The Nine Shifts: Shift 9

Pre-shift 9: I had a dream that I was at a church meeting and out of nowhere I was awarded the Stanley Tool “Against the Grain” Award for Excellence in Respiratory Care. I felt it a bit ironic at first but happily accept the award. I also dreamt about lupus. Checking my email after waking, I find my friend Jenny has sent me an MP3 of “Eye of the Tiger” in commemoration of Shift 9. I am grateful and listen to it repeatedly. I shadow box as well.

Shift 9: At this point, success seems a foregone conclusion. Nothing short of dismemberment will keep me from completing my shift. I wonder if the greatest accomplishment of The Nine Shifts is that I spent 9 shifts or 108 hours in the children’s ER without coming down with any kind of illness. To wade waist high in gastroenteritis and viral upper respiratory infections and kids spewing forth pure contamination from every bodily orifice without getting a fever. Not even a runny nose. I feel my immune system so strong that I could lick the counter tops in the ER and come away healthy. I decide to not put that theory to the test. I am awarded my diligence with one more shift in the 3-6’s, by far my favorite pod. The ER fates, once my enemy, have now accepted me. No longer trying to destroy me, they give me in parting a final peace offering. They give me ear infections. The bread and butter of outpatient pediatrics. I see more ear infections in my last hours than I did in a month of ER. Every one of my final patients has an ear infection. Whether they came in for fever or diarrhea or cough, they are revealed to have ear infections. Even as it is happening I realize the surrealism of it all. I am surprised to learn that our cafeteria periodically has a Cajun food bar. While a strange thought, I learn the jambalaya has an even stranger taste. In my final moments, I rejoice in the moment. My friend Melissa presents me with a certificate for my achievement. We take commemorative photos of the final moment of victory. The moment is one of completeness. I walk out of the ER like every night before for the past 8 but this time to not return, my victory complete.

Post-shift 9: I ride my bike home in the cold for the last time at 1:30 am. I drink an orange soda and eat a candy bar while watching TV, the sugar and high fructose corn syrup not as sweet as the sense of accomplishment. I fall asleep on the couch watching the Cosby Show.

The Nine Shifts: Shift 8

Pre-shift 8: Each morning I lay in bed a little longer, putting off the inevitable as long as I can. I have run out of milk for breakfast cereal. I eat my cereal in yogurt. I have also run out of bread and chips. Considering that all I eat is breakfast cereal and peanut butter sandwiches and chips, I am almost completely out of groceries.

Shift 8: I feel strong. I float for the first half of the shift but preferentially take the high acuity patients. I feel at peace in the ER able to lose myself in the work. My first rotation in the ER as an intern was my first real rotation as a doctor. While hardly a great pediatrician now and in fact bordering on incompetence at almost every turn, I was lost, dazed and confused then. I was in fear of what the next patient would bring, always afraid that the next patient would expose me as a fraud. The year-and-a-half that has passed has been good for my knowledge and confidence. We talk how the rotations and months and even years pass quickly but without the feeling of actually learning or progressing. It is times like these that allow me to look at myself and realize that I have grown. I admit a lot of patients. At one point I count and realize that over half of the patients I’ve seen have been admitted. I don’t know if that is good or bad luck. At least it is a change from the feeling of not seeing anything significant. With the last hour of the shift, the fates start to rail against me trying to finally break me in a way the previous 7 shifts haven’t been able to. I treat a girl with altered mental status lasting weeks who has been admitted multiple times at another hospital with countless tests and no diagnosis and a boy with the worst foot odor I’ve ever encountered in a patient under 10. I wear a mask to help mask (pun intended) the smell and say that it is for infection control. I remember that a large reason that I became a pediatrician is for utter disdain and repulsion by the smelly feet of old people. The boy is sadly years ahead of his time. I eat hummus and grapes for dinner. I find it strange that our hospital has hummus and grapes.

Post-shift 8: I ride home in a light snow fortunate that enough hasn’t accumulated to compromise my bike ride. It feels that my only connection to a world outside of the ER, my couch, and the road in between is when I check my mail. It reminds me there are places out there beyond my small sphere now. All I get is junk mail. I fall asleep on the couch watching The Cosby Show.

