Saturday Night at Four in the Morning

I worked a 4 pm to 1 am Emergency Department shift last Saturday night, which is one of the unique requirements of this program. Most third year students do not do an independent Emergency Medicine clerkship in their 3rd year, so we are lucky to get this experience. The pace of this clinic is drastically different from Internal Medicine or Psychiatry. In the latter, I may spend an entire hour with a patient before presenting him or her to my attending, then we spend another 15-20 minutes talking to the patient together. In the ED, it's patient after patient after patient. Rapid fire. Where I might focus on "prevention" in other clinics, in the ED I always have to think, "What's going to kill this person right now?" Is it normal back pain or a ruptured abdominal aortic aneurysm? Are you having a heart attack or reflux? Is this a stroke or a migraine? The questions are different, and I have a short amount of time to get all the information (my attending will often enter the room before I've even gotten to the physical exam, because I'm taking too long to extrapolate all the salient info).

During this last shift, two of my patients were surgical candidates. I had a kid my age with presumed appendicitis, and an elderly lady with a perforated colon due to diverticular disease. As I was finishing up my shift, the surgeon on call met with both of these patients before taking them to the OR. Needless to say, I asked if I could join him as first assist, since I had worked up both patients with my ED attending. So, at one in the morning on a Saturday night, instead of being out and about or sleeping off a bottle of Chianti, I was back in the operating room. I'd spent a good bit of time on Ortho Trauma last semester, scrubbing in on cases throughout the year to keep up my skills, and every time I headed back to the OR I felt energized. While my energy had started to fade at around midnight in the ED, three hours later in the OR I again felt refreshed and ready. The sterile field, the bright lights, the calm. It was as if I had just gotten my 8 hours and I was up for another day.

What I've realized over the past few months is that not only do I enjoy the technical aspects of the OR, I also deeply care about working up the surgical patient. Understanding the underlying disease process, taking a full history and physical, and preparing for postoperative care are equally as enjoyable as holding a scalpel. I love all aspects of this type of care, and many of these patients are very, very sick. This lady with a ruptured colon had fecal contents all over her abdominal cavity - a life-threatening condition. Last July, I scrubbed in for a splenectomy (removal of someone's spleen - that funny little organ in the left upper quadrant of your belly), and I thought it was the coolest thing I had ever seen. I remember thinking, "Damn, I really can't see myself doing anything else. I have to do this some day." But, I thought the novelty of these surgeries would wane. What made the whole splenectomy experience that much better was rounding on the patient for two days before his operation, and then again for the next week post. I got to know the man as a person, even in a short amount of time, and developed an intense relationship. I enjoyed studying about his condition, understanding the pathophysiology, and caring for him after his surgery.

When we finished the appendectomy at around 4 am, I grabbed my bags and headed home. On the short drive back I was wired, ready for another case. I looked at the clock and realized that very few things in life are going to get me this revved up very early on a Sunday morning. As a physician, no matter what you do you will be up at four in the morning on a Saturday night at some point. Whether it's Surgery, Internal Medicine, Radiology, or whatever. There will be plenty of night calls, and plenty of overnight shifts. If I'm going to be woken up at 4 am, I want to be doing something that I love; I want to do something that excites me.

I know I have a long road ahead of me, but on that drive back, I thought, "Yes, I could do this."