DURING the day, it’s not so bad. But at night, sleepy mistakes make it difficult to keep people moving safely and quickly through the emergency room: a tired lab technician misplaces a tube of blood, a nurse flushes a urine sample, or I flip through page after page of test results on a patient with a productive cough and shortness of breath, unable to remember if I have looked at his chest X-ray.
I picked up Emma Lowery’s chart from the rack under the clock in the nurses’ station, and clamped my mouth against a yawn. I clicked my pen and noted the time: 2:57 A.M. I walked toward her room. A homeless man with matted hair snored on a stretcher in the hallway, and in the next cubicle a patient from a nursing home filled the department with the stench of liquid stool oozing from the edges of his adult diaper. A phone rang unanswered.
At this time of the morning—two, three, four o’clock—lonely people seek solace in the fluorescent light of the emergency room. If you’ve been to a twenty-four-hour grocery store late at night, you may have seen the same people. They hesitate, put a can of soup back on the shelf, then take it down again and put it back in the cart. Refugees from the daylight world, they move with the timidity of those whose lives don’t mesh with others’.
Night is the time when the lucky people get to sleep. But toothaches throb more in the dark, and backaches become unbearable. People in pain abandon their restless beds and flee their empty kitchens. They go out into the night, in search of comfort.
“Good morning,” I said to the young woman as I entered her cubicle. “I’m Paul Austin, one of the ER doctors. How can I help you?” I pulled the curtain closed behind me, and sat in the chair next to her stretcher.
She sat with her legs crossed, and her hands in her lap. Her auburn hair was pillow-flattened and her face was that of a child woken too soon from an afternoon nap. As she talked, she motioned vaguely with her hands, hammered silver bracelets jingling up and down her forearm. “I’ve been having this headache for a month now,” she said, rubbing her right temple with her fingertips. “I’ve been to the ER once and my own doctor twice. He sent me to an ear, nose, and throat doctor. He said that it wasn’t my sinuses. No one can help me.” She ran her fingers through her hair. “I’m so spacey and confused. It’s just not like me.”
I nodded, and listened as carefully as I could. So far, the ER had been busy, but not out of control. I’d been running several charts behind all night, but was beginning to catch up. The shift, which had begun at 9:30 P.M., was my third of three nights. The other ER doc had gotten off duty at one o’clock, and I was by myself until seven in the morning, when I would lurch gratefully back into the daylight. I’ve been an attending physician in the ER for ten years, and nights are still scary: one bad wreck involving multiple patients can put a strain on the entire department. No one works as efficiently at night as they do during the day. The Exxon Valdez oil spill, the Three-Mile Island meltdown, and the chemical plant explosion in Bhopal, India, all happened on the night shift. I just wanted to make it to daylight without hurting someone.
As soon as she said she’d had the headache for a month, my interest began to wane. If it took a month to get this bad, it’ll probably be okay for at least a few more hours. Why did she wait until two o’clock in the morning to come in? I have an abiding fear that while I’m grinding through an ER full of non-emergencies, there’s someone I’ve not gotten to whose coronary arteries are clotting shut, or whose inflamed appendix is about to burst.
I began the physical examination, but was called away to another room for a patient with chest pain. Then the paramedics wheeled in two patients from a motor vehicle accident. I tried to get back to the woman with the headache, but sicker people kept coming in.
At six o’clock, Lisa, one of the nurses, said, “Paul, you need to make a decision about that girl in room eight.”
“Yeah, I know,” I said. “There’s nothing wrong with her.” I thought about discharging her right then, but I hadn’t done much of a neurologic exam, and hadn’t examined her retinas. I yawned. “Lemme go take another look at her, and then we’ll let her go.” I knew her exam would be normal, but it would only take a couple of seconds.
I went back to Ms. Lowery’s cubicle. “I need to look in the back of your eyes. There’s an important part of your retina, and I can’t stop looking until I see it clearly.” I took the ophthalmoscope from the bracket on the wall as I talked. “I know the light’s bright, but the stiller you hold your eye, the quicker I’ll be done. Okay?”
She shrugged. “Sure.” She fixed her blue eyes on the far wall, and waited.
