How do shifts work on really long medical operations?

Submitted by TerjiD t3_zww6ac in askscience

First time asking here, hope I'm within the rules.

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I saw some picture of a doctor and nurses sitting on the floor in exhaustion after a 36 hour life-saving surgery (or so the post claimed).

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I then found myself wondering - how do the shifts work in such a procedure? Surely it wasn't the same staff for 36 hours, right? Is there an overlap where a second team takes over and is fully briefed over an hour or more, or what? If the scope of the operation is uncertain, how are the shifts designed?

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In my mind this is a scientific question about procedures in the field of medical science. I hope you agree and that someone can offer some valuable insight.

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swollennode t1_j1yl74s wrote

Everyone except for the surgeon gets rotated out.

Usually big long surgeries have 2 surgeons. One is the primary surgeon and the other is assisting. The assisting one may be another attending surgeon or a resident surgeon. Even big surgeries have a point where the patient is stable enough to temporarily pause so one of the surgeons can be relieved for a minute to get some food, use the restroom. So the patient is never without a surgeon, but surgeons don’t operate through a 36 hour case without a break.

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bananaforsteve t1_j1ymy49 wrote

But... what about sleep?

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Satire-V t1_j1ysg7z wrote

I don't know much about the reality of medical professionals, but from what I understand sleep seems to be one of those "do as I say, not as the structure of my employment has me do" for them.

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LonelyGnomes t1_j1zkse9 wrote

Especially in surgical specialties (and especially as a trainee) sleep deprivation is a constant. It’s kind of hazing

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sky_blu t1_j1zs6ka wrote

"if you see a transplant surgeon, give them a coffee and point them in the right direction"

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Acrobatic_Safety2930 t1_j2123vp wrote

You people seriously think that our bodies don't get used to caffeine?

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you get almost 0 effect from it at some point

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MagicTheDudeChef t1_j21h14m wrote

As an aside, I think there was a study on caffeine where they put people with varying levels of caffeine tolerance through a series of performance tests with and without caffeine, and it showed that even people who had built up a high tolerance and didn't consciously "feel" the effects of caffeine still experienced the same performance benefits of the caffeine. Sorry I don't have the details or the reference (so I can't speak to the robustness of the study), but it's out there somewhere.

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deldr3 t1_j2224hq wrote

and even if you feel less of the stimulant effect, it still messes with your adenosine neurotransmitters impacting your ability to sleep.

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WookieeSteakIsChewie t1_j1zqi0u wrote

Wonder how much the surgery death rate and success rate would change if they didn't do this.

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Cyclops_is_Right t1_j1zr1bt wrote

Unfortunately, we’ve learned that continuity of care is better for patient outcomes in practically all scenarios compared to physician rest. Handovers may occasionally result in loss of information leading to poor outcomes which is just the nature of switching hands.

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thegypsyqueen t1_j20dllp wrote

There is no true comparison study of these strategies and for every study looking and finding handoff errors there is another showing long shift lengths also increase errors. We very much do not know which one is “better” but physicians would argue that it’s not humane to accept a system that forces them to work 24, 36, or more hours in a row. We are already working an incredible amount of hours in a week. My point is, this is not a forgone conclusion and the biggest study looking at your argument of increased hours being superior for reduction of errors was a biased study conducted by a group of resident directors.

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LonelyGnomes t1_j21i7uh wrote

Pretty sure a study was recently published that physicians on average thought fewer handoffs were better for patient care, but would not want to be seen by a doc at the end of a 24 hour shift. So basically we’re hypocrites.

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TheRomanRuler t1_j20mkgd wrote

But why can't you do them in such a way that you got 2 surgeons working at the same time, each with 8 hour shifts but which start 4 hours apart. So you got 4 hours working at the same time, but after 4 hours one of them is changed. After another for hours one who has not yet changed is changed. Every time one who has been working longer is the primary surgeon at the moment, other assists.

That way you got 4 hours of time to get in touch with current state of the operation.

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Kael_Doreibo t1_j216kom wrote

Your biggest problem with this, particularly in the emergency departments, is the sudden onset of emergencies, their scale, and the time needed for certain surgeries/procedures. There are times when you, as a medical practitioner, need to be on for the entire period that it takes to resolve the onset of cases before you because any switch-over will result in loss of information and potentially death. With so many emergencies happening all the time in a larger population/operational radius of the hospital it become untenable to keep to that kind of schedule consistently and any inconsistencies results in a cascade effect across rosters/schedules.

It's good to at least attempt to keep to that kind of schedule and it makes sense to try it at least but ultimately it is impossible to just say "this is the solution" for every scenario.

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ninecat t1_j21qd73 wrote

There is already an international shortage in all of the medical professions. Emergencies don’t work to rosters and medical culture trains doctors and especially surgeons that they are super human and can carry on robotically despite fatigue.

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Boring_Vanilla4024 t1_j203ty7 wrote

Yep, and as much as residents love to complain about how much they work, there really is no other way to pack all of the training a physician needs in a few years. There is still a ton to learn and master as an attending.

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El-Diable t1_j207eo8 wrote

Then why not pack it in a few more years?