The Nine Shifts: Shift 7

Pre-shift 7: The hardest part of the day comes on awaking. It gets better quickly.

Shift 7: I start to shift into survival mode. The physical wear of the shifts isn’t bad but emotional wear of virus after virus starts getting to me. Even though baby after baby is congested but smiling and happy, I feel bad that I don’t have any medicine to offer to cure the common cold. Bulb suctioning and saline drops a poor imitation at a cure. My favorite patient of the day by far is a 16-month girl who is sitting on my lap and drops her pacifier over the railing of the bed. She looks down after it and with the collective frustrations of 16 months lets forth a perfectly pronounced “sh**”. After a moment’s reflection as the pacifier remains yet out of reach, she unloads another five “sh**” in rapid succession. I am extremely happy and fortunate that she cannot see my face, so my huge grin and attempts at holding in laughter go unnoticed by her so I can in no way be accused of encourage her behavior. One of our program’s chief residents Jamie had pizza with a group of residents at π and drops off two pieces as encouragement. Even cold, they are quite possibly the two best slices of pizza I’ve ever had. Despite trying to eat them in secrecy, the smell incites jealously among staff members. Perhaps these shifts have made me selfish because I don’t think at all about sharing. One of my last patients is a teenage boy who overdosed on psychiatric medications. Within 2 hours of this possible suicide attempt with his mouth still blackened by the activated charcoal we made him drink, he is sleeping in bed with his girlfriend lying next to him with a couple of family members sitting in the room. While not usually a policy to let girlfriends lay in bed with patients, in his confused state he was trying to dangerously climb out of bed to sit next to her. This compromise seemed the safest option. It is a lingering image, almost sweet on the surface but ultimately deeply unsettling, love and death and pain and fear all mixed together in violent hues. Now seven shifts complete, my emotions blunted by the hours and work, it is an image now made foreign. I am afraid at times by my lack of emotion.

Post-shift 7: The air is cold but the skies are clear and for the first time during The Nine Shifts I can ride home with my head up and eyes open instead of focused on dodging water puddles. The one mile ride home goes too quickly, I ride a few extra blocks. At 1:30 am Sunday night/Monday morning, there are no cars on the street. I ride down the middle of the road and feel like a kid. I fall asleep on the couch watching The Cosby Show.

The Nine Shifts: Shifts 5 and 6

Pre-shift 5: I go through my morning ritual at 12:30 pm in order to get to the hospital by 1.

Shift 5: I refer to my halfway point as the hump shift until I realize that sounds kind of weird and inappropriate. Rather than be assigned a POD I am left as the float resident. Free to search out patients wherever they may be, I am also always an intruder, a presence that must be always explained and apologized away. Perhaps the monotony starts to wear at me as the shift goes by in a faceless, nameless blur. Fractures and respiratory distress and vomiting and all over again. Breathing treatments and antibiotics and oral rehydration. I pass out popsicles and anti-vomiting medication with equal nonchalance. While I can remember the fried catfish and popcorn shrimp I ate for dinner, I can’t remember my patients. Maybe that is the cost of efficiency, or at least of proficiency. The cost of ability being that only the failures are memorable. For all the children I’ve seen and treated it is the failures that stay with me the most. It is the ones that I couldn’t save that haunt me. Secretly I am grateful that my passion in medicine comes without as much risk of failure than other specialties. Cancer kills and hearts fail but joints only hurt. I am strangely giddy at the end of the 12 hours.

Post-shift 5: My life seems increasingly redundant and I find monotony even in the quest for greatness. I fall asleep on the couch watching the Cosby show.

Pre-shift 6: I wake up earlier than usual because I am out of deodorant. Rather than sleep until the last possible minute to wake up, I wake up 20 minutes earlier. I remember having a dream that I was married with a newborn son and I was scared when I realized that he had an extra pair of eyes on his stomach and knew this was a very very bad sign and cried for him.

Shift 6: The ER is strangely slow. Or it is overrun by doctors. Or both. I am convinced that I could have either gone home or taken a long nap in the middle of my shift and nobody would have noticed or cared and regret not doing this. My replaceability seems contrary to the greatness I am about to achieve by completing The Nine Shifts. I only saw one patient in my pod the entire day. An intern asks me to supervise her doing a lumbar puncture. I find it funny as I view myself as hardly any more competent than her and am a little secretly glad when an attending agrees to help her. The slow pace of the day illicit a jocular nature among all the doctors. We wonder and joke about the causes for which some of our patients come in. The teenager who comes in because he had a muscle cramp the day before. The boy who comes in because of neck pain cause from playing too much video games. Sometimes I feel I have to wade through too much to find the truly sick. I find it strange sometimes that people come to the hospital seeking my comfort and consolation and expertise. I learn that I love gummi butterflies. I show off my awesome knee high argyle socks – patients and ER staff are all impressed.

Post-shift 6: I ride home in the rain as a cold wind blows. I fall asleep on the couch watching the Cosby show.

The Nine Shifts: Shifts 3 and 4

Pre-shift 3: I wake up in good spirits. I realize there are two threats to me successfully completing The Nine Shifts. The first is infection. At any time, I could be stricken down with a gastrointestinal virus, pneumonia or any number of maladies I face daily in the ER. The second is laundry. With about 2 hours of waking hours at my apartment, I don’t have time to do my laundry. I have already run out of white socks which are my clear preference for the ER. My feet might feel the effects. I think I have enough underwear. I hope.

Shift 3: I engage in a turf war with nurse practitioners for my POD until I realize that each room they take over is one less patient for me. I feel I’m in a place without time, a place without beginning or end but not in a bad way. As if I had been born of the ER and this is the only life I have or will known. For better or worse, at home. The shift flows by with near mechanical efficiency, a master of my craft. Until I face an 11-year-old girl with abdominal pain that moves and much more attitude than I think an 11-year-old girl should have. For reasons that escape me, she alone undoes the momentum of hours and days and shifts until I am nothing but a sad patchwork of guesses without conviction, actions without emotion. I feel like an El Camino on blocks. Or at least what I think an El Camino on blocks would feel like if granted somehow the ability to feel. At hour 9, I grab a snack and drink from the cafeteria. I guiltily consume a bratwurst with kraut, potato cakes and an orange soda. I don’t eat my chips or my sandwich.

Post-shift 3: I ride home in the fog. It is very creepy. I am overcome by a feeling of déjà vu. I fall asleep on the couch watching the Cosby show.
Pre-shift 4: I listen to “I Get By With a Little Help From My Friends” repeatedly. I realize that I, too, am getting by with a little help from my friends. My friends, in this case, are various legal drugs.

Shift 4: I manage to get assigned the 3-6 POD again and bask in the independence and isolation. The ER is surprisingly less busy than days before, so while other PODs are getting closed down my rooms enjoy a constant flow of patients. I work happily unaware until my POD is invaded by nurse practitioners. I feel that I have been targeted for some reason. They must know that I am on the edge of greatness and are conspiring against me. I try to hold my ground but am ultimately unsuccessful. In shame, I begin to float and see patients wherever they may be. I am sad and wonder if I am uncovering just a small part of a larger conspiracy. I wonder if the entire staff is out to see me fail, if my success would destroy the mystique of the ER. The ER fellow Eric's jesting barbs seem to hold a deeper purpose. I decide to fight back in the only way I know how – to annoy people with random facts about lupus. I raise the question of the possibility of lupus in all patients, not just my own. I find an unlikely accomplice in the overnight ER resident who joins my cause and raises the classic war cry “It might be lupus”. I feel like William Wallace -- even down to the Argyle socks. I am truly my father’s son. With the slower pace of the shift, I steal away at hour 9 for a bacon cheeseburger and fries. I finish my shift strangely giddy, more aware now of my opponent and the stakes.

Post-shift 4: I walk home alone. The rainy weather has been causing muddy scrubs and I couldn’t afford to run out of clean scrubs. I am overcome again with a strange sense of paranoia. The building seem to a be a poor veneer hiding emptiness and deceit. I feel as an accomplice to it all. I shouldn’t think when I’m tired. I fall asleep on the couch watching the Cosby show.

