I have read a lot of doctor and medical books but Rana Awdish opening to In Shock is the most harrowing medical experience I have ever read. She recounts beat by beat how a normal day progresses to her (near) death from hemorrhagic shock.
She begins the description of the day by remarking the ordinaryness of how it started:
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.
Her digression into the banality of describing the ordinariness of the days what I loved about the book. Repeatedly Awdish is diverted into describing interesting observations she ha about the world and she weaves them effortlessly into the narrative in a compelling way. Love these details.
This ordinary day is upset initially by cloudy thinking and loss of concentration, then by severe, breath taking, short lived spasms of pain that progress to severe unremitting pain, which leads to uncontrolled emesis. Her husband, Randy (major hero) races her to the hospital after Awdish calculates that being able to direct herself to her own hospital is more important than calling an ambulance.
One of the aspects that makes her recounting of the tale so harrowing is the amazing degree of awareness that Awdish brings to the narrative. She plays dual roles in the recounting a patient spiraling towards death and an omniscient critical care doctor and narrator. This first place this plays out is in the arrival to the ER when a security guard notes that she is over 6 months pregnant and redirects her from the trauma emergency to labor and delivery:
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.
In the ER Awdish is slipping away as most of blood volume bleeds into her liver. She is orthostatic and has moment of clarity when she realizes she is in shock. The medical teams seem to be frozen in indecision of how to proceed. There is disagreement about sending her for a CT scan as the surgeons are reluctant to perform a blind exploratory laparotomy. Her hemoglobin drops to 3 and the OB department sends in a resident to do a fetal U/S. In a scene that if it happened in a TV show you would scream in disbelief, Awdish diagnosis her own baby’s demise as the resident struggles to recognize the images:.
“Bear with me,” the obstetrical resident warned, his foot tangling in the cord. “I’m not great at these yet.”
He didn’t need to be.
Here I could still be a physician. From the first grainy images I could see the small ventricles still and pulseless—like a four-chambered pool filling with slowly falling snow. “There’s no heartbeat.” The words cascaded out of me on a torrent of agonized breath.
“Can you show me where you see that?” he asked. The words reverberated in the suddenly hollow space behind my eyes. I heard my own gasp, and shuddered in a shock of pain. It was as if the subtle movement of my diaphragm with the breath had spread open some barely healed gash, freshly exposing the injury. As my breath caught, I stared at him, incredulous. Could I show him how to interpret the ultrasound images of my dead baby? The baby whose impossibly small dresses were still hanging expectantly in the guest room closet.
The thought of losing a pregnancy is a mind numbingly tragic, but to have a doctor ask you to trace out the still heart on the ultrasound screen left me slack jawed. I had to put the book down and catch my breath. This episode is one that Awdish returns to a number of times. It is Exhibit One in Awdish’s demonstration of the harms of depersonalizing patients into cases. The desire to see a silent heart while being oblivious to the emotional carnage around you is a direct result of treating diseases instead of people.
One of the intriguing threads of the book is Awdish’s journey of forgiveness for this resident’s offense as she begins to see him as a victim of a flawed medical education system.
Following the loss of the baby, the surgical and obstetric teams were able to move forward. She goes to the OR for an emergency c-section. During this time she runs into the Triad of Death, a positive feedback loop where due to massive blood loss the patient becomes hypothermic and acidotic preventing coagulation leading to further blood loss, transfusions and acidosis. This resulted in her losing and being transfused gallons of blood. Despite being in shock and under anesthesia she can hear the anesthesiologist exclaim that “We’re losing her” and “Guys! She is circling the drain here!”
These are the last things she hears before she undergoes an out-of-body experience that she succinctly describes as “I had died”
The beat by beat description was painful to read. My stomach was tied into knots hearing about the agony and the delays and the banality of some of the treating physicians. In Shock wastes no time in dragon the reader into Awdish’s world and it pulls no punches.
Joel Topf,
Nephrologist, Detroit