At the Still Point of the Turning World
Residency is over, NOW what? (While I'm waiting for the answer, I'll get some spinning done....)

Sunday, February 09, 2003


It's been a while since I shared the gory details of a night on call, so here's the lowdown on what happened last night. As always, patient information has been altered to guard confidentiality.

6:30am: It's not a good start to the day when I arrive and the outgoing staff are talking about what a horrendous night they had. At about 2am, a woman walked into Labor and Delivery in excruciating pain, was placed on fetal monitors where fetal bradycardia (a heart rate too slow to sustain necessary physiologic functions) was found. Her abdomen was tense and painful and did not relax between contractions as in the normal pattern for labor. These are all signs of significant placental abruption, a condition in which the placenta separates from the wall of the uterus, interrupting the flow of blood between mother and fetus. The significance of placental abruption depends on how extensive the degree of separation, with minor abruptions having no bad consequences at all, to this patient's case, in which 95% of the placenta had separated from the uterus--which is what the surgeons found at the time of the emergency C-section that followed. The infant had an intial Apgar score of ZERO, and the second-year resident on call at the time told me, "I thought the baby was dead." An enormous resuscitation ensued, with intubation, chest compressions and administration of cardiac stimulants, and within ten minutes of life the baby had an Apgar score of seven. However, he was still intubated and was in the process of being transferred by helicopter to a tertiary-care hospital as I walked in.

Shudder! I vowed to review the neonatal resuscitation algorithms just as soon as I can. We do a lot of neonatal resuscitations at our hospital, but most of them never go beyond noninvasive respiratory support. What would I do if another crisis like this arose? I would not want to panic. After working with a variety of doctors over the past nineteen months of residency, I've learned to emulate those who keep their heads in an emergency, and who calmly assume their role in resolving the crisis. TV shows like ER show a lot of yelling, running down hallways, shoving people aside, grabbing instruments, barking out orders, and general pandemonium--and none of this should happen in a real emergency. Certainly there will be a lot of chatter, bustle, and busy hands, but the best-run Code Blue happens in the quietest room in the hospital, where everyone can be heard.

9:00am: While rounding on postpartum mothers, I'm called to a C-section to "catch," or resuscitate the baby when it is born. In contrast to last night's drama, this is a non-emergent C-section and my role is to make an immediate assessment of the baby's status, assign Apgar scores, then bundle the new team member up in a blanket and carry her over to her mother, who is awake under spinal anesthesia and can give the fruit of her womb a little kiss on the cheek. This baby's mother had worsening preeclampsia, a pathological condition of pregnancy associated with high blood pressure, loss of protein in the urine, and risk of serious complications, such as seizures or liver rupture. We see a LOT of complicated preeclampsia in our hospital, most recently a woman whose liver ruptured after delivering a healthy baby, who then spent two weeks in the ICU receiving all the blood products available in three counties in between trips to the operating room to control the bleeding. Consequently, we take preeclampsia pretty seriously. In this case of today's patient, her preeclampsia was mild but worsening, so the decision was made to deliver her five weeks before her due date to head off complications. Because she'd had a C-section in the past, her labor could not be induced for fear of uterine rupture (another dread complication of labor, and not an unheard-of event at our hospital), so she was delivered by repeat C-section. The baby, thanks to all the gods in all the pantheons in all the world, is born small but vigorous. I have to admit her to the NICU because of her relative prematurity and small size (less than 5 pounds), but she's good and stable so I ask the nurse to tuck her in while I finish postpartum rounds.

Noon: I'm finally done rounding on postpartum mothers. In theory, this is a quick task, but recently we've been having a flood of birth at our hospital and we've got new mothers everywhere. They have overflowed the Mother-Infant Unit, into the MIU annex, and even into the Medical-Surgical floor. I'm tired and grumpy from rounding by the time I get back to the NICU to whip out the admission on the little girl born by C-section earlier, who is "acting like a preemie" according to the nurses--feeding poorly and demonstrating transient decreases in her oxygen saturation, both of which are typical in premature infants.

12:30pm: Here comes the next admission. Mrs. H is a 69 year-old woman is in the ER with chest pressure. The kicker is that she was just discharged a week ago after having had a heart attack. Because of her other illnesses, including chronic kidney dysfunction, which makes using the intravenous contrast necessary for cardiac catheterization perilous, the decision was made at that time to forego invasive attempts to improve circulation to her coronary arteries in favor of "clot stabilization" with a host of cardiac medications. Just to review, coronary artery disease (CAD) describes the gradual blockage of the arteries supplying blood to the heart by atherosclerotic plaques, which consist of ugly lumps of lipid deposits and blood clots. To minimize the impact of CAD, patients need to control illnesses such as hypertension, diabetes and high cholesterol, and take anti-platelet drugs like aspirin, because platelets are a major determinent in clot formation. In Mrs. H's case, the fact that she's had a heart attack means she has significant CAD, so she was sent home from the hospital a week ago on two anti-platelet drugs, in addition to a bunch of other medications. She took them faithfully and yet--the symptoms returned. This probably means her CAD requires invasive methods to re-establish blood flow, but I won't address that possibility today. Instead, I tuck her in to the ICU on a continuous nitroglycerin infusion, a blood thinner and the remainder of her other medications. I make a note to check her cardiac enzymes, a blood test, later in the evening to make sure she hasn't had another heart attack.

