OT: 'You're too tired to operate on me'

[W5]

As this subject has come up here in the past, I thought I would post it here.

Patients should be able to tell surgeon 'You're too tired to operate on me': Editorial

Read more: http://www.canada.com/health/Patients+should+able+tell+surgeon+tired+operate+Editorial/4038300/story.html#ixzz19YFj9j3F

Drowsy doctors are potentially as impaired as drunk doctors and shouldn't be allowed to operate without a patient's written, informed consent, say the authors of a controversial editorial published this week in one of the world's top medical journals.

Studies have found a near doubling in the risk of complications, such as massive hemorrhage or organ injury when surgeons pick up a scalpel after a night on call if they got fewer than six hours of sleep.

The authors of the editorial, to be published Thursday in the New England Journal of Medicine, say patients should be "empowered" to ask their surgeons just how much shut-eye they had the night before — and given the choice to either reschedule or to have a different doctor operate.

Movements are afoot to restrict the work hours of interns and residents. This summer, Montreal's McGill University hospitals eliminated 24-hour shifts for residents in internal medicine. But no such regulations exist for fully trained doctors, according to the editorial.

The authors use the example of a surgeon who hasn't slept all night after performing emergency bowel surgery the night before scrubbing up for an elective colostomy at nine, the following morning.

"We don't believe that patients should have to make the decision (over whether surgery should proceed) — institutions should take responsibility for this," says first author Dr. Michael Nurok, an anesthesiologist and intensive care physician at the Hospital for Special Surgery in New York.

"Institutions should say, 'we're simply not going to permit surgeons to schedule elective cases on the day after a night on call.' That avoids the issue altogether."

If that doesn't happen, then the doctrine of informed consent should prevail, Nurok says. "And that simply says that any patient having any elective procedure has the right to be informed of the risks, the benefits and the alternatives to that procedure. And there is now clear data to show that there is an increased risk" from drowsy operating.

A 2009 study published in the Journal of the American Medical Association involving post nighttime procedures found an 83 per cent greater risk of complications when surgeons had less than six hours sleep. The most common surgical complications were organ injuries and bleeding.

Sleep-deprivation impairs a person's psychomotor skills as severely as alcohol intoxication, Nurok and his colleagues argue. What's more, the sleep-starved are not very good at "self assessing" their degree of impairment.

Nurok says that if busy hospitals are unwilling to take steps that would keep surgeons from scheduling elective cases on the day following a night on-call then at a minimum, they should prohibit seriously sleepy surgeons or anesthesiologists from performing elective, non-emergency cases, such as hernia repairs or tubal ligations, and should give priority to rescheduling these cases. "There are emergencies which have to be done and there's no choice," he says.

Should patients decide to stick with a surgeon who hasn't slept in 22 or 24 hours, "they should explicitly consent to do so," Nurok and his co-authors say — in writing, on the day of the procedure and in front of a witness.

The American College of Surgeons begs to differ. In a response published by the journal, the college says mandatory disclosure is unwarranted, and that most "professionals of this caliber" would find the recommendation that they be forced to disclose how many hours they've slept "oppressive and insidious."

"Many other factors — including marital difficulties, an ill child, financial worries, and so on — negatively affect performance. Are we going to demand full disclosure of these problems as well?" the college writes in its rebuttal.

Instead, surgeons should be trained to accept their "human limitations," the college says, and to understand how acute fatigue impairs mental and physical function.

While a surgeon who has spent a night on call might be "hard-pressed" to safely perform an operation as complicated as a liver transplant, most doctors could handle a relatively simple elective procedure "with or without a good night's sleep," the college argues.

Nurok says routine and simple tasks are most vulnerable to the effects of sleep deprivation, perhaps because people tend to operate on autopilot. As a result, simple operations, because of their routine nature, may be even more prone to complications when a surgeon is sleep-deprived.

"It's a patient advocacy and safety issue," he says.

According to the editorial, surveys suggest most patients would worry about their safety if they knew their doctor hadn't slept in 24 hours; 80 per cent would ask to be operated on by another doctor.

"It's a complex issue. We're just trying to bring attention to the problem and hope that there will be public debate on how best to address it," Nurok says.

With files from Montreal Gazette

skirkey@postmedia.com

Read more: http://www.canada.com/health/Patients+should+able+tell+surgeon+tired+operate+Editorial/4038300/story.html#ixzz19YFsLPXw

[Kip Powick]

The American College of Surgeons begs to differ. In a response published by the journal, the college says mandatory disclosure is unwarranted, and that most "professionals of this caliber" would find the recommendation that they be forced to disclose how many hours they've slept "oppressive and insidious."

