The Pathologist. Pt1&2

 

     The 'Pathologist'!

           It is hard to believe that the time I am writing about was almost a half century ago.  Tempus, as they say, surely does fugit.   For reasons related to health I was out of sync with my graduating class and was desperately looking for an internship job.  

            When I  showed up at Dr Pickles, the medical director's (They used to be doctors in  those days!)  office on Monday morning I was greeted by a pleasant smile .

            "I have good news for you," he said to me  "Although all the regular internship positions have been filled, there's a vacancy in pathology, that normally would have to be filled by a second year pathology resident.  He cancelled out at the last minute, so we can offer that position to you for four months and that will bring you into sync with the regular rotations.  It will be quite a valuable experience as well as allowing you to earn some money "

            I was relieved to have a job, but a little apprehensive about my ability to do justice to a position normally occupied by a person with two years more experience than I had.

            "Thank you, sir, but do you think I'll be able to manage it satisfactorily?"

            "Oh don't worry about that.  You'll be working directly under the supervision of Dr. McMurray, and she'll give you all the supervision you'll need.  It will be a wonderful educational experience because there are no more senior residents between  you and your consultant.  You'll get the opportunity to do things that a junior rarely gets near."

             Monday at eight-thirty I arrived at Dr. McMurray's office, ready to start work.

            "Good morning," the pleasant -faced middle-aged secretary smiled.  Then, in a slightly remonstrative way, added, "Dr. McMurray is down in the morgue doing an autopsy.  She said that you're to go down there right away.  She starts at eight sharp, you know.  Don't worry  though, I'm sure she will take into consideration that it's just your first day."

            "Gee, I'm sorry, I thought we started at nine."I answered apologetically.

            "Just take the elevator at the end of the corridor down to the basement and turn left.  You'll see a big gray double door in front of you.  Walk right in."

          I followed the directions and saw the door..  I turned the handle and walked in.  Standing at the operating table was a woman clad in operating room attire, a scalpel in her hand and so pregnant that she could barely get close enough to the corpse to do the autopsy.  Unusual in those days

            "I glad you could make it," she said irritably. "now get yourself gowned and gloved.  I need a hand."

            "I'm sorry, Doctor, I thought we started at nine.  I should have checked with you.  It won't happen again."

            As I slipped off my jacket and tie and secured the rubber apron that protected from neck to ankle I felt like a butcher about to butcher a carcass.  I pulled on a white gown, tied it up at the back and stepped up to the mortuary slab.

            "Okay," said Dr. McMurray, "step up here and get another suture around the esophagus, above the one I've already secured, I can barely stretch that far, with this in front of me," she said pointing to her swollen belly.

           I leaned forward, slightly nauseated from the pervasive  smell  of  formaldehyde and still a little shaken from what was the rather bizarre picture of a very pregnant woman doing an autopsy.

            "Okay, cut right here, between the two sutures, then dissect away from the posterior thoracic and abdominal wall right down to the duodenum, and then cut between the lower two ligatures that I had secured earlier.  That way we can get the whole segment of bowel out, without spilling gastric content all over the peritoneal cavity.  Unless, of course, you puncture the bowel wall.  And, by the way, don't get a fright when Jim starts the saw going.  She introduced me to the autopsy room orderly.

              Jim was the operating room orderly.  He nodded his head at me and smiled.

              "Ah, you'll get used to all this stuff quickly enough, doctor.  Just don't mind the noise."  He added this as he continued a transverse scalp incision and then pulled the apron of scalp forward to cover the face and got busy with an electric bone saw.

            Meanwhile, I continued the dissection carefully, anxious to avoid the humiliation of perforating the bowel, let alone the miasmic odors that would follow.  The loud vibrations of the saw cutting through bone provided the background for the next half-hour, and the effluvium of bone dust was added to the other odors.  Meanwhile Dr. McMurray carried on dissecting and supervising me at the same time.  Following the gross dissection, Dr. McMurray showed me how to section the removed organs and place the specimens in formalin for later histological microscopic examination.  We were all finished before noon.

            "Do we have another to do this afternoon ?" I asked.

             Dr. McMurray laughed.

            "We don't kill all our patents, you know.  I've assigned you to Tom Morgan, the chief laboratory technician.  A good pathologist has to be able to do and to supervise everything a technician can do."  I thought it would be imprudent to mention that I had no interest in becoming a pathologist.

