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....)

Tuesday, September 02, 2003

CALL FROM H-E-DOUBLE HOCKEY STICKS


The Saturday before last was the worst call I’ve had in a while, bar none. You’ll see how busy we were, but the worst part of it was how impatient I felt with my residents, and how I had to struggle with my tiny, mean self all night long. Read on.

7:30am: I arrive on a busy Labor and Delivery unit. The intern--we'll call her M for the rest of this narrative--is there as well, although she has to go and round on the Medicine service, so I shoo her away. There are five women in labor and one woman in preterm labor at 33 weeks of pregnancy. The woman in preterm labor has been given a dose of corticosteroids to help mature the baby's lungs and magnesium to halt labor long enough for the steroids to work, and still she's "banging out contractions" according to the nurse. The outgoing on-call intern is exhausted and not too clear on the details of all of these women, which annoys me because I have to spend some precious time figuring out what's going on. I have to tell myself to be patient, because we're still early in the intern year and board sign-out is an art acquired over the course of time. I ask the nurse to increase the magnesium on the preterm labor patient. The last thing we need at this moment is a preterm baby screaming into the world.

8:30am: Two women are getting close to delivery at the same time, not an uncommon scenario on the Deck these days. One is a "multip" who has had two children before, the other is a "primip" laboring with her first. I rupture the multip's membranes and linger for a moment in her room to see if she will deliver quickly, as common wisdom predicts. Yet we can never predict when a baby will be born, just as we can't predict when labor will begin. The standard joke is, "If I could tell you when your baby will be born, I'd be a millionaire." In this multip's case, she is so calm in labor that her urge to push is not strong at all, so I excuse myself just in time to....

8:40am: ....run into the primip's room at the behest of one of the nurse's. The patient has been pushing for only a few minutes and is making good progress. I get my gloves and gown on and prepare for a delivery. Then the OB Attending arrives, not Dr. Bloody Unpleasant this time, but Dr. High Strung who tends to freak out easily. The baby's heart tones are mildly depressed as the head comes close to delivering, which is not at all uncommon--and not really an emergency. Yet Dr. H-S starts hollering when she sees the tracing. She orders the nurses to get a vacuum and me to place a fetal scalp electrode for more accurate measurement of the baby's heart rate. From long experience, I know there's no arguing with her when she's in this kind of mood, so I put the electrode on. A nurse informs us that the cable attachment for the electrode is not functioning. This is Dr. H-S's last straw. She commands me to put a vacuum on the baby's head to assist delivery and yanks the electrode off the baby's head. As I begin the vacuum delivery with the mother's next push, she reaches right over me and cuts a huge mediolateral episiotomy to aid delivery. The baby is born easily, looking a bit stressed-out from the delivery, with a big suction-cup mark where the vacuum was placed. Now that the baby is safely out, Dr. H-S resumes her mask of calmness, and leaves me to sew up the episiotomy she made. Yippee.

9:00am: While I was repairing the episiotomy, the second-year resident on call--I’ll call her P--was delivering the multip in the other room. That makes two deliveries already, and the ER is now calling me. There’s a 9-year old girl with cerebral palsy and seizure disorder who came in by ambulance in status epilepticus. Her mother comments that the patient often has worsening of her seizure disorder after treatment with antibiotics, which is interesting because she recently finished treatment for an ear infection. The level of seizure medicine in her blood is low, so perhaps mom is right. The child is pretty drowsy after her half-hour long seizure, poor kiddo. I give her the once-over and send out a page to M to get her admitted.

10:00am: Back to the Deck, where the pregnant women keep arriving in droves. The preterm labor patient is still contracting, so I discuss the case with Dr. H-S who recommends another big dose of magnesium and an increase in the continuous magnesium infusion to hold her over. Another woman has arrived for induction of labor--she has had mild but worsening preeclampsia for several weeks, and has been admitted twice before for induction of labor. Neither attempt worked, and both times she was discharged home on bedrest to wait until she was closer to her due date. Now she’s back, and her physical exam tells me she’s more likely to have a successful induction this time, so I admit her and start Pitocin to stimulate contractions.

