Cape Town - The Western Cape Health Department gave the Cape Argus permission to shadow an intern doctor at Tygerberg Hospital for a full on-call shift. This comes after an article published two weeks ago revealed that junior doctors were being forced to work dangerously long hours, putting themselves and their patients at risk.
Cape Town - Dr Greg Dyer has been off sick. He caught a lung infection from one of his patients. But today he is back at work at 7am, and says as long as he is still standing, he will treat patients. He’s done it between vomiting spells before.
We’re in the paediatric ward on the ninth floor, where each room has a different speciality. Greg is on pulmonology - children with respiratory infections or lung diseases.
Far below the doctors’ room window, street lights blink out and a neon glow rises in the east. Tinny speakers deliver Whitney Houston’s Greatest Hits as Greg begins his ward rounds.
A trolley rattles down the corridor, serving up two slices of bread, some jam and an apple to the children.
By 9am, the first can of Red Bull makes its appearance in the doctors’ room. Greg doesn’t like coffee or energy drinks, but he keeps a bottle of caffeine pills in his bag.
“The whole public health service is under pressure, although interns do take the brunt,” he says.
It has only overcome him once: during a 35 hour shift of no stopping.
“I broke down, cried, got over it and got back to work.”
Greg is a second-year intern. He was born in KwaZulu-Natal and studied at the University of Pretoria. He applied for an internship in Cape Town in the hope that he wouldn’t have to steal syringes from other departments to treat patients - a necessity in poorly resourced Gauteng hospitals.
At Tygerberg, Greg says he is only paid for 56 hours’ overtime a month. The number of hours he actually works depends on the department - but seldom less than 80. Weekend rounds of 16 hours a month aren’t counted.
“If you count it in eight-hour day shifts, we work every day of the year and then some extra.”
Paediatrics is one of the nicer rotations because there are always senior doctors on hand to help and overtime isn’t excessive, Greg says.
During his internal medicine rotation, the registrar would leave the ward to pray - and not return. Greg was often left to make decisions without consulting the senior doctor because his phone calls weren’t answered.
Three or four of his patients died every day. They came to the hospital with end-stage tuberculosis, Aids, kidney failure - there was little hope of saving them.
In that ward, a moment’s sleep during on-call shifts is so unlikely that there aren’t even beds. But in paediatrics, Greg expects at least two hours in a night.
I ask if he’s going to stay in state medicine after his community service year. He laughs for a good 20 seconds before answering.
“Hell no. I’m never going back to state if I can help it. I want to have a lifestyle I can tolerate. That’s where the public system collapses - no one wants to stay here because they’re overworked.”
Around 3pm, whatever virus booked Greg off work earlier in the week returns with a vengeance. His voice goes croaky and jumps up and down the scale.
“I feel like I’m hitting puberty all over again,” he says.
At 4pm, Greg’s work on the ninth floor is done. His day job is over, and his call shift begins. We take the stairs to the ground floor - the Tygerberg Children’s Hospital.
Here, children arrive with everything from gastro to tuberculosis.
They are triaged as the nurses divide them into red, yellow and green cases. Red children jump the queue for Greg’s attention while green children can wait up to four hours.
But by 5pm, Greg’s hoarse throat has given up completely, and he can barely whisper. He wears a mask when seeing patients. He is frustrated and struggling to communicate with children and their parents.
Machines monitoring heart rate, temperature and saturation beep incessantly, each with a different tune and at different intervals. It’s like a cuckoo clock shop frozen at 12 o’clock.
Except that it’s punctuated by the agonised wails of children, held down by nurses as doctors poke needles into them. Drips, blood draws, lumbar punctures - all too much for a baby who doesn’t know what’s happening.
“I love kids, but I don’t like sticking needles in them,” Greg says.
He’s considering specialising in oncology or radiology one day.
At 7.30pm, Greg gets dinner. He’s only eaten two packets of Lay’s lightly salted all day. Dinner is a naartjie and handful of almonds.
Back at the doctors’ room, the fridge is packed with half-finished juices and yoghurts, abandoned because somebody ran out of time to drink them. A cooler bag bursts with Red Bull and instant coffee sachets. Greg pops Myprodol for the headache and sore throat.
The cacophony of bleeps, screams and coughs dies down in the 34-bed ward as the last room goes dark at 9pm, and the nurses switch on Heart 104.9’s top 10 countdown.
Greg’s eyes are ringed with red. The shift remains calm, but fatigue and illness take their toll.
At 1am, a patient arrives with organophosphate poisoning. Greg has hit the lowest point of his shift.
He hasn’t covered this territory since fifth year of med school; he’s too tired to think properly, and the registrar is asleep. But he treats the child, then slumps down at the nurses’ station to fill in the new patient forms.
Not much later, Greg finds me with my head on a table, fast asleep. He guides me to one of the doctors’ sleep rooms. At 2.30am, his head finds a pillow of its own and he rests until 6am.
We emerge with creased clothes to find the first young mother and child already waiting, hoping to be first in line.
At 7am, the new day’s nurses take over.
“Everyone else is going to come in all energetic, and expect us to be the same,” Greg says. “I’m tired and I’m sick. I really just want to go home.”
He sits with the registrar who usually works in trauma. They share photos on their cellphones of their most horrific cases: a man who changed his mind about committing suicide under a train just too late to save his mangled leg; a woman who didn’t wear a seat belt and was scalped in a car crash; a man with a knife handle sticking out his back.
By 10am, the ward is thick with doctors, recognisable only by the stethoscopes around their necks. They dress in whatever normal clothing they are willing to risk being vomited, bled and coughed upon.
Greg rubs his eyes and raises his eyebrows as if to keep his eyelids from closing. The end is in sight.
“It’s so hard to focus mentally on what a kid needs. It’s not fair for the patient,” he says. “I’m not catering to their emotional needs - I’m just treating them physically.”
At 11.30am, it’s time to throw in the towel. Greg has just given news to a mom and dad that left them shocked and angry, but he has no emotional reserves left to be sympathetic.
“I don’t have empathy any more. I don’t want them near me. I just want to do my work and go home.”
We walk down the ward corridor, past the rooms of waiting patients, and out into the sunlight.
As he checks his pedometer, he sees that from the time he started his day at 7am, until he finished it more than 29 hours later at 11.30am the next day, he has walked 25.63 kilometres - in one shift.
As Greg approaches his low-slung black convertible, he can’t decide what he’ll do first when he gets home.
“Sleep! No, shower. Or eat! I’ll sleep in the bath with food.”
He has the weekend to rest before facing his next string of shifts: six calls in 13 days.
That’s 83 hours’ overtime in less than two weeks.
HPCSA guidelines for medical interns:
* Interns should work 40 hours a week.
* Interns should not exceed 20 hours of commuted overtime a week, resulting in a maximum 60-hour work week.
* Interns should not exceed 80 hours of overtime a month in a four-week cycle.
* Continuous service should not exceed 30 hours and interns should be relieved of duty after this period.
* Interns should not work full weekends, unless there is a 12 hour break during the weekend.
* The frequency of night duties should allow for sufficient recuperation. Being on duty every second night is unacceptable.
* Interns should be off at least one weekend per month.
* Interns are not permitted to refuse to work overtime.
* If an intern has been trained for the domain, they can be used to cover other departments’ after-hours calls.
* It is the responsibility of an intern to decide when to leave a patient.
If the patient suffers unduly or dies as a result, the intern concerned will be held accountable.