             I spent the next couple of days in the lab, learning to do tests that a computer does nowadays, in a fraction of the time.

           

      

Autopsy Time. 

         Two days later, I showed up in the hospital morgue bright and early, for an eight am autopsy.  I made sure to be there a few minutes early, so that Jim and I  could make sure that everything would be laid out just the way Dr. McMurray liked it.  Eight o'clock came and went, without sign or sight of Dr. McMurray.  I was getting a little nervous. 

            "She's late," I said, "I just hope everything is okay."

            "Ah, don't be worrying," Jim said optimistically, "everything will be just fine."

            "I hope so, I'd hate to be left to do this on my own."

            Jim grinned that leprachaun smile that the Irish sometimes have.

   "Ah sure if the worst came to the worst, you and I could do it ourselves.  I've been hanging around these post-mortems and helping out long enough to be able to do them myself."

            There was a knock at the door, immediately a the secretary poked her head around it.

            "I'm afraid you fellows are going to have to do the post-mortems on your own.  Dr. McMurray was admitted to the hospital in the small hours of the morning in labor, so I don't think she's going to be in to help you out today."

            With that the door slammed closed and she was gone. I almost panicked, then I re-called Churchill's war time credo. 'keep calm and carry on!' and  I determined to try to do just that.  And, after all, the patient was dead before I got to him.

            "We'll have to find another pathologist right away, Jim."

            "There's no other pathologist available.  There's a critical shortage of pathologists in Dublin right now." Jim laughed.  "How do you think you, a first year intern, got the job in the first place.  That job usually goes to a senior house officer, who's specializing in pathology.  They knew Dr.McMurray was going to be having a baby soon and I suppose they thought that having you was better than nothing." Jim answered unceremoniously.

            That certainly sounded more realistic than my previously held belief that they had just conjured up a position to slot me into, to help me out. What a fool I was, they were helping themselves out, albeit with a grossly under-qualified candidate.

            "Anyway Doc, don't worry, I'll show you how to do a post-mortem.   Sure, who do you think taught Dr. McMurray to do them?" he asked modestly.  "She was just at your stage when she first came down here to learn how to do autopsies.  And there's one piece of good news, the house officer who does or helps with an autopsy gets a fee of five pounds and five shillings.  Not many junior interns get a deal like that.  They usually give me a pound for my help," he added, meaningfully. 

            "Don't worry about that, Jim.  If you can get me through that, I'll give you twenty-five shillings.  Do you really think we could do the complete job ourselves?"

            "Sure I'd teach you to do an autopsy on my old Granny for twenty - five bob!" he laughed.

            "So, if we're going to get out of here tonight we'd better get started," I said.

            "Yep, Doc, now you've got to decide if you want to do it Dr. McMurray's way or the quick way!" Jim said.

            "Well, what's the difference?" I asked..

            "It's like this Doc, in the long run it doesn't make any difference.  In either case, the stiff, er, I mean the corpse, ends up nicely put together and is sewn up neatly, all ready for the undertaker. But one method takes two hours and Dr. McMurray's method takes four or more hours.  It's up to you."

            "Now wait a minute, what's the point of taking four hours when you can do the procedure in two hours?  Dr. McMurray is a very practical doctor, why would she opt to spend four hours doing a procedure that could be done in two hours?" I asked.

            Jim shrugged his shoulders.

           "I asked her the very same thing myself.  What's the difference, Doc, I asked her.  'Ah Jim,' she answered, 'the difference is the human dignity and respect that every human being is entitled to.'   That's where we differed and I told her so.  You got it wrong, Doc,  Jesus Christ himself is looking after the immortal soul and its dignity, all you're looking after is an auld corpse!"

          So we agreed to disagree, and she was the doctor and all I was, was a morgue porter, so of course, we did it her way.  But we had some grand discussions.  Which way do you want to do it, Doc?"

            I knew that everything took at least twice as long as anticipated and sometimes three times, so I had no difficulty in making the decision.

            "I want to do it the fast way."

            He answered without hesitation.

            "I can see we're going to work just fine together. Now Doc, you just pick up this scalpel and make a long incision, starting right up here at the sternal notch and extending down to the xiphi-sternal joint."

            I picked up the scalpel.

You Never KNow!

 

You Never know!