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Boring_Vanilla4024 t1_j208dob wrote

That would be one option. But physicians already aren't making real money and starting their lives until early to mid 30s as it is. I think most residents today wouldn't want that option though. They essentially want more money for less work hours/less training. They have high confidence and really don't understand what it is like to be out on your own, making most of the decisions on your own without being able to ask your attending what to do.

I personally was happy to get done in a shorter time even if that meant several years of 80-100hr work weeks.

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Purecasher t1_j20ib8n wrote

Do you really believe this, or have you gotten used to hearing and/or making up these excuses. If you looked at how other countries train their physicians, you would know this is not true. I mean, just by reading this, I know what country you work in, doesn't that mean something to you?

Residents are needed to keep continuity of care, and they are cheap and profitable. There's also no good reason they can't be paid more... You act as if wanting more money and less work/hours is in any way a bad thing. But clearly, because of people and a mindset like you, this is neigh unchangeable.

Just stop pretending it's a good thing that people are getting used like this.

More rest and free time add to better learning.

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Boring_Vanilla4024 t1_j20k581 wrote

Less work hours means less exposure to learning cases. End of story.

Also, residents certainly do a lot of work. But every decision they make needs to be supervised by an attending. A private practice attending often can do the work a team of residents does at a training facility. I really don't think they're grossly underpaid. Maybe somewhat, but it isn't like they're working in sweatshops. And, at the end of the day, they are being paid to be trained. It costs serious money to train a resident.

I'm all for more rest and free time if the number of years of training is increased to compensate the loss of experience.

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Purecasher t1_j20m8md wrote

That's the only reasonable alternative in your mind, which does not surprise me. Except, it is possible to train physicians without significant quality difference, with less exploitative working conditions in the same amount of time. AND there are fewer medical errors.

To me, it is truly laughable that you consider it a privilege that residents are paid to be trained when you calculate how much they bring in as revenue and quality of life for the graduated physicians. Admittedly, I don't know much about the numbers in your country, to that regard.

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Boring_Vanilla4024 t1_j20pn99 wrote

It can cost upwards of $180k per year to train a resident in the US. Stop with the BS about how much revenue they bring in... they don't, and they're a liability.

When I worked at an academic center my residents were often out the door on non-call days hours before I finished. And you spend a ton of time teaching, looking for and catching errors, and explaining to angry family members why what the PGY1 said on pre-rounds was incorrect. Residents don't bring more quality of life to attending, but quite the opposite. Academic attendings are rewarded by being paid less than their private practice colleagues.

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jbeansyboy t1_j21b0ez wrote

I tend to agree with most of what Vanilla says. I’m a relatively new private practice general surgeon and I’ll tell ya, I wish I had more time in residency, or at least more time for what I do.

I trained in the days of the “80 hr work week”. All the older folks say they are much better than us because they worked 120 hrs, etc. I think they may have graduated slightly better at overall surgery because they didn’t have to deal with as much administration as we do and most things were operative back then, AKA trauma solid organ injuries, AAAs, or intraabdominal abscesses are a few quick things that come to mind vs now we nonop most of those things.

Additionally I think they had the confidence to think they were good to go after residency because they had more autonomy back then. Most hospitals require attendings in the room now vs back in the older days, residents could operate alone. The ACGME leaves it up to the attendings to allow residents to operate alone but the hospitals have rules that supercede that if more conservative.

This all being said my 80hr work week was never such. Always in the high 90s and on transplant in the low 100s. But we log it as 80. Because we don’t want to get in trouble or losing credentialing.

I would be in favor of lengthening residency with the last year kind of a…. Pseudo attending year where you can operate alone with someone in the hospital in case you need it. You run your own clinic, take your own call, etc. and then having less hrs per week.

But I don’t think I would be in favor of tacking on more years for that. I’d like to get rid of some of the basic science in medical school. I spent a year relearning basically everything I learned in undergraduate courses. That I never use now. I’d just put those things as prerequisites to medical school.

I’d also like to see more direct pathways to specialities ~5 years if one chooses. I do private practice MIS/gen surg. I spent many many many hours and days helping with liver and pancreas transplants that I do not feel help me on a regular basis, or ever. Maybe see a few but not spent 20 weeks on the service. That time could have been seeing and doing more bread and butter surgical cases. Same with endovascular and etc. vascular and CTS are moving toward this.

For those that aren’t sure what they want to do they would have to finish formal residency and then do fellowship like we currently have.

For things like family medicine, emergency medicine, peds, and derm, it already seems very doable how it’s set up. They didn’t seem to work many hrs at all given how their speciality. Good for them!

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Raddish_ t1_j20noxq wrote

Uh is training a resident really that expensive? At what point are they just getting money back from not having to hire mid levels.

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Boring_Vanilla4024 t1_j20oy5g wrote

It can be upwards of $180k per year. This was in 2014.

The Costs of Training Internal Medicine Residents in the United ... https://www.amjmed.com/article/S0002-9343(14)00596-8/pdf

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passwordisnotaco t1_j20qiok wrote

Good thing that, in 2015, over 25% of hospitals received more than $180k in government funding for each resident they trained. https://www.fiercehealthcare.com/practices/study-suggests-medicare-overpaying-1-28b-annually-to-support-residency-programs

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Boring_Vanilla4024 t1_j20tbs6 wrote

Great. Pay them more, and be sure to pass along some to the attendings that have final say in all decisions and bear all the liability. Don't train them less.

