Lack of sleep prompted pilot’s breakdown. System error?

You may recall the incident back in March during which a JetBlue pilot raved about Jesus, al-Qaida, sins in Las Vegas and other things causing the co-pilot to lock him out of the cockpit.

According to the Associated Press story, the pilot, who had to be subdued by passengers, “had a brief psychotic disorder due to lack of sleep.” At a recent trial, he was declared not guilty by reason of insanity of the crime of interfering with a flight crew. The diagnosis of psychosis from sleep deprivation was made by a forensic neuropyschologist who testified that the psychosis lasted a week.

The article goes on to say that the FAA is still investigating and has not decided if any official policy changes will be made. A previous rule change requiring pilots to have 8 hours of uninterrupted sleep opportunity will go into effect next year. The current rule says a pilot must get 8 or 9 hours of rest but does not specify “sleep opportunity.”

This episode is making me nervous because it sounds like a “system error” may be invoked when the cause may simply have been human error.

I say this because it seems more likely to me [disclaimer: I’m not a forensic neuropsychologist] that the pilot might just have gone nuts for no good reason. That does happen occasionally. The problem with the sleep deprivation argument is that JetBlue said the pilot “did not fly March 24 or March 25, and worked a round-trip flight March 26 that gave him 17 hours of off time leading into the flight March 27.” Also if sleep deprivation can make one psychotic, just about every doctor I know must be crazy.

He had 17 hours of time off, which seems like more than enough time to rest. In fact, a “sleep opportunity” of 8 hours would have comfortably fit into that window of time with a little dinner and a TV movie thrown in. If he didn’t take advantage of the allotted time to rest, it was his choice. He already may have been unstable.

This reminds me of a recent blog I wrote about a paper on supposed medical errors caused by sleep deprivation. Orthopedic residents in that study, whether working day or night shifts, averaged only about 6 hours of sleep per 24 hour period despite having ample “sleep opportunity.”

Stay tuned. Let's see if the FAA falls for the old "system error" fallacy.

See more of my posts on system error here.

Ask Skeptical Scalpel-Why Do We Still Use Pagers?

Stephen Zintsmaster ‏(@szintsmaster) tweeted me this question:

“@Skepticscalpel - I need some wisdom as a new 3rd yr. Y do they still use the damn pagers? This will forever annoy me!”

Stephen, I believe there is still a use for pagers in medicine. This question came up in some comments on one of my more popular blogs called “What happens when a doctor is paged.”

Chris Porter, a surgeon who has a popular blog called “OnSurg,” took me to task by asking why my hospital still used pagers and hadn’t I heard about cell phones?

I replied, “I don't know about your area, but where I practice, cell phone service can be spotty. The hospital is one of the worst places. Some cell phone carriers have little or no coverage. You can be in the OR or radiology and have no bars on your phone. Since pagers work by radio, there is no coverage problem. When cell phones are 100% reliable, let me know.”

I also pointed out to another commenter that when the nurses have your cell phone number, they may call you when you’re not on call. This has happened to me. When they have to look up your pager number, they seem more likely to check the on call schedule.

To me, phone calls are also more intrusive and harder to ignore. I was debriding a pressure sore in a patient's room the other day when my phone rang. Because I was wearing gloves, I couldn’t hit “Ignore” and it went on for 30 seconds. A pager stops beeping after just a few seconds.

Dr Roy Arnold, ‏who tweets as @Cholerajoe, pointed out that another reason to use pagers is that there may be one pager for the on call doc that gets handed off when call changes. Nurses know to always call the same number.

Update 7/10/2012. Dr. Mary L. Brandt (@drmlb) tweeted a link to a blog that describes the history of the pager and another important reason we still use them--the "group page" for codes. The blog also mentions some new ideas for eliminating the pager.

Bottom line: I know in some areas, doctors are happy to completely rely on cell phones. This has not worked for me.

Ask Skeptical Scalpel-Learning Surgical Skills

Medical student Sara ‏@Stichflamme asks, “What exercises such as suturing and other skills can I do to prepare for a career in surgery?

