Doctors earn most of their money on call. Call night, especially when the hospital is bulging with admissions, can be a high-risk, low-sleep affair. Luckily I cope with broken sleep very well. I can go from any level of wakefulness to dead-away slumber in 10 minutes flat, unless I am sleeping on broken glass, in which case it takes about 13 minutes. So middle-of-the-night phone calls don’t faze me as much as they do some.
Nonetheless, like all people who take call, I have a Death Hour. The time of night when a page is especially, excruciatingly painful. Though it may be different for other people, my Death Hour is between 4:30 and 5:30 AM. At that time, if you awaken me, you are resurrecting a person so deeply buried in unconsciousness that a dose of morphine would probably lighten my sleep a little. The worst thing about the Death Hour is not the waking up, but instead the possibility of having to go into the hospital. If I have to get out of bed, I am in for at least an hour of work, and when I get back home – 5:30 to 6:30 – it is too late to go back to sleep. If I am called in after 4:30, I am up for the duration. This means a painful, foggy morning relieved only when I get my usual afternoon legs. It is like suffering a hangover without having had the pleasure of the hang.
Some time ago when I was taking call at a hospital I won’t name I got a page in the fullness of the Death Hour. A nurse came on the line. It was a voice I might have recognized instantly in the daylight, but in my clouded recollections she sounded like one of those digitally distorted voices used by unnamed, out-of-focus informants on “Sixty Minutes.”
“Dr. Hebert, I am calling about Ms. Henderson in room 723. She is a mouth-breather and is on oxygen. Is it okay if I get an order for a face mask?”
“Sure, no problem,” I said. “Go ahead and do it.” This happens from time to time. Patients are routinely given nasal cannulae for oxygen, but if the patient does not breathe through the nose, she will not get the benefit of the oxygen. The mask overcomes this problem.
“Doctor, do you have any other orders?”
Any other orders. That question froze me. Well, actually I was lying motionless in a bed, so the question only froze my mind. My consciousness, having answered what I thought was a simple question, had turned and was lumbering towards the blissful silence of sleep. Now it stopped, its eyes averted from the darkness. Any other orders?
This is the kind of question nurses ask me when a patient is making a turn for the worse. The question means, “I don’t know what I should be doing. What should I do?”
Usually when a nurse calls me in the middle of the night, she has a specific question. She may ask for a pain pill, or a medication for nausea, or something for fever. When a nurse feels in control of a situation, she asks for what she needs. Most nurses won’t ask an open-ended question like, “Any other orders?” unless they are fishing for ideas.
To put this into perspective for non-medical readers, I offer this translation. You are in your kitchen cleaning up after dinner. Your teenage son walks in and asks where the clean glasses are. You say, “I just washed the ones sitting on the counter. Take one of those.”
Your son proceeds to fill the glass with water, then turns to leave the room with the glass. On his way out, he says, “What else will put out a fire besides water?”
This is what I heard in the nurse’s question. She was saying, “The patient can’t breathe. What else should I do?”
My heart stepped faster. I was in the barren fjord of the Death Hour, and in a confused sort of a way, this nurse was hinting that I was sleepily gazing at the tip of an iceberg.
I stammered a bit, then said, “What is wrong with her? Why is she in the hospital?”
“She has an infection on her leg.”
Oh, no, I thought, though I used a different word than no. An infected leg means immobility. She could have developed a deep venous thrombosis, a clot in her leg.
“What happened? Did she get short of breath all of the sudden? How was she before?”
“She was fine until she got up to go to the bathroom a few minutes ago.”
I saw two possibilities. One: she had a deep venous thrombosis, got out of bed and dislodged it. That clot passed up her femoral vein, into her inferior vena cava, through her right heart, and is now peacefully showering chunks of its former self into her lung. A pulmonary embolism.
Two: she was an obese middle-aged couch potato too poorly conditioned to abruptly bound out of bed in the Death Hour without getting out of breath.
The odds were with number two. So I did what every doctor does in the Death Hour – I temporized. “Give her a respiratory treatment,” I said. “That should open her lungs up. If she doesn’t get better in 15 minutes, give me a call back.” I knew that sudden changes evoke panic, even in myself, and that as long as the patient is stable that watchful waiting does wonders. Give it a few minutes. If she didn’t improve, I would be in.
I hung up the phone with some anxiety. My luck I would be on it again in 15 minutes. And the nurse – God bless her, I don’t know if she was dumb or inexperienced or overworked or just nervous – did not put me at ease. She started off with a simple, misleading question and then indirectly tipped me off that there might be a serious problem. Did she not know what she was doing, or was she just trying to be excessively tactful and not appear alarmist? A more confident nurse would have simply said, “Doctor, something is wrong.”
I don’t want to be excessively harsh, though, because in the end, the message was conveyed. In the end, I was on the alert.
I spent the last few minutes of the Death Hour awake, but the phone did not ring. She made it to the day shift alive.
Mission accomplished, for doctor, patient, and nurse, all three.