Last Night on Call

I Want To Resign, Take 1

It was everybody else's last day in internal medicine.

I was on call.

I was going to be alone from 10pm.

And it was the day before Easter weekend.

Result : chaos.

Patient after patient, the files never stopped.

A 29 year old woman presented with shortness of breath. On chest xray she had a white out of her right lung, meaning we couldn't see any normal tissue. The team attempted to put a needle in and remove the fluid they thought was around the lung, but nothing came out but a little bit of blood. 

When my senior placed an ultrasound probe on her chest, what bloomed on the screen was a big mass - behind it was some fluid. Even with a spinal needle, it was difficult to get it out. 

The clock struck 10pm, and my senior was on route out for the night. I was going to be alone until the next morning. There was just one more to see on the list. I smiled and waved as he left. "Call if you need," he said. 

I had just finished my notes and was about to head to the next patient, when a lady on a bed next to me caught my attention. "There is something wrong with that man." She pointed to a bed close to hers. The man was on his back, shaking softly. I looked around the EC, but other than me, hardly anyone was around. A code blue had been called in the ward on the first floor, and the emergency doctors had run to sort it out. 

I called the nurse and asked for 10mg diazepam immediately to stop the seizing. Luckily the man had a drip line in already. The diazepam went in, and he slowly, slowly stopped shaking. I looked at the tag around his arm, and he was the man I was set to see next. I sighed. Well, obviously, with my luck.

I opened the file, which started with a referral letter from the clinic. A 40 year old male, HIV positive with a very low CD4 count (i.e. advanced disease) who kept defaulting his medication, came to the clinic acutely confused, with a depressed level of consciousness. We measure this on a scale of 15 to 3, 15 being fully awake and alert, 3 being in a coma. When he left the clinic, he was a 12.

Someone from the emergency room saw him at 5pm that day, and at that stage his GCS had dropped to 6. That means he should have had a pipe in his throat to help him breathe. He should have been in the resuscitation room, not here in the general EC, wedged between two stable people, ignored for 6 hours.

At this stage, he began to seize again, and I called the nurse to give another 10mg of diazepam. I knew I was way out of my depth, so I called my senior and explained.

"What were the notes from the EC consultant?" He asked me.

I paged through the notes. "Says here he is not for LP or a CT of the brain. He's for stabilizing and review."

I turned the page and saw that a blood gas had been done around that time, it showed that he was acidosis, with a potassium of nine, circled in pen.

"Shit, his potassium was nine," I said, paging to the medication script. "And he wasn't shifted."

"You need to call the referral hospital, " my senior said. "Tell them the story and see if they will take him for an emergency brain scan. It sounds like he might have TB meningitis with a hydrocephalus."

I called. They told me it sounded like the team at my hospital had already decided he wasn't for resuscitation, as he wasn't intubated, and that it didn't sound like he was safe to transfer.

He hadn't stopped seizing, so I loaded him with antiseizure medication and pushed two potassium shifts.

There was no ECG so I had to do my own one.

After the shift, I needed to take blood from him and run it through the blood gas analyser to see if it was working. So I placed my tourniquet and found a vein, and tried to take a sample. But it wasn't working, so I withdraw the needle to try another vein.

It happened then, so suddenly and so unexpectedly. The needle pricked my skin, so sharp and so quick, like a knife into butter.

The world stopped as I processed.

No. No, no, no, no. No ways. Not to me. No. Please.

I dropped the syringe like it was a hot coal.

Everything was a blur: a swirl of bleeding my own finger into a sink, whimpering to the EC doctor who'd been helping me, waves of panic crashing through me, tears streaming down my cheeks. 

I made one mistake.

Couldn't it have been a simple heart failure patient? Why did it have to be a man dying, HIV swarming his system, a man too sick to be resuscitated?

Forms were handed into my shaking hands, my blood had to be taken, I had to take more of his blood for tests. The feel of that needle forever changed in my hands, the sight of his blood a terror to me now. 

"Don't look at the results," one of the doctors said to me. "You'll just freak yourself out. Take your ARVs every day. The seroconversion rate is almost nothing. You'll be okay." 

But I didn't feel okay. 

I felt so angry at myself - how could I let this happen? I felt so angry at the patient - why couldn't he just take his medication? Why wasn't I concentrating?

Why did I choose this job? 

I wanted to resign. I didn't want this to be happening to me. 

I swallowed my first ARV tablet and held the rest of the bottle in my hand like it would save my life. When I went upstairs for my break, I wept my panic onto the pillow until I slept. 

The man died the following day.

And I just had to keep on keeping on, like this hadn't happened. I had to keep seeing patients and taking blood and being a doctor.

I couldn't be a patient.