                                 

  "Is there a physician aboard the aircraft?" The Captain's authoritative voice rang out over the intercom system of the 747.

    I lingered in my seat, as long as my conscience would allow me to.  If there was another physician on board, I wanted to give him a chance to come forward before I did. This was the first holiday my wife and I had managed in several years, and our first trip to Hawaii. I knew I'd been too preoccupied with work for too long, and I hoped this holiday would give us a chance to relax and dispel some of the tension we'd been living with recently. No one volunteered and after a minute or two my wife said,

    "You better go and see what's going on."

    I put down my martini and pushed myself wearily out of my seat, and identified myself to the stewardess.

    "We have him up in first class, doctor, there's more room there. He's having a fit," She said.

 I moved up to the front of the aircraft, beyond the curtained partition, into the comfortable, spacious, first class area. A disheveled, heavy-set man was convulsing on the floor. A stewardess knelt beside him, trying to push a wooden tongue depressor between his teeth. White foam escaped from his mouth as amidst the seizing he attempted to turn his head away.

    "What sort of medications do you have on board?" I asked the stewardess as I knelt down beside the patient, and taking the tongue depressor in one hand, I firmly grasped the man's chin with the other, forcing his jaws apart sufficiently to insert the wooden stick between his teeth to prevent him from biting his tongue.

    "I'll get the medications bag," the stewardess said, moving quickly into the storage area in the front of the cabin. I loosened the man's collar and tie, and then took the black medications bag that she handed me. I quickly rifled through it's untidy contents, then emptied it on the seat beside me. I found a small cardboard container of ampoules of valium.  Not my first choice, but , that would have to do. I found a syringe and sucked up the contents of two ampoules into the syringe.

    "Need any help?" one of the passengers who had been watching apprehensively, asked.

 "If you can give us a hand to get his jacket off, I'll be able to inject this right into the vein and get this seizure stopped," I said.

    With the help of the man, the stewardess and I got the patient's jacket off and I managed with difficulty to get the needle into the vein and inject the valium. The seizures diminished, and stopped within a couple of minutes and the man slipped into an uneasy sleep.

    "Has this man anyone with him?" I asked the stewardess.

    "No," said the stewardess, "he's on his own."

    Another crew member appeared on the scene. "Captain wants to know if he should turn back to Vancouver, in another few minutes it will be too late."

   "No, I said," I think he'll be okay now, but he should be checked over by the airport physician when we land and be taken to the hospital for further investigation and treatment. We'll need to find out about his previous history, and if he's on any medications, to decide what needs to be done next. How long will it be before we land?"

 "About two hours, we'll radio ahead to make sure the airport physician is available to look after things".

 "Well, I'll go back and join my wife, you can come and get me if you need me," I said.

    "Would you give us your name and address, doctor, so we can account for the drugs we have used?"

    I gave them my name and address, and went back to join my wife. "No rest for the wicked," I said.

    "The least they might have done is moved us up to first class for the rest of the flight," She said.

     A couple of months later I received a letter from Air Canada saying thanks and including a certificate appointing me Honorary Flight Surgeon. I scrunched it up into a ball and threw it at the waste paper basket and scored!

    About three months after the Hawaiian holiday I had to attend a meeting in Toronto. The professional association to which I belonged and served on the executive, met several times annually, usually in Toronto, about a three hour flight from Regina, where I lived.  Earlier in the day, the chairman, Don Watson had suggested that after the meeting, the group go out to dinner in a nearby restaurant that had recently opened.

    "Great," said my colleague Rick,, "I hear this place is really good, although I haven't actually eaten there yet."

    "It's superb,," Don said, "Will I make reservations for about seven o''clock?"

    Everyone agreed that this would be a great idea. and a few minutes after seven o'clock, when I walked into the Magnolia Grill, (I can''t even remember its real name) everyone else was already working on their first drink. Several members of the party spotted me enter the restaurant and waved to me..

   "I'm with the Watson party over there," I indicated to the hostess who greeted me."

 She waved me on, and I made my way through the noisy restaurant over to the group of several physicians sitting in an alcove that slightly muffled the ambient sounds. I took the empty seat next to Danielle Levesque, who I knew slightly from previous meetings.   She. was a lively, attractive thirty something year old physician from Quebec.

