To explore what fatigue is and how medical professionals working in flight differ from their aviation and hospital colleagues.
The fusion and learning between aviation and healthcare is apparent in air ambulance and commercial retrieval and repatriation, with healthcare learning from initiatives undertaken in aviation. There are many examples of aviation-to-healthcare translation: ground-breaking initiates such as simulation training (Gaba, 2004); checklists for pre-theatre assessment (WHO, 2009); and Just Culture (Eurocontrol, 2012), all of which has changed healthcare for the better regarding safety and quality standards. However, one area healthcare is slow to adopt from aviation is fatigue management, its guidelines and regulation of medical professionals (doctors and nurses) who are involved in retrieval and repatriation medicine.
There has been an attempt to regulate working time in UK healthcare through the introduction of the Working Time Regulations (1998), which implemented the European Working Time Directive into UK law. These reduced the maximum working hours to 48 hours a week, averaged over 17 weeks, which could arguably be a step closer to the flight time limitation scheme as seen in the airline industry. However, within healthcare, and especially within the sub speciality of retrieval and repatriation medicine, there is evidence that problems with inadequate rest and fatigue continue to persist (McClelland et al, 2017). Is fatigue management being ignored by the industry and medical professionals undertaking retrieval and repatriation to the detriment of patient safety?
What is fatigue?
The Faculty of Intensive Care Medicine (2017) describes fatigue as ‘extreme tiredness resulting from mental or physical exertion or illness’. Susceptibility to fatigue depends on many factors, including those directly related to the individual such as their workload, home life, colleagues, critical care unit, and hospital. Further factors such as age, changes in family life, and our own physician and mental health often fluctuate the effect of, and susceptibility to, fatigue. There are two types of fatigue, acute and chronic (The honourable company of air pilots, 2017).
Acute fatigue is short term and can be experienced during a sequence of duties that may be within prescriptive limits. It is rectified by allowing a suitable period of rest for the individual member concerned.
Chronic fatigue has long-term medical consequences, and can be brought on by irregular sleep patterns, circadian rhythm changes, eating at odd times, and a whole host of domestic and personal factors. As this disorganised time progresses, the normal pattern of life begins to break up and minor irrelevant things become very important to the affected person. Conversely, very important things become minor, so compliance with safety procedures, normal balanced speech and temper can change. Some of the behaviours and symptoms of an affected person can include aggression, ignoring warnings, feeling very depressed, crying and laughing inappropriately, and repeatedly falling asleep. This has a direct influence on crew resource management (CRM). There are a myriad of symptoms frequently misunderstood and misdiagnosed by those with limited knowledge. If left unchecked and undiagnosed, it can take many months, even years, to correct.
Acute or chronic fatigue can affect our actions, causing deleterious effects on patient outcomes. The 1999 report To Err is Human stated that 98,000 patients die annually from preventable medical errors (Kohn et al, 2000). Does fatigue play a part in this, or even exaggerate the risk? Fatigue can be insidious and develop over months or years. It is very important that we look after both ourselves, and our colleagues’ welfare. It’s easy to forget in the rush to get home that it may be safer to have some food and drink and have a rest before travelling and putting yourself, and others, at increased risk. Sleep-related vehicle accidents account for up to 20 per cent of all road traffic accidents and drowsy driving is as important a factor in accidents as drink driving. If the flight crew or medical professional commutes by car, they should be reminded that they may be driving after lengthy periods of time on duty at the end of the mission. In addition, they may be at further risk due to crossing several time zones and their circadian rhythm for alertness may be at a low point due to travel. Medical professionals are not legally counted as flight crew, and are therefore not subject to flight time limitation schemes, thus lack overall fatigue management regulations specific to their role in flight. This is an area of concern for the authors as it allows individual companies to potentially task medical professionals to lengthy retrieval and repatriations.
Does fatigue management differ between the aviation industry and healthcare?