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YoureGrammarWronger t1_j20tadx wrote

Yes withy he exception of breaks. With breaks, even with the handovers, there is an increase in positivity of outcomes.

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SleepyMonkey7 t1_j21qzpg wrote

I've often wondered about this. Are there any studies showing this? I've heard from a few doctors that's it's this way just because 'it's the way it's always been done.' Also wonder if there is truly nothing that can be done about information loss during a handover. We've become pretty good with information these days.

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B1u3baw12 t1_j1zr3cw wrote

Main issue I see if you have someone step in they need to know exactly what has happened and what's next. Problem is making sure all the info would be passed. Which is easier to happen that most people think

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Dorsai56 t1_j20y9b0 wrote

"Well, that's how I learned to do it, and I survived. These kids just need to learn to toughen up."

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[deleted] t1_j1zupnw wrote

[removed]

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wishingtoheal t1_j1zx4pg wrote

This reads like someone who isn’t familiar with how physicians are trained.
The number of residency slots is effectively stipulated by the Medicare budget. There are more and more medical school grads who go unmatched to postgraduate training because there simply aren’t enough spots.

The answer to our healthcare woes is not to relax medical school standards and physician licensing standards.

The increasing degree burden you’re speaking of has nothing to do with physicians. Non physician provider education has been increasingly bloated by degree inflation for the sake of monetary gain on the part of the educational system. An NP, for example, used to require many years of bedside nursing followed by a masters degree. Now, you have for profit universities churning out new grad nurses who have gone straight from undergrad into all online “doctoral” NP program that allows them to practice unsupervised in some states, while having fewer than 500 clinical hours.

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jfichte t1_j20erri wrote

Exactly, medicare funding needs to increase and be updated accordingly to allow for more residents, which would on turn increase the number of medical students, and ultimately, trained doctors.

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wishingtoheal t1_j20h6zj wrote

Perhaps in the long term, but not necessarily in the short term. The process of medical school accreditation is separate from the number of residency slots, increasing program sizes, or creating new residency programs.

There are still MDs who go unmatched into programs and the job market for general practice without being board certified is very limited. I think it’s pretty illogical that in many states midlevels (usually NPs) can gain fully independent practice (FPA) shortly after graduating while physicians cannot (licenses require 1-2 yrs of residency training before you qualify for licensure).
A lot of this comes down to lobbying, unfortunately.

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JewishSpaceTrooper t1_j218mko wrote

ABSOLUTELY 💯 agree!!! The for-profit institutions, specifically the Nurse Practitioner schools, that, for the sake of aforementioned profit, have dropped pre-requisite skills and experience, to virtually the bare minimum. And, let’s not mention the ONLINE education slide (of abomination) from BSN to NP…how the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN) signed off on this is beyond me. Soon enough, the poor people in this country, will only see a physician very rarely….while NPs already handle cases far too complicated for their expertise. What a time to be alive

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HogSliceFurBottom t1_j20lzid wrote

Similar to the treatment of Ignaz Semmelweis when he discovered washing hands saved lives, today's medical world ignores the facts that sleep deprivation causes mistakes which results in patient deaths.

The profession prides itself on working long hours even though evidence shows sleep deprivation is equal to or worse than being drunk. Pilots, truck drivers, air traffic controllers all work under regulated hours, but the medical world's hubris blinds them into believing they are impervious and the exception.

Medical error is estimated to be the 3rd leading cause of death in the US leading to 250,000 deaths each year. It's unconscionable that the profession does not take proactive steps to minimize these errors by starting with the elimination of sleep deprivation.

The model of working longs hours in residency was promoted by Dr. William Halstead, a cocaine addict, who expected his residents to be on-call 362 days a year and handle a workload that was difficult to maintain without artificial stimulants. It's a deadly rite of passage that continues today.

I haven't even mentioned the effects on residents and doctors themselves. Many residents and doctors commit suicide because of sleep deprivation or in the very least, develop mental illness. And guess what? Seeking mental help in the medical world is frowned upon; especially for students. Mental illness among the ranks is a mark of disgrace. The medical profession disregarding the Hippocratic Oath for their own is one of the worst ironic hypocrisies in the modern world.

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fastspinecho t1_j213rno wrote

> Medical error is estimated to be the 3rd leading cause of death in the US leading to 250,000 deaths each year.

This is a highly controversial article. Among other things, it considers any intervention that leads to patient death an "error".

In other words, suppose you have an advanced brain tumor. Without treatment, you will die in 6 months. Your surgeon offers an operation that can cure you, but has a 10% mortality risk. You accept the risk.

According to that paper, if you die on the operating table then your death will be counted among the 250000 "deaths by medical error". To avoid errors, surgeons should not operate at all on high risk patients.

I don't think most people would equate known risk with medical error. And that's the only way the authors end up with such a high figure.

