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DiscussionReflection

Last Call: Reflections on the Neglected Hours of the Day

Jonathan L. Temte
The Annals of Family Medicine September 2023, 21 (5) 463-464; DOI: https://doi.org/10.1370/afm.3020
Jonathan L. Temte
University of Wisconsin Department of Family Medicine and Community Health, Madison, Wisconsin
MD, PhD
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  • For correspondence: jon.temte@fammed.wisc.edu
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Abstract

An academic family physician reflects on 30 years of night call on the very last night of call. The experiences of the drive to the hospital, interactions with resident physicians, and caring for patients through the “neglected hours of the day” blend together in the narratives of patients. Night call is an essential and disappearing part of being a family physician, tied to the intimacies of the faces, grit, words, and stories.

Key words:
  • family medicine
  • night call
  • narrative

Saturday, November 30, 2019; my last official call night as I transition from residency faculty to associate dean. This is the terminus of roughly 1,000 such nights over nearly 30 years. My record is clean: no deer, no raccoons, no possums—despite the 10-mile drive mostly through countryside. No accidents; only 1 spinout under a bridge with unexpected ice. Fortunately, that was well past midnight with no one on the road to watch the folly of killing the engine when hitting dry pavement going backward. An occasional stay in a cramped call room. Hospital food. Bad coffee. Wee-hour stops at Taco Bell for a bean burrito as it was on the route home, and they were open late.

The trajectories of the characters tonight are typical… cellulitis of a leg; chest pain; weakness due to Parkinsonism coupled with laying on the floor for 20 hours (mild rhabdomyolysis); 2 falls, one with severe hypoxia due to morbid obesity and the other with a wrist fracture; community-acquired pneumonia; rectal bleed. These problems, however, are all people, admitted in the late evening and early morning hours, sometimes confused, sometime scared, entering the dark and quiet wards cloaked in vulnerabilities. In over an estimated 5,000-6,000 hospital admissions, I have seen a lot, supervised and cajoled residents, been grumpy at times, and tried to convey the essential elements are knowing where someone was born, what they have done over their years, and sometimes knowing how big the dairy herd is. What is essential is often invisible to the electronic health record (EHR). The narratives, however, are the glue that binds us together. Here are some of their stories, extending an invitation to contemplation, compassion, whimsey, connection, and wonder:

BALL TURRET GUNNER

Peter, 92 years old, arrives with multiple fractures after a fall. Our brief conversation in his darkened room at midnight reveals that he served as a WWII airman—a ball turret gunner in a B-17—owing to his 5′5″ stature. He went on to marry his high school sweetheart, run a hardware store, and have 8 children. All this information is missing in the resident’s EHR template-driven history and physical. The next day I send Randall Jarrell’s poem, “The Death of the Ball Turret Gunner” (https://www.poetryfoundation.org/poems/57860/the-death-of-the-ball-turret-gunner),1 to the resident team as I contemplate the industrialization of medicine.

VODKA

With my second drive in of the night, and knowing that sleep will be short and the upcoming day long, I tuck my burning resentment away and proceed to the emergency department bay where a young woman lays on the gurney. She has increased her daily intake of vodka to nearly a half-gallon, and has chosen—only God knows why—this day to detox. Then I see her father in the corner and note that she is about the same age as my oldest daughter. We all enable to some degree… we all make mistakes, but we can be present. In this moment, I see the fragility and the strength of the human spirit, and, too, am present for my patient; anger for my lost sleep replaced with humility and compassion for lost children and families.

BABE RUTH

I greet the elderly man, introduce myself, and extend my hand. Feeling the very strong grip and, considering his rural address, ask whether he grew up milking cows by hand. A grin, followed by, “Nope, playin’ ball.” He made it to the majors (White Sox) for a year and even played against the Bambino (Babe Ruth); then left of his own accord. “The pay was better in the minors,” he said, “and you had to travel less…” and he had a new wife and daughter to care for. A gem in the neglected hours of the day.

