Edition: U.S. / Global

For Three Interns, Fatigue And Healing at Top Speed

Published: November 15, 1999

The interns felt they had to watch ''E.R.,'' because it was about them. Or it was about them spiced with a lot more melodrama. Sometimes it was silly. Sometimes it was maudlin. Sometimes it was all too real.

One evening on ''E.R.,'' an intern nearly comatose from working all night miscalculated a dosage because her vision was blurry, sending a patient into cardiac arrest. As she watched, weary herself from the tornado of work these early weeks, Dr. Jennifer James thought, ''Wow, that's really true''; her vision got blurry as well during overnight duty. And then she worried a little more about her long hours and the paralyzing possibility that she might do something wrong.

What with New York's much-publicized assault on interns' hours, Dr. James and the other new recruits might have expected the issue to have gone away. Instead, as St. Luke's-Roosevelt Hospital Center struggled to cope with relentless cost pressures, hours seemed to be driving everyone crazier than ever before.

Everyone talked about hours. Opinions flew back and forth. Were the interns working too long for their own and their patients' good (as the interns themselves insisted) or not long enough (as many of the senior doctors felt just as passionately)? Were their brains active or inactive when they did that lumbar puncture at 4 in the morning?

Dr. James's days were merciless assaults on her circadian rhythm. They started in the dark, and seemed never to end. She came out of sleep slowly, everything swaying foggily before her. Since her husband insisted on further rest, she flicked on a flashlight to rummage through her bureau for clothes. Then she ate a soundless breakfast.

She and the other interns lived in apartments opposite Roosevelt Hospital, the buildings preternaturally quiet since their inhabitants were perpetually at work or asleep. So many ate at the Olympic Flame Diner on 60th Street that it was christened the resident dining room. Everything proceeded so fast in their lives that one resident conserved precious nanoseconds by having coffee delivered to his door.

As she hurried across the street to the hospital, amid waves of rumpled white coats, Dr. James mulled the day's prospects: it was her ''Good Day,'' which, in the converse thinking of the hospital, meant she was likely to be swamped with work. Sure enough, once she was inside the residents' room, with its sharp smells of moldering food from the night workers, the senior resident, after a chummy, ''Hiya!'' inquired, ''What are you, Jennifer, good day?''

''Yes, Good Day,'' she replied, and three patients and two sets of transfer orders were flung at her. She woke up fast.

The interns sorted their days into three categories: Good Days, Bad Days and Call Days. On Call Days in some rotations, they officially worked from 8 a.m. until 8 the following morning (in practice, closer to 10:30 or noon). You only admitted patients on Call Days. A Bad Day was the day after call, when supervisors tried to be easy on the fatigued interns. Good Days came between Bad Days and Call Days, when you were supposedly reinvigorated and the hospital felt free to pile on the work.

So Good Days really became Bad Days, and Bad Days came closer to being Good Days. Given that the interns never felt fully rested, all days felt like Mediocre Days interspersed with Hideous Days.

Hours had become a hot issue a decade ago, when, after the death of 18-year-old Libby Zion at New York Hospital, the state fortified supervision and barred residents from working more than 80 hours a week and 24 hours straight. Before then, interns at St. Luke's-Roosevelt had worked in excess of 100 hours and commonly went 48 hours straight caring for patients.

Now, schedules called for six-day, 80-hour weeks, with Call Days coming every fourth day on the wards and every third day in intensive care. Undoubtedly, the workload had eased up -- some.

To the older doctors, though, the new work rules threatened to render the interns soft. They hated the rules and seemed to make no great effort to ensure that they were enforced. As they saw it, patient care was being compromised and teaching hours lost; each time a patient was handed off to another doctor, they argued, something was sacrificed in the ''continuity of care.''

''Society is pushing doctors to be cops and firemen,'' Dr. Michael Lesch, the chairman of the department of medicine, liked to say. ''You work shifts and you don't take the patient home with you. How would you like to have a 14-hour surgical procedure and after 8 hours they change doctors? They do it in Sweden.''

This inevitably led to a lesser-of-two-evils debate: Who would you rather be treated by -- a walking zombie who knew your case or an alert intern who did not? Dr. Lesch's choice was the exhausted intern familiar with his case, not a night-shift worker.

Dr. James voted for the alert intern, especially with hospitalized patients so much sicker these days. She had only to assess herself during the latter hours of call. Tiredness blanketed her, blotting out much cerebral activity. Her speech was hesitant.

And the issue had been muddied even further by staff cuts and other new demands on the interns.