How Can I Combat Call Fatigue?

Sara Cohen, MD

Disclosures

April 30, 2010

Question

Even with work-hour restrictions, I find that I am frequently sleep deprived. Do you have any useful tips for dealing with fatigue during long or overnight hospital shifts?

Response from Sara Cohen, MD
Fellow, Polytrauma/Brain Injury, VA Boston Healthcare System, Jamaica Plain, Massachusetts

Early in my intern year, after a particularly rough call that kept me awake and on-the-go for roughly 30 straight hours, I was finishing up some paperwork on my patients prior to sign-out. I consulted my "Things to Do" checklist and went to retrieve a form from a nearby file cabinet. During that 60-second journey over to the file cabinet, I forgot what form it was that I needed. I consulted my checklist again, then restarted my search. As I leafed through the thick stack of forms, however, I again forgot what I had been seeking. I've never considered myself a particularly forgetful person, but episodes like this were not uncommon when I was post-call.

Being responsible for the lives of patients while extremely sleep deprived is far from ideal. A 2009 study published in JAMA noted that higher levels of fatigue were associated with self-perceived medical error.[1] After the 1984 death of Libby Zion was attributed to resident fatigue, strict rules were instituted in training hospitals to help prevent medical errors related to fatigue. However, 30-hour shifts still exist in some residency programs. Working nights is the norm during most residencies, and according to a survey, more than one fifth of residents reported getting 5 or fewer hours of sleep per night during the previous week.[2] Unfortunately, fatigue during clinical training cannot be avoided entirely. Rather, it is something with which medical students and residents must learn to cope.

The most important first step is to recognize when you're fatigued. Signs of sleep deprivation include nodding off during conferences or while driving, difficulty focusing on tasks, forgetfulness, difficulty solving problems, and irritability. The best antidote to fatigue is sleep. Try your best to get a good night's sleep prior to an overnight call. Whenever possible during a night shift, try to take a nap. I've found that even a 20-minute nap can be refreshing.

Unfortunately, naps can sometimes backfire. In a phenomenon called "sleep inertia," if you are awakened from deep sleep, you may emerge from a 1-hour nap feeling even groggier than before. Not surprisingly, a study of napping conducted with astronauts found that the longer the nap, the better.[3] Additionally, the researchers found that napping at night for someone on a nocturnal sleep schedule is a risk factor for sleep inertia. So a nap, while sometimes helpful, may end up leaving you in worse shape than before.

The LIFE curriculum (Learning to address Impairment and Fatigue to Enhance patient safety), which provides an online training course for residency programs, suggests using caffeine as needed in order to increase alertness.[4] Many medical students learn early to start their day with a cup of coffee, but for students like me who don't like coffee, caffeinated sodas, teas, and candies are good substitutes. Caffeine should be avoided near the end of a shift, though, to prevent post-call insomnia.

I found that when I was at my most sleep deprived, it helped to be extremely organized. When I was post-call, I kept careful notes on each patient and checkboxes of all tests that I needed to follow up on and orders I needed to place before leaving. Prior to leaving the hospital, I consulted my checkboxes to make sure that I had done everything I needed for my patients. I found this method invaluable in preventing fatigue-related medical errors.

Other tips that I have found helpful for staying alert during my shifts include:

  • Avoiding dark or warm rooms;

  • Interacting with other people;

  • Staying active; and

  • Completing tasks that are most important to patient care early in the call shift, before fatigue sets in.

Most important: If you ever feel that you have reached a point beyond normal fatigue, when your patients' medical care is compromised, you should alert your senior resident or attending.

Another frightening consequence of fatigue is the increased risk for a motor vehicle accident. A 2005 study in The New England Journal of Medicine showed a 16.2% increased risk for a motor vehicle accident in people with extended work shifts.[5] In New Jersey, Maggie's Law creates a legal liability for tired residents, stating that "a sleep-deprived driver who causes an accident, after being awake for more than 24 hours, can be convicted of vehicular homicide."[6] For your own safety and for the safety of others, if you find yourself so tired that you might fall asleep behind the wheel, it is crucial to take a nap in a call room prior to driving home, or find another means of transportation. If possible, avoid living in a location that will give you a long commute from the hospital.

Unfortunately, sleep deprivation is a necessary evil in the current medical training model, but it is possible to minimize its effects. The most important thing is to be vigilant with respect to your own safety and the safety of your patients, and to recognize and admit your limitations.

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