There was a time in my life (not so long ago) that I physically felt my body buckle under the pressure of overnight calls. No matter how much I would sleep, hydrate, meditate and pep talk myself the day before, my body began unraveling at the seams. My usual steady state of functionally tired morphed into dysfunctional fatigue.
There is a stupid notion that exists amongst doctors/people that you can “sleep in advance” so to speak. I guess the logic behind that is if you store enough sleep in your cells, you can cash these “sleep tokens” in at 1:00am on call, when you desperately need it. I can say with utmost certainty that this does not exist. Because If it did, I would pay real money for such a thing.
I’ve said this many times before- people outside of the medical fraternity really don’t know what goes on behind closed doors.
People assume that not sleeping for 24 hours is just that and it really never is. You pulling an all nighter to travel or watch Netflix or even studying is not the same thing. The mental fatigue of making life-altering decisions when you can’t keep your eyelids afloat is so traumatizing. The responsibility of a whole life resting in your tired hands is not a burden anyone should have to bear. The aftermath of decision making sometimes leaves you paranoid and doubtful.
Redbull can unfortunately only carry one so far. After 30+ hours, your body starts rejecting anything you put in it. Your human instincts fight your mindful responsibilities and all it brings is chaos.
I dont have to dig deep for memories of calls where I felt faint, jittery and slightly manic at times. The beeping sounds of dropping sats machines and alarm ridden ventilators was only drowned out by the sound of my own racing heart beat. My adrenaline tachycardia kept me going.
I started of the call in good spirits, 500mls of water, 2 empty beds and all results logged and pending on labtrack (hooray for no missing specimens). Things were looking up for me (no they were not).
The “call phone” rang! Thinking back.. I miss the ring tone of the call phone. A simple standard samsung ring tone, equivalent to the old Nokia 3310 mp3 tones, unmissable, unavoidable and a phone that never actually went to voicemail. Just endless rings of potential admissions. The phone that had been through and seen it all. It had passed by hands of countless number of tired registrars, consultants, medical officers, interns and nurses day after day after day. It had a battery that could outwit, Outlast and outplay any survivor including Jeff Probst. I had seen that battery on 5% for an entire day and refuse to die.
The moment the phone rang and “Labour” flashed across the screen, I knew my luck was in the boots.
“HI, its Sister so and so from labour ward, we just received twins. They are premature at 1kg each. They are both in severe respiratory distress and very cold. They were born before arrival [(BBA) Now I was sweating] 4 hours ago… Twin 1 is very pale and is also gasping.. (Now I was hot to touch…I couldn’t hear the rest over my pounding tachycardia in my ears).
So naturally, I grabbed neopuff (Google it) and ran. Sweat dripped of the back of my neck and coupled with the breeze of a light jog, I cooled down.
The 1km jog woke me up. I eyeballed the 4 hour-old twins. I caught a glimpse of the mother and approached her to let her know about the twins needing admission but she didn’t look so well herself. She had been at home bleeding out of her floppy uterus for 4 hours non-stop after birthing not one, but two human beings without any form of pain medication or assistance. She brushed me off with a moan of pain. I looked at the twins again- Both needed the whole shebang. By some slight miracle, no one’s sugar was low and no one required immediate CPR.
We loaded them up in the not-so-warm incubator and made the long trek back to the nursery ICU. I started formulating the plan in my mind- lines, bloods, fluids, antibiotics, paperwork, prepare CPAP and surfactant. There goes my 2 empty beds.
The call phone ringing interrupted my thoughts.
“HI this is Dr so and so in theatre 1. The spinal is going in for a fetal distress with fetal bradycardia and meconium stained liquor.”
I flipped my list out my pocket of all the current booked cases and obviously didn’t find it there. I would have definitely remembered a case like this.
I simply didn’t have any energy to get into a scuffle regarding why I wasn’t told about this case. I mean a bed could have been prepared and information is just generally helpful!
I didnt have time for emotional distractions, I needed to figure out what to do with the twins and quickly. I called the intern doctor who was busy with drips and asked him to please accompany the twins to NICU while I ran to theatre. I called the consultant quickly to update him.
What a guy! … but that deserves a post on its own. An epitome of a paediatrician and neonatologist. One of the best teachers I have ever had. Someone who really made me think about medicine, pathology, patients and myself. Whenever I think about how to behave in certain situations- I ask myself: what would JJ Van Rooyen do?
He advised me solidly and I felt somewhat in control for a while.
I arrived just in time to greet a completely flat, floppy, blue-green baby with absolutely no respiratory effort and meconium pieces everywhere. Heart rate flashed 166 sats 66 (ominous sign)I knew we were in big trouble.
The suction catheter was clogged with pieces of meconium. His vocal cords however were surprisingly meconium free. We secured the tube and gently neopuffed. I was dreading this phone call.
