In Shock
In Shock

About the Author

Rana Awdish is an intensive care doctor and the director of the Pulmonary Hypertension Programme at Henry Ford Hospital in Detroit. Dr Awdish’s mandate is to improve the patient experience across the US health system and speak on patient advocacy at healthcare venues across the country. She was awarded the Critical Care Teaching Award in 2016 and, in 2017, the Press Ganey Physician of the Year Award and The Schwartz Center’s National Compassionate Caregiver Award.

About the Book

Seven months into her first pregnancy, Dr Rana Awdish suffered a catastrophic medical event, haemorrhaging nearly all of her blood volume and losing her unborn child. She spent months fighting for her life in her own hospital, enduring a series of organ failures and multiple major surgeries.

Every step of the way, Awdish was faced with something even more unexpected and shocking than her battle to survive: her fellow doctors’ inability to see and acknowledge the pain of loss and human suffering, the result of a self-protective barrier hardwired in medical training.

In Shock is Awdish’s searing account of her extraordinary journey from doctor to patient. From a unique perspective, she sees for the first time the dysfunction of her profession’s disconnection from patients and the flaws in her own past practice as a doctor.

Shatteringly personal yet wholly universal, it is both a brave road map for anyone navigating illness and a call to arms for doctors to see each patient not as a diagnosis but as a human being.

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First published in the United States of America in 2017 by St Martin’s Press LLC

First published in Great Britain in 2018 by Bantam Press an imprint of Transworld Publishers

Copyright © 2017 by Rana Awdish

Rana Awdish has asserted her right under the Copyright,
Designs and Patents Act 1988 to be identified as the author of this work.

Jacket design by Beci Kelly/TW

Hospital band photograph © Getty Images

The names of some individuals depicted in this book have been omitted and identifying characteristics changed. A select few portrayals are composites.

Every effort has been made to obtain the necessary permissions with reference to copyright material, both illustrative and quoted. We apologize for any omissions in this respect and will be pleased to make the appropriate acknowledgements in any future edition.

A CIP catalogue record for this book is available from the British Library.

Version 1.0 Epub ISBN 9781473552463

ISBN 9780593079492

This ebook is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the publishers, as allowed under the terms and conditions under which it was purchased or as strictly permitted by applicable copyright law. Any unauthorized distribution or use of this text may be a direct infringement of the author’s and publisher’s rights and those responsible may be liable in law accordingly.

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Dedicated to Randy

Contents

 Cover
 About the Book
 Title Page
 Dedication
 
Introduction: A Chance to Die
OneBled White
TwoA Hollowness
ThreeWaiting to Fail
FourSequestered Words
FiveIncrements and Impediments
SixShifting Frames
SevenVulnerable Masses
EightCensors of Light
NineRevolutions
TenDeliverance
ElevenRelapse
TwelveBroken Vessels
 
We Can Do Better—Communication Tips
 Acknowledgments
 About the Author
 Copyright

Introduction


A Chance to Die

MEDICINE CAN BE a magical lens through which to view the human body. Focus its light on an unsorted pile of symptoms and it will converge them neatly into a diagnosis. A swollen, red “strawberry” tongue in a feverish child will lead the doctor to examine the heart and affirm a diagnosis of vasculitis. A man’s burning stomach pain transforms into gastritis, which has both a cause and a cure, whereas his nonspecific pain had neither.

Medicine does this by asking questions and listening for not just what is said, but what may be true. If empathy is the ability to take the perspective of another and feel with them, then, at its best, the practice of medicine is a focused, scientific form of empathy. Truly caring for a patient necessitates traversing borders and inhabiting the view of another with the humility of a visitor who knows he or she can choose to look away. They each possess the power to heal.

The first time I viewed the world through medicine’s transformative lens I was five years old, listening as my mother offered a seemingly vague description to the pediatrician by phone. My brother was leaning forward in the crib, onto his hands, drooling, and seemed to be gulping the air rather than breathing. The doctor understood this to be epiglottitis, an often fatal swelling of the airway. He instructed her with a calm but firm urgency to bring him immediately to the emergency room, where he would be waiting. That ability to translate symptoms into diagnoses and treatments, the power to save lives through knowledge and listening, struck me as the most beautiful job description I could imagine.

Attending medical school was like entering a secret society, complete with its own language, uniforms, and societal norms. We learned to translate the genetic code and sequence genes that produced proteins that made up organs. We were granted cadavers to dissect and study, each structure’s name rooted in ancient Latin or Greek. We spent a year immersed in the divine elegance of the human body, so that in our second year we could learn to recognize pathology. We were instructed by professors who spoke of the innate intelligence of disease. Parasites that exploited their host, small changes in genes that resulted in defective hearts, and endlessly replicating cancer cells. By learning the pathway to disease, we were taught, we could unlock cures. The knowledge was intoxicating. I followed the vectored curriculum, believing I would emerge transformed and able to heal.

I couldn’t have imagined the circuitous form my training would actually take. The forward progression through residency and fellowship was nothing more than a comfortable lie my body would ultimately dismantle. My body somehow understanding that despite completing my training, despite being surrounded by every form and severity of disease, I had yet to learn what it meant to be sick. I would experience an illness—followed by a long, painful recovery—that took me apart, piece by piece, and put me back together in a conformation so different I questioned if I still existed at all.

The wish for the cure is seductive; it captivates and charms. Devastating illness, despite its ability to utterly transform, is not revered in the same way. Illness is viewed as an aberrant state. It is a town we drive through on a journey home, but not a place to stop and linger. We pass through with gritted teeth, as if it were a storm, with no regard for the illuminating beauty of the lightning as it strikes. But those shattering moments that break our bodies also allow us access to wisdom that is normally hidden, except in times of utter darkness.

From my new vantage point in an ICU bed, I would begin to sense a dark hole at the center of a flurry of what was otherwise highly proficient, astoundingly skillful care. I couldn’t name it at first. I would have glimpses of clarity, only to have it recede out of focus. I had to train myself to see it, like negative space on a canvas. It took years of being a patient to understand that though the healing potential of knowledge is magical, it is also a lie.

Medicine cannot heal in a vacuum; it requires connection.

As a patient, it’s upending to be confronted with the actual fragility of everything you once believed to be a constant. To inhabit that vulnerable space, and to have no one around you who is open to discussion of the devastation is patently surreal. We all desire to be seen, to be known, to share our experiences and feel heard. To have our life events given context and meaning, redirected back to us in a way that we can understand and integrate into our understanding of who we believe ourselves to be. This need is more acute in times of sickness. When organs and limbs function without fail, we can indulge notions of self-reliance and agency. We believe ourselves to be the narrators of our own lives. When we are sick, we are humbled by our dependency on others, the loss of control, the uncertainty of the ending. This change opens channels for communication we are hardwired not to tune into during the monotonous routines and spaces of normal life.

Recognizing those open channels and fostering connection in full view of the knowledge is what heals. Making the choice to be present for someone else’s suffering requires a kind of anticipatory resolve. Because it does get hard, sometimes even unbearably so. The choice to be present means deciding at the outset that you will be there for the duration. That premeditated sort of intentionality may not resonate with the kind of effortless empathy we’d imagined, until we remind ourselves that all forms of love require work and a fierce commitment.

Had our training somehow taught us to avoid these channels? Did we know what to do when we recognized them?

I work at a large urban hospital, in the center of a busy and diverse city. We are sent patients, by helicopter and ambulance, who have run out of options elsewhere. The kind of clinical excellence, determination, and teamwork necessary to care for these uniquely complex patients far surpasses what I’ve experienced in other hospitals during medical school or residency training. I have the great privilege of working at an amazing institution. The shared purpose and the pride that comes from doing hard work well is one of the reasons I chose to stay on after my fellowship training.

The hard times, the times when I knew we missed the mark, can almost always be understood and rationalized. Health care is exceedingly complex. Errors will inevitably occur, at even the best hospitals. What seems different to me is our transparent willingness to acknowledge that we are a learning organization. This orientation causes us to look honestly at each lapse, whether it be in communication or drug delivery. Acknowledge it, determine the point the process broke down, and address it. Perhaps it is because of our awareness that all systems attempting remarkable things will at times fail that we’ve learned to cultivate resilience. We never allow a failure, however small, to be the end of the story. It’s always the beginning of a better way of being.

It’s how we heal.

I was recently rounding in the same ICU that I had once inhabited as a critically ill patient. I stood at the head of the team, as their attending physician, with a group of eager medical residents presenting the critically ill patients in sequence. The patient we were discussing was on the waiting list for a lung transplant and had been waiting in the same ICU room for months. I had first met her years earlier, when she was transferred into our hospital for evaluation of a leaky heart valve.

When the resident completed his presentation, the ICU nurse added her report on the events of the night. She had cared for the patient many times, and the longitudinal relationship provided a depth of understanding the resident couldn’t hope to match. She wore seafoam green scrubs that bore her handwriting near the knee, a potassium value she’d jotted down when the lab called and she couldn’t quickly find paper. Rounds required standing in place and so she fidgeted, a substitute for the constant movement she was more adapted to. Her brown hair was pulled into a ponytail, and she spoke with purposeful brevity, not referring to her notes.

