Midnight medicine: A time when difficult decisions must be made

Some wounds never heal entirely. An abscess lanced long ago might erupt without warning, suppurate and drain; then recede to lie dormant in deeper tissues.


The body might be immunodeficient; perhaps the microbe remains relatively resistant. Or perhaps at core there lies some sort of autoimmune disorder like Wegener's granulomatosis—or something more profound.


Some clinical entities have no cure; and time, purportedly the supreme healer, remains impotent, unforgiving. Only when we leave it behind are we cured for good.


It is midnight. I have made my final rounds, checking 
each of my temporary charges in turn on the 7th floor pediatric ward. Mercifully, no one is spiking fevers; tonight not one child seems distressed. I peek into the last room to witness a night aide rocking a freshly fed infant to sleep.


I traipse to the call room at the end of the corridor, close the solid wooden door behind me, and peer out the window at the lights of the sleepless city. I sit on the cot with my shoes on and glance at the clock on the wall: 8 more hours on watch before the relief of morning rounds.


Tonight I am the only pediatric provider in house, the sole clinician at the beck and call of ward nurses, the emergency department, the delivery room. Tonight you're on the front lines, I remind myself, reciting regimens for emergency drugs under my breath as my eyelids close.


Minutes later the beeper at my waist breaks the silence with its high-pitched pulse. I sit bolt upright, glimpse the narrow luminescent screen, reach for the bedside phone, and punch in the numbers. Momentarily, a voice breaks through on the other end of the line: "We need you in the D.R., a set of twins—"


I slam the receiver down, tear open the door, and dash across the hall to the back stairwell. Two steps at a time, I fly down to the 6th floor, Labor & Delivery.


A nurse clothed in green scrubs points to a door directly across the hall from where she stands. She wears a cap and mask, her gloved hands smeared with blood. "In there," she points, panting with a hoarse voice.


For a moment I'm caught up short, confused. The doorway she indicates leads to the utility room, the place where dirty instruments and soiled linen are tossed after use.


I cross the threshold into the sharp white light. There, on the stainless steel table by the sink, cast in a pile of bloody towels, are two small human forms. One struggles to fill his tiny chest with air; the other lies completely still.


As I reach for the stethoscope draped across my shoulders, my mind jumps to a colleague's description of the birth of what became known as "the bedpan baby." Six months ago a young mother-to-be showed up at the hospital in premature labor. A tocolytic drug was administered to arrest the uterine contractions. Confined to bed, the young woman called for a nurse when she felt the urge to move her bowels. The nurse brought a bedpan; and as the woman bore down, she pushed out a 23-week-old fetus.


Paged stat from the nursery, my colleague transported the baby immediately to the special care unit—still in the bedpan. The staff sprung into action, administering oxygen via bag and mask. Miraculously, the child survived. I recall the panic in my colleague's voice when she related the incident. "The kid's eyelids were fused," she said, indicating the extreme prematurity of the baby.


In a visual blur these thoughts run through my head as I survey the scene before me. Although they are roughly the same gestational age as the bedpan baby, these twins will not require resuscitation. They are products of a second-trimester saline induced abortion, not wanted by anyone. I have been summoned in the middle of the night by a shaken delivery room nurse to merely document their demise.


I insert the stethoscope into my ears and rest the diaphragm against the tiny chest. Despite periodic twitching of the thorax, I hear no breath sounds. These lungs are not sufficiently developed to expand with air.


I listen to the final beats of a tiny heart and note the time on the white-faced wall clock.


Afterwards, I wrap each child in a clean towel, the same way I have learned to swaddle full-term newborns in the nursery. I leave them there together on the stainless steel table by the sink.


The nurse is waiting for me outside in the corridor. "Are they—is he still moving?" she asks.


"No," I say flatly, then walk off down the long corridor, keenly aware of the hollow sound my footsteps make against the tiled linoleum floor.


In her February 5, 2009 New York Times piece "When Doctors and Nurses Can't Do the Right Thing," Dr. Pauline Chen defines moral distress, a nebulous dread that many practicing clinicians harbor for years, perhaps for lifetimes.


Moral distress: when clinicians feel they cannot do the ethically appropriate thing. Midnight medicine: when difficult decisions must be made with no time for consultation and critique. JAAPA