In Shock Read online

  She looked squarely at me. “You shouldn’t be so short of breath just rolling onto your side, hon. What did the doctors say today?”

  “Nothing, really. My labs were about the same. My incision looked OK. I don’t know. I guess there wasn’t much to say.”

  “Hmm. Did they see your breathing?” she asked.

  I shook my head. “I was just sitting when they came in, so my breathing was OK,” I offered.

  She’d tell the on-call team but urged me to discuss it with the rounding team the following day, as she doubted the level of ownership that the covering intern would have at night. I agreed. I asked if she would call engineering to turn up the heat in the room. She smiled at me and said, “Hon, it’s so hot,” as she mimed mopping sweat off her forehead. Then, “Of course I will.”

  By morning my difficulty breathing was worse, and the team ordered a chest X-ray in response to her concerns. It showed a significant amount of fluid had accumulated around my right lung, my body’s response to the trauma.

  “We’ll monitor it,” they said. They didn’t feel the risk of putting me through a procedure to drain it with a needle, given how poorly my blood was clotting, was worth the potential benefit. “Your breathing is still OK at rest. If we need to drain it, we will, but let’s wait for now.” They reminded me of how difficult it had been to stop the fountain spray of blood out of my wrist. “Imagine if that happened internally, and we couldn’t apply pressure,” they added ominously.

  We weren’t able to wait for long. The next morning a new nurse came in, preparing to do her assessment. She adjusted my bed so that it was flat, and then looking at the supplies she brought in, must have realized she had forgotten something and left the room.

  Left flat, the excess fluid that had been held in other parts of my body suddenly began to redistribute. It moved through unseen channels, lymphatics and veins, toward my heart and lungs. Minute by minute, my lungs became heavier and heavier as they slowly filled with fluid. I gasped and gagged, feeling as if a garden hose had been placed in my mouth. I gulped in useless breaths, a breathing pattern referred to as guppy breathing, and felt I was getting no air at all. I tried to pull myself up to sit but didn’t have the strength. My flailing movements propelled the remote with the call button onto the floor. Well, there goes that option, I thought. I heard my monitor alarm and felt momentarily hopeful. But by this point in my stay, the nurses at the station had alarm fatigue, a condition familiar to anyone who has spent time in an ICU. The alarms are always going off. It becomes impossible to differentiate an urgent alarm from a nuisance beep. My alarms were always going off for either a high heart rate or low oxygen and were rarely an indication of an actual change in my clinical status. The nurses knew that, just as they knew me. No one was coming.

  As I drowned, my vision tunneled, until all I could see was a small circle above the head of my bed. My eyes focused on a small blue square button, labeled CODE BLUE. The universal alarm would activate the code team in the event of a dying patient. I struggled to raise my arm and pressed it. Within seconds, the team rushed in. They had been rounding just feet away, oblivious to my distress. The first two to arrive looked at each other, and one of them asked, “But who called the code?” before quickly realizing that was, in fact, not the most pressing issue.

  They worked quickly, almost wordlessly, with a grace that suggested it had been choreographed. A tube was placed to decompress my stomach, a higher level of supplemental oxygen was supplied. A portable chest X-ray was shot. A wordless decision was made to drain the effusion surrounding my right lung, and a thick needle entered my chest wall like a dart. They attached a catheter to a vacuum bottle and I watched as liters of foamy red liquid drained.

  My nurse reentered, a look of shock spreading over her face. She joined the efforts without asking questions, drawing blood for labs and assisting where she determined she might be needed.

  Within minutes, I could breathe again.

  “I called the code,” I said, addressing their forgotten question. “I couldn’t breathe.”

  “You called a code on yourself?”

  I nodded.

  They smiled, incredulous. Their work done, they began filtering back out to return to rounds.

  “I nearly died,” I said to myself as much as anyone. It seemed like there was more to say. That we should discuss what had happened and how to prevent it from happening again, and that bit about how I had nearly died.

  “But you are OK now. Just rest,” was the sentiment offered by the last straggling physician.

  I asked if he could stay. I was terrified to be left alone.

  “No reason to worry. Your nurse is here. And look, you’re connected to all of these monitors. We know everything that’s happening every second. Even if we’re not in the room.” He smiled as he left.

  I did not feel reassured. The monitors were of zero use thirty minutes ago, why should I believe them useful now? You had no idea what was happening. I couldn’t say if it was a result of the surge in adrenaline, or some rapid-onset post-traumatic stress disorder, but I was certain I was not safe. I studied the monitors, inspected each of my IV lines and obsessively wondered what would happen next.

  “What is my platelet count today?” I asked the nurse.

  “It was around 50, I think,” she replied, as she sat down to log in to the computer. Pulling up my lab results she confirmed, “Yes, it was 45.”

  But that’s too low. They just tapped my chest with my platelets at 45? Did anyone check them first? I visualized the oozing blood that was probably filling my chest cavity as I sat there. I checked the monitor again. My oxygen level was OK, but I was certain it would fall at any moment.

