In Shock Read online

  I had believed we owed it to him to guide him, given our knowledge, to talk honestly about what lay ahead. We needed to know what he hoped his remaining days would hold. We wanted to discuss the option of hospice and palliative care. We all knew the inevitability of his death, and by extension, how awful it would feel to perform CPR knowing we couldn’t save him. We knew what it would feel like to have his ribs break beneath our hands, and his lifeless eyes bulge with our efforts. How it would feel to have our shoes soaked in his blood that already would not clot. We were traumatized in advance of our efforts by ghosts that had yet to arrive. I prayed, as much for him as for our team, that he would not want us to put his body through those paces.

  The palliative care team was going to be present to aid in the discussion of end-of-life issues. I steadied myself for the discussion, mindful of my feelings, my own internal dialogue. The doctor first asked the patient, gently, what he understood of the situation, knowing that this last round of salvage chemo had failed. She asked with humility, as we all wondered if he had allowed himself to approach the edges of his mortality. We listened as he told us he had always hoped to live to see his oldest child graduate from high school. I smiled at the sacredness of that wish, grateful that it could be shared, that there was trust enough to allow it to be expressed. The palliative care doctor frowned, knowing that child’s graduation was still eighteen months away. The patient turned his head, and his eyes fogged with tears, embarrassed by the grandness of his wish. We broke his heart and told him that wish could not be made to come true, that we were looking at weeks and not months. He sighed and shrugged, as if he knew it was too much to hope for.

  We talked about getting him home. He didn’t want his children to see him die at home. We offered to hold a makeshift graduation in the hospital and offered to contact the school and ask if they would be willing to generate a diploma in advance of graduation. He smiled, glad for the compromise. We left the room, feeling as if we’d done something useful. Though we couldn’t fix the disease, we had found a way to bring meaning to his final days. We felt connected, and for a moment that felt like everything. We’d navigated some tightrope with him on our shoulders, and we hadn’t fallen. We hadn’t hurt each other.

  He died anyway that night, before we could arrange anything. He died before he was ready, before he had decided not to have us attempt resuscitation. And his ribs broke, and his blood soaked our shoes. And as I told his family I prayed they wouldn’t look down. That they wouldn’t notice my shoes were squeaking, as if I’d just walked in from a winter storm.

  * * *

  “Are you worried?” Randy asked, turning his body so he could look in my eyes. “You’re awfully quiet.”

  “Just thinking about a patient that was in this room,” I answered honestly.

  “Hmm. Do I want to know?” he asked.

  “Probably not,” I answered and sighed.

  “Did that patient die?” Randy asked.

  “Yep. Sure did,” I answered, remembering the sound of the audible bleeding as blood hit the floor.

  “Do you want to talk about it?” he nudged.

  I sighed and shook my head. What could I say? That trying to do good can sometimes hurt so much that you break inside and you don’t know if you can go on doing good anymore? That we see terrible, awful, bloody things and it hurts? And we don’t feel we have a right to hurt, because we are in the outer circles of the diagram and everyone around us is right in the center of it and it hurts so much more for them. So feeling anything that resembles sadness or grief feels terribly selfish and entitled. That though we don’t feel sorry for ourselves, because we know it’s not our sadness, it sometimes just feels as if we are seeing all the sadness in the world at once and we just need a second to breathe, but we haven’t built in a mechanism to allow us to breathe, or pause, or feel all the feelings. That when we feel them it guts us, and we hate it, so we joke or we drink or we run or we harden. And that it worried me that that was all any of us knew how to do, to joke or drink, or run, or harden. That I wanted to learn how we could truly be there for everyone’s hurt but not to have it transfer onto us like some sort of prickly dark matter. That sometimes I felt I got a glimpse of what that could look like, to heal and not to be haunted.

  “We wanted … to help him,” I said.

  “Of course you did. You do help! You all do amazing things,” he said, attempting to reassure me as I broke down crying.

  “I thought I was going to die in the stupid elevator.” I added a half-laugh to my cry.

  “No one was going to let you die.”

  “That’s the thing, we can’t stop it. We don’t ‘let’ people die, they just die. We can’t stop it.” I thought of my team after our patient’s death, their faces as sad and raw as circus clowns who had just wiped off their painted-on masks.

  “It’s not your fault, I didn’t mean that,” he said, recognizing we were not having the same conversation.

  “I know you didn’t. It just … I don’t think anyone understands.” I tried to think of how to explain what those losses were like. “Sometimes, sometimes it feels as if we’re all juggling so many balls and if any one falls and breaks it’s actually someone, and we can’t ever fix it. And sometimes it’s actually you yourself that you let fall. Like maybe you can save the others, but to do that you have to accept you’ll be broken by it.”

  “You feel broken?” he asked.

  “Oh, we’re all broken, in some way. Broken and haunted.” Even as I admitted that I knew it wasn’t the whole truth. I realized I wasn’t capturing something intangible about why we kept coming back for more.

