Residency Without Rest
After 27 hours in labor, it happens in a flash.
Doctors wheel the gurney down the hallway and into the delivery room, mother moaning.
Friends, doctors and nurses work in unison, clenching the mother’s hands, running fingers through her hair, whispering and squeezing encouragement.
Latex gloves on, Dr. Christina Zaro--one of 13 first-year residents at the Ventura County Medical Center--stands ready to deliver her 14th baby.
The top of the head peeks out. Then the eyes, the nose. Down to the neck. But then the tiny shoulder is snagged. The baby’s head begins to turn purple.
Push up her legs, the attending doctor says coolly. Down on the pelvic bone.
Zaro firmly takes the baby’s head in her hands, then eases out its tiny shoulder. Seconds later the baby emerges.
The mother--her forehead damp, her hair stringy with sweat--throws back her head in a wide, ecstatic, glorious smile.
“Es una nina,” she says, softly, her eyes following the baby. “Call her Maria de Los Angeles.” Maria of the Angels.
“I used to cry at every single one,” says Zaro an hour later, even now awed by the miracle of delivering a new life.
Nearly six months into the first year of a three-year residency at the Ventura County Medical Center, the 13 young doctors-in-training are immersed in the life of the hospital.
As part of the hospital’s prestigious family practice program, they have collectively worked an estimated 25,920 hours, delivered 200 babies and seen more than 20,000 patients. They have spent 450 nights in the hospital, and worked more than 5,200 hours in the emergency room. Like Zaro, they have all felt the joys of being the first to touch a newborn’s head. And most have experienced the pain of being the last to care for a dying patient.
The residents have been pushed to the limits of emotional and physical exhaustion. Their experiences are emotional, intense. Sometimes they are back-to-back.
On this day it is barely 6:30 a.m. as Zaro rushes briskly about the labor and delivery floor, checking contractions and cervical dilations on mothers-to-be, and monitoring the half-dozen newborns wrapped in little white bundles in the nursery. At 8 a.m. Zaro is called down to the conference room to give a lecture on a patient who died three weeks earlier of an unusual disease.
The patient was the first she lost.
Her presentation is clinical, professional and detached.
With poise she fields difficult questions from colleagues and attending doctors.
A scholarly discussion follows.
But out in the hall Zaro becomes emotional.
“It really shook me up,” concedes Zaro, who says she still thinks about what she could have done differently, even now, three weeks later. “I am much more paranoid. I have taken steps--to send for the attendings. To run more tests. I don’t know if people with more years behind them would do this.”
Zaro was one of four physicians working on the patient--including a second-year resident and two attending doctors. But still not accustomed to death, it is perhaps she who feels it most intensely.
She doesn’t know, because no one talks about it.
There seems to be an unspoken code that doctors do not become emotionally involved with their patients. And now she agonizes because her patient died, and because she cares so much.
“This is the first time I really felt this responsibility,” she says, shaking her head.
But Dr. Lanyard Dial, head of the hospital’s prestigious UCLA residency program, sees this as one of the most valuable experiences young doctors encounter. “Ego and self-doubt are the hardest part of medicine,” Dial says. “They are particularly hard as you start out. Everywhere along the way you are going to be damaged.”
“The ambience of all of medicine forces people to try to look more capable and more confident than they are. That’s the bad part of medicine. We struggle to fight against it. But you don’t want to give patients the sense that you don’t know what is going on.”
For the young physicians, the emotional intensity of witnessing births, deaths and traumas daily is only exacerbated by mounting exhaustion. During residency, the young doctors toil 80 to 100 hours a week, working brutal schedules that stretch them to the limits of their endurance.
On their most demanding rotation--treating surgical patients--they pull 36-hour shifts every fifth day, staying up all night then groggily forging through another eight hours.
They are on that most demanding rotation every other month. And even when they are not, they are usually on call every fifth or sixth night in the emergency room.
They started their rotations in July. By fall, the long hours are taking their toll.
Dark circles show under their eyes. Sometimes they doze as they fill out seemingly endless files of paperwork, or nod off listening to morning medical lectures. Their immune systems worn down by fatigue, many are constantly battling low-grade colds and infections.
They complain that their memories are getting worse. Often they cannot remember what patients have said to them only minutes before. They mix up the numbers on the blood pressure.
