WHEN I finished my residency training in Pittsburgh, we moved back to North Carolina, where I spent two years as an assistant professor in the Department of Emergency Medicine at one of the medical schools. I enjoyed thinking of myself as a mentor and teacher, and had a secret hope of becoming a favorite of the house staff. I projected the persona of an enthusiastic, tenure-track academic, and within two years I had presented original research at national meetings and had published a chapter in Rosen’s, the major textbook of our specialty. I won the Teacher of the Year Award my first year on the job. But I didn’t really enjoy my accomplishments and I was exhausted from working rotating shifts, giving lectures, and writing research papers. Between clinical shifts and academic work, I could go a month without having a single day in which I didn’t go into the hospital. Although I loved the idea of being an academic emergency physician, the reality of it gave me very little pleasure.
Obsessed with a career that I wasn’t enjoying, I resented the fact that Sally, who had chosen to be a full-time mom, seemed to be having a great time. Sally’s master’s degree and nursing experience had been in adolescent psychiatry, and she believed that children can benefit from having a mother at home to nurture the development of their characters and personalities. Sally was attuned to the issues facing working mothers and stay-at-home mothers, and wished that she had the energy to do both. But she was afraid she’d feel torn if she had to call out from work because a child was sick at home. She’d rather feel calm while doing one job than tense while doing two.
Although my job paid enough for Sally to stay at home, it didn’t leave me much energy to help take care of kids. With the addition of Sam, our third child, Sally was even busier than before. But she was strong, and smart, and loving, and she was doing great at her job while I hated mine.
She’s since told me that many mornings after I’d pulled out of the driveway to go to the hospital, leaving her with our five-year-old, two-year-old, and newborn, she’d lean against the wall and slide down until she was sitting on the floor. Crying about the tension I’d left in my wake as I walked out of the house.
I remained relentlessly focused on making full professor, and Sally maintained her own facade of happiness, but we finally realized just how miserable we were. We decided I needed a situation where I could work my shifts and go home. With a job, rather than a career, maybe I’d relax, and feel free to take some time off. Read more, do some woodworking, spend time with the kids. A move to Durham would make us all happier.
I took four days off work so we could look for a new house. The realtor had shown us a dozen places, but there seemed to be something unsuitable about each of them. At the end of the fourth day, she showed us a house that had just come on the market. We stood at the curb, looking down a slate walkway that ran between two magnolia trees shading the front of a two-story brick house.
“I like it,” Sally said, hugging my arm. We were both excited about the move.
I put my hand over Sally’s, and squeezed it. I liked the dense, towering magnolias in the front yard. I liked the granite curbstone. This house, with the small brick house next door, and the white bungalow across the street, seemed perfect.
“The extra lot goes with it,” the realtor told us as she led us inside. “You could probably take the woodstove insert out,” she said, gesturing to the black iron doors covering the fireplace. “Nice cabinetry on either side of the fireplace.”
“Oak floors,” Sally said, looking at me.
“Tall ceilings, too.”
Sally scrunched her shoulders and smiled. “It’s nice,” she whispered.
“It is, isn’t it?” We wandered upstairs, down into the basement, and back outside. A car drove by and slowed down, the man and woman inside craning their necks to look at the house.
“Let’s buy it,” I said.
“But there isn’t any place for you to sleep when you’re working the night shift.”
“I’ll be fine.” I could sleep in the basement if it came to that.
“You’re just ready to buy something, it doesn’t matter what,” the realtor said.
Sally rolled her eyes. “You have no idea.”
But what was there to discuss? It was an ideal house: safe neighborhood, shady streets, a nice mix of older houses. Even came with an extra lot. If there wasn’t a quiet place for me to sleep when I was on night shift, I’d deal with it.
On the drive back, I told Sally, “I love the staircase, with the banister that curves out at the bottom.”
“That was the house in Trinity Park,” she said.
“Oh.”
We drove through the flat green fields of Piedmont North Carolina.
“It’ll be nice to have a full basement, with a workshop,” I said.
“That was a different house,” Sally said apologetically. “But ours has a half-basement.”
“Oh.” I kept driving. “Does it have a big front porch?”
“Yes,” Sally said, laughing. “The porch goes all the way across.”
“I really like the porch,” I said, wanting to like something about the house we’d just made an offer on. “Does it have a swing?”
“Yes.”
“Good, ’cause I liked it a lot.”
We loved our new house, but it offered no space in which to get away from each other. That became a problem when I had to work three or four nights in a row. It’s difficult to express what a grind the night shift can be. I remember pulling “all-nighters” as an undergraduate—endless cups of coffee fueled the midnight scramble to cram in enough information to pass the next morning’s exam. There were runs to all-night pancake shops and small thrills of pleasure at being awake while everyone else was asleep.
