In Shock Read online

  He attempted to stick with the ritualized formality of the paperwork. “Does anything make the pain better or worse?”

  He was met with silence.

  He sighed, frustrated. Sensing he was going to get nowhere, he paged his resident. While only twelve months his senior, she had just enough experience to know when she saw me rigid from the pain, with unstable vital signs, that there indeed was no time. That was all the insight I needed her to have. “Who is your attending?” I asked her.

  The trauma surgeon on call that night was someone I had worked with in the Surgical ICU. I’ll call him Dr. G. He was thoughtful, meticulous and incredibly skilled. I asked her to please page him and tell him it was me, and ask him to come up to L & D. She did just that, with the limited information she had. He was told only “I don’t know what’s wrong but you know her and she’s really sick.” Surgeons are, as a rule, not usually tolerant of such incomplete reports from their resident teams. They are not accustomed to “I’m not sure” and “I don’t know.” Their field demands certainty. They expect to be summoned to the bedside of a patient when the work has been done, the labs and imaging complete and interpreted. They expect to be given a diagnosis, an assessment, a plan and even an operating room time. They would rather you be wrong, but take a principled stand based on conviction, than to say, “I don’t know.” While another surgeon might have berated her, he simply sensed her fear and humbly showed up.

  Dr. G checked my lab results, winced, shook his head and began listing the possibilities. He listed the differential of possible diagnoses: “Fulminant liver failure, perforated ulcer, ruptured appendix…”

  I heard those possibilities and thought, no, I’m dying faster than any of those can kill you. This is worse. I don’t know what it is but it’s something worse. And although none of the proposed diagnoses captured the gravity of the situation, I felt a relief that there was at least a list of possibilities. I wanted to know what was causing the pain and to fix it; I didn’t want to pretend it wasn’t there, silencing it with morphine as it killed me. I worried, being physically located in the OB triage area, that the baby would be prioritized over my own well-being.

  Ten years into my training, I’d seen enough to know the possible outcomes. I had seen women lose pregnancies; I had seen mothers die and babies survive. I feared the latter. I feared the uniquely awful incongruity of a baby entering into the world through a portal of death. Muted celebrations of birthdays, superimposed onto anniversaries of deaths. Motherless children. Balloons and gravestones. I shook my head deliberately to release the vision of gravestones.

  I looked up and my mother was at my side, her face betraying her worry. Her lips were pursed, brow furrowed, a result of receiving the call that all mothers dread. During her perfectly normal evening routine, the phone had rung. She heard the fear in my husband’s voice. She had driven thirty miles in the dark of night to an inner-city hospital.

  “You called my mom?” I accused Randy. I couldn’t remember him even leaving my side long enough to make a call.

  “Of course he called me,” she replied for him.

  I sunk into the gurney, feeling defeated. I was upset not because I didn’t want her there, but because it confirmed that I could not confine the pain to my body. I was sick enough that the people I loved would be hurt by it.

  “I don’t know what’s wrong,” I apologized, feeling useless in my inability to reassure anyone of anything.

  The tube draining my urine filled with blood.

  “Maybe it’s just a kidney stone,” my mom directed her statement to the doctors. “Her dad had horrible kidney stones.”

  * * *

  They pushed more morphine. It didn’t touch the pain. The nurse reported back to the obstetrician in charge of triage that night, and he replied, “If she wants more, give her more. But that baby’s going to have a hard time if we have to deliver her. Whatever she wants.”

  Whatever I wanted. What a curious thing to say.

  I had never specifically wanted morphine. I wanted the pain to stop because they had found the cause and fixed it. I was struck by both the flippancy of his reply and the stupidity of him volunteering me as the physician in charge of my care. I knew I was not in any condition to direct my care. But I did understand what he was implying when he said the baby would have a hard time. All of the morphine that entered my system would also enter the baby’s small system. Theoretically, if the baby were delivered that night, the baby probably would not breathe effectively on its own. My pain, or rather, my unwillingness to endure it, was compromising the baby.

