Between a Rock and a Hard Place: ACGME Passes New Duty Hour Regulations

Yesterday, the ACGME officially approved new duty hour regulations to be effective July 2011. The initial proposals have been a hot topic of discussion since they were first introduced in June. Read a prior post, Resident Duty Hours: Loopholes in the New Regulations, for a more detailed analysis of the fine print. The current interns and second year residents are now officially “the residents who got the short end of the stick.” No one seems to care. We labored through intern year and we survived. Yes, it was difficult, but we made it. So did all of our predecessors. And now we are limiting hours to “protect” interns – we are switching the pyramid such that senior residents, rather than interns, are spending more time in the hospital. The senior residents, PGY-2 and above, will now be required to stay for 24 hours – the interns must leave after 16 hours.

Great idea in theory, but far more difficult in practice. Hospitals across the country are going to struggle to comply with these new regulations. Options include switching to a night float system, bringing in more hospitalists and PAs, or – and this seems like the least reasonable, but the most likely – just let the senior residents sweat it out. They can deal. Right…

I am curious how many people who sit on the ACGME board were interns when the new computer order systems began to replace handwritten charts. With the advent of computer ordering, residents are more closely monitored and are required to place electronic orders in a timely fashion – or else. I cannot count the number of times that I have been running a code, intubating a patient, placing an urgent central line – and have been interrupted because I need to find a computer to type in a laundry list of orders. Regulations and systems can be helpful – but they become a problem when they are so cumbersome that they compromise patient care.

And this is where the intern comes into play. Although the job of an intern is tiring because of the hours, it is not overwhelmingly difficult from an intellectual standpoint. An intern can always ask for help. As senior residents, however, we rely on interns to help us with some of the more mundane tasks – order writing, note writing, etc. Although these tasks may seem mundane, (1) they are important and (2) in retrospect, I realize that I learned a lot from them – by directing a patient’s care on the micro level, even if I am only writing orders that someone else has instructed me to write, I gained substantial amounts of medical knowledge during my intern year by doing, rather than by reading or thinking.

Another problem is that second year is not easy. Do the board members remember what it was like to be a second year resident, and do they have a sense of what it is like now? I worked as an intern in the medical intensive care unit in my last month of intern year, and one month later I worked as the senior resident in the coronary care unit. Which was harder, and which did I need to be less fatigued for? Most definitely the latter. In those first months of second year, fresh out of intern year, residents run the intensive care units, the emergency department, the medical floors. And it is important that we have time to think. If we are bombarded with our job as a senior resident and the tasks of the intern – order writing, note writing, etc. – we cannot do either well. In a 24-hour time period, it is the senior resident – more than the intern – who needs a short nap. After all, the seniors – not the interns – should be the ones making critical decisions about patient care in the middle of the night.

The 24-hour rule has also been changed with these new regulations, from 24 hours of patient care plus 6 hours of transfer of care to 24 hours of patient care plus only 4 hours of transfer of care. I find it almost comical that we are going to try to cut hours in the intensive care units, where rounding on new patients can take until noon or beyond – which far exceeds the proposed limit. The loophole I mentioned before – that residents can stay later to take care of one patient – is going to be used to excess, and not necessarily for the right reasons. There is no possible way to finish medical rounds earlier than we do on post-call days. Programs are already struggling to meet the current work-hour regulations.

Good ideas in theory are not always good ideas in practice. Although the ACGME has good intentions in mind (I agree with the principles behind them), the hospitals are left to fend for themselves. With limited money and limited residents, these new regulations put hospitals between a rock and a hard place. And ultimately, that will put senior residents in a difficult situation. I hope that implementation of these new policies will be a matter of concern – it is easy to publish guidelines, but much more difficult to execute them appropriately.

Living for Tomorrow

Today was difficult. A busy Monday in the emergency department. The volume was the highest we have seen in a while. I did not stop moving for 12 hours. Movement makes the time go faster, but not fast enough. Today I am living for tomorrow. Until now, I have always tried to live in the moment. There is a beautiful piece by Nadine Stair, an 85-year-old woman who was asked what she would do if she had to live her life over again.

