Phonecalls at 1am

18 December 2009 Comments

Being a doctor entails now and then (and sometimes more often than that) dealing with strange situations at unusual hours. I have worked in emergency medicine on and off for nearly 10 years and some of the most interesting cases I have been involved with have needed help at some of the most cruel and dark times of the night.

Throughout my time here in Pakistan, the emergency room is regularly busy into the wee hours and I am frequently on the phone at those times helping the on-site staff make decisions about patient care. As a result of our recent withdrawal from the field due to security concerns, I am not able to be on site in the hospital at all at the moment, and I am now spending more time on the phone that ever.

I am not a 1am person. Sleep in all its essential deliciousness is very important to me and my brain shuts down somewhere round ten thirty in the evening. But here I have had to adapt to a different routine: the phone rings sometime after I have fallen asleep. Initially, the noise is incorporated as an aspect of my dream, but eventually I wake up. With scratchy eyes and croaky voice I answer. Frequently the line drops or the connection is too bad to make out the story on the other end (frustration!) and a little cycle of call-backs from both sides begins until finally we can hear one another clearly. It will be one of the MSF ER nurses. Perhaps there is a patient with a bad head injury after a road accident or assault. Maybe it is a known cardiac patient with severe chest pain and low blood pressure or a tiny newborn who is struggling to breath. What to do?

We go through the standard checklist of presenting problems, examination findings and vital signs. Are there any blood results available? What is the chronic medication? What treatment has been given so far? My team is well practiced and they know what I need to hear to grasp what is happening. We discuss the case until a plan can be made. Perhaps a dose of an emergency drug is needed, sometimes additional tests must be requested first. On difficult days it is a discussion about whether to terminate resuscitation for a patient that has collapsed and shows no signs of life despite a long and concerted effort at revival. We have faced all these scenarios together many times and I have come to rely on the sound judgement and dedicated efforts that my team makes for all our patients. Sometimes there will just be one phone call in a night and on rare occasions none at all – how I cherish those uninterrupted hours of sleep! But usually it is necessary to discuss a case several times before a final decision is made. These are often rushed conversations in urgent tones, there is no time to waste and the tired brains on both ends of the phone are urged into a higher gear. We do what we can, watch closely always ready to respond and hope for the best outcome. Sometimes all goes well, sometimes not and we know that tomorrow night we can expect more of the same.

I don’t think I will ever get quite used to the penetrating sound of the late night phone. It will probably remain an alien and unnatural thing. But, certainly here and now, it is a reality I must continue to face.

As a result of the excellent standard of care MSF staff continue to provide in our emergency room despite limited resources, more and more patients are presenting with emergency problems at all hours. Whilst before they would have bypassed our little hospital in (sometimes blind) hopes of better treatment in a bigger city, now they know to stop and let us help them. And so, to be woken a few times at night is really just part of the job, as it is for doctors all around the world. Though the rings under my eyes are darker than they were a few months ago, I am happy to be able to support a service that is there for people who really need it. So I better get off to bed and get a few hours in while I can!

Sleep well all of you who are able and, for those of you who, like me, are sometimes called on to guard the night, know that you are not alone and your efforts are not forgotten or in vain.