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Human factors in medicine: Sleep deprivation results in D… : Emergency Medicine News

sleep deprivation, well-being in ME:

Wakefulness rises and falls throughout the day depending on the sleep drive and circadian rhythm. Work nights disrupt this.

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We doctors learn early in training that sleep has to be sacrificed for our careers. We routinely work long hours, often when our bodies are supposed to be sleeping, and almost no attention is paid to how to deal with the inevitable sleep deprivation and resulting fatigue.

Two main systems regulate human sleepiness. The first, the homeostatic sleep drive, is like an hourglass. It is full after a full night’s rest, but the sand immediately begins to drain and wakefulness decreases as drowsiness increases throughout the day.

The other is the circadian rhythm, which regulates a number of biochemical processes to maintain a 24-hour sleep-wake cycle. This internal clock naturally keeps you awake during daytime hours and promotes sleep at night. These systems are synchronized to initiate and maintain sleep at night, at least when all is well in the sleep world.

However, night work is particularly difficult for the human body due to its innate disruption of circadian rhythm. Worse still, trying to sleep during the day is difficult and often leads to an increasing sleep deficit. (Centers for Disease Control and Prevention. March 31, 2020; https://bit.ly/3tDNjzM.)

Sleep deprivation is associated with short-term performance deficits and long-term health consequences. Numerous studies have shown that reduced sleep results in shorter reaction time, irritability, loss of humor, apathy, impaired communication, and a greater likelihood of mistakes. Night shifts and chronic sleep deprivation are also associated with an increased risk of dementia, depression, obesity and even reduced longevity.

Fatigue management

I was shocked the first time I heard about the crew resting. I had just completed an exhausting month of midwifery as a third-year medical student. The crushing fatigue was never questioned and no consideration was given to its effects on student and resident performance. (Go Flight Medicine. Feb. 25, 2014; https://bit.ly/3xy9Grb.)

I did my first military flight medicine rotation the following month, and the day before my first F-15 flight, I was told to leave the clinic early for crew rest. I was sent home, just like that. I was appalled, but learned a different approach to fatigue over the next few years, one that not only trains humans for a particular job, but also teaches them to do their best while performing it. One of the responsibilities of a flight surgeon is to educate the crew about health and wellness, including sleep and fatigue. The US Air Force takes fatigue so seriously that it created the Counter Fatigue Management System. (Aviat Espace Environ Med. 2009;80:29; https://bit.ly/3xvh6vl.)

I have incorporated many aspects of this into my well-being as an emergency physician. Almost all EPs are expected to provide life-saving care in the middle of the night at some point, but few have considered how best to prepare and do their best at night. My nighttime routine involves shifting my circadian rhythm while ensuring that the sleep drive remains as full as possible. The ultimate goal is to maintain alertness and optimize performance.

  • Work night shifts or stack them. An occasional night shift is quite easy as you start well rested and only suffer from circadian sleep disturbances. A missed night’s sleep is easily recovered. Working a week of night shifts allows the body to shift the internal clock, which is why I do a month of night shifts every quarter instead of occasional nights every month.
  • Prepare for night shifts several days before the actual shift. Many behaviors can help shift your internal circadian clock in preparation for the nights. Exercise, exposure to light, and the timing of your meals and bedtime can alter your circadian rhythm before your first night shift. But getting seven or eight hours of sleep is still essential if you use them to stay up later and not start your night shifts with a sleep deficit.
  • Power naps and short sleeps. A power nap lasts 30 to 45 minutes. The goal is to regain alertness while avoiding the inertia of sleep that accompanies awakening from the slow-wave deep phases that begin one hour after the onset of sleep. Research suggests that these naps provide two to four hours of useful awareness.

Short sleep lasts three to four hours and allows you to experience all stages of sleep while avoiding sleep inertia. I divide sleep into two short periods during my month of night shifts. I try to get four hours of sleep after I finish my shift and exercise immediately after waking up while avoiding caffeine. I sleep again about five hours before my shift with the goal of sleeping another three to four hours. This gives me about eight hours of rest and allows me to start my shift with a full hourglass. I substitute a 45 minute nap before my shift if I am unable to complete two short sleep periods.

  • Avoid sleep inertia. Synchronizing my sleep aims to avoid sleep inertia, a feeling of drowsiness that lasts 20 minutes to an hour. This puts you at high risk for errors, which is not a great way to start a shift.
  • Use caffeine and stimulant behaviors wisely. I train lightly with push-ups as soon as I wake up from my second short sleep, then take a shower to wake up. I turn on all the brightest lights and make myself a cup of coffee. The circadian low point is between 2 a.m. and 6 a.m., so I have another cup between 2 a.m. and 3 a.m. to stay alert and decisive until the end of my shift.

Click on the links in this article to find resources for developing your own plan. Sleep well, my friends!

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Dr. Jedickis a board-certified emergency physician who works in the Las Vegas emergency departments and as a clinical professor at the University of Utah. He also practices aviation medicine, previously serving as an active duty flight surgeon in the US Air Force with several fighter squadrons and now in the Utah Air National Guard. He is also an FAA Aviation Medical Examiner and previously completed a space medicine internship at NASA. Follow him on Twitter@RockyJedickMD. Read his previous columns onhttps://bit.ly/EMN-HumanFactors.