It was a stab injury to the lower chest. Patient was breathless and dying. I suspected tension pneumothorax, and that was why I had taken him in.
He was rapidly anesthetised, and I put a chest tube in. The ventilation improved dramatically. The patient was saved.
Umm… No. His blood pressure continued to plummet. But there was no blood from the chest drain.
“Jimmy, something is wrong.” Unnikrishna Varma, an astute anaesthetist, was emphatic.
It took me hardly five minutes to do a small diagnostic incision into the abdomen and insert a ryles tube. Bright red blood welled up into it.
I opened the abdomen. Sucked out a litre of blood. Suck, retract, pull out loops of bowel. Look, feel, suck again, feel, look again. A lone intern struggled to retract. The picture was clear.
The knife had penetrated in between the ribs, opened the pleura, punctured the diaphragm, and entered the abdomen. There, it had sliced cleanly the spleen almost in two. There was a rent in the greater curvature of the stomach, and the contents leaked out.
I was finishing the splenectomy when Anil, an Associate Professor stood behind me. It was 2.00 in the morning and I did not expect him there. Someone must have summoned him. I had not.
I had just joined back as a surgical tutor in Thrissur Medical College, my alma mater. I was fresh out of an MS residency in JIPMER.
“That was impressive” Prof Anil remarked.
I had to thank the intense training that I underwent in JIPMER. I had cursed it while doing it- sometimes. Working hours were brutal. I had felt that it was not fair.
I have strong feelings about working hours and conditions. In fact, I believe that all doctors should not HAVE TO work more than 48 hours or so per week. One must do this for thirty or forty years, dammit. How is ‘more’ sustainable with a balanced life?
Yet, and yet, what about the training period?
What we know about the problems of making doctors overwork during training are clear (1, 2, 3). We can have 50 percent more serious medical errors when doctors are so situated. There is a diagnostic error rate that is five times more in a standard intense internship than that in a more relaxed control state (1).
The European and Uk working hours stipulate 48 hours a week. With strict rules regarding duty hours, night shifts etc. It is a better system. But there is a general perception among trainees that the quality of training is affected by this (4,5). But still, it is a kinder, more rational system, and the problems can be addressed.
But the real issue is time. Let us take General Surgery. It takes 8 to 10 years to train a surgeon in the UK. That is the key thing with a 48 hour work week.
There is a difference in the US. For Residents, the working hours are capped at 80 hours per week. That is quite stiff. 13-hour days with a single day off per week. Predictably, it takes less time to train a surgeon there. It is generally, around 5 years.
In India? A recent NMC taskforce has recommended a maximum of 74 hours per week, and never more than 24 hours at a stretch.
There is some clarity that is emerging now. Residency does require self-discipline and motivation. We have only three years to train a specialist. Intensity of experience matters. It is not meant to be easy.
I think we should have systems in place to implement this NMC directive. But the focus should be in eliminating toxicity. There is no place in modern times for cruelty and harassment. At the same time, we should have a system for weeding out trainees who simply cannot perform adequately. From whatever I have seen, it is the lack of respect, callous attitude, verbal abuse, and harassment that is the problem. Younger doctors are generally keen to work hard and does not mind putting in long, arduous hours in a nurturing, learning environment.
(Jimmy Mathew)
- Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine. 2004 Oct 28;351(18):1838-48.
- Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. Jama. 2002 Feb 27;287(8):955-7.
- Samkoff JS, Jacques CH. A review of studies concerning effects of sleep deprivation and fatigue on residents’ performance. Academic Medicine. 1991 Nov 1;66(11):687-93.
- Datta ST, Davies SJ. Training for the future NHS: training junior doctors in the United Kingdom within the 48-hour European working time directive. BMC medical education. 2014 Dec;14:1-6.
- Maxwell AJ, Crocker M, Jones TL, Bhagawati D, Papadopoulos MC, Bell BA. Implementation of the European Working Time Directive in neurosurgery reduces continuity of care and training opportunities. Acta neurochirurgica. 2010 Jul;152:1207-10.
