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

Cognitive pills for Cognitive ills: Errors in Emergency Medicine

Cognitive errors underlie most diagnostic errors that are made in the ED. And with time I have realised that our speciality is a vulnerable one, because we often commit some errors (delayed diagnosis, missed diagnosis, unnecessary imaging) which look like no-brainers to people upstairs in the ICUs and wards. Then why do we commit such errors?

May be because as everyone else, we often have a tendency to pursue more readily attainable goals.

There is a story about a jogger who came across a man on his knees under a streetlight one evening. He explained that he had dropped his wedding ring. The jogger offered to help him search, and he accepted. With no luck after a half hour, the jogger asked the man if he was sure he had dropped the ring at the place where they were searching. The man replied that he actually dropped it several yards away in the shadows. ‘‘Then why are we looking here?’’ asked the jogger. ‘‘Because the light is better,’’ came the reply. 

This is a topic in medicine which is rarely talked about, despite being a really important one for patient safety. These errors are universal but since we are often the first responders as Emergency Physicians, the brunt falls on us and we face the limelight. So, we need to find out a way to minimise these errors by developing a conceptual framework and strategies in this critical aspect of patient safety.

COGNITIVE ERRORS

Diagnostic errors arising through cognitive errors are those that are associated with failures in perception, failed heuristics, and biases are referred to as cognitive dispositions to respond (CDRs). There are a number of strategies for reducing them (‘‘cognitive debiasing’’)  like METACOGNITION, a reflective approach to problem solving that involves stepping back from the immediate problem to examine and reflect on the thinking process.

Some unique operating characteristics of ED predisposing to medical error:

• High Diagnostic Uncertainity
• High Decision Density
• High Cognitive Load
• High level of activity
• Inexperience
• Interruptions and Distractions
• Shift Work
• Shift Changes

There is huge list of errors which we can come across as clinicians and not surprisingly, all of them are evident in Emergency Medicine, a discipline that has been described as a ‘‘natural laboratory of error.’’ Lets familiarise ourselves with some of them:  

Various biases leading to errors:

1. Anchoring Bias: Anchoring bias causes physicians to stay with their initial impression of a case and fail to adjust to new information that would make the initial impression less likely. This often leads to prematurely ending their search or premature closure.
2. Gender Bias: the tendency to believe that gender is a determining factor in the probability of diagnosis of a particular disease when no such pathophysiological basis exists. Generally, it results in an overdiagnosis of the favored gender and underdiagnosis of the neglected gender.
3. Availability: Recent experience with a disease may inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it may be under diagnosed.
4. Premature closure: a powerful bias accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decision- making process, accepting a diagnosis before it has been fully verified (When the diagnosis is made, the thinking stops)
5. Search satisfying: reflects the universal tendency to call off a search once something is found. Comorbidities, second foreign bodies, other fractures, and coingestants in poisoning may all be missed. 
6. Ascertainment bias: occurs when a physician’s thinking is shaped by prior expectation; stereotyping and gender bias are both good examples.
7. Fundamental attribution error: the tendency to be judgmental and blame patients for their illnesses rather than examine the circumstances that might have been responsible. In particular, psychiatric patients, minorities, and other marginalized groups. 

Few Cognitive de-biasing Strategies to Reduce Diagnostic Error Develop insight/ awareness: Provide detailed descriptions and thorough characterizations of known cognitive biases, together with multiple clinical examples illustrating their adverse effects on decision-making and diagnosis formulation. Consider alternatives: Establish forced consideration of alternative possibilities. Encourage routinely asking the question: What else might this be? eg: any pt who presents with flank pain/hematuria, force yourself to consider aortic dissection. Metacognition: Train for a reflective approach to problem solving: Metacognition is the process of actively stepping back from the pushes and pulls of the immediate situation (de-anchoring), reminding oneself of the limitations and failings of memory, seeing the clinical problem in a wider perspective than that dictated by the obvious presentation, perhaps reminding oneself of specific lapses or failures in the past, and finally activating known cardinal rules or caveats.   Decrease reliance on memory: Improve the accuracy of judgments through cognitive aids: mnemonics, clinical practice guidelines, algorithms, hand-held computers. Simulation: Develop mental rehearsal, ‘‘cognitive walkthrough’’ strategies for specific clinical scenarios to allow cognitive biases to be made and their consequences to be observed. Construct clinical training videos contrasting incorrect and correct approach. Make task easier: Provide more information about the specific problem to reduce task difficulty and ambiguity. Make available rapid access to concise, clear, well-organized information.Write the ddx in chart upon initial evaluation and re-visit the ddx when initial tests are back and when deciding disposition. Formalizing Handover: 'S BAR' Mneumonic for Handover - Situation, Background, Assessment, Recommendation Minimize time pressures : Provide adequate time for quality decision- making. Have the the attending doc and and the handover doc seeing patient/imaging together, its always better to review the H&P for handed over cases.  Feedback: Provide as rapid and reliable feedback as possible to decision makers so that errors are immediately appreciated, understood, and corrected, resulting in better calibration of decision makers. Understanding "how we think":  Type 1: The Intuitive/Reflexive Approach involves automatic decision making based on pattern recognition. It's fast, requires little effort and usually brings you the correct diagnosis, but it's very prone to error. Type 2: The Analytical/Problem-Solving Approach is more critical and logical. This is when you step back and think more carefully about the patient's presentation. It involves estimating pretest probabilities, continuous self-questioning, and considering alternative diagnoses. While it takes more effort, more time and is more resource intensive, it's reliability is much better than the intuitive approach, and is more likely to give you the correct diagnosis.  High Risk Situations where errors are likely: Night shifts, during handover, with patients at the extremes of age, the 'difficult patient' and the "difficult relatives"

Some Classic Errors:

1. Failure to consider a closed-head injury in an intoxicated patient
2. Incomplete consideration of AMI mimics before initiating thrombolysis 
3. Inadequate assessment of immunocompromise status in patients with animal bite wounds
4. Failure to fully assess the medical status of psychiatric patients before transferring to a psychiatric facility
5. Failure to consider tetanus immune status in patients with open wounds. 

Take Home:

1. Learn, practise and teach Metacognition.
2. Develop your own strategies to reduce errors (discussion, checklists, Incorporating simulation)
3. Use a Problem Solving approach instead of a Reflexive Approach.

For Further Reading:

1. http://www.cjem-online.ca/sites/cjem-online.ca/files/pg271(2).pdf
2. http://home.comcast.net/~jasoncillo/Cognitive.pdf
3. http://www.ncbi.nlm.nih.gov/pubmed/12915363