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Newman's Notions

Work hour limits: No gain without pain

From the March ACP Hospitalist, copyright © 2009 by the American College of Physicians

By James S. Newman, FACP

Hello, Mr. Jones, I am Dr. Hedges; I will be a member of your care team. I read from the emergency room report that you have been having two days of severe flank pain, and hematuria. Excuse me? Oh, that means blood in your urine. It’s probably a kidney stone. Yes, you can have some pain medicine, you do look very uncomfortable. Yes, I believe you when you say it’s 11 out of 10. I’ll order some intravenous morphine for you. Allergic to morphine, are you? OK, no worries, I’ll get some fentanyl ordered up in a jiffy.

BEEP BEEP BEEP. Excuse me, it’s my nap time. I need to check out to Dr. Benson.

Nobody would want their child riding on an icy road at 70 miles per hour in a school bus driven by someone whose head keeps nodding, or to fly in a plane with a pilot who is on her 15th cup of coffee because she just can’t keep her eyes open any longer. Similarly, who would want to be cared for by a physician who is so fatigued he can’t remember the difference between the cranium and the cremaster? Thus, the Institute of Medicine and work hour limits. In its most recent report, the IOM recommends that residents work no more than 16 consecutive hours without sleep.

The overwhelming conclusion of the evidence reviewed suggests that as fatigue increases, so do the number of errors, as well as the risk of injury from motor vehicle accidents and needle sticks, putting not only patients but also housestaff at risk. The current system of limits, however, is not working: Residents frequently work past their allotted periods, as much as 43% of the time.

Hello, Mr. Jones, I am Dr. Hedges. Oh that’s right, we did meet before. How is that morphine working for you? Oh right, fentanyl. Please don’t be angry. What do you mean it never got started? Right away. OK, the order is in the computer. Now we need to see how that old kidney is doing. It’s probably a stone. I think we need to get a CT scan, or some kind of imaging. I need to wake up my resident and ask her. OK, here’s the nurse with your morphine. Just joking.

BEEP BEEP BEEP. Excuse me, I have to take checkout from the other service. Be back in a flash.

Aside from shorter hours, the IOM report also recommends better supervision of residents by faculty. This may end up as a boon to those hospitalists who most enjoy teaching. Few faculty want to spend the night in the hospital, so those night owls already on duty may find the nighttime hours offer an opportunity to teach. Additionally, protocols for handoffs, the critical transitions between clinicians, need to be improved. The system is already suffering from fragmentation with current work hour restrictions, and shorter work periods might only exacerbate this disconnect. Hospitalists, by the nature of their practice, are in an ideal position to teach about transitions of care.

Hello, I am Dr. Hedges. I will be part of your care team. Oh that’s right, we have already met. Feeling better? Have you had your CT scan yet? No? Let me check. Whoops, looks like it wasn’t scheduled. My bad. I could have sworn I put that in. Let me look. Yes, the order was placed hours ago. Radiology shift change. I’ll call them right now.

Can I get radiology scheduling on the phone please? Just a minute, Mr. Jones, I’m on hold here. OK, yes, I’d like to get a CT scheduled. Is he NPO? Mr. Jones, did you eat? A few bites of egg and toast? Hold on. Yes, it looks like he ate. Wait a minute. Nurse, can you get some Phenergan in here? OK, I’ll put the order in first. Mr. Jones, I am on the phone here, the basin is on the table right next to you. Good aim. No, he’s NPO now. That’s one empty stomach.

BEEP BEEP BEEP. Lunch break, hope they are serving meatloaf today.

The era of the 36-hour shift is gone, and I for one won’t miss it. However, what replaces these killer (in more ways than one) shifts will have a profound impact for years to come. Perhaps it will be enforced naps, something that never worked with my children. Perhaps shift work or dedicated days off may be the answer. With better supervision, improved transitions and well-rested residents, perhaps errors will decrease. But as in all closed systems, no change will occur without an equal and opposite reaction, as dictated by Newton’s Third Law. And those unexpected consequences may not be to anyone’s benefit.

Hello, I’m Dr. Hedges. That’s right, you’re the guy we thought had a kidney stone but turns out has that huge renal mass with thrombosis all the way up the IVC. What do you mean nobody told you about it? I’m sure Dr. Benson said he was going to. My bad, again.

Mr. Jones, please don’t get so upset. Why are you breathing so fast? Are you having a panic attack? Let me get you a paper bag to breathe into. Nurse, do we have any bags? Why yes, he does look kind of blue. OK, we can check his pulse oximetry. That can’t be right, 72% with a pulse of 130. Try another finger. Yes, I’m sure. That’s better, the pulse is 80. No, make that 20. What is the matter with this thing? Go get another one. At least he isn’t breathing so fast. Yes, you’re right, he isn’t breathing at all.

Mr. Jones, have you ever had a cardiac arrest before? OK, you’re right again, let’s start compressions. Somebody call the code team. They’re on break? Well, continue compressions. That’s right, get the paddles. Here’s the call team now. Yup, witnessed arrest, probably a saddle embolism. What’s his code status? That’s a good question.

BEEP BEEP BEEP. Excuse me, coffee break time. Be back in 15 minutes.

Dr. Newman is a hospitalist at the Mayo Clinic in Rochester, Minn., and editorial advisor to ACP Hospitalist.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated