Question: “In most groups and departments, are anesthetists giving anesthesia during the workday after they have been on night call and up working; how do you evaluate whether they may be fit to do so or is working the next day no longer even considered?”
Answer: “Fitness” to administer anesthesia is difficult to assess, define, evaluate, or measure. The ability to administer anesthesia safely requires alertness, vigilance, reflex action and reaction, knowledge and psychomotor skills and coordination. How do we determine “fitness” in the anesthesiologist who has been on call the previous night? Is it obvious by appearance after sleeping in the on-call room? Is it related to age or physical fitness? Can it be assessed by language skills? One could go on ad infinitum asking similar questions, all of which would have the same negative answer.
History is replete with episodes of catastrophic occurrences which have been attributed, after the fact, to fatigue and “human error”. This is true in anesthesiology as well as in flying, driving, machine work, etc. The most recently publicized event in health care appeared in the news media and related an unfortunate medical outcome to the house officers’ fatigue and work schedule. The “effects” of inadequate sleep in an anesthesiologist have only been speculating.
Two straightforward episodes will serve to demonstrate the anecdotal character of the evidence that sleep deprivation is a cause of critical incidents in anesthesia. The first was a patient who was anesthetized for a laminectomy and fusion of the back. The patient had become progressively more hypotensive and the young anesthesiologist was unable to determine the cause. He requested some help to provide a “fresh look” and, indeed, it was pointed out by the anesthesiologist responding to the call that over two units of blood had been lost and this loss had been unrecognized and not replaced. The second episode was a 26 year-old patient who experienced a cardiac arrest during the middle of a breast biopsy under general anesthesia. Cardiac activity was restored when a hypoxic mixture of nitrous oxide and oxygen was recognized and corrected. Both of these episodes occurred under the aegis of two very fine physicians who are extremely capable, intelligent, and excellent clinicians. But in each circumstance, the physician had been “on call” and awake most of the previous night.
In view of sporadic reports of catastrophic occurrence allegedly related to fatigue, sleep deprivation or long continuous periods of work, moderately uniform practices have evolved. In most of the departments with which I am familiar and in which the numbers of personnel allow this, anesthesiologists are relieved of clinical responsibilities the day after having been on call. This practice is not based on any hard objective data relating to the practice of anesthesia per se, but rather is in recognition of the requirements for providing safe anesthetic care, and also in recognition of human and social needs and values of anesthesia care providers. This becomes somewhat of a problem in departments where there are only one or two anesthesia providers and more than a minimum number of anesthetizing locations. Nonetheless, I abhor the practice of disregarding fatigue or sleep deprivation in order to expedite a schedule which has not considered the status or the number of professional personnel available.
It is impossible to generalize on this subject. There are many factors involved in one’s ability to function efficiently and safely for prolonged, uninterrupted periods-physical stamina, motivation, basic personality, etc. However, in general, the average individual exhibits some decrement in performance with prolonged periods of uninterrupted or repetitive activity, or with sleep deprivation. This has been reasonably well documented in the literature. 1-5 Many of the studies were carried out with volunteers or paid subjects in the laboratory. As a result, it is impossible to extrapolate these findings directly to the practice of anesthesia wherein motivation, expectation, and incentives play a major role. Nonetheless, the evidence is mounting that among professionals, motivation and incentives notwithstanding fatigue certainly must have a negative effect on performance in the average individual. This is the basis for the practices referred to above in which any individual who has been on call is relieved of clinical responsibilities the following day.
I would like to suggest that the more cogent questions to be addressed are “For how long a continuous period of time should an anesthesiologist administer anesthesia or supervise the administration of anesthesia?” and “Is a 24-hour stretch of duty for an anesthesiologist or anesthetist too long a period of continuous work for safety9” These are questions that must be addressed soon and before any further evidence of relating fatigue to morbidity or mortality develops.
- Teichner WH. ‘Me detection of a simple visual signal as a function of firm of watch. Human Factors 1974; 16:339-353.
- Riemersma JBJ, Sanda3 AF, Wildervark C, Gaitland AW. Performance decrement during prolonged night driving In Mackie RR Ed. Vigilance: Theory, operational performance and psychological correlates. Plenum Press, New York 1977.
- Lisper HO, Kjellberg A. Effects of 24- hour sleep deprivation on rate of decrement in a ten minute auditory reaction time task. J. Exper Psych 1972; 96:287-290.
- Morgan BK Brown BR, Alluisi EA. Effects on sustained performance of 48 hours of continuous work and sleep loss. Human Factors 1974; 16:406-414.
- Paget NS, Lambert TF, Sridhar K. Factors affecting an anesthetist’s work: Some findings on vigilance and performance. Anaesth Intens Care 1981; 9:359-365.
Answer by George E. Battit, M.D., Vice Chairman, Department of Anesthesia, Massachusetts General Hospital, Boston.