Worked To Death: Fatigue and the health professions, the dirty little secret.

Submitted by Charlton Stanley (aka Otteray Scribe), Guest Blogger

The dirtiest secret of all in the health care professions is not insurance. It is about tired staff.

Nurse Emblem Letha's MarkerOn March 16, 2013, Registered Nurse Elizabeth Jasper had just gotten off work. She was driving her small SUV eastbound on Ohio 50 when it left the road, going airborne, and hitting a tree. The wreckage careened into a parking lot. One does not need to be an accident reconstrucionist to know the crash was not survivable, by just taking one glance at the wreckage.

Beth Jasper, RN, is dead at the age of 38. She leaves her husband and two children. The preliminary investigation so far has revealed Nurse Jasper was supposed to work three 12-hour shifts that week, but had been held over to work extra doing specialized procedures. She is believed to have fallen asleep at the wheel.

Since that time, James Jasper, her widower, has filed a lawsuit against her employer, Jewish Hospital and its parent company, Mercy Health Partners of Southwest Ohio. As details of the lawsuit emerge, it shines a spotlight on a fact of corporate health care in this country which most people never knew.

While the pay for health care providers overall is quite good, the hours are not. I am not going to get into the details of the Jasper v. Jewish Hospital lawsuit. I have posted a link to the lawsuit which outlines the allegations by Beth Jasper’s family and they are there for all to read. Like all such lawsuits, it presents the allegations by the plaintiff, and as of this writing the hospital has not responded.

It is not just nurses, but many health care providers have the problem of unrealistically long hours, unstable work schedules, and being called in on days off. There are hospitals with adequate staffing, and the state of California has laws regulating health provider staffing in hospitals. Other states have not passed similar legislation, but the Nurse’s union, among other groups, has been pushing for such laws.

Think about this. When you or your loved ones are very sick, do you want to have the nurse giving you medications or starting an IV to be the one who has been held over an extra shift after finishing a twelve-hour shift? Recall Beth Jasper, who had completed a twelve hour shift, but was held over at work to perform specialized procedures. One wonders why this one particular nurse is the only one trained and available to operate the equipment, and why could it not have been handed off to a nurse on the next shift?

I have some personal knowledge of how bad it is. My wife was an RN, and Head Nurse (they are now called Nurse Managers) at a large hospital. They had three eight hour shifts. I lost track of how many times she had to fill in when they were short staffed. It was not at all unusual for her to work a double shift—sixteen hours—and then return to her regular shift the next day. And then there were emergencies, when the phone would ring at 3:00 AM. Sometimes she didn’t even have time to put on her uniform, but jump into whatever was handy and race off to the hospital to help deal with the emergency.  I remember a half-dozen bomb threats. There were severe weather and tornado warnings, when all patients had to be moved from their rooms into the central corridor to get them away from the windows. Sometimes a visitor in a patient’s room would light a cigarette and set off the smoke detector, which triggered automatic fire alarms and all hell would break loose. Did it affect her health? You bet. She never ran off the road as did Beth Jasper, but she did hit a huge pothole that almost tore the right front wheel off her car.

It did affect her health. She loved her work, but began developing shortness of breath. She had numerous tests, and the result showed that her heart was failing—a condition called idiopathic cardiomyopathy. At the rate her heart failure was progressing, she did not have long to live. Her cardiologist insisted she retire early and wanted to put her on the heart transplant list, but she refused. She was dedicated and loved her work, so resisted retirement until she could no longer respond to codes or do CPR. After she retired, a strange thing happened that baffled her cardiologists. Her heart function began to return. Damage had been done and it was never fully normal again; but nevertheless, her ejection fraction recovered enough that she could once again function in day to day living. Her job had been killing her.

My son is an emergency room physician and has been Medical Director of more than one Emergency Department. He describes staffing problems at hospitals both large and small.  Sometimes it literally comes to a choice of being short-staffed or shut the ER down altogether. No hospital administrator is willing to shut down the Emergency Department, so they stay open.  Sometimes an ER doctor works as many as eleven or twelve days straight, 12-hour shifts, get one or two days off, rinse and repeat. On top of that, alternating between night shift and day shift. Instead of being the exception in medical care, that is more common than anyone knows. He tells me that despite the fact the job pays well, it is really hard to recruit physicians.  I am not sure if the problem is too many hospitals or not enough doctors. Probably a combination of both.

A number of years ago, shortly after he got out of his residency, he went to sleep at the wheel and ran his SUV off the Interstate, plowing a path through a grove of trees. It is a good thing he was in his Suburban and the trees were fairly small instead of full grown pines.

There was one ER doctor who lived in one state and commuted about three hundred miles to another state. He was filling in to help out at a short-staffed Emergency Department in a small rural hospital. He used his own small twin engine airplane for the trips, which he made two or three times a week, landing at the small town airport near the hospital. One night, he forgot to put the landing gear down, and when he felt the prop strike pavement, he poured on the power. The prop strike had killed the engine on one side, and with full power on the other, it flipped inverted and crashed. Of course, he was killed. Since he was a high-time pilot with a lot of hours, if he had been thinking clearly, he would have chopped all the power, cut off the fuel and let the plane settle onto the runway. The only damage would have been some sheet metal work and new propellers. Fatigue kills.

