Sleepiness, stress, and medicine

Way back when I was an intern (1971) at Strong Memorial Hospital, Rochester NY, the 6 of us were the last of the every other night Pediatric interns, 36 hours on duty, and 12 hours off duty for the whole year. To get a weekend off, we worked 48 hours on duty, then signed out, returning 48 hours later. The medical world was changing. There had been a resident's "strike" at Boston City Hospital, demanding and got, no more than 24 hours on duty at any one time. What has subsequently become law, no more than 80 hours a week on duty, came after a medical resident miscalculated a dose of digitalis for Andy Warhol, the painter, and he died in NY City. In a major press report detailing a medical liability claim, the resident blamed his mistake on his lack of sleep. There had been a study of NY City medical residents and their ability to interpret EKG's; demonstrating a degredation in accuracy with progressive increases in drowsyness. Shocking news. US Senate investiagations followed; state legislators deliberated, and we now live under the 80 hour week law. Of course, this was not new information. Airline pilots are forbidden to fly without adequate sleep, the descriptor "adequate" remained in question for a while; nonetheless, sleepiness leads to calculation errors; known to the airlines, of course, since the 1930's.

At Strong, we would take our vacations out of the nursery rotation since ALL premature babies, ie, those 5 lbs or less, died. Our nursery attending was a kindly fatalistic Catholic physician who talked to us about the cherished children going to meet God. The year, 1971; the date, July 1st, when we began our first rotations. In the lead article of the New England Journal of Medicine, June 1st 1971, Gregory, from the San Francisco Medical Center reported rescuing premature infants who had developed Respiratory Distress Syndrome (RDS) with the use of Continuous Positive Airway Pressure (CPAP) Ventilation. This new way of approaching RDS was a hitherto unremarkable footnote in the wilds of UpState New York except for Alex Stalcup who was one us 6 Pediatric interns. Alex had been a 4th year medical student doing a rotation in the newborn nursery at the SF Med Ctr. He learned how to set up CPAP Ventilation. In August 1971, Alex and I introduced CPAP technology at Strong, that is, we cobbled scrounged pieces of equipment, including a meter stick and a water manometer with which to measure airway pressure, none of which were meant for children let alone premature infants, requisitioned special tiny needles from Usher's Laboratory in Montreal Quebec, and began the task of saving premature infants. That means, we interns stayed with the infants ALL the time, as, at that time, unlike modern times, nurses in the nursery were generally kindly grandmotherly people able to feed and rock to sleep normal newborns. There were of course a few young nurses in the nursery, who were newly hired, had to do their "nursery" rotations prior to being allowed to work on the much more dynamic Pediatric Floors.  Well, once we had a means of rescuing premature infants with RDS,  there was an excitement and enthusiasm for doctors and nurses to do something that had yet to migrate to the East Coast "wellknownmedicalcenters," developing new techiques of care, writing protocols for nursing and physicians to save "premies," by trial and error finding what worked, what we thought worked and didn't, trying something out of the serendipitous blue. Sooo, the short story is, we turned a one month rotation, where the interns had previously taken their 2 week vacations, leaving the remaining intern learning what a normal newborn was and what some of the usual problems encounter in that set of infants, and turned it into a frenzied, sleepless, high energy, very high stress, innovative experience. The rest of the year was only 36 hours on and 12 hours off, a tale of chronic fatigue. I believe I hadn't paid back my sleep bank until well after my third or fourth year of being an attending physician at MSU almost 7 years later.

When one calculates the money I made as an intern that first year, I made $0.71 per hour, which, compared to the previous 5 years intern's salary, and at the Boston City Hospital where the strike occured, they were making $ 50.00 per month and they were on duty All THE TIME. Yes, that's right, 24/7 for the year, a pay rate of $ 0.07 per hour. You see, I had it great! Yes, I hear you: "Yes, but you chose that way of life...." Oh, by the way, no one was married during those previous "house officer" days.

Those days are thankfully gone. I believe the medical resident who made the miscalculation in NYC that drew attention to the issue of chronic fatigue in physicians, didn't do the right thing: ie, check his calculations/interpretations, with his senior resident, or the staff nurses who work alongside resident physcians in hospitals, before submitting his order. Airline pilots, each and every time he/she flies, goes through a check list with their co-pilot before starting the airplanes engines. Partnering is the answer for doing tasks that are critical yet repetative and mind numbing or that lead to sleeplessness and fatigue.