I was on call last night, and I was lucky. Although I worked moderately hard for 19 hours, the final 5 were spent dozing off and on in a noisy, cold “sleep” room. Departing for a 7:00 am department meeting, I promptly locked my lab coat and my keys in the call room. A quick change of scrubs made me feel a little fresher, until I spilled a dribble of my morning double espresso on them. I found myself searching for the right word a few times during the meeting, not unusual as I age, but a noticeably more common problem today. I was lucky again after the meeting; while most of my colleagues went to face a challenging day in the OR, one fewer outpatient rooms on the schedule spared me from placing a patient’s life in my hands. My group once eschewed working post-call; with declining reimbursement from profitable insurance conglomerates, it is now considered an economic necessity to maintain the status quo. I have to finish writing this article and get some sleep; I have 2 cardiac cases tomorrow, which means a 4:45 am wake-up time.
The concept of performance-enhancing drugs has gotten significant press lately, and the buzz is overwhelmingly negative. Professional athletes searching for a competitive edge are vilified as cheats in the rare instances that they have been caught using anabolic steroids. However, like many other effective tools, performance-enhancing medications used correctly could decrease suffering and improve life: lost in the hype about steroids are potential benefits to society of a wide range of medications unrelated to steroids, and in my view, not at all analogous. Let’s focus on one.
Modafinil is a pill that improves mental alertness through a novel mechanism, probably involving dopamine reuptake. It does not have the adrenergic side effects of amphetamines; in fact, most subjects cannot readily perceive the difference between active drug and placebo. It does not decrease the user’s ability to recover sleep when an opportunity arises, and does not deliver a rebound effect. It does improve performance on a host of laboratory tasks, including tests of vigilance, memory, mood, and attention, as well as real-world tasks such as flying combat aircraft. The military has a compelling interest in performance and fatigue because combat operations are typically 24/7, and the stakes are extremely high for the participants. Hence, there is serious, ongoing research on the use of modafinil by sleep-deprived aircrews, and the results are encouraging. Modafinil works nearly as well as dexedrine and better than caffeine in maintaining performance during severe sleep deprivation. It does have occasional side effects including headaches and nausea, and undoubtedly more will be found. However, sleepiness is not only detrimental to our patients; it is not entirely benign for the practitioner. Research shows that the sleep-deprived anesthesiologist drives home at least as impaired as one legally intoxicated with ethanol.
One could argue that the work hours of critical health care providers should be regulated; society should make the investment to train and pay enough personnel to provide the same level of expertise to everyone, whenever their need for care arises. However, that is not the case. Sleepy people are keeping people asleep. Before it was confirmed scientifically, it was widely known empirically. Anesthesiologists and nurse anesthetists in busy clinical practices are excessively sleepy. Fatigue affects performance. While we know it empirically, this is a bit more tedious to establish scientifically, but progress is being made. Morbidity and mortality are at stake. In 1999, the Institute of Medicine report described a previously underappreciated number of deaths that were attributable to medical error. I have no doubt that these incidents are more common when the practitioner is fatigued, and my early morning follies today indicate that I was ill-prepared to deal with simple tasks, much less the complex, rapidly evolving catastrophes that my surgeons and patients occasionally conjure up. Unlike professional athletes, whose primary goal may be to win personal fame and fortune, our goal is to maintain vigilance against disaster for our patients. We have an ethical duty to maximize our potential and to carefully and pragmatically consider any reasonable aid that presents itself.
Cognition is complex, and delivering anesthesia is not the same as flying a plane. Exactly how modafinil improves performance is not known, and its effects on memory, problem solving, mood, motivation, interpersonal interactions, and a variety of other factors important to the practice of anesthesia have not been fully investigated. Perhaps modafinil will prove to diminish management of complex diagnostic decision-making, or worsen multi-task management. However, we have the means of testing performance in realistic simulators, so we could begin to answer these questions. College students are taking modafinil to cram for finals. Journalists are using it to combat jet-lag on overseas assignments. Residents are using the drug to maintain alertness while on call. It seems reasonable to study this new frontier of patient (and practitioner) safety, to potentially arm ourselves with both well crafted shifts, good sleep habits, strategic napping, and a safe pharmaceutical to be used when absolutely necessary, to help us maintain our motto: “vigilance.”
Dr. Smith is an attending anesthesiologist at the Washington Township Hospital in Fremont, CA, and serves as an Adjunct Assistant Professor in the Department of Anesthesiology at the Stanford University School of Medicine, Stanford, CA.