No sleep till Brooklyn

A veteran hospitalist reflects on work hour limits for residents.


It was February 1st, 1994—my first day in the medical ICU at New York University's Bellevue Hospital Center. Normally I would have been a bright-eyed and bushy-tailed intern, ready to get cracking. The problem, however, was that I was tired. Really tired. The night before I'd been on call, finishing my month on the medical wards, and had rolled into bed at 3 a.m. So I dragged myself in, hoping to suck it up, push through the day, and start fresh tomorrow.

Photo courtesy of Neil Winawer
Photo courtesy of Neil Winawer.

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 problem was, they all looked equally run down.

Houston, we have a problem...

Turns out, every intern had been busting his or her butt on call the night before, the odds of which are incredibly small. Rare or not, someone still had to tackle this first overnight shift, and for whomever it was, it was going to royally stink.

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 my 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, 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 roads 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. After wading 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 the car wasn't budging. Luckily I saw some friends passing by who graciously took pity and helped push the car onto the street.

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

And then the story gets crazy…

Okay, right then and there I should have called it a day and slept till morning, but you see, I had a basketball game back in Manhattan at 8 p.m. I know, it sounds incredibly ridiculous now, but during your residency you'll do anything to make yourself feel human. For me, it was basketball.

I had played in college, so 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 p.m. 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 there.

I worried that a nap on my bed would turn into a full blown snoozefest, so I sat cross-legged on the floor, my back against the bed and 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 punctuated by gunshots in the distance, followed by sirens. In other words, 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” tool to help me break in. After walking several blocks and waiting for what seemed like an eternity, the officer emerged and gave me 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.”

I headed out to the gas station and, sure enough, found a scraggly-looking dude in an unregistered car.

“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 had come and gone. It was 8 p.m.

And the story becomes painful…

Any rational person would have marched his 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. I'm so thankful 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 kept ticking...

I did 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.

That night 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.

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 say that the hours we worked in training were acceptable—they weren't. However, I also want to be clear that 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 his or her 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.