Comment by armchairhacker | Hacker News Reader

Comment by armchairhacker | Hacker News Reader

I've never worked as a nurse or doctor but it's hard to imagine what they go through. Every day they deal with people in serious pain, people with traumatic injuries, rude people, rude people with traumatic injuries, screaming children and babies. Apparently nurses in particular are also routinely disrespected by higher-ups, put in danger by higher-ups, and don't get paid much.

In college I heard insane stories from the nursing majors. Apparently going on shifts working 72+ hours non-stop is the norm. Imagine spending 72 hours in that hell: delivering this guy's meds, then checking this guy's blood pressure while he berates you, then typing in some paperwork, then giving this baby lab work while he's screaming, then doing more paperwork, etc. for 72 hours straight. I can't imagine it, I can barely imagine spending more than 3 hours.

Anecdotally, the few times I've been to doctors' offices and hospitals, I always notice the stress on doctors. Doctors and nurses are rushing everywhere, and they try to act nice but are simultaneously drained of emotion from disrespectful patients and general fatigue. Ironically sometimes they don't look that healthy, with all due respect, probably because of the immense stress and that it's hard to fit in exercise when you work 12-hour overnight shifts.

Also, I live in Massachusetts where hospitals haven't been near capacity for some time now. Everything I described is just regular operation, pre-Covid.

I find it absurd that we allow medical staff to work 24 hour shifts. We don't let pilots do that. We don't let truckers do that.

There seems to be a strong hazing culture in the medical industry.

It's a complicated problem. Tired healthcare providers make more errors. But the majority of harmful errors happen in handing over patient care from one provider to another. Shorter shifts mean more care transitions. A patient in the ICU isn't like a truck that you can park and leave alone for 8 hours.

That's a really interesting point I'd never thought of before. Do you know of any discussions/articles on this topic? Would be interested to learn more, I always just assumed long doctor shifts was a combination of lack of workers and stinginess.

Also, unlike say a trucker, the work of doctors and nurses is very reactive to environmental conditions (feast or famine), so it allows for limited downtime where you might sneak in a nap between 20-60 minutes, or might be 100% your entire shift. It might make scheduling slightly easier is some regard, but it's actually a very expensive way to staff.

As a follow up question, I know I’ve read a lot about the handover issue in the general sense. Does anyone know of any research that has been done to see if the long shifts exacerbate the issue? It wouldn’t surprise me if handover would go more smoothly if the people weren’t at the end of such massive shifts, but it’s equally possible that intuition is wrong. What I don’t know is if there exist places where they tried shorter shifts in recent memory for us to even have the data on.

Yeah, what specifically is causing the issues with handover? Lack of information transfer seems like the obvious issue which being very exhausted could be responsible for.

This article has pretty good data on the patient safety impacts of doctor shift length.

https://www.nejm.org/doi/full/10.1056/NEJMoa1900669

Thank you very much!

That article doesn't support your assertion:

In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors.

The comment reminds me of an old joke:

A mechanic sits down next to a doctor at the bar. They get to talking. Before long, the mechanic says, "hey, you and I aren't so different. We both open things up and fix 'em. How come you get so much more credit than I do?"

The doctor says, "You get to turn the cars off before working on them."

This reminded me of an old quip. “The doctor can bury his mistakes, but an architect can only advise his clients to plant vines.”[0]

[0] https://quoteinvestigator.com/2011/05/03/architect-vines/

> But the majority of harmful errors happen in handing over patient care from one provider to another

I've heard this claim before, but this seems like a communication problem more than anything else. Keeping insane work schedules as a means to address it seems really suspect to me.

Communication is certainly part of the problem. But nothing comes for free. It takes time to properly update the patient chart and brief the relief shift. Plus there are things that can't really be communicated effectively. After monitoring a given patient for a while, an experienced provider will start to pick up subtle cues about their condition. How would you even communicate that?

Keep this in mind when dealing with the medical field: They won't learn from anyone.

The culture of medical education in the west places doctors in a bubble where 48 hours exhaustion marathons are glorified and considered a rite of passage. Other fields have found ways to do handovers with minimal to no impact on the continuity of operations.

Century old standard set by drug addicted doctor, continues to this day despite the evidence proving it foolish and dangerous.

Funny tradition that refuses to die.

I'm not sure what this comment is steeped in beyond a lack of reading on the topic.

He's referring to William Halstead, whose cocaine habit let him work long hours without sleep, and who was one of the instrumental figures in developing the modern medical residency system (with its brutally long hours):

https://en.wikipedia.org/wiki/William_Stewart_Halsted

Yeah, it took me slightly too long that he was a founder of but not John Hopkins, so it was hard to drop the wiki link, thanks.

Great show called “the Knick” where I learned about this.

I don’t think I’ve failed to read up on this topic, if you look at the link from the other user, you may be shocked…

Most mistakes happen on the hand-offs, known as "continuity of care", which is both shift-to-shift and phase of care back to health. Longer shifts help with the former at the cost of fatigue-based mistakes, so it is a balancing act, but not as simple as "shorter shifts". The challenge is unlike pilots and truckers the process points when you can naturally terminate a shift are far less defined and predictable. Ex: a pilot who's forced to divert and enter a holding pattern will extend his shift, regardless of the number of hours flown; every hospital shift in an ER is like this.

