Medical Residents / Drs. in Pakistan work 24 – 36 hours – IS IT DANGEROUS?

Last month I fell asleep on nursing counter. I literally couldn’t even make it to my car to go home after finishing my shift. If we are working on just four to five hours of sleep, that can have the same effect as if we’re driving under the influence. If you lose just two to three hour of sleep, your focus and reaction time on the road can actually suffer. You do increase the risk of serious medical errors and medical errors that cause harm to patients.

Hey guys. I’m Dr Ishtiaq Ahmad. Over the past years I’ve been doing duties in the hospital and doing these long hour call shifts. And you know… It’s been interesting that so many of you have been shocked and actually worried that doctors are working under such sleep deprived conditions and so it makes me wonder: Would you actually want a doctor to be treating you or operating on you when they’ve already been awake for 20 or 30 hours? So medicine is not the only field where people’s lives are at stake. And so I went in and researched other safety-sensitive jobs and wanted to know how many hours they’re allowed to work.

According to the world renowned, US Federal Aviation Administration, pilots can fly a maximum of 8 hours in any 24 hour period. And if they have a really long flight, like 16 hours, they must have at least four pilots on board to rotate and prevent exhaustion. Truck drivers carrying passengers can only work for ten hours at a time. And the railway operators have a strict maximum at 12 hours. So what’s happening in medicine? Why are we okay with residents working such long hours when mistakes are really high?

But you know, I didn’t want to assume, you know maybe it was just in Pakistan that we had these crazy hours. So I decided to look at some other countries around the world and find out how many hours residents are working.

• Alright, so starting in the USA, Residents can work a total of 24 hours continuously and they get four hours on either side of their shift to be able to hand over information to the next doctors coming on. Also, they have a maximum of 80 hours that they can work in a week and that was capped starting in 2003. That’s still a really long work week.
• In Europe the European Working Time Directive enforces a 48 hour work-week. 48 Hours, that’s not bad. But from what I read, I understand that residents can sign a waiver and be allowed to work for more hours if they want. So there’s a chance for that kind of peer pressure in the system. You should always give in to peer pressure. But what if someone bad tells me to?
• Always! New Zealand has a maximum of 16 hours per week and their work week maximum is 72 hours. Plus they get every other weekend off. I mean… You get like the scenery of Lord of the Rings, you get these great hours. I think I might have to think about New Zealand a little more seriously.
• Australia has more vague recommendations. But the Australian Medical Association released a statement that working over 50 hours puts residents at risk and that working over 70 hours per week puts them at higher risk.

So that brings us back to Pakistan. As you guys know, we can do 24 hour call shifts and plus we need to attend ward rounds on next day too. That’s our maximum. And they can schedule us in the hospital to do this once every 4th day. But that’s once every 4th day on average per month. So on a busy week you could be on-call Tuesday, Friday, Sunday and all of a sudden you’re easily working more than hundred hours that week. The day after a call shift is called a post-call day.

So you have the right to go home and sleep and you know… Have a shower and all of that good stuff. But it’s not enforced and there are some specialties or some residents will feel pressured to stay in the hospital and keep working. And that’s where you have people working for 36 hours straight and the reason they can do that is because we don’t have a weekly work hour maximum here in Pakistan.

So I mean this seems really straight forward to me. You don’t sleep as much, you don’t feel as good, and you don’t function as well in the short term or in the long term. There’s a reason that we need to sleep, but if you need some more evidence, let’s look at some other studies.

Studies have shown that being awake for 24 hours has a similar effect on the brain as having a blood-alcohol level of 0.1 percent, which is above the legal limit to drive. A study by Dr. Kaisler, who is a sleep specialist at Harvard, showed that residents, surgical residents who’ve been awake for more than 20 hours were 70% more likely to stab themselves with a scalpel or prick themselves with a needle. Another U.S. study found that residents were more likely to crash their cars, but 16% more likely after they’ve had these extended crashes.

So with all of this, why has there been no change? I mean… I’ve seen lots of people say different things, but what I hear the most is the discussion around handover. So when a doctor finishes working, they pass on the information to the next doctor. So the shorter the hours that you work, the more times you’re passing on information. So it’s kind of like a game of telephone and people argue that maybe you’re actually going to make more errors that way. But to me that just makes me think: Come on, let’s just get better at doing this handover rather than continuing 24 hour shifts.

