Love Is the Best Medicine

by Dr. Nick Trout

  Alone in my office, I sat behind my desk, getting a feel for this new weight on my shoulders and the relentless tug at my heart. My patient was dead and I was responsible. I owned her passing. The fact that I never so much as raised a scalpel blade to Cleo’s skin made no difference. Perhaps it would have been easier if I had made an obvious blunder—a heart problem my ears failed to hear, a liver enzyme off the charts and somehow overlooked—something more tangible than my weak misgivings over a hat trick of broken bones. The agony of death would be shared by those of us left behind but I must take the blame. I would brace for the anger, absorb the accusations, and offer honesty and humility.

  As a veterinarian I should always be competent, caring, and communicative, but our innate talents and, more importantly, our ability to learn, are best tested in a crisis. Be it the operating room or the examination room, how we deal with a crisis situation can set us apart. In the OR, I have witnessed the surgical ego manifested in temper tantrums that lay blame on the technical failings of equipment or on the challenge of striving for perfection. Not that swearing or tossing instruments fools anyone. Everybody sees the fear and reads the insecurity. None of us are immune, but for the most part I try to acknowledge my fallibility because the surgeon who doesn’t get scared from time to time is like the surgeon who claims he never has complications. And I confess, as I waited for my encounter with Sonja Rasmussen, I felt fear—fear of her overwhelming sadness.

  Police officers, military personnel, and health-care professionals will tell you there is an art to delivering bad news. I know for a fact there are many veterinarians out there far more gifted in this department than I, but I do know some of the basic moves. When I met Ms. Rasmussen, my opening line would not be the dangerously vague “I’m sorry but we lost Cleo.” It would not be the geographically indeterminate “Cleo has gone to a better place” either. I knew I had to get right to it. No pussyfooting, no preamble, no excuses. Deliver the blow and deal with the consequences.

  At some point during the two-hour wait, self-reproach paid a visit, the “what ifs” and “if onlys” attacking like mosquitoes at dusk. I knew it wouldn’t change anything but I accepted the bites as part of my burden. I didn’t see any point in swatting them away. I just hoped they might be something I could get used to over time.

  Let’s not forget that Cleo had been a second-opinion case, so I needed to telephone her veterinarians in both Bermuda and Canada. The conversations were remarkably similar—a description of the anesthetic protocol, a summary of the resuscitative efforts, an inability to offer a specific explanation, and a sincere apology for having failed the dog, the owner, and their trust in me and the hospital. In both instances I was overwhelmed by their understanding, their compassion, and their appreciation for everything we had done. I had tried to be descriptive and dispassionate but no doubt sadness laced my every word. Perhaps they were relieved that it had not been them, that they had not attempted the repair themselves. More likely their empathy lay with the fact that they knew exactly what I was experiencing because they had been through similar situations themselves.

  There was one topic I knew I must broach with Ms. Rasmussen, though I wasn’t sure I had the stomach for it. Truly unpleasant as it was, perhaps unthinkable with the shock of loss so fresh and superficial, I must make a difficult but necessary request for a postmortem examination of Cleo’s body. In veterinary medicine we might use the term necropsy rather than autopsy, but the premise remains the same, a scientific exploration of a dead body in order to discover what went wrong.

  Cleo’s body was being held in a large walk-in refrigerator, pending a decision Sonja could never have imagined having to make. Desensitized by TV shows like CSI and Bones that lure the audience into vivid autopsy scenes with the phrase “viewer discretion advised,” we all have access to a relatively unsanitized view of what a postmortem examination entails. So why would I suggest submitting Cleo’s dead body to such an investigation when reaching inside her chest to work on her heart had seemed too invasive when she was alive?

  For me, the answer lies in the distinction between life and death and the transition between the two. Beyond the certainty of knowing there was nothing I could do to heal Cleo’s failing heart, part of me recognized a need to keep her body intact. If she was going to die, at least let her die with dignity, not slashed open and hastily stitched back together. Sonja Rasmussen might want to see Cleo’s body. Keeping her whole simply felt like the right thing to do as she passed from our world into the next. In death, however, the situation had changed because the essence of what I had known as Cleo had moved on. What remained of her was something she no longer needed, something she had left behind, and in this instance, I believed she was offering us all a chance to learn the truth.

  THE liquid crystal display on my pager announced her arrival—“Sonja Rasmussen here to see you”—the words feeling awkward, like a hostess whispering in my ear at a noisy party rather than a somber declaration before a wake.

  When I scrolled down, the pager display told me she was in Room 25. Most of our examination rooms have two doors, one providing an entrance to the public, the other providing an entrance to the staff from a central work area. The staff door has a peephole, a tiny fish-eye lens to prevent people from barging in on an examination in progress. I remembered that I had this chance to pause, to take a final look into Ms. Rasmussen’s world of “before,” but I decided against it. Accepting the invisible violence in my chest, I took a deep breath, opened the door, and stepped inside.

  There was Sonja smiling, relaxed, as though she could taste the relief, glancing up at me under her red eyelashes. Once again she was wearing that long gray winter coat, numerous bulky shopping bags at her feet, as though she had been enjoying herself splurging on Newbury Street as a distraction.