10:45am: One of the nursery RNs is worried about the infant I delivered earlier. The baby’s scalp is bleeding at the site where the fetal scalp electrode--placed so hastily, and never used--was removed by Dr. H-S. The bleeding is not excessive, but is steady and has seeped all over the pillow the mother has been using to prop the baby at her breast. I examine the infant and confer with the NICU attending. We agree that the problem is that the scalp electrode mark is located at the same spot to which the vacuum was applied, so the resulting swelling is making the scalp electrode mark ooze watery, blood-tinged fluid. Neither of us think the situation is serious, just messy and visually disturbing. I confer with the NICU nurse, and we agree to wrap the baby’s head in a turban dressing to maintain pressure at the site of bleeding. This is what comes of losing your head in a crisis, I conclude after reviewing the dramatic events leading up to the delivery of this baby.

11:15am: M, the on-call intern has resurfaced and is fretting with the nurses over the fact that four of the laboring women are getting close to delivery. She hasn’t been here long enough to know that we’ve handled this situation many times before. Once, when I was an intern, I had six women pushing at once. I stood in the hallway and RAN towards every call bell and every cry of pain. In the end, I caught only one of six, while the others were delivered by their private physicians or on-call attendings. These experiences teach you to cultivate a certain tranquillity in the face of chaos....

12:10pm: ...as well as the life-preserving strategy: Eat when you can! Dr. H-S--who has her good points--has ordered burritos for all of us, and they have arrived. I wolf mine down while writing out another admission note for one of the laboring women. M is being dragged in six different directions by the L & D nurses, attending to the women in labor. Another thing she has to learn is to prioritize her work while on call. Dozens of people will demand your immediate attention, and you have to learn to decide which demands can wait and which must be addressed right now. Nothing sounds life-threatening, so I make M sit down to eat a few quick bites before the next explosion of birth occurs.

1:00pm: M is with the anesthesiologist in room 206, learning to place spinal analgesia. I wander into room 204 because I think this patient might benefit from a spinal as well, and there's no better time to offer one than when both M and the anesthesiologist is available. As I walk into the room the patient’s husband approaches me in a panic. His wife is rising up from the toilet, hold herself between her legs. “My baby’s coming!” she hollers in Spanish. “Sit down!” I tell her. She seats herself on the toilet. There are gloves in the bathroom, which is a good thing. I pull a pair on and peer between the patient’s legs. Indeed, the baby is crowning. Very calmly, I turn to the patient’s husband and tell him, in Spanish, to get the nurses who are at the front desk. When I turn back, the baby’s head has delivered. It’s an interesting sight, looking between a woman’s legs to see a head dangling just above the level of the water in the toilet. I attempt to deliver the baby with the mother seated. After all, water births are meant to be very popular, aren’t they? Well, I soon discover that there’s a reason why water births take place in a big bathtub, and not on a toilet. There just isn’t enough room for a safe delivery.

“I need you to lie down on the floor,” I tell the patient.
“I can’t!” she says.
“Yes you can!” Miraculously, one of the RNs has appeared and helps me get the patient down onto the floor of the bathroom, where I deliver a little girl onto a cold tile floor. Great. “Can I get a towel?” I ask plaintively, and the RN--bless her heart--arrives with the needed supplies. Dr. H.S is now in the room as well, eyeing me suspiciously as if I’d PLANNED to deliver the baby on the floor of the bathroom. We get the woman back into bed to deliver the placenta, and I’m explaining the quite unexpected turn of events to Dr. H-S, when we hear one of the nurses hollering from the hallway...

