The New York Times Book Review: "Awdish's book is the one I wished we were given as assigned reading our first year of medical school, alongside our white coats and stethoscopes...dramatic, engaging and instructive."
A riveting first-hand account of a physician who's suddenly a dying patient and her revelation of the horribly misguided standard of care in the medical world
Dr. Rana Awdish never imagined that an emergency trip to the hospital would result in hemorrhaging nearly all of her blood volume and losing her unborn first child. But after her first visit, Dr. Awdish spent months fighting for her life, enduring consecutive major surgeries and experiencing multiple overlapping organ failures. At each step of the recovery process, Awdish was faced with something even more unexpected: repeated cavalier behavior from her fellow physiciansindifference following human loss, disregard for anguish and suffering, and an exacting emotional distance.
Hauntingly perceptive and beautifully written, In Shock allows the reader to transform alongside Awidsh and watch what she discovers in our carefully-cultivated, yet often misguided, standard of care. Awdish comes to understand the fatal flaws in her profession and in her own past actions as a physician while achieving, through unflinching presence, a crystalline vision of a new and better possibility for us all.
As Dr. Awdish finds herself up against the same self-protective partitions she was trained to construct as a medical student and physician, she artfully illuminates the dysfunction of disconnection. Shatteringly personal, and yet wholly universal, she offers a brave road map for anyone navigating illness while presenting physicians with a new paradigm and rationale for embracing the emotional bond between doctor and patient.
|Publisher:||St. Martin''s Publishing Group|
|Product dimensions:||5.60(w) x 8.20(h) x 1.00(d)|
About the Author
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Death is the dark backing that a mirror needs if we are to see anything.
— SAUL BELLOW
All pain becomes abstract in retrospect. It is a merciful truth that no one is capable of summoning to the surface the actual intensity of pain endured. As I sit now, reflecting on the pain that first brought me to the hospital, I can sketch an outline, delineate the general size and shape, but it's become separate from me. A kind of sensory satiation occurs, in much the same way repeating a word endlessly causes it to lose its meaning. I remember knowing the pain was not compatible with life. I remember thinking I knew absolutely nothing of the meaning of the word pain before that moment and that anything I had labeled as pain prior to that was nothing more than a shadow of a construct called pain. The pain that tore into me was excruciating and unsustainable.
I knew instinctively that if pain of that magnitude continued, it would kill me.
I was writhing miserably on a gurney in a triage room of Labor and Delivery, the walls an institutional gray-green tile. Curled on my right side, my face was close enough to the squares to pick up the scent of bleach embedded in the grout. My eyes tracked the tiles to the ceiling, designed to facilitate easy cleanup of blood splatter. I shivered, haunted already by what was yet to come. I found the premeditative aspect of those easy-to-mop wall tiles unnerving, the same way watching Dateline footage of someone at a hardware store purchasing duct tape just before a murder is frightening. The dull monotony belied the ensuing violence.
The pain had begun suddenly an hour prior, over a neglected dinner. It was the kind of featureless day I would easily have forgotten, had it not ended so disastrously. Instead, that bland day has become the beginning, a designation that can only be granted in retrospect.
"It was an entirely ordinary day."
I hear this often from patients or families, the survivors of devastating illness or tragedy. When they reflect upon the subsequent life-changing events of any one day, they inevitably comment on how bland and unremarkable the day had been up until that moment. The peaceful calm of the water the day of the drowning. The cloudless, clear blue of the fall sky the day of the plane crash. The absence of any premonitory clues, where we've been conditioned by Hollywood and literature to expect foreshadowing, leaves us feeling somehow cheated of a chance to anticipate the outcome. Cheated of a chance to change it.
It was an early spring day, bright with the promise of an approaching summer. The air in the shade was still bracingly cold, but in squares of sunlight, the sharp edges of the chill had been softened. I had a day off from work and planned to run some errands before dinner. I had a list of supplies I needed to purchase for a knitting class I had signed up for. The idea of knitting struck me as almost comically inefficient, which is probably why I was attracted to it. After so many years of each moment being assigned to reading, study and patient care, the idea that I might have time to knit felt gloriously liberating. And the nostalgia of making something for the baby by hand, that she could keep, was enchanting.
