3AM, and the all-too-familiar beeping starts.  I awake to the dull amber glow of my pager.  Call the nurse for bed 29, please.

“Zac… we have a patient who is scaring us and we need you to come see him.”  I rub the sand out of my eyes and stumble out of bed.

It’s quiet in the hospital, but there is an ominous tone hanging over the night.  Wind whips past windows and the rain has been coming in bursts.  The nursing station is silent except for the gentle beeping of the monitors.  The lights are dimmed in the ICU, except for Robert’s room, bed 29.  He’s a psych patient who landed himself here by driving full-bore into a concrete median.  He’s been in and out of consciousness since day one.

I walk down the darkened hallway and towards his room. Eerie noises emanate as I get closer; a mixture of wails and shrieks.  It’s Robert.

Nurses stand back against the cabinets, and I see Robert lying in his bed, ripping and tearing at his restraints.  A thin line of spittle hangs down his mouth and a small trickle of blood trails from where he has chafed at the wrist cuffs.  He’s hurting himself.  He moans like a caged animal.

“Robert, it’s the doctor, just coming to check on you…” I stammer, but his eyes are wild and rolled in the back of his head.  The rain starts to pick up outside of the room, first brisk and then torrential. I don’t want to be in the room alone with him, but the nurses file out now that I’m here.

He mumbles something, eyes darting around the room.

“I can’t hear you, Robert, please speak up.”  He meets my eyes for one brief moment, lucid, and motions me over.  Slowly, I advance.  I’m keenly aware of the darkened hallway behind me.  This feels like something out of a horror movie and I have the distinct sensation that something is there.   I glance over my back.  I’m being silly, it’s nobody.  The hairs on the back of my neck crawl anyway.

Nervous, I lean in. “Robert, I can’t understand you.  You’re speaking nonsense.”  He grunts some more.  I edge closer.

Suddenly, he sits bolt upright, his face inches from mine.  I jump back, startled. Panting, sweat beading off his brow, his arms are cords of muscle  as he fights the restraints.

Robert’s head starts turning, slowly, staring straight forward, breath fetid.   A slow, terrifying grin spreads across his face as he fixes his gaze to mine, his cracked yellowing teeth in a rictus of madness.  Slowly, his head tilts, his bloodshot eyes boring into me.  The patter of rain is the only sound in the room.  And then he speaks, his voice deep, hoarse, and gutteral.

“Look… out… the WINDOW!”

Panicked, I spin around as a single bolt of lightning illuminates the room.  A shadow flits across the glass – no, it must be my imagination – but my heart is pounding.  The rain traces lazy rivulets down the window.  I turn back quickly, but Robert, spent, is lying back in bed, breathing softly, eyes closed.  The room is silent again except for the rain.

We’ve got a medical student rotating on service with us, and I have grown to hate him.

Now, I don’t dislike very many people.  In fact, I would argue that I’m a pretty friendly guy all around.  But this one, he has pushed all of my buttons.

I’m on Surgical/Trauma ICU this month, and as an emergency resident, I don’t have quite the pull that the surgical residents do.  Chest tubes, intubations, and other procedures somehow seem to fall in their laps a bit more often than in mine.  I’m also not expected to know as much – both a relief and insulting at the same time – and my plans for patient care are often ignored on rounds, the attending turning away to flirt with the nurses while I’m talking.  This is pretty frustrating, as I’m training at one of the most elite emergency medicine programs in the country, and it took a lot of percentiles to get here.

Medical Student has recognized this power dichotomy, and as such, has shown me his true colors.  Unlike the surgeons that he’s trying to impress, he doesn’t bother to hide from me that he’s incompetent, unpleasant, and lazy.  He figures I’m not evaluating him at the end of his rotation.  He is quite mistaken.

“Honestly, man, I can’t say I’m thrilled to see patients this morning.”

