Sleep medicine is no longer just a glimmer in someone’s eye; it is a very real, very important subspecialty of medicine. We know from literally thousands of journal articles and just as many inspections of huge data sets that sleep is to be taken seriously and never given short shrift.
The question, then, if we know this and certainly those in positions of authority in medical education know it, remains why would you give the care of patients over to sleep-deprived individuals? How can someone who has worked 24-28 consecutive hours with huge demands to make life-and-death decisions function anywhere near what is required toward the end of their shift? Can people die from the decisions made by sleepy docs? Of course they can and in New York state there’s a provision that supports limiting the working hours of physicians in training. Now all that appears to be up in the air again as hospitals push for a return to longer shifts again in what they claim is the best interests of the patients.
What is the rationale for pushing student-physicians to their physical and mental limits and mandating that they provide quality care to patients? Let’s see. Could it be that this kind of training is really, really good for them? Might it be that they will learn that medicine is like being on the battlefield and you always have to perform at your peak and at a moment’s notice? How about sharpening diagnostic skills in the blink of an eye? None of them sound plausible, do they?
They don’t hold much credence with me, either. The online articles of relevance point to residents (forget about interns, or don’t they exist anymore?) working 30-hour shifts. When we’ve read how difficult it is to insert a central line into someone, how difficult do you suppose it would be when you’re at the point of hallucinating? How steady would your hand be or your eye alert for any out-of-the-ordinary physical change? If all you are obsessing over is getting some sleep, where’s your judgment?
Pontificate as they will, I’m not buying what they’re selling and I refer you back to a wonderful article written by the father of a young woman who died most probably from care by tired, under-supervised medical personnel. But if you can’t find Sidney Zion’s Op-Ed piece from the New York Daily News, read the article that was written in the Penn State Law Review. In part, the article states:
“In March 1984, Libby Zion was a Bennington College freshman living at home in New York during the Vermont school’s winter-work term. She was just finishing up an internship in the office of Manhattan Borough President Andrew Stein. On Sunday night, March 4th, Libby was at home with her two brothers, recuperating from a tooth extraction several days earlier. Her parents, who had been hesitant to leave Libby at home, were at a friend’s party at an apartment nearby. Although she had been running a fever that occasionally spiked as high as 106 degrees, she reassured her parents that she was feeling a little better and would get some rest. At about 9 PM, Libby’s brother Adam called their parents: Libby’s fever was spiking again, and she was terribly agitated. The parents returned immediately to their Upper West Side apartment.”
Libby was ultimately taken to a prestigious hospital, New York Hospital (aka Columbia-Presbyterian Hospital) where she died within the next 24 hours or so. She was treated by tired physicians-in-training (residents), never seen by a supervising physician and given contraindicated medication which they should have known was wrong if they had looked it up in the PDR (Physician’s Desk Reference). She had told them she was on Nardil and they gave her Demerol in addition–a combination that could cause death and it did.
The case received a great deal of attention not because the young college freshman had died but because her father made it his mission to change residency training to avoid having anyone else dying this way. He succeeded in prompting the state to pass the Libby Zion rule (“405 Regulations”).
The lawsuit brought by Libby’s father, Sidney Zion (a well-known New York City writer), would wend its way through the courts for 10 years as the hospital refused to admit any wrongdoing. It was the way physician training had been for over 100 years and it was working just fine, according to the administrators. If it worked just fine, why did Libby die and how many others had died in this “working just fine” system? Did anyone know or care?
How did the jury find in this case? The fault broke out in a 50/50 split; 50% the fault of the hospital and residents and 50% Libby. How did she come to be at fault? Seems Libby had used cocaine at some time and it was still in her blood when she was taken to the hospital. She denied drug use several times, so they never checked her blood for it. Mistake? Probably.
The medical field has now taken a step backward in the search to keep physician with their patients longer and to avoid handing off patients to others too soon. How much personal contact does a patient have with a resident who is running around and desperately trying to catch some sleep as they’re called every 20 minutes to see a patient? For Sidney Zion, it was a measure of greed on the part of hospitals, physicians and administrators not of maintaining superior patient care.
Even after the settlement, as Zion and others saw it, the hospitals had all flaunted the rule and left residents working sometimes 100 hours a week. Now they will work 80-hour weeks. Have you ever worked 80 hours in a week on multiple projects because that’s what this is; not one project, multiple projects aka patients. Try to keep them all straight in your head because you don’t have time to review the entire chart and you will make mistakes and some of them will be fatal. But is the hospital to blame? No, you are and that’s where the buck stops because you asked for this residency.
I have seen psychiatrists, not residents, with many years experience working at hospitals where they ordered lethal doses of lithium and patients died. The reason? No one thought to get a blood test to check the patient’s lithium level. Anyone in medicine knows that while lithium seems like a pretty innocent salt, it must be kept within a strict and very limited range to be safe. Go outside it and you kill the patient or they may become manic and then something called iatrogenic illness may enter the picture.
Physicians in private practice who aren’t sleep deprived make mistakes, too, and so do technicians in hospitals who don’t read orders properly. A case in point was a woman who was allergic to shellfish and needed a CT scan with contrast. The physician forgot to write that she couldn’t have contrast because of her allergy, and the tech read that it was to be contrast, so she was given it. Mind you, this was done even as the patient told the tech that she was allergic to contrast. The tech didn’t listen to her and the patient died.
Do all your medical caregivers listen to you when you tell them of your medical history? Another case which I heard of recently was where a woman went to a medical specialist for blood work. After she left the office and had informed the physician and nurse that she wanted a copy of the final report, she received it. But it had major mistakes in it regarding her medical history.
What was the problem? The physician is a member of a medical practice that is in the patient portal network of the hospital with which they have an affiliation. Someone, at some time, made a mistake in several areas and everyone down the line just kept repeating the mistake in their reports.
When the physician was asked to fix the errors the answer was almost laughable. “I can’t do that because it’s in the computer and I have no way of changing it,” he said with not a hint of a smile.
Have you ever asked for a copy of a medical report that detailed some findings at an exam or do you assume they’re always correct? You might want to read one or two just to check.