A Time To Die

Arnold Tweed

The wisdom literature of our cultural heritage often provides remarkable insight into current issues. We are now in the midst of a national debate, particularly challenging to the medical profession, on choosing the time to die. This is a very old question, addressed in Book 21 of the Old Testament, Ecclesiastes (3:1-8) in a passage often quoted at funerals: “To everything there is a season, and a time to every purpose…a time to be born and a time to die…” In Ecclesiastes one’s role and tasks are defined by divine order and the time to die is part of His plan. The right time is when one’s appointed tasks are finished, when one has fulfilled his role in creation. But this is not much different from the evolutionary world-view where our place in the natural order and time of dying are also determined for us, not by a divine plan but by random selection. Both theology and evolutionary science describe a natural order, a cycle of life, and a time when that cycle is complete. This acceptance of life and death as part of the natural order was brought home to me by one of my most memorable patients, Mrs. Lena B.

I was a junior resident on the medical service in the autumn of 1970. We admitted an old woman from the ER to a medical bed, mainly because there was no other place to send her. Her admission history was not exceptional. She lived alone in a small apartment and had managed, in a way, until now. A neighbor, who looked in on her regularly, had called an ambulance because Mrs. Lena B. could not, or would not, get out of bed. We had no medical history and, even with an interpreter, were unable to elicit anything of significance. However, bit by bit, we were able to piece together a social history.

Lena B. was a survivor; she had survived both poverty and persecution. During the Stalin era she escaped from the 1932/33 famine in the Ukraine, walked for days carrying her two children, and eventually got to Sweden. Her husband had been ‘drafted’ into a work camp and she didn’t see him again for almost 10 years. Eventually she made her way to Canada and eked out a living working in a factory. It was enough of a living to educate her children, keep her husband supplied with cigarettes and a little whiskey, and with just enough left over to sustain her. Now, her husband long dead, her children dispersed, she had lived like many other old widows: her church and a few old acquaintances her only interests.

Lena did not refuse to leave her bed; she simply did not cooperate. Neither did she converse, eat or drink. She answered questions appropriately in her mother tongue but was otherwise passive and seemingly unconcerned with our attempts to stimulate her. She did not exhibit signs of depression or psychosis, nor a medical condition that we could identify, other than old age, and therefore there was nothing to treat. Tube feeding and intravenous fluids were considered but we didn’t have a diagnosis to treat, had no permission to intervene, and were uncertain what to do.

Lena died quietly on about the eighth day after admission, with no medical diagnosis and no active treatment. The cause of death was heart failure due to “old age.”

In the years since I have often questioned our decision not to intervene more aggressively in Lena’s care. However, at the time, her disinterest in living seemed clear and aggressive intervention looked to us more like assault than treatment. In retrospect her life and death were the embodiment of Ecclesiastes: her tasks had been accomplished; the cycle had been completed; her time had come. Of course, at that time physician assisted suicide was both illegal and unthinkable and, even now, she would not qualify.  She exercised her autonomy in the only socially acceptable way available to her; she didn’t actively seek death, she simply stopped living.

Our attitudes towards death and dying have undergone dramatic changes, largely because we now accept that these are in the domain of individual rights and autonomy. Decisions about life and death, formerly left entirely to external resolution (either the divine or natural order) are now matters of personal concern. Only a few years ago both abortion and assisted suicide were unthinkable; now they are almost commonplace. Prior to 2015 aiding or abetting anyone in committing suicide was a criminal offense. This changed with the Supreme Court decision (Carter v. Canada) in 2015 that these laws denied Charter rights and consenting adults with “grievous and irremediable” medical conditions should not be denied the access to assisted death. The new Liberal government (this is now 2016) has proposed legislation, Bill C-14, that would allow MAID (medical assistance in dying) with strict constraints; these constraints are now the topic of intense debate.

We have not seen the end of this debate. The legislation being currently debated, Bill C-14, is not broad enough to satisfy all. It places definite limitations on MAID: in particular patients must be mentally competent and able to consent. This excludes, for example, those with Alzheimer’s or other forms of dementia who may meet the other criteria but, for reasons of age or mental capacity, are not considered competent. There may be a provision to honor advance directives, but only if made in that small window of opportunity after the disease had been diagnosed but while the individual was still mentally competent.

There are important ethical and social issues at stake. Society and the Courts have agreed on the general principle that one’s life is a personal possession; it does not belong to God or the state; it is ‘my life’. We have also agreed, through the Courts and Parliament, that it is legally and socially acceptable, under some circumstances, to request and provide medical assistance in dying (MAID). Those limitations are now the subject of debate and the dilemma is to draft rules that satisfy the demands of individual autonomy while at the same time providing acceptable protection for the vulnerable.

