Prevention, Identification & Management of Fatigue

Beyond Duty Hour Restrictions

This presentation is brought to you by:

»Dr. Ed Tagge

»Dr. Mark Reeves

»Dr. Chris Church

WHY SLEEPAre you wasting 1/3 of your life?

Sleep

»Improved alertness

~ Faster reaction times

~ Improved dexterity

»Improved cognitive function

~ Frontal lobe function

~ Better mood modulation

~ Improved Memory

»Improved resistance to stress and immune function

»Decreased obesity, Type 2 diabetes and

atherosclerotic diseases

SLEEP PHYSIOLOGYWhy people get sleep at 3 AM

Normal Sleep: 90 minute cycles

To sleep; perchance to REM» Just being asleep is not beneficial

» Restorative sleep MUST include REM

sleep

» All OTC sleep aids, alcohol,

barbiturates, most benzodiazepines,

narcotics and anesthetics (Including

propofol) inhibit REM sleep

» Result in “hung over” or groggy feeling

afterwards

» BTW: Sundowning

Circadian Rhythms» Assuming there is not a schedule

dictating when to sleep

~ Children tend to prefer to sleep

earlier in the evening

~ Young adults tend to stay up later

at night and get up later

~ As adults age, the preferred time

to sleep shifts back earlier

» Most people function best with a

brief siesta after lunch

» Most sleepy times of day:

~ 3-6 AM & 3-6 PM

MANAGING SLEEP & FATIGUE DURING RESIDENCY

Fatigue Differential Diagnosis

»Too little sleep

»Fragmented sleep

»Circadian rhythm disturbance

»Other conditions that masquerade as fatigue

~ Mood disorder/burnout

~ Hypothyroidism

~ Medications or other substances

»Primary sleep disorders

~ Obstructive sleep apnea

~ Narcolepsy-Cataplexy

Too Little Sleep

»Most young adults require 7.5 hours of sleep

each night (52 hours per week)

»Impacted by both duty hours and what

physicians do when not on duty

»Shige Okawara, MD

Fragmented Sleep

»Being awakened to disrupt REM sleep also

leads to fatigue

»Knowing you are on-call changes how you sleep

»This occurs with home call as well as in-house

call

Circadian Rhythm Shifts

»Night Float changes sleep patterns like jet lag

»Trying to re-set from daytime waking to

nighttime waking takes days

»Even when well rested prior to a night float shift,

most people will feel sleepy around 3-6 AM

Symptoms of Sleep Deprivation»Boring lectures put you to sleep instead of annoying you

»Yawning

»Inattention

»More microsleeps

»Increased tolerance for risk

»Mood

»Psychomotor slowing

»Decreased cognitive functions & Increased Errors

»MVA

»Under-estimating how sleepy you are

Confusional Arousal

»Increased following sleep deprivation

»Occurs after being asleep for 30 minutes while

in deep (slow wave) sleep

»AKA

~ Sleep inertia

~ Sleep drunkenness

»Symptoms

~ Confusion

~ Amnesia

Assessing Sleepiness

»Acute

~ Reaction time

»Chronic sleep deprivation

~ Do you feel rested after a sleeping?

~ Epworth Sleepiness Scale

http://web.stanford.edu/~dement/epworth.html

David F. Dinges, PhDPsychologist, University of Pennsylvania

Intern Intermediate SeniorMaximum Hours of

Work per Week80 hours averaged over 4 week rotation

Extra Hours 8 additional hours based on sound educational rationale

Moonlighting Not Permitted Included in the 80 hours

Maximum Duty

Length16 Hours 24 Hours + 4 Hours Transition of Care.

Strategic napping after 16 hours between 10 PM and 8 AM.

No continuity clinic after 24 hours.

Can provide care to one patient after hours with documentation.

Minimum Time Off

Between Scheduled

Duty Periods

Must have 8 hours

Should have 10

Must have 8 hours

Should have 10. Must have 14 hours

off after 24 hours on.

Must have 8 hours. Should

have 10. May return to work

sooner under RRC-defined

circumstances.

Night Float Maximum of 6 consecutive nights on in-house night float

Maximum In-House

On-Call FrequencyNone Every 3 nights averaged over 4 week rotation

At-Home Call Not Permitted Not limited specifically, but must not be so frequent or taxing to

preclude rest or reasonable personal time.

Did Duty Hour Restrictions Improve Patient Safety?» 2004

» 2011

SURVIVAL GUIDE TO DOCTORING AT NIGHT

Maintain Healthy Sleep Habits»Sleep in a cool, dark, quiet room in a comfortable bed.

»Avoid napping > 90 minutes during the day.

»Sleep at the same time each day when possible.

»Avoid large meals, large volumes of liquids, caffeine,

nicotine, and alcohol close to bedtime.

»Exercise in the morning or late afternoon.

~ A relaxing exercise, like yoga, can be done before bed.

»Get exposure to natural light while awake.

»Establish a regular relaxing bedtime routine.

»Associate your bed with sleep. Avoid “tossing & turning”

»Do NOT use sedatives on a regular basis

Fatigue Mitigation - Before

»Be well rested

~ Start night float without sleep debt

»Prior to a night float shift, take a 1 sleep cycle

nap in the afternoon

»Before starting night float, eat a good meal & be

hydrated.

»If you can shift your sleep cycle, postpone sleep

~ Days→Evenings→Night

Fatigue Mitigation - During

»Nap 20-30 minutes early in a night shift

~ set an alarm to avoid a full sleep-cycle nap

»Eat a meal in the middle of the shift

»Stay hydrated

»Work in bright lights

~ especially between 3 AM and 6 AM

»Consider use of caffeine BEFORE getting sleepy

~ Take caffeine just before a nap because the effects of

oral caffeine start 20 minutes after consumption

~ Benefit lasts about 4 hours

Caffeine Dosing Options (mg)

»Average cup of instant coffee (200 ml) 75

»Average cup of brewed coffee (200 ml) 100–250

»Average cup of tea (200 ml) 50

»Herbal tea 0

»Decaffeinated tea or coffee 3–5

»Hot chocolate 5–7

»Coke or Pepsi (regular or diet) 30-45

»Red Bull (250 ml can) 80

»Bar of plain chocolate (50 g) up to 50

»Bar of milk chocolate (50 g) up to 25

Fatigue Mitigation - Afterwards»Avoid driving long distances

~ Especially after a night shift

~ Cab rides OR Loma Linda Inn

~ Use sunglasses

»If possible, go to bed prior to 10 AM

»Sleep in a cool, dark quiet room

~ Eye pads, ear plugs, white noise

~ Avoid interruptions

»Do NOT use alcohol, OTC sedatives, narcotics, or

Propofol to initiate sleep

»When you get the chance, repay sleep debt.

Fatigue Mitigation: Expertise

»David Hinshaw, Sr., MD

»Recognizing when the

unusual is present and

slowing down

Competence in working safely at night

»Patients will get sick between 3 AM and 6 AM