For the last fourteen months I have practiced the specialty of emergency medicine at a hospital where the doctors in the emergency department (ED) work 24-hour shifts. When I signed on there last spring, I wasn't sure if I would like that kind of scheduling. I had never worked 24-hour shifts before.
Such shifts are typically scheduled 7 AM to 7 AM. Obviously that is a long time to work at a mentally demanding job with no sleep. Its feasibility depends on two things. First, how busy is the ED between 7 AM and midnight? Second, how many patients typically come in between midnight and 7 AM? If the workload between 7 AM and midnight is moderate, and few patients come in after midnight, it may be reasonable. So, in a community in which no one goes to the hospital in the middle of the night for things that are not true emergencies, it can work.
Increasingly, however, we live in a 24-7 world. People go to Wal-Marts and supermarkets that are open round the clock. So, when the sore throat for three days or the back pain for two weeks is just too annoying in the middle of the night, they go to the ED at the local hospital. They expect that the staff on duty are there to take care of them at 3 AM the same as 3 PM.
You might think the problem with 24-hour shifts is that the doctor won't be at his or her best at 5 AM when there is a patient who is critically ill or injured, or who requires clear thinking about a diagnostic puzzle or a meticulous repair of a wound in a cosmetically important area of the body. But I've been doing this for more than 25 years, so my diagnostic and procedural skills are not easily challenged, even when I would much prefer to be napping. And for the critical patients, the adrenaline rush can sharpen my edge in a flash.
No, for me the true challenge is that sore throat for three days or back pain for two weeks - the "reason for visit," as the phrase on the patient's chart reads, that makes me wonder, "Why now?" Why not 8 hours ago, when I wasn't hoping for a nap, or any time in the primary care doctor's office? I have to draw upon my dwindling inner reserve of niceness, because I know patients expect the same cheerful, eager-to-serve attitude and demeanor whether it's 4 AM or 4 PM.
The published scientific literature says 24-hour shifts for emergency physicians are not a good idea, except in hospitals that don't get many patients in 24 hours - and very few (meaning only true emergencies) after midnight. I've decided they're probably not best for me. I'll be doing them for only another month and then moving to a different hospital, although primarily for other reasons, having to do with what I really love in the practice of my specialty. I will surely write more about that in times to come.
Well, I was really excited to read this blog, and am really saddened at the end. We have had the discussion many times about how hard the 24 hour shifts are on the body. They will no doubt be what ultimately cause me to go away from EMS as a full time profession.
ReplyDeleteRegardless, you hit every single nail right on top of the head. The "why's" dominate my thoughts at that time of night, as I know they do yours. Why didn't the patient go to urgent care in the morning? Why is this even an issue?
I am so saddened to hear that you will be returning to Pittsburgh. There are two reasons for this, my own personal ones of course. I know that any time I contact you for a medical command consult, there is a reliable expert on the phone that will give me the best guidance. Secondly, I know that any patient I bring you will be well served. I am a utilitarian, however... I have always believed in doing the greatest amount of good for the greatest amount of people. There is no doubt that the people of Pittsburgh will be well served with you as their ED Physician.
We will miss you greatly at EMS, and rest assured, when I come to Pittsburg on an inter-facility transfer, I'll look for you! You'll have to tell me later where you're headed. I will truly miss serving in the EMS system under your medical direction.
There is a larger problem than one of attitude when non-emergent patients bother you at night. Disrupting you circadian rhythm over long periods is detrimental to your health, both mental and physical. Almost anybody can stand up to an occasional all-nighter (although it takes longer to recuperate after age 40), but doing it on a regular basis for years is associated with work dysphoria and burnout, as well as hypertension and immune related illnesses. Workers who change shift loose about 10 years of life expectancy. And there is no way to acclimate to a 24 hour shift, unless you can rely on undisturbed sleep during about the same hours. You will not be maintaining this pattern on your off days.
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