When the night in the hospital passes very quietly, the doctors fear that the worst is yet to come. In the obstetrics service of the University of Toledo they did not remember a shift as calm as the one two Thursdays ago. It was already early in the morning and they had not attended even a single birth. Not even one normal, when the average in the center is seven a day. Until five to 10 in the morning. Everything that had not happened before happened in a little over three hours: three births, including two emergency caesarean sections and an anal tear. The gynecologists had to perform at 100% after more than 21 hours of work. It is the guard system in Spain: after the normal day of consultations or operations, 17 hours of extraordinary work, which some unions and professionals question as excessive and undermining the safety of doctors and patients themselves, but which is part structure of the system and the salaries of the doctors.
Those 24 continuous hours are sometimes extended due to service needs. According to the survey Physical and emotional well-being of the doctor, from Mutual Médica, 4.5% of doctors work 36 hours or more. In quiet moments, like the one they had in the Toledo hospital, it is normal for the doctors to go to bed, and the nurses (in this case midwives), who work in shifts, wake them up only if necessary. “You go in two seconds from deep sleep to being under a scalpel; you have to act immediately and that is a challenge for me”, confesses Vanesa Aguilar, head of the Gynecology service at the University of Toledo. “You don’t have time to go to the bathroom or wash your face, you run and you don’t know what you can find,” Rocío Escudero, an associate at the same hospital and a guard companion of her superior, intervenes.
If the midwives call the doctors, it means that something has gone wrong. the deliveries easy They do not require the presence of the doctor. With them, even in the difficult ones they almost always go well, despite the accumulated fatigue. But the fatigue of the guards is not innocuous, neither inside nor outside the hospital. Returning to his home in Madrid, Escudero has suffered two small traffic accidents. Touches without gravity at traffic lights as a result of lack of sleep. A study showed that after a 24-hour guard, the risk of having an accident is multiplied by 2.3. Medical failures also appear to be increasing: other research published in The New England Journal of Medicine it ensured that residents made 35.9% more serious errors in 24-hour shifts than those who made 16-hour shifts, and diagnostic failures multiplied by 5.6.
In a survey by the Spanish Association of Resident Internal Physicians, 60% of those questioned said they had made a serious mistake in the exercise of their profession due to fatigue, and up to 34.7% said they had suffered an accident in the road after finishing watch. These are all data published almost two decades ago, but nothing indicates that the situation has changed substantially.
Faced with this reality, medical unions and some professionals wonder if this is the best way to care for patients and if, with the available human resources, there is another possible way. Javier Ortega, from the Amyts union, explains that “the most advanced countries in labor matters”, such as the United Kingdom, have long implemented a maximum of 12 hours. Others have recently moved towards this model, such as France or Iceland, while 24 hours are available in neighbors such as Portugal and are possible in Germany, for example, which combines them with another system of 12. “Our model is very old, it dates from the 1970s, and it has practically not been updated”, he points out.
The organization varies between hospitals, and there are exceptions that have implemented 12 hours in some services. But the scheme in almost all of Spain is very similar: 24 hours in a row. “The guards are an administrative and economic slavery, because a good part of the salary depends on them, so many doctors prefer to do them,” says Ortega.
A survey of the State Confederation of Medical Unions from this year it showed that 87% of doctors perform shifts, although practically 60% of them would prefer not to. Although from the age of 55 they are voluntary, 70% continue, which Ortega explains by the substantial portion of the salary they represent. They also complain that these hours do not count towards their retirement and that, in the event of sick leave or illness, it is a part of the salary that disappears.
This economic dependence is especially pronounced for residents. With a base salary that starts the first year at around 1,200 euros gross per month, they normally work between six and seven on-call jobs a month, which often means more money than their regular income. Rates fluctuate and range from 9.98 euros gross per hour for first-year residents in the Canary Islands to 29.76 for an assistant in Murcia, according to data from the Study Center of the Medical Union of Granada. This means that each guard (17 hours) is paid between 169.66 and 505.92 euros gross on business days, a figure that rises on holidays and even more on special dates, but with withholdings it can be a little more than half .
