Drowsiness is Red Alert

Old timers will say they never had the resident work hour restrictions (30 hours/shift) and took better care of their patients without them. Champions of patient safety will argue that these limits protect patients from errors borne of fatigue. Counterarguments include the fact that with shorter work hours, there are more patient hand-offs from one provider to another, potential avenues of suboptimal care. I've explored these ideas in previous blogs, but now that I'm an acting intern, I've seen the effects first hand.

Long hours are necessary; I'm resigned to that. While some specialties like emergency medicine and anesthesia are shift-based, I'm not sure if traditional inpatient disciplines like medicine or pediatrics translate as well into such paradigms. There is something to be said about working a new patient up and being a part of their care for the first 12-24 hours. That's when all the action happens. That's when the critical decisions are made, the initial results come back, and the plan of action is determined. The educational value in this cannot be underestimated; house staff learn how to manage patients by seeing the results of the choices they make. The problem with shorter shifts is that you hand-off your patients without seeing the results of your plan or you get patients whose plans are determined by their previous providers.

So then it becomes the balance between fatigue and handing off patients. In my last call night, I didn't sleep at all, and I feel that for me, fatigue does play a role. My thinking is slower, the justifications for my decisions less complete, my reaction time prolonged. I have to addend my presentations after I finish them because I forget a key component and my notes are either rambling or too sparse. I take circuitous routes around the maze that is SFGH rather than the shortcuts. I'm tired and my head hurts.

As I get more efficient, as straightforward things become more reflex than cognition, as I solidify confidence, I'm sure things get easier. I can build my endurance, learn to steal those precious moments of rest, multitask better. But I think in the end, there is a limit to how good someone can be when they are exhausted. The key is to find the balance between that and the risks one takes when patient care is handed off from one person to another.