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shapesize t1_j20r2bk wrote

All of that is true, except they’re not enough of us. Most sub-subspecialists are the only ones at a given institution. The decades of training and dedication is not something that everyone can (or wants) to do. Laws aren’t really helpful here, as obviously you’re not going to let a patient suffer just because there is no one else to handoff too. Of course, that means in the end the physician and their family suffer, but unfortunately that comes with the territory. Mostly people need to understand and have respect and patience for their doctors.

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YoureGrammarWronger t1_j20tv70 wrote

At one of the hospitals I cover, we’re down to one urologist who takes all the calls. Because the other two left and there aren’t any others to help.

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Wireeeee t1_j1yw1qa wrote

This, I don't understand. Surely, anything above even 15+ hours of concentration is counterintuitive, right? Like, what about the loss of focus, accuracy, and drowsiness? Maybe 24 hours is doable since they've had a lot of practice, but 36 hours is insane.

Like, I start going delirious and dissociating from reality at 30 hours mark (without any stimulant drugs), can't imagine a surgeon not tripping balls from the sleeplessness haha.

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przyssawka t1_j1z1sdu wrote

Head and neck surgeon here. 24h shifts are the norm, it’s something you just get used to. It sucks but that’s the reality of it. 36 hours of nonstop work does happen, especially in residency. It’s definitely taxing and impacts your productivity especially during low stake work like charting. I had instances of my prechart notes being absolute gibberish due to sleep deprivation. But when it comes to procedures your body runs on adrenaline, tired or not it feels like a reset button was pressed, even during longer procedures like laryngectomies. Getting distracted doesn’t really happen unless you are a med student holding the retractor then all you have left is praying for mercy and sweet release

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Wireeeee t1_j1z2ub0 wrote

ah, that's amazing, some superheroic stuff. Crazy what the human body and brain can achieve with practice beyond limits. Do you have sugar/caffeine too intermittently during these work hours or is it just adrenaline/chronic stress

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przyssawka t1_j1z3ra4 wrote

We eat and drink coffee during shifts, nothing different compared to an office job. Part of resilience is definitely adaptation though, residency is exploitative. My speciality doesn’t have those 20-ish hour procedures (at least none that would be all-HNS team) so no surgeon rotation, if it’s 4-5h in the OT you’re stuck there for 4-5h. Then again, hunger or sore legs is the last thing you’re concerned with assuming you’re actively participating, even more so if you’re the primary surgeon.

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skisushi t1_j1z6n2a wrote

Head and neck surgeons do orchestrate some of the most complex and difficult surgeries though. You may have several teams doing different parts of a surgery and take turns. I have seen as many as 4 or 5 teams work together. Neurosurgery, ophthalmology, plastics, OMFS and ENT/ HNS all can participate on some large tumor resections and reconstructions. When actively involved you can get so focused that food, pee breaks, etc don't cross your mind for 8 to 12 hours. Then you finish and it all catches up to you.

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przyssawka t1_j1z731i wrote

Yes but as you mentioned for stuff like anterior or lateral approach skull base surgery or large tumor dissections we do take turns. it’s usually a combined effort by neuro, maxfac and ENT. Compare it to stuff like transplantology where one team usually handles the entirety of the procedure.

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DukeSuperior_Truth t1_j21d1m5 wrote

Exactly. Just because people can’t imagine doing something extraordinary, doesn’t mean it’s crazy or dangerous. People do ultramarathons that run 36 hours with no sleep as well. Adaptation is the operative word here.

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Parappappappa t1_j21pubh wrote

Running a marathon is not a daily occurence though. Pulling an all nighter once in a while is very different than constant sleep deprivation. Also if someone chooses to run an ultramarathon but they lose focus the only person whose wellbeing is at risk is themselves - however if a doctor (or other staff) loses focus and make a mistake it impacts the patient as well.

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DukeSuperior_Truth t1_j23ls9o wrote

Good points! I really just mean the analogy to be about how people can do extraordinary things when they are trained over time to do them. Surgery very difficult to get into, training excruciating and those factors help weed out most. The few left in the subspecialty surgery groups really love it, really deserve to do what they do and are of a different breed. Even among doctors, who are all pretty good at working hard and focusing.

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Larrygiggles t1_j20aw82 wrote

Does stuff like polyphasic sleep ever come up as a possibility?

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przyssawka t1_j20bd9t wrote

Polyphasic as a necessity more like. Jokes aside not really, the work is structured in a way that wouldn’t allow for the polyphasic sleep cycle outside of on-calls (and even then ER can wake you up at any moment). Not to mention I have yet to see research that proves that it’s a valid and sustainable alternative to regular cycle.

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drerw t1_j211f4m wrote

That’s why you’re not a surgeon, right? I’m imagining this whole thread being about Navy Seals. They’re just different. It makes sense that someone who started an operation finishes it. It’s like learning an entire machine no one has ever seen, working on it, and then handing it off halfway through to someone else who has never seen it. Except the machine dies if you take to long to figure it out again.

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Iced____0ut t1_j214ix9 wrote

30 hours without sleep should not have you going delirious and disassociating.

