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Wednesday, July 13, 2011

Life at Grady: No Sleep Till Brooklyn

The following post is adapted from the blog Reflections of a Grady Doctor, which is run by Kimberly Manning, FACP, a hospitalist at Grady Memorial Hospital in Atlanta. It is reprinted with permission.

I'm going to continue the saga and fireside tales of life during internship and residency, pre-duty hours reform (a.k.a "back in the days when nobody cared how long you worked").

This is partly to underscore why having some limits on how long young doctors (and old doctors) can work is a good thing. But like any great story, it's also just a chance to chronicle it—and then shake our heads while asking, "What were you THINK-ing?"

Today, we bring you a story from another Grady Doc, Dr. Neil W. I suggest you imagine a wonderful New York accent as you read this.)


The date was February 1st, 1994—my first day in the medical ICU at NYU/Bellevue Hospital. Normally I would’ve been a bright-eyed and bushy-tailed intern, ready to get cracking. The problem, however, was that I was tired, like really tired. The night before I’d been on call finishing my month on the medical wards and rolled into bed at 3 a.m. Dragging myself in, I was hoping to suck it up, push through the day and start fresh tomorrow.

When I arrived in the ICU, the first order of business was to determine the call schedule. (Normally the chief residents did this, but for some crazy reason we were left to figure it out for ourselves.) The interns rotated overnight every fourth day, and somebody had to be first. I hoped that my haggard appearance would prompt one of my three colleagues to step up and offer to take that night's call. The only thing was that all of them looked equally run down.


(Click "more" below to continue reading this post.)

Houston, we have a problem. . . . .


Turns out, every intern was busting his or her butt on call the night before! For those less familiar with residency training, the odds of this happening are incredibly small. Rare or not, someone still had to tackle this first overnight shift, and for whoever it was, it was going to royally suck.

Nowadays a calamity like this would send the residency leadership into a mad scramble to produce a fresh body from the "jeopardy" (emergency backup) schedule. Back then however, you didn’t go crying to the administration with every work hour-related problem (probably because we’d be simply told to suck it up); you fixed things internally.

So we decided to do it the democratic way and drew straws. As fate would have it, I pulled the shortest one. After a brief sulking session (and contemplation of demanding a recount) I rolled up my sleeves and got to work.

That first day (and night) was a blur; getting to know the super-sick patients in the unit as well as the ones who were getting admitted rapid-fire from the emergency department. Before I knew it, the following morning had arrived without me getting even an ounce of sleep. My fellow interns arrived well-rested and were sympathetic to my plight, but there were still too many loose ends to tie down, so I plowed ahead into the early afternoon. With my back-to-back calls finally done (50+ hours), I headed out at 2:30 pm.

I walked to the Bellevue parking garage and jumped in my dad’s car, a 1977 Cadillac Coupe De Ville (my car was in the shop). It was the middle of winter in NYC and a snowstorm had blanketed the streets while I had been working. I headed out cautiously on the 30-minute ride back to Brooklyn, and as I neared my apartment the driving became progressively worse over the unplowed snow. As I pulled into my driveway, towards the backyard parking lot, the wheels began slipping on ice and the Caddy became stuck, blocking several cars. After several minutes of flooring the gas and rocking the car in “drive” & “reverse”, I gave up.

I pushed open the huge coupe’s door and landed in thick snow. Leaving a quick note (to apologize for temporarily blocking anyone who needed to leave) I waded several blocks in my scrubs to a local hardware store. I lugged back bags of rock salt and sand, strategically tossed the mix under the tires and gave it another whirl-- but the Caddy still had no traction. Finally, after several more gear changes and wheel spins, it was clear that this car wasn’t budging. Luckily I saw some friends passing by who graciously took pity and helped push out the car onto the street.

With my tumultuous afternoon finally behind me, I glanced at my Swatch watch, which read 5 pm.

WARNING: This is where the story gets crazy. . . .

Okay, right then and there I should’ve called it a day and slept till morning, but you see, I had this basketball game back in Manhattan at 8 pm. I know, it sounds so incredibly ridiculous thinking about it now, but like Kim said last week, during your residency you’ll do anything to make yourself feel human.

