On Call
On Call
The time is 0135. In red. The same colour as my bedside clock at home. But some in-built position sense tells me it is another clock, I am not at home; like when I am staying in a hotel room; as if I am a migrating bird, sensing the earth’s magnetic field. The faint light from outside is coming from a high window above the head of the bed. There is the hum of a heating system. My wife of 36 year is not beside me. I must be at work. I get up to the toilet, remembering to turn right, not left, as I get out of bed. I find my way back to where I am supposed to be sleeping. It takes me a while to get back to sleep.
I am doing a night shift. Marcus has handed over the 20 patients on the ward. Many of them are well known to me already. Frequent fliers. The usual suspects. I hope nothing happens to them overnight. There will be new patients arrive. There are 35,000 people out there somewhere in our community not in hospital. After six o'clock in the evening, if people phone in believing themselves to be sick and in need of a doctor, they will be told that their own doctor no longer provides that service and will be put through to the hospital. People seem to think that bed-time is a good time to see the doctor, symptoms that feel safe in the middle of the day are not to be trusted at night. I wait up for a bit, make myself a hot drink, say hello to the nurses who are coming on; the staff members who have to be awake and will be in the front line overnight.
Marcus has left a crossword, mostly completed, on the table. Like a cat leaving a dead bird on the doorstep. Except he has not quite killed it. I decide to finish it off. I am not in a hurry to go to bed. My contract says I am allowed to sleep if nothing is happening, but it's not that simple. There are four clues Marcus doesn't have the answers for. These clues may be made up. Remember, I am a doctor not a crossword compiler. Four across: "At home it sounds like a battlefield in France in a strange order for lack of sleep," eight letters. At home: in; IN — . Sounds like a battlefield in France: Somme; — SOMme — . In a strange order: in a; — NIA. Insomnia. Lack of sleep.
Twelve across: "Loss of mind of French men with a temporary stroke," eight letters. Of in French is DE. Indicating belonging. The same two letters in English indicate loss. As in the word depopulation; loss of people; not a big problem in Central Otago in recent years. Deforestation, deflowering, dementia? Dementia, of course, that will be it, dementia is the answer here. I think about the meaning of the letters and words. DE. Belonging. Loss. Opposite meanings on different sides of the English Channel. Two meanings separated by 34 kilometres of water. Like a Napoleonic war of language. The middle bit, MEN: that's obvious. Marcus is from England not France: he has missed the French part of the clues, but I'm disappointed he missed the bit about the temporary stroke being a transient ischaemic attack, a TIA — clearly needs more training. I am not from England, I am from New Zealand, but I do speak English, I could have got most of the other clues, using my knowledge of the English language. Two different countries connected through a common language, separated by 20,000 kilometres of ocean.
The nurses ask me to see a patient on the ward. She is suffering from delusions. Loss of something, obviously. She has been going round the rooms collecting shiny objects from the other patients. Like a magpie at a carnival. They are all laid out in a neat pattern on the bedside table in her room. An organised delusion? I decide that the woman is at no risk of causing harm to herself or other patients or staff during the night. Any more harm than a real magpie would cause. I close the door and leave her to it. And quardle oodle ardle wardle doodle the magpies said. Live non-migrating birds on the doorstep.
I go back to the crossword. Four down; "Disintegrate quickly for a meal," nine letters. Disintegrate? Could it be an anagram of something? Can't find it. Quickly? Could it be one of those musical instructions? Allegro? Vivace? Presto? Is it some Italian word this time? Heading further south in the Mediterranean? No. Doesn't fit. Turns into a meal? Make a meal of? Mealy-Mouthed? Doesn't make sense. Can't think of it. A disorganised non-delusion. Time to move on. Next clue. Eighteen down: "Exist timed badly at the end of the evening," seven letters. Exist: BE. Timed badly: DTIME. Bedtime. I head away from the ward towards the on-call room.
The phone rings beside my bed. 0236. The ambulance. A man has called 111 with chest pain. He would have told the ambulance, although they don't tell me, about the circumstances, what he had been doing, who else is at home, what he ate for dinner, when and how the pain started. The ambulance do tell me that the patient lost his father at an early age from heart disease. Degeneration, you might call it. On ECG the ST segments in II and III show 2mm depression. Depression. Sagginess. Sadness. Loss of pressure? His life, his hopes, his fears, his disrupted whakapapa have been reduced to a few letters and numbers. He needs to come to hospital. ETA 0256. He arrives. His TNI, a sensitive blood test for heart muscle damage is elevated at 0.23. He needs to have a coronary angiogram, a pictorial representation of the vessels around his heart. We have progressed in etymology across the Mediterranean, and back in time, to ancient Greek.
Do you remember those mostly unwanted Christmas presents from a generation back called Paint-By-Numbers, where the numbers dictate what colour to put in each section? 1 is for blue. 2 is for green. 0135 or 0236 is for red. 111 is for an ambulance to bring the patient to the hospital, at 0256. A TNI of 0.23 is for angiography. Put the right colour or do the right action depending on the number. Without thinking. Clinical care has become like that. We are mourning the loss of the art of medicine. Instead, we have numbers. Instead, we have guidelines, protocols, algorithms.
No creativity, I think. But we do need to change with the times; we don't each have to make it up based on a decreasing understanding within our own brains of an overwhelming amount of new medical information. We need to change the way we practise, to keep everyone safer, most of the time. There are many different right ways to stage Hamlet, I remember reading somewhere, but maybe only one agreed right way to deal with a particular medical emergency. And many wrong ways.
Other patients turn up. Injuries, fractures, cuts. People distressed through the night with symptoms that might be tolerable during the day. Others with the strange belief that strangers at the hospital in the middle of the night can do a better job for them than their own doctor in daytime, understandable I admit if they have had the experience of phoning in the morning and finding their own doctor can’t see them for several days. Parents taking advantage of the fact that we do not charge them to see their sick children. I eventually see them all and get back to bed. Tired, I sleep well.
My alarm goes off. 0710. Those red numbers again. I have not had enough sleep, but it is time to get up and hand the patients back over to Marcus for the day shift. First, I need food. I find some cereal, peaches, toast, before the cooks assemble the meals for the patients and take all the food away. An early bird catching the worm. I still have the crossword. Four down; "Disintegrate quickly for a meal," nine letters. Now is the right time to solve this last remaining clue. I look at the last crossword clue while I eat. Disintegrate: BREAK. Quickly: FAST. Break my fast. Break Fast. That’s it: breakfast.