher and could outlast the hardships. But the difficulties didn't go away and, instead, became emotional black holes. My sympathy for her turned into my own misery.”

Once, in response to an email request by a research student on assault, he answered the questionnaire but had trouble with some of the questions because they were geared to women, such as “Who was the first man who assaulted you?” When James explained that he was a man and had been assaulted by a woman, the student said “Women don’t assault men. You’ve got to be lying.”

In fact, studies estimate that about 2 in 5 victims of domestic violence are men. They are less likely to report than women and less likely to be believed.

“Does stuff that happens in childhood affect what happens later in life?” asks James. He points to his parents, who loved him but also believed in physical discipline.

Raised by a extremely strict parents, James’ mother would use a switch to punish him, which is a branch with the leaves removed. It was painful and left large welts. This history of harsh corporal punishment in childhood is strongly linked with developing relationships in later life that involve domestic violence.

To date, 53 countries have banned corporal punishment because of the lasting impacts on children. I know this is a contentious issue for many who believe in corporal punishment, however, the evidence is unequivocal.

I am deeply moved that James told his story. It is a story that shows that men can be victims of domestic violence. Men are less likely to come forward and more likely to be dismissed when they do. Let’s change that.

I’ll leave you with another story about James. He met a very intriguing woman. She was sexy, smart and funny. She swore at him a few times. He asked her never to speak to him like that. She continued. She tried to sleep with him but he had concerns, so he refused to sleep with her. When he left her after she swore at him yet again, she said “If you slept with me, you wouldn't be leaving me now.”

James said “She was right. It’s easy to get sexually besotted and then emotionally unable to walk away. Enticing as she was, I realized she wasn't going to change. I felt I had grown up just a little. It is the high passion of a woman that draws me in, but that highly charged, highly sexual passion can be a cover for a whole lot of problems.”

Yes it can.

07 October 2018

Talking Turkey


Tomorrow Canadians celebrate Thanksgiving and, in case you wondered, Liberia celebrates Thanksgiving the first Thursday in November. The time or place matters little to bachelors who celebrate the holiday much the same no matter when or where.

A Bachelor Thanksgiving
in honour of the Canadian holiday
arrangement in ironic pentameter
by deservedly anonymous


Thanksgiving cornucopia
I think I shall never sniff
A poem as lovely as a whiff
Of turkey and mashed po—
tatoes and frozen snow–

Peas in vast disproportion
As I gulp another portion.
Cranberry sauce, count me a fan,
Maintains the shape of the can.

Cheap beer and cheaper whiskey
Makes the shallow heart grow frisky.
Three litre jugs of screw-capped wine
First tastes horrible, then tastes fine.

Deli turkey, cellophane wrapped.
Processed ham and all that crap.
Sherbet, ice cream, anything frozen,
Packaged cupcakes by the dozen,

Ruffled chips and onion dip,
Reddi-Wip and Miracle Whip,
Maple frosting found in tins
Hide the worst culinary sins.

Seven-fifty millilitres of
Grain vodka labeled Scruitov,
Cheap brandy and cheaper beer
First smells awful, then tastes queer.

Pumpkin pie and store-bought cake,
Anything I need not bake.
If it’s boxed, if it’s canned,
I’m no gourmet, only gourmand.

Chorus    

Baseball, football on the TV.
One spilt bowl of poutine gravy.
This little poem with each verse,
I give thanks if it grows no worse.
vintage post card wreath turkey

vintage post card children, turkey, pumpkin

We admit nothing except Happy Thanksgiving. Graphics courtesy of Antique Images, The Holiday Spot, and Spruce Crafts.

21 September 2018

My Father Died Today


My father died today and I am left here, with my keyboard and memories. 


My father was born in Ceylon in the 1930s, but he had no sense of the place or time he landed on this planet. He was always immersed in books -philosophy, the classics and his beloved biology- and he had little regard for the social norms that were simply invisible to him.

My father got his PhD in Biology at Oxford University, at Christ Church College, in the 1950s. When my son asked him about Oxford, my father - one of the few non-whites there - did not comment on the prestige of Oxford, or the lack of diversity. That was not my father’s style. He was unfailing honest, so he talked about what mattered to him: how, as a poor student, he was able to buy so many of his beloved books at second hand stores and how he had his first sexual relationship there. Yes. That is what he said. That sealed the deal for my son - he was going to university.

