A matter of time
news.mysanantonio.com By Tom Kim San Antonio Express-News Web Posted : 01/13/2003 12:00 AM It's about 2 a.m., and Dr. Claudio Nunes is in his 19th hour of caring for the nightly troop of assault victims and drunken drivers.
Surgical resident Claudio Nunes (center) works with University Hospital emergency room staff during the first minutes of a trauma patient's arrival. Nunes' long workweek includes three 24-hour shifts and one 12-hour shift. Joshua Trujillo/Express-News
Paramedics rush the injured one by one through the double doors into the fluorescent glare of University Hospital's emergency room.
Whether they're aware of it, these patients have put their lives in the hands of Nunes, a second-year medical resident who has been working around the clock. The 28-year-old native of Brazil typifies the young doctor-in-training: dedicated to his profession and determined to get by on very little sleep, with the occasional aid of adrenaline and caffeine.
"It's my time to sacrifice now," he said during a 24-hour shift. "I'll rest when I'm old."
Nunes and most medical residents are a lifeline for many hospitals, especially teaching institutions affiliated with universities. They care for patients just like fully trained doctors, but at a fraction of the cost.
But long hours and hefty responsibilities have thrust these residents into the center of a national debate that has much of the medical community divided.
The Accreditation Council for Graduate Medical Education decided last year to limit the number of hours a medical resident can work. The standards, which take effect in July, cap the workweek at no more than 80 hours. Nationally, residents can now average 60 to 130 hours of work each week, depending on their specialty or the location of their residency.
The national cutback comes amid concerns that patients are at risk in the care of exhausted residents.
But some residents aren't convinced the limits are a good idea. And some hospitals aren't sure if they'll be able to meet the requirement or what effect the reduced hours will have on patient care.
Many institutions, such as University Hospital, already are facing severe staffing shortages, and complying with the mandate might theoretically require residents to have to walk out on their patients while providing care.
Nunes' workday usually begins near dawn when he often struggles to get out of bed. Waking up is never easy, and it usually takes about three hits of the snooze button before he finally rises.
On this particular Thursday morning, he arrives at University Hospital at 7. The emergency room where he is assigned for the month is in the basement. It has an otherworldly feel that makes it seem insulated from the rest of the planet.
There are no windows. Time has a way of slipping to the back of the mind.
"It's like Vegas down here," said Adam Blanchette, a third-year medical student who also works in the ER. "Six hours just goes like that."
For Nunes, the day is just beginning. He is briefed by the previous shift's resident-in-charge about the patients he's inheriting. One is from near the Mexican border. He suffered the loss of his hearing when a tree branch lodged in his right ear while he was being chased by Border Patrol agents.
Another is a jail inmate who claims to have lost feeling in his legs.
Known as the ER's "pit boss," Nunes assesses the hundreds of trauma patients who come through on his watch. It is his job to assess the extent of their injuries, as well as decide who needs surgery.
Because most of his waking hours are spent in the hospital, most of his life revolves around this place, leaving him little room for a social life. He works three 24-hour shifts and one 12-hour shift a week.
The idea of working fewer hours is appealing, but it also raises questions.
"I think the scale-back is great," Nunes said. "But it's not going to work for surgical residents because we do everything medical residents do, plus we operate."
Often, Nunes stays at the hospital after his regular 24-hour shift to watch surgical procedures because he couldn't when he was on call.
Such observation, he said, bolsters his training. But under the accreditation council's guidelines, any of those extra hours would count against his 80 hours.
He said limiting the number of hours he can stay at the hospital will affect his education.
"We have to be at the hospital to learn," Nunes said.
Another fear is that reducing hours might result in longer residencies, which already can last four years after medical school.
Much of the burden in figuring out how to comply with the new rules falls on faculty of teaching hospitals.
At the University of Texas Health Science Center at San Antonio, that's Dr. Lois Bready. The associate dean for graduate medical education says she's had trouble sleeping ever since the accreditation council made its decision.
She blames her insomnia on the logistical nightmare she and other faculty will face in trying to comply with the new standards.
University Health System has close to 700 residents who are overseen by about 600 full-time faculty doctors at the health science center.
The hospital, like almost all hospitals nationwide operated by colleges and universities, depends heavily on medical residents, who diagnose, treat and operate on patients. Faculty doctors oversee and assist residents, but residents can carry much of the responsibility of patient care.
Residents also provide a large and relatively inexpensive labor pool for hospitals such as University Hospital. However, if hospitals violate the allowed hours for residents, they risk losing accreditation, putting their federal funding at risk.
"We're trying to figure out how to contract all these hours and find out where we are going to have voids," said Greg Rufe, an administrator for the University Health System. "It's not like we can run out and get more residents."
The solution shaping up is to hire more physician assistants and nurse practitioners. But those people haven't yet been hired. And so the hospital still has its voids.
4:30 p.m. Nunes' pager goes off. A man who has fallen off a 60-foot billboard is en route. At 5 p.m., the patient is wheeled in.
