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Spring 2014
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To Sleep, Perchance to Dream
The darker side of long shifts.
For the next 24 hours I am responsible for seeing every trauma patient that arrives in the emergency roomócar crash, stabbing, fights, and falls. In the morning an hour might pass without a new patient, then a few come at once, and then many, as the evening progresses and bars around the city fill and empty.

The first eight hours go smoothly. I am compassionate and thorough; I take pride in suturing and splinting. The  work interests me and I engage it. As the afternoon wanes and the pace picks up, my back and feet begin to  ache slightly. I eat an energy bar and then gobble a piece of pizza. After 16 hours Iím tired but functional.

The next eight hours begin to erode my humanity. By the end I donít just hurt from being on my feet, Iím tired in a way that makes me nauseated and fuzzy minded and angry. When my phone goes off the sound is  physically painful. I begin to hate the nurses for calling; the patients annoy me with their stupid accidents and whining. I snap at people and curse under my breath.

Every doctor can tell you stories of being on call and profoundly fatigued. Sleep deprivation is a universally miserable experience. Oddly, though, these stories are often recounted with some bravado. A notoriously competitive bunch, doctors compete in hardship. Iíve heard one-upmanship over falling asleep at traffic lights driving home post-call, and senior doctors complain with pride about how their hours were even worse back in the bad old days. Sleep deprivation is part of medical culture, and trainees are eager to prove themselves and become part of the club.

As a profession we are not blind to the impairment caused by fatigue, not to mention the damage to personal relationships. Regulations in 2003 first limited the hours a resident doctor can work, and revisions last year tightened those rules. But we have not decisively embraced shorter work hours, citing concerns about  adequate experience and the increased number of potentially dangerous patient care hand-offs.

Perhaps, though, our reluctance to move to new staffing models has as much to do with our cultural legacy as it does with the inevitable trade-offs. These issues are complex and far more nuanced than I can do justice to here. But as we continue to evaluate our practice we should take care to act in the interest of our patientsí and our own safety, unbiased by nostalgia for these long shifts.

That night I did finally get an hour of sleep as the sun was coming up. But the heavily fatigued, interrupted,  and hypervigilant sleep on trauma-call is full of surreal dreams. Every hospital alarm jars me, from the echoing chime of the patient call button to the squawk of my radio. When code bells went off overhead announcing a ďcode redĒ I shot out of bed and found myself in stocking feet half way in the hall before the rest of my brain realized that I donít care about a fire as long as it is not in my room. When I went back to bed, my sympathetic nervous system still twitching, I dreamed I had arrived in the room of a new trauma patient without my shoes, and blood was spreading over the floor.

Noah Rosenberg attended Oregon Health & Science University School of Medicine. He is in his fourth year of Alpert Medical Schoolís emergency medicine residency program and a member of the programís creative writing group.
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