Burnt Out

I just finished working 17 days in a row. It wasn't entirely by choice; I was supposed to have Christmas off and work over New Year's, but when one of my partners quit and left on December 13, that left one person short to cover the hospital during Christmas. That meant 7 doctors for as many as 240 patients. I was supposed to work the night shift over New Year's (which I did not feel ready for), so I volunteered to work over Christmas. That way, with 8 hospitalists, the average census per physician would be 20-25, which was much preferable to 30.

The drawback, of course, was that toward the end of my 17 day stint I felt like I was losing my mind. I was averaging about 5-6 hours of sleep per night, and during the last week I was taking call from 5 to 10 pm every other day. This was a mistake on the scheduler's part; she'd originally put me down for three 5 to 10 pm calls in a row, which is straight-up suicide. There was a time when I worked back-to back 5-10pm calls, and I am never doing that again. Let me tell you, Q2 call is not fun at all, especially when most nights I wasn't physically able to leave the hospital until around midnight. And it was during one of these 5-10pm shifts that I experienced my worst call ever: 10 patients in 5 hours (capped out). Neither my partner or I left the hospital before midnight that day.

Christmas Eve was bad. There were lots of patients anxious to go home before Christmas, and I broke yet another record by discharging 9 people in one day. I couldn't even see all my patients on time because I had to see the imminent discharges first, and by the time I saw them and did all their paperwork, it was already very late. I'd had plans to have Christmas Eve dinner at a family friend's house at 6:00 pm, but I wasn't even able to leave the hospital until 6:30pm (still had 5 pts to see at 5:30pm, but I rounded extra-fast). Fortunately my friends had just started eating when I arrived, and the beef tenderloin, homemade mashed potatoes, red wine mushrooms, pomegranates, and cabernet sauvignon soon made me forget what a horrible day I had.

Christmas Day itself was better; I was still happy and smiling from dinner the night before (it was just the breather I'd needed), and I discharged two patients that were more than ready to go home. But a few bad things happened, too. A woman who had meningitis (I'll have to write a whole post about her in the near future) needed an emergent ventriculostomy for rapidly progressing hydrocephalus (went from AOx4 and talking to fixed pupils in 30 minutes), and another patient developed massive hemoptysis and went into PEA arrest during a bronchoscopy. Needless to say it was the Christmas from hell for the covering pulmonologist (who works every Christmas because he's Jewish); to quote him, this was his fourth massive hemoptysis since he first began practicing in the 1980s, and it put him in a foul mood for the rest of the day. Needless to say the pulmonology director had a lot of apologizing to do for his disgruntled colleague when he returned from vacation today; doctors, nurses, and even patients and their families complained about the other pulmonologist's unprofessional behavior. Thank goodness he's usually at another hospital.

The day after Christmas (today) was another day from hell. I'd barely seen 4 of my 22 patients when they announced "CODE BLUE, ROOM _____" (this hospital never says "Code Blue;" they use another term), and I immediately recognized the room number of one of my patients. He was an 86-year-old man who came to the hospital with a pathologic hip fracture from metastatic prostate cancer, and he'd been doing pretty well post-op. Just yesterday I was telling him that the Christmas cookies his family had brought him looked delicious. As I soon found out, PT had found him pulseless and unresponsive. The poor man had at least 2 shocks and 15 minutes of CPR (plus epi, amio, bicarb, atropine pushed into him), and when we  reached the family, they asked us to keep him alive until they got there. Fortunately after the amio and the 2nd shock we got a "strong pulse" and we were able to transfer him to the ICU. There, his pressures were in the 50s-60s. I wanted to start pressors, but one of the nurses (wisely so) told me to talk to the family first. I met with the family and explained the situation, asking how aggressive they wanted to be. Fortunately they were very  reasonable and his daughter said she didn't want any aggressive life-saving measures to be done. "We just wanted to see him," she said.

To me, the timing could not have been better. I would never want anyone's last memory of their loved one to be of doctors and nurses pounding away at their chests and shocking them to keep them alive. My patient had regained a pulse long enough so that his wife and children were able to see him lying peacefully in bed. They had enough time to summon a chaplain to the bedside, and they were together when the patient was extubated and eventually died. It was a good, peaceful death, which is what I wanted for him.