I have always felt that more important than technical skills are knowing both whom to operate on and when. I’m reminded of a blog I wrote in November of 2011 called “I could teach a monkey to operate.” I pointed out that this cliché has been around for a long time, but so far, there are no reports of a monkey successfully operating.

At one time, applicants to surgical residencies had to pass dexterity tests such as carving something from a block of soap or making a model airplane. I know of no program that still requires such activities.

By the time you finish training, many operations may be robot-assisted. Surgical robots purportedly eliminate tremors and facilitate precise dissection. Devices such as the Ligasure have revolutionized both open and laparoscopic surgery and reduced the need for tedious knot-tying. Staplers for organs and skin have almost eliminated sewing. We even have looped and barbed sutures that don’t require knot tying skills to secure.

I posted a version of this on Sermo yesterday. All of the commenters felt that skills such as knot tying will be necessary for the foreseeable future. However, I can think of many common minimally invasive procedures that can be done without tying a single knot.

The consensus was that a budding surgeon should learn to tie knots and sew. A study showed that surgeons who played video games performed better at laparoscopic skills than those who didn't play video games. This is hardly proven but you would be surprised at how many people believe it.

Bottom line: Practice knot tying on the bedpost until you can do it quickly and smoothly with your eyes closed. I suggest using string or even clothesline at first so you can see how the knots are formed. Regarding video games, I defer to “docpark” on Sermo who said, “I would have to add that not all video games help. 1st person shooters not as good as a 3rd person games, and classic games are best. I recommend Defender, Asteroids, or it's iOS update Meteor Blitz.” I trust you will know what that means.

Good luck.

Disease mongering? Germs found on more surfaces

Two recent studies have uncovered still more inanimate objects that are crawling with bacteria. I’ve scoffed at research like this before [here, here & here] but this time it’s serious. Bacteria have been found in offices and hotel rooms! Call the Hazmat Team.

Headline: "The most contaminated surfaces in hotel rooms." Investigators have found that bacteria are not only rampant on hotel room toilets and sinks, they are all over the TV remote, the bedside light switch and even the housekeeping carts. Not surprisingly, sponges and mops were particularly bacteria-laden.

The study comprised a total of 9 [yes, 9] hotel rooms in three different states. Way down at the end of the seventh paragraph of the report is this sentence, “The researchers cannot say whether or not the bacteria detected can cause disease, however, the contamination levels are a reliable indicator of overall cleanliness.”

Headline: “Dirtiest Places in the Office: Men’s Desks.” Researchers from the University of San Diego “found high levels of bacteria that come from human skin and mucus membranes, as well as tons of bacteria from plants and soil when they sampled offices. The researchers also found tons of bacteria on phones and chair armrests.” You read it right, tons of bacteria.

The research was done in 2007 at a total of 10 offices in three cities, New York, San Francisco and Tucson. Tucson?

Why were men’s desks more contaminated than those of women? The study says men are larger and thus shed more bacteria and [allegedly] men are dirtier. Chairs and phones had a many more bacteria than desktops, keyboard and mouses. Once again, the seventh paragraph of the story quotes one of the authors, "These surfaces are pretty inert. You are getting mostly what you are putting out or shedding, or what's blowing in through the door and window," [Scott] Kelly said. "It's harmless; you bring it in with you."

Oh, it’s harmless. I see. One can also see why it took 5 years to analyze and publish this work.

So here we have anxiety inducing headlines and stories until near the end when it turns out in both cases, as seems to be the pattern with studies like these, no disease transmission can be link to the hordes of bacteria.

But if you want even more to worry about, you must check out this infographic headlined “Germs Really Are Everywhere.” After pointing out the many places where bacteria can be found, it advises “Use soap, alcohol swabs or gel sanitizers frequently.”

Alcohol hand sanitizers have been linked to skin problems in hospital workers and the head of infectious diseases at Rush University Medical Center in Chicago advises against their routine use in non-medical settings except in flu season. He says to stick with soap and water.

For now, I say it’s still OK to go to the office or stay in a hotel.

