Fatigue
Implications for the Medical
Profession
Eleanor M. Duduch M.D.
Program Director
Anesthesiology Residency Program
University of Massachusetts Medical School
Why So Much Concern in
Medicine About Being Sleepy?
 Significant increase in sleep research and


outcome studies in recent years
Negative outcomes secondary to fatigue are
so well documented that industry has led
the way in developing sleep regulations
- Military
- Maritime
- Trucking
- Aviation
Where’s Medicine?
History of the Problem

1986 Libby Zion vs. New York State



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


18 yr. old with recent hx cocaine and MAOI use
admitted to New York Hospital with agitation and temp 103
medical team consisted of a PGY-1 (18 hrs awake) & PGY-2
(19 hrs. awake), with little attending involvement
rigors treated with 25 mg. Demerol
died next a.m. with seizures and temp 108
11 year trial, split verdict (cocaine & negligence both factors)
Jury claimed fatigue, inexperience and lack of supervision
as contributing factors toward claim of negligence
……Rapid Response…..

1987 Bell Commission
 A blue ribbon panel responsible for work hour recommendations in
New York that eventually became the “405 Regulation”

1989 NY State 405 regulation instituted
 Largely ignored for first 10 years; financial penalties instituted
and ignored as well

1999 Institute of Medicine published a patient safety report
“To Err Is Human: Building a Safer Health System”, revealing that
medical errors contribute to many hospital deaths and adverse events

2000 Presidential Task Force developed to address the issue
….Rapid Response…

2001 OSHA was petitioned by Public Citizen group to implement
new regulations on resident work hours
 This brought the issue to national prominence

2001 Patient and Physician Safety and Protection Act HR3236
was introduced in Congress

2002 ACGME quickly proposed their own standards

2003 Standards approved

July 1, 2003 Compliance required
ACGME STANDARDS

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80 hours maximum/week
24 hours max per shift; add’l 6 hours for
education and transfer of care
1 day in 7 free of patient care responsibilities
In-house call q 3 nights averaged
10 hour minimum rest period
ACGME STANDARDS

In order to provide high quality education & effective
patient care, residency programs must:

Recognize & monitor residents for signs of fatigue

Apply preventive & operational countermeasures

Make clinical assignments that recognize a collective
responsibility to patient care
The Extent of the Problem
 2002 Multi-center Survey of Medical
Residents vs. Patients @ Cleveland VA
Sleep Disorders Clinic
Self-reporting survey re: likelihood of dozing
 Results recorded on Epworth Sleepiness Scale
 8 items, scored 0-3 scale, with 24 as highest possible score
 Results: Sleepiness in residents is equivalent to
that found in patients with serious sleep disorders

American Academy of Sleep Medicine
Epworth Sleepiness Scale
Narcolepsy
20
Residents
Sleep Apnea
15
Normal
10
Insomnia
5
0
Mean
Normal
Insomnia
Sleep Apnea
Residents
Narcolepsy
5.90
2.20
11.70
14.70
17.50
Sleepiness in residents is equivalent to that found in patients
with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002
© American Academy of Sleep Medicine
The Potential Impact of Sleep
Loss & Fatigue Is
Underestimated

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In general there is a lack of knowledge about the biology of
sleep, particularly by physicians
Signs of sleepiness are often unrecognized by the individuals or
observers
There is no drug test to evaluate fatigue level
The culture of medicine
 “sleep is optional (and you’re a wimp if you need it)”
 “less sleep = more dedication”
MYTHS ABOUT FATIGUE

