In Shock Read online

  One of the complications I feared the most was what is called an entero-cutaneous fistula. In this nightmare, a loop of my intestine would attach itself to my abdominal wall, and a connection would form between my intestines and the skin. As a result, the contents of my intestines would leak through. There would be a bag to attach to catch the stool as it spilled out. The risk of this happening in my particular case was cited as between 5 and 10 percent. The surgical approach, type of mesh used and a host of other factors all had an impact on increasing or decreasing the possibility of this happening. I wanted to take advantage of every possible opportunity to mitigate the risk. My questions to the surgeon suggested as much.

  “Have you decided which mesh you are planning on using? The synthetic seemed to have advantages over the bio-prosthetic, when I was reading, but I know you mentioned you thought bio-prosthetic would be your preference and I don’t think I understand why.”

  He answered patiently, and our conversation looped into discussions of tensile strength and strain, risk of infection and the latest expert consensus from the Hernia Society meetings. They were perfect answers, well thought-out and honest. And yet I still felt terrified.

  As physicians, we often don’t recognize emotion. And if we don’t recognize it, we certainly can’t respond to it. We hear our patients ask questions and we believe they want data, facts and explanations. So we dutifully provide them, as we were trained to do. Then we listen as our patient again asks a permutation of the same question, and we wonder if we perhaps weren’t clear. It is difficult medical content, after all. Perhaps we’d slipped and used some jargon. So we explain it again. We are trained to do this from the very first day of medical school. Learn the answers, regurgitate when asked. We commit them to memory and feel it is a mark of success when we can provide the correct answer. Being the person who can provide accurate information at the necessary time is a very gratifying and enviable position for us.

  Did I actually want to know the relative tensile strength of varying types of mesh? No, I didn’t. Did I on some level believe that I needed that information in order to make decisions about my surgery? Yes. On some level I believed that I did. But it was never going to work. I was scared. I knew my surgeon had thoughtfully considered each and every option and had chosen a plan that took so many different variables into account that I wasn’t even capable of enumerating what they all were. He is brilliant and trustworthy and thoughtful. But fear doesn’t respond to data.

  Emotion shuts down the rational, cognitive portion of our brains. Anyone who has attempted to reason with an angry spouse or use logic to get a toddler over a tantrum understands this on a visceral level. Emotion demands to be acknowledged and appeased before it will disengage its controlling grip on the higher centers of cognition.

  He looked at me and seemed to know that there was only actually one single answer to any of my questions. “It must be so scary to think about developing a complication like a fistula. I can’t tell you how much I don’t want that to happen to you.”

  Yes, it’s really scary. I am worried and feel out of control.

  It becomes obvious, the necessity of pausing to acknowledge emotion, when one understands the role that our “emotional” brain plays in decision making. The part of the brain that drives our behavior and is responsible for a majority of our choices does not even possess language. The limbic system, which makes rapid yet finely honed judgments about who we can trust and where to place our loyalty, is entirely nonverbal. It relies on a kind of symbolic shorthand to assess threat, gauge appeal and catalog discrepancies. It is the voice of your gut saying, “I’m not sure why, but I just know I can trust him.”

  And I didn’t know why, but I knew I could trust him.

  * * *

  It’s a strange thing to enter the hospital that you work at every day as a patient. Everything looks different from that perspective. Even if I entered through the same doors I normally entered through, I found I looked for and noticed different things. It mattered to me as a patient if the staff appeared happy as they walked through the lobby. If a trash can was overfilled, I wondered if there were staffing cuts in departments like environmental services that might impact cleanliness of supplies and, by extension, patient safety. I looked at the nurse’s face as she placed my IV for signs of fatigue or distraction. I noticed if multiple people asked the same question about drug allergies and worried it was evidence of poor communication. I had a very low tolerance for evidence of dysfunctional systems. Though as a physician I knew the incredible quality of the care we provided, as a patient, I was always looking for the cracks.

  My surgery was far larger in scope than anyone had anticipated. Rather than locating a few isolated defects that the surgeon could quickly repair, he instead found that the entire layer of connective tissue meant to keep my intestines in place was a useless piece of tattered sinew. The graft he placed was six times larger than he’d planned, the incision three times as long. The surgery was twice the duration expected. I came out of the surgery feeling as if I had swallowed a flaming sword and had spent hours lancing myself with its fiery tip, carving circles in my flesh from the inside out.

  The anesthesiologist responded quickly, administering more of the pain medication through my IV. He promised rapid relief, but nothing changed. They asked if they should allow family back into the post-op care unit to see me, and I begged them not to. It was all I could do to breathe against the pain. More medication and still no change. Then my mother’s voice: “Why is her arm so swollen?” She was the first one to detect the problem. My IV had stopped working. Sometime during the surgery, in fact, it had failed, the tip slipping out of the vein and into the soft, fatty place beneath my skin. When this happened, the drug simply seeped out into the fatty tissue and the medication stopped entering my bloodstream. I still received sedation during the operation, administered through another IV line, but effectively nothing for pain. Instead, the opiate sat uselessly below the surface of my skin. It was no wonder I felt I’d been gored alive, left bloodied and raw.