3:00pm: Labor and Delivery is hopping, as is usual these days. I'm not in charge of running it today, and I'm very grateful because I had my share of deliveries yesterday, when I was on duty. We had seven deliveries in nine hours. I delivered five of the seven, barely getting my gloves on in time for a couple of them and having to deliver at least one baby while crouched on my knees at the foot of the bed. My body still aches from yesterday's hullaballoo, so I'm perfectly happy to stay out of the fray today. Besides, I keep getting phone calls from all over the hopsital, and these need prompt reply. If you don't return your pages in a timely fashion, you get a bad reputation with the nurses, and no resident wants to make an enemy of the nurses.

4:30pm: Just as I'm sitting down with a cup of tea, I'm called to catch a baby in room 206. The amniotic fluid is green-tinged, which means the fetus passed meconium, or the first stool, in the uterus. This is a frequent occurrence but carries an increased risk of serious pneumonia in the infant, if the meconium is inhaled into the lungs with the first breath. I've been called quite early because the mother is a first-time mom and still has an hour of pushing to do, but I stand by and enjoy the scene. Several members of her family and her husband's family are present, with digital video cameras at the ready, all cheering her on. At one point, between pushes, the husband whips out a candy bar from his pocket. "Anybody want some chocolate?" he asks, and offers a square to his wife, who declines. We all have a good giggle, which is nice. The mood in a delivery room can get so tense at times.

Just as things are getting interesting in 206--a tablespoon of scalp showing with each push--we hear hollering from room 207. I poke my head in to make sure everything is okay, and the delivery nurse says, "Well, we're close." She's not kidding. An apricot-sized portion of scalp is showing with each push, so we call for the attendings and I get my hands in position for delivery, just in case. As the head is delivering, the attending physician arrives and gets into gown and gloves just in time, so I slip my hands out of the way and run back to 206, where the baby is finally crowning after an hour of good pushing. A couple of pushes later, a TEN AND A HALF POUND baby is born. I take a look down his throat with a laryngoscope and don't see any meconium, so we pass him--with effort--into the arms of his new parents.

5:30pm: I look at the Labor and Delivery board, and I see we've again had seven babies in nine hours. There is no one in active labor, now that 206 and 207 have delivered. "Do we win some kind of prize?" I ask in wonder. This is only the second time in over a year and a half that I've ever seen the board this empty.

6:00pm: Time to think about dinner. The attendings are treating us to Chinese take-out, so we make our selections from the menu. Dinner is the most important part of call, and a hot dinner goes a long way towards pushing the call team over the hump to the next morning. Once the food arrives, we sit down together in Labor and Delivery, and the war stories begin. What is it about doctors that we have to talk abou the most horrendous case of this-or-that we've ever seen? It starts at a young age--I catch myself sharing my own war story and stop myself. It's a bad habit to get into. It smacks of one-upmanship.

Lately I find myself stopping mid-sentence a lot. I worry about becoming the kind of doctor I never liked--loud, bossy, overconfident. Medicine is a field that overvalues confidence and expertise, and undervalues humor, nuance, a tolerance for uncertainty, or a soft touch. Our residency has produced many excellent doctors among the recent graduates, one of whom is our Family Practice attending tonight, but not all of them are nice people. This woman, for example, is smart and competent but also demanding, judgemental, argumentative. I trust her medical judgement, but I also find myself wanting to leave the room when she begins one of her rants against the staff, the residents or her colleagues. The worst part is that she likes and trusts me, which makes her think she can confide all of her judgements about everyone else to me. I don't want to participate in this kind of interaction, but it's difficult to extricate myself diplomatically, as I've had to do many times today.

At least the food is good.

8:00pm: Indulgence! I sneak into the upstairs lounge to watch Law and Order and knit for a while. It's a relief to leave the endless chatter of the wards for a while. Some days, my ears literally ache after the constant yadda-yadda-yadda of a day a the hospital. It's lovely to escape into a couple of hours of legal drama.

10:00pm: The pager never stopped beeping during L&O. I deflected most of the problems over the phone, but now I have to go to the ICU to tidy up loose ends. "Cross-cover" refers to the art of fielding these phone calls at night, especially now, at bedtime, when every patient in the hospital seems to start itching, vomiting, acting out--or at a minimum, realize they can't sleep against a background of constant hospital activity. My calls are coming from the ICU, and some of them are a bit more complicated than usual, so I head over there to look people over, check the chart, sign my orders, and reassure the nurses that I will come around if they need me.

