This week’s Grand Rounds are dedicated to two of my nieces, Ghastly Ashley and Crazy Katie, and my nephew, Luckless Chance. I attended these three, along with my own two children, as they went Trick-or-Treating last Halloween in Metairie, Louisiana. It was about two months after Hurricane Katrina, and only one in five houses in the neighborhood were even inhabited. Most were dark and empty. There were huge piles of trash piled everywhere on the street as people tore out carpet, flooring, and threw ruined furniture out on the curb.

We negotiated the piles of trash and made it to the few inhabited houses. We were the only ones on the street, and the kids were probably the only children left in the neighborhood. They collected a small but precious treasure of candy, but more importantly, they kept the tradition of Halloween alive in their neighborhood for another year.

There has been considerable rebuilding in that neighborhood in the last year, and most of the kids are back. Here’s hoping Ashley, Katie, and Chance have a better Halloween this year.

And now, without further delay, and with apologies to Edgar Allen Poe, I present to you

The Intern

Once upon a midnight dreary, while I rounded weak and weary
Stomach hot and rumbling, I came bleary and a-stumbling
For a cup of hot caffeine through the doctor’s parlor door.
On the sofa lurked before me a shadow breaking silence with rumbling snore.
‘Tis some visitor, I muttered, slumb’ring loudly, bell'wing out that roar.
A sleeping Intern, nothing more.

Ah, distinctly I remember twins delivered last September
Sadly recalled by the Fat Doctor, a patient that she had before;
Or maybe Ghosts the Tundra froze, that living were Yupik Eskimos.
I steeled myself – made no fuss, recalled a day on the Singing Bus
Traveling happily through Uganda, Borneo Breezes dancing
           on the wooden floor.
Simply this, and nothing more.

Though it was not in my plan, commenced I to worry once again
Just like the Keagirl – high creat her nerves gravely implore;
Gulping coffee got me to shaking, like Michael Fox I was a-quaking
Jon Swift was right about that Limbaugh’s ever fetid roar
I peered into the dying darkness: a white coat outline, pristine, markless
Darkness, intern sleeping, nothing more.

The intern’s lips were lax and puck’ring, like a Diabetic suckr'ing
The drop of blood Diabetes Mine says on a digit tastes so fine.
Then the building was struck with a gust that rattled Doctor Gordon’s bust
Estimable estimator of SIDS and of the pacifier’s crust
His impassive face stood unmoved in its place above the parlor door –
Dr. G was never a bore.

My knees and legs went then a-slack, I fell straightaway on my back
Thinking for relief of pain, I could go pick Dr. Shadowfax’s brain;
I sadly knew not how to reach him, so that I could then beseech him
As Mother Jones RN has said, to find a doctor can make one insane
Or Protect the Airway: A shock extorts all mem'ry from the brain
Anything more would be a pain.

Then the room was filled with light, though iridescent – shak’n with fright
I remembered Doc Palter’s ease of using odd light to diagnose disease.
Nausea then stuck me, struck me though I had no proof
Sneezing could be the culprit – I should consult with the savant Moof.
Liz Edwards did Tech Medicine’s Choi, quite thoroughly please
A doctor respecting a lawyer’s wife – wonders never cease.

Back to the coffee pot turning, all my soul within me burning,
I spied some black food Cynthia Sass concocted for the peasant hoard
Could it be another lead error, as The Antedote softly bellowed
Cancer study results mellowed, survival rates in error soared;
Many babies died from sepsis but no guilt admitted by the hospital board
For this, Parallel Universe is abhorred.

Open here I flung the shutter, mammogram films went flit and flutter
NICURNmama starts to stutter about an Area of Concern.
I pinched the films ‘tween thumb and finger, tension in my back will linger
Many hours shall they linger, unless I stretch my back will burn
Says The Fitness Fixer, so I her test will surely learn
But waking now is the Intern.

Then this darkling ‘Tern beguiling my sad fancy into smiling
Scared to Health might not approve, trust she wants her docs to prove.
“Do we, dear ‘Tern, commence to fight? Bruises never put wrongs a-right.
Teen Health’s words thus decide what relationships are for?”
Intern though remained impassive, the ranks of doctors are too massive
Fixin' Healthcare settles the score.