TATTOO

As the days shorten, we are blessed with more chronic obstructive pulmonary disease exacerbations. Joe is typical. Late 80s, oxygen via nasal cannula, and working a bit to breathe. A retired farmer, full of hard work, laid low by chronic lung disease and a virus. It is then that I see a fading United States Navy tattoo on his forearm. I inquire, mention that my dad, too, was Navy. He looks up, suddenly with tears in his eyes; “So many of them killed.” He was on a battleship in the Pacific theater and came under kamikaze attack. He survived, but spent his life pursued by ghosts. A chance notice of a tracing in those quiet hours opens the door to more intimate understanding.

AN ANGEL IN GREEN CAMOUFLAGE

Lake Monona is famed for its perch; an attractant for those who don warm clothing and boots and arm themselves with ice augers. My patient was alone when she broke through the ice, shocked by the cold and unable to cross to safety. After warming in the emergency room, I meet her in her room—coincidentally overlooking the lake—after admission for observation. She is now at a toasty 97°F. She tells of the “angel in green camouflage” who waited with her—chatting and praying—until the rescue squad made it out. As I depart, I meet a young man waiting in the dim hallway who asks if he can see her. He is short, a bit pudgy, ruddy of face, and balding, and dressed neck to foot in green camouflage.

As I drive home for the second time on this dark and rainy and cold night, the words of William Carlos Williams lightly descend into my awareness:

“These are the great neglected hours of the day, the only time when the world is relatively perfect and at peace. But terror guards them. Once I am up, however, and out it’s rather a delight…”2

I am far from that first intern call night at University of Wisconsin Hospital: in over my head, sleepless, and terrified. I drive slower than usual—something interesting on Wisconsin Public Radio—knowing that I have been subtly blessed by the intimacies of faces, and grit, and words, and stories. As I turn into my driveway this last time, I think it’s been a relatively perfect and peaceful night; rather a delight.

More than 3 years have passed since I wrote these words. When recently asked if I miss call, I could genuinely say, “Yes, I do.” I miss the banter with our residents in the relative quiet of the team room, the stories of our patients, the vulnerabilities that the dark hours reveal, and the many reminders of both the frailty and resilience of the human condition. I also worry that as medical practices change and as we abandon overnight call and cede it to hospitalists and other functionaries, we become increasingly divorced from this intimate contact during those great neglected hours of the day: late at night, guarded by terror, exposed, yet blessed by humility and the richness of narrative.

Footnotes

  • Conflicts of interest: author reports none.

  • Read or post commentaries in response to this article.

  • Received for publication December 1, 2022.
  • Revision received March 22, 2023.
  • Accepted for publication April 12, 2023.
  • © 2023 Annals of Family Medicine, Inc.

Reference

  1. 1.↵
    1. Jarrell R.
    The death of the ball turret gunner. In: The Complete Poems. Farrar, Straus and Giroux; 1981: 144.
  2. 2.↵
    1. Williams WC.
    Comedy entombed: 1930. In: The Doctor Stories. New Directions Books; 1984: 108.
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The Annals of Family Medicine: 21 (5)
The Annals of Family Medicine: 21 (5)
Vol. 21, Issue 5
September/October 2023
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Last Call: Reflections on the Neglected Hours of the Day
Jonathan L. Temte
The Annals of Family Medicine Sep 2023, 21 (5) 463-464; DOI: 10.1370/afm.3020

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Last Call: Reflections on the Neglected Hours of the Day
Jonathan L. Temte
The Annals of Family Medicine Sep 2023, 21 (5) 463-464; DOI: 10.1370/afm.3020
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More in this TOC Section

  • The Day I Almost Walked Away: Trust, Gratitude, and the Power of Teamwork
  • What Are Doctors For? A Call for Compassion-Based Metrics as a Measure of Physician Value
  • The Shoeshine Stand and the Renaissance of Primary Care
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