  I had received 50 milligrams total in 2- and then 4-milligram increments. It was enough narcotic to kill me had I been well, by shutting down my center of respiration, but due to the ferocity of my pain, my body barely acknowledged it. It couldn’t and hadn’t touched the pain.

  “Isn’t that bad for the baby?” my mom asked, as the nurse pushed another syringe into my IV.

  “Probably,” I conceded. I was just frankly no longer able to prioritize the baby in any of this. I felt as if I had awoken in a house engulfed by flames, and my first instinct was just to get out. Let someone else worry about the others.

  * * *

  There were arguments over whether I should be sent down to radiology for a CT scan to help delineate the source of the pain. Radiologists were reluctant to perform a CT, concerned about the radiation risk to the baby. Dr. G was hesitant to operate without a CT, as it rendered them unable to anticipate, and therefore to plan. Nothing was happening, but that inertia seemed preferable to being transported away from the doctors and down to radiology. I knew, the same way one could sense an approaching thunderstorm by the air going thin, that I was too unstable.

  “I think it’s a mistake … to let me travel. I think I’ll die if you send me down,” I implored them, breathless from the pain.

  My intuition was validated by my second set of lab results. I had lost nearly my entire blood volume somewhere in my abdomen. I felt momentarily vindicated, like an eager medical student who had nailed the diagnosis her superiors had dismissed. I believed they would now see the necessity of operating, of identifying the cause of the intractable pain. Rather, in a squall of black irony, I watched as the values only served to amplify their concern for the baby, and they wheeled a portable ultrasound machine to my bedside.

  “Bear with me,” the obstetrical resident warned, his foot tangling in the cord. “I’m not great at these yet.”

  He didn’t need to be. Here I could still be a physician. From the first grainy images I could see the small ventricles still and pulseless—like a four-chambered pool filling with slowly falling snow. “There’s no heartbeat.” The words cascaded out of me on a torrent of agonized breath.

  “Can you show me where you see that?” he asked.

  The words reverberated in the suddenly hollow space behind my eyes. I heard my own gasp, and shuddered in a shock of pain. It was as if the subtle movement of my diaphragm with the breath had spread open some barely healed gash, freshly exposing the injury. As my breath caught, I stared at him, incredulous. Could I show him how to interpret the ultrasound images of my dead baby? The baby whose impossibly small dresses were still hanging expectantly in the guest room closet. I hadn’t gotten around to setting up the baby’s room, but she had belongings. Small socks and onesies. I’d just begun to prepare.

  I felt an emptiness begin to envelop me from the inside, a kind of meditative panic. The baby we’d imagined—that was at least, transiently, very real and tangible—was dead. I was dying as everyone watched, a roomful of doctors and none of them able to grab the yoke to save me from crashing into the sea.

  “Can you show me where you see that?”

  I realized the resident’s perspective in that moment was aligned squarely on himself. I imagined an alternate reality in which I would reach up from the gurney to trace my index finger around the outline of her perfectly elliptical, and utterly motionless, heart, delineating the an
atomy the way he requested. The insensitivity of what he was asking struck me hard. I felt invisible to him.

  His detachment reveals an unsettling, largely unspoken reality. We aren’t trained to see our patients. We are trained to see pathology. We are taught to forage with scalpels and forceps for an elusive diagnosis buried within obfuscating tissues. We excavate alongside our mentors in delicate, deliberate layers, test by test, attempting to unearth disease. The true relationship is forged between the doctor and the disease. This bond is disclosed when we reencounter these diseases: we greet them respectfully as the worthy adversaries they are. Their reappearances evoke devastating losses, past insults when they prevailed. The patients carrying the diagnosis are at risk of becoming an accessory to the whole affair, just another vector.

  As his question echoed, I discerned a tone in his voice that I hadn’t initially noticed. It was genuine curiosity. I realized, with an uncomfortable tug of recognition, I was indeed not a person to him, but a case. And an interesting case at that. I was Abdominal Pain and Fetal Demise to him. I affixed my eyes onto his, willing him to see me.

  I needed him to see me. I instinctively felt that if he didn’t see me, if he didn’t connect with me, he might not care enough to do what it would take to help me to survive. The baby had already died inside of me of a placental abruption, a grave and deadly situation where the placenta separates completely from the uterine wall, and the baby is deprived entirely of blood flow. They would later explain this was likely caused by lack of blood flow due to lack of blood volume from the massive internal bleeding I was experiencing. I was well on my way to dying as well. I saw two possible versions of the night that lay ahead of the resident. One, a sleepless night, with transfusion orders, countless pleas to the blood bank for more blood products, the micromanaging of lab values, ventilator settings, and expectations. I saw too how easy it would be to concede instead under the burden of it all. The alternate possibility: She was very sick, and she died. I’m sorry.

  The baby, having declared her own distress, meant the surgery I’d been begging for came easily now, briskly even. I was pulled so quickly into the operating room, my IV pole struck the obstetrical resident in the face. He had never met my gaze. He was still attempting to decipher the ultrasound images on the screen.

  Although by all accounts I’d been begging for the surgery, I never actually believed I would survive it. I had heard my lab values recited, gravely. I knew I had almost no circulating blood volume with a hemoglobin of 3 grams/dL. I knew I had almost no platelets, the component of the blood responsible for clotting. There hadn’t been time to arrange for cross-matching and transfusion, so there was no hope of the numbers improving any time soon. I knew I was already in shock, with a blood pressure so low that it was barely detectable. Patients like that don’t survive a surgery.

  I had long regarded deathbed conversions as a self-indulgent shortcut to absolution, but I suddenly understood the temptation. I was dying, with still inchoate beliefs, having always planned on having time to be surer of something. Though there were times I had sensed the grace of something truly holy in my life, it wasn’t tangible enough that I could build a physical structure around it and engage in worship. Like a soft wind, it just didn’t have a substantial enough mass for me to wrap myself in it.

  As a physician, I fully expected to die in the operating room, and as a physician I didn’t think it would do anyone any good to disclose my conviction via some emotional good-bye. I believed people would be hurt when it was time for them to be hurt, and there was no sense anticipating the pain for them. So rather than frighten or warn my family, I simply said, “Ugh, such drama.” And with that I was wheeled through the open steel doors into a harshly lit operating room.

  * * *

  Memory, the recall of specific events into the forefront of our minds, requires a reimagining of the event. And recall is far from passive. Unlike retrieving a mug from a cupboard, the simple act of recalling a memory changes the synaptic framework of the memory itself. It is retrospectively molded as we attempt to fill in the gaps. As if the cup is made of still pliable clay, and the warmth of our hand indents the surface. When we next retrieve that memory, we are recalling our last memory of the memory; we are in effect retrieving the indented mug. It’s with this necessarily flawed data that we construct the narrative of who we are. And so the endlessly iterative process of rewriting ourselves goes on.

  I remember the frigid operating room and the blue blur of scrubbed bodies moving briskly, voices muffled by masks in a way that recalled scarved children in winter. The square, snow-colored tiles covering the walls. The cool smell of volatile alcohols. The steel of the table, the drain in the floor to hose the still-warm blood into. The scrub tech pouring Betadine on my abdomen as a quick prep for the incision. It was as cold as gasoline. As they began sedating me, I heard the anesthesiologist’s voice: “We’re losing her … her systolic is 60.”

  I was drawn back into myself, from failing consciousness, by those words. Are they losing me? I attempted to survey the situation. Focus, I told myself.

  “We’re losing her.”

  Words echoed, or were they repeated this time?

  “Guys! She’s circling the drain here!”

  You know I can hear you, I thought.

  I struggled to maintain consciousness, trying to surface against a submersive force, a weighted pull into an obliterative darkness. My arms were so heavy and stiff. A movement of a millimeter was an impossible effort. My eyes darkened. My throat tightened. I sank below the still surface of the water. A heavy water that was dense as mercury, the crush of it accelerating my descent.

