The Longest Call
Friday, April 3, 1998
6:00 am. Beeep, beeep, beeep. The alarm beside my bed ended my restless slumber. I had been awake intermittently for several hours. I had a vague feeling of uneasiness and abdominal discomfort. Sometimes I would feel this way on Friday mornings. Looking ahead to seventy-two hours on call can have that effect. Perhaps I was becoming ill. This would not be a good time to get sick. I lay in bed a while longer, hoping to feel better before getting up. I did not know when I would get to rest again.
7:00 am. The cramps and diarrhea answered my question. Aware that I was not well, my 11-year-old son asked if I was going to work. “That’s not good,” he said. “When I have a stomachache, I go lie down, listen to a tape, and fall asleep.” His treatment plan sounded good, but unfortunately not very practical.
7:30 am. I stood in the operating room supervising a junior partner performing a D&C for a missed abortion (early fetal demise). Still cramping and anxious to move on to “rounds,” I wished I could just perform the procedure myself. I got my wish. She perforated the uterus. I had to complete the operation. The patient did well, but throughout the day, I worried about her.
8:00 am. I began rounds in the obstetrical unit. The first patient was 37-weeks pregnant and had pregnancy-induced hypertension. We had decided to induce her labor. She was scheduled to have prostaglandin gel placed in the afternoon. Next, I saw a woman in the 4lst week of her third pregnancy who was to have her labor induced that morning. However, she was already contracting on her own. I ruptured her membranes. In a different unit, I visited a 60-year-old man with chronic obstructive pulmonary disease and an empyema. I had done a thoracentesis earlier in the week to remove some of the fluid. He continued to struggle and needed a chest tube for adequate drainage. He was on three different antibiotics. In the intensive care unit, I saw an 80-year-old woman who was in a coma receiving mechanical ventilation. She was trying to recover from a myocardial infarction and the subsequent cardiopulmonary resuscitation.
10:15 am. During rounds, I paused for a few moments to talk with a lab technician who is the grandmother of an infant I delivered at the first of the week. The baby was severely depressed at birth, for reasons we could not determine, and required tracheal intubation and respiratory resuscitation. He had experienced seizures for several hours, but never cried. Unable to care for him in our small, rural hospital, he was transferred to the children’s hospital in Knoxville. His family had expressed concerns about the care his mother had received during her labor. I worried all week and, especially, all day yesterday.
11:00 am. I finally finished rounds and headed to the office to do some paperwork. Soon after entering the clinic, I saw a nurse in the hallway holding an ill-appearing baby. The nurse, mature and not easily worried, appeared very anxious. This made me nervous. The infant was being evaluated by ournurse practitioner. Reluctantly, I decided to intervene. I examined the infant who was known to have congenital heart disease (Tetralogy of Fallot) and had presented to the office with fever and lethargy. Agreeing that this child was potentially seriously ill, I sent her to the emergency room to complete the evaluation. Leaving all the unfinished paperwork on my desk, I hurried over to the hospital to perform a lumbar puncture on the baby. Having finished the work-up without firmly identifying a diagnosis, I transferred the patient to Knoxville.
12:00 pm. I missed lunch.
3:20 pm. The patient in labor delivered. Her labor had been uneventful. The delivery, however, was complicated by a mild shoulder dystocia (the baby’s shoulder was temporarily “stuck” behind the mother’s pubic bone). The infant was depressed at birth and required resuscitation. I could not identify any other reason for the baby’s distress. Having two such cases in one week added to my own distress. The mother bled excessively after the delivery, requiring prolonged attention and several doses of medication to control her hemorrhage. She had experienced similar problems with her first two deliveries as well.
4:00 pm. I was called to the emergency room to perform a paracentesis on a 60-year-old man suffering from alcoholic liver disease and recurrent ascites. He required this procedure every two weeks. I removed 4 liters of fluid from his abdomen as we talked about his life growing up in our community.