I tilted my head back, so I could peer through my bifocals and the ophthalmoscope, and saw the red reflex, like a flash-bulb eye on a color snapshot. I moved in closer, until my cheek almost touched hers. I could smell her sleepy breath. Peering through her pupil like a keyhole, I turned the dial, click, click, click, until her retina came into sharp focus. Tracing the retinal arteries and veins back to where the optic nerve attaches, I expected to see a pale white disc against a deep red background. The junction between white and red is normally well defined, crisp. In the back of Ms. Lowery’s eye, streaks of white blurred into the red of the retina. Damn.
“Now the other eye.”
She pulled her hair back again. “Am I holding my eye still enough?”
“Yeah, you’re doing great.” The ophthalmoscope is so bright it’s uncomfortable for the patient, and some people sigh loudly as I peer into their eyes, or pull their head away just when I’m about to see the disc. I appreciated her cooperation.
I peered through the ophthalmoscope into her other eye. We both held our breath, while I clicked the retina into focus. The disc margins were indistinct in that eye, too.
Blurred discs are a sign of increased intracranial pressure. It could be a brain tumor. Or it could be something much less serious.
I leaned back, and put the ophthalmoscope back in its holder. “Ms. Lowery, the back of your eye is called the retina, and in the middle of the retina is the optic disc, where the optic nerve connects. Yours are swollen. I need to get a CAT scan of your brain.”
She frowned. “Is it bad?”
“It could be something simple, or it could be something serious. Let’s get the CAT scan and see.” I didn’t want to make it any more scary than it already was.
Rick Earnhardt, my relief, showed up at 6:59 A.M. He’s the quintessential ER doc—smart, funny, and decisive. “How was your night?” He took a sip of coffee from a Styrofoam cup.
“Not as bad as it could’ve been. I was just getting ready to discharge the woman in room eight—came in about two o’clock with a headache that she’s had for a month. I thought it was bullshit until I went back and looked at her retinas.”
“And?”
“Her discs are blurred.”
“Oops.” Earnhardt hunched his shoulders and pulled his head to the side. “Dodged that bullet.” He grinned. “You want me to follow up on the CT?”
“I’ve got some charting to do.” I glanced at my watch—7:03. She should get back from CT by 7:20, and I’d get the results by 7:45, so I could probably get out of the ER by 8:00. I’d been hustling all night, hoping to get out on time. I was tempted to let Earnhardt deal with it, but I felt bad for misjudging her. “I’ll stay.”
Thirty minutes later, the CT technician wheeled Ms. Lowery back to her cubicle, and then walked over to the nursing station. The technician sat down next to me, and pulled her chair close. “She’s got a mass this big,” she whispered, forming a circle with her thumb and middle finger. “It’s the size of a golf ball. The radiologist’s going to call you in a minute with the formal report, but the mass is pretty obvious.”
The radiologist called. I spoke with Dr. Davis, the neurosurgeon on call. He asked a few questions, and said he’d be right in. I was glad I’d be turning Ms. Lowery’s care over to him. Some of the on-call doctors try to dodge admissions. They look for reasons that I should send the patient home or to another hospital—anything to keep from having to come in and deal with the admission. But Dr. Davis seemed ready to take care of whatever problem I called him about. His approach made my job easier and inspired confidence he’d take good care of Ms. Lowery once he got to the hospital.
I sat in the dictation booth, not looking forward to telling Ms. Lowery she had a brain tumor. But the sooner I talked with her, the sooner I could go home. I took a deep breath, and went to her cubicle. “How are you doing?” I paused at the curtain.
She shrugged and slowly scratched behind her right ear. “Sleepy. Still have the headache.”
I pulled a chair a little closer to her stretcher, and sat. “Ms. Lowery, is anyone here with you?”
“No.”
“Is there anyone I can call for you?” It would be easier for both of us if she had someone with her.
She shook her head again. “Not really. Why?” She squinted. “Did the CAT scan show something bad?”
“It showed a mass in your brain.” I paused, to let it sink in. “I’ve already spoken with a neurosurgeon, Dr. Davis. He’s smart, and he’s nice.”
Ms. Lowery nodded slowly. “How bad is it?”
