User talk:Jproenca

Is Your Doctor Sleep-Deprived?

It’s one A.M. and the city is deep in slumber. The calm of the night is all-pervasive. The night watchman at the city hospital is trying to keep awake, while at the emergency room the doctor on call, heavy lidded, is hoping that all will be quite. And just then, the shrill ambulance siren cuts through the night. Its wheels screech to a violent halt at the steps of the ER. Pandemonium ensues. The paramedics shift the anguished patient onto the gurney en route to the ER. “It’s an acute abdomen and it needs immediate exploration,” pronounces the erudite but bleary-eyed surgeon. Pandemonium again as the gurney now zooms the opposite way towards the operation theatre. The doctor donned in his green surgical coveralls waits, hoping that his facemask will conceal his sleep-deprived state. He works on the gangrenous appendicitis with all diligence. He knows he has the skills for he has performed many of these before. However, he hopes that the arm of Morpheus will not overwhelm him at this crucial moment. “Oh my God….” yells his assistant. Forcing his eyes open, he sees a torrential spurt of bright red blood. And he knows his worst nightmare is here. A major artery severed and no heroic measures can now undo the inevitable.

It is a sorry but a true tale. All across the globe, even in the best health centers, there have been reports of such events. Sleep deprivation, which is very common among training doctors, has been the chief attributing cause for these unpardonable catastrophes in medical schools. The British Medical Journal 2001 states that sleep deprived surgeons may be putting their patients at risk for life threatening complications that could be avoided with a good night’s sleep. In the United States, interns working a traditional schedule of 77-81 hours per week caused 36% more serious medical errors than when working an average 65 hours per week. Sadly in India there are no such studies Lack of good sleep not only affects our manual dexterity but also hampers our analytical ability. Just like the surgeon’s sleep-aided errant nick, so also the treating night physician could make similar errors in judgment. And all the while, the unsuspecting patient pays the ultimate price.

The European working time directive was implemented for doctors in training, in the UK and elsewhere in Europe, in August 2004. Junior doctors' working hours are now limited to a shift of no more than 13 hours followed by a break of at least 11 hours. In India, no such measures have been attempted. Most of the training doctors are burdened with a barrage of continuous night shifts, markedly lowering their performance levels and pushing them towards the precipice of a mental breakdown. This cumulative sleep debt also brings about mood and personality disturbances making them irritable, less communicative, and even setting in hallucinations. All these factors in turn impede the patient-doctor rapport, which is vital in the overall outcome of the healing process.

So what can be done to overcome this major health hazard. Views are conflicting on the optimum number of consecutive night shifts needed to retain acceptable levels of performance. However, it is clear that a long stretch of night shifts results in an accumulation of daily sleep deficits and does not encourage adjustment of circadian rhythms. A week of night shifts is the pattern most associated with poor performance and accidents. Risk increases exponentially over the course of the night and increases further still over consecutive nights. Any shift system should have as few successive night shifts as possible, with a maximum of three consecutive nights. A single night shift, with a day off before and after, has shown to have the least distortion of circadian rhythm.

To implement these various recommendations, the hospitals and medical schools should appoint a committee that looks into the sleep debt of its training doctors. The medical consortiums through the offices of the Medical council Of India and the Indian Medical Association should address this issue and come up with the Indian working time directives for our doctors. The emergency team operating both the trauma and critical care units should be staffed with an adequate number of both junior and senior doctors so that certain flexibility is maintained in the duty roster. Sleep awareness, through seminars and workshops is mandatory among the medical community It is inevitable that some doctors must work night shifts. But they should be taught how to cope with night work. They must have adequate, high quality, restorative sleep during the day, aided if necessary at home by using heavy curtains, eye masks, and earplugs, and silenced telephone answering machines and mobile phones, and wearing dark glasses when returning from work. It is not the sophisticated medical gadgetry, but healthy well rested doctors that are pivotal in the better outcome of the health care process.

By  Dr. Joaquim Proenca