Of course, the whole case with this patient took up a good hour of my time, so I spent the rest of the day struggling to see the rest of my patients in a timely manner. And honestly, between the death of my patient and the fact that this was my 17th straight day of work, I was in a pretty foul mood. I told my colleagues that I felt like death, could barely keep my head on my shoulders, and was at the point where I simply did not care anymore. I spent 17 days taking care of other people, but never had time to take care of me. I didn't leave work until 6:45 p.m., and I am pooped.

Thank goodness it's over.

I Need a Dreamcatcher

It seems like death just can't leave me alone in my dreams. Last night I dreamed that a childhood friend whom I haven't spoke to in years threw himself off a tall building to his death, but not before calling me on the phone and saying, "You ready?" just before the fatal jump. What I remember most vividly from the dream was hearing his voice on the phone, then the horrible silence that told me he'd jumped, me screaming, and then the accusations that followed about who was to blame for his death.

It's strange that I dreamed about this particular person, whom I considered a close friend in our teenage years, but we grew apart after high school when he became a complete rebel. He couldn't seem to stay in school and became a gay porn model (not joking) for some time. Fortunately, from what I read on FB, he's turning his life around and making a name for himself in other ways. But still, maybe it was because of his troubled background that had me dream of him throwing himself off a building. The first thing I did when I woke up was check FB to make sure nothing had happened to him. He was fine.

But seriously...what's with all these dreams involving death? Is something horrible about to happen?

Mortality Bites

I rarely remember my dreams more than a minute or so after I wake up, but last night's dream (more like a nightmare, actually) was on a whole new level. I think it began with me being in the hospital, knowing I was ill (cancer, maybe?) and with a limited time to live. I remember looking in the mirror and seeing my face appear gaunt, with hollow cheeks (which has never happened; I've always had a round face), and having friends and family take me home, asking me what I wanted for "after I go." I distinctly remember being in a room surrounded by familiar things, looking through them, and telling my next door neighbor (whom I've known since he was a baby) I wanted to be buried with my childhood journals. It was around then that I woke up, a good 30 minutes before my alarm was set to go off, and no matter what I did, I couldn't fall back asleep. I just lay in bed, feeling uneasy.

As a hospitalist, I'm no stranger to death. Fortunately my white cloud has prevailed as I've only had to sign 3 death certificates so far since starting my job in September. Even still, I've been working three weeks straight with only 1 day off in the middle, and in these past three weeks I've seen a lot of depressing things. For example, a patient with metastatic esophageal cancer came to the hospital and decided the following day he wanted hospice. He even knew which hospice facility he wanted, and knew he wanted to be comfortable in the end. His oncologist told me 1 week later that he'd died peacefully after several days in hospice; that same oncologist also said he'd lost several patients in the past 2 weeks to terminal cancer. I had another patient with ESLD who got a TIPS in hopes that it could curb his ascites. It didn't; one week after I sent him to rehab, I ran into him in the hall on the way to IR to get a paracentesis. He'd gained 27 lbs in 1 week. "Doc, I can't do this anymore, I want to die," he'd said, "and I don't want to die at that place (rehab), I want to go home." Because we were in the hall, the only thing I could tell him was to get the paracentesis, then talk things over with his gastroenterologist and sisters.

I don't think my dreams are prophetic, but there have been a few instances in life where I had a twinge of deja vu and thought, "I think I dreamed of this before." A few dreams I recall that (fortunately) did not come true include a childhood friend being wheeled into a hospital with a needle in his arm (ironically, he's now working as a nurse in Seattle) or me being pregnant and not knowing who the father is (which will never happen if I can help it). But this dream with me dying of cancer? It could happen. I've seen young people in their 20s and 30s be diagnosed with leukemias, sarcomas, and everything in between. Some (a 31-year-old woman with ALL, a 32-year-old with metastatic rectal cancer) are most likely dead now. I've been extremely fortunate to be healthy all my life, but who knows? That could change in a blink of an eye.

Death is not something I try to think about. I've watched my parents grow older these past few years, and I dread the day I have to bury them. I hate it when my dad makes comments like, "Oh, I've probably got about 10 good years left," but the truth is he might be right. And who knows how many years I have left? Everyone would like to grow old and die peacefully, but those of us in medicine know all too well that it rarely ever ends like that. Anything can happen. I can only hope it won't be anytime soon.