MAID places a heavy responsibility on medical doctors, a responsibility they fear that could lead to misuse or coercion. The conditions for MAID all require subjective medical interpretation. The first is to determine what medical conditions are eligible. The official (legal) definition of the Supreme Court states only that they must be “grievous and irremediable,” a rather broad description that includes congenital disorders, mental illness, Alzheimer’s and other forms of dementia and chronic disease. The next condition addresses the stage of the illness: “an advanced stage of irreversible decline.” Stable conditions, no matter how grievous, need not apply. Projected length of life must also be considered: a natural death must be “reasonably foreseeable.” Don’t apply if your problem is low-back-pain; it may be intolerably painful but not lethal. But “enduring suffering that is intolerable to the individual” will be a consideration. How much suffering is intolerable is, of course, a personal decision. Most restrictive is the requirement that the applicant must be mentally competent to give voluntary consent. This is necessary to protect the vulnerable (including minors) from exploitation, but also excludes a large number who may fulfill the other criteria.

We should understand where MAID stands in relation to current medical practice. The object of MAID is to deliberately hasten death in a competent and consenting adult. Moreover, it is to hasten death as the primary intent. Hastening death in the terminally ill as ‘secondary intent’ (or unintentional) is unavoidable in palliative medical care. We understand, clearly and without equivocation, that potent drugs which are necessary and desirable to relieve the symptoms of pain, nausea and fear, may also shorten life. Patients, doctors or the law have never questioned the ethics or legality of this practice. This might also be called the doctrine of the ‘lesser evil’, where withholding treatment and tolerating unremitting and unrelieved suffering is the greater evil. In MAID there is no excuse of ‘secondary intent’, relief of symptoms is total and permanent. Life itself becomes the ‘greater evil’.

How do we see this issue unfolding? First, in recognition of personal autonomy and one’s right to decide, I believe there should and will be increased emphasis on ‘Advance Directives’, essentially end-of life-instructions. This might even take the form of a simple statement. “when I have reached a stage of dementia when I do not recognize or appreciate family and friends I instruct you to euthanize me.” But who is the “you” who will make the decision that it is time for me to go? Certainly, in order to protect the vulnerable (that is me), it should not be someone who will gain from my death. This excludes my doctor, because he will get a fee and get rid of a nuisance, and my family and beneficiaries. In fact, it excludes almost everyone I know. The only situation that I can conceive that would protect my vulnerability would be to pay a disinterested third party a fee every three months to examine me and pronounce me ready or not ready. In order to continue collecting fees it would be in his interest to pronounce me “not ready “and thereby collect the next quarterly fee. His interests would therefore counterbalance the interests of those who might benefit from my departure.

Since Ecclesiastes was written we have come a long way in our thinking about the time to die. There are many who are kept alive beyond their ‘appointed’ time while others will be assisted to die in advance of their ‘appointed’ time. Lena B. was the exception, not the rule, but her choice foretold the future. The time to die can now be framed as a personal decision and we have the option to exercise that right. Each of us can decide which is the greater evil:  on the one hand to live on in helpless incapacity or mindless dementia or on the other hand to ignore natural law and prearrange our demise. Fortunately, we now have the means to exercise our choice by writing advance directives. Just be sure they are directives that can and will be honored. Perhaps the greater evil is to make no plans and leave the decisions entirely to others.

Postscript: Since posting this story I have had an interesting email from my friend, Mike Czuboka. He suggests that patients with terminal illness may fear intolerable pain more than they fear dying. This is a medical problem for palliative care physicians. I have observed instances where medical professionals were unwilling to prescribe or administer sufficiently large doses of narcotic analgesics for fear of making the patient addicted. This is absolute nonsense in treating terminal disease. What does it matter if I become addicted in the last days or weeks of my life.

Pain can always be treated and large doses of morphine are one very useful option. Of course morphine, like all potent narcotic analgesics, has side effects, and these may hasten dying. For many that is a reasonable trade-off and I consider morphine to be the dying patient’s best friend.

I Have Seen a Miracle!

Arnold Tweed

Medical miracles get a lot of publicity but most of us have never seen one. Would you recognize a medical “miracle”? I expect we would all agree that an unexpected recovery from what was believed to be an incurable and fatal disease would qualify. But miracles are more than just good outcomes: they are rare events, otherwise they wouldn’t be called miracles; and unpredictable; and defy medical explanation. Miraculous cures contradict the best medical opinion and leave us amazed and perplexed. Jacalyn Duffin, who holds the Hannah Chair in History of Medicine at Queen’s University, has made a study of medical miracles, especially those which have been accepted by the Catholic Church for canonization of Saints (Medical Miracles, 2008)[1]. Her interest was piqued when she was asked early in her career to review a 5+ year old set of slides, blood and bone marrow slides from a young woman with acute myeloblastic leukemia. She assumed the patient was long dead but was surprised to learn that she was in remission and doing well, and the request for an opinion was from the Vatican. “They wanted to know if I had a scientific explanation for why this patient was still alive.” Her evidence was crucial in the canonization of Saint Marie-Marguerite d’Youville (1701-1771), founder of the Grey Nuns of Montreal and the first native-born Canadian to be canonized as a Saint. Still, Dr. Duffin’s opinion of medical miracles is very pragmatic: “these events were miracles for the people involved. The miracle, the thing of wonder, lay in the contemporary inability to explain the recovery.” They are cures that defy scientific explanation.