    "Half the department heads in medicine are so busy with their administrative work that they only see patients one or two half days a week. No one can maintain either their credibility or their clinical skills with that limited amount of practice," Andy Hamilton was saying, He interrupted himself,."Hi Stan." he said to me.

    "I hope you guys aren't going to talk shop all night. Haven't you had enough all day?" I said to the group in general.

    "Dr.Smith wants some scintillating conversation," Danielle Levesque said in her French-Canadian accent.

    "Well, I wouldn't actually expect that from this group," said I, facetiously.

    "I just had an interesting experience on my way back from Moscow," Don Watson's timely interjection aroused some interest.. "I got the Moscow - Toronto  flight  a couple of weeks ago and we were barely in the air, when the Captain wanted to know whether there was a doctor on board. Well, I sat for a moment, hoping some eager young physician would rush forward and leave me sipping my scotch, but of course no one did, and I reported for duty to the stewardess.

 'just up there in first class, Doctor' she directed me.'

 He said, "I went upstairs into the first-class lounge.lounge, and found a perfectly healthy looking young woman, who had some pain in her left shoulder and had read somewhere that this can be the first sign of a heart attack, which very obviously it wasn't.  She was anxious.  So I gave her the appropriate reassurance and was heading back to our economy seats in the back of the aircraft, when the stewardess said, 'we'd like you and your wife to enjoy the first-class facilities for the rest of the trip, Doctor.' So Ann and I came forward and got the royal treatment for the rest of the trip."

 A chorus of "lucky so and so " went around the table.

 Then I couldn't help interjecting my story. I said, "I guess that wasn't Air Canada, then. Let me tell you what happened to me," and I recounted my story of a few months earlier, finishing with, "and I didn't even get a thank you note."

 "What you want, they kiss your ass?" said Danielle, her French Canadian accent sounding sharper than I had heard before.

 "No," said I, a little taken aback at the strength of her reaction,and the obvious resentment in her voice, "all I wanted was a little common courtesy."

 Danielle pulled a cigarette out of the packet sitting on the table beside her, put it in her mouth and lit it herself, and then rummaged around her bag, finally pulling out a pen. She then fixed her angry gaze on me.

 "What flight was this supposed to be on?" she quizzed me.

 "It was January 17th. Air Canada. I don't remember the number, but how many flights can there be from Toronto to Honolulu in any given time."

   "Yes, we can find that out" Danielle replied, noting the date that I had given her.

 "Why are you so interested in this?" I asked.

 "Because my husband is the Head of public relations for Air Canada."

 A chuckle came from everyone around the table except me.

      ."Oh," I said, embarrassed.

 She scribbled some notes on the back of her cigarette package, looking a little annoyed.

 "Air Canada routinely sends out a letter of appreciation to all passengers who come to the aid of others."

    I didn't tell her I received a note promoting me to the status of honorary flight surgeon that I had promptly garbarged.  That would have made things worse.

  "I'll talk to my husband about it."

 "Thanks" I said, wishing I hadn't mentioned it at all.

 She continued scribbling on the back of her cigarette package.  "I will give this information to my husband and you will hear from him, if you didn't get a letter." she said sourly.

    "Don't worry about it," said I casually, eager to end the conversation.

 The evening wound down and at about 11.30pm the group stood up and started their goodbyes.

  "See you in the morning," said Don Watson, "We should have our business completed by noon, so those of you with early fights should have no problem."

  The gathering broke up, with those with cars making sure that everyone had a ride back to their hotel.

   Following the meeting I took a limousine out to the airport to catch the mid afternoon flight back to Saskatchewan. I was glad to be getting back at a reasonable hour for a change and to have a little time to spend with the kids before bedtime, and a pleasant long evening at home.

 Eight O'Clock Monday morning I was at Family Medicine Rounds. The rounds, usually over by nine am dragged on until nine thirty. As soon as they were over I slipped away to my office to check the mail as I had been away for several days. It was the usual rubbish, advertising literature which had slipped past my secretary, and usually not much did, some teaching activities from other departments, a complimentary copy of a book in which I had written a chapter and some notifications of upcoming events. A pretty boring assortment, all in all. I was getting ready to go over to the clinic, when the phone rang.

 "Hello," I said.