“You want to teach me about heart failure?  Why on earth would I ever want to know about that?  I’m going to be a surgeon, not a hospitalist.”

“Well, you emergency guys just admit all sorts of crap anyway…”

As such, I have found a vast, previously unknown wellspring of pure malice lurking deep within my person.  They say power corrupts.  I never really understood until I wasn’t at the bottom of the hierarchy.

Now, I don’t stoop so low as to scut him out to fetch me coffee (like my surgical residents did to me as a medical student), but I have started to call him on his bullshit.  When he bitched about being asked to learn something for rounds, my response turned decidedly nasty this morning.

“Maybe if you already knew it, you wouldn’t need to look it up in the first place,” I sneered, “but of course, it’s not like ventilator management is important for your education, now is it?  You’re going to be a Surgeon, right?  ’Course, you need to actually match into a surgery program first…”

I’m not a mean person, but I must admit I get a perverse sense of pleasure from watching him squirm on rounds.  I usually pantomime answers to medical students on rounds to make them look good in front of the attending.  Instead, I just smirk when he roasts on the spit under the rapidfire questions.

A big part of this is being immersed in the surgical culture.  The same mean streak emerged last year when I was a general surgery intern.  Being surrounded by so much poison makes it next to impossible to maintain a good attitude.  I simply do not fit in with this culture of harsh, trust-nobody, work until you drop self loathing.  But being submerged in it for a month, it takes its toll.  It’ll be a few weeks before I detox all the Surgeon out of my system and go back to being a fun, good-natured emergency doc.

In the meantime, I’m carefully crafting my end of the month evaluation for Medical Student… the bus, my friend.  You’re about to be thrown under it.

And like that, it’s finished.  No fanfare, no awards.  Walk out of the hospital one day an intern, return the next a resident.

My parents called to ask if it felt any different.  To my surprise, I answered, “yes… it kind of does.”

Countless books have been written about intern year.  Every physician gets a bit misty-eyed when thinking back to the nascent, formative moments of their career.  Medical students peer forward, trying to pierce that impenetrable veil of transition from student to doctor.

The difference between an intern and a fourth year medical student is simply the M.D. behind their name.  But, of course, that’s everything.  Someone has accredited an intern to make decisions about patient care.  An order for a CT scan will result in the same scan, no matter whether an intern, resident, or attending authorized it, but no medical student can give that order.

Exactly one year ago, on my first night on call as an intern, I got a call from a nurse for the simplest of things.  ”Doctor,” she said, “your patient in bed six has a fever of 102.4, and there is no Tylenol ordered.  Can I give him some?”

I panicked. Tylenol is the oldest of drugs.  Parents give it to their kids like candy.  There are elixer, flavor, chew tab, and extra strength variants.   It has countless brand names across the world.  I was a doctor now, and I should know the answer.  Just a simple Tylenol order.  And yet.

In a patient with liver failure, Tylenol can be lethal.  The primary team didn’t think there were going to be any problems with this patient overnight, and suddenly I was presented with a fever.  Fevers in the hospital setting are often the harbinger of massive bacterial infections, lethal blood clots, wound infections, sepsis from urinary tract infections, and so on.  A simple order for Tylenol… well, it’s not so simple.

I sprung out of bed, hair mussed, wild eyed, heart racing.  The patient was sleeping, but I woke him up and grilled him for 10 minutes to make sure he felt alright.  Gruffly he responded, “well, I was doing just fine until you woke me up!”  I pored over the chart, trying to comprehend his care, his underlying pathology.  He was postoperative from an appendectomy.  Nervously, I reasoned that his fevers were from atelectasis, a common and benign cause of postop fevers, and ordered the tylenol.

What if I was wrong?  What if it was infection?  What if lying in the bed had caused clots to form in his legs, rocketing off and wedging themselves in his lungs?  I went back to my call room and laid awake for hours, exhausted, the dim blue glow of the computer suffusing the room with bits of the electronic medical record.

