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....)

Saturday, March 20, 2004


I haven't made any notes about call recently, but this doesn't mean I haven't been on call. I get a bit weary of work from time to time and don't feel like talking about it. Last night had a few high points, however; here they are.

4:45pm: On Fridays, the call team covers from 5pm to 8am the next morning. I happen to be on an elective right now, and I deliverately try not to schedule anything on Friday afternoons before call so I can take a nap. This was especially important this weekend because--dagnabbit--I came down with a wee head cold on Thursday and needed the rest. (Note: Having read this, my mother is now wigging out because she thinks that I should take to my bed for two weeks every time I have a sniffle. It's okay Mom, I'm feeling better.) Yet I have to take call, because it's not like I can easily find someone else to fill in for me, is it? I walk into the building just before starting time, equipped with a Thermos of homemade minestrone, a bottle of DayQuil to beat back the week head cold, a Thermos of Marks & Spencer tea, and a back-up Thermos of M & S tea. On my way into the building, a young man who is smoking a cigarette outside the ER complains to me that he has been kept waiting for over five hours. In my grumpy state I think: "This is the county ER, what do you expect?" I mean, anyone who is well enough to betake himself outside for a smoke...

5:00pm: The call team has assembled on Labor and Delivery for board rounds. We get the scoop on the laboring and antenatal women from the outgoing team. Immediately, we get called into room 206 where the fetal heart rate is decelerating. The mother is complete and pushing, and after a bit of a flutter, we have her resume pushing once the fetal heart tones have recovered. I'm reassured by the overall picture, but this occurance means that we have to keep one physician on the Deck at all times until the baby is born....

5:05pm: ...which is going to be inconvenient because one of the outgoing attendings has notified us that there is a 10-month old infant on the Pediatrics unit who has a fever without an identified source. One of the other residents has already done the paperwork to admit the infant, but we, the Call team, have to do a lumbar puncture (aka LP aka spinal tap) on the infant to make sure she doesn't have meningitis. Now, this is one of my greatest sources of aggravation on call: having to do procedures in the middle of 50,000 other things we have to attend to. The second-year resident, P (you will remember some of her anticts from the 8/23/03 call entry), is in a flutter because of the half-dozen cross-cover calls she has just received and has to attend to. So I fix a stern eye on the intern and say she's going to do tap. How many has she done? Exactly none. This means she has to be supervised doing the procedure, and BOTH of us have to leave L & D. Luckily the Family Practice attending has arrived. I ask her to supervise the intern's LP, but she prefers to cover the Deck because she hasn't done an infant LP in three years. Truth is, I haven't done one in two years, but we're running out of choices, so off I go with the intern.

5:30pm: After explaining the LP procedure to the infant's mother, we obtain her consent and whisk the poor little nipper off to a procedure room, where an RN is ready to hold the kiddo in position while we stick a needle into her back. Now, I'm not feeling 100%, so my explanation to the intern goes something like this: "Look, it's just like adult anatomy except smaller." Brilliant. With only minimal poking, pointing, and prodding, the intern proceeds to do the most gorgeous LP I have ever seen. This includes every single one I've ever done. The cerebralspinal fluid flows out, clearer than tap water. Amid congratulations from everyone on the unit, the intern begins to speculate about the traditional bottle of champagne owing to her if the lab reports no red blood cells in the fluid--a "champagne tap" as we call it in the business. We'll see.

6:05pm: I dash back to L & D, where P--who has tidied up all those cross-cover calls--is gowned up in room 206 and preparing to do a vacuum delivery. The heart tones haven't been as been as bad as before, but they're not fantastic and the time has come to help this baby out. Since P is going to deliver the baby, I have to assume her role and be ready to resuscitate the infant if it arrives with evidence of stress from the delivery. After a certain amount of fiddling around, P does a very nice vacuum delivery and hands a floppy baby to me. I'm getting ready to intubate the new specimen, but at that moment the the little critter gives a lusty cry and I can relax.

Scorecard: We've been on call for exactly one hour and five minutes, and done two significant procedures. If this pace keeps up, I won't survive until morning. I take a small slug of DayQuil, just in case.

7:30pm: The LP results are back, and it's a champagne tap! Huge applause for the intern. I have a moment of trepidation when I wonder how much a bottle of decent champagne actually costs these days, but she reassures me that a mere magnum of Martinelli's sparkling cider will suffice.