The medical history that follows is a true story; It is Ian Dickson’s story and I will let him tell it in his own words.

MANITOBA MELANOMA MIRACLE

In late October, 2005 my wife Donna and I were in Florida for a holiday. While applying suntan lotion to my back, Donna noticed a mole that was discolored and jagged in shape, and we agreed that I would have it examined upon our return to Winnipeg. Our family doctor removed the mole and it was sent to Toronto for pathology. In December I was heading home one afternoon, singing along with the radio as Xmas was only a few weeks away and retirement was good to me. I stopped at the doctor’s office to have him replace the bandage on my back. He asked me to sit down and told me the lab results were back and were not good, and I had melanoma. I would need to see a dermatologist and oncologist as soon as possible. I went home in shock and told Donna the bad news.

We contacted a close family friend who was head of surgery at Health Sciences Center in Winnipeg and asked for advice regarding my next steps. He outlined the four stages of malignant melanoma, the treatment and prognosis for each stage and asked that the lab results be sent to him for review. He called the next evening and advised that “we had a lot of work to do” as the melanoma was larger than 4 mm – an indicator of a likely poor prognosis. Through him, I was seen by both a surgeon and an oncologist very quickly, and my first surgery was done on January 23, 2006. I was able to avoid skin grafting in the area, but the sentinel nodes under my right arm were black – a sign the surgeon said was clearly cancer, and the first time she had seen such a color. A second surgery took place a few months later to remove the lymph nodes from that arm, six of which were involved with cancer.

Treatment of malignant melanoma involved interferon – a booster of my natural immune system. The side effects were that of a very bad flu, as interferon is the body’s immune reaction. One month of IV treatment was followed by a proposed year of self-injections 3 times per week. I was advised not to make any big decisions during that year, and that the effects of interferon may be reduced after finishing the IV treatment. I was also told that I may be giving up a good year for a bad one, given the seriousness of my diagnosis.

The flu like effects did not subside after 4 months, and I spent most of the time sleeping and unable to enjoy much of anything. My oncologist had told me that I was in charge of my treatment, and if I decided to stop at any time it would be respected by the staff at Cancer Care.

In August of that year, Donna and I had a “come to Jesus” meeting and agreed that the additional year that I might get was not worth continuing the interferon, as quality of life was more important than quantity. As promised, the doctors respected my decision to stop treatment, and I was told that based on statistics of melanoma, I would probably have about one year to live. This led to my identifying short term goals such as playing the bagpipes again at the Grey Cup in November in Winnipeg; and to join one of our sons for Xmas – and what a good Xmas it was!

My life returned to normal as I gained weight, returned to my workouts at Reh-Fit, and again enjoyed various activities with friends and family. I was seen every 3 months at Cancer Care for checkups, then every 6 months until 2015 when both doctors and I agreed that I could finally stop these visits. The only residual effect of the interferon treatment is that I still have occasional difficulty articulating words and phrases. And my experience has made me appreciate the wonderful family, friends and medical system that help one through such difficult times. I am especially grateful to my son who gave me a diary at Xmas, 2005 with the notation “Dad, I thought you might want to write down your journey experiences as you move through this challenge of your life”. I wrote in the diary until 2011, helping me with the memories of this experience.

……………………………………………

What can we learn from this story? Is this a medical miracle? If so, do we have any clues as to the cause? Most important, is there a lesson here for others in similar straits?

Survival with malignant melanoma depends on the stage of the tumor. The worst is Stage IV which has spread to tissues distant from the primary site; in medical terms it has metastasized. The prognosis for Stage IV disease is, and was then, very grim. The latest authority, the Final Version of 2009 AJCC Melanoma Staging and Classification states, “the overall prognosis of all patients with stage IV melanoma remains poor”[2]. The ten-year survival rate is so low they don’t give a number. Ian was given a generous prognosis of about one year.

Does Ian’s story qualify as a miracle? There are several flavors of medical miracle. One is the dramatic human interest story that the media love: unexpected survival from a tsunami or airplane crash. These events are rare but they do not violate natural or physical law and do not interest us here. The cure as described by Ian is properly called a “spontaneous remission,” very unusual for cancer of this type. Standard medical wisdom assumes that there is a natural cause for the remission, and even if that cause is not currently known it may someday be revealed by research. However, there is another explanation held by many, a theological explanation. If a miracle cure has been preceded by petitional prayer and is also scientifically inexplicable it may be accepted as a “sign” of divine intervention and be labelled a “miraculous cure”, a requirement for canonization of Saints. Of course “spontaneous remission” and “miraculous cure“ describe the same event and differ only in assignment of cause.

