The Wrong Wife

 

Arnold Tweed

 

Our most heroic efforts sometimes yield unexpected results. No medical drama on the streets is more galvanising or more disorganised than resuscitation from cardiac arrest. Crowds, hysterical relatives and unfamiliar circumstances can be distracting, and it is also an opportunity for my personal Evil Genie to take advantage of haste and confusion to play his tricks.

In the late summer of 1977, my young family and I were returning from Europe on Wardair, Max Ward’s charter airline that was eventually swallowed by Canadian Airlines. Since they had served good food and free booze on our transatlantic flight I was in a mild state of foggy fatigue.  We queued up for customs inspection at Winnipeg’s International Airport, shuffling our feet impatiently as the grim faced customs officers methodically searched the suitcases of the pensioners in line ahead of us. The tremulous, perspiring old lady just in front of me should have caught my attention, but the August heat provided sufficient explanation for her perspiration and my mental lethargy. Just at the exact moment that she heaved her suitcase onto the counter, she collapsed, folding up into a small forlorn heap at my feet. That immediately ended my lethargy. Five years of teaching CPR triggered the instinctive response: “Are you all right? Can you speak? Does anyone here know CPR? Call 911 for an ambulance.” I followed the prescribed steps, opening the airway and checking for breathing, but I knew she was in cardiac arrest. A crew-cut young man, who I later learned was a North Dakota state trooper, slid onto his knees beside me and we started methodical two-man CPR: one-one-thousand, two-one-thousand…….five-one-thousand – breathe. I swear that the customs inspector continued to inspect her suitcase as we sweated on the floor to save her life.

After what seemed like eternity, but was actually less than twenty minutes, a Winnipeg Ambulance Services crew arrived. In the zeal of the moment I had no intention of leaving her fate in their hands alone and into the ambulance with her we went, both the State trooper and me. Just as the crew had secured the stretcher, a small bald head timidly appeared at the ambulance door and a querulous voice interrupted us: “Is that my wife?” I had neither time nor patience to deal with this distraction. My response, “Does she look like your wife?” was answered uncertainly, “Yes, I think so.”  “Help him into the front seat of the ambulance and let’s get going.”

In the ER, thirty minutes later, it was obvious she was not going to make it. Asystole was unresponsive to bicarbonate, adrenaline, calcium, and, for good measure, several attempts at defibrillation. This was my hospital, my domain, my colleagues, and we were a smooth functional team. We had had a few successful resuscitations from prehospital cardiac arrest and we did our best, but his was not to be one of our saves. Reluctantly we stopped and I went to find the little old man.

Informing the next of kin is never easy but there is a standard formula, even when you’re exhausted. Find a quiet room, sit down, hold his hand, and break the news as gently as possible. “It was her heart, cardiac arrest. We tried our best but we couldn’t start it. Yes, she has passed away. Yes, of course you can see her just as soon as the nurses tidy her up a bit.”

I thought about my family, forgotten and marooned at the airport. For a minute I sat dejectedly at the nurses’ desk, waiting for a chance at the telephone to call a cab. Anne, the charge nurse, was on the phone, listening but not talking. Then she cupped the phone in her hand and turned very slowly towards me. “Dr. Tweed”, she said, “I hope I’m hearing this wrong. This call is from the security services at the airport. They’ve found a woman in a wheelchair, a large, loud and very angry woman, and she’s looking for her husband. And what she’s threatening to do with him when she finds him should not be repeated by a nice girl like me. It seems they’ve also found a somewhat senile little old man who’s lost his wife.”

Let me digress for a moment. This story was told at a dinner party in Bahrain, twenty years later and half the circumference of the globe away. We were being hosted by Tom and Casey O’Leary, now in Edmonton. I had known Tom as a resident; he had finished his anaesthesia training in Winnipeg a few years after me.  But the anecdote was really for the amusement of others, American friends who had been regaling us with tales of their own mishaps.  Over the intervening years I had not repeated this story often, at least not until I thought that the principals would all be dead and the story had been long forgotten by everyone but me.

“Yes”, Tom said, “I remember that case, I was covering emergency that day. Before I joined Anaesthesia I worked as an ER doc.  After you stopped the code and talked to the old man I took him in to see his wife. He cried and kissed her cheek, held her hand for a minute, then said he wanted to be alone.”