Yes, the aviation industry recognised in the 1950s that aircrew fatigue may have been a contributory factor in some aircraft accidents (CAP 371, 2004). The Bader Report (Air Navigation Order 1974) was commissioned and the Flight Time Limitation Board convened, with the object of regulating the hours worked by aircraft crew. Restrictions placed on the number of hours worked, developed over the years, have gone a long way towards ensuring that crew are sufficiently rested prior to commencing a flying duty period.
In healthcare, following the traumatic death of an anaesthetic trainee who was returning home after a night shift, a study by McClelland et al (2017) in hospital fatigue demonstrated that fatigue is definitively prevalent among junior anaesthetists. This study found that fatigue has effects on physical health (73.6 per cent), psychological wellbeing (71.2 per cent), and personal relationships (67.9 per cent). Fifty-seven per cent (55 to 59.1) stated that they had experienced an accident or near-miss when travelling home from night shifts.
The medical repatriation and retrieval environment (IATA 2018) has additional risks such as:
• A hypobaric environment, hypoxia and decreased humidity.
• Turbulence, vibration and noise.
• Discomfort arising from cabin layout and sustained relative immobility.
• Irregular lifestyle; especially with regard to sleep cycle, local time change, irregular shift patterns, family and social life.
• Repeated changing of team, climate, culture, work and off-duty routines.
• Changing time zones, disruption to circadian rhythm and jet lag.
This is exacerbated by the fact that not all medical specialists are occupationally screened for retrieval and repatriation work (unless working within helicopter emergency medical services). Medical standards for professional and private pilots have long been clearly specified in international regulations (ICAO, Annex 1, Chapter 6); however, there is generally no equivalent for medical professionals on flights. Exceptions do exist; a certain number of countries require cabin crew to be licensed to private pilot standards, but this does not apply uniformly for medical professionals. The airline may determine the appropriate pre-employment health assessment required causing potential variation in standards.
Does fatigue management differ between air ambulance and commercial repatriation and retrieval?
The view of the Civil Aviation Authority (CAA) regarding air ambulance movements is that most companies view the medical professionals as ‘passengers’ and are thus not part of the flight crew. Hence, they do not have to train them in emergency safety procedures and fire and smoke drills. This is usually phrased in operations manuals as ‘the person responsible for patients in air ambulances’. This then removes them from a formal flight-time limitation as stated by The Air Navigation Order (2016). Conversely, this regulation does apply to the Commercial Air Transport aircraft operator. However, the following groups are currently exempt from these regulations:
• Air taxi operators of aeroplanes of 19 seats or less.
• Emergency Medical Services (EMS).
• Single-pilot operations.
• Helicopter operations.
The guidelines are clear for actual aviation crew. Should these be adopted by air ambulance operators and assistance companies? There could be flight-time limitations added, including all the hours the flight medical specialist works in conjunction with working time directives, for example:
Journey log, crossing time barriers and options
This journey log demonstrates flight routings for a medical repatriation from Australia (Perth) to London, and with aviation advances such as the Boeing Dreamliner more direct routes are now an option. This does not take into consideration the pre-hospital visit, the ambulance or taxi journey at the beginning or the end of the journey, handover to receiving care or the time taken to check in and collect luggage. This can add approximately six hours to any flight and is estimated in the working time. Consideration by the organising company needs to also include the journey from the person’s home to their end destination, which should also be included in total working time. These estimates do not account for potential flight delays that may be incurred on a long haul flight with a scheduled airline.
For a one-person medical specialist this is a considerable length of journey at best. It is also vital to consider the impact of travelling from London to Perth to pre-position prior to the transfer of the patient back to the UK. Some companies will add a second medical personal onto flights but this is not standard or consistent.
Additional areas to take into account in terms of fatigue risk:
• Rest time for the medical specialist prior to leaving the UK to travel to Perth.
• Impact of crossing time zones from East to West to pre-position in terms of jet lag, and resulting disruption to their circadian rhythm before the transfer even commences.
• Short period of rest (24 hours minimum) on the ground in Australia before travelling back with the patient.
In terms of jet lag, if you travel across six-time zones, it will typically take the body between three and five days to adjust. Jet lag causes tiredness, exhaustion, poor sleep quality and concentration and memory problems (NHS choices, 2017).