For me, it was basketball. I had played in college and breaking a sweat once a week while seeing my former teammates was the only connection I had with the outside world. My plan was to set the alarm for 7 pm and see how I felt. The game was on the Upper East Side, close to my girlfriend (now wife) Tamara's place, so I would just crash (bad omen) there.

I worried that a nap on my bed would turn into a full blown snoozefest, so I sat cross legged on the floor, back against the bed with my head slumped forward. I was trying to drift off, when a realization suddenly overwhelmed me with nausea.

In all the excitement and rush to get some rest, I had locked the keys in my dad’s car.
Now the spot where I lived--though close to the medical school I'd graduated from the year before (SUNY Brooklyn)—was in a very tough neighborhood. A typical Friday or Saturday of studying was always punctuated by gun shots in the distance followed by sirens. But hey, if you were a student they pretty much left you alone and the rent was dirt cheap. So even though I knew I'd be working in Manhattan, I decided (after NYU’s subsidized housing fell through) to commute. In other words what I’m trying to say is that my dad’s car was not safe on the street, let alone with an inviting set of keys in the ignition. I dragged myself up and proceeded to get a wire hanger out of the closet.

I was no stranger to breaking into cars to retrieve keys so I pretty much had the coat hanger loop trick down. But this Caddy had a metal frame running around the window which made it impossible. After an hour or so of trying, I gave up. I then realized that the security office at my old medical school might have a “Slim-Jim” to help me break in. After walking several blocks and waiting for what seemed like an eternity, the officer emerged and gave me the disappointing news.

“We can’t seem to find our Slim-Jim, but there’s a homeless guy who lives in a car on the corner gas station. I know he’s broken into several students’ cars to get their keys." (Not making this up).

I headed out to the gas station and sure enough in an unregistered car was this scraggly-looking dude.

“Excuse me, are you the guy that helps break into cars?”
“Yep, that’s me.”
“Can you help me out? I left my keys in the ignition.”
“It’ll cost you 20 bucks.”
“I got 17 in my wallet.”
“Let’s go.”

The guy then pried up the metal frame with a screwdriver (Why didn’t I think of that?) and asked me for my looped hanger (hey, don’t I get some additional discount for tool rental?) Before I knew it, he had the door knob hooked and pulled open.
“There you go, my man,” he remarked as he headed back to his car 17 bucks richer.

Okay, NOW I had the keys back in my hand, but my window of opportunity for sleep AND basketball for that matter had come and gone. It was now 8 p.m.

WARNING: This is where the story becomes painful.

Any rational person would’ve then marched their butt right into bed, but I was so aggravated, so frustrated and hyped up, that I knew that it would take a while for me to settle down. I really needed to share my “day from hell” and sadly, I also knew that when I did finally settle down, I would need a mule kick to get me going again. I called Tamara and asked if she'd mind ordering dinner from my favorite pizzeria on 79th and 1st Avenue. I was on my way.

I headed out and crossed over the Brooklyn Bridge onto the FDR parkway with
very little fanfare. I exited at 42nd St. and turned right at the United Nations, stopping at a red light. I still remember Beck's "Loser" blaring on the radio as I started accelerating up 1st Ave.

“I’m a loser baby, so why don’t you kill me?”

Darkness suddenly overwhelmed me. I fell away into an absolute calmness and serenity, devoid of any conscious thought. That was until…

BAMMMM!!!!

My flaccid body lunged forward and was catapulted into the steering wheel at high force as the car’s momentum came to an abrupt halt. Parts of the dashboard went flying as I was thrown back into my seat. For a moment I had no idea what happened, let alone where I was. I squinted up at the overhead street light and saw myself to be on the corner of 52nd Street.
People came running out of the nearby restaurant and I heard one concerned patron through my clouded consciousness.
“Hey man, are you alright? It sounded like a bomb went off!”
I motioned I was okay and slowly got out to survey the damage.

What had happened. . . .
Heading north on 1st Ave I had drifted across several lanes of traffic and veered right, eventually running out of real estate and colliding with a parked car along the southeast corner. The first vehicle I hit was a Toyota Corolla, whose trunk was now in the rear seat. Walking further ahead I noted that the Corolla slammed forward into the back of a Renault Alliance, crushing its rear bumper. As I walked even further, I cringed when I saw that the Renault had rocketed into the back of a brand new Benz—with the owner idling inside.

