the call night

by Sachin D. Shah, MD

(with apologies to edgar allan poe)

once upon a midnight dreary,
while i pondered, weak and weary,
stomach empty, eyes quite bleary,
which tone to set my pager beep;
i tried to read, though on call,
gazing mostly at the wall
and felt myself start to fall,
fall into a fitful sleep.
drink a cup of coffee, thought i,
for i mustn't fall asleep;
my vigilance, i must keep.

ah, distinctly, i remember,
it was in the bleak december,
short of rest, and short of temper,
down my will began to creep.
desperately i wished a nap,
with book laid shut upon my lap,
for at this moment i was sapped,
sapped and pining for some sleep.
but the night was young and i had not capped,
so from my chair up i leaped;
my concentration, i must keep.

so on i went with my reading,
the inner pleas for rest not heeding,
and though feeling like my eyes were bleeding,
my focus once again was deep.
as i read about the liver,
down my spine i felt a shiver,
while in my hand the mug it quivered,
quivered as the steam did seep.
i took a sip and set cup down,
and resolved tonight to count no sheep;
my wits about me, i must keep.

but in blurry protest against my will,
both eyes with tears again did fill,
with throbbing head and stomach ill,
down my strength began to creep.
despite reminding myself aloud,
of the wakefulness i had vowed,
within a moment i had been cowed,
cowed into a broken sleep.
restful images rushed in like water,
and the slope to slumber proved too steep;
my guard aloft i could not keep.

ascending to a state of peace,
flying, gliding, a flock of geese,
but now a sound that refused to cease,
brought groggy curses: my pager beep.
out of sorts and foul of mood,
belly growling for some food,
ready to cop an attitude,
i shook myself awake from sleep.
grumbling i dialed the phone,
and bemoaned my scattered flock of sheep;
but clear my mind i tried to keep.

having signout for all the floors,
at night becomes the worst of chores,
for every patient is suddenly yours,
and from the call room talk is cheap.
the pages soon become incessant,
for midnight stirs the convalescent,
mr davis wants a cough suppressant,
miss randolph's dressing starts to seep.
stumbling i climb the stairs,
and walk the halls half asleep;
suppressed a yawn i try to keep.

an elderly man begins to wheeze,
as the epileptic starts to seize,
and since problems seem to come in threes,
i uneasily await another beep.
after a quick fix, as was the plan,
using albuterol and ativan,
off to the seventh floor i ran,
and into my call room bed i leaped.
but before i could even count to ten,
another 3 pages denied me sleep,
my will to live i try to keep.

two fires out, but three more raging,
hence the continued ceaseless paging,
and deep inside me a war is waging:
the need to work against the will to sleep.
mental status gone awry,
status post UTI,
i scratch my head and wonder why,
why they won't just let me sleep.
how nice it'd be to just ignore it,
but what you sow is what you reap;
sound my judgement i try to keep.

for fevers, a headache, syncope,
i get cultures, tylenol, an EKG,
i briefly consider a head CT,
but decide against and let him sleep.
then mr cox falls out of bed,
though they didn't think he hit his head,
but now his pillow's soaked in red,
and he's unarousably asleep.
up the stairs again i march,
the flights they seem to grow more steep;
open my eyes i try to keep.

checking labs as the clock strikes four,
while hoping, begging, please no more,
but then a page from another floor,
stirs awake my angst from deep.
mr smith was just on the commode,
and now it seems his pulse has slowed,
he passes out, and they call a code,
so from my keyboard up i leap.
i think while running up the stairs,
in six short hours i'll be asleep;
my motivation i try to keep.

by six am my notes are done,
as the interns stroll in one by one,
while one last time the list is run,
and the check boxes get a final sweep.
finally the weight is lifted,
and on to another soul is shifted,
while standing up on rounds i drifted,
drifted off and fell asleep.
i woke up when i lost my balance,
and caught myself without a peep.
my dignity i try to keep.

as rounds are ending at half past nine,
my senior resident winks the sign,
i'm free to cross the finish line,
so from the team away i creep.
notes in charts and out the door,
a pleasant daylong nap in store,
and then tomorrow back for more,
but for today at last i sleep.
postcall dreams are always pleasant,
but such peace of mind is never cheap.
closed with ease my eyes i keep.

there will be time, there will be time

this year has been one of intermittent confidence racked by bouts of extreme self-doubt.  there are days i feel like i am finding my way, ascending steadily to a place i aspire to reach in a profession that will one day entail my calling.  there are others when i wonder if i'm really going to be any good at this, if i'm even committed enough to truly be a great physician.  these are the days when i long to spend time reading fiction rather than physiology, writing prose rather than progress notes.  learning medicine can be so singular, so one-dimensional in its focus.  and while i want to put forth the effort and dedication necessary to be not just good but one day truly respected and admired in my profession, i need to keep the other passions in my life alive.  and i'm not doing it right now.

