Night Shift Work and the Emergency Physician
Ronny M. Otero, MD FAAEM
Vice President, GLAAEM Board of Directors
“Sleep, How I loathe those little slices of death.” - Author contested
As emergency physicians we understand the necessity of working afternoon and night shifts (aka: shift work). Those of us that either do not work nights or prefer not to work night shifts should appreciate the courageous practitioners that have adapted to this non-circadian lifestyle. Not all individuals can adapt easily to working afternoon or night shifts. Among emergency medicine residents, younger single residents without children tend to tolerate night shifts better than their older, married colleagues who have children.1 One study looked at the characteristics of individuals who can more readily adapt to this non-circadian lifestyle and found the following traits to be predictive of adaptation: age less than 40, male gender, less “morning type” preference, more extroverted or higher self-esteem and possibly a genetic predisposition (short allele of SLC6A4 gene).2
A longitudinal study has found that emergency physicians attribute night shifts with decreased career satisfaction and among emergency physician retirees, the night shift is often cited as a major reason for retiring. Up to 43% of emergency physicians surveyed stated that they considered leaving emergency medicine due to night shifts.3
Effects of Working Nights:
Studies have shown neurocognitive discrepancies in physicians after working night shifts. Physician’s abilities to perform specific tasks decline with sleep deprivation.4 Night shifts have also been associated with physician errors and the highest incidence of motor vehicle accidents among emergency physicians occurs after working a night shift.5
Night shift work in particular has been associated with lower cortisol and melatonin levels. It is believed these deficiencies may be at the root of why physicians working night shifts are at increased risk of metabolic syndrome, hypercholesterolemia, poor mood, grogginess, digestive problems, and insomnia. Providers affected by lack of sleep to this degree may go on to develop shift worker sleep disorder (SWSD). There is now greater recognition of this problem but the incidence among emergency physicians is unknown.
In both the lay-media and scientific journals, worse outcomes for cardiac care have been associated with patients treated during the night shift or on weekends–the so-called “weekend effect.”6, 7
Improperly rested physicians can lead to medical errors. A better understanding of how to adapt to night shifts should emphasize protecting physician and patient health.
Preparing for Night Shift:
The transition from a day shift to a night shift is often the most difficult transition. To prepare for a night shift it is important to shift your normal wake period and sleep to accommodate for staying up all night. The first step is to stay up late on a day or two prior to your night shift.
For example, if you have an overnight shift coming up you should try to stay awake until
3:00-4:00am the prior night and sleeping in as late as possible the day of your night shift. Additionally, an extra brief nap before going in for your shift will give you more energy.
Before your night shift, eat your largest meal of the day in order to have sufficient calories to get you through your shift.
During Night Shift:
Try to keep active during the shift. Increased muscular activity will keep you more alert. If there is downtime during your shift you should try some brief exercises, such as stair climbing or a walk around the department. If the shift is particularly long, a short “cat-nap” of 15 minutes will energize you for the latter half of your shift.
During your shift, eat foods with a low glycemic index such as whole grain breads or crackers, almonds, or carrots. Avoid eating a heavy meal in the middle of the night as this will be difficult to digest after your shift. Avoiding spikes in blood sugar by eating low glycemic snacks every three hours is better than a large fatty meal in the middle of your night shift. Make sure you keep yourself well hydrated by consuming water several times throughout your shift.
Light therapy has been shown to increase alertness and can help shift workers adjust to different schedules by shifting sleeping patterns. Use of bright light in the early part of your shift (first three hours) can improve wakefulness. Commercially available lights are obtainable for this purpose. The combination of bright light exposure early in your shift should be complemented with dim light later in your shift. Decreasing exposure to bright light should be continued as you make your way home or to your sleep chamber after a night shift. Consider wearing sunglasses as you make your way home to sleep.
Caffeine is well known to help individuals stay awake and alert. Combining a nap before your shift followed by consumption of caffeine in the beginning or during the early part of a shift is complementary. As little as 100-200mg of caffeine is effective to stave off fatigue for a few hours. A typical cup of coffee has approximately 65-125mg of caffeine so one to two cups may be all that is needed. Try to avoid the use of caffeine later in your shift as this will remain in your system for hours after consumption and potentially disrupt your sleep. Yerba Mate has been used as a substitute to coffee due to less jitteriness associated with its consumption. There are no studies to compare the efficacy of Yerba Mate vs. coffee as a stimulant for night shifts.
