Memorial Weekend

It’s Memorial Day weekend here in the US, which means it’s a four-day weekend. I volunteered for call. I was first-call for 24 hours on Friday, ending at 7 a.m. Saturday morning. I was back on first-call Saturday evening at 7 p.m until 7 this morning. I’m on backup call tonight at 7 pm, and off for good Monday at 7 a.m. I’ve been able to sleep through the night both nights so far, except for some early-morning stuff I’ll describe in a moment. So it hasn’t been too bad. The day-shift people have been pretty busy, however.

Our practice moved to 12-hour weekend call shifts a few months back, and it’s been a vast lifestyle improvement over our previous 24’s. It’s our custom to have people completely off after a call shift — for safety reasons — so we can cover a weekend with fewer people by doing 12-hour shifts, compared to 24’s. Believe me, as I get older, I appreciate more and more not having potentially to work 24 straight hours without relent. You really don’t want to be the patient whose anesthesiologist (or surgeon, for that matter), is in hour 22 or 23 of working non-stop. No matter what anyone says, you are just not 100% sharp after working that long without sleep. They don’t let airline pilots do it, and we in healthcare are finally getting around to acknowledging human limitations in the way we construct duty shifts. It’s about time.

So far it’s been a bad weekend to be an appendix; we’ve taken out two of them, one yesterday and another today, both at around 6 a.m. as my call shift was ending. This is a frequent trick of surgeons — every single one of whom in my 25 years of anesthesiology I’ve found to be impatient by nature. Neither case was a pressing emergency that couldn’t have waited a couple hours, but the OR’s already had some cases booked to start around 7:30, and the surgeon would have had to wait until mid-morning to do the case. So the idea was to sneak it in before those other cases start.

This virtually guarantees that the outgoing anesthesiologist will work beyond the end of his/her shift. It also guarantees that the surgeon has jumped the queue, and will likely make his colleagues late to start their cases. I hate early-morning cases for these, and other, reasons. Both of these two cases indeed went beyond the end of my shift, but I stayed to finish them. That’s how we do things in our practice, unless the case is going to go hours beyond end-of-shift. In that case, the incoming call person would have taken over.

Hospitals have their culture, just as other workplaces do. 7 am is the traditional start of the day nursing shift, which applies to OR staff as well as floor nurses. The traditional first-case OR time is 7:30. A non-emergency case booked to start at 5:30 or 6 a.m. is simply not going to start on time. Everyone knows it; I don’t think I’ve ever seen such cases start on time. (An emergency case is one in which death or permanent injury is likely to occur if the surgery is not done within 6 hours.) Humans evolved to be asleep at 5 a.m., not to be awake doing high-intensity, meticulous, stressful work. It’s the worst time of day for human efficiency and alertness, and many small delays and inefficiencies accumulate so that things just don’t happen fast.

Many pieces have to fall into place to make a case happen; hospital staffing is at its lowest ebb in the early-morning hours, which means patients are often (usually) late being brought from ER or floor to the OR pre-op area. They frequently arrive without IV’s, needed paperwork, or lab testing. Getting those things done consumes further time. Outgoing OR personnel are anticipating the end of their shifts, and are often fatigued by sleep-pattern disruption, even if they haven’t been working. The result: in both of these early-morning cases we were no less than 30 minutes “late” beyond the arbitrary “start” times we gave the surgeon. It is ever thus.

OR’s typically staff to run a certain number of OR’s, with a bit of slack in case something truly urgent comes through the door. There aren’t as many of those as you might think. Most-efficient OR utilization is simply to tell booking surgeons to take a number and take a seat, first come, first served, filling the available OR’s as cases are booked. If a surgeon thinks her case should take higher priority, she should talk to her colleagues ahead of her in the case queue to get hers moved up. Not surprisingly, surgeons being the impatient sort that they are, politics dictate that efficiency loses most of the time. This is just how it is. I show up and do the case when it’s booked.

What about the truly urgent case? Don’t worry. If you are actively trying to die right in front of us, things will move quite fast in larger hospitals, especially at level I or II “trauma” centers. We can get you from the hospital door to an empty OR in a matter of minutes if the shit is really hitting the fan. But things are rarely that dramatic; life doesn’t emulate “Gray’s Anatomy”.

We also did an exploratory laparotomy for a perforated duodenal ulcer in a frail octogenarian last night — right at the start of last night’s shift. I came in a bit early to start it rather than have the outgoing guy stay over, repaying a courtesy I myself have enjoyed. She did well, despite having a belly full of spilled gastric contents, which tends to make people quite sick. Ulcers perforate for a variety of reasons, bad luck foremost among them. Aspirin and anti-inflammatory drugs, which the stiff-jointed elderly often consume in bulk quantities, are probably the number-one reason when a cause can be attributed, followed by alcohol. If people were reliably and consistently logical and prudent, I’d likely be unemployed.

This weekend, spare a thought or prayer for those who have given their lives in the service of this country. No more needs to be said, but “Thank you.”

Michael Sebastian @mikeseb