My father was born into a wealthy family, one of a long line of doctors and scientists. Growing up in Ceylon, a country with a rigid social stratification, he had a servant whom he chatted with and respected. My father took him on collecting trips and was amazed at his fine mind. We knew him only as ‘Dr. Johnson’ because that is what my father called him. Whenever we returned to Ceylon, Dr Johnson would accompany my father on his collecting trips and lectures.  It was not until I was older that I realized that Dr Johnson was not a professor and he was different than the famous scientists that I often met. Dr. Johnson had no qualifications - not even a high school diploma - and as an adult I found out that my father had given him some family land, helped him build a house and sent him money every month to allow him to educate his children and live a life of ideas. ‘Social justice’ wasn't in my father’s vocabulary - he just did what he felt was right. Whether he was sitting with Maasai in the plains of Africa, or world famous scientists in the halls of a university, he was the same - it was people that he loved and he remained blind to the differences that others saw.

He fell in love with my mother, and stayed in love with her for 62 years. In my mother he found someone as oblivious of norms as he was: she was an MD/PhD with a passion for Parasitology. My father - with his eyes on science -  missed the chauvinistic memos of the 1950s. In my mother he saw a mind that he thought was finer than his. He supported her through her career. He also felt he was a better cook, so he cooked for her all his life, leaving her free to do her work. He supported and fought for many women in science in his lifetime - it was their minds, not their sex, that he focused on and championed.



He took our family around the world, through Africa, South East Asia, the Americas and Europe. He felt at home wherever he was, as long as he could talk bugs and fish, eat good food and share stories and laughter.

Deeply moved by democracy and fairness, my father had no tolerance for political despots. I know this not from what he said but from what he did. He took our family - often at young ages - through dangerous countries in search of fish and bugs. He faced men with machine guns and machetes with equal calm. He had a job to do and we simply went with him. Nothing speaks of his boldness as well as when he was in Singapore, on his way to the Philippines. We were not with him but called to tell him that the Philippines was in the middle of a coup. He said: If I stopped my work for every coup, I would never get anything done. My father felt strongly that political despots, dictators, and even civil war, were transient. Science, that careful, meticulous work of men and women around the world, that is what would endure and he would do his small part to contribute. Looking back - he was right. The despots are now dead or overthrown. The work of the men and women of science has lived on.

My father’s sense of fairness, and his support of my mother, occasionally made his life miserable. We were traveling during his sabbatical year, were in Malaysia, and my mother asked my father to bring some samples from chickens when he visited Burma (now Myanmar). In my father’s mind, if you took anything you paid. So, he offered to pay to collect chicken feces - chicken shit -in an isolated village.  As he was depositing samples into carefully labeled bottles of formaldehyde, he looked up to see many villagers, all carry bags, some of them in various states of degeneration, all filled to the brim with various animal feces. The word must have gone around the village that there was an odd man paying for shit. My father could see how poor these people were and so he did what few people would do - he left with his biological van filled with shit and his wallet empty. He told us this story over a meal, coupled with laughter.

Oddly, for a man of science, one thing my father would never accept is the death of people he cared about. He refused to go to any funeral. Ever. He simply could not bear it.

My father taught me to eat a good meal with people I care about and find a good book to read - every day of my life. He taught me to find every person, in every country, as comfortable as home. He understood - ahead of his time - that the world is a very small place. He taught me that chauvinism and racism are to be ignored in the face of larger, more important pursuits.

Unlike my father, I do go to funerals and I will go to my father’s funeral - my second this year. Why? Because my father - literally - gave me the world.

12 August 2018

He Had Plans for Her


“He laughed a lot, but not loudly. Other people naturally deferred to him. He was a skilled communicator,” she said, in that famous voice, like smooth whisky with a touch of honey. “We married very quickly. I was very young.”

After they were married, he began to reveal his plans for her. By humiliating and belittling her daily, he made her feel small, unimportant and made it easier for her to be controlled. It taught her that she was no match for him. If she disagreed with him, embarrassed him in any way, there would be consequences. There would be beatings. She learned to never disagree. Never to say anything he would disapprove of. She learned to avoid other people. To become isolated, because that too, made her easier to control.

