The day I ‘declared myself’ — and was in surgery just hours later
I was about to begin rounds in the intensive care unit when I bumped into the liver specialist on call. My team had asked her about a patient with advanced liver disease who was not responding to treatment and was quickly deteriorating.
“If she’s infected, she will declare herself,” the hepatologist said, evoking a centuries-old diagnostic concept in medicine. It presumes that a sick-enough patient will eventually develop symptoms so distinct and profound that she or he will “declare” the mysterious illness at play, making it possible to readily identify the culprit disease.
I didn’t realize it at the time, but that phrase would apply to me in just a few hours.
For about six weeks, my body had been signaling that something was awry, though I misinterpreted what it was telling me. I was once again overtaken by insomnia, which I chalked up to being an overworked and generally stressed second-year resident. Searching for a quick fix, I called my therapist and drowned my blazing neural synapses with sleep medications.
Then I began feeling slightly nauseous. I had in place an intrauterine device (IUD) — a long-acting contraceptive device with a failure rate of less than 1% — but just in case I wanted to rule out pregnancy as the cause of my nausea. I was falsely reassured when the home pregnancy test was not positive, even though I knew I probably hadn’t given the test an adequate urine sample.
One morning during rounds, I became severely nauseous and dizzy and started sweating profusely. I sat down and reached for my water bottle, and my symptoms quickly subsided.
That’s unusual, I thought at the time, but not totally crazy. A number of my friends have fainted or nearly fainted at some point during med school or residency. I was just hungry, I told myself, and frankly overdue for a presyncopal event.
Having successfully concealed my symptoms from my fellow doctors, I worked for the next 27 hours.
On rounds a few days later — not long after talking with the liver specialist — the nausea, dizziness, and sweating gripped me once again. This time they were overpowering. I turned pale, my legs gave way beneath me, and I collapsed onto the hospital floor. After vomiting into a bucket in front of my entire team of 10 doctors, nurses, and medical students, some of the hospital staff urged me to go to the emergency department to get evaluated. Insisting I was fine, I went home instead.
When I got there, I decided to redo the pregnancy test. This time though, there was no doubt: I was pregnant and had “declared myself” on rounds.
Getting pregnant with an IUD is rare. When it does occur, the pregnancy is likely to be ectopic, with the fertilized egg implanting itself outside of the uterus, most often in one of the fallopian tubes. An ectopic pregnancy is not only unviable but also creates a dangerous, potentially fatal situation when the fertilized egg outgrows the fallopian tube and causes it to burst, leading to life-threatening bleeding.
I immediately called my gynecologist, then went to the hospital to get evaluated. I didn’t think the pregnancy was more than a couple of weeks along, and I was feeling better after collapsing on rounds, aside from some abdominal cramping. And beyond all of that, I was a doctor. Wouldn’t I know if I wasn’t OK?
In the emergency department, I bypassed the waiting line as I stated my credentials and concisely relayed my concerns: “I’m a resident here, have an IUD in place, had a positive pregnancy test, and am coming to rule out an ectopic.” I distanced myself from my body, signaling that I remained squarely on the physician side of the patient-doctor divide.
“Do you ever have thoughts about harming yourself or others?” the nurse doing my intake asked, screening me for any suicidal or homicidal inclinations.
“Only after I stay here for too long,” I replied, showcasing my fluency in the black humor of medicine.
“We all feel that way,” he said, tacitly acknowledging my membership in The Tribe.
As I waited for the physician, I pulled out my phone and scrolled through UpToDate, just as I might have done if I was managing a patient in a similar situation. I ran through the different possible scenarios, weighing the probability of each as my test results came to light. Initially, I was reassured: vital signs stable, hemoglobin within normal limits.
Then I underwent an ultrasound. Toward the end of the exam, the ultrasonographer paused. Catching her eyes, I asked, and she confirmed, that I had an ectopic pregnancy that had ruptured my left fallopian tube. I needed emergency surgery.
Until that point, I had largely succeeded in remaining cerebral and detached, systematically cataloging my symptoms and charting my course. I was still playing detective, still playing doctor, still envisioning myself as a clinician in a white coat rather than what I really was at the time: a patient in a hospital gown.
When I found out I would be heading to the operating room for an operation, fear and sadness shredded that scientific veneer. My clinical knowledge had helped me streamline my care and understand my diagnosis, but it also served as an antidote and escape from my own apprehension. Confronted with surgery, an army of medical facts could no longer shield me from the reality of my feelings, and I now deeply yearned for emotional support from my family, friends and caregivers.
As I learned later, the pregnancy had sheared an artery and I was bleeding profusely into my belly. The abdominal cramps that began after I had vomited earlier in the day represented the visceral sensation of blood pooling inside of me, growing in intensity and climbing upward as my belly filled with blood.
From the moment we take our first class in medical school, physicians are indoctrinated into a culture of hubris and imbued with a sense of invincibility. Patients are passive “cases” to whom sickness happens while doctors are active. We believe we are in control of our fate and the fate of those for whom we care.
Reminded daily that our role is distinct from those who are sick, we cling to the delusion that we will always be well. Equipped with the ability to generate multiple plausible explanations for a set of symptoms in others, we rationalize away medical problems in ourselves.
That’s what I did during my ectopic pregnancy: discounted my physical and emotional unease, attributing them instead to something relatively benign. Even after vomiting and “declaring myself” dramatically on rounds, I resisted help from my colleagues, preferring to manage things myself.
While it may have been perfectly human for me to have difficulty thinking of myself as sick enough to merit hospitalization, because I was a doctor I felt it was perfectly fine to weigh my own biased judgments over others’ objective medical advice. My decision to go home rather than seek help immediately put my health at risk, and I was lucky to get to the hospital in time to have surgery without complications.
I walked into that emergency room thinking I would be prepared for the emotional impact of my predicament because I could understand what was happening inside my body. I left the hospital with a profound sense of humility, dumbfounded by a degree of anxiety and trepidation I had never before experienced, and shaken with the realization that no amount of medical knowledge could let me fully comprehend the degree of pain and suffering another person might be experiencing.
Raw clinical information did not protect me at my most vulnerable, did not alleviate my discomfort, did not support me when I struggled to stand. And if I as a physician was left hungering for greater emotional intimacy, I wondered how I had shortchanged my patients in the past with dry explanations of therapies and their side effects.
Back in my white coat, I am more wary of not letting the process of gathering clinical data and assigning medical labels obscure a patient’s larger truth or distract from emotional connection. Medical expertise is, of course, vital to diagnosis and treatment. But it is the stitches of compassion, empathy, and humanity that allow us to fully heal.
Jessica Lichter, M.D., is a resident physician in internal medicine at NYU Langone Health and Bellevue Hospital.