Downsizing - Short Story by Mike Oppenheim

The question has come up before, so I'll answer it now. This is fiction. I made it up.


Downsizing

by Mike Oppenheim

In 1974 the county hospital budget added money to keep the laboratory open all night and hire aides to draw blood. During the previous fifty years, interns or medical students drew blood and carried it to the lab. At night, with the lab closed, they had performed urgent tests in a small room called the intern's lab. In 1974 this was closed and used for storage. Everyone loved the change except a few old professors who maintained that a good doctor drew blood and performed tests himself. No one paid attention until a generation had passed.

In 2004, after a fifth year of budget cuts, the Department of Hospitals closed the laboratory at night and fired the blood drawers. A single technician performed emergency tests, but others had to wait till morning. Like all cutbacks, it produced a chorus of complaints from hospital staff. This irritated county officials who wished they'd cooperate. No one wanted to endanger patient care and who better to advise than those who cared?

County officials knew that previous cutbacks that closed wards and laid off employees couldn't endanger patients because the hospital continued to provide all services. Urgent services took priority; the rest took longer. Closing the lab proved trickier. Complainers pointed to devastating consequences of tests unavailable or tests performed by the clumsy hands of the medical staff. This delayed the change for years until one official had a stroke of luck. Moving into the office of the hospital public affairs department (closed in 1996) he came across an ancient clipping file. Leafing through, he discovered a yellowed editorial, a wistful essay by an emeritus professor deploring the technology-obsessed hospital of the 1960s.

During the 1920s, the professor wrote, patient care was no abstraction. If an intern wanted an X-ray, he loaded the film, took the picture, and developed it himself. If he needed information on a patient's body fluid, he extracted that fluid himself and performed the test. Handing responsibility to a faceless technician did not represent progress but the opposite. A good doctor cared for his patient, and care meant care with the doctor's own hands.

A cutback that improved patient care seemed like magic, but there it was in black and white. The professor, still alive at 96, was dazzled by his short burst of fame. The newspaper reprinted the editorial. State law required licensed technicians for X-rays but said nothing about lab tests, so officials listened politely to forecasts of doom from doctors then closed the lab at night and laid off the blood drawers.

Maintenance personnel cleared out the former intern's lab and bolted a microscope and centrifuge to the bench. An incubator and refrigerator arrived along with a cabinet for glassware, chemicals, and a few tools. Half a dozen reference books were quickly stolen, but they weren't essential. Wall posters pictured common blood and urine abnormalities, and senior residents were assumed to know any subtleties.

The administration revived the system in place before 1974. Third year students arrived an hour early, consulted their intern's orders, drew blood, then carried the tubes down to the main lab, stopping in the intern's lab to pick up tubes and cultures that had accumulated during the night. Dropping off their load, they picked up lab slips for the previous day's tests. Students drew any blood required during the day; at night they or the interns used the intern's lab for tests that couldn't wait.

That was the revived system in theory. Before the cutback, employees who drew blood attended a class first. Under the new system, when medical students arrived, an intern demonstrated on the nearest patient then sent them on their way. Most students grew adept, but drawing blood takes modest dexterity, and a minority had trouble, tormenting patients with repeated attempts. Everyone except a few virtuosos had trouble with addicts and chronically ill patients lacking visible veins.

Formerly, an employee was fired if caught drawing blood from a femoral vein. Students were merely told it was dangerous. To reach that vein, one plunges the needle deep into the groin. A huge vessel, it's hard to miss. Impatient students or those who'd made a few unsuccessful jabs found the femoral vein irresistible. Accuracy was important because the femoral artery runs along one side of the vein, producing a geyser of blood if punctured. Erring on the opposite side hits the femoral nerve.

A month after the new system began, a nurse found a patient lying in a pool of blood. Although a gruesome sight, he survived. A student had drawn blood from his femoral vein then hurried off. The rule on femoral punctures required pressing the site for five minutes afterward. Neglecting this usually resulted in nothing worse than a large hematoma in the groin. Unfortunately, this patient was a semiconscious alco¬holic with liver disease and deficient clotting factors, so the site oozed for hours before anyone noticed.

The staff assembled to be lectured. The technique of femoral punctures was reviewed, but it was described as an absolutely last resort. The lab offered to revive its blood drawing class, and a few students signed up. Interns were admonished to supervise students more closely, but they didn't. Interns had too much work, and most students were reliable.

Students had exams and vacations plus a week between semesters when no student was assigned to a ward. Interns handled blood on those occasions. When students got sick or took a day off to study or slept late, interns drew blood - sometimes late if there was no warning that the student wouldn't arrive. Students resented the new system, but interns resented it more.