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FALSE: “As long as I’m awake, I’m OK to work”
TRUE: Being “awake” does not mean that your cognitive performance,
judgment or reaction time is not affected by lack of sleep. Performance
starts to decline after 15-16 hours of continued alertness.
FALSE: “I’m still OK to drive home after 24…30 hours on call”
TRUE: The period of most limited attention span after being awake for
24 hours is between 6 a.m. and 11 a.m.
FALSE: “I can learn to get by on less sleep”
TRUE: You cannot change how much sleep you need. It is a
physiologic need, genetically determined
FALSE: “A good nights’ sleep and I’ll be fine”
TRUE: Recovery of sleep debt developed over a 24 hour call period
without sleep can take 2 full nights’ sleep to get back to baseline
FALSE “I can tell when I’m too tired to work”
TRUE: Many studies have shown that individuals have little insight into
their level of sleepiness. The more tired you are, the less accurate is
your perception of how sleepy you really are!
Anesthesia Resident Study

Daytime sleepiness was assessed in 11 residents using the
Multiple Sleep Latency Test

Daytime sleepiness was assessed in the baseline, post-24 hour
call, and extended sleep (they were allowed to sleep as long as
they needed x 4 days) conditions via polysomnography, EEG,
EMG,EOG

Results: Residents’ daytime sleepiness in base-line and postcall conditions was near or below levels associated with sleep
disorders. Extending sleep time resulted in normal levels of
sleepiness.

Residents did not perceive themselves to be asleep 49% of the
time there was physiologic sleep identified by EEG

Residents were wrong 76% of the time when they reported having
stayed awake
Howard et al, Acad Med 2002; 77(10):1019-1025
SO HOW DO I KNOW WHEN I’M
NOT GETTING ENOUGH SLEEP??


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You and/or others notice your work performance is not up to
your previous standards
You find yourself “nodding off” to sleep during lectures, breaks,
lunch etc.
You become less efficient in your work routine, taking longer to
accomplish the same tasks
You have trouble focusing
It is difficult to become motivated
You became more impatient with patients, friends, family
members and colleagues
Wakefulness and Sleep
The key determinant that underlies fatigue is the
interaction of sleep homeostasis and circadian
rhythm
 Homeostatic sleep drive
 regulates the length and depth of sleep

Endogenous circadian rhythms


Influence of external and internal stimuli


influence timing and duration of daily sleep/wake cycles
Workload, stress, boredom, motivation, environment all effect
sleep. It is important to note that environmental factors can unmask
fatigue (a warm/dark room, boring lecture, uninteresting topic), but
do not cause sleepiness.
Optimal performance =
adequate sleep + circadian wakefulness
In Other Words…..
Sleep Is Not Negotiable!
It is a physiologic drive…….
Q. What is “Adequate” Sleep?
Balance between
sleep quantity
and
sleep quality
HOW MUCH SLEEP IS
ENOUGH??
MYTH
“I’m one of those people who don’t need much sleep”
FACTS
Avg. sleep need for optimal performance is 8hrs.14min
 Individual variance is from 6-10 hours
 Individuals have varying tolerance to effects of sleep loss….BUT
self-assessment of sleepiness has been proven to be inaccurate
 Acute sleep deprivation: 0-4 hrs sleep in 24 hours
 Chronic sleep deprivation: repetitive sleep cycles of <7-8 hrs./day.
 <5 hrs of sleep increases sleep drive and propensity to sleep, with
associated decline in cognitive performance.
 Creation of “sleep debt”

SLEEP DEBT



Definition: The accumulation of ‘lost sleep’
‘Lost sleep’ averages 1-1.5hrs/night for most individuals
Sleep debt is not repaid hour for hour
 Example: 1.5 hrs. less sleep/night x 5 nights=
7.5 hrs. of sleep debt requiring (2) 8hr sleep
periods
WHAT MAKES A GOOD NIGHT’S
SLEEP??