“Then a curse on you shall be your fate, I make you Do Not Rescuscitate
Contrivances of Doing Good I cast with scorn upon the floor,
Cursed, you ‘Tern, shall be your fate – no HIV certificate
Shall clarify to you your fate when a negative test comes to your door.”
The “Tern seemed like Health Impact calculating the Cost of Death as 
         health bills soar.
Quoth the Intern: “Nevermore.”

Startled at the stillness broken like a patient who has spoken
To get the information Cancer Treatment says from doctors to implore;
My mood turned quickly to ferocious, like advanced Multiple Sclerosis
Which though an illness quite atrocious Dr. Kavokin will carefully explore.
“As Kevin MD describes, to what hideous heights to get my attention
           will you soar?”
Quoth the Intern, “Nevermore.”

I hefted in hand a Halloween treat and hurled it at him in his seat
The Family Fork hath said this treat hath health risks for the kids galore.
His figure faded into fog like promises of Squibb in Healthcare Business Blog
No time for regrets said Hearty Life Blog, spending time with people is 
       what healthcare’s for.
“Mercury vaccine for you,” I said, “a poison from Disease Proof’s store!”
Quoth the Intern, “Nevermore.”

Once more I thought of M. J. Fox and of his quaking, shaking locks
What Billy Ruben thought first, I thought last, “If you like Limbaugh you’re
      a real jackass.”
The ‘Tern looked bloated, like a ‘betic with kidney disease
Could Clinical Cases be right, did he skip his ARBs?
Perhaps he had MRSA, as per Medicine for the Outdoors?
Quoth the Intern: “I have no sores.”

Still I sat engaged in guessing, the Science of Telehealth progressing,
A Rural Pediatrics case could he have been some many years before?
There is no peace, no kings to laud, homeopathy’s a fraud
Said Scientia Natura once before; there is no cover for quacks any more.
“Fool ‘Tern,” said I, “Rise from slumber and attend to patients on the floor.”
Quoth the Intern: “Nevermore.”

But the intern, sitting lonely on that placid sofa, spoke only,
As if a Wandering Visitor did the contents of his consciousness outpour
Like Healthcare Law Blog's Missing Patient Data, oh I can’t think
        it’s getting late-a
His mind as empty as the state of, a patient in antidepressant withdrawal,
Let my heart be still a moment and this mystery explore.
Quoth the Intern, “Nevermore.”

“Prophet!” said I, “Lion or Lamb! Be the leader I think that I am!
“Ultrasounds to read and scan, or radiologists reclaim that store!
Poll the patients! Poll the docs! Harvest the embryo the patient adopts!
Men with breast cancer, eagles with socks, are as rare as the intern
         who sleeps on the floor!
Take thy stethoscope from thy own heart, and take thy form posthaste out my door!”
Quoth the Intern, “Nevermore!”

And the Intern, never flitting, still is sitting, still is sitting
With a pack of Ketek in his pocket on the sofa near the door;
And his beeper keeps on beeping like a demon that is speaking,
And he won't consider seeking to find whoever needs him on the floor.
As for me I have a headache, knowing too much from
         Gruntdoc's words before.
Try this again? “NEVERMORE!”  

Next week's Grand Rounds will be hosted by MSSP Nexus Blog. Hope to see you there! 

Notes

Photo credit: Pencilling by Gabe, coloring by Sunshine (I found it in Flickr)

Poem of course inspired by "The Raven" by Edgar Allen Poe. I will try in the next week to write up a post discussing the text of "The Raven" and how I painfully and laboriously integrated it into this post. 

Dr. Nicholas Genes interviews me in anticipation of my Grand Rounds entry next week. Yes, I know I talk too much.

WARNING: If it makes you uncomfortable to read about murder and dismemberment, or if it would offend you to read  humorous remarks about said murder and dismemberment, you may want to skip the following passage. I will tolerate no complaints! You have been warned! 

