An overly familiar alarm buzzes at 4:20 a.m. My first thought was, “I should have slept more.” I lazily brush my teeth with the combination of spearmint and reflux mixing in the back of my throat. With heavy arms and legs, I wearily climb into scrubs in the dark and carefully exit the house – a thief in my own night. The pitch-black drive is less interesting this morning. News radio in the background drones on about the ongoing conflicts and controversies of the world. A quiet 45-minute drive on country backroads solemnly foreshadows a heavy day. I arrived 20 minutes early, as planned. My grandfather’s voice echoes in my head, “If you’re not early, you’re late.” A last walk across a mostly empty parking lot before the first rays of morning light flicker onto the red emergency sign. I scan my badge at the door, and it slides open one last time, welcoming me as it has for the last 12 years. I walk through a deserted hall, passing a row of portraits of current and former medical staff leaders. These solemn witnesses, the Hall of Chiefs, are reminiscent of the ghosts of Christmas past – I think to myself, we proudly had four members of our group serve as chief of staff over eight of the last ten years. I’m thankful for the leadership they brought to these halls and the many battles they fought on behalf of working docs.
I push open the department door that has a sign proudly announcing renovations would begin 6 months ago. We’ve been promised renovations for the last 12 years that I’ve been coming here … but I’m glad they’re finally coming. We’ve had largely the same overcrowded, undersized house for over a decade. Most families across America can sympathize. I walk into a well-worn department, a familiar mess. A few years ago, several of our staff came in on a weekend off to re-paint the walls. The paint, now peeling, and the walls, battered and bruised, reflect the weight of a post-pandemic health care system. A jumble of beds, wires, and carts line the hall. Thankfully, I only see two hallway patients at a quick glance. My heart sinks as I pass the beds of patients that lay waiting “for there was no room for them in the inn.” My mind wanders briefly to thoughts of how Mary and Joseph must’ve felt in the days before EMTALA and screening exams. I notice several familiar faces from my last shift 2 days ago. This is the new reality in health care as we are called to continually do more with astonishingly less. We are forever stretching the fraying fibers of the safety net to catch the last few souls before they slip through a labyrinthine system.
The nurse station is a quiet hive – the night shift weary and running on the last fumes of caffeine as they await the final grains of sand in their hourglass. I offer a weak smile and walk into the doc box. As I’ve always done – Cardinal rule #1: “Gotta get the night guy out.” The new night guy looks up at me and stands leaning heavily on a black cane. His first night shift here has already aged him. It doesn’t help that he’s recently had hip and back surgery and things have been touch and go. I think to myself, “this guy has seen some stuff in his life.” He carries a giant suitcase – I don’t ask what he’s carrying as we generally don’t have the luxury to lay down and sleep here. But he’ll discover that soon enough.
An all-too-familiar routine starts. I wipe down the mouse and dictaphone with chlorhexidine wipes. I open the printer and grab a plain sheet of unlined paper on which I’ll record the souls that I touch today. And I’m off … Dental pain in a young man with decaying central incisors and multiple eroded teeth. I can’t provide him with the extractions and dentures he desperately needs, so I offer a dental block and antibiotics as a consolation prize. I weave between acute and chronic back pain patients to find a dialysis patient desperately short of breath. Her lungs are drowning in their fluids. She’ll have to be admitted to dry her out, so I start the lengthy workup and make the ask. Several patients with COVID symptoms begin to check in, and I strap on a mask and a prayer as I run out to triage. I try to see these patients on arrival to keep them from coming into the main ED and creating an exposure risk for our staff. Cardinal rule #2: “Meet patients where they are.” Several car accident patients later, I return to the desk for a brief respite. I rattle out some dictations and tap the clicks defining these encounters. My throat’s already dry, and I’ve really gotta use the bathroom. I’m only two hours in.
As the static-filled EMS radio sparks to life, Mrs. Doris in her maroon scrubs comes in to clean the doc box. I look up at her as she moves gracefully through the room – the most tenured employee in the entire hospital. She has been a treasure for decades with little appreciation for her work ethic and commitment over the last 40 years. I move the chairs and watch as she cleans out our office with an efficiency that comes with experience. She asks if “I’m staying through all this transition nonsense.” I say, “I’m afraid I’m not.” But I thank her profusely for everything she’s done, for asking me how I felt, and more importantly, for her caring. I’ll miss her and her inspiring work ethic. Cardinal rule #3: Respect the team. And everyone is on the team.
The afternoon is filled with patients with intractable vomiting, patients gasping for air arriving by ambulance, and the elderly being shipped from nursing homes for failure to thrive. What does thriving in a local nursing home really look like? I shake my head. The rhythm of the shift prevents you from having to dwell on these existential questions. A case of right lower quadrant pain in a kid that’s less appendicitis and more constipation. A schizophrenic patient trying endlessly to win an argument with the voices in his head and a homeless man feeling despondent and depressed. What homeless person doesn’t feel despondent and depressed? As I’m walking back to chart, a patient arrives by ambulance gushing blood from her nose with blood pressure in the 200s. And of course, she’s on Eliquis. Cardinal rule #4: One hand giveth, and one hand taketh away.
Patients post-op from recent surgeries, patients whose primary care offices are closed on the holiday, patients with nowhere else to go and no other resources – we proudly see them all. Our ministry is for all in need, with no questions asked. It’s always been a great source of comfort and pride for me. We come to work and try our best to suspend judgment and simply listen and treat. Sometimes I have to remind myself of that – that this is a calling and a deep privilege.
The day remains tinged with sadness. A goodbye to some of the best nurses and humans I’ve ever worked with. And to the memories of so many staff over the years. So much has changed, and so little for the better. We were here to witness the promising start of so many careers, new grads from nursing schools, PA students who went on to join us after graduation, and newly minted attendings in their first wild adventure in the community. I say my goodbyes and have a thin slice of pineapple cake that Mrs. Brenda, our unit secretary, baked; I make it a point to go by the break room and have a few crackers and a thin slice of cheese. The staff, many of whom are new and don’t even know me, have really been amazing in showing love. I pray for their success and for those in the community that deserve more than we were able to give. Resources are finite but medicine demands that we give as much of ourselves as we can. And then more.
My partner comes on to relieve me, and I offer a weak salute. Working with some of these guys and gals has been one of the proudest moments of my career. I instantly regret the days that I’ve taken for granted. And I’m thankful for all the times they picked up a patient that returned after I saw them earlier. Our stories are forever interwoven.
I grab my bag, return the phone, and walk out of the ED. The mic drop is anti-climactic. There is an irony in walking brusquely past the darkened doors of the administrator’s office. Working on this Monday, Labor Day. I don’t dwell on this further – reminding myself that it is a privilege to be alive, whole, and have had this opportunity to serve.
Yogin Patel is a physician executive.