The gray haze of early morning light got brighter as I ascended from the depths of sleep toward the surface. The squeaking of a supply cart rolling along the corridor was probably the cause of my awakening. As I pried my burning eyelids open, I realized I’d slept for maybe an hour. I quickly checked my pager and found the battery was still good. I had always had a horror of not hearing a stat page, but this was unlikely when one slept in the lounge near the critical care area, where a nurse could easily pound on the door if she needed you in a hurry. Both the intensive care unit and cardiac care unit were only steps away.
Swinging my legs over the side of the lumpy mattress, I dizzily arose, still fighting the wave of sleepiness caused by my circadian alarm trying to tell me that something was not right. Were people really supposed to work for 24 hours on two hours of sleep? My scrub suit, probably laundered a thousand times, felt like friendly old pajamas, inviting me to flop back onto the bed for a quick nap. But knowing that in a half hour my chief and all the fresh residents would be arriving and expecting me to look sharp, I got myself together and trudged to the shower.
The night had started off rather slowly, with only a few requests for ABG’s and an IV restart or two. A diabetic patient on 7 East, delirious and sweaty, perked right up after a glucose infusion and spent the rest of the night enjoying a normal sleep. A CHF patient, Mrs. H., who frequently strayed across the clinical line, required yet more Lasix to relieve her nightly shortness of breath. I reviewed her chart. She clearly was running on fumes, and these were the days before ACE inhibitors; beta blockers were just coming into use. I recalled one of the older attendings describing how he used to use mercury diuretics when Lasix didn’t exist. I glanced at her Foley bag to be sure that the “golden effluvium,” as urine was called by another staff attending, was increasing appropriately. Downstairs in the intensive care unit, things were quiet. The hum and buzzing of the respirators were like elevator music — you didn’t really notice it unless it stopped. One afternoon during a thunderstorm, the main electric power supplying the critical care area suddenly failed, followed by a profound silence. This justifiably sent the staff into a momentary panic. Cool heads prevailed, however, and after a brief interval to grab the Ambu bags, we were able to function as human ventilators until the big auxiliary generators kicked in. This night there were no surprises, however. I had visions, albeit unrealistic, of maybe getting a few straight hours of sleep.
The most dreaded pages always came from the emergency room (ER). No matter how quiet the wards appeared to be, the ER was always the unknown quantity. Only on those rare but blessed occasions when the house was full and the ER went on “re-route” to ambulances could we take comfort in knowing we wouldn’t get a call for a medical consult. Sometimes we’d get several consultation requests in a row. This night at 3 a.m., my phone jangled unforgivingly to notify me that I was wanted in the ER for a new admission. The nurse there pointed out a young man lying supine in one of the cubicles, sound asleep. The admission request tersely stated, “S.O.B, cause unknown.” The initial lab workup and blood gases were basically normal, as was the chest x-ray. No fever. No tachycardia. No dyspnea — not even a cough. I remember feeling resentful that he seemed too healthy to have come to the ER in the first place, while I, on the other hand, was shuffling around as if walking ankle-deep in wet cement, dead tired and longing to stretch out on the gurney in the adjoining cubicle.
I had to get a history from this guy. I shook him gently. He immediately said, “Leave me alone!” Another shake, with more gentle explanations as to why it was necessary, evoked the same reply, only with an increasingly hostile edge. Followed by more snoring — the delicious, enviable, energy-restoring kind, not the pre-coma or drug-induced kind. He even rolled away on his side to avoid facing me. In desperation, I did what limited physical exam I could on an uncooperative patient, scrawled a few lines on the chart, and resolved to do better in the morning. There had to be a five-minute window of opportunity sometime before the cold light of the review of the night’s admissions shone mercilessly upon me.
At morning report, I was astounded to see that our chief, fresh from a full night’s sleep at home, seemed inordinately interested in this seemingly healthy patient. What’s all the fuss, I asked myself? The patient is healthier than I am! The fact that our chief was a chest specialist should have given me a clue. Somehow he’d heard about the case (they always do when you wish they hadn’t) and had seen the patient before I could go back to fill in the considerable gaps. Peering over the tops of his spectacles he asked, in the beguiling, measured manner of those film villains who already know what the correct answer is when interrogating a prisoner, “Doctor, what is this patient’s occupation?” Occupation, I thought? Why, I couldn’t even get him to tell me his name! I mumbled some feeble and generic guess rather than admit I didn’t have the slightest idea and wasn’t prepared. Bad choice! The other residents sitting around the table in the conference room all bore witness to my humiliation, looking askance and shuffling uncomfortably in their chairs. Nobody wore a look of righteous superiority, though — we were all brothers and shared good and bad moments in equal portions.
Suffice it to say that the patient turned out to be a worker in a paint factory somewhere in the hinterland and had been troubled by recurrent attacks of dyspnea on the job, only to get better at home and on weekends. It was then a short leap from paint to toluene and then to hypersensitivity pneumonitis — one of our chief’s all-time favorite topics — just my luck! These cases were relatively infrequent at our hospital and our chief’s face just lit up with pleasure because he was now given the privilege of expounding at great length on the pathophysiology of this disease. Chemical factory workers, pigeon breeders, silo fillers and cheese washers were a scarce commodity in our geographic area — we couldn’t afford to miss this teachable moment. I was never taken to task directly for my error. The chief, I believe, realized that the episode would have an enduring influence on my future behavior without having to subject me to public humiliation. And he was right!
Ever since that night over 40 years ago I have felt the compulsion to gather as much focused history as possible during each office visit despite the pressures to keep up patient “flow” and “productivity” — actually just euphemisms for the financial standards to which physicians are held and by which they are often rated. I believe that the time spent talking with a patient has paradoxically shrunk over the years despite all the advancements in technology, the hiring of paramedical and ancillary personnel, and the elimination of those long, handwritten histories of old. Medicine of the kind pictured in those old Saturday Evening Post cover drawings by Norman Rockwell, once a reality, is rapidly becoming just a fond memory.
Attending Physician Guest Writer
Ospedale Privato Santa Viola in Bologna, Italy
Dr. Williams attended the University of Bologna (Italy) medical school and subsequently completed his Internal Medicine residency at Providence Hospital in Washington, D.C. in 1978. He then returned to Bologna after twenty years of office practice in the D.C. area. In Bologna, he continues to care for students and expatriates, working with Italian housestaff as well.