“I’m not sure,” I said. “Some are easier to treat than others. Dr. Davis can explain it to you better than I can. Be sure to ask him about anything you don’t understand. He’ll take good care of you.”
Ms. Lowery slowly nodded, looking more sleepy than scared. Was she in denial, or was she relieved to finally have an answer, even if it was a scary one?
I waited. “Any other questions?” I hoped she didn’t have any, because I felt sleepy and stupid.
“Not right now.”
I’d done my job, but I felt bad leaving her by herself. On the other hand, if I sat much longer, I’d probably doze off. I stood and opened the curtain to leave. “Open or closed?” I asked her.
“Closed is fine.”
I pulled her curtain behind me and went to the locker room, hung my stethoscope in the locker, stripped off my scrubs, and tossed them in a hamper. Wearing jeans and a T-shirt, I walked outside into the cool morning air. Dr. Davis was just pulling into the parking lot. I walked over to his car. “Good morning,” I said, as he got out of his BMW.
“Good morning to you.” He smiled. “Bad night last night?”
“Not as bad as it could’ve been.” I glanced back at the hospital. “If you think about it, tell me how Ms. Lowery does.” I walked to my truck, glad to be outside under a dawning sky.
When I got home, I pulled into the driveway and set the emergency brake. I sat for a moment, feeling the morning sun on my closed eyelids. I wanted to step out of my truck and into a daylight world where I didn’t feel sluggish and dull, where my movements were free of the jittery imprecision of too much coffee. But I’d crossed the border between night and day too many times to expect such a quick transition. It always takes a couple of days to settle back into a normal circadian cycle.
After a string of night shifts, I lose a day just catching up on sleep. There’s an empty spot on my work schedule so that it counts as a day off, but it feels more like a day of recuperation. But I can’t complain; sleep lag is one of the costs of working rotating shifts, the price I pay to avoid carrying a beeper—the price of keeping home and work separate.
I walked to the house, unlocked the front door, and quietly slipped inside. I didn’t smell coffee or hear movement. Everyone was still in bed, sleeping late on a Saturday morning. Part of me was relieved. I would have enjoyed a warm welcome, but I’d been interacting with people all night, and it felt good to be left alone. I made a cup of French roast decaf and poured a bowl of Cheerios.
Sitting at the kitchen table, I thought about Ms. Lowery. I was glad I’d gone back to examine her retinas. Sometimes it’s skill that keeps you from making a mistake, sometimes it’s luck. But usually it’s just doing the drill. I hoped Dr. Davis could resect her brain mass without scrambling her personality and dulling her intellect.
I wondered how she’d face the next few days. I sipped my coffee. Would she jumble her words after the surgery? Walk with a limp? I ate a spoonful of cereal. I was glad those would be Dr. Davis’s concerns, not mine.
My real concern was how close I’d come to sending Ms. Lowery back out into the night. I could imagine her standing under the lights of the ER parking lot, brushing a stray curl of hair from her face and wondering why she felt so spacey and why her headache wouldn’t go away. The near miss made me wonder what other errors I had made. Most of the cases had been pretty straightforward and I’d been careful all night, but working a night shift is as impairing as a serving of alcohol.
I yawned, feeling too tired and dull to think anymore. Mistakes are inevitable. I’d made them in the past and would make them in the future. But I was pretty sure I hadn’t this shift. And I could accept that as good enough.
I stared at the front page of the newspaper and finished my cereal, but my mind wouldn’t focus. I felt my thoughts slowing, my head bobbing. I started awake, then carried my dishes to the sink. Upstairs, I took a hot shower and felt the water beat down on my shoulders and the steam rise up to my face.
Clean and relaxed, I slipped into bed next to Sally.
She murmured and shifted around to face me. “How was your night?” She drowsily opened her eyes and smiled.
“Sad.” I hadn’t really felt it until that moment. I shifted closer to her. “Can we be spoons?”
“Sure.” She turned back over and burrowed her bottom into my lap.
The pillow cradled my head gently, my hips and shoulders eased into the mattress. I felt the weight of my body fade. The morning sun was pale through white lace curtains and the sheets were soft with Sally’s sleep.
Sally turned her head to face me. “Good night,” she whispered. Her breath had the same sleepy smell as Ms. Lowery’s.