“She had a setback overnight, and she’s on high-flow oxygen now, fifteen liters,” she began. “She’s spent the morning listening to recorded sermons by her pastor. She’s different today. If you ask me I think she is really scared.”

The resident frowned, having just reported that she was stable clinically. He appeared tired, the whites of his eyes fissured by fine red cracks. There was a spot of hair at the crown that was sticking straight up, the only visible evidence that he had laid down at some point in the evening. It reminded me of my son’s cowlick and I had to resist my maternal urge to smooth it down. He was wearing a hooded sweatshirt under his white coat. Residents often add this layer, sometime around hour twenty of their assigned thirty-hour call. Something about being awake for so many hours straight dysregulates the hormones that control body temperature, and we were all always cold on post-call mornings.

I had been through setbacks with this patient before; many of us had. They were usually a sign of worsening heart failure, and though she had always managed to recover, they took a severe toll on her emotionally. It was as if her body was insisting that she acknowledge the possibility of her death. Her resource in combating fear was hope and prayer, and she immersed herself in both.

“I asked her about her breathing, but I didn’t get that,” he said, apologetically.

“Every listener hears a different story,” I reminded him. “The fact that she shares something different with her nurse than what she tells you or me is to be expected,” I explained. I knew she had different answers for different people. We each had different relationships with her. “It doesn’t devalue what she told you, it’s just different,” I added.

I saw a blank index card in his pocket.

“Did she give that to you?” I asked.

“Yes, she wants me to write a message of hope for her wall,” he said, sounding defeated. “To be honest, I’m uncomfortable writing anything because I think she is going to die before she gets a transplant. Transplant says she has a lot of antibodies and it’s going to be hard to find a matching donor.” He paused. “It seems like I’d be lying if I wrote something encouraging.”

I saw in his expression the same discomfort I often felt in the face of uncertainty. I saw the disillusioned fatigue, a by-product of the effort expended wrestling the facts to the ground so that we could stare at them and more honestly represent them. Not just to ourselves, but to our patients. Our feeble attempts to understand how to allow for optimism, when the truth seemed intent on blocking out the sun. It was so hard to palpate the borders of authentic hope, to know where falseness began.

“It’s hard, right? When we don’t know,” I said, lacking articulate words.

“Listen, I get it,” I continued. “You don’t want to provide false hope. It’s hard. What if we took our lead from her? What do you think she needs from us?”

“We have to coordinate her care so that she is ready when an organ becomes available, make sure the lab work is ordered and she has the IV access anesthesia needs for when it’s time to go to the operating room, make sure her fluid balance in her body stays stable, and titrate her medications to ensure that,” a resident answered.

I nodded. “That’s all true, and we absolutely have to do all of that. But, is that what she is telling us she needs in this moment?” I asked.

They quietly shrugged, in a way that suggested they were doing what they knew how to do and were at least somewhat exhausted by it.

“Let’s see what other people have written,” I suggested.

We entered her room, leaving the lights off. She was sleeping, her body attempting to recover from the terrible night. Even when she was awake, her lung disease was so severe that she only managed to speak in small, choppy fragments, one or two words at a time. I had visited with her earlier in the morning, and had shared her fear that her difficulty breathing was escalating. Even sitting felt like a struggle lately. She was spending more of her day in prayer. Sitting quietly with her, I knew she was days away from death. I wanted to talk to her about that imposing reality. The “what-ifs” that were seemingly more likely each day than her undergoing a successful transplant. I thought it was time. She met my eyes and smiled. She expressed her disappointment that the new residents this month hadn’t completed the cards. “I just want to know that they are hoping along with me,” she said. I looked down, breaking our gaze and feeling guilty for anticipating her death.

She had glossy, framed, full-color pictures of her standing proudly with her family, personalizing the room. They were the first things that confronted the team, forcing everyone to acknowledge how she identified herself. This is me, not what you see in the bed, but this, they seemed to say.

I turned to the dark blue wall, peppered with white cards filled with messages of encouragement and read them quietly. “I am in awe of your resolve, your strength and your faith. Thank you for allowing me to be a part of this journey with you.”

“You are the bravest person I know,” said another.

“I have hope that I will see you on the other side of this, when you can breathe freely and be well,” read another.

