In Shock Page 4
During the day, the sedating effect of the medications was thin and porous enough to allow the sound of voices to occasionally permeate the black silence. The words fell toward me, sinking to meet me where I lay. The drugs clouded my thoughts. In my muddied consciousness, I struggled to maintain alertness long enough to piece together clues: the warbled texture of speech, the bloat of my body, the gurgle of fluid in my lungs. In those days before my memories were coherent, I believed I had been drowned—drowned by bags of other people’s blood, with insultingly shutdown kidneys that couldn’t excrete the excess volume. The fluid had turned my lungs into heavy wet sponges. My body, with its fixed capacity, swelled with an additional forty-five pounds of fluid over the course of a night, in an effort to make up for the massive amounts of blood lost. Pale and turgid, I looked and felt as if I had been dredged up from the bottom of a lake.
During periods of alertness, my eyes darted around the room, silently imploring those present to explain what had happened. Eyes diverted. I attempted to talk, but the breathing tube in my throat prevented me. I attempted to make a gesture with my restrained hand, wanting to write questions.
“Just rest,” I was told.
Hmm—unlikely.
I had suffered a stroke that affected the area of my brain responsible for vision and balance. I saw everything in duplicate, and people oscillated before me in nauseating waves. The stroke would later make walking terribly difficult, but we wouldn’t know that for weeks. The congestion caused by the fluid resuscitation left my hearing impaired, with speech muddled and difficult to decipher. I heard phrases I had once spoken to families: “Her body has survived, but we’re not sure at what cost.” It was unclear if the words were floating up from my subconscious or sinking to me from above.
There were no mirrors in the ICU. Instead, I gauged my appearance by the reaction of the people entering my room. Physician colleagues—who were masters of the reassuring, permanent half-smile—gasped and cried instead. I understood what it took to generate that kind of a response, and I realized it was probably best that my vision was impaired and that there were no mirrors.
When I was deemed no longer at risk of pulling out necessary tubes and lines, my wrists were freed from restraints. I would palpate my own body, in a sculptor’s attempt to see. I found it unrecognizable to the touch. The integrity of my skin was violated by thick tubes that accessed every available large vein. My face and neck expanded into new territory closer to the periphery of the pillow’s landscape. My thighs were serpentine, with flat flaps on either side of the rounded center. My skin was an ashen shade of yellow with large swaths of blue and purple bruising. Twenty-nine sharp staples held my abdominal wall closed. I could indent my skin around my knee with a gentle poke of my index finger and it would remain for hours.
A man who looked like my brother walked in, but upon seeing me abruptly turned and left the room. I thought it couldn’t be him, not just because I didn’t trust my vision, but because he lived in Boston. But then time was so elusive, I had no idea what day it was. Had enough time passed for him to get here from Boston? I didn’t know.
I awoke to the voice of my childhood priest as he made the sign of the cross on my body. As an ICU physician, I had only ever seen priests enter patient rooms when last rites were being administered. I hurriedly surveyed the room for more evidence that I could be actively dying. My brother was there, with others, heads bowed deferentially in prayer. I read the room as sad but not gravely solemn. I surveyed my body for evidence I was dying, and though I was very cold, my fingers didn’t appear blue or mottled, which would suggest poor blood flow. Nurses were adjusting drips that they wouldn’t have bothered with if there were no hope of recovery. I noted the head of my bed was at thirty degrees rather than the flat position we usually allocated to terminal patients, and I accepted that I was probably not dying in that moment. I allowed myself to once again drift out of consciousness.
* * *
I opened my eyes and it seemed my entire department was in my room at once. They were arguing about some aspect of my care. Something about the ventilator and fluids. One was discussing possible strategies, while others stared at the floor or out the window.
“We shouldn’t be here. Looking at her when she’s like this. It’s not right,” one of them said to everyone and no one.
“Have you told her yet?” I recognized my mentor’s voice. The question seemed directed toward my right side, which I knew from the feeling of his hand on mine was where Randy always sat.
“No, I want to wait until she’s off the breathing machine, so I know she’ll remember,” Randy said, with a tone of resignation.
“I’ll tell her if you don’t think you can. I’m used to giving bad news.”
They don’t think I can hear them.
I directed my gaze squarely in the direction of the colleague who had suggested everyone leave. He’d been ill, and I knew from his discomfort that he understood the indignity of exposure that comes with a critical illness.
“Come on, let’s leave her alone.” He ushered everyone out.
My mentor didn’t follow the others. He leaned over and reassured me, “You are going to get better now. It’s not your heart, we looked at your heart. I have to go to Argentina tomorrow. When I come back you’ll be fine.” There was something in his tone that revealed his last statement to be more of a wish than a promise.
He then turned to the surgical team and began giving instructions on how to get me off the ventilator.
What were they waiting to tell me? I couldn’t fathom what I didn’t know.
I watched silently as dusk fell outside my ICU window. The nursing shift changed, and the night nurse came in to do her assessment. She listened to my heart and lungs, checked each of my IV lines for signs of dysfunction or infection. She drained and measured what small amount of urine had collected in the bag draining my bladder. She administered medications and asked me questions I couldn’t answer. I would wince or withdraw when some movement worsened the pain, but I had no other means of expressing myself. I gagged as she passed the suction catheter down the breathing tube, trying to clear my lungs of secretions. I wanted to somehow communicate to her how unbearably cold I was, but couldn’t seem to coordinate my body to replicate a shiver. I just looked as though I was shaking my head and shrugging my right shoulder.
I knew it was officially night when Randy fell asleep in the chair at my bedside. I envied his ability to sleep despite any noise. The absence of even a full minute of silence combined with the constant pain made sleeping difficult for me. Every other moment an alarm would sound, a monitor would beep. This bag was out of fluid, that IV was kinked, my heart rate was too high, my blood pressure too low. Near-constant noise, activity in the hall, codes called over the PA system. Time passed one slow second at a time, punctuated by constant beeps and the dull hum of machines. After a thousand beeps the nurse would collect blood, so that the results would be available by morning rounds. A few alarms later and a sleepy surgical resident would enter and do a cursory exam, then report to the team how my night had been. At daybreak the radiology techs would try hopelessly to rouse Randy in order to take my morning X-ray without irradiating him. It brought back memories of his alarm clock at home, which was marketed for the deaf, vibrating his pillow in waves of larger and larger amplitude.
* * *
The breathing tube was removed in the morning. Though I still required oxygen, this was the first tangible success. Breathe on my own again. Check. Though I found I needed to remind myself to breathe; the time spent with the machine bearing that burden had reset my mind to believe it was someone else’s responsibility. As long as I did nothing else I could breathe, but I quickly found I couldn’t combine tasks. Shifting positions in the bed left me breathless and exhausted.
“I’m really cold,” I said with great urgency and an inexplicable sadness.
The nurse left to get more blankets from the warmer.
Randy squeezed and
attempted to warm my hand in his. A pained expression clouded his face.
“I need to tell you something,” he began.
This must have been what I had overheard them discussing. I looked at him and realized it was about the baby. They didn’t think I knew yet that the baby had died.
“The baby didn’t make it.”
My eyes welled, not with sadness for the baby, but with empathy for him. I recognized that he was trying really hard to break this news to me gently. They had discussed who should tell me and when, probably even how.
It had never even occurred to me that the baby was anything but dead. Of course the baby hadn’t survived. I had barely survived. But seeing his face, I somehow understood it was best to play along. I nodded, solemnly.
“I’m really sorry,” he added.
I had little voice from the irritation of the tube in my throat, so I whispered instead, “Yeah. It’s OK. We can have other babies. But only if I’m not dead.”
He smiled at me, appearing relieved.
“I’m really cold,” I repeated, as the feeling recalled the events of the first night. I knew I had to tell Randy what had happened. In case I forgot, or died.
“I could see myself,” I attempted, wanting to explain the moment in the operating room when the pain stopped and I was dying. I cleared my throat, wanting to have a voice. “There wasn’t any pain; it all went away. And it was like I knew if I wanted to, I could always feel that way. I didn’t have to go back to the pain. I don’t know how I knew, but I knew there was a choice I had to make, you know?” I was trying so desperately to explain something to him that I had no words for. I searched his face for evidence that he understood and that I should go on. I paused to just breathe, not able to both breathe and talk at the same time.
“But you chose not to die,” he smiled, as if we had conversations about out-of-body experiences every day.
“Yes.” I was grateful that he seemed to be understanding despite my painfully vague description. I gave him my left hand to hold and warm. “Only I didn’t know that was what I was choosing between. It’s weird. It was almost like an invitation to leave the situation and the pain, but I knew if I left I was leaving everything. But I don’t know how I knew, I just did.”
“How did you feel?” he asked.
“Just completely safe. I wasn’t scared of anything. I felt as if I were so expansive, like the edges of me were fuzzy and blurred and I was part of everything, but I also felt really small at the same time. I had absolutely no fear.” I paused, wanting him to know the absolute peace I had felt. “Really, there isn’t anything to be afraid of.” I stopped, knowing how crazy I sounded. I glanced at my IV pole, with the various pumps and drips, thinking I could always blame the narcotics I was on for my magical thinking.
“Thank you,” he said.
“For what?” I asked.
“For deciding to come back to me,” he answered, tucking the additional blankets the nurse had brought around me.
* * *
I overheard myself being presented by the surgical resident in the hallway. It was time for morning rounds. “Thirty-three-year-old female with HELLP syndrome, post-op day four, status post-crash C-section for fetal demise. Intraoperative observation of a large subcapsular hematoma.” The acronym he used, HELLP, stood for Hemolysis, Elevated Liver enzymes, and Low Platelets. It is shorthand for a poorly understood, often fatal condition that affects less than 1 percent of pregnant women. A condition in which the blood is shredded into useless shards, the liver fails, the platelets responsible for clotting the blood are consumed and women bleed to death. In addition to understanding that they thought I was suffering from HELLP syndrome, I also learned that I had bled into the space around my liver. Until that moment, I had no idea what had caused the excruciating pain. The diagnosis was disproven later, when the tumor was surreptitiously identified on a CT scan, but for now it would do.
