At a little past 7:30 in the morning, a Manhattan doorman was wheeled into an operating room at one of New York City’s premier teaching hospitals. He wasn’t exactly relaxed, but he was resigned to what he was facing. His doctor had stopped by earlier to give him a pep talk and to recap one last time what had to be done. Repairing an abdominal aortic aneurysm was a complicated procedure. The operation would last at least four hours. But the doctor told him not to worry. He did this particular fix several times a week.
As it turned out, the surgery went pretty much as expected, and the doorman was in recovery around lunchtime. By late afternoon, he was doing well enough to be moved out of intensive care. The surgeon checked in on him at 5:30 and found no issues. His post-op progress was good. Everything was exactly as it should have been.
But by the next morning, barely thirteen hours later, something had gone terribly wrong. When the doctor came in to see the doorman at 6:30 a.m., he was in full respiratory distress and on the verge of acute cardiac arrest.
The surgeon shifted into crisis mode. He inserted a breathing tube in the doorman’s throat to get air into his lungs, which had filled with fluid. Quickly but with precision, he threaded a pulmonary-artery catheter through the patient’s neck and down into his heart and lungs. He gave him a shot of lasix and one of dobutamine to stimulate his heart, which had nearly stopped pumping. Then he began chest compressions.
The surgeon didn’t know it at that moment, but his patient’s reversal and near death were the result of two critical decisions made during the night by a resident: an overextended, underequipped junior resident, responsible for taking care of more than 50 patients. The problem was compounded by the resident’s unfamiliarity with those in his charge. To put it bluntly, he had never laid eyes on many of them before: not during office visits, in the operating room, or in the course of postsurgical care.
In fact, only half of them were actually his patients. He was covering for three surgical services, each of which had its own residents who, theoretically, were supposed to handle their own patients. And on some nights, the system worked according to plan. There would be one junior resident from each group watching over his own fifteen to twenty patients.
But because of New York State’s 405 law, which limits the number of hours residents can spend in the hospital, the situation is often more complicated. Once they reach the maximum number of hours, residents have to leave the hospital. No exceptions. And this means that hospitals are frequently left without enough medical staff to handle the caseload. On those nights, taking care of patients can get a little hairy. And at some New York hospitals, it’s a scramble just about every night.
With residents working fewer hours, hospitals have been forced to find ways to fill in the gaps. Most don’t have the money to hire more nurses or physician’s assistants. Even if they did, nurses and PAs willing to work the night shift are in extremely short supply. The well-intentioned 405 law, adopted to prevent exhausted residents from taking care of patients, has instead produced an often dangerous lack of supervision.
“We used to have two senior residents and three junior residents in the hospital at night to take care of surgical patients,” says one chief of surgery. “Now we have one and one. It’s really a very small number to take care of all the sick people in the building. And there may be no one in the hospital familiar with the nuances of particular patients. It’s really not so hot for continuity.”
The doorman’s surgeon is more direct: “From my perspective, it’s absolutely horrible patient care. We see at least one or two patients a month put at risk because of the work rules.”
Here’s what happened to the doorman. At one in the morning, a nurse reported to the covering resident that he had no urine output. If the resident had been familiar with the doorman and the kind of surgery he’d had only hours earlier, he would have immediately recognized this as an important post-op sign.
However, since he’d come to the patient cold, a quick, informed judgment wasn’t possible. He didn’t even have time, because of his patient load, to do more than skim the most recent chart entry to figure out what was going on—though, given the usual perfunctory nature of the ten to fifteen pages of chart notations, a more thorough reading might not have helped anyway.
A little background: An aneurysm is a ballooning of an artery, much like a bubble in the sidewall of a tire. It weakens the wall and is prone to rupture. If an aortic aneurysm bursts, it is almost always fatal. Fixing the aneurysm requires inserting a piece of tubing, in the doorman’s case a six-inch piece, into the blood vessel to strengthen the compromised area. In a case involving the aorta, the surgeon opens up the patient from the sternum down to the pelvic area. Then the aorta is clamped, which completely cuts off circulation to the lower part of the body—the kidneys, the intestines, the legs.
To get to the aorta, the surgeon has to move the intestines out of the way. When everything is put back in place, there is usually lots of fluid shift, meaning fluid normally in the bloodstream leaks into the tissues. Once the aorta is unclamped and the procedure is completed, normal circulation should resume. One potential problem following any major surgery is the patient can become intravascularly depleted. In lay terms, the body’s organs are not getting sufficient blood flow.
Surgeons monitor kidney function as a kind of early-warning system. When there’s not enough fluid in the body, the system tries to retain whatever it has, so the kidneys don’t produce urine. Which is exactly what happened in the doorman’s case.
Once the nurse alerted him, the resident had three options. He could choose a policy of benign neglect, hoping the patient’s condition wouldn’t worsen as the night wore on. He could call the surgeon’s senior resident—who was at home and easily reachable. This would seem to be the obvious and most prudent step.
Except that he knew that if he made this call, the senior resident almost certainly would have instructed him to move the patient to the ICU, run a battery of tests, and spend an hour making sure the problem was properly dealt with.
“When you’re taking care of so many patients,” says the doorman’s surgeon, “and you have no background on any of them and one guy’s having chest pains, someone else has shortness of breath, another guy’s got diarrhea, and somebody’s running a fever, and you multiply it times 50 or 60 patients, you quickly realize you can’t spend a lot of time on any one person. So you run around trying to put out fires and deal with everything as expeditiously as possible.”
Consequently, the resident opted to “buff the chart.” In doctor argot, this means he did something—not necessarily the right thing—so it would look like he responded to the patient’s needs. What he did was order an intravenous diuretic. This forced the patient’s kidneys to produce urine but actually worsened his condition by further depleting his body of fluids.