Night Call

“I was surprised when the emergency doctor at Cityside Hospital said he was going to call you to discuss my case”, Farmer Carr said when I saw him today. “I figured you’d be asleep at that hour.”

I smiled as I recalled the cell phone call that had come in at 9:30 the night I had sent him back to the hospital for a reassessment.

“No, I was sitting in my camping recliner in the tack room in our horse barn, writing on my iPad and listening to the barn animals chewing their hay.”

I saw his eyes soften. He no longer had a hundred head of cattle, but he was still Farmer Carr, and he loved animals.

I had been working on my post “This is America, You Don’t Have to Do Anything”, and I kept thinking about Farmer Carr. He had been hospitalized with pneumonia and when I saw him in followup he was weak, pale, short of breath and tachycardic; his resting pulse was 125 and after I had him walk down the hall, he reached 145. His EKG showed sinus tachycardia. His oxygen saturation was in the low 90’s, which wasn’t bad, but he had a little swelling and tenderness in his left calf, so a blood clot was a possibility. His white blood cell count was elevated, and his chest X-ray had some hilar fullness and some streaking in the mid right lung. I didn’t have access to his hospital X-ray, but even if I did, he looked like there was more going on than a slow-to-resolve pneumonia. He agreed to return to the hospital for reevaluation, and I called ahead and sent my records.

I remember, working on my post, hoping I would get a call from the hospital, and my mind wandered further back in time to call nights over the years when I had wished the opposite – that no one would call me.

When I started working at our clinic thirty years ago, one year out of residency, our town had a volunteer ambulance corps without Advanced EMTs, and it was the on-call doctor’s duty to meet the ambulance at the scene of car accidents, cardiac arrests and other calls that could use skilled care during transport to the hospital. It was also our duty to open the office, with no staff to help, for emergency cases that requested that we do so.

I remembered cleaning a facial road rash on a mean looking leather clad motorcyclist from Massachusetts in the middle of the night. He was twice my size, and he didn’t like the way I caused him pain picking out the pavement residue from his scraggly chin.

I remembered treating allergic reactions and asthma attacks with injectable medications, alone with the patient in the clinic.

I remembered the times I had to do CPR, in a motel room off Route One, in a trailer at the end of a dirt road and in the jalopy town ambulance with howling sirens over icy and snowy roads.

I remembered the sense of dread on call nights when anything could happen. I remembered trying to quiet my crying infant son late at night, with the little black Motorola beeper on my belt, and every cell in my body knowing that at any moment the shrill beeping might tear me away from him and out into the night to face situations I might or might not be able to handle with little equipment and little assistance.

Times have changed. We have a professional ambulance service. The hospital has full time hospitalists and we don’t open the office at night anymore. Some people miss the old days when we were available for emergencies right here in town, but most know that medical technology and the standard of care have advanced over the thirty years that have passed. A normal EKG doesn’t rule out a heart attack anymore, and no one rules out a fracture in a trauma case without X-rays anymore.

We are still available to triage and coordinate care after hours. And with remote access to our EMR I can even send a patient summary to the emergency room from my iPhone. Primary care doctors don’t try to do everything themselves anymore. But we take our job of coordinating care seriously.

Oh, I almost forgot: Farmer Carr’s CT scan didn’t show a pulmonary embolus, just an almost resolved pneumonia; his pulse was normal in the ER and when I saw him back today at the emergency doctor’s request, he did look a lot better.

“Today, you’re able to walk and talk at the same time”, I pointed out as we walked down the hall a ways together.