First though, I would take my swollen feet shopping for new shoes. I was into my seventh month of pregnancy, and my body was bloated and heavy. I had stopped wearing attractive shoes entirely, and even my flat brown orthopedic shoes now left deep indentations around the circumference of my feet by midday. I entered the large shoe warehouse and looked for the row of flats.
I had a vague sense of disequilibrium as I walked toward the aisle. I realized I didn't remember driving there. I looked around, suddenly unsure if someone had driven me. No, I was alone, I had driven. How odd that I had already lost that memory. I wondered if my sleep deprivation was catching up with me. I'd just come off a demanding ICU month, spending every fourth night on overnight call, and I was finding it difficult to stay awake if I sat down anywhere remotely comfortable. I wondered if I had lapsed into a microsleep while driving. I touched my pregnant belly, almost as an apology. I knew I had to be more considerate of my body, given the baby.
I found an area that had a series of unattractive, practical shoes and studied my options. A woman repeated, "Excuse me, excuse me," with increasing irritation as she attempted to pass me in the aisle. Apparently I'd failed to hear her the first four times. I shook off the fog and realized that I had been standing, blocking the aisle, while staring at the two shoes in my hands for far longer than necessary. I awkwardly pretended that I was just unable to choose between them and brought both pairs to the register.
I thought I should head home, but I stopped at the grocery store, thinking I remembered needing something. It seemed larger and more difficult to navigate than usual. Walking only a few steps, my breath quickened as though I were biking up a steep hill. My mind slowed, with long stretches of cloudy silence distancing elusive thoughts. I was unable to remember what I had come for and left inexplicably with only a small jar of vanilla sugar. I was meeting my friend Dana, who was also a physician, for dinner. Perhaps she could help me brainstorm why I was feeling so bizarrely off.
When the pain began, it came in a breathtaking wave that receded just as swiftly as it approached. My first thought was, OK, so there really is something wrong; I'm not crazy. I looked across the table at her and said, "I don't think I can eat." The look on my face told her more than the words I had managed. I tentatively pushed away from the table, afraid any movement could bring on the next unwelcome wave, and walked out of the restaurant to anxiously pace the sidewalk.
The adrenaline surge from the explosive pain had cleared my mind. I knew I had to use this time well, before whatever was to come. After calming myself, I called my husband, Randy. "I'm not feeling well ... my stomach ... it's weird, there is this pain ... I don't know ... but don't worry, the baby is fine."
I cringed at the casual lilt in my voice. In attempting to reassure him, I had overcompensated and failed to convey an appropriate sense of urgency. I tried starting over. "I think you may need to take me to the hospital." I considered trying to explain my sense of displacement all day: the fugue state that I found myself in at the shoe store, the breathlessness and confusion I felt at the grocery store. Instead, I settled on adding, "I don't think I should drive," hoping that would suffice. That was at least a tangible fact. Randy, who was an attorney at a law firm in the city, answered something about leaving as soon as he responded to the mythical "one final e-mail," confirming to me that I had failed to convey the immediacy of my need.
Dana, from her view out the restaurant's window, recognized the elliptical and casual narrative I was constructing. She was well versed in my personality. She knew that I was not an alarmist by nature, that I generally assumed things would work out fine and I wouldn't want to worry him unnecessarily. My husband didn't have the benefit of that insight, having been married to me not quite a year. Dana thankfully prioritized action above reassurance and called him the moment I hung up: "I don't know what she just told you, but come home now. I'm going to drive her and we'll meet you there."
He did. To this day he insists it was without responding to the e-mail, although I am less certain of that. I imagine, knowing what he knows now about what would happen that day, he can't allow himself to imagine he sat at his computer a moment longer than necessary. In his retelling of the events, he may have even run to the car.
