Sleep tight ... Don't let the errorbug bite
Peter* was 19 hours into his 24-hour shift and he was the only medical officer remaining in the emergency department. At around 3am, a 10-year-old girl was brought in after falling from her bunk-bed, then vomiting and becoming agitated.
By Dr Paul Eleftheriou
Peter* was 19 hours into his 24-hour shift and he was the only medical officer remaining in the emergency department. At around 3 am, a 10 year old girl was brought in after falling from her bunk-bed, then vomiting and becoming agitated.
Peter wasn’t keen to admit a paediatric patient in an adult hospital and at that stage didn’t think that the child’s condition warranted a prolonged period of observation. The parents were told to take their daughter back home and she finally settled.
The next morning the child was found unresponsive in bed with fixed and dilated pupils. A few hours later, after multiple resuscitation attempts at the childrens’ hospital, the child was pronounced dead secondary to a significant extra-dural haematoma.
What does the Chernobyl power station disaster have in common with the one described above? Answer: sleep deprivation, which has been said to be the main cause of many other world disasters, hundreds of road fatalities and countless adverse events in healthcare. Why? Many argue it’s all because modern society pushes us to work harder for longer.
As this may be true, as a society we must never forget the fundamental reason for sleep - good health - but also not forget that a sleepy someone can be dangerous to everyone. A sleepy doctor can be as much a killer as a sleepy airline pilot. The coroner in the above case attributed fatigue as a major causal factor and highly recommended safer hours for doctors.
Do we blame doctors?
One study showed that interns on overnight call slept less than the recommended pre-call period and also had less post-call recovery sleep.
Is this a Spartan culture side effect, where junior doctors don’t want to seem ‘human’ in front of fatigued predecessors? This probably is a component but we should not let the ‘system’ take advantage of our vulnerability. If we did we would take up Queensland Health’s recommendation to drink six coffees a day to get to the end of our shift: absolutely shameful ‘advice’.
Multiple studies demonstrate that sleep-deprived doctors are less efficient and make more mistakes. No study has tried calculating associated costs, yet undoubtedly this damage bill will be enough for any authority to pay serious attention.
Some have realised the benefit of a good nap, with hospitals in Queensland instituting ultra-trendy sleep pods where junior doctors can hand their pager off and take five. However, when there is no other doctor watching your back, how do you silence the relentless beeper?
In some ICU units, the nurses have a system whereby, over a 12-hour shift, the neighbouring nurse holds the fort while you enjoy two sessions of half-hour sleeps. Why don’t doctors follow this safety measure overnight by handing their pager off to a registrar, resident or intern? Research shows that 20 minutes is all you need for minimal REM sleep, delayed fatigue and perhaps prevention of a fatal error.
Education obviously plays a major role. In the US and more recently in Queensland Health, fatigue risk management programs aim to educate junior doctors in the importance of attaining good sleep hygiene but, more importantly, this message should also be conveyed to our employers and peers - those responsible for perpetuating bad work ethic.
Eventually, culture is also changing, thanks to groups such as the AMA Council of Doctors in Training heavily promoting doctors’ health, safe hours and a healthy work-life balance.
Peter might have been educated about fatigue and have a healthy lifestyle but how about his ‘workstyle’? He was let down by the authorities: how could anyone expect us to function normally after so many hours? Perhaps Spartans.
Next time your hospital is asking for more beds, ask them to send us one or two.
Dr Eleftheriou (email@example.com) is a surgical residentMD student, Melbourne.*Peter and the associated case are based on a true event with names altered for privacy.
Stucky ER et al (2009). Intern to attending: assessing stress among physicians. Acad Med 84(2):251-7.
Feddock CA et al (2008). Do pressure and fatigue influence resident job performance? Dept. of Internal Medicine, University of Kentucky.
Arora V et al (2006). The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med 6;144(11):856-7.
Arora VM et al (2008). Improving sleep hygiene of medical interns: can the sleep, alertness, and fatigue education in residency program help? Arch Intern Med 25;168(4):435.
RBWH Fatigue Risk Management Team, Medical Administration, 19/11/2009, v1.0
“Sleep pods”. http://www.metronaps.com.au/australia/solutions.aspx
“Queensland first State to clamp down on doctor fatigue”. http://www.cabinet.qld.gov.au/mms/StatementDisplaySingle.aspx?id=57627
“Safe hours = safe patients”. http://www.ama.com.au/node/4051
“Coroner’s case”. http://www.courts.qld.gov.au/OSC-Inquest-NevilleES20080912.pdf
Markwell A & Wainer Z (2009). The health and wellbeing of junior doctors: insights from a national survey. MJA 191 (8): 441-444.
Published: 02 May 2010