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.
Most trauma professionals are shift workers to one degree or another. It is well documented that sleep problems and fatigue can occur with this type of work, depending on the structure of the shift. A number of studies have been carried out in physicians and prehospital providers. But what about prehospital air crews?
Air medical providers are faced with two challenges: critically ill and injured patients and a challenging work environment. Typically, work consists of 12 or 24 hour shifts, and all of this is conducive to sleep problems and fatigue.
The University of Pittsburgh looked at this problem, performing a battery of questionnaires and cognitive tests in their air medical service before and after each shift. They studied 37 subjects, and found the following interesting tidbits:
- 95% of all crew members had poor baseline sleep quality
- Fatigue levels decreased over the shift (both 12 and 24 hr)!
- Crews were able to get some sleep while on duty (1 hour in a 12 hour shift, 7 hours in a 24 hour shift)
- There was a mild increase in cognitive test performance at the end of the shift, although it was not statistically significant
Bottom line: Don’t anyone try to generalize these results to all flight crews! This was a sample of a single flight service, and is not necessarily representative of others. Poor baseline sleep quality is likely due to the fact that many flight nurses and paramedics hold other jobs. In this particular case, the decreasing fatigue may simply be due to the fact that they are encouraged to get some rest while on duty and actually do it. Make sure that your agency has fatigue reducing and fatigue avoidance policies and procedures. It’s for your safety as well as your patient’s!
Reference: The effect of shift length on fatigue and cognitive performance in air medical providers. Prehosp Emerg Care (early online, 2013)
Fatigue is a major problem for many healthcare providers, from prehospital those working in post-discharge institutions. Some interesting and underappreciated statistics about work-related injuries and shift work:
- Work related injuries increase on off-shifts. Compared to day shift, 15% more injuries occur on evenings and 28% more on nights.
- When working long shifts, there is a 13% increase in injuries after 10 hours, and a 30% increase after 12 hours.
- When working consecutive nursing shifts, there is an 8% increase in injury risk the 2nd night, a 38% increase the 3rd night, and a 70% increase the 4th night.
We know sleep deprivation and fatigue are bad. The laundry list of adverse effects is lengthy and includes confusion, memory problems, depression, weight gain, headache, diabetes, cardiovascular disease, and as we’ve discussed all week, serious performance problems.
What can be done about it? The key is to raise awareness, along with acceptance of the remedies. Many hospital workplaces are doing something about it. Here are some successful interventions that reduce workplace fatigue:
- Authorize a real break system. A break is a 30 minute period which is ideally away from the immediate work setting, where there are no disturbances (phone, pager)
- Ensure effective “handoffs” between co-workers when taking breaks
- Encourage workers to identify fatigue in their co-workers and find ways to decrease it
- Modify schedules to adhere to the Institute of Medicine’s standards
* No more than 20 hours of overtime a week
* Limit the number of 12 hours shifts
* No double shifts
Some workplaces are unfortunately not as progressive, and the work culture takes pride in showing how individuals can “power through” even when tired. Just remember, this is bad for you and bad for your patients. As you grow older, it becomes even more difficult and dangerous. It’s only a matter of time before someone, somewhere goes too far, and they or their patient will end up “dead tired.”
We’ve all experienced it. That moment of wandering attention. The semi-blank stare. You can’t remember that question you were going to ask. It’s the “zoning out” phenomenon. It happens more frequently when you are fatigued or sleep-deprived. What is really happening in your head when you go blank? Your’re neither asleep nor fully awake.
The University of Wisconsin at Madison has been able to shine a little light on this problem. While we are awake, neurons in the cerebral cortex fire irregularly, which results in rapid fluctuations on an EEG. As we sleep, the brain alternates periods that look like an awake EEG with periods where the neurons stop firing altogether.
The researchers monitored activity in focal areas of rat brains (tough to extrapolate this one). They found that after prolonged sleep deprivation, small random areas of the brain would switch off and look like they were asleep. However, the animal appeared to be awake, and the EEG looked like that of an awake rat. If neurons switched off in the motor strip while tasks were being performed, performance errors increased dramatically.
The lead investigator believes that these “tired neurons” may be responsible for attention lapses, poor judgment, mistakes and irritability when we haven’t gotten enough sleep, but don’t feel sleepy. This phenomenon may represent a global state of neural instability, and individual neurons switch off to save energy or restore themselves.
Reference: Nature 472:443-447, April 27, 2011.
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.
Reference: The effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons. Am J Surg 196(6):8133-820, 2008.