Friday, November 28, 2008

The Beatings Will Continue Until Moral Improves...

I am on call tomorrow. Tonight I sit and wait. For those of you unfamiliar with exactly what that involves, allow me to elaborate.

Imagine this: tomorrow morning you will wake up, get dressed, then be marched off to face a firing squad. The anticipation. The agony. Will you be beaten first? Will the shots kill you? Will you know what's coming, and from what direction? As you stand there, blindfolded, contemplating exactly which wrong turn lead to this moment, the waiting seems endless. Suddenly, shots go whizzing past your head; you sense your fallen comrades around you. Walls are crumbling at your feet and chaos is everywhere. When will your turn come? Then, as quickly as it started, the dust settles, and you are marched back to your quarters, where you are told that there has been a stay of execution for you today. You have survived; you get to rest for now. In 3 days, you will face it again. Next time you might only be pummelled with rocks instead.

For any given rotation, this is sort of how it goes...

The day starts anywhere between 4 AM and 6 AM, depending on the rotation. After trying to milk those last few minutes out of the snooze button, as this may be the last bit of rest you get for the entire day, you pry yourself from the bed covers. You grab your call bag, which conveniently stays packed with the essentials: toothbrush, toothpaste, sweatshirt, On-Call reference book, iPod, crackers/snack, cell phone charger, and extra blanket. You don't dare bring a project to work on, as this will ironically assure that you get at least 15 extra admissions.

When you get to the hospital, you pick up the pager from the post-call resident, who has been there for the last 24 hours and just got a call about an admission coming from the ER, who is your problem now. Yay. There are already 10 patients on your list, all of whom you need to see in the next 2 hours, formulate today's plan, answer random questions from the nurses, and write thorough, articulate notes on each one before rounds. And all the while, stay pleasant and polite to everyone, be respectful and attentive. Clearly, part of this plan is flawed and will have to be sacrificed. Your choice which part.

As the pager goes off for the 5th time during pre-rounds, you sort of hit your stride, you've got a bit of a rhythm going, and you just might get done in time to hit Starbucks. Thank God most of your patients are either intubated or asleep, so there's limited patient interaction, as that will considerably slow your progress. The solitary goal of this morning is to see all your old patients, get the orders written, and get the discharges done before the new admissions start pouring in. Too bad for you, that ship has sailed, and you have 3 admissions waiting by the time rounds start at 9.

Rounds are the time when the team discusses each patient and comes up with the plan for the day. They can last anywhere from 15 minutes to 7 hours. There are obviously innumerable variables in this equation, mostly dependent on the number of patients and the attending physician. The nature of rounds is a topic for another blog entirely.

So after rounds are out of the way, the pager goes off again, this time with an emergent situation or a critically ill patient, or any number of other things that demand your complete and urgent attention. By now it's 2 pm and you haven't sat down for longer than 3 minutes, much less had time to eat lunch, so you grab a pack of graham crackers, peanut butter, and a Diet Coke from the nurses station to chow down while you run to see the next catastrophe. Your next patient is very sick, has a dwindling blood pressure, no IV access, and is struggling to breathe. Holy crap, what first? You intubate her, place a large catheter in her subclavian vein for IV access, and start blood pressure medications to keep her heart and blood pumping. She is someone's mother, wife, sister, daughter, and she might live or die based on what you know, your skills in procedures, what you can remember from the last lecture, what resource you can find to help you find the answer, how fast you can think on your feet. At this moment, you are one of God's instruments, and you wish desperately that He didn't trust you with this, call on someone else. One minute she is clinging to life, yet after a few interventions she seems to be hanging on a bit better. The satisfaction of this moment, and a dozen others like it today, is among the reasons why you got out of bed today. Their family sits in the waiting room in agony, looking for any news. One is weeping, others are pacing, and one sits alone with only a blank stare. You struggle to find the words, just the right words, that are not too bleak but still convey the appropriate intensity of this tumultuous situation. At an inappropriate moment in your discussion with the family, your pager goes off again, this time it is the clinic calling about your patient on chronic narcotics whose monthly prescription is due today. Terrific. You add it to your list.

This onslaught continues in varying levels of intensity for the remainder of the evening and will press on into the early morning hours. You watch the day shift people leave, and the night shift arrive, with fresh faces and peppy steps. Ugh, it's 7 PM already? You shrug it off, sneak off for a bite of dinner, and forage ahead. Finally, around 3 AM, all the labs have been checked, the orders written, every urgent page for Tylenol answered, and you selfishly head to the call room. 

