The Hardest Night

There are a lot of hard nights in internship. I can probably recall a night on each call month that was particularly difficult, whether tough emotionally or technically or due to patient volume or fatigue. Recently, I had a hard night in the emergency department due to patient acuity and emotional stress. One of the early patients I picked up came in with respiratory distress, breathing at 30 times a minute. As I sorted out his history, I realized he was sick; he recently had chemotherapy for a liver tumor, and he looked awfully uncomfortable. A stat lactate came back at 18. Lactate is a marker of anaerobic metabolism, an indirect measure that the body's tissues aren't receiving enough oxygen. We usually call ICU if a lactate comes back >2, and I'd never seen anything as high as 18. Then his chemistries came back showing acute renal failure with a creatinine of 5 and fulminant hepatic failure with an AST of 6000 and an ALT of 3000. We quickly got him on BiPAP and called ICU. It was hard for me, however, because this patient took my entire attention; I sat in his room writing notes, following up films, trending labs, and reassessing the situation. But I also had 4 other patients who I could not keep up with during that time. My mindset is that of an anesthesiologist: one patient at a time. So my night started off rocky with a patient close to death, difficult to resuscitate, and teetering on intubation.

The patient acuity did not lighten. I picked up a patient put in one of the less acute rooms along the back hall for a seizure, no deficits noted at triage. But when I talked to him, I learned he had two prior strokes from cerebral aneurysms. He had 6 known aneurysms ready to bleed, two of which had been clipped by interventional radiology in the past. He was also hypertensive to 200/100 and had the worst headache of his life. I had to quickly move him to room 1, the highest acuity, and start him on an esmolol drip and get stat neuroimaging. I could feel my catecholamines surging.

The final difficulty of the evening was a woman at 12 weeks of pregnancy with vaginal bleeding. Our pelvic exam showed products of conception, a failed pregnancy. How do you break the news in the emergency department? I met the patient for the first time that day, I did not know a single thing about her hopes for this pregnancy, whether she was decorating a room, whether she'd dug out the old baby toys. I had no idea whether she'd torture herself with guilt, deny what happened, or hide the fact from her friends and family. I didn't even know whether her husband would be supportive or abusive. There are so many roads this could go down. I'd delivered bad news before, but never like this. And here, in the emergency department, rocking in cacophony, chaotic beyond tolerance, loud and dirty and noisy and unsubtle, I had to tell this woman. Even more than that, she did not speak English, and I had to deliver the news with an interpreter. And though I tried, tried so hard, at the end of this night, it was the hardest thing to do.