"Many other factors — including marital difficulties, an ill child, financial worries, and so on — negatively affect performance. Are we going to demand full disclosure of these problems as well?" the college writes in its rebuttal.

Instead, surgeons should be trained to accept their "human limitations," the college says, and to understand how acute fatigue impairs mental and physical function.

Insert "Pilot" for surgeon...same - same.

[J.O.]

Kip, I'm not so sure that pilots would be as unwilling to disclose their rest levels as their employers would be.

[Ex 9A Guy]

Doctors bury their mistakes, Pilots are buried by/with them.

[Thebean]

The Mythbusters recently did a show that clearly illustrated that being seriously overtired when driving a vehicle resulted in far higher level of impairment than when driving with a BAL of .05, which, in BC, is enough to get you in serious trouble with the law.

[Maverick]

The Mythbusters recently did a show that clearly illustrated that being seriously overtired when driving a vehicle resulted in far higher level of impairment than when driving with a BAL of .05, which, in BC, is enough to get you in serious trouble with the law.

Ya, but there's no quick and easy way to measure/tax fatigue so...

The new BA limits are ludicrous, it's turned a crime into a tax grab. You can now be plastered and get away with a large fine and no criminal charge.

It's the guy/gal that has a couple of beers after work and is home by 1800 that really gets screwed though. The police now have extraordinary seizure rights

that they could only dream about in the past.

Due process?? Not in BC.

[Thebean]

Ya, but there's no quick and easy way to measure/tax fatigue so...

The new BA limits are ludicrous, it's turned a crime into a tax grab. You can now be plastered and get away with a large fine and no criminal charge.

It's the guy/gal that has a couple of beers after work and is home by 1800 that really gets screwed though. The police now have extraordinary seizure rights

that they could only dream about in the past.

Due process?? Not in BC.

It's intrigung to me that western European countries that lived under Nazi occupation for almost 5 years in WW2 do not allow their police today to have extraordinary seizure rights.

They recognize it's never a good idea to let the police have the right to accuse, try and execute you on the side of the road, with absolutely no right of fair trial.

Not so in BC.

[sustainable]

When it was time for me to get "fixed" I showed up at the urologist's office at 9:00am. He appeared somewhat fatigued and I asked him if he had had a good night's sleep to which he replied, no, I've been on call at the hospital all night and it was busy. I was off the table in a moment asking when we could reschedule. He looked genuinely perplexed. I told him that I flew overseas for a living and that I knew what fatigue looked like and there was no way he was going to go near my nuts with a scalpel in that condition, period end of story. I got in a week later on a day when he had gotten a decent sleep.

[AME]

It's intrigung to me that western European countries that lived under Nazi occupation for almost 5 years in WW2 do not allow their police today to have extraordinary seizure rights.

They recognize it's never a good idea to let the police have the right to accuse, try and execute you on the side of the road, with absolutely no right of fair trial.

Not so in BC.

Doesn't BC have a Liberal Government?

[Don Hudson]

Doesn't BC have a Liberal Government?

Brett...No it doesn't, not according to the original notion of "liberal" - the notions of "conservative and liberal" switched places about 25 years ago. BC has a neoliberal government, fashioned after Thatcherism, Reaganism and the now-broken capitalist model with which ordinary people now question.

Bean:

I know you're stirring the year-end pot a bit, but regarding your two confusing comments:"The Mythbusters recently did a show that clearly illustrated that being seriously overtired when driving a vehicle resulted in far higher level of impairment than when driving with a BAL of .05, which, in BC, is enough to get you in serious trouble with the law.",

and,

"It's intrigung to me that western European countries that lived under Nazi occupation for almost 5 years in WW2 do not allow their police today to have extraordinary seizure rights.

They recognize it's never a good idea to let the police have the right to accuse, try and execute you on the side of the road, with absolutely no right of fair trial.

Not so in BC."

I gather from this you support the lower BAC level law but don't like the ability of the state to enforce the law... - to stop you at the roadside to enforce the new, lower level that business now complains about? (Also )

We could expand a bit on these two notions for more understanding. I think we'd all agree that getting drunks off the road under a lower BAC law is not the same having a fascist state detain, interrogate and execute one purely for one's beliefs.

Also...perhaps the term "execute you on the side of the road" is exaggerated? ... (I see Quebec has refused to deal with this serious and tragic social issue but that discussion is in another thread.)