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Wireeeee t1_j21kulk wrote

Thank you for knowing more than me about how I’ve felt when I’ve got 30 hours without sleep

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Iced____0ut t1_j21tcqz wrote

Just have to make yourself a victim? I said you should not, as in that isn’t a typical symptom of 30 hours awake.

You might want to look into your health if you are having that response to 30 hours awake.

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Modernfallout20 t1_j1zm6jx wrote

They don't do that. Maybe catch a 15-30min nap at most but surgeons and surgical techs/nurses can work 24-36hrs consecutively without sleeping. They shouldn't, but they can and do.

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DickButtDO t1_j21twpa wrote

Are nurses and techs doing 24 hour shifts? I've never seen that...

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Modernfallout20 t1_j221zx8 wrote

The only hospital I ever worked at certainly did, but it was out of necessity due to staffing issues.

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MurkDiesel t1_j206ztf wrote

that's what malpractice insurance is for

and it's not like malpractice lawsuits are easy or successful

so why would they sleep?

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ryanveilleux1 t1_j1y5ifb wrote

The nurses and scrubs rotate out for lunch and breaks and shift change; CRNAs too. The surgeons usually will stay in the whole time, no food, no drinks, no breaks. But it’s usually rare to have a case last that long, but I’ve seen poly trauma run longer than 12 hours and some big OMFS cases run long too.

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Sylvurphlame t1_j1z93ti wrote

The poor dude running the fluoroscopy might have to stay there the whole time. Source: I’m that dude. My personal record is about 9 hours, although I took a couple quick pee breaks. (Busy day so no longer term relief available.)

I’ve also seen a few cases where a partner comes in to relive the attending on particularly long spine cases. I’ve seen a couple 10-12 hour cases. I don’t have personal experience with those legendary 16-24+ hour traumas though.

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Red_Icnivad t1_j1y6qnr wrote

No drinks? Does the surgeon not even get a chance to have someone hold a juice box to their face? Or is that more likely to make them have to unite, which would take them away for longer.

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Mr_Zaroc t1_j1yepy3 wrote

Uniting urinating is an interesting topic, I can't imagine they can't do without for hours on end, but then again the whole suiting up etc. is time consuming
Would also like to know how they work around it

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Fedekz3215 t1_j1yx6xl wrote

You pee shortly before going to the OR so you're usually good for a few hours. There's a "first assist" which is usually a resident or PA scrubbed in helping. In long procedures there can be tedious dissecting so the attending can break scrub and go urinate or eat a quick snack while the resident keeps working. Only takes a minute or less to scrub in these days (Avagard replaced the old 4 minute scrubbing, and the scrub tech will have your gown and gloves ready for you) so that's not a barrier at all.

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kazin29 t1_j1yjxgo wrote

They don't excrete. It's not uncommon for surgeons to develop kidney and back issues from operating.

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Bosno t1_j1z2m19 wrote

Surgeons take short breaks too. During non critical points in the surgery, the surgeon might step out while the resident continues.

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gu_doc t1_j1zgp88 wrote

Or just straight up take a break and there’s a pause in surgery. The surgeon needs nourishment and a mental break to do their best surgery and make good decisions. I have seen (and participated in) breaks of 10-15 minutes to go to the bathroom, eat, and let your brain rest a little while the patient is on the table with nobody working

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thedavecan t1_j1zvvfe wrote

I'm a CRNA in a mid sized regional medical center. We only trade out up to a certain point. After 8pm if I'm on call I'm the only anesthesia provider in the OR (we have one dedicated to OB but it has to be an all hands on deck emergency to ask them to come down) and so there's no bathroom breaks after that time. Surgeons, scrubs, and circulators can all scrub out and go pee but anesthesia can't leave the patient unattended, ever. Every facility is different and it's super rare for us to do cases longer than 8-9 hrs here but the potential is always there when you work in the OR.

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Mert_Burphy t1_j20d4v0 wrote

Just curious what happens if you get a case of the need to shits suddenly. I get why you can't leave an anethetized patient alone even for 30 seconds but still..

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thedavecan t1_j20muzq wrote

Hold it. I wish there were any other solution. Desperately hope the OB person isn't busy and can come down and break you for 5 min but they're usually busy. Your bowel habits adjust honestly.

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ryanveilleux1 t1_j214stq wrote

Much respect! I worked at a level 1, all run by CRNAs, the best group of providers I’ve ever seen.

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HobgoblinKhanate t1_j1yqfat wrote

What’s a scrub?

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Idgie-Threadgoode t1_j20lrez wrote

A scrub is a guy who can’t get no love from me, hangin out the passenger side of his best friend’s ride tryin’ to holla at me.

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Sylvurphlame t1_j1zrhoe wrote

You can have nurses scrub in and assist directly with the surgery as the other redditor said.

Also some hospitals will employ surgical technologist “scrub techs” who help the surgeons manage instrumentation and sterile equipment but these techs will not be nurses themselves. The nurses in these cases will just be circulators who document and grab extra supplies and generally keep the room running smoothly.

At my hospital we have several nurses who were originally surg techs and have kept up their credentials. They’ll sub in when needed but we typically have separate scrub techs and circulator nurses.

