In Shock Page 12

  Introductions over, the resident began presenting his first patient. “The patient in C521 is a thirty-four-year-old woman, postpartum day seven, transferred from an outside hospital with liver failure and a presumed diagnosis of HELLP syndrome.” He paused to swallow loudly. He raised his eyes from his paper and quickly scanned my face for evidence that he should continue. I have no idea what expression met him. I was completely stranded in a fog of his words. Did I appear disoriented and lost? Or did I present a picture of stoic shock? I felt incredulous; it hardly seemed statistically possible that this could happen on my first day back. That the first patient I would be charged with caring for was in essence a static replica of me from six months prior.

  I studied her through the window to the room as he went on describing her liver failure, kidney failure and her attendant issues with blood clotting. Her skin was discolored by a yellowish tint, and she was terribly bloated from the resuscitation efforts at the outside facility. She was connected by a tube to the ventilator, which steadfastly delivered her breath even though she appeared to be cringing against it. Her soft brown hair was gathered in a loose bun on top of her head. Her mother was at her bedside, straightening the collar of her blue hospital gown and patting her bruised and swollen hand.

  I looked back at the resident as he reported a torrent of lab values, imaging studies and eventually his assessment and plan. It seemed to me there was something missing in his very comprehensive presentation. Something about it wasn’t sitting right with me, though it was difficult to pin down precisely what it was.

  I began asking questions, trying to identify the gap. “So, how long after she delivered the baby did she begin to deteriorate?”

  “That same day, the afternoon of the birth, she had worsening mental status, but as I mentioned, the signs really began prior to delivery, with her lab derangements,” he answered dutifully.

  This was a woman who had one single day with her baby and now was perilously close to death, her body cascading before us in an ever-deepening downward spiral, with her mother holding vigil at her bedside, her husband and father in the waiting room. What was missing, I realized, in his reporting of her case, seemed to be any acknowledgment of the absolute shattering horror of this particular sequence of events. They didn’t see her as a person. She was a case to them.

  I stared at the team. There were five residents, a medical student and a critical care fellow. They, like most of our trainees, had chosen to travel long distances from disparate locations to avail themselves of an “interesting case mix,” as it was portrayed in our residency brochures and website. An inner-city hospital with advanced subspecialty services that took care of the sickest of the sick. They wanted to see as much as they could of every type of disease, to soak in the exposure like vacationers in the sun, before launching into practice.

  I looked again at the patient, then back at the team.

  “What did she name the baby?” I asked them.

  They stared at me blankly.

  “It seems like something we should know, doesn’t it?” I asked curtly. The team looked decidedly uncomfortable now, unsure of what to expect next. I wanted them to see her as the mother of a baby whose name they knew.

  “The baby’s name is Charlotte,” her nurse answered.

  “Thank you.” I paused.

  “So, what else do we need to include in the differential for elevated liver enzymes in a patient who is immediately postpartum?” I asked the resident.

  He answered, impassively, reciting a list memorized from years of study.

  I continued, with a steely conviction, to drill him with questions. I challenged him to broaden differential for her fulminant liver failure. I redirected his choice of antibiotics, challenged his interpretation of the lab data. I was determined to care for her perfectly, as utterly impossible as that may be. The team rallied in response to my questioning, this being familiar ground to them. They also seemed to let go of their apprehension about how I would handle the coincidence. They seemed to understand that while my illness was similar, I was well in control of my emotions, and could in fact be channeling my experience to elevate her care.

  When we were done reviewing her case and formulating a cogent plan, I knocked and entered the room, my team following behind me.

  “Hi, I’m Dr. Awdish, and I’ll be in charge of your daughter’s care while she’s here in the ICU,” I began.

  “Oh, Dr. Awdish, it’s so nice to meet you. I heard from a friend of ours who is also a doctor at this hospital that you went through a similar illness, and now you are well! I can’t tell you what a comfort that is,” she exclaimed.

  Her words surprised me. I hadn’t thought she might already know. I had been weighing carefully whether to ever share any piece of my experience with her. It wasn’t that I needed it to be a secret, it was just that I worried doing so could create an unrealistic expectation of recovery. I was cautiously trying to determine how best to structure the boundary while still offering personal insight and hope. I thought I would learn more about the family, their level of openness and their coping skills before deciding what was best. But then, before I could figure out any of it, the boundary, like a line scratched in the sand, was reclaimed by the shifting tides. Someone had made the choice for me.

  Fine, I thought, time to regroup. And really, no harm done. I could still navigate this. I just needed to manage expectations while finding ways to thoughtfully insert relevant experiences and simultaneously be a beacon of hope. I could do this.

  Then she looked me in the eye and asked with genuine curiosity, “So how old is your baby now?”

  I heard a gasp from behind me and remembered I had an audience of trainees and nurses, a pharmacist, and a respiratory therapist. I felt the warm pressure of tears building in my eyes. If someone was going to share my story for me, the least they could have done was share the whole story. My face flushed with irritation and embarrassment.

  “Oh, no … actually, unfortunately my baby died,” I managed, thankful that my back was to the team as I tried to push back my emotions.

