Nursing And War Require Alert Personnel. These Researchers Are Studying Fatigue Countermeasures

Respiratory therapist Gina McCarthy cares for COVID-19 patients in overflowing MultiCare Tacoma General Hospital. Never in her 28 years in the profession has she worked hours like she does now.

“I mean, I worked 84 hours in one seven day stretch,” McCarthy said. “We’re all working long hours. But I just know that everybody I work with is doing it. If I felt I was being dumped on or something, that would be one thing. But I know the entire place is on the same page.”

McCarthy said there’s a “we’re all in this together” spirit in her work group that keeps the caregivers going despite incredible fatigue and emotional strain.

“None of our vacations are getting approved,” McCarthy said. “I’m going to physical therapy on my days off because we’re working so hard. We’re working 16 hour shifts and we’re exhausted.”

Long hours. Extreme fatigue. You couldn’t miss it in the faces of soldiers and refugees at Kabul Airport last month and you can’t miss it now in the faces of caregivers in hospitals here at home. It just so happens that Washington State University Spokane is in the midst of a series of studies of how sleep deprivation affects people in high stress, high risk jobs.

Washington State University College of Nursing researcher Lois James designed a realistic experiment to explore the risks. She recruited nurses from two Spokane-area hospitals to stop by her lab at the end of three 12s. That’s a common schedule where nurses work 12 hours on, 12 off, 12 on, 12 off, 12 on and then get four days off.

“What we did is we brought nurses into our simulation lab and tested them both on patient care scenarios and then also in a driving simulator to see how much their patient care performance, but also their driving safety was impaired,” James explained.

To evaluate quality of care, the nurses entered a mock patient room and treated a talking, coughing mannequin. For comparison, the nurses also ran through the tests when rested after three consecutive days off. The data collection with real-life nurses was completed right before the pandemic hit.

James summarized the study results as encouraging for patients, but not so good for commuters.

“Nursing performance on the patient care scenarios — with some exceptions — overall didn’t suffer tremendously,” James said. “In terms of patient care, it seems that many nurses seem to be fairly resilient to the effects of fatigue.”

However, James said she is concerned about nurse safety on the drive home. Especially nurses on the night shift risked running off the road based on their performance in the driving simulator.

The study results are coming out in multiple papers. The International Journal of Nursing Studies published the first one in July.

James said she suspects the risks her team studied are amplified now in light of the extended shifts and incredible stress nurses are under from the surge in hospital admissions.

“I do think it is very relevant” James said. “Our test was fairly conservative and the risks are very, very real for this group.”

Not just nurses, military too

A new study now underway at WSU Spokane is measuring how well certain stimulants help sleep deprived people maintain alertness. It will also delve into the underlying brain processes. This experiment is funded by the Department of Defense and led by professor Hans Van Dongen with backing from a big team. WSU College of Nursing Assistant Professor Stephen James, spouse of the sleep researcher Lois James, developed lab simulations applicable to wearied warfighters.

“Within this study, they come into my lab and they have a driving task and they have a shooting task where we have a modified M4 rifle that no longer fires bullets. It now fires infrared beams at a screen,” James said. “We ask them to identify friend from foe targets.”

James said the closely watched, live-in subjects will be kept awake for 24 hours beforehand. Some will get the benefit of caffeine pills, similar to a shot of espresso, prior to entering the simulators. Some will get a prescription stimulant named modafinil (which is sometimes used to treat narcolepsy in the civilian world) and some will swallow placebos.

“They start taking the pills every four hours to see if the stimulant supports their performance as they’re being sleep deprived,” James explained. “One of the things it may be important to understand is that it’s really difficult to recover from the effects of sleep deprivation. It is more effective to try to support that cognitive function before you are sleep deprived.”

By the time you feel tired, it’s too late to reach for that cup of coffee, James added.

“If you do feel that 3 p.m. slump on a regular day, have your cup of coffee at 2 p.m. so it has time to get into your system and support you through that circadian dip in the afternoon,” he said.

James said the WSU Sleep and Performance Research Center is also looking at fatigue risks in other professions including long-distance truck drivers, taxi drivers and in aviation.

Before becoming a sleep researcher, James served many years in the British Army. During combat tours in Bosnia and Herzegovina and Afghanistan, he experienced the sorts of extreme sleep deficits that his department is now dissecting. James said he wishes someone had told him when he was a young soldier about the biology of fatigue and the effects of sleep loss on safety and performance.

Because service members have long had to cope with 24-hour shift operations, the military has a rich history with stimulant use and research. The Vietnam War was notorious for use and abuse of amphetamine derivatives such as “speed” to sustain extended combat. In the U.S. military, prescription stimulant drugs such as dextroamphetamine and modafinil are now generally restricted to use under the direction of a flight surgeon by military pilots on long-duration missions, according to a 2021 Department of Defense report on sleep deprivation submitted to House Armed Services Committee Chairman Adam Smith (D-WA) and his Senate counterpart.

The DoD report said surveys of active duty Army, Navy and Marine Corps service members found coffee to be the most popular drowsiness countermeasure overall, with energy drinks being most popular among young male soldiers. The report was commissioned by members of Congress who were concerned about deleterious effects of sleep deprivation on military readiness and service members’ health.

KNKX reporter Kari Plog contributed to this story.