When Young Doctors Are On Call

by Jenny Blair, MD

 
It is midday - 2 a.m. I’m home, awake, listening to my pet crickets chirp. I just ate lunch. There are night shifts coming up and I might as well get into the rhythm.

After four years of medical school at Yale and two more as a fledgling M.D. at the University of Chicago’s emergency medicine residency, I’ve stopped thinking of night as a sacred time of rest. Too many of my nights have been work days. I sleep when I can, and have learned to create artificial day during the wee hours.

Emergency medicine schedules are relatively tolerable. In fact, I chose the field partly for the work-hour flexibility it offers. Shift work isn’t easy, mind you, particularly when the shifts constantly change. As with medicine in general, the Darwinian forces at work in ER training select for people who don’t need much sleep, or who can nap easily.

But no matter how fragmented my days and nights, they are all spent working limited shifts in the emergency room. At this stage in my training, I no longer work in ICUs or trauma wards, and I can therefore be thankful that one thing is behind me forever: the nightmare of being on call.

Though I’d been on call as a medical student, there hadn’t been much responsibility, and my first experience with the real thing was early in the first year of residency. It was a four-week trauma surgery rotation. The daily routine was thankless, but being on call made the month close to intolerable. What is call? For us residents, call is 30 hours of work, unless we can catch a nap. It is part of the normal schedule for any doctor-in-training who works on a hospital floor or intensive-care unit. That last month, on the ICU, the schedule went something like this:

You wake at 4:30 or 5 a.m., drive to work and visit your patients, then write daily progress notes. You and the team make morning rounds, go to a lecture and do patient-care tasks. In the afternoon, the other ICU residents give you reports on their patients, whom you’ll be caring for overnight. They go home, and the pages they would have answered now come to you. “Are you on call? Bed 4 is satting 80 percent; you might want to come look at him.” You don’t know the patient, so you look at the sheet you were given. Will you need to intubate him? “Did you want 4 of morphine, or 2? This order is unclear.” Go and untangle what the other resident wrote on the order sheet. Don’t forget to check everybody’s evening labs. If they’re abnormal, you have decisions to make.

8 or 9 p.m. You heat up dinner, or order out. Or maybe you don’t, for the workload often gets heavier as evening sets in. Patients come up from the ER. You talk to and examine them, then write a two-page admission note and a set of orders. People “code” elsewhere in the hospital and you have to run over, think fast, do CPR, put in a breathing tube (i.e., intubate) or central line, or pronounce somebody dead. The other patients need you when you’re through. You have worked without a break all day and you’re flagging, but there is no time to rest.

1 a.m. You are still working on admission notes and answering pages and nurses’ questions. Gradually, you grow brittle. You laugh at something that no one else finds funny. Something irritates you and you clam up, pouting. A few minutes later, you find yourself crooning the tune of some patient’s ventilator alarm. Then you pull yourself together because another patient is here from the ER, waiting to be examined. She is a woman in her 30s dying of breast cancer. Upon hearing that, you feel a strong longing to hug someone.

2 a.m. You finish your note. Your tongue is thick and your steps are heavy. There is another new patient. Before you can see him, you’re paged again: Someone already admitted is sicker.

4 a.m. You tied up that last admission and took care of the other sick guy. Things seem to be quieting down. You make a last pass through the nursing station, then trudge to a bunk in the call room. The nurses are good people; they won’t page you for anything trivial once you’ve lain down.

4:30 a.m. Beepbeepbeepbeep. Another resident stirs in the adjoining bed. “It’s just my alarm,” you murmur aloud. You twist around, turn it off and lie back down in the dark.

Dimly, a thought arises… maybe someone paged me.

You sit up, nauseated, trying to remember what to do. Dial. The nurse’s voice is brisk and alert. Bed 4, whom you decided a few hours ago not to intubate, is getting worse. “I’ll come see him,” you say huskily. Slip stinking feet into loafers. Take white coat off the bedpost. Breathe slowly. The air seems to burn in the chest.

At that hour, the brain works differently. Some filter that stratifies things by importance is lost. The eye wanders to handwriting on a chart, a torn piece of paper, the patient’s dry-skinned knee, just as easily as it does to the vital signs or heaving chest. This makes it difficult to make decisions.

