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Creating a Culture of Caring: An ICU Patient Profile

The world of Rana Awdish, MD, changed on the last day of her pulmonary and critical care fellowship at Henry Ford Hospital in Detroit, Michigan, USA. It was 2008, and Dr. Awdish, who was seven months pregnant, was eating dinner in a restaurant to celebrate with her best friend when she was struck with sudden, unbelievable pain. “It was so severe that I didn’t even think the word ‘pain’ described it,” Dr. Awdish said. “As I went through my doctor brain differential trying to think of what it could be, I just kept thinking, no, this is killing me faster than any of those could kill me.”

Dr. Awdish did not die, although she came close. Twice. But she survived and, while she was a critical care patient, she learned how to be a better critical care physician. Since then, she became a tireless activist for cultures of caring in the intensive care unit, encouraging her fellow clinicians to focus more attention on the patient experience and strengthening empathy through the use of better connections and communication. She documented her journey in the book In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. She lectures to physicians and medical leadership across the United States about the lessons she learned along the way. In February 2019, she shared her story at the Society of Critical Care Medicine’s annual Congress.

Dr. Awdish was five years old when she first fell in love with medicine. Her brother was found drooling in his crib and unable to breathe, so Dr. Awdish’s mother called the family’s pediatrician. He was worried about the boy’s airway so he had them meet him in the emergency department. “I listened as the pediatrician put the seemingly vague pieces together into a diagnosis of epiglottitis,” Dr. Awdish said. “And that really saved his life, that decision that pediatrician made on very limited information. I think from that mo-ment, the idea that listening and science together could save lives was so attractive to me.”

She decided to focus on medicine and, throughout her educational career, residency, and fellowship, she focused on how to become a better care provider. Then came that fateful day in 2008. The in-credible pain she felt during dinner turned out to be a tumor in her liver that ruptured, and in the span of two hours, she went from enjoying an evening with her friend to having multisystem organ failure. Her liver failed. Her kidneys shut down. She was placed on a ventilator and had a stroke. Her baby died from lack of blood flow.
Dr. Awdish spent the next six months recovering physically while also mentally processing disappointing cultural observations she witnessed as a patient. The disappointment began before she had even checked in as a patient.

She went to Henry Ford Hospital because she knew the level 1 trauma center there and thought she would need emergency surgery. Unfortunately, when she arrived at the hospital, she was met by a security guard who, upon seeing that Dr. Awdish was pregnant, rerouted her to labor and delivery. Dr. Awdish felt at the moment that misdirection could cost her her life, but she did not say anything. “Thinking back on it now, it’s hard to imagine that I allowed myself to be triaged by a hospital security guard,” she said. “I know now how quickly, as patients, we lose a sense of agency. We can lose our voice in the face of authority.”

Dr. Awdish saw a series of gaps in communication and discoordination of care throughout her stay. For example, she first found out about the loss of her baby after overhearing her care team talking about it in the hallway, although she had asked about the baby many times. She also heard the team say, “She’s been trying to die on us,” which simply was not true.

Then there was the time a nurse accidentally left Dr. Awdish lying flat on her bed and alone. Fluids redistributed in her body and she was barely able to breathe. The nurses’ alarms for her room were off, so there was no way to communicate with them. “The last thing I saw as my vision tunneled was the code blue button above my head, so I pushed it,” she said. “And in rushed the medical team, whose first question was, ‘Who called the code?’ The medical team resuscitated her, made sure she was okay, and then left. There was never a conversation about what happened or, more importantly, why it happened.

More than anything else, Dr. Awdish felt disempowered. Then she realized that if she, as someone with a medical background, felt that way, then many patients must feel the same thing. “As a patient, I didn’t feel at all empowered to be vocal about my needs or fears,” she said. “Once I framed it that way for myself, I felt a responsibility to admit the ways in which my own system had in many ways failed me because, if it was failing me, then it was bound to be failing others.”

She did encounter some unlikely heroes during her hospitalization. One transporter who took her to radiology heard her break down when she was asked about the baby, whose little wristband was still attached to Dr. Awdish’s chart. The transporter went out of his way to tell colleagues not to ask about the baby again. Radiology technicians began to throw a lead blanket over Dr. Awdish’s sleeping husband, rather than wake him to leave the room when they would come to take a portable radiograph.

Dr. Awdish knew that, once she recovered, she would be a different physician. She realized that, in her training, she had learned to remove emotion from medical care in order to remain objective and demonstrate sound medical judgment. But the problem with that is that she stopped seeing patients as the people they were, and in the process was not able to empathize with the impact their medical experiences had on them.

As a patient, she saw that same lack of empathy in her care team. “It wasn’t that anything was ma-licious or intended negatively, it was just that no one was really engaging with me from a standpoint of compassion and my emotional needs,” she said. “It was all about the medicine.”

That changed as soon as Dr. Awdish returned to work. She wanted to share her story not just with her colleagues, but in a book, in published articles, and through speaking engagements to influence other clinicians. She wanted to demonstrate the importance of recognizing patients’ emotions and understanding how those emotions change throughout their experience. She wanted to show the need for a culture of caring.

Keith Killu, MD, has known Dr. Awdish for years and has heard her story many times. Each time he hears it, it reminds him to take a step back and consider the reality of what his patient is thinking. “Listening to details of her story gives us as providers a bird’s eye view of how our daily interactions with our patients can be improved,” Dr. Killu said. “Her story makes us reflect on our practice as critical care providers. We focus on resus-citations and practicing the latest evidence-based medicine, but we forget to ask ourselves repeatedly, ‘What is my patient thinking?’”

Beyond sharing her story, Dr. Awdish launched the CLEAR Conversations Project at Henry Ford. CLEAR stands for Connect, Listen, Empathize, Align, Respect. The pro-gram uses improvisational actors to train physicians in patient-centered empathetic communication.

“It’s been transformative,” Dr. Awdish said of the project, “because what it trains [us] to do is actually switch channels, to leave that cognitive mindset and enter the emotional mindset, to recognize the emotion and respond to it. “It’s changed how I practice medicine. It’s changed what I view my role in my patients’ lives as being.”