The dangers of fatigue in a hospital emergency department

Emergency departments are places of high stress and, often, fatigue. Source: AAP

We all need to be aware of the effects of fatigue on shift workers in health, writes emergency physician Michelle Johnston.

I experimented with food. All types. In the end, the most effective combination was morning air streaming through an open car window and an apple, green. But when this wasn’t quite enough, I would rely on the klaxon sound of the car horn behind me, waking to find the lights had changed and I was creating a traffic jam. In those days, red lights were a desirable little sleep oasis in the disorientating drive home from night shift.

Shift work is bad for sleep. Rafts of studies have documented the deleterious effects this has on cognitive function and physical dexterity. I work as a consultant in the Emergency Department of a tertiary hospital, a mecca that hums twenty-four hours a day. Here there is little distinction between services provided during the day and through the night. It’s a fluorescent, constantly clamouring circus. Thankfully the brutally long shifts of old have been legislated against, but like many employees in health, we still work all chunks of the clock. Fatigue is a constant, disagreeable companion. I have fallen asleep in a patient’s cubicle taking a history, sitting at a desk writing reports, and once in the distressed relative’s room in the ashen hours of night, only to be awoken by a rather confused cleaner.

I have missed a diagnosis of an intracerebral haemorrhage of an elderly man ... because I was too tired to take notice of my washed-out gut feeling.

While much work has been done on understanding the effects of fatigue on measurable qualities such as cognition, decision-making, and ability to perform physical tasks, I am more interested in the unmeasurables. The subtle effect tiredness has on empathy, compassion, patience, and prioritisation. Over the years there have been times where I’ve left work deeply disappointed in myself, that I didn’t have the energy to sit longer with a patient, explain things better, or take on an extra patient load as the midnight hour approached. One’s own cognitive biases are magnified, internal alarm bells are dampened, and decisions skewed as exhaustion mounts. Diagnoses, family discussions, counselling, and treatment decisions all become more difficult with fatigue.  I have missed a diagnosis of an intracerebral haemorrhage of an elderly man at odds with his stairs, because I was too tired to take notice of my washed-out gut feeling and go that extra step in ordering the late night CT scan. Thankfully, it was picked up soon afterwards, in a system with staunch checks and balances.

The fatigue that creeps up on shift workers is multifactorial. Those in environments such as the Emergency Department and other critical care areas have many issues competing for their alertness. The sleep debt of night shifts is cumulative. Those with other jobs (feeding or transporting small children who have, rudely, little respect for your 2.30 am bedtime of the previous night), must slip in and out of those worlds if not seamlessly, then at least keeping upright. The other major issue we face is a high stress environment.  Running an Emergency Department is a role dense with decisions. Constant interruptions, crashing resuscitations, relentless attention shifting between high stakes tasks, and questionable coffee – all of these things deplete your reserves. Sometimes a ten hour shift can feel like twenty. And then there is the unwelcome occurrence of dragging oneself home and tucking oneself in bed, only to be so wired that a detailed re-examination of every single decision made, each action taken, and every word uttered seems to be the frolicsome activity chosen by one’s brain. It’s an exhausting job alright.

I am more interested in the unmeasurables. The subtle effect tiredness has on empathy, compassion, patience, and prioritisation.

We all expect society, in this day and age, to be non-stop. Services should run round the clock. Access to groceries, utilities, transport, entertainment should be ceaseless. Hospitals, at the very least, have some justification for operating this way. After all, the sick and the injured do not respect the diurnal tides. But we can build all the systems and develop the best hospitals we want, knowing that despite all of these things human biology has not evolved. We still do not function well when we are out of circadian whack. Gratefully this is, for the most part, recognised. There is plentiful sound advice around concerning managing shift work and sleep in order to offset some of the damage.

We all need to be aware, on both sides of the hospital wall, of the effects of fatigue on shift workers in health. Ourselves as the workers, so that we may have insight into when our abilities may not be optimal, and as a society, to realise that we should not always expect homogenous service provision through a twenty-four hour period. Don’t get me wrong. Australian Emergency Departments are extremely safe places to come to. Robust processes are built into their function, and staff, on the whole, are happy and eager to be working there. It is a privilege to provide care to the flotilla of people whenever they arrive with their bodily disarray or distress. It can just be very tiring.

 

Michelle Johnston is an emergency physician and will be appears on Insight episode, Sleep, looking at whether we are getting enough sleep in our increasingly busy lives | Catch up online now: