Am I Dreaming Yet?

dinosaur hanging from the ceiling of the Field Museum in Chicago

It was 4PM. I snapped awake at the desk, looking around quickly to see if anyone had noticed my moment of weakness. 

No one was watching.

Relieved, I continued to dictate the patient’s discharge summary. As words tumbled from my lips, I realized they were not making any kind of sense. I stopped the recording and replayed what I had just said.

A bunch of gibberish.

I tried again, rewinding back further. Still gibberish. 

Fully awake now, heart racing, I trashed the whole dictation and started over again, jotting down a quick outline so my brain would not get lost.

My whole body ached from the fatigue. All I wanted was a bed. Nice cool sheets. A fluffy pillow. Maybe a soft blanket or two. Darkness would be nice but was not critical.

Then my pen started to laugh at me.

Wait. 

Was that a dream or a hallucination? After 38 hours of awake, I was no longer sure…

It was the very first hospital shift of my intern year of residency. I had never been up that long at one stretch before.

When people talk about how hard residency was, this is what I remember… the bone aching fatigue. When I was moving, things were better, so when I was on the hospital service I got into the habit of dictating and writing orders while standing up instead of sitting down. I think I got used to the sleep deprivation, if you can imagine. 

Resident work hour restrictions went into effect my last year of residency. Rather than coasting to graduation, letting everyone else cover call, I found myself covering intern and second year primary calls overnight at the hospital, filling in their gaps. My class worked much harder than anyone before or after us. We were caught in the middle.

Interestingly, while everyone believes work hour restrictions save lives, what they don’t realize is that it has increased medical errors from more frequent hand offs. When you go off duty, you have to check out your patients to the next physician. It is not possible to discuss in detail every event of the preceding shift, so you give a short summary. It is thought that the more frequent hand offs, increasing those lost details, has caused an increase in medical errors that cancels out the fewer errors from sleep deprivation.

So in the end, it’s a wash. 

Seriously.

Personally, I think the longer hours made me tougher, taught me that I could do and survive much more than I ever thought possible. It reinforced my work ethic. It exposed me to a lot more medical knowledge than I would have gotten otherwise. It helped shape me into the person I am now.

Does that mean we should go back to insane work hours? 

Not necessarily. 

Sleep deprivation clearly does increase errors, but that isn’t the only source of medical errors. We need to drill down on those. We need to figure out better ways to do patient hand offs. We may need to add a year to family practice residency in order to get the proper exposure, to ensure we are graduating solid physicians. 

I love that people are looking at these things more closely now, identifying where errors are coming from, but dang if we don’t move painfully slow on this front. Work hour changes in the U.S. went into effect over a decade ago…. Seems like we should have a better handle on this by now.

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75 thoughts on “Am I Dreaming Yet?

  1. Indeed. Humans’ reaction to sleep deprivation is very complex. When I was driving long haul, we got a lot of experience with that – against government hours of service regulations. I’ve seen my fair share of elephants crossing the road in rural areas during the night. When I was safety director for a tanker company, I did a lot of work on errors and when they occurred and how they occurred. I also got all the current industry stats on accidents. It turns out that length of shift, as far as we went, up to 16 hours, was irrelevant. Accidents and incidents had a much higher frequency (in fact almost 100%) at the beginning and end of shifts with no apparent link to length of shift. All anecdotal evidence but pointing in the same direction – thinking about what you were doing before or were going to do after the shift. In other words, lack of situational awareness. When immediate actions had preceding and proceeding work connections, the error rate was minimal and the types of errors were less serious.

    From an administrative perspective, we found the same as you did – changeover was when errors occurred. For that reason virtually all dispatch positions are now 12-14 hours per shift in transportation. The longer shifts are are also to allow an overlap of at least 1 hour and preferably 2 hours to make sure all info is transferred.

    Oh,hey Victo,here’s a piece of stats that I discovered in our operation that i have never seen explored in official documentation. I suspect it is because of egos – the old boy network. I wanted to know if our training was effective as it was very subjective – ratings done by various trainers. Drivers were required to have a minimum of 5 years of transport experience with zero accidents or tickets. They also had to have at least three years of what we called heavy-haul : which is multiple trailers and three or more axles per trailer, which would be gross weights between 100,000 and 150,00 pounds. We then trained on fuel hauling for three to four weeks, depending on the recommendations of the trainers.

