Last Night on Call

The night has only just begun

Another wild thing about graduating as a doctor is that when you write things on a script, patients get them. 

It's no longer an academic exercise of, what would you give the patient?

It's for reals now - what dose? How many times a day? And if you write the wrong dose, chances are the patient will get that dose.

I am grateful every time pharmacy phones me now and says, "Doctor, I just want to double check this dose with you..." or "You wrote furosemide but did you mean hydrochlorothiazide?" Oh my gosh, yes. Please and thank you.

At times, I've looked back on this night and all the stupid questions I asked Belle and I think that woman deserves a tower of chocolates and sweets. 

'Where do I put the file?' 'Where do I put the patient?' 'What's the dose of clexane?' 'Where do I find blood culture bottles?' 'Where do I find the patient's xrays?' 'How do I book an xray?'

She smiled and answered patiently every time. When the clocked ticked to 11pm I wasn't even tired yet, I was just pumped full of adrenaline and overwhelmed. She guided me gently up the stairs to the intern on call room and told me to meet her back at EC at 3am, where we would see the patients referred overnight and then see all the ward patients before the round. I think my eyes grew wider because she tapped me on the shoulder and said, "Don't worry, you're doing just fine."

When my head hit the pillow, the first few minutes were a blur of panicked thoughts that sounded something like, did I do the blood gas for the man with pneumonia? I wonder if that drip is still okay. I forgot to book that xray, I must do it when we get back to EC - 

And then a wall of dark deep black sleep.

When my alarm went off at 3am I scrambled from the bed like I'd been shocked. All the residual adrenaline, I suspect. Sometimes I think back to that night, not knowing what a blessing it was then not to be called by the wards or EC even once during a three hour nap. Not even once. 

I ambled downstairs in a fog a sleepiness and found 3 referrals waiting. 

1. A young girl who overdosed on paracetamol after her fiance broke things off with her. She was on an infusion of the antidote already, and the plan was to monitor her liver function to see if it was coping with the overdose. She was down when I saw her, but seemed fine. The following day I was almost ready to send her home when I got her liver function test, which showed worsening liver damage. When I checked her sugar it was dangerously low. She was sent to high care immediately, where she recovered well. Lesson: wait for labs. Sick people don't always look sick.

2. An older lady of 70 who overdosed on rat poison and herbicide. For those who don't know a lot about rat poison, much like me that morning, it is a superwarfarin - ie it thins the blood dangerously, ultimately killing rats by causing them to bleed to death internally. It takes a while to work, and her blood tests only showed dangerously high risk of bleeding three days after she came in. She had a full healthy life with no hospital admissions before this, but a financial crisis brought her in that morning, wishing her attempt had been successful. It took a few days, but she stabilized, and after some counselling by the psychiatrists, she was assessed to be safe to send home. I hope she's doing well. 

3. A middle-to-older-aged man came in that night, confused and chronically sick-looking. He looked just like a cancer patient to me. On the round that morning, the more experienced doctors felt the same way. But after a workup, no cancer was found. We did, however, find tuberculosis. 

Something astonishing I have learned is that tuberculosis is very, very prevalent; and sometimes it looks nothing like the textbooks tell you it will. You can get TB of the genital system, of the spine, you can get small masses of TB in the brain. You could get a man who came from a home where he lived with one other person who wasn't ill and he has TB too. 

This man, for some reason, reminded me of someone in my family. I saw him every day, checked his labs, checked he was getting his treatment, assessed if his confusion was improving or not. He was quite sick, and thin, and I kept talking to him gently every day, looking for signs of improvement. TB treatment has come a long way, and I was expecting his recovery and return to baseline any day. 

The next time I was on call, I found him behind a white hospital curtain, having stopped breathing. 

I walked into the room and felt my jaw slacken. 'No,' I said softly, approaching the bed. 'No.'

He lay there, still, one of his eyes half open, his mouth stained orange from the TB drugs. Still so sick-looking. So thin. 

Gone. 

Something cracked in my chest. I was snapped back into reality when one of the nurses walked in, to tell me the death notification book was waiting in the doctors room. 

'Thanks, on my way,' I said softly to her. 

No response to stimulation. No central or peripheral pulses. No breath sounds or heart sounds on auscultation. Pupils fixed and dilated in response to light. Body cooling, rigor mortis setting in. I had done an assessment like this earlier in the day, when I could hear him breathing, and now it was just gone. I wrote all the legal things.

I closed the curtain behind me and felt the crack in my chest aching. I think it was because he reminded me of a family member, and in that moment the reality of mortality was hitting me, right in the center of my being. 

I wrote the legal notification numbly. I felt something rising from that hurt, something heavy like tears. But my phone rang. I had another someone to go and see to. There was no time to sit calmly with my heaviness, no time to allow it to bleed out and heal. No debriefing. 

So I did what we all do: I swept it beneath the latest patient and carried on.