Here is an email I got from an RN who works in the ICU. Read what she wrote to me when she learned I was working on this story:

People just don’t understand how short staffed we are! And the CEOs just keep adding more!  They wonder why some health care providers end up addicts and there are lawsuits!!!  ……working 16 hr shifts and having 10 patients ….I woke up in a ditch off the Interstate one day.  Luckily I walked away unharmed. Working 80 hr work weeks is common.

When she refers to “ten patients” keep in mind she is an ICU critical care nurse. The sickest of the sick. Like most other nurses and medical staff, she is concerned about the risk of medication errors by tired staff. It happens.

My wife had to call doctors frequently when taking orders off patient’s charts. Finding orders for wrong medications or wrong doses was almost a daily occurrence. I recall one night when she was working the graveyard shift. She called me in the wee hours of the morning, clearly shaken. One of the doctors had written an order for patient medication that would have been fatal had she not caught the mistake at the last moment before administering the medication. It was a math error in calculating dosage. When the doctor wrote that order, he had been at the hospital for more than 24 hours straight because there was no one to relieve him.

I recall a surgeon who seemed to never go home. No matter what time of day or night I went to the hospital, I would run into him. Wearing scrubs, going or coming from the surgical suite, or in his white lab coat, sitting at the nurse’s station writing in patient charts. He stayed fit and trim, and looked in perfect health. He died. Still a relatively young man. Heart failure.

One of the problems is nurses being called in for extra duty when they are already bone tired. One of my friends, a now-retired RN, wrote about that, and how she taught her nurses to deal with it:

I always worked 7 PM to 7 AM and often fell asleep in the car when I got home. Nurses like working “twelves”, as we call it, because of the extra days off. The obvious downside is that hospitals have a larger pool of nurses to call in for extra shifts. I worked with lots of Filipino and Indian nurses who didn’t know how to say “No” when they were asked to come in extra, so I held a class for them one night. “When you answer the phone and get the request, say ‘I’d love to help but I’ve been drinking.’” Teetotalers all, they got the giggles and said they couldn’t say such a thing. “Sure you can! Repeat after me: I’D LOVE TO HELP BUT I’VE BEEN DRINKING. Hospitals cannot ask you to come in once you utter those words.” I had them practice the words all night long, and many of them then managed to avoid extra unwanted shifts.

I notice in the comment sections of news articles about the lawsuit, some commenters suggested just leaving at the end of the shift. They don’t understand that a good nurse or doctor is not going to leave the hospital with patients unattended. Not going to happen, and hospital administrators know that. Not only know it, but count on it. Additionally, if a nurse, respiratory therapist, X-ray tech or anyone else is called at home and refuses to come in for extra shifts, they can—and likely will be–fired. That is why my nurse friend taught her nurses to say they had been drinking. That is about the only excuse that will fly with staffing managers. Claim you are sick, and they want proof.

I hope that Nurse Beth Jasper did not die in vain. Just maybe, her death will serve to shine a bright light on a serious problem in our health care delivery system. The World Health Organization studied numerous critical factors when they ranked every member country’s health care delivery system. We do not have the best health care system in the world. That distinction goes to France. The US ranked 38th, right behind Costa Rica. However, the US did rank #1 in one area. Cost per patient. France, with their world class health care delivery system, ranked #4 in cost per patient.

Before anyone who doesn’t like the UN starts complaining, I don’t think anyone would accuse Bloomberg of being biased against the US. Bloomberg’s organization conducted their own study of health care delivery systems in the 48 countries with more or less advanced economic systems. In other words, they eliminated so-called third world economies from the study. According to Bloomberg, Hong Kong, Singapore and Japan occupied the top three slots. The US ranked 46 on the list of 48 countries. Serbia and Brazil were 47 and 48, respectively.


What this story is really about, is sleep deprivation and fatigue. Some commenters in the news stories have taken a “blame the victim” attitude. There are comments to the effect that people ought to know better than to drive when there is danger of falling asleep, and that Beth Jasper was responsible for her own death. Aside from being cruel to the point of sociopathy, most of those types of comments ignore what we know about the science of sleep, as well as the manner in which people make decisions.

First of all, sleep deprivation is cumulative. Miss one or two hours of sleep a few days in a row, and you cannot make it up by one really good night of sleep. In fact, studies have shown it may take longer to recover from several days of sleep deprivation than the total amount of sleep lost in the first place.

For those who expect people to have insight into when they are driving sleepy, I have news. There is a phenomenon called microsleep. It means dozing off for a few seconds at a time, without even being aware of the sleep. Several news programs have done stories on microsleep. Reporters who were filmed dozing off for a few seconds at a time, some while driving, were both startled and frightened at how quickly and easily micorosleep happens. Most of all, how frequently. The video below is a story done by an ABC reporter for Nightline.