She learned his rules. In the midst of fear and humiliation - she knew if she followed his rules, the beating would be less. And the beating would stop when she was pregnant. And he didn't beat the children.

She didn’t go to the hospital to give birth to her first three children, because he didn't want her to say anything when he couldn't control her.

When she was nine months pregnant with her fourth child, she said something that upset him. He threw her down the stairs, broke her coccyx and sent her into labour. He took her to the hospital.

To keep her in line, to make it clear how unimportant she was, he parked and made her walk, bleeding and in pain, the long distance to the hospital doors. 

When the x-rays showed her broken coccyx, she told the nurses and doctors that she had fallen down the stairs. No one, no nurse, no doctor, asked her if she had been beaten, if she felt safe. When she went into full labour, she refused all pain meds, fearful that she would say something she shouldn't if she was drugged.

After she delivered her baby, she began to realize that there were no rules that could keep her safe. Before, her pregnancies had protected her from severe physical violence. Now she knew that he was eventually going to kill her. And then who would take care of her children?

That provided the impetus to get help from a women’s shelter. Here she voraciously read their literature on abuse, found solace in those who cared for her and her children. 

But he still had plans for her. 


Before she could escape and build a life for herself, he kidnapped her children. To get them back, she had to go with him. She went with him.



For three days, he tied her down and he tortured her. Beat her. Humiliated her. Raped her. She still remembers that moment during those horrific days that she caught a glimpse of herself in the mirror. She was filled with loathing for the woman she saw in the mirror. She hated what she saw. What he had made her. 

“I now know I was just doing my best,” she said, whisky voice turning soft. “I was being extraordinarily brave to take the only path forward I could see for my children. For myself.”

That path was to get her children back, escape him and make a life for herself. 



You probably know her as Eve, or by her twitter handle @BrowofJustice. She is a nurse who is fierce about the care of her patients and the raising of her children. She is fierce in defending others. You can’t scare her, because she has been to hell and she walked out. On her own two feet. And she has other things that terrify her.

Eve is not alone, not only because she now has friends and colleagues. She shares the same story as the one out of every three women worldwide have been the victims of physical and/or sexual violence by an intimate partner or sexual violence by a non-partner at some point in their lives. Less than 40 per cent of the women who experienced violence sought help of any sort. Less than 10% sought help from the police.

Healthcare providers - doctors, nurses, nurse practitioners, PSWs - all need to be trained to see the signs of domestic abuse. We need to ask - do you feel safe? We are trained to recognize heart attacks and strokes. We need to be trained to help curb the epidemic of domestic abuse. 

Eve is the voice of these women and her story is their story.

One of the reasons women don't speak, don't escape, is that they are frightened that their ex-partner will eventually find them and make them pay for breaking their silence. They are scared that they will never be free. Never feel safe. 

When I write the rest of Eve’s story next month, it will become clear why Eve, like many women, is justified to have these fears.

17 June 2018

Someone Else's Nightmare


“Some men hear the word ‘no’ from a woman, and they push harder with a side of violence,” says Dr. Sampsel. 

As a Clinical Forensic Medical Examiner, Dr. Kari Sampsel is the only Canadian physician with a fellowship in Clinical Forensic Sciences. Dr. Kari Sampsel is an Attending Staff Emergency Physician and the Medical Director of the Sexual Assault and Partner Abuse Care Program at The Ottawa Hospital. As the Medical Director of the Sexual Assault and Partner Abuse Care Program, when victims of  sexual violence come into the emergency room, she is in charge of the rape kit, assessments of sexually transmitted disease and pregnancy as well as setting up long-term physical and mental health care for these victims.

She states that statistics show that one out of every three women will be sexually assaulted in their lifetime. Although those who come into the emergency room are overwhelmingly 18- to 24-year-olds, women of all ages are raped, even those in their 80s.  Since 85% of rape victims know the attacker, Dr. Sampsel says that one of the crucial questions to ask is,“Do you feel safe?” and that this should be a screening question for all rapes. 

Interestingly, Dr. Sampsel says that younger woman are more likely to come into the emergency room to prevent disease and pregnancy, but it is women in their forties who are more likely to complete the evidence kit. Older women want justice but younger women may only want physical safety. 