If we consider natural causes in Ian’s case, we should look to the immune system for a medical explanation. Cancer treatment now includes immunotherapy to redirect the native immune system to recognize malignant cells as foreign and to attack them. Genomics research is yielding more information about genetic factors that affect susceptibility and resistance. In this case, it may have been his own native immune system, released from the chemotherapy, which destroyed the cancer cells. Probably a number of factors acting in unison, rather than a single factor, were responsible. This is a plausible biological theory, but still a tentative and inconclusive explanation of the event. We all have an immune system; why did Ian’s react so much more effectively than others? The miracle is in the features which make this case unique. We can congratulate him on a happy outcome, but only with the rather banal, “You were the lucky one, old son!” But what is luck but random selection? Random selection is capricious and this is an unsatisfactory explanation for an experience of such personal consequence.

Ian and Donna recognized their helplessness in the hands of capricious chance. This reached a crisis point with their “come to Jesus” meeting, expressing a need for some certainty and autonomy, for some control over life events. For Ian, continuing medical treatment offered only the certainty of feeling terrible and the uncertainty of living longer. The outcome was still governed by the randomness principle. The decision to stop treatment can be seen as his attempt to retake control of his life and his willingness to accept the consequences, but on his terms. But “come to Jesus” also suggests a plea for hope, for at least temporary respite from suffering. Hope is an intangible asset, but essential to mental health in a crisis. Hope is the affective expression of optimism that the outcome can be influenced beneficially, and is usually accompanied by a plea for intercession. If medical treatment offers no hope where does one look for intercession?

Our less skeptical and more spiritual ancestors did not find this a perplexing problem; to them miracles were evidence of divine intervention which were invoked by intercessory prayer. Miracles demonstrated that nature is subservient to a higher authority, a reminder that randomness did not rule unchallenged. Moreover, the gift was free for the asking; it need only be accepted in faith.

How do we react today to the prospect of incurable disease? Normally we seek the best medical care and hope that chance will favor us, but we may also pray for divine intervention. It should be noted that these are in equal measure expressions of faith, not certainty. Ian chose an independent path that reflected his need for autonomy and hope for relief from suffering. Some might describe his fortunate outcome as simply a “spontaneous remission,” others may choose to call it a “miraculous cure”. The former is a descriptive explanation that emphasizes the diagnostic uncertainty regarding cause and accepts that in the end we are, like all creatures, the victims of chance. But the sense of awe and wonderment elicited by these marvelous events is not satisfied by statistical logic. Our emotional response is to search for personal significance and spiritual meaning, and a “miraculous”, not a statistical, explanation. But these approaches are not mutually exclusive; we do not need to choose between one or the other? The end result does not distinguish one from the other? That is my view, but I’m afraid that you, the reader, must decide for yourself. If you place your faith in modern science and accept the element of chance you are with the majority; but if you have faith in miraculous intervention you may pray with corresponding confidence. Dr. Duffin’s conclusion still holds: “the event is a miracle for those involved.” Perhaps best to hedge your bets and go with both.

 

  1. Duffin, J., Medical miracles : doctors, saints, and healing in the mode rn world. 2009, Oxford ; New York: Oxford University Press. xv, 285 p.
  2. Balch, C.M., et al., Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol, 2009. 27(36): p. 6199-206.

In Memory of Garm

In Norse mythology Garm was the ferocious hound who guarded the gates of Hell. Our Garm bore only a passing resemblance to his mythical namesake. Guard dog he was not; he treated open gates as pathways to adventure, not to be guarded. He was a family pet, or more precisely the boys’ pet. They were fascinated with Norse mythology and heroic figures, and perhaps hoped that Garm would live up to his name. The boys were 14 and 9 years; Garm was 3 months when we adopted him. He was a black Labrador retriever, or mostly so, and true to his breed was gentle, friendly and handsome. Most of the time he was quite likeable and might even be credited with some intelligence, though later behaviour would cast doubt on that assumption.  In particular, he had the one quality that distinguishes all Labs, a good nose. This product of genetic selection, over which he had no control, was eventually to be the cause of his downfall.

Garm was a house dog, but with limited privileges. The house rules were simple but strict; he had a pad in the kitchen and was to stay there. However, like the camel outside the tent, he was always prepared to test the limits. While we were eating Garm would lie in the doorway between kitchen and dining room with his nose exactly at the dividing line. First the tip of his snout would edge across the border, followed by half his head, and one paw very gingerly, then very slowly and quietly the other would follow. All this without a sound, trying his very best to be invisible. “Out, Garm”, not even spoken harshly, and he would recoil back to his lair in the kitchen. He never required or received physical punishment; harsh words were quite enough to make him obey, if only temporarily.