The first few nights in the ER, I felt a similar frisson of excitement—but it was accompanied by crampy abdominal pain from the fear that someone would come crashing in with a problem I wouldn’t be able to handle. I’ve talked with other ER docs, and they experienced the same gastrointestinal response to the night shifts when they first started out. Of course, no job remains an adventure forever—the night shift eventually loses its novelty, and all you want to do is get home and go to bed. But daytime sleep is fitful at best, and when it’s repeatedly disrupted, it’s a jangling, maddening experience.
One Saturday morning a few years after we’d moved, I came home after a busy Friday night. Chart after chart, problem after problem; I finally made it through the shift, got home, and crawled into bed.
I’d begun drifting toward sleep when Sarah started singing in her room, right next door to ours. I knew she was sitting cross-legged on her bed, earphones on. Her voice was loud and tuneless as she sang along with “Doe, a deer,” from The Sound of Music, a video she’d seen so many times she’d memorized every line. She was almost yelling out the words. I tried to ignore her, but my head began to throb. I got up and knocked on her door. Hearing a muffled reply, I walked in.
“What?” she demanded, glaring at me. As well as having Down syndrome, Sarah was a twelve-year-old and had become as sullen and impatient as any other preteen.
“Your music.” I gestured toward her earphones. “It must be up too high, because you’re singing way too loud.”
“No I’m not,” she said, in the loud flat voice of someone who can’t hear themselves.
“Take it off,” I said.
“Why?” she asked, as she pulled the earpieces down to her cheeks.
“You’re singing way too loud,” I said. I pointed to the wall between our rooms. “I’m trying to sleep.”
“Nuh uh,” she said.
“If you don’t sing softer, I’ll take your CD player away.”
“Can you just go now?”
I raised my eyebrows to let her know I meant business.
She turned the little volume knob down a fraction. “Just go,” she said. “Okay?”
I turned, and went back to bed. I could barely hear her singing through the wall. Glad for the near quiet, I began to drift off. I shifted my shoulders, scrunched the pillow under my head. As my breathing slowed, I heard Sam say, “John, I didn’t lose it.” Sam was seven at the time, John nine.
Hopefully, Sally would intervene and I could continue drifting toward sleep.
John said something I couldn’t make out through the wall.
“Johhhn,” Sam said louder. “I mean it.”
“You were the last one to play with it,” John said, his voice scaling upwards.
I was fully awake. And I still had two more nights to go. Why wouldn’t they let me sleep?
I got up, used the bathroom, and knocked on the boys’ door as I walked into their room. Sam and John were facing each other. John clutched a plastic action figure.
“What’s the problem?” I asked.
“Sam lost the light saber.” John pointed to the empty, upraised fist of his toy.
“Did not.”
I’d just finished nine hours of unrelenting problems. And I needed to sleep. I went to the hall. “Sally,” I called loudly down the stairs.
She walked to the bottom of the stairs and looked up at me.
“Can you keep the boys quiet,” I asked, “so I can sleep?”
“They didn’t seem that loud to me,” she said.
We’d been through this over and over. She had a “Princess and the Pea” theory about me and sleep. To hear her tell it, a cat walking outside would wake me. Her assertion was that I took things too personally.
But it seemed obvious to me that the need to sleep isn’t personal. It’s physiological. Like needing food or water or air.
Sally looked at her feet, then back up the stairs at me. “Buddy,” she said, “I don’t know what to tell you.” She thought it was my responsibility to take care of myself.
“You don’t know what to tell me?” I took a deep breath. “You could tell me you’re going to do something to keep the kids quiet.”
“They’re kids.” Sally put her arms out to the sides, palms forward. “They’re going to fuss a little. That’s what kids do.”
I was stuck. I had to sleep. If I didn’t sleep, I’d make careless mistakes at work that would hurt people. I walked back to the bedroom and stared at the clock—9:10. If I could get to sleep by 9:30, and sleep till 12:30, that would be three hours. Then I could eat lunch, sleep another three or four hours, and I’d be okay.
I put a CD of ocean sounds on, and turned up the volume. I crawled into bed, and pulled a pillow over my head. If they knew how much I needed to sleep, they’d be more thoughtful. I tried to forget about all that and concentrate on the sound of the ocean. I imagined lying on a beach, the sun beating down on me, my muscles relaxing against the hot summer sand.
I felt I was in that delicate threshold, floating up toward sleep. I imagined my brain cells settling, the chatter from ridge to ridge in the cortex dampening down. The tiny flashes of light twinkled off, like the lights in the windows of a small town, one by one, turning off, until the town is quiet and dark. The light, lazy, drifting awareness that I was slipping into sleep.
