Around the country this month, thousands of newly minted MDs face their first night on call. In solidarity, I will share the story of my own first call 26 years ago, back when there were no work hour limits, no fallback positions, no handholding program directors—just pimping, dumping, buffing and turfing.
It was the broiling summer of 1985. In my misplaced zeal to leave the frozen tundra of Minnesota, I found myself in the steam-room heat of Houston. I had traded barren, frozen wasteland for sun-baked, urban concrete. My car lacked an air conditioner, my apartment was minus a refrigerator, and I didn't have a clue.
I had come from a school that was hands off, pass/fail, learn-what-you-want. I was going to a residency that was do-it-yourself, don't-screw-up, you'd-better-know-it-all. These were in the days where you drew your own blood, did your own gram stains, and usually transported your own patients.
My first day at the VA would turn into a 40-hour marathon of medical misadventure. Time passed quickly as we learned all 30 patients on the open ward, the beds separated only by curtains. Every patient knew the intimate details of her neighbor. All shared a sonic, aromatic, palpable miasma of misery.
We strolled among the patients—a long-forgotten attending, a resident, two scared interns, and a handy-dandy medical student (HDMS). Ahead of us, we pushed a rack of charts that were prone to scatter papers at the most inopportune times, only to be hastily shoved back into the clipboards in the wrong order. No electronic records, usually no old records at all.
My soon-to-be long-suffering resident, the much esteemed Moises Bucay, was on that night. My first page came in, for a febrile patient. Bucay looked me square in the eye. “OK, Mayo Boy, that patient has a fever. What you gonna do?”
I answered, “Blood cultures, CBC, U/A chest X-ray.”
“Very good,” he replied. “Now go draw those labs.”
I looked at him. “Can you show me how to draw blood?”
He threw himself on the floor, screaming “I'm dyyyinnnggg; my intern can't draw blood!” Then I told him I did not know how to put in a Foley, either.
The night progressed. The other intern on call got increasingly delirious as he tried repeatedly to draw blood. Finally he began to stick everyone in the femoral vein, running down the hallway yelling “Cherchez la femme-oral!” It seemed pretty early in the game to crack up.
My own phlebotomy skills were soon tested. After an hour of labor, many needle sticks, and much undue pain and suffering for the poor pincushion of a patient, I was able to draw enough for blood cultures and a CBC. As I walked in triumph from the bedside, feeling like a vampire in training, holding the prized, red-topped tube, Bucay stared at me in disbelief. “A red top? That's for chemistries, not blood cultures or a CBC!”
When I returned to the patient's room, he assured me, despite shaking chills and diaphoresis, that he was afebrile and cultures were unnecessary. Of course I believed him.
The night continued. Our team was deluged with admissions. Pneumonia, CHF, cellulitis, diverticulitis. Not too different from my admissions last week. I scrambled to take histories, perform physical examinations, make diagnoses and devise treatment plans. No cutting and pasting. My indecipherable chicken scratch filled many yellow sheets. My orders were enigmatic, illegible and unfathomable, but somehow the pharmacist sent antibiotics, diuretics, narcotics and antiemetics to patients, who then seemed to get better. Was it “Primum non nocere”, pure chance, or the fact that patients sometimes get better no matter what you do? I tended to think it was my expertise and innate healing aura. I might have been delusional.
The pager beeped again and it was another febrile patient, this time with altered mental status. I realized I needed to do a lumbar puncture. I had never done one and I was on my own. I got the tray, looked at the tubes, the needles, the lidocaine, and the Betadine, and was stunned, like a deer in headlights. Then: my salvation. I saw the HDMS scuttle by.
“Hey,” I called out. “Want to do a spinal tap?” He rushed over. He had never done one, but had seen a few. “Go ahead,” I offered, “I'll supervise you.”
I watched him assemble the kit, load the syringe, attach the pipettes and open the collection tubes. I was paying close attention. I held the somewhat unresponsive patient by the neck and knees while the HDMS went to work. The needle seemed so long. But there was no fluid forthcoming despite many tries.
Finally, in desperation, I switched places with the HDMS. “Let me help you out,” I nervously commanded. I took the long skinny needle, aimed between the vertebrae buried in layers of adipose, and plunged into action. I wasn't sure if I'd hit his aorta or his gallbladder, but miraculously, a few cc's of relatively clear fluid dripped into the collection tubes. I looked smugly at the HDMS. “That's how you do it,” I said.
It was trial by fire, with inadequate supervision and too long hours, but somehow the patients got decent care. The facts I'd learned in medical school gelled under the pressures of the onslaught. Could I have done just as well with fewer patients, more sleep, better oversight, and more time for contemplation? Maybe, but then I wouldn't have so many great war stories to tell. In the age of evidence-based medicine, these stories are my corpus, the foundation of my anecdote-based medicine. I would not change them—but I also would not wish them on my interns, or especially, my patients.