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Equal-Dinner t1_j1ylblq wrote

Daughter of a spine surgeon here: They DO eat and drink, just not a meal. Nurses give them "bite size snacks", like a piece of chocolate, or some water/juice with a straw. The surgeon does not touch the food, the nurse gives it to them, and this keeps them going till the end of the surgery. However if they know they have a long surgery ahead they will eat and drink well before going to the surgery room. They also DO go to the toilet if they really need to. Even though surgeries do have critical moments in which everybody must be concentrating at 110%, there are also moments that are a bit less "critical", and these are the moments where they can go for a quick pee or take the snack from the nurse (bare in mind there are usually more than 1 surgeon so the other one can keep things stable and safe). They try to hold if they can, and rarely go number 2, but if they have an emergency diarrhoea they must go, simply because it would not be safe for the patient if the surgeon is performing a delicate operation while having massive cramps :/ in those cases is best to just quickly go to the toilet and come back.

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Sylvurphlame t1_j1zbc82 wrote

They give them food in the OR itself? As opposed to having a first assist take over while they step out for that quick snack or pee break?

I cannot imagine infection control being cool with that.

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Equal-Dinner t1_j1zdv3k wrote

they do, but is not like they would eat cookies which would crumble, but yes. The OR is clean but not completely sterile, what's sterile is the tools, instruments, operating bed and some other things that go in direct contact with the patient. So like a bonbon is not that weird. Plus, they don't feed them while being directly over the patient.

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fastbullets t1_j20h33c wrote

Absolutely. Much greater risk of contamination by having a surgeon scrub out and back in, open doors, etc.

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armadylsr t1_j1ziw1b wrote

Multi-level surgeries are a thing. What they are is you have a 15 step 30 hour surgery you need to do. You do steps 1-8 for x hours sew up or cover up, rest for several hours for both the surgeon and the patient, then complete steps 9-15 at a later date.

10-15 hour surgeries are relatively common but 36 hour surgeries are nearly never done all at once unless the patient will die very soon without the surgery and they cannot afford a few hours of rest. Most likely in that situation they would have an extremely high likelihood of death during the surgery so most times these surgeries would never be done and family wishes talks come into play.

Usually traumas get the special service of repeated surgeries with long total operative time with ALSO an extremely high risk of death within the next few hours that would prevent taking breaks. But even then patients can be stabilized long enough to take breaks, breaks for the patient are usually more important than breaks for the surgeon.

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aedes t1_j1zanp5 wrote

To add to what others have said, and to make this more generalizable outside of just medicine...

Swapping out people who have been working a long time for fresh people is limited by two factors:

  1. The availability of fresh people. There are often alternate nurses available for a very long case. In some situations there may simply not be another surgeon available. This is part of the responsibility that comes from being in positions of leadership, or having a very specialized knowledge base and skill set. In times of “crises,” you may be working absurdly long hours for a very long time.

  2. Transitioning to a fresh team is associated with its own risks. The fresh team will be less familiar with what’s going on, and miscommunications about the situation may occur during the transition. A critical event that happens during the transition may also be disastrous due to unclear individual responsibilities and communication flow.

There have been scientific studies on patient outcomes with physicians working either very long shifts, or shorter shifts but with more “signovers” of care happening. There was no improvement in patient outcomes with shorter working hours, presumably because of the risks that occur due to care transitions.

Balancing the above points is something that must be done in many situations, not just medicine.

How does the military decide when to switch out troops in a war zone?

How should government deal with decision making during a prolonged and intense period of time?

Etc.

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YoureSpecial t1_j1znzcc wrote

IIRC the Navy did a couple studies after a rash of collisions and other ship casualties. The net result was to shorten the shifts in certain critical command/control positions - Officer of the Deck, Navigator, helmsman, Weapons Officer, etc.

The critical factors in all the casualties they investigated was that decision-making abilities and accuracy declined dramatically after a fairly low number of hours where these people were dealing with a state of constant information overload.

The shortened shifts flew in direct opposition to the prevailing “man up and deal with it” culture prevalent for so long. In the end, safety won out.

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PerspectivePure2169 t1_j22k3ar wrote

They haven't followed their own advice very well, because they still seem to be colliding and near missing ships pretty regularly.

Just had two in San Diego bay a short time ago.

I agree the watchstanding needs an overhaul or at least get it back to it was in eras our ships didn't burn down pierside or collide with freighters regularly.

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Tidorith t1_j25vo9s wrote

>IIRC the Navy did a couple studies after a rash of collisions and other ship casualties. The net result was to shorten the shifts in certain critical command/control positions - Officer of the Deck, Navigator, helmsman, Weapons Officer, etc.

Perhaps the takeaway really is that we need to invest significant resources into developing better procedures for hand offs that mitigate the negative consequences of them. Then we can shift the equilibrium closer to optimising for the first order effects of shift length itself.

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Fellainis_Elbows t1_j1zfigf wrote

You mean no benefit to longer hours. That’s how the study should be interpreted

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AnonymousWritings t1_j207vix wrote

No benefit to longer hours, except that shorter hours makes for a profession that is kinder to the people working in It and easier to convince people to join it. Good when we have healthcare worker shortages....