A friend and patient from my old practice in New Orleans came to see me last Thursday, and as a favor brought me a copy of the New Orleans Times-Picayune. My nurse left it on the desk in my office, and as soon as I glanced at it I was compelled to pick it up. On page one, in bold sans-serif type ran the headline:

BOYFRIEND CUT UP CORPSE, COOKED IT

It made me laugh. No, it shouldn't have, but I would expect that kind of headline on the front page of the National Inquirer, not a local newspaper. It was the word "boyfriend" that especially stuck me as peculiar. Most headlines in serious papers start with words like governor, or hurricane, or catastrophe, or school board. Boyfriend? So this was going to be a love story, gone very, very bad. Funny as it was, the headline was true; all of it.

This was a story that goes far beyond proving that truth is stranger than fiction. It is an obnoxious taunt at the fiction writer: "Don't even try to beat this one. You can't dream up stuff like this."

The story, even in its vaguest outlines, is marvelously awful, so impossible that it has to be true. A boy named Zackery Bowen met a girl named Addie Hall in the New Orleans French Quarter just before Hurricane Katrina. They "fell in love" on the night of the storm and stayed in New Orleans through the horrible week afterwards.  In the anarchic days after the hurricane they survived by trading aliquots of an enormous beer and liquor stash for food and water. Together they emerged from the storm arm-in-arm, a his-and-her bartender tandem, serving up fire water to the recovering city. On the horizon, the happy ending.

But then hints of danger surfaced like ice cubes in a Bourbon street cocktail. He and she both had vague pasts.  He said he was a soldier once, offered no proof, but during heavy drinking bouts waxed darkly about his army days and something about a discarded wife and kids. She maintained she was from Pennsylvania, turning up in the French Quarter in 2001, also with a nondescript but invariably sad history. They lived together in an apartment above a voodoo supply shop (and no, I am not making this part up).

They fought. They split up. They got back together. They split up again. She failed to show up at her bartender job on October 1. He was found lying in the street in front of the Omni French Quarter hotel on October 18. He had jumped off the roof.

Zackery Bowen left a suicide note in his room at the Omni. The suicide note said he had strangled his girlfriend Addie at 1 am on October 5th, and, well, let me just quote directly from the note itself:

This is not accidental. I had to take my own life to pay for the one I took. If you send a patrol to 826 N. Rampart, you will find the dismembered corpse of my girlfriend Addie in the oven, on the stove, and in the fridge along with full documentation on the both of us and a full signed confession from myself.

It was nice of him to provide full documentation. If Lee Harvey Oswald or O.J. Simpson had thought to do that, it would have saved us all so much trouble.

One could say that the suicide, or the dismemberment, or the corpse gumbo is the most astonishing thing about this story. But I don't think it is. The most astonishing part of this story is that after Zack murdered Addie he checked his financial reserves, and, finding that he had $1,500, then quit his job and resolved to spend it "being happy" until he paid his debt back by killing himself. According to Zack: "That's what I did: good food, good drugs, good strippers, good friends and any loose ends I may have had."

It reads better than an Albert Camus novel. Jean-Paul Sartre would gotten on his knees and begged God for a plot like this. Zack Bowen kills his girlfriend, and then calmly decides to kill himself out of some twisted sense of cosmic karma. Then he stops himself and says, "Wait. I still have $1,500 to  burn. Let's put the suicide thing on a back burner until the party's over."

He realizes his ex, now ex in more ways than one, will start to smell in the next few days. He turns the air conditioner down to 60. Then he chops her up in the bathtub and cooks her. And again — no French existential novelist could ever hope do better — he cooks her head on the stove, and puts her butchered legs in baking pans inside the oven and sprinkles seasoning over them.  On the counter top next to the head-in-a-pot were sliced carrots and potatoes. The killer left no indication in his "documentation" if the vegetables were to go in the stew or if he intended to serve them a la mode.

The police said in a public statement that there was no evidence of cannibalism found during the autopsy of either the victim or the perpetrator. But consider this: They had to check. For your typical murder, it is not necessary to rule out cannibalism. I filled out a Louisiana death certificate the other day, and though there is a check box in the cause-of-death section for homicide, there is no check box for cannibalism.