  “Is the oxygen working? I don’t feel it coming out.” I took the nasal cannula out of my nose and felt for flow. “It’s barely coming out, feel this.” I tried to hand it to the nurse.

  She dutifully walked to the wall and turned the dial, increasing the flow so that I could feel it. “See? It’s working fine. Just rest.”

  I couldn’t rest. I was far too busy being preoccupied, imagining every impending disaster.

  I asked for my labs to be printed. My vision didn’t allow for me to read the numbers, but I needed to have them in some tangible, concrete form. Then, unsatisfied by the idea of isolated data points, I asked for a printout of the trend in my labs over the past week. I stacked the pile of papers neatly on my tray table. I put my face close to the papers, inhaling the scent of printer ink on freshly printed paper. Closing my eyes, I could imagine I was at a clean, organized desk in an office somewhere far from blood and catheters filled with urine. I imagined how good it would feel to hold a cold, heavy stapler. To use staples to hold important papers together, rather than my abdominal wall.

  The emotions of patients are encoded in their behavior. It’s an easy task to recognize a crying person as sad. But a compulsively attentive patient, documenting every lab result and asking well-formulated questions about antibiotic choices, is less easy to decode as anxious. I myself didn’t recognize my own anxiety at the time. I believed I was appropriately adapted to my environment. An environment that required intense vigilance and anticipation of some impending cataclysm. The casual complacency I observed in others struck me as horribly naïve. Every solicitation to “just rest” filled me with contempt. I knew what would happen if I left the watchtower untended. I would die. I believed it was entirely up to me to ensure my own safety.

  In an ICU in a world-renowned hospital, with around-the-clock care by highly skilled medical teams, I felt responsible for myself. That is the power of anxiety.

  * * *

  I took to surveying my body frequently. I believed the cursory examinations the team performed were unreliable. I found a deep-blue stain discoloring my right inner thigh. Like ink dropped onto wet paper, it was spreading, a thin ominous storm cloud. The blood that had been confined in my liver capsule was finding a way out. It was quietly forcing its way between planes of my tissu
e, squeezing itself between thin sheets of sinew called fascia, dissecting me like a liquid scalpel. I stared at it, gauging its intent. I had anticipated and sought evidence of some looming disaster, but having found it, promptly covered it with my gown. I was unable to face it. I pressed my fingertips to my lips, as if to hold the news in.

  When the rounding team arrived, the attending ran through the preformulated plan for the day. He was bright, methodical and articulate, and I knew he had considered every lab result carefully before formulating a plan. We had worked together in the ICU before, and I had a vivid recollection for how hard he had been on himself when he had made an error. It was the only error I ever saw him make, and it changed how he talked about decisions to the teams. It changed the set of his jaw, and the way he listened to patients. My blood count was lower, but no cause for alarm. Likely just a result of frequent lab monitoring. They were considering giving me a unit of blood, just to “tank me back up.” My chest X-ray looked better following the drainage. I sat silently. When he finished, I uncovered my mouth and whispered, “There is something I need to show you,” and pushed off the covers and raised my gown.

  “When did you notice that?” he asked, with a pitch that did little to conceal his worry.

  “Just now,” I lied. I had spent an hour at least in wordless shock.

  He sighed and frowned, and nodded. Plans would have to change.

  The day was hastily rearranged to accommodate a stat CT scan. Individual images shot at two-millimeter intervals throughout my body, reconstructed into a virtual image of my chest, abdomen and pelvis. They had been piecing together an impression of the chaos that resulted from the catastrophic bleed as best they could from lab results and glimpses of the edge of my liver in the operating room, but I had yet to be stable enough to travel for any scans. The actual images revealed the situation to be far worse than they had imagined.

  The blood collection was the size of one of those globes elementary schools had in each classroom. In the process of expanding, it had reorganized my abdomen. My liver was pushed into a thin crescent on the opposite side of my body. My stomach’s capacity was reduced to a tablespoon. My right lung was less than half the size it had been, and the space around it had already refilled with a murky fluid. Worst of all, the contrast they had injected into my bloodstream could be seen not only in my veins, but leaching out of my vessels, into the still-expanding hematoma. A blush of white against the old dark blood. I was still bleeding.

  The energy of the room changed. Nurses moved quickly and more purposefully, with economized steps. The hall outside the room filled with specialists and anxious chatter. Opinions were sought, entertained, and rejected. It felt as if a deck of playing cards had been thrown into the air, and everyone was scrambling against the clock to make a hand.

  When my attending eventually reentered the room, he did so with a tense, solemn expression and reverential tone. I recognized the look as well as the tenor of his speech. It was how I spoke to people I knew were going to die regardless of what we did. The plan was outlined for us. If the bleeding continued, I would be taken back to the operating room, they would reopen my abdominal incision, evacuate the hematoma, try to find the source of the bleeding, pack thick gauze pads around my liver and leave me open. They would leave me open. As in, they would not close the incision at all but cover my exposed organs with a plastic-wrap-like layer of film and wait. Wait for the surgery to declare itself a success or a failure. Wait for me to re-bleed, wait for the bleeding to stop, wait for infection to set in, whatever. They would wait, and then they’d take me back again. Fix what needed to be fixed and regroup.

