Last call

It is nearly midnight on a Thursday in early June. I am sitting at an empty table in the CCU, having just entered admission orders for a patient who came up from the cardiac catheterization lab. He arrived by ambulance from another hospital 45 minutes away. His wife had called emergency from home when his squeezing chest pain persisted through four television commercials and, short of breath, he broke out in a sweat. At the other hospital, he had heard the emergency department nurse point at the EKG and say, “Look, tombstones.”

Now, after the catheterization procedure that saved his life, he is fast asleep. All the patients here are fast asleep. In all the patient rooms the lights are off. In some rooms, flimsy peach-coloured curtains are drawn across the glass doors that compose the front wall. Nurses calmly chart vital signs and medications. I decide to take a break and record this moment in the black pocket notebook that I have carried with me since last July.

Last July. My first month as an intern, one of four working here in the CCU. At the beginning of this notebook is an entry about my first night on call.

I received a page early that evening. It was Jim, a savvy nurse who has been working in the coronary care unit for five years. That night he was taking care of beds 26 and 27. He asked if I was the intern covering everyone.

“I need you to come here right now,” he said. “Room 26.”

I hurried from my call room to the CCU. The patient lay supine, sweating gently, breathing shallowly, his hands folded across his chest. Jim held up two EKGs. “This one's from this morning,” he said, “and this one's right now.”

For a few seconds I stared at the thin black scrawl on the graph paper. Then I watched the monitor. I looked at the latest EKG again. I could feel the patient watching me closely.

“Mr. Anderson here has chest pain,” said Jim. “Seven out of ten.”

“Eight out of ten,” said Mr. Anderson.

“Chest pain.” I repeated nervously. “You say you've got chest pain?”

“Eight out of ten,” said Jim. “Just started. Isn't that right, Mr. Anderson?”

I froze at the doorway. Chest pain, I panicked. What should I do now? Slowly, I examined Mr. Anderson. At first I felt a racing pulse, and then realized it was my own. I stared at the monitor: blood pressure, heart rate, rhythm, oxygen saturation — all normal. I stared at Jim standing next to the bed; he seemed particularly nonchalant. I looked at Mr. Anderson, who was staring back at me. He was still sweating, and now I was too.

I don't have a clue what I'm doing here, I thought. I can't think straight. Medical school graduation was just two weeks ago. I could do this if you gave me five choices and asked me to pick one answer. You wouldn't ask a medical student to save you, would you? No, I thought, you wouldn't. Well, I'm not much better than that.

“It really hurts,” said Mr. Anderson.

Chest pain, I thought. What do you do for chest pain? Seconds dragged like minutes. I watched the monitor and wracked my brain, regretting all career choices made since the age of eleven.

“Hey, Doc,” Jim said, at last, “you want me to give him something?”

I could feel my eyes bulging. “Give him something?”

“Maybe a couple of nitros, Doc?”

That's it! Nitroglycerin! This word conjured up a flurry of memories: my last year as a medical student, when I was an acting intern writing orders for newly admitted patients with coronary artery disease. Then I suddenly remembered rounds the year before, when someone told me that “when MONA goes to the ER with cardiac chest pain, she gets Morphine, Oxygen, Nitros and Aspirin.” Finally, I thought of a pharmacology lecture in my second year; I could visualize the sketch that depicted vasodilation and decreased cardiac preload. This is it, I thought, this is the answer; I can do this doctoring after all.

“That's right,” I nodded. “Nitroglycerin. Let's give sublingual nitroglycerin.” The heaviness of new responsibility began to lift. I could not help feeling satisfied that the moment was over.

“Good,” Jim answered. “I already gave three. What do you want me to do now?”

My jaw dropped, my eyes wide with renewed terror, my brain frozen, my heart accelerating again.

“You want to page your resident?” he asked.

“Good idea … Jim,” I stammered, “… I'll be right back.”

Eleven months later, I get a strange feeling sitting here in the CCU, as if I am not so afraid. Now I know where to find the blood gas syringes and the pacemaker pads. I am ready to put a central line into the patient in room 24 if her blood pressure drops too low. I know a little about clinical trials with hopeful acronyms like SAVE and CONSENSUS. I remember where to get cans of ginger ale, if a patient is thirsty for one.

I am not sure where my resident is right this moment, but that doesn't bother me. This is my last call night for the intern year and I am excited to see what the rest of the evening will bring.

I can see Jim wandering over from a room at the end of the unit.

“Hey, Doc,” he says.

“Hey, Jim.”

“Need you down in room 31. Chest pain. Ten out of ten.”

“Got it.”

“Start with the nitros, right?”

“Please.”

“Already gave him three,” he says. “Now what do you want me to do?”

Time to close the notebook.

“All right, Jim. I'm on my way there.”

Hunter Groninger Department of Internal Medicine University of Virginia Health Sciences Center Charlottesville, Va.