Happy Birthday?… Happy Birthday!
The night float rotation and its unpredictability quickly lectured me on the value of knowing the patients beyond what was written on the sign-out list, and every day after the teams’ sign out, I would start my “preventative rounding” on the sickest patients of the wards to get a sense of their baseline status.
Abstract
My turn as the night float intern came early in the academic year. From 7 PM to 7 AM, I had to take care of the usually around 40 patients treated by the medicine teaching teams. The 2-week rotation had been described as one to “learn how to put out small fires,” such as managing hyperglycemia or hypertension, renewing this or that order, and reassuring patients. The rotation was also described as an opportunity to hone clinical skills in situations requiring quick and appropriate decisions. Consequently, due to the high patient volume and turnover, and the expectation of unplanned events occurring during the daunting cross-coverage period (eg, cardiac arrests, status epilepticus, and massive gastrointestinal bleeds), I had assumed that I would not be able to establish meaningful relationships with patients. Fortunately, my assumption was quickly disproved. Mrs B, a lovely 79-year-old woman, had been hospitalized for pneumonia but eventually developed respiratory failure and required endotracheal intubation. After improving, she was transferred from the intensive care unit (ICU) to a step-down unit, where we met during my second day as the night float intern. In her sign out, the managing team included “Extubated yesterday. Had shortness of breath during the day. Please check at least twice overnight.” She was, indeed, dyspneic when I first saw her, but a few interventions improved her shortness of breath, and she was able to sleep that night. The night float rotation and its unpredictability quickly lectured me on the value of knowing the patients beyond what was written on the sign-out list. Thus, every day after the teams’ sign out, I would start my “preventative rounding” on the sickest patients of the wards to get a sense of their baseline status. Mrs B was always one of those patients. She looked frail, was debilitated, and was agitated most of the time, struggling with her supplemental oxygen device. The discomfort made her take the device off, but the immediate shortness of breath forced her to put it back on. One night after listening to my “your-lungs-are-notstrong-enough-to-breath-by-themselves” lecture for the third time, she said “I’m... done... with this, I... I can’t no more,” with her voice still hoarse from the previous intubation. She tried to explain herself further, but those words never came—although words were not necessary as her gesticulations were easy to understand: Despair. That disheartened me. I asked if there was any way to help, but she did not answer. Wishing to make her feel more comfortable, I tried my luck by offering something to moisten her mouth. She did not want water, but ice chips were “ok,” and applesauce, “applesauce would... be great.” I handed her one cup with ice and another with applesauce; the dexterity of her weak and trembling hands was enough to move ice chips from the cup into her mouth, but not enough to use a spoon. I held the spoon with applesauce for her and observed while she ate slowly, savoring each of the few spoonfuls she could handle. Our nightly routine was established. I would greet Mrs B and ask about her needs as early as allowed by the shift. Some nights she would not ask for ice, but applesauce was a must. I think applesauce and my companionship helped her to keep sorrow and hopelessness away. However, those nights were also eventful for her: urinary retention, multiple episodes of nonsustained ventricular tachycardia, and a gradually declining respiratory status. One night, 3 hours into the 12-hour call, the nursing staff notified me that Mrs B was working harder to breathe and that her oxygen saturation was dropping despite the use of noninvasive ventilation. She was developing respiratory failure again. I explained to her that her lungs were failing and despite her previously apparent hopelessness, she asked to be intubated again. “Intubation... I better call the ICU.” She was intubated at 11:30 PM that night and was transferred back to the ICU. Ten minutes past midnight, I opened her chart to write about the events. I started with “Mrs B is a 79-year-old...” but stopped after I looked at her age. She had turned 80 years old with the start of the new day, and her birthday gift had been an endotracheal intubation with an uncertain outcome. Days passed by, but Mrs B remained intubated even after my night float rotation ended. Days later, while looking at her chart, I noticed she had been extubated, so I visited her in the ICU. “I’m glad to see you’re awake and doing better.” I said, “How are you feeling?” She nodded affirmatively. “Is there anything I can do for you?” “Applesauce... applesauce,” she answered with her whisper-like voice, a consequence of her second intubation. “Before giving you applesauce, I want to make sure that it’s safe for you to eat.” She nodded again. I said goodbye and headed toward the ICU staff, feeling happy that she was improving and feeling better. Then it hit me. “How could I forget?” I asked myself aloud. I made a U-turn and walked back into her room.