Doctors and nurses automatically agree to a certain degree of shift work when we join the healthcare profession but I dont think any of us knew what we were truly getting ourselves into.
“A call” refers to the overnight shift doctors do during their time in the public sector, which ranges from 24 to 36 hours. In my 4 years of working in the public sector I can safely say I have grown to slightly (read: majorly) dislike calls.
Friends and family have often hypocritically sympathized with me, “I’m sure you’re used to it by now”. But the reality is, if you have never had to live through a call, work through a call, keep humans alive through a call and often meet death during a call, you really have no cooking clue what it’s actually about. No one really knows what happens behind those close doors and for the most part, you’re lucky if you dont.
The “Pre-call blues” have been appropriately coined by our forefathers owing to their depressive nature. Nights before calls are reserved for soul searching. “I should have done accounting or law”. “Why didnt I think of starting my own YouTube cooking or makeup channel? “
Scrolling through your debit orders just to confirm that you do infact, really need this job. (You do). Comfort food like pasta is a must. Packing on call food and snacks is a poor but necessary consolation for the hours to come, and ofcourse: bubbles (non-alcoholic) Soda water, coke, Pepsi, fanta and anything that can prevent and treat hypoglycemia. To that, add a classic series or movie (half watched because, who has time for that) and some sad music and you’re good to go.
Calls completely annihilate your delicate-almost-non-existant-sleep-cycle.Between poor eating habits, high anxiety and stress situations on the daily, lack of social stimulation and and overall minimal exercise schedule, you’ve finally found a way to tip-toe around sleeping and one call kills it in an instant. You’re awake for 24 hours running around, trying to make sure no humans die on your watch, giving your adrenals the good ol’squeeze, riding that high until the next morning which fizzles off until the afternoon because you can’t just walk out of a pressure cooker and step into your duvet and expect to sleep?
No. You’re worried.
Are your humans still alive at noon? What’s happening at 3PM? Is the FBC still pending and why? Let me check on Labtrack, the barcode is still on my forearm. Did someone fetch the blood at the blood bank and commence it? It’s now 5PM and your eyelids feel like a Wet Vaslap but you might as well push yourself until 8pm and sleep through the night because, you know, you’re a pusher. But now you haven’t slept at all in 48 hours and you have a major deficit.
Will the Sleep-Gods or the Tooth-fairy forgive you for the lag? Who regulates this anyway? Is it Father time? Will He reward you with a Migraine or let you off with a warning this time? Because you have a full day of work tomorrow. Your mind is racing ahead, anticipating the fatigue you will feel tomorrow, forgetting the fatigue you should feel now. The constant overzealous thinking and planning is in itself, exhausting.
It’s strange how doctors are inherently wired. We’re always looking ahead, planning for the next one, thinking about what’s after what is actually in front of us. I guess in a way, we are trained to be fore-thinkers. When you’re in a race with death, if you’re not quick enough, you will find yourself a bitter loser.
Looking at my every day life I find this mindset a staple. I’d go as far as saying, it is a joy-thief. I lack “mindfulness” and “in-the-moment” presence. If I’m eating, I’m thinking about what to eat next. If I’m sleeping, I’m planning when to wake up. If I’m awake, I’m planning when to sleep.
I convinced myself to be a basket case and sought help from an expert once, A Monk. Who better to advise me on mindfulness than A Monk? After our conversation he told me I would need a minimum of 6 months away from my current life in order to “Re-set” my thinking pattern. Automatically, I asked, ” What happens if after 6 months if I am unable to achieve mindfulness?”
Then i realized it, I’m actually a complete lunatic.
You close your eyes and drift into the worst sleep of your life. Replaying the call all over again. Running, sweating, racing, moving, dying.
You remember your call the night before and somehow, laying in your bed, you dont feel quite the same. Can one night change you? Yes. Yes it can.
Every single day in medicine is different, even if you have the exact same patient, you’re not the same doctor. Things are constantly changing and demand your attention and action. During the day, you have the entire team as your backstop. Everyone working in unison to make sure the work is getting done timeously. After sunset, it’s just the On-call team- and as Murphy would have it, that’s when all the sh*t goes down.
I’ve had calls when admissions would roll in, in torrents 10 minutes after the team had left, leaving me to my own devices. I learned quite painfully how to structure my call, what to do first and what to do last. How to delegate but still be supportive and hands-on. How to teach but not waste time. A process that’s still very much in motion until today. Over the years I’ve learned to anticipate this- Once the day team leaves, the action starts.