“Sometimes I am so tired I can’t even talk,” says first-year resident Steve Mills at the end of a 36-hour shift. “It’s scary. I discharge patients and I wonder if I forgot something.”
Perhaps nowhere does the fear of error due to fatigue and inexperience run higher than the emergency room--where residents can be on the front line.
It’s just before midnight and first-year resident Andrew Bruton has seen more than 11 patients since he began his shift in the emergency room at 8 a.m.
He has removed battery acid from a farmer’s eye, stitched up a bloody knee, removed sutures from an 8-inch gash, counseled and comforted a woman who is dying of cancer, diagnosed a case of diabetes and taken care of several feverish children.
And now, Bruton is about to remove his first bullet.
There has been a gang scuffle in Oxnard. St. John’s Regional Medical Center can’t take any more patients and all the emergency room cases are being sent to the Ventura hospital.
A 17-year-old has taken a bullet in the hand, and two police officers hang over him, interrogating him as he cradles his bloody fist. He is all bravado.
Until the doctors get ready to remove the bullet.
The kid screams as they unwrap the layers of gauze.
“That medicine don’t help. I’ll take it. Just do what you gotta do,” he says, as they shoot needles of painkiller into his wound.
Bruton, daring but inexperienced, takes the scissors and begins to probe deep into the bloody flesh, searching for the bullet.
Blood leaks out of the palm.
“It’s big, so it’s going to be difficult to pull out,” the attending doctor coaches. The bullet expanded on impact, fracturing the hand. The scissors go in, a half inch, three-quarters of an inch. The youth’s jaw is clenched so tight it’s white. The tendons seem to leap from his neck. His legs are shaking.
Still, Bruton probes. Then he finds it. Slowly, he extracts the bloody metal mass--a three-quarter-inch fragment. He pops it into a plastic vial.
“That was pretty cool,” Bruton says, back in the doctor’s office.
But the toughest part of the long night is still ahead.
From midnight, Bruton is on his own with only a second-year resident NERD (night emergency room doctor) there to supervise him for the next six hours.
Upstairs, an attending doctor slumbers, ready to be awakened should anything go horribly wrong. Bruton sees three more patients. He is yawning, leaning more heavily on the counter as he flips through his endless paperwork.
At 3:30 a.m. he throws water on his face and drinks a cup of coffee. Just two more patients on the board. Then one.
It appears he will finally be able to sneak upstairs to snatch a few hours of shallow sleep, curled on the bed in the residents’ room.
But at 3:45 a.m. a woman throws open the door to the waiting room.
“Hey, there’s someone bleeding out here!” she yells.
Bruton walks to the door and looks out. A man in his mid-30s stands there, bloody and seemingly drunk. He has a huge gash above an eyebrow. Blood drips down his face and is spattered over his shirt.
He is Bruton’s. There will be no sleep tonight.
The man is babbling. The drink seems to have made him immune to pain.
“I’m bleeding. I don’t want no moguls on my face. I want it tight, man. And I don’t want no cheap-assed doctor on this one.”
He gets the first-year resident.
The wound is deep and long. Bruton sticks his finger in up to the knuckle to clean it. The wound is so deep he has to make inner stitches. Then outer ones. Slow with sleep, it takes Bruton more than an hour to sew more than 30 black stitches. The man never stops talking.
At 5:50 a.m. he finishes. Giddy from lack of sleep, Bruton wraps up his patient’s head like a Revolutionary War hero and sends him home. “Dude, that is a sweet job,” the man says, pumping the tired young doctor’s hand enthusiastically.
At 5:55, his shift is done. Bruton stumbles out of the hospital just before the sun rises.
“It’s a weird thing after 24 hours to go outside,” he says, striding into the parking lot. “To see, wow, there’s life outside the hospital.”
He will fall exhausted into his bed, and be back in less than 24 hours.
Some health-care advocates question whether the long hours are anything more than a form of hazing that young doctors must endure to earn entrance into the elite medical establishment. And there are those who argue that the hours residents work compromise the health care they provide.
In a high-profile case in New York, a father began a furious crusade against the grueling 36-hour shifts worked by many residents, and filed a $2-million medical malpractice suit against the hospital and the four doctors who cared for his 18-year-old daughter the night she died in 1984.
