Why the Doctor May Fall Asleep on Your Case
Catastrophic consequences can and will occur when we schedule work without heed to biological requirements for sleep. The list of human-error accidents continues to grow--committed by people who can’t stay awake.
The National Transportation Safety Board has ruled that the Conrail collision in Thompsontown, Pa., in January, 1988, which caused four deaths and $6 million in damages, was due to the “sleep-deprived condition of the engineer and other crew members.” The nuclear disasters at Chernobyl at 1:23 a.m. and Three Mile Island at 4 a.m. are two of the most dire incidents occurring at times coinciding with the early morning hours when human-error accidents are most likely.
Investigations of the last two stealth fighter crashes revealed that the pilots were overworked. In addition, the pilots did not attempt to eject or otherwise avoid a crash and the planes showed no signs of mechanical failure. These are the classic indications of fatigue-related accidents. Since the grounding of the Exxon Valdez tanker and subsequent oil spill into Prince William Sound took place at 12:04 a.m., crew fatigue may have played some role in that tragedy also. People fall asleep according to biological laws and have been doing so since prehistoric times--often while at work. When people try to work without adequate sleep, dangerous impairment occurs. What is worrisome is that so many more people can be hurt when a train driver or a nuclear power engineer falls asleep in 1989, than when, say, a stagecoach driver fell asleep in 1889. The chances of someone sleeping on the job during round-the-clock operations have not changed. Rather, it is the costs in life, property and our global environment that have changed.
The public is unaware that errors related to fatigue frequently occur in the practice of medicine. Residents work 36- to 60-hour continuous shifts and are on duty for 90 to 130 hours per week. Often, because they have not slept, they are in a dulled mental state. Yet they perform surgery and treat patients. Think of it--an auto crash victim may undergo brain surgery by a resident who has not slept for the last 60 hours.
Attention focused on these issues in 1984 when Libby Zion, a 19-year-old college freshman, died unnecessarily. A grand jury found that her death at a New York hospital was due to an undiagnosed but treatable infection missed because of inadequate medical supervision and resident fatigue.
Chances of physician error have greatly increased because technological advances now allow critically ill patients to survive longer. But they require more complex clinical judgments. One typical case, unfortunately, occurred two years ago when a middle-aged Nevada man was rendered unconscious by potassium given by rapid, rather than slow, injection. The proper drug and dose had been given, but at an incorrect rate. This happened because the on-call resident was awakened briefly from a sound sleep and gave an incorrect order that to this day he cannot recall.
Surgical residents have literally fallen asleep onto their patients, a problem commonly discussed among residents. In a study conducted by the California Board of Medical Quality Assurance, fully 75% of residents queried reported knowledge of negative impacts on patient care due to long hours on duty. At best, tired physicians lack the energy for thorough and compassionate care; at worst, they commit serious errors while impaired by sleep deprivation.
Present physician work hours reflect economic considerations: Residents are the cheapest source of physician labor. However, rational and biologically sound limits to residents’ work hours have already been legislated in New York, as well as in Britain, New Zealand, Australia, Canada and Ireland. Last year, similar legislation was introduced in California but killed, in part by pressure from organized medicine. Reasonable limits would be a maximum shift length of 24 hours and a maximum overnight duty of once every third night. Work weeks should average no more than 72 hours in seven days, allowing sufficient daily flexibility for medically sound and compassionate transfers of care.
Since organized medicine has not provided adequate regulations on residents’ working hours, we must look for legislative solutions. The long list of catastrophes wrought by sleep-deprived workers in medicine, transportation and other industries demands that we find safe and economical solutions to the scheduling and risk management problems created by modern, round-the-clock operations. The scientific foundation and expertise are now available. But we must have active leadership from labor, management and government. Will it take another catastrophe to get going?
