In Shock Page 6

  I looked at her and was immediately back in that ICU room with her perched in the window, the daylight silhouetting her and obscuring her features in shadow.

  “That was a bad night,” she said.

  Yes, I thought, it was a bad night.

  “This is going to be better,” she reassured me, with a deep exhalation that made it sound like she was making a wish over birthday candles.

  I certainly hope so, I thought, willing my premature infant son’s lungs to start functioning. I had yet to hold this baby either. It was nearly Christmas, and hanging on his incubator was a tiny stuffed Santa. A Christmas ornament, just slightly smaller than his struggling three-pound body. I stared at the cheery red figure, wondering if it would be a cherished memory that one day hung on our tree, or if it would be become another prop in a remembrance box.

  * * *

  This declaration of the “badness” of that night for others became a theme. A shocking number of people entered my room after that with the express purpose of telling me what a bad night it was for them. The night I died. I didn’t recognize the OB resident immediately. It had been over a week since I last saw him, and the right side of his face was now distorted by a purplish-black eye. Then the image of the IV pole striking him in the face surfaced and I remembered.

  Can you show me where you see that?

  He took a seat in the corner.

  “You know, that was a really difficult night … for me,” he began, haltingly. Looking at him, it was clear his pauses were measured attempts to keep tears at bay. As he bit his lip and sniffled, I wondered how it was possible that of all the people in the room, he was the one fighting back tears.

  “I was in a different residency program. I started off in Neurology, but I switched into obstetrics because I thought, you know, delivering babies, I thought it was a happy field,” he admitted.

  I sighed and pushed, defeated, on my PCA button to self-administer a dose of morphine. I somewhat hoped it would dull the pain of the impending conversation. In those first few days, I was not feeling at all sorry for myself; rather, it seemed to me a tremendous good fortune to have survived the catastrophic hemorrhage relatively intact. I had, by that point, seen a world’s weight of suffering come through the doors of the hospital and I could use it as a sort of camera obscura to shrink the image of my own suffering. I felt genuinely lucky. But I also had a quick actuarial mind that could tally the suffering of the person before me and inevitably found they came up short.

  They were violating the basic rule of the Ring Theory, which I first encountered in a Los Angeles Times article by Susan Silk and Barry Goldman. The concept is an etiquette lesson in complaining during times of crisis. Imagine concentric rings. The center ring represents the sick person, in this case me. The next circle is composed of the closest family, people who are also affected by the illness or loss, in this case Randy and my mom. The next circle, less close family, friends and so on, until eventually random acquaintances conceptually inhabit the outer rings. The person at the center, by virtue of being the most vulnerable, gets to say anything she wants at any time to anyone. That is the sole benefit of being encased in that awful central ring. That person should not be the recipient of complaints from people in the outer periphery. They can say how they feel, how the trauma is affecting them too, but only to people in larger rings. The rule, as described in the article, is simple: “comfort IN and dump OUT.”

  For example, I was entitled to blatant outbursts of self-pity and could say, “I feel like I failed everyone; everyone was so excited about the baby.”

  However, if a random family member said, “We were so looking forward to the baby coming; it’s just been horrible news for us,” that would not be OK.

  Everyone in those days seemed intent on dumping in.

  “It wasn’t just your case,” the resident elaborated. “We had a really bad outcome the night before too. That mom died. You were lucky.”

  I looked at Randy, who, without the benefit of the narcotic fuzzing of his emotions, looked ready to fight. He explained later the only way he managed not to strike him in the face was that the disfiguring bruise suggested he had already been punched.

  “It won’t always feel like this. The happy outcomes will outnumber the bad,” I offered, helpless but to comfort out. It wasn’t that I was being unselfish, it was just that looking at him, I felt as if I were looking at a dumbstruck deer that had wandered out into the road. He had left us no choice but to collide. And I knew the look of abject defeat. I too had experienced bad outcomes as a physician, and they had rightly gutted me. I had certainly dumped in. I recalled admonishing a patient, “You really scared me last night.” Recalling that memory was like watching a fabric quilted of self-centeredness rip open before me at the seams.

