Three or four nights a month, I work as a moonlighter in an intensive care unit.
Moonlighting is a funny thing. If you’re sick during those 12 hours — I’m your doctor. Then morning comes and I leave the I.C.U. and head home, eat too much, take a nap. When I wake up, I’m back to the daytime world. I do this all for extra money. And chances are, I never see you again.
Almost every doctor I know has moonlighting stories. When night falls, we leave our labs and clinics to venture to shifts in emergency departments and intensive care units and general medical floors. When I was growing up, my father — a cardiologist with no formal training in emergency medicine — would spend one 19-hour stretch each month as the only doctor in an emergency room some 60 miles outside of Boston. It is a vast nocturnal underground, in which continuity of care fades when the sun goes down.
The patients change, but the pattern doesn’t. Each shift begins with a sign-out. In the I.C.U. where I do most of my moonlighting, there are 10 beds and the daytime doctors walk with me from room to room. We stand outside the door and they tell me what I’ll need to know for the night. I take notes in the margins of my patient list.
Haldol, I instructed myself on one recent shift, for a man who tried to climb out of bed the night before. Goal negative, I wrote for another, a woman with heart failure who the team was helping to urinate out liters of excess fluid each day.
Then we got to Ms. R. New, I jotted down. She had come in just a few minutes before I did, around 7 p.m. She was only 60 but appeared older, aged by surgery and chemotherapy for uterine cancer. Her belly was swollen, the rest of her body wasted. I could see her ribs rise and fall as the breathing machine pushed air into her lungs.
I introduced myself to the nurses clustered around her bed in their yellow isolation gowns.
“I’m on tonight. Moonlighting. I’m Daniela.”
Ms. R. had actually been in the hospital for three or four days before coming to the I.C.U., one of the nurses told me while struggling to find a vein in the patient’s mottled arm. She had been recovering from a bad urinary tract infection, but today, something had gone wrong. Her blood pressure dropped. The level of acid in her body skyrocketed. She grew confused.
The daytime team wasn’t sure what had happened, but worried that her cancer had eroded her colon and perforated the delicate organ. CT scan? I wrote on my list. Then, as if I needed a reminder, Sick.
I told the daytime doctor that we were good, that he should head home.
After the day team left, Ms. R’s blood pressure plummeted. My overnight intern and I spent hours at her bedside, struggling to place a large intravenous line in one of the veins in her neck or groin. By the time we finally got it, her blood had left splatters on my scrubs.
The CT scan showed what we had expected; part of her bowel looked as if it had been deprived of blood flow and died. I called her son.
“I’m the overnight doctor who’s been taking care of your mother,” I introduced myself, a nameless voice over the phone. Most likely, we would never meet.
During the day, I might have asked him to tell me about his mother. What did she like to do? What mattered to her? But here, at night, I was just the moonlighter. And so I told him that I had just met his mother, that she was very sick. Her son cried and asked questions and then thanked me. He would be in first thing in the morning with his father. He knew they were probably coming in to say goodbye.
Would he meet me then? I wasn’t sure.
By the time the sun rose, my patient hadn’t gotten any worse, but she hadn’t gotten any better. I told the daytime doctors as much when they came back at 7 a.m. and we walked around the unit, as we had 12 hours before. The delirious patient had been quiet. He hadn’t needed any extra Haldol. We had met the volume goals for the heart failure patient. Ms. R. was still dependent on the ventilator and high doses of medications to keep her heart functioning. Her son was on his way.
“Busy night,” the daytime resident commented. He gave me a high five. I handed him the pager and readied to leave. “Hope you can get some sleep.”
I walked out the unit doors, half-hoping my patient’s son would arrive in time for us to talk in person. I wondered if I should wait, but I really needed to sleep before my afternoon clinic session. In that moment, I was still immersed in the hazy overnight fog of sickness, but I knew that when I got home, I would take off my dirty scrubs and get in a hot shower. The night would begin to feel, as they all do, like a long strange dream. The faces, the smells, the son’s voice on the phone, they would all fade into memory.
In a few weeks, my moonlighting check would come. And then I would sign up for more shifts.
Daniela Lamas is a pulmonary and critical care fellow at Brigham & Women’s Hospital in Boston.