Sleep Like a Boss

[et_pb_section][et_pb_row][et_pb_column type=”4_4″][et_pb_text admin_label=”Text” background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid”] Two weeks ago LIJ EM and EM/IM residents participated in the semi-annual wellness day.  This session was dedicated to building resiliency through mindfulness and an exploration of sleep strategies.  We also enjoyed a Wilderness Medicine presentation by current chief and future FDNY EMS Fellow, Dr. Rich Menaik. The day began with a brief intro about the beautiful Sands Point Preserve in Sands Point, NY (formerly the Guggenheim estate – yes, those Guggenheims) which sits on Long Island Sound and provides expansive views towards Westchester and points north. [/et_pb_text][et_pb_image admin_label=”Image” src=”http://theempulse.org/wp-content/uploads/2016/04/20160322_094059.jpg” alt=”Long Island Sound from Sands Point Preserve, by David Marcus” title_text=”Long Island Sound from Sands Point Preserve, by David Marcus” show_in_lightbox=”off” url_new_window=”off” animation=”fade_in” sticky=”off” align=”center” force_fullwidth=”off” always_center_on_mobile=”on” use_border_color=”off” border_color=”#ffffff” border_style=”solid”] [/et_pb_image][/et_pb_column][/et_pb_row][et_pb_row][et_pb_column type=”2_3″][et_pb_text admin_label=”Text” background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid”] It’s a Walk in the Park. The next 45 minutes were spent in – relative – silence during a Mindful Walking exercise and debrief. For a summary of mindful walking, and some tips, see Meditation in Action on Huffington Post and also visit What is Mindful Walking on Wildmind.org.  We aren’t endorsing or promoting any products on these sites – mindful walking is a completely free activity – but their explanations are very useful. [/et_pb_text][/et_pb_column][et_pb_column type=”1_3″][et_pb_image admin_label=”Image” src=”http://theempulse.org/wp-content/uploads/2016/04/20160322_100742.jpg” alt=”The Great Lawn at Sand Point Preserve, by David Marcus” title_text=”The Great Lawn at Sand Point Preserve, by David Marcus” show_in_lightbox=”on” url_new_window=”off” animation=”off” sticky=”off” align=”right” force_fullwidth=”off” always_center_on_mobile=”on” use_border_color=”off” border_color=”#ffffff” border_style=”solid”] [/et_pb_image][/et_pb_column][/et_pb_row][et_pb_row][et_pb_column type=”4_4″][et_pb_text admin_label=”Text” background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid”]

And now, for something completely different.

Dr. Menaik showed us how to jet ventilate with a syringe-ETT connector-angiocath, and how to cric with a ballpoint pen, a sawed off IV drip chamber, and his handy pocket cric-o-matic.  After that we walked a little longer and ended the day with a discussion on sleep strategies and some of the literature around the chronic jet lag – read Shi(f)t Work Disorder – that dogs us all and which contributes to burnout and, it turns out, is a leading cause of premature departure (1) from the field of Emergency Medicine.

Sleep on. Sleep off. 

We all sleep differently.  Some people actually are Early Birds while others are Night Owls (based on differing patterns of body temperature variation). So some folks do better with earlier shifts and others really do function better in the evenings, but almost everyone has trouble shifting phases.  Yet most ER docs are expected to frequently switch between days, evenings, and nights.  This results in desynchronosis. Also called jet-lag or shift-lag, desynchronosisis the condition in which the body’s endogenous circadian rhythm is out of phase from the environment (day/night, etc).  After a period of adjustment, to the new order of days or nights, phases align again and the body re-achieves entrainment.(2)  Constantly switching back and forth results in the distressing and exhausting shift-lag we all know and hate.

What’s a doc to do?

There is a large body of literature about sleep cycles and the resulting difficulties shift workers face when trying to function safely.  We have all heard that sleep-deprived physicians operate at levels of dysfunction that equal those of intoxicated drivers but desynchronosis, even if not sleep deprived, can be just as dangerous. Some people develop coping strategies, either helpful or maladaptive, while others just power through it until they burn out. While there are no guaranteed fixes, researchers have found the some methods work better than others.  Read on for a brief review of what individuals and schedulers can do to help reduce shift-lag and improve personal wellness.  All references are listed at the bottom of this post.

Conclusions From the Literature – Scheduling:

1. The best way to feel better is not to work nights
2. Scheduling solutions appear to be more effective than any individual strategies in promoting healthy sleep patterns.
3. Shorter shifts seem better than longer – 12 hour – shifts.  Variable length shifts are preferable and, if possible, high stress periods (high volume, overnights, high strain areas, etc) should be scheduled for shorter shifts. For example, if using 8 or 10 hour shifts, the overnight could be split into 2 shorter shifts, allowing for anchor sleep (see below).(4)
4. Shifts should be scheduled in a clockwise progression; start with mornings, then swing shifts, then night/s, then a day off before resetting to days. Humans naturally gravitate to a 25 hour cycle and so staying up later is easier that shifting to an earlier cycle.(2, 4)
5. Three main philosophies exist around night scheduling:
   1. Work only 1 or 2 nights in a row (up to 3), then day off, then back to days.(2)
   2. The Thomas Schedule: Individuals to do most of their nights for the year in a block (1 or 2 months) with intermittent days off during which time they are covered by other members of the group, but should continue to stay on an inverse schedule so they do not readjust to days.(3)
   3. Slowly rotating schedules.  Work 3 week blocks in each shift: Day >Swing >Night, then a few days off.  This allows for entrainment, but may result in sleep debt.(2)
6. The literature seems universally in agreement that blocks of nights between 3 and 7 shifts in a row should be avoided.  It takes almost that long for the body to adjust and results in chronic desynchronosis: shift lag.
7. Random scheduling is bad for sleep.

