am

Early morning is the prize for those who labor all night

And its slanted golden light and stillness

And all the memories of summers gone 

(and the smell of breakfast cooking)

And things that might yet be just dreams

And all that promises to be

My tired eyes face unblinking

 

Blow-by-blow: On Call

Here’s what’s going on right now.

I’m eating an apple. By all appearances it’s a Red Delicious. But it tastes too good. It’s not mealy, and it’s sweet plus tart.

I can measure my life, maybe, in Red Delicious apples. I remember when they were just like this, when I was a child. They were my favorite apple, the quintessential fruit. No wonder Eve and Adam fell into sin. But then, a result of grafting the same monoclonal stock onto millions of trees over decades, it was lost. They became mealy, bruised. No longer shiny. I lost interest.

And now this? A last-minute resurgence?

I’m taking a break from my upstairs life. I wandered down a few minutes ago to the doctor’s lounge and found this apple.

Clinic this morning was a mess. Several complex medical patients were either very vague historians to the point where I realized 20 minutes into the interview I still had no idea what we were talking about, or they had stopped taking their medications and but wouldn’t really tell me that until I asked three different ways. For reasons clear to no one I had 6 patients booked in the last hour before I went on call. I’m not sure I ate lunch.

Clinic work spilled into the afternoon because everything in the hospital could be managed by phone. Triage called and I logged into the remote monitor so I could watch a patient’s strip while dictating at the same time.

Then GB called.

“Hi, how are you?”

“I don’t know.”

“Oh, okay. Well, I’m about to put the kids down for a nap.”

“Cool?”

“So I just wanted to see how your day was.”

“Um, busy. I’m on call.”
“Okay. Well, T.P. was jumping out of a mulberry tree four hours ago and cut his hand.”

“Wait, what? Is it bad?”

“Well, yeah, it’s pretty deep. I mean, it’s not into the tendons or muscles I don’t think, and it didn’t bleed much, and I just put a bandage on. So should I just put him down for a nap?”

“Um, I should probably at least look at it. Can you bring him in?”

So they came in. And it was deep. Into the fat on the palm of his little right hand. And of course I decided to sew it up.

Why? I don’t know. The ER would be a long wait, and the wound had already been gaping for hours. But a teeny part of me thought I’d do just as good a job. And that if I didn’t, I’d only have myself to blame. And that if I had someone else do it, I’d have to go through the work of comforting him anyway, and then be powerless to fix the problem.

Yeah, I don’t know. I just did it.

He made a big fuss of it until finally we just held him still and gave him some lidocaine. Then he kind of got into watching the suturing.

The triage phone barrage thankfully held off until almost the end of that.

Next I had to go to the hospital. I checked in with a tachypneic baby and a laboring mom, and sent some other people home.

I was in the hallway trying to remember where I was going next when I got sent to assist on a stat c-section on a trauma patient in the main OR. I put on some scrubs and jogged downstairs to the doctors lounge. I passed some bored-looking orthopedic surgeons and confirmed I was heading the right direction.

At OR 2 the scrub nurse was getting ready. Then I saw that She, my nemesis, would be the primary surgeon. She chatted perkily with Swiss, my pediatrician friend, who looked a bit panic-stricken. The patient was nowhere to be seen.

She left, and Swiss looked at me. “Why do we have to do it in the main OR? They said she’s only 31 weeks, and we don’t even have a warmer down here. I can’t even find the elevator to get the kid to the peds floor if we need.”

So we talked with the nurses who brought down a warmer. We went through the masks and tubes and checked the suction and bag mask until everyone descended at once in the OR.

The patient writhed in pain, blood and stitches all over her face. Her left leg was in a splint. We moved her to the operating table and she screamed. I didn’t know yet that she had a femoral fracture.  Lines went in. They forced a bag onto her face, white milky propofol into her veins. She went limp.

Shenemesis and I hurried out to scrub, the quick kind where you use that gel from the wall instead of water. I gowned myself while She got her gloves. Then gloves for me too. Next the drape while the intubation was finished. Then skin, fascia, bovie, muscle. Bladder blade, uterus, bulging bag, child. Limp, little.

The sewing started. The uterus was floppy and I kneaded it constantly. The bleeding slowed.

In the baby’s corner it was still chaos. Swiss intubated, then I heard a scuffle as anesthesia was upset for some reason. Another pediatrician arrived. The baby needed to be ventilated, but no chest compressions yet, so that was good.

