In Shock Read online

  I realized he was responding to the tears that I hadn’t realized were streaming down my face. He saw a girl in bed crying, saying she was cold and possibly worried about the quality of the equipment on that floor. He took my belief that I should be transferred to the ICU as a request to move to a place where I might feel safer. While he was correct in his assessment that I was profoundly frightened, I was not generically anxious; rather, I was terrified because I knew exactly what lay ahead. While it can be immensely valuable to name the feelings of the patient, it is somewhat less valuable to attribute physical manifestations of illness to a presumed feeling. Disregarding my symptoms as representative of anxiety was a misappropriation of empathy. By naming my emotion, incorrectly, he was in effect invalidating my own assessment and usurping my agency.

  Sepsis is notoriously difficult to recognize early. A variety of algorithms have been introduced specifically to address this issue. Our hospital had been a leader in revolutionizing early treatment of sepsis and improving mortality. But on the granular, micro-level of a single patient, we could still be blind. His dismissiveness ignited an anger in me I didn’t have the energy for. I tried explaining, loudly, that the combination of high heart rate, shaking chills and abdominal pain should probably elicit a different or at least broader differential in his mind than anxiety. Even in women. Within an hour I was sicker than he could have imagined, having not recognized the occult nature of my septic shock.

  William Osler famously said, “Listen to your patient, he is telling you the diagnosis.” It is almost always true, the patient is almost always telling you the diagnosis, but listening is harder than it seems. The story the patient relays can be circuitous, or filled with content we believe to be extraneous. We might feel pressed for time and wish that our patients could somehow just tell us what we need to know, despite knowing that no patient can do that; they can only tell us what they know. We listen imperfectly, through a fog of ghosts and competing priorities.

  Once in the ICU, large-bore intravenous lines were placed to allow for the simultaneous administration of antibiotics, fluids and other medications called vasopressors, which squeezed my peripheral circulation to allow for some semblance of a blood pressure. I continued to shake violently with chills, my teeth chattering against each other with such force, I felt certain they would crumble.

  “Are you cold?” Randy would ask, knowing the cold made me miserable.

  “It’s the infection,” I would answer, understanding the severity implied by the rigors.

  * * *

  I was boarded for a procedure to remove the stents the following morning. The procedure required being placed on a ventilator and being given general anesthesia so that a camera could be placed in my esophagus, allowing the retrieval. This required being positioned face down for between one and three hours, depending on the complexity and complications encountered. I met the anesthesiologist in the pre-op area, a middle-aged, soft-spoken man with a surgical mask hanging around his neck. He recognized me from a lecture I had given to their department.

  “Oh, I am sorry to see you here,” he said. He then turned to the nurse anesthetist who would be assisting him during the procedure. “Were you at Dr. Awdish’s talk last week?” he asked. His colleague shook her head no.

  “Oh, it was a terrific reminder about how sometimes—especially in our field—we say things around patients that we don’t think they can hear.” He seemed genuinely to see the value in the lecture I’d given. I’d projected statements I had heard in the operating room, that no one would have thought I could remember, like, We’re losing her. She’s circling the drain here.

  “Thank you,” I said, beginning to get uncomfortable. Is this what it was going to be like for me from now on, I wondered? Every time I needed medical care being reminded of all the times I lectured on what not to do? I began to question my strategy of attempting to change the culture of the hospital in which I was still a patient as well as a physician.

  “No, thank you. It’s important work you’re doing.” He smiled before turning to my chart. “So, it says here you get nauseated sometimes with anesthesia. You’ve been through a few of these procedures; what drugs work best for you?”

  “Oh, I don’t know exactly the combination they used last time, but that seemed to work well,” I said. “I know they gave me a little steroid to help with the nausea, but that’s all I remember.”

  “Ok, we’ll do the same thing this time then! I don’t want you to worry, it will be fine!” he reassured me.

  I resurfaced from the anesthesia out of a dream of drowning. The water was heavy, almost leaden, and I could see nothing through it though my eyes were open. I was surrounded by a murky, opaque, Prussian-blue sea. In my paintings I never allowed that the water of my dreams could be translucent. I’m sure this depiction was construed by others as a novice’s best effort. Water’s density in my paintings was more easily interpreted as a lack of refined skill, rather than what it was: a clear vision, a memory committed to canvas. Even once fully awake, I found it impossibly difficult to breathe, as if my airway and lungs themselves had brought back that leaden water from my dreams.

  “I can’t breathe,” I alerted the nurse anesthetist who was by my side.

  She looked at me and suggested, “You might just be congested from being face down for so long. Maybe a nasal spray will help?”

  I knew plainly that she was wrong, but not how to convince her. I’d experienced nasal congestion, and this struggle to breathe bore absolutely no resemblance to that minor nuisance. I tried to shake off the fog of the anesthesia-induced sleep, to be more alert and articulate. I wondered if my spacey fatigue was disadvantaging me. I studied the monitoring equipment attached to me: my oxygen level was fine, heart rate was a little fast, but otherwise no obvious issues.