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aedes t1_j1zr8nj wrote

You might think I was referring to some of the NEJM papers that came out around 2018 comparing standard to “flexible” scheduling?

I was more talking about the older papers that came out in the first decade of the 2000s when duty hour restrictions first came into place... which compared old-school scheduling to duty-hour restrictions and found no difference in patient outcomes (or occasionally worse patient outcomes with restrictions in some of the surgical literature).

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coilycat t1_j1zphnl wrote

Could you explain the difference? Are you familiar with the studies being referenced? I am familiar with how the null hypothesis works, if that helps.

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zebediah49 t1_j1zrhqg wrote

They're saying that if the two are statistically indistinguishable, "there's no benefit to forcing staff to work long hours" is a 'better' way of phrasing it compared to "there's no benefit to not forcing staff to work long hours". The first implies that being good to your workers should be the default choice; the second the opposite.

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Sammystorm1 t1_j1zzy0g wrote

Handoffs is one of the highest areas for mistakes to happen. Medical professionals are taught to avoid them if possible

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Saxdude2016 t1_j1y5kma wrote

Traditionally the scrub techs and nurses are employed by the hospital, and as such are required to have 2 15 breaks and 1 lunch. They have a float person cover for breaks. Nurses give a brief rundown of what stage they are at and any pertinent medical history or charting stuff. Same for the scrub techs who cover breaks.

The doctors are independent contractors and usually work all the way through a long case. Longest was maybe 8 or 12 hours that I’ve seen. If they do need coverage usually their medical group has someone who they can contact to hand it off. Usually not though 99.999% if times

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Great_Creator_ t1_j1z9sie wrote

Doctors aren’t employed by the hospital they work at?

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AshenRex t1_j1zgfny wrote

Depends. Some are employed by the hospital, some are under contract with the hospital. Usually specialists and surgeons are under contract due to the high skill level and broad need, they will often have their own practice and contract with different hospitals or medical agencies. At least here in the US, this is why your billing following a procedure will come from the hospital and the different practitioners.

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BagelAmpersandLox t1_j211ay7 wrote

Typically surgeons, proceduralists, and anesthesia are outside contractors. This varies and some or all can be hospital employees, especially when the hospital is an academic medical center.

This is how a surgeon can have what’s called “privileges” at multiple facilities.

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Individual_Divide333 t1_j1zfn2f wrote

Nope! Doctors are independent contractors. They also have a right called Refusal to Treat, that nurses don’t have the privileges of either.

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RsquaredxHD t1_j1zqtux wrote

I work in surgery as an x-ray tech. Vascular surgery and cardiac to be exact. There are a total of 8-12 people involved in our cases. X-ray, crna, attending, residents, fellows, research team, reps of the devices, circulating nurse, scrub tech, additional scrub/nurse. The anesthesia team gets breaks since they monitor the patients status non stop. The physicians do not get breaks if alone but some work as a two doc system. They don't leave the resident alone with the fellows. It's a teaching hospital. I work in 4-6 hour surgical cases daily in a level 3 trauma center. We have 46 OR rooms crazy right?

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BentleyMcBatman t1_j204rpp wrote

So typically surgeries don’t last that long anymore. Having said that, extremely complex surgeries or multi patient surgeries (organ retrieval and transplants) can be very long. Typically the surgeons will plan ahead and have a colleague who scrubs in for a portion of the surgery so they can rest, eat, take a nap etc.
The same occurs for the Anesthesiologists, although it’s more likely they would switch every 12-16 hours as even the most complex operations can be handed over without the risk of major errors.

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astrofuzzics t1_j20i8z4 wrote

I work at an academic hospital with a cardiothoracic surgery training program.

Depending on the case, the attending does not always need to be present the entire time. A routine aortic valve replacement, for example, has multiple steps, some of which are more critical than others. Once anesthesia has the patient asleep, a senior CTS resident or fellow should be perfectly capable of cutting through the sternum with a bone saw and incising through the pericardium to expose the heart and great vessels. Once the attending surgeon arrives, the resident will place+connect the cannulas for cardiopulmonary bypass, and the perfusionist will deliver cardioplegia (to arrest the heart) and begin the pump run. The surgeon then joins the case hands-on for the team to perform the critical incisions on the heart and aorta. For more complex operations, sometimes the attending will call for another attending to join the case (for example one surgeon may be comfortable with the aortic valve, but may call a colleague to help if the patient needs a mitral repair or a septal myectomy). Once the aortic valve prosthesis is in place and the heart is stitched up, the team will return the blood from the cardiopulmonary bypass circuit reservoir, restart the heart, and ensure the heart has restarted in stable condition - the anesthesiologist will look with a transesophageal echo probe to see if there are any problems. If everything looks okay, the attending will leave and the resident (maybe a different resident if the first one had to leave) will wrap up, close the pericardium, close the chest, and suture up the incisions.

So the case is done in continuity, but the attending surgeon only really needs to be there for the critical part of the case. What’s “critical” vs. what’s not depends on the case, of course, and if there is significant troubleshooting because something goes wrong then that obviously requires a longer time.

TL;DR people rotate in and out of the operation to execute their particular roles when they are indicated. Not sure how it works in other specialties but I bet it’s something similar.