I’d dare to make more mistakes next time. I’d relax. I would limber up. I would be sillier than I have been this trip. I would take fewer things seriously. I would take more chances. I would take more trips. I would climb more mountains and swim more rivers. I would eat more ice cream and less beans. I would perhaps have more actual troubles, but I’d have fewer imaginary ones.

You see, I’m one of those people who lives sensibly and sanely hour after hour, day after day. Oh, I’ve had my moments and if I had it to do over again, I’d have more of them. In fact, I’d try to have nothing else. Just moments, one after another, instead of living so many years ahead of each day. I’ve been one of those persons who never goes anywhere without a thermometer, a hot water bottle, a raincoat, and a parachute. If I had it to do again, I would travel lighter than I have.

If I had my life to live over, I would start barefoot earlier in the spring and stay that way later in the fall. I would go to more dances. I would ride more merry-go-rounds. I would pick more daisies.

But my moments are stolen, consumed by this job – eat, work, sleep, and wake up the next day to begin again. There is no time for bare feet, as I trudge along this path of residency. The work is draining. But this is different from anything else I have experienced. I have put in hard work – long hours, challenging intellectual puzzles, sheer physical work – before. Although hard work is difficult and tiring at times, it is always possible. Residency is a different beast. And my perspective now is unique, is time-sensitive – I am in the eye of the storm, looking out around me at the rest of the world, quite far removed.

Parisian children riding merry-go-round in a playground, 1963.

It is as if I have departed, at least for now, to the underbelly of the world. My lens is medicine – and all of my thoughts are filtered through that lens. When I see a child on the street, I do not simply see the child. I see him through my lens, and I think to myself not, Here is a boy riding a bicycle on the driveway with his brother – laughing and racing in the sun. Instead, I think, Here is a young boy who is not in the hospital. A young boy who is not dying. A young boy who is not struggling to breathe. And he is not pale and withered. How strange. He must not be sick.

As I drive on the highway, I do not simply think about driving, changing lanes, watching the cars, pressing the gas and the brakes. Instead, I am watching at all times – like a hawk – for an accident. One is bound to happen, I think. I saw three horrible accidents just yesterday, one patient with his arm completely off, one patient dead on arrival, another with a horrible facial laceration layers deep. One is bound to happen again. Which lane? Likely the third where cars are going the fastest. Which driver is looking most reckless?

When I went to the grocery store this morning to get breakfast, I did not simply stand in line and wait for my order. I watched an older man in the adjacent aisle almost slip on the floor – I watched his right foot slide, and was almost ready to leap towards him to prevent him from falling. But, miracle of all miracles, he caught himself. A million thoughts raced through my head in that split second. He is going to fall, hit his head, and need to go to the emergency department. And I will probably need to stay here until that happens. I watch the man at the counter who is making my sandwich – obese, red, diaphoretic. What if he is having chest pain but is not telling anyone? He looks like someone who might have a heart attack. I need to leave before something bad happens.

It is such a peculiar place – this underbelly. A world of disease and grief. I glimpse the faint shadows of healthy people far in the distance, obscured and barely visible. I see just enough to wish I could be there and not here. But they are strangers to me – unreachable. And so I dive, yet again, back to the depths of the world. The sun rises and sets, but I only know this because I trust it is happening without me. Time passes because it must, but I am barely aware. Down in the underbelly, I look up through dark waters. I try not to hear cries and screams which reverberate in the water. I try not to see blood which darkens a beautiful blue. Through all this murkiness, I am certain that there is light and air above me – but it is far out of reach.

Needlestick Injuries

Yesterday I cared for a nurse who was in tears – she had a needle stick exposure in the hospital and is nine weeks pregnant. Needle stick injuries are far too common in the hospital – approximately 600,000 to 800,000 needle stick and other percutaneous injuries are reported annually among US health care workers. And the true frequency is underestimated given that many health care workers do not report needle stick injuries. The operating room, of course, presents the greatest risk. Needle stick injuries place health care workers at risk for transmission of HIV, Hepatitis B, and Hepatitis C. An article in The New England Journal of Medicine, Needlestick Injuries Among Surgeons in Training, discusses the prevalence of needle sticks among surgery residents – and the all too high frequency (51%) with which they go unreported.

