Minutes from the joint MSA & LSA Meeting
11th October 2018
Rounded with a Sleep- why we need to talk about fatigue.
Dr Mike Farquhar, Sleep Medicine Consultant, Evelina London Children’s Hospital
Dr Clare Howard opened the meeting and welcomed everyone especially the new Core Trainees. She then installed Dr Ed Djabatey as the new President of the LSA and handed over the Presidential Medal. Dr Djabatey then introduced Dr Mike Farquhar to give the evening’s lecture.
Dr Farquhar started by explaining his day job of helping families with children who do not sleep well. He said since he had become a consultant, he had been pursuing his interest in the effects of sleep deprivation and fatigue on healthcare workers. He said more recently a lot more attention & focus had been given to the subject and this was in a large part due to anaesthetists and the RCoA & AAGBI.
Previously, Dr Farquhar thought that it had been difficult to get people to think about the impact of fatigue in healthcare but now it was hitting the front pages of publications such as the BMJ, so he felt that we were making progress in getting people to think about sleeplessness and how this mattered. He thought that we were all used to making excuses about not getting enough sleep and not prioritising it in our lives; he then showed an excerpt of a BMJ editorial stating that modern life was affecting our sleep but then revealed the quote came from a 1895 edition of the journal. His interest had reading stories of junior doctors crashing whilst driving home after night shifts, despite working European working time directive compliant rotas. He said the coronial and fiscal enquiries determined that sleep deprivation was the most significant factor in these deaths. This was just the tip of the iceberg and there has been much work done since including surveying anaesthetic registrars on the impact of fatigue on junior doctors’ lives personally and professionally. He said the survey asked specifically about driving home and 90% of doctors had felt unsafe driving home and 50% had had a near miss or accident driving home.
Dr Farquhar showed data from the GMC trainees’ survey regarding the intensity of workload across specialties. Anaesthetists rate their workload intensity as lower than most other specialties and therefore in these areas, fatigue must affect performance to an even greater extent. He showed several documents on how to manage fatigue and working at night, but said most of them received little publicity and were not widely read. Even when work had been done in the area of fatigue, it has not translated to meaningful change on the ground.
He said to lose an hour of sleep a night was not unusual, but when added up over a week, the total can be the equivalent of one entire night a week. He said most adults in the UK are sleep deprived before any other factors are considered. Sleep is absolutely fundamental to every aspect of physical & mental well-being and if compromised, the brain and body start to feel the consequences. If already sleep deprived prior to entering an environment where the work is intense and pressurised, the consequences of that fatigue will increase.
Dr Farquhar compared fatigue to drink driving with reaction times becoming similarly impaired. The latter had become far more socially unacceptable compared to the former. Reaction times become impaired having been awake for more than 16-18 hours and the impact of fatigue is exponential. Consequently, our attitude to fatigue should be similar to that of alcohol.
Dr Farquhar then spoke about jet lag which can take up to 4-5 days before the body’s circadian rhythm is reset. He compared this to asking people to work night shifts. Physiology changes at night: heart rate slows, blood pressure and temperature both fall. Therefore working at night is very unnatural and the consequences of this are rarely considered.
There is an increasing understanding of what is known about sleep in general. He said sleep medicine is a relatively new specialty and the more the consequences of sleep deprivation are understood, the greater the realisation about the effects on every aspect on physical & mental health. Fatigue is associated with increased risks of developing type 2 Diabetes, obesity, Alzheimer’s and some forms of cancer. Shift workers have higher morbidity and mortality.
Dr Farquhar talked about the implications for patients. He showed an experiment demonstrating medical staff taking more risks when fatigued. This was because decisions were less likely to be thought through but confidence remained high in their ability to make them. The incidence of needle stick injuries and drug errors were also higher at night and levels of empathy also fall with fatigue.
Dr Farquhar showed the A9 road signs in Scotland saying ‘take a break’ to try and reduce lorry crashes. He said that it is important for us to take breaks at work, to sustain our performance so we can care for patients. He made a comparison with air traffic controllers who are only allowed to work for 2 hours before they have to have a mandatory 30 min break and similarly strict regulations in transport where the results of fatigue are better recognised.
Other examples included crew cabins in long haul aircraft. Despite the cognitive load on pilots being much less than that compared to A&E or ICU doctors, the safety standards in the airline industry are much higher. Dr Farquhar spoke about the rest advice for drivers in the Highway Code, which was written by a world expert in circadian physiology. The law assumes that any driver who falls asleep at the wheel knew that they were unsafe to drive. He gave the example of a Scottish nurse who was banned from driving after having an accident after a busy night shift. The judge told her that despite his respect for her and her work, she knew she was too tired to drive, so was guilty of dangerous driving. To date, there has not yet been a similar case for a doctor however, but has been seen in other industries where the employee and employer have been found guilty of manslaughter after fatal crashes.
Dr Farquhar thought that some progress was beginning to be made by introducing education into induction regarding optimising core sleep, good sleep habits, working night shifts, taking power naps and recovering after night shifts. He said that this had been done for the last 4 years in paediatric induction in London which had been valued by junior doctors. He said that there are still a lot of hospitals who do not understand the benefit of night shift power naps and penalise staff for taking them. His own organisation had started to encourage staff to take their breaks with a change of culture, installing a regular linen supply to staff rooms for power naps and for senior staff to lead by example by taking their breaks. He spoke about the new doctor’s contract and the specificities it makes about breaks, their length and the legal obligations of trusts to provide areas for sleep for fatigued staff.
Dr Farquhar ended by speaking about the Challenger Space Shuttle disaster. The cause of the accident was partly due to fatigue with tired, target driven and dedicated staff working long hours. There was a difficult decision about the timing of the launch of the shuttle and the final decision was made by a group of people who had been awake, on average, for over 24 hours. The group collectively chose to make the riskier decision resulting in tragedy.
He concluded his talk by summarising the ways in which Royal Colleges, hospitals and staff should be thinking about fatigue, rest and breaks with a more positive outlook for the future.
Honorary Secretary, Liverpool Society of Anaesthetists