These factors, coupled with general fatigue from physically working extended hours medically supporting a patient, mean the medical specialist is at a much higher risk than their hospital and flight crew colleagues. Conversely, there are routing options that can be considered to reduce fatigue and this is demonstrated with anticipated working times.
In this journey log, it is clear to see that with different time zones, retrieval and repatriation operations are not always conducive to a regular sleep/wake schedule and can affect sleep and circadian factors in two ways, which can further lead to fatigue (IATA, 2018). The first is as a result of duty periods occurring at unusual or changing times in the day/night sleep cycle and the second when there is a requirement for time zone crossings. This leads to:
1. Conflict between the environmental time (in the case of unusual or changing work schedules) or local time (in the case of changing time zones) and body times.
2. Circadian disruption when the body is required to adjust continuously between day and night schedules.
In addition, a further factor that can create sleep loss is a prolonged period of continuous wakefulness. So, should companies look at two sector (or more) flights with a different medical specialist to take over in transit to breakdown the risk of fatigue irrespective of cost but to add value to patient safety?
The scope of the problem for fatigue management within the industry for medical professionals has not been addressed on a global scale. Some of this may be related to staffing availability, cost constraints for companies by using two professionals, and also a general lack of awareness of fatigue management. While some companies may have a robust policy on fatigue management, this is not a legal requirement to date. The length of time medical professionals should be expected to work should be similar to that within comparable clinical roles such as hospital length shift, with adequate break facilities and in an adequate location. It is also important that longer term factors are kept in mind; sleeping habits, social life, personal fitness, alcohol, caffeine, taking regular holidays and so forth. These are all very important to pay attention to in our attempts to prevent fatigue and this should be closely considered by companies and all medical professional hours in all roles should be recorded and monitored. Individual medical professionals should also be more aware of fatigue management, and also take ownership and accountability for its prevention in the planning and delivery of medical repatriations and to say ‘no’ to long retrievals or repatriations without safe rest. As Still (2014) stated, nurses who experience impairments due to fatigue, loss of sleep, and inability to recover between shifts are more likely than unimpaired nurses to report decision regret.
For future management, it is key to use resources such as ‘I’m safe’ – a checklist adapted for clinicians to assess fatigue and fitness to work. This covers key areas such as: illness, medication, stress, alcohol, fatigue and eating. Awareness should be raised and all individual medical practitioners and assistance dispatches should ask these questions before sending staff on a repatriation, and the individual should also be empowered to risk assess themselves before the return leg of the flight.
Regulators and industry should look upon fatigue management as a crucial area to regulate and to ensure they have transparent plans for their professionals while keeping a log of hours worked in all roles. The Royal College of Nursing will shortly release the date of its fatigue symposium looking at creating guidelines for nurses working within the aviation industry.
1. There is no specific aviation law covering medical professionals’ fatigue management nor flight time limitations. Companies should take action and monitor all flight staff’s hours, especially those working ad-hoc hours and freelance work to ensure compliance with working time regulations.
2. An industry-wide approach is required, viewing medical professionals in the same way as pilots and cabin crew, with change driven by medical professionals and regulators.
3. Assistance companies and medical professionals need an enhanced appreciation of fatigue management when planning a repatriation.
4. Medical professionals need to be empowered to say NO to retrievals or repatriations based on fatigue risk and the potential effects on patient safety. This can be achieved by heightened awareness of fatigue and its identification and management.
5. At home and before duty – get the best possible sleep before starting a trip. A nap can improve subsequent alertness and performance and will decrease the period of continuous wakefulness. If napping immediately before a duty period – limit the length of the nap to no more than 45 minutes. At other times, naps can be longer.
6. The repatriation does not end until you are in a place of rest (i.e. at home) and corporate liability needs to be undertaken to ensure this is considered and factored into logistical planning.
7. On a trip – try to get as much sleep in every 24 hours away as in a normal 24 period at home.
8. Trust your own physiology – if the crew member feels sleepy and circumstances permit, then they should sleep where possible, provided it is safe to do so.