This may vary by region, but I believe that the original idea of the 24 hour shift is that a physician is present, but only working as necessary depending on patients. A slippery slope if the hospital is generally understaffed.

Anyway you slice this problem it just sounds like hospitals aren’t hiring enough employees. Sure maybe transitions produce errors but then I’d argue you had overlapping shifts where your prior carer was transitioned to a new one over a period of hours.

> Anyway you slice this problem it just sounds like hospitals aren’t hiring enough employees.

Over the decades hospital administration has grown (because health insurance is complex). Seems obvious that money would be better spent on people that provide healthcare to ease the pain of those currently providing it.

24?

Try being in EMS.

24... 36... 48. The private ambulance company I used to work for allowed you to work 60 hours straight, and then required an 8-12 hour break, if you wanted to work up to another 60.

> Apparently going on shifts working 72+ hours non-stop is the norm.

Absolutely not and it’s insane to even think that could be true.

Might be true some places but FWIW its not like that everywhere:

Around here the absolute maximum I've heard about is 12.5h and that includes at least two mandatory breaks.

It depends what one means by "shift".

For example my brother-in-law is a firefighter. He spends 3/4 days straight in the firehouse and then comes home for 3/4 days and works something like 12 hours straight when he is on call and gets rest periods when not actually doing firefighter work. This is possible because the firehouse basically has a small dorm in it. When I ask him when he is going to work he says he has a three day shift coming up. Because he doesn't come home, my sister definitely considers it "non-stop".

I can easily imagine health care workers being on-site for a few days at some sites, like a firefighter. Especially in areas where commutes could be prohibitive.

As a firefighter, even for firefighters that's beyond the norm. He's picking up extra shifts, there.

The typical maximum scheduled is 48 on, 96 off.

Around here (west coast) it's typically called a Detroit schedule (so not just west coast, I guess!)... 24 on, 48 off, but even more closely around here we use a Modified Detroit, which is a nine day rotation, where you work a 24 hour shift on days 1, 3 and 5 of the rotation, and have days 2, 4, 6-9 off.

On the Canadian west coast, my brother works as a firefighter. Their schedule is 4 days of work. 2 day shifts followed by 2 night shifts. Day shifts are shorter than night shifts.

I believe it’s 10 hours for the first two days (you’re off in your own home in the evening). The next two nights are 14 hours, and the fire fighters are in bed if there is no calls. I think day shift is 7 am to 5 pm, and night shift is 5 pm to 7 am.

It’s amazing what type of hours Americans are doing.

Thanks for the comment. That is interesting.

I'll be the first to admit I don't understand precisely what is going on or the challenges involved. Still, my understanding is that this scheduling is just for drivers. Overworking drivers is somewhat scary but necessary because their district has a severe shortage of them. It seems they're hard to hire because they need special certifications, training, and additional experience, and local firefighters have struggled to pass the necessary tests. Therefore, the city "asked" the existing drivers to do extra shifts while hiring new drivers.

At least that is what they said about two years ago...

Looking at the numbers a bit more closely. 48on 96off is 1:3 uptime per firefighter. 72on 72off is 1:2, increasing the uptime but also giving at least some amount continuous away time. Probably the odd 4 day shift is because of extract coverage days, like the fourth of July, or something. Or if a driver needs a vacation. Which is one nice thing they did. They did increase the amount of paid vacation the drivers get as a kind of compensation. Not enough to make up the difference of course, as that would defeat the whole point of the long shifts, but something.

"Apparently going on shifts working 72+ hours non-stop is the norm."

C'mon, that's 3 straight days, i.e. skipping 2 nights. How can that be 'the norm' anywhere? Extraordinary claims requires extraordinary evidence - or in this case, just any evidence.

Ok, it’s probably not the norm, but i’ve heard from multiple people saying they needed to stay awake for 80+ hours. Maybe because it was college and they were also taking classes?

I can reliably say that they’re still very overworked. 12+ hour shifts is the norm, and sometimes even 24 hours.

> i’ve heard from multiple people saying they needed to stay awake for 80+ hours

This vague allusion doesn't do much to convince me of the 72-hour claim. While we're doing anecdotes of extreme sleep deprivation, check out this personal account and AMA of someone who claims to have stayed up for 81 hours straight. What makes me doubt your "multiple people" is that after missing only two full nights of sleep (so ~48 hours), people start hearing and seeing hallucinations, and can't reliably hold conversation, much less deliver healthcare: https://old.reddit.com/r/AMA/comments/6sab7t/i_stayed_awake_...

yup. And in every scenario they have to show compassion and empathy even to screaming patients or people trying to argue with them. It's very draining.

Most girls I've been on dates with said it's very boring. It's not like ER. If anything they usually say that certain patients get really annoying. Blood, fecal, urine, etc done even bother them.

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