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lubib123 t1_j2052ku wrote

I'm on call for 72 hours every 6th weekend, so technically, if there is an emergency case that goes for 24 hours, I'm supposed to stay. But usually for situations like that, my coworkers will voluntarily take over for a few hours so I can have a break even though they're not on call. For safety reasons of course, I speak up if I get exhausted and usually we can figure something out.

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enricobasilica t1_j1z5kfv wrote

Watched a couple of BBC documentaries on specialty surgeries. Depending on the kind of surgery and if you are lucky enough to have 2 specialists in the same hospital, you miiiight be able to do a handover partway through. In cases where its not possible, you would try and limit the amount of time the specialist is actually working (eg where they let someone else do the "easy" bits and only have the specialist work where needed). But otherwise it seems 12-18 hour operations arent uncommon. Not sure if this is varies by country, but at least the episodes I saw, if it was going to be crazy long they might try and see if its possible to do the surgery in 2 phases to break it up so the surgeon can have a break in between. But thats not always possible obviously.

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JewishSpaceTrooper t1_j215fpa wrote

1.) TRIAGE: complicated emergency cases, that may need long-haul surgical intervention, get triaged to the best equipped hospital (often a teaching facility) with lots of highly experienced staff. 2.) these large institutions, each State usually has several large medical teaching hospitals, don’t just employ General Surgeons. These lovely places will provide several sub-specialty doctors depending the need and often include vascular surgeons, orthopedic surgeons (often with a sub-sub specialty in pelvic or shoulder injuries), plastic surgeons, neurosurgeons and the list goes on and on. I’ve literally seen long-haul surgeries that necessitated 5 different surgeons to go in, with two scrubbing in, and one finishing up his/her part. 3.)Surgical techs/nurses usually work on strict 12 hour rotations, especially if they’re unionized. So these guys/gals are never really ever in need to work to sheer exhaustion. Well, at least time wise….I’ve seen some nurses/techs literally be stomped into the ground by dipshit surgeons, but that’s another story.

So, in today’s environment, the overworked-heroic surgical staff trope, isn’t a thing any more. You have to be in extremely remote places where even helicopters can’t triage an unfortunate soul. Lord have mercy in most places if Dr. “Neurosurgeon” is going to miss his soirée or golf game due to an unforeseen complication….Anyways, all of the above are good things! You DO NOT want anyone performing surgery for longer than 8 to max 10 straight hours. Even Mr. Big Brain Neurosurgeon with his/her extra-long fellowship declines rapidly after 7 hours. Disclaimer: Yes, yes….this Redditor may be partial toward the great field of Neurosurgery, and the big-headed minions that staff this hallowed field.

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halfgod50zilla t1_j21ze08 wrote

I know it isnt your specific question, but I worked during the California Wildfires. They brought in extra beds. If you werent asleep you were working. My shifts could last about 34 hrs before I had to sleep. I could only do that I think twice. Everything else was more of a rotating 20 hrs shift. 20 on, 6 to 10 off. And I mean that for everyone, I wasnt there for more than 4 or 5 days if memory serves me right.

I know the literature says you cant make up for lack of sleep, but I had about 8 days off after that scenario and slept for most of it.

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Sammystorm1 t1_j1zzavo wrote

36 hour surgeries don’t really happen. In the US the other staff is often given breaks and lunch’s as required by law. A different staff member replaces them for 15-30 minutes. The surgeon does not change out. So an 8 hour surgery it will be the same guy or gal the entire time.

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Hot_Stick_1040 t1_j209ih9 wrote

Not surgery related but in our icu our intensivists shifts are literally a week long. They are on site for as long as they need to be during the day (07:00-19:00 but as late as 23:00 some days) rounding /doing procedures /meeting with family /admitting new patients /consults /code team then they go home when all of that is done, but come back for any problems /crises and are on call the entire time they are not on site. We had a patient ask his long the doctors shift was and when we told her, her eyes got really large lol. It’s unfortunate but it’s the model that is the least taxing.

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rosespetaling t1_j21k6n4 wrote

im a surg tech. usually, everyone but the surgeon gets switched out. BUT if they have a team they want with them for the case, they all stick it out together!! ive worked w some docs on not as long cases and he would say if i dont get a break, you all dont either. pretty much depends on the doc

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sighthoundman t1_j21lnp2 wrote

I saw a tv show that showed a surgery to separate twins conjoined at the top of the head. It was a 24 hour surgery. The lead surgeon performed the first 8 hours, some other surgeon on the team performed the second 8 hours, and the lead surgeon finished up the last 8 hours. It didn't mention food and restroom breaks.

PBS is amazing.

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Terrorfrodo t1_j20jqxt wrote

I cannot imagine a continuous procedure that takes 36 hours to complete. What exactly are they cutting for such a long time?

If this is about making extremely delicate incisions in the brain of the patient or something like that, I cannot imagine that a surgeon who has been working for 35 hours and probably was already sleep-deprived when they started will do the best possible job.

Just seems very likely to me that handing over to a rested person after 12 hours or so, when some kind of milestone has been reached, would lead to better results for everyone involved.

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