In order of awesomeness

Things that are awesome:

1. Chicken schwarma for dinner
2. Pictures of Sam on the Golden Gate Bridge
3. Three tickets to Tuscany for my vacation in April
4. A day off from night float

In no particular order

Things that suck:

1. Night float
2. Night float
3. Night float

Night float

It's almost 2 AM and I'm camped out in what passes for a "hotel room" in our hospital. It looks more like a drab dorm room: narrow twin bed, non-functional lamp, cramped desk. Even the alarm clock is broken. Tonight's my second of fourteen nights on night float and my pager has been relatively quiet but I can't sleep because a) ever the pessimist, I drank an enormous quantity of coffee four hours ago and b) I'm waiting for a repeat hematocrit on a bleeding patient, anxiously refreshing and refreshing my computer screen.


Night float is a necessary evil in medical training. In years past, before new limits on duty hours for residents were adopted, the on-call resident handled cross-cover and admissions, but this genius system resulted in marathon shifts lasting far longer than the supposedly enlighted 30 hour maximum that's the current standard. So now we have night float and for the next two weeks, I'm it. My shift starts around 8 PM and lasts until the primary interns and residents return to the hospital in the morning to resume care of their patients. I cover patients for 12 doctors overnight -- typically about 80 -- but I'm not responsible for admitting new patients. All night long, I answer pages about Ambien and hypotension, I follow-up on recommendations made by subspecialty consultants, and I see and evaluate patients for whatever comes up overnight: pain, agitation, abnormal vital signs.


Night float is generally considered to be a pretty miserable time, and so far, I'd say that's right. It's lonely, it's boring, it's annoying, it's frightening. The good stuff about residency -- the honor of a patient's trust, the commaradie among residents, the satisfaction in mastering a new skill -- is essentially absent. What's left is the chaff of residency: paperwork, a never-ending succession of pages, uncertainty and inadequacy. For instance, I just took a break from writing this post to see a patient downstairs who's nauseated and vomiting. I have no idea why he's vomiting. A quick review of his chart reveals that the vomiting is a new problem for him, so the doctors who know him well haven't left me any clues. He could have an infection, or the vomiting could be the result of his kidney disease, or maybe it's from the medicines we're giving him. I suppose he could have an entirely new problem: heart attacks and pancreatitis can cause vomiting. So can a million other conditions, like migraine headaches, toxic exposures, small bowel obstructions. But my patient doesn't have a fever or an elevated white blood count. He's getting regular dialysis that appears to be adequate. He has no additional symptoms like chest pain, abdominal pain, headache. So here I am. Other than medication to treat his nausea and a couple of simple blood tests that I don't expect to be spectacularly revealing, I'm not sure what to do. It's now 3 AM and frankly 7 can't come soon enough.

Day off

Yesterday morning, post-call and semi-delirious, I was rushing around the hospital to examine each of my patients before our early rounds in the CCU. One of my patients this week is a lovely woman in her mid-50s with radiation-induced pulmonary fibrosis and severe damage to her heart from chemotherapy many years ago. The radiation and chemotherapy cured her cancer, but that's small comfort now that her heart and lungs are failing. She's been virtually confined to bed for years, but lately she's taken a turn for the worse. Her left lung is full of fluid and she can't so much as roll over in bed without becoming severely short of breath. Making matters worse, several times each day, her heart goes in and out of a very fast rhythm that exceeds the upper limit of her pacemaker. After listening to her breathing (crackly in some regions and eerily silent in others) and her heart (fast with a loud whoosing murmur), I started to leave her room, already ruminating on my next task. Once I was halfway to the door, I thought to turn around to ask my patient if there was anything I could do for her before the day got underway. "Just enjoy your life," she said sadly.

Whew.

So today, my first day off in ten days, I am determined to do just that. I started the day with an early morning hot tub soak and massage, then biked home to play with Sam and feed him lunch. This afternoon, my sister and I will pick our youngest brother up at the airport and I'm hopeful that we'll have time to take Sam to the park before the gang of us go out for dinner. Maybe after Sam's in bed, we five can sit in the backyard and share a bottle of wine. There's laundry to do and dirty dishes in the sink, but they can wait. Today I'm enjoying my life.