Dana drove me the short two blocks home. I saw the baking soda out on the counter when we walked in. It reminded me that my acid reflux had been terrible that morning, and I'd taken cold milk and baking soda to try to calm it naturally. I'd been trying to avoid any medication that could interfere with the baby's health, even very innocuous antacids. I wondered if the pain meant the acid had eroded through my stomach wall and into my abdominal blood vessels. All doctors were prone to attempts at self-diagnosis, though the results were seldom reassuring. Recognizing that a perforated ulcer could potentially explain the corrosive pain did not actually help the situation, because I could easily list fifteen other possible causes in order of decreasing severity. Being able to pick the one that suited me in the moment left me nowhere.
We walked to the living room, which is where Randy found me ten minutes later. I was on the floor, kneeling, compressing a pillow tightly against my abdomen. It was the latest effort in a series of awkward contortions aimed at reducing the pain. I eventually found that if I laid horizontally across the arm of the leather sofa on my right side with my right hand on the floor bracing me, the pain would just slightly quell. I had no way of knowing then that the pressure I was placing against my liver with the sofa arm was slowing the blood gushing from my liver, and that I had less than two hours before that blood loss would empty my arteries, veins, and heart entirely. I reasoned, poorly, that if the pain was manageable in that position, perhaps we could wait before going to the hospital.
"When I lay like this, it's not so bad," I announced, proud to have finally found a position that worked.
They shook their heads at me, unimpressed, while debating between them if we should drive to the hospital or call an ambulance. An ambulance seemed the safer choice, but would eliminate the ability to control which hospital I'd be taken to. I wanted very much to go downtown, to my own institution. It wasn't that I thought I'd receive better care because I worked there. We were an enormous system, with far too many doctors for us to all know each other. But having worked in the intensive care unit for the past three years, I'd witnessed on a daily basis the quality and safety of the complex care we delivered. I knew we could do things no one else could. I trusted us.
Presenting to any hospital as a patient struck me as a radical decision. I still wanted to think the situation was potentially manageable, although I didn't actually believe that it was at all manageable. Somehow I felt if I admitted it wasn't, then it would become incontrovertibly real. I would just stay there, lying across the couch in our living room in an inverted U-shape, until the pain passed.
For years to come, I would complain endlessly and irrationally about that couch. I disliked the orange tone of the brown leather, the bulkiness of it. Randy would defend it, having paid far too much for it and having special-ordered the leather, believing it needed to be that particular shade of brown. He interpreted my dislike of the couch as an indictment of his bachelor years, as symbolized by an abundance of brown leather furniture. I realized the stupidity of endlessly expressing my dislike for the couch, without honestly discussing why it bothered me, what memories it brought back. I would instead begrudgingly attempt to embrace the couch until I found I just couldn't anymore. Just this year, in a fit of transference, I pushed the heavy sofa into the garage and declared I never wanted it in the house again, haunted as I was by my memory of that night. Randy, finding it in the garage, shook his head and said, "Please tell me you didn't move it yourself," followed by, "Why didn't you tell me you hated it that much?"
"I did tell you," I'd reminded him. "I've always hated it," although it wasn't entirely true. There was that one night, when I was eviscerated by pain, that it had provided much-needed comfort.
I moaned, which was interpreted as an invitation for them to proceed with their plan. "Enough. You can't just stay here strewn over the couch forever; you're going to the hospital," they both said in their own exasperated way. Possibly this was communicated by one of them entirely with a look. In the time it took them to reach for me, to help me stand, the pain changed. I became nauseated and began vomiting profusely. I experienced what others have described as seeing stars. But to me it seemed rather that most of my vision had fallen away, leaving only pockmarked circles of light. The beams advanced and retracted in time with the sharp stabs that began in my right side and radiated in a band across my body. I closed my eyes and could still see the light, as if it were burned into the dark backing of my eyelids. I doubled over, gagging, unable to stand upright. I braced hands on my knees and moaned, incredulous. What was this? There was no more wait-and-see. Dana pragmatically found Tupperware containers to put on the floor of the car, knowing the vomiting was unlikely to cease. I was laid in the back of the car and never saw that house again.
