Welcome to wellness! That sounds appropriately optimistic, but a bit misleading, given that wellness is certainly not a destination to be reached and luxuriated in. Achieving good physical and mental health is a constant process, and almost ironically, it can be quite a struggle to maintain a balance between the rather unique pressures of our job and lifestyle, mental, social, spiritual and physical health.
There’s rising awareness that physicians must begin to take better care of ourselves, instead of focusing exclusively on the health of our patients. Well Aware will find us exploring self-care and wellness to help our community become healthier.
We’ll start the series with a fundamental aspect of Emergency Medicine: shift work, and specifically how it disrupts that bedrock of wellness, sleep. The double-edged sword of shift work sets us apart from almost all other specialties of medicine, and all “normal” jobs. The flexible schedule holds appeal, but it’s not without drawbacks. In fact, according to ACEP, “The adverse effect of constantly rotating shifts is the single most important reason given for premature attrition from the field.” Read that again. We stop working because of the fundamental nature of our job, one of the very things that brought many of us to this specialty in the first place.
Shift work alters the circadian rhythms, the body’s natural 25-hour clock. When people attempt daytime sleep it is generally 1.5 to 2 hours shorter than night time sleep, with disproportionate loss of restorative sleep. Thus when we are working at night we are not only combating our usual Circadian rhythm nadir of alertness, but doing so less rested.
One study showed that after 28 hours of wakefulness, hand-eye coordination was reduced to a degree equivalent to a blood alcohol level of 0.1%. You might be thinking that’s irrelevant, because after residency there will be no long call. True. Except chronic partial sleep loss is a phenomenon you’ll continue to experience. When a person consistently obtains less sleep than they would if given the opportunity to sleep more, cognitive abilities are similar to after a single night of total sleep deprivation. So there you are after a string of swing shifts essentially intoxicated again. You’re more likely to have a needle stick (fatigue is a contributing factor in 31%), and more likely to fall asleep at the wheel, causing an accident. As if to add insult to injury, insufficient sleep also acts as a risk factor for obesity, heart disease, and life expectancy.
I’m dedicated to not using this space as a repository of personal anecdotes, but I’m tired so my judgment is impaired. A few years ago I worked a night shift and left a reasonable 30 minutes after my shift. Promptly hitting the traffic. Literally. On the homestretch I suddenly heard a crunch indicating the loss of a side mirror before I even realized I’d closed my eyes. Shaken, I pulled over, and on the back of a prescription pad left a note for my new iPhone contact “Woman Whose Car I Hit.” I haven’t resolved the ongoing sleep issues that plague any EM doctor, but hopefully you guys won’t need this kind of wake-up call to modify behavior.
So what to do?
First, identify if you are sleep deprived. If you find yourself irritable and annoyed with colleagues and loved ones, falling asleep in conference, checking your work repeatedly or having compassion fatigue, now is a good time to implement changes.
- Respect sleep. Emphasize often and assertively to your loved ones that your sleep is not optional. You aren’t “just sleeping” as an expendable activity in the daytime, and they must learn not to disturb you, as you must learn to dedicate the time to sleep in lieu of other activities.
- Try to get anchor sleep, and have at least a few hours of your sleep be during the “normal” night time hours.
- Nap before you drive. The hospital call room, a friend’s house, your childhood bedroom. Driving tired is like driving drunk.
- Use caution with stimulants and sedatives. 89% of surveyed EM residents use caffeine during night shifts, and 36% use sedatives to sleep. These can both be disruptive to your sleep patterns, especially when caffeine is drunk < 4 hours before you go to sleep.
- Recognize none of this gets easier as you age, so try to develop good habits now.
Shy BD, Portelli I, Nelson LS. “Emergency medicine residents’ use of psychostimulants and sedatives to aid in shift work.” Am J Emerg Med. 2011 Nov; 29 (9): 1034-6.
Comondore V, Wenner J, Avas N. “The impact of sleep deprivation in resident physicians on physician and patient safety: Is it time for a wake-up call?” BCMJ, Vol 50, No. 10, December 2008, pp 560-564.
Circadian Rhythms and Shift Work, ACEP Policy Resource and Education Paper (PREP), September 2010
Dr. Marinelli is an attending physician at Advocate Lutheran General Hospital and the director of the UIC Wellness Curriculum.