Long working hours is the mainstay of
medical education. This huge devotion of
time over many years engulfs the doctor-to-be into a dizzying world of medical
maladies, providing the breadth of experience necessary for the creation of a
doctor ready to practice independently. A resident can
work up to 80 hours a week, taking in-house call up to every three days, with
shifts lasting no longer than 24 hours, with at least one day a week off.
Though daunting as this sounds, residency
was more ungodly in the past. Back in my
day, we often worked 100 hours a
week or more, with shifts lasting more than 36 hours, often without sleep, many
times on-call every other night. We rarely had a
day off. Sleep-deprivation was a way of
life, which did not affect performance, so we were told by many of the surgical
attendings who erroneously believed that.
But concerns for patient
safety did arise; mistakes and errors came about not so much from lack of
expertise, but from fatigue and sleep-deprivation. This eventually lead the Accreditation
Council for Graduate Medical Education (ACGME) to develop those rules limiting
work hours in 2011.
I would’ve killed for 80-hour weeks and a day off a week. We rarely had a day off unless we took vacation, limited to two weeks a year. It’s hard to describe the experience of working so many hours, quite unimaginable to those not familiar with medical education. But I’ll try. What follows is my attempt to explain the experience, from a first-hand account as an intern (1st-year resident) in a steady stream of consciousness (or unsteady flow of unconsciousness), if you can bear to re-live it with me.
* * *
0530 rounds. Alarm fires off at 0445 after having head hit pillow a little after midnight, shower, rush out the door before sun-up and drive to the hospital for 5:30 rounds and begin another long day of every-other-night on-call in-house, in-the-hospital for a full month of cardiothoracic (CT) surgery, and it’s my turn for call today, tonight, alternating with a second-year surgery resident since that’s how the wise Attending-doctor-folks felt was best for the patients on CT surgery, a first-year paired with a second-year, the first line in the trench, first to be called, first to see sick patients both new and already on the wards—the floors—and in the various ICUs spread across the wide medical campus, each working 100+ hour weeks in continuous states of somnolence, with the CT fellow as our back-up, calling him in the middle of the night at home whenever we weren’t sure or completely ignorant of some bigtime problem, and here we are again, starting at 0530 first in the ICU and then the floors and writing down the number of things and tasks and chores that must be done on my SCUT list and all before surgery start at 0730 including preoping and consenting the elective surgeries for the day, then turning back to do what needs to be done in the ICU with changing central lines, removing sutures and staples, pulling chest tubes and other tubes and placing new IVs or arterial lines, inserting nasogastric tubes, urinary catheters, adjusting IV drips and meds, running to radiology to view x-rays, calling for lab results, responding to the audible pager permanently stuck to the waistline beeping incessantly for anything and everything anywhere in the medical complex, searching for a phone (no cell phones back then) to answer the page from the hospital floors when in the ICU or from the ICU when on the floors or from the ER and rest of the hospital for consults or another ICU on the other side of the medical complex in a separate hospital and holy cow there’s so many different ICUs with medical ICU, neurosurgery ICU, surgery ICU, trauma ICU, cardiothoracic ICU, cardiac ICU, and please don’t make us head to Children’s Hospital for the pediatric ICU and why can’t they centralize all of this into one behemoth hospital rather than three hospitals each farther from the other and connected with an insane engineer/architect’s nightmarish design of interconnecting underground tunnels? by god he/she/they created tunnels as a freakin’ joke; and the tasks and chores are so many, starting with removing aortic balloon pumps--oh man I hate those—tubes as wide as a garden hose snaking up the poor patient’s groin and ascending way up into the large descending aorta helping a weak heart do its work, and when no longer needed we must cut the ties and quickly pull the wide and long hose and out comes the large deflated balloon much like a placental after-birth and push on the wound with a stack of 4x4 gauzes controlling the bleeding which alas is not controlled since it is shooting out in red lines crisscrossing my white coat and the far wall at the foot of the bed. Terror grips in hard pulsing waves from the middle of my chest up into each side of the head, loudly roaring into each ear, despite an awful simultaneous chill from a cold sweat. Hey, need help! I scream out for the second-year resident out by the nurses’ station who sprints into the room and we both apply pressure to the blood-squirting groin, and thank God the bleeding is controlled just as the Attending walks in, “What the heck happened here?” to which we explain as he gazes at the Jackson Pollock creation of blood splatted on the wall opposite the foot