The Nine Shifts: A Triumph: The Clayton Sontheimer Story

The ER in St. Louis Children's Hopsital is an interesting place. We work twelve hour shifts and usually only work 2 or 3 days in a row. Sometimes we trade days with other residents and work more days in a row to get larger blocks of time off. Usually 5 days in a row is about as much as anyone will do. There are urban myths in the program about people who have worked 7 or 8 days in a row. I recently traded some days with another resident so I could have a couple of days off before going to Dallas for the weekend. I had been working 8 pm to 8 am shifts, so I wanted to try to get my body used to being awake in the day so I wouldn't be useless on my trip. As it turned out, I ended up with 7 straight scheduled days in the ER. These 7 shifts also happened to be the 1 pm to 1 am shift, which is, by public opinion, the worst shift. 12 hours of pure craziness. Never one to settle for average or even impressive, I decided to trade again to total 9 shifts. Based on my research, this will be a record among current residents. This is my story.

The Nine Shifts: A Triumph: The Clayton Sontheimer Story

Author’s note: the experiences and encounters of The Nine Shifts story are all true. Names have been changed when appropriate to protect patient identities.

Glossary:

POD -- a geographic grouping of exam rooms in the ER, residents are assigned a POD and they usually see see all the patients in those rooms. Most of the PODs are grouped closely around the doctor's work station.

EBV -- the virus that causes mono, also known as the kissing disease

H&P -- history and physical

Pre-shift 1: I awake with a strange mix of trepidation, anxiety, and a sense of general awesomeness. I realize that I have all of the tools and talent to overcome any obstacle. Somewhere in the distance, inspirational music plays. I also realize that this will be a bad hair day since the airport stole my hair gel because it might have been a bomb. Sadly, this isn’t the first time that has happened.

Shift 1: I start this experience in self-discovery pod’ing the 30s. Granted, when I came my pod was full so I figured I could relax until people dispo’ed their kids. But no! Jared wants me to see kids out of my pod. My brief foray into the teens is much more medical than I was prepared for – a Kawasaki’s disease and a teenager with fever for 19 days (but not lupus, POOP! ). Finally I get back to my pod, ready to rock. Nothing too out of the ordinary – a couple of psych kids, a non-accidental trauma, a couple of pelvic exams, nothing I can’t handle. The highlight was probably an 11-year-old with ongoing symptoms from EBV about 2 months after infection. At the beginning, I tell him that my goal is to say poop as many times as possible during the H&P. I said I average about 15. We had over twenty in less than five minutes. It progressed to the point where we would greet each other with the word poop. That kid is awesome. At hour 11, I realize that I haven’t eaten so I eat my sandwich. I don’t have time to eat the chips.

Post shift 1: I ride home in the fog. It is very creepy. I fall asleep on the couch watching the Cosby show.

Pre-shift 2: I wake up early as Theresa calls me to ask if I have seen an email she sent me. I then ask who I am talking to. Twice. Then I ask what email. Then I mumble something and go back to bed. On the ride to work, I experience chest tightness. Upon arriving, I realize that I didn’t bring my albuterol. It will be sorely missed.

Shift 2: Like a desperado or ninja, I work alone. Sentenced to toil away in the anonymous depths of the 3-6 pod, I work like a man possessed. Unfortunately, the man possessed has poor balance or sense of self in space. This manifests itself as sometime midshift I run my head into a door frame. No blood. No tears. Only the gritty determination to go on. I deliver a little bit of ER magic. Despite a large volume of patients, I don’t admit a single one. This culminated with me strongly disagreeing with an attending who wanted to admit a kid who was drunk. I totally sent that drunk kid home -- let him be hungover on his own time. As the shift goes on, I realize that my head is pounding worse and worse. I’m not sure if it is a migraine, the start of sinusitis, or symptoms of my concussion. I don’t have time to figure it out. The frustration of knowing that one of my patients from shift 1 came back unsatisfied with my care is cancelled out by the fact that it’s the kid who says poop. I don’t treat him, we only shout poop across hallways at each other. At some point, a radiology technician comes to congratulate me on one of my decisions. I give her a hug. At hour 11, I realize that I haven’t eaten so I eat my sandwich. I don’t have time to eat the chips. At hour 12, I realized that I didn’t use the bathroom the entire shift. I also realize that it isn’t for lack of need but that I blocked out my natural bodily sensations.