  I had my hand on the handle, closing the door behind me, when I noticed the door at the other end of the room had been left wide open, affording me the sights and sounds of a bustling waiting room. My anger at this failure to achieve my goal of privacy rushed up to meet me, all consuming. I could feel my facial muscles betraying anxiety and I willed them to regain concern and solemnity.

  Who left that door open? Don’t they understand what is about to happen?

  No time for “Why would they? How could they?” No time to blame myself for this glitch.

  After only the briefest eye contact, the open door forced me to look away. I moved past Sonja, knowing she was searching my eyes the whole time, feeling like the action of closing the second door was loaded, inappropriately intimate, and a signal of hesitation.

  I felt the silence tighten all around us and Ms. Rasmussen tuned in to it, up now, on her feet as I began to speak. Adrenaline had worked its predictable sorcery in my mouth, the sudden absence of saliva making the consonants crackle, underlining the tremble dancing on my tongue. I cannot remember the exact language I used, but I remember it happened fast, terror building in her eyes as I watched my words worming their way inside her, helpless as her pain took shape, suddenly bright and hot and razor sharp.

  The scream came first, a piercing, agonizing wail filling the room, and then the weight of the disaster took hold, pulling her down, and she collapsed in increments, agony giving way in layers, from top to bottom, like a tower crumbling to the ground leaving nothing but rubble.

  Hand clasped across her mouth, she warned me she couldn’t breathe, that she might be physically sick. Clearly my message had found its mark, but then she asked me to repeat myself as though I must have made a mistake, as though the last twenty seconds had never taken place.

  I was kneeling on the floor beside her for the repeat performance. She began to swear, not in anger but in anguish, curses bent by pain into another frightening scream. If it was possible, she lost even more color, blanched enough to accentuate her freckles once more. Her body began to shake, and like a nervous fool I was talking through her tears and mucus and her fight for air, describing the details, how we tried and
did everything we possibly could and how it came from nowhere and how we got nowhere. Feeling helpless I watched her reel and swear and cry, pummeled by my description, trapped on the ride, beginning the transition from shock to grief. The pain had taken all the light from her eyes and I watched as they faded toward waxy and dull.

  Every examination room is stocked with a box of tissues in case of an emotional outburst. Precisely where they were hidden in Room 25, I had no idea. It would have been tactless to walk in, box in hand, telegraphing my bad news as if I were wearing a black armband. So I was forced to reach for the only alternative at hand—brawny, coarse paper napkins—the kind used to mop up urinary accidents. Ridiculous the way a small thing could make a difference, leaving me convinced I had compounded her sorrow as she worked rough wads into bleeding black mascara.

  Not that Sonja appeared to care. After her initial shock, the pain began to change its shape, becoming tidal, hitting her in waves that would crash and ebb away. She got it together. She fell apart. She smoothed her breathing. She began to gasp in jagged little breaths. After a time, her questions began in earnest and so I told my story over again, slowly, in detail, retracing every step, and she listened intently, interrupted occasionally, but I could tell she heard only 50 percent of what was said if I was lucky. In the end, at this stage, I felt as though there were only a few facts that really mattered. I needed her to know that healthy young dogs are not meant to die under anesthesia. I needed her to know I didn’t have an explanation at this time. I needed her to know that we all fought long and hard to save Cleo’s life. Most of all I made her see the assurance in my eyes that Cleo’s passing occurred without fear or pain, that we may have been relative strangers, but she left this world surrounded by people who cared.

  “I told my mom how nice this hospital was and how Cleo was getting the best possible care and all about how great you were and we all did our research on you and we know everything about you right down to your pant size and we thought we were doing everything right.”

  The words came out too fast, without a single blink, and when the outburst trailed off, it was replaced by tears and I watched her head dip, shoulders finding their weeping rhythm. There have been few moments in my professional career when I have felt more crushed or more of a failure than that day sitting with Sonja on the cold exam room floor.

  “How do I tell my mom? She knows I am meeting with you. This is her baby. I can’t call her. I can’t tell her all is well.”

  I offered to be the one to call her mother and break the news but she was unsure. I asked if she could discuss what to do with her husband, or a sibling, to get some advice as to how to proceed. Again she hesitated, but for the first time, behind bloodshot eyes, I glimpsed the cogs of accountability beginning to turn. She began to pull herself together, but not before delivering her coup de grace.

  “I’m so sorry,” she said. “I can’t imagine how hard this has been for you. Do you have to be somewhere else? Is there something else you need to be doing?”

  This, by far, was the low point. After all I had done to this family, Ms. Rasmussen was apologizing to me.

  Time was all I had left, all I had to offer, and it was a relief to give it away. This was Sonja’s moment of grief and I would share it for as long as it took, knowing she needed to maintain the dialogue, knowing that as soon as she stopped and left this room, she and grief would be spending a lot more time together alone.

  At some point I asked about a postmortem examination and Sonja handled the question with calm and understanding. She said she would have to think about it and talk to her mother and I insisted they take all the time they needed.