 "Hi Stan," said Peter Graham, executive director of the College of Family Physicians, "I'm afraid I have some very bad news for you. Danielle Levesque was pulling out of the parking lot, leaving her hospital this morning, when she slumped unconscious over the wheel of her car. By the time they got her into the emergency department she was dead from a brain hemorrhage."

    “What?”  I said,shocked feeling guilty about our quarrel, as though that had anything to do with anything.

 "We are going to send regrets from the executive, and suggest that we would like to establish a scholarship in her name. As an executive member would you be supportive of setting up such a fund?" asked Peter.

 "Of course," said I, sadly.

Health Care in Canada.

I'm ashamed.

I'm ashamed of a Government that can close down health care during a national emergency on Christmas and Boxing day, while people are dying and others are justly fearful of dying.

   I'm ashamed at the shameful way we have neglected health care for the elderly and provided so miserably for the people who built this country.

   I'm ashamed when elected officials can have the unmitigated gall and brazen effrontery to issue directives to the people who put them in power and fly (both literally and figuratively) in the face of those directives.

   I'm ashamed when the premier and /or the prime minister hesitate to fire these hypocrites and that leaves me with the feeling that the main offence in their eyes is that their satraps got caught.

   I'm ashamed that members of my former profession have not stood up and spoken out loudly and clearly and I'm ashamed that I didn't do a better job in teaching them to do that.

   I'm ashamed at the poor protection advocacy of physician health care that our professional organizations provide in these perilous times.

   I'm ashamed that we in Canada have gone from being near the top in medical care in the developed countries to near the bottom.

   I'm ashamed of a prime minister whose words mean nothing and whose ethics are non existent.

   We have a lot to be ashamed of, so let's stop patting ourselves on the back and roll up our sleeves.

   

survivor.

 

                                    

Survivor

                The phone rang shrilly, as I sat at my desk writing

 notes on the patient I had just seen.  I picked it up.

            "Dr. Smith?" A  female voice.

.           "Yes," I said.

            "Could you come out to the house and check the baby?"

 the voice had a flatness, an indifference, that a more

 experienced physician might have recognized as a warning sign.

            It was ten in the morning, I was running late and still had

 four patients waiting in my waiting room.  It was my first week

 in practice, and it was different to be solely responsible for the

 patient's care. Frightening to know, or at least to think, that

 your every decision might be a life and death issue. Difficult to

 make decisions quickly, difficult to know how to handle simple

 non medical issues for which medical school and internship 

had not prepared you.

            "What seems to be wrong?" I asked.

            "The baby has diarrhea," Mrs Y. answered tersely.

            "How bad is it? How many times a day ?

            "Oh, I don't know, he just seems sick. Are you coming out?" she asked.

            "yes, " I said, "I'll be out as soon as I've finished seeing 

my patients in an hour or so."

            "Okay," she said, gave me the address, and hung up.

 It was one of those bright, hot, prairie days, under a radiant

 blue sky.  It was about two hours after the phone call as I drove

 northward through the city, into progressively seedier

neighborhoods.  I finally identified the house.  It was a small

 wood framed house that had once been green. That much 

could be deduced from the occasional green chip of paint that

 was still adherent to the wood.  The small front yard was

 overgrown with weeds and strewn with garbage.  The front 

door was slightly open and when I tried to ring the door-bell

 there was no sound.  I could hear a baby crying inside the 

house.  I tried rapping on the door with my knuckles, but still no

 response.  I pushed the door open and walked inside. 

            The stench was unbelievable. The house was strewn with

 every type of litter imaginable.  Dirt in every corner, crusts of

 bread, paper, dirty clothes, unwashed dishes, toys, garbage.  A

 baby was crying, I assumed it was my patient.  I worked my way

 toward the kitchen and opened the door.  Inside, a four or five

 year old boy had opened the refridgerator, and seemed to be

 eating at random.  He looked grubby, his face smeared with

 food, and a purulent discharge running from his nose.  A dirty

 little girl was trying to drag him over to the table to no avail.

           A door opened and a fat, unkempt young woman with

greasy looking hair slouched into the room. 

            "He's in there," Mrs Y said pointing to another room. 