Here is some of the basic information. First question: if the percutaneous exposure involves a patient with Hepatitis B, HIV, or Hepatitis C, what is the seroconversion rate for the exposed person? For Hepatitis B, the seroconversion ranges from 23 to 62%, with higher rates associated with patients who are HBeAg positive, as compared to HBeAG negative. The seroconversion rate for HIV is 1:300, or 0.3% from a hollow-bore needle stick injury (Marcus, Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus, The New England Journal of Medicine 319: 1118–1123). The seroconversion rate for Hepatitis C is 1.8%.

Next question: how effective is treatment? For Hepatitis B, multiple doses of HBIG within 1 week of percutaneous exposure to HBsAg-positive blood provides 75% protection from HBV infection (Stevens et al., Perinatal hepatitis B virus transmission in the United States, JAMA 253: 1740-5). Hepatitis B vaccination (assuming you have an appropriate vaccine response, which can be determined by checking antibody titers) prior to a percutaneous needle exposure is the best way to prevent seroconversion.

For HIV, information is limited because seroconversion rates are low and studies are limited by small sample sizes. In one retrospective case-control study, after controlling for other risk factors for HIV transmission, use of zidovudine was associated with a reduction in the risk of HIV infection by 81% (95% CI of 43%-94%) (Cardo et al., A case-control study of HIV seroconversion in health care workers after percutaneous exposure, The New England Journal of Medicine 337: 1485-90). To be most effective, the treatment should be administered within an hour of possible exposure and no longer than 72 hours post-exposure.

For Hepatitis C, there is no approved prophylactic treatment available. There is no vaccine and no cure for the disease. And the virus, which can ultimately cause liver failure, is a serious one.

An excellent resource for more information, complete with references, is Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.

There are a couple of frustrations with this process. First, although these percentages are useful when looking at the data objectively, it becomes difficult when it happens to you. After all, what do percentages matter if you end up on the wrong side of the data? What if you are the 1 in 300 who will convert to HIV or the 1 in 56 who will convert to HCV? The HIV post-exposure prophylaxis (PEP) medications have quite severe side effects, including nausea, vomiting, malaise, fatigue, and – for the pregnant woman – unknown consequences on fetuses less than 12 weeks. Thus, PEP is not without its consequences.

Second, it is still possible for patients to refuse to get tested for HIV. Laws vary on a state-by-state basis regarding the requirements for patient consent. This process can be frustrating for the exposed health care worker – and with good reason. Their lives are at stake – and no matter how small the risk, it still exists. The patient’s status can help the health care worker make a better informed decision regarding PEP.

When patients come into the hospital, they should agree to consent to HIV testing if a percutaneous exposure occurs. The health care worker should not be exposed to unnecessary anguish – and uncertainty – during this process simply because a patient refuses to consent. As health care workers, we willingly put ourselves at risk every day – for transmission of TB, meningitis, influenza, H1N1, and the list goes on. When the H1N1 pandemic broke last year, there were very few health care workers who refused to come to work – we were all there for our patients. Many emergency department workers put themselves at risk for physical and verbal abuse on a daily basis. I do not know many emergency health care workers who have not been exposed to blood, vomit, viruses, and other bodily fluids during their career. As a group, health care workers must accept that there are certain risks that come with this profession. But, to ease the added burden and stress that comes along with percutaneous exposure, the laws regarding patient consent in these situations need to be re-examined.

Floundering

I like the word floundering. It describes my state of existence as a second year resident. I am sandwiched between the most novice of physicians – interns – and the most senior residents, who will be full-fledged attendings in a matter of months. A four-year residency program is not unlike high school. In that scheme, I am the sophomore. Legend has it that the word sophomore is derived from the Greek, sophos (wise) and moros (foolish), or wise fool. It represents a time in training when you have gained just enough knowledge for it to become dangerous. It is the period of learning where there is a tendency to become overconfident – in medicine, this means that you are able to recognize most things, but you are not always cognizant of why you might be wrong or what you could be missing.

