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The Bullet's Yaw

Ballard, Dustin MD

Emergency Medicine News: March 2010 - Volume 32 - Issue 3 - p
doi: 10.1097/01.EEM.0000369266.92781.18
Articles

Dr. Ballard received his medical degree from the University of Pennsylvania, and completed his emergency medicine residency at the UC Davis Medical Center in Sacramento. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and contributions to Hoops Nation (Owl Books, 1998). He currently works as an emergency physician in northern California where he lives with his wife Angela, daughter Hayley, and Labrador retriever Gary. The Bullet's Yaw is available through Amazon atwww.amazon.com/Bullets-Yaw-Reflections-violence-unforgettable/dp/0595476481and through his web site,http://incisionanddrainage.blogspot.com.

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Chapter 6: An Unforgettable Stranger

You had a hundred billion chances and ways to have avoided today. But you decided to spill my blood. You forced me into a corner and gave me only one option. The decision was yours. Now you have blood on your hands that will never wash off. … I didn't have to do this. I could have left. I could have fled. But no, I will no longer run. It is not for me. For my children, for my brothers and sisters that you (expletive), I did it for them. … You just loved to crucify me. You loved inducing cancer in my head, terror in my heart and ripping my soul all this time. … When the time came, I did it. I had to.”

Excerpts from the video Seung-Hui Cho sent to NBC News, April 16, 2007

On April 16, I turned on the television, and what I saw brought the Jeffrey Mains saga cascading back into my consciousness. Seung-Hui Cho, an angry and reclusive senior at Virginia Tech University in Blacksburg, had committed the deadliest act of gun violence in recorded U.S. history. For days, the story was inescapable, morbidly engrossing and full of horrific stories and images: students locked in Norris Hall classrooms being picked off one by one; people leaping from second-story windows; a professor holding the door to a room shut so that his students could escape, absorbing fatal gunshots in the process; one boy protected from the assailant's bullets by a classmate's dead body; evidence of more than 200 rounds of ammunition scattered throughout Norris Hall; the still photos of the killer, a young man with drawn lips and hollow eyes. Nine minutes into the carnage, just as police broke through Cho's barricade and into the building, Cho delivered his final shot, to his own temple. In all, he killed 32, injured 25 and reignited the smoldering issue of gun violence in America.

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As I began to process the shock of the Blacksburg tragedy, I realized how it echoed the Joseph Ferguson shootings of nearly six years before. The profile of the killers was an obvious similarity. Both Cho and Ferguson were withdrawn young men with untreated psychiatric issues. While Ferguson, who by all accounts exhibited the affect and behavior of a depressed adolescent, never received entry into the mental health system, Cho had. By the fall of 2005, Cho had alarmed teachers and fellow students with his macabre writings and antisocial behavior, referring to himself as “Question Mark” and avoiding eye contact with classmates.

In December of that year, two female students filed a complaint against him for harassing them with instant messages that included cryptic lines from Romeo and Juliet. After police warned Cho to leave the women alone, he e-mailed a roommate, stating that he might as well kill himself. This threat landed him before a community services board that declared him “mentally ill and in need of hospitalization” and then in front of state justice Paul Barnett who agreed that Cho presented “an imminent danger to himself as a result of mental illness,” but nonetheless released him into involuntary outpatient therapy. In hindsight, this approach was obviously a tragic misstep; Cho never showed for his outpatient treatment. A Washington Post article quoted the director of the Cook Counseling Center, which was where Cho was to have sought treatment, as explaining that “when a court gives a mandatory order that someone get outpatient treatment, that order is to the individual, not an agency.” Despite a state law requiring that local community service boards monitor a patient's compliance with mandatory outpatient mental health treatment, Cho slipped through the cracks and never received a full psychiatric evaluation, let alone treatment.

A second similarity between the shootings was the ease with which these two disturbed young men obtained lethal weaponry. I found an archived LA Times article that speculated that Ferguson, or perhaps his father, had legally obtained Chinese-made assault rifles and converted them into automatic weapons. Garen Wintemute had told me that despite California's assault weapon ban, it wouldn't have been difficult for Ferguson to legally obtain these weapons in another state. On the other hand, the legality of Cho's firearm purchases had, after the shootings, become a topic of intense debate. Cho bought his guns a month apart, one through a web site based in Wisconsin and the other at a gun shop in Roanoke, VA. Both times, he filled out the appropriate paperwork, and underwent state and federal background checks.