During the ten years Dr. Sampsel has run the unit, she has seen a marked rise in the number of rape victims coming for help. However, she points out that it is only 10-20% of rape victims who seek help immediately. Some rape victims don't come in because stigma and shame keep them from reporting the rape. Interestingly, Dr. Sampsel says that after being raped, many are confused about what happened. This is only in part because of the use of alcohol or drugs. More often it is that trauma makes it difficult to remember. Later, they may get snippets of memory of the event.

A large proportion of rape victims develop recurrent symptoms like headaches and abdomen pain. Dr. Sampsel’s work is also to educate doctors in the emergency room and family doctors’ offices to recognize these symptoms and ask the right questions. 


I asked Dr. Sampsel how we can decrease the incidence of rape. She hones in on education. On three fronts.

The first thing we need to do to reduce the incidence of rape begins with our children. Young people should be educated in the need for consent on all levels. You don't have to give a hug unless you consent. If you are uncomfortable, you should walk away and adults should support this rather than be embarrassed.

In the emergency rooms and doctors’ offices: there needs to be an education campaign by those in the field, clarifying what to do with rape victims who seek help immediately and also those who come in later. Protocols for treatment need to be in place and these have to be adequately funded to mean anything.

On a societal level, Dr. Sampsel would like to see a public campaign, perhaps like the one that educates people on the signs of stroke. One piece of this would obviously be about consent and how it needs to be given in every circumstance of physical contact. This might seem extreme to some; however, if I rephrased it and said that every person entering your home needs consent and an invitation, it seems like common sense, does it not?

The other piece of this is what Dr. Sampsel calls a social contract: what is done privately between people should be up to the standards of what is allowed in polite and civil society, where we all adhere to the basic principle that how we treat others is how we would like to be treated. This has the perfect makings of a public campaign. 


With one in three women being assaulted, this looks like a healthcare epidemic to me. It rivals the chance of getting cancer or having a stroke. So, perhaps the same steps to reduce the problem are in order. The steps outlined - prevention, identification and public awareness - seem long overdue.


One final and haunting statement from Dr. Sampsel: “People need to realize that their flirtations may be the makings of someone else’s nightmare.”

08 April 2018

Hell hath no fury...


Imagine being so ill that you cannot even get out of bed. Or being too sick to spend time with your family and friends. Now imagine being too frightened and ashamed to tell anyone you are ill. Being so humiliated by your disease, that you can’t even tell your own doctor that you are ill.



One out of five people, 20% worldwide, have a mental illness. Many often go through this scenario. Some bravely ask for help. Some hide in the shadows. Some hide in alcohol or drugs.

When I was a young, inexperienced doctor, I was certain that the unfair stigma of mental illness would and should be eradicated in my lifetime. I felt that mental and physical illness were both simply illnesses to be treated. Now, after treating mental illness for decades, I know that I was correct.


The suffering of those with mental illness is real, and as varied, as patients suffering from anything from a broken leg to heart disease. Just as there is nothing shameful in having cancer, there is nothing shameful about having a mental illness.

Where I might have been a tad optimistic was in my hope that all the stigma of mental illness would be eradicated in my lifetime. However, since I am not dead yet there is, indeed, time. I have seen a lifting of the stigma of mental illness, a willingness to talk about it and reach out and get help.

What we still need to do is reach into the dark corners, the places where this stigma grows, and open the curtains and let the light disinfect the place.



The one prevailing myth that needs some attention is that the mentally ill are dangerous. This comes from articles about murders or violent crime, where mental illness is brought up as a possible cause. Also, from the books where murderers are often mentally ill: yes, I mean novels about crime.

If there is a disinfectant for myth, it is fact.

Since the U.S. has one of the highest incarceration rates in the world, with 666 citizens in jail per 100,000 of the population, we can assume that most of the dangerous people do end up in jail. However, if all those who are mentally ill were dangerous, that would mean that 20% of the population, more like 20,000 per 100,000 population, would be in prison.

How about an analysis of those who are in prison? Large scale reviews have shown that, in the prison population, less than 4% have psychotic illnesses.

