You have just finished an overnight shift and are driving home after you stayed in the emergency department an extra hour to complete your charts. It was a difficult shift, with one STEMI, a bad child-abuse case, a trauma resuscitation that did not go well, and an overabundance of abdominal complaints necessitating multiple rectal exams—you are 100 percent exhausted. You came to a stop in a line of cars at the red light and must have drifted off to sleep for a few seconds because you now have an angry driver from the car ahead of you at your window screaming, “You hit my car! Have you been drinking?” Your overnight shift is turning into a morning-after nightmare!

As emergency physicians, we are shift workers and have to develop strategies to accommodate the disruptions that occur with shift work. How do we prevent such episodes as the one above from occurring?

Assess Your Sleep Situation

To start, let’s look at your current situation. Answer the following three questions by choosing the answer with which you identify most.

1. In anticipation of an overnight shift, my plan of attack for sleep is:
   1. What plan? I can sleep whenever and wherever. I can sleep until 6 pm if I want!
   2. I try to take a nap before the overnight shift, but it never works.
   3. I try to sleep until at least 3 pm the day after an overnight, but I find myself awake at noon and exhausted but unable to fall back asleep.
   4. What plan? I have two kids and administrative duties. An overnight is just a missed night of sleep.
2. On a typical overnight shift, I find myself:
   1. Ready for anything!
   2. Inserting a caffeine IV while taking shots of espresso.
   3. Fading around 4 am and desperately pacing to stay awake.
   4. Wondering how comfortable the stretchers are for napping.
3. Working overnight shifts is:
   1. The best thing about EM.
   2. A necessary evil.
   3. An impossible task.
   4. Easier when you are younger.

If most of your answers are A’s, you are lucky and kind of a freak of nature. Are you interested in joining our practice? We always can use more “night people.”

If you answered mostly B’s, C’s, and D’s, read on for some strategies you can use.

Combating Sleep Disorder

Shift work sleep disorder (SWSD) is common in people who work nontraditional hours. It is defined as difficulty sleeping and excessive sleepiness due to a noncircadian-based schedule. Some people with the disorder have an increase in accidents or work-related errors and increased irritability. While most of us do not have true SWSD, we probably all can identify with some aspects of the disorder.

Anecdotally, a 32-year-old physician commented that her husband has diagnosed her with “decision fatigue” after she arrives home from a night shift, citing that she has difficulty making small decisions such as what to eat or drink.

Multiple studies have shown that night shifts are hard on the body in many ways. Studies suggest that people who work nights are at an increased risk of developing breast cancer, metabolic syndrome, and type 2 diabetes.¹ One study has determined that short-term memory is most affected by both overnight and day shifts.² Anecdotally, a 32-year-old physician commented that her husband has diagnosed her with “decision fatigue” after she arrives home from a night shift, citing that she has difficulty making small decisions such as what to eat or drink.

The good news is there are ways to combat the evils of night shifts. I will make a few suggestions here, but I’d also like to hear from you about the strategies that you have found helpful. Send your tips to acepnow@acep.org.

1. SLEEP!

This one seems obvious, but sleep needs to be a priority. The day after an overnight is not the best time to have someone cleaning and running the vacuum in every room of your house. Don’t schedule a meeting in the middle of your daytime sleep and assume you’ll be OK. Be selfish with your sleep! Let family and friends know that you are out of commission until a certain time and request that they avoid texting or calling during your sleep times. Put a sign on the door that reads, “Day sleeper, do not disturb, and do not open the door.”

2. DARKNESS

Our bodies want to sleep when it is dark. Create a dark, quiet place for daytime sleeping. Think about installing blackout shades on your windows to create artificial nighttime. Unplug the phone and use earplugs. One overnight attending in the Bronx wears blackout goggles on his way home from work to avoid seeing the bright sun and throwing off his sleep cycle. (Just to paint a picture, this man is 6’5” and riding the subway home during morning rush hour in a hooded sweatshirt and black metal goggles.) You can wear sunglasses home instead of blackout goggles. Your fashion sense will guide your decision.

3. SCHEDULE

A schedule that bounces from day to night, then night to day without a second to breathe is going to be hard for anyone. Some emergency physicians bundle their night shifts together, while others find that night shifts randomly worked throughout the month is better. You should experiment with both strategies and find which best fits your biorhythm and lifestyle.

4. REWARD FOR WORKING NIGHT SHIFTS

It is possible that some people just can’t do night shifts. One emergency medicine program just implemented a policy where employees do not have to do nights in the third trimester of their pregnancy. Many EDs do not require physicians over a certain age to do night shifts. One hospital in the Northeast has shortened the night shift from midnight to 6 am so that the overall impact on sleep is less.

Certain medical and psychiatric conditions, for example, seizure disorders, depression, and attention deficit hyperactivity disorder, are also affected by overnight shifts. Does your practice have specific guidelines for who is not required to work night shifts? This is a discussion that should take place. Many departments offer compensation for night shifts to ease the pain.

5. DRIVING

The solution to driving after a night shift was developed by a residency director in Washington, D.C. She recommends that if you come to a stoplight, put your car into park. If you then doze off, drivers behind you will beep their horns and alert you that it is time to move. You cannot inadvertently run into the car in front of you with this fail-safe strategy.

The reality of emergency medicine is that night shifts are not going to disappear. Further, most hospitals are trying stay fiscally sound 24-7. The general population is working a less-traditional 9 am to 5 pm business schedule, leading more and more people to work nontraditional hours in the future. We will need to know how to treat this disorder not just for ourselves but also for our patients.

Dr. van Leer is assistant program director of the emergency medicine residency program at St. Luke’s-Roosevelt in New York.

References

1. Wang XS, Armstrong ME, Cairns BJ, et al. Shift work and chronic disease: the epidemiological evidence. Occup Med (Lond). 2011;61:78-89.
2. Machi MS, Staum M, Callaway CW, et al. The relationship between shift work, sleep, and cognition in career emergency physicians. Acad Emerg Med. 2012;19:85-91.