Surgery & Work-Home Conflict

An article published ahead of print in Archives of Surgery [full text here], reported the results of a survey of over 7100 members of the American College of Surgeons. Over 52% said they had experienced at least one work-home conflict in the 3 weeks preceding the survey. Work-home conflicts were more common in those surgeons who were young, female and had young children.

Surgeons with a recent work-home conflict were more likely to have symptoms of burnout, depression, alcohol abuse/dependency, and were less likely to recommend surgery as a career option to their children.

A surgeon I follow on Twitter, Dr. Mary L. Brandt, posted a link to a video produced by Redefining Surgery, “a project sponsored by the Association for Academic Surgery, the Society for University Surgeons, and the American College of Surgeons to provide information for young bright students contemplating a career in Surgery.” This 12 minute series of interviews with surgeons young and old, male and female was intended to show how one can be a surgeon and still have a life.

Here is the video. Just watch a few minutes and you will get the idea. 

I watched it all the way to the end just to see if anyone really seemed to believe what they were saying. My reaction was that most of the participants lacked conviction. It all seemed rather forced, as if they were trying to persuade themselves that all was well with the balance between family and work.

So what’s the point?

I am surprised that only about half of surgeons polled admitted to having recent work-home conflicts. When my children were younger and I was a surgical chairman with a fairly manageable schedule, I still faced at least two or three work-home conflicts per week. Despite what the video rather unconvincingly tries to portray, surgery does present huge challenges to maintaining balance in life.

Is there a solution? I’m not sure. I know many people with responsible jobs in finance and business. They have stress, burnout and work-home conflicts too. Also note the recent buzz about Anne-Marie Slaughter’s Atlantic piece on why women “can’t have it all.”

Maybe there is no answer. I would be interested in hearing what you have to say.

Ask Skeptical Scalpel

The Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research is pleased to announce a new service.

As of July 1, 2012, you may “Ask Skeptical Scalpel” any question you wish on any topic.

Advice, information, medicine, surgery, whatever. All questions are welcome.

All you need to do is email me, SkepticalScalpel(at)hotmail.com. [Replace (at) with @.] Upon request, names will be withheld from questions that are published. Comments will be permitted if appropriate.

Spammers will receive robotic orchiectomies without anesthesia.

Patient Complications & Surgeon Collateral Damage

"Collateral damage: the effect of patient complications on the surgeon's psyche" was a brief but interesting paper that probably went unnoticed by many. Using the results of a survey completed by only 123 of the 403 surgeons who received it, the paper studied the effect of complications on the emotional well-being of surgeons. You could argue that the response rate of 30.5% renders the conclusions suspect. But that’s not the point.

The subject matter hits close to home for any surgeon who cares about his patients and what he does to them.

There are two types of complications—those that happen despite your best efforts, such as a postoperative MI in a seemingly healthy patient or an infection that develops after proper surgical technique and appropriate antibiotic prophylaxis were used.

Then there are the complications that occur because you made a mistake. Examples of this are sepsis due to an anastomotic leak due to your well-intended but erroneous judgment that the patient’s bowel wall would hold the staples or your failure to operate soon enough on a patient with a bowel obstruction.

Of course when any complication occurs, we feel bad for the patient and the family. But the latter type of complication can keep you awake at night, undermine your confidence and your ability to function and even effect your enjoyment of life in general. Eventually, you get over it and move on, but the next time is no easier. According to the survey, about two-thirds of the surgeons felt it was difficult to deal with the emotional aspect of  complications throughout their careers and experience did not seem to lessen the impact.

Not everyone is affected in the same way or to the same degree. I once had a surgeon tell me, “I’ve been in practice for 22 years, and I’ve never made a mistake.”

But for us mere mortals, mistakes happen and leave scars. A South African blogger named Bongi said it much better than I in a post he called “The Graveyard.” In it, he describes a case of his with a delayed diagnosis that resulted in a patient’s death. He said every surgeon has a graveyard in the “dark recesses of his mind” where “names engraved on the tombstones” can be recalled.

I have a graveyard. I think most doctors do.

Note: This post appeared on Sermo yesterday and generated some thoughtful comments.