I worked for 20 years doing eight- and 12-hour shifts, days, evenings, and nights. It was a standard life in our specialty. But I embarked on the locums life about eight years ago, and I discovered along the way the unique wonders of the 24-hour shift in the critical access hospital.
I don't recall exactly where I worked my first 24-hour shift on that locums journey. It might have been in Indiana or Colorado. But it was the first time I had intentionally worked that long since the occasional brutal call schedule of residency when I was younger but, oddly, less resilient.
The 24-hour shift is typically found far off the beaten path. It is found in hospitals on mountainsides and in vast valleys where corn grows in the summer. It is found in the cold North and the desert South. It is unusual in more populous areas. Its location and the very nature of the small outposts where one can actually find a 24-hour shift makes it is a kind of work balanced tenuously between boredom and terror.
During busy shifts, unsettling or tragic shifts in small, remote hospitals, the desperately ill come with conditions far beyond the capacity of the staff and resources of the hospitals. All too often, these patients cannot be transferred by ground or air due to lack of paramedics or hazardous weather or, lately, the lack of beds for hundreds of miles. This can make the 24-hour shift a slog of exhaustion and misery. At the end of it, however, weary and having given one's best for those most in need, you can feel a remarkable sense of satisfaction, accompanying the aching need for sleep, that makes the cool air of morning even sweeter while walking out the door.
Days Are Gone?
Still, the 24-hour shift can be a thing of joy. Whether it's due to weather, the stoic nature of some rural populations, or simply dumb luck, sometimes nothing happens. Literally nothing. I think my personal best was two patients in 24 hours. I have eaten hospital food and watched movies in lavishly apportioned call suites during such shifts. I have reclined by fires in the lobby and watched midwestern snow swirl outside or tumbleweeds blow across in the West. I have stretched out in a warm bed as the moon rose and the local area fell into a wonderful repose. I would wake in the morning rested and with money in my account, earned for just being ready in case something happened.
These delightfully challenging shifts may one day be a thing of the past. Volumes fell during the pandemic, but they seem to be rebounding. Down time is less and less even in critical access facilities because patients have fewer and fewer options for care and visit even these facilities in greater numbers. And many of these sites are closing as rural hospitals become less financially viable. Patients in remote areas will struggle more than ever as their only options are shuttered.
Those that stay open will be increasingly staffed by nurse practitioners, physician assistants, and others not trained in emergency medicine. My sense is that this is because emergency physicians see such work as insufficient use of their training and skills. This attitude is a tragedy because it will leave remote populations and subcultures even more vulnerable when tragedy strikes.
Of course, I understand why younger physicians might steer clear of emergency departments with 24-hour shifts. The pay is typically lower, and it can be daunting, especially right out of training, to go from having every resource possible to being the only resource available. Many of us learned to be in these places through independent moonlighting, a thing less available to modern resident physicians.
All of this makes me a little sad for the hospitals that aren't busy or rich but can offer willing physicians an experience both educational and restful. It makes me equally sad for physicians who will work in ever busier departments and never know the way medicine use to feel, when a shift didn't always mean a smackdown, when the night meant being paid simply for availability and willingness rather than speed and productivity.
The new year brings a change in career for me. My days of 24-hour shifts may be fading into the rearview mirror. But I'll always think back fondly on lives saved, as well as naps taken, on those marathon shifts in rural America. And I'll always recommend that docs who want a fun change of pace consider working around the clock, far from the hallowed halls of modern medicine, if only for the snacks.
Share this article on Twitter and Facebook.
Access the links in EMN by reading this on our website: www.EM-News.com.
Comments? Write to us at [email protected]com.
Dr. Leappractices emergency medicine in rural South Carolina and is an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available athttps://amzn.to/2T60WET, and Working Knights, Cats Don't Hike, and The Practice Test, all available at www.booklocker.com, and of a blog, http://edwinleap.com. Read his past columns athttp://bit.ly/EMN-Emergistan.