To sleep, perchance to dream

Tuesday, August 4, 2009

Falling asleep on the job is probably not a good thing. Ask the two Mesa Airline pilots who did just that last year en route to Hawaii and missed their stop. The National Transportation Safety Board concluded their investigation and found that getting to the airport at 540 AM, three days in a row contributed to their sleepiness. Five in the morning may seem early, but for many that hour comes in the middle or the end of their work day. Our society has come to expect business and service 24 hours a day and then forgets that actual people have to deliver those services.

Medicine is not immune from the 24 hour cycle. Patients tend not to get sick Monday through Friday, 9 to 5 and care has to be provided when it is needed. By necessity, shift work is the fact of life for nurses, technicians and a variety of support staff. If has also become more prevalent for physicians. Emergency physicians, hospitalists, radiologists and anesthesiologists have gravitated to the shift work model instead of taking call. The idea was to provide fresh faces and alert minds to care for patient needs in the middle of the night. This all seems good in theory until it bumps into the reality of circadian rhythms and disturbed sleep cycles.

The US Department of Health and Human Services has spent significant time studying the effect that the lack of adequate sleep has on performance and safety. It comes as no surprise that fatigue affects judgment and reaction times. But it is interesting that the amount of sleep does not correlate with the amount of fatigue. All sleep is not created equally.

The ideal amount of sleep varies for each individual but ranges from 6-10 hours with an average of 8 hours per night. Sleep debt can start to happen even after one relatively sleepless night. Studies show that after one night with jus t5 hours of sleep, performance can fall by 25%. If 5 hours of sleep happens for 2 or 3 days in a row, performance can fall almost in half. Many people can catch up and repay their sleep debt, but shift workers not only fight longer hours but the effect of disturbed circadian rhythms, the innate need of the body to follow the sun. 60-70% of night shift workers have sleep disturbance issues including sleep disturbances, less REM sleep where dreaming occurs and waking up feeling less than rested. Shift workers were found to be less alert and perform less well tasks that require reasoning and also on repetitive tasks.

Still, hospitals need to be open and care fro patients when the need exists. Dilemmas arise. Should an operation take place at 3 in the morning with a tired surgeon, anesthesiologist and nursing staff or can it wait until 7AM when a new crew comes in. Does the wait cause more harm than having care provided by sleep deprived individuals? And what about the patients who were scheduled to be seen at 7 AM. Is it fair to make them wait?

There is no solution that can turn humans into nocturnal creatures. The Department of Health and Human Services has taken a pragmatic approach to the issue:
“Finally, fatigue among medical personnel may not be fully remediable and human errors are, in the end, inevitable. The ultimate solution for healthcare organizations will likely require a systems-based approach that both limits the potential for human error and intercepts errors that do occur before they reach patients. (
The two pilots wakened when their plane was thirty miles past their destination and flew it back to safety. Just another near miss; no harm, no foul. But it was a high profile case that reminds us that perhaps the world shouldn’t be open 24/7.

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