When he was alone with the boys he knew he had the freedom of the house. Of an evening he would snuggle between them, relaxing comfortably on a soft chesterfield in the upstairs family room, watching TV or dozing. But the moment a car entered the driveway, signalling the return of parents, he bolted back to his place in the kitchen. Usually he beat us and he would raise his head sleepily as we entered the house as if asking what had kept us so late. Occasionally, perhaps because the TV was too loud or the sitcom too engrossing or he was sleeping too soundly, he missed the noise of car tires crunching gravel and didn’t realize his peril until the front door opened. Then he came careening down the stairs, tumbling head over heels in his haste, with no pretense at deception, to cringe under his blanket in the kitchen.

He was the boys’ pet, and you can guess the division of responsibilities for his care. I fed him; they treated him to snacks. I took him out each day, summer and winter, for his E&E (exercise and excretion); they encouraged him to loaf with them in the family room. I disciplined him; they indulged him. Did this indulgence foster the character flaws that later led to his problems with the law? I suspected so but I got little support for that view, neither then nor now.

We were a reasonably peaceful household until Garm started to feel the surges of young manhood. I realized that his brain was subservient to his hormones when he picked a fight with the neighbour’s German shepherd, four times his weight and strength. My intervention certainly saved his life and cost me several lacerations and a tetanus shot. Garm was unabashed and acted as if he had won the fight. At that point I should have done the obvious and removed the source of his surging hormones. I procrastinated and events overtook us.

As I said, Labs have good noses. Garm could sense the pheromones of a bitch in heat from across the city. He started to bolt from the yard, completely ignoring our calls to stop, and several hours later we would find him with a pack of like minded juvenile louts, vying for the attentions of a preening female. When we dragged him home he seemed contrite but did not reform his behaviour. The next enticing waft of a bitch in oestrous and he was off again.

Garm was confined to quarters. I reinforced the fence around our yard, six feet high with sharpened pickets along the top. The gate was kept locked and when outside the yard he was always on a leash. Still I avoided the obvious solution.

Then disaster struck, the nadir of his delinquent career. Garm was a little short of his second birthday. It occurred on a late afternoon in midwinter; we were all indoors, preoccupied by routine tasks. Garm was more alert than was his usual habit at that time of the day, but he studiously avoided the door, avoided even glancing at it. Interested in going outside? Not him! The front doorbell rang and I forget now who was the caller or why. The door opened briefly, only a little, and Garm was gone. Like a sprinter out of the starting blocks, a black projectile, he bolted past the surprised caller, bounded to the top of a small snow pile bordering the walkway, and launched himself at the closed gate. Unfortunately for him, he cleared it with room to spare and disappeared. A search until dark of his usual haunts proved fruitless. The boys were disconsolate.

Two days later the city’s pound keeper phoned. Garm had been apprehended and his offences were serious: caught with a pack of dogs in Assiniboine Park chasing deer. The only one with a collar, he was positively identified. The boys were delighted; they wanted him home at once. The fine to spring him was $53, and would increase for every day he was an unclaimed guest of the City.  I was at work; grocery money on hand was insufficient; piggy banks were emptied and I think it was still not enough. My wife claims that she had to search behind the cushions for loose change, but she does tend to exaggerate. I didn’t witness his release but apparently he was a sorry specimen: fawning, contrite, chagrined, and apologetic. How could a decent young fellow have sunk so low? Oh! The evils of bad company!

I was resolved that the definitive treatment could not be further delayed. The source of his tempestuous hormone surges had to be removed. It had been a busy day at the hospital and we had guests coming for dinner but the pound keeper had warned us that the fine would double each time he was caught. My chief lab technician was alerted and Garm was bundled off to our animal operating room.

My experience with veterinary anaesthesia had been limited to one species, sheep. Our sheep were docile, phlegmatic creatures that readily accepted a mask with halothane and oxygen. Compared to a sheep’s breath it was a fragrant mixture and that might explain their lack of resistance. We usually induced general anaesthesia with about 3% inspired halothane. Using an old ether bottle as we did, and opened about half way, it might deliver anywhere from two to five percent. However, we had done this a hundred times and had never killed a sheep.

Garm was contrite but suspecting he was to be punished, he cowered; he whined; he cringed under the bench; he struggled when offered the mask with sweet smelling halothane. His adrenaline level soared.  I sat on him and opened the old ether bottle a little more, trying to get through this trauma quickly. In my impatience I forgot, or perhaps I never knew, some basic dog physiology. Dogs have an irritable myocardium and are prone to adrenaline induced arrhythmia.

