I’m Already Exhausted...

Cut to the Chase: General Surgery Survival Series — Post 30

An intern stopped me in a stairwell in November and asked how long a person stays this tired.

She wasn’t complaining. Four months in, good at the work, and she wanted to know whether this was the floor now or whether the exhaustion lifts on its own at some point.

It changes shape. It doesn’t lift on a schedule you can plan around, and that’s the least useful thing I know about it, because there’s nothing you can do with it tonight.

Here’s the part you can do something with. Being tired doesn’t take what you know. It takes the walk back down the hall to somebody you already decided about.

You’ll still recognize a rigid belly at four in the morning in your fourth month. What goes is the second look at the patient you signed off on at nine at night.

The nurse says the belly is soft, the chart says the rate is 96, somebody laid eyes on her an hour ago. All of it is probably true. So you write the order from the workroom instead of walking down there.

Nothing about that looks wrong from outside. It looks like a resident who’s finally gotten fast.

And you won’t feel the tiredness take it. The first bad night announces itself, and after that the feeling stops moving while the work keeps sliding underneath it.

By the fourth night of a stretch you aren’t judging how tired you are. You’re repeating what you decided about it on the first night.

Stop asking yourself whether you’re too tired for this. You’ll answer no every time, and you’ll go on answering no right up to the night you were wrong about it.

So the check on you has to be something you wrote down earlier, while you could still see straight, instead of a question you ask yourself in the middle of the night.

Ask it at six in the evening, when it’s still easy. Which of these patients could look different in the room than they look in the chart tonight.

Decide before the night starts which two you’re going to lay eyes on yourself, and write them on the corner of the list. At three in the morning you’ll do what’s written down and very little else.

Write down every number somebody gives you over the phone, as it arrives. The version of you at ten at night holds six things in his head. The version at three holds two and will swear it’s still six.

The worst part of your night is the ten or fifteen minutes right after somebody wakes you out of deep sleep, and that’s exactly when a nurse is on the phone with a blood pressure, waiting on an order.

You’ll sound awake. You’ll use the right words in the right order.

Say the numbers back out loud before you give an order in the first ten minutes after somebody wakes you. From the inside, that window feels like every other one you’ve worked.

Standing up helps. Turning the light on helps. Reading the numbers back to her helps more than either, because it makes you handle something you’d otherwise only have heard.

When your shift ends and you hand the pager over, the list you’re handing over has two kinds of patients on it. The ones you saw yourself, and the ones somebody described to you.

“These two I’ve laid eyes on since midnight. This one I haven’t seen since noon, and the outputs are secondhand.”

Say which ones you saw and which ones you were told about, including the part that’s embarrassing. Everybody taking a list assumes all of it was seen.

Chief year, third night of a stretch where I was sleeping in the call room and driving home to change.

Around two the intern called me about a woman on day three from a Hartmann’s. She’d put out 20 cc an hour for four hours, he said her belly was soft, and the nurse had been in with her twice. I told him to give her a liter and call me if the output didn’t pick up. Her room was across from the workroom I was sitting in.

He called again at five. She went back to the operating room at seven. He never brought any of it up with me, and he was the one who’d done his job at two.

By four in the morning the question worth carrying is a small one. Did I look at this patient, or was I told about her.

The last decision of the shift is the drive home, and it’s the only one all day that nobody supervises. Work out how you’re getting back before the shift starts, while you’re still somebody who can judge it. Post-call, whoever asks if you’re okay to drive has nothing to go on but your face, and you’ll say yes, and you’ll mean it.

Give them the hour instead of the adjective. Three hours of sleep since yesterday is something they can plan around. Tired is a mood, so it gets handled like one.

One thing sits outside all of this. Ordinary tiredness moves when you finally get a day off. If a day off doesn’t touch it, or you notice you’re flat about a patient you’d have cared about in August, that’s something else and nothing above fixes it. Say it to your program director or your own physician. I’ve been on both ends of that conversation.

Twenty years in, I still open the labs myself after an intern tells me they’re fine. On a long day I write the two things I’m worried about on the corner of the list at six in the morning, because by ten at night I’m not confident I’d come up with the same two.

Some night in the next month you’ll be exactly this tired and nothing will happen. You’ll walk down and look at the patient on the corner of the list, the belly will be soft, the number will be the same number, and you’ll write nothing and walk back.

You’ll be this tired again on Thursday. The list will have two names on the corner of it.

What to Read Next: Post 31, “The First Patient Who Was Yours When They Died.” Everything above assumes the week stays ordinary. One of them won’t, and the hours after are worth knowing something about before you’re standing in them.