8:00pm: I've dispatched the intern to admit a 50-ish man with hypertensive urgency, which means his blood pressure is sky-high with some worrying symptoms. In his case this includes a bad headache, so the ER physician orders a CT scan of the brain to make sure the high BPs (200s/120s!) haven't caused any bleeding into the brain. The CT is normal, so off the champagne-tapping intern goes to tuck the man in for the night, with blood pressure medcations and a bit of acetaminophen for the headache.

8:02pm: My instructions to the intern were a bit spotty, because as I was telling her about what to think about in hypertensive urgency, my own pregnant patient is getting close to delivery. She's a 16 year-old first time mother and proceeds to have a beautiful delivery of a baby girl, 7 pounds and 6 ounces. Not for the first time it occurs to me that the body of a teenager is the perfect substrate for a successful delivery, even though we disapprove of teenage parenting for sound socioeconomic reasons.

9:45pm: The dreaded overhead page: "BEEEEEEEEEEEEP: Cardiopulmonary STAT to the Emergency Room! BEEEEEEEEEEEP. The long beep is courtesy of the operator leaning on a telephone key button as she activates the PA system. I get that sinking feeling. What this means is that someone is gravely ill in the ER, and an ICU admission is pending. The alternative is that the patient will not survive resuscitation in the ER and the coroner, not the residents, will be called down to assist.

Confession: All of us have experienced the unbidden hope, when hearing the dreaded overhead call, that the patient will die, and not require a complicated and usually futile ICU admission. Whenever this thought flits through my mind I feel guilty, but I know it is not a purely selfishly motivated impulse. Even a good doctor has a hard time setting limits of care, and the decision-making process at each step of a critically ill patient's care can be an agonizing balancing act between trying to improve the patient's condition and subjecting him or her to invasive procedures or treatments that will--often--be futile.


10:20pm: The intern and I have discussed the hypertensive patient's case, but she wants me to listen to the man's heart to see if there is a murmur. In my vast experience, I've determined that you can't hear anything in the ER, but I trot down dutifully. No murmur. While listening, I'm distracted by the sight of the bustle going on in ER bed #6, otherwise known as the trauma bay. About five nurses are surging around, wearing throwaway plastic gowns and bloody gloves, hanging IV fluids and struggling with a rapid-infusing blood transfusion setup, drawing blood, and dodging the X-ray technician.

I sidle over to the ER attending and say "I see you've got a little present for me." The attending smiles at me wryly and explains that the patient in #6 is a woman who came in vomiting blood, but was able to talk and answer questions in the first few minutes after her arrival. Suddenly she lost consciousness, presumably due to the bleeding, and her blood pressure dropped precipitously. The attending intubated her and the staff put in two huge IVs to push fluids and uncrossmatched blood. I look at the old chart and see there's not much information on this patient: a history of hepatitis C and alcohol abuse. These two facts immediately suggest advanced cirrhosis causing abnormal clotting factors and redistribution of blood flow away from the diseased liver and towards the esophagus and stomach. This abnormal blood flow creates varices, or dilated veins, in this areas which have a tendency to bleed enormous quantities of blood at the smallest perturbation, causing hematemesis, or vomiting huge quantities of bright red blood. This patient is also passing bright red blood from the rectum, which suggests that the bleeding in the esophagus and stomach is so severe that the blood is passing undigested through the entire digestive tract. A very bad sign.

The ER is eager to move this patient up to the ICU, so I start writing orders and call P down to take over the admission. She takes one look at the patient and flies into a panic. "I have to call Dr. T (the gastroenterologist)!" Then, "I think she needs to go to the OR."

"What are they going to do for her in the OR?" I ask with some asperity. "Remove her esophagus, stomach AND liver?" The truth is, this patient is not stable enough to undergo any procedures, and her underlying cirrhosis means that the likelihood of recovery is small even if heroic measures are taken. P and I go back to look at the patient again, and a small fountain of bright red blood is bubbling up from her mouth and dripping down to the floor. I estimate that the two units of blood she has already received have already bled back out. Not a good sign at all.

With P in a panic, I call the Internal Medicine attending myself and explain the gravity of the situation. This is my favorite Medicine attending, an ex-Navy doctor with a foul mouth and a heart of gold. He listens to the story and outlines the dismal prognosis for this patient. The rapid bleeding--outpacing maximal efforts to restore blood and fluid volumes--the laboratory evidence of advanced cirrhosis, and most of all, the critical vital signs (very fast pulse, very low blood pressure) that suggest the patient is in shock--all of this means the patient is probably going to die tonight. As a team, we agree not to resuscitate the patient further, because in the setting of massive blood loss, chest compressions and cardiac medications are unlikely to be of any use.