A second layer of suture closed over the first on the uterus. I followed the stitch, kept the uterus firm, dabbed blood off the places She needed to see. “You’re a pro under fire,” She said, not bothering to conceal her surprise.

“Yeah, that’s because I actually know what the hell I’m doing,” I didn’t say.

“Sure, well, we do what we can,” I mumbled.

We talked about where I work, about kids. She called herself jaded. I figured it was an honest admission.

Baby was stable enough to take upstairs, to get ready for transport to the city. We finished up and closed the various layers, finishing with a haphazard subcuticular, honestly the sloppiest layer She did.

Then, my work was done. There’s that satisfying “pop” when you grab your scrub gown by the sides and break the string that ties it, rolling it away from yourself until the bloody parts are inside a nice blue ball. I retraced my steps upstairs as the ortho team set up. “We’re going to put a big rod in the middle of the femur,” the jovial one told me when I asked. “Should be quick.”

Upstairs my tachypneic baby still needed oxygen, so it was time to investigate a bit further. I ordered some tests and visited him again. He wasn’t working hard to breathe. He was eating fine. All the other vital signs were stable. He was a chunky 8 pounds next to his 18-year-old mom.

I started to order the tests when the overhead pager went off “Neo-code, room 3914.”

“Fuck,” I said, at the nurses’ station. I’ve never been clear on whether or not this is appropriate to say at the nurses’ station.

I ran to the other ward. Swiss and the team were already there, but the baby had lost his airway. The other pediatrician was bagging, but it wasn’t going well. A very pregnant nurse tried to get IV access. RT was arranging supplies for another intubation attempt. Another nurse dug through the crash cart for meds, and another kept shouting about the vitals. “O2 sat in the 40’s!” 17 other people stood all around.

“I need another mask!” Swiss said. I crowded past a few folks and dug through the cabinet. No one knows where the hell anything is in a code. We needed a smaller mask. We found one. Then no one could find the right tube. Then the tube was in. Then we weren’t sure. O2 sats still low, kid bradycardic. Bring out the epinephrine. Hard to ventilate. Get some surfactant. Xray. Xray again. Look at the xray.

It wasn’t my code to run, thank God. But it’s hard to watch, not able to do much. Mostly what I did was listen for what folks were saying and try to bring them what they needed, or pass on a message. Because no one else was doing that, maybe. It’s always hard to say.

Finally, there was an airway, a heart rate over 100, and saturations in the 90’s. The transport team was on their way.  There were still too many people around, so I left.

I checked on a woman who was in the throes of labor. She really wanted an epidural. The anesthesiologist, of course, was occupied with the neo-code. “There’s been an emergency. We’ll try to get it as soon as we can.”

Then I was in the hallway again, unsure of how I got there. Some men were installing some kind of screen into the hallway. I had to find something to eat.

I went downstairs to find bars over the cafeteria entrance. I missed it. It must be late? I decided to visit the bathroom next to it.

I walked in and wasn’t alone. A woman, rail-thin, wild hair down her back and a soul-less crazed look in her eye stared at me through the mirror she faced. She furiously mopped up what may have been water from the sink. Her pants fell halfway down her ass, and she had on no underwear. I avoided eye contact, thought about leaving. Somehow, I figured she might be less likely to kill me if I used the bathroom as planned and acted as though I routinely find half-naked women shooting up in the bathroom. Or whatever she was doing, totally normal, you know? I washed my hands next to her and she turned back to the other stall and began vigorously cleaning the walls.

And then I walked past a couple of folks in biker leather fighting with security. And then I hid in the doctor’s lounge, where Fox News was playing, and I was the only one there.

And then I found this apple. And here I am.

I look at the clock. It’s 8. All this, in only 12 hours.

There have been many times, many calls in which I’ve felt the world turns over in 24 hours. Not just one rotation of the planet, but a lifetime goes by. I can measure my life, maybe, by a call or two I remember.

Will this be one of those?

Another bite, and nothing is left but a thin core. My phone rings. A new life is about to begin. It’s time.

I wish I had a dermatologist in my pocket. Instead I have syphilis.

Wednesday was Rashes No One Has Ever Seen Before Day.

A lovely pregnant patient came to see me complaining of an insect bite. It was not an insect bite. Unless insects bite you only on your groin and instead of creating a small pink welt they cause grouped clusters of yellow or blood-filled vesicles crossing several dermatomes and only mildly itchy or painful. I got out the atlas. Then I pulled in the Dinosaur. “I don’t know what that is,” he said.

 Awesome.

In the hospital on call a VBAC awaited. Her bag of waters broke early in the morning and there was thick meconium. She had no contractions yet. This is called PROM, only no one wears fancy dresses, least of all me. The nurses needed me to talk to her also about why we weren’t starting her on Pitocin to induce her. The reason is because it increases your chances of uterine rupture from 4 in 1000 to 11 in 1000. And uterine rupture is a bad thing, since it has at least a 10% mortality rate for baby. But the longer we wait the longer we risk infection, which is more likely, just less dangerous. And she could always opt for a c-section, which is less dangerous for baby on all accounts, but riskier for mom. So, a complex discussion to be sure. Try doing it in your second language.

Arguably more fun than regular prom, though.

After I finished the nurses asked me to stay for 2 minutes and translate for their assessment. They have no translators today. They are woefully understaffed.

I needed them to watch my strip for me because I just got called to the ER.

Dr. ER Green Zone had a baby for me to opine on. “He won’t move his arms. He’s 8 weeks old. His xray looks weird. I’m not sure what it is.” Cool. I’m sure I’ll figure it out right away since I know so much about orthopedics in 8 week old children.  We look at the xray right away. The distinguished radiologist has created a differential diagnosis for the diffuse periosteal inflammation that includes several vitamin deficiencies and a disease I have never heard of, Caffey’s. I go in to see the patient. He’s cute, but he hates it when I touch him. His arms seem weak. And there’s a weird rash on his arms.

I should have put on gloves, but the rash is unexpected. I touch the soles of his feet, where the skin is peeling. A scalloped red border extends to the sides. There are plenty of raised pink and red bumps, but in circumscribed areas. There are some ring-shaped lesions. It looks for all the world like nummular eczema, except the two spots that look like ringworm, and the spot on his chin I can’t convince myself isn’t an early herpetic lesion.

Shit.

I ordered some labs and started reading. I asked Swiss to come look at the rash, too. I called the patient’s PMD, who took care of his mother in pregnancy. She came late to care and never did her labs. The hospital drew a paltry few when she was in labor.

I decide it’s syphilis. Swiss, the resident, the medical student and I go back to the ER to take another look. We keep refreshing the computer screen waiting for the RPR to come back. I call the lab. “Oh it is send-out. 3 to 5 day.”

I ship him to the University hospital. He deserves specialist consultation, which we don’t so much have here. Not for derm, not for ortho, not for 8-week-olds, anyway.

The VBAC PROM is still hanging out. I go home and take a nap.

At 1 am a woman arrives at labor and delivery and goes from 5 cm dilated to delivering a baby on the floor in 10 minutes. The resident was sort of in the room at the time.

And then… nothing. My hands may have syphilis. It is not confirmed. That is all.

Good thing I don't smoke.

Had a delivery last night that I think shaved 2 years off my life. 8 minutes of terminal bradycardia, probably more but the nurse was lackadaisical about the FHT and wouldn't get me an FSE. And I had to ask another nurse who got me an IUPC instead. And the woman was so Mg-ed out we couldn't move her side to side. And then the first nurse told her she just needed to relax and I said "no, she needs to push this kid out" and finally she was barely +2 so I vacuumed the kid out and then he was gray and the nurse said "he's just stunned." and then we resuscitated him.

And then I forgot the name of the 4x4s for the repair and all I could do was ask for "more of those white things. The little ones."

Oh, and there was a resident.

When I Hate My Job

Potter

“He looks like he’s ready to go to the disco,” K said, impressed. It’s been a while (never) since I went to a disco, but I had to agree. Wide collar, sparkly shirt, perfect hair.

Attentive, focused, by his wife’s side. It won’t be long now.

She’s a day shy of 35 weeks, but her body decided to have the baby today. I don’t have records, because it is the weekend and apparently we live in medieval times. Or 1975. It’s never really clear in the middle of the night.

She says it was a normal pregnancy, and she seems like she knows.

To be safe, I checked with Swiss. Sometimes we have these folks deliver in the city. She thinks we can manage here tonight, and she’ll be there.

It takes a while but it’s her first baby. An epidural helps her relax. Finally it’s time to push. Slowly the baby’s head comes down. Slower than I’d expect. An hour and a half into the pushing we’re getting close. She is quiet, focused. He is always by her side.

Swiss comes into the room, checks the warmer. We’re ready.

The baby’s head delivers. But then he’s stuck. I apply extra pressure. K and another nurse pull back her legs and help roll the shoulder forward from above the pubic bone.