In the 24th hour of your working day, on half-an-hour of sleep, you sedate a desperately ill person, open his mouth with a metal instrument and put a breathing tube down his windpipe.

By 6:30 a.m., the other residents begin to arrive. You fill them in on the night’s events, then check on your own patients and write another day’s batch of progress notes. On morning rounds you present the new patients to a crowd of colleagues and attendings. You attend a teaching session, where you are expected to participate, not drowse off. You finish what needs to be done on your patients and sign out to that day’s unlucky on-call resident. (You’ll be back the next morning, and on call again in four days.) In theory, you are to leave at noon. In practice it can be much later.

You fall asleep at the red lights.

Sleep deprivation is not a benign condition, although it is treated as such by the medical establishment, which ought to know better. Medical school, when a few hours’ sleep nightly is all too common, is when all of us begin to explore the outer limits of our endurance, when the normal prerequisites for sleep - solitude, darkness, comfort - become unnecessary.

In medical school I fell asleep while gazing through a microscope. I fell asleep while taking notes in afternoon lectures, jerking awake to look wonderingly at the drooping line my writing had trailed into. I sleepwalked. One morning, I awoke, looked at my watch, and found I was late for morning rounds - unthinkable. Frantic, confused, I scrambled out of bed. There hadn’t been a power outage, as the lights worked and the alarm’s display was dark, not blinking 12:00. I followed the cord around behind a bookcase and found it unplugged. I had no memory of getting up and shoving the bookshelf aside to unplug the alarm. Now that I’m a resident, I have far too many memories of looking up the wrong drugs and catching myself just in time, of staring blankly at a nurse when asked to make a decision, of forcing friends to talk to me on the cell phone the whole way home so I wouldn’t fall asleep at the wheel.

Researchers are beginning to conduct studies of fatigued residents, and their findings confirm the greatly increased risk of car accidents and medical errors. This surprises none of us.

There are alternatives to call, and ways it could be made more tolerable. Some hospitals use a “night float,” a resident who works nights and goes home in the mornings. There could be simple protected time on call nights, in which one resident gives up his pager to another for a guaranteed few hours’ sleep. In fact, the Residency Review Committee, which controls the accreditation of the nation’s residencies, several years ago created a set of work-hour rules. This includes a rule that a resident can work no more than 80 hours a week, averaged over four weeks, and no more than 30 hours at a stretch. This is patchily enforced.

But many older physicians feel, whether they state it openly or not, that since they had to go through this, so should the current generation. They are often heard to argue that one learns more under these conditions.

Such reasoning mystifies me. Truck drivers and air-traffic controllers, with their strict limits on working hours and their mandated rest periods, seem to have more sense than we physicians do.

In a hundred years, perhaps we will look upon call as we now do on slavery, because call, as it currently works, is cruel and inappropriate. Perhaps the current movement to prevent medical error should establish two obvious rights: No one who is not at war should be forced to work 30 hours straight; No one in a decent hospital should be treated by an exhausted doctor.

There is a sensation of physical outrage that washes over one in the wee hours when one has had little or no sleep and is faced with the task of caring for sick human beings. There is a wrongness to it, a sense of betrayal of both oneself and the patient. The instinctive need to decline the responsibility and lie down is so strong that rage wells up when there is no way to do so. In a profession where sloppy work is never excusable, residents on call are set up to fail.

Call has changed me. It has aged me, I think. I feel frequent waves of gratitude that it is over. As an ER resident with a shift-work schedule, my circadian rhythms are cacophonous, and I rarely feel fully rested at work. But at least when I open my eyes an hour before my shift starts, I look around my bedroom and realize I’ll be back in 14 or 15 hours. It is the simplest privileges that one cherishes most.

During some of the worst moments on call, when I dragged myself to my tasks, and patients’ families looked to me with hope and trust, it gradually became clear that none of them had any idea of the condition I was in. I often fantasized of saying to them, “Hello. I’m Dr. Blair. I’ve been awake since 4:30 yesterday morning. How can I help you today?” I never did, but still can’t help thinking: If they only knew.

The author, Jenny Blair, MD, wrote this article while a resident in Emergency Medicine at the University of Chicago. She can be contacted via her website: www.strangeviolin.com. This article originally appeared in the Hartford Courant on October 8, 2006. Republished with the author’s permission.