“Hemoglobin is 7 after 26 units. Up 45 pounds, low urine output,” he went on. So by rough math, I calculated I had received enough blood products to replace my entire blood volume three times, and my kidneys weren’t functioning. Perfect.
“She’s been trying to die on us.”
Um, no, I thought, becoming angry.
No, I was not actually trying to die on anyone. Though perhaps not manifest by outward appearances, I was trying desperately not to die. And though I might not have had a lucid enough mind to articulate it, by blaming me I felt he was positing me as an adversary. If my care team didn’t believe in me, what possible hope did I have? I felt the ice I was balancing on detach and begin to float me away.
Then I cringed with the discomfort of an uncomfortable memory. I had used that phrase, often and thoughtlessly, in my training: he was “trying to die on me.” Oh my God, we all said it all the time. And inherent within that phrase is the reality that we attribute intention to patients, rudely hurling themselves toward death. We construe ourselves as barriers between the patients and their transparent though unstated goal. We subconsciously construct a narrative in which the doctor-patient relationship is somehow antagonistic. I recalled the relief I would feel in the ICU after a night of being alone on call, when the day team would walk in. “I kept them all alive, my work here is done.” I would congratulate myself and sink into a chair. Others might gloat: “He may die today, but at least he didn’t die on my shift.” That was often what sign-out rounds devolved into, one doctor telling his or her colleagues how difficult it had been to prevent someone from dying.
My identification with the rounding team was short-lived. The attending looked at me from the doorway and shrugged. “So, give her Lasix.”
His answer, to give me a medication to offload my body of some of the fluid, addressed only one small issue in the pile of problems facing me. And while it may have been the most obvious choice, it was the wrong choice. What wasn’t immediately apparent to the team was that because my kidneys had been deprived of blood while I was in shock they were intent on not functioning, which was why I wasn’t producing urine. This medication, Lasix, would challenge them, and they simply weren’t up for it. Instead they would shut down further, propelling me into overt kidney failure. In some ways, this was something that could only be known in retrospect, when the micro-experiment produced results. The choice, to give me that drug at that particular time, represented a kind of casual negligence afforded to physicians practicing an imperfect science. A seemingly benign effort to effect change, that when scrutinized would only have resulted in harm. Casual choices sometimes come to horrific ends. And it’s not only casual choices. Often, physicians will scrutinize a choice intensely, debate and discuss endlessly before deciding on the most seemingly sound course of action. These decisions are often punctuated by hesitation: “But what if we’re wrong?” To which I myself have replied, echoing my mentors, “The only person who can tell us that now is the patient. He will declare himself.”
As physicians, poor outcomes that are the result of well-intentioned choices are harbored under the safe umbrella term “the principle of dual effect.” As the name implies it refers to one action with two distinct outcomes. One effect is intended and anticipated; the other is unintended and undesirable. It is often evoked in situations when a drug administered to help with one symptom causes another. For example, when a patient suffering severe pain is given morphine, the patient could suffer terrible nausea and itching as a side effect. The morally good effect, relieving suffering, is the focus. The discomfort of nausea and itching is the unintended consequence of the morally sound choice. If one had given the morphine with an intent to cause the uncomfortable side effects, that would have been morally wrong, but as an unintended but foreseeable side effect, it was forgivable. As a physician, I could accept some element of risk. In a sense, we all had to, or risk being paralyzed by fear and indecision. As a patient, I found it much harder to accept the risk each decision conferred. Ultimately, for me, the attending’s choice to give me that drug at that pr
ecise time resulted in my kidneys failing.
I knew I couldn’t afford for things to get worse. I needed a steady trajectory of forward progress, however slow, with no setbacks. In a misguided attempt to reassure myself, I performed a rough risk evaluation with the new data. It was something we routinely did in the ICU to give families a gross estimate of prognosis. Each organ failure increased probability of death by 20 percent. I counted silently: liver failing one, kidneys made two, then lungs three, blood four. Shit. I had reached 80 percent faster than I had expected and tried to forget that there were any other organ systems remaining, lest I count them and get to 100 percent.
I was already predisposed, as a physician, to imagine the variety of possibilities that could potentially result in my own death. Would it be a medication error, a complication of a procedure, a hospital-acquired infection, or some unfortunate combination? As I began to see the potential for error, each imagined possible ending suddenly felt more likely. I expected my death to come as the adjunct of some trivial oversight. It was in those moments that I came closest to understanding the illogical nature of true anxiety. A parade of seemingly plausible possibilities marched over reason and judgment. Anything seemed possible because nothing was preventable.
I worried that I might die. And then there were the times, just as terrifying, when I was worried I might not get to die. In those early ICU days, what I feared most was that transition space between life and death: The purgatory where someone connects a bag of liquid nutrition to a feeding tube and comes to suction your secretions every four hours, rolling you shift by shift so that the pressure ulcers don’t form. One long, permanent night, punctuated only by beeps and hums. I feared the small complications, the missteps, knowing they led directly to that non-space. I feared decisions that were made without looking at the whole picture. I feared errors that led to dialysis.