  You really scared me.

  That was a bad night for me.

  I will never say those words again.

  He nodded and left, shoulders just slightly less slumped than when he had entered. Randy vented, incredulous at his audacity. “How dare he think he was justified complaining to us?” I shrugged and shook my head.

  It took time for me to feel genuine compassion for him. Improbable though it seemed to me at the time, it would come. Before I connected to it, I scheduled meetings to complain to his superiors about this particular resident’s lack of insight. One physician who was the unlucky recipient of my tirade was a kind, middle-aged man with energetic eyes. He listened attentively and nodded. I would believe that by nodding, he was agreeing. I believed he would understand how poorly suited this young physician was to the role he was in. Instead of that, I got a reflective dissertation on a flawed system and the shame it cultivates, and the untold burden of suffering on the trainees. The pressure we place on them and the unseen toll of our collective expectations that they function on some superhuman level. I thought he had completely missed the point. I wanted to see indignation, an indictment of this particular resident’s capacity. Instead, he demonstrated nothing but compassion toward him and encouraged me to do the same. I left his office with books on mindfulness and the power of gratitude. I didn’t understand his position at the time. Of course medicine was high pressure; that was how we were shaped and molded. Medicine was a place for people who thrived under that pressure. It was no place for self-pitying doctors who cried to their patients. We didn’t have the luxury of being broken. Our patients needed us to be strong. Or so I believed at the time.

  The traits we revile in others are often the ones that remind us most of our worst selves. And we react most strongly to the faults and flaws we see in others that we are most ashamed of in ourselves. The OB resident had allowed himself to feel his sadness, something I had denied myself. In coming to our hospital room to cry, maybe he hadn’t chosen an appropriate outlet for his grief, but he was searching for one. He was broken, and he was admitting it far before I allowed myself to do the same. I didn’t have the insight to see myself in him then. But as these things usually go, life saw fit to keep him at my side until I did understand that we were far more alike than we were different. And that I owed myself the same compassion I owed him.

  He resurfaced repeatedly through the next three years, like a buoy marking some distance we’d traversed in a vast sea. He was the resident rotating when we met with the high-risk maternal fetal medicine doctors to plan our next pregnancy. He was the resident rotating on reproductive endocrinology when we thought perhaps a surrogate would be the safest route. He never sank. He sometimes pretended not to recognize us, but more often he reflected on the sheer awfulness of that night, or his resolve to see his training through to the end. Had he appeared as a social worker at the adoption agency we visited, I don’t think either of us would have been surprised. And when he failed to appear at the delivery of our son, we felt blissfully free. I had earned our uncoupling.

  A curse was undone.

  Three

  Waiting to Fail

  There is a saying in surgery: “All bleeding
stops eventually.” I first heard this in an operating room, as a medical student, uttered by a colorectal surgeon as he addressed a squirting blood vessel. I interpreted it as an abbreviated pep talk, a reminder to the surgeon from himself, of his own skills and ability. The subtext, like the wry smile beneath his surgical mask, was not accessible to me, his verdant student. It wasn’t until I repeated the phrase myself, as the doctor responsible for stopping a patient’s blood loss, that I understood the morose connotation. The bleeding will stop, because either you will gain control of it, or the patient will die because you couldn’t. And then it will stop.

  One week into my ICU stay, I was reminded there is a third way that bleeding stops: tamponade. I had bled into a relatively fixed space—the fibrous capsule surrounding my liver. As volume increased in the space, pressure proportionately rose, the blood politely obeying the laws of fluid dynamics. Pressure here was both a blessing and a curse. A blessing, in that it caused the bleeding to stop, or tamponade, when the pressure in the space exceeded the pressure in my arteries. A curse because that static column of viscous blood had displaced my liver, and the weight had compressed it to one-tenth its size. Crushed and confined, the cells of my liver began to die. The liver unfortunately bears responsibility for the manufacturing of blood products responsible for clotting. Without these clotting factors, all blood loss becomes unstoppable. Despite the horror of this condition, it has a rather poetic name: compressive hepatopathy with consumptive coagulopathy. They are beautiful phrases, with the quantitative meter of iambic pentameter. Their lyrical cadence melodic, until one considers their meaning: my liver was failing and I could bleed to death in a moment.

