Sunday, April 3, 2011

To Tired to Work?

I just realized that this May I will be celebrating an anniversary; 30 years of night call. Not an auspicious one but one deserving of reflection.

Nobody in my family was in medicine, so I had no idea of what the lifestyle of a doctor was. I figured it would be like on MASH where Hawkeye and Trapper John sipped Martini's in the swamp in between tormenting Frank Burns and boinking the nurses. Or maybe like Doc Adams who spent most of his time arguing with Festus in between digging bullets out of the Marshall. I at least figured that I would only be seeing really sick people who needed urgent attention. Why else would you work after hours?

I was moonlighting in emergency during my residency and was suturing up a rare treat, an unobnoxious drunk around around 1 am. "You must be pretty smart to be a doctor," said the drunk. "If I am so smart," I replied, "what the hell am I doing here at one in the morning on a Saturday." Even back then I had it figured out but I am apparently no smarter.

I am pretty certain that anaesthesiology is the only specialty that works harder on call than they did 25 years ago when C/S rates were under 20%, labour epidurals were uncommon and fractures were actually treated with closed reductions.

This has become an issue lately because of complaints by my colleagues related to on call especially on weekends. Our department like many around the city has developed what is at face a very civilized call system. Nobody is on first call for 24 hours. We have a Day Call who works from 0700 to 1600 after which he becomes second call until 0700 the next morning. Night call starts at 1600 and goes until 0700 the next morning. Night call usually follows Day Call which means that after being on Day Call you don't work.

This system works well on weekdays, it is weekends when it is beginning to break down. The problem is that if you are Day Call on Friday or Saturday; you effectively become second call for the next 24 hours after which you become first call. This should not be a problem as second call should normally only be coming in for life and limb threatening emergencies when first call is tied up. Think again, our OR is staffed to run two rooms until 1100 on weekdays and from 0800 to 1600 on weekends. On top of that we have a not that busy Caseroom which we also have to cover. Increasingly surgeons and administrators are asking (demanding) that we run two rooms on evenings and weekends. This means that it is possible to work until 2300 on Friday, be called in at 0900 on Saturday and then work until 0700 Sunday. It is unusual to work all night, however the Case Room can make for a lot of interrupted sleep.

We could of course fix this by having a second call on weekends that is separate from Night Call. The problem with this is that we are a relatively small department and to bring in a second call would result in call every 1 in 3.75 weekends during the year and 1 in 2.75 during the summer (somebody else calculated that not me). Most people are prepared to just grin and bear it. Many weekends are not that busy. Adding a second call in addition to increasing our weekend call load would dilute our income from on call.

Switching to shifts is an interesting option and one that emergency docs have been doing for years. As one staffman explained to me during my residency however, the reason we work 24 hours or longer on call is so that we get more weekends off. As most of our work is done during the weekdays, shift work is something that would be harder to schedule for anaesthesiology without a lot more redundant manpower.

But what about if we only did cases that actually need to be done? Imagine being on call and only doing appendectomies, compound fractures, and caesarian sections. You would still be on call as often but would be earning a lot less under the fee for service system. Occasionally I get a day or an evening on call where there is nothing booked, and the Case Room is completely quiet. Those times are almost as bad as working. There you are tethered to being within a 20 minute radius from the hospital, if you and your wife go out you have to take 2 cars. Start doing something and the phone is sure to ring. So you sit around watching mindless TV or reading; later on you go to bed for a fitfull sleep worrying that you are going to sleep through the phone. It was a lot worse before cell phones; I can remember going out with a pocketful of change for the pay phone in case my beeper went off. So the answer is that most of us want to work but not a lot.

On call work is very surgeon dependent. One man's emergency is another man's put it off until Monday. Kidney stones are a case in point. Some surgeons like to operate on all of them before something happens (like the patient passes it). Others are happy to send them home with some analgesia. Our hospital actually has a stone room on Fridays to allow urologists to do their urgent stones during the day. This still doesn't stop a small sub-group of urologists from booking stones on weekends. (As an aside in my first job, one of the urologists before he went home on Friday would in his illegible scrawl, book "John Smith" and "Bob Jones" for ureteroscopies on Saturday morning. His rationale was that two patients were sure to present during the evening or night and he wanted to go first. He died in his sleep a year or so after I left, which may or may not be karma.) Many surgeons believe that if they are going to be on call they want to work. Many years ago an orthopedic surgeon was caught telling patients on his wait list for arthroscopy to go to the ER with "locked knees". Much less egregious abuses of on call operating time still occur. The chief of surgeon recently confirmed what I had always believed. As he said, if we (which means if I) am not busy and I have a patient with a gall bladder who is not coping well at home I will call them in. There are also surgeons who figure that if they have to do one case, they may as well do two. The less urgent case is always booked first, so that you have to do the more urgent case regardless of how late it is or what else is booked. I could go on with examples.

