09 August 2007 21:29 -06:00 GMT

Today is August 9th, and I started my Internal Medicine rotation on July 27th. In that interval, I have been on call three times. Here is what it was like.

I was on call the first night, and it was fast-paced for a number of reasons. First, I was fresh off of no time spent on the wards for at least two months. Second, it was near the end of the service month for the more senior members of the team. Third, there were a lot of sick people being admitted to the Tinsley Harrison service at the University of Alabama at Birmingham Hospital. Those added up to a steady flow of work for me from noon on day one to at least noon the following day. I did not sleep during that period. I didn't even approach the call room except to get my toothbrush for a quick exercise in hygiene. That time, combined with the orientation that started at 07:45, I worked 30+ hours that day.

Isn't it a farce when you work more than twenty-four hours in day?

I passed that rite, slept at least twelve hours the following night, and arrived back to the hospital at about 04:00 hrs the following day.

The average day of work thus far has been about eleven hours a day, not including the call days, which would skew the curve to some undefined number.

Orientation is a realistic preparation. You are told that you are expected to be the go to person for your patient needs. I'm not a doctor yet, but I get to train as if I am one. That means that the plan I have in my mind is going to be the patient's immediate health care plan.

That, my friends, is pressure. That, my friends, is scary. It's also as much a challenge as anything we've faced in medical school. However, there's back-up in interns, residents, and attending physicians. Overall, I view this service as taking care of my patients. They are my responsibility, and it is I who will succeed or fail in caring for them. And only parenthetically is there back up available to protect the patients from my inadequacies.

Back to call. It's Q4, which is a notational symbol meaning every fourth day. So one gets a half day plus two days between call days. This accommodates for eleven to twelve hour days in between call. Sleep becomes a priority.

Second call was more difficult than first because our patient volume increased and because of fatigue. On this day I was up and at work for almost the entire period of 35 hours. The only respite I had was about an hour of sleep that was interrupted by a third year student who snored like my Dad. Scott Denham, who is a good friend that I have known for several years, snores like a horse at the end of the Preakness.

That's a no-fault observation. It's just a fact. Be forewarned.

Scott is more advanced than I was at his stage of third year; I think he's going to be a better than fine doctor. But damn if my wee bit of sleep was disturbed!

That was just about 35 hours straight, folks, with enough break to eat a meal, pee, and sleep restlessly for an hour, but nothing else.

The last five hours or so of second call were spent rounding, trying anything to not fall asleep in front of my Attending, reconciling patient medications, learning the computer-based documentation system, writing notes on my patients, and finally, checking out. Check-out to the night folks extended my pain to levels that are difficult to describe. Just imagine you have been up at work for 24 hours straight. Then add ten hours to that, and keep active the whole time. And just when you are done, stay for one more hour to tie up loose ends. It was brutal.

I remember feeling bitter for still being at work after the first thirty hours, but that victimized feeling of brutality was tempered. We have an excellent Attending (read: boss) doc, who, at the beginning of our team's call day, gave us a brief lecture on keeping the patient as our focus during ward rotations. He remarked on how doctors are often leaning toward the door as soon as we enter a patient's room. He further remarked that we need to remember why we came to medical school and why we are there in the hospital for hours that exceed a day at a time.

Thirty hours after that lecture, I was faced with an internal struggle.

There I was, tired as I'd ever been, agonizing over the tens of minutes being spent in every patient's room, but at the same time, the echoes of my Attending's words kept reminding me...we are here to serve our patients, and these hours are the price we pay. Even in my fatigued moments of bitterness, I recalled his words, and saw his attention to the patient - team fatigue be damned - and I respected his living by example. In the immediate hours after his telling us how it should be done, he was living his profession for the sake of giving his patients all that they deserve. He never addressed the fact that we had been on all night. He never mentioned that we might be tired. And I think, despite myself, that he was correct in doing so. If it were my mom or dad or sister or brother there in a room needing answers and complete understanding to provide the best care, I wouldn't much care whether my team had slept much. Just give me the best medical care possible, because that is why I have entrusted you with my life in this moment.

When I got home after call two, I slept seven hours. I got up at 23:00 and worked on my residency application for four hours. Then I slept for five hours more. (I must've had a day off..) The following day I took naps with my wife, watched movies, and recuperated.

Eleven hour days followed, then third call came faster than I thought possible on this Q4 schedule. This was a much less difficult call.

By 22:00 I was able to sleep. At 22:15 I got paged. I answered the call, helping to manage a diabetic crisis with fluids and insulin. I returned to bed about twenty minutes later.

I laid in the top bunk in a small room that has two bunk beds. You have to go through this room to get to the call bathroom, which is equipped with a shower, sink, and toilet. I climbed up the end of the bunk bed on the left of the room. I laid down, face down. I put my phone in the gap between my pillow and my neck. I put my pager in the same space. I tried to sleep. I imagined that gravity was pulling me down into the cushion of the mattress. Oh, I tried to sleep. After several minutes of wakefulness, I adjusted the pillow and pulled the sheet and two blankets over my waist. I started thinking about gravity again. Then my pager went off a second time.

It was the same patient, complaining of pain. The same nurse was tending to him. In my bleary state, I emerged from the call room, visited my patient, was unable to elicit any complaint of pain. I reported to Shakela, the nurse, and returned to bed.

I climbed up to the top bunk on the left. I laid face down. I tucked the phone, with the morning alarm, and the pager, with the too-loud beeping setting, into the same space between my pillow and my neck. With partial deafness in my left ear, I didn't want to miss a call. My pager was turned up, and my phone was set to vibrate. I didn't bother to pull the bed clothes up. I drifted, and just when the peaceful waters of slumber were resting their son to sleep, I was paged again. It was Shakela with the same patient. His blood glucose was over 400.

I rose. I put on my short white coat, buttoned two of the three front buttons, and went out to the nurse's station. I sat down next to Shakela and asked about our patient. I caught Shakela glancing at my deformed hair as she told me about Mr. Diabetic X. She apologized for waking me so much. I said it was OK. I knew that our patient's hyperglycemic, hyperosmotic state would need much attention in the following hours.

He was also HIV positive.

We sorted out fluids, I visited Mr. X, and when I was done, opted against the call room. It was midnight. I visited all of my patient's charts, extracting a blank yellow sheet, and filled out a skeleton progress note for the following day. That's Subjective, Objective, Assessment and Plan, folks - a SOAP note. I folded each of the yellow sheets in half and tucked them into the right hand pocket of my white coat.

I knew that Mr. X would have new lab results at 02:00, so I paced and checked labs and checked email and wasted my time.

'Round about 2:20, Mr. X's blood sugar was still over 400 which, while half of his admission level, was still too high. We administered 10 Units of insulin, and increased the normal saline rate going into his vein. I visited him and his girlfriend of 20 years, who was sleeping in the chair to my patient's left, on the far side of the room.

Finally, I made my way to the call room again. I clambered up the end of the bed, trying not to make noise or otherwise disturb the interns and night float residents who were sleeping in the other three beds. I flattened out in the same bed I had, and tucked in the phone and the pager. I don't remember anything else about that night other than waking at 05:20 to the vibrations of my phone under my chest.