Cho did not offer and the background checks did not reveal that he had recently been adjucated “mentally defective,” and under federal law should have been barred from purchasing a firearm. However, under existing Virginia law, patients undergoing outpatient psychiatric therapy were not reported to the federal government's National Instant Criminal Background Check System. Two weeks after the massacre, Gov. Tim Kaine closed this loophole and mandated that reporting to the federal database be based on threat level rather than location of treatment. “The key criterion that should trigger a report is a finding of danger,” he said at a press conference. I read this announcement with skepticism because it smelled of cover-your-ass politics, as did the talk that Congress was considering legislation that would ban the mentally ill from buying guns.

A third resemblance between the two killers was their choice of ammunition. Cho, like Ferguson nearly six years before, used hollow point bullets. Unlike Ferguson, who fired with an assault weapon and a handgun, Cho's shots were delivered exclusively by 9 mm semi-automatic pistols, a Glock and a Walther. Regardless, the common choice of ammunition was a destructive one. Because hollow point bullets expand rapidly on contact, mushrooming the cavity of injury, they can cause significantly more damage than conventional, jacketed ammunition. Despite being a class of bullet banned by international treaty (The Hague Convention of 1899), some American police departments, including New York City's, use hollow point ammunition, primarily because it delivers more effective “disabling” of hostiles, and is less likely to cause secondary damage by ricocheting through one person to another. From a police perspective, this rationale made sense, but I wondered if there was a justifiable reason for public sale of hollow point ammunition. Perhaps, I discovered, there was. Some hunters who want to kill humanely choose to use hollow point ammunition rather than leave a disabled animal in the woods. But, did sportsmen need to use handguns with hollow point bullets? What self-respecting hunter tried to off a buck with a 9 mm? Why not then, ban hollow point bullets for handguns? Sure, a motivated killer could make his own by digging out the copper of the bullet tip, but a convenience barrier to lethality made sense. As I had already learned, however, making sense was not something that U.S. gun policy was particularly adept at.

After consulting the Internet, I discovered that others had picked up on the symmetry between Ferguson and Cho. An April 2007 clip from the local CBS station in Sacramento focused, predictably, on each killer's use of video footage to chronicle his hate and to forecast its culmination. The piece replayed snippets of Ferguson's grainy six-minute video, including his boast about putting on “a hell of a show” and his promise to “just pop” himself by sending a “bullet to the brain” at the end of it all. Although I'd read the video transcripts many times, this was the first time I'd seen the footage. Except for one moment when he pauses to wipe his face with his right wrist, Ferguson appears more mechanical than human: a flat-affected and murderous drone. This observation didn't surprise me, but some of the disturbing footage that followed certainly did. Against a nighttime panorama of streets, cars, and lights, gunshots in bursts of four and five are heard, and then the clip cuts to a man being carried by three law officers. The victim, wearing a white shirt and jeans is hauled away from a white pickup truck with an open door and still luminescent tail lights. He is a big man, and the three officers clearly struggle to move him, holding his arms and legs as his pelvis bows in a v-configuration, nearly touching the ground. Then, without identifying the victim, the clip abruptly returns to the compassionless visage of Joseph Ferguson. Watching this, I felt a deep and cramping paroxysm seize my chest. and I exhaled deeply. I hoped that Jeffrey Mains had never seen this video.

Emotionally sucker-punched by the events at Blacksburg and feeling sick because, just like the Jeffrey Mains shooting, they were preventable, I experienced an uncomfortable awakening from complacency. I was nearly three years out of residency and working in a community hospital in affluent Marin County, CA. After a year or so of adjusting to a new work environment and the scary yet liberating reality of making my own clinical decisions, I had settled into a comfortable routine. Emergency medicine was, more and more, becoming just a job. I moved the patients in and out using a set of routines that I had developed for most complaints and conditions. When a nurse handed me a chart for a middle-aged patient with chest pain, I didn't need to think twice before accessing my internal protocol and scribbling out orders. Same for a young man with flank pain and blood in his urine or a woman of child-bearing age with vaginal bleeding, or an elderly man on blood thinners who had fallen and hit his head. While moments of adrenaline still occurred, they were rare, and even the care of critically ill patients was often rote. After most shifts, I returned home tired but far from spent, fully capable of asking about my wife's day and making simple decisions such as what to have for dinner and which DVR selection to watch afterward. My job was still challenging, I often worked long hours and nights and was constantly multitasking, but it no longer sapped my life force on a daily basis. I still felt empathy for my patients (some more than others), but slowly, shift by shift, year by year, I was building emotional defenses to protect myself from feeling too much of their pain. If I didn't do this, I rationalized, I could never survive this career for the long haul.