The ideal hope: to actually fall asleep for a couple of hours. The actuality: short bursts of horizontal drowsiness, interrupted by call after call. Forget meaningful sleep, or REM cycles, or even a light rest. Your only prayer is that there is not a CODE between now and when you have to get up to start seeing patients again, because this is not the time of the morning to have someone try to die, as your brain is now slowing to a dull crawl. The focus is only on finding a small piece of quiet time, just sweet peace for 5 or 10 minutes, where you can lay still without all the ringing and alarms and paperwork and lists. Surely that is enough to recharge me for tomorrow, which now starts in 20 minutes.

When the alarm goes off at 5 AM, you either:

a) awake with a start, throwing off the covers and knocking your pager to the floor/under the bed in the dark, paranoid that you missed a page while your eyes were closed
b) barely stir because you are comatose from an interrupted REM cycle
c) were awake already and waiting for it to go off because you never got to sleep at all.

Now you are off to pre-round on your patients-- only now with the added challenge of the dense brain fog of sleep deprivation, sore, swollen legs from standing for 20 of the last 24 hours, and the post-call nausea the comes from being awake through 6 mealtimes. Right about now, the day-shift, the same day-shift that was leaving yesterday, is now coming back to the hospital. Resentment towards them turns to actual anger when you think that they have all been home, showered, eaten, and done regular life stuff, all while you have still been digging away in the trenches. Bastards. 

As the morning progresses, you continue to lose speed and mental acuity. You "hit the wall" around 10 AM. Perfect timing, in the middle of rounds, when the details of all your patients are running together, you can't seem to speak coherently, and it takes all you have to just find the next patient. You finally wrap things up for the day, check out your patients to the next on-call team, and head home around 1 PM. You ride with the windows down and the music up so you don't fall asleep in the 20 minutes it takes to drive home. You debate whether the extra 15 minutes it will take to get lunch on the way is worth it, decide that it's not, and keep driving. Your bed has never felt so good. Don't forget to set the alarm, not for this evening, but for the morning, as you will likely sleep from now until tomorrow, when you will get up to do it all again.

As patients, we only see that apparent part of our caretakers' interactions with us, the part where they come in the room, talk to us and our family, listen to our heart and lungs. It is more brief than we think we deserve. Where does the rest of their time go? What else are they doing back there? I hear them cackling and laughing; don't they know I'm waiting? As patients, we do not see the iceberg of time and commitment that lies behind the door: reading old records, checking labs, researching the current medical literature for the latest recommendations, discussing the case with specialists and other physicians and nurses to try to cover every base, documenting the appropriate paperwork, answering phone calls, and a hundred other things that go on day in and day out. 

Expect your physician to treat you like a person, not an illness or a number. We, as physicians, have been entrusted with your lives, your children's lives, your families, and it is the greatest responsibility you can give to another human being. It is deserving of the utmost respect and compassion, and I will do my best to honor that.

It is all I ask, that I also be treated like a person, that you may remember that I am just like you. I go to the gas station and the grocery store and get called for jury duty. I have a family, and I have sacrificed time with them to be here with you. I have heartache and sorrow and sickness; I love and hurt and dream, and I will push forward with everything I have to try to help you now. And it's not for the glory, or the money, or so I can walk down the hall in my long white coat. If you only knew the heavy weights that sit deep in its pockets.

At the end of the day, I do have one of the best jobs in the world. I work with some of the smartest, most compassionate and caring people, whose mission is to teach me how to be the best I can be. I get to make sick people well again. I get to make esoteric science into something with meaning and purpose. I get to play with kids. I get to help families' grieve. I get to give a wake-up call to a heroin addict after a heart attack. I get to hold tiny babies in my hand and see their tiny arms wrap around my fingers. I get to talk a daughter through her grief as she accepts her father's Alzheimer's disease. I get to prevent thousands of illnesses with vaccines, education, and medicines. If it all ended tomorrow, I have still been blessed by the bucket-loads.

With each day, I gain a little more ammunition for my arsenal. I am a little less scared of what will be thrown at me tomorrow. If I can store up enough, I just might make a battle plan of my own.

And so I will face the firing squad again and again and again.


  1. Heather, that was so very beautiful. Such a glimpse into your life that I never would have had; thank you for that. And thank you for your sacrifice. It makes me upset at myself that I have gotten upset in the ER for having to wait too long, or frustrated for something trivial. Thank you for bringing a personal side of the physician's reality to a level where we as the patients can get a glimpse of how hard you all work to keep us healthy...sometimes at the risk of your own precious health. (((HUGS)))

  2. Amen, Sister! Could not have been said better. You should publish this somewhere!