The Rules

It's 5:55 AM. I check the kids to see that they are still covered by the blankets. The next time I see my children will be in another 36 hours, I'm on call today. Locking the door behind me, I take a deep breath of the morning air. It's cool and damp with some light fog beginning to disperse.

I've always been a night person. Especially during my bachelor days and while in school, I used to either study and/or party all night and wake up at noon the next day (at the earliest). Now, I'm forced to wake up at 5 AM and be at work by 7:00. The truth is, it's not all that different. I'm still awake at the same hours, just my sleeping schedule has changed. When I would come home at 5 AM after a night of pubbing, I always enjoyed the stillness of that hour, before the world wakes up. It's still the same, except for the opposite direction of travel.

I enjoy observing the "regulars" on the bus ride to Be'er Sheva. There's the pretty young woman with the Barbara Streisand nose, perfect coif (not a hair out of place) and the smart ensemble. Always, black pants: low cut. On this cool morning she wears a thin sweater with one shoulder bare. It looks so spontaneous but I'm sure it's all planned. How does she do it? There are the soldiers; they seem to be immune to the early morning chill. The naval officer, with all sorts of impressive pins and insignia. Just before he steps on the bus, he always looks to his left, warily eyeing the surroundings. He has an expression that says that he is a match for any situation. He is definitely not a navy commando officer. I've known a few of those. They are the most humble and unassuming people I know, yet they lack no self confidence.

There's the security guard and the girl who works at the gas station - they get on the bus at the same stop. There are some people who prepare the bus fare or the prepaid ticket before getting on. There are those who put their bags on the first seat and then rummage around looking for spare change. I like to be prepared; I've never understood people who get on the bus unprepared, I just don't get it. They are the ones who usually get on first and then block the aisle for all those following them.
I get off the bus at the hospital, and another workday begins. Routine operations, mostly. Since my internship I've been expanding a list of rules I invented. They are modeled on the rules set out in a book called "The House of God" by Samuel Shem. Every doctor has read the book, usually in med school. It's a very satirical take on the internship year and the "Rules" have become classics. Some of the humor is very morbid, but sometimes one needs such a release when working day in and day out in a stressful environment. So here are some of the "rules" of Soroka University Medical Center:

1. The intern/resident (depending on your stage of training) is always to blame.
2. If there is work to be done at the end of the day, the intern/resident can do it, even if he/she is not on call.
3. All roads lead to X-ray.
4. The swiftest doctor in the hospital is a rotationer after morning rounds. (Explanation: residents on rotation: these are residents doing a rotation outside of their specialty, for example plastic surgeon rotating through general surgery as part of the syllabus. These residents are usually studying for the board exams and tend to be found in the library 5.5 milliseconds after morning rounds are over.)
5. All patients speak Russian until proven otherwise. This rule is true also of doctors, nurses, nurses' aids, x-ray techs, lab techs, orderlies, landscape crew, housekeeping staff and the laundry workers. It is NOT true of secretaries for some esoteric reason.
6. Each unit of blood ordered involves at least 4 telephone conversations with the blood bank. (Invariably, when one has ordered blood immediately for an emergency operation, the blood bank tech will ALWAYS call and ask: "do you really need that unit NOW?" This is when I wish I had Bugs Bunny's ability to reach through the telephone and strangle the tech with my bare hands).
7. When the noradrenaline drip (for supporting blood presure in unstable patients) is discontinued, the patient's condition immediately improves which means prolonging dying for another three days.
8. If it looks, acts, walks, talks, smells, sounds and feels like septic shock, it's probably septic shock. (This rule resulted from and argument between two senior physicians in the ICU about the cause of a patient's unstable condition. The more senior doc's diagnosis was invariably, wrong.)


The day runs smoothly, routine operations. At 3 PM, the on-call starts. The doctors who are not on call finish their operations and sign out. We start doing the trauma cases that have stacked up during the afternoon, mostly orthopedic cases. I was sent to CT to anesthetize two children who needed emergency scans. Back at the OR, the hours fly by without noticing. It's midnight and the general surgeons bring up an elderly patient with a small bowel obstruction. The patient is stable during the operation. The cause of the obstruction is adhesions due to a previous operation (a common complication). At 2 AM we are done. I send the other anesthesiologists to get some rest and finish up the log of the day's cases.

At 3 AM, I'm woken by the telephone: get to OR 5 quick, a stabbing victim is being rushed in. I wake up another anesthesiologist to help with the case. The patient is a 20-something Bedouin, barely conscious with no palpable pulse. I wonder who the hell gets stabbed at 3 in the morning: was it a drug deal gone sour? A fight among thieves? (Most law-abiding citizens, except bachelors and students, are usually asleep at that hour.) The surgeons cut open the abdomen while we put in some big IV lines, I start infusing warm fluids with a pressure infuser (capable of infusing fluids and blood at 1 liter per minute at body temperature). When the surgeons get to the abdominal cavity the patient's almost non-existent blood pressure is explained: All the blood has spilled out of a cut artery. I ask the surgeon to clamp the aorta (the largest artery which is a conduit to the rest of the arteries in the body). In the meantime, I get blood units hooked up and infuse them. The patient now has a blood pressure, low, but existent.

There may be hope for this patient - providing the heart and brain didn't suffer too much from the lack of perfusion. The surgeons suction out the blood and look for damage made by the knife. They perform what's known as "damage control surgery." The minimum is done to prevent further bleeding, and then the patient will be taken to the ICU for stabilization. The blood pressure is depressing, and the patient dies soon after arriving at the ICU. The vital organs just couldn't overcome.
These kinds of cases always weigh heavily on my mind. I always replay the events, second-guessing myself. Was there something I could have done better, or faster, or just more? Considering the patient's condition upon arrival, it's a wonder he survived that long. But still...
A few hours later, I'm home. Tired? That doesn't quite describe it. I feel like I'm observing the world from inside an aquarium. I glance through the morning paper, and come upon an item that puts everything in perspective. A short article about the stabbing victim. It turns out he was a wife beater, and also used to beat his children. After years of abuse, and very uncharacteristic of Bedouin wives, she took the law into her own hands (she probably never complained to the police before), and stabbed her abusive husband.
She was a murderer. The children were taken in by the victim's family. A tragedy that punctuates years of a family's tragedy. Somehow I felt the failure to save the victim less acutely. I don't condone such violence, but perhaps, in such a brutal environment, brutish justice was served