5:00 pm. Very hungry, I was grateful I could go home for dinner, hoping this busy day was coming to an end. However, before I could sit down at the table, I received a page from the wife of one of my partners. Her husband was out of town at a conference. Their one-year-old twins were both ill. One seemed more serious than the other with rapid breathing, nasal flaring, and retractions. I left home without eating and went to their house to evaluate the children. Although neither was critically ill, one child was experiencing some respiratory difficulty. I decided to accompany the mother and this daughter to the hospital for further evaluation. Since we had to admit her for overnight observation, the other daughter spent the night at my home so I could watch her for signs of worsening (but I never got back home!).
7:00 pm. My pager went off again. This time it was my wife asking me to come to our neighbor’s home. A friend of ours visiting our neighbor had fallen and was unable to get up. I drove there as quickly as I could. She was 67 years old and was lying on the floor, near a small step leading from the den to the kitchen, complaining of hip pain. A quick evaluation confirmed everyone’s suspicion that she likely had broken her hip. I arranged for an ambulance and met them in the emergency room. The radiograph was not conclusive but certainly supported the diagnosis of a hip fracture. By 8:30 p.m., the evaluation was complete, and the arrangements had been made for referral to an orthopedic surgeon in Knoxville.
8:35 pm. Just as I was preparing to leave the hospital, fatigued and eager to go home, I noticed the radiology technician place an abdominal x-ray on the view box. It was taken as a part of the emergency department physician’s evaluation of a 20 year-old woman who had presented complaining of abdominal pain and bloody urine. The x-ray clearly showed a term baby in the young woman’s abdomen. She was reportedly unaware she was pregnant. Prior to seeing the film, the doctor had concluded that she likely had a kidney stone. He had admitted her under the care of our local general surgeon who was on call for unassigned patients.
Somewhat reluctantly, but without any choice, I went to the radiology department to evaluate the patient and whose heart was not beating. The pattern of her pain and the manner in which she responded to it both suggested that she was in labor. After a very brief introduction provided by the I emergency department nurse, I did a quick vaginal examination and confirmed my impression. Her cervix was fully dilated, and the baby’s head was firmly engaged in the birth canal. Yet, the head did not feel normal. Using the small, portable Doppler machine handed to me by the nurse, I was unable to find the fetal heart sounds. In the span of just a few minutes, I informed my new patient that she was pregnant, in labor and soon to deliver, and that I was concerned about the health of her baby.
I sighed deeply (I would not be going home soon) and accompanied the patient to the labor and delivery suite. I had time to quickly review her chart on the way upstairs. Her blood pressure was quite high, and her urinalysis indicated the presence of a large amount of protein in her urine. Neither the obstetrical nurse nor I could identify any evidence of fetal cardiac activity. I performed an ultrasound that revealed a 37-week baby who was not moving and whose heart was not beating.
I sat on the foot of her bed and tried to share all this information with her. She did not have a kidney stone (or, at least, this was not her major problem). She was pregnant, near term, and in labor. She was suffering from toxemia, and her baby was dead. I had only met her thirty minutes before. As anticipated, she was quite shocked by this news. Unexpectedly, however, she persistently denied ever having had intercourse. She simply could not, she maintained, be pregnant. After a lengthy conversation, I finally convinced her that we could discuss the circumstances around the conception of her baby later. We had some important decisions to make first.
We reviewed the options in detail. I offered to transfer her to the regional perinatal center I in Knoxville. Her pregnancy induced hypertension was severe and might lead to further complications. I really hoped she would accept. She did not. She elected to stay in Jellico for the delivery.
She was admitted, and all the paperwork was completed. I reexamined her and determined her labor had not progressed and her contractions were inadequate. Intravenous infusions of pitocin and magnesium sulfate were begun to augment her contractions and to lessen the risk of seizures.