The Times-Picayune article says Zack Bowen "descended into madness" prior to the murder. From the facts in the article, I would say this is an unsubstantiated guess. It is certainly clear why the reporter, Walt Philbin, would think this. Could anyone who would murder another so callously, then dispose of the body in such a ghastly fashion, still be sane?

As a writer of a scant amount of fiction and a reader of much more, I'll answer that question: Maybe. True, no normal person would do what Bowen did, but abnormal and wacko are not necessarily synonymous. Was Meursault crazy when he murdered the Arab in The Stranger? Albert Camus's novel depends on the fact that he was not. Was Hamlet insane? Probably a little unhinged, but not nutty enough to ruin a ripping good plot.

Bowen can't be completely insane because it ruins the sense of the whole story if he were. Bowen murdered Addie Hall and then calmly decided to live it up until his final accounting. Fifteen hundred dollars got him all the drugs and strippers and great food he could want for 13 days. This may not be a normal decision, but it could be rational one, if one believes in a certain brand of karma. If you go nuts and kill your girlfriend and then feel you have to give up your own in return, there is no reason to feel guilty about it. You play by the rules. Go ahead and live it up, get your kicks, and then settle with the Big CPA in the Sky. It's as simple as math.

The story is sprinkled with evidence that Bowen was at least partially rational. Hamlet rational, perhaps, but rational nonetheless. He says he planned out the method of disposing the body. He wrote out an eight page suicide note that, from the excerpts I have seen, is fairly well written, considering who he was. Consider the final words of his suicide note:

Halfway through the task, I stopped and thought about what I was doing. The decision to halt the first idea and move to Plan B (the crime scene you are now in) came after awhile. I scared myself not only by the action of calmly strangling the woman I've loved for one and a half years, but by my entire lack of remorse. I've known forever how horrible a person I am (ask anyone).

Not the words of a lunatic. Someone with a farfetched ethical system, perhaps, but not a lunatic.

Once Zack decided he would go ahead with the plan of burning through the $1,500, he really seemed to enjoy himself. The Times-Picayune reports that his neighbor, Voodoo Priestess Miriam Chamani, said that on the Saturday prior to his death Zack looked "all jolly . . . . He was (in) a great mood, best mood I've ever seen him in."

Okay, he burned himself with a cigarette 28 times prior to killing himself, once for every year of his life. He and rationalism were not completely copasetic. Still, the murder-suicide, taken as a whole, does not suggest someone descending into madness. Instead, it hints at a person with an absurd sense of morality who decided at the end of an argument with his girlfriend that he would pursue that absurdity to its logical conclusion.

What those two weeks must have been like! He killed his girlfriend, and in his conscience, such as it was, he knew payback was due. While he sat in strip bars stuffing dollar after dollar into a dancer's G-string, did he think to himself that each dollar brought him 1/1500th closer to suicide? Or did he block it out of his mind, refusing to keep count?

This dilemma could be the hook of a fabulous short story. The Devil gives a man $1500 and tells him when the last dollar is gone his soul goes straight to hell. The man shrewdly invests the money in a sensible bond fund so it will grow forever, and His Satanic Majesty is eternally frustrated. Then, in an O. Henry finish, there is a Wall Street scandal and it turns out that the money was stolen and not a dime remains.

To his credit, Zack never considered doing anything but spending the money.  There was to be no cheating the devil. He exhausted his bankroll with the decency of a player fairly beaten and then goes willingly to his sleep. Knowing all the time that his bed in Hotel Hell was made, he was intent on living it up until his last dime was gone, and then accepting his fate. Like the city of New Orleans these days.

Remorse? There is no need for remorse when you live by Zack Bowen's ethos. You pay back a life with a life and you are even. Since life is nothing more than a celestial debt repayment plan, once the debt is paid the deal is complete. There is no more need to fuss over a murder than there is to feel guilty about spending 99 cents on a hamburger. Seller and buyer are satisfied with the result and the ledger is reset to zero. By Zack's accounting, he came into the world as a zero, left it as a zero, and did a lot of drugs and women in between.

Those blissful two weeks were a poetic completion of his life. He gave himself the opportunity to do something terrible, then paid it back, and lived for the two weeks in between knowing that he would have to settle his accounts in the end. It may be that in his mind he created an opportunity in killing Addie. I had a cousin once who, to create a credit rating for herself, borrowed $500 from a bank and then paid it back over 6 months. She did not need the money and spent none of it, but by making the payments on time she created her own credit identity.

