Lessons Learned: Get Up and Go See the Patient

By Dr. Alan L. Kaplan

For as long as anyone can remember, surgical interns at Veterans Administration Hospitals have covered all of the surgical services for an entire hospital while they are on overnight duty. They handle everything from spine fractures and broken hands to appendicitis and arterial embolus, earning the moniker "Surgeon of the Day."

That came to an end in July 2011. In response to increasing concerns regarding resident fatigue and patient safety, the American College of Graduate Medical Education (ACGME) restricted medical intern work hours to a maximum of 16 contiguous hours, effectively eliminating the traditional 30-hour shift.

There have been mixed reactions to the changes. Some believe the work restrictions will lead to less fatigue and improved safety. Others feel that reducing hours limits the experiences a resident accrues, threatening a resident's competence and confidence.

All that remains to be seen. For me, the most valuable lessons of my training occurred during a particularly challenging shift. I'd arrived at the hospital at 4 a.m. and hadn't eaten anything or gotten a moment's reprieve the entire day. My pager finally quieted down the next day at 2 a.m. so I decided to get a little sleep before having to wake up in two hours to gather data for rounds that morning. Like some cruel prank, my pager went off the exact moment my head hit the pillow. A nurse wanted to let me know that a patient who was three days out after a colon resection for cancer had "blood oozing on the gauze over his incision."

Incisions always ooze - that's what they do, I told myself. This can wait a few hours, can't it? But the words drilled into every intern who's on overnight call echoed in my ear: Go see the patient. When I took down the patient's dressing I was staring at his intestines trying to poke through the staple line reinforcement. The wound had opened up and the bowel was exposed - a true surgical emergency. I covered the wound with moist gauze and alerted the senior resident and operating-room staff. The patient was in the OR within the hour, his wound was closed, he was given strong antibiotics, and he ultimately did very well. The next morning, the attending told the patient to "shake this young doctor's hand. He saved your life."

The diagnosis was not difficult. I was staring at bowel, after all. And the decision to go see the patient may not seem so admirable; as a doctor, that's what I am supposed to do. One could argue that had I not been in the hospital for 22 hours, maybe I wouldn't have even had that internal discussion as to whether or not to go see the patient. But that night will stick in my head as a quintessential learning experience in decision-making. The new crop of surgical interns will have to work twice as hard to learn the same amount of decision-making skills in half the hours.

On my last call night as an intern, I actually slept for more than four hours between pages. At 3 a.m., I was called to the bedside of a patient who was terminally ill with metastatic bladder cancer. In discussion with the palliative-care team and his family the day before, we instituted comfort measures. Over the phone, the nurse told me that his heart rate had slowed. I had grown close to this man and felt comforted sitting at his bedside as his wife and daughter mourned. I moved deliberately and carefully as I checked for breath sounds and a pulse. As I announced the time of death at 4:50 a.m., I took a moment to appreciate the honor of caring for this veteran and realized that the grueling long nights on call had afforded the most valuable of lessons that a young surgical trainee can learn: Go see the patient. The action is at the bedside.