In Shock: How Nearly Dying Made Me a Better Intensive Care Doctor

by Dr Rana Awdish

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.

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.

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.

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.

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.

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.

“No, she needs us to see her, even as sick as she is, not just to see her as sick, but as being healed.”

I knew we valued the cure, the goal, the win. We were far less comfortable in the gray, shadowed area of suffering.

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.

was indeed not a person to him, but a case. And an interesting case at that. I was Abdominal Pain and Fetal Demise to him.

It struck me that they were right; they were losing me. If I could see myself, perhaps I was already lost. I felt nothing. The pain miraculously gone. The panic surrounding the pain was gone. An anodyne peace. I felt weightless, buoyant and very small. I watched the events unfold before me, unattached to any outcome, with an easy stillness. I had died.

I later recognized these periods as weaning trials, brief routine episodes every morning when nurses turn off sedatives and pain medications to allow respiratory therapists and physicians to assess whether the patient may be able to breathe independently,

Time passed one slow second at a time, punctuated by constant beeps and the dull hum of machines.

If my care team didn’t believe in me, what possible hope did I have? I felt the ice I was balancing on detach and begin to float me away.

“the principle of dual effect.” As the name implies it refers to one action with two distinct outcomes. One effect is intended and anticipated; the other is unintended and undesirable.

The value of experience and position were impressed upon us, value that was meant to supersede even our own judgment. I wondered about the reliability of a system that was set up to ensure obedience rather than an honest exchange of information.

We weren’t trained to listen. We were trained to ask questions that steered people to a destination.

The traits we revile in others are often the ones that remind us most of our worst selves.

From my new position of vulnerability, everything had taken on a different weight. I felt the impact of even the smallest choices.

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.

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.

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

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.

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.

It wasn’t that I wanted to be alone, or that I was ungrateful for the support. It was just that there was no longer such a thing as an effortless word.

began to feel that perhaps all the anxious worry was, in fact, actually useless. After all, it wasn’t really preparing me for anything, except to die. And if I did die, well, that would be how the story ended. I divested from any outcome. I stopped believing worry could change anything. I learned to wait and see. More often than not, the following day brought with it some small but tangible measure of improvement.

I realized that the only difference now was my starting point. I was in pain, I was defeated, I couldn’t stand, much less walk, but I still had agency. An agency that allowed that I could inhabit my broken body with a reverence for what it was capable of in the past and what it was able to do in this moment.

then they’d feel bad about asking, and then I’d feel bad that they felt bad.

was reidentifying as myself and it was uncomfortable. In the gown, I was a sick patient, depersonalized and part of a larger community. By clothing myself, I was in effect reintroducing a version of me. A bloated, scarred, disabled and inferior me. What should have felt like a victory felt instead like a resignation.

was mourning the imagined and unmet future. A vision of what I had thought lay ahead, but couldn’t quite bring into focus.

Fortunately, no one seemed to expect much of me, except to be on the stage and to answer that I was doing much better whenever asked. Then the performance would continue without me.

I learned that everyone had expectations for the trajectory of my recovery.

My days had devolved into a dull monotony of pain, pill, sleep, wake, pain, pill, sleep. I was praying for a doorway back into the life I wanted.

I was not aware of this dysphoric reaction to opiates, though it had been described in the medical literature. It seems the body is wired not only to control subconscious processes like breathing and heart rate, but also to receptively interpret them.

Though I had no psychological dependence on the medications, my body had become habituated to them. I had become physiologically dependent.

answer in this moment was more medication, another bout of acute withdrawal would always be in my future. I set the small bottle back on the shelf, warily. The bottle took on a magnetism far greater than its actual physical size should have allowed. It was the center, and I was in orbit around

The power of those miniature, compressed disks of white powder shouldn’t have shocked me. I had seen addiction ravage the lives of people far stronger than me. What shocked me was that the narrative of dependency could nearly supersede my agency.

I found that the pain was one thing to contend with, but totally separate from it and equally important was the message I told myself about what the pain itself meant. My experience of the pain depended upon what I agreed to attend to. If a sharp stab came on suddenly, and I felt fearful that it indicated some impending

I learned to look at the pain, rather than hide from it. When I refused to look at it honestly, it grew like a shadow in a childhood bedroom.

felt humbled and very small in the cavernous space, precisely how the architects had intended.

I began to sense that I represented something to them. It meant something to them that I had survived. My recovery had empowered their hope with a bright flame of tangible success.

In the context of medical decision making, declaring a belief in a divine intervention is viewed as an expression of unfettered optimism, where doctors wish only for acceptance of the situation at hand. We

Hope was an orientation, a way of being in the face of a reality that was not of their choosing. Hope was a destination they had arrived at when the situation had been wrestled to the ground and stared at, bravely.

The possibility that my formal education had not been as complete as I had believed it to be occurred to me. It was not lost on me that my true education had begun the moment I had gotten sick, and it would likely continue for years to come.

In medical school we did not study people; rather, we obsessively studied disease states.

began to think the timing of my illness was more appropriate than I could have possibly known. As much as I had always believed my training would be completed by some date that could be anticipated on a calendar, I clearly wasn’t done. I hadn’t seen all that I had needed to see in terms of suffering, identity and illness.

In my mind, the carelessness of the resident’s conversation revealed what little regard he had for the potential impact of words on the broader context of patient emotion, healing and recovery.

As physicians, we often don’t recognize emotion. And if we don’t recognize it, we certainly can’t respond to it. We hear our patients ask questions and we believe they want data, facts and explanations. So we dutifully provide them, as we were trained to do.

It’s a strange thing to enter the hospital that you work at every day as a patient. Everything looks different from that perspective.

It mattered to me as a patient if the staff appeared happy as they walked through the lobby. If a trash can was overfilled, I wondered if there were staffing cuts in departments like environmental services that might impact cleanliness of supplies and, by extension, patient safety.