  A doctor entered the room early in the day, in rumpled clothing and an ink-stained coat. He was still chewing whatever food he’d put in his mouth while on the way to my room.

  “Hi, I’m from transplant.” He introduced himself through what smelled like an onion bagel. He wiped his hand on his coat before offering it to shake.

  I offered a feeble wave from my bed instead. He awkwardly attempted to give purpose to his outstretched hand and redirected it to push his glasses back up his nose with his index finger. A ridiculous circular gesture that only added to his informality. His pale, gangly frame backed up until it found a surface to rest against.

  “So, listen. Your surgical team consulted us, because of your liver failure. Sounds like we’re going to have to find you a new liver, unless you want to live here forever.” A weak attempt at humor, which fell flat. Except for his own half-hearted snort.

  Randy was incredulous. “What are you talking about?”

  He attempted to explain the damage being wrought by the sheer weight of the blood. Then began saying, mostly to himself, “I guess we could try to drain it. I don’t know if we’d thought of draining it.” He glanced backward, as if to look outside of my hospital room for someone from his team who might know the answer, might rescue him.

  “I thought … that the reason I’m alive is that the capsule around my liver stayed intact?” The panicked oscillations in my voice surprised me.

  He paused for a moment, seeming to take my fear seriously. “Nah, you’re right. I think draining it would mean certain death,” he offered.

  “Perhaps you could not offer options that would result in her certain death,” Randy suggested, in an authoritative tone.

  “Well, I’d discuss any plan with the transplant team, of course, prior to really solidifying the plan. I mean, what I’m talking about are really just possibilities,” he stammered.

  I glared at him. He began to back out of the room, pulling the other half of his breakfast out of his pocket.

  “I’ll be back later. You know, with the team, we’ll talk more,” he said. He waved the bagel hand in the air, in a sort of bizarre salute. And with that, he was out of the room, leaving us to consider his poorly formulated plan.

  I recalled in residency, after a particularly poor decision by a resident, the attending ICU physician stating simply, “These patients deserve your full attention. They are the sickest patients in the hospital, possibly the entire city, and they deserve our best efforts. You must not accept anything less of yourself, because they cannot afford anything less of you. We owe it to them.” Our patients deserve our best efforts.

  Onion Bagel’s senior, and eventually his attending, later came in to apologize for him. It seemed he had gone a bit rogue, discussing a plan that the team had never endorsed or vetted. I was assured if I needed a transplant, the discussion would occur at a far higher level and with far greater consideration than what we’d seen that morning. Though we understood this cognitively, it was difficult to absorb the shock of the miscommunication even within the same team. I was relying on them to keep me alive, and yet I was left feeling as if they were not entirely worthy of my trust.

  Less than an hour after they had left my room, a fountain spray of blood arced out of my left wrist, toward the door, as if to punctuate the declaration of my liver failure. The nurse moved quickly, placing a bucket underneath my suspended arm. The plastic line dwelling in an artery in my wrist had fractured and was rhythmically spraying blood with each heartbeat.

  A friend who was an older physician entered with a cheerful balloon, only to find me pale and hemorrhaging. He was in charge of a number of innovative initiatives for the health system and cared deeply about patient safety. The nurse darted in front of him with a WET FLOOR sign in his path and left to notify the on-call physician. I took one look at my friend and reminded him, “These are the new arterial line kits you approved, aren’t they?”

  “I’m sorry, we’d heard some reports that they fracture more, but the hospital was looking for less expensive…” he trailed off, staring alternately at the bloody ground and the balloon, feeling visibly stupid.

  From my new position of vulnerability, everything had taken on a different weight. I felt the impact of even the smallest choices. I was secretly glad he had decided to visit at precisely that moment, so he could watch my blood spill.

