How to not let that 4 AM presentation of left toe pain give you a myocardial infarction – Night Shifts and Physician Health

Working in the ED is a shiftwork job, which for many, is part of the draw. We never get paged after hours. We work less overall hours than many of our physician colleagues in other fields. And we can avoid crowds when we run errands or enjoy popular attractions on weekdays when everyone else is at work. However, these advantages come with the price of working less desirable times. Unfortunately, people get sick on nights and weekends, and we have to be there care for them.

Caution: Biohazard

Working long blocks of overnight shifts is part of the job, but it is exhausting. This has been found by researchers to be dangerous to the health of shift workers, as it predisposes to mistakes and contributes to high rates of physician burnout. A study has demonstrated that night workers are more predisposed to heart disease, stroke, depression, metabolic syndrome, stomach ulcers, cancer, obesity, GI dysfunction, poor outcomes in pregnancy[1]. It also predisposes to infertility, chronic pain, chronic fatigue[2], hypertension, cardiovascular mortality, and increased risk of being in a motor vehicle collision on the way home from work[3]. Needlestick injury rates increase by 61% during night shifts[4], and a 13-year longitudinal study on 82,000 person-years showed an increase in occupational injuries overnight with a hazard ratio of 1.3[5]. Still with me? From a pure mental health point of view, night workers are more prone to depression, mood swings, divorce, and absenteeism1,2,3. Among 814 emergency medicine physicians, 58% cited night work as a cause of decreased job satisfaction, with 43% of them considering leaving the field altogether for this reason[6].

OK, but forget providers for now.

Let’s talk patient safety. It’s been documented that serious medical errors are 35% more likely to occur at night4; studies specifically examining ED providers found slower mannequin intubation skills after working nights and as the night shift progressed[7]. Physicians undergoing batteries of cognitive testing before and after night shifts showed acutely reduced attention span and cognitive processing[8] with such decline worsening with each additional night worked in a row[9]. Furthermore, it takes two full days for full mental capacity to return to baseline[10] – something to think about the next time you work a shift after having precisely 24 hours off.

You came here at 4 AM for toe pain? TOE PAIN???

On second thought, perhaps it’s legit.

Of course, there will always patients between the hours of 7PM and 7AM. It therefore falls on us, as providers, to recognize our own vulnerability and be extra vigilant on that sixth night shift. It’s also important that we take care of ourselves the best we can in order to prevent mistakes and the aforementioned laundry list of adverse health effects. This is especially true as it has been shown that younger age and not having kids increases the tolerance one has to working nights[11]. So what can be done? Some tips are below.

 

 

 

Damage control

-Bright light upon waking has been shown to help with the adjustment to working at night2,[12].

-Sleep hygiene is important. This means sleeping in a cool, dark place with blackout shades if sleeping during the day. Avoid coffee, and yes, alcohol before you go to sleep. Some advocate ear plugs if you live in a noisy environment (like NYC)2, 3.

-Try to avoid working long blocks of night shifts in a row. This is less applicable to us as residents who have less control over our schedule, but working isolated night shifts has been shown to decrease the amount of caffeine ingestion and sedative use among ED doctors compared to those working block schedules. Isolated nights are also associated with decreased recovery time compared to working many in a row[13],[14].

-Rotating shifts in a clockwise fashion may also help with adjusting. An example of this would be working a 3PM – 11PM shift, and then the next day working an 11PM – 7 AM shift (rather than a shift that starts at 7 AM). Again, this may be more applicable to practitioners in a non-residency environment, but it’s something to think about3.

-Some advocate a shift schedule that allows for ‘anchor sleep’ – making sure you sleep for a short period of time at the same time every night. This might mean making sure you’re asleep from 3AM-9AM if you work shifts from, say, 6PM to 2AM and then 11AM to 6PM on consecutive days.

If people have any suggestions for warding off fatigue, please leave them below!

 

[1] Wright KP, Bogan RK, Wyatt JK. Shift work and the assessment and management of shift work disorder (SWD). Sleep Medicine Reviews 2013;17(1):41–54.

[2] Vallières A, Azaiez A, Moreau V, Leblanc M, Morin CM. Insomnia in shift work. Sleep Medicine 2014;15(12):1440–8.

[3] Whitehead DC, Thomas H, Slapper DR. A rational approach to shift work in emergency medicine. Annals of Emergency Medicine 1992;21(10):1250–8.

[4] Boivin D, Boudreau P. Impacts of shift work on sleep and circadian rhythms. Pathologie Biologie 2014;62(5):292–301.

[5] Dembe AE, Erickson JB, Delbos RG, Banks SM. Nonstandard shift schedules and the risk of job-related injuries. Scandinavian Journal of Work, Environment & Health 2006;32(3):232–40.

[6] Smith-Coggins R, Broderick KB, Marco CA. Night Shifts in Emergency Medicine: The American Board of Emergency Medicine Longitudinal Study of Emergency Physicians. The Journal of Emergency Medicine 2014;47(3):372–8.

[7] Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Annals of Emergency Medicine 1994;24(5):928–34.

[8] Saksvik IB, Bjorvatn B, Hetland H, Sandal GM, Pallesen S. Individual differences in tolerance to shift work – A systematic review. Sleep Medicine Reviews 2011;15(4):221–35.

[9] Dula DJ, Dula NL, Hamrick C, Wood G. The effect of working serial night shifts on the cognitive functioning of emergency physicians. Annals of Emergency Medicine 2001;38(2):152–5.

[10] Malmberg B, Kecklund G, Karlson B, Persson R, Flisberg P, Ørbaek P. Sleep and recovery in physicians on night call: a longitudinal field study. BMC Health Services Research 2010;10(1).

[11] Steele MT, Ma OJ, Watson WA, Thomas HA. Emergency Medicine Residents’ Shiftwork Tolerance and Preference. Academic Emergency Medicine 2000;7(6):670–3.

[12] Reid KJ, Abbott SM. Jet Lag and Shift Work Disorder. Sleep Medicine Clinics 2015;10(4):523–35.

[13] Krakow B, Hauswald M, Tandberg D, Sklar D. Floating nights: A 5-year experience with an innovative ED schedule. The American Journal of Emergency Medicine 1994;12(5):517–20.

[14] Nelson D. Prevention and Treatment of Sleep Deprivation Among Emergency Physicians. Pediatric Emergency Care 2007;23(7):498–503.

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Kyle Kelson, Downstate/Kings County Emergency Medicine resident. @kelsonmd

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