On call

I am post-call, so this post will be post-call, angular, unedited or strangely so. Like the jokes you make post-call, this post may be just a little too sloppy, a little too specific, a little too true.

The worst part of call is the anticipation of call. The night before, everything feels extreme and over-precious. I have to read just one more book to E because I won’t see her again for almost FORTY-EIGHT WHOLE HOURS. I stroke her hair. I snuggle her little body close. “I have to remember her smell,” I think to myself, as if I am being deported to interstellar space on a mission of national importance with no return ticket. Later, instead of sleeping, which is the only rational way to prepare, I decide to stay up with C watching a movie, because I deserve it in advance. Or I waste a precious hour of sleep reading about the 27 most important things your grandparents would want you to know on buzzfeed. On some level, it feels like if I don’t go to sleep, call won’t come.

The vibrations of my phone alarm signal the worst hour of the whole enterprise. I lie in bed and worry. What if E doesn’t wake up from her sleep? What if the brief migraines I have been having turn out to be a massive AVM and I bleed into it and die before I see C and E again? I’m too tired to do it. I just can’t do it, I think to myself. I just can’t do it again. I don’t have it in me. I wish for death. Not really. But sort of. Or maybe just a permanent disability. Then I get up and stumble through the dark like a blind person getting ready as my most loved ones sigh and shift in their sleep. I only own five pairs of scrubs and have spent more than 5000 hours in them since medical school. In my scrubs I am neither fat nor thin, short nor tall, beautiful nor ugly, girl nor boy. I am just a person who is capable of continuing to function no matter what. The drive to work in the shuttered, sleeping world is ethereal. On the radio, BBC world is telling me about Italian tire factories or sex workers in Malaysia and I am balancing my open container of yogurt between my thighs and trying to avoid black ice. I pray to nobody and everybody: Please don’t let me make a mistake and hurt someone.

Here’s what I love about my job: The faces of children, marked by whatever emotion they are inhabiting in the moment. I love the moment when, despite the chronic exhaustion, despite the parent’s fear and frustration, despite the child’s innate distrust of strangers, you make a connection. You make them laugh, or you acknowledge their fear, and something in the room shifts. You answer a scary question and it is less scary. The kid who is initially clawing at their mother and crying ends up holding the stethoscope against their own chest and they look up at you with curiosity as you hear the familiar acoustics of a beating heart.

Once I step into the workroom to get signout on my patients, the worst part of call — the resistance to call — is over. Now the only way through is through. My co-resident confided to me that he writes the hours 1 – 30 out on a piece of paper and X’s off each hour as it passes. The inevitability of time’s motion will carry you through. As I assemble the little idiosyncratic bundle of checklists and signouts that will be my point of orientation for the next 30 hours, I feel like I imagine any athlete might before the jump, before the climb, before the big game. I’ve done this before, I remember. I can do it again.

What is a more effective method of teaching and learning: Meticulous apprenticeship or trial by fire? Nurses at the hospital where I work are oriented for weeks, even months, to a particular floor before they are allowed to work independently. They work alongside an experienced nurse, first watching them, then being observed and critiqued by them. They are taught exactly what to do. As a resident I switch to a new floor every month — which usually means a new organ system or set of diseases — and am lucky if someone tells me where the staff fridge is. Maybe there is a handout or binder with information on the most common order sets for that floor or the phone numbers of the case manager and social worker. But as far as decision-making goes, it’s luck and guts and humility and intuition and misses and near misses. There are always people you can reach out to for advice, but you have to know what you don’t know.

Yesterday I arrived on the Cardiology floor for the first time ever at 6am and twelve hours later I was the one fielding all the floor calls from nurses who in some cases have been taking care of cardiac patients for 10-15 years. “Can we give the anti-rejection meds for this heart transplant patient late? They’re down at radiology.” Um, sure? Or no? “Is 2000mg of magnesium too much for a patient with heart failure?” (Me making a thinking sound as I madly look up magnesium dosing in the hospital formulary.) “Baby P with the BT shunt looks a little blue and his sats are down. Can you come take a look?” You better fucking believe I’ll come take a look. I will be running there. All I know about BT shunts is what was in the handout I was given just this morning: “BT shunts carry 15% mortality. They can clot off anytime. If anyone is concerned about a patient with a BT shunt, assess them right away.” The last resident on this rotation told me that he was paged about a BT shunt patient who was vomiting and before he could slip on his shoes the child went into bradycardic arrest. As I am staring down at the patient’s tiny blue hands, I am grateful for each of the thousands of hours I have spent assessing patients and watching other people assess patients. At least I know where to begin. Mental status, perfusion, vitals, physical exam. All the hard-won habits.

When I am called to a bedside to assess a sick child, I try to assemble as many other people around me as possible — the parents, the nurse, a respiratory therapist.  Anyone with eyes and, preferably, more experience than me. I listen, I try to make a good decision, I elicit feedback on my decisions. As more time passes and I get a little better at this job, I am more confident about what I know and more confident in admitting what I don’t know and asking for help. During a 30 hour call, one thought dominates: What could I be missing?