At my new ED, we saw trauma victims, but their injuries were of a different quality and severity than what I'd treated at UC Davis. In three years in Marin, I hadn't seen a single patient with a gunshot wound. I hadn't seen victims of baseball bats or light rail collisions or middle-of-the-night nail gun mishaps either. What I saw were a whole lot of recreational injuries: ankle sprains, head bonks, skinned-up knees, sore wrists, and bruised egos. These included mountain bikers who ate trail dirt, skateboarders who biffed and tumbled, and surfboarders whose boards jumped and popped them in the face. I sewed lacerations, reduced fractures and dislocations, and prescribed copious amounts of pain medication. Occasionally, a high-speed car crash victim would be brought in, and we would activate our trauma protocol, but rarely were these patients seriously injured. In fact, since starting in this ED, I'd only seen one life-threatening traumatic injury, and this was the only time I'd felt alone without the coordinated mayhem of a Level I trauma response.

A young man from the Canal district in San Rafael, one of the few rough neighborhoods in a county where the median house price tops the $1 million mark and gun violence is as rare as a reasonably priced spa treatment, had been attacked with a machete in the middle of the night and suffered a deep arm laceration. He arrived in our ED with two paramedics desperately holding pressure on his right elbow. During transport, his wound had burst loose with arterial bleeding. I walked into Room 2 and saw a young Hispanic male who was pale, shivering, and covered with sweat droplets. A river of blood ran down his arm and splattered onto the white linoleum floor. For several long seconds, the nurses looked at me with uncertainty. A trauma code had been called, but this was not the well-rehearsed environment of a Level I trauma center, and our surgeon would be coming in from home rather than from around the corner. One by one, people began to move; a nurse took his blood pressure: 80 systolic. Another nurse helped the paramedics with the dressing on the injured arm. IV fluid was started, oxygen applied, and labs drawn. I assessed “A” and “B” of the trauma protocol and then attended to the injury. He had a full-length wound just above the elbow, down to the bone. It must have been a long and sharp blade because this man's arm was nearly severed and he was bleeding profusely, so much so that I couldn't visualize the vessels. His blood pressure remained, and he shivered like an off-kilter washer. We ordered blood, and I put a blood pressure cuff above his injury and inflated it to 200. As the pressure of the cuff exceeded the arterial pressure, the bleeding slowed to a crimson ooze. Minutes later, with the patient still in obvious shock, the surgeon arrived and immediately paged for backup.

After what seemed like an eternity, but was actually less than an hour, and multiple units of blood transfusion later, the patient left the ED for the operating room. Room 2 was left with the debris of a frenzied trauma resuscitation: discarded oxygen tubing, piles of blood-soaked gauze, a Level One blood transfusion pole, rolls of the paramedic's tape, and large puddles of fresh blood. In the middle of it all was a nurse's glittery pink clog, kicked off and abandoned in the rush to move the gurney to the operating room.

The patient survived, and despite the complete disruption of his nerves, he regained some motor function in his hand. For several weeks, I felt the residual surge of fear and excitement this case stirred in me and not long afterward I decided to return to work at UC Davis Medical Center ED as an adjunct attending. It was only one shift a month, but those days were brutally long. I would get up at 5 a.m. and drive 90 minutes to Sacramento to work an often grueling 12-hour shift. Every time I got in the car to make the drive, I asked myself what I was doing, and at the end of shift, after dealing with a steady stream of gore and severe illness, I'd repeat this question. But a day or so later, rested and flush with perspective, I would feel grateful to have the opportunity to work on the front lines of medical care and to refresh my empathy reserves. It was in this spirit that I resolved to once again call on Jeffrey Mains.

In June 2007 I emailed Jeffrey Mains, not particularly hopeful that I would receive a reply. We had been in brief email contact, but my last message, months earlier, had gone unanswered. About a month after the five-year anniversary of the shooting, I had met him and Linda Mains for dinner and confirmed the news of his downturn. We met at an Italian café in the late afternoon, a time of day at which we were the only patrons of the restaurant and were offered both lunch and dinner menus. Both Linda and Jeffrey seemed nervous, Jeffrey more so. They sat across from me at a rectangular table, and Jeffrey was fidgety and restless. At one point he got up abruptly from the table to run to the bathroom, and at another I noticed a fine film of sweat on his forehead. Neither mother nor son ate much. Jeffrey sipped at potato leek soup, and Linda picked at a Caesar salad, and while they both answered my questions, neither expanded on their answers.