    To get a comparison, I divided our 80 drivers into two groups by seniority – 40 drivers per group. I then went through every reported at fault accident and incident for a year and recorded the group to which the driver belonged. I was astounded by the results – the over 200 accidents and incidents (most were very small like hitting a curb) broke out exactly, to the accident , perfectly into half in each group. If I recall correctly the dividing line was around 10 years – half with more seniority and half with less. This made me feel very comfortable that our training was working perfectly as designed – our new drivers had no more errors than our more experienced drivers. I realized this also had other implications – the types of errors made were not related to experience : training was giving the new drivers the information they needed to avoid rookie mistakes. Which meant we could focus our ongoing training on new info and reinforcing basics without worrying that different drivers needed different training. Perfect.

    One last thing when it came to errors. Believe it or not we found a correlation that was unexpected. We had mandatory drug and alcohol testing and we found that drivers who used had a continuing history of small errors even when they were clean and sober. There was an effect on safety that was on going after the effects of the drugs/alcohol had worn off. We removed drivers with positive results immediately and offered professional assistance but none ever came back.

    Liked by 5 people

    • Great info, Paul. Correlation is one thing, causation is another. I think these interesting results deserve deeper investigation, to figure out actual causes behind accidents. Especially in the case of the former substance abusers. There’s something lurking there, that could be useful to identify.

      Liked by 3 people

      • It is interesting Tippy. My sample sizes were way to small to call it anything but anecdotal, and my position was so busy that I did not have time to go any deeper, however you are right – there is something there. Those who set hours of service for the industry also did not do any peer reviewed studies – it is an under studied topic with a lot of implications in our work world.

        To address Victo’s comment I don’t think it is risk taking. I knew each of the drivers involved personally and their risk profiles were all over the map from ultra conservative to flamboyant. They were also from various cultures: English,French, Pakistani, Mexican, etc. There was one commonality and that was they were more often than not exactly following rules and procedures. Precisely the opposite of most non-user incidents (commonly caused by not following procedures). The users were unable to adopt the rules and procedures to exceptions. For instance we had “plot plans” or site cards for every delivery. Those plans showed every obstacle, overhead wires, traffic flow, storage tank locations, sizes, etc – and they showed how the driver was to approach the site (mostly gas stations) and where to park while unloading. We updated these plans as soon as a change was reported and we were anal about getting the new plans to every driver within one day. That said, we emphasized to every driver that they were to make their own decisions based on circumstances – no one was ever punished for not following a plan. One driver, who months later tested positive for marijuana, entered a site in Northern Quebec in daylight hours with perfect weather. The owner had that morning placed a large ice chest for bagged ice sales to customers beside the building in the path the plot plan showed for truck entry. The driver saw the chest, knew it was new (he had delivered there just the previous week) and said he thought it was tight but that the plot plan said to go in that way,so he did. His bumper caught the chest and tore it open, dragging it across the lot and causing #2,000 damage. He saw it, knew it was new, doubted he would clear it and went that way anyway because the plan said to.

        I could go on but all the examples are the same – knowledge of rules and procedures which were followed even when it did not make sense.

        Liked by 2 people

      • Wow. Maybe their problem is, they need to learn how to think for themselves. Isn’t it peer pressure that gets many people addicted to drugs or alcohol?

        But I guess all we can do is speculate, until scientists take a deeper look into this phenomenon.

        Liked by 2 people

  2. Yet another reason why I didn’t choose the medical profession. I’d hate to accidentally kill someone while doctoring in my sleep. Seems to me like the best solution is to figure out how to communicate more effectively during the handoffs.

    Liked by 1 person

    • I felt the same way. I considered medicine as a career, and even was pre-med for a while in college. But I need more, and more regular sleep than most people. I went through a period of sleep deprivation in college that probably wouldn’t even show up on a medical student’s radar screen because it would be considered so minor, but it just about did me in. In my case, the problem wasn’t that I made intellectual errors. I could still function cognitively, but sleep deprivation messed me up emotionally. I got depressed and anxious when sleep deprived. My ability to empathize or care about myself or others took a hit also. I decided to get a PhD rather than an MD or an MD-PhD.

      I agree about improving handoffs. But I still wonder if the negative effects of sleep deprivation might show up more if longer term outcomes were measured. I know it’s hard to measure the quality of the doctor-patient relationship, or the physician’s empathy.

      Liked by 2 people

  3. It seems crazy that a profession involved in something as crucial as giving potentially dangerous drugs could be allowed to work that much to fatigue in the past, whereas jobs like assembly line work would definitely not allow workers to be fatigued to that extent.