  “There is more though. It’s not all sad.” I struggled to put into words how it felt in those times when I truly believed in medicine. I thought of one of my patients who had survived lung cancer twice. She had wanted only two things: to make it through Christmas with her grandchildren and not to be a pulmonary cripple, dependent on oxygen for every movement. She was very clear and articulate in expressing what she valued, and because of that, we were able to formulate a plan together. We decided we couldn’t operate on the second tumor, even though it would improve her likelihood of survival, as it would leave her with too little lung remaining to function the way she wanted to function. We planned instead on radiation. I did very little but to listen and outline the possible avenues available to her while giving her a sense of what each path would look like when all was said and done. In the end we chose a plan together that aligned with her values. I held my breath with her through the radiation treatments, hoping they would be enough to get us through to the end of December. I woke up at night worried we were being too cautious, not aggressive enough. I reminded myself this was what she wanted, but I couldn’t fall back asleep.

  She did make it through Christmas; in fact, she cooked the whole meal. She prepared a turkey with stuffing and mashed potatoes, and a sweet potato casserole and green beans and two different pies. She bought gifts for her grandchildren and she was there when they opened them. The letters she had written to them in case she wasn’t remained in a drawer. When I received her Christmas card in the mail, with a picture of her standing with her grandchildren, it was the best thank-you I could possibly have wished for.

  “There is magic too,” I said, attempting to distill my memory into some cogent statement. I wanted to explain that when I was able to truly be present, there was a sacredness in what we did every day that was intense and intimate and perfect. It was those times, they were so fleeting, but everything about life was wrapped up in those moments … love and respect and humanity and science. It was all there. And it was better than anything.

  “So the good outweighs the bad,” he summarized in his own linear way.

  I sighed and nodded, and we both smiled, happy that I had decided to embrace his reductive version of a far more complicated notion. “The good outweighs the bad, yes.” I thought that was a fair enough representation of something I would never be able to articulate, b
ut that every cell in my body understood. My cells had the advantage of not being constrained by actual words.

  I thought of how remarkable it was that he was always there, to the right of my hospital bed, holding or rubbing my hand. Whether I was suffering in pain, or with loss or grief, he was always right there. He lacked the ability to heal that the others around me were graced with, and yet his presence had been the most healing aspect of all. I realized that his willingness to witness my suffering had changed it somehow. He held what he saw and was never repulsed by it. He didn’t attempt to evade it, but he also didn’t intrude on the parts that were wholly mine. Because he understood there were parts I was possessive of, accepted that while I wanted him to know what I felt, I also needed him to know my pain was unique to me. Not all of it could be shared. He believed in humility, in asking questions. It struck him as a fragile pretext to assume anything, so he always asked. He taught me to believe in the healing power of us.

  As physicians we so often feel we aren’t enough. We’ve seen too much. We know the disease is stronger than the cure, we feel the deck is stacked and that we can’t possibly win. We frame our losses and successes in terms of the disease, which is a mistake. The language alone implies a battle and a clear outcome, a victor and a loser. If we are honest and allow ourselves to see death for what it is, an inescapable inevitability, then our story can change. In that light we can accept that our greatest gift is not in fact healing, because all healing is transient. Our greatest gift is, in fact, our ability to be absolutely present with suffering. To allow it to transform us, and, by holding the suffering of others, transform it for them as well.

  As young physicians, we had each imagined ourselves as barriers perched at the top of a steep cliff, our patients hurling themselves toward the abyss below. We were, in this version, the catchers, and when successful, we were the saviors, the heroes. We didn’t talk about the inevitability of the fall. Our back was always to the void. And this orientation suited us just fine; we didn’t want to face the gaping hole that swallowed each of our losses. We would stand and catch our patients and throw them back a few feet, and not let them look down. We didn’t want them to see what we had seen. We didn’t want them to see the magnitude of our capacity to fail.

  If we instead had faith in the meaning of our presence, we could turn and stand at the edge of the chasm and face it together. We could acknowledge its vastness and darkness. We could speak openly about our fears. We could offer insights of what we’d witnessed when others faced this same darkness. Our orientation would change. We could look in the same direction. We could have faith that our presence was meaningful, that in many ways it was everything.

  It took me ten years to figure out I should stand and face the same direction as my patients. It took that long to lose my vision of myself as someone who could help others defy death. It took losing colleagues to guilt and addiction to learn to soften, to bend rather than break. To value community and shared grief. Imagine if we trained physicians from the very beginning to know their value came from partnering with and being present for their patients. Imagine if we augmented their knowledge base with a resilience that came from a revised understanding of their role in their patients’ lives. The burden of guilt we could lift.

  That orientation—turning together to face what our patients face—is what allows us to not only bear witness, guide our patients and treat disease, but also to bring more compassion to each moment, a compassion that extends even to ourselves.

  In believing that his love was enough, that his presence at my bedside was needed, Randy showed me what could be.

  I didn’t dream of drowning that night. Instead I dreamt I was walking a tightrope, anchored on the edges of two cliffs, above a murky, opaque, Prussian-blue sea.

  Twelve

  Broken Vessels

  I worried that after what we had been through, we risked being overly protective of our son and never allowing him to experience the sorts of hardships that conferred a toughness, a grit below the surface of his character. I didn’t know how to not do that to him, so I set about trying to at least name what I wanted him to become.

