Stories from a Night On-Call

Stories From a Night On-Call or How I Spent My Youth

Saying Goodbye

Mr. T.Y. had difficult problems.  He was a 60 something pipe fitter who was suffering from metabolic disease.  Metabolic disease is a term that doctors use to lump together health problems that are related to problems with glucose and fat metabolism and often lead to heart attacks, stroke and kidney diseases.  Mr. T.Y. was overweight, had high blood pressure, diabetes, kidney disease, and he had some smoking-related lung disease.  

I had met him several times over my first two years of my internal medicine residency.  Usually we met late at night in the emergency room.  He would come in, finding it hard to breathe, leaning forward on his swollen knees huffing and puffing saying “Doc, I just can’t catch my breath, my feet have swollen up and I feel like crap”.  Our usual routine was to do some tests, and start him on some diuretics; often he was suffering from heart failure related to underlying heart disease.  Often he had angina; many times he had mild renal failure.  He usually responded well to treatment, and would go home in a few days, feeling much better.

This night was different.  Mr. T.Y. had been having more frequent visits for heart failure, and angina. I was the resident on-call to the coronary care unit, or CCU.  Mr. T.Y. came into emergency  and was having a lot of trouble.  He needed oxygen and his ECG showed that his heart rate was irregular and rapid.  Blood work showed that he was acidotic and his kidneys were not functioning well things looked worse than usual and Mr. T.Y. just didn’t have his usual good humor.  

He had been on the ward and in the CCU, before and my colleagues and I had been up many nights, helping him weather the storm.  As a resident doctor, I was fortunate to work with excellent Cardiologists, and nursing staff who taught me a lot about managing acute problems like this - it was fairly routine, and I was comfortable with managing this type of problem.  I’d grown fond of Mr. T.Y. over the past couple of years, and he knew me well.  We had the kind of rapport that showed respect for one another - he the great big hulking bear of a man that he was, and I the somewhat small female resident who had been part of his recovery countless times.  I’m pretty certain the first time he met me he had his doubts - but he soon came to realise that I and my resident colleagues were hard working and dedicated and supported by excellent caring teaching staff and nurses.  

This time Mr. T.Y. was more restless, he just wouldn’t / couldn’t settle.  His breathing was labored, he was sweaty and hot, and had a lot of time getting in and out of bed.  We worked for a couple of hours giving him diuretics, oxygen and CPAP (Continuous positive airway pressure) - which often reduces the fluid in the pulmonary bed, easing the shortness of breath.  Mr. T.Y’s kidneys just weren’t cooperating in spite of state of the art therapy.  

I remember pausing at the bedside and looking at the nurse, who looked back at me. it was about 2 AM and Mr. T.Y. was just not getting any better.  Together we did not know what else to do.  Mr. T.Y. suddenly sat up at the edge of the bed and said breathlessly:  “Doc, I just can’t do it anymore, I want you to let me go”.  I tried to reassure him and the nurse and I both gently urged him to lay back.  He was resistant, he had a far off look on his face, a sad look.  He just looked at me as I reassured him that soon things would start to respond.  He was weak and teetering on the edge of the bed, but agreed to lay down when I pointed out that he might fall and it would be tough to help him back into bed”.  Then he just simply stopped breathing and died.  

