Tag Archives: fatigue

Fatigue IV: Trauma Surgeons And Residents

The effects of fatigue on the surgeon have been looked at a number of times over the years. Most of this work focuses on resident physicians, however. Another problem with the majority of these studies is that they did not test the surgeon or resident on tasks that reflect real life practice.

A study from Arizona State University used a laparoscopic simulation that tested both psychomotor and cognitive skills that would be called on during real surgical procedures. In addition to the purely manual task of stacking varied sizes of rings using laparoscopic instruments, exercises were developed and validated that tested attention, tracking and other critical components. Monitored parameters included hand and tool movement, smoothness and economy of motion, and time required to complete the task. An overall proficiency score was calculated.

Five residents and nine attending physicians were tested. They were all given 4 practice sessions with the simulator before the study began. Sleep hours and caffeine use during call were recorded using a questionnaire. Each individual was then tested three times prior to being on call and three times post-call.

As would be expected, attending surgeons showed higher proficiency scores than residents both pre-call and post-call. However, both groups experienced significant declines in proficiency and significant increases in cognitive errors post-call. Interestingly, attending surgeons made 25% fewer cognitive errors post-call when compared to residents, and their psychomotor skills were unchanged. This suggests that the attendings were focused on skills at the expense of decision making.

Two other interesting items from this paper:

  • Errors increased exponentially with subjective reported fatigue in the attending surgeons. This means that a small amount of attending surgeon fatigue led to a large increase in errors. The implication is that the older attendings had less reserve, and that their greater skills and experience could be quickly overwhelmed.
  • Caffeine intake had no effect on motor skills or cognitive errors.

Bottom line: Fatigue from post-call sleep deprivation impedes psychomotor and cognitive functions, as well as performance. Residents are affected more than attending surgeons, but attending performance declines more rapidly as they grow fatigued. As any post-call surgeon knows, activities the day after call should be limited to the mundane to optimize patient safety.

In the next installment, we’ll look at the impact of poor sleep on our patients!

Reference: The effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons. Am J Surg 196(6):8133-820, 2008.

Fatigue III: Impact On Nurses

Although 8-hour shifts are the most common work arrangement around the country in all most occupations, they are a bit less common in nursing. Nurses have work and sleep patterns equivalent to prehospital providers. And critical care nurses probably have the most variable and punishing work patterns.

One may think that just increasing to a 12-hour shift is not that big of a deal. The nursing school at the University of Auckland performed their own survey of ICU nurses in two separate hospitals in New Zealand. They administered the Occupational Fatigue Exhaustion/Recovery Scale and evaluated differences in relation to a number of demographic variables.

Here are the factoids:

  • There were a total of 67 participants in the two hospitals and all worked 12-hour shifts.
  • Nurses at one hospital (A) worked mostly day or mostly night shifts and tended to be younger. Shifts were more mixed at the other (B).
  • About half of the nurses reported low to moderate fatigue acutely, and two thirds re-ported this level between shifts as well.
  • Factors that correlated with increased fatigue were younger age, fewer children, less years of experience, and less exercise.
  • Higher fatigue levels were reported at hospital A, which had the younger, less experienced nurses.

Bottom line: This is another survey study, but it does illustrate some common issues. Some factors could be changed by rearranging the shift structure to all day or all night shifts. Exercise was associated with less stress and could be encouraged. But the nature and pace of work in the ICU remains constant and is difficult to control for. Some strategies for positive change are listed on the next page of the newsletter.

In my next post, I’ll review the impact of sleep problems on trauma surgeons and residents.

Reference: Exploring the impact of 12-hour shifts on nurse fatigue in intensive care. Applied Nurs Res 50:151191, Dec 2019.

Fatigue II: Sleep Quality and Fatigue in Prehospital Providers

EMS providers across the country are assigned to a variety of schedules, ranging from shift work to continuous 24 hour service. Overnight duty, rotating schedules, early awakening and sleep interruptions are common. Unfortunately, there are not many studies on the effects of fatigue on EMS. I did manage to find an interesting study from last year that I’d like to share.

A group of about 3,000 providers attending a national conference were surveyed using 2 test instruments (Pittsburgh Sleep Quality Index (PSQI) and Chalder Fatigue Questionnaire (CFQ)). The PSQI measures subjective sleep quality, sleep duration, disturbances, use of sleeping meds and daytime dysfunction. The CFQ measures both physical and mental fatigue.

Only 119 surveys were completed, despite the fact that a $5 gift card was offered (not enough?). The most common certification was EMT-Basic (63%) and most had worked less than 10 years. Most were full-time, with most working 4-15 shifts per month. The following demographics were of interest:

  • Self-reported good health – 70%
  • Nonsmokers – 85%
  • Moderate alcohol or less – 62%
  • Overweight or obese – 85%

A total of 45% reported experiencing severe physical and mental fatigue at work, and this increased with years of experience. The sleep quality score confirmed this fact. Also of interest was the incidental finding of a high proportion of overweight or obese individuals. Sleep deprivation is known to increase weight, and increased weight is known to increase sleep problems, creating a vicious cycle.

Bottom line: This is a small convenience study, but it was enough to show that there is a problem with fatigue and sleep quality in EMS providers. Federal law mandates rest periods for pilots, truck drivers and tanker ship personnel. The accrediting body for resident physicians has guidelines in place that limit their time in the hospital. Prehospital providers perform a service that is just as vital, so it may be time to start looking at a more reasonable set of scheduling and work guidelines to protect them and their precious cargo.

In my next post, we’ll cover the impact of sleep loss on nurses.