Residents are also the basis on which continuous hospital care is based. While the assistants usually do one or two shifts a month, the MIRs frequently reach six. And they are the ones who deal with most of the cases. The night of the obstetrics service at the University of Toledo is a good example of how they are organized. In command, the head of service and a deputy, the two doctors with the most responsibility on duty. On the next step, three MIR: a third-year, a second-year and another who is doing the rotation within the Family specialty. And for the most routine procedures, a shift with six midwives, three auxiliary nursing care technicians and an orderly, the only man on duty.
The residents attend to the emergencies that come in and only notify the assistants if something complicated arises. They follow a ladder. “You are evolving,” says Paula Gutiérrez, a third-year MIR (R3). “The emergencies of a small resident bring you a lot, but when time passes you get tired because it is always the same, it is the ABC. Most of the cases are not serious, but patients who do not want to wait for a gynecological check-up or pregnant women who live that time very intensely and when they notice anything they come ”, she relates.
That night, the first line guard is Andrea Curiel (R2). It’s almost two in the morning, and as they tell the story, her pager rings, which she carries because she is the “little resident.” She picks up the phone and her face doesn’t change. “Since she is calm, I am calm,” says her fellow guard. A pregnant woman’s monitor showed abnormal signs and a midwife alerted her. But it’s a false alarm.
“I am in the worst moment. Because emergencies don’t help me much anymore, but they don’t let me intervene in caesarean sections or complicated deliveries either, ”Curiel laments on returning to check the monitor. “Well, today you have done two curettages. A few months ago I was with the pager, but now I have gone through a phase of a lot of learning because I can help with caesarean sections, with the assistant supervising”, Gutiérrez replies.
In good guards, they say, they sleep for a couple of hours. In bad times, nothing. “If I have half an hour between when I ask for an analysis and the results come out, I do it because I know that they may be the only minutes I spend lying down,” says R3.
For the adjuncts, the guard is usually calmer. Some early mornings are hectic, but since they only let them know when something is complicated, there are even nights that they spend sleeping. “One in 10, at most,” Vanesa Aguilar qualifies. The two doctors organize themselves in shifts: one is notified if something happens from 12 to four in the morning and the other from four to eight. But often they have to call both of them.
If it weren’t for the presence of an editor and a photographer from EL PAÍS, surely Aguilar and Escudero would have been sleeping until approximately five in the morning. At 4:50 a.m., an orderly takes a woman in labor in a wheelchair. A few minutes later the cry of a newborn is heard. What looks like a quick and uneventful delivery has torn the mother’s anal sphincter.
While they are suturing it, another one enters with a breech baby. She is not in labor yet, so in principle she can wait a few hours for the cesarean section. But Rocío Escudero realizes that the umbilical cord is in the path of the baby’s exit. With her hand inside her vagina to hold it, she has to go to the operating room to have the baby delivered by caesarean section. And, at the same time, another mother, who had lost a child in an instrumental delivery a few years ago, shows worrying signs: the fetal heart rate is too low. The nightmare seems to repeat itself. Faced with this situation, it is best not to take risks, so the gynecologists proceed to another emergency caesarean section.
The service went from absolute calm to debauchery. They finished at 8.10. Aguilar had been awake since just over five in the morning the day before and Escudero for an hour later. They had a day ahead that the residents define as similar to “a hangover in which you come back from a party.” The youngest go to bed to sleep until lunchtime. The older ones no longer sleep a wink until night. “We have disrupted the dream,” they justify.
Are there alternatives to this model? Tomás Cobo, president of the Collegiate Medical Organization, sees a radical change as very complicated. “It is very difficult to establish 12-hour periods in some surgeries that can last longer than that,” he points out, although he qualifies that they are labor issues that the unions have to negotiate, if appropriate.
Fernando Hontangas, CSIF Health representative, believes that to begin with they should be voluntary in all cases. “The model that exists up to now endangers the safety of the patient and of the professionals themselves. Sometimes the workloads are unbearable and a system cannot be maintained based on the lack of conciliation of the health workers. But there is a reality: to have a decent salary, you often have to do guard duty ”, he assures.
Another model would involve hiring more professionals. And in a context in which Primary Care is in crisis due to a lack of doctors, it is unrealistic to think that hospitals are going to provide themselves with many more human resources. It is a debate in which not even the doctors themselves agree, so changing it does not seem like a priority for the administrations, they already have several holes open in the National Health System. Operations after 24 hours of work are here to stay for a while.
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