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Something Has Gone Terribly Wrong
It's midnight in Charleston, South Carolina, and something has gone terribly wrong in room 749 of the Medical University of South Carolina Children's Hospital. The patient, Lewis Blackman, is a 15-year-old boy recovering from surgery to correct a relatively common birth defect called pectus excavatum, or sunken chest. The condition is not life-threatening and never seemed to slow Lewis down. A whiz in every school subject, he acted with the South Carolina Shakespeare Company and, at age seven, appeared in a long-running TV commercial for Sun-Drop soda with Dale Earnhardt. But a sunken chest can sometimes lead to respiratory difficulties, so Lewis and his parents decided to go for a minimally invasive surgical correction: inserting a metal strut to support the breastbone.
Three days after the surgery, Lewis should be feeling better. Instead, despite doses of a powerful painkiller called Toradol, the boy is racked with agonizing pain -- "five on a scale of five," he pantingly tells his mother, Helen Haskell, an archaeologist. Oddly, the pain seems centered in his abdomen, not his chest. Nurses are certain the boy is suffering from gas, a diagnosis reinforced earlier that evening by Dr. Craig Murray, the chief resident on call. Dr. Murray had stopped by and prescribed a suppository for what he believed was probably constipation, a common problem after surgery.
"I had no idea what to do," recalls Helen. "They're all saying it's the same thing, and they're the experts, so they must be right. But at the same time, I didn't see how they could be right."
As the night wears on, Lewis grows weaker. His heart rate climbs to 142 beats per minute (normal is 60 to 100), and his temperature drops to 95 degrees. His eyes are hollow, his skin is pale and he's sweating cold buckets. Helen is terrified, but because it's the night shift, there is not much she can do. Dr. Edward Tagge, who performed the surgery, is not available. Nor, it seems, is any other veteran doctor.
"There was no one around," she says. "It was very lonely, and almost surreal, like we were laboratory rats. I just sat there in this universe of my son's pain." Neither Lewis nor Helen sleeps all night.
Morning finally dawns, and with it the usual frenzy of the day shift, as surgeons, lab workers and administrators hustle into work, and patients with scheduled procedures file through the doors. At 8:30 a.m. nurses can't get a blood pressure reading from Lewis. They spend two hours trying different machines. By noon, Lewis is extremely pale; the color is draining from his lips. "It's... going...black," he tells his mother. Helen calls for help, and Dr. Murray, the resident, returns. "Lewis! Lewis!" he shouts.
There are many reasons to feel anxious when entering a hospital. In April, a HealthGrades study showed that some 248,000 patient deaths over a three-year period were preventable. What's less widely known, at least to the general public, is that mistakes tend to multiply on the night shift. You won't find it in any hospital brochure, but within the medical world, the dangers after dark are well known.
A 2005 study of 3.3 million births in California found that babies born late at night were 16 percent more likely to die than those born in the daytime. Other recent research found that patients going into cardiac arrest at night were more likely to die. In a review of pharmacy and patient records, significantly more medication errors were made at night. Daytime deaths can also be attributed to nighttime hospital errors: An analysis of 15 pediatric intensive care units found that kids admitted to the units at night were more likely to die within 48 hours.
Weekends can also be dangerous; a long-term study released in March showed that heart attack victims admitted to New Jersey hospitals on the weekend were less likely to receive lifesaving angioplasty treatment, and more likely to die within a month.
What's going on? Given that the vast majority of hospital workers care deeply about their patients, why has the night shift become so risky? Some reasons are statistical. Nighttime surgery, for instance, is performed only on high-risk, acute-emergency patients, whereas scheduled operations like hip replacements carry a lower risk of complications.
Another key reason: skeleton crews. You're not likely to see many top surgeons and specialists wandering around hospital hallways at four in the morning. And it's not just doctors who are home sleeping. "At night you have fewer resources in mental health, social services, directors and administrators," says Michelle Coner, a registered nurse at the Codman Square Health Center in Boston. "There are just fewer people to bounce things off."
Fewer people, and less experience. Since workers with seniority tend to get first dibs on the daytime positions, the night shift is often staffed with newbies -- right down to the nursing assistants and lab technicians. You have to learn sometime, and more often than not, on-the-job training happens in the middle of the night.
When you add to this mix same-day surgeries and tightwad insurance plans that have driven the not-so-sick out of overnight stays, who's left? The really sick.
"It used to be, people could stay a few days after they felt relatively well," says Barbara Williams, a nurse at Dominican Hospital in Santa Cruz, California, with 15 years' experience on the night shift. "Now they are sick the whole time, and they require a lot more pain management, IVs and other assistance. Patients have called 911 from their beds because they thought nobody was there."
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