Perhaps in his logically mad mind Zack was creating a credit rating for himself. Perhaps he felt his life amounted to nothing, and in the murder and suicide he forced an accounting. Knowing he had created his debt but would soon pay it off, he lived out his last 13 days in a kind of peace.


  

The eye of a cat, the groan of a dirge
This year Grand Rounds and Halloween converge.
The shades of medicine I call that dark night
For tales of clinic and hospital fright.

The slip of the scalpel, the rattle of the hearse
The woe of the patient, the sigh of the nurse
Goblins of the ER, snot of the child
Screaming hospital bills that drive accountants wild.

The evils of medicine arise on this day
The dark arts are practiced, its victims decay.
Come one, come all, send submissions to me
Prepare for the terrors of every specialty.

Your submissions — please send each ghastly tale
To gumbodoc, then "at," followed by hotmail.
I'll reap this whirlwind, and serve up a hijinks —
A bowl full of candy, tasty medblog web links.

The deadline is Sunday, one minute to midnight*
And by dead, I mean dead, CST, get it right.
With my wizardly potions I conjure one spell
This weekend an extra hour  — evil writers, use it well.**

* In other words, 11:59 pm on Sunday, October 29.  The email address is gumbodoc, then "at," then hotmail.com.

** In the US, daylight savings time ends October 29, and the clocks will be set back 1 hour.

When I was a child, the holiday season meant the week between Christmas and New Years’. Now, thanks to modern marketing it more or less means Halloween to Super Bowl Sunday, or at least until the end of the College bowl season. Since the blessed season devoted to our god Excessive Spending is beginning in a few weeks, I want to take a moment and offer some advice on one of its most crucial elements.

Yes, I’m talking about M&Ms.

In my life I have eaten more than my body weight in M&Ms. This dietary staple, this American contribution to the pantheon of world cuisine, is now the cruel victim of Holiday over-marketing. I am here to help.

A PAUSE THAT REFRESEHES: One M&M is nothing special. It is when you take more than one, by bunches or by serial popping, that you feel the joy. Each M&M has a hard sugar coating, and at first the taste is just pure sugar. Then, one after another after another after another after another, the chocolate builds up in your mouth, your taste buds exalt in the milky chocolaty flavor, and everything is smooth, so smooth, interrupted only by the crackle of each new morsel. Did I mention that I like M&Ms?

They are one of my kitch pleasures. I am an elitist. I admit it. My bookshelves are loaded with Pulizer and Nobel laureates, Shakespeare and Montaigne. Philosophy is summer reading. I won’t listen to Top 10 radio, and the Nightly Network News is too simplistic for my highfalutin taste. No Budweiser, I take microbrews. No Wild Turkey for me; I’ll have a single malt scotch, thanks.

But I’ll throw $200 worth of Godiva Chocolate overboard for a 5 pound bag of M&Ms.

My daughter used to call M&Ms “nemis.” At two years old she would wait up for me to come home from work, sometimes until 10 o’clock at night, so I could feed her nemis on the sofa as we watched blissful television. These days I have two offspring that assault me for M&Ms. Whenever I sit down in my living room ottoman after dinner with a handful, my kids are on me in a cracklin' instant. My daughter says, “I just want to sit with you daddy, I love you daddy,” and starts prying my fingers apart. My son says nothing but simply barges onto my lap, tossing newspaper, book, or drink aside. Then I am pecked clean. I have to remember to slip a few candies into my shirt pocket to insure that I will get at least one for myself.

When I was a kid, there were only two types of M & Ms. Plain M & Ms came in a chocolate bag and in red, yellow, brown, green, and tan. Peanut M & Ms came in a yellow bag and in red, yellow, brown, and green. I knew this so well from personal experience that, in the early 1990s as I watched an episode of Jeopardy, I correctly answered that tan is the one color that comes as plain only. And I knew this by picturing a handful of M & Ms in my mind and counting up the colors.

