Sleep deprived Critical Care?

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Well, I’ve been following this debate on this listserve and in the
surgeons’ lounge, and in the pages of the Bulletin of the ACS for it
seems eons. This, along with my own experience as both a pilot and
basically one of the last resident classes to go through the “old”
way (admittedly we were mandated 3 days off a month and no every other
night call more that 2 calls in a row) leads me to make a few points
that I hope some will find interesting:

Much of the fatigue data to which I’ve been privy reports decrease in
ability in repetitive, boring tasks of low motivation e.g. pressing a
button in response to a signal at random time intervals or doing reams
of math problems after sleep deprivation or flying a simulator in
similar conditions. Whether or not these models apply to residency
training is a HYPOTHESIS not an obvious fact.
There is no decent data in my experience (if someone on the list knows
of some please post) that shows that medical outcomes are made worse by
sleep deprivation. This probably has a number of reasons such as:
1. It’s hard to study
2. Tired residents usually have not-so tired attendings to backstop big
decisions
3. Medical decisions of import tend to be non repetitive and of higher
motivational content (no-one falls asleep during surgery unless you’re
just hanging hook)
4. Systems are in place to backstop those “routine” decision
mistakes (i.e. mistakes in drug dosing due to math problems, etc.)

There is NO data (and I’m fairly certain of this, correct me if I’m
wrong) that limiting work hours from the “unlimited” system to the
current 80 hours system has had ANY positive effect on patient outcome,
resident education, resident research, resident reading time, and for
that matter divorce rate, suicide rate, car accidents or any of the
other myriad of things that people quote as reasons the old system was
“bad”. It’s been 20 years since the Bell commission
recommendations have been implemented in NY and 6 since they went
nationwide – where’s the data?

All the studies on this issue I’ve seen report that they found no
difference in anything objective at all and then fall back on
“resident satisfaction” surveys.
I’ve seen one study that reported a decrease in medical errors in the
ICU using interns, no difference in patient outcomes, no mention of
handoff errors (they just followed each physician)

There IS decent data that error rates go up with increasing number of
“hand-offs” mostly from the ED physicians.

So based on this crappy or absent data the boffins in medical education
have decided NOT that limiting work hours is useless, or unnecessary, or
at the very least needs a better implementation plan to work but that
THEY DIDN’T DO IT HARD ENOUGH!

This is the equivalent of the FDA allowing a drug company, after
trialing a drug that is found either to a) not do a damn thing or b)
kill exactly the same number of people that it cures to release the same
drug in a higher dose because they are POSITIVE the drug really works.

And in the end the government with the help of the PhD Educrats and the
craven compliance of those that have climbed the political ladder to the
leadership of the medical societies will destroy a system of education
that has produced well-trained, dedicated physicians for 200 years. In
return we will have “satisfied” clock punchers, buck passers,
wage-earners, and expensive, interchangeable, replaceable employees
accelerating the downward slide of our profession to yet another
“job”. In my most cynical moments (usually after my 2nd
scotch) I come to the conclusion that this is actually the plan – and
then I have my 3rd and don’t care any more (kidding, I get headaches
after 2).

William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412

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