Except the shoulder is already under. I can see both shoulders, they’re out. But baby still won’t come.

I don’t get it. This is not in any book. All the maneuvers I ever learned had to do with getting the shoulders out, but they’re out, and the baby’s still stuck. What is stuck? Is there another kid in there? An omphalocele?

Swiss is watching me.

I bring the head anteriorally. No movement. I try some sort of Wood’s screw, if you can call it that with the shoulders already out. I think about cutting an episiotomy. Finally I loop a finger under each armpit and slowly and firmly pull out. There’s belly, belly, and more belly.

The child is before me. A huge abdomen, 40cm in circumference, floppy. Little flipper feet. Tiny chest. Blue. No tone.

Swiss freaks out. I hand her the child as quickly as I can cut the cord. She starts to resuscitate, then moves the whole operation out to the nursery.

It’s quiet again, panic in their faces now.

I have no idea what just happened. I tell them it looks like their baby was born with some problems.

They’re terrified, and want to know what is happening. I duck into the nursery, where about 18 people are trying to intubate the child. A neocode has been called.

I go back in and tell them what I know.

The next six hours I split between their bedside and the unfolding drama. More of “We’re not sure what this means, but this is what is happening and here is the plan.” Transport arrives but hangs out for a couple hours with Swiss to stabilize. More tubes, lines, xrays, consults, taps, needle thoracostomies. The lungs are too tiny. The belly too big. There’s a mass near the bladder and the kidneys are huge, maybe cystic? The oxygen is lower than expected.

Finally he’s ready to go to the city. I bring them over to see their son for the first real moments. I have to give them permission to touch him; the lines and tubes have a way of keeping folks away. A few minutes of the three of them, and then he has to go.

The next morning, at the University, he codes again. This time, he doesn’t make it.

They were on their way. But the first time they were able to hold him, he was already gone.

And why? Well, it was the Potter sequence, you see. He had posterior urethral valves, meaning the urine couldn’t leave the bladder and backed up. The pressure got high enough to blow a hole in a kidney, filling his abdomen with urine. Meanwhile, over weeks, he made virtually no pee, so the amniotic fluid was chronically low. Thus his legs never developed fully, and, more importantly, neither did his lungs. He died because he was born 5 weeks early with lungs that were 15 weeks early.

Yes. I understand. But why?

Dreamy

Last night I was on call with a resident. She told me she had a dream in which she was evaluating a woman in OB triage when all of a sudden the patient’s baby came out without any warning.

Here is the sort of dream I have.

I am running through a maze of doors, under a dark sky with trees. Several rabid deer are chasing me. The doors are crumbling, so when I close them behind me the deer can still get through. Finally, a room seems safe, and there is a piñata. I stand next to it and it breaks open and millions of tiny chainsaws fall out.

The good news is neither of those things happened last night.

House of Scorpio

My last few calls had been cake. Not bad. Maybe I even thought I was just a super awesome doctor/efficiency master. And then I’d return to clinic, where reality would set in. But no matter: call was not so bad.

Then it was my Hospital Week.

At no time during Hospital Week did I have fewer than 9 patients to round on in 5 hours, and often more like 15. Most of them had pyelonephritis and were vomiting. Rounding on those patients was totally do-able. I am totally awesome at treating uncomplicated pyelonephritis and vomiting.

Except that I was also in charge of all 30ish-week twin pregnancies who may or may not have been in labor and needed to be evaluated and possibly transferred to the University for seeing spots and having their right hand spontaneously weaken vs. having their bag of waters rupture prematurely. Of which there were 3. During which I was also in charge of all placental abruptions at 35 weeks bleeding half of their blood volume into the bed. Of which there was thankfully only 1.  And of all of the babies who seemed to be doing very well but then immediately prior to discharge developed extremely high bilirubin levels. Of which there were also 3. Or 27. I lost track.

And also of teaching residents. And of taking the amniotic fluid samples to the lab downstairs 55 times because the bulb is out on the microscope on Labor and Delivery.

And of locking my keys in the car in the middle of the night with the car running and not noticing until I came back out after a delivery.

“It’s crazy around here,” I mused as I sat next to a nurse. She was scanning through the computer. “Yeah. It’s the Supermoon, which is in the house of Scorpio. Or something like that.”

Obviously. That explains everything.

Monster Hospital

Yesterday I woke up and I didn’t like my job anymore.  I had a bad feeling in my stomach as I backed out of the driveway.   Then I made an attempt to identify the factors which led to this feeling.  I outlined the following:

1)   It is 6:30am

2)   I was hanging out with the kids all weekend, leading to:

a.     Utter exhaustion

b.     Wanting to hang out with those guys even more

3)   I’m afraid of the hospital

Then I had the following self-dialogue.

“Um, you are 30 years old.  You are a doctor.  Why are you afraid of the hospital?”

“I’m a crappy doctor.”

“Why do you think you’re a crappy doctor?”

“Because that one lady was mean to me.”

“Because a lady was mean to you.  What lady?”

“Let me fill my self in.  Last time I was on call there was a lac I thought was a third degree and I’ve never repaired one and I didn’t want the patient to be incontinent for the rest of her life, so I called Her.”

“You called the patient?”

“Uh, no.  I called Her.  The OB on call.”

“Ah.  The one who told you you couldn’t do a pelvic exam.”

“Yes Her.  And She told me if I can’t repair my lacs maybe I shouldn’t deliver babies.”

“And you believed Her?”

“Yes.”

Yes, yes I did.  This is the thing about me.  I believe what other people say.  I take it seriously.  And so probably I shouldn’t be delivering babies.

That makes me sad.  Also it makes me not want to go to the hospital.  Because what else should I be able to do that I can’t?  What else should I know that I don’t? 

I’ve said I believe in family medicine, more than I believe in myself.  I believe that competence can be something other than knowing everything, being able to do it all.   Competence is listening, understanding, explaining.  Taking care of most things, and perhaps most of all, knowing when to ask for help.  Yeah, that’s what I believe.

Except on the days I don’t.

All I really want is what’s best for the patient.  Almost always I believe that they should all have family doctors who care and have a relationship with them and only very rarely need to ask for help.  Almost always I believe this will provide excellent care with better outcomes at a lower cost.

Except when I don’t. 

And when I figure, maybe I should just stay home with the kids.

I feel defeated.  And now I’m already halfway to the hospital.  I’m lame.  I don’t want to go but I’m in too deep to get out of this, so I sheepishly keep showing up to work.

But I also feel a little bit angry.

Who is She, to take away my fire?  Who is She to turn someone like me into a defeated apathetic heap?  I mean, at least I’m nice.  Also, I speak Spanish.  Also, I’m conscientious.  I’m reasonably intelligent. 

And I care, damn it.  I care about these people. 

Hundreds of folks have invested in my training.  I’ve invested years of my life.  I’ve shown up at 4am for Surgery rotation, stayed ‘til 9pm after clinic.  I’ve spent countless hours away from my kids, so many nights away from my bed.  I’ve studied about and rounded on and written notes on and talked with and sat with and broken bad news to and operated on and bargained with and delivered babies to thousands of patients all day and all night and all day again for seven years.  All because I believe.  I believe I might one day make a difference for my patients.  Who is She to stand between me and my patients?  Because that’s what She’s doing.

Because I’m letting Her.

The hospital looms like an ungainly monster.  It’s snowing hard.  I park next to the helipad and sit in the drivers seat.  The temperature plummets as I turn off the car, step outside the car. 

There’s still a little fire in my belly.  I hardly notice the chill as I run for the Emergency Room door.

Mi Vida

Daughter

She’s 16.  Since the process takes 9 months, she was 15 when it all started.  And now she’s going to have a baby.

She’s brave.  Braver than I was then.  Braver than I am now.  15 for me was about running wild through the woods and creeks and camping with friends.  It was about bowling.  Clandestine driving on county roads.  Algebra II.  Big dreams.  The world at your doorstep.

Fighting with my mother, or “becoming independent.”

Because, for some reason I’ve never understood, I was lucky.  I wasn’t raped.

Her mother sits now, at her side.  English is her second language.  She smiles at me as I describe why we need to keep her daughter overnight for extended monitoring, even though she’s very early in labor.  She has another contraction.  Her face barely registers the pain.

Is it because this pain, what many of us consider the most intense experience of our lives, pales in comparison to what she’s already seen?

Mother gets up from the chair to hold her hand.

Two hours earlier, Mother had called me to ask when she should bring her daughter in.  Contractions had been every 5 minutes for a while.  We talked.  I asked some questions, gave some advice.  Here’s what I didn’t ask:  “Do you have a ride to the hospital?”

The nurses learned she didn’t.  They arranged a taxi voucher.