Trial By Fire

It was my first week as an internal medicine resident.  I was in a new city, I didn’t know anyone, and I felt very alone, scared, and inadequate.  For several weeks before July 2, the official start date of my new life as a resident in internal medicine, I had felt this way. Terrified.  I was coming from another city. I had not done an elective as a medical student in this city, so I was unfamiliar with everything.  On top of this, I felt woefully unprepared to act as a resident doctor.  Even though I had my bright shiny new MD, it didn’t feel real.  After all I was just, well, me.  Young, inexperienced female.  I’d never really had a serious job at least not one that was life and death.  I’d never held a position of “authority” and at least as a medical student, I considered residents to be “authorities” by the way.   I did not want to screw up.  I did not want to make mistakes that might hurt patients, miss diagnoses that might cause long-term injury or death.  I didn’t know drug dosages; after all I had never really ordered anything other than the occasional insulin dose or aspirin (these things, the more senior house staff considered boring, easy and beneath them which by the way, is patently wrong).  I had spent a lot of time “watching” residents do these things; but as a medical student, I had had very little “authority” in my alma mater.  Everything was doubly and triply cosigned and there was a lot of competition for even the most basic procedure; as it should be with an inexperienced young clerk.  Here I was in a very different place where the medical students ran codes, drew blood, did their own ECG’s and all kinds of procedures.  Students routinely ordered drugs and tests, all without co-signatures!  There was oversight, but it was much different than what I had experienced.  It all scared the crap out of me.

My first day on the ward, I was On CTU Purple.  CTU means “clinical teaching unit” and charts on different teams were differentiated by a colored tag.  I met 2 other residents on the other team at my hospital, and found out that one resident was away.  Neither of them seemed particularly scared to me, and I did not share with them my abject terror at being a doctor!  I had hoped that I would not be alone in my fear, and that there would be someone to nurture me until I felt like I had some clue about where I was and what I was doing.  However, this was not to be. I was going to be alone with my staff man Dr. Z. , at least until the fourth resident returned from vacation; surely she was to be on our team.  

Dr. Z. was a favorite of the students, staff and residents.  He was a solid clinician, and a good teacher.  He was a divorced, middle-aged handsome man with a no-nonsense manner.  He dressed a bit older than his age wearing suspenders under his white coat.  Personality-wise, he was not warm and fuzzy, and he was distinctly unimpressed to find himself saddled with me; immediately recognizing that I was woefully inadequate compared to the house staff he was accustomed to.  He looked me up and down, pointed me in the general direction of the charts and told me to get to work.  He had a reputation for working hard, ran a busy consultative practice and inpatient internal medicine service.  His colleagues loved him and everyone knew that Dr. Z. would take care of complicated cases no matter what.  His pager was constantly going off with Dr. So and So on the other end asking for his help.  He really was tireless, and I must have looked totally ridiculous the first day, trailing after him in my long white coat with my pockets bulging with tools and books like “The Washington Manual of Medical Therapeutics”, “Sanford” - the infectious disease pocket bible, a pocket ECG bible, and an “on-call” reference guide for residents, literally scared out of my wits.  What I would have given for the smart phones the residents carry now!

On my first day,  we had 5 inpatients that I had to familiarize myself with.  That seemed to me like a good days work ,and in fact was about the right resident:patient ratio in my opinion, based on my experience in my alma mater.   Dr. Z. had not reviewed the patients with me, instead advising me to familiarize myself with them and round on them; he would be back in a while to go over things with me.  As I pulled the first chart off of the cart, the nurse asked me to check on Mr. T. who was having trouble voiding.  Mr. T. was a 75 year-old man admitted with pneumonia, who was ready to go home; save for the fact that he couldn’t pass his urine.  He was hard of hearing and I had to yell as I peered over  the bed to find out what the problem was.  I remember struggling to think of something other than prostatic hypertrophy that might cause difficulty voiding. I had no experience with urology, I couldn’t remember much else and my manuals were failing me.  I had even less experience with 75-year-old men who were hard of hearing.

It must have taken me 2 hours to figure out that the most likely problem was actually constipation! In the meantime, Dr. Z. had returned, expecting that I would be done rounding on all 5 of the patients, ready to give him an overview and move on the consults in other areas of the hospital.   I had not yet even looked at the other 4 charts!  He probably cringed inside but said nothing.  In about 30 minutes we finished rounding on the other 4 patients, and just as we did, his pager went off and we were called to do a consult in the emergency room.  