So I’ve been doing these crazy long 24-36 hour shifts for the past few years and it has its ups and downs, you know. It’s a unique experience. I love feeling the adrenaline pumping, you got your caffeine in your system, and you’re running around the hospital dealing with emergencies, working in teams. I love that, I love being a part of patient care. But you also have those times when you are so exhausted that you’re actually feeling nauseated and your eyes are kind of fluttering shut and you’re struggling, you’re struggling, you’re asking people for help because you don’t want to make a mistake. You’re having others check your work, because you always want to provide the best care possible. But you wonder is the system setting you up for success when you’re feeling that way?!

Can we empower our residents / doctors by having them be at their best so that they can provide the best patient care possible? Because at the end of the day, these are people who have come into medicine because they want to alleviate suffering. They want to actually help people and I would hate for anything to stand in their way of that.

I’m actually so excited to hear what you guys have to say in the comments, because I want this to be the beginning of a conversation. Tell me. Like what do you feel like when you’ve been awake for 24 or 36 hours? Do you want your doctor to have been working for 24 or 36 hoursstraight? And would you want to know? Ah, I’ve got so many questions. There are so many thoughts going on right now. I’m excited to hear what you have to say. Anyway, if you want to read more articles like this, don’t forget to visit my website every now and then. Thank You

EXPERT REVEALS TRUTH ABOUT MASKS: Why Healthcare Workers Are Catching COVID-19

Hey guys. I’m Dr Ishtiaq. Today we’ll be tackling an issue that’s very important these days. And that’s healthcare providers who have contracted COVID-19. Out of all the patients 10-15% of them are healthcare workers. So are we just not protecting ourselves properly? We’re gonna tackle this question head on and I have invited My esteemed colleague 

Dr. Mujeeb Ullah Makki (B.Sc, MBBS, MBA, MPH, MRCP (UK), MRCP (Ireland)

There are many factors that go into why health care providers are catching COVID-19. One of the most important ones is how much virus the person is exposed to. So your body has natural defense mechanisms. And if you’re exposed to a small amount of virus, you have a better chance of fighting off that infection. Let’s see what Dr. Mujeeb Ullah Makki  had to say about this.

“In general, especially younger, healthier health care workers, shouldn’t be getting sick at these levels. But they are around people that are very sick, are literally in so many cases coughing in their face. And they are getting repeated inoculants. So I might get a high inoculant from person A, a medium from person B, another high one from person C. By the end of the day I have had maybe 10 inoculants. So that night I’m dealing with something that is far different than the casual grocery store visitor, who might have wiped an apple and caught a little bit of virus off that apple because 2 days ago someone coughed on it. It’s a totally different ball of wax. And so the amount of virus that I’m getting as a health care worker is therefore gonna put me at much higher risk. So clearly we need to reduce the exposure, the number of exposures that health care providers have to the virus. And that’s where PPE comes on board: Personal Protective Equipment. That’s everything from gloves, goggles, masks, gowns. It’s what keeps us safe.

There has been a lot of discussion about Personal Protective Equipment in the media and the big questions are: What kind of masks should we be wearing? And what do we do with these shortages that we’re seeing. It’s so heartbreaking to see health care providers that aren’t properly equipped. Especially seeing nurses in Pakistan (Different Hospital) wearing garbage bags. So if you have health care workers out there because their hospital said: ‘Go out there and use this one mask for the week or for the month”, and that’s all they have. They are wearing it. Maybe there is a leak; maybe that thing is starting to break down. Maybe it’s soiled; it’s not even working right. And yet they’re forced to wear it day in day out. It’s not like they are just getting these high inoculants, they are getting them on top of not having right, adequate protection. There has been a debate about whether we need surgical masks or N95 masks. And this all comes down to whether we think the Coronavirus is transmitted by droplet or aerosolized procedure.

Let me explain! The difference between droplets and aerosols is just about the size. So droplets are bigger and then they fall faster out of the air. Whereas aerosols are small and they can stay suspended in the air. So surgical masks were originally designed to prevent surgeons from contaminating patients and reducing wound infections. But now we’re using the surgical mask to protect ourselves. And that’s something that we actually haven’t studied that much. But overall we know that it stops bigger particles. On the other hand N95s are designed to stop 95% of particles in the air. And that includes the small particles. Science tells us that infections can easily be put into boxes, like droplets or aerosols. It’s probably somewhere in between, a combination of both. We know from some studies that Coronavirus is found in the air around sick people.