After the Night Shift:
Getting to Sleep
As mentioned before, as the shift is winding down or on your way home you should wear sunglasses to slowly decrease light exposure. However, if you have a long commute home, consider a short catnap before driving home to avoid drowsiness at the wheel. Once you arrive home you should prepare for sleep.
Eat Breakfast Before Sleep
A small balanced breakfast is important before going to bed. You should not go to bed hungry so try eating a balanced meal such as fruit with yogurt, a boiled egg or perhaps some cereal or toast. Do not eat a heavy meal as this can lead to gastric distress. You may also consider a protein-enhanced smoothie.
It goes without saying that when you plan to sleep after a night shift you should have a dark and quiet area–free from disruptions. Leave your pager and cell phone outside of your sleep chamber. Ideally where you slumber should have thicker, light dampening curtains. Avoid exposure to laptops, tablets or other light-generating electronic devices, as this will also affect melatonin levels. Consider a sleep mask to completely black out your sleep chamber. Some advocate pleasant smelling herbs such as chamomile or lemon balm in your sleep chamber to enhance sleep.
Generally the body is accustomed to lower temperatures during sleep so your sleep environment should be in the 60-68 degree Fahrenheit range. Some advocate use of a “cooling pillow” to keep the head cool and make you more comfortable as you sleep.
Try to limit interruptions of your sleep. Some shift workers purchase a white noise generator, which allows for a less intrusive background noise to drown out other environmental sounds. Make sure your telephone or cell-phone is turned “off.”
Taking melatonin two-four hours before intended sleep time might help with going to sleep during the day. The most commonly available dose of melatonin is greater than what is needed to help induce sleep. Melatonin doses as low as 1mg may be sufficient. Too much melatonin can upset your sleep by waking you in the middle of your intended sleep time or it can cause grogginess.
Herbal sleep enhancement has been around for many years. Some advocate the use of valerian root, chamomile tea, passionflower or kava.
In general, emergency physicians do not utilize substances to increase wakefulness apart from caffeine but a larger percentage of emergency physicians utilize a sleep agent. Of the agents used to promote sleep emergency physicians most often use diphenhydramine followed by a benzodiazepine and less commonly, melatonin.8
Shift work is a reality of emergency medicine. Preparation for a night shift requires careful planning and a respect for the importance of good sleep hygiene. Emergency physicians should protect their intended sleep periods aggressively to avoid digestive problems, exhaustion, insomnia and most importantly, burn-out.
- Steele, M., O. Ma, and W. Watson, Emergency Medicine Residents' Shiftwork Tolerance and Preference. Acad Emerg Med, 2000. 7(6): p. 670-673.
- Saksvik, I., B. Bjorvatn, and H. Hetland, Individual differences in tolerance to shift work- A systematic review. Sleep Med Rev, 2011. 15: p. 221-235.
- Smith-Coggins, R., K. Broderick, and C. Marco, Night Shifts in Emrgency Medicine: The American Board o Emergency Medicine Longitudinal Study of Emrgency Physicians. The Journal of Emergency Medicine, 2014. 47(3): p. 372-378.
- Rollinson, D., N. Rathlev, and M. Moss, The effects of consecutive night shifts on neuropsychological performance of interns in the emergency department. Ann Emerg Med, 2003. 41: p. 400-406.
- Steele, M., O. Ma, and W. Watson, The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med, 1999. 6: p. 1050-1053.
- Peberdy, M., J. Ornato, and G. Larkin, Survival from in-hospital cardiac arrest during nights and weekends. JAMA, 2008. 99(7): p. 785-792.
- Boodman, S., Shifting the risks at night. The Washington Post, 2011. June 6 2011.
- Shy, B., I. Portelli, and L. Nelson, Emergency Medicine residents' use of psychostimulants and sedatives to aid in shift work. Amer J Emerg Med, 2011. 29: p. 1034-1036.
Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM, its chapter divisions or affiliates. These articles are intended for the individual use of AAEM members.