The Road through Residency:

Habit and Apathy

We're taught in medical school and residency that our responsibility to our patients often supersedes all others in times of crisis, but "crisis" is a vague term. In reality, crisis tends to be defined by those moving through an experience. A young asthmatic needing intubation will very likely recover, although family members may well believe they're facing a terminal situation. An elderly grandfather hospitalized multiple times in several months for the same worsening heart failure may have few good options for treatment, despite his family shrugging off another of grandpa's "episodes." We are creatures of habit, and habit breeds apathy.

It's fifteen hours since I've slept or eaten. The on-call period is long and arduous but a great teacher. The two pagers on my hip start beeping at the same time. I call one number, and a nurse says that a 67-year-old woman admitted for diabetic ulcer is complaining of heartburn. At the second number, I'm told a 40-year-old has a sudden onset of shortness of breath following orthopedic surgery. I go to see him first.

The patient, his left leg bandaged at the knee, is breathing deeply. My heart sinks, and I fear he has a pulmonary embolus. His vitals are more concerning: tachycardia, tachypnea. When I speak to the patient, he tells me he has severe anxiety, and "No one's giving me my anxiety pill." I order a chest CAT scan with contrast. Thirty minutes later, the patient is back in his room complaining about how small the CAT scan machine was, and he is very claustrophobic. I'm sitting at the computer screen checking the scan. The final read: no pulmonary embolism, normal lung. I give the patient some Ativan, his shortness of breath subsides, and he sleeps comfortably for the rest of the night.

I then move on to the 67-year-old with heartburn. The patient looks my grandmother, and countertransference occurs-I can't help but feel an immediate emotional connection.

"My heartburn is acting up really bad," she says.

"What does it feel like?" I ask.

"An elephant sitting on my chest-"

"STAT EKG!"

Thirty minutes later, I'm calling the cardiologist about what I suspect to be a myocardial infarction. The patient goes to heart catheterization, does well, and eventually goes home. Despite this good outcome, I don't feel well. I can't sleep. Tonight, I chose the wrong patient to see first. What if other calls had suddenly occurred? What if she hadn't described her symptom so perfectly? What if the outcome had been poor? We can live our whole lives wondering "What if?" but put simply and succinctly, medicine is not perfect. Like everyone else in life, physicians try, but we do not always succeed. Even the most seasoned attending in any specialty makes mistakes sometimes, and if we don't remember that, we won't be able to function.

Calls about heartburn happen often, and habit breeds apathy.

I sign out and give my summary of the night to the senior resident. After noon conference, I walk down to my car and climb in. I'm so very tired, but I couldn't sleep even if I were lying on a California king. The drive home is long and full of more stoplights than I feel entitled to. Coming home fatigued and sleep deprived has become a routine, a habit. In our apartment, my wife Sarah turns to me and smiles, our son in her arms.

"Daddy's home," she says.

I pick up my son and hold him close. He looks at me, his face blank, and then, as if by magic, he smiles. He doesn't need any words. That smile says more than words ever could. I kiss my wife and excuse myself to get some rest, as I always do after a night on call.

"I thought we could get a Christmas tree on your day off," she says.

"OK," I say, moving to the bedroom. I think, I hope I never get used to this habit.

"And we still need to get a Christmas present for…"

She walks into our bedroom, but I'm already passed out on the bed. She closes the door, and so I sleep deeply.