My readers will by now have guessed the sad ending of this story. Every anaesthetist knows the risks of mixing high levels of endogenous adrenaline, an irritable heart and halothane anaesthesia. Garm struggled a little then suddenly became quite still, the knife never got near his tender parts. When I saw his dilating pupils I instantly realised what had happened — cardiac arrest. We tried to resuscitate him but to no avail. Open chest cardiac massage, endotracheal intubation, and oxygen were ineffective. I considered calling 911 for a defibrillator but Wayne, my technician, balked. He was, perhaps, anticipating tomorrow’s headline in the Winnipeg Free Press, “Laboratory technician Wayne P. at HSC calls paramedics to resuscitate mongrel dog.”

Although I could justify the necessity for my actions, the outcome was certainly a product of haste and carelessness. My evil genie at work again. I could anticipate the questions and reproach that faced me at home. After all, Garm had left home a lively and healthy dog for a small operation that would cure him of his lusts. Would they think I had killed him deliberately? Would they doubt my sincerity and good intentions?  I was a professional anaesthetist; would this blunder stigmatise my career?

There were tears, of course, and as expected there had to be a heaping dollop of guilt and reproach. How did I explain my miscalculation? I fell back on the anaesthetist’s oldest and lamest excuse: “He took the anesthetic badly.” It was a low point for us all.

Why do dogs have such an emotional hold on us? First, consider that the domestic dog (Canis familiaris) and humans have a long shared history, 20-30,000 years [1]. Still, it is debatable who adopted whom. Did wolves attach themselves to hunter-gatherer groups to share in the spoils of the hunt or did humans capture and domesticate the (now extinct) megafaunal wolf? Though they may have hunted together, they were not chummy; that came much later. When hunting strategies became more dependent on dogs, the relationship deepened. Dogs were buried with humans, as trusted servants of the deceased. After the shift to an agricultural economy, about 12,000 years ago, dogs took on domestic roles as herders, pack animals and guard dogs and probably lived more closely with humans. Domesticated dogs thus have had about 12,000 years to study humans, learn their body language and anticipate their moves. They do this so well that we have anthropomorphized them; we assume their behaviour reflects human feelings and qualities. It is understandable that people put their dogs in their wills, delay vacations when their dog is ill, and are prepared to pay veterinarians more than doctors. Dog owners assume that the unconditional loyalty and love of their pets deserve a reciprocal response. But all dogs, some more than others, carry traces of the wolf ancestor. That remnant of the ancient past defines my memories of Garm; a dog that at his best was totally civilized: obedient, charming, and lovable. But when the instincts of the wolf were stirred he acted like a wolf. He followed his nose and did what nature demanded of him.

The boys have a different point of view. They favour the old myths that portray dogs in mystical and heroic settings. There are many examples: Garm in Norse mythology, Cerberus in Greek; Romulus and Remus were suckled by a wolf. Constellations and stars honour dogs; Sirius, the Dog Star in the constellation Orion, is the brightest star in the heavens. These are the images they relish. They see Garm, the black hound of Hel and guardian of “Gnipas Cave”, leading a pack of savage wolves across the heavens into the battle of Ragnarok. They see the heroic Garm in a death struggle with the God Tyr. Fight bravely, Garm!

  1. Morell, V., From wolf to dog. Sci Am, 2015. 313(1): p. 60-7.

A Typical Saturday Night in the ER

The Bugger Missed! 

Saturday night in the big city is the time for partying, for unwinding at the end of the week. Families and friends get together to socialize and quaff a few beers, recount the events of the week and argue. The Winnipeg General Hospital was located in the core area of the city, noted for its Saturday night volatility. Week-end call was the proving ground for residents in the ER, surgery, anesthesia and ICU, when they learned their trade by full immersion. Too often happy family parties turned into deadly brawls; mayhem and violence fueled by a few too many beers. At times our stalwart citizens resorted to lethal weapons and the knifings, gunshot wounds and beatings that resulted gave the on-call teams plenty of practise in the management of trauma, and usually keep them busy well into Sunday.

Alex C. was a fairly typical example of Saturday night celebrations gone awry. He was brought to the ER by ambulance, full lights and sirens, from a somewhat seedy area near the hospital. Initial assessment was started even as he was being wheeled into the trauma room. He was rapidly exsanguinating from what appeared to be a gunshot wound in the right side of his abdomen, just above the umbilicus. Although substantial external blood loss was obvious we were sure there was much more inside his abdomen. He was on the verge of hemorrhagic shock: cold, clammy, vaso-constricted, with a thready pulse and undetectable blood pressure. No other signs of injury. At that moment a detailed history was unnecessary; the police would see to that. But in any case, he was confused and incoherent, either from booze (the aroma of which clung to him like dog hairs to a carpet) or shock. On quick assessment he appeared to be relatively young, about 30, a little below average size and fortunately in good physical condition. The sort of sport he had been indulging in was not well tolerated by the old and infirm.