In Paediatrics, I started to believe that the children are so smart, they know exactly when the day team leaves, and start strategically pulling out their drips one by one. How else would you explain 5 drips out between 4pm and 5pm ?!?! Exactly.
You insert 5 drips and think your problems are over but the baby who has been stable on the ventilator in PICU has now began to desaturated to ZERO.
Your mind goes back to the hand-over round. “This baby should not give you any trouble. He Is stable on the vent” sounds like a statement of sabotage.
You get there and start with chest compressions before questions because the pulse is 59. You do some nice things and work the suction and the sats have come up to 99. You connect the ventilator back to the ETT and conclude the baby is not sedated enough and prescribe a stat dose of dormicum. You confirm tube placement. You examine thoroughly. You check other parameters. You use this opportunity to do a review because you dont want a repeat of this episode. You call your boss just for good measure. You did good. You averted a major disaster.
Surely your problems are now over.
Your phone rings. You hate the generic ring tone on the second ring. You learned long ago never to put any song you remotely like as your ring tone because calls will quickly butcher it for you.
A clinic sister is calling you because 3 siblings have ingested paraffin in 1 go. You have so many questions but you ask for vitals only and accept all of them. You’re worried, hoping none of them have aspirated the paraffin into the lungs.
As she is about to put the phone down, she hesitates. You wait. She wants advice on a 6 month old chubby baby with diarrhoea with no signs of dehydration and whom she feels has “slightly low pulses”. You shift uncomfortably in your seat. She doesn’t know what’s a capillary refill time (you start sweating) and the palms are warm. He isnt vomiting but isnt eager to drink either. Shes failing with a drip and has no NGTs. She isnt very worried. You know dehydration can easily be hidden in the chubsters so you ask her to send him with the parafffin-drinkers for further assessment.
The ward is calling you, theres a baby having a seizure and the drip has also, miraculously come out again. You call your colleague and attend to the baby. Seizure aborted. No one has died. You look at the time. Surely, being so busy, you’re excited, time must have flown by!
Its 7PM. Only 3 hours into your call.
You’re still expecting 4 children and God alone knows what else.
You decide you deserve to eat the pasta for dinner, so you whip it out and take a few minutes to admire your meal, Jamie Oliver would infact be proud; and then you hear your phone ring. The ward is calling about a baby who is a known Spastic Cerebral Palsy baby who choked on his juice and now cant breathe very well.
Again, you’re running.
You get there and it’s obvious, his lungs are flooded with OROS, it smells like your childhood but tainted somehow. You can smell the familiar orangey tinge. You do some nice things with the suction and oxygen but it’s not working this time. He is struggling to breathe. His SP02 is 80%. You know he needs a ventilator but you dont know if he qualifies and if it will actually help in the long run. You call your boss. Boss says No ventilator. We dont have a bed and CP excludes him from the ICU criteria. Supportive measures.
Okay. Supportive measures, it is. But what does that actually mean.
We prop him up and put him on high flow oxygen with a nebulizer and antibiotics. We call for a bedside X-ray. Theres still OROS coming out of his nose. You explain the situation to the Mother who has been in and out of hospital since he was born and made it this far (he is now 5). You want to sit and talk to her and absorb her words and tell her how sorry you are and lend your support, but your phone rings. You abruptly silence the call trying to buy yourself 5 extra seconds, watching the hospital number flash on your screen. You speak quickly. You know this may be PICU calling about the ventilated baby. What if his Sats are ZERO again? You excuse yourself, feeling guilty because you cant even counsel a grieving mother properly.
The parafffin-drinkers are here + 1. The ambulance needs you to assess them before leaving and they’re in a hurry. You run. The parafffin-drinkers aged 3, 4 ,5 years old on first eye ball look stable. The 3 year old is on oxygen but the other 2 are fighting (a good sign. If you can fight, you can breathe). The chubster with diarrhoea is asleep but looks very shiney. Why on earth is the mom rubbing his entire head and body with vaseline??? Somethings I will never understand. I reconcile with my thoughts and sign the EMRS book. My colleague and I start triaging.
I just remember, I have to do an arterial blood gas on the ventilated baby in PICU and a PM review round in ICU and high care and….it’s already 8:30PM. I look at the monitors and am relieved to see 99% on the screen, MAPs of 50 and pulse of 140. Pristine.
I run down to casualty to process the blood gas because my intern colleague is still busy sorting out the flock of children.
I realize I haven’t hydrated since 4PM and i am now starving. I take my bottle of water with me and a jungle oats bar to eat along the way , the pasta will have to wait.