1:20pm: ...”They’re intubating a baby in 201!” Great. Dr. H-S. waves me out of room 204, so I stumble down the hall to 201 where P has gotten drawn into yet another delivery. The baby’s amniotic fluid had thick meconium, and he was suctioned on the perineum before delivery, yet he still refused to breathe. P attempted intubation, but couldn’t manage it, and all the carrying-on and exposure to cold air has finally stimulated the baby to breathe by the time I arrive. P is giving continuous positive airway pressure to support the baby’s breathing, and I supervise her a bit because, to be honest, P can be a bit of a spaz and lose track of details in a crisis. Soon enough, the baby has perked up and is breathing on his own, so I bow out of the room.

1:55pm: I regroup with M. Room 206 and 207 managed to deliver somewhere in the middle of all the excitement, mercifully without any emergencies or drama. Suddenly the Deck looks calmer, with “DEL’D” written next to the names of the new mothers. Not for the first time during my residency, I hope I never see another baby enter this world again. M, P and I sit down to write notes on all the recent fun and games. We snack on cold burritos and warm guacamole while we write.

3:15pm: And yet, the women keep coming. There’s a new patient we’re admitting, a young woman with her first pregnancy who recently moved from Puerto Rico. Two days ago, in fact. She’s only 20 weeks pregnant and has been contracting since earlier in the morning. We’re picking up her contractions on the monitor, and each one is associated with a steep deceleration in the baby’s heart tones. Not good. I review her recent history--no rupture of membranes, no illnesses, no drug use. However, before leaving Puerto Rico, she was diagnosed with “incompetent cervix” and had a cerclage, or a big stitch, placed in her cervix to hold it closed. With Dr. H-S present, we do a physical exam and a bedside ultrasound. It’s not clear whether the mother has ruptured her membranes or not, but the ultrasound shows a 350gram, 20 week fetus. We start some magnesium, but I have an uneasy feeling about this patient. I think she’s going to deliver her extremely preterm infant today. I explain to M that, if born, the infant will be pre-viable and we will not make any attempts to resuscitate it. M seems shocked at this news--she is really green, even compared to the other interns, and perhaps she needs more time to absorb the news because she herself has recently had a baby, a girl, who is now two months old. She had several weeks of light rotations so she could spend more time with her newborn and now is being introduced to the real rigors of internship. The difficult transition shows on her face.

4:30pm: The pre-viable patient’s blood count is abnormal, and she has a rising fever--both signs of infection. Dr. H-S and I hypothesize that she must have an infection of her cerclage, and further attempts to hold off delivery are both futile and place the mother at risk of serious systemic infection. We recommend induction of labor to the mother, and she agrees, her face a mask of shock.

5:30pm: Overhead, the call goes out. ”BEEEEEEEEEEP. Cardiopulmonary, radiology, laboratory to ER STAT!” Great. That’s our next admission. I whip through a pile of paperwork on the pre-viable patient, in preparation for the inevitable phone call from the ER....

6:00pm: ...which arrives in short notice. The stat overhead call was on behalf of a 35 year-old woman who was acting bizarrely at home after overdosing on heroin. She went into cardiopulmonary arrest after the police arrived. Paramedics resuscitated her and she arrived in the ER intubated. It’s unclear how long she was “down” before adequate circulation and oxygen delivery was restored to her. When I examine her, she is in coma with ominous signs on her neurological exam--it’s apparent she has anoxic brain injury. The prognosis is terrible. The ER attending wants orders written on her right away, they need the trauma bed back in case another emergency comes in. “Don’t jinx me,” I tell him grumpily. I write orders and call P to finish up the admission....

7:00pm: ....which is turning out to be the first of FIVE the ER is trying to hand me. The outgoing ER attending has an emphysema exacerbation, the ER physician’s assistant has a man with pneumonia and psychotic disorder, and the incoming ER attending has an acute appendicitis and a--get this--103 year-old woman in acute renal failure and with altered mental status. The woman is so old she doesn’t even look human anymore; instead, she looks like a lichenous rock with eyes. That sounds terrible, but it’s true. It’s a rare event to meet someone that old. She is surrounded by her grandchildren, who are in their sprightly 70s. At home, she just hasn’t been acting herself since yesterday, not eating and not responding to her family as usual. Her laboratory results show evidence of mild multiorgan failure, and I think she is “shutting down,” or succumbing to extreme old age.

