Duty Hours Pre-Form Part 2: No Sleep 'til (or in) Brooklyn.

*NOTE: no YOUMAN beings were hurt or injured during this blog post.

image credit

"Foot on the pedal - never ever false metal
Engine running hotter than a boiling kettle
My job ain't a job - it's a damn good time
City to city - I'm running my rhymes. . .

. . . .NO . .  SLEEP.  .  'til BROOKLYN!"

from The Beastie Boys 

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Today we continue the saga and fireside tales of life during internship and residency--pre-duty hours reform (aka "back in the day when nobody cared how long you worked," aka "The  Other Fight Club").

This is partly to underscore why having some limits on how long young doctors (and hell, old doctors) can work is a good thing. But like any great story, it's also to just a chance to just chronicle it--and then shake our heads while asking, "Dude, what were you THINK-ing?" Anyways. There's just something about hearing something that's cringe-worthy in that Seinfeld-y/Curb-your-enthusiasm-Larry-David-y/trainwreck-y kind of way that intrigues most folks. . . .okay, me.  

As promised, in a Reflections of a Grady Doctor first, we bring you this story from another sho' nuff and bona fide Grady doctor. . . . .

Now y'all put your hands together and show some gradydoctor love for Dr. Neil W. . . .
(Oh yeah--and just a suggestion--imagine a wonderful New York accent as you read this--makes it much more fun!)

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 No Sleep 'til (or in) Brooklyn: A series of unfortunate events.

Bellevue Hospital-- America's Oldest Public Hospital

 The date was February 1^st, 1994—my first day in the medical intensive care unit (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 3am. Dragging myself in, I was hoping to suck it up, push through the day and start fresh tomorrow. *

*(Those who read Duty Hours Pre-Form Part 1, already know that this isn't how it always went down.)

Bright-eyed and bushy-tailed: Neil W.'s (pictured on left) first month of internship, July 1993

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 the that night's call. 

The only thing was that all of them looked equally run down. . . .  

Houston, we have a problem. . . . .

Turns out that every intern was busting their butt on call the night before! For those less familiar with residency training, the odds of this happening are incredibly small (1 in 256 to be exact--wait, actually even smaller than that now that I think of it.) Rarity 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.

gradydoctor commentary: Unlike mine, this double-call was NOT voluntary--OUCH! (image credit)

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. That said, 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 as mine (an 84 Eldorado), was in the shop. 

(Yes--the Winawers love late-model Caddys.)

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 house 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 which read 5 pm.

gradydoctor commentary: A SWATCH? Damn, now THAT'S old school, for real!

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

Okay, right then and there I should’ve called it a day and slept til 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, 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 snooze fest, 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 out 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 seventeen 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 pm.

gradydoctor commentary: Am I the only one wondering why Neil's so skilled at car break-ins?

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 fan fare. 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. . . .

“Soy un prededor,

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 1^st 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--which reminds me of another story that I'd be happy to share upon request. . .)

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 would take 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.  

WTF? 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.

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Living to tell: Neil and Tamara W. now.

Taking it to the Bridge: Grown Man Commentary 

Amid much controversy, the work hour rules for residency finally changed in 2003. Now, as Kim mentioned, they have changed again as of July 1, 2011. First year-fresh outta med schoolers (aka 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 (from the comments/questions raised in Duty Hours Part I) 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 2 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 handoff 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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Shout out to Neil W. for a great post--worthy of a Grady doctor fo' sho! (Now y'all know how we treat "company" when they come by to visit us. . . .drop a comment, why don't you?)

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Now playing on Dr. Winawer's mental iPod. . . .

 
and still playing on mine. . . .


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Happy Sabado, y'all.