Emergency treatment for this sort of trauma is pretty straightforward. First priority is to insert at least two or three of the largest intravenous cannulas possible, in whatever veins, peripheral or central, that can be located. The ER nurses and physicians are pretty good at this, and usually it’s the nurse who gets the first line. From that point it’s a struggle to transfuse enough saline, colloid and emergency blood to keep ahead of his ongoing internal blood loss until you can get him to the operating room. Surgical exploration is the definitive treatment. The OR nurses were counting the instruments and the surgical residents were scrubbing as we wheeled him out of the elevator. Anesthesia induction is critical in these cases, the wrong agent can kill the patient. That was the unfortunate experience when sodium pentothal was introduced to field anesthesia at Pearl Harbor. It inhibits the reflex mechanisms that maintain circulation and cardiac arrest quickly follows. Fortunately ketamine had just been approved, and ketamine, muscle relaxants and an endotracheal tube had Alex ready for surgery in minutes.

A 12-gauge shotgun shell primed with #4 buckshot at close range can do a lot of damage. After the bleeding vessels had been located and ligated there was a long night’s work ahead to find the multiple holes in his bowel and repair/resect and re-examine. The surgical residents had plenty of practice in suturing bowel that night and well into Sunday.

I didn’t get to see Alex again until Monday. Since I was the junior member of the team it was left to me to complete the charting, that is to record a proper history and physical. He was awake and conscious, though obviously painfully aware of an abdominal incision that extended from his xiphoid (the lower end of his sternum) almost to his pubis. (The surgical maxim is big surgeon-big incision, small surgeon-small incision). Although movement was particularly uncomfortable, he was in reasonably good humour and prepared to talk.

We got the usual pleasantries of introduction and past medical history over with fairly quickly. Then I got to what I considered the gist of the matter; how did he manage to get himself shot at close range by a 12-gauge shotgun. I didn’t ask in those words of course. I said something like, “Alex, do you remember being brought into the hospital?” “No.”

“Alex, do you remember what you were doing Saturday night?” This caused him to reflect a moment, but he nodded affirmatively.

“Alex do you remember getting shot?” There was again a minute’s hesitation. “Did I get shot?”

“Yes, Alex, you were shot in the belly. Tell me what you remember about Saturday night.”

Alex thought for a minute, as if he were not accustomed to long speeches. “Well my brother-in-law and me were having some beers, eh! We usually have a few beers and talk about hunting. I’ve known the bugger all my life and we hunt together every fall.” He stopped then as if that were the end of the story.

“Go on, Alex, what happened next?”

“Well, we got to arguing about who was the best shot, eh! Well, I got to admit, I like my brother-in-law, but he can’t shoot worth shit. I got all three bucks that we shot last year.”

“Go on, Alex.”

“Well, I told him that and he got real mad. Said I was a lying little shit and he would kick my ass until it was up between my shoulder blades.”

“Yes, then what happened?”

“Well, I didn’t like that much so I grabbed a knife and told him: you try to kick my ass you bugger and I’ll cut your balls off.”

“Yes, and what did he do then?”

“Well, then he grabbed his shotgun and started waving it around and shouting at me, ‘don’t you come any closer with that knife you little shit. You take one more step and I’ll blow your bloody head off’.”

“Yes, and then what happened?”

Then Alex did the most unexpected; he started to laugh. Not just a chuckle but uproarious, uncontrollable laughter. When you laugh the first day after a major abdominal incision it hurts. It doesn’t just hurt; it is agonizingly painful. Your belly feels like its coming open again. Alex hugged a pillow to his belly as tightly as he could and grimaced with pain but it took some time before he regained control.

I was completely perplexed. “Alex, what’s so funny? What the hell are you laughing about?”

He almost started to laugh again, but his belly was still on fire. Choking back his mirth, his reply clearly indicated that he was satisfied he had won his point.

“The bugger was waving his shotgun around and shouting at me, ‘you take one more step and I’ll blow your bloody head off’. Well I did and he missed. I told you, he can’t shoot worth shit.”

 

A Brush With A Train

Mary Bear

Canada’s native Indians are much maligned. White folks usually see them at their worst: drunk and disorderly, fighting or in court. We don’t often see their human side. Doctors see them at both their worst and their best. At their worst, in the ER, they are bruised and bleeding, victims of the mayhem and violence they inflict upon each other when drinking. At their best we see the stoicism, resilience, humanity and humour that that they often display, even in the face of humiliation.

One summer, when I was a young crusading doctor, I did a locum in The Pas, Manitoba, then a small pulp and paper town on the banks of the Saskatchewan River. It has achieved some notoriety recently because of an old unsolved murder. It seems that everyone in town, except the police, knew of the three white boys who had raped and murdered a native girl fifteen years back. That is not part of this story but does point out the long roots of mistrust and anger between the two populations. Most whites abuse the Indians, some try to reform them.