The ER attendings and the PA are smirking at me as I collect all the charts on these new admissions. “You guys,” I tell them, “are OFF the Christmas list this year.”

8:45pm: I’m STILL in the ER. My job is to see all the patients who get admitted, get the short story on them, and make sure the intern and second-year residents don’t make any stupid mistakes. While I’m down here, I go ahead and admit the appendicitis patient, who is actually feeling better and sounding less and less like an acute appendicitis with each passing moment. I have sent up the flares to M and P, and they are both flying around the ER doing their admissions. The ER attending, who is actually a good guy but NOT on my Favorite List tonight, gives me yet another admission to do--a woman with many prior abdominal surgeries, now with a small bowel obstruction--which I consider making M do, but decide to whip out myself, all in the interests of time and for the sake of my own sanity. I can do a small -bowel obstruction admission in exactly 20 minutes. It will take M at least an hour and a half, and she’s still pounding through the 103 year old and the psychotic man with pneumonia.

And, in violation of the Fundamental Rule of Eating, I have missed dinner, and am feeling GRUMPY!

11:30pm: Even though we’re not done in the ER, M and I have to run back up to L & D because--you guessed it--a whole bunch of women are getting ready to deliver. One is the pre-viable patient, who delivers her extremely preterm infant in an intact amniotic sac. He is not breathing--sometimes the pre-viable infant is born moving and breathing, and there is nothing more horrifying in the entire world, I can tell you that. There is a foul odor in the amniotic fluid, confirming our idea that an infection precipitated this very sad event. M is pale and woozy-looking, and I order her to go sit down. I have to keep reminding myself that she’s new to all of this, the joy and sorrow of birth and death on call. I’d like say I feel a deep compassion for M, for all of us--but I have to confess, I’m hungry and exhausted and slip into the power-resident mode, and I just move on. I feel a wave of mixed grief, anger, empathy and fear as I move from room 208, where the parents of the one-pound baby are weeping, into room 206, where...

12:25am: ...my own clinic patient is in active labor. She arrived while I was trapped in the ER, and walked and walked until her cervix dilated to four centimeters. Now she’s seven, and glad to see me. I chat with her for a few minutes, then leave the room where the next wave of strange emotions strikes me.

One of the worst part of residency, maybe about doctoring in general, is the need to move on from one scene to another, without the chance to sit down and let the experience seep in. The transitions from grief to joy, if you get to feel them at all, if you can remember to feel them, whip by so fast that it hurts your head. Maybe even breaks your heart.

1:00am: While I was working on the paperwork for my own patient, room 207 delivered (by the way, these are different patients that the 206 and 207 who delivered earlier in the evening, that’s how fast things are moving tonight). I wandered in while M was pushing with the patient, and I realize--guiltily--that I never did “check in” with her after the shock of the pre-viable baby. “Are you okay in here?” I ask her. She nods back at me. and I have to admit a grudging admiration for her in that moment. She’s got a backbone, M does, and that’s a good thing. A memory appears before me, of the time I delivered a dead baby into its sorrowing mother’s arms, then had to run down the hall to another delivery of a live baby. That moment before the second baby was born, crying and pink, was one of the worst of my life, because I didn’t believe that any baby could be born safely, or alive. That’s a terrible feeling to bring into the birth room; having it, and not being able to shake it off, is another casualty of the rapid transitions of call.

1:45pm: My patient, in 206, delivers a beautiful little girl. She’d been expecting a boy, but she’s so pleased. “What are we going to do with all those clothes?” the happy father asks, but you can tell he’s tickled by his new daughter.

2:00am: We have an Acute Rehabilitation Unit in our hospital, where recent stroke and injury patients can go for in-depth physical, occupational and speech therapy. The ARU patients are supposed to be pretty stable, but the director calls me and informs me that one of them has been noted to have a pulse of 160. This patient has a history of a supraventricular tachycardia, or aberrant fast heart rhythm caused by an overexcited bit of cardiac muscle which overrides the usually well-ordered mechanism of the heart’s constant beating. This is a potentially dangerous rhythm, and if it has returned, the patient must be transferred to the ICU straight away. I call P and tell her to get over to ARU right away. The staff at ARU fax me the patient’s EKG, and it looks like SVT all right, even on the crappo fax copy. Great.

2:30am: Okay, we’ve been going nonstop for ninteen hours, and I can no longer finish my sentences. Poor old M can’t do much better. We’re still trying to think through her two admissions from hours ago, and she keeps asking me the same questions over and over again. I suddenly remember my high school Biology teacher. I took me forever to understand Mendelian genetics, and I used to ask him over and over again, how to figure out inheritance patterns. Every time I asked, he started over from square one, patiently, as if he’d never been asked the questions before in his life. He was a great teacher, but I am not. I’m feeling extremely testy, a consequence of fatigue, hunger, and unvoiced grief. M has cooked up some extremely complex, elegant, and totally implausible explanation for the 103 year old woman’s lab results, and I explain to her--five times--that these are more likely due to multiorgan failure as a result of extreme old age. Finally, after the fifth repetition, I say, “Look, M, I know you’re tired--but we’ve been over this already.”

I need to get some sleep, and then another job.

3:10am: M is working on her notes, so I’m running the Deck. Again. A schizophrenic woman in her 30s has arrived. She’s in her 7th month of pregnancy, and feeling “anxious.” She tells the RN that she wants to wander into traffic to hurt herself, and she tells me she feels like hurting her husband. I order a toxicology screen on her urine, and try to get our Crisis Team on the phone to come and see her, because she might be a danger to herself and others. I’m waiting for the phone to ring, when the dreaded overhead call comes:

”BEEEEEEEEEEEEP! Code Blue, ICU room 306! BEEEEEEEEEEEEP!”

Dammit! I tell the RNs on L & D to answer the phone when Crisis calls, and tell them I’m at Code Blue, then sprint upstairs to the ICU....

3:25am: ....Where I find P doing energetic chest compressions on the 35 year-old woman we admitted earlier, in coma. Apparently the patient bit down on her endotracheal tube, cutting off the oxygen flow. Her heart stopped soon thereafter, hence P’s furious pumping on her chest. P is YELLING at all the nurses--I said before, she’s a good egg, but a total spaz in a crisis. Feeling totally calm--I’ve used up all my adrenaline by this point--I put on a pair of gloves and feel for the patient’s femoral pulse. There it is, bounding away. “P, stop compressions,” I tell her. “No, stop now!” She stops, and the pulse remains steady. “We’re okay here, “ I say, and yet two of the young Med-Surg nurses jump in to resume compressions. “No, he has a pulse!” I tell them. P and M, who has arrived to see what’s going on, are staring at the cardiac monitor, which shows a terrible-looking tracing. I tell them, as nicely as possible, to quit gawking; if P had been pounding on my chest for a minute and a half, I’d have a terrible tracing too. I debrief with P for a moment, suggesting that she try to keep a calm head in a crisis, then head back downstairs to the Deck.

4:30am: The schizophrenic woman’s toxicology is positive for methamphetamines, which explains her paranoid behavior. She has “crashed” after her high, sleeping soundly in her room. I don’t disturb her. After conferring with Crisis, we agree to admit the patient for observation for the rest of the night, so the psychiatrist can see her in the morning. More paperwork. Meanwhile, M has dashed into yet another room to deliver yet another baby. I don’t even bother to follow her. We’ve done ten so far, and it gets to the point that you just don’t care anymore.

5:20am: P is calling me urgently back to the ICU. The 35 year-old coma patient is so agitated that it’s difficult to maintain her ventilation settings. The respiratory therapist wants P to order a paralytic agent, but I nix the idea. The whole point of watching coma patients is to see if they’ll recover some degree of consciousness in the first 72 hours after the brain injury, difficult to do if they are given medications that render them motionless. I recommend continuous short-acting narcotics and sedative agents in stead. so we all agree to try that strategy for now.