He was no worse for wear, but the car did get pushed into the intersection—luckily with no oncoming pedestrian or automobile traffic. If I hadn’t been stopped by those parked cars, I might’ve drifted further rightward, over the curb and into the window of that busy restaurant. All I can say is thank God no one was hurt.

It wasn’t long before the police were on the scene. I showed them my Bellevue ID and shared my story. (Just for the record, there’s a bond between inner city police officers and inner city doctors.) One of the officers pulled me aside and I never forgot what he told me:

“Listen, we peel people off the side of the road every day. Just feel fortunate you didn’t hurt anyone. This here is property damage ($30K + worth to be exact). That’s why you have insurance. Just use better judgment next time.”

I thanked him and called Tamara from a pay phone (no cell phones back then if you can believe it). She hopped in a cab and arrived immediately.

While the Caddy sustained some damage to its grill and front bumper, the car was a tank and was otherwise unscathed. Unfortunately I couldn’t say the same for the other vehicles, as the tow trucks were lined up to whisk them away. With Tamara’s help, the Caddy cruised the final 25 blocks to her apartment.

Took a licking but still was ticking. . . . .
I did immediately notice however, there was a problem with the radio. While it could tune in stations, a tremendous amount of static was ripping through the speakers, even after the car was turned off. Why would the radio still be getting power? I knew the battery would be dead in the morning but I was too spent to deal with it. We went upstairs, finally had that Italian food I’d been looking forward to and slowly calmed down.

After that I slept like a baby, but had to be up early to take my dad’s car on the 50-mile trek back to Long Island. I called the Bellevue ICU and told them the news. My colleagues were amazingly supportive and offered to cover me while I was gone (the only sick day I took in three years of training).

When I got back in the Caddy, the radio static was still roaring. I expected the car not to start, but surprisingly it turned over. I made it home and together with my dad, brought the car to the owner of a local auto body shop. I told him about the radio problem and looked confused when he asked for the keys and walked to the back of the car.

Huh? Clearly the radio had been damaged from the frontal impact.

He opened the trunk and right there—clear as day—was my brother’s boom box, which had slammed forward from the impact. It was turned on some random AM frequency, and was bellowing static with its speakers face up. I got the hairy eyeball as he slammed the trunk shut, not even bothering to turn it off. I just looked down in embarrassment; things had to get better from here.


Taking it to the bridge: Grown man commentary
Amid much controversy, the work hour rules for residency finally changed in 2003. Now they have changed again as of July 1, 2011. Interns will only be able to work 16 hours straight, whereas upper level residents can work longer. Is this a good thing? Certainly for the well-being of the trainees it is. The harder question is whether physicians will be as well trained and whether patients will be safer.


Now I don’t want to be a hardliner and dare say that the hours we worked in training was an acceptable practice—it wasn’t. However, I also want to be clear there are significant differences when comparing medicine to industries like trucking or aviation. When a driver passes over the truck keys or a pilot taxis into a gate there is very little information transfer required. Safety will be determined by the competency/alertness of the driver and a rudimentary checklist of operating systems. In medicine, information transfer is everything.

Getting to know a single patient with all their complexities takes time. When doctors have to leave the hospital they pass on this information in the form of a handoff. During that process as many as 10 patients may be handed over to the on-call intern. That on-call intern will then receive similar handoffs from two other doctors. So you can see that information communicated during this period, if it is vague, poorly detailed or not thoroughly understood can mean all the difference in a patient’s outcome.

Now envision that the on-call intern who has received these handoffs needs to go home (16-hour rule in effect). That person will now have to hand off his own patients AND the ones he/she knows little about. It’s basically the telephone game with human lives in the balance. That is why critics of work hour restrictions believe we are simply trading one problem for another. They also worry about a “punching the clock mentality” which will erode professionalism.

The old way clearly needed changes but the pendulum may have just shifted too far in the other direction. It will be up to all of us in the medical community to design innovative strategies that maintain the rigorous standards of the profession while ensuring the safety of our patients.


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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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