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The dead don’t rest

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It’s 12 February, 2009. The time is 9pm at Newark Liberty International Airport. Dr Alison Des Forges is waiting to board a flight to take her back to her home in Buffalo, New York. Alison’s spent most of her work life in Rwanda, investigating killings, kidnappings and human rights transgressions. She was one of the loudest voices to be heard on the world stage in 1994, when she called for the recognition of what we now know as the Rwandan genocide.

She was named a MacArthur Fellow in 1999, as well as taking a senior position with Human Rights Watch. But the year isn’t 1994, and we’re not in Rwanda. It’s 2009, and she’s flying home to be with her family in the USA.

The plane has already been delayed by two hours, and the bleary eyed passengers are finally allowed to board the plane. They aren’t the only tired people on-board, however. First Officer Rebecca Shaw has made the commute from Seattle to Newark to co-pilot the flight, and complains to her pilot of feeling tired and unwell. Similarly, Captain Marvin Renslow complains of fatigue, due to a lack of rest over the preceding few days and abrupt changes to his sleep-wake cycle.

What follows is a series of errors that ultimately result in a fatal stall during the landing approach. The Captain responds incorrectly to the stall, as does his First Officer, and the errors are compounded. The plane ploughs into the house of Douglas and Karen Wielinski, and a total of 50 people perish that day, including Dr Des Forges.

To err is human, but we often don’t like facing this harsh reality. This is equally as true in medicine as it is in aviation.

Our workforce is by no means in balance, and it poses a headache for doctors and employers alike.

We’re awash with graduates, but hospitals struggle to fill gaps in rosters due primarily to a lack of workforce coordination. This leads to over-employment of current doctors, increasingly unsafe shifts, workplace dissatisfaction, absenteeism and resignations, all which continue to compound the initial problem.

Sound dramatic? Good. It should. We’re human and we’re not that special. You’d no sooner go to work with a blood alcohol level of 0.05 than you would eat your own face, but we know that after eighteen hours of continuous work, humans behave as if they’re too drunk to drive a car.

In the case of Eastman vs Namoi Cotton Co-Operative (2014), an employee was awarded $498,950 in compensation for a car crash where she drifted into oncoming traffic. The cause? Six 12-hour night shifts in a row with a two-day break. I can name at least five hospitals around Australia off the top of my head with similar rosters, and that’s without breaking an investigative sweat.

Around the time Dr Des Forges was being named a MacArthur Fellow, the AMA was adopting a National Code of Practice for Safe Working Hours.

The code was, and remains, a flexible and common sense guide to work hours. Rather than being a prescriptive and unmanageable set of rules, the code instead highlights patterns and situations which lead to unsafe working hours.

It outlines the responsibility of both the employee and the employer, recognising that fatigue management involves both parties. It’s tailored to the Australian medical workforce, and it has recently been renewed and updated by the AMA Federal Council.

In August, the Council of Doctors in Training will be conducting its five-yearly safe working hours audit, to see whether we as a country are getting better or worse at managing fatigue.

I’ve heard many emotive arguments for and against the importance of fatigue management.

I’ve heard people glorify the dark old days as a superior form of education. I’ve seen workforce units threaten doctors with future offers of employment as incentive for unsavoury rosters. I’ve seen doctors belittled by other doctors for their lack of ‘commitment’ to their vocation. But I’ve also seen a 66-year-old human rights activist, and fervent advocate for hundreds of thousands of slaughtered Rwandans, die partially as a consequence of poor fatigue management.

 

It is unconscionable to think that fatigue management isn’t core business for doctors, and a key element of good patient care. After all, if one person can fight for thousands of oppressed people, surely I can fight for the welfare of my patients.

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