  “Oh, I am so sorry! I didn’t know,” she said.

  “Of course, no, no, please don’t feel sorry. You couldn’t have known.” I felt worse for her embarrassment than I did for my own. I took a deep breath and on my exhale began again.

  “Anyway, let’s focus on your daughter. She is who matters now. I want to assure you we are going to take the best possible care of her,” I said. That declaration seemed to animate the team, and I observed a pair of them move to her bedside and begin to unceremoniously examine her. One pulled at her eyelids to shine a light at her pupils looking for evidence of swelling in her brain as the other shifted her covers to examine her skin for rashes and pressed the skin of her shins with his thumb to disclose swelling of the tissues. I ran parallel mental tracks; one speaking to her mother, the other lost inside my own head, trying to assure myself that their behavior was acceptable, while feeling distinctly uncomfortable yet unable to articulate why. I couldn’t shake the feeling that so much of what we did and how we did it felt like a violation. A violation of her body, of her personal space. All so well intended, but with her unable to participate or grant permission, I felt we were systematically chipping away at her dignity.

  We eventually exited her room, ninety minutes after first starting rounds. As we moved on to the second patient, I marveled that I somehow had to find the strength and composure to round on fourteen more critically ill patients.

  To say I left rounds that day completely exhausted does not begin to capture the overwhelming, leaden fatigue that draped around my shoulders. My liver felt heavy and pulsatile, my breath felt short, and the pain enacted by speaking so much more than usual was unrelenting. I worried obsessively about my patients; I thought of their families as I drove home, as I showered, as I lay in bed. I sat with my discomfort over the small indignities I had watched inflicted on the patients, and wondered where we had all gone wrong.


  I thought about the fourth patient we’d rounded on that long morning, a young man with a habit of injecting heroin who had an unsurprising indolent infection of his heart valve. A by-product of an obviously unsterile technique when he administered the drug. The resident presenting the patient was practically giddy as he described the dark-red, linear streaks in the nail beds of the patient’s fingers and toes, known as splinter hemorrhages, and the small densities he could palpate in the pulp of the patient’s fingertips known as Osler nodes. His enthusiasm was the result of years of reading and hearing about such findings, only to finally see them manifest in an actual patient.

  In medical school we did not study people; rather, we obsessively studied disease states. We memorized their signs and symptoms so that when they appeared in our patients we would recognize them. The disease states were exalted. They represented the mission and the destination. Like explorers, we suffered in pursuit of them, sometimes spending years on their trail. I saw the team now, with their brains laboriously imprinted with sheets upon sheets of the clinical features and laboratory findings of every possible condition, superimpose those sheets like transparencies over their patients, searching for a best fit. Those sheets were the filter through which they viewed the world. The patients were placeholders, positions in space where the diseases would land.

  I thought back to all the times on rounds that a patient had been exhibited for the team as a specimen of disease. My mentors would place their stethoscope on the patient, and after locating a characteristic heart murmur, solemnly remove their earbuds and hold the bell of the stethoscope in place on the patient’s chest with one hand, urging us to take turns listening with the other. On patients’ backs we’d be encouraged to differentiate the sound of fine Velcro-like crackles in fibrotic lungs from the fine wheezes of asthmatic lungs. We stared, curiously examining rashes and skin discoloration with our eyes. We probed and prodded bellies and joints, like scavengers on a hunt. Now I was in charge of a pack of these earnest young physicians and somehow needed to reorient them to the patient beneath all of their entrancing discoveries. I thought of the young OB resident who had asked me to outline for him the still anatomy of my baby’s heart on the ultrasound screen. I felt a sense of awakening. Of course that was how he approached the situation; it was all that had ever been modeled for him.

  I began to think the timing of my illness was more appropriate than I could have possibly known. As much as I had always believed my training would be completed by some date that could be anticipated on a calendar, I clearly wasn’t done. I hadn’t seen all that I had needed to see in terms of suffering, identity and illness. It seemed to me a tremendous imbalance, to have spent all of those years focused on acquisition of information without also having cultivated sufficient space for empathy.

  I’m sure it seemed to my residents that each time I came to rounds, I brought a new idiosyncratic habit with me. I felt them eye me quizzically as I leaned down to speak into an unconscious patient’s ear, “You’re doing much better. You have a pneumonia, but the antibiotics are working, and you are getting better.”

  “I believe he can hear us,” I’d explain. “And if it was you, wouldn’t you want someone to explain what was happening?”

  They would shrug, unable to imagine such a thing.

  Another patient, also unable to communicate while attached to the ventilator but more alert, had hands so disfigured by arthritis that she was rendered unable to write even short notes to us. This posed a new challenge. I located her cell phone in her bag of belongings and handed it to her. It was a simple flip phone, unlocked and charged. I programmed my number into her contacts and told her, “You can ask us anything you want.”

  Her eyes began to tear as she began to type with her thumbs, the only joint not deformed by contractures.

  “Can you call my son?” she asked. Then, “What’s wrong with me?”

  We explained and she listened, inserting questions so fluidly it seemed an ordinary conversation. We called her son.

  “That was amazing,” the residents exclaimed as we exited the room. I tried to convince them it was anything but amazing. It may have bordered on human, but it was far from amazing.

  Sometimes, despite my aggressive scrutiny, or perhaps in spite of it, the team regressed into old behaviors. The lapses that always infuriated me the most were when they spoke about a patient as if the patient couldn’t hear what they were saying.

  I was observing a resident place a large IV line in a very ill and unconscious pregnant patient, as the fellow instructed him on the technique and steps involved. I was really present to evaluate the fellow’s teaching skills as they walked the trainee methodically through, and there he was succeeding. But when they reached a point of comfort with the procedure, where concentration gives way to muscle memory, the conversation devolved and they began to discuss the patient just beneath the sterile gown.

  “Do we know who is going to get the baby, when she dies?” the resident asked, with a casualness that suggested he was almost disinterested in the answer.

  “Out!” I said. They both froze and looked at me, attempting to assess my level of seriousness.

  “Stop what you’re doing and get out,” I instructed the resident. “Your fellow will complete the procedure.” They seemed unsure of what to do.

  “Now,” I added.

  I knew from the look on the resident’s face as he removed his mask that he was not feeling anything that resembled remorseful accountability. What he was feeling was embarrassed for being called out in front of a peer, and what he was thinking was somewhere between “Oh please,” and “OK, she’s officially lost it.”

  We’d reviewed the CT scan of her brain together just hours earlier. The patient had so much swelling, it was unlikely she would survive, much less recall a conversation. I didn’t care. I wanted to stop our mindless habit of having casual and thoughtless conversations within earshot of a patient.

  While the team was increasingly thoughtful with regard to what they said directly to patients, they lapsed in those times when the involvement of the patient in the conversation was less clear. The conversations that occurred around rather than with patients; patients who couldn’t participate or who had clouded mental acuity due to medication or illness. It was the arrogance in these conversations that galled me, an arrogance amplified by the abject vulnerability of the patient. The conversations presumed the patient’s mind was inaccessible or unimportant, and consequently everyone felt they could speak with impunity. In my mind, the carelessness of the resident’s conversation revealed what little regard he had for the potential impact of words on the broader context of patient emotion, healing and recovery.

  I pulled him aside later, privately, wanting to calmly explain the effect of such a careless statement and to remind him that we must not speak in a way that erodes trust, devalues the patient or delivers news carelessly. We are most at risk of doing this when we do not perceive the patient has an ability to absorb or integrate our words. Those times require intense vigilance to the standards we would adhere to if and when we spoke directly to the patient.

  But I didn’t have those words then. I didn’t know why what I heard him say made me so angry. I only knew that when I was dying, the very last thing I heard was She’s circling the drain here. We’re losing her. And that statement could have been the last thing I ever heard. So I told him that. And I think he understood.

  * * *

  I never ventured very far from being a patient that first year. At most, I’d be back rounding at the hospital for a month or two and something would deteriorate, something would fail and require an intervention. I learned that there is something uniquely awful about being able to anticipate a surgery. Though emergent operations are horrific in their own way, they also eliminate the possibility of maintaining a constant terrorized state of expectancy. With a planned surgery, one has the opportunity to indulge in a protracted state of existential awareness of one’s own mortality. “Ther
e’s a 5 percent chance that in two days I’ll die, and a 30 percent chance I’ll come out of the surgery with a complication,” I’d remind myself.

  And so it was with my first scheduled surgery that I behaved in a way I loosely characterize as pathologically controlling. My abdomen, having been so hastily closed that first night, was coming apart. Loops of my intestines were pushing out, and I’d have to knead them back in like balls of dough. I required surgery to place a thin layer of mesh over my intestines to keep them inside. Having a relatively elective surgery meant there was time to do my own research. Not unlike my patients who came in to appointments with printouts of their Google search results, I studied the various types of mesh that could be used to repair my pockmarked abdomen. I found primary sources and cataloged respective rates of infection and incidence of complications. I filled my surgeon’s in-box with just-one-more-quick-question e-mails based on some late-night click on a link. It always seemed to me that the next click might hold the answer I was looking for. I found it difficult to stop.

  Dr. G graciously indulged me. After all, I was a colleague, so perhaps I really did want that level of detail. Or maybe he understood that I came by my dysfunction honestly. He had in fact been there with me from the beginning and knew what I had been through. Maybe he believed I was overcompensating for not being able to play a role in my own care that first night. That was actually the explanation I provided him in one of those late-night e-mails, so perhaps he accepted it at face value.

  I am not sure I understood what was motivating my behavior. I know I didn’t recognize that an emotion was driving my compulsive research. I would not have characterized myself as particularly anxious. In fact, I would have labeled it something else entirely if asked. I was advocating for myself. I was educating myself. I was taking an active role in my care. In retrospect, I can recognize that I was also completely terrified and, not knowing how to quiet my fear, took the only option I thought available to me: to attempt to bludgeon the feeling into submission with data. The problem with responding to emotion with data is that emotion doesn’t recognize it. Ironically, I was making the same mistake with myself that physicians make with their patients. I was not naming or tending to my own emotion.