Meanwhile, the ARU patient’s heart rhythm converted back to normal on it’s own after his arrival in the ICU, so we don’t have to do anything but start a rhythm-stabilizing agent and watch him closely. Phew.

6:00am: This is the worst moment during an overnight call. We’re SO close to being finished, yet anything can happen. M is finally done with her admission notes. While she was working, I wrote down a To-Do list for her--checking on new pregnant patients, finishing paperwork on newly-delivered babies, writing admissions papers on new labor patients, etc. She takes a look at the list and says, in a small voice, “Is that all for me?” I resist the temptation to backhand her into the next room. I hate to fall back onto the old, when-I-was-an-intern storytelling mode, but....When I was an intern, I would have been expected to do five of the seven admissions we did tonight, as well as much of the L & D paperwork I’ve been doing as we’ve been chugging along. Instead of backhanding M, I tell her, with only a bit of asperity in my voice, “Listen, before you feel victimized, you should know I didn’t give you the schizophrenic woman to admit, just an average labor patient.”

I really need a new job.

6:30am: M, bless her heart, is trying mightily to finish up her to-do list. She is falling asleep while writing notes. Whenever she starts awake, she looks at me and asks, “How do you stay up all night?” It’s a learned skill, I tell her. I give her a little pep talk, despite the fact that I feel scaly and mean. It will get better, I say. You find a depth of efficiency and mastery during your intern year that is completely obliterated by the pain and horror of the learning process itself. You don’t know what intern year will teach you until it’s all over, then you’ll be amazed at how much you’ve learned. M’s doing much better than average, actually, and I tell her so. She’s seems a bit pluckier after our chat, and I make a silent prayer of thanks to the Divine presence that makes me appear much kinder than I actually feel.

7:00am: Some woman whose arrival I didn’t even register is delivering, and M runs to catch the baby. As soon as that infant is out, the preeclamptic woman begins pushing. M robes up to catch the baby. Dr. H-S arrives to supervise and, in an eerie replay of one of our first deliveries of the call, the heart tones go down, H-S freaks out, and before you know it, poor old M is shoved aside so that H-S can do a vacuum delivery. I assist H-S by stretching the opening of the birth canal to permit easier passage of the baby’s head, and by clamping and cutting the cord after the baby is delivered. The baby looks just fine, even though I and the rest of the staff are the worse for wear after the usual H-S kerpuffle. Dr. H-S gives me a heartfelt thanks, though. I guess this habit I have of simply going with the flow--whether it be calm or chaos--appears, to her, to be supportive and “good doctoring.” I’m too tired to reflect upon the wisdom or rightness of this, and it’s almost time for morning report anyway.

7:30am: The new call team has arrived! Yippee! We sign out Labor and Delivery to them, wouldn’t you know it, now almost all of the names have “DEL’D” written next to them, and it looks like we didn’t do any work at all! I tell them we delivered TWELVE babies over the course of 24 hours, just to give credit where credit is due.

8:00am: MORNING REPORT! I thought the moment would never come. M and P are there promptly, and deliver their presentations efficiently. In addition to the seven names of admitted patients I’ve written on the board, I add:

“12 Deliveries
1 Code Blue
1 transfer to ICU
No dinner!”

Because, if you haven’t noticed by now, I believe in getting credit for everything my team does!

So, what did we learn from this night of call?

1. Eat when you can, even if you can’t. You’ll regret it later.
2. Even if you think you’ve delivered everyone in the county, some new citizens will arrive when you least expect it.
3. Why do we pray? So that the Divine will make us kind, when our spirits fall short.
4. Just when you’re about to murder your junior residents, they will rise to the occasion, and make you proud.
5. Finally, just when you think you’ve done it all--on your 240th delivery, you’ll find yourself doing something new. Like delivering on the floor of a bathroom.




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