Elephant Seal, Piedrras Blancas, California.

And so this is the proverbial sophomore year. And I am in the proverbial sophomore slump. In the UK, this is more commonly referred to as the “second year blues.” I am in a holding pattern, observing as time passes – in slow motion – around me. Waiting for enough time to pass so that I will have persevered through the most difficult part. Patients and stories are blending together. My enthusiasm for the hospital is dwindling, as every ounce of energy is drained from my reserves. Life in the hospital has become tiring.

But through it all, I know – intuitively – that I am learning. And my knowledge is increasing exponentially, although I am too exhausted to take notice. I walk into the emergency department with a new calm about me. I am not sure if it is sleep deprivation, or that dangerous over-confidence, or sheer emotional exhaustion. But the calm persists throughout the day, no matter what comes in that door – blood, screams, cries, swelling airways, exposed bone. Nothing surprises me anymore. I never realized that this is emergency medicine in its truest sense – a lack of adrenaline, a variety of tools and knowledge with which to analyze any and every problem quickly and efficiently. Triage remains the most important principle of this type of medicine.

I always keep my respect for the airway, and for the subtle details about patients’ lives that will change a diagnosis, but aside from those things, much of the rest of medicine is – finally – beginning to make sense. And much of it is at my fingertips. Yesterday, I was able to distinguish – from my history and physical exam – a kidney stone from appendicitis in a young man with right-sided abdominal pain. I would never have been able to do this just a year ago. I did it with ease, confidence, and humility – and still considered both diagnoses and ordered the appropriate tests.

The common piece of advice when you encounter a stressful situation as a physician – a code, a catastrophe, a surprise – is “first, check your own pulse.” My pulse has become constant. I am at peace in the emergency department. When things get crazy, I ride the wave and take care of the important things first. For the rest, I have learned to let go – to place things in the back of my mind, tucked away for a later time. This is how you manage medicine in a crisis. Prioritize, triage, and use your “medical instinct,” if you will – those years of knowledge which amount to a gut feeling – to do what is best. It is not out of the realm of possibility to succeed at this job. But this is the viewpoint of the sophomore. A couple of years from now, I will be writing that it is not out of the realm of possibility to fail at this job. But for now, I will embrace the sophomore slump and take from it the small amount of satisfaction – small successes, growing knowledge, and my sharpening clinical skills – that is has to offer. Floundering all along the way, flopping in the sand, an elephant seal navigating nowhere in particular – only waiting for the setting of the sun, the passage of time, and the imminent release of stress as I plop head first into the cool, salted waters of third year residency.

List of grievances

In the spirit of upcoming Grand Rounds, to be hosted by Doctor Grumpy in the House, I have decided to embrace my less flattering side and share it with the world. Lists are sometimes a nice way of condensing life – or work, or whatever else – into a concrete set of points. This list of grievances will ultimately be followed by a list of gratitude, once I muster up enough positive emotions in the weeks to come. In the life of a medical resident, it is easy to come up with a long list of grievances – I will only focus here on highlights.

1. Call. 30 hours of work in a row, often without any sleep, is exhausting. But weekend call is the worst, because just as I go to lie down for my 20-minute nap of the night, I remember that the cleaning staff  (unlike the resident staff) is off on weekends. The call bed is unmade, dirty, with wrinkled sheets and strands of hair still lingering from the night before. And spending the time to go back to the supply room to get new sheets and make the bed? Well that just took up 10 minutes of my 20-minute nap. Lovely.

2. The 3AM phone call from a nurse, right in the middle of that 20-minute nap, to inform me that a patient wants to leave AMA (against medical advice). In the middle of the night. With IVs in and all. As I contemplate my trek up to the patient’s room, and as I contemplate how on earth I am going to convince him to stay when I myself don’t want to stay, I only have one word, still vivid in my mind from the first season of Grey’s Anatomy. Seriously? I mean, seriously.