The orders are written, P has calmed down slightly, and the patient is on her way up to the ICU. There are bloody footprints following her path out the door.


11:30pm: I take a little break in the call room. To be honest, the scene downstairs has cast a pall over the whole evening. Whatever anyone says, the sight of a woman bleeding to death is never routine. I have heard of massive hematemesis before, but have never seen it, and now I have. And don't be fooled by the TV shows, a lot of the most dramatic events in a patient's management are not dramatic at all. After the big IVs have been placed, the blood transfusion started and the endotracheal tube inserted, the most important decisions are made, rather quietly, over the telephone, such as the decision not to resuscitate this patient further, if we are not successful in replacing her lost blood and fluids.

As a member of a team and as an individual, I've made a big swing tonight. That secret hope, after hearing the overhead stat page, that the patient might die, then witnessing the grim scene in the ER which prompted the reasoned decision-making to allow her to die if those desperate initial measures prove to be inadequate. These swings between hope and the attenuation of hope, panic and calm, doing everything and doing what's right, they take a toll after a while. I feel absolutely drained, and it's not just because of this patient in the ICU, but the whole string of patients we've taken care of recently, some who have walked in critically ill after living with a difficult disease for most of their lives. At this point in my training, I can take care of most problems initially, but the constant on-the-edge-of-my-seat gnawing uncertainty and, most of all, WORRY is getting to me.

I'm too old for this.

12:30am: I haven't heard from P about the ICU patient in a while, which might be a good thing but probably isn't. The hospital operator pages me to invite me for a cup of coffee, which is probably what I need before facing the ICU. The operators in our hospital are the heart and soul of the place. They locate patients, send us cheerful pages when someone is looking for us, and, in the middle of the night, brew coffee and hold secret midnight feasts to keep us all hale and hearty. Once my mother, in a panic because she couldn't get hold of me on my phone, cell phone or pager, called the hospital operator who immediately sent out the hounds to look for me. I got a cluster of pages from the other residents who had been informed of my absence: "YOUR MOM IS LOOKING FOR YOU--CALL HER ASAP!!!" When I finally returned home--from going out to dinner, mind you--not only did I have to call my mother but I also had to explain myself to the operators. They were relieved to hear from me, but ticked me off severely for having made my mother worry so much. They're like my aunts--they take my mother's side.

Anyway, Operator Josefa has made coffee, so I partake of some in her office and we chat for a few minutes. Then I excuse myself, thinking I should stop at L&D on my way up to the ICU. Josefa pops her head outside of the switchboard room: "Dr. Chan, they need you in ICU ASAP."

Dammit, dammit, dammit.

12:45am: I sprint up the stairs to the ICU. Now, I have gotten a bit, er, robust over the three years of my residency. All those midnight feasts, you know. But I can still bolt up two flights of stairs without running out of breath, thank you very much. However, as I slow down to a brisk walk as I approach the doors to the ICU, I realize my legs feel as though someone has marinated them in chiles and thrown them on the barbie. I seem to be in some danger of musculoskeltal collapse but I make a good show of strolling to the patient's bedside, cool as a cucumber. P and Dr. J, the on call gastroenterologist (it wasn't Dr. T after all) are wearing throwaway plastic robes, face masks, and gloves and working hard on the patient. They've placed a central line to be able to push plasma in, but the patient's pulse has just decreased steeply--a sign of cardiovascular collpase. Despite the earlier decision to withhold cardiac meds, P has given atropine and epinephrine. I think this is okay to do but I review with P the reasons against resuscitation. Chest compressions and cardiac medicines rely upon an intact circulating volume to be effective. Since most of the patient's circulating volume is currently soaking the sheets and dripping on the floor, atropine and epinephrine aren't going to do anything helpful. Indeed this is the case: after an initial rise in pulse, the patient's heart rate trickles down again and we decide to withdraw care. A quick call to the Medicine attending achieves consensus. The ventilator is turned off, and the patient dies just before 1:00am.

Another confession: There is a feeling of profound relief when a patient you've been very worried about finally dies. Again, it's not just a selfish emotion, the end of the physician's responsibility, but also a relief born of knowing that the suffering has ended.

