Interns and residents know how vital sleep is. A dozen interviewed for this story were unanimous in the view that sleep deprivation negatively affects the care patients receive, even when it doesn't cause an error.
At night, especially, patients and their families come to be seen as the enemy, devouring precious time that could be spent sleeping.
"You actually start wishing patients would die so you could get some sleep," said intern Michael Greger, echoing a view expressed by other residents that is rarely articulated to outsiders. Greger finished his internship at a Boston hospital last year.
Anesthesiologists say they sometimes fall asleep while they are supposed to be monitoring unconscious patients. Some surgeons say it is not unusual to see residents fall asleep in the operating room, sometimes while holding scalpels or other instruments. Occasionally sleeping residents actually topple into the sterile surgical field, contaminating it.
Risa Moriarity said trainees at Johns Hopkins Hospital employ several strategies to stay awake: Some sling icy towels around their necks, hoping it will revive them before they operate. Moriarity, who said she routinely worked 90- to 130-hour weeks and frequent on-call shifts that sometimes stretched to 60 hours, said she would engage in "self-mutilation": She pinched herself and stepped on her own toes in attempts to stay awake.
"It's insane. You are so sleep-deprived you are dangerous," Moriarity said. A year ago she quit her coveted seven-year plastic surgery residency midway through the third year; she has left medicine and now works for an Internet company. "I literally could not stand falling asleep at the wheel anymore. Another reason I quit was that I got to the point where I was tempted to take dangerous shortcuts, like letting myself drift off for another 20 to 30 minutes and not getting up to see a patient. And if you do that, a patient could die."
John Cameron, Hopkins' surgery residency director, said Moriarity, whom he called "a great favorite of mine," was exaggerating when she said trainees routinely fell asleep in the operating room. "I've been here for 43 years, and I can think of two or three people who fell asleep in all that time," he said.
Internists and pediatricians, whose tasks are more dependent on cognitive function than the motor skills required of surgeons, say it is not uncommon for them to order the wrong drug or miscalculate a dose.
"Mistakes are pretty common," said a third-year pediatrics resident at Children's Hospital National Medical Center in Washington, D.C. "I'm used to being called by the pharmacy for the wrong dose or the nurse or X-ray because I ordered the wrong test."
One intern said she was so busy and exhausted recently that she forgot to assess for a possible heart attack a woman who had been admitted with multiple problems. Others say they have trouble writing coherent notes in charts after 30 hours on duty.
"One of the worst things is that you don't feel like you're part of the world anymore," said Greger. "You can't think, you can't remember phone numbers, and that's the state in which you're making life-and-death decisions. It's about survival--yours--and everything else falls away."