i think many of us have our alternate scenarios.  what would i be doing if i weren't doing this?  and when we speculate on what it might've been like, an element of regret almost inevitably presents itself.  'what could've been' starts jockeying for 'what should've been' status.  i think i'd be traveling and writing.  i think i would've seen most of continental and eastern europe, greece, egypt, and southeast asia by now.  i think i would've had countless more adventures and stories of hilarity and hijinks that i would nostalgically tell my grandchildren about.  i think i would've watched more films, seen more theater, listened to more music, and read more literature.  i think i would've published a number of magazine articles, and perhaps even a book by now.  i think i'd have more friends, more of niche, and be living in an urban, cosmopolitan city.  i think i'd be more interesting.  i think i'd probably have found someone that i wanted to spend the rest of my life with by now, and she me.  i think i'd probably still be in debt, just not nearly as much.  perhaps i'd be happier.

i think i'd also still be searching for a way to put more meaning into my life.  i think i always will be.  i'd wonder if what i were doing truly represented my calling, if there was something more.  here's what i like about what i'm doing now and the path i'm on: there is and will always be the potential to acheive something truly meaningful.  on balance, i think it is what i should be devoting my time to right now, even though it is at the expense of so much else. 

it's the opportunity cost that troubles me, i guess.  i'm sacrificing my twenties, surrendering adventures, missing chances to meet extraordinary people who might've become lifelong friends.  i'm losing track of people who are close to me and sometimes wonder if i'm truly close to anyone anymore given the self-centered vacuum i've been relegated to these past few months.

but who knows?  that's the difference between 'what could've been' or 'what should've been' and 'what is.'  only the latter of the three counts.  still, there is always some solace to be taken in what lies ahead, despite what might've been left behind.  to quote ' the love song of j. alfred prufrock,'

there will be time, there will be time
to prepare a face to meet the faces that you meet;
there will be time to murder and create,
and time for all the works and days of hands
that lift and drop a question on your plate;
time for you and time for me,
and time yet for a hundred indecisions,
and for a hundred visions and revisions,
before the taking of a toast and tea.

of course if you read the whole poem closely (as you should), you realize that even this can only be true for so long.

nicu

the neonatal intensive care unit (nicu) takes care of sick, newborn babies. most of them are premature, born at 28, 30, 32 weeks, instead of the 38-40 weeks that they need in the womb to fully develop, to have the defenses against what the outside world will throw at them. they're tiny, weak, and helpless. when their pacifiers fall out of their mouths, they sometimes try to substitute their thumb. but lacking the coordination, they usually end up in the vicinity at best, inadvertently poking their eyes or picking their nose instead.

most of the infants are just small and need support to make sure they're getting enough calories to grow and don't stop breathing when they get tired ('feeders & growers,' as we call them). i watch their tiny chest walls expand and contract with the ventilators, their tiny fingers clench into fists around my little finger as they flex their arms and twist their faces in agitation when i disturb them from their slumber.

but sadly, babies die here, too, and there are few things that are harder to see. some are just too sick to make it. they have had a severe bleed in their brain or their lungs just weren't developed enough; their bowels perforated or they acquired an infection in utero and couldn't fight it off with their weak, naive immune system, even with the help of antibiotics. these are all consequences of prematurity.

we go to the high risk deliveries to be there in the delivery room to resuscitate babies when they come out. i'm often the 'baby catcher,' the one who takes the baby as soon as it's pulled out and bring it over to the resuscitation crib. they are often blue and floppy and not breathing, and though most of them start right up with a little stimulation, it's always a little nerve-wracking at the beginning, no matter how many times you do it. and of course there are always a few that don't start on their own -- be it their breathing, their heart beat, or both -- and that's when we have to start chest compressions and intubate (put a tube down their trachea) them. so far there have only been 2 of the 50 or so babies i've been to the delivery room for that we haven't been able to resuscitate despite trying everything in our protocol, but those are the ones you remember. the normal ones you forget.

when we learn resusitation on adults, we are taught to get down on our knees, straddle the individual, and push both palms, stacked upon each other with fingers intertwined, down on the chest wall with most of our weight behind us to provide adequate chest compressions. with a newborn we use two fingers.

the nicu -- just like any intensive care unit -- is aptly named. there are a minimum of 4 fires to be put out any given moment, it seems, and the key is efficiency and clarity of thought. you cannot forget things, and you cannot afford to miss things. the margin of error is slim. looking at how small the babies are -- 1.2 kilograms, 800 grams, 2.7 kilograms -- it becomes clear why.