1:05am: As usual, there's not much time to contemplate our human frailty. The ER is calling to tell me about another admission. A woman with blood in her stools (not nearly as dramatic as the patient who has just died) presented to the ER, where she was noted to be completely jaundiced. The patient herself wasn't troubled by this change in her coloring at all. People are amazing. The intern, who was trying to track me down while we were making the decision to withdraw care from the patient with massive hematemesis, finds me getting off the phone with the ER. Sorry, I tell her--another admit. She's very cheerful about it though. Goes right down to see the patient. That's what a champagne tap will do for a girl.

1:30am: My cold is catching up with me a bit. I'm feeling weary, so it's back to the call room for a sit down. P joins me and we talk for a while about the patient who just died. Reviewing our care, there wasn't anything else we could have done, although many things we could have tried that might have cause more suffering to the patient--not to mention hazardous exposure to the staff--that would not have saved her life. The intern joins us, and we all have a snack from the call room fridge. The intern tells me about the jaundiced patient downstairs. She thinks the patient has ascites, or fluid in the abdomen, and wants my help getting a sample of the fluid for analysis. Great. I take a few healthy swigs of DayQuil to get me through this next challenge.

2:00am: P and I go to see the jaundiced patient together. When I ask her what brought her in to the ER tonight, she mentions only the small amount of blood in her stools. The fact that she is the color of one of the Simpsons has completely escaped her. Feeling her belly, which is the size of a term pregnancy, I can't feel the dull shifting of ascites fluid. So, while the intern organizes the supplies needed for a paracentesis (sampling of ascitic fluid), I run upstairs to get the ultrasound machine from L&D. This is a practice frowned upon by the obstetricians, stealing the ultrasound in the middle of the night to look for ascites or pleural (lung cavity) fluid, but what's a resident to do? I have to know if there is any fluid in this woman's abdomen, and the ultrasound tech is not going to come in at 2am just to mark fluid. I drag the ultrasound onto the elevator, then to the ER. Not an easy task, because the machine weighs maybe 180 pounds and travels on wheels with all the handling capacity of a bad shopping cart. A quick scan of the patient's abdomen reveals no ascites at all (just fat), and I reassure the intern that she'd had a good thought, considering ascites. Better to be wrong than not to think about it.

2:30am: As I return the cumbersome ultrasound to L&D, I realize I've taken too much DayQuil. I'm feeling woozy and there's something wrong with my equilibrium. The nurses laugh at me: Leave it to a doctor to take the wrong dose. Teaches me to use the little cup instead of taking healthy swigs from the bottle. I stagger off to the call room to curl up on the loveseat.

3:00am: I'm woken out of a sound sleep to attend a delivery. Still woozy--the horrible thought passes through my mind that someone might think I was drunk--I stagger down to room 201, where the intern is gowned up, the attending is present, and the patient is pushing. I explain the DayQuil problem and everyone waves me out of the room. Not much good to anyone, at the moment. As I stagger back past the nurses' station, I tell them, "Call me for emergencies only. I'm sicker than average tonight."

5:30am: Wow! I awake to find that over two hours has passed and NO PAGES. The DayQuil has worn off and I can sit upright without the whirlygig inside my head going off. I drink some water and wander out to L&D, where nothing is happening. The intern is rounding on her service, so I keep an eye on things on the Deck. I'm feeling better, and the dawning hope of the end of call lifts my spirits.

7:30am: A few patients have shown up in labor and I've admitted them. The least I could do for the champagne-tapping intern. The day team has arrived and I give them the Board signout on the laboring women. We've done a good job taking care of all the details, so the Board signout is, as I say, tucked in. I take a lot of pride in handing over a Board that is 100% maximally managed, so the next team doesn't have to do a million little things we left behind.

8:00am: Morning Report! We have only a handful of admissions, so we spend some time in the group talking about the woman who died. The attendings review the case and agree that we did everything we could. Interesting, this need we all have to go over and over and over the care of a patient who has a bad outcome. When something bad happens to one of our patients, something bad happens to us, too. That sounds self-centered, and it never comes out right when I try to explain it, but there is a truth at the heart of the statement. This is why I've been so weary lately, burdened by the weight of accumulated "what ifs" and "guess what happeneds."

But this night is finally over. I congratulate the team, and walk out of the building into the sunlight. And I will never, never again take so much DayQuil at once.