Her labor was very difficult. After frequent, strong contractions were established, she was encouraged to push. She did so, for two hours. Finally, the infant’s head reached the vaginal opening. Exhausted and very scared, she was unable to continue pushing effectively. I attempted to assist her by vacuum extraction. As this was unsuccessful, I applied forceps and was able to deliver the head. I was unable to deliver the rest of the infant. This was the worst case of an impacted shoulder dystocia I had encountered in my ten-year career. I attempted all the standard maneuvers for delivering an infant under these circumstances. As the health of the infant was not a consideration, I was able to be quite aggressive. Nevertheless, all my attempts were unsuccessful.
Weary and worried, I spoke with the perinatologist in Knoxville about my options. He recommended that we proceed to the operating room and continue our attempts under general anesthesia. Transporting her at this point by ambulance to the regional perinatal center would have been very difficult as the infant’s head was still outside the vagina. The patient agreed with the plan, and we moved her into the surgical suite at 5:00 a.rn. After adequate general anesthesia was obtained, her uterus and vagina relaxed and delivery was accomplished. It was a very difficult and emotional extraction. The infant was macerated. I had to deliver the baby’s posterior arm first, then the anterior arm, and then pull the baby out. Several small perineal lacerations occurred and bled continuously, requiring several sutures.
The patient was taken to the recovery room and then back to the labor and delivery suite for continued monitoring of her blood pressure and bleeding. The infant’s body was prepared for transport to the pathology laboratory in Knoxville. Exhausted and discouraged, I returned to the obstetrical unit to reevaluate the first patient I had seen on rounds the previous morning. She was now in labor.
Saturday, April 4, 1998
7:00 am - 9:00 am. Morning rounds were completed.
9:00 am - 11:00 am. I conducted a lengthy conference with the family of the patient on the ventilator in the ICU. I reviewed the patient’s condition and prognosis as well as all our options for treatment. The family was unable to reach an agreement about how to proceed.
4:00 pm. Another delivery.
8:00 pm. Yet, another delivery.
Sunday, April 4, 1998
5:20 am. The final delivery for this weekend on-call.
Father, I tired. Exhausted actually.
I began this weekend sleep-deprived and ill. I ended it fatigued and discouraged.
I did well, I believe. My patients all received good care. My decisions were sound ones. My procedures were performed with care and competence. I cannot always say this, but today I feel I can.
Yet, I am weary; in spirit as well as in flesh.
Some days the load is too heavy; the burden too great. Some days the work is just too hard. Too many decisions; too many very important decisions; actually; too many critical decisions.
Should I go to work at all today? Will my patients (although not my partners!) be better served if I remain home in bed, convalescing, and allow someone who is fit in mind and body to care for them?
Should I intervene now, when my colleague seems to be struggling with this surgery, or wait until she asks for help? How much should I tell the patient about what happened while she was asleep?
Should I induce labor or wait another day? Can this patient truly understand the risk/benefit analysis that must be considered in order to make this decision? How hard do I try to help her understand?
Should I put in this chest tube? I want to. I can. But I’m tired, late, busy, and uncertain. Another physician is available who can do it better.
What else can I do for this poor woman on the ventilator? She is not going to get better. How do I tell the family?
Did I make a mistake, or mistakes, earlier in the week with the baby who seized? What did I miss? Nothing. I’m sure. I think. Should I talk to his grandmother here in the hallway? Does she want reassurance and comfort or is she looking for evidence?
Why didn’t one of the doctors see this baby with the defective heart? Who assigned her to a mid-level practitioner? Should I keep the child in our hospital for antibiotics, like the mom wants, or send her to Knoxville, like I want?
A second unexplained resuscitation this week it turn out like the other one?
I have to drain four liters of this man’s abdomen every two weeks. The specialist said this was the best we could do. Is it? Should I try to find another consultant and get a second opinion?
Taking care of friends and their families is a privilege but a challenge also. How clear is my judgment? Am I caring for her like I would for any other one-year-old? Am I being more cautious? or less?