In the morning, I called the primary team to let them know I had given tylenol to their patient overnight.  ”Cool, man, thanks, he probably just had atelectasis,” said the resident.  In a single moment, a night of agony validated and dismissed.

I soon learned that with experience, confidence builds.  With every mistake identified, every correct decision confirmed, I grew as a physician.  4,000 hours spent in the hospital, 80 hours a week, 50 weeks a year.  Bathed in the milieu of medicine day in, day out.

And at the end of it, one step up the ladder.  One layer of supervision, peeled away.  One more level of scrubs asking me the questions. One year of training down.

I saw a new intern walking into the hospital on her first day as a doctor this morning, uncomfortable in her starched new white coat, the hospital logo emblazoned proudly on her sleeve.  She kept grabbing at the pockets, adjusting her stethoscope, buttoning and unbuttoning, checking her pens.  Nervous, but deathly afraid to show it.  I remember that feeling well.

“Morning!” I greeted her, cheerfully, “You excited?”

“Yeah…” she allowed.

“It’s going to be a fantastic year, ” I assured her.  ”Come find me if you have any questions.”

Reading this post from an old friend (hi Al!) reminded me of my favorite Mommy Line call ever.

Now, Mommy Line calls tend to vary from stupid to stupider.  Why?  I don’t know – but questions like “Can I drank while pragnint?”  or “I think my water just broke and I’m having contractions, but can I stay home and finish watching Cougar Town?” are a dime a dozen.

One night the good Dr. F was fielding calls, and the conversation transpired as follows:

So, I’m 40 weeks pregnant, and I keep getting this feeling like I have to poop.

Ok, well, sometimes that can be a sign of contractions.  Has your water broken?

No.  When I feel like I have to go poop, I go sit on the toilet, and I do.

Do… what?

Poop.

Ah. Let me get this straight, just so there’s no confusion.  You feel like sometimes you need to poop.  And when you feel that way, you do, in fact, poop.

That is correct.

… you should probably just poop.

She was 70, and her family noticed she wasn’t moving quite right.

By the time she got to the ED, her entire left side was paralyzed and her mental status was poor at best.  The massive, ongoing stroke was getting worse by the minute.  Her pupil was getting progressively more and more dilated.  Gurgling, choking sounds were emanating from her throat – a sure sign that if she hadn’t already swallowed a large volume of stomach juices and oral secretions into her lungs, she would soon.

First and foremost.  ABC: the axiom by which Emergency Medicine doctors live.  A is for Airway, the first and most important part of any emergent case.  She has officially failed to Protect The Airway, and it’s time for me to do it for her.

I’ve just finished my anesthesia rotation and for the rest of my career, I’m officially cleared to intubate when needed.  More importantly, I’ve done enough of these that I feel comfortable handling myself without guidance.

Equipment: check.  Always make sure your equipment works first.  It’ll save your ass when the clock is ticking and you suddenly realize your light doesn’t work.

Drugs: pushed through the IV.  Now she’s sedated and comfortable, and the paralytic quickly starts working.  I give her oxygen with an ambu bag because she can’t breathe for herself.  Completely paralyzed, her life is in my hands – a responsibility not to be taken lightly.

And so.  Scissor the teeth open.  Blade carefully inserted through the open mouth, tongue swept aside for easy visualization.  Vollecula pulled upwards and out.  Momentary pause –  I don’t see vocal cords.  Gentle pressure applied to the throat – ah, there they are – assistant’s hand placed just so to keep them in view.

“Tube please.”

Hands steady, I slide the endotracheal tube gently through the vocal cords.  I inflate the cuff to keep it in place, and hook her up to the ventilator.  Oxygen flows to her lungs.  Immediate crisis averted.  One of the nurses gives me a wink, “Doctor Z, you made that look easy!”

There is a particular satisfaction when you glimpse the beginnings of competency.  A month ago, I wouldn’t have known how to do this.  I’m far from an expert – but it will come.  I’ve got my whole life to practice.

Going back through my dictations today, I found this gem that I dictated at the height of exhaustion in the wee hours:

HISTORY OF PRESENT ILLNESS: This is a 30ish-year-old African American male who apparently was drinking heavily and fell asleep on the train tracks. He awoke when the train ran over his legs yet managed to call 9-1-1. Paramedics on scene report that he had a GCS of 15, was talking well and somehow moving all extremities, although they noted that his legs were not attached to his body.

And suddenly the surgical department realized – we need someone to cover the Surgical/Trauma Intensive Care Unit for the night.

Though some unfortunate planning on my chief’s part I ended up being the one who lost this particular Russian Roulette. I find myself amidst beeping monitors, medication drips, and unfamiliar patients.

Let me back up a moment. Intern year is all about uncomfortable firsts – your first prescription for narcotics, your first lab orders, your first blood transfusion, your first CT scan, your first crashing patient. All of these things are difficult in their own way. That being said, usually the degree of autonomy is matched to skill level.

Unfortunately, a mistake was made in the schedule and nobody was scheduled to run the trauma ICU tonight. Now, I’m on trauma this month, but there is a HUGE distinction between covering the regular floor and the ICU. The floor I can deal with. The ICU I simply do not have the experience to run.

Unfortunately I don’t have much choice, as I find myself here with pager on hip. Currently I have a gentleman on the razor’s edge of dying from his intracranial hemorrhage, another who chose to up and stop breathing about an hour ago, and one woman who is trying her best to grab the famous pink elephant.

I’ve got people I can call if I need to, and so far I’ve been pretty liberal with the phone-a-friend. But even though nothing has happened for the past hour, I’ve been lying wide awake.

If someone dies tonight… is it my fault?

Many of my stories happen at 4:30 in the morning.  Why?  Because that’s when I’m forced to make the choice: my sleep, or my patient?

This was a particularly nice 16 year old who lost control of his car on black ice, careening into a tree at high speed and breaking most of his ribs.  The crash caused his windshield to instantly shatter, giving him a few scattered cuts across his face  and one huge slice through his lip.

Ribs will heal on their own, but the lacerations to his face need sewing.  Now, I’m no plastic surgeon, but I am an ER doc and I sew up a lot of wounds. Importantly, the vermillion border – the demarcation between the lip and the face – is one of the most cosmetically important areas of the face. Even a millimeter of disunion is instantaneously recognizable by the human eye.

And so, 24 hours into my trauma call I was faced with a choice.  Let one of my less experienced colleagues fix his lip in a few hours, or take the time to do it now, myself?  My body was screaming from a difficult call night; 15 or so trauma codes in the last 12 hours, sleep deprived for a month, contorting my back to examine patients in c-spine collars all night long.  I felt the overwhelming, primal need to crawl into a corner and sleep.

I suppose, in the end, it was a false choice.  I went into this profession for a reason – to help people.  Knowing full well that these 30 minutes of my time would directly impact every interaction he has with people for the rest of his life… well, that’s time well spent.  The repair went wonderfully.  He’ll have a barely noticeable whitish scar through his lip.

What I’ve gotten used to in medicine is this:  most patients will never realize how important my small time in their life really was.  A missed diagnosis here, a well-repaired laceration there, a timely intervention when needed.  I think it’s a large part of why I went into emergency medicine – I want to be there for the important stuff.

When he gets out of the hospital, I’ll tell him.  ”Your lip looks great, man.  I’m glad you’re doing better.”  He’ll probably never know why I was more concerned about his lip than his ribs.

I remember all my first deaths.