Electing to go to the emergency room became racing 100 miles per hour to the hospital, praying we'd get there fast enough. I was certain something inside of me had burst. I couldn't be sure if the pain was indicative of a perforated ulcer as I had thought or something else. I recalled in medical school hearing a description of how the digestive enzymes of the pancreas, if unleashed, could erode through the internal organs like battery acid, destroying any architecture within the body. I took the torturous, spreading burn to mean my organs were being reduced to that sloppy pulp. I knew I needed surgery. At the door to the emergency room as I was loaded into a wheelchair, Randy asked if I wanted one of the Tupperware containers in my lap.
A security guard saw me, a pregnant woman who was clearly nauseated, and asked exactly how pregnant I was. "Seven months?" I replied, not seeing the relevance of disclosing this personal fact to hospital security. We were calmly redirected to Labor and Delivery and away from the Level 1 Trauma Center that I was targeting. It was policy, he explained. "Anyone over six months pregnant goes to L & D." I knew there was no point in arguing. Our hospital valued policies. It was in large part how we ensured the safety of our patients. Reliably providing excellent care required standardization. And yet my years of medical training, my own assessment of my abdomen as being a surgical emergency, my understanding of the need for evaluation by a surgeon was in this case all negated by a hospital policy. I'd been triaged by hospital security who, in the space of five seconds, had made a determination of who I was and what I needed. I looked at my husband with an expression that said, Just so you know for later, that decision may well be the one that kills me.
When I arrived in Labor and Delivery, I was briefly made to stand in order to be gowned, and immediately appreciated how much had already changed. My vision tunneled, leaving only a central focal point in view. My mind felt bubbly, as if it had gone without me on an effervescent New Year's Eve binge. A morbid curiosity allowed me to transiently focus my attention, as I realized that I was experiencing shock firsthand. I knew the stale drunkenness was indicative of a lack of sufficient blood flow to my brain. The blood vessels in my body could redirect the flow well enough when I was lying flat, by allocating more to my brain by squeezing down in other areas. But upright, they couldn't compensate against gravity. The small amount of blood that remained within my vessel walls would pool at my feet, depriving my brain of adequate flow.
A hand shoved a small orange-capped specimen container into my field of view. Did I think I could give them a urine sample? I imagined the coordination involved in fulfilling that request. I shook my head no. I was unceremoniously turned over to the OB nurses with the single-minded intention of evaluating the baby.
"The baby ... is fine," I grunted, breathless from pain and speaking in choppy fragments, "but something ... is wrong ... with me. Please ... call surgery." They responded by clocking fetal heart tones and attempting to strap a fetal heart-rate monitoraround my tender, swollen abdomen. I couldn't bear any additional pressure and attempted to wriggle out of the constricting belt. I was shot a stern disapproving look each time they caught me. "Leave that on! What's wrong with you?" a nurse clucked her tongue in disbelief. A catheter was placed in my bladder, an indictment of my failure to provide urine the "easy way." An IV line was placed in a difficult vein that was reprimanded for its defiance.
There were myopic smiles directed toward the then reassuring fetal heart tones. Nurses hummed while they charted. The blood pressure cuff cycled and recycled tightly around my arm, struggling to register my very low pressure. A single IV line in my arm allowed a slow trickle of saline to enter, inefficiently expanding my blood volume. I reached across with my other hand and furtively adjusted the roller mechanism, allowing for the faster rate of IV fluids that I knew I needed.
Excerpted from "In Shock"
Copyright © 2017 Rana Awdish.
Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Introduction A Chance to Die 1
1 Bled White 11
2 A Hollowness 32
3 Waiting to Fail 59
4 Sequestered Words 75
5 Increments and Impediments 91
6 Shirting Frames 116
7 Vulnerable Masses 138
8 Censors of Light 160
9 Revolutions 175
10 Deliverance 196
11 Relapse 207
12 Broken Vessels 234
We Can Do Better-Communication Tips 255