The myths of mental illness and murder arise most frequently with the worst offenders: mass murderers. Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century, has found that only one in five are psychotic or delusional. This means that 4 out of 5 mass murderers are people who are clinically sane. 

Even analyses of those who are mentally ill and commit crimes shows that only 7.5 percent were directly related to symptoms of mental illness.


So, is there NO connection between mental illness and crime, particularly violent crime? The answer is that there is a very small connection, and one that is present largely in those who are not treated and who also abuse alcohol/drugs.

Those who are depressed are three times as likely to commit a violent crime. However, 60% of people who kill themselves have a mood disorder and suicide is the tenth leading cause of death in the US overall, and the second leading cause of death of 15-34 year olds. Since there are twice as many suicides as homicides, the most likely violence done by depressed people is to themselves, not to others.

With schizophrenia, the risk of committing a violent crime was 3-5 times greater, but this was found largely in those not on medication. This research on violence and mental illness also showed that those who are mentally ill are more likely to be victims of violence than perpetrators.

For a final look at mental illness and murder, I present the full quote from the title of this article: “Hell hath no fury like a woman scorned.” Most of us would say that scorn is a good motivation for murder and that Shakespeare was insightful for writing this. However, Shakespeare didn't write it - it was written by the playwright William Congreve. Further, this isn’t even what was written – the actual line is ‘“Heaven has no rage like love to hatred turned / Nor hell a fury like a woman scorned.”

Common, widespread ideas can be wrong – like the origin of this “Shakespeare” phrase and the idea that those with mental illness are inherently violent. Certainty is meaningless unless it can be backed by facts, and in this case the facts do not support the certainty that most people feel.

Sometimes our first impression is wrong. Even with things we feel that we know, such as Shakespeare or mental illness.



The US has the highest civilian incarceration in the world. — Ed.

11 February 2018

A Voice for the Dead


“I don't believe it, and none of us believe it.”[1]

That was the response to the police assessment of murder-suicide from one friend of billionaires Honey and Barry Sherman. This was followed by a chorus of agreement from many prominent Canadians, and subsequently by an expensive independent investigation which resulted in a revised new assessment of double murder.

Leigh Lundin asked me to look at this now high-profile Canadian crime being played out, blow by blow, in the news. So here I am looking at it. But with Canadian eyes.

Honey and Barry Sherman
Honey and Barry Sherman
My question isn't about what happened in this particular crime. I feel confident that it will play out in the investigation, and that the truth will emerge. My question is this: What would happen if a family disagreed, but did not have powerful friends or the money to conduct their own investigation? What if the family were poor, but still vehemently in disagreement? What if a murderer was on the cusp of getting away with it? Who would stop them? 


I brought this up with Dr. Coroner – not his real name but it would be a good one, because he is indeed a coroner. He is called in if a death occurs outside a hospital, and occasionally in it. His job is essentially to assess the manner and cause of death. Is this death natural, an accident, a suicide or a homicide?

The body can be photographed but cannot be touched until he is finished his assessment and releases the body. He looks at the story, told by the body, of the manner and timing of death. There is also the story told by the place of death, and the question for him is whether it is consistent with the story the body tells.

My question: If the family disagreed with a murder-suicide verdict, but were neither educated or moneyed – what would he do? What if the family was unable to articulate a story as well as the friends and family of the Shermans? What if they were angry and threatening, or in general made themselves unsympathetic?

He said often his job is to help reconcile the disbelief with the reality. Some counselling is often part of what he does with families.

Also, he argues that marriage – by the nature of the long term relationship – can lead people to kill each other, even if they look to others like they are happy. Marriage itself can be the reason for murder.

Those caveats aside, Dr. C. said there was enough from the story of the “murder-suicide” of the Shermans to make him suspicious, largely because the story is wrong. Domestic murder is often more violent, angry. Hanging is not what he would expect as a means of murder or suicide in this case. Hanging is more often seen in cases of mental illness or extreme distress. Further, why would a man who has copious drugs available to him choose this manner of death for himself and his wife?

