In The Wee Small Hours

I’ve learned that in rural Kansas, frigid cold and high winds are the ER doc’s best friend. In a world where the entire health care system seems designed to drive you to the ED so “real doctors” can see paying patients at their own pace and get their beauty rest at night, weather is one of the few disincentives to convenience care. If you come to the ER on a night where the wind chill is 30 below zero (or degrees above absolute zero, if you like to know that sort of thing), you’re either really sick or totally bonkers, which is probably sick behavior in and of itself. (Indeed, you could make a case that to come to the ED for anything short of a near-death experience on such a night is clear evidence of suicidal ideations and mental illness.) It’s a little different in the city, where cold weather brings out…or in…the homeless for a place to stay the night and maybe get a stale sandwich and a cup of juice And while I can’t prove it, based on what comes in to the ER I’d suspect that police blotters swell during cold weather, as people get themselves arrested for minor offenses to ensure their “three hots and a cot.” (The more astute ones who know the system and have a severe allergy to the stainless steel found in handcuffs will complain of chest pain and rattle off a list of cardiac risk factors, virtually guaranteeing at least a 24 hour hospital stay. By the time they’re discharged, the police have completed their paperwork and have moved on.) But in rural America, these are the nights you dream of, the nights when you look around an empty department just before midnight and think, “Tonight I get paid for sleeping.”

The problem, of course, is that you don’t sleep. You walk back to the physician’s sleep room, and before lying down you move the phone close to your bed so you can answer it when it rings. And you know it will ring, but you don’t know when. So you sleep fitfully, tossing and turning, opening an eye every fifteen minutes like clockwork; and when the phone doesn’t ring after an hour or so, you get up and wander out into the department because you’re convinced that there’s something going on that you’ve missed. And it’s doubly difficult because you’re in the middle of an argument between your body telling you to sleep and your mind noting that you’ll only wake up again and feel even worse than before.

So what do you do when you can’t sleep? Well, I would like to say I use the down time to be incredibly productive, to write on my blog, to read the latest medical literature, to conduct in-depth research about why we’re worried about air traffic controllers who work one night shift every two weeks suffering from critical fatigue and falling asleep but why we’re perfectly okay with doctors, nurses, policeman, and firefighters chronically working at night or even 24 hour shifts. I mean, all these folks do is save lives. (The air traffic controllers will now get double coverage in the towers at night and a mid-shift nap. The aforementioned groups get nothing. Yep, I’m a little bitter.)

The truth is that the last four or five hours of a twelve hour night shift is spent in a special kind of limbo that reminds me of the drug ketamine. Ketamine produces something called dissociative amnesia; the patient is awake and conscious, but not responding to words or sounds. It’s really kind of spooky to watch. The eyes are open, the heart beats, the chest rises and falls, but they just lie still like you might see in a morgue. The best way to think about it is that the lights are on, but nobody’s home. From the view of the patient, dissociation means that there’s an awareness of something going on, but no way to figure out whom it’s happening to or how you might be personally involved. (To be frank, it's the same feeling I got chewing coca leaves hiking the high-altitude Inca Trail in Peru. I was fully alert, climbing, and interacting with the guides. And I could feel someone’s heart beating fast, could hear someone with quick, raspy breathing, but I had no idea that it was me.) When you work that back half of the shift in the early morning hours, you know something’s going on but you just can’t quite place it. You know someone is awake and that someone is tired, but you nonetheless slog on through the disembodied haze. Every now and then a patient in real danger will momentarily rouse you from your torpor, but despite what you see on television in real life those moments are few and far between. Frankly, it’s hard to get excited about chronic pain or a fussy child at 4 AM. It’s lot easier to care before midnight.

(I should note that some people do better with night shifts than others, and that there are real differences in biologic clocks. Shift length makes a huge difference as well. You can rotate your schedules to simulate a “physiologic workday” in eight-hour blocks and make an 11 PM to 7 AM night shift work quite well, but there’s nothing physiologic about 12 consecutive hours of continuous toil. Personally, I have always been much more of an evening and night person than a day shift guy. I truly find the hours between 7 and 11 AM painful to work, and on days off I tend to wake up about ten AM and go to sleep an hour or two after midnight. But even as a night guy I get tired about 3 or 4 AM, and that’s where the doldrums kick in.)

So you can’t do anything useful, and you can’t sleep. So you wind up doing that which is both not useful and not sleeping and burn a few more hours of your lifespan watching television. . (The one exception to the “time wasting” is on those days when I can watch Jerry Springer, which is always a useful exercise in Social Darwinism gone horribly wrong.) It gets to the point where you can plan your shift by reruns; it’s Home Improvement from 3 to 4; M*A*S*H from 4 to 5; I Love Lucy runs 5 to 6. Every now and then the cable channels will shuffle their lineup to keep you honest, but the only real problem comes on the weekends when the regular schedule changes. During those times, you rely on infomercials to keep you occupied, and while the schedule is less predictable after a while Chef Tony, the Magic Bullet Guy, aging pop stars from Time-Life, my med school classmate Troy Burns talking about vacuum pumps, and the gaggle of well-built women (my father would call them “deep breathers”) talking about “performance” become as familiar as Tim Taylor, Hawkeye Peirce, and Ethel Mertz. Here’s an example of how familiar these things can get: One of the “performance” programs features a very blonde and buxom PhD...specifically Victoria Zdronk, PhD, "Best Selling Author and Relationship Expert"...with a small mole on the inner upper aspect of her breast. That’s not unique in itself, but if you look closely you’ll see that every other shot flips her from one side of the screen to the other in a mirror image, including moving the mole from side to side.

(Incidentally, the first time I saw my friend Troy on TV, I sent him a Facebook note about it. Turns out he did a mock interview for the show as a favor for a friend ten years ago, and didn’t realize it was going to air in perpetuity. Turns out he doesn’t get any royalties, either by the airing or by the inch.)

TV time stops at 6. That’s when some of the more early-rising administrators start to poke their heads out of the sand, and one needs to be ready to respond to questions like “How was the night?” with totally politically correct answers like, “Any night serving the citizens of this fine community is a night well spent.” (Took a week to come up with that one. I’ve got more.) So I leave my little room, but on a brave face, and count down the last sixty sweeps of the second hand.

Speaking of my room, I’ve been spending a lot less time in it lately. This is because a few weeks back, an intoxicated patient who was waiting for a ride home went AWOL. This promoted a brief but vigorous search of the area, but by all accounts he appeared to be long gone. That is, until about two hours later when he was found dozing in the bathroom adjoining the ER doctor’s sleep room, pants down around his ankles, with a pool of what was suspected to be not-yet-digested burritos in front of him and a similar conglomeration of product in the bowel behind. Yes, my friends, he had managed not only to get into the doctor’s private office and to use to toilet, but also to both barf and fall asleep in the act of elimination. And while the room was cleaned by ED staff that night and again by housekeeping the next day, I refused to go in there until at least two days had passed I was sure that one of my colleagues had used the facility. I wanted to make sure there was a layer of trusted germs in between Mr. Elimination’s use of the seat and mine.