call nights, when we are responsible for all 55-60 babies and have to attend and admit all the high risk deliveries, take virtually every ounce of energy from me. post-call it takes an entire day of sleep to recuperate so i can come back early the next morning and do it again.

q3

the days fall away without warning, the weeks drone by into months and you lose track of time. you're often working during the night and sleeping during the day, oblivious to the sunlight and circadian rhythms that guide everyone else. you see other bleary-eyed residents--pre-call, on call, post-call--and exchange knowing glances of stoic solidarity. you see your neighbors sitting outside on their stoop, enjoying their second beer, their leisure time, with their friends on a wednesday night as you trudge home, wondering how you'll manage to find the energy to make dinner. you change your clothes, wash your face, and play music that triggers nostalgia of easier days, not daring to sit down anywhere lest you fall asleep before eating something. after your meal you finally do fade into a post-prandial slumber on the couch, into a dream measured by a song, less than 4 minutes, but seemingly so much longer, or shorter, or... it's time to go to bed now if you want to get enough sleep to make it through the next day and night, as there's nothing worse than waking up tired, 30 hours before your shift is over.

tati

as an intern, you are the bottom of the totem pole. you're responsible for writing all the daily patient progress notes, calling all the consultants, writing all the orders, following all the lab results, and being on top of everything in general. this translates into a lot of time spent sitting at a computer, with charts, and on the phone going through a long list of things that need to be accomplished over the course of the day. it also means that if you're not careful, your time with the patients and their families can be compromised.

these last two weeks i've been working hard on the floors of our pediatrics service. i've felt pangs of regret several times over this period of time for not being in the rooms with the patients enough, not having longer interactions and forming better relationships with the kids i'm taking care of. too much of my time is being sucked away by the daily work that i'm relied upon for. i try to spend time each day with all of my patients and go through the plan with their parents, but i'm not sure i always do it as well as i'd like still.

i've been taking care of this little 23 month old girl (tati) whose family brought her from puerto rico to investigate a mysterious collection of fluid in her abdomen. it's called ascites, and there are various reasons one can have it. liver problems, heart problems, infections from parasites -- it's a long list. but no one has been able to figure out why this little girl has it. she underwent an extensive workup in puerto rico and then a pretty exhaustive investigation here. and she's been an absolute angel through it all. she just sits patiently in her mother's lap with a pacifier in her mouth, looking at you curiously as you listen to her heart, push on her belly, and tap across her abdomen. some days, since we consulted a lot of different services (gastroenterology, infectious diseases, transplant, cardiology), 7 or 8 people would come do this to her. still, she just sits or lies there patiently and allows you examine her. and she's the sweetest little girl. the family only speaks spanish, so it was also fun to use my broken spanish to communicate with them, and they genuinely appreciate the (modest) effort to explain things to them in their own language. i would've been much better at this towards the end of january when i came back from peru, but the spanish has come in handy, and i need to stay sharp.

anyway, we never figured out why she had ascites. we put her through a bunch of tests (a battery, you might say) and imaging, but we still couldn't figure out what was going on. and somehow, over the the fourth of july weekend when we sent them home for 2 days (they are staying with an uncle who lives in rochester), she managed to get rid of the fluid on her own. go figure. she comes back and it's gone for the first time since it initially appeared back in october 2005. shows you what we know.

but we did a few final tests today and then sent her and her really wonderful family home. they were all at the hospital -- older brother, older sister, uncle, aunt, granparents, and mom & dad -- almost all the time, supporting each other, taking turns walking around the ward with tati, and remaining all the while in the best of spirits. we talked about world cup soccer, discusssed where i learned my broken, somewhat archaic, spanish from, and ate ice cream. they were terrific, and displayed a remarkable patience through a long, difficult process that was clearly reflected in the precocious stoicism of their little girl.

in any case, at about 6pm today i completed their discharge paperwork and wrote the orders to discontinue the iv and send them home. as i sat in my chair at the desk at the nurses station working, the family, two by two, walked by on the way out. they all stopped and thanked me and said goodbye. i wished them luck. last was tati and her mother. as i'm sitting there, tati waddles up to me with her ever-present pacifier in her mouth, takes it out in her hand, and plants a big old kiss on my cheek. it was the sweetest thing, and i'll never forget it.

earlier in the day (less than hour before) i was performing an unpleasant (but fairly painless) procedure on a 5-year-old girl (also very sweet), who was screaming pure venom at me at the top of her lungs. i was not popular. 45 mins later, tati comes up to me and makes my week on her way out of the hospital after we solved nothing for her. but that's all it took to make all the work over the past 15 days worthwhile. and that's why i love pediatrics.

