Rest when you’re dead?

“Resting is fitness training”

–Jenson Button

The well-documented struggles trainees have suffered recently are compounded by training requirements and clinical workload. So how do the pressures of modern day training affect physical, psychological and social well-being? McClelland et al. looked to answer this question by conducting a national survey of trainees and assessing the impact of night shifts on fatigue. Over half of all trainee anaesthetists responded, with an even spread of training grades. After finishing a night shift, nearly half of the respondents needed to drive on the motorway to get home, and nearly a fifth travelled for more than 60 minutes. This is compounded by the fact that 84.2% of respondents claimed to be too tired to drive home after a night shift, and more than half having experienced either an accident or a near miss (including falling asleep at the wheel) on their post-nights homeward journey. Less than a third of trainees were aware of rest facilities following night shifts, and if they were available, they could cost up to £65 a shift. Night shifts commonly led to sleep disturbance and the use of substances such as caffeine to mitigate the adverse effects of their fatigue. Finally, the study authors found that personal relationships, physical health, psychological well-being, the ability to do the job and the ability to manage exam revision and projects were all negatively affected by fatigue in more than half of respondents. All in all, McClelland et al. have reported highly concerning adverse effects of the working patterns of anaesthesia trainees.

Michael Farquhar has followed this up with a telling editorial, questioning the ‘hero attitude’ that trainees have been encouraged to develop, and describing the measures his institution and specialty have taken to mitigate the worrying results reported by McClelland et al. These include breaks that are not voluntary, mandatory training in sleep hygiene, and changing culture to accept that self-care is not ‘an optional luxury.’ We should no longer believe that we as doctors can fool physiology, particularly at a time when morale is plummeting, and burnout is on the rise.

In a very different study, Suehana Rahman et al. present a much-needed review of the literature pertaining to patient medical alert identification (ID) tools, something that seems to have slipped under the regulation radar thus far. Medical ID tools can be in the form of jewellery, body art such as tattoos, personal devices, medical ID cards, or other forms such as key rings or bag tags (Fig. 1).

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Figure 1. (a) MedicAlert wristband and (b) bracelet worn over the traditional ‘pulsepoint’ location

They could present a range of material, including allergy status, information of medical conditions the ID carrier suffers from, pharmacotherapy, and contact details of next of kin. The authors conducted a systematic review of medical databases as well as a Google search, and found four reports of adverse events due to medical alert jewellery, and 32 online vendors of medical alert jewellery, with no evidence of any standards and minimal involvement of physicians. There was no evidence reported that medical IDs ‘work’ or are even safe. With little guidance available, the authors proposed four principles:

Medical IDs should be substantiated by messages conveyed by patients
In unconscious patients, healthcare workers should not conduct ‘disproportionate searches’ for medical IDs
If medical IDs are discovered in unconscious patients, staff should interpret the information rationally and proportionately
Conscious patients should convey all relevant information directly and not rely on the information in IDs alone

Could these proposals be the start of a new era of international standardisation of medical alert IDs?

Contrary to this scarcely-researched question, Stens et al. reported another interesting study, fuelling the ongoing debate regarding the value of intra-operative cardiac output monitoring on perioperative outcomes. They assessed the addition of pulse pressure variation and cardiac index to arterial blood pressure monitoring via the non-invasive ccNexfin device in patients undergoing general surgery. This multicentre, double-blinded trial randomised 244 patients to either be monitored with just continuous arterial pressure, or adding pulse pressure variation and cardiac index monitoring to standard arterial pressure monitoring and managing fluid therapy according to a specified algorithm. They found that there was no difference in 30-day complications, total fluid and blood products infused, fluid loss and blood loss, or return to mobility. Notably, fewer patients in the control group needed vasopressors. So, does this add further fuel to the fire against goal-directed therapy with cardiac output monitoring? Or does this simply suggest that the Nexfin device does not reliably contribute to improved patient outcomes? Only time will tell.

Another question of time relates to pre-operative fasting guidelines. We mandate a six-hour fast for solids and two hours for clear fluids, but what is really going on in the stomach in emergency patients after this duration of time? Dupont et al. performed gastric ultrasound assessment, determining the volume of the gastric antrum, in 263 patients who were starved for > 6 h and having emergency surgery (Fig. 2).

Figure 2. The distribution of gastric volume estimated for 263 participants before unplanned surgery, after at least six hours of fasting

They found that more than a third of patients had volumes consistent with unstarved stomachs, and the size of the antrum was associated with BMI and the pre-operative consumption of morphine. Moreover, one patient in their cohort suffered from pulmonary aspiration, yet this patient did not have a gastric antrum that suggested a full stomach. The data presented by Dupont et al. suggests that the duration of pre-operative starvation may not be related to gastric antral area, and thus volume, in emergency surgery – so what does this mean for aspiration risk without rapid sequence induction in all emergency surgery patients?

On the subject of food, there is plenty of food for thought from novel, thought-provoking and practice-changing papers published in the September edition of Anaesthesia. The dynamic research group working with the NIAA and The James Lind Alliance Priority Setting Partnership explored the difference in anaesthesia and critical care research priorities between clinicians, carers and patients. Despite all groups prioritising patient safety, they found a discrepancy between patients and clinicians – the former favouring patient experience while the latter favouring clinical effectiveness. A surprising result? Perhaps not. However, in another paper published this month, Berning et al. surveyed nearly 500 patients to compare the effect of quality of recovery from surgery on patient satisfaction and they found little correlation. So how is patient satisfaction, experience, quality of recovery and clinical effectiveness all linked, and what is most important? Expect a flurry of research trying to answer this question in the coming years!

Also in the September edition, Chen et al. reported an increased success rate of double-lumen endobronchial intubation using a novel wireless videostylet, the Disposascope® versus conventional intubation (Fig. 3), Shah et al. found that psoas muscle mass is associated with mortality following elective AAA repair, and Pillai et al. discovered that Luer and non-Luer spinal needles are equally as strong! All this and much more in one of the most diverse editions of Anaesthesia this year – eat, drink and sleep well!

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