We already live in a society where most people do not get adequate sleep. Most people who read these words will have experienced at least one episode of microsleep in the past few days without being aware of it. Of all the physical and psychological effects of sleep deprivation, one of the most curious is the fact it causes lack of insight as to how sleepy one is. Sleep loss impairs judgment. People who don’t sleep much and describe themselves as “doing just fine,” are wrong. Sometimes dead wrong. When working at tasks where good judgment, sound decision making and attention to detail are required are far more likely to make mistakes.

The people most at risk for microsleep episodes while driving or trying to multitask are those who work rotating or swing shifts, who work long hours with little rest, and whose work schedule prevents them from getting enough sleep or even time to relax.

According to sleep researchers, there are numerous health risks associated with sleep deprivation. Some of the most serious are various types of heart disease, such as that which affected my wife. In one famous study, British sleep scientists studied the sleep patterns of more than 10,000 British civil servants over two decades. The results, published in 2007 as the “Whitehall II Study,” showed that civil service employees who reduced their sleep from seven to five hours or less per night nearly doubled their risk of death from all causes. In particular, lack of sleep doubled the risk of death from cardiovascular disease.

This list is just several of the commonly known adverse health effects of sleep deprivation:

  • Heart disease
  • Heart attack
  • Heart failure
  • Irregular heartbeat
  • High blood pressure
  • Stroke
  • Diabetes
  • Weight gain
  • Loss of sex drive
  • Lowered nighttime testosterone production in men, associated with sleep apnea.
  • Clinical depression, which if severe enough can trigger suicidal thoughts. Additionally, depression often causes insomnia, which then becomes a vicious cycle.
  • Aging skin, i.e,, skin thinning and wrinkling at an earlier age than normal. Deep, unbroken sleep is needed for the body to release hormones that preserve a more youthful skin texture.

Here is a PDF of the lawsuit filed by James Jasper, widower of Beth Jasper. It sets out the particulars of her circumstances at work.

Here is an observation and a question.  Modern scientific sleep research is one hundred years old this year. Professor Henri Pieron published “Le probleme physiologique du sommeil” in 1913.  Dr. Nathaniel Kleitman, regarded as the father of American sleep research, began his work in Chicago in 1920. Many hospitals have their own sleep labs and sleep research centers. Given that so much is known about the adverse health effects of sleep deprivation and chronic fatigue, hospitals are put in the position of “knew or should have known.”  Therefore, how can a health care agency such as a hospital claim they don’t know they are literally killing their employees—and possibly their patients?

The image at the top of this story is the engraving detail on my wife’s memorial stone at the cemetery. It is the Nurse’s Caduceus. It seems appropriate for this story, about nurses like Beth Jasper, who literally give their lives for the sake of their patients. My wife had a stroke several years ago, losing part of her vision as a result. She died in 2011. I can only wonder how much longer she might have lived had it not been for her lifelong dedication as a nurse in a broken health care delivery system.


77 thoughts on “Worked To Death: Fatigue and the health professions, the dirty little secret.”

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  3. pcm,
    I didn’t see anything in the spam filter. The spam filter has been emptied several times so far today. Whenever a comment is left over from the previous day, keep in mind that several hundred spams come in overnight. Whoever empties the spam filter in the morning always checks to see if there are any familiar usernames, but it is easy to overlook individual comments in all the clutter. Sorry ’bout that; suggest you try again.

  4. Help!

    2 comments from yesterday with link from NYT still stuck. I only need one released. Thanks.

  5. OS,

    Excellent post!

    I’ve always wondered why bus drivers and airline pilots had stricter guidelines for sleep than health care professionals.

  6. brerrabbit,
    The truckers I have come across seem to be under pressure to be on time, no matter what the risk might be. I wish that all drivers would take your advice and pull over when they are getting sleepy.

  7. Brerrabbit:

    Thank you for taking a nap. I wonder about driver exhaustion whenever I share the road with truck drivers. Driving can be so mind-numbing, especially at night.

  8. O S

    i know of several top tier nurses who have left working in hospitals because of the hours and low pay. hospital administrations seem to think the best way to cut costs is to reduce the number of nurses.

  9. One more comment I will make about trucking. Every trucking company I have worked for, give them credit, will tell you that if you start getting too tired or sleepy to drive, then pull over somewhere and stop and get back in the sleeper compartment and go to sleep, and it is your decision to make. I know they would much rather deal with a driver being late somewhere than deal with an accident.

    I had to do that one time, and I sent them a message and told them I was stopping because I was getting too tired to drive, and I was going to be late, and nobody ever said a word to me about it.

    But probably there are plenty of truck drivers out there with their own horror stories. I’d hate to think what some of these companies would do (or try to) if they did not have these hours-of-service rules about how long you can drive before having to take a break.

  10. MabelM,
    Thank you. I never really understood the comic strip “Dilbert” until I tried going to work for a mental health center. Talk about a contradiction in terms! That didn’t last long.

    Your experience and the experience of the ER Doc who commented upstream is exactly why the profit motive needs to be removed from health care. The money is there, but it is drained off for executive pay and bonuses, plus stockholder dividends. Even when a health care agency is “nonprofit,” that is a paper charade. The profits are there, but there are lots of ways accountants can shelter them.

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