first call

monday night was my first call night. i had started to feel fairly comfortable with the wards by the second or third day of work, and the fourth day was my first call. i've been on call plenty of times in med school, and i've routinely worked all night on busy services without getting any sleep, without much trouble. i do fine without the sleep, i just make it up later. but monday night was different. i got paged a lot about important things that i had to take care of. and there were usually at least four or five things happening at the same time that i had to be on top of. i felt like a waiter at a busy restaurant--while i was in the middle of doing one thing, i got paged to do three others, some of which trumped what i was doing priority-wise. this patient is in respiratory distress; this one needs to be discharged; this one is asking to see his doctor about the results of his CT scan. and there were admissions just pouring into the ER all night, so i had to go downstairs regularly to evaluate and admit them. we ran out of beds on the wards, so we'd have to see the patients, admit them, and manage them while they were sitting in the ER waiting for room to open up on the floors. i didn't even know where my call room was let alone think about using it for a nap that first night. after rounds finally started in the morning at 7:30am, i caught myself falling asleep while standing up three times between 9-9:30am. that's never happened to me.

so i was tired. but it went ok. it certainly put my expectations in a good place for subsequent call nights. even getting an hour of sleep on call now will seem like a bonus, so i'm glad it started that way. and by all accounts, it doesn't get any busier than it did that first night, so that's a good way to get started.

my second call on friday night was more manageable. the admissions were more spread out and i only was called a few times for minor events during the night. i even slept an hour and a half, which felt like a long time and helped me avoid the narcoleptics of tuesday morning. some call nights are better than others, and i suspect they'll even out over time. i have many call nights ahead of me left, but there are now at least two down.

day one

today was officially day one of my intern year. different people react in different ways to the notion of being looked upon as a real doctor, with all the attendant responsibility and accountability, but we're all nervous, at least a little. anyone that says otherwise is lying.

i started on the pediatrics floors. i showed up a little before 6am and tracked down the person i was supposed to take signout (the transfer of information about and responsibility for particular patients from one physician to another) from and got my list of patients that i was to see and be ready to round on at 7:30am. the first few days -- and, since every month is a new floor, unit, sometimes hospital, probably the entire first year -- will largely be about learning logistics. how do i order this test? how do i find out this piece of information? who do i ask about this paperwork? where is my call room? it will take time to be comfortable with the procedural aspects of the work, and in the meantime, i need to be learning as much as i can about patient care and management, but the two are inextricably linked.

the day went fairly smoothly, all told. i had a co-intern with me that went to medical school at rochester, so she was familiar with a lot of the logistics, and i had a good, supportive senior resident backing me up. i was home at 6pm with the relief of my first day behind me.

i fully expect these next four years to be the most demanding of my life so far, but i have faith in my ability to handle the stress, the hours, and the exhaustion that will come with the work. and though i'm well aware of the inescapable reality that i will make mistakes, and that i must learn from them to become a better physician, i'm afraid of making mistakes that will adversely affect (or even end) people's lives. i think this is something i will lose sleep over regularly.

but i'm also excited by the prospect of really learning medicine. i get the sense that by the end of these next four years, i'll be a pretty good doctor. and i love the realm of possibility before me once i'm in that position and have confidence in my skills as a physician. i chose this route because once i know what i'm doing (an admittedly difficult point to reach), i will have an incredible amount of freedom. in the meantime, though, i'm pretty locked in. i have been since i started medical school, and i knew that i would be while i trained. but i've always seen this process as a means to an end for me. the autonomy i'll have once i'm through it, i suspect, will be well worth it.

back to reality: i'm on call monday. again, i'm a little nervous. it's a lot of responsibility, and i'm still in the process of proving to myself that i know enough to be entrusted with it.

i don't know what i'll write about in this space. i just want to make sure that i write regularly. my guess is that it'll be stories, thoughts, rants and raves i have along the way so i can look back and remember them as i move forward. there will probably be the occasional (inevitable) 'silly poem that rhymes,' and who knows what else? so if you're interested in checking in on me, come visit here.

i think i'll be a pretty lousy friend/family member for long stretches when i just get inundated, but i hope you'll forgive me, stay with me, and keep me up on your doings. i'll try to write to this blog regularly, and please know that just because i'm not always able to be in regular contact doesn't mean i'm not thinking about you. thanks for reading.

until next time, much love,
sachin

the beginning of intern year

'maybe you could be my intern, and in turn,
i'll show you how i cook up summer, in the winter...'
---kanye west, 'gone'