Imagine this scenario: It’s 5 a.m., your fourth night in a row, and this one’s a doozy – a pediatric cardiac arrest followed by a rapidly deteriorating headache, topped with rotten toenail fungus.
Caffeine paradoxically makes you more tired. The three-day sleep deficit is catching up. And then Mrs. X appears on the tracking board. You know it well – chronic pain, undertreated psychosis, substance abuse and homelessness.
His ER visits run the gamut, from seeking drugs to blossoming psychosis to the occasional physiological emergency. This morning, she is here with a simple request: a meal, some warmth and a taxi voucher. But you don’t see the simplicity. You seethe in annoyance at her and at the broken system that has her in your emergency department.
You don’t feel generous and want to kick her out. Compassion and altruism seem absent from your emotional reserves. But in a moment of insight, you ask yourself, “Why is that?”
The data has consistently suggested that America is an undersleeping nation. Centers for Disease Control and Prevention survey data from 2017 to 2018 estimated that more than 30% of working adults in the United States sleep six hours or less per night. (MMWR Morb Mortal Wkly Rep. 2020;69:504; https://bit.ly/3R6a48j.) That’s less than the CDC’s recommended seven-hour minimum, and perhaps that shortfall contributes to our collective angst and irritability.
New research also suggests that sleep deprivation is associated with more selfish and less altruistic tendencies. A fascinating study found evidence for this at the individual and population level. (PLoS Biol. 2022;20:e3001733; https://bit.ly/3dDEAZh.) Single-night sleep deprivation was associated with decreased willingness to help others (strangers and familiars); functional MRI imaging revealed a decrease in social cognitive network activation.
Subjects in another test completed a Self-Rating Altruism Scale questionnaire twice a week apart. Half the group started out as a rested cohort, while the other half had been kept awake for 24 hours. We know how it feels!
The following week, the two groups switched places, allowing each participant to serve as their own control. The questionnaire asked them to indicate how they would react to social scenarios at the time using a five-point vertical Likert scale ranging from “I would definitely help” to its opposite. In one of the hypotheses, the participants met a stranger struggling with her grocery bags. Would the study subject stop to help?
You can guess how it went. Rested participants were more likely to lend a hand, and those who lacked sleep were more likely to leave the woman to fend for herself. It’s easy to translate this to ED. We’re at our best when we start a day shift fully rested: “I’d be happy to get you a blanket, call your daughter, refill your blood pressure meds. But our reserves of helpfulness can dwindle as much as our energy when we see our last patient after a series of night shifts: “Call your own daughter; let her give you a stinky blanket.
These investigators observed a significant decline over a 16-year period at the population level (a 10% adjustment) in the amount of charitable donations made the week after the start of DST that was not present in states without daylight saving time or within a week of its end. Even an hour of sleep disruption reduces our altruism.
The answer is that we need more and better quality sleep. Sleep is good medicine for us and our patients. Easy to say, but how to actualize? There are, of course, common tricks of the trade: regular exercise, blackout curtains, hypnosis, and 4-7-8 breathing patterns. Unfortunately, many sleeping pills, while not likely to be harmful, have not been shown to be beneficial, which has been the conclusion of systematic reviews of two popular sleep supplements, white noise and valerian. (Sleep Med Rev. 2021;55:101385; 2007;11:209.)
What if our pineal gland was called Dr Melatonin? Melatonin once seemed like a smart way to market a placebo to long-distance travelers, but the evidence has evolved and melatonin is now recommended by the American Academy of Sleep Medicine for daytime sleep in night shift workers with sleep disorders. shift work. Recent evidence suggests it may be helpful in other populations, such as middle-aged people with insomnia. Sound familiar? (Medical Sleep. 2020;76:113; https://bit.ly/3Lz2OjU.)
Another solution is to mitigate the pesky effects of natural light on shift workers by trying to reverse the galley on sleep patterns. Melatonin production by the pineal gland is regulated by the light-dark cycle, so it makes sense that its same effects could be achieved by carefully regulating our exposure to light. (Sleep medicine clinic. 2015;10:435; https://bit.ly/3f8j5Ak.)
In concrete terms, this means that shift workers must manipulate their light environment as much as possible. Coming down as the sun rises? How about blue light blocking sunglasses for the drive home? Waking up at 11 a.m. after a few hours of sleep? Adjust those blackout curtains. Waking up at 9 p.m. before the night shift? Get out the natural light and reset your circadian phase.
You don’t have to work summer shifts in Scandinavia to make this possible. If you’re shopping for a light, look for something that provides around 10,000 lux exposure with minimal UV light.
Back to Mrs. X. Luckily for you and her, the well-rested and (mostly) energetic morning shift arrives just in time to inject some selflessness into this situation. She’ll get her meal and voucher and a pat on the shoulder on the way out, and you’ll go home for a restful rest.
Dr Vinsonis an emergency physician at Kaiser Permanente Sacramento Medical Center, chairman of KP CREST (Clinical research on emergency services and treatment) Network, and Adjunct Researcher at the Kaiser Permanente Division of Research (https://www.kpcrest.net). Dr Ballardis an emergency physician in San Rafael Kaiser, past president of KP CREST Network, and medical director of Marin County Emergency Medical Services. Follow him on Twitter@dballard30. Read his past articles onhttp://bit.ly/EMN-MedClear.