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Surgeons Who Operate Post-Call

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Fatigue is a big deal for trauma professionals. I previously devoted a week of posts to detailing research on fatigue, and dedicated the June 2012 Trauma MedEd newsletter to the topic. So I just reviewed a paper suggesting that it might not be such a big deal for attending (consultant) surgeons who operate after they’ve been on call.

The whole idea came about because residents in the US (registrars) have had restrictions to their work hours in place for 10 years, limiting them to only 80 hours per week. Yet the attending physicians, who are older and more likely to show the effects of fatigue, have no such limits. They can work as long as they want. Maybe their greater experience or long-established habits of occasional sleep deprivation are protective?

The group in Memphis looked at this phenomenon, performing a retrospective review of patients operated on by surgeons post-call and those who were not. They looked at 737 patients over 3.5 years, of which 15% were performed by post-call staff surgeons. Here are the key points:

  • Only cholecystectomy, hernia and intestinal procedures for bowel obstruction, ischemia or bleeding were evaluated
  • The authors used complications and readmission as outcomes to monitor
  • Complications occurred in about 13% of both post-call and no-call groups. No difference.
  • Readmissions within 30 days occurred in about % of both groups. Again, no difference.

So it looks like it’s okay to operate after the surgeon’s been up at night, right? Wrong! This is another perfect example of why it’s so important to read the whole paper, not just the abstract. Major problems:

  • The actual amount of sleep or fatigue levels are not quantified, so it’s a mix.
  • It’s a teaching hospital, so the surgeons always operate with a trainee at some level. The residents either do the work, or can “double check” the surgeon’s work to prevent any significant errors.
  • Complications and readmission rates are very crude indicators of error. Only the most egregious problems would manifest as one of these.

Bottom line: There is plenty of non-medical literature out there that shows that fatigue is bad (aviation, trucking, marine operations). And as much as we’d like to believe it, surgeons and other physicians are in no way immune to its effects. What this paper really showed is that if you are supervising a well-rested trainee and looking at outcomes that aren’t directly related to fatigue, everything looks great! It’s not, and all trauma professionals need to be aware of the fact that, even though they feel invincible and that they can do anything after sleep deprivation, it’s just their fatigue talking. Protect your patients and make sure that everyone who takes care of them is in tip-top shape.

Reference: Outcomes of operations performed by attending physicians after overnight trauma shifts. Journal Am Coll Surg, in press 11 Jan 2013.

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