The emergency room was a big open area with a large nursing desk in the middle.  At the periphery were curtained rooms, each with patient behind it.  There were a dozen or so of these curtained rooms and most of them were filled.  off to each end there was a bigger room with a table, surgical light and a host of equipment - ventilator, monitor, and surgical set ups.  It was in this room that we were greeted by the emergency room doc who advised Dr. Z. of a woman, who had come in with a hypertensive crisis, and was literally writhing on the bed, confused, disoriented with chest pain.  The monitors showed that she was tachycardic and her blood pressure was 220/118!!! Normal blood pressure is ideally less than 140/90 and as it gets higher and higher there is greater pressure on many vital organs, including the heart, kidneys and brain.  It’s a very dangerous situation.  Everything came into vivid focus for me.  I realized that I needed to get over my terror, stop feeling sorry for myself, and start paying attention because these were serious issues and people could die.  I vaguely pined for my alma mater where sick patients like this would be seen by the senior resident first, who would stabilise her, write orders and the admission history and physical and then send her to the ward for the junior resident (me) to assume ongoing care.  This woman, Mrs. B, was 70 years old was in seriously unstable condition and I had no idea what to do, and no Senior resident to shield her from me; I just had Dr. Z. who was increasingly unhappy with me.  Without so much as a blink, Dr. Z. stepped into action, he took a history, examined the patient, while giving the nurse orders to administer an antihypertensive drip that quickly lowered this patient’s blood pressure to safer levels; but not so low that she would have a stroke.  All of this seemed to transpire within minutes.  He then wrote up admission orders, turned to me and said - “write up the history and physical” and meet me in dialysis in 15 minutes.  I gulped.  Fifteen minutes, I don’t think I’d ever done a history and physical in less than 2 hours!.  At least the patient was stable and I had learned a few things about how a doc might approach a sick patient like this.  I knew I was in over my head, but I was determined to do my best.

As the day wore on things just got worse.  By 5:00 that night, we were admitting our 13th patient.  Our service, now up to 18 patients, seemed to be bursting at the seams.  I noted that my colleagues, two of them, on the other team had not done any admissions that day and shared about 12 patients between the two of them.  A bit envious, tired and overwhelmed, I asked Dr. Z. just when he was going to “cap” our CTU.  Where I had come from, a team with a senior, 3 junior residents, and 2-3 medical students was capped at 15 patients.  It seemed an entirely reasonable question to me, especially given that it was just the two of us and I wasn’t much help.  At this point in the day, after realizing that I was completely inept, Dr. Z. turned to me, one hand on his hip, the other elbow on the desk and said “Well, you just let me know when you’ve had enough”.  And with that he turned abruptly and continued to write orders.  That night, I went home feeling stupid, and defeated, and I had a very bad feeling in my gut.  I was not sure I was going to survive two months of this, and this was day 1.

The next couple of weeks were a blur.  I scrambled furiously to get through the ward rounds, take efficient histories and physical examinations in the emergency room and learn how to be a doctor.  Every night, I fell into bed, exhausted at midnight, after getting home at 8:00 pm, and reading around my patients, frantically trying to make up for my inadequacy.  I was quietly angry as well.  I felt that my alma mater had failed to prepare me for this job as a junior resident, angry that I came from a system that didn’t expect this kind of service and competency until the third year of residency.  It was daunting.  I had an “internal medicine headache” for the first two weeks.  

My first night on-call came on day 3.  I was dreading it and the medical student, (now a cardiologist), offered reassuring works, and to lent me his on-call manual (which offers a coles-notes version of an approach to many acute-care problems residents see at night), as he headed out the door.  I and one medical student were covering the medicine service that night which included the ward, emergency room and the ICU.  My first patient, was someone in renal failure, who was short of breath, and going downhill fast.  the nurse paged me and said that the staff doctor wanted me to draw blood gases to evaluate this patient’s response to treatment so far.  I had never collected blood gases and had no idea how to do this.  I was saved by one of the other residents who knew and offered to do them for me.  I watched, but still, this was the closest I had been to this procedure , and had yet to do one.  I gulped, hoping and praying that it would be a quiet night, and that no one would need me.  