If the stories of the body, manner of death and family assessment make Dr. C. suspicious in any way, he has many options to augment the evidence he gathers.
  • The authority of the coroner overrides privacy of information, so he can seize records from sources such as the family doctor, psychiatrists, and psychologists. This could provide a more fulsome picture.
  • He can seize all radiological and dental records, to see if there is evidence of previous abuse.
  • He can order a post mortem, or a forensic autopsy and refuse to complete the death certificate or even provide the funeral home with a warrant to bury, until he is fully satisfied.
Ultimately, the story must hang together. Regardless of the ability of the family to articulate their concerns, or their resources to investigate on their own, Dr. C. relies on having a coherent story told by the manner of death, the body, the family and the records seized. If there are inconsistencies – then a further investigation is warranted.

If a family were unable to mount the same vigorous objection and investigation as the Shermans have, it could be the coroner who stands between the constructed truth of the murderer and the actual truth of the victim.

Ultimately, all crime writing is social justice writing. And the poor have a voice – the coroner. The story of the body, uncovering the life lived, the manner of death, might be the key to catching a murderer. The background knowledge and tenacity of the coroner is what most of us rely on when our bank accounts are meagre.

Dr. C. said that the job of the coroner is to provide a voice for the dead, to listen carefully to the story they tell. This is the first step towards social justice for those without money and connections. They do this by asking the simple question:
Does the story of this death make sense?

07 January 2018

Radiology and Murder


Doctor John Doe (DJD) is a radiologist. That is not his real name, but it is his real profession. DJD is the doctor who reads CTs, MRIs and various other images that help diagnose illness. He is dedicated, competent, and once said a line which should be famous: ’When life hands me a lemon, I put it in a bag, find the person responsible and hit them over the head with the lemon.’ I adore him because feisty is always the way to go in life.

I asked him about his thoughts on murder:

DJD: I would be interested in seeing a two victim murder, in which the murderer uses the first victim as a pawn, believing that their death will cause such a deep grief for the the second victim, who is the person the murderer really wants dead, that their staged suicide will appear plausible. To the murderer, it appears like an undetectable crime. The murderer gives the first victim  a blow to the head and then throws them down the stairs or in front of an oncoming car, making it look like a terrible accident.

The second victim is someone who deeply cares about the first. They could be murdered by numerous means made to look like a suicide resulting from grief. Often people are prescribed sleeping pills or anti-anxiety meds to cope with a grievous loss. DJD suggests one easy way to kill them is to get them drunk and grind a deadly dose of the pills they have on hand into one of the drinks. At first blush, this looks like a drinking binge of a depressed person who decided to kill themselves because of grief. The murderer simply has to leave the staged evidence of a booze bottle and an empty, opened pill bottle. 

Could the chain of murders be unraveled, starting with a critical examination of the first, apparently random act? The radiologist could first examine cutting-edge radiological evidence postmortem.

DJD is sometimes called in when the coroner has questions about the cause of death. For example, did the blow on the head occur before the car accident, or was the victim lethally struck on the head and then pushed down the stairs? Using radiological evidence, that distinction can be made.

Although the forensic autopsy still remains the gold standard for post-mortem forensic assessment, the ‘virtopsy’ is catching up, sometimes augmenting or even replacing the autopsy. When there are religious or other reasons for excluding an autopsy, the virtopsy is the only evidence available. Sometimes, even with a pending autopsy, a virtopsy will be used. 

A virtopsy is the pre-autopsy whole-body CT or MRI scan, used to identify cause of death. Some studies have shown that a CT scan may be more effective in detecting some causes of death, and that the imaging may be better than a full autopsy to detect such causes of death as intracranial pathologies (such as strokes) and pneumothorax.

If someone is killed first, say with a blow to the head, and then pushed into the path of an oncoming car or thrown down a flight of stairs, most people assume that the serious and extensive injuries of the fall or impact will hide the original blow to the head. However, careful examination for the radiological evidence can clarify the timing of the injuries. And again, this can be done even if the family rejects, for religious or other reasons, a full autopsy. 

Impact from a car or a fall may show multiple bone fractures of the skull, ribs, vertebrae and extremities, as well as damage to organs. However, these impact lesions will lack the relevant surrounding hemorrhage which would have been expected under these circumstances. In short, if you die before impact, the lesions of impact will bleed less because your heart isn't pumping blood. This bleeding pattern will help identify the actual blow that caused death because of the extensive hemorrhage at that site of injury. 