Anne must have gotten the response she expected. I was numb, dumbfounded; my first reaction was hope it was a hoax. How can a day turn out so badly? You just try to do what is right, what you’ve been trained to do, and the whole world conspires against you. Meanwhile, Anne, ever resourceful as ER Head Nurses must be, checked his and her identification. The dead lady was definitely not his wife! Who is to tell the old guy and how can one explain such a fiasco?

Back to the quiet room, holding his hand, speaking slowly, carefully choosing my words. This was not a task I had practised before. “I’m sorry, Mr. Brown, for upsetting you so, but how could we know? The lady in the ambulance, yes, that lady in the other room, who is dead.  Well, Mr. Brown, you see we’ve made a mistake. We don’t think that lady is your wife Mr. Brown. In fact, Mr. Brown, we’re sure that she’s not your wife. Your wife is at the airport Mr. Brown. She’s at the airport, very much alive, and she’s looking for you.”

He sat quietly for a moment or two, saying nothing. I didn’t know if he had heard, or understood, or was about to collapse himself. Then a little tear slipped out of the corner of his eye and ran down his cheek. I left before I confounded my folly further.

 

About the Absurdity of Life

Arnold Tweed 

This story is about suicide and begins with a case that shocked everyone in the hospital, even the battle-weary ER nurses. Suicide strikes most of us as horrifying and repugnant, but might it also be gentle and welcome? With physician-assisted suicide so much in the news, there is a social debate raging on that very topic and I hope this case will show that our attitudes about suicide are significantly conditioned by our experiences.

It is difficult to imagine a life so meaningless, futile, and unbearable that suicide is a logical choice. Probably none of us have been there, but many of us have encountered suffering souls who have faced that dilemma.

One hot afternoon late in the summer of 1965, I was the junior interne in the Emergency Room of the Winnipeg General Hospital. I was not only the junior interne, I was also the only and therefore the senior physician in the ER that afternoon. The ER was our proving ground, the front line for all the mayhem, violence, tragedy and despair of the city. Fortunately, few cases were as tragic and pathetic as the one I describe.

The oppressive heat of the afternoon had just abated when the paramedic team called that they were bringing in a patient who had been brutally mutilated. There were few details. Apparently she was attacked in her small apartment where she also carried on business as a seamstress. A late afternoon customer had found her and called the police. The only evidence that might identify her assailant was a pair of blood-stained tailors’ shears, found beside her. The police hoped there would be fingerprints on the shears. She had said nothing to them except to request that someone call the Humane Society to collect her cat.

At first glance there was nothing particularly remarkable about her: she was conscious but uncommunicative, perhaps in her mid-thirties, plain but regular features, overweight, and not in any obvious distress. In fact, considering the report we had received, her affect was remarkably flat and unperturbed.

Only when we removed the sheet covering her torso did we realize the severity of her injuries. Her abdomen had been viciously slashed, and much of her bowel was extruded. The bowel that was visible had also been cut across in several places. It is not easy to open a person’s abdomen; ask any surgeon. Even with a sharp scalpel there are several layers to incise and it takes determination, dexterity and time. This was obviously the work of a determined assailant.

When we had completely removed the sheet, more was revealed. She had an indwelling urinary catheter and both her legs were withered. She was paraplegic, had been for some time, and lived and worked from a wheel chair. All this had already been noted by the paramedics and police. It was the identity and motive of her attacker that had them puzzled. Apparently she lived alone, had no obvious enemies, no immediate family or friends, and there were no signs of a struggle.

There was, in reality, little that we could do for her in the ER. We started an intravenous drip to replenish her lost blood and fluids, called the surgical service and arranged for her admission to the ward. It was not until we were well into the mundane details of admission that we recognized the obvious connection. She had neither complained of pain nor asked for pain medication. She was not only paraplegic but was totally anesthetic (without sensation) from the rib cage down.

This had all the hallmarks of suicide, but the callousness of the method had confused us. She had apparently disemboweled herself with a pair of sharp tailor’s shears just as if she were cutting a piece of wool serge for an overcoat. At the same time, the option she’d chosen was without doubt brutally effective ­­­– since neither the abdominal wall nor the bowel had sensation she was able to do it deliberately and methodically.

The surgical team took several hours to identify and repair all the tears in her bowel and to close her abdomen. It was all in vain. She got her wish and died of septic shock from peritonitis three days later in the ICU. No visitors came to comfort her.

This happened almost fifty years ago and the picture still haunts me. Is suicide in such a brutal yet systematic way impulsive or carefully planned?  Was she in suicidal depression, or was this a rational decision? Was it a last, desperate attempt for autonomy in a life where she had lost control, or a desperate plea for attention?