  I wondered what she would remember of this meeting, what little details would be forever imprinted—the smell of antiseptic, the sight of a Neiman Marcus logo like the one gracing the bag at her feet, the sound of animal footsteps parading just outside the door. I didn’t know but I knew this moment would linger for her in a visceral way, as it would for me.

  When we stood face-to-face, about to say our good-bye, somehow the formality of a handshake seemed ridiculous. She had every right to be angry at me, to hate me, to blame me. Instead she leaned forward and opened her arms wide and we hugged. As we parted I made a point of locking eyes, wanting her to see that although I did not share her tears, she was not alone in her grief.

  She picked up her bags, covered with now inconsequential names and logos of boutique stores from another world and another time, and I walked her into the lobby. Icy January air baited us as we stood too close to the blast from the automatic entrance doors. I offered to call for a cab but she declined, as though she had made up her mind to walk even before I asked, and I could tell it was the right decision. I promised to call first thing in the morning, and Ms. Rasmussen stepped out into the darkness.

  HE decided to join me on the drive home from work, determined to carpool, that niggling, contrary little voice I get inside my head whenever I’m emotionally vulnerable. You know the one, the diabolical confidant that despises the distractions of talk radio or NPR or books on CD, insisting we proceed in silence, ready to strike with a viperous jab or a whispered innuendo. Oh, he was in fine form that night, savoring the crush and crawl of Boston commuter traffic to offer his highlights from the day’s audio and video, and long before I pulled into my driveway, simple melancholy and remorse had been superseded by his implication that there would be far more alarming ramifications following Cleo’s death.

  Not to be left out, paranoia also hitched a ride and insisted on staying over for dinner with the family. On the outside I was poor company, distracted and monosyllabic, with no appetite. On the inside I was feasting on an “all you can eat” buffet of panic-inducing words and phrases—lawsuit, negligence, punitive damages.

  Shortly after the plates were cleared, I excused myself to the office for a little online search and reassurance mission, beginning with a trusted favorite, the Web site for the Royal College of Veterinary Surgeons.

  Mouse scurrying, I sent the curser arrow flying across the screen like a medieval warrior, ready to fight these demons with pragmatism. As I mentioned, this was not the first time (and sadly, it was unlikely to be the last) that I had been responsible for an anesthetic death. However, on this occasion, I had yet to speak to Cleo’s real owner. What if Sonja’s mom was far less understanding, but rather litigious and hungry for retribution?

  “Get a grip, Nick,” I told myself. “Remember, there is a big difference between ‘things went wrong’ and ‘you did something wrong.’”

  Then I clicked on a drop-down menu that said “disciplinary hearings” and heard a chuckle, courtesy of my copilot from the ride home.

  Sure, Nick, live in that dream world if it helps you sleep tonight, but what if Cleo’s postmortem examination tells a different story?

  I churned inside, knowing there was some truth to this notion, as I opened a series of press releases regarding British veterinarians who had landed in trouble with one of our profession’s governing bodies.

  The concept of “when good vets go bad” is wholly unpalatable, unacceptable, the stuff of tabloid fodder and shock journalism. It is one thing to be outraged that your pet’s doctor has no veterinary education and has been found guilty of impersonating a vet, but quite another when the person you entrusted with the care of your pet has an addiction to controlled substances, or neglects the fundamental tenets of his veterinary oath. Vets are just as human as MDs, dentists, pharmacists, and chiropractors, just as flawed and susceptible to the same weaknesses and vices as all of us. So why do we feel so pained, so violated by unprofessional veterinary conduct?

  Perhaps the answer lies with the victims, placed in harm’s way by us, the pet owners. Pets attain a heightened sense of innocence since their place in the health-care system is passive, at the mercy of their most trusted advocates, their owners. If we failed to spot a problem, were blind, conned, or worst of all, failed to look, the burden of responsibility will come back to ha
unt us.

  To be fair, veterinary misconduct is extraordinarily uncommon, and I was thrilled to note that the disciplinary body of the Royal College of Veterinary Surgeons deals with only a handful of cases every year. On the whole, most of these transgressions are unpleasant but predictable: driving drunk, abuse of available narcotics, forging health certificates, threatening or aggressive behavior toward clients and staff. Back when I was in veterinary school in England, glaring lecturers would warn that the consequence of any professional misconduct would be that most heinous and damning conviction, the most definitive punishment of all—being struck off! More evocative than “losing your license to practice” or “being disbarred,” I believe this phrase was meant to strike fear in the hearts of cavalier veterinary students: I always envisaged a crusty, gowned gentleman in a powdered gray wig working his way down a ledger, fingering my name written in bold curlycued copperplate, and savoring his chance to take quill to ink before scratching it out as though it had never existed. The years of study, the credentials, the credibility—swept away in a single stroke. Indoctrinated by this image, no wonder I was flustered and questioning my professional liability.

  I moved on to Google, and felt myself succumbing to all the endemic negativity of the Internet.

  “When a pet or other animal is injured or killed by a person or another animal, the owner is often entitled to damages even if the animal was not harmed on purpose.”