Fatigue and inexperience, he argued, had led the doctors to treat his daughter improperly, and to administer a drug that he contended helped cause her death.
He lost the case.
But it has had far-reaching repercussions.
In 1989, the state of New York adopted new regulations limiting the long hours that hospital residents can work, to 80 hours a week, and no more than 24 hours at a stretch. In emergency rooms they can work no longer than 12 hours.
California has no such law.
Although there are no limits on the total number of hours residents can work, the national Accreditation Council for Graduate Medical Education sets some standards: No one can work more than six days a week, and no one can be on call more than every third night.
Typically, family practice residency programs are less demanding than specialty training, such as surgery, where residents may be forced to stay up all night every third day. But among family practice residency programs, the Ventura County Medical Center course is known to be one of the most rigorous. And Dial, the head of the residency program, makes no apologies for the long hours.
Rather, he portrays them as an advantage. Indeed, a necessity.
“My preference is erring on the side of more work,” Dial says. “I would rather give someone too much to do . . . than have them sitting around twiddling their thumbs. We maintain a heavy workload to teach people all they can learn. . . . We sell it as training.”
The hospital, however, does not leave them alone to stagger under the heavy workload.
Indeed, as the year progresses and they grow steadily more exhausted, the residents are encouraged to rely more and more on each other for support.
So critical to the hospital system is the bond forged between the young doctors that the hospital goes out of its way to cultivate it.
“We have an agenda to get them together,” Dial explains. “I want to build within them the sense that they are reliant on each other.”
Toward that end, the residents are encouraged to socialize together outside the hospital. Although he cannot force them to do so, Dial says, residents on the community medicine rotation--considered the least strenuous--are strongly encouraged to organize a party at least once a month.
Also, each fall, all the first-year residents are given an entire weekend off for a retreat.
“We want them all to stay together,” Dial says, outlining his ideal retreat. “We would rather have them in one large house than separate hotel rooms. They drive together. Eat together. Hang out together. This solidifies their bond--so if something happens they will help each other out.”
For this year’s group of residents, that evolving bond has already been put to the test.
In late September, first-year resident Jennifer Scott’s mother was hit by a car in France. For two weeks Scott forged on, doing her rotations, trying to balance her work with her increasing anxiety over her mother, unconscious in a French hospital.
Finally, she flew to France to be at her mother’s side.
The 12 remaining first-year residents--already pushed to exhaustion by their own grueling schedules--pitched in, working additional hours to cover for her.
Steve Mills took on six consecutive weeks of the surgery-medical rotation, an assignment so demanding that residents often can’t stand up at the end of it.
Scott is now back at the hospital, her mother on the slow, uncertain road to recovery. On weekends, Scott shuttles up to Santa Cruz--a six-hour trek after a strenuous week in the hospital--to nurse her.
And with the crisis still far from over, Scott must begin to make up for what she missed.
The system does not always work smoothly. Some residents are willing to pick up the slack. But there is also a thread of resentment from some--already pushed to the limit of what they can do.
On the first weekend of November--finished with a long day at the hospital--the residents pile into a caravan of cars and head to Lake Arrowhead for their retreat.
There, in a rented A-frame in the woods, they collapse. They sleep, drink and play board games. They cuddle their spouses and significant others. They revel in each other’s hidden talents. Three play guitar. One sings like a nightingale. Bruton carries a tin of Indian spices and cooks up a mean bowl of garbanzo beans.
And there, as they unwind and sleep sweetly for two straight nights, they ponder their predicament. They complain about attending doctors. They gripe about lack of respect. They laugh about crazy patients. They talk about Scott. And they marvel at how much they have learned.
“Damn if I won’t park in the doctor’s parking lot now,” says one resident, increasingly confident.
Adds another: “What a change. Remember when we were so happy to get our coats and our new prescription pads.”
“Well, we’re doctors now,” shoots back the first.
They are almost halfway through their year.
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About This Series Making of a Doctor: A Boot Camp for Family Medicine follows medical school graduates through their first year of residency at the Ventura County Medical Center. Today’s installment, the second in a continuing series, focuses on what it’s like to be a first-year resident: the highs and lows of life in the hospital, the increasing exhaustion from long hours, and the growing bonds forged between the young physicians.