Post-shift 2: I ride home in a cold rain. For the first time, I sense my own mortality. I am both frightened and amazed by it. I take a couple of puffs of albuterol. I feel my lungs open in sweet, sweet, ectasy. I cherish the rich night air filling my lungs. I fall asleep on the couch watching the Cosby show.

Will Clay succeed in his quest for awesomeness? Will he be overcome by insanity or illness? Will he ever get to eat his chips? Will he ever be able to fall asleep in his bed again? Stay tuned for more updates on The Nine Shifts: A Triumph: The Clayton Sontheimer Story.

Online tarot reading = eerily accurate

2010, so much like 2009, but colder. At least in St. Louis.

So it's about 6 in the morning and I've been here in the Children's ER for about 10 hours now. Despite an seeing an unsettling amount of head traumas this shift, I've had the chance to reflect on my life. I realize that my life is missing direction. Direction not to be provided by jobs or purpose or anything. Direction that can only be provided by internet tarot readings. Fortunately, in the medical marvel that is the St. Louis Children's Emergency Room we have computers with internet, thus providing quick and easy access to internet tarot readings.

I will share excerpts from my internet tarot reading. I've got to say, though, that before this I wasn't much of a believer in tarot readings, let alone internet tarot readings, let alone free internet tarot readings. For those of you who know me well (shout out to my 3 blogspot follows -- up 50% from last post! Holler!), this internet tarot reading is eerily accurate. I think I got goosebumps and/or chills when I first read the results. It's like someone looked past the disheveled and unkempt exterior and looked to the very core of me. Here it is.

For the internet tarot site to work, you have to ask it a question. So I asked the question on everyone's mind.

OK, so that isn't too helpful, just a bunch of cards. But when you see what the cards mean? Eerie.

The significator is the card you have chosen to embody your presence and the focus of the reading. Dr. John (The Magus) Mastery over word, mind, and matter. The ability to turn ideas into actions, handle problems, and control one's life. The initiation of new projects, great works, or a new way of life. Eloquent and moving communication. Arcane and eldritch technologies.

Not only does it call me doctor, but it uses my middle name. And it totally nails my presence. Mastery over word, mind, and matter? Eloquent and moving communication? Spot on. Apparently, Dr. John (like Dr. Clay) looks like a party animal with his workout ball of fire.

The card at the top left represents how you see yourself. Rada Mambo (Queen of Swords), when reversed. The dark essence of air behaving as water, such as a cold rain. A person gifted with both keen logic and natural intuition, giving them uncanny powers of perception and insight. One who easily sees the weakness in any argument and savages friend and foe alike with biting sarcasm. Dry and vicious wit covering a hollow sense of isolation and dissatisfaction with life.

Yes. Who hasn't felt amazed by my perception and insight? Who hasn't felt savaged by my sarcasm? Who hasn't sensed the depth of my isolation and dissatisfaction with life? Oh wait, that's kind of sad...

The card in the lower right represents what your partner feels about you. Legba (Six of Swords), when reversed. Conceit and intellectual pride. Being stuck in a problem with has no apparent solution. Frustration and anxiety that are left unsettled. Travel and exploration are delayed.

Granted I don't have a girlfriend or a wife, so I will apply this to people I've dated or who have wanted to date me (grand total of both, 4 1/2).

The card in the center represents the present status or challenge of the relationship. Congo Hounsis (Page of Cups), when reversed. The dark essence of water behaving as earth, such as a wellspring. An unexpected new relationship that is childish and foolish. An idle dreamer oblivious to the realities of the world. Moodiness, sad reflection, and retreat from society. Seduction and deception in personal and business relationships.

Wow. It is now clear why my relationships fail: childish and foolish. Moodiness. Sad reflection. And retreat from society. Ironically, this entire post has ended as a sad reflection. And when I get off work, I'm going to go home and go to sleep until my shift tonight (or "retreat from society").

In the end, I think there are valuable life lessons to be learned from this experience. The internet is a wonderful thing. Internet tarot readings can be incredibly accurate. Clay shouldn't be allowed internet access at work.