“HI Sister so and so, I’m so sorry to do this. I wasn’t aware of this patient. Meconium aspiration in theatre with NNE and needs a ventilator”
“Haibo Dokotela! you are unfair. We are busy setting up CPAP for twins from labour ward which you didn’t Inform us about and now you want a vent! You going to wait wena. And dokotela, twin 2’s sugar is 2.8 now, we need a drip. The intern doctor is here but is struggling”
I appogised profusely while remembering I forgot to inform the nursing staff about the BBA twins before rushing to theatre. I cringed. I knew better than to not communicate well and make everyone run around like headless chickens. I made a mental note of it. And I needed to admit the twins and get umbilical venous access and start fluids. Shit.
Theatre was being scrubbed, the mother had been wheeled out and the ringtone of the call phone began once more.
“District hospital” ….
I whipped the phone out hoping it was a nonsense referral we all hated. But for once, I hoped it was something trivial that could he managed at base. Please waste my time!, I thought.
“HI Doc, I’m so sorry to disturb. I need to discuss a patient. ”
“Sure. Is this an emergency?”
“Actually, Yes it is”
My heart dropped onto the just scrubbed theatre floor. I asked the midwife to take over managing the airway. She looked at me stiff. I was already wasting her time by making her wait for the vent bed. I think she softened when she saw my tattered condition.
” 22 year old primup, gave birth 1 hour ago, flat floppy baby with low apgars and Thompson score of 13. I think he would benefit from therapeutic hypothermia”
But where? There was no bed. I was already in a deficit of -1. I started with 2 empty beds and have a 3rd admission and now possibly a 4th.
Time to play the age old musical chairs. Shuffling and moving patients all over in the middle of the night while people are busy admitting new patients. A perfect way to really tick people off.
I called the consultant to get the go ahead to move patients around. I called the district to tell them to send the patient across. I emphasized on the time sensitivity as all we had was 6 hours (5 now) to save that little brain.
I grabbed my redbull and poured it into my mouth while simultaneously swallowing and almost aspirating. I knew I had to admit all 3 patients before the NNE arrived from the district.
The count down began.
4.5 hours: in between umbilical lines and giving surfactant- how far is the baby? Has the baby left yet? Is the ambulance there?
Time is brain!
No. The ambulance has not arrived but is on its way. I Google mapped the hospital- 32minutes away. It’s 1am so most garages/KFCs are closed so hopefully no food or bathroom breaks for the ambulance.
I continued toiling with my admissions. The meconium aspiration from threatre made a good come back. Neurology improved dramatically. Ventilation on point.
Twins were also trying their best to survive. Both on CPAP, both given surfactant, both coping well.
3.5 hours: WHERE IS THE BABY? Time is flying. We don’t have much left. We need to cool this baby ASAP. The district doctor is busy in theatre and hasn’t had a chance to check if the baby has left.
3 hours: This I ridiculous. I called the ambulance service and start demanding to speak to supervisors at 3am. The supervisor has COVID and is off sick.
2.5 hours: twin 1 looks paler by the second. I’m concerned. Check formal results and suprised by quick turn around time. Hemoglobin is 7. Probably bleeding from the uncut umbilical cord for 4 hours. I’m ordering emergency blood. I run to the mother hoping she is in a better mental state to consent for a transfusion for her baby. I get to labour ward high care and she looks much better, pink and alert. I breathe a sigh of relief! She signs and I run. The intern doctor is at the blood bank collecting the blood.
1 hour left: the baby from the district still has not arrived. My head starts pounding. I call the doctor at the district and she says the baby has just left. I knew it was cutting it so fine but there was still hope.
I started doing the ritualistic morning gases for all the ventilated patients. I realise I am starving and squash a decomposing banana into my mouth with a swish of red bull. It’s felt it get stuck in my oseophagus but I gave myself a few chest slaps and moved on quickly.
45 minutes left: I see people in green with an incubator while doing gases. Praise God. Just in the knick of time…
“Dokotela, the cooling machine is not working…..”
I feel the undigested banana and rebull migrate up to my throat.
After all of the logistic drama, now a technical problem. No!
I look at the machine. I know nothing about the cables, connections, sensors and attachments.
I didnt know what’s right to know what’s wrong. I fiddled desperately, said a quick prayer and hoped by some miracle nothing would alarm. And It didn’t. I finally digested my banana mixture and felt a wave of relief.
Success. Brain saving maneuver started.
My eyes felt heavy. I knew the morning was near but every minute felt like an hour. I waited patiently for the soothing choir of the nurses morning hymns and prayers. I closed my eyes and allowed myself to really rest for those 8 minutes. There is nothing more comforting that that sound.
I had 8 blood gases in my pocket and haven’t started morning reviews yet. Did everyone pee? Who vomited? Who’s drip is out?
But no one has died. Not only did we bite the bullet, but we did do some light chewing too.