Reference: Sleep quality and fatigue among prehospital providers. Prehos Emerg Care 14(2):187-193, April 6, 2010.

Fatigue: Sleep Deprivation Changes The Way We Make Risky Decisions

I’m expanding my series dealing with the issues surrounding lack of sleep. As you all know, trauma professionals are expected to perform even if they have not had adequate sleep. This can occur with certain shift schedules, long periods of work, or due to call schedules and duration of call. What do we really know about the effects of sleep deprivation on us?

For the next few weeks I’ll be writing about the effects of fatigue on trauma professionals, including prehospital providers, residents, surgeons, and nurses. And I’ll finish up with some new research on the effects on our patients.

In this post, we’ll talk about decision making. Neuroscientists at Duke looked at how we approach risky decisions when we are sleep deprived. A total of 29 adults (average age 22) were studied. They were not allowed to use tobacco, alcohol and most medications prior to sleep deprivation, which lasted for 24 hours. They were given a risky decision making task (a controlled form of gambling), and two other tests while in a functional MRI unit to watch areas of brain activation.

The researchers found that, when well rested, the subjects had a bias toward avoiding loss in the gambling test. After a single night of sleep deprivation, this shifted to pursuing gain. The MRI also showed an increased activity in the reward anticipation parts of the brain. Overall decreased vigilance was noted, but this did not correlate with the shift away from risk avoidance.

Bottom line: Sleep deprivation appears to create an optimism bias. Fatigued individuals act like positive outcomes are more likely and negative consequences are less likely. One of the most common and important things that trauma professionals do is to make decisions that may affect patient outcome (e.g. choose a destination hospital, intubate, order and interpret a test, move to the operating room, choose a specific operative procedure). We all have a set of thresholds that help us come to the “right” decision based on many variables. It appears that a single night of sleep deprivation has the potential to skew those thresholds, potentially in directions that may not benefit the patient.

In the next post, I’ll turn my attention to the impact of sleep loss on prehospital providers.

Reference: Sleep deprivation biases the neural mechanisms underlying economic preferences. J Neuroscience 31(10):3712-3718, March 9, 2011.

AAST 2019 #7: Trauma Surgeon Fatigue And Burnout

I love this topic, especially since I’m getting a bit long in the tooth myself. The impact of night call is significant, even if it’s less noticeable in my younger colleagues. Theories (and some real data) abound that long stretches of stressful work is unhealthy and may lead to burnout. Modifications such as reduced call length or varying work type have been tried, but there is little data showing any real effect.

The trauma group at Grant Medical Center in Columbus, Ohio performed a month-long prospective study involving six Level I trauma centers. They set out to monitor fatigue levels  due to varying call shift schedules and duration, and to see if they could identify any relationship to risk of surgeon burnout.

The authors used an actigraphy type device to monitor fatigue using an unspecified alertness model. These devices are typically worn on the wrist, and have varying levels of sophistication for determining sleep depth and fatigue. The surgeons self-reported their daily work activities as “academic”, “on-call”, “clinical non-call”, or “not working” and the lengths of time for each. A validated burnout inventory was taken at the end of the study to gauge burnout risk. The impact of 12 vs 24 hour call shifts was judged based on these variables.

Here are the factoids:

  • The number of surgeons involved in the study was not reported (!!!)
  • Mean  and worst fatigue score levels were “significantly worse” after a 24 hour shift compared to 12 hours
  • The proportion of time spent with a fatigue level < 70 (“equivalent to a blood alcohol of 0.08%”) was significantly longer during 24 hours shifts (10% vs 6% of time)
  • There was no real correlation of call shift length or times spent in various capacities on the burnout score
  • Pre-call fatigue levels correlated well with on-call fatigue, but not working pre-call did not

The authors concluded that fatigue levels relate to call length and correlate strongly with fatigue going into the call shift. They also noted that the longer shifts brought fatigue levels to a point that errors were more likely. They did not find any relationship to burnout.

There are a lot of things here that need explanation. First, the quality of the measurement system (actigraph) is key. Without this, it’s difficult to interpret anything else. And the significance data is hard to understand anyway. 

The burnout information is also a bit confusing. Other than putting an actigraph on the surgeons and having them log what they were doing, there was no real intervention. How can this possibly correlate with burnout?

The authors are trying to address a very good question, the relationship between call duration, configuration, fatigue, and error rates. More importantly, but less studied in trauma professionals, is the impact of disrupted sleep on the health and longevity. These are very important topics and I encourage the authors to keep at it!

Here are my questions for the presenter and authors:

  • Please provide some detail about the device used for actigraphy and exactly what was measured. There is substantial variation between devices, and very few are able to show sleep disturbance as well as actual brain wave monitoring. If this information is not extremely well-validated, then all of the results become suspect.
  • How many subjects actually participated, and how can you be sure your fatigue score differences are really statistically significant? It’s difficult for me to conceive that a difference of only 3.7 points on the “fatigue level scale” from 83.6 to 87.3 is significant. This is especially relevant since the abstract states that a score < 70 is similar to a blood alcohol level of 0.08%. The average level is well above that. And does statistical significance confer clinical significance?
  • And how about more info on the burnout inventory used? I presume the surgeons didn’t suddenly just start taking call for a month. They’ve been doing it for years. So why would a month of monitoring give any new indication of the possibility of burnout. It would seem that the usual surgeon lifestyle across this group is not leading to burnout. And I’m not sure this is accurate.

Reference: More call does not mean more burnout: a multicenter analysis of trauma surgeon activity with fatigue and burnout risk. AAST 2019, Oral abstract 52.