Tuesday, March 29, 2016


     A couple of weeks ago Dr. Wheelock (from the UK) was kind enough to discuss their June 2015 paper published in the Annals of Surgery regarding the negative consequences of OR distractions. It seemed befitting to discuss the recent paper and commentaries I have reviewed concerning the effects of sleep deprivation, fatigue and their effects on surgeon performance, over the past month.
In August, Dr. Carlos Pellegrini, reissued a consensus statement for the American College of Surgeons on “addressing surgeon fatigue and sleep deprivation”. Here he conceded that the evidence regarding sleep deprivation in health care is equivocal at the moment, but advised “I believe a balanced and reasonable approach is needed in addressing this issue.” In this statement he implored surgeons to partner with their Health Care enterprises to work out a viable solution based on sound judgment. He expressed to me the need to for us to be able to simultaneously assure there are surgeons available to our institutions and to provide “support for institutions and systems supporting surgeons who believe they are tired”. In addition, we discussed the fact that measuring sleep deprivation in surgeons is difficult at best due to no effective means of measuring the sleep character of surgeons who are not on call and theoretically getting a good night’s sleep (i.e. what other stressors occurred causing a restless night or fatigue).
Also in August Dr. Nancy Baxter’s group (from Toronto) published in NEJM their results of a review of procedures whereby Surgeons were at the hospital seeing patients between the hours of Midnight to 7am and subsequently performed major operations during dayshift the rest of that day, with no significant morbidity or mortality compared to surgeons doing the same operations but without working during that 7 hour window. This paper has been grossly misquoted all across the internet. Fortunately, Dr. Baxter was gracious to discuss this paper with me today (synopsis of that conversation to be noted in a minute).
The desire to compare aviation and medicine safety has been ongoing for decades and the consequences of sleep deprivation have been at the top of that list for some time. A 2000 study by Sexton and Helmreich compared the beliefs of pilots and surgeons on potential sleep deprivation and fatigue when they were asked "even when fatigued, I perform effectively during critical times." In this survey 26% of pilots agreed to this statement compared to 70% of surgeons.
In 2010 the FAA released an immediate release statement regarding pilot fatigue in response to the outcry after the crash of Colgan Air Flight 3407 on Feb 12 2009. The author of that statement explained to me that the FAA was already in the process of revising their recommendations for pilots prior to this accident (as noted by their 2008 conference on pilot fatigue), but that this pushed the issue to the forefront. The NTSB determined that Colgan Air accident was a result of the pilots’ inability to respond properly to the stall warning regarding their excessively slow speed. That report concluded that “The captain spent the night before the accident sleeping in the company crew room, where he obtained, at best, 8 hours of interrupted sleep…..” In the report, the NTSB chairperson, added that “Fatigue-impaired performance is not unlike alcohol-impaired performance…” whereby she recited lessons learned in a 2003 study in Sleep in which sleep deprived performers did worse than intoxicated performers in tasks.
One of the responses to the 2010 FAA statement was an outcry by some in the medical community for patients to be provided with informed consent when their surgeon was up all night. This includes one from the past president of the American Sleep Society, Dr. Czeisler (Nurok & Czeisler NEJM 2010) in which they quote the American Academy of Sleep Medicine’s endorsement that “model drowsy-driving legislation stipulating that the functioning of a person who has been awake for more than 22 of the previous 24 hours is impaired by sleep deprivation”. This group also quoted a 2009 study by Rothschild whereby providers who were up for 12 hour prior to operating the following day did not have significantly more complications than those who worked less than 12 hours the night before, while those who had less than 6 hours of sleep had close to twice as many complications as those who slept more than 6 hours the night before. The response to these papers varied from “Surgeons don’t get tired and patients don’t need to know if I am tired” to ”we get tired and need regulations to protect us now.” To make matters more complicated a recent study concluded that a junior resident who had been on call (associated with sleep deprivation) had reduced performance efficiency but more senior residents did not seem to be as affected by this.    So what do we make of all this?     Back to my conversation with Nancy Baxter today….. First of all their group concluded that “sleep loss resulting from the provision of overnight medical care did not measurably affect the short-term outcomes of elective procedures performed the next day.” Next they stated that “broad-based policy shifts in duty hours.. may not be necessary..” But most of all she clearly states that “the effect of profound sleep loss may warrant further study AND it remains important for physicians to critically assess the effects of ALL sources of fatigue…” She clearly pointed out to me that to their group the entire spectrum of issues that affect our ability to care for patients should be assessed more fully before we institute blanket policies. A surgeon who is not up performing patient care the night before may be more stressed over other issues and sleep less soundly than one who was up all night. A surgeon who was up for 6 hours prior to a day in the OR may actually find his awareness and acuity has been heightened for the first 6 hours of the day and then exhausted at the end of the day when no further patient care is required. Experienced surgeons commonly state this to be true. After this awakening conversation I would state that it is difficult at best to develop a true conviction regarding the outcomes of the available studies on sleep deprivation and its consequences. Unfortunately, it is not clear that there is a true transition from other industries to medicine. There is undoubtedly some degree of sleep deprivation that will cause decrease effectiveness in decision making and manual skills in the field of surgery, but it does not appear to be a static period of time, as it likely varies with other physical and mental factors of the physician, the type of care being provided the night prior, the type of care being provided the following day and the total length of wakefulness. Driving a car after being up all night and working all day is a boring tedious task and has been shown by several to be dangerous (at least in residents, per Tan) but doing an exciting case may actually stimulate a surgeon enough to prevent the untoward effects of sleeplessness. Whatever the answer is, it will better for everyone if we develop data and guidelines rather than others.