This was not to be.  As the night wore on, things got busy and I found myself being paged from ward to ward, bed to bed, and to the ER and back.  I managed to investigate a fever here, chest pain there, high blood pressure, shortness of breath.  Each time I would call the on-call internist and relay what I had found and done.  I’m sure it was painful for them as well as usually such routine calls were not needed.  I however needed to be sure I was not going to miss anything.  I was called to the ICU by one of the nurses who had a patient with a tachycardia.  As I sat down to look at the ECG, she laughed at me because I pulled out my ECG handbook to work through the tracing; again not wanting to miss anything - this was ICU after all, and I had never ever had any experience in an ICU.  There was a staff physician on-call to whom I would report, but I did not want to appear completely stupid.  It was painful to endure this type of treatment.  Many of the nurses were very helpful and sympathetic, but a significant few were harsh, rude, unsupportive and just plain mean.  I am forever grateful and indebted to those nurses who walked me through my very first blood gas collection, resuscitation in the ER, running a code on the ward.  I soon came to realise that the nurses could make you or break you, and those who were supportive, sympathetic, and helpful greatly enhanced my learning.  At the end of that night, just as I finally got to sleep exhausted and ragged, filled with self-doubt and worry, my code pager went off.  

In those days, every resident carried their own pager, and the on-call resident carried the “code” pager.  Code pagers were carried by several members of the team  usually nursing staff who were in charge of the code chart, a respiratory technician who could help with patient ventilation, a medicine resident and a surgical resident.  This was the team that went to all resuscitations.  Codes were called for any patient who didn’t have a pulse, wasn’t breathing, or had dangerously low blood pressure.  I awoke with a start and ran to the ER where I was called to assist with the  resuscitation of a 25 year-old woman who came in with a pulseless arrest after her car was T-boned on the highway.  It was 6:30 am.  We worked frantically, everyone, even me, seemed to have a job to do.  Nothing was working.  I noticed that the patient’s left chest seemed to be more tympanic than the right when I percussed.  her trachea was deviated to the right.  Gingerly I inserted a 16 gauge needle, to relived the air pressure on that side, but nothing happened.  The surgical resident, thankfully, was a senior resident and he immediately inserted a chest tube, which relieved the pressure caused by a puncture in the wall of the pleura (the lining between the lung and the chest wall).  It was too late however, and in spite of this, our young patient died.  

I left the ER, stunned, saddened.  I had been practicing codes in my head, every day, scared that I wouldn’t know what to do.  I had been certified in ACLS and knew that book well.  It was the one thing that I knew.   I knew that we had done everything we could.  The surgical resident was familiar with ACLS, the ICU nurse on the team, was also ACLS certified and knew the protocols as well.  This was not a failure of our attempts, it was just fate.  The surgical resident and I had bonded in that moment, and whenever I saw him after that in the next 3 years, he was friendly, respectful and we both remembered what had happened here today.

It was too late to go back to bed.  I went to the ward to do some rounds before our teaching rounds began at 08:00.  When I gathered in the teaching room with the other residents, and relayed the nights events, ending with the unsuccessful code, I could see a change in their attitude towards me.  One of the residents, an arrogant, blonde athletic man of about 25 had been particularly hard on me since I had arrived.  He was often excluding me or scoffing at my questions and answers to cases presented in rounds.  He had seen me a clearly incompetent, but now I seemed to have passed some kind of test, I was one of them. 

Over the next few weeks, slowly things started to change.  I started to feel more comfortable, and was no longer terrified, no longer going to bed with the “internal medicine headache”.  I was familiar with the hospital, the staff now greeted me, and most of the nurses were  supportive and collegial.  The other residents, recognizing my ineptitude, who had been instrumental in  helping me catch on, offering advice, sharing their manuals on call and just generally propping me up now saw me as a colleague.  I belonged.