How tired is too tired?

InstrumentsMany years ago, I was working as a registrar in plastic surgery. In this unit, we did a lot of complex head and neck reconstructions for cancer. One case I remember especially well was a wonderful lady who had a particularly nasty cancer on the floor of her mouth. She was scheduled for surgery on a Thursday. Thursday was reconstruction day. We started her operation around 8am, finished around 5am on Friday morning. I raced home for a quick shower, got changed and came back to work. No sleep. A lot of make-up. I came back into the ICU to see our lady and the free flap reconstruction was not looking great. It was likely that there was some problem with the blood supply of the tibia, muscle and skin we had borrowed to reconstruct the defect. An hour of trying things like manipulating blood pressure, taking pressure of the neck and heparin to dissolve any clot didn't work and so we headed back to the operating theatre to revise the flap. It was about 5pm on the Friday when I realised I had fallen asleep on the operating microscope.

This is not the first or last time I had been awake for several days. I am overly familiar with the reasons sleep deprivation is used as a form of torture. It is awful. In surgical literature, there has been a growing body of evidence that suggests sleep deprivation can be associated with mistakes made, especially by junior doctors. They are also at risk for traffic accidents, needlestick injury, burnout and other mental illness. Work-life balance is undeniably important.

In Europe and in the United States, working hour restrictions were brought into place to try and improve the safety of patients and doctors. In Australia, we have shift length restrictions and minimum breaks but in my experience, some hospitals play fast and loose with these areas of the award. 24 hour shifts still exist.

The European and US restrictions do have some drawbacks in surgery. Firstly, the increased number of shift changes may mean that a patient's care is 'handed over' to doctors resulting in the potential for Chinese whispers of the medical variety. Errors can be made each time we tell the story again, things forgotten. For training purposes, the reduced time on the ground may decrease training numbers and exposure to emergency cases.

An ambitious study was released today in the New England Journal of Medicine where investigators looked at the ACGME-compliant group versus a group with more flexible work hours. The main differences was that the conservative group couldn't have shifts over 16 hours (24 hours for more senior doctors) and had to have 14 hours between shifts. The flexible group could work over the 16 and 24 hour limit and did not have to have a 14 hour break.

Flexible working hours were not associated with any increase in adverse events, which is very reassuring. The flexible group residents did also not report any dissatisfaction with educational opportunities and were less likely to leave during an operation. The residents didn't report any adverse personal outcomes to working more hours.

What is very interesting about this paper is that the residents involved were not aware nor were they consented. Neither were patients, when care may have been affected. In my opinion, this is an ethical whoopsie. It may have changed outcomes as doctors changed behaviour or perception, but medical research is not in the business of not consenting its subjects.

Other data which would be great to see was not picked up would be incidence of needlestick injuries, a validated burnout scale or longer term well being or skill acquisition data. I think these things would make for a fascinating look at the effects of the things we do to ourselves.

I think work hour restrictions are actually important for training doctors. The weight of evidence to suggest that tired people are sad, burnout, dissatisfied, potentially error prone, divorced, unhealthy and so on is quite strong. We all know someone who has had a near-miss or actual accident being so tired after work. I had a bike accident one day, coming home from a long shift. I was too tired and didn't see the car pull out in front of me. An obstetrics registrar was killed in an MVA, a plastics registrar hospitalised. I don't know many surgical trainees or surgeons who haven't woken up in their cars, nearly underneath a bus.

That being said, I also believe that it is important to know how to operate when you're tired. Someone's life is going to depend on that one day. The first time you're doing an emergency procedure after a long day shouldn't be when you're out on your own. I also think that handing over mid-operation is not good for patients or doctors learning. Some flexibility must be afforded to experience emergency, tired and middle-of-the-night surgery. It should not, however, be the norm.

As with most scientific literature, we don't usually change practice based on one study alone. That should be the case here. More information is needed so that we can find a 'sweet spot' where the needs of both doctors and patients are looked after.

Back again in my plastic surgery days, those hours were long. We operated most nights, not just on true emergencies, but on urgent but not emergent cases. We needed to get the work done because there was no other time. On call for plastic surgery rarely meant home before midnight and back at 5am.

One night, I went to see a patient with the senior registrar. This man had been waiting to have a second operation on his hand after an injury. It was around 7pm and we were hoping to do him around 9 or 10pm that night. My senior told the patient this and he refused to consent.

"I've seen you here after midnight every day this week, mate. You're too tired"

The senior was seriously jacked off that his competence had been called into question.

In all likelihood, had he had his operation by the tired registrar that night, it may have gone well with no problems. In medicine, we try not to play too much with 'may have' or 'she'll be right mate' because when it comes to people's lives, close enough is not good enough.

Close enough is not good enough for our patients or our doctors. It is incumbent upon us to work out what is good enough.