Why tonight? Why did she have to fall and break her hip tonight? Should I just send her to the emergency room and let them take care of it? She only needs an X-ray and a referral? Anyone can do that. Why do I need be involved?
Yes, I agree. She’s pregnant. The x-ray clearly demonstrates that. I haven’t been consulted, though. They haven’t even told the attending physician yet. I should go home and wait for them to call me, shouldn’t I?
Pregnant, in labor, ready to deliver; severe hypertension and toxemia, and a dead baby-that certainly constitutes a high-risk pregnancy! Should I even offer her the option of staying at our hospital to deliver? No one would doubt the legitimacy of this transfer: But, I can care for her here. We have the equipment and the expertise to do so. Do I really have a good reason to send her an hour away from her friends and family - just because I’m tired and ill?
She’s going to have a baby in the next few minutes, and she insists she has never had sex. I suppose it is possible. It happened once. But the odds are decidedly against it! How hard do I persist in my efforts to break through her denial? I should have sent her to Knoxville.
Now what do I do? The head is out, but I can’t get the rest of the baby out. I know we can do this in the OR with her asleep. I don’t want to, though. It’s going to be very difficult and very ugly. The hour is late, and I’m so tired. I should have sent her to Knoxville.
No sleep. Morning rounds and more decisions. How can I keep going?
Why can’t this family understand? Their mother is not going to recover. Continuing her life support at this point is futile. Am I speaking clearly enough? Am I telling them everything they need to know? Am I being patient, compassionate, objective, and open? Am I awake?
Father, you heard me ask each of these questions. You hear me ask them again just now, at the end of the day, as I reconsider my answers earlier.
I’m too tired to keep thinking about them. But they Won’t go away. I’m feeling sorry for myself right now. This is a hard life, or at least, a hard job. The hours are long. The stress is intense. The margin for error is slight.
I have to occasionally work when I am i1l; often without sleep; and frequently when I am hungry. And under these conditions, I have to make many, many decisions. Not just simple decisions. Hard ones. Complex ones. Critical ones. Decisions which can afflict another person’s health, or even his or her life.
And yet, Father...
My illness is trivial and transient. My fatigue, though real, is temporary. I will sleep tonight or tomorrow night. My hunger is superficial and soon to be satisfied. My stress is manageable and intermittent.
I have not and do not face what these people faced today.
I am not in the midst of a long, difficult, intense, and painful experience that cannot be avoided, as were my patients in labor today.
I am not chronically ill with a chest of pus and lungs that do not function well.
I am not in a coma on a ventilator without hope of recovery. Nor is my mother or sister or aunt.
My liver works fine. I have not ruined it with alcohol while tryiong to relieve the despair of my life.
My children are well tonight, asleep in their own beds. They are breathing fine. No fever or cough.
It's not my hip that is broken and needing surgery. I do not have to ride in the back of an ambulance, in the night, to a strange hospital to see a doctor I do not know.
My story is not so badly broken that I must incessantly and persistently deny the obvious and maintain the incredulous. I have not, in the same moment, been told that I have life Within me, but yet I do not.
I know, Father.
My life is comfortable and safe and well. My vocation is good. My service is needed, welcomed, and beneficial. The rewards are many; the pleasures, frequent; the opportunities, endless.
But, I’m tired, Father. I really am very, very tired.
David McRay, MD, is a family physician in his 19th year on the staff of Dayspring Family Health Center, a community health center serving the vulnerable and disadvantaged in rural Appalachia. He recently resigned his positions as CEO and medical director and is beginning a transitional year at the end of which he and his family will be moving to Fort Worth, TX Where he will join the faculty of the john Peter Smith Hospital Family Practice Residency to teach obstetrics and to pursue his interests in international health and development, primarily in the Occupied Palestinian Territories. He can be contacted at davidm [at] dayspringfhc [dot] com.