Tonight there turns out to be a lot of questions I should have asked.  A 20-year-old just had her second child. I had seen her in the office a week ago, and asked if she was safe in her relationships.   I asked if the father would be involved.  Yes, and he also lived with her.  I asked, as politely as I could, why she didn’t come earlier to prenatal care than 37 weeks.  What I didn’t ask, in my condensed 11-prenatal-visits-in-one, was “Do you plan to keep this baby? Or will you be adopting the baby to a relative who lives with you and the father of the baby, from whom you are officially separated?”

Sometimes you just don’t think to ask these things.  If you did, you’d open a door into someone’s world that they maybe don’t even want you to know.  Some patients want to hide their pain from the doctor.  But you cannot hide it from your mother.

My aunt posted a picture on Facebook tonight.  It is my grandmother, whom I never met.  She is around 2, holding someone’s hand, clutching a stuffed toy.

She looks EXACTLY like my daughter.  Down to the curls, dark blond.  The small, rosebud lips.  The round, serious face breaking occasionally into a silly, ecstatic laugh.  My daughter carts around a similar toy, called “Creature.”

The other baby, my grandmother, lost her ability to move from the neck down at the age of 25.  She died of pneumonia, after 8 years raising her daughters from a hospital bed, at 33.

Suddenly my eyes burn.  My own girl is tucked into bed, sleeping quietly in that beautiful way she does.  And I brought her into this world, on a day not unlike today, knowing how much it could hurt her.  Her life is a piece of my heart, walking freely through the world.

I saw a flash of myself in the 16-year-old.  Then in the mother’s face, bent low over her daughter, kissing her gently at the crest of the contraction.  The girl goes back to sleep between the pains.

I saw myself older, then, sitting next to a hospital bed, next to a handicapped child, with children of her own.

The phone pulled me out of my reverie.  A different woman’s baby was about to make her debut.  No pants could be found in my size.  The nurses said the baby was in a hurry.  The only options were 2XL. I briefly considered delivering the baby without pants on.  How much worse could it be than delivering one without gloves on?  I’ve done that.

Drawstrings are a nice invention, though.  I rushed into the room and caught the child, and handed her to her mother.

“Ah!”  She cooed, like many of my Latina patients do.  “Mi Amor!  Mi vida!” 

I delivered the placenta.  No one ever says these things about the placenta.

Mother went on.  “Mi amorcita!  Ay, bebe!  Ay, mi vida!”

Yes.  My thoughts exactly.  My daughter.  My beautiful.  My life.

2am

What It's Like

If you can ever help it, don't get sick at night.

People get sick at all times of day or night.  Babies like to be born at night.  This is either because of the lunar cycle or because they like the infomercials their parents are watching in the labor room.

In the middle of the night, brains, even doctor's brains, don't work like they should.  Or maybe they do, it's just that they should be dreaming instead of trying to figure out if a patient's fetal heart tracing is going south.  Or if it's okay to dissolve nitrofurantoin in peach juice. 

When babies are about to be born, my brain becomes aware of the phone ringing, a special ring I chose just for work.  I believe it is called "night of the living dead."  My brain "wakes up."  This means I get to stop dreaming about taking care of patients (having nightmares about codes) and actually take care of patients.  My body finds keys, stumbles over dogs, and climbs into the car.  I drive down empty streets, peering out a tiny clear spot in the frost I forgot to scrape off the windshield.  There is one hospital in town, which was excellent planning on the city's part.  That way I won't show up and deliver the wrong baby at the wrong hospital.  At least I can get one thing right tonight.

It's cold outside the hospital, and the badge system isn't really designed to allow you in the building, just mainly to trap people in the stairwell.  Why is the light flashing red?  Ah.  Wrong badge.  Somehow I make it in and find the call room.  Automatically I enter the door code I used for three years in residency.  Astonishingly it doesn't work.  Then I remember where I am and finally bust through the door. 

I wash my hands in the sink.  The automatic towel dispenser fires next to my ear and I jump a couple of vertical feet.  I look around the counter.  There is a bottle of rice vinegar and a jar of Jif.  This reminds me I'm thirsty.  There are no cups.  I drink tap water out of a giant square tupperware container.

And then I go take care of patients.

The only thing worse than my brain at 2am is the brain of someone with less experience, who is even more tired than I am, from being up without sleep every fourth night.  Like the brains of, for example, all the interns out there tonight, running all the major hospitals in the country.  Once, when that was me, I saw a bear in the hallway.

Dear God, help us.  What is wrong with this system?