In order to appreciate the events of Mary Bear’s mishap you have to know the geography of The Pas. At that time the town site was located on the South side of the river, directly across from the Opaskwayak reservation, where most of the Indians lived. There were two bridges across the river, a railway bridge and a road bridge. The Canadian National Railway line (now the Hudson Bay Railway) bisected the town, spanned the river with a long steel bridge and one set of rails, and continued through the reservation to Churchill. Stern warnings posted at both ends of the bridge cautioned pedestrians not to use it as a short cut. Each week, at 2 a.m. every Sunday morning, the Churchill Express passed over that bridge and through the town. The road bridge, which included the only pedestrian walkway, required a detour of about one mile south of town and a mile back to the reserve.

Mary was a good citizen who worked during the week to support her family of three school age children. I never saw or heard her mention a male provider. She came regularly to the |Health Clinic for her diabetes and chronic cough. When I examined her she was quiet, respectful, and almost taciturn and didn’t waste our time with idle chatter. Her main concern seemed to be to get back to her work and family. Mary had some vices, minor or major depending upon your moralistic bent. She was too fond of sweets and cigarettes and it was frustrating to treat her diabetes and bronchitis. I tried to educate her, and she listened politely, but my lectures had absolutely no effect. Her other vice, and apparently her sole source of recreation, was to get drunk on Saturday nights. This was a ritual in most small towns of western Canada, for both whites and Indians, and it would be unfair to slur Mary by calling her a Saturday night drunk. However, that was her life and her habits were well known.

Generally, Mary and a small entourage of fellow revelers would walk into Town after supper on Saturday evening. Because it was still daylight in summer and they were sober, law abiding citizens at that time of the evening, they would make the long trek by the highway to the footbridge. It was well known that after the pub closed most would return by the short cut across the railway bridge.

Mary and her company went directly to the Paskoyac Lounge and Beverage Room, a fancy name for the local beer parlour. By the time the bar closed at midnight they would all be quite soused.

I was on duty that weekend but it had been quiet, with only one or two minor cases in the ER. About 3 a.m. the telephone ended my slumber. As always I was awake before the first ring ended, preparing mentally for the summons to patch up contestants from the inevitable late night brawls. The ER charge nurse was apologetic. “Don’t rush.” she said, “its only Mary Bear. Her drunken friends found her on the railway bridge about a half-hour ago, after the train went through. She made it about half way across. Must have passed out and was run over. You’ll have to pronounce her and sign the death certificate before we can send her to the morgue, but take your time. We’ll just cover the body with a sheet and keep it in the ER till you can come.”

I arrived about fifteen minutes later to officiate at what appeared to be a tragic but routine ceremony. Removal of the sheet and a cursory examination revealed that she was indeed dead – dead drunk. Painful stimuli elicited a grunt but no eye opening. The only remarkable physical findings were the stench of booze and complete absence of any signs of recent trauma. There were no lacerations or bruises that were not several days old, and absolutely no sign of head injury. Since she was breathing and otherwise stable we decided to put her in the recovery position and let her sleep it off.

Next morning Mary was awake, sitting up in bed, head cradled in her hands. She was suffering from that remorseless tyrant of the once a week drinker, an awful hangover. As well, she was confused as to why she wasn’t home in her own bed. Although she remembered part of the evening, she couldn’t recall leaving the pub or starting across the railway bridge. I explained the sequence of events, as best we knew, that had brought her to us. She had left the pub shortly after midnight and had fallen asleep, or had passed out, on the railway bridge. Fortunately for her she must have stretched out between the rails. The Churchill Express roared over her on its regular schedule without touching her or waking her. When her friends found her they thought she was dead and had brought her to the Hospital.

Mary listened to this account in complete silence; her way was not to interrupt or question the word of authority. She was attentive, pensive, perhaps contemplating her near miss and good fortune to be alive. Maybe this was to be the turning point in her life, cleansing her of her vice and bad habits. Would she see the hand of God in her salvation? A chance to redeem herself? Although certainly not an Evangelist, I saw this as an opportunity for some explicit health education in the guise of a moral lesson. I reminded her that that because of her excessive drinking her children had come very close to being orphans. Maybe this miracle was a message to her to take stock of her lifestyle and reform her bad habits.

She had listened thoughtfully but her response was quite unexpected. “I guess it’s a good thing I drink so much, eh!”

I was perplexed, “How can you say that, Mary? Why is it a good thing you drink so much? Getting so drunk almost got you killed last night.”

She was unperturbed by my disapproval and remained adamant “Yes, it sure is a good thing I drink so much. If I hadn’t have been so drunk I’d have sat up, and that bloody train would have taken my head right off.”

Mary was not a flippant woman. This was said with a most sober tone of voice and serious mien, but without a hint of remorse. Her demeanor was grave but her eyes were laughing. My lecture had not impressed her, nor had it offended her; it had amused her. Not only did she not believe me, but in her own unassertive way she was mocking me.