I am of that genre of doctors educated in a very traditional system; we have sworn the Hippocratic Oath and earned our public trust as defenders of life. The very core of our professional values is the assumption that every human life has worth. Deliberately discarding life in this manner contradicted all our beliefs; and we had difficulty comprehending what sort of life was so devoid of meaning as to justify this treatment?

I have struggled with these contradictions for most of my career and I still do not have a satisfactory answer. Recently, the essays of Albert Camus has helped me to view suicide and assisted suicide more sympathetically, though I recognize that I cannot share the victim’s emotions and thoughts.

Albert Camus (1913-1960) experienced firsthand the senseless brutality and privation of both the Algerian struggles for independence and the Nazi occupation of France during WWII. During the war he was an active supporter of the French Resistance as an underground journalist, and at various periods he was also an anarchist, communist, and social activist. His writings distilled the public mood of the period. In 1957 he was awarded the Nobel Prize for literature “for his important literary production, which with clear-sighted earnestness illuminates the problems of the human conscience in our times” [1].

One of his essays, The Myth of Sisyphus [2], is devoted to a philosophical discussion of suicide and begins with the statement, “There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy”.

Sisyphus was a mythical Greek king who annoyed the Gods with his pranks and, most egregiously, by preying on his guests. This sin particularly angered Zeus, the God of hospitality. The punishment of Sisyphus was, for all eternity, to roll a boulder up a mountain only to have it roll back down again each time. His punishment encapsulates the idea of eternal futility, and Camus calls him “the absurd hero”.

Camus expanded on this age-old theme in his idea of the absurd, which probably reflected the chaos of the world in which he lived. ‘Absurd’ describes the longing for meaning and clarity in a world which seems to offer neither. In Camus’s philosophy life per se has no intrinsic or sacred value; it is the experiences of living that give it meaning. He framed the philosophical idea of ‘the paradox of the absurd’ as a contrast between our expectation that life should have meaning and significance and the harsh reality that despair and mortality are our only sure reward. This leads to the philosophical question: if life has no meaning and no value, is suicide logically justifiable? In such a world is it a rational decision to choose death over hope?

Camus did not discuss the special case of the terminally ill, but on philosophical grounds he rejected suicide as a general solution to the absurdity of life, not because he valued life but because he opposed nihilism. Death does not confer meaning to life. Suicide is the ultimate negation, the decisive act of nihilism which extinguishes both life and hope.

Let us now fast forward to 2016 where physician assisted suicide is the topic of the day, not the ethics of suicide but the guidelines by which patients are to be screened and euthanasia administered. The preferred name now is ‘medical assistance in dying’ (MAID), perhaps a less threatening term, but with the same intent.

Now we can rephrase the question posed in the introduction: Are there circumstances in which suicide is a rational solution to the absurdity of life? We have already discarded the ethics of the past, which were based on a theological construct that has no traction in today’s society.  Having accepted that life has no a priori intrinsic or sacred value, we return to Camus. Life is only significant for the experiences it offers. The variety and satisfaction of those experiences define the ‘value of life’ and the absurdity is the paradox of expectations versus reality.

By redefining life in social rather than theological terms we make suicide acceptable and permit an ethical role for physicians. Remember though, that absurdity does not demand death. Sisyphus did not consider suicide and Camus objected to suicide as a nihilistic solution that extinguishes both life and hope. There are no other examples of nihilism in medicine and philosophically nihilism and medicine are not good companions.

I recognize, however, that this argument has been directed mainly at physician participation rather than patient motivation. The decision to request MAID is not just a recognition of the absurdity of living, it may also be an attempt to assert personal autonomy in the final closing of the curtain. This may also reflect a certain apprehension about end-of-life care. Perhaps some terminally ill people prefer the certainty of a gentle, welcome death over the uncertainty of the alternatives. If this is true, palliative-care proponents (that includes me) face a challenge in public perception. The slogan “dying with dignity” has been linked so often with assisted suicide that they are considered inseparable. Patients who choose palliative care must be reassured that natural death in an atmosphere of comfort, love, acceptance, peace and even gratitude is also dignified.