Non-REM sleep (75-80%) (low brain activity)



Stage 1 @ sleep-wake transition “light”
Stage 2 “true” sleep
Stages 3 & 4 “deep” or “delta” sleep
• Highest arousal threshold-most difficult to awaken
• Most restorative
 REM sleep (20-25%;4-6 episodes/night)
 Nearly absent muscle tone except respiration
 High levels of cortical activity- dreaming, irregular respiratory
and heart rates
FRAGMENTED SLEEP
Interferes with a good night’s sleep
 Most common in those age > 50 years
 Sleep Disorders

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Alcohol


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Obstructive sleep apnea
Restless leg syndrome
Insomnia
• Learned/conditioned
• Medication induced
REM suppressant first half of night
Rebound REM as ETOH concentration decreases, with
increased awakenings & decrease in total sleep time
External stimuli – pagers, phone call, anticipation,
etc.
American Academy of Sleep Medicine
Sleep Fragmentation
NORMAL SLEEP
= Paged
MORNING
ROUNDS
ON CALL SLEEP
© American Academy of Sleep Medicine
The Circadian Factor

Suprachiasmatic nucleus (SCN) of hypothalamus

Sets the biological clock to 24.18 hours
•
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Easier to stay up late than go to sleep early
Controls body temperature cycles ↑ during day, ↓ at night
Uses light as synchronizer via retino-hypothalamic pathway
Melatonin as complementary synchronizer of SCN
• Secreted at night by pineal gland
• Suppressed by light
Controls physiologic, behavioral & mood functions
• 24 hr. sleep-wake pattern
• Daily digestive activity, BP changes, renal function
• Hormone secretion – prolactin, testosterone, GH
The Circadian Factor
 Circadian

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Lowest levels of alertness, activity & performance
Greatest vulnerability to errors and accidents
Increased sleepiness from 3-6 a.m. and 2-5 p.m.
• Peak in fatigue-related MVA between 6-9 a.m.
 Circadian

nadir
peak
Maximal alertness from 9-11 a.m. and 9-11 p.m.
holdemqueen@hotmail.com
CONSEQUENCES OF SLEEP
DEPRIVATION
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Safety Issues
Performance Issues
Medical Errors
Health Correlates
Medical Education
Professionalism
Personal and Family Life
…..Consequences
 Skills
that are especially vulnerable to
fatigue and sleep loss are uniquely
human:
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Motivation
Creativity
Judgment
Decision-making
Interpersonal happiness
Safety Risks of Fatigue
SOCIETAL
 Three Mile Island and Chernobyl nuclear accidents
 Circadian factors
 NASA Challenger
 Flawed decision making from poor work-rest patterns of
managers
 Exxon Valdez marine grounding
 Alcohol and fatigue
PERSONAL


Increase in blood-borne pathogen exposure incidents
 Risk is 50% greater at night
Motor vehicle collisions: 100,000 crashes, 76,000 injuries &
1,550 fatalities annually
 NTSB 2001 poll “1:2 drivers report driving while drowsy; 1:5
report “nodding off” while driving”
4 SECONDS CAN END YOUR
LIFE
All it takes is a brief 4 second break in
your attention to cause a fatigue related
crash
RECOGNIZE THE SIGNS OF
DROWSY DRIVING

Getting home and not remembering driving past the
usual landmarks i.e. not remembering driving the last
few miles
 Difficulty focusing on road
 Wanting to “rest your eyes” for just a second or two
 Drifting across lanes
 Missing exits
 Closing your eyes whenever you have a chance i.e.
at stoplights, crosswalks etc.
 Be aware of microsleep
MICROSLEEP

Brief, uncontrolled and spontaneous episodes of
physiologic sleep

Significant performance reductions sufficient to
create safety risks before & after a microsleep

Usually no subjective awareness
FATIGUE RELATED CRASHES

<5 hours sleep increases risk of involvement in sleep-related vs. non
sleep-related crash by 4.5 times

Greater likelihood of serious injury

Usually a single occupant off-road accident

Risk increases with certain conditions
 Alcohol - it doesn’t have to be a lot!
 Medical conditions including sleep apnea
 Medications
 Solo driving
 Driving for long stretches or along roads with little visual
stimulus