of the bed and He remarks, “give him two units” of blood as he walks away. Composure returns as heartrate slowly decelerates while that urge to pee in my pants passes as the bleeding stops and I go about the rest of the day’s work while the damn beeper never takes a rest and it’s well into nightfall and the cafeteria is already closed so I’m screwed for any dinner, but a nurse found a cup of pudding still covered with plastic wrap that Mr. Smith did not want and I devour it in 2 seconds and thank her profusely, and I venture to another floor and a nurse taking pity on me scrounged up some more food, which to my great fortune is a completely untouched dinner plate with meatloaf covered in glorious semi-brown savory gravy and a scoop of grayish-green cooked canned green beans that I devour in a minute or two since who knows who will page me for some urgent emergency. Nurses are angels but too often it’s a hard choice between searching for food or catching a little shut-eye and the latter usually takes precedence except when meatloaf is there. The call room--covered with a sickly yellow tile, much like an old bathroom or public shower, which I believe it was in the day, since this old hospital was built at the turn of the 20th century--was no doubt designed to discourage sleep, but sleep overcomes me instantly as head hits pillow, but the damn beeper always goes off minutes later interrupting a very deep slumber and never get the proper REMs. A patient in the ER, a problem with blood pressure or urine output in the ICU, tachycardia on the floor, a transplant recipient arriving needing to be admitted, prepped and consented—from a first-year intern with less than 3 months into the job, while the donor team is arriving via air, draw the labs stat, start the IV, get the patient transported to the O.R. Scrub at the sink eyes half-closed or half-open as The Attending makes small talk or merely grunts at the cardiothoracic fellow, follow the surgeons into the OR and help drape the patient, the fellow makes the incision, they both open the chest, find the failing heart, I hold retractors but can’s see much with The Attending leaning on my arm and blocking my view as He and the fellow work diligently to cut away the large attaching vessels but my eyes are shut anyway to catch a minute or two of sleep, and they said only horses sleep standing up, and the steady hum of the large cardiopulmonary bypass machine to my left moves bright red blood through a network of clear tubes to the variety of whirling wheels and cylinders in that monster of a machine and then back into the patient, and the machine sounds regular and soothing and highly conducive for napping, but then the donor team crashes through the door with the donor heart contained in a small Igloo ice chest, and the scrub tech or someone gowned grabs the heart from the opened Igloo and brings the dense mass of muscle onto the table, the Attending takes it and places it into the splayed-open chest cavity and attach the many this-and-that’s to one another, bring in two long paddles to each side of the lifeless organ and shock the living daylights with bursts of electric current once, twice and miraculously the third shock stimulates the lifeless organ just like Frankenstein’s monster and it beats in normal sinus rhythm! and this ought to be outrageously astounding—and it is, to a degree--but much of the appreciation is lost since I only crave sleep and we de-gown and I stagger in the direction of the call room on another floor far away or crash on an empty patient bed and get maybe an hour or two of sleep before morning rounds only to find The Attending on the donor team wants to “make rounds” on his patients since he feels “fired up!” and has the following day off anyway, dragging me along so I can give status reports from memory at best I can, as he chit-chats that he’ll be off taking his son to “Peter Pan” but he can be reached on his pager, and he rolls his eyes, “you know, as a father we have to do these things once in a while,” to which I want to scream “I’ll take your kid to Peter Pan and you can take call for me!” but proper resident decorum is to keep one’s trap shut, and finally his rounding ends, the pager goes off once or twice or perhaps a half-dozen times more, I pass a window and a thin ray of sun hums onto the tile floor, a harbinger for another long day that awaits until I can go home late, later that evening (hopefully before midnight) so I can take some reprieve from this haphazard stream of semi-consciousness—or unconsciousness—of the likes that would make Virginie Woolf and Jimmy Joyce smile—or not--but The Attendings found it in the kindness of their hearts by allowing the post-call intern to leave no later than 10pm the following evening, meaning we could end our shift after ONLY 40+ hours of sleep-deprivation and little or nothing to eat, and this never happens because we’re still there until midnight or later, only to mercilessly repeat the same ordeal, maybe after 4 hours of unbroken sleep, to awaken again at 0445 for rounds at 0530.
©Randall
S. Fong, M.D.
For more topics on
medicine, health and the weirdness of life in general, check out the rest of
the blog site at randallfong.blogspot.com
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