“John!” another plaintive yelp from Sam ricocheted into our room, jolting me awake. I jerked free from the covers, swung my legs out of bed, and put my bare feet against the cold wooden floor of the bedroom. “I can’t do this. I can’t keep working without sleep.” There are plenty of things I don’t want to do, but this was a different issue. It wasn’t that I didn’t want to keep working night shifts while my family woke me up during the day—I wasn’t able to do it. I walked downstairs to the laundry room, where Sally was sorting laundry. “Sally,” I said. “I can’t do this.”
She looked at me with a bored expression, then tossed a pair of jeans onto a pile of dark clothes. We’d had the argument before. She thought it was just another example of my wanting to control other people. I thought she was being passive-aggressive.
I pointed upstairs, toward the boys’ room. “I don’t know what I can say to make you see. I can’t do it.”
“Paul,” Sally said, picking up one of Sarah’s blouses, “I know you’re exhausted, but the boys aren’t making that much noise. If you hear any noise, you wake up.” She shook her head the same way she had every other time we’d had the same argument. “And you’re taking it way too personally. The boys didn’t mean to wake you up.” She tossed the blouse on top of the pile of whites. “They’re just kids. And kids make a little noise when they play.”
“I know that.” I was angry that she was patronizing me. “Sally, you just don’t get it. It isn’t personal. It’s a physiologic imperative. I’ve got to get to sleep.”
“Physiologic imperative,” Sally repeated.
“I can’t do this,” I said, beginning to cry. My chest began to ache. At forty-four, was I having a heart attack? If so, I wouldn’t have to get to sleep, wouldn’t have to go back to the ER. But I didn’t get short of breath, didn’t break out in a sweat, didn’t have any pain in my arm, jaw, or neck. It wasn’t a heart attack. I was still on the hook. “Sally,” I whispered “I’ve got to sleep.” Maybe she would see.
“Paul, I don’t know what to tell you.”
“Tell me you’ll keep the kids quiet.”
“I’m not the sleep police,” she said.
“The fucking sleep police?” I raised my voice.
“You’re being irrational,” Sally said calmly, as she left the laundry room.
“Irrational?” I yelled, following her. “Irrational? I’ll tell you what’s irrational.”
She continued walking.
“You’re out of your fucking mind if you think I’m going to keep working my ass off while you and the kids wake me up every fifteen seconds. That’s what’s fucking irrational! If I go to work sleepy, I’ll fuck up and kill somebody. You know that.” I jabbed my finger toward her back. “You know it and you don’t care.”
Sally turned and went to the kitchen.
“I’m not going to keep doing this,” I shouted. If I went nuts, maybe Sally would see how badly I needed to sleep.
“I’m not going to talk to you when you’re like this,” she said, as she turned to walk back to the living room.
“Not going to talk to me when I’m like this?” I could feel my voice getting hoarse, but I couldn’t stop myself. “You’d better talk to me, because I’m not going to keep going through this every time I work a cycle of nights.” It felt good to be scorching toward a resolution. Something was going to change.
As I yelled, Sally took the kids outside, onto the front porch. Was it because she knew I wouldn’t hurt anyone in public?
Sally sat down in the porch swing, John on one side, Sarah on the other. Sam sat in a wicker chair.
“I can’t do it,” I whispered to Sally. “I just can’t.”
When Sam saw me crying, he thought I was joking, and laughed.
I grabbed him by the upper arms and jerked him to his feet. “I will hurt you,” I said, through clenched teeth.
“Paul,” Sally said, in a stern voice. “Give Sam to me.”
“You’re telling me?” I shook Sam hard, once, snapping his head back.
“No,” her voice softened. “I’m asking.”
I looked over at her.
“Please,” she said gently. “Paul,” she said, as if calling me from a distance. “You don’t want to hurt Sam.”
I looked at Sam. His face was pale, his eyes frozen wide.
“Please, Paul,” Sally’s voice was calm and gentle. “You don’t want to hurt him.”
Sally was right. I didn’t want to hurt Sam. I looked around. The morning sun was bright. John sat pale and motionless, his mother’s arm around his shoulders. He watched me like he would a snake, afraid to move. Sarah sat quietly on the other side of Sally. I wondered how much of this she understood. I looked back into Sam’s face, and let go of his arms. “I’m sorry, Sam.” I reached out to stroke his hair, but he pulled away. “I’m sorry,” I whispered again. I walked inside, and up the stairs.
The house was empty.
The quiet was absolute.
In bed, I curled up alone.
I couldn’t sleep.