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The Perfect Turf

Dodging a case is sometimes a matter of survival

The New Physician May-June 2007
It was 1:00 in the morning; I was lying on my bunk bed in my on-call room, on the eighth floor of the hospital, staring at the ceiling and trying desperately to fall asleep as so many nights before. The bed linens were always too stiff and the mattress never thick enough. The water faucet had a slow, rhythmic leak, like some kind of torture tactic. In the distance, a cacophony of alarms began chiming away, each with its own rhythm—a reminder that hearts were still beating and patients still breathing.

I knew the page was going to come; it was just a matter of time. I had one more bed to fill on my service, and I was praying for an easy admission. Or better yet, an admission that I could turf to another service. If I turfed the patient, I would still get credit for the admission and then sleep the rest of the night knowing that I wouldn’t be bothered again.

You may be wondering, what is the definition of “turf”? In the medical context, turfing is taking a patient who is supposed to be admitted to one service, like general surgery, and redirecting that admission to another service, like internal medicine. But why would a physician even think of doing such a thing?

Ask yourself this: When was the last time you worked 30 straight hours without sleep, especially in a field that is so intimately associated with life and death? Moreover, when did you last repeat this process every third day for months on end?

Like clockwork, my pager went off, and the operator told me we had an admission from the emergency department: a trauma patient with multiple injuries after a car accident. Calling the ER directly, I inquired why the patient was coming to my general internal medicine service and not going to the surgical one. They informed me that, although the patient had a liver laceration and a broken femur, he also had a complicated medical history, including hypertension, chronic lung disease and diabetes, which the surgeons claimed they wouldn’t be able to take care of.

I had to give it to them. A perfect turf, I thought to myself with animosity glazed with admiration. What could I say? I had been beaten. The orthopedic surgeons would fix the broken bone, the general surgeons would repair the liver injury, and I would manage the rest. Could I really expect a general surgeon to handle a medical problem that doesn’t involve a scalpel, or an orthopedic surgeon, a drill? Now the question was not what orders needed to be written or what procedures needed to be completed to stabilize the patient, but rather, how I could still turf this patient off of my service to another.

Maybe the patient was too sick to be on a regular medicine floor. Could I send him to the ICU? But his blood pressure and heart rate were normal in the ER, which would not suggest shock or the need for close monitoring, lots of intravenous fluids or even lifesaving medications.

What if his liver started to bleed more, or his femur fracture got displaced further? But the laceration was small, and the femur was only partially fractured, so this was unlikely to cause any major complication. It looks like I would have to take this one. Those surgeons may not be so lucky next time!

The institution of turfing is not a product of laziness, or a lack of compassion or interest in patient care, but a result of the long hours and the unyielding demands, both physically and mentally, that physicians are exposed to during their careers, particularly in residency training.

In July of 2003, the Accreditation Council for Graduate Medical Education instituted a resident duty hours standard, which states that physicians-in-training—residents—are to be limited to no more than 30 straight hours in the hospital at one time, and no more than 80 hours a week averaged over a one-month period. The goal of such guidelines is to improve both patient and resident safety.

Ironically, patient errors are still being made and resident safety is still at risk, despite these attempts at regulating work hours. Personally I have seen countless violations of these work-hours regulations and the repercussions that have resulted. Residents have been told since the beginning of medical school to go the distance; to work the long hours, and the rewards in the end will be infinite. But I don’t see the rewards in falling asleep while driving home, or injuring a patient because of extreme fatigue and lack of mental clarity.

It is disturbing that any human being, particularly a physician, needs a work-hours regulation that limits him or her to an 80-hour work week. What ever happened to the 40-hour work week? Physicians are the people on whom you depend in times of illness, distress and crisis. Can you think of another profession that carries the same weight or the same consequences if mistakes occur? If your broker chooses the wrong stock, you may lose your money. If your physician falters, you may lose your life. Which risk would you rather take?

So now I hope you are beginning to understand the origin, and thus the nature, of the turf. It is a form of self-preservation that physicians-in-training have been using for years to protect themselves from making devastating mistakes. If turfing a patient, even just for a night, as the surgeons had done, meant that there would be a little more sleep, better decisions in terms of medical management and, even more importantly, getting home safely, it was worth it.

I went into the medical profession to do my best at healing individuals with medical illnesses. The last thing I expected when I chose this calling was that I would be making errors and compromising patient care, along with my own well-being, because I am working too long with not enough time off for both mental and physical recuperation. In the end, physicians and patients are human beings, made of the same organic molecules. If your physicians are not healthy, then how can you expect them to ensure the same for you?

With these ideas rattling around in my head, I sluggishly got into my car after spending the entire night examining the new patient who had been turfed by the surgeons, writing orders for the nurses and preparing for morning rounds with the attending physician, my boss. Fumbling for my keys, I started the car and began driving the 30 miles home, hammered by extreme fatigue. My eyelids felt like they weighed 50 pounds, my legs and feet ached, my brain felt like a pile of mush and I was on a freeway driving 60 miles an hour with the morning rush-hour traffic beginning to build. The highway was riddled with cars filled with children going to school and men and women heading to their offices. I vaguely remember my eyes slowly closing, and then silence.

A sudden jerk of the wheel prevented me from hitting the freeway barrier and causing what could have been a devastating traffic accident. I was lucky this instance, but what about next time?

Maybe I will be the next patient to be turfed.
Dr. Andrew W. Seefeld is a second-year
resident at the UCLA Medical Center Department of Emergency Medicine.