The Deadening Hour

8/7/12

Posted by Amanda Thornton, MD (a third year Internal Medicine resident from Kaiser Permanente, Oakland while on a global health elective in Lusaka, Zambia with University Teaching Hospital).

The hours after I wrote the last blog were very tough. We work from 7-8am on call days until we are finished implementing plans the next morning. And this particular call day, we were all already tired due to Sunday’s call. Usually, when there are 4 interns, they take shifts, with each one taking 4 hours off through the night, and then when rounds start at 4:30am, everyone feels… well, if not rested, not desperately fatigued.

It’s not out of some sense of machismo that the residents and attending physicans work so hard and long here- it’s because there is a desperate need for more physicians and support staff in order to keep up with the increasingly complex admissions for poor patients with complications of advanced antiretroviral disease. The work to be done is not simple, must be performed with an eye for cost and understanding of the limited lab and imaging resources and cannot be handled by staff who are not at least partially trained physicians.

This is best demonstrated by the report of one of my attending physicians on going to help out at a clinic set up for a cholera epidemic. There had been a partially trained medical assistant who had set up and was running the clinic, and though he was doing the best that he could, when the physician went to help, he discovered that patients were receiving fluids through small bore IVs not keeping up with their large volume fluid losses and the patients themselves were not organized into wards that facilitated easy triage or treatment. There was no lack of funds or medical supplies, but still, patients were dying. I, admittedly without too much thought, asked why wasn’t the clinic only stocked with large bore IVs and support staff to insert and maintain them so the one with the most medical training could see new patients and answer questions- and the physician said- “Do you know why you say that first? Because you’re trained as physician- we all think that way.”

I hadn’t really thought about the process that took place in medical school and the way it changed how I thought about the body and problems of the body, but in terms of that particular sort of problem solving it’s true. There are special skills that we stop thinking about when we graduate from medical school and enter our clinical training because we (rightfully) assume that all of our peers have them. It’s part of the specialized training in medicine.

In any case, one of the interns had a needle stick injury the day before and was feeling poorly due to the protective antiretrovirals prescribed to decrease the chances of HIV transmission from the accident. After trying to work through the queasiness and achy flu-like side effects, the intern (with the whole-hearted support of the entire team) asked for sick leave and went home.

With that intern off on sick leave, the remaining hours were divided between the two remaining interns… but it was quickly discovered, around midnight, that the steady stream of admissions were too much for a single intern to handle. As tends to happen- as anyone who knows who has worked a very difficult call night- is that very sick patients keep coming, and then patients who had a single problem that can be fixed with a simple procedure or medication don’t get treated as quickly and the whole system backs up.

Around 8pm, I slipped back into the hospital to get evening blood sugars on two of our diabetic patients who would be able to leave the next day if their blood sugars were controlled with their new insulin regimens- due to the glucose test strip shortage, nursing had been unable to do the blood sugars before. There are TVs on each floor of the female and male wards, and I had to smile at my patient, a gangly 19 year old who had come in severely jaundiced and was developing purpura (reddish-brown bruises which are a dreaded complication of very low platelet levels) sitting inches away from the wards TV glued to an egregiously dubbed Spanish soap opera. She was obviously feeling better than she had been when we did work rounds this morning- but as one of the sicker patients on the floor, she was also conveniently right by the nursing station for monitoring while receiving her blood product transfusions. By the time I got back to the filter clinic, the attending physicians had finished their second set of rounds and the interns were in the admissions clinic working on admitting the 15 patients waiting in the lobby.

And the stream of admissions never slowed down. At one point, I was sitting with the intern, helping to collect all the material for a history, and there were screaming patients on the other side of the curtain (which separates the admission clinic from the rest of the emergency room). Though you wish you could go out and help who ever is making the noise, we had 4 full beds with patients who were not stable in the admission clinic, and we still had to make runs back into the main part of the hospital for supplies. We had two patients sitting on chairs instead of beds because we were so backed up- and, as one of the attendings pointed out the next morning- the patients who are well enough to make a lot of noise can sometimes wait longer than the ones who are slumped over, not moving and barely breathing.

Our team has medical students as well as several people who have graduated from medication school and are on the 4 month unpaid provisional training before they are accepted into a residency program. I went with one of the provisional interns into the main hospital looking for a catheter to perform a thoracentesis (removal of fluid which had collected in one of our patient’s lungs), only to have nurses stop us and request that a patient, who had been waiting for a paracentesis (removal of fluid in a patient’s abdomen) be started. The provisional intern performed the tap and I waited, exchanging the deflated IV bags we use for fluid collection, until we’d removed the 3 L the team and planned to drain while he went to look for another catheter for our patient in the filter clinic.

Around 2am, I went again with one of the interns to the intensive care unit, which stores the EKG machine as we had two patients with chest pain who needed EKGs sooner rather than the morning. Neither one of us were feeling quite up to the task, and after we’d gotten the machine, we stopped by the cafeteria (thankfully, open all night- though typically the fridges are stocked with Coca Cola and other sodas) to pick up something sugary so we could keep going.

It’s odd, here none of the residents have pagers. The team communications are all via cell phones- and between the cell phones of the patients and the residents- even in the worst of times there’s always the moment when someone’s cell phone rings with a recognizable or incongruently cheery tune and everyone has to break for a minute and smile. There is absolutely no effort to make the cell phone ring anything but personalized and upbeat- I’m beginning to think it is a cultural preference for the Bantu part of their love for joyful life.

At 2:30 am, when I finally crept into the Doctor’s Rest Room (which is what they call the call rooms- where physicians can sleep in close proximity to the nursing and their sickest patients) the TV in the filter clinic, again- only tuned to the fluff on the Zambian airways- was showing nature facts. Did you know that giraffes have no vocal cords? I certainly didn’t.