  No one liked that option. No one would have even suggested it if there had been a single better option. No one thought this was an option that ended with me leaving the hospital intact. But they would do it if they had no other choice. They would do it to say they had done all they could. They’d done it before in similar situations. Those girls were all dead.

  Everyone believed I was bleeding diffusely from the surface of my liver, which was a feared complication of HELLP syndrome, a condition that only affects pregnant women. That diffuse oozing being the presumptive diagnosis, they couldn’t simply go in and block a bleeding vessel, a procedure called embolization. No one knew at the time that there were two very vascular tumors in my liver, one of which had ruptured, gushing blood into my abdomen. We couldn’t cut off their blood supply because we couldn’t see them. They couldn’t be seen because like a pair of chameleons, they had blended in and matched the shade of the liver surrounding them. Later, when we knew to look for them, we timed the injection of dye just right and caught them blushing. Then they could be embolized. But that wouldn’t be for another year. In the meantime, I was hemorrhaging without any mechanism to stop the flow.

  They allowed for the possibility that the blood loss would somehow just stop. Then they could augment my body’s supply of clotting factors with transfusions. Assuming my liver somehow began to recover, despite the pressure of the weight. They’d give me blood as well, and hope that my kidneys could take on the difficult task of expelling some of the extra fluid.

  The fuse had been lit. We would wait and see.

  * * *

  The fluid around my lung reaccumulated at a faster rate, a by-product of all of the transfusions. I had such poor nutritional status, having been unable to eat more than a tablespoon at a time, that the protein content in my body had fallen. This made all of my tissues boggy, as water leached out of my veins, following the principle of osmosis. I’d learned to sense the weight of the fluid in my chest, and when it reached two or three liters I would ask my team to drain it. It seemed a simple enough solution and provided me some measure of control. That plan proved sound for about two weeks, until one day when they placed the needle and only a small amount of fluid was evacuated. I felt a sharp pain.

  “Something’s wrong,” I warned them. It had never hurt like this before. I felt certain they had collapsed my lung with the needle.

  “I’m not getting much fluid out. Someone get the ultrasound machine,” the pulmonologist asked.

  As the ultrasound probe was placed on my back, I watched the screen. I knew there was a large amount of fluid; I could feel it. And on the screen, I could see the fluid surrounding my compressed lung, but there was something new. Strandy fibers, like seaweed at the coast, waved in the fluid.

  “It’s loculated,” he said, seeing the same strands I was.

  The protein in the fluid had coalesced around itself and grown into hard ropes, like a rock sugar growing along a string in some childhood science experiment. The strands separated the fluid into discrete pockets, each one a separate compartment, and they were no longer accessible by a single needle.

  “We can’t drain it, I’m sorry.”

  I struggled to grasp the implications. If we couldn’t drain it, then I would always be unable to breathe. I would always be dependent on oxygen. There’d be no trajectory of recovery, only unremitting chronic illness.

  “That can’t be,” I countered. I had been confronted by the limits of therapeutic options as a physician, and cognitively I understood that it was possible to run out of options. But as a patient, I just couldn’t accept that we had hit that wall. My heart raced. I dug my nails into my palms to keep from crying.

  “So what do we do?” Randy asked.

  “To clear the loculations would require surgery. And even surgery doesn’t guarantee success. Anyway, she’s not well enough to have surgery. She just has to live with the fluid.”

  I’d have to live with it. Live with the fluid and wait to re-bleed. I couldn’t fathom how I could possibly do that and stay sane.

  I felt the kind of panicked desperation and disbelief I had seen in the faces of my patients with terminal conditions. I recognized it as the same feeling that drove people to embrace unproven alternative treatments. It felt distinctly as though I had nothing to lose. I thought of my patients who had spent their final days away f
rom their children, traveling for experimental therapy only offered at distant cancer treatment centers. The patients who had spent their life savings on vitamin infusions, purified herbs and tonics. I thought of my patient who had unwittingly overdosed on a toxic Chinatown tea, brewed in pursuit of fertility after a series of miscarriages. And in that moment, it all seemed perfectly rational.

  Four

  Sequestered Words

  Visitors came in the afternoon, so I learned to feign sleep. Some brought flowers, which were unceremoniously discarded by nurses. Gifts that carried any risk of infection were not permitted in the ICU, they explained. Others brought magazines I couldn’t read, or food I couldn’t eat. Everyone brought with them questions. And every question led down a circuitous path to more unanswerable questions. First we placed signs on the door: PLEASE CHECK IN AT NURSING STATION PRIOR TO ENTERING or PATIENT IS RESTING, DO NOT DISTURB. Naturally, no one thought the signs applied to them. So I enlisted Randy to man the waiting area and politely apologize to each person individually that I was resting, that today was a hard day and I was not up for visitors.