It seemed like a perfect world, but in 1993 Mars Company started fooling with perfection. It couldn’t help itself, I know. Every American company thinks it has to go New-and-Improved! every couple of years to scare off competition. But I would have rather they took a chisel to the Pieta to “fix a couple of things.” You can’t eat the Pieta, thought I don’t doubt someone makes one in chocolate. Anyway, Mars gave into the pressure to perfect the perfect, and started a campaign, allowing users – ahh, consumers – to vote on a new color. Blue won the day, and tan was eliminated, along with the basis of the Jeopardy question, because blue was added to both peanut and plain.

So far, so good, but the Mars marketing department was by no means done. In 1996 Mars introduced the M&M mini, an abomination. Minis are way-too-small versions of the plain candies. The regular candies have the perfect sugar-coating-to-chocolate ratio. Minis have less chocolate, because they are smaller, but the sugar coat is still the same thickness, and this upsets the balance. They taste like sugar cubes. You have to eat a hundred to really taste the chocolate, and I won’t tell you how I came to that determination.

In 1998 we got crispy M&Ms. They taste like Milk Duds to me. If I wanted Milk Duds I would have bought Milk Duds.

In 2002 the purple M&M was introduced. Also a work of Satan. One of the nice things about M&Ms is the sharp, primary color look. Purple is so, well, shady. Instead of standing out as a clear color itself it bridges the gap between the bright red, yellow, and green and the mysterious dark brown. We don’t need ecumenical candies in this world. What’s next, fuchsia?

Then came dark chocolate last year. This was an innovation I was looking forward to. I like dark chocolate – in fact, I prefer dark over milk chocolate every time unless it is in an M&M. Dark chocolate M&Ms are fair. Unfortunately, the sugar coat cuts the bitterness of the dark chocolate and makes the dark M&Ms taste very much like the plains. The only way to get a dark chocolate experience with dark M&Ms is to chain-pop them into your mouth until enough chocolate builds up that it overwhelms the sugar coat. I have tried this a few times and it is a pleasant experience, but I do not recommend the chain-pop technique to amateurs without first consulting an experienced professional. And never chain-pop drunk. Trust me.

Another recent "improvement" has been the seasonal colors, which, come to think of it, is the reason I started writing this article in the first place. I hate them. For Christmas we get bags of green and red M&Ms. For Easter it is pastel pink and green. And for Halloween last year it was black and white, which looked creepy, so this year Mars changed it to orange and black. I have a bag of the orange and blacks in my cupboard right now.

The problem with these seasonal packages is that they invariably do not taste as good as the regular bags. I do not know why, but I can hazard a guess: They are old. Anything that is only sold once a year tends to be made months in advance. It is much like Christmas TV specials. You get to see the precious Osmond family dancing around in the snow and singing carols with cheeks pinked by the chill, but you and I both know that right after the taping of the show was completed the whole bunch stripped down to their shorts and went out into the 100-degree Los Angeles July sun. That’s how it goes. The folks in the M&Ms factory are mixing up batches of holiday cheer in late April, probably. Then the product sits and sits, and by the time I pick up a pack they are old enough to apply for Social Security benefits.

On the other hand, the plains just keep moving year round. They are never out of style so they do not sit on the shelf (or in storage) in the off-season. In fact, I am willing to bet that plain secular M&Ms are even fresher than usual in the holiday season because Mars probably cuts back production to make room for the seasonals. This means there aren’t enough plains to sit on the shelf for long.

Of course, that is just a guess – so don’t sue me, Mars – but I am telling you as an M&M connoisseur that the holiday M&Ms don’t taste as fresh as the regular, secular kind. They taste dusty. They don’t crackle the same between my teeth. And when the shell comes off that milk chocolate flavor doesn’t jump out to get me like a sex-starved widow dropping her robe.

Take my word for it. When you are out shopping for chocolate for the holidays, pick up the regular M&Ms. If you are one of those Martha Steward Christmas types that has to have that color coordination going, get the regulars anyway and take out everything except the red and green. You can ship the detritus to my address.

And please, for Halloween, stay away from the M&M Minis. They are godawful. Don’t make me come looking for you. I have a grim reaper costume, and the scythe is real.