Its all guts and glory? No. Its guts, and more guts. A few of us may remember Samuel Shem’s “House Of God”. Those who do? Re-read it. Those who don’t? Read it! It is one of the best books ever written about the reality of being a doctor and altough published in 1978 it is, with a few small moderations, in essence still as acutely true as it was then. When you read it (not “if”, when – I m trusting my readers to be intelligent people interested in a really good read!), you will come across quotes such as this: “It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society”. Truer words……
Let’s not make this into a great literal story. Lets get this right, no frills, no sugarcoating. Let me take you on a factual ride on the 24+ hours of a typical day in a surgeon’s life!
5.30 a.m. Your alarm goes off. Its early yet but it is summer and so the temperatures are already in the low 70’ies and it is light outside. Thats good! Easier to motivate yourself to get up when its not pitch black like it would be in winter. As you get up, your feet hit the floor, you hit the shower your brain is already on that film roll of the upcoming 24+ hours. You have 45 minutes to shower, get dressed, drink your first two cups of strong black coffee and pack everything you need to survive the coming day and night away from home – clothes, toiletry kit, food, snacks, drinks. Of course there is a cafeteria at the hospital where you work – but you have no idea whether you will get to go there during opening hours so you want to be on the safe side rather than rely on the the vending machines and their very limited choices. Your brain is already working on overtime; you are still at home but your thoughts are with your patients, on the cases you have scheduled for today. Your family is still asleep. For now it is just you and the universe.
6.15 a.m. In your car on your way to the hospital, the roads are just starting to get busy. Listening to the morning news. Contemplating if you should drink coffee number 3 that sits in the travel mug beside you but – that will only make you need to pee. Not a good idea.
6.50 a.m. You park your car at what you hope is a safe spot; with the hospital entrance in plain view the feeling you have in one of elation – you get to save lives again today! – and one of dread – you are looking at 24+ hours of complete and limitless availability, likely no sleep, no food and loads of stress.
7.10 a.m. In your office. Your name on the door with the letters M.D. attached to it jumps out at you and for a second you feel like you are in the twilight zone. Is that really you? Can you really do everything expected of you today? As you shed your street clothes and put on scrubs and a white lab coat you go through a process of dissociation. The private “you” – the mom/dad, the spouse, the friend, the YOU with all your doubts and fears and insecurities is safely boxed, sealed and tucked away into some hidden corner of your mind. The professional “you” – the doctor, the surgeon, sure and confident and even a tad arrogant – emerges. This is what is expected of you, after all. You are an attending surgeon. There is NO ROOM for doubt or hesitancy. With a straight spine, a strong gait and a winning attitude you start your day.
7.15 a.m. You step onto the ward and automatically you are envelopped in an air of hectic. The hallway smells antiseptic and faintly of puke or excrements, hard to tell. As you grab a cup of bad coffee you realize you need to pee. Well, tough luck. Later. You meet up with your residents and interns at the nurses’ station so they can tell you about the last night. You have only been gone from this place for 12 hours but a lot has happened. As you try to register and file away all the information thrown at you, automatically assigning residents to certain tasks for the day, an alarm goes off down the hall. Code blue. A patient in real distress. You push your half empty coffee cup at the next available intern and your feet hit the hallway running just as a dishevelled nurse appears in the doorway of said room screaming for your help. From that moment on everything is on autopilot. Everything fades away – the noise, the hectic, the chaos; the argument you had with your wife last night, the planning for an upcoming birthday party for one of your kids, the “To Do” lists in the back of your mind. Its as if everything falls out of focus but this.
7.19 a.m. The room looks like a war zone. 3 patients – two really scared and one not looking good at all. A femoral bypass revision surgery from the day before – which means that one of the arteries from the groin to the leg was replaced with an artificial one. Arteries are the vessels that pump blood from the heart into the body. If you have a blood pressure for example of 160 over 90 that means that there is enough pressure in your arteries to pump blood about 5 to 6 feet into the air from ground level. Thats a lot of pressure, folks. With patient X – lets call him Mr. Jones – the new bypass sutures ripped, the blood accumulating underneath the skin quickly tore the skin sutures and blood has squirted everywhere – the bed, the linen, the walls, the furniture, the floor, the nurse, even the ceiling (remember? 5 to 6 feet……). As a result, Mr. Jones has lost quite a bit of the 2 gallons of blood in his body in a very short amount of time and is coding – which means that he is unconscious with no measurable puls or blood pressure.
