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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, November 2, 2015

Constant Jet Lag in Emergency Medicine

Emergency Medicine is high risk speciality that brings a lot of stress with it and maximum burn out rates among its providers. A major reason why people quit EM is due to the rotating shifts. And as we turn older, it gets difficult to cope up with this ever changing shift work schedule. Many of us suffer from this under appreciated problem of shift work disorder. Rather than accepting Shift Work Disorder (SWD) as something that always comes along with EM, we should find out ways and learn how to cope up with it. 


What is Shift Work Disorder?
SWD is clinically recognized condition that develops in some individuals who work at night, start work early in the morning (4am-7am), or work according to a rotating shift schedule. SWD consists of a constant or recurrent pattern of sleep interruption that results in difficulty sleeping when you should sleep or excessive sleepiness when you are supposed to stay awake and alert. 

Problems that might occur with Shift workers:
Medical errors 
Disturbed circadian rhythm
Risk of peptic ulcer disease
Cardiovascular disease
Hypertension
Chronic Fatigue, insomnia
High Divorce rate
Substance abuse and Depression
Immunosuppression
Fertility issues
Poor dietary choices
Thyroid issues
Most circadian rhythms have both an endogenous component (regulated by suprachiasmatic nucleus of the hypothalamus) and an exogenous component. The exogenous component is composed of various time clues called zeitgebers. One of the most powerful zeitgebers is the light/dark cycle (e.g. Sun). Other examples of zeitgebers can be food, television, exercise, caffeine, sports. We can synchronise with these zeitgebers and give the right cues to our body to promote wakefulness/sleep. 

For instance , prior to starting a night shift, exercising OR eating typical breakfast foods OR exposure to bright light gives subtle clues to your body that it is time to get up and start the day. Similarly, having a cup of coffee, bright light exposure and exercising after a night shift is a bad idea!!


Few Strategies for setting up night shifts:
1. If you can work it out, then the best way is to do a stretch of nights for 6-8 weeks once in a year. This way you would need to change your sleep cycle only twice a year (not every week!). No meetings/academic sessions after night shifts.

2. Casino Shifts: With casino shifts, one long night shift is cut into two short shifts, from 10pm-4am and from 4am to 10am. With these shifts the "early risers" turn up for the 4am shift and people who prefer to sleep late in the night leave by 4am. Both these groups can then continue their next day normally without affecting their social liv. Some people like and prefer to work like this.


3. Avoid doing >2-3 nights in a row.

Shift Length: Some physicians prefer shorter shifts (6-8hrs) and some like to stick to the 12hr shifts. With shorter shifts, it is found that physicians are more alert and respond better while with the two 12hr shifts, you get more days off per week. 


Here are some things that we can do to cope up with Shift work:

1. Education and Awareness (For shift workers as well as their families)

2. Individual Strategies

Prior to night shift, To promote wakefullness:
  • Make sure you get some sleep during the day time (Never start a night shift in sleep deprivation)
  • Exercise in the evening 
  • Expose yourself to bright light 
  • Having more staff overnight is beneficial
  • Have dedicated breaks, with coffee and high protein foods
During night shift, To stay alert 
  • Keep your naps short (<30 minutes)
  • Stay exposed to bright light
  • Have a high carbohydrate/protein snack to keep you awake
  • Caffeine (only during the first half of shift)

After night shift, To promote sleep:
  • Use sunglasses while travelling back home to avoid bright light exposure
  • Use ear plugs/eye protectors, black curtains 
  • Make sure that your room temperature is comfortable 
  • Keep your kids and pets away to avoid disturbances while you are asleep (Noisy environments cause sleep fragmentation)
  • Have a dedicated quiet area to sleep
  • Avoid fatty/ spicy food before you sleep
  • Avoid early morning caffeine 
  • Switch off your phone and try using an answering machine


Shift schedule should be made by someone who understands SWD


ACEP endorses the following principles:
  • Scheduling isolated night shifts or relatively long sequences of night shifts is recommended. 
  • Overly long shifts or inordinately long stretches of shifts on consecutive days should be avoided whenever possible. In most settings, shifts should last twelve hours or less. Schedulers should take into consideration the total number of hours worked by each practitioner and the intervals of time off between shifts. 
  • ACEP strongly recommends that practitioners have regularly scheduled periods of at least 24 hours off work. 
  • Rotating shifts in a clockwise manner (day to evening to night) is preferred.
  • Night shift workers' schedules must be designed carefully to provide for anchor sleep periods, and those workers' daytime responsibilities should be held to an absolute minimum. 
  • Groups should consider various incentives to compensate those working predominantly night shifts. 
  • Schedules for emergency physicians should take into account factors such as ED volume, patient acuity levels, non-clinical responsibilities, and individual physician's age. 
  • A place to sleep before driving home after night shifts should be provided.


3. Pharmacolgy

To promote sleep:
BZDs (addiction, side effects)
Zolpidem is better than BZDs
Melatonin: take few hours prior to sleep, dose: 0.5-5mg

Stimulants to promote wakefullness:
Modafinil (Dopamine reuptake inhibitor, Also activates Glutamate and inhibits GABA)
Caffeine: Too much leads to agitation, tolerance overtime and withdrawal. Avoid taking caffeine during the second half of your shift.
Energy drinks: Caffeine + sugar 



Key Points
  • Educate your family and colleagues about Shift Work Disorder
  • Learn how to play with the zeitgebers
  • Do not overly on medications
  • Consider incentives for those who work the unpopular night shifts 

References:
1.Haney Mallemat - Shift Work Disorder: http://www.emedhome.com/cme_infocus.cfm
2.https://www.acep.org/Clinical---Practice-Management/Emergency-Physician-Shift-Work/
3.Boggild H, Knutsson A. Shift work, risk factors and cardiovascular disease. Scand J Work
Environ Health. 1999;25:85-99.
4.http://www.acep.org/Clinical---Practice-Management/Circadian-Rhythms-and-Shift-Work/
5.http://www.gru.edu/mcg/clerkships/em/documents/shiftwork.pdf
6.http://cjem-online.ca/v15/s1/the-impact-of-“casino-shifts”-on-emergency-physician-productivity

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