  * * *

  All at once, I felt a sudden release and lightness. I could see the operating room clearly, although I struggled to orient myself. The view was deceptive, in the way pilots staring for too long at the horizon can sometimes suffer sensory illusions that cause them to mistake the sea for the sky. My orientation was inverted. I was falling up. I could see the frustrated anesthesiologist who was working on placing IV access as I crashed. I could see the monitoring equipment surrounding me, the obstetrical team readying with instruments to extract the baby. I could see myself on the table.

  It struck me that they were right; they were losing me. If I could see myself, perhaps I was already lost.

  I felt nothing. The pain miraculously gone. The panic surrounding the pain was gone. An anodyne peace. I felt weightless, buoyant and very small. I watched the events unfold before me, unattached to any outcome, with an easy stillness.

  I had died.

  It would be a year before the surgeons who were present described to me in reverential tones the series of catastrophic events that occurred in that operating room. I had what was referred to in trauma as the “Triad of Death,” the combination of hypothermia, acidosis and coagulopathy. In simple terms the phrase describes a self-perpetuating process in which the blood is too cold and too acidic to allow clotting, which means more bleeding, which requires more transfusions, which results in more hypothermia and acidosis. A sort of unremitting, suicidal spiral of the blood. They described the gallons of blood lost, the gallons frantically replaced, some run through a warmer to mitigate the hypothermia. The moment my kidneys shut down. The rapid accumulation of potassium in my bloodstream. The deterioration of my vital signs. The gradual acquiescence of my heart, irritated by the toxic milieu, beating aberrantly, then not at all.

  With each disclosure, I’d share what I remembered. The location of the anesthesiology resident in the corner, by the computer. The harried requests for surgery to be called back to place a larger trauma line when the need for rapid infusion of blood products became apparent. The frantic search for the source of the blood loss.

  You couldn’t possibly remember that, I was told. You’ve reconstructed the memories from what you’ve heard, or read in the chart.

  No, I was there. I can’t explain it, but I was there.

  That coldness, which I equated with
the feeling of having been dead, remained for months. I was incapable of getting warm. Engineering would be called to my ICU room to adjust the heating apparatus until everyone entering the room would remove a layer of dress and comment on the warmth. Blankets were piled upon me, fluids warmed before hanging, but nothing touched that unshakable coldness. Years later, the Midwest was privy to a weather phenomenon termed the “polar vortex,” and wind chill estimates reached thirty below in Michigan. Standing outside in the snow that winter, I thought it odd that people referred to that feeling as cold. How strange we only had the one word for both feelings. Cold to me was internal and unremitting and came with no promise of a spring.

  Two

  A Hollowness

  I resurfaced, overtaken with a sudden fear. I felt a breath delivered, without having drawn it myself, and shuddered at the sensation. It was like trying to breathe with your head out the car window; the force of the air made movement of breath impossible. I was wholly dependent on machines; I understood the magnitude of catastrophe this signified. I resolved to breathe independently and tried to pull a breath against the gush of the machine breath, setting off sensitive alarms. I fatigued quickly. I found I couldn’t maintain the intense vigilance that breathing required. Over time, there was a resignation to the reality and a gradual dampening of the waveform that was panic. I fell out of consciousness.

  The cycle repeated: I regained consciousness, suddenly aware of my surroundings and filled with terror. I struggled to breathe and panicked that I couldn’t get enough air in to ease the feeling that I was suffocating. I gave up trying to breathe and accepted the breaths the machine offered instead. After struggling on my own, the mechanical breaths became a welcome relief, despite their peculiar uniformity. I heard the artificial puff of my exhalation, every six seconds. I would again tire and lapse out of consciousness.

  I later recognized these periods as weaning trials, brief routine episodes every morning when nurses turn off sedatives and pain medications to allow respiratory therapists and physicians to assess whether the patient may be able to breathe independently, with minimal support from the ventilator. This protocol isn’t generally communicated to the patient. They are instead left to awaken to abrupt pain and anxiety precipitated by withdrawal of the medications that had quietly sustained them. Cyclic episodes of panic and darkness.