As you enter the room the energy shifts. Everyone – every single person – looks at you and to you. You have the answers, you have the solution, you are the saviour. Small wonder so many surgeons have a God complex! You have to make decisions and you have exactly 30 seconds for that. And suddenly, you are in the zone.
7.20 a.m. You throw away your lab coat now ruined, bark out orders for lab works, blood units and fluids to be administered, put on the gloves a nurse throws at you from across the room, give orders for medication, materials, to book an OR, to inform anaesthesia; you order an intern to your side and when he just stares at you blankly you just shout at him, bark, order to put his hands into the open wound and press and compress with his whole body weight while you start chest compressions. No point in trying to get the heart back to pump if it just pumps out blood at the groin, is there? Your “human intern plug” looks pale, slightly green and ready to pass out but you haven’t got the luxury to coddle or comfort him; you just tell him to man up and pull himself together or make room for someone who is up to the job. The intern looks at you across the bed, his eyes roll back and he faints. Blood squirts from the wound all over you – scrubs, arms, face. No time to wipe it. No time to think of protecting yourself while you have a life to safe. In a split second you make decisions, again. Heart beat is back so you climb on the patient and put your own hands into the gaping cavity and the groin, find the artery and compress with all you’ve got.
7.22 a.m. You should be on your way to the morning surgical conference. Instead you are sitting on your patient with you hands deep inside of him being rushed into the OR. You still need to pee – no time. You haven’t eaten and your blood sugar levels drop to a point where you feel nauseous yourself. Tough luck, for you don’t have the luxury of giving in to that.
7.32 a.m. In the OR. A nurse has taken over the compression and you scrub. Time to focus. The antiseptic runs in rivulets down your arms and it’s smell hits your nostrils. This, you know. This is home. This is where you belong. Your mask tight over your mouth and nose, your bladder and stomach ignored, your brain busy with solutions for Mr. Jones’ groin. As you step into the OR with your hands in the air and get dressed by the scrub nurse you are fully awake, hyper alert and totally focussed because you have to be. There is no room for failure or mistakes. Mistakes mean people die. This man on your table, Mr. Jones, you know him well. He is a father, a grandfather, a husband. You know his family. They are all relying on you to fix whatever is wrong. So nothing else matters, can matter now, but this.
7.47 a.m. Before the day has even officially begun, really. Just a flicker of a thought that your kids are just now getting ready for school, that your wife is making them breakfast or is under the shower, that you miss them. Then: “10 blade” holding out your hand, taking the knife and cutting. The show begins.
8.15 a.m. Your phone rings. One of the nurses answers and puts it on speaker. The resident who makes rounds on the ward with two PRESSING questions that can’t wait. You answer while your hands keep on working.
8.27 a.m. Phone. The resident again. He forgot your answer to question number 2.
8.39 a.m. Phone. Of course, the resident. You silently wish him a painful death. But you answer his questions, with all the patience you have left.
9.12 a.m. You have been at it for an hour and a half. Its touch-and-go. Your lower back is aching from standing at an ackward angle for too long; you STILL need to pee and abandon the thought as quickly as it came; serves you right for drinking 2 and a half cups of coffee! On you go.
9.47 a.m. Phone. You tell the nurse that if its the resident he can go fu** himself. Kindness and patience have flown out the window by now. But instead, it is the radiologist. He has an emergency – he perforated an artery while he was doing a radiological intervention. There is bleeding. Can you come take a look? Hmmmm…… let me think. NO?! Call someone else, I am busy.
9.59 a.m. Phone. Radiology. Everyone else is busy, too. What to do? You tell the nurse to call your best resident and send her and then call you with whats’ what.
10.28 a.m. Cold sweat trickles down your back. The XRay gear you wear is heavy and pulls on your limbs. You feel lightheaded. You stand up straight, crack your back, close your eyes for a milisecond, take a deep breath, then another, and continue. Your bladder wants to burst. Fu**ing hell.
10.43 a.m. Phone. Your resident. Patient Y – lets call her Mrs. Smith – from radilogy needs surgery; she will prep her to be the next in line.
