Preface, 2008: Now that I'm re-reading these posts from my old blog, I have to cringe at some of my sappier meditations on the nature of life and death. Not that I have changed my opinion on many important issues--end of life care, for example--but these days I am less poetic and more hard-headed about them. If I were admitting Mr. J tonight, for example, I would no longer presume that 72 hours of observation on a patient with brain death or profound anoxic brain injury was the appropriate plan of care, and I would be more candid about his prognosis when I met with his family. The past six years have given me a better vocabulary, a more direct line of approach when it comes to family meetings.
As for staying late to attend the birth of my own patient, I'm luckier now in that my schedule permits me to make my own decisions about whether to sacrifice sleep for a "special" delivery. Recently, I've had a lovely run of second births with women whose first delivery I attended, and it has conferred a certain ritual of maturation to my professional development.
Here's a few highlights from yesterday's 24 hour call:
6:45am: I arrive early to round on the post-partum mothers in our Mother-Infant Unit. Currently I'm assigned to obstetrics, so this is part of my weekly responsibilities. Sometimes I have to round all by myself, but fortunately the entire OB team is on call today so we divide the mothers up evenly. Rounding on post-partum mothers is relatively quick and straightforward, because most of the moms are healthy young women. I spend a lot of time encouraging breastfeeding and contraception, however. I wish more primary-care doctors took the time during the many months of prenatal care to address these two issues, because it's really hard to give a woman enought information during the 2-3 day postpartum stay for her to make a well-informed or personally satisfying decision about these topics.
8:00am: My notes are done, so I'm off to the Morning Report to hear about the newly-admitted patients. The outgoing call team looks exhausted; that's what we're going to look like tomorrow!
8:30am: Board rounds on Labor and Delivery. The on-call intern runs through the actively-laboring women and then we all report on the postpartum patients on the Mother-Infant Unit. It's nice to sit down and talk things through at the beginning of the call day, because we'll be running around like crazy soon enough.
9:30am: I go upstairs to round with the Intensive Care Unit (ICU) team. As the second-year resident on call, I'm responsible for covering questions and problems about the patients in the ICU. I like to sit in on rounds whenever I can to get a sense for how sick people are and the kind of problems that are likely to arise during the night.
11:30am: I get called to do the first admission of the day--a baby breathing too fast and with a bit of a temperature has to be admitted to the Neonatal Intensive Care Unit (NICU). He's a big boy born by C-section, so this is all probably due to transient tachypnea of the newborn, but alas--he needs to come to the NICU for antibiotics and close observation until his blood cultures are negative. I've done so many of these admissions, they're not much of an intellectual challenge--but the paperwork!
12:30pm: Darn it--another admission. Mr. J is an 86 year old man who had a stroke several months ago, which left him unable to use the left side of his body. He's not able to swallow properly, either, so he receives liquid feedings directly into his jejunum (the second segment of the small intestine) at home. This morning he appeared to choke on his own saliva--always a danger when the muscles that control swallowing are injured by a stroke--and stopped breathing. It took the paramedics 10 minutes to arrive at his home and pronounce him dead on the scene. Then--a tiny bit of cardiac activity. Unfortunately it was asystole--an ineffective heart rhythm that does not produce the heart motion needed to pump blood to the brain or other organs. Mr. J got intubated and received a lot of epinephrine to get his heart going again. He was in asystole for about 20 minutes, however, and by the time he arrived in our emergency room it was apparent he was in a coma caused by twenty minutes of absent circulation to the brain. I have a long talk with the tearful family. Mr. J's primary doctor has already addressed the topic of the limits of care with his family. They tell me that if the possibility exists that Mr. J could return to some level of consciousness in which he was aware of his surroundings, then they want all life-sustaining treatments to be given. If, however, he is in coma, then they would consider withdrawing life-sustaining treaments. This is obviously a well-thought out position on their part, which I admire. What it means for Mr. J, however, is a period of 72 hours of observation to see if he recovers consciousness. His prognosis is poor, and I caution the family that people are unlikely to recover from the hypoxic brain injury that he has probably sustained. Yet now--in the emergency room, with the uncertainty of the next 72 hours looming before us--is not the time to rob them of all hope, so I say we'll wait and see.
2:30pm: I'm called from the ICU, where Dr. Sagemen and I are reviewing Mr. J's orders, to catch the baby at a vacuum-assisted delivery. The fetal heart tones have not been reassuring while the mother has been pushing, so the third-year resident puts a vacuum (picture a big suction cup) on the baby's head and pulls while the mother pushes. This is a method of assisting a vaginal delivery that is less treacherous than using forceps but still higher-risk for the baby. The main problems are trauma to the baby's face if the vacuum is not properly applied--not a common occurrence if the birth attendant examines the position of the baby's head carefully. A more common problem is a cephalohematoma, or big bruise under the scalp where the vacuum was applied. This can cause a lot of stress on the baby and also more neonatal jaundice as the blood inside the bruise is broken down into bilirubin. For these reasons, the birth attendant is limited to 20 minutes of vaccum attempts and no more than three "pop-offs," or loss of vacuum so that the suction cup pops off the baby's head. Fortunately the little boy is born with no pop-offs and give us a lusty howl as soon as he's delivered. Phew! Now all I have to do is fill out six pieces of paper to document the happy event. As Eeyore always says....bother!