  The nurse and the anesthesiologist listened to my lungs, one on each side of my body, and shook their heads. He told me, “Well, you sound clear and your vitals look good. We’ll send you back to the ICU, and I bet you’ll feel better soon.” As he walked away, I heard him remark to his nurse, “We gave her exactly the same combination as last time, so I don’t see why it should have gone any differently.”

  It occurred to me that he may have believed I was blaming him for my difficulty breathing. And, feeling blamed, he would have become defensive, a reaction to thinking I was accusing him somehow of causing my problem. I had in no way meant to imply that I blamed him or his choices for how I was feeling. I had no idea what to say or do next.

  By the time I was in the elevator headed back to the ICU, I was becoming itchy and sensed my lips swelling by the second, as if being injected with collagen fillers in a plastic surgeon’s office.

  I pointed at my face, finding it increasingly difficult to move my tongue. “Lips swollen?” I asked Randy.

  “Yes, they look huge. Is that just from the scope they placed in your mouth?” he asked.

  “I wish,” I replied, my voice sounding raspy and faint. I was having a full-fledged anaphylactic reaction to one of the antibiotics that had been administered during the procedure. As the severity of my distress escalated, I became more annoyed. I thought it would be exceedingly stupid and anticlimactic if after everything I’d been through I died of an allergic reaction in an elevator. Surely, if I had demonstrated anything in the past five years it was that I was more difficult to kill than that.

  I realized we had lost the window of time when I could be treated for an allergic reaction in the post-anesthesia care unit. Somehow miscommunication and defensiveness had muddied their assessment, which left me stuck in that elevator having an allergic reaction, far from anyone who could help.

  The transporter responded by wheeling me quickly down the series of long hallways to the ICU, where the team was waiting for me. Immediately upon seeing my swollen face and difficulty breathing, the Ear Nose and Throat physician on call was paged to examine my airway with a fiber-optic scope she passed through my right nostril. It’s an odd t
hing to have to tolerate when you can’t breathe as it is, and someone places a camera through your nostril and further blocks your airway. Fortunately she was very quick.

  “Yep, it’s swollen. Definitely probably an allergic reaction,” she confirmed. “Benadryl, steroids and Zantac,” she recommended. “And discontinue the antibiotic,” she added, stating the obvious.

  Pharmacists rushed in to try to pinpoint the antibiotic that had caused the reaction by graphing the temporal relationship between administration of the drug and my reaction. I was getting three different antibiotics in an attempt to kill a wide variety of organisms that could be implicated, which naturally confounded the issue. It was vitally important that we identify which drug was the culprit, as I still needed to be able to receive antibiotics for the sepsis. They offered the most likely offender, with a caveat that they couldn’t be sure and I’d have to be monitored closely with any future doses.

  Breathing treatments were administered in an effort to improve laminar flow through airways made narrow by the swelling. I closed my eyes so as not to have to watch a roomful of people look as panicked as I felt. I tried to calm my breathing and focused on silencing the fearful thoughts. As I distanced myself from the agitated energy around me, I was able to consciously step into an internal stillness. It was a practice I had learned in yoga class and encouraged my patients to try. Purposefully slowing the breath, using the long stretches of inhalations and exhalations to signal the body that it could relax. Disarming the “alarm” system with elongated breaths that implied a state of calm long before I arrived at one. I gathered stillness toward me, drawing it in with my breath, and exhaled the unwanted frenetic energy away from me. I reminded myself that cultivating stillness was most necessary when it seemed most improbable. Even in the destructive power of a hurricane, there is a center, and within it there is perfect peace. I recalled the perfect peace I had once felt in the operating room as my body unraveled. A peace that was at once diffuse and expansive as well as intact and whole, just like the breath. Long minutes passed as I tuned out all that was happening around me.

  I opened my eyes and smiled. I saw the fear in the room and resolved to share the peace I had found. I said in short bursts, “Well, the good news is … I think … I’ve officially had … every form … of shock now: hemorrhagic … cardiogenic … septic and … anaphylactic shock … I’m done.”

  My joke broke the tension in the room and I saw the team around me visibly exhale. I saw their masks fall, and recognized I had scared them. They were watching their friend and colleague suffocating in front of them and trying to judge when and how best to act to save my life. I knew the stress they were under and further understood that it was exacerbated by a lack of any systematic approach or even any language to alleviate stress and accommodate resilience. There was no training within our medical education that addressed how to cultivate a space for ourselves, a space of stillness within a storm.

  “There’s still neurogenic,” my friend joked, winking at me. “Don’t give up yet.”

  I shook my head, incredulous at the dark humor we sometimes employed to get through difficult times. I thought of the transplant resident who joked about needing to somehow find me a new liver. I thought of another physician who smiled while walking in to assess me and said, “You’re not going to die on me, are you?” I wondered if perhaps each attempt at humor was an indirect indicator of fear, a joke as a subtle bow to a nearby ghost, an admission of vulnerability. By discouraging other outward manifestations of emotions, had we been left with humor as our only sanctioned outlet? In lieu of actually feeling our feelings, had we subverted them into quick, pithy one-liners to deflect emotion? I worried that if we couldn’t recognize and respond to our own emotions, what possible hope did we have of helping others to navigate the complex emotional sea of illness and recovery?