11.12. a.m. Last stitches. Done. You step away from the table, pull off your coat and your mask and oh thank heavens the XRay apron. Here is what you look like to an outsider: there is a dark V of sweat covering your back and front. Splotches of blood are on your face, your scrub hat, your shoes and socks. Luckily, other people will clean up the mess. You walk to the locker room, slowly, as if there is lead in your feet. Everything hurts. You take off your bloody, sweaty clothes and finally PEE. And then just sit there, numb, for a minute or two, trying to process it all.
11.15 a.m. Locker room door opens. The head OR nurse tells you that Mrs. Smith is being put under right now. You have 10 minutes to clean up a bit, dress and eat. While you do that you call the secretary back, two residents and the admin.
11.28 a.m. You are scrubbed again and ready for round two. A text from your wife just came in that you should call her asap, something at school with one of your kids. Later. Now, focus. Mrs. Smith is waiting.
11.28. a.m. – 5.17 p.m. Back to back surgeries all day with just enough time in between to pee. You haven’t called your wife back, just texted : in surgery, will call when I can. She will understand. You hope.
5.32 p.m. You are back on the ward. Your resident waits for you to go on rounds with him. You do.
6.47 p.m. Rounds done, residents gone home except for the one on night shift. The nurses from the morning have long been replaced by those for the afternoon and will at 9 p.m. get relieved by the night shift. But you are still here. You are on call, after all. You fall down onto the uncomfortable chair in the kitchen on the ward after nuking the dinner you brought from home. On the table beside it stands an energy drink. You shouldn’t. Its bad for you. But well, screw it. You need to be awake. You yawn and close your eyes, tired and worn out, fatigue in every cell of your body. Finally, you text your wife back. Her answer is: never mind, sorted it already. Busy making dinner for the kids. Love you, have a good shift! And so it goes. Your life goes by, the blink of an eye, and a lot of it without you present. No time for regrets, though. Relatives of patients want to speak to you, the resident in the ER needs you to look at a patient and you haven’t dictated a single OR report of the day yet. So, you get up, throw away your half eaten dinner, chuck down your red bull and hope that even if it doesn’t give you wings a pair of feet that don’t hurt would be pretty awesome right now.
9.13 p.m. Night has fallen. You have been busy and have just taken your overnight bag to the on call room. Shower! Blissful!
9.25 p.m. Shower cut short, demented homeless guy in the ER with a possible leaking abdominal aneurysm – that is when your biggest artery, your aorta, gets weak and the walls slack so that it looks more like a balloon. Very dangerous and life-threatening.
9.31 p.m. The homeless guy doesn’t have an aneurysm – while you did the echo on him you found a) signs for gastroenteritis in his stomach and b) he threw up on you.
9.35 p.m. Under the shower again.
9.38 p.m. Shower again cut short. Patient with a gangrenous diabetic foot/ leg and sepsis in the ER. High fever, the shakes.
9.42 p.m. The foot is indeed a mess of puss and rotten flesh, so is the lower leg. Luckily whats left of it is covered in maggots which may just have saved the guy – maggots clean wounds! Still, he needs an emergency amputation.
10.01 p.m. Tried to eat an apple on the way into the OR; while you took a bite you saw a maggot crawling on the arm of your lab coat courtesy of Mr. Diabetic Foot. Gross. No apple then. Who needs food anyway?
10.36 p.m. While you are busy with the saw cutting off a man’s leg the phone rings. Its the ICU. A patient has died suddenly and unexpectedly. The relatives have been informed that they need to come to the hospital. Can I come talk to them? Sure. I will slip into the role of “preacher” as soon as I have finished being the “butcher”.
11.17 p.m. On the ICU. The Patient was 57 years old. She died post surgery from a sudden blot clot and pulmonary embolism. She looks peaceful, still in her ICU bed, with all the tubes and catheters removed. Her family is here, husband and two kids. They don’t know yet. As I walk out into the waiting room I know what I have to tell them as I have done on countless occasions during my professional life and I prepare myself for the onslaught of their emotions – anger, disbelief, grief. They see me, look at me with hope and just a hint of despair in their eyes. I take a breath, introduce myself, and say the words I need to say: I am sorry to tell you ….. despite our best efforts ….. sudden and unexpected….. nothing we could do. They hold it together until they see her. Then they fall apart, and I feel like coming apart at the seams, too. So I leave them be and walk away, the hospital halls quiet and semi-dark.