3:00pm: Because the other two residents are busy finishing up deliveries, I field a phone call from the ER attending physician. He's asking us to admit a patient whose lab results are not yet available. He says, "well, I'm leaving now, I have to go to the airport, so can you guys get down here and see this patient?" Essentially he's trying to get us to deal with the workup of a patient who may or may not need admission, depending on what his labs show. This situation is a great source of frustration for the residents, because often we get conned into doing admissions that are criticized by other attendings the next day as unnecessary and poorly thought-out. All because the ER doc wants to go to the airport! I politely explain that we're all busy now, we'll get down as soon as possible, and then tell the senior resident what's going on. This is destined to turn out to be a big fight between the ER doc and the accepting physician, with all of us stuck in the middle. Bother!
5:00pm: I take advantage in a little lull in my work to go to Medical Records to plow through a stack of charts that need my signature. This is another bane of a resident's existence. While on call, we have to give a lot of verbal orders for things like Tylenol for headaches, and these verbal orders must be signed within 48 hours. I can never remember who I ordered things for at the end of call, so I don't chase after these charts, and they come back to haunt me in the form of a bunch of nasty pages from the records clerk. More bother!
5:30pm: A more pleasant task--dinner. We decide not to suffer through the cafeteria fare again (Saturday dinner looks suspiciously like Friday's lunch to me) and order pizza. It takes a fair amount of time to negotiate between the vegetarians and the carnivores, the spice lovers and the beige-food contingents. Once the food arrives, however, we are all united. I suppose we could eat a healthier dinner, but this is CALL, remember? There's somthing about being on call that makes me think every meal is my last, so I refuse to sip wheatgrass juice in the name of restraint and high-fiber.
8:00pm: I'm lucky--I'm the second-year on call. This means I get to rest between admissions. So I have a little lie-down in the upstairs lounge and feel only slightly guilty that the poor intern is still trying to run Labor and Delivery.
10:00pm: Back down to Labor and Delivery to catch a baby who manages to get born without my being there, pink and hearty. I admit yet another woman in active labor because the intern is stuck downstairs admitting someone in the ER. Then I stand by for yet another delivery until the intern gets back--interns have first dibs on all deliveries at our program. The baby's heart tones are depressed during the last five minutes of pushing, and he comes out floppy and not breathing. He needs a full seven minutes of resuscitation, but recovers well. Double phew! And now more paperwork.
Midnight: I get to lie down again, but it's not a real sleep. Every half-hour I get a page from the ICU about this patient's blood sugar or that patient's agitation. In between I fall deeply asleep and have to re-orient myself every time the pager goes off. So strange to awaken in the dark lounge, in that stage of REM sleep when your body won't move and your memory can't quite reconstruct a troubled dream.
3:00am: Mr. J has spiked a fever of 104. This is not entirely unexpected--remember that he probably aspirated his own saliva into his lungs, and this occurence can cause a terrible kind of pneumonia that is hard to treat. I order Tylenol and increase his IV fluids--he's already getting antibiotics. The nurse's notes show he is no more conscious than he was upon arrival. His family has been quarreling in the ICU, revealing the tension that taking care of an sick relative can create.
4:00am: Another admission! Mrs. P is a 78 year old woman with really bad emphysema from 65 years of cigarette smoking. She even smokes now, when she needs to use oxygen at home--a big no-no (think explosion). She's also quite demented and comes in with an old diaper on that has not been changed in days. I'm admitting her to the ICU even though she has stabilized nicely after a breathing treatment. She needs to be admitted if only to let the social workers find a skilled nursing facility for her. Unlike Mr. J, she has no family in her life. How does a person get to be 78 years old, and alone? I have to admit, I'm frightened of the possibility of being all alone when I'm old. I have a good friend who lives in Maine; neither of us plan to have children, and we have a deal: once we get to the point of not being able to live alone anymore, we'll band together and look out for each other. Sort of a post-modern Golden Girls, with a Duran Duran soundtrack instead of Frank Sinatra.
5:15am: Well, one of my own patients has arrived in active labor. I say hello and do her admission paperwork, but have to tell her I won't be here when she delivers. The one time I stayed post-call to deliver my patient, I was literally sick to my stomach by the time I got home. Human physiology is largely controlled by the sympathetic (fight or flight) nervous system, which controls the many components of the stress response that make it possible, say, for me to leap to my feet if I hear an emergency page called over head; and the parasympathetic (rest and digest) nervous system, which is reponsible for the maintenance functions of the body, such as digestion, growth, and fertility. My theory is that being on call involves too many continuous hours of fight or flight, and not enough of rest and digestion. Hence the nausea that follows a long night of call. Despite all of this, I feel a twinge of desire to stay for the birth. I love being at the delivery of a woman I've followed for so many months.
5:45am: Time to start rounding on the postpartum mothers again. I'm so very tired, despite those cat-naps I was lucky to get. Sometimes interrupted sleep is worse than no sleep at all, you don't get that buzz of nervous energy that happens when you've been running on fumes for 24 hours. I see three new mothers, only one of whom has the support of the baby's father. The other two live with friends. They're away from their family--one is estranged from her own father, because of her out-of-marriage pregnancy--and I can't help but worry. Then I see them patting their babies, or working hard at breastfeeding, and have to admire the force of nature that is motherhood. Amazing.
8:00am: Morning Report again. We present last night's admissions. I have to prop myself up for the ensuing discussions. I wish I could be in the right mindframe to learn post-call, but I'm simply not superhuman.
8:30am: Very fast postpartum rounds, with a fresh OB attending who sympathizes with our post-call state. Five minutes and done--thank you! Within 20 minutes I'm home and in bed. And five hours later, updating the blog. Not bad, if I do say so myself!
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.