Wednesday, July 26, 2017

Last Night on Call

July is the beginning of the new academic medical year and the end of my neurology group's nighttime emergency room contract. We had previously turned over the daytime responsibilities to the full time neurohospitalists.  For months I have been ruminating on what is likely my last working venture. There is not a simple fork in the proverbial road, more like a traffic circle, with several exits not reading "Physicians This Way". I could work in the outpatient clinic, continue to teach the first and second year med student's basic science courses, or both. I also know I would be entirely content as a full time gardener, stone mason or bike bum. On my recent cycling trip to Spain I felt confident I would make great progress on this dilemma, having a perspective set by the distance in both miles and duties. Also I was surrounded by lifelong friends who would be happy to listen and opine. At the end of my vacation I was no closer to the solution than I was two weeks earlier.

Almost everyone hates call. I cannot remember if this was always the case. When our new washer and dryer were delivered, the owner of the appliance store proudly told me his daughter was in training for ENT surgery at a prestigious university program and she was loving the entire experience with the exception of "call" which she hated. I guess it starts early. Our neurology group had shared this "on call" responsibility for decades but had notified the Med Center we were no longer interested in continuing this duty. Recently it was my turn for the "last night".

At 11:30 PM the ER called about a patient with some unusual "jerking" movements. This did not seem to be a critical problem but I was clueless by the phone description and preliminary test results. It is fairly easy to go back to sleep in a non life threatening situation, as long as there is a definite explanation. Since there was not, I felt I needed to take a look. Did I like driving there? No. At least there was little traffic. The Rolling Stones song What a Drag It Is Getting Older wafted through my mind. Once arriving and going over the patient I confirmed she was not too sick; she needed a brain wave test (EEG) in the morning and a medication change. It could have waited. Oh well.

While there I received calls regarding three more patients.  One was easily handled by phone, another had to be sent from a distant hospital where I gave routine instructions on a straightforward case, and lastly a patient in our ER. This one was a puzzle. An elderly women with known multiple medical problems came to us by ambulance complaining of recent onset generalized weakness. The ER doc determined she had severe anemia secondary to GI bleeding, proven by finding old blood in her stool sample. She received several units of blood, then had a procedure in the GI lab under light sedation to find the source of the bleeding and to coagulate it, all performed without incident. She returned to her ER room awake and alert.

She then had sudden neurological change becoming less responsive and unable to speak. The treating physicians felt she was having a stroke and perhaps needed the clot buster, risky in a patient with a bleed even if allegedly fixed. It took me awhile to do the examination, always a challenge in the poorly responsive patient. When completed I was certain she was not having a stroke and she did not need the risky medication. The change in her status was due to a combination of medical issues likely to be corrected with time and support. The CAT scan of the brain was of no help.

While doing the neurological exam on this sick person, I realized how much I enjoyed doing it and how confident I was in my assessment once done. I forgot the unpleasant wake up, the drive to the ER and even the Rolling Stones.

The ER and inpatient duty is a complicated ride. It is analogous to going down a steep hill on the bicycle. When I was young and on a soaring mountain descent I was absolutely confident nothing could go wrong and what a thrill it was. I have always been intrigued by the medical puzzles the hospital provides, the more bewildering the better. Early in my medical  career I had the same confidence and thrill as on the bike over equivalent treacherous terrain. Young riders and young doctors are naturally fearless and this likely works both for them and against them.

I have had seriously crashes on both venues. On the bike I am now very cautious and the downhills are not nearly as thrilling. In the hospital there has been a parallel evolution but more complex than simply being cautious. I have put hubris aside and uncertainty has become my constant companion.
Maybe it was the drama of the "last night"  on call or perhaps I would have had this insight on another occasion, but I so clearly realized that evening how gratifying it is to have the confidence of a young doctor entirely generated by the ability to do an accurate bedside examination. "Putting the hands on" is the old description. This is rapidly becoming a lost art.

The Indigo Girls song comes to mind,

     " I got to get out of bed and get a hammer and a nail
       Learn how to use my hands not just my head"

There is something beautiful about building a stone wall yourself instead of using a contractor, pedaling the bike into the breeze verses sitting in a closed moving car, and solving the medical problem by the bedside physical examination rather than ordering a number of tests which are always expensive, sometimes risky and occasionally misleading. I am not sure what part of the brain these activities stimulate, but I am certain everyone has it.

I am now in an ideal position to pass this on. With very short notice I was able to set up an inpatient Neurology service with every third year med student required to participate. An all day one on one relationship for a week where they learn to properly perform both the physical and the neurological exam on a real patient with immediate feedback from me.

I hope I can convince them what I know to be true. I hope at some point they will regularly experience the rejuvenating feeling I had in the ER that evening. I hope I can continue to handle the patient care uncertainties and the inevitable occasional bad outcome.