11.32 p.m. I do a last check-up on the wards where I am the attending surgeon before I retire for the night … nothing that needs my immediate attention and I could weep with gratitude for that.
11.47 p.m. In bed in the on-call room. Weary, I take a look at my cell phone and see two missed calls from my wife and eventually a text at a quarter to eleven telling me Good Night and that she goes to bed now. My eyes are gritty and tired; if I were home I would take out my contact lenses to give my eyes some rest; here I can’t of course – and glasses are out of the question; I hate to operate wearing glasses! Down the hallway I can hear the ever present beepings and sounds that characterize a clinic but it doesn’t disturb me, instead it has a rather meditative effect. In my scrubs, laying on the small cot, I am aware of every one of my 40 years, my aching back and shoulders, my stiff neck and my growling stomach. I am exhausted, mentally, physically and emotionally, and hungry. I let my eyes drift shut.
0.17 a.m. The phone rings loud, hard and unforgiving. I sit up with a start, fumble in the semi-darkness of the room for the light switch and the evil contraption Alexander Bell invented once upon a time. The ER. Obviously a guy has been brought in from a nursing home with a bladder tamponade – that is blood filling the bladder and not being able to flow out like urine because it is too thick – and the resident has been torturing the poor old man for half an hour trying to get a catheter past a huge prostate. I hear screaming and crying in the background and the nurse is a veteran whom I trust implicitly. There is no option to say “no” or “later” or “just let the resident keep on trying”. My ethic code forbids it and so does my conscience. I roll out of bed one aching limb at a time, pee (since you never know when you get the next chance!), wash my face, brush my teeth and slip on my sneakers and lab coat. Time to tackle the next round.
0.32 a.m. The ER is overflowing with sick people for all disciplines, mostly for internal and surgery. Since my hospital doesn’t have a urologic department, the surgeon on call covers those emergencies. The bay where the resident – lets call him Ali Baba – is tormenting Mr. Nursing Home reeks of UTI (urinary tract infection), shit (one look at the discarded diaper on the floor tells me why that is) and despair. My patient is thrashing almost wildly on the cot with his pants around his ankles and a crazy look on his wrinkled face with two nurses trying to hold him down while Ali Baba tries to push a hard plastic catheter the size of a pen through the opening in a small, shrunken penis into a urethra with the diameter of a hair. It’s almost 1 a.m. and I yell. I look at the scene and at the impersonated incompetence of my resident and take in the horrible degradation unfolding in front of me and I just lose it. I yell at the resident to stop RIGHT NOW whatever the fuck he is doing and at the nurses to let go of the patient. With angry, erratic movements I take off my lab coat, grab gloves from the wall dispenser and walk over to Mr. Nursing Home. I know from what the nurse told me he suffers from dementia but right now I need him to know he is ok, that I will take care of him, that he will be ok. So I ask him his name. I tell him that I am the doctor and I will make the pain go away but he needs to help me a little. I get a nurse to grab a blanket, cover his shivering body and take a hold of his frail hand with the too long dirty nails. He looks at me and I see a moment of lucid thought in his eyes. Jim. His name is Jim. Mr. Nursing Home is a human being, an old man in desperate need of help. He isn’t some rabid animal to be treated whichever way we want to. I look up and catch Ali Baba looking at me with disgust. Mistake. Then he opens his mouth to tell me with a heavy accent that the patient stinks and is revolting. Bigger mistake. And that he is SURE that even I won’t be able to get a catheter into this mess of a man. Biggest mistake. In the midst of chaos, I am calm. It is a character trait that has been helpful to me on so many occassions in my professional life. The crazier everything around me is, the calmer I get. So, calmly, I ask for a small silicone (really soft) catheter with a lead wire (a very thin but strong wire inside the catheter to help push is through smaller cavities), for pain medication to be administered through the vein and for a local anaesthetic gel I freely squirt all over the catheter as a lubricant. I tell Jim to trust me and try to relax. A nurse takes over holding his hand. I go to work gently and determined and within 10 minutes I have placed the cath, removed the blood in the bladder and have a rinsing system in place. Jim has fallen asleep during the procedure. I am glad. Outside of the bay I catch up with Ali Baba. I am telling him that I never want to see him treat a patient this way again, talk about a patient this way again or hurt a patient like this without any need to. I can see him wanting to sneer at me because after all, I am just a woman. I am a female surgeon in a world still dominated by men. I am used to this. And I have about 1000 come backs. I am also his attending surgeon so lucky for him, he thinks better of it and shuffles to his next head laceration or twisted ankle. The nurse coming out of the bay winks at me and says something in the sense of: whatever would we do without you Doc? Yeah. Well. Go on. You would go on and find another “me”. But I only think that. I am too tired for a philosophical conversation at this hour.
