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ON THE NIGHT SHIFT, LIFE, DEATH AND DISTURBING DREAMS

At 9:30 p.m. I'm walking out of a meeting at a hotel's conference center. A group of us, pretty well dressed overall, are walking out to our cars. We pass the bar.

"Hey," a couple of women yell at us. "Where's the party?"

No one's answering them, and I feel like breaking the uncomfortable silence, so I say, "Hey, I've got to go back to work."

"Yeah, right." one of them says, offended.

"No, I'm serious. At ECMC."

"Right."

I get in my car and drive to the hospital. I page the guy who is covering for me and meet him in the unit to take the sign-out. It's just me and an intern taking care of 45 acute medicine patients overnight.

I look in one of the rooms, and there's an anesthesiologist I know looking at a patient, and I ask him what's going on. It turns out they're going to do an operation I haven't seen before, so I ask if I can watch, and he says OK. It's 10 p.m.

Fifteen minutes later, I'm down in the OR, feeling out of place as usual, in paper scrubs because my ID card won't work on the machine that dispenses the real ones. The attending surgeon says I can scrub in.

What the heck, I figure. Everything's under control on the floor, and I can leave at a moment's notice if I have to.

I don't get a chance to see real live lungs and hearts very often, and the surgery is unusual, too. Things are going well until I start to get hot. The air conditioning in the room isn't working. I start to soak under the operative gown. It's probably only about 75 degrees, but under the Goretex and latex it's hard to take. The singed-hair smell of the cautery and the bright lights start to get to me.

The inside of the patient's abdomen, a big swath of red and tan and moisture, is laid bare, surrounded by blue drapes, all lit by from above by high-intensity lights. I can see the lungs inflating with each breath the machine gives, and the pericardium is hiding the heart beating, which sends pulses of blood that I watch through the arteries that fill the intestines. There is stool in the colon, doughy, heavy stuff underneath the thin layer of flesh.

I start to realize why I didn't go into surgery. These guys are so intensely working, and it's midnight and they sometimes go all night and all the next day. Furious concentration.

The senior surgical residents are harassing the junior guy, I guess an intern: "What the hell are you doing that for?" "Hello? I'm waiting." You can really see the difference in dexterity and skill between the fifth year and the first year resident. The senior guy knows the next move in the operation and starts right in before the attending tells him what to do. The junior guy hovers around the outside, tying things off, suctioning out blood, doing a little blunt dissection here and there.

Through some weird hierarchy rules established by the attending, I'm not the junior person, and I don't get any flack.

I have to leave after a while; up on the floor I have to take care of a few things, and about 1 a.m. I get to bed. An hour later I hear the operator announcing "number five," and I jump out of bed and run down to the coronary care unit, where the nurses are already doing compressions on a guy and are getting out the cardiac paddles: he's in ventricular fibrillation.

I'm the senior guy on the scene, so I start running the code. It's become natural at this point, not so frightening. After about six hair-singeing shocks, we get the guy remotely stable, but given his history, we know it's not for long.

I spend the next three hours assessing and reassessing him, and talking to his family, and they decide it's time to let him go. He's been through too much.

We extubate him, and with their permission, I give him some morphine. I walk out of the unit, and since it's about 5 a.m., I go down to take care of a consult I have to clear for surgery, a woman who had a hip fracture yesterday.

Within minutes, the nurses call me to tell me the guy in the unit is gone.

I go back up to pronounce him dead. The monitors are flat. His eyes don't react to light. His heart is making no sound. There are no breath sounds. He doesn't respond to what would bea painful maneuver. I turn to his family and try to give them a comforting look, and after a few minutes leave them to their grief.

There's the death certificate, and some other paperwork. I have to call the medical examiner's office to see if they want to do an autopsy, and they don't, as the death was not unexpected.

At 9 a.m., after going over three admissions with the intern, I'm in rounds with my team and our attending.

When you're just standing still for an hour after a night like that, it can be hard to keep your eyes open, and I shut mine briefly despite my best efforts. Instantly the image of a heart monitor appears before me, and the hallway is distant. The heartbeats are slowing down, dangerously slow now. In the background my attending is teaching the medical students about interpreting a blood test -- the bilirubin level -- and I think, "Can't he see this man is dying?" and I wake back up.

Before I go home, an intern and I have to put a central line into a guy who needs parenteral nutrition. His digestive tract isn't working too well, and in order to feed him predigested food through the veins, a catheter into the central chest veins is needed.

The intern is quite good, and I admire the way she is teaching the medical student as she works.

The patient, who has been sedated, opens his eyes and looks up at me from under the sterile drape and says, "This is like TV."

"No," I want to say, "TV is like this."

MIKE MERRILL, M.D., is a resident in internal medicine and preventive medicine at Buffalo-area hospitals. He also works in medical informatics for Univera Healthcare, a health insurance provider. His first-person accounts of the medical profession appear regularly in Viewpoints.

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