For me, all calls contain the following elements:

1) The click: Sometimes only once, sometimes more than once, you make a decision, you have a good conversation with a family, you get in the groove with a nurse, you help a patient get better and you think: I nailed that one. Maybe I am, in fact, learning something. This moment is usually followed by:

2) The total fail: No matter how many times you make your list and check it twice, you will inevitably miss something — you didn’t look in the ears?! you didn’t order a lipase?! or bigger, scarier things like forgetting to get antibiotics approved. Often this mistake will become the disproportionate focus of the team on rounds. I have learned to embrace the total fail. It’s like the imperfection in the Persian rug through which God is allowed to enter. I am imperfect!, I want to shout into the whirring fluorescent hospital lights, I am broken and divine! (Actually, I obsess endlessly over these mistakes whether small or large and have great difficulty forgiving myself.)

Corollaries to the click and the total fail are:

3) The tiny point of light: The attending turns to you and asks a question like, “What was the last bicarb on the previous admission?” And from somewhere in the recesses of your exhausted, addled, overstuffed mind, the right answer pops out: 16! The human brain is a miraculous thing. Everyone seems impressed even though they are all also using the electronic medical record via which this piece of information is readily available. There there’s:

4) The endless sea of ridiculously specific questions you don’t know the answer to: “What dose of metoprolol was this patient on in 2012?” “Was the pancreatic duct visualized on the CT scan three years ago?” “Do you know if this patient has ever seen a dermatologist?” Um, no idea, don’t know, and no. This was my sixth admission last night and I’m not a soothsayer.

And no call would be complete without:

5) An assortment of bizarre physical sensations: A hand momentarily goes numb. I am awoken from the abyss of sleep by my pager and I jerk out of bed, convinced that I am lying in a pool of water. I catch a glimpse of one of my own hairs out of the corner of my eye and am momentarily convinced that there is a squirrel running up the wall. The exhausted human mind is a den of snakes. And:

6) An interpersonal glitch: On every call someone will do something so strangely anti-social, so rude, or so galling that you have to sit back and marvel. It might be a nurse, a fellow resident, and attending, a patient or a patient’s parent, or (most likely) a subspecialist consultant whom you are forced to call overnight. The other night I had to call the dermatologist on call (key words being “on call”) and he said, “Um, I’m trying to sleep.” Ha! Sorry, buddy, we’re all here in the hospital trying to take care of sick people! Everyone who is working overnight is at least a little tried and stressed out. It’s a cauldron of bad behavior. Then again, people are also the kindest to each other during these moments. It can go one of two ways. When you encounter people who are kind to you in spite of an annoying request you are forced to make of them, you remember that forever. Similarly, when someone lets slip a racist comment or yells at you over the phone, you remember that forever too. The stress of call has a searing effect on memory (though not the kind of memory that helps you memorize the nuances of pathophysiology).

Call time is a vortex. Admitting a patient at 2am, you have to keep asking them, “Do you mean yesterday, like the yesterday that just happened or the yesterday before yesterday?” The cafeteria closes at 7:30pm and you can almost never make it there even if you start trying to get there at 4:30. You can complete a five page note in ten minutes and then it can take you 45 minutes to figure out what the right home dose of a seizure medication is. One minute it’s 5pm, then next its 2am and you still haven’t finished your admission notes from the daytime. I am getting off the elevator on my way out of work and a woman gets on the elevator with two pieces of pizza and a Diet Coke. “Ew,” I think to myself, “who eats sausage pizza for breakfast?” Then I remember that it is actually noon. Since I started work, that woman had gotten up, eaten breakfast, come to work, eaten lunch, worked some more, went home, ate dinner, slept all night, gotten up, eaten breakfast, come to work, worked all morning, and gotten her lunch. No matter how you cut it, it’s just crazy. As the hospital doors slide open, my eyes sting with the light and the cold and the wind.

The end of call should be the best part, but for me the best part is when the first of my colleagues arrives for signout in the morning. A blessing on the head of each of my co-residents who, moored to their own undulating schedule of exhaustion and relief, has rescued me from the solitary crucible of call. It’s so nice to be able to run a decision by someone, to laugh about that crazy thing that mom said, to hand a patient back to the clinician who knows them best, hopefully none the worse for their time in your care. It is a tradition that the on call person brings the post-call person breakfast and no eggs are ever sweeter than those eggs. The only thing worse than call would be having to take it all alone.

And then it all begins again. Driving home, I have to put the car in park at each stop light because I am nodding off. My body feels too light and too heavy at the same time. This afternoon, I will sleep without any awareness of time and space, then the ecstatic reunion. “Mommy!!!” E will shout and then run in the opposite direction because that’s her way of saying hello. There will be cuddling. There will be cookies. I will not demand anything of myself nor will I make healthy food choices. I will rest because I will be capable of almost nothing else. The post-call flop-out doesn’t cancel out the exhaustion and stress but it does help.

One thing I have learned from residency is that it is hard to kill a human. The patients I am taking care of these days have one, two, even more holes and misdirected parts in their hearts. They undergo surgery after surgery, unattaching and reattaching their vessels too many times, and yet still, the blood finds its path through the madmade maze. Life is amazingly committed to its own continuation. The same, I think, can be said of people’s souls. People are remarkably resilient! They find a way, in spite of everything, to survive.