Fatigue and compassion: reflections on a New Year's weekend

Humanity

CJEM 2001;3(1):58-59

I expected the transition to January 1, 2000, to be greeted with greater fanfare. I only noticed that a new millennium had dawned when a paramedic working in the emergency department of the New Halifax Infirmary said "Happy New Year." I overheard him from behind the curtain, where I was starting an arterial line in a patient who was trying to die. I guess I was expecting a countdown, an anticipatory hush, or at least a small cheer to usher in the New Year, the new millennium, but no one's heart seemed to be into it.

Patients don't take holidays from illness. Neither can hospitals. A concession we make to enjoy the privilege of being physicians is finding ourselves working at all times of the day and all days of the year. As an emergency medicine resident doing an intensive care rotation, pulling the short straw had given me the New Year's shift. Partly, this was a relief (has there ever been a holiday event with such pressure to have the time of your life?), but mostly it was another sacrifice to add to the list that we all make during our residencies.

New Year's Eve, 0800: I arrived at work resigned to my fate, but determined to remain upbeat despite what I perceived to be my great misfortune. The day nurses were in great spirits, but I found myself in no mood to be jovial. I remained just civil enough to retain access to the huge amounts of snack foods that were scattered everywhere.

1800: The day remained miraculously admission free, although I was busy dealing with problems on the ward for most of it. It was hard to put a positive spin on the fact that people's loved ones were in the ICU on such an auspicious day.

2200: Despite an invitation to attend a party in the ICU, I didn't have the energy to deal with the inevitable awkward round of hugs, cheers and kisses. I retired to my call room while I had the chance. As I lay there on a lumpy mattress in my windowless, unventilated call room, my thoughts drifted. What were my family and friends doing at home in Winnipeg? My brother was in Toronto with his wife and 7-week-old son. My fiancée was working in the Montreal Children's emergency department. I hoped that this would be our last holiday apart. My melancholy was peaking when my pager went off and interrupted my reflections.

2330: A patient was in the ED with respiratory failure and a Pco₂ of 177! His condition had deteriorated while flying home after visiting a relative, and he had slipped to respiratory failure soon after the plane landed. A friend called 9-1-1 when he collapsed, and on presentation he required intubation. Now his blood pressure was dropping.

2345: My initial assessment was complete, and a fluid challenge underway. As I examined him, I couldn't help but notice the clock out of the corner of my eye. What would this New Year bring?

I looked furtively around the department, but no one else seemed concerned about the time. I wondered about etiquette, when bringing in the New Year with a bunch of semi-strangers. Does one wish patients a "Happy New Year," or is this a faux pas in light of the fact that they were sick enough to come to the hospital?

I turned back to my patient — still hypotensive after 2 litres of fluids. He looked sick! In fact (as our staff-man was fond of saying), he "looked like stool." I started infusing dopamine peripherally and prepared for a central line. My mind returned to the job at hand. Before I knew it, I heard the infamous phrase "Happy New Year!" Great! Self-pity again.

January 1, 2000, 0800: I'd been up all night stabilizing the same patient and resuscitating another, who had a massive pulmonary embolism. The day staff had arrived, and I was looking forward to going home.

1000: A young woman presented to the ED with fever, headache and generalized purpura — meningococcemia! She was transferred to the ICU with due speed. I gave silent thanks that I didn't have to admit her (I was asleep on my feet), then felt immediately guilty. Once again, fatigue was thwarting compassion. I needed to prepare for call the next day; one-in-two was the necessary evil that facilitated a Christmas break. She was stabilized, and I left.

January 2, 0800: Back to work and still feeling sorry for myself. I worked steadily all day and through the night without setting foot in the call room. I had been up for 62 of the last 72 hours and felt like it. On the other hand, so had the parents of the young woman.

0400: She was deteriorating. She was on huge doses of dopamine and norepinephrine and suffering from DIC. Both legs and her left arm were ischemic -- black and lifeless. An hour before, I had devastated her parents with the news that her pupils were fixed and dilated. She had probably bled into her brain. The final insult. Having let this sink in, I returned, donning a mask as I did so. I thought I should uncover my face when I broached this subject, but was unwilling to take the risk, hating myself for not being able to.

I told them that, despite our machines, antibiotics and medicines, we could not beat this terrible infection, but if we stopped her vasoactive drugs, her heart would also stop. We could do CPR, but this could damage her and would not stop her demise.

I don't remember my exact words, but I'm haunted by the expression on their faces. I struggled to suppress the tears filling my eyes. After a short discussion, they agreed we should do no more. Numb, I left the room to compose myself.

Few professions provoke such an array of emotions, from the boundless joy of new birth to the abject misery of pointless death. Patients like these rekindle the compassion that arduous call schedules beat out of us, at the same time reminding us of the limitations of our art.

Later that morning, as we withdrew treatment, I realized that missing a New Year's Eve party was a small sacrifice. My self-pity was absurd. A vibrant young woman had died abruptly, her family was in turmoil, and they would never welcome another new year without remembering these terrible nights in our ICU. Would they also remember my small efforts? I was exhausted, but I had my health, family, friends and loved ones to go home to, and a full life and career to look forward to.

What more could anyone ask for?