    Liked by 2 people

  4. This is a perspective I’ve never heard before – the hand-off from one shift to the next. I can think of other areas where It’s what we forget to communicate, or think is unimportant, that comes back to haunt us. This one is so obvious – now that you’ve mentioned it!

    Liked by 2 people

      • The elimination of long medical shifts was no doubt necessary but the rate of medical errors is still unacceptably high. It would not be tolerated in many other professions such as airlines or the military. From my military perspective, I blame high medical errors on a cultural resistance to a team approach, as in the use of check lists and protocols. Distraction is the enemy. No matter how good the training or experience level, we are all human and sometimes doctors operate on the wrong limb.

        A very interesting post.

        Like

      • We use check lists and protocols rather extensively now…. The trade off is that physicians, primarily primary care, and NPs and PAs, are losing their ability to think, to be able to address the unexpected with flexibility and creativity, which fits into part of what Paul was saying above.

        Like

    • Truthfully, I don’t think they have studied it much. When you do a literature search, there are only a few studies I could find. Lots of people with opinions but not enough people studying the problem.

      Like

  5. Now see, this is when I think the overdocumentation of notes might be well-used. I work not in a medical field, but I do intake of sorts. I document all the details and those details prove handy. Initially I thought it was a bit redundant and a waste of time, but the longer I work there, the more I see how some well-documented notes help out. Medical hand-offs could be bettered by this, hm?
    I have a lot of medical-field friends, mostly RTs, and sometimes I get concerned about how effective they are at the ends of their shifts. They tell me they don’t make mistakes with patients, they make stupid mistakes in rapid succession, texting the wrong person, putting salt in their coffee, trying to leave with someone else’s coat. Then I wonder, are they okay to drive?
    I could never do it. I’m one of those people for whom sleep is not optional. I get anxious and sick if I wear myself too thin. Having babies and puppies left me with blurs.

    Liked by 2 people

    • Speaking of which, I was going to do a post for you, but it occurred to me that you might need the info sooner. You were asking about the military and PEDs. Provigil is a fascinating drug, currently in use for all sorts of things, including wakefulness during long flights. Amphetamines, and god knows what else, have been used in the past. I don’t want to get all conspiracy theory here, but there is no way the military is NOT experimenting on its soldiers, trying to make them stronger, faster, smarter.

      Liked by 1 person

  6. Everyone in the hospital needs an advocate. I was at my wife’s side during most of her hospitalizations and have avoided a number of errors. I remember talking to a resident put in charge and reminding him that my wife had no spleen. I could see the gears grinding slowly in his head (he was obviously very tired) before he made his next step. Another time in the ER, she was on both vitamin K (a coagulant) and heparin (an anticoagulant). When I asked why, it took the ER chief a while to come up with an answer. He then thanked me for being there.

    Liked by 2 people

  7. Very interesting post, Victo, and Paul’s comments are fascinating, as is the rest of the discussion. I’ve always been in awe of doctors’ stamina – I have a friend who works in IC, I don’t know how she manages all the shifts, plus she has 4 kids at home! Scary stuff in some ways. Having said that, I don’t think that, whatever you do, you can eliminate human error totally.

    Liked by 1 person

  8. Very interesting. Do a lot of Doctors live on Red Bull type drinks to get through? I guess I can only think from my own perspective. I miss one nights sleep and I don’t function well. I do know there are some who function quite well on less sleep.
    I guess I’m a person who thinks that looking after ourselves means we can better look after others. If we’re running on empty, we have nothing left to pour out to others. I know however that’s not the way most of the world thinks or runs.

    Liked by 1 person

  9. I never understood why they made doctors do this. They always come out with studies that say tired driving is just a dangerous as drunk driving. Well, I wouldn’t feel comfortable with an exhausted doctor working on me any more than I would with a drunk doctor working on me. I hope since then you’ve replenished your sleep bank. 🙂

    Liked by 1 person

  10. I remember my daughter’s residency… Two residencies actually. The lack of sleep was terrible. I don’t think it is that necessary. But then you seem to identify Patient handoffs. So it is a matter of communication and passing on the right information. Updating the patient’s file the right way? I keep thinking about that article about the Mormons… the article is in french, no use to you I guess, but let me check the reference of the Mormons’s health system… (tut, tut, on hold…tut, tut) It’s called Intermountain. You might find that interesting. Bonne semaine Victoire.

    Liked by 1 person

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