"This one is a pretty big emergency," Nunes said. "He has a collapsed lung on his left side."
They put an oxygen mask on the patient to help his breathing. But a problem has developed.
The air being built up in the patient's chest because of the collapsed lung is beginning to restrict his heart. Nunes has to act quickly or the man will go into cardiac arrest.
Nunes takes a scalpel and cuts above the left side of the ribs. The patient is still conscious as Nunes works. Nunes grabs a surgical clamp and pushes it into the slit he's made. The patient screams, but the oxygen mask over his nose and mouth muffles the sound.
Nunes is trying to puncture the wall surrounding the patient's lung to let the air escape. He is holding a long needle in one hand just in case the clamp doesn't make it through. The needle will provide an instant hole to release the air.
Nunes continues working the clamp. All of a sudden, a hissing noise fills the room. Nunes has broken through the sac surrounding the man's lung, releasing the pent-up oxygen. Nunes then inserts a chest tube into the hole and begins to sew the wound shut. Disaster has been averted.
Nunes often is thrust into these kinds of life-and-death situations as a resident. Faculty doctors are accessible if he needs to consult them, but sometimes, as in this case, he has to make a decision at the spur of the moment.
Teaching hospitals can't afford to have a doctor standing over the shoulder of every resident working at a hospital.
Most residents are paid salaries just above $30,000 a year. But when averaging 80 hours of work or more each week, that comes out to about $8 an hour before taxes — a figure less than the $8.25 lowest hourly wage set by University Health System last year. Most hospital employees receiving that wage are workers in housekeeping, food service and maintenance positions.
Because the system is Bexar County's tax-supported health provider, most of the money for residents' salaries comes from taxpayers.
If the number of hours a resident can work is reduced, additional staff will have to be hired to make up the difference. But with tight budgets, hiring more staff will be next to impossible, Bready said.
"Most teaching hospitals are hanging by a thread right now," she said.
The cutback comes at a time when states and the federal government have slashed health care dollars for this year. Publicly funded hospitals are wondering how they will be able to provide the same level of patient care with people working fewer hours with less money.
University is grappling with staff shortages and budget deficits that have, in part, resulted in patients being turned away from the hospital's emergency room. Nationwide, nurses have been leaving the profession in droves because of inadequate salary and long hours — a problem from which University Hospital has not been immune.
The accreditation council knows the pivotal role residents play in hospitals, but a resident is a student first, said Dr. David Leach, the accreditation council's executive director. Having full staffing levels shouldn't come at the expense of fatigued residents, he said.
"Residents are students," Leach said. "The primary purpose of students is education."
Changing the way hospitals approach health care is one way to resolve problems that could arise from the cutback, he said. Doctors, nurses and other support staff should find more effective ways of working as a team, he said.
"The lone ranger is not the best metaphor," Leach said. "The U.S. Navy SEALS is a better approach."
In preparation for the mandate limiting a resident's hours, the health science center's departments have been told to limit their residents to no more than 80 hours of work a week. Most appear to be doing so, Bready said, though a new survey is under way to determine that.
And a subcommittee organized to study the issue is recommending that some departments be able to apply for an exemption under special circumstances, increasing the limit from 80 to 88 hours.
5:30 a.m. Nunes is less than two hours from going home, but his shift is far from over. Another vehicle accident victim arrives. She tells Nunes she had been drinking and was on her way home.
Nunes works his hands across her body, performing an assessment. Despite having a night filled with patients — some belligerent and many unappreciative — Nunes is cordial.
He addresses her as ma'am when he speaks to her, though it's obvious she is younger than he is. He appears alert.
Whether working 100-hour or 80-hour weeks, Nunes said staying awake has never been a problem.
"Here, there is no way you're going to sleep because you're too busy," he said about the hospital's emergency room.
But not all residents feel like Nunes.
Dr. Maurice Sholas, who recently completed his residency at the health science center and lives in Chicago, believes the guidelines make sense. Sholas has served as the vice chairman of the resident and fellow section of the American Medical Association, which has endorsed the mandate.
Patient safety should be the first priority at all cost, he said.
"We're not supermen, immune to the need of sleep," he said.
In New York, state law already enforces an 80-hour limit for residents. The restriction, which has been in effect since 1989, came about after an 18-year-old woman died under a medical resident's watch. The woman's father blamed her death on the resident, whom he alleged was overworked.
Even doctors who are skeptical, if not directly opposed to the cutback, are divided on why they think the mandate is a bad idea. Some, like Bready, support giving residents more time off.
Residents should get more sleep and free time, she said. She's just not sure how to accomplish that.
Others, however, feel that the new policy could pose a philosophical problem for future doctors.
Though scaling back hours might appear good on the surface, some doctors in reality work more than 80 hours a week, said Dr. Ronald Stewart, associate professor of surgery at the health science center.
Pushing residents to work when they're tired instills in them a sense of service, he said.
"It must be taught, patients' problems come first," he said. "A doctor's mindset has to be that a patient comes first. Not that a patient comes first if you're well rested."