The threat of the first two state actions, (accuse/detain & try) does however, exist, without citizen comment or protest, in the United States where, under the extraordinary powers of the Patriot Act, the state can suspend citizens' rights - rights which are guaranteed by the First, Fourth, Sixth and Ninth Amendments.

As well, academic freedom - not that practiced at universities but the kind a citizenry practices every time they question their government, (after all, that's what the Second Amendment was originally created for - to enable citizens to rise up against a renegade government), so precious and necessary to a functioning democracy, are even now threatening the public dialogue especially that which disagrees with "the war on terror" as defined by Washington, a definition which tacitly makes criminals out of the very citizens the state says it wants to "protect". We're back to New Speak again.

In some circles, particularly religious and/or right wing ones, such questioning is variously labeled as "disloyal" and "anti-American", (especially if asked by non-citizens). Regardless, researchers and teachers must be careful what they say, as must employees of corporations. This isn't a personal opinion or an "anti-Americanism"- there's plenty of research substantiating this phenomena, (Academic Freedom After September 11). I am genuinely concerned about the subtantial loss of prestige, power and influence the United States has suffered by it's own hand and wonder what will fill the increasing vacuum.

A number of other thoughts also come to mind. - First, these same European countries, notably Germany and for the same reasons you cite, recognize and have very strict privacy-of-information laws. I know this from examining their way (specifically, Lufthansa's) of handling their pilots' "FODA",. (Flight Operations Data Analysis) data. By law this data belongs to the individual pilot only, and cannot be used without his/her permission. The Australians are as strict.

In stark contrast, Canada has no laws whatsoever, securing access to a pilot's information in flight data programs but instead relies upon the judgement of the Justice Department. On the matter of fatigue while performing professional duties in high-risk environments, it is long past time for the medical profession to start recognizing that they too are human and that the safety notion of "human factors" applies to them equally as it does to pilots. The medical profession needs to drop the "hero" and "trial by fatigue" initiation into the profession - a trial which, to an outsider, appears more like a ritual hazing than it does "preparation" for being a doctor.

To make it abundantly clear to those who may disagree, let us take the counter-example whereby pilots are required to go through a similar process. That, as part of becoming a commercial pilot, the requirement for the pilot "intern" would be to stay up 24hrs before undertaking his/her next flight.

How much sense does that make? Why, or why not? Why are doctors different than pilots when it comes to fatigue risk management?

I submit the question can't be answered physiologically or even psychologically. It can only be answered "professionally", which means in truth, the answers are economically and therefore politically based.

The effects of fatigue on humans are known to be worse than alcohol intoxication. Mental and physiological fatigue cannot be mitigated or avoided except by proper and sufficient rest/sleep?

What makes the medical profession believe that such fatigue can be mitigated through training or practise as is required during internships? As pilots, we know from experience that, regardless of contracts, regulations and beliefs, one cannot "train" or "teach" or even "require" one's mind to be alert after staying awake for 24hrs. The conclusions should be blindlingly obvious to a profession which deals with the human body and mind yet the old ways persist.

So, sustainable...I don't blame you one bit! Wise choice, as the notion of "success" under those circumstances may be variable...

Risk management of fatigue, whether in the health industry or the transportation industry, is not based upon science but upon economics and therefore upon politics.

Today, Transport Canada permits pilots to remain on duty as long as 23 hours, providing there is one augmented pilot above the normal crew, (that means 3 pilots these days, a SAE-standard bunk, (no bunks I've ever used met this standard) and no pilot spends more than 14hrs in the seat. Here is the CARS that states all this.

The commercial aviation industry has edged towards a serious effort in managing what is not an economic problem but a human factors problem, by forcing pilot associations to spend their limited negotiating dollars on contractual flight safety rules which more properly are the responsiblity of the regulator. While the aviation safety notions of CRM are beginning to be seriously discussed as ways of reducing the still-spectacular fatality rate in the health industry, they have yet to dump the anachronistic notion that making a young doctor earn his/her 'bones' by staying up for days at a time is appropriate "preparation" for the profession.

Our health care system requires that we be the responsible caretakers and advocates of our own personal health. Perhaps it is time to consider that part of that responsibility and advocacy is the phenomenon of, "You're too tired to operate"? It's complicated and such an intervention would be a stop-gap measure until the industry began regulating itself to ensure that human factors such as fatigue are appropriately managed.

Anyway, enough of the serious stuff - Happy New Year everyone! Toast health and happiness. Be well.