Like the last time we'd met, Jeffrey's appearance surprised me. His head was closely shaven, and he had a faint goatee, an inverted-T of blond on his chin. He wore thick Elvis Costello-ish brown glasses that provided an attractive contrast with his clean and recessed scalp. I noticed, for the first time, a small gap between his two upper front teeth that gave a touch of boyishness to his otherwise intelligentsia appearance. Externally, he looked good, but the internal torture was clearly still present. We spoke about his medical bills. Linda was picking up the tab for his antidepressant and antianxiety medications, and he hadn't been able to afford basic follow-up blood tests for his liver and gallbladder.

We also spoke about the anxiety and how it could be disabling, freezing his body with tingling and an uncomfortable warmth. Jeffrey told me that it was severe enough to take him to the ED one day recently, but he calmed down when a nurse sat him in a quiet triage room, and he left without a workup. Eventually, our discussion turned from medicine, and I learned about Jeffrey's departure from his apartment in Cotati, which was prompted by boredom and loneliness, and his new part-time job at the front desk of Sacramento's premier art museum, the Crocker. He was excited about the location of his job because to work in the art world was his dream, but he was discouraged by the pay rate, hours, and lack of health insurance. He was considering applying for state disability based on his post-traumatic stress symptoms, but if he did this, we would have to stop working at the Crocker. He was still conflicted and still scared. After an hour or so, I noticed that Jeffrey was fidgety, and when the waitress offered dessert, he quickly demurred. Already disheartened and not wanting to push matters, I wrapped things up, and we went our separate ways.

Nine months later, I was surprised when Jeffrey rapidly responded to my email: “Hey Dustin, how are you doing? Well, I hope,” he wrote. “Things are going well around here,” he continued. “It would be nice to see you if or when you come to town.” I was optimistic that Jeffrey might actually be on the rebound. It would be a couple weeks before I'd return to Sacramento, and I knew there was no guarantee that Jeffrey would want to rehash old memories. In the meantime, I decided to talk to Garen Wintemute again to see if he could help me make sense of the Virginia Tech tragedy and to inquire about whether there was now some hope for practical gun violence prevention measures.

Dr. Garen Wintemute had just published important public health research in the journal Injury Prevention based on his observations of U.S. gun shows. Gun shows had long been recognized as an important source of crime guns, but had never been investigated in a formal or scientific way. Increasingly, these shows were also being implicated as a major source of firearms for Mexican drug lords (an estimated 80% of illegal guns in Mexico come from the U.S.) and Canadian criminals. Motivated by the realization that “it was obvious that illegal commerce was going on at these gun shows above board and that somebody needed to tell the story,” Wintemute immersed himself in the culture.

Starting in April 2005 and spanning 11 months, he attended 28 gun shows in five states: California, Nevada, Texas, Arizona, and Florida. The comparison of California and the four other states allowed for a “natural experiment” between a state that regulated gun show activity (California) and four that not only did not regulate it, but were major sources of California crime guns. To carry out the experiment, Wintemute infiltrated the gun shows, subtly documenting firearm sales using a hidden camera and his cell phone (he called his voice mail to dictate observations). He paid particular attention to assault weapon sales and straw purchases (illegal surrogate purchases). What he found, in short, was that California's regulatory policies (requiring promoter and seller licensing and outlawing direct sales between private parties) worked. Despite finding that gun shows in California did not have a lower number of attendees per gun vendor compared with the other four states, Wintemute observed that California had a much lower rate of assault weapon and straw purchase sales.

While he observed only one straw purchase at a California gun show, Wintemute saw 24 at shows in the other states. The manuscript describes one of these, occurring at the Florida Fairgrounds in Tampa in March 2006: “A woman in her 20s is purchasing an SKS rifle with a bayonet and 30-round magazine from a licensed retailer. Her male partner selects the gun, then stands 15 feet away while she completes the paperwork, undergoes a background check, and pays for the gun in cash. While waiting for the background check, he talks with the retailer about the gun, the type of case he would need, and proper ammunition. He takes possession of the gun when the transaction is completed and proceeds to buy the case and ammunition.” Straw purchases like these, Wintemute said, were commonly out in the open, with no evidence of attempts at concealment. “I was surprised over and over again about how out in the open all of the illegal activity was,” he told me, and he inferred from this observation that there was no significant effort to enforce the federal law (the Gun Control Act of 1968) banning straw purchases of firearms.