I doubt that our patient had read Camus, but she understood him better than we did. Her extreme self-mutilation may have been her last attempt to draw attention to her misery. If she had had the option, would she have preferred a more gentle and peaceful death? We can’t know. We know only that she had lost control over many aspects of her life, and by Camus’s criteria her life would be considered “absurd”; but she exercised her final and only remaining autonomy in a most dramatic fashion. This story is her legacy and our lesson in humanity. We cannot and must not judge the person who is in that situation. Our ethical aims as physicians are the same today as when I graduated. They are to relieve pain and suffering and observe the “utmost respect for human life” [3]. Respect does not require either futile efforts to prolong life or avoidance of compassionate treatment that may shorten life.

 

 

1. “The Nobel Prize in Literature 1957” Albert Camus.
2. Camus, A., The myth of Sisyphus, and other essays. 1st American ed. 1955, New York,: Knopf. 212 p.
3. Hippocratic Oath, Declaration of Geneva. Available from: https://en.wikipedia.org/wiki/Hippocratic_Oath.

 

Arnold Tweed

One of the most memorable patients from my ICU days was an exotic dancer, a young lady who claimed to be of Mexican origin and had adopted Juanita as her stage name. Her partner, a young, virile western diamondback rattlesnake, played the straight man in her act.

Exotic dancers in Winnipeg were pub entertainers. In the main they were a pathetic lot. The only prop provided by the beverage room owners was a small, elevated stage near the centre of the pub. In the larger pubs there would be three or four noon-hour acts. Each girl would rush in, perspiring if it were summer and shivering if it were winter, clutching her meagre accessories. There was no introduction or any attempt at finesse. Each had to first set up her own portable stereo player and select her music. Most could then do a workman’s job of undressing with some provocative movements and arranging their clothes in a pile at a corner of the stage. Clad only in g-strings they would gyrate their hips, more or less in synchrony with the music, make some suggestive thrusts at the front row drinkers, dip their nipples in a couple of beer glasses, then pick up their bundle of clothes and rush to change in the ladies toilet. A hasty exit was required, not to escape the clutches of the aroused audience, but to be on time for the next engagement.

The male clientele of these pubs were a study. Even though the front row tables were always the first occupied, the men seated at those tables pretended that they were there only for the drinking. They studiously ignored the dancers, barely glancing at the stage, except when the female anatomy was inserted into their field of vision. Otherwise, they feigned total disinterest. No one could figure why the pubs with dancers thrived and those without failed.

Juanita’s act was different. In fact, for several months she was the most popular pub act in town. She teased her male audience with the snake, which both fascinated and repelled them. The snake has special sexual symbolism for some men and “trouser snake” is a vernacular term for the male organ. I think this inspires macho images of sexual strength and dominance: coiled and ready to strike, dangerous, potent, and so on. Juanita capitalised on this male identification with the reptile and when she and her partner performed they had the undivided attention of every man in the pub. Not a word was uttered, not a drop of beer drunk. They gazed intently as the snake’s head disappeared between her thighs, then would crane their necks to see if it reappeared behind her. They didn’t clap of course, which would have suggested unbecoming interest. But they certainly didn’t try to molest her either. Within a few weeks she had developed a certain notoriety among the good citizens, tempered of course with proper expressions of disapproval.

Apparently the snake did not enjoy the performance as much as was thought. One fateful day, near the climax of her act, he bit her. It is the natural thing for a western diamondback rattler to do when handled. Juanita was not naïve about snakes and had had his venom glands removed, but she had neglected to have him defanged. Since he was a robust young fellow, he left two very visible puncture marks in her anatomy. Perhaps he didn’t have a full charge of venom on board but we weren’t about to take a chance. Juanita was admitted directly from emergency to the ICU where we could provide the care and attention that her unusual condition deserved.

She was admitted to the ICU on Thursday evening and antivenin injections were begun that night. There was swelling and cyanosis around the puncture sites, but she adamantly refused to even consider surgical debridement, a standard treatment in those days. In fact she had been bitten before and planned to go right back to work. Surgical dysfiguration might make her unemployable.

By Friday morning every doctor in the Hospital knew about our exotic patient and her erotic accident. Not only was snake envenomation a rare event in our sub-arctic climate, but the tender circumstances in which she had been bitten piqued the curiosity of our distinguished medical staff. Some may even have seen her act and knew how perilously close that snake’s head came to her private (or not so private) parts. The medical teams came in droves and every medical speciality made the ICU their first stop for rounds that day. Not only internal medicine, surgery and gynecology, but every other hospital speciality (including sports medicine) dropped by. Her case obviously presented a unique learning opportunity for students, interns, and residents of almost every Department of the Hospital.

