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Emergency Medicine News:
doi: 10.1097/01.EEM.0000451952.37507.2f
Second Opinion

Second Opinion: To Sleep, Perchance to Dream (of CHF, ODs, and PEs)

Leap, Edwin MD

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Dr. Leapis a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, a member of the board of directors for the South Carolina College of Emergency Physicians, and an op-ed columnist for the Greenville News. He is also the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, all available atwww.booklocker.com, and of a blog, www.edwinleap.com/blog. Follow him @edwinleap, and read his past columns athttp://bit.ly/LeapCollection.

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Tonight I will sleep in bed for thei whole night with my wife. The hours will pass in pleasant dreams, and I'll wrapped in a blanket, warm beside my darling. We are on vacation, and our teenage children will be sleeping in their beds, too, after they have watched enough bizarre videos on YouTube and eaten all the chips in the house.

But many of you, my dear colleagues, will be wading through the morass of the night. I still work nights here and there. And I once worked nights full-time. Those days are thankfully gone, but I remember what it means to work at night. I remember that sometimes it seemed the night would never end. It's difficult to explain to anyone who hasn't lived the experience. But I know.

I remember hot summer nights when I came to work and walked through a parking lot that looked more like a field of tailgaters before the Clemson-Carolina game. Sitting on the beds of trucks, smoking in open car doors with music playing as toddlers only in diapers climbed around the seats eating French fries. The masses seemed to find solace in the red glow of the ED sign, their assorted illnesses mere pretext for the grand social event of the evening.

“Hey, Doc, get in there, and hurry things along, will ya?” I'd smile and cringe.

Once inside the door, a registration clerk or triage nurse would always say the lines I hated most: “If I were you, I'd leave.”

“Don't you think I would if I could?” I would respond. Filling rooms and lining hallways will be my night. Typically, my cross-covering partner would be up to his gluteus in large reptiles, and spend the next three hours trying to clean up the mess. So I would wade right in and begin.

There was always some chest pain, young and old, high risk and low. A young woman who passed out, the old man with CHF. Most nights would include the screaming girlfriend of the loser of a fight, his chest slashed open or his face caved in by someone's fist.

Some patient would have a hip fracture, one an overdose, another just wanted to die but was angry about being held. In the midst of it all would be a nice, tolerant patient with something horrible, a subarachnoid hemorrhage or a pulmonary embolus.

Capping it off, several would just need chronic illnesses evaluated — weakness or numbness or a strange bump under the skin, the Mayo Clinic having failed miserably to elucidate the cause. Without fail, someone would need a multilayer closure because he was so drunk that he fell and split his lip.

All of this would build until about 3 a.m. The next four hours would be devoted to sorting out and disposing the night's dramas and traumas. The waning shift was sometimes punctuated with mundane requests for narcotics or with those terribly injured in a rollover accident, their swimsuits still sparkling from the mica in the creek where they had been swimming.

Even before EMRs, charts had to be completed by hand or dictation. I would be the one to close that complex lip because I was usually alone after 1 a.m. Between all of the disparate complaints, it was imperative that I not fail to read a c-spine or collate the results of all of the head CTs, abdominal CTs, angio CTs, EKGs, and serial troponin levels.

As the night crawled on, there were annoyed consultants to query, transfers to arrange, admissions to sell, and family members to contact. Police officers needed “clientele” cleared, and sometimes, sadly, coroners were contacted, and death certificates were signed.

But the remarkable and reproducible aspect of it all was the way that time lurched to a stop. One year as we were coming off Daylight Savings Time, we kept moving the clock back to 2 a.m. to torture a young nurse. “This night is never going to end!” she said as we laughed. How right she was!

Nights always lingered, and as my mind slowed and the paperwork piled up, I wanted nothing as much as another pair of hands, another person to help chart or see the 5 a.m. ectopic workup.

I recall looking outside, past the ambulance bay, wondering if dawn would ever come. Nothing helped when that fatigue arrived — not caffeine, not snacks, not nurse runs to MacDonald's. Your mind is a fog. It's an absolute effort of will to see the patient, do the procedure, and then document all of it, and nothing in all the world is better than 10 minutes face down on the desk with sleep instantaneous. That's sheer joy until the next nurse question, x-ray tech call, or “chest pain in room 9.”

I don't miss full-time nights. I still do one here and there, but I hope to do them less and less. And I hope one day medicine will evolve in such a way that we don't have to risk our patients and ourselves with the real danger of pure exhaustion in the never-ending misery of the night, where fatigue meets necessity, where human limits meet unlimited human need.

Nights are meant to be enjoyed, not merely tolerated. Sweet dreams.

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Wolters Kluwer Health | Lippincott Williams & Wilkins

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