Conclusions From the Literature – Individual Strategies:

1. Substances:
   1. The use of stimulants to stay awake, and EtOH or other sedatives to help us sleep, can easily become pathological and maladaptive.  Although EtOH will help you fall asleep it results in an abnormal sleep architecture by reducing the amount of REM sleep, basically rendering the sleep useless.  Sleep aides often result in varying degrees of hangover and abnormal behaviors for some.
   2. Try to avoid caffeine during the last 4 hours of a shift as it will make it harder to fall asleep once home. best practice to drink caffeine midway through the shift when energy starts to dip. This gets complicated for people with long driving commutes who may feel that the caffeine jolt will help them get home safely.
   3. Melatonin: Good support in the literature around its benefits for jet lag in travelers and pilots. unclear efficacy in ED docs.  May be worth a try after shift when trying to sleep during the day, downsides appear to be minimal.  Does not change sleep architecture. Optimal dosing and timing relative to sleep time is unclear. Works by increasing Melatonin, a naturally nocturnal phenomenon which is associated with sleep and lower body temperatures.  Before starting any new meds or supplements, be sure to talk to your doctor or professional advisors.
2. Sleep strategies:
   1. Anchor Sleep: The practice of maintaining a 4 hour block of sleep within the same time in a 24 hour period (for example, 2 am to 6 am). Cannot be done if working 12 hour shifts, but seems to help reduce the stress and fatigue associated with irregular sleep.(4)
   2. After an overnight, the later you go to sleep, the shorter the sleep you are likely to get.  The trend reverses after 12 pm when you will again be able to sleep for more hours. Try to go to sleep right after getting home.
   3. Split Sleep:
3. Exercise helps maintain sleep hygiene.  Try some cardio after waking up, but not before going to sleep.
4. Napping:
   1. Napping before shifts: Good.  People often feel better and cognitive function is improved.  Exact timing doesn’t matter much. Some people find it easier to sleep during the classical siesta period in the late afternoon.
   2. Napping during a shift (<1 hour): Impractical for most.  Also, these short naps of result in sleep lag after waking up and people tend to feel just as sleepy at the end of the shift, whether or not they napped.
5. Sleep hygiene:
   1. Wearing sunglasses on the way home from an overnight may help prevent the body from going into a “day” cycle.
   2. Turn off all electronic devices.
   3. Dark room/blackout curtains during the day. Consider also earplugs, sleep masks, white noise machines/fans or air conditioners to drown out other noises.  Cool temperatures help most people sleep.
   4. Avoid stimulating activities before.
   5. Preserve the bed and bedroom for sleep and sex.
   6. Avoid scheduling meetings or other daytime activities after an overnight.
6. Family support:
   1. Discuss with your partner/family/significant others so they can plan to assist with childcare duties or other chores and keep a quiet house.
   2. Plan family events, when possible, away from post-overnight days.

 

Sleep Like a Boss – You Can Do It!

It’s true, your bosses probably also suffer from interrupted sleep and occasional desynchronosis.  But they’ve been doing this long enough to have learned what works for them. Not all of these strategies are practicable for everyone, and some things, like scheduling, are often out of our hands.  But if you are at the start of your – hopefully, long – EM career, reflect on which of these makes sense to you and try them out.  I hope you’ll find that you sleep better, feel better, take better care of your patients, and continue loving your job for many years to come!

 

Do you have any thoughts about these techniques?  Experience with other tools or methods that work for you?  Let us know by commenting below. Be sure to visit our Wellness page for more on resilience and burnout prevention. 

 

[/et_pb_text][/et_pb_column][/et_pb_row][et_pb_row][et_pb_column type=”4_4″][et_pb_text admin_label=”Text” background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid”] Citations: 

1. Thomas, HA. Circadian Rhythms and Shift Work. ACEP Clinical & Practice Management. August 2003. Accessed online at: https://www.acep.org/Clinical—Practice-Management/Circadian-Rhythms-and-Shift-Work/
2. Kuhn, G. Circadian Rhythm, Shift Work, and Emergency Medicine. Ann Emerge Med. 2001 Jan;37(1):88-98.
3. Whitehead, DC. Optimal Scheduling Strategies for Emergency Medicine. Found on ByteBloc.com. October 1999. Accessed online: https://www.bytebloc.com/Blog/optimal-scheduling-strategies-for-emergency-medicine.aspx 
4. Nelson, D. Preventing and Treatment of Sleep Deprivation Among Emergency Physicians. Pediatric Emergency Care. 2007 Jul;23(7):498-503

Additional Readings: 

1. Schmitz et al. Strategies for coping with stress in Emergency Medicine: early education is vital. J Trauma Shock Emerg. 2012 Jan-Mar;5 (1) 64-69.
2. Steele et al. Emergency Medicine residents’ shiftwork tolerance and preference. Acad Emerg Med. 2000; 7:670-673.
3. Nickson, C. Sleep and ICU (a brief review on sleep followed by discussion about ICU patients). Accessed on 4/5/16.
4. Jones, S. Burnout in the ED: Too tired to sleep, too wired to weep. Accessed on 4/5/16.

[/et_pb_text][et_pb_team_member admin_label=”Person” name=”David Marcus” position=”Editor, theEMPulse.org ” image_url=”http://theempulse.org/wp-content/uploads/2015/11/ALIEMphoto_DSC02779_thumb.jpg” animation=”off” background_layout=”light” twitter_url=”http://twitter.com/emimdoc” linkedin_url=”https://www.linkedin.com/in/david-marcus-4480a858″ use_border_color=”off” border_color=”#ffffff” border_style=”solid”]

David Marcus is an editor at theEMPulse.org and Director of Student Education in Emergency Medicine and LIJ Medical Center.  He also blogs at EMIMDoc.org 

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