The intern's lab worked, but certain problems remained unsolved. Within a week of opening it was filthy and stayed filthy, and no one knew a way to keep it clean. Janitors swept the floor and emptied the trash, but rules forbade cleaning sinks, benches, and equipment. These contained chemicals and body fluids that might be dangerous. Technicians in the main laboratory kept their own areas clean, but no one worked permanently in the intern's lab. People hurried in, performed a test, and hurried out. Neat individuals cleaned up after themselves, but these were a minority. Chemical stains spread over the benches and spotted the sink. Food wrappers and broken glass nestled in every corner. Most glassware was disposable, but larger flasks and measuring cups quickly grew dirty. Users were supposed to clean glassware before testing, but sometimes they didn't. Now and then someone left the cap off a bottle of reagent, ruining the contents. The next user should have thrown it out, but it was often the only bottle available.

Keeping the microscope usable was easy, but the centrifuge smelled and overheated. Everyone understood about balancing a centrifuge. After putting a sample in one receptacle, one put a test tube filled to the same level with water in the receptacle 180 degrees opposite. Otherwise, as the unbalanced centrifuge gathered speed, vibrations shattered every container. At intervals someone forgot the second tube or grew casual about equalizing the water level. As soon as the unbalanced machine began to shake, the offender turned it off, but looking inside always revealed that the contents had vanished. No one had time to clean the centrifuge, especially since it usually continued to work. When its motor eventually failed from abuse--a spectacular event replete with smoke and a shower of sparks--the main lab replaced it, another source of bad feeling between departments. Replacing equipment remained a laboratory responsibility and came out of its budget. Equipment maintenance had been privatized years before. It was up to the department of medicine to contract for that service, and it didn't.

From an educational point of view, everyone agreed that students and even interns benefited from performing their patients' tests, but concern arose about accuracy. Three weeks after the new system began, a patient entered the hospital at midnight and died the next day. Daytime lab revealed aplastic anemia--a low count of all his blood cells. Since a nighttime count was normal, suspicion arose that a student had performed a sink test. A laboratory joke, the sink test occurs when an overworked technician pours his sample down the sink and writes a normal result on the slip. Since most tests turn out normal, a sink test's results are usually correct. The chief resident ordered interns to check every student's test, but this was unenforceable and largely ignored. Interns had too much work, and most students were trustworthy.

Three months after the new system began, two students and two interns developed hepatitis. Obviously they had neglected strict blood precautions. The staff assembled to be lectured. Warning posters appeared. Matters improved, but they were never ideal. In former times, blood drawers wore thick, uncomfortable rubber gloves. They had no choice. Between morning duties, a student or intern might draw blood a dozen times and handle blood several times in the lab. Only the most obsessive wore gloves every time; the rest tried to be careful.

At the end of the year the department of hospitals reviewed the new system and found it satisfactory. Laboratory expenses were down. Quality of care seemed unaffected despite a few glitches and the usual grumbles from the medical staff.

One administrator floated the idea of closing the lab section devoted to simpler tests such as urinalyses and blood counts, giving 24 hour responsibility to medical staff. This would save money as well as advance the new policy of maximum hands-on care. Expecting complaints, the administrator was not disappointed. The laboratory director arrived at the hearing with an elaborate slide presentation. He projected tables of tests performed by technicians versus those done at night. In every case, nighttime results on the same patient varied more widely, implying a lack of accuracy. Another table revealed that spoiled or improperly drawn samples arrived three times as often as when hired blood drawers did the work. Officials agreed this was a genuine concern, but one staff could address by more training and closer supervision.

A dean pointed out that third year students were free at night but had classes during the day, so this change would pile more work on already overworked interns. Another genuine concern, agreed officials. Perhaps the medical school could assign first and second year students to blood drawing and lab duty. Although this would take them out of class, it would provide early experience of hands-on care. Hands-on care was important.

As for the overworked interns, everyone agreed they had done a magnificent job. For a time, they would have to perform even more magnificently because one of the smaller county hospitals would close at the end of the year. However, relief was on the way. Years of legal battles were ending, so the county would soon limit care to US citizens except in emergencies. The budget would drop to compensate, so interns would only benefit for a year, but another change would lift a great burden. Fourth year students would work as interns.

To an extent, this was already happening. Students spent their last year on electives such as pathology, neurology, or pediatrics or in research. One elective went by the name of "subinternship" during which a student spent two months on a medical ward. Two students worked per ward, rotating admissions, so each cared for half as many patients as an intern, but otherwise their duties were identical. Only a sprinkling of students chose this, but in the future half the fourth year would consist of subinternship. Everyone benefited, the Department of Hospitals explained. Students performed more hands-on care; interns lightened their loads. Although a minor consideration, the budget also benefited. Subinterns remained students, so they weren't paid.

Responding to a predictable protest, the Department of Hospitals assured the dean it appreciated how electives enrich medical training, so the remainder of the fourth year would remain elective. There was no plan to change this.