The blood gas shows the baby is retaining CO2 slightly but oxygenating well. PC02 is 6. P02 is 15. PH is 7.34 He does have a dense pneumonia, could it be the lung pathology? He also does have secretions and needs regular suctioning. I need to make sure the circuit is free from moisture. I’m in ICU trying to maneuver the ventilator and its connections. Time is running. And ofcourse, the drip is out! I am in search of veins on the scalp, trying at all costs not to displace the tube stuck in his throat. I cannot afford a sketchy drip and him waking up and pulling tubes out. He looks sedated and synchronous with the ventilator but he is on SIMV mode for now.
I review his parameters and discuss with my boss. I use the opportunity to update him on the flock. Our conversation is interrupted by my cellphone ringing once again… I can’t even think in peace!
I return to the crowd only to find 2 more children have joined with somewhat angry parents who have just walked in from the street. Main complaint: fever and runny nose. Classic.
The children are stable on room air. I do quick assessments and explain to the parents that we work on a system of TRIAGE ie. The sickest children get attention first. Obviously they feel their children are extremely sick and should be attended to first. And while I do agree that they are sick, I dont agree that they are the sickest children in the room. They are pissed off because they had to leave their warm beds at 10pm and grace us with their pleasant presence. I see intense eye-rolling and lip smacking. Someone leaves for a smoke break. I hear some comments about “how this would never happen in private”.
I dont engage. I have to preserve my energy for the rest of the night.
The intern doctor alerts me of the issues she has identified. The 3 paraffin-drinkers are stable. She has made notes and we are observing for any respiratory distress. Shes called poison centre and has gotten the relevant advice. The chubster woke up and had 2 sips of Oral rehydrate solution but is still very dehydrated and is now still sleepy and drowsy.
I’m worried. I approach to examine him and struggle to grip his wrist as he slips between my finger tips. He is not in shock but severely dehydrated. Vaseline is everywhere. I probe about the frequency of loose stools and the mother completely ignores my questions. I claim language barrier and ask for an interpreter. The interpreter is ignored. The mom is upset.
I ask to speak to her privately and the story is revealed. Shes upset about the treatment she received at the clinic. In an effort to move forward fast and extract information, I apologize on behalf of the clinic, the hospital, the south african government, the district, the department of health and myself. She lightens up. Baby is having diarrhoea for 3 days. Poor appetite. 6 loose watery stools today. No vomitting. He has been asleep and drowsy since she arrived at the clinic.
We need IV access urgently.
We are struggling. The more we tell ourselves we need the IV line, the more veins we pop. Theres no backflow. It wont flush. We’re frantically poking blindly. Every second means potential shock and circulatory collapse. The anxiety and frustration is building. I don’t want to poke bones and use intraosseous lines unless I really have to.
And the DAMNED VASELINE!
The chubbiness is against us. The rolls of adipose mask the veins and the vaseline is not helping at all. Every time I grip him, he slips. Damn! He doesn’t fight because he has no energy. Finally, we succeed with a scalp vein. Success. We make sure to secure the drip with a bandage but I am not satisfied. It seems too flimsy. I double bandage the head and tell the mom how precious the drip is. I really do contemplate adding a small piece of plaster of Paris or a back slab to reinforce my precious drip. There is no time.
Half Darous Dextrose is running.
Blood gas shows a severe metabolic acidosis and a hypernatremia of 160. I move him to high care for close monitoring.
I still haven’t done the PM round at midnight and the parent who is back from the smoke break, is now demanding to see “A manager”. I resist an urge to remind him that this is not Woolworths. I keep quiet and apologise, reassuring them we have done their vital signs, reduced their temperatures and are observing them over the next hour. They’re demanding to go home because they’ve been here for “2 whole hours”. I’m confused. Why did you come here if you want to go home? I nod and say nothing. Saved by the dreaded ring tone. The CP baby is dying in the ward.
I run, again.
I arrive to find him in severe respiratory distress, hungry for air, almost obtunded. The OROS in his lungs has created a VQ mismatch and he is suffocating and drowning. I feel helpless. I intensify the nebs, holding it myself silently eyeing the intercostal recessions hoping for a miracle. His muscle spasms, so severe and so intense, he feels like rods and wires. I dont know how to help him. Infact, I cant. And while I know the prognosis is poor, watching him die and suffer makes it no easier. Suffering remains so, barring medical terms like prognosis and diagnosis. Pain is pain. He looks at me almost begging to be poked or prodded. I ask the mother to sit with me and I relay the bad state of things. She understands but again, pain is pain. I see the heartache in her eyes and I hope she sees it in mine.
