Confessions of a would-be nocturnist

“Hope it’s not too busy.”

I smile and kiss my well-meaning husband goodbye, the man who has just cursed my night.

In fact, I was swamped all night. It was the equivalent of the “Q word.” First rule of the emergency department: never talk about how “quiet” it is. We all know too well Newton’s law of the ED: for every moment of calm, there is an equal and opposite hellfire of activity. Straight out of Field of Dreams, if you acknowledge it, they will come.

I have been working nights for one year now, full time. To be fair, it was at my own suggestion, borne from a need to stabilize my schedule with a nursing baby at home and two more kids in school. If I work nights, I reasoned, I can set my schedule, make dinner, go to school functions, have regular date nights with my husband, and see my children every single day! In short, I can do it all! Never mind one small but critical detail — I have to stay up all night to do so.

I have a confession: working nights has made me a little crazy.

At our small community hospital, the night person is single coverage for all but the first three hours of the nine hour shift. That leaves six hours during which I alone greet the birthing and the dying, the intoxicants and the drug-seekers, the guys who were “minding my own business when two dudes jumped” them, and the patients with chronic problems that become emergencies in the dark, lonely hours of the night. Sometimes they arrive one-by-one in a steady trickle and other times, it feels as if a bus packed with patients decided to stop and let everyone off at my emergency department door.

The blessing and curse of the emergency department is that those of us holding down the fort never know who or what is going to come through those doors in the next five minutes. It makes our jobs exciting. It also makes many of us very superstitious, maybe even a little crazy.

My first glimpse into this cultish aspect of emergency department life was during my third year of residency when an attending asked me about my “voodoo pocket.” I stared back blankly, confused. A “voodoo pocket” is what you carry in your white coat to ward off “badness.” Hers consisted of a 14-gauge angiocatheter, a scalpel, a lumbar puncture needle, and ACLS and PALS cards. In this way she was “warding off” tension pneumothoraces, cricothyrotomies, lumbar punctures, and codes. Such preparations obviously didn’t work, but that didn’t stop me from adopting my own “voodoo pocket.” To be prepared, of course.

But a slippery slope it was. My voodoo pocket began to hold other things too: a penny found “heads up” with the year of my birth on it, a rubber “popper” toy from my oldest son, a paperclip with a yellow and red striped pattern on it. None of these things had any significance that I can recall, excepting the popper, which gave me an overuse injury of my left thumb due to secretly popping it in my pocket while talking to patients. I also had a lucky pen, a lucky coat (the one with ink stains from the lucky pen), and a lucky stethoscope, adopted as such only because it hadn’t yet been stolen or lost since medical school.

When I began working nights, other beliefs began to creep into my mind. What I wore, for instance, was crucial. I began to believe that my scrubs, my underwear, and my socks all had to fall within the same coordinating color palette. Polka dot socks were specifically prohibited after the weekend that I wore the first two pairs of a new five-pack and had a patient with a tension pneumothorax in fulminant alcohol withdrawal on the first shift followed by a patient with a ruptured intra-abdominal AAA on the second shift. That both patients survived might lead some optimist out there to suggest that these socks were in fact lucky socks, but not I.

And the parking routine! Night after night, my arrival to work became a carefully coordinated affair where any deviation from the scripted pattern would result in badness. I must park under the second light on the far side of the parking lot. The parking space to the left of it is also acceptable, but only if the first-choice spot is full, having discovered that it cannot be parked in preferentially because that will result in a pediatric code. Third choice is the spot with a stone missing in the wall, which I have endearingly referred to as the parking spot missing its two front teeth. Fourth choice is on the opposite side of the lot, anyplace in that row. Beyond those options is no man’s land, and I assume all risk of what might happen that night.

Please don’t judge! I worry this reads as the confession of a person who needs a psychiatric consult. Clearly all of this is a means to control the uncontrollable, to achieve some order out of the chaos. Night after night, it’s only me in the emergency department and me alone, armed with my voodoo pocket and striped socks to combat the inevitable. It’s a fight against fate that traces back to the Ancient Greeks.

I have a another confession to make: I am just not a nocturnist.

It’s true, I have noticed my overall level of exhaustion, my irritability, my new anxiety about upcoming shifts, my physical feeling of “unwellness,” and what is likely now a sleep disorder, making it difficult to sleep soundly day or night. Numerous studies predicted these  developing symptoms, but I needed my personal n=1 to comprehend them. Stubborn, I know, I know. Still, those things alone weren’t enough to sway me. The truth is, it’s not the physical effects, it’s that I’m mentally tired. My faith in the voodoo pocket has dwindled and I don’t have the strength to keep post as the city’s lone midnight crusader for health and safety.

Tomorrow is my first day shift in one whole year. Like the first day of school all over again, I have my scrubs laid out, my bag packed and readied, my food in cute new storage containers. I am ready. Ready to see what kind of patient comes to the emergency department during the day. Ready to see how differently my consultants will greet my daytime phone calls for follow ups and admissions. Ready to go home and sleep at night, like most people do. I am excited again for whatever comes through those doors. And just as Freud supposedly once said, “Sometimes a cigar is just a cigar,” I look forward to the day when I can turn into the parking lot and say, “Sometimes a parking space is just a parking space.”


By Nadine Himelfarb

Nadine Himelfarb (@DinaHfarbMD) is an emergency medicine physician at Memorial Hospital of Rhode Island and a Clinical Instructor of Emergency Medicine at the Alpert Medical School of Brown University. A former high school classics teacher and mother of three beautiful boys, she is interested in medical education and thrilled to be a contributor to the growth of humanities in medicine.

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