  “I didn’t know you were this sick. I wouldn’t have brought a balloon, I’m sorry.” Despite my anger, he sat beside me, abandoning the balloon in the corner.

  “I have to tell you something. Because no one else will be honest with you,” I said. Sentences that began this way were usually the benefit of some disinhibition by narcotics. I could see him steel himself, prepared for some indictment of his medical decision making. His prioritization in this instance of cost over patient safety. Instead I surprised him by saying, “You have to stop wearing these awful ties with cartoon characters on them. You are too old and you look ridiculous.”

  I was dead serious, but we both laughed at the absurdity of my making this declaration while I was bleeding into a bucket. We were amused by the equal gravity I had given to both accusations. We talked about the obvious problem with the new lines. He listened intently, appearing chastened. He took my case back to the hospital administration and they agreed to go back to stocking the more expensive lines. My frustration was venerated. He announced this proudly to me, wearing a new bow tie.

  It might seem an impossibly naïve position to suggest that everything matters, always. But when one considers that regardless of the seeming insignificance of a choice, it will affect a patient, then everything does matter, always. We often get the big things so perfectly right only to fall apart on the smallest detail, like the four cents saved per line.

  There are items left at the door when one enters the hospital, chief among them comfort, a bit of dignity and any semblance of control. Decisions are often made with little input from the patient. Rather, the patient is informed of the plan and left to reconcile it with their best understanding of what could be. Patients rarely have the advantage of a comprehensive understanding of the array of available choices from which the proposed plan was selected. Even with the knowledge I had amassed by the time my liver failed, I was unable to contribute to the discussion. I was dependent on the efforts of oth
ers.

  At the intersection of a lack of control and absence of rigorous attention is distrust. I couldn’t trust the transplant resident, or the choice of arterial line kits, precisely because I had to trust them, and both presented me with just cause to doubt their worth.

  When faced with a difficult decision, such as whether a patient requires a transplant, there is an inordinate amount of discussion and deliberation. For the sake of brevity, physicians sometimes make the mistake of distilling this down for the patient. One sentence is presented—You may need a new liver—rather than the cohesive narrative. In my case, it is likely that a number of experts from several different disciplines reviewed my case, conferring about the implications. There would have been a multidisciplinary meeting, with discussion of the arc of the lab results and contingency plans made for every possible scenario. The risks and benefits of the various options, like draining the hematoma by creating a defect in the liver capsule, would have been carefully weighed and sorted.

  When I reflect back upon times when I confidently declared a singular course of action the best route, I know at the core of that posturing was insecurity. I disliked the optics of admitting how many opinions I had elicited. I worried that to a patient, modesty would be read as indecisiveness, caution would be reinterpreted as a lack of authority. I was trained in an era when an edge of arrogance was considered an essential character trait of a truly skillful physician. I calibrated my confidence to match that of my mentors. Ego, the conscious portion of the psyche that is so concerned with external perception, wants to be fed. It will slyly interject itself as a wall against self-doubt. But allowing ego to dominate, coddling it as a mechanism of self-protection, is nothing more than allowing weakness to masquerade as strength.

  * * *

  As my distrust of the surgical team grew, I found myself relying more heavily than ever on my nurses. They truly knew how I was doing, having the advantage of spending a larger part of the day with me than any physician team could. There was a humility, too, that I came to favor. They didn’t seem to have an agenda for what they would find when they examined me. They were objective, and reconciled their findings with what the team had laid out. When things didn’t fit, they pushed back, forcing closer scrutiny. My favorite ICU nurse called me “hon.” Normally, I’d recoil if a nurse or physician used that sort of diminutive endearment, but with her I didn’t mind. I felt the warmth of her intention. And because she worked the night shift, and I slept most of the day, we had lots of time to spend together. She’d help me to bathe, confined as I was to the bed, referring to it as “spa time.” She could deftly change the linens on the bed, with me still in it, a skill I still can’t comprehend. She rolled me onto my right side and had me hold the handrail while she spread out the sheets. She reached up to the monitor to silence the alarm. My oxygen levels were falling with the slightest movement.