This new radiological post-mortem examination is a cutting edge means of identifying cause of death and timing of injuries that were sustained. We will, I think, hear more about it as the techniques evolve.

One interesting use of CTs is identifying those who have been poisoned and then hit by a car or who have sustained other injuries. The amount of blood from impact injuries is reduced when the victim is previously killed by any means, including poison. 

A complex chain of events, like DJD’s proposed double murder, can be unraveled by tugging at the simplest loose threads. For radiologists, a virtopsy provides a cutting-edge method to find these loose threads and exploit them.

12 November 2017

Breathing


I still remember standing there, in that hospital room, decades ago. We had news to tell the patient and her family. Although at first it didn't look like it was going to be a bad diagnosis, it was indeed, very bad. That is medicine in a nutshell: we see behind and beneath and in the end the news is ours to tell, but not to craft.

As we told them the news the patient and the family held their breath. A whole room not breathing. Me too.

Afterwards, my supervisor, not fooled by my tough exterior - which I have found fools no one at all- gently said to me ‘When patients tell us their stories and let us help them, it is a privilege. Never forget that. Even if the story ends in tragedy, it is a privilege. Honour it by serving those who trust you.” Sometimes you are lucky enough to find people who define you, who are in your life and shape you to be better. This was the man and he shaped my approach to patients for the decades. It taught me to serve. To know it is a privilege. And that patients don't breathe when the news is bad.
I scuba dive. In the boat, at the dive site, the ocean stretches out, and there is a sense of glass and ripples. Diving in, there is coral, turtles and fish. I love that there is another world under the water. I love the beauty of it and how hidden it is. Most of all I love being able to breathe underwater as I move forward deep in the ocean.
Back to patients. There is nothing that prepares you for what medicine is either. What the surface of medicine looks like is nothing like the truth of the practice. Yes, you help. Yes there are medicines to offer but the reality is the stories. The ability and privilege to immerse yourself in the lives of patients where you see their hopes, their loves, their fears and finally, even their deaths. And this brings me back to breathing.

In many books, authors will say that, in response to bad news, people feel ‘punched in the gut’ or ‘their world collapsed’ In reality, what I have seen is that patients, and the people that love them, hold their breath. And I recently learned why.

I have had many people who have shaped me, made me better, because goodness knows, I have needed that, perhaps more than most people.

The person who shaped me most, I met when I was about 6 or 7. She had a blond pixie cut and bright blue eyes. We were the same age but she was much smaller than me. When the large school bully kicked the cello she was carrying, she grabbed his arm and twirled him around and around and sent him flying into a wall. She would wander streams, ride her bike in the woods, and strangely, at the corner store while the rest of us bought chocolate, she would buy a carton of milk. An original from start to finish. I did what any sane person would do: loved her for life.

In our teens she grew and became a 5’10” blond beauty, who towered over me. Which was fitting because she was built for the life she wanted to lead - bold and strong.

Over the last fifty years, she and I have talked every few days. When she headed off to Europe at 18, with a backpack and panache, I stayed in university and worried about her. When she wandered into the woods for long camping trips on her own, I would worry while writing my exams. She got a PhD and turned into a crack research scientists who still takes off for lone camping trips that worry the crap out of me. The real truth of who she is to me is that she was the first person who came when my children were born and the first to come every time I needed her. If she detected a tremor in my voice, I would find her on my doorstep even if we lived in different cities and she had to travel for miles.

This summer, while we sat sipping coffee on a patio of a restaurant, she gently told me that she had breast cancer. I stopped breathing. I looked at her, blond hair now darker and longer, lines around her eyes, and I finally took a breath. Because the not breathing was wanting to stop the world, to go back to before, when illness wasn't real. And the breathing part was because I knew that I had to breathe and move forward. Because she needed me. Because I needed to be there. Every step.

And I was. The mastectomy was hard, and I was there for that. I was there at the hospital, and when she was home, we laughed in our zany way about all things cancer related. Then after she had eaten the food I had made for her, she gently told me that that cancer had spread to her bones. I couldn't breathe. This time, my lungs simply refused to take in any air. Then I did. Because I had to be there for that too.

When tragedy hits, and in books it must, I think it is important to dive in and write about breathing. Because that tells the story. Of wanting to stop time, and go back. Of breathing and moving forward.