Night watchman in the emergency room

It’s my first night on call alone in the emergency room of the country’s largest eye hospital. There is no one to help out. No in-house supervisors, no senior residents and no “yonkies†– Dutch for “young ones,†in this case other first-year residents – with whom to discuss difficult cases. Behind me in the night ER sits a veteran secretary who registers patients and helps with triage. Upstairs on the ward are a few nurses who are ready to rinse the eyes of caustic trauma patients but are otherwise busy taking care of inpatients. The senior staff members are a phone call away, but at this point I still consider calling as a last-resort option.

It’s barely 5pm, I’ve just started and the waiting room is already half full. I’m a little nervous and I haven’t yet slipped into the comfortable, repetitive rhythm that I’m able to develop during normal clinic hours: “Hi, hello, I’m Dr Spielberg – please come in – take a seat – how can I help you? Red eyes – pain – decreased vision – since when? Flashes & floaters? Right. Can you read those letters on the wall? Good, now let’s take a look at your eyes. Here’s an anaesthetic drop – it might sting a bit – look at the blue light – you won’t feel a thing. OK, pressure’s good. Here comes a dilating drop – you might see a bit blurry – yep, lasts a few hours – see you in 20 minutes. Next!â€

Nope, right now I can’t even seem to figure out how to use the equipment, which is for whatever reason not the same as the units we use in the daytime clinic. The buttons are all in different places and the patient’s chair goes up instead of down, the lights dim inappropriately and the table jerkily locks at a weird angle. The patient looks at me and probably wonders whether I’m just a random guy who wandered in off the street, pulled on a white coat and started playing jokes on patients. Hidden camera, maybe?

But forget about the equipment. That’ll work itself out just fine. What I’m really trying to get used to is the unprecedented feeling of responsibility that I’m now experiencing. Tonight is the first time in my medical career that my own decisions will have actual consequences. The patients in the waiting room have likely heard that our eye hospital is highly specialised in eye disease. Their family members come here for check-ups and their friends have been operated here. They have read about the hospital in the local paper or have seen the recent Rotterdam Eye Hospital documentary in the movie theatre. The name says it all.

What they don’t know is that the primary decision-maker for the next 16 hours is a first-year resident. Sure, he has studied a big book on the topic, passed a few tests and has managed what must be several thousand patients by now, under the close supervision of the attendings. But to sit there before a patient and say, “Sir, something has blocked the main artery leading into your right eye. The visual prognosis is not good,†is not easy. People are coming to me for their eye problems, but who am I to say this to someone? Am I really qualified for this?

Big Challenge

Making the diagnosis of a central retinal artery occlusion in a patient with sudden, painless loss of vision, a pale fundus, a cherry-red fovea and significant cardiovascular risk factors is not a big challenge. Telling someone you’ve just met that they will likely no longer have functional use of one eye, that is another thing entirely. Most people would be startled by these words alone, not to mention the further discussion regarding the necessity of further cardiovascular screening, the sweeping lifestyle changes and the possibility of daily anticoagulant therapy to avoid even more devastating occlusive events. Wow! And all this news coming from someone who has seen maybe three CRAOs in real life before.

It is often said that the transformation from “student†to “doctor†via “resident†is a mostly gradual evolution. If that’s true, then this must be the big moment when the asteroid hits the Earth and changes everything.

The conversation goes well enough and the patient seems to understand what has happened. He also seems to understand the limited treatment options: yes, I’m sure it’s not cataract; no, sorry, but laser surgery is not useful for arterial occlusions; no, there are no eye drops for this condition; no, glasses won’t help – as well as the follow-up protocol he has been advised to follow. We will see the patient a few more times and during that time he will gradually get used to the dramatic loss of visual acuity. I hope that I have done everything possible to get him psychologically ready for this process.

The onset of blindness, even if only unilaterally, is a difficult thing to accept, and I keep in mind what the poet John Milton said: “To be blind is not miserable; not to be able to bear blindness, that is miserable.†Fortunately, this patient is not bilaterally blind, and I would like to keep it that way while allowing him to be able to bear the unilateral near-blindness he has developed.

The next several patients present with simple pathologies before someone with what looks like post-op endophthalmitis sits down in my examining chair.

After just one night on call, I feel as though I’ve somehow been initiated into a new order. I have developed a totally different perspective on my role as a physician. No longer am I just an evaluator, an observer, a preliminary examiner waiting for the supervisor to help make a final decision. I am now the one who is making the decisions and actively managing patients – at least within the bounds of my abilities.

Leigh Spielberg is an ophthalmology resident at the Rotterdam Eye Hospital in the Netherlands.