Sleep is precious on call. Yet sometimes it’s interrupted for the dumbest reasons: “Doctor, Mrs. Jones is constipated. Will you order some Milk of Magnesia?” This befuddles me in a number of ways. First of all, why would a patient wake up at 0200 and call the nurse because she’s constipated? And why is this something that the nurse believes needs to be addressed at this hour? I have so much appreciation for the job nurses do, but sometimes I wonder when I get calls like this.
A number of such calls were in store for me my last call night, ranging from the above to correcting electrolyte abnormalities. Another patient I went to see had lupus, rheumatoid arthritis, and major cellulitis with abscesses. The primary team had stopped the i.v. morphine and i.v. Dilaudid because the patient was over-sedated that day–she’d fallen asleep while eating! (Good move.) Her still-potent-yet-orally-taken Norco just wasn’t doing the trick controlling her pain. So after getting the story, reviewing the chart, and examining the patient, I said, “I’ll ask the nurse to bring you a little morphine.” I felt sorry for her with all these ailments, and I believed she was in pain.
“Actually, morphine doesn’t work for me, Doctor,” the patient replied. “That i.v. Dilaudid is much better. I need you to write for that. And besides, I would hate to have that morphine just go to waste, because it really does nothing for me.”
I paused. Something was amiss. The “drug-seeking” vibes had nearly knocked me off my feet. As I gathered my wits together again, I took control of the encounter. “Hmmm…I understand what you’re saying, but your primary team was concerned you were over-sedated today, and that Dilaudid is pretty strong stuff. I think morphine is a reasonable step up from Norco. We’ll go with that.” By commanding a “this is what we’re going to do” tone, I staved off any protests. No more calls from that patient that night!
My final call of the night came at 0300 and with a definite Indian accent. “Doctor, we need your help. Patient has died. Can you please pronounce him?” I pulled on my scrub shirt, wrapped myself in my white coat, and with my eyes still bleary, made my way down to 3-west. “Which room?” I asked, stumbling by the nurse station. They pointed down the hall.
The hospital is quiet at night, but this night was stiller yet. Upon entering the chamber, I closed the door for privacy. The body lay motionless, the morphine infusion still pumping into the the pooling veins. “End-stage AIDS, on hospice care,” is what somebody had murmured as I passed the nurse station. I donned a gown and gloves and performed several objective tests to tell me that yes, this corpse really is dead. Around the time I got to the corneal reflex, I started to feel weirded out. Quickly I finished this patient’s last medical examination and scribbled a death note.
Maybe it was the quietness of the room interrupted only by the humming of the morphine pump, or maybe it was the speed with which I fell back to sleep, but the whole memory still has an eerie, dream-like quality to it. Unlike my last pronouncement, this one was totally isolated from any sense of suffering. I had seen no family, and my entire time with this patient was after he had died. This is what you get when you distill out the art of comforting and of walking with a patient though his final days and hours. This was plain science: Doctor and cadaver, scientist and object. A few straight-forward tests, a simple experiment. And then back to the call room for a couple more hours’ sleep.