I asked Wintemute about the reaction to his study and received a measured response. Some in law enforcement, especially at the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) were very excited, but others quickly became defensive. He described blogs on which gun enthusiasts denigrated his results, and referred to him as a “boob,” a “leftard,” and a “douchebag.” On the web and at some gun shows, “wanted” posters had appeared with Wintemute's photo and the warning that the man pictured was an anti-gun “researcher” known to stalk gun shows. His methods and credibility came under attack, and the National Rifle Association (NRA) and others dismissed the existence of a gun show problem all together. I found one blogger from Kennesaw, GA, “The Conservative Scalawag,” whose posts captured the mentality of some in the pro-gun camp. “Once again here is some boob, propagating the gun show loop[hole] myth,” he wrote. “I'm not saying there aren't irresponsible people or unscrupulous people at gun shows. But, I doubt however if they're selling full auto AK-47s. … To me gun shows are a piece of Americana and it is what makes the nation so great. To loss [sic] them is to loss [sic] our identity as a free people.” Elsewhere, at the debate between Democratic presidential candidates sponsored by YouTube, a man from Michigan, while cradling his assault rifle, expressed concern that Democrats would take away his “baby.” “If that's his baby,” retorted Sen. Joseph Biden, “he needs help.” The mentality of pro-gunners like this was perfectly captured by Erik Larson in his 1994 book Lethal Passage: How the Travels of a Single Handgun Expose the Roots of America's Gun Crisis: “Theirs is a reflexive opposition based on the rather paranoid belief that any step toward firearms regulation must necessarily take us one more step down the road to federal confiscation of America's guns and, willy-nilly from there, to tyranny and oppression.”

I had read Wintemute's paper before talking with him, and knew that it had garnered coverage in USA Today and The Christian Science Monitor. I was hopeful that it, along with the memory of the Blacksburg killings, had sparked interest among saner minds in Washington, D.C. The message, after all, that regulation without prohibition can diminish illegal gun commerce, ought to be of some importance. Wintemute was pessimistic. An unnamed senator was interested in introducing a bill to regulate gun shows and close the “gun show loophole” that allowed unlicensed gun dealers to make illegal private party sales, but the prospects of getting anything passed were poor. Congress’ focus, he informed me, was to address public concern about the Virginia Tech shootings by passing an NRA-supported bill regulating the sale of guns to the mentally ill. This, we both agreed, was a necessary reform, but one that attempted to plug a boulder-sized problem with a pebble. For certain, legislation that provided incentives for states to share criminal and mental health records with the feds would be useful. At the time of the Virginia Tech shootings, only 22 states (including Virginia) supplied such information to the federal government.

But why, I asked, limit reform to the mentally ill, a diverse population that accounts for only a small percentage of violent crimes? But I needn't have asked; I knew that the answer was because the issue of gun control was too emotionally charged and that the nation did not have the stomach to seriously address the issue of gun violence. This, of course, has been the case for quite a long time. A certain subset of the American public is so invested in the issue that public policy has evolved to the point that not only is banning guns off the table, but studying the problem of gun violence is almost impossible. Wintemute told me that he was one of less than a dozen public health researchers in the country studying the problem of gun violence.

As of 1996, the Centers for Disease Control and Prevention was forbidden from funding any studies that could be construed to support gun control, and between 1973 and 2002 the National Institutes of Health (NIH) had only funded two grants addressing injury prevention from firearms. In the past several years, Congress has passed the NRA-backed Tiahrt amendment, ostensibly to protect law enforcement (but actually to protect gun manufacturers), that makes it a crime for law enforcement to share information on sources of crime guns unless they are directly involved in an investigation involving a specific gun. This in a country that is home to 220 million guns and each year witnesses four million gunshots and 430,000 gun-related crimes (including 11,000 homicides).

Reflecting on this, I was reminded of a quote from the National Academy of Sciences’ landmark publication Accidental Death and Disability: The Neglected Disease of Modern Society: “The long-term solution to the injury problem is prevention, and the major responsibility for accident prevention rests not with the medical profession but with educators, industrialists, engineers, public health officials, regulatory officials and private citizens.” This was written in 1966, and preceded a remarkable transformation in the safety of our nation's roads that was defined by public consensus on what constituted the best interests of the country, a transformation driven by an approach to accidents that treated them as a disease, a disease that could be controlled. Nearly 40 years later, the quote from the National Academy of Sciences is still applicable, only now to the problem of gun violence. Maybe, I thought, Wintemute's study would be the first step toward sensible gun policy, but perhaps it would just add fuel to the flames of conflict and debate.