Often dependent on time of day – most occur between 6 a.m. and 9
a.m.
Number of Crashes
Accidents vs. Time of Day
450
400
350
300
250
200
150
100
50
0
0:00
3:00
6:00
9:00
12:00
Time of Day
15:00
18:00
21:00
DROWSY DRIVING: WHAT
DOESN’T WORK!!
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Turning up the radio
Opening the car window and letting the cold air
blow on your face
Singing/talking to yourself
Eating/chewing gum/drinking fluids
DROWSY DRIVING: WHAT
DOES WORK

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If you are really tired, don’t try to drive home. Thinking “it’s just a
short drive…I’m fine” is dangerous. Get someone to drive you
home, take a taxicab or a bus.
Take a nap before driving home. Although a short 30 minute
snooze will help, a 2 hour nap is best (allow sleep inertia to pass
before getting into a car)
If you notice any of the warning signs of drowsiness, don’t
ignore them. Get off the highway/road, pull into a safe area
(parking lot etc.), lock your car and take a nap.
Automobile Accidents and EM
Residents & Faculty

Prevalence rates for:
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Collisions up to 8% (74% post night shift)
Near misses up to 58% (80% post night shift)
Correlated with:
 # of night shifts worked
 Resident’s self-reported tolerance of shift work
 Self-reported adaptation to drowsiness
Steele MT, The occupational risk of motor vehicle collisions for
emergency medicine residents. Acad Emer Med 1999;6:1050
Automobile Accidents and
Pediatric Residents & Faculty

Prevalence Rates for:
 Falling asleep at the wheel:
 Residents
49%
 Faculty
13%
 Motor Vehicle Accidents
• Residents
20
• Faculty
11
 Traffic citations
 Residents
25%
 Faculty
18%
Marcus CL. Effects of sleep deprivation on driving safety in house
staff. Sleep 1996, 19:763
PERFORMANCE ISSUES
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Reduced vigilance, impaired memory & decision-making,
prolonged reaction time
Increased risk for errors and critical incidents
Increased performance variability – consistency in knowledge,
judgment and actions diminishes
Speed-accuracy trade-off i.e. in order to maintain same level of
accuracy in decision-making, it takes more time to think through
the situation
Impairment from 24 hr. sustained wakefulness is equivalent to
0.1% blood alcohol level
Effects of Sleep Deprivation on
Functioning
Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;388(6639):235.
Effects of Sleep Deprivation on
Functioning
Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;388(6639):235.
IMPACT ON PERFORMANCE

Surgery

24% more errors & 14% more time to perform simulated laparoscopy
post-call
Taffinder et al, Lancet.1998; 352

2-fold increase in errors & 38% increase in time required for same
task
Grantcharov et al, BMJ. 2001; 323
Internal Medicine
 Efficiency & accuracy on simulated ECG interpretation deteriorated
Lingenfelser et al, Med Educ. 1994; 28
Pediatrics

Efficiency on task performances decreased significantly at 24 hours of
wakefulness
Storer et al, Acad Medicine; 64
MEDICAL ERRORS

Surveys: 60% U.S. anesthesiologists & 90 % Australian
anesthesiologists report making fatigue-related errors
Gravenstein et al, Anes. 1990;72
Gander et al,Anaesth Intensive Care 2000;28

IM residents- 41% their “most significant medical mistake” was
secondary to fatigue
Wu et al, JAMA 1991;265(16)

Case reviews of fatigue-related complications:
 3% of 5600 reported anesthesia incidents/10 years
Morris et al, Anaesth Intensive Care2000;28

5% of “preventable incidents” & 10% of drug errors
Williamson et al, Anaesth Intensive Care 1993;21

Post-op surgical complication rates 45% higher when
resident post-call
Haynes et al,S.Med J. 1995
American Academy of Sleep Medicine
100
100
80
80
60
60
40
40
20
20
0
0
< 4 hrs
5-6 hrs > 7 hrs
Work Hrs/wk
Percent
Work Hrs/wk
Work Hours, Medical Errors, and Workplace
Conflicts by Average Daily Hours of Sleep*
% Reporting
Serious Medical
Errors
% Reporting
Serious Staff
Conflicts
*Baldwin and Daugherty,
1998-9 Survey of 3604 PGY1,2 Residents
Hours of Sleep
© American Academy of Sleep Medicine
HEALTH CORRELATES

