Attending physicians who work too many hours need restrictions too

Dr. Lewis didn’t sleep last night.

All day he stood, heavy in full surgical scrub with a human heart in his hands, replacing damaged valves and calcified arteries until the heart beat on its own again. After he finished, there were a few hours before the transplant to get some dinner, to call home.

The heart came on a helicopter. A young man, a bad accident, a perfect heart. Dr. Lewis pierced the veins and the arteries and connected the sick dying man to the bypass machine that would pump and breathe for him in the time between the cooler arrived and the heart in the cooler started to beat inside the dying man’s chest.

They had to shock it a few times to get it going, but it beat with the vigor of a heart taken out of a young man’s chest. He finished in the morning when the day shift nurses arrived. He did a perfect job.

And then he decided to keep going. The surgical fellow, the scrub nurse, the physician’s assistant and the anesthesiologist all asked him to stop, to reschedule the case. But Dr. Lewis was in charge, and he wanted to keep going.

There are work hours rules for residents. A maximum of eighty hours per week and twenty-four hours at a time, with one day per week completely away from the hospital. When we are finished with residency, we make our own rules.

I thought about walking out, past the nurses’ station and the ladies’ restroom, past the anesthesiology office and the lunch room, out to the preoperative waiting area to Estelle Johnson, whose coronary arteries were going to be bypassed by Dr. Lewis.

“Mrs. Johnson,” I would say, “I’m here to tell you that Dr. Lewis has been awake and operating for twenty-four hours and I’d like you to decide if you would prefer to have this surgery today or if you would prefer to postpone it until Monday. Dr. Lewis will have the whole weekend off and will be well rested on Monday morning.”

“Monday,” she would say. “I’ll have the heart surgery on Monday.”

But I was sitting at a computer in the break room overhearing all of this, and I puzzled again at the ultrasound images of cardiac diastolic dysfunction on my screen. I sipped my coffee.

Dr. Lewis did a perfect job. Estelle Johnson’s coronary arteries run fast and smooth. Tonight he will sleep a deep and perfect sleep.

I imagine the worst things. When the bridge over the river is icy on the drive home I picture wrestling the kids out of their car seats after the car flies over the guardrail and drops into the frozen river. Cars honk at me when I crawl across the bridge, but the boys babble in the back seat and we haven’t gone over the guardrail yet. I imagine what Estelle’s husband dreamed about while she was on the operating room table.

He should have done it on Monday.

All the research has shown one thing: sleep-deprived doctors are bad doctors. Crises happen at all hours, so we will always need to be able to stay awake through the night, however painful. But as residents our hours are diligently recorded and after twenty-four hours we get kicked out of the hospital. Why not, then, for the man in charge?

Felicity Billings is an anesthesiology resident who blogs at One Case at a Time.

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