  I hoped that humor was more of a way station than a displacement. That it represented a bookmark meant to be revisited when we could stop and examine our emotions. That it was a space from which paths led out in all directions, into transformation and acceptance of our own limitations.

  “It looks like your breathing is getting better,” the ICU fellow reassured me. “And I think I can see the swelling starting to come down. The medicine is working. I want you to know, I’m not leaving. I’m going to be here all night. We won’t leave your side until you can breathe. You are safe.”

  He was part of a new generation of physicians that was being deliberately trained in empathy, trained to recognize the emotions of others and reflect them back. I took a deep breath by way of testing his observation. The tide was receding. Though I knew I wasn’t entirely out of danger, I felt comforted by his words and by his reflection of the situation back to me. His messaging spoke to his assessment of my fear, his ability to empathize with me and his understanding of what I needed to feel secure.

  What was immediately stunning was the hard-won sense of trust his few sentences brought into that ICU room. I thought in those words there was more actual doctoring than in the prior twenty-four hours combined.

  It was so surreal that I had actually run the communication training program that he had taken during his orientation. I knew the steps that had been outlined to him. And yet, even as he demonstrated the skills, it felt completely genuine, almost effortless. I understood his simple statement required a situational knowledge of how it must feel to be unable to breathe. It required an emotional humility to suspect that I was fearful and would benefit from being reassured. It required that he allow himself to feel with me. It required a self-knowledge of what feelings he was bringing into the room so he didn’t dump in. I looked at a medical student standing in the corner and wondered if he recognized the skill involved. I wondered if after witnessing such an exchange he would be able to break it down into replicable, manageable chunks, or whether to him it just looked like magic.

  I had the opportunity to ask him two weeks later when I rejoined the team as the attending. I pulled the medical student aside after rounds and acknowledged that it might feel awkward for him to have me as his attending after witnessing me so ill as a patient.

  “No, not at all,” he answered genuinely. “Just because you’re a doctor doesn’t mean you are different than anyone else. We all will be patients at some point.”

  I smiled. “When I was scared, when I couldn’t breathe, I thought the fellow did a really good job of reassuring me, and I noticed you in the room. I wonder if you remember what he said?”

  “I think he just offered support, said things were getting better and he wouldn’t leave until you were safe. Something like that.”

  “Yeah, actually, that’s exactly right,” I said.

  “I know you’re really interested in communication, so I wanted to share something I think you’d find cool,” he said. “Our med school stopped doing traditional interviews, you know, where they ask you about your research experience and aspirations to be a physician. Instead, now we have to sit in a room, our chair back-to-back with another candidate. One of us has a LEGO structure that is already built in front of them and the other candidate just has the LEGO pieces. And we are judged on whether we can communicate effectively enough to recreate the piece. Isn’t that cool?”

  “That’s incredibly cool.”

  “It is, but at the time it was really challenging. I mean you really realize how deliberately you have to choose your words,” he said. “And you have to listen to really hear what is being said.”

  I thought about how often I listened to truly hear rather than thinking about advancing my agenda, or mentally rehearsing the next thing I wanted to say. How often does anyone listen generously, without ears pretuned to what they hope the answer will be? We hope it’s just nasal congestion and not something we’ve done. We hope the baby’s heart is still beating even though we can’t see it on the ultrasound. We hope the patient isn’t so sick that nothing we do will save them. We hope the swelling in our patient’s brain will lessen so s
he can see her child. We hope that the events of the day will allow each of us, physician and patient, to leave the hospital free of permanent scars.

  Our preformulated agenda is often nothing more than another mechanism of self-protection. We might be simply hoping for a good outcome, both for the patient and for ourselves. We enter conversations with patients and families with each of our personal ghosts trailing behind us. We enter them not always aware of our capacity to bear more grief. We are not adept at gauging our resilience or counting the shadows in the room. I wondered if the new skills I was seeing in the fellow and hearing from the medical student were indications of a shift. If training was changing, perhaps we would soften at the door of a patient’s room rather than steel ourselves. Perhaps we would stop believing we had to make impossible things look effortless. We could believe instead that we were there to truly listen.

  * * *

  My breathing continued to improve, and my room slowly emptied of doctors, nurses and students. It wasn’t until I was nearly alone with just Randy resting in the chair that I realized I was in the room that we generally regarded as being cursed with terrible luck. In an ICU used to so much death and sadness, it isn’t easy for one room to stand out, but this one did. For the past week it had been the site of so much heartbreak. I looked around for evidence, some permanent mark or acknowledgment, but found none. I thought about the last patient who had been in the room, the last time I had been here.

  He was a young man whose body was riddled with cancer, so much so that his muscles had been cannibalized to feed the tumor and only a gaunt skeletal frame remained. We had discussed his case on rounds, the failure of this third round of salvage chemotherapy, the failed surgery, the progression. We were burdened by the knowledge of what his future held. The conversations that should have occurred far upstream of the ICU had been tabled, out of respect for the age of his children and his ardent hope of a future. But we had found ourselves against a wall. It was a different place than he had been before, and it was a hopeless place.