Physiologic alterations

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Depression of immune function
CHO metabolism & endocrine dysfunction


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Cerebral metabolic & cognitive function

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Abnormal glucose tolerance
Decreased thyrotropin concentrations
Increased SNS activity
Decreased CMR in thalamus, frontal & parietal cortices
Adverse pregnancy outcomes
 Independent risk factor for CV and GI disease
American Academy of Sleep Medicine
Adverse Health Consequences by Average
Daily Hours of Sleep*
60
% Reporting Signif
Wt Change
Percent
50
40
% Reporting Med
Use to Stay Awake
30
20
% Reporting
Increased Alcohol
Use
10
0
<4 hrs
5-6hrs
Hours of Sleep
>7 hrs
*Baldwin and Daugherty,
1998-9 Survey of 3604 PGY1,2
Residents
© American Academy of Sleep Medicine
IMPACT ON
PROFESSIONALISM

Negative change in attitude toward patients
 Conflicts with staff and colleagues
 Loss of empathy/compassion
 Role resistance
 Resentment and disenchantment with
profession
Negative Effects of Sleep Deprivation
on Professionalism
Decreased Motivation:
“I keep thinking he’s blue enough to go the ICU. I
keep hoping he’s too blue to go anywhere. Probably
a nice man with a loving wife and concerned children,
but I don’t want the SOB to make it because I’ve got
one patient who is going to keep me up two more
hours…I don’t want the asthmatic SOB to live if it
means I don’t sleep. I don’t want the patient to live if it
means I don’t sleep. I just want to sleep.”1
1.
Excerpt from trainee diary: L C Groopman. Medical internship as moral education: an essay on the system of training
physicians. Cult Med Psychiatry 1987; 11: 207–27.
IMPACT ON PERSONAL AND
FAMILY LIFE

Mood disturbances
 Increased stress/anxiety
 Potential for alcohol and substance abuse
 Negative effect on motivation
HOW TO STAY ALERT
 Naps
 CNS
Stimulants
Caffeine
 Medications

 Melatonin
 Better
 Sleep!
scheduling
NAPS
Temporarily improve alertness but do not replace a
good night’s sleep!!

Types



Length



Preventative (pre-call)
Operational (on the job)
Short naps < 30 min. helps avoid grogginess known as “sleep inertia”
Long naps 30-240 min.
Timing

Take advantage of circadian windows (2-5 am & 2-5 pm)
SLEEP INERTIA
WHAT IS IT?


Grogginess or incomplete arousal from sleep
Most likely to occur after 3-4 hours sleep
WHAT ARE ITS EFFECTS?


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Slowed speech
Poor memory
Performance deficits
Impaired decision making
May take up to 1 hour to clear
CAFFEINE



Key is strategic consumption during periods of vulnerability
Effects noted within 15-30 minutes, lasting 3-6 hours
Significant response from 200mg
Be aware of the negative effects:
 Tolerance may develop
 Diuretic effects
 Disruption of subsequent sleep
 Dose-related tremors & palpitations
MEDICATIONS

Melatonin





Modafinil, Methylphenidate,
Dextroamphetamine


Promotes sleep at 0.3-80 mg doses
Circadian phase-shifting effects
Food supplement, no FDA involvement
Insufficient evidence that it eases adaptation to changing
workshifts
Avoid using stimulants
Alcohol

Alcohol may make you sleepy initially, but it will disrupt
a full night’s sleep as the night progresses
Take home message!
 Sleep,
sleepiness and performance are
inextricably bound with each other
 Know your limits
 Appreciate the subtle but destructive &
catastrophic effects of sleep deprivation
 Realize that the need for sleep is not
negotiable
holdemqueen@hotmail.com
holdemqueen@hotmail.com