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Mindful Practice

A light at the end of the night

Littner, Michael MSPA, PA-C

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Journal of the American Academy of Physician Assistants: March 2020 - Volume 33 - Issue 3 - p 1-2
doi: 10.1097/01.JAA.0000654196.11064.8d
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My hardest day as a PA came at night. I'm not surprised. At baseline, no matter how uneventful, night shifts are trying. When lack of sleep frays nerves, overexposes emotions, and reduces cogency to drivel, making reasonable medical decisions is challenging. The stakes go up when those medical decisions involve a young person's health. Adding an extra element of intrigue is a child's uncanny ability to get sicker at night.

The shift of which I write broke me to pieces and brought me to uncharted territories of distress. It also proved, without a shred of doubt, that I am doing exactly what I want with my professional life. For this reason, I look back upon the very same night as my most magical.

The Komansky Children's Hospital is like any other North American pediatric facility during respiratory season—busy and sick. My PA team heads up the step-down unit, where we see everything from asthma exacerbations to Kikuchi-Fujimoto syndrome. During a typical shift, there is one of us to five or six patients. On this night, I had nine.

Nine patients. I didn't know whether to laugh or cry. A high census doesn't guarantee trouble for the covering provider. Caring for 20 kids with no issues can be easier than caring for three who need constant attention.

Maybe it was a full moon. Maybe Mercury was in retrograde. Maybe I had unknowingly insulted the patron saint of pediatrics. All of my actively sick kids were getting actively sicker at the same time. There had to be some explanation, scientific or supernatural, for such profound misfortune.

A problem arose. An intervention took place. Another problem arose.

The newly admitted 13-month-old with flu-positive pneumonia had oxygen saturations in the mid-80s: nasal cannula at 1 L.

The 17-year-old with cellulitis secondary to a lip piercing had pressures of 86/50: 20 mL/kg normal saline bolus and send cultures.

My 6-month-old with bronchiolitis, nearly discharged 2 hours earlier, started retracting: deep suctioning.

My 2-year-old with rotavirus was having episodes of diarrhea every 15 minutes: increase to two times maintenance fluids.

The 3-year-old with croup was stridorous at rest: racemic epinephrine.

And so it went. With each issue addressed, my composure wore thinner and thinner.

An overnight can strip a provider of the ability to retrace steps or look forward. The mind is simply too tired for such executive function. Like an Etch-A-Sketch constantly shaking, you only see the line you're drawing as you're drawing it; once drawn, it disappears. Because of this phenomenon, I was unable to experience relief or build confidence from what proved to be successful interventions.

Supplemental oxygen brought oxygen saturations of 88% up to 99%. Fluid resuscitation restored BPs to normal. Epinephrine opened up airways. Kids were sick one minute and better the next.

Medicine is magical in how fast and effective appropriate treatments take hold. But there's a catch. The expectation with magic is that it always works. The reality of medicine is that it sometimes doesn't. Children don't always get better. Those that vanish do not reappear.

I was about halfway through my shift when a patient I wasn't caring for did the unthinkable. Her fourth birthday was the previous week. This would be her last night. I may not have been working with this patient, but I watched as her ECG showed asystole. Passed by her parents while they stumbled aimlessly around the unit. Caught a glimpse of the nurse brushing her hair. This was the first time I was on service when a child died. She was there one minute and gone the next.

What made this night harder than all other nights wasn't the number of kids I was carrying or the degree to which they were sick, or even the passing of a 4-year-old girl. The difficulty came from my inability to process what I was feeling. I needed to sob and scream and rage. I needed a hug. I needed my mom. I needed a moment to reflect on the good I was doing. But there was only time for what existed in front of me. And what existed in front of me were my patients. Nine of them. They needed a steady hand and a clear mind. I could cry later.

Morning came in a blink. I bit my lip several times to fight off tears while signing out to my colleague. Exiting the hospital into the bright sun reflecting off Manhattan's East River felt like entering an alien world. I reached my bed wanting nothing more than to extricate this night from memory.

Sleep brings perspective that eludes us in the middle of a night shift. The Etch-A-Sketch stops shaking. Time continues. Nine struggling patients, now stable, are back at home. A 4-year-old who had spent weeks on life support is no longer in pain. The yesterday I wanted to forget now informs my every today.

Today I make myself remember. Today I honor a child taken too soon. Today I recognize our darkest nights make way for our brightest days. In the words of an icon known to medicine for the disease bearing his name, but known to many others as one who lived his wildest dreams, “Today I consider myself the luckiest man on the face of the earth.”

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