  We were determined to raise a kind, adventurous, autonomous child, one who saw the value in art, who was willing to take risks and to fail, and who knew the meaning of perseverance. From there, we worked backward. If we wanted that to be true, we had to create an environment that presupposed our vision of who he could be. We had to live as if it were actually already true. So it followed that he would have to know from the earliest age that he could trust his own judgment. To ensure that he would trust himself, we would have to demonstrate that we trusted him and allow him to take calculated risks. We would permit him to fail on a small scale and reward the attempt, not the outcome. So that by the age of four, if he asked, “Can I walk to the creek?,” I had conditioned myself to answer, “Sure, I trust you,” even if my first thought was of him drowning in the shallow water. And we pretended not to watch as, empowered by our trust, he changed his shoes in search of better traction on the slippery rocks. He judged his distance from the house and assessed whether we could still see him before running ahead.

  He made good choices. Or he made small, bad choices, and the lessons he learned were valuable. He collected things, small bits and pieces of matter that are only a treasure to a child. He would take a small, special stone out while he played in the leaves, despite our observation that it might be difficult to keep track of. The precious thing would predictably become lost in the pile, and he would feel the loss and understand it was his choice to take that risk. We allowed him to be hurt. And though the temptation was to fix it for him, we resisted. We rewarded failure. Practicing yoga together, I’d congratulate him if he fell. “That was amazing! You took such a big risk that you ended up falling. I am never more proud of you than I am when you fall.”

  I wanted to enliven him with an intense curiosity about all things but especially the world around him, so while I made dinner, he would make art or conduct science experiments. Armed with baking soda and vinegar, he would inflate balloons with carbon dioxide gas until they exploded. Randy would return home to piles of powder fueling volcanic eruptions or finger paint covering the kitchen counter, and I’d smile and say, “The mess you see is the price you pay for dinner and curiosity.” He would nod and say, “All right then,” and roll up his sleeves to help tidy the mess.

  I wanted him to know the power of perseverance and armed him with magic tricks that required hours of practice to master. Magic was the perfect tool in that I couldn’t do it for him; he had to learn how to perform the illusion convincingly, independent of any adult help. The reward, of truly surprising an adult with a trick that elicited genuine awe and applause, was something he learned to want, to work toward.

  So perhaps it isn’t surprising that our curious, brave and adventurous child broke his arm the summer he was five. He jumped from the highest platform of a schoolyard playscape and landed squarely on his left forearm. It was the kind of fall you felt through the mulched ground more than heard. He cried, briefly, before sniffing the tears back and shrugging it off. In the fall, he fractured the elbow of his left arm. His reaction was so mild that over the next few days I didn’t even consider that it could be broken. I thought rather that he was just a bit bruised and favoring it slightly. Though he was generally unwilling to turn it and winced if it was mistakenly touched, he still went to his Saturday swim lesson and practiced karate. I mentioned the fall to his pediatrician at his well-child visit over a week later, almost dismissively, as an FYI.

  “He fell pretty hard at the playground last week, complained for two days, but seems fine. And also he gets a rash if he eats too much red dye,” I offered, having recently witnessed the outcome of a Strawberry Quik binge.

  He held my gaze as he manipulated his left elbow, nodding solemnly as Walt winced. “It’s the real deal,” he said, with a sideways glance. I read his look as, “How could you not know that?” He looked at
his watch and ushered us toward radiology to get imaging before the radiology department closed.

  I had been completely blind to the extent of his injury. Why?

  I was simply unable to be objective as it related to him. I wanted him to be fine, so my observations of him were filtered through a lens of what supported my desired truth. He hadn’t cried for very long. Children cried excessively when they broke arms, that was a thing. The next day seemed better and by the second day, he barely mentioned it. That didn’t seem to be the natural history of a fracture. Wouldn’t it hurt more, and for far longer? I was choosing to pay attention to the information that supported my belief while ignoring any information that challenged it. It was classic confirmation bias. I didn’t want anything to be wrong with him. And not wanting it to be true colored my view of the situation. I came to the situation with an agenda, which didn’t allow me to objectively observe and embrace the truth as it actually was. I was only able to see how I wanted it to be.

  As I looked at his X-ray, I felt shame. I hadn’t allowed myself to be present with the reality of his pain.

  The doctor brought in the temporary casting materials and a sling. He wet the material, which would polymerize and form a support for his arm, then wrapped it in an elastic bandage. It would stay in place until we could see the orthopedic surgeon. As Walt patiently held his arm in position, I explained that the doctor had found a fracture in his bone.

  “It’s broken?” he looked at it, appearing surprised.

  “Seems so.” I showed him the fine crack on the X-ray and the piece of bone that had chipped off in the fall.

  “And this will fix it?” he asked of the cast.

  “Yes, it will hold it in place while your body heals itself,” I said. Then, wanting him to understand how bizarrely magical and resilient the human body was, I added, “And the really amazing thing is, when it heals, it will be the strongest part of your arm, because the places we’ve broken form strong new bone.” I paused and looked at him to see if he understood.