So what we don’t know is: Will those viruses found in the air… Are they able to infect people? We don’t know if they are still viable and that’s why we need more research. This explains why health authorities like the the World Health Organization have created a list of medical procedures that are most likely to create those tiny particles. And we’re using N95 masks in those scenarios, because they’re such a scarce resource. For me, I mean right now, often what’s being seen in the hospital is you wear a surgical mask and unless there is an aerosolizing procedure, then you put on an N95. I can’t help but wonder sometimes when I’m walking into a room if a patient has just coughed or sneezed. It could have been seconds before. And if you walk in, how is that not an aerosolized procedure?! Or do you think that is aerosolized in coughing and sneezing? Yeah of course, obviously. I mean… Put it this way. It doesn’t make any sense to think: ‘Oh an N95 is necessary for intubation.’ But if someone is coughing and sneezing one minute before you enter. Maybe you don’t even know that! In fact they have been coughing and sneezing for the last hour. And before they were in that room, 10 other patients were in that room coughing and sneezing. You can walk in there and think a surgical mask if sufficient. It’s absolutely not. It’s a joke. And so I think we absolutely need N95 masks at all times for health care professionals that are working with COVID-19 patients. Their lives are at risk and it’s just an absolute tragedy that we don’t have that as a mandate.

What a great discussion. I mean… The reality is: We face these types of decisions every single day. Not just during a pandemic. And definitely not just in health care. I wish that every single person in this world had the opportunity to go to university, but that’s not the case. I wish that we all had a personal trainer and a chef, so that we could make a difference in the rates of obesity. But we know those resources aren’t there. So every day we are making decisions based on limited resources. And I’m hoping that out of this pandemic we can start thinking about resources and which ones we never ever want to compromise on.

Another way the virus is probably spreading is through asymptomatic carriers. So people who have the virus, but who have no symptoms and have no idea. I mean, it could be me. I wouldn’t know. You can actually spread it asymptomatically. In fact, one of the things that have become very evident with COVID-19 is that you can spread it through conversation. You don’t need to cough on someone; you can just talk to someone. And that goes through your airways and gets out into the space. We also know that if you touch your nose and your mouth and if it’s there, now I touch stuff, that I’m getting it on objects. You know I’m not coughing; I’m actually getting it there with my hands. This is likely why many hospitals are moving towards universal masking, so everyone is wearing a surgical mask. In the hospital where I work, when you get there in the morning you’re given a little paper bag. And there are 2 surgical masks inside it that you can use for your shift. There are some cool studies that have been done about surgical masks and Coronavirus. They took patients who were sick with Coronavirus and they just had them sit there and breathe. They weren’t coughing, they weren’t talking. And it turned out that they were spreading droplets and aerosols around them. They took the same patients, put on a surgical mask and those patients did not spread the virus. But again, they weren’t coughing. Another study looked at patients wearing surgical masks, but they were coughing. And it turns out that the virus was escaping the mask and still getting into the air. So this is why it’s really important to still do physical distancing, even though people are wearing masks. Physical distancing. Okay, we know that it’s working. We’re seeing that the curve is flattening in many parts of the world. But it’s really hard to do in the hospital. I want to say like even in hospitals it’s hard to have social distancing. I don’t know if you have had the same experience. But you know, you’re at a nursing station and you’ve got to reach for things. It’s almost impossible. You try to wait your turn, but you’ll never get anything done. And people have to talk to each other, consult each other. It’s been a real challenge in the last couple of weeks, personally anyway.

So I wonder if that… Yeah, I totally agree. Distancing in the hospital is a joke. I mean… It’s not… It’s not real. It doesn’t happen. It can’t happen for a lot of practical reasons. I think what we need is better PPE (Personal Protective Equipment). So you can see there are a lot of issues at play here. Trying to balance new scientific research with real limitations to our resources. But the good news is that our strategies and all of our efforts are really working.

 

I’m hoping that this article will get us to start thinking about how to better protect our health care providers. We know there will be pandemics in the future, so will we be better prepared next time? I think we should start thinking about it now.”

 

Thank you for reading this article and special thanks to Dr. Mujeeb Ullah Makki for his detailed opinion on this highly important matter

Stay safe, continue to do your physical distancing.