1.45 a.m. Back in the on call room. My scrubs still smell a bit like Jim but hell, I am past the point of caring. I just want to sleep. Shoes off, lights out.
2.17 a.m. Phone. Disoriented. Grumpy. A child with acute appendicits. Girl, 9 years old. I sigh. Pee. Shoes on, lab coat. ER.
2.33 a.m. The girl’s name is Larissa. She does have appendicitis. And two very frightened parents. She needs surgery and she needs it right now. She is brave, her parents just crazy with worry. I calm them, explain in detail what is going to happen, and that she is in very good hands. On the way up to the OR I wonder briefly if I have lied. The hands attached to this body are tired. The brain that needs to focus on this surgery is fuzzy and my eyes have trouble focussing. Then I think of my children and what if it was them? I splash cold water on my face. In the OR kitchen, while Larissa is being prepped, I raid the fridge, eat someone’s joghurt and left over cookies, drink two coffees and a cold coke. Showtime. I am awake, alert, here. I need to be. No other way.
3.45 a.m. Surgery went well, Larissa is being rolled to her room and I inform her grateful, relieved parents. They hug me. I am used to that, too. I smile at them and wish them a good night. Sleep. All I want is sleep!
4.44 a.m. I slept for almost 45 minutes when my phone rings, again. The ambulance brought in a young hooker who got sliced up by her pimp. Normally not something a resident can’t handle. But Ali Baba is running so far behind and patients are piling up that she would have to wait for three hours with her face cut in criss-crosses. I get up. Of course I do.
5.55 a.m. It has taken me the better part of an hour to suture the hooker’s face the way a plastic surgeon would and I am confident it will hardly scar. When I leave the ER one of the nurses asks me if I am headed back to bed. Nah, I say. No point anymore.
7.15 a.m. I have showered and seen all my patients from the night, have written up their orders for the day and have eaten a bowl of cereal; I am now meeting with the same residents on the same ward as almost 24 hours before. I have slept about an hour but I am awake and jittery. Fatigue will come later, I know. I do rounds, morning conference and look at a bunch of Xrays. Then I open my locker and prepare myself to switch personalities. As I put my labcoat on the coat hanger, pull on my shorts, shirt and sneakers and walk out of the hopsital I am me again. Just me. I feel great for everything I have accomplished; I also feel drained and a sense of freedom by leaving the clinic.
9.00 a.m. In my car, on my way home, with the windows rolled down for fresh air (otherwise I will fall asleep behind the wheel) and the radio on. I am looking forward to getting home!
9.45 a.m. Home. I park my park. Its Saturday morning. Our kids come running out of the house, excited and happy that I am home; they hug me and start talking a mile a minute about all the things that have happened yesterday, at school, with our animals and about everything they want to do with me / us on the weekend. The fact that I have hardly slept and worked for 26 hours isn’t new to them – but its a foreign concept, of course. My wife smiles at me with a cup of coffee already in her hand and asks: Long night? I just grunt the affirmative and we hug for a good long minute – before the kids want in on the hug. Of course. Sigh. Over breakfast my thoughts are still partly at the clinic and I wonder how all my patients from the night are; but more than that I am happy to be home and I want to start my weekend with my family. Sleep? Who needs sleep? I can sleep when I am dead 😉 Or hopefully tonight when I drop dead like a lead weight around the kids’ bedtime.
I hope you have “enjoyed” the walkthrough of my day! I would love to hear from you so if you want to leave a comment it would be greatly appreciated! Thanks!