It was a sweltering July day when I drove up to Sacramento to meet with Jeffrey Mains. Driving in our 1993 Plymouth minivan, which no longer had functional AC, I tried to imagine what Jeffrey would look and sound like. It was difficult, though, because the heat distracted me, and I repeatedly reached my hand into the cooler on the passenger's seat in order to feel something refreshing against my skin. By the time I neared Sacramento, I was damp from sweat and feeling detached. In the eastern foreground, a large bank of clouds rose from the valley: mountains of white. Straight ahead, I imagined the two claws and mouth of a crab emerging from the cloud line, trying to push free. I considered, for a moment, if that crab would work as a metaphor for Mains, and then decided that a story like his was too complex for that.

We met up that evening. It was still hot but had cooled some, enough to clear my head. I saw Jeffrey walking down the sidewalk along Folsom Boulevard, a tall and confident walk. Physically, he looked similar to when I had seen him last, he was wearing green cargo shorts, a white shirt, and flip flops and sporting close-cut blond hair, dark-rimmed glasses, and a hint of a goatee. His affect, however, was fresh and assured. We walked together down Folsom Boulevard to East Sacramento Hardware so that Jeffrey could pick up some electrical tape. He was working full time, he told me, at the Crocker Art Museum, but the pay wasn't great, so he did some work for a contractor friend on the side. The day before he had mistakenly cut through the cord of his power saw on the job. He didn't seem too perturbed about the mishap, and was shrugging it off with a “no worries” attitude. We traded home improvement disaster stories as we waited in line at the hardware store before we were interrupted by a middle-aged woman who asked Jeffrey if he knew where the sprinkler heads were displayed. He considered the question for several seconds before admitting that he didn't know. When the customer persisted with her query, he politely explained that he actually didn't work at the store and was just waiting for the cashier. Then he gave me a grin.

I had planned for us to eat at the same Italian café, but it had closed early that afternoon because their dishwasher was MIA, so instead we sat outside a small taco stand several blocks down from the hardware store. We were the only customers and had the outdoor tables and mist fan all to ourselves. I had brought a notebook with a list of questions, both medical and personal, but I felt uncomfortable disrupting the easy flow of our stroll from the hardware store. I resolved to lock the details of the conversation into my memory and at first was successful.

Jeffrey was still living at home with Linda, but now was doing so in part to help her out by paying rent. The job at the Crocker was going well, and there was a good chance he'd get a city position as the director of art placement with them. If that happened, he'd have health insurance, but even if not, he was now five years past his injury and eligible for an affordable rate. His anxiety was much better, and he rarely required Xanax. His rerouted guts were working well, and while he still hadn't received any follow-up testing, he wasn't experiencing any intestinal discomfort. Jeffrey told me that he was starting to paint again, mainly still life and in black and white, and his work at the Crocker had helped him believe that he had the ability to produce art work that people would buy. He had some ideas for figures, he told me, simple scenes like a couple sitting at the bar or a couple of dudes at a taco joint.

Jeffrey had been dating a career-oriented woman for several months, and now spent most nights at her place. He seemed happy with the relationship, and I could tell that it gave him footing. After a while, I began to lose some details of the conversation as we moved beyond bullet points to a back-and-forth about art, writing, books, and careers. I found myself describing my own evolution into a part-time writer, and lamenting the difficulty of finding the time and inspiration to pursue this interest. We talked about how John Grisham, when he worked as a lawyer before becoming a best-selling author, used to wake up at 5 a.m. to dedicate one hour to writing and that over several years he had written his first novel this way. We also traded ideas on how Jeffrey could cash in on his artistic talents with a commercially hot image, one that perhaps, I suggested, captured the surreal nature of the annual Burning Man festival in the Nevada desert. After we'd finished our burritos and started to notice the expectant looks from the taco shop attendant waiting to close down, I realized that this wasn't an interview anymore. It was two 30ish-year-old guys with similar interests hanging out and shooting the shit. This story had progressed far beyond a young doctor and the patient that he saw for two minutes each morning. It was now about the life that lay beyond the bullet's yaw.

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