Surgeons it is true also take call and often take call more often that do anaesthesiologists. Surgeons do have much more control over their workload however, there are very few surgical cases that have to done right away. If they are feeling tired, they can and do put cases off until the next day. Surgeons also have several layers of buffers between them and the patient; nurses, hospitalists, interns and residents. They are therefore only seeing the tip of the iceberg of their on call work. The problem is of course that while we have multiple surgical subspecialties, we only have one (or two) anaesthesiologists. These means that after the orthopedic surgeon decides around 8 pm that he has had enough and puts off the rest of his huge trauma list until the next day, we are still stuck with whatever appys, D+Cs and the real emergencies that come through the door. I am now starting to accept what I should have always known. I am just not as sharp after 8 hours of working. I start to cut corners, I do stuff I know I shouldn't do. Sometimes looking back at a specific case all I can think is, "what was I thinking?" This is not limited to anaesthesia. I have blogged in the past about operating on no sleep. Having recently had the "pleasure" of some long ortho trauma lists on Saturday I have noticed that as the day goes on the work get sloppier. Locking the IM nail that was easy at 0900 seems to take a lot more time at 2000. I remember watching a really tired Ob-Gyn trying to do an ectopic laparoscopically late at night and it was not pretty.

A couple of years ago at a meeting, I ran into some anaesthesiologists around my age who I worked with in my first job before in a long moment of insanity I moved to the C of E. The discussion topic we arrived at was the techniques we use to stay awake during cases late in the evening and at night. One person had an interesting technique. She would sit in the chair of anaesthesia and lean on the machine so that if she fell asleep she would not fall off her chair. There are other techniques of course: playing your music loud if the other people in the room will allow it, turning up the volume on the monitor, setting alarms to go off all the time, talking to the nurses. I remember late at night trying to stay awake during a really boring head and neck case. One of the nurses finally took pity on me and brought in some Readers Digests. "Read these," she said, "that will keep you awake." I started bringing in books and magazines. I once read most of an entire novel during an all night case.

Some cases of course are easier to stay awake during that others. Ruptured aneursyms, major traumas come to mind. Adrenaline and the need to actually do something during the case keep you awake. Sometimes the effect of having done 12 hours of mind numbing orthopedics, makes you less fresh.

Compounding matters is that I no longer recover well from those all nighters. I have never been able to sleep well on call. The odd time when from shear exhaustion I do sleep, I am groggy almost drunk when I am awakened. I am crabby when I am tired. I say things I shouldn't say. I have gotten in trouble for this in the past. I did one in three call for most of my internship and for 6 months in my residency. I have no idea how I survived. I would quit Medicine if I knew I had to do it again.

If you get a group of anaesthesiologists together long enough, the conversation will inevitably come down to call and the whining will start. This is my whine.

1 comment:

burnttoast said...

Huge issue. I hoped Canada would be different. I was fine with coming in for the things that could not wait without increasing risk to patient. But as time passes, you realize that the surgeons use the system to do what they want when they want. If a surgeon only does this a few times a year, say before leaving town for a week, surgeon believes it is OK. If there are 20 surgeons doing this for 5 weeks a year apiece, no math needed, the anesthesia providers are hosed. The only option is to tell the hospital, if they want to provide this much service, they need to pay a salary line to do it. And by the way, Mr./Ms Administrator, IF we have a caregiver up all night, we will need to close a line, because we don't have extra manpower available. No hospital administrator will go on record as saying "We make our docs work more than 24 hours." They will turn a blind eye to it happening forever if the anesthesia dept keeps taking it in the shorts, silently. And it does always come down to money or time. I have wondered if hiring someone parttime, to either work Saturday/Sunday during days, or even working evenings would help. Or if even hiring a parttimer to cover some days, giving the night 2nd call person a shorter shift would help. It is a dilemma. We tried having a week of nights 4pm-7am 2 MDs alt first and second call, team intact for a 6 day shift, some people loved it, some hated it so it got killed. We even tried evening shift for a while, we had a MD that hated getting up in the morning. But he moved away, and there was always someone in the group who felt the evening guy was getting an unfairly sweet deal.
But the bottom line is, the system is not going to change. The anesthesiologists need to protect themselves and their patients. Part of that is informing the hospital administrators when their expectations are overworking your department. My hospital had 20+ ORs and only ran 1 elective room on Saturday. If you have 2 rooms staffed, what is the hospital and surgeon position on tying up resources so that a true emergency will have to wait? The desired goals need to be clearcut, and then your department can impliment their protocol. (But calling in someone not on call can never be part of the protocol!!!) And what about C-sections? Are they included in this? The best way is to have guidelines for appropriate usage, and have surgeons review cases pegged as questionable. Our heart surgeons had to do this, and although it did not stop abuse, it did limit it somewhat. (and the best fights were when a heart surgeon would bump another heart surgeon, we could have sold tickets and popcorn!)