  They quickly got another IV placed, and got pain medication into my system. But we were already so behind it that it took hours to get ahead of the pain. On the recovery floor, I pressed my call light for the nurse repeatedly. She had soon exhausted the post-op orders that had been written and had run out of available options.

  “Are you sure your pain is at an 8? I just gave you morphine an hour ago,” she questioned me. “They wrote for you to get it every hour, not more often. I’m going to have to call the doctor if you need more.”

  She harrumphed her way to the phone and sent her accusatory remarks to the on-call team, audibly. They arrived, irritated and already biased. The on-call team was a group of residents assigned to cross-cover patients for whom they weren’t primarily responsible during the daylight hours, when the primary teams returned. They were tasked with troubleshooting, dealing with acute issues overnight that couldn’t wait for morning. They had little knowledge of any of the patients on their service, as sign-out was generally very concise, reserved for only critical issues. In general, the cases that necessitated substantial discussion between the two teams were the ones that had demonstrated the potential to decompensate or die overnight. I was not one of those patients. They had only the barest of knowledge about me when they were called by the nurse. My age, medical record number, room number, the surgeon who operated on me and the type of surgery would have been on a printout in one of their pockets, but little else.

  “How much pain medication do you take at home?” was his first question, shot from just steps inside the doorframe. He appeared tired and irritable.

  “I don’t take anything at home,” I replied, understanding the subtext of his accusation.

  “Well, you’re requiring more medication than most people would, so that makes me think you do. And we need you to be honest about that, or we aren’t going to be able to help you,” he added, barely veiling his threat to withhold medication
.

  I bristled at his condescending tone. “I don’t take anything at home,” I repeated. I didn’t know how to explain away something that I hadn’t done.

  “Well, I’m going to have to call anesthesia to see you. They deal with … patients who are used to the effects of narcotics and need higher doses,” he declared and left. He had stopped just short of calling me an addict to my face.

  I broke down crying.

  “Don’t cry, he’s not the end of the line.” Randy had his phone out, wanting to call my surgeon directly. “Who does he think he is?” Randy was frustrated with him and with me, not understanding why I didn’t tell them I was a physician and threaten to go above their heads. I didn’t want to play that card. I knew that disclosing that I was a physician would make them no less suspicious that I was abusing narcotics. For all I knew, it may have even been part of their sign-out. Maybe they already knew.

  Why was everyone’s first assumption that I was a closet addict? The easy answer is because that was their construct. They were biased in the direction of that belief. They perceived patients who asked for “extra” pain control negatively as a group relative to other groups of patients. While they might never verbalize the feeling, and indeed might not even identify as having had that preconception about me, their bias influenced their behavior. While explicit bias requires that a person is aware of their dislike, believes it to be justified and acts on it, implicit bias operates in an unintentional, sometimes subconscious manner. It is activated by situational cues like race, or even profession. It exerts its influence often without our awareness.

  Something about my situation triggered a judgment, whether consciously or unconsciously. It’s possible that at some point in their training, they felt manipulated into supplying drugs to someone who was just trying to get high off them. Addiction is a pervasive enough issue that they almost certainly would have encountered it at some point in their training. They may have made associations; they may have stereotyped. Explicit bias dictates that they recognized this and believed acting in a defensive and obstructive manner was justified, based on the experiences that led to their biases. Explicit bias allows for overcorrecting as a means of recouping some imagined loss of control, some perceived indignity or slight. If they instead entered the room, saw someone who they knew was a physician, who was not tearful or outwardly anxious and yet describing terrible pain, they could be influenced to withhold medication without even understanding why. That is implicit bias.

  When the anesthesiology resident entered my room, I felt immediately relieved. We knew each other, he had worked under me as my resident in the medical intensive care unit. He had soft brown eyes and floppy, straight dark hair that he couldn’t keep out of his eyes. Something in how he was constantly smoothing his hair back implied an unending patience. He found me crying in the bed and looked at me with such compassion, I knew he would help me. He immediately promised to do whatever it took to get my pain under control and apologized for how I’d been treated. He looked genuinely mortified that the surgery team had refused to even attempt to control my pain. He asked if I were open to receiving an injection of a numbing medication directly into my spine to get control of the pain quickly. Honestly I would have agreed to anything, including disarticulating the lower half of my body and burying it in a deep hole. I agreed.

  Within thirty minutes I was numb from the ribs down to my toes. I understood why in medical school an anesthesiologist told me he felt he had the best job in the hospital: “You show up and people are in pain, and within minutes you’ve magically made it disappear. They are so grateful. Wherever I go, people are happy to see me. There aren’t too many doctors who can say that.”

  I began to believe I would be able to make it through the night.

  It’s a terrible feeling to believe you are being taken advantage of by someone for whom you’ve sacrificed so much of your own life. And there are certainly times, perhaps most commonly associated with treatment of exaggerated or imagined acute pain, when physicians perceive they are being manipulated and used. It’s arguably a worse, more isolating feeling to be in legitimate pain and be deprived of relief. This withholding of pain relief by an emotionally guarded physician is damaging to everyone involved, patient and physician alike. The only thing that seemed at all clear was that we all stood to benefit from understanding each other better.

  The surgery resident came back and offered an apology the next day, having been reprimanded by someone for not making an effort to control my post-op pain. He appeared genuinely contrite, though his words felt weak. I wished I knew what to say to make him understand what it had felt like to be judged by him, without any evidence.

  “You had no right,” I began, but couldn’t finish the sentence. I only sat shaking my head. I felt I should stand, to meet his eye level, but as I placed weight on my feet, the spinal anesthesia forced me to sit ungracefully as my legs buckled beneath me. The resident lunged toward me and reached out as if to catch my fall. The extent of my helplessness, my inability to even stand without assistance, humbled me quickly. I sighed and began again, with more compassion than anger this time.

  “You know, if you trust your patients are telling the truth, you’ll be right far more often than you are wrong. They aren’t all just trying to get something from you,” was all I could say.

  Physicians often enter the lives of patients on their absolute worst days. They meet without the benefit of social graces. Patients appear depersonalized in generic hospital uniforms. They lack means to project their identity through dress or choice of hairstyle. They lack ability to control their circumstances. They might be in pain, scared and suffering. They might be angry, frustrated and disenfranchised. They might be worried about bills at home or who will feed the dog. They might be addicts. They might have made terrible choices. They might be easy to judge. They might not have the skills to be kind while in pain; they might never in their lives have had kindness shown to them. They might have been abused or violated by someone they trusted. They might be many things. But one thing is true: they are doing their best. The patient, even the accusatory and fearful patient, is doing their best.

  They are doing their best to trust that this person whom they just met, whose name they barely caught during the introduction, will stay up the whole of the night to care for them. They are doing their best to believe that their past choices will not be held against them. They are doing their best to withstand the pain before pushing the call light again. They are doing their best to believe that they are worthy of the compassion and humility of a stranger. A humility that dictates that while we cannot possibly understand every patient’s story perfectly, we can trust them to tell it, without imbuing it with our own biases. And when they tell their story, we can receive it, and bear witness to it. And in return for their willingness, however tenuous, to put their faith in us, we can do our best.

  Seven

  Vulnerable Masses

  By the middle of rounds each day, I would feel an unmistakable aching heaviness in my right side. By the end of rounds, it could truly be called pain. At first, I allowed myself to dismiss it, attributing it to either the old, shrinking hematoma or inflammation related to the mesh from the hernia repair. But I knew it was different, and I knew it was new. I also knew admitting it would set off a series of events that I would have no control over. Once I said it out loud, everything would take on a momentum of its own. So I ignored it for as long as possible, which turned out to be three months. Three months of solid denial and pretense. Observant friends would comment, “You’re holding your right side, is everything OK?”

  The truth was, I didn’t know if everything was OK. In fact, I knew something was probably very wrong, but I wasn’t yet ready to face it. In an odd way, my medical training had prepared me to ignore my body. Medical training demands a kind of disembodiment by doctors. It begins in Gross Anatomy lab, where bodies are studied but the lives those bodies led and the deaths that followed are not. It con
tinues into a training that dismisses the need for sleep, demanding thirty-six-hour workdays. It is illustrated by the denial of bodily functions in the operating room. A twelve-hour case meant twelve straight hours in which you did not move from the operating room table. You learned not to drink or eat, you learned not to feel hunger or indulge thirst. Corporeal needs were marginalized, ignored and dismissed. To do what needed to be done, we believed we had to be superhuman. And there was, sadly, an implied superiority in those achievements. Doctors, we believed, were just different.

  I recognize now that I carried this disembodied persona into my first pregnancy. I saw what was happening in my body as something to be minimized. To be a good doctor to me meant not having my pregnancy interfere with my work, in any way. I ignored signs, like the horrific swelling, that were identifying a problem. I put on compression stockings so that I could still round for hours. I refused to sit, believing it weak and a concession. And so when the aching, right-sided heaviness started up, I was again disadvantaged, having not yet learned to truly and shamelessly inhabit my body.

  In an attempt to address what was steadily becoming a real concern, without actually formally pursuing it, I walked down the hallway from my office and asked my friend, a doctor who I had also done fellowship with, if he would take a look at my liver with the ultrasound machine. He was a bright, kind man. He had completed medical school in Nigeria and had an interest in ultrasound, a modality that was very useful in areas of the world that had less access to sophisticated diagnostics like CT scanning and MRI. We had been hired as attendings the same year. I trusted him and knew his judgment would not be clouded by our relationship as colleagues. When we had been trainees together, we had gained proficiency in ultrasound primarily by examining each other’s lungs and hearts and vessels in on-call rooms and offices. It didn’t strike him as a strange request.