  1. I asked Dr Pellegrini his opinion on this and his statement deserves much consideration when we debate the effects of sleep deprivation and fatigue. It was a strong a reminder that the debate is NOT if sleep deprivation, fatigue, and stress cause us to be prone to error with lapses in judgement but at what point that occurs and that is what surgeons need to be at the forefront in defining. It is clear that fatigue, sleep deprivation and other stressors make any professional distracted and error prone.
    I could not find a way to paraphrase his eloquent commentary so Here is his clarification to me for those interested:
    "I am a bit concerned with the ending message in the last paragraph. It seems to me that it suggests, again (others used to say this all the time in the past), that we surgeons can perform at “peak” performance even if we are tired because an operation excites us enough to get us through. I think logic indicates that at some point you are going to be too tired to do a “routine” operation, a long operation or a complex operation….and that the statement suggests that the issue of deciding whether or not you are tired rests with the surgeon. Unless we set up systems that protect the surgeon, hospitals are going to make it more difficult to accommodate “tiredeness” as defined by surgeons because they are going to say “other surgeons can do it…what is wrong with you?”….I would favor ending with a statement that fatigue diminishes performance. That is clear to all those who have studied it. It may diminish it more or less, the surgeon may or may not recognize it, but surgeons should be aware of it, and hospital systems should also be aware of it, of the issues associated with it, and plan accordingly."

  2. I was fortunate to have Dale Roberts (Air Transportation Division, flight standards service, FAA), Tom Nesthus, Chester Piolunek (Aviation Safety Inspector AFS-220, Air Carrier Operations Branch) and Steve Hursh talk to me this week. They all run, work for or advise the FAA Pilot Sleep Deprivation Protocol Program.
    Turns out that Dale Roberts has a wife who is a nurse so he has first-hand knowledge how medical professionals work in sleep deprived conditions.
    We discussed things currently in use in aviation including the PVT (Pilot psychomotor vigilance task test), use of actigraphs, alternatives to mandatory restrictive rules including the use of split duties and naps (as currently used by pilots who are on long flight patterns and would otherwise not be able to conform to mandatory restrictions) and other thoughts on measuring sleep deprivation and methods to overcome this in a reasonable process.


  3. I had a chance to talk with a very young pilot this past week while waiting at the airport. He was very much in favor of the current Sleep Management arrangement, but acknowledged that this called for more pilots to fill in the schedule. Of interest he said "your passenger planes have pilots currently under FAA restrictions but did you know that the commercial / transport pilots flying over your home have no restrictions?"

  4. I took a moment to chat with a flight crew in the lobby of our hotel and mentioned that the staff at the FAA admitted that they did not know what people in the field were saying about flight hour/ sleep restrictions. The pilots and crew said "oh it does not bother us any... We don't even come close to the 19 hours awake". I also asked about the reported cognition tests for transcontinental or transoceanic flights and they said "we just look at our partners eyes to see if they look sleepy".