Like two ships passing in the night....

It was 3:00 am in the morning on a call day/night. I wonder sometimes if the memorable cases come at that time or if I just happen to remember the cases that come at those hours. Anyway, I had been awake for 24 hours and was fighting sleep. I waswriting some orders for a patient that we had admitted earlier that night. It was the last thing to do before, hopefully, getting some sleep. My pager went off and I rolled my eyes. "Please, not another admission" I thought, hoping that I would get some sleep before the day broke. It was another admission. It was to be a transfer from another hospital. I accepted the patient: a 70-something female with 'pancreatitis'. My mind was already framing the things I would do: bowel rest, IV fluids, should I do some prophylactic antibiotics?

When the patient arrived, I realized this was not going to be 'simple'. (If they transferred from another hospital at 3:00 am in the morning, they usually never were). If it was plain-vanilla pancreatitis, they wouldn't be coming here now, would they? What was I thinking?

Turns out my new admission had metastatic stomach cancer. In addition, she had an elevated Tn I (0.8) and a stable AAA. Oh well. I went to evaluate her. She had severe abdominal pain. Made sense, I thought, she has pancreatitis; only here abdominal pain was diffuse. It wasn't the classic epigastric pain radiating to the back. My sleep dissappeared as I began to feel uncomfortable. Something wasn't right. This wasn't pancreatitis, was it?

After several rounds of fentanyl and then morphine, I began to feel even more uncomfortable. After checking that cardiology didn't want to do anything with her (the Tn I wasn't high enough), I ordered an abdominal CT scan for the morning. It was almost morning anyway.

A nurse casually remarked about the strangeness of the situation: it seemed that my patient's husband was admitted on the opposite side of the corridor on this same floor. He had come in for a heart angiogram and they had discovered severe three-vessel disease. He was on the schedule as the first case for a triple vessel bypass that morning. This couple was not having a good day.

To cut a long story short, by the afternoon of the next day (I was well past 40 hours without sleep by that time and 'wrapping up' to get out of the hospital). the CT results showed that my patient had thrombosed two major arteries in her gut and her gut was almost dead. The vascular surgeons told me that the case was hopeless and that she had less than 12 hours left to live. Ironically, when her gut died, her pain went away and she felt better. That was an ominous sign.

Sleepless and discouraged, I broke the news to tearful daughters and a dumbfounded patient. Her only request of me before we moved her to the palliative care unit (where she would go to die) was that she get to see her husband. The last thing he knew was that he was taking in his wife for some belly pain and vomiting.

By this time, he was in the post-op recovery unit, coming out of anesthesia after his triple bypass. He was dazed, confused and combative (as patients can be coming out of anesthesia). As my patient was wheeled in her bed to our palliative care unit in another building, compassionate nurses and transporters arranged for her to see her husband for the last time. He was not conscious. She wasn't quite all there either. Their daughter told me that in 53 years of marriage they had spent all of 3 nights apart. This night, they passed each other like two ships passing in the night.

Now I have a confession to make. By the time I took care of all this, I was well past the legally allowed limit for working continously (30 hours for us residents). I was more like in my 45th hour without sleep. I wasn't making clinical decisions. I was saying goodbye to a dying patient and trying to get her to see her husband one last time. I wasn't about to leave a scene of death simply because my 30th hour was up. Doctors can't punch a clock. What would you have done?