Book review: In Shock: From Doctor to Patient — How Nearly Dying Made Me a Better Intensive Care Doctor by Rana Awdish

A medic’s traumatic experience opened her eyes to the failings of her profession, and led to this outstanding memoir

Review by James McConnachie

Getting on with the job: a medical team wheel a patient on a gurney
Getting on with the job: a medical team wheel a patient on a gurneyVINCENT HAZAT/GETTY IMAGES

Survivors of sudden, shocking illnesses, notes the American doctor Rana Awdish, always comment on how “bland and unremarkable” the day was, right up to the moment when they were struck down.

When it happened to Awdish, she was shopping for shoes. She was six-months pregnant and still working as an intensive-care doctor. Her feet were swollen.

It began as “a vague sense of disequilibrium”. Then, “in a breathtaking wave”, the pain hit. A hidden tumour in her liver had started to bleed. Within two hours almost all the blood circulating in her body had poured out invisibly inside her, shutting down her liver’s capacity to stop it by making her blood clot. When she arrived at hospital, the staff prioritised her unborn child. She was given an ultrasound before any other treatment and had to convince the obstetrician that her baby’s heart was no longer beating.

Meanwhile, her condition plummeted. Despite surgery and blood transfusions, she slipped into what trauma medics call the “triad of death”: hypothermia, acidosis and coagulopathy. Her blood became too cold and too acidic to clot, in other words, triggering further bleeding, intensified cold and more acidity. She was experiencing an “unremitting, suicidal spiral of the blood”.

She survived, of course, to write this book. And it is no ordinary memoir of illness. What marks it out is not the scale or urgency of the trauma, although I read the first chapters at such pace that I almost had to remind myself to breathe. It is the writing.

It sparks and crackles with a dark energy. On the gurney in the triage room, Awdish’s face as she lay next to the tiled wall “was close enough to the squares to pick up the scent of bleach embedded in the grout”. Resurfacing after anaesthesia, she finds herself “pale and turgid … as if I had been dredged up from the bottom of a lake”. Seeing her newborn son in an incubator when she eventually becomes pregnant again, she observes how everything is “incredibly minute and precise, like wiring a doll’s house for electricity”.

The writing is not just intense, but intelligent. She describes how she resisted false optimism, as a doctor, because “it was hard to palpate the borders of authentic hope”. She praises colleagues for supporting her recovery so that “the nidus of hope buried within my debris could grow in the direction of the light”. A nidus is a site of growth, and Gavin Francis is perhaps the only other doctor-writer I can think of who would be bold enough to deploy the word.

In Shock stands above other patient memoirs for another reason: Awdish’s experiences unleash a profound reevaluation of her own profession. Throughout the book, she quivers with cold rage at the inappropriate, dismissive, condescending or heartless things that medical staff say to her — or about her, within her hearing. “Maybe you’re just anxious.” “At least you didn’t die.” Worst, when she is lying on the operating table, conscious but close to death, she hears the anaesthetist shout: “Guys! She’s circling the drain here!”

Awdish’s anger sometimes feels self-righteous, a kind of entitlement to customer service that feels distinctively American, and sits awkwardly with the fact that those same medical staff did, in fact, stop her going down the drain. I struggled to see what was so wrong with doctors telling her that “you really scared me” and “that was a bad night for me”. Is this not a kind of reaching out, with a little understandable gallows humour?

Her ultimate response, though, is deeply thoughtful. She questions why doctors fail to empathise with their patients. She finds her answers thoroughly ingrained in medical culture, where coolness and distance are deliberately cultivated. The mantra is “if you want to treat disease, become a doctor. If you want to care for patients, become a nurse”, and she was trained “to be sparing of myself … as if I were made of some quantifiable measure of stuff that once given away would leave me depleted”.

From the moment a medical student starts work on a cadaver, she concludes, “the true relationship is forged between the doctor and the disease”, not between doctor and patient. The doctor-patient relationship, as a result, is fundamentally “antagonistic”.

This is not just a problem for patients. Developing a professional carapace does not allow for flexibility when doctors are severely emotionally tested — as they inevitably are. Awdish describes her tearing guilt when patients die, and how expressing that guilt is professionally unthinkable. She writes about the colleagues who turn to alcohol and about the endemic sleeplessness and disregard for the body. She recalls the suicides of two interns during her residency.

As a remedy, she offers empathy. In truth, this idea has featured in medical schools for many years now, and has always been present in the best individual doctors. Awdish captures something important, nonetheless. Doctors have “imagined ourselves as barriers perched at the top of a steep cliff”, she writes, standing between patients and the void. Instead, “we could turn and stand at the edge of the chasm and face it together”.

Bantam Press £14.99 pp272

Book review: In Shock: From Doctor to Patient — How Nearly Dying Made Me a Better Intensive Care Doctor by Rana Awdish | Culture | The Times & The Sunday Times

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