11:00pm: It's time to start banking naps, as I like to say. Most residents agree that any sleep is better than none, so if you can sock away a few minutes here or there, you'll end up getting at least some rest during the night. The wisest advice I've ever gotten was from a recent grad of our program, who told me, "Even if you think you've only got ten minutes, lie down. You'll be surprised how often those ten minutes turn into an hour."

11:45pm: See? I got a forty-five minute nap before the next beep. This one is bad news: Mrs. H's enzymes are now hugely elevated even though she has no chest pain and her EKG looks exactly the same as it did a few hours ago. This requires consultation. I call the cardiologist on call, Dr. S, tell him what's going on, FAX the EKGs over to him, and wait for his call back. We debate back and forth whether to add yet another medication to Mrs. H's regimen--Integrilin, a major inhibitor of clot formation. We don't automatically use Integrilin in every patient like Mrs. H, because the risk of bleeding is significant, but in her case, she's having another heart attack while on every other clot-stabilizing agent we've got, so there's no other choice. It's clear that the ICU team is going to have to re-visit the need for cardiac catheterization with Mrs. H and her family, which will require the opinion of several other learned consultants, but none of this is going to happen tonight. I write orders for Integrilin--after consulting a bunch of books to make sure I'm dosing it correctly for her kidney disease--and roll back to bed.

2:00am: But not for long. The intern calls me. She's going to admit a patient, Mr. D, with viral meningitis and needs me to go with her, because Mr. D is well-known to all of us for having threatened to kill one of the current third-year residents when he asked Mr. D if he used drugs. In fact, Mr. D does use drugs, and sells drugs, and has a urine test positive for cocaine tonight. The reason why the intern needs me to go with her is because our third-year on call tonight is, in fact, the resident Mr. D threatened with death a couple of years ago. I'm needed to make sure the interview goes well and because Mr. D and I have always managed to get along fine--don't ask me why.

Mr. D is clearly feeling terrible--he's got an awful headache, and the lights and noise of the ER are making him miserable, so he's not in a fighting mood. I'd advised the intern to be very straightforward and polite with Mr. D, but not to spend a lot of time on long explanations or unnecessary humor, which he tends to find threatening--I know, I've taken care of him many times. Together, the intern and I survive the interview. We both take a big, deep breath as we leave the exam area. The intern proceeds to write orders for Mr. D, while I....

3:00am: ....get paged, for a change. This time it's a postpartum nurse who's worried about a baby with a mild temperature elevation and poor feeding. I run upstairs to examine the baby, who weighs about nine pounds and is crying fiercely during my exam. Otherwise, he looks perfectly healthy, and there's nothing in the prenatal or delivery record to suggest he's at risk for infection. I suspect the mild temperature elevation--not a true fever--is due to dehydration, and ask the nurses to cajole him into taking a formula feed. I call the attending to let her know about the baby, and she agrees with this watchful attention for now.

Back to bed.

5:00am: Get this--NO PAGES for two hours. I awake in wonder. It's cold in the lounge, and I'm snuggled under two hospital blankets. The urge to go back to sleep is tempting, but it's almost time to start rounding on postpartum moms again, so I drag myself out of bed to brush my teeth. That's another good piece of advice I got when I started residency: brushing your teeth is equal to a half-hour more sleep, and a shower is equal to two hours. Today, I'll setlle for clean teeth.

5:45am: I check on the fussy baby I saw earlier--with some coaxing, he took a one-ounce bottle and now his temperature is normal. He's sleeping soundly, and peace finally reigns on the Mother-Infant Unit.

6:30am: While rounding on our many, many new mothers, I get a page from the ICU. Mrs. H has started to ooze blood from her IV site, so her nurse has stopped the Integrilin. I order a bunch of labs to make sure nothing else is contributing to this problem.

8:00am: Morning Report = the END OF CALL! We present the admissions from the last twenty-four hours, and they are suprisingly few. The previous night, they had ten admissions and the placental abruption, whereas we got away with six admissions and a bunch of straightforward deliveries. You can never predict how call will go, but you're always thankful when it goes well.

9:00am: After signing out the postpartum mothers to the OB attending on call, I swing by the ICU one last time. Mrs. H's labs are normal, so the incoming ICU resident has restarted the Integrilin until she can tackle the issue of cardiac catheterization. It's going to be a complex discussion, but that's the nature of critical care medicine, and the permutations of if-this-or-if-that are 'way over my head at this point, so I bow out.

And that was it! No emergencies, a good meal, and almost three hours of sleep. But I never did review neonatal resuscitation--remind me to do so, please?