            I felt anxious, for a moment.  I had expected to be

 directed to another room where I had heard the crying coming

 from. Even though I had visited many slums before, and as a

 student did many home deliveries in the slums of Dublin, I felt

 peculiarly uncomfortable.  I walked into the room to which she

 pointed, which was as grubby as the rest of the house.  She

 pointed to a crib in the middle of the room.  Under a pile of

 dirty covers lay a small body, white, with a sort of yellowish

tinge to its waxy skin, motionless, its limp form not much bigger

 than a ragged doll at the bottom of the crib. I pulled back the

covers, horrified. Could the baby really be dead?  Surely not in

this day and age. How could this have happened?  Was it my 

fault?   Maybe if I had dropped everything and came to the

 house as soon as she phoned I could have saved this little life.

            Although the baby was obviously dead, I senselessly went

through the ritual of performing a physical examination on the

 little body.  Or perhaps not so senselessly, for what does ritual

do more than give one an opportunity to reflect on the present

 situation and give one an opportunity to collect one's thoughts.

            "I'm very sorry to have to tell you the baby is dead," I said.

            "Oh," she said, as though all this had nothing to do with

 her, "What do I do now?"

            This was my first week in practice in Canada.  Nobody in

 medical school ever taught me what to do about anything like

 this.  After all, medicine is all about saving lives, relieving pain

 and suffering, not disposing of dead babies.  I did know enough

 to know that unexplained deaths had to be reported to the

 coroner. From the next room I heard the sister call to the small

 boy "get away from the fridge, Gary, you can't just keep taking 

food any time you want".

            " I have to call the coroner," I said, embarrassed to have

to mention such a thing.  "I think there will have to be an

 autopsy, so you will have to bring him down to the hospital."

            She didn't seem perturbed, as though nothing had

 registered at all.

            As I walked out of the house I glanced back.  My last 

glimpse was of little Gary, being pulled away from the fridge by

his sister, two twin tracks of yellow-green snot, running down

 his upper lip, delicately poised at the slightly upward

 incline,where the white skin met the pink.

 

            Doctors have been trained to take a lot of responsibility

even for things they are not responsible for, and as I drove back

 to the office that afternoon I felt, quite unrealistically, that

perhaps if I had only dropped everything and run straight out

there maybe I could have saved that baby.  As I walked up to

my office I stopped at the office of one of my senior colleagues,

whom the clinic had selected as my mentor.  They did this to all 

the 'newbies' as it's easy for a new member to get lost in a clinic 

of sixty doctors crossing all the specialities.

            "What are you looking so grim about?" he asked me. 

           Jamie was a wirey, lean guy, kind, but with a short temper

that went well with his clipped Canadian accent.  He had been a 

fighter pilot in World War two, and somehow looked it.  He

usually had a carton of cigarettes on his desk, or in his hand,

and when he had his heart attack a few years later, he got into

his car and drove down to the emergency room and walked in

 saying, "I'm having a heart attack, someone better do an ECG."

 He was right, he was having a heart attack.

            "I just made a house call on a dead baby," I said.  "If I

 had just run straight out when I got the call, maybe I could have

 got the kid into hospital and we could have got some fluids into

 him and saved his life, but he didn't sound that bad over the

 phone and the mother gave me no idea how sick he was."

            "How long was it between the phone call and the time you

 got out there?" he asked.

            "A couple of hours," I said.

            "Perfectly reasonable," he said, "you know perfectly well 

there was nothing you could have done.  You responded 

perfectly reasonably.  Why don't I give the coroner a call on your

 behalf. I know the routine." 

            Although I never had a chance to repay Jamie for his

 kindness and support, over the years, many young physicians

 benefited from his kindness.  He called the coroner, put me in

 touch with the appropriate social services, who went out and

 visited the home, decided the parents hadn't the skills

 necessary to look after children. Not that they were deliberately 

cruel to the children, they weren't.  The children were placed in

 foster home, I was informed later.  From time to time I thought 

of little Gary Y, no regular eating hours, just foraging through the

 fridge whenever he felt hungry, and that last glimpse I had of

 him, the snot running down his nose, his sister, not much older

 looking after him.

 

            Many years later, one of my duties was as medical officer

 for a high security psychiatric prison.  I was seeing patients

 regarding their general medical conditions, when a young

 man came in to see me.  He looked vaguely familiar, and I

 asked him where he was from.  He mentioned the  city I had left

 some 15 years earlier, so I looked to see his his surname.   

 It was Gary Y.

(The crime for which he was imprisoned was non violent and

he was being mentally assessed prior to his court appearance.)