We walked out of the room and tried to process what we had read. Was it appropriate and just to provide hopeful support to someone on the cusp of death? Was it rational to prioritize hope, even as we struggled to provide the highly technical medical care she needed to survive? I believed it was. The cards gave her tangible evidence that each of us were going to acknowledge the primacy of her version of her patient story, that we saw her suffering and shared her fear. By writing something hopeful we were allowing ourselves to imagine with her the range of the possible: not just the likely outcomes but the expansively possible.

One resident began to formulate a thought, about how completing the card was essentially one side of a transactional exchange. “I see, so we give her something she needs, and in turn—”

He stopped himself short and the post-call resident began speaking.

“No, she needs us to see her, even as sick as she is, not just to see her as sick, but as being healed.” His simple description of how our attending to her allowed us to better represent her was beautiful. He went on. “Those cards make the hope visible.”

“Wow.” I was stunned by his statement. “Think about that. If in the end, that’s what we do today, somehow manage to make hope visible …” I couldn’t quite complete my thought.

“That would be success,” the nurse added, nodding.

“Well, that and she gets a transplant,” a resident added with an edge of apathy. The others laughed quickly, like childish conspirators. I understood the discomfort they were feeling.

I knew we valued the cure, the goal, the win. We were far less comfortable in the gray, shadowed area of suffering. We excelled at providing complex, precision medicine in a way that appeared almost effortless, yet at times struggled clumsily when it came to empathy. I recalled a time when I had responded to a tearful patient’s question, “But how could this have happened?” with explanations of the complex interplay between genetics and environment, behaviors and predispositions that had led to the terminal diagnosis. I had been trained to believe that all questions were a request for data. Because of this orientation, I recognized neither the fear nor the existential nature of the question. It would be years before I understood the subtext behind the questions. And even then, once I recognized them as an opportunity to connect, I still didn’t believe in the healing power of just being present to bear witness to someone’s struggle. I didn’t value the intangible, the moments of shared understanding.

I had distanced myself from my patients the way I had been instructed to do in training, in the same way the team was doing now. I had subscribed to the paradigm of medicine set forth by my mentors, one that advised me to cultivate space, to be sparing of myself. I was taught that connection begets loss, which in turn begets disillusionment and burnout. As if I were made of some quantifiable measure of stuff that once given away would leave me depleted. I don’t know if I fully believed in that model, but until my own experience as a patient, I didn’t allow myself to envision an alternative where I was unguarded, receptive and freely giving of myself. I didn’t understand that open channels would replenish my supply of self. That there was reciprocity in empathy.

Luckily, I had the chance to die.

Acknowledgments

I’ve written a book that is about the darkness, the shadows, and the times when we failed. Implicit in the fact that I was even able to write this is the truth that my life was saved on more than one occasion by teams of people who are experts in their field. I will forever be indebted to each of them, and I hope that my efforts to change our profession for the better are seen as what they are—an effort to honor your life’s work, the passion you bring to it, and our shared commitment that we can always be better.

To Tony—You are the hero of this story.

To Marwan—You are everything I aspire to be. Resilient and wise and humble and generous. You are ALL OF THE THINGS.

To Maria Z.—You truly showed me another way. It is so clear that medicine is your calling, and you exemplify compassion. You know I adore you.

To Dave—You showed me what bravery looked like. What showing up every day for your patients looks like. And how to know when it was time to blow everything up and start over.

To Jacqueline—I have no idea how you knew I could write a book, but thank you for finding me. Your e-mail changed my life.

To Karen—Thank you for believing in this project, for being its tireless, passionate advocate, and for getting half the world on board! And above all, thank you for making me believe I was a writer, when I was quite insistent I was not.

To Father George—Thank you for your endless support. During every crisis, you were a tremendous comfort to us. And for enthusiastically sharing our joys as well.

To the Pulmonary and Critical Care Department (especially Geneva, Razaq, Mike E., Paul, Bruno, Jenn, Lisa, Ron, Joey)—Thank you for your support during this time; the coverage you provided when I was endlessly sick; the leadership, mentorship and friendship; the sideline consults, the guidance and the treatment. You’re like family.

To Hector—You taught me everything I know. And I entertain you by eating bananas with a knife. So I’m pretty sure we’re even.

To Rose and Vanessa and Kelley and Vicki and Michelle (and the whole CE team)—Thank you for partnering with me in the actual, tangible, hard work of improving patient care. I’m so proud of what we are doing together.

To Kristen, Erin, CLEAR facilitators and actors—What you do is MAGIC. Kristen, thank you for bringing the VitalTalk format to our institution. It has been a game-changer.