Don

[AME]

No it doesn't, not according to the original notion of "liberal" - the notions of "conservative and liberal" switched places about 25 years ago. BC has a neoliberal government, fashioned after Thatcherism, Reaganism and the now-broken capitalist model with which ordinary people now question.

"Gordon Muir Campbell, MLA (born January 12, 1948) is the 34th Premier of British Columbia, a former real estate developer and teacher. As the leader of the British Columbia Liberal Party

http://www.gov.bc.ca/premier/

http://en.wikipedia.org/wiki/Gordon_Campbell_(Canadian_politician)

Sorry I didn't know Gordon wasn't a real Liberal

p.s. my original jab was actually meant for Dagger

[Don Hudson]

No it doesn't, not according to the original notion of "liberal" - the notions of "conservative and liberal" switched places about 25 years ago. BC has a neoliberal government, fashioned after Thatcherism, Reaganism and the now-broken capitalist model with which ordinary people now question.

"Gordon Muir Campbell, MLA (born January 12, 1948) is the 34th Premier of British Columbia, a former real estate developer and teacher. As the leader of the British Columbia Liberal Party

http://www.gov.bc.ca/premier/

http://en.wikipedia.org/wiki/Gordon_Campbell_(Canadian_politician)

Sorry I didn't know Gordon wasn't a real Liberal

p.s. my original jab was actually meant for Dagger

While we haven't heard from dagger in a long while, I believe from past comments, he would support "neoliberal" economics, ala Milton Friedman and "the Chicago Boys"; In the past he has told employees to "get used to what the market will bear", and while that is certainly a truism, it is also only one way of "doing an economy". Since the early '70's wages have plummeted, retirement plans have all but evaporated, ordinary family life is under great stress where both parents must work not by choice for the second Mercedes in the driveway but because wages are so low in comparison to housing, food, education, transportation, taxes and retiring. Who here, who is raising a family, is actually able to save for their retirement and still buy a house, clothe, feed, educate their kids and perhaps afford a vacation? Who here now anticipates a secure retirement?

Fordism in part, encompassed the notion that those who made the products of capitalism should be able to particpate in such a system. What's more, it contemplated that those who did the work could house, feed and educate "replacement workers" and that those who filled the ranks could retire in decent circumstances - not wealthy, but not paupers either. Today, who among us raising a family, has the time let alone the expertise to do well in the shell game called "Wall Street" such that one can build a retirement plan? Who is saving these days, and if so, where are you putting your money so that it grows?

The system has dumped workers as "liabilities" and a millstone around profit's neck. A speculation economy has destroyed an entire society's ability to care for itself without specialist (inside) knowledge. The Financial industry (the Finance Sector) arranges for itself billions and billions in rewards while casting what used to be a vibrant and working middle class aside as so much detritus which was in the way of making money.

The measure isn't whether we are (somehow) "better off" today primarily because we are...compared to the Middle Ages where disease, longevity, poverty and ignorance claimed huge numbers. But the promise of a vibrant economy has been reserved for those who make the rules - the Bankers and other financiers who in October 2008 brought us the latest iteration of their boom & bust theology. The problem isn't so much a growing poverty as it is a renewed slavery masked by the entertainment industry and both our society's need due to poor wages, purchase kitsch from China and our willingness to call that a "lifestyle". To enhance the illusion, we have mortgaged our future both nationally and personally. By what measure is this "success"?

I see increasing awareness of the new slavery and the justifying society in which this has emerged. It's never "too late", because it is never "too early" - change is inevitable if sufficient numbers of "slaves" want it and this, like it or not I think, is what "the market" is going to have to deal with. Ordinary people are tired of losing their homes, working three jobs, not being able to support and raise a family all the while watching a select few patricians collect billions while hiding behind the new laws that legalize this entire scam. We'll see just what who's market will bear then.

Don

[Mitch Cronin]

When it was time for me to get "fixed" I showed up at the urologist's office at 9:00am. He appeared somewhat fatigued and I asked him if he had had a good night's sleep to which he replied, no, I've been on call at the hospital all night and it was busy. I was off the table in a moment asking when we could reschedule. He looked genuinely perplexed. I told him that I flew overseas for a living and that I knew what fatigue looked like and there was no way he was going to go near my nuts with a scalpel in that condition, period end of story. I got in a week later on a day when he had gotten a decent sleep.

Good on ya! That's exactly what needs to be done to put an end to that kind of nonsense. Well done.