3. No windows in the emergency department. I have yet to find an emergency department with windows. If one exists, please let me know. But there must be a reason. In one of the old emergency departments, several years ago, the psychiatric rooms did have windows – close to the ceiling. A patient tried to escape by jumping out the window, broke his arm, and walked back into the emergency department through the front door – now complaining of a broken arm. So maybe windows are not a good idea.

4. Getting paid $10 an hour after over 5 years of post-college education. $10 an hour, with hundreds of thousands of dollars of loans still to be paid. When one of my patients, who left school after 10th grade and now works part-time mowing lawns, found out how much a medical resident makes, he said to me, “Are you crazy? Why on earth are you doing this?” I smiled. No need for an answer – I’m pretty sure that question was rhetorical.

5. My first month in the emergency department. I walk up to a patient to introduce myself as his doctor and to see how he is doing. I am greeted with a string of words which do not need to be mentioned, followed by spit – yes, spit – in my face. A good reason to wear protective eye wear at all times. After number 4 above, isn’t it wonderfully rewarding to care for people who appreciate it?

6.  No lunch. I have yet to eat lunch while working. Whether the shift is twelve hours or fourteen, it makes no difference. At noon you think it’s fine. I can do this, you tell yourself. By 3pm you are tired and famished. By 6pm you are delirious and cannot remember most of the events of the day. Whenever the resident staff increases, people should buy stock in companies that make granola bars and snack packs. On the upside, the less you eat and drink, the fewer bathroom breaks you need to take – those aren’t always feasible either.

7. No snow days. That one is painful. I can no longer turn on the radio to listen to the long list of school and business closings after a huge – and I mean huge – snow storm. Driving conditions are dangerous, they say. Streets are not plowed. Not a time to brave the roads. Everything is closed. But the hospital is open. And the emergency department will need to be caring for all of the people in car accidents who went against better judgment and did brave the roads – most likely the only people crazy enough to be out there are health care workers anyway. This December I will be there yet again, digging my car out from under snow banks to get to the surgical intensive care unit by 5:30AM. All through the holidays. Life is wonderful.

8. The parking garage. On the one hand, this is a perk – I do not know how I would survive residency without the parking garage, which shelters me from the elements and is so loyal in providing me with a parking spot. Not that I don’t pay for this kind of service, mind you. I do. But it is the absolute worst when, delirious after a 30-hour shift, you cannot remember where in this 10-story garage your car was parked. You can spot one of us a million miles away – wandering aimlessly through the rows of cars like lost souls – the post-call residents, tired as death, pale from exhaustion and dehydration, barely able to walk straight (in fact, studies have demonstrated that driving post-call is similar to driving drunk), searching for an escape from this place. Tragic, really. But the security guards monitoring the cameras must have a good laugh as they watch us trudge up and down the stairs, through the rows, pressing car alarms which always seem to run out of battery at the most critical time.

9. Screaming patients. No, I do not mean yelling loudly. I mean screaming at the top of their lungs. There is a difference. And these patients are determined – they open the curtains, open the doors, flail about for attention, and even follow physicians to their seats in the center of the emergency department. Relentless. And then they proceed to scream at the top of their lungs. It inevitably begins with “doctor” or “nurse” followed by a long string of often incomprehensible (and maybe it’s better that way) grievances of their own.

10. And the last grievance – on a more serious note, it is difficult to be an emergency physician because we often go unnoticed. Internal medicine physicians and specialists are able develop relationships with patients and their families over time. Because of this, they can see the effect of their work and can receive gratitude from their patients. Emergency physicians are there at the most critical moment in a patient’s life. Although, if the job is performed well, we do make an impact, it is only fleeting. And we are often not thanked – when people think back on their hospital stay, they probably cannot even remember the emergency physician’s face or name let alone their interaction together. We are the unsung physicians in the hospital. But we play an important role nonetheless.

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