Juanita was delighted to be the centre of attention. She welcomed her new admirers and was willing, even eager, to display her wounded part for their inspection. But their interest was short lived. After a cursory glance, most decided they were late for more important tasks. Contrary to the rumour that had been started by a mischievous ICU resident, Juanita had not been bitten on her most tender anatomy. The snake had sunk his fangs into the web between her thumb and index finger. Medical interest in her condition rapidly waned.

The two miscreants featured in this story probably wouldn’t be recognised as such today. Both are successful and respected specialists, exemplary role models for the residents and interns entrusted to their teaching. One has just received a distinguished alumnus award from our alma mater. At the time of this incident, however, they were hell-raisers, their pranks familiar to a generation of staff and trainees at Winnipeg’s Health Sciences Centre. If there was mischief afoot one or both were sure to be behind it. This incident is exceptional because it was not widely publicised, for reasons that will be obvious. It was a scam concocted while both were junior residents in the ICU. I think that only two other people, a patient and myself, knew the full story.

The patient, Mr. Scott, had been admitted to intensive care, ward H7, for treatment of an intractable cardiac arrhythmia. Despite exposure to all the usual anti-arrhythmic drugs, and some that were still experimental, he continued to generate an alarming number of ectopic ventricular beats. Since he was not incapacitated by his condition it was unnecessary to confine him to bed. Also we wanted to see how exercise affected his heart. Fitted with a Holter monitor that he could slip into a pocket of his bathrobe he had the complete freedom of the ICU. We were nervous about his going further in case he had a bout of malignant arrhythmia but within these confines Mr. Scott was our guest for several weeks. His only medical problems were the occasional side effects of his treatments and his heart otherwise ignored every medication offered. His perambulations around the ICU became part of our daily routine.

Mr. Scott and I became friends. At that time I was the senior resident in the ICU but he was a cardiology patient and not my direct concern. Most days we would have a brief chat over a cup of coffee. He was quiet and introspective, kept his own counsel and patiently endured his doctor’s experimentation. When he wasn’t walking he read. His habits were monkish, certainly not one given to vices or excesses. My picture of him now is a good-natured, private, thoughtful chap.

When Mr. Scott began to look like a permanent fixture I suggested to my two erstwhile junior residents that it was time to talk with his attending cardiologist about freeing up his bed. They would not hear of it. He might have a fatal arrhythmia. The consulting cardiologist was sure a new drug would work but it had to be closely monitored for a few days. His arrhythmia was of a rare type and was invaluable to their cardiology education. I thought their intense interest in his condition rather curious since they rarely went near him, but accepted their protestations.

It was not long after that Mr. Scott decided to confide in me. He approached me discretely one afternoon when the residents were out of the Unit. We were standing in front of the Director’s office, where the inbox for mail and pharmacy supplies was located. Speaking in a low voice, with a hand on my arm, only the intensity of his manner indicated his concern. “Dr. Tweed,” he said, “I must have a word with you. This has been bothering me for some time now and I think you should be informed. You know that I walk up and down this hallway several times every day. I mind my own business and I don’t talk much but I keep my eyes open and I don’t miss much either. Now every day I glance into this box to see if there are any cards for me. Every day there is a box from the pharmacy here, containing six bottles of beer, with my name on it. Now Dr. Tweed I haven’t touched alcohol in years and this is a puzzle to me.”

I doubt that it was much of a puzzle to Mr. Scott and it certainly wasn’t to me. Beer was available from the pharmacy, by prescription, as an appetite stimulant or general comforter for some patients. Mr. Scott was the only patient on H7 taking a regular diet, thus the one for whom a daily beer prescription would not raise questions. Certainly it wasn’t difficult to guess who might be quaffing his beer. A short walk up the back stairs to the resident’s call room revealed the answer. One wall was almost hidden by a stack of beer cases, filled with empty bottles. Happily settled in front of the television, each fondling a bottle of Labatts, were my two indulgent junior residents.

They were neither chagrined nor apologetic. But I was reluctant to start an investigation that would probably get them dismissed from the hospital. Despite their bad record they were good doctors. On the other hand continued misappropriation of the hospital’s supplies would land us all in jail. We reached a compromise. Mr. Scott would be discharged, the empty beer cases would disappear and I would develop temporary amnesia. Pharmacy prescriptions in the future would be only for patients.

I was confident Mr. Scott would keep his counsel to himself and I was right. He was a most discreet patient and having done his duty nothing more was said of the affair.