Guest Blog: It’s time to talk about fatigue
By Roopa McCrossan, Specialist Trainee, Department of Anaesthesia, Royal Victoria Infirmary, Newcastle-upon-Tyne NHS Foundation Trust and Honorary Secretary, Association of Anaesthetists Trainee Committee on 03 September 2019 Maternity Services Caring For You campaign
As the end of the summer approaches, those of us in the business of bringing new life into the world are braced and ready for the one of the busiest times of year. The Office of National Statistics has published data showing that more babies are conceived in the weeks leading up to Christmas than at any other time of year, leading to a peak in the birth rate in the last two weeks of September.1
With September around the corner and the inevitable short staffing across maternity services, it's more important than ever to look after ourselves so that we can deliver the best care to our patients. The Royal College of Midwives couldn't have picked a better time to lend their support to the Fight Fatigue campaign. Night shift is part of the job for many of us, but its only recently that we have started to explore the pitfalls of working nights and how it affects us and the care we deliver to our patients. Although the Fight Fatigue campaign's roots are in anaesthesia, it aims to help all healthcare professionals. At the core of the campaign is education around fatigue and its effects. Once we are aware of the dangers, we can take steps to mitigate the risks.
Why is fatigue important?
This may seem like a trivial problem at first glance, but it's one we need to take seriously. This campaign started because of a tragedy that shook the anaesthetic community. Dr Ronak Patel was driving home after a set of three night shifts. Press reports describe how he was talking to his wife using a hands free mobile; they were singing to each other to help him stay awake. His wife said that the phone cut off suddenly. She rang him back, again and again; 14 times in total, but there was no answer. She started to drive along his route home and was met by the police. Ronak had collided head on with a lorry and died at the scene. The inquest heard that he had likely fallen asleep at the wheel. His wife was 33 weeks pregnant at the time.2
Sadly, Ronak's case isn’t in isolation, experts think we lose a doctor or nurse every 6 months due to driving whilst fatigued.3 Our survey of over 2000 anaesthetic trainees showed that 57% of people have had an accident or near miss driving after a night shift.4 Sleep deprivation causes a phenomenon known as, "sleep lapses" or "microsleeps". These are short, uncontrolled episodes of sleep, lasting seconds, that occur without warning. The brain is so tired it just shuts down and sleeps. It is these microsleeps, as well as the slower reaction times present when you are fatigued, that make driving when tired dangerous.
But it's not only our ability to drive home that is affected, fatigue reduces our cognitive processing abilities. Fatigued individuals make more risky decisions, yet are more confident in the decisions they have made.5 Simple safety checks such as the concept of "fresh eyes" on a CTG trace become even more relevant at night. Cognitive psychomotor impairment starts to appear at just 10 hours wakefulness and by the time you have been awake for 20 hours, reaction times are equivalent to a blood alcohol level of 0.10% (100mg.100ml-1 blood), well over the drink drive limit in the UK6.
The effects on overall health make concerning reading. Night shift workers have an increased risk of hypertension, heart disease, diabetes, obesity, stroke7 and there is an association with night shift working and breast cancer8. More research is required, but we are starting to understand some of the mechanisms behind these negative effects on health. A recent publication in Anaesthesia journal describes how sleep deprivation and sleep disruption can lead to DNA damage9. Work related fatigue not only affects our physical health, but also our mental health and relationships. In our survey, 71% of anaesthetic trainees stated fatigue had a negative effect on their psychological wellbeing and 67.9% said it negatively affected their personal relationships.4
What can we do to manage fatigue?
Its not all bad news, we have developed a set of resources to help you manage working at night. Simple strategies such as power napping during and after your shift can prevent the microsleeps that make driving tired dangerous. Improving your core sleep between shifts can help your body cope with the demands of night shift. All of our resources can be found here. These were designed to be displayed where you work, please put them on the walls and share them with your colleagues; you might just save someone’s life.
- Office of National Statistics. How popular is your birthday? https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/articles/howpopularisyourbirthday/2015-12-18, accessed 14/8/19.
- Suffolk Free Press, Ixworth doctor who died in head-on crash in Honington ‘probably fell sleep’, inquest hears, 11 July 2016. https://www.suffolkfreepress.co.uk/news/ixworth-doctor-who-died-in-head-on-crash-in-honington-probably-fell-sleep-inquest-hears-1-7471971/, accessed 18/8/19.
- Personal communication Dr Michael Farquhar, Consultant paediatric sleep physician, Evelina Hospital, London.
- McClelland L, Holland J, Lomas JP, Redfern N, Plunkett E. A national survey on the effects of fatigue on trainees in anaesthesia in the UK. Anaesthesia 2017, 72(9):1069-1077
- Capanna MV, Hou R, Garner M, Yuen HM, Hill CM. Risk taking in junior doctors working night shifts in intensive care. Intensive care medicine 2017, 43(5): 709-10
- Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388: 235
- Ferguson K, Howard F, Idzikowski C et al. Fatigue and Anaesthetists Guideline, 2014, Association of Anaesthetists of Great Britain and Ireland, available at https://www.aagbi.org/sites/default/files/Fatigue%20Guideline%20web.pdf (accessed 17/3/19)
- Hansen J. Night shift work and risk of breast cancer. Current Environmental Health Reports, 2017, 4(3):325-339.
- Cheung V, Yuen VM, Wong GTC et al. The effect of sleep deprivation and disruption on DNA damage and health of doctors. Anaesthesia 2019, 74(4): 434-440.