The very first was our cadaver in medical school.  As first year medical students, we shuffled quietly into anatomy lab, nervous giggles escaping pockets among the crowd.  Lying cold, still, aseptic, was our body.  Charlie.   It’s an unsettling feeling, laying hands on a dead body.  There is a quiet dignity about death, a final stillness that is unmistakeable.  I remember stainless steel tables with stainless steel scalpels, and the subtle scent of formaldehyde barely masked by the cloying smell of wintergreen.  My hands shook violently as I made the first incision.

The second was the first death I ever witnessed in person.  Surprisingly, it took until my 4th year of medical school, on an ER rotation in Seattle.  He was an elderly gentleman who had shot himself in the head after downing a 5th of vodka when his wife divorced him.  His features were barely recognizable with all the damage.  He was intubated, paralyzed, and barely had a pulse on arrival.  CPR continued only for 5 minutes before he was pronounced dead; somewhat of an afterthought.  The only thing keeping his heart beating until he reached the hospital were the massive doses of epinepherine circulating in his bloodstream.  I remember being sorry for him, but not devastated – he was already DOA.

Last night, my patient died.

The page came: ADULT TRAUMA CODE ONE FIVE MINUTES OUT BY AIR

I sprinted downstairs and into the trauma room, a sea of faces greeting me.  My favorite nurses, our best physicians, waiting.   These are the most capable people I know.  They were ready –  I prepared myself for the survey.  As the trauma intern, it’s my job to perform the whole physical examination in front of everyone and call out significant findings.  All we knew is that the patient was a 70-ish woman in a car accident.

The medics rolled the stretcher in, and instantly the mood changed; suddenly silent and tense as we saw how bad off she really was.  For a second, the only sound was her quiet wailing, “Oh, Lord.  Oh, Lordy, my arm hurts.  Please, my arm hurts so badly…”

The moment ground to a halt.  I remember utter quiet as the seconds ticked by, as long as minutes.  Her forearm had three joints where it should only have two…

Silently, I took in the damage.  Horrific, tenting fracture to the left forearm.  Right wrist splayed off to the side, every bone in her hand likely shattered.  Right ankle sideways.  Left shin with shards of bone sticking out the front.  Amazingly, she was still talking and protecting her airway, the first thing ever said in a trauma assessment.

So I spoke.

“Airway… is currently intact.”

Time sped up, sounds and colors rushing in to fill the void.  What once was silence and stillness was bedlam and cacophany.  Everyone talking.  Everything moving.  I was lost in the exam, hoping against hope that if I could just find the one thing that was wrong, I could save her.  But there was too much.

Broken bones were quickly realigned, blood lost was quickly replaced, but we were waging a war against death and we were losing.  For every vein that we accessed, another collapsed.  For every unit of blood given, she bled two more.  I was struck for a moment by how beautiful it was, all of these people working in harmony to try to save one life.   Grim faces and furrowed brows desperate to help this stranger.  People at their best.

Blood pressure started dropping.  I had my hand on her pulse and felt it ebbing away, slowly, surely, towards that final quiet stillness.  I remember at one point looking up at the clock and realizing an hour and ten minutes had elapsed.   There was the chill, certain realization that nothing would stop this woman from dying.  My fingers felt her pulse getting weaker.  Slower. Fading.  A few minutes later, she was dead.  Everyone shuffled out of the trauma bay until it was just me and her.  I was struck by how cold she was.   Like Charlie.

And then the page came:  PEDIATRIC TRAUMA CODE ONE 6 MINUTES OUT BY AIR

Off to save a life, this time.

Tomorrow I start trauma surgery.  Gunshot wounds, stabbings, and falls from ladders, oh my!

Stories to come, and lots of them… one thing I’ve never been quite clear on is why all gunshot wounds happen when a patient is “standing on the corner, minding my own business” when “some dude” (or occasionally, “a couple dudes”) just happen to walk up and start firing.

Here’s a warning to everyone in this city for the next month.  Avoid all street corners. Mind someone else’s business, never your own.  Perhaps most importantly, when Some Dude strolls on by, RUN!  You’ll know him when you see him.