This is my column in the July edition of Emergency Medicine News. It’s my way of trying to put to words what we all feel during our night shifts, when morning seems an eternity away. Rest well, my friends, whenever you can!
Tonight I will sleep in bed, all night, with my wife. The hours will pass in pleasant dreams, wrapped in a blanket, warm beside my darling. We are on vacation, and our teenage children will be sleeping in their beds as well; after they have watched enough bizarre videos on YouTube and eaten all the chips in the house.
But as I sleep, many of you, my dear colleagues, will be wading through the morass of the night. I still work nights, here and there. And once upon a time, I worked nights full time. But those days are thankfully gone. Nevertheless, I remember. I remember what it means to work at night. And I remember that sometimes, it seems that the night will never end. It’s hard to explain it to anyone who hasn’t lived the experience. But I know. And maybe you can share this with them, so that they will also understand.
I remember hot summer nights when I came to work and walked through a parking lot that looked more like field of tail-gaters before the Clemson-Carolina game. Sitting on the beds of trucks, smoking in open car-doors with music playing as toddlers in only diapers climbed around the seats eating french-fries, the unwashed masses seemed to find solace in the red glow of the ER sign. Their assorted illnesses mere pretext for the grand social event of the evening.
‘Hey doc, get in there and hurry things along, will ya?’ I’d smile and cringe.
Once inside the door, someone, a registration clerk or triage nurse would always say the lines I hated most. ‘If I were you, I’d leave.’
‘If I could don’t you think I would?’ I would respond. And inside, filling rooms and lining the hallways, would be the contents of my night. Typically, my cross-covering partner would be up to his or her gluteus in large reptiles, and spend the next two or three hours trying to clean up messes. So I would wade right in and begin.
There was always some chest pain, young and old; high risk and low. And some that began with ‘I was really upset and had this pain after my wife and me got into a fight.’ There was also the young woman who passed out, and the old man with CHF. Most nights would include the screaming girlfriend of the loser of some fight, his chest slashed open, or his face caved in by someone’s fist.
Some patient would have a hip fracture and one would have an overdose and one would just want to die but be angry about being held, and in the midst of it all would lurk a very nice, very tolerant patient with something horrible; a subarachnoid hemorrhage or a pulmonary embolus.
And to cap it off, several would just need their chronic illnesses evaluated, whether weakness or numbness, or strange bump under the skin. (Mayo clinic having failed miserably to elucidate the cause.) And without fail, there would be a multi-layer closure to be performed because Jim Bob or Mary Sue became so drunk that they fell and split open their scalp or lip.
All of this would build and build until about 3 am, when things would seem to slow down. However, the next four hours would be devoted to the sorting out and disposing of the night’s dramas and traumas. Although peace was not a certainty, and the waning shift was sometimes punctuated with mundane requests for narcotics, or with those terribly injured in a roll-over accident, their swimsuits still sparkling from the Mica in the creek where they had been swimming.
Even before the advent of EMR, charts needed to be completed, by hand or by dictation. And since I was usually alone after 1 am, I would be the one to close that complex lip, reeking of Jim Beam. Between all of the disparate complaints, it was imperative that I not fail to read a c-spine or collate the results of all of the CT heads, CT abdomens, CT angio’s, EKG’s and serial troponin levels.
As night crawled on, there were annoyed consultants to query, transfers to arrange, admissions to sell and family members to contact. There were police officers who needed their ‘clientele’ cleared and sadly, sometimes, there were coroners to contact and death certificates to sign.
But the remarkable and reproducible aspect of it all was the way that time lurched to a stop. Once, when we went off of Daylight Savings, we kept moving the clock back to 2 am to torture a young nurse. ‘This night is never going to end!’ she said, as we laughed. But how right she was!
Nights always lingered, and as my mind slowed, and the paperwork piled up, I wanted nothing so much as another pair of hands, or eyes; another person to help chart, or just to see the 5 am ectopic work-up, or the 6 am wrist laceration.
I recall looking outside, past the ambulance bay doors, wondering if dawn would ever come, and thinking that if it didn’t, I must surely have died and gone to eternal punishment. When that fatigue arrived, no caffeine, no snack, no nurse MacDonald’s run, nothing helped. When your mind is a fog, when it’s an absolute effort of will to see the patient, do the procedure and then document all of it. When nothing, nothing in all the world, is better than ten minutes, face down on the desk with eyes closed and sleep instantaneous; sheer joy until the next nurse question, x-ray tech call, or ‘chest pain in room 9.’
I don’t miss those full-time nights. And even though I still do one here and there, I hope to do them less and less. And more than that, I hope that one day medicine will evolve in such a way that we don’t have to risk our patients, and ourselves, with the very real danger of pure exhaustion in the never-ending misery of the night, where fatigue meets necessity, where human limits meet unlimited human need.
Because as I go off to bed, I can say that nights are meant to be enjoyed, not merely endured. Sweet dreams..