Tricia and Jillian and Erin and Kelsey and April and Susan and Debbie and Barbara and truly all of the nurses—Your presence through those days meant more to us than you’ll ever know. I learned more about how to be there for my patients from watching you than I can ever hope to explain.

To Rosemary—I will forever be grateful that a chance encounter in a grocery store brought you into my life. You made this book better. You led me to an introduction that was so elusive, for so long. You are a gifted and generous teacher.

To Maria—You are my Guru. Your wisdom and compassion are boundless. You have made me into a smarter, braver version of myself through your friendship and coaching. I wish everyone had an opportunity to learn from you.

To Cara—Thank you for teaching me to trust the reader. You were a Godsend. And I don’t know which aspect of you I adore more: Talented editor, with amazing insight? Or late-night dance partner and karaoke singer? I hope our yearly trips together continue for-EVAH!

To Jim—You can say things to me that no one else can. And you are ALWAYS right. I don’t think I’m overstating it when I say this book would have been unreadable without your insights. Thank you for reading the horrid early drafts.

To Mechelle—Thank you for insisting Jim re-befriend me. And your endless encouragement.

To friends that I trusted with the awful early drafts (Bryan, Lisa, Sara, Lynn, Kelly)—Thank you for your guidance and encouragement to keep going. You helped me to find my voice.

To Sara—Thank you for being my partner. Your dedication to our work has allowed me to do more than I ever could have alone.

To Dana—Thank you for being there for ALL OF IT, the pain and the healing and the work that followed. Thank you for asking the hard questions and for always prefacing them with, “OK, so … loaded question, but …” For wearing the Spanx, for the -erfect wedding toast (even though everyone kept talking), and for telling me I am your favorite human. And I totally forgive you for making me walk up the hill.

To our families and friends who visited, fed EVERYONE and provided comfort (esp. the Awdish/Ayoub/Kouza/Chammout/Sharrak/Shaya families)—Thank you. Though I couldn’t participate at the time, knowing you were there was a great comfort.

To Kamal—Thank you for dropping everything and driving to get to me. You have always been there for me when I needed you. And I’m so glad we share so many memories that no one else understands.

To Nellie—Thank you for teaching me to look for the light, in every situation, to be grateful always, and that GIRLS CAN DO ANYTHING BOYS CAN DO. Everything I am is because of you and Dad.

To Randy—Just like everything else in our lives … this book is proof of your love and your willingness to sacrifice for us. And yes, you can use this as a testimonial if you ever have to date again. But I hope you never have to use it. Because nothing would make me happier than living our -erfect life together forever.

One


Bled White

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 excel lent 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 monitor around 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.

As I stared at the hideous wall tiles, I silently worked backward, terrified by the velocity of my deterioration and somehow searching for reassurance in the utter ordinariness of the day. I wanted to buy yarn. I had gone to the store and had bought two pairs of shoes, a size bigger than I normally wore because of the swelling. All pregnant women swell, that’s not interesting. I went to the grocery store and bought vanilla sugar. I went to dinner, I thought I’d have the salmon. Salmon had high levels of omega-3 fatty acids that were supposed to be good for the baby’s brain. Then the pain started. It was a beautiful spring day. The sky was cloudless.

Several men arrived, first a resident, then the attending obstetrician.

“She’s a doctor here,” I heard one of them alert the others. “ICU I think,” he added.

I took his cue, channeled my adrenaline, and attempted to engage them as a hybrid physician-patient, providing my relevant history in the concise medical vocabulary that was just barely still accessible to me. I struggled to convey urgency, but the pain made me dysfluent. Each spasm engulfed my intended words. I looked to their faces for a sense of identification, but instead found grimaces of pity. I was an abstraction—a sick patient, a mother. My pain was interpreted through the distorting lens of my pregnancy. They were united in the orientation of their concern—the baby.

The attending doctor ordered morphine, which caught my attention. Oh my God, they are giving me morphine. We almost never gave pregnant women heavy intravenous narcotics, understanding that it put the baby at risk. How had I gone from not wanting to take an over-the-counter antacid to getting intravenous morphine in the space of a day? I tried to reframe my fear about morphine’s possible effect on the baby as evidence that they were appropriately concerned about the seriousness of my illness. As they pushed the morphine, I waited, wondering if it could even work against the crushing pain. It did nothing. So, they pushed more.

Surgery was called. They sent the intern.

He walked in, young and earnest, with a blank template he was expected to fill with my comprehensive history and physical examination prior to reviewing his work with his senior resident. I didn’t understand how he could think for a moment there was time for any of that.