He closes his eyes for the last time at 1:20AM. I don’t have time to cry although I would really like to. I add this to the 3 year emotional backlog into the pit of my mind and start moving along to high care.
Its 2:00AM and you have PM (Now AM reviews) to be done. You haven’t received any reports from that side of the world so you’re consoled by that. Surely someone would have called if there was a problem? You arrive in high care to find 2 drips out and antibiotic doses due. You know NOT to mess with Meropenem doses so you start your struggle.
You start tapping on forearms and scalps and feet and ankles, in search of veins but there are none. You feel the fatigue and hunger creep up on you. Your eyes itch and your bladder feels heavy. You crave the feeling of a pillow just for 10 minutes. The vein pops, the child moves, the drip tissues. You still have not done your reviews.
You decide to pull out your big gun: redbull. You feel no shame in this. Infact you’re proud you made it so far without having to use it. You down it in 1 minute and pump yourself up. You shave the whole head and start vein-finding. Success. Its 3:00AM and you’ve finally done your PM/AM reviews.
Your energy levels are up but the redbull has triggered a gastritis cascade from hell and your stomach mucosa has started to self-digest. You remember your pasta. You sit down and decide the treatment for your gastritis is pasta. You gobble. It’s only after the first 5 bites do you notice something odd and…. sour? You didnt refrigerate it. Because you obviously thought you would eat supper at supper time, and not at 3:00AM. Your food is sour and you ate almost half of it. You do a quick calculation in your head expecting the worst, food poisoning and diarrhea 6 hours from now that’s at 9AM so my call would be over. You whip your phone out and set an alarm. “Expect AGE 9AM” I am safe for now atleast. I eat an apple. No biggie. Maybe, just maybe..my cheek can meet the pillow for 10 minutes…
After 2 minutes, the intern doctor calls you. The chubster has had a seizure in high care, the snotty nose in PRU temperature is 39 degrees and the 3 year old paraffin drinker pushed the 4 year old paraffin drinker off the bed and he grazed his cheek on the floor. You also have an AM gas to do on the ventilated baby. You checked on him twice, and he seemed fine but you need that Gas to be sure.
You run. You know sunrise is coming. You can’t wait. The prospect of the night ending fuels you. You look through all the windows, waiting for the orange hue to show itself. The excitement is mounting. You’re smiling.
You dont care what happens at this point, you can deal with it.
You’re channeling your inner Rambo. The redbull is helping.
The moment you see the peep of the sun, all hope is restored. The sign of the end of turmoil. You can almost hear Mandela, Cyril, Martin Luther King and even God Himself speak every word of encouragement into your ear. The people who have been soundly asleep with absolutely no idea of what you have been going through would now rise and come take the batten out of your bruised hand.
Only a post-call doctor can know such a joy.
Suddenly, its 7:45AM and you’re struggling to collect your thoughts to present to the Day team. You have so much to say but your mouth wont cooperate with your brain. You start talking but your sentences look alot like your hair- confused and all over the place.
Your scrap piece of paper was soiled with hibbertane so you’re struggling to read what you wrote down. You don’t want to miss a single piece of information. Your forearms are shining with vaseline. Everyone notices, thinking you had time to moisturize during your “busy call”.
You leave relieved its finally over, but still concerned about what you’ve left behind. No one wants to hand over problems.
You drive home feeling pangs of hunger, a headache but mainly pure exhaustion. You convince yourself you’re able to be productive for a few hours in the day, so you stop at the mall for a “few groceries”. Standing in the Que makes you realize what a bad idea this was. You’re suddenly buying heaps of things you dont really need. Afterall you deserve everything the world has to offer after the night you’ve had. You drive past Mercedes Benz and the thought crosses your mind. Luckily, you’re too tired to stop.
You climb in the shower relieved to be at home doing normal humanly activities like showering and eating.
But your mind cant help but wander… how is the baby in high care? What’s the sodium now? Did he have another seizure? Are the paraffin-drinkers home safely? How is the mother of the CP baby who demised? I wish I had more time to speak to her.
You wake up suddenly and abruptly the next morning, confused and disoriented. Your calves ache.
You wake up wishing you had never slept. Your eyes are puffy. You feel a wave of fatigue submerge you. Your head is throbbing. Your mouth is dry. You’re dehydrated and hungry. Your basic human needs surface like never before.
You forge on because its 7:00am and you’re already late. Everyone at work spots the “Post-Post call person” (yes, it is a thing) and acknowledges their scruffy look. You go through the motions of the day and reach some level of normality the next day.
You’re finally feeling like yourself again but alas, the time has come for your next call.
And the cycle continues…