Asleep at the Wheel Managing Sleep & Fatigue Vincent Hanlon MD, CCFP(EM) PFSP assessment physician

PFSP PFSP supports a healthy culture of medicine in

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5 Learning objectives ● Raise awareness about risks of fatigue and insufficient sleep. ● Leave the room with a few more strategies to increase alertness and manage fatigue. ● Discover one more way to assist colleagues and co-workers who are tired and sleep deprived. 7

7 7 Sleep deprivation and physician performance: Why should I care? Steven K. Howard, MD

1. safe and effective patient care 2. physician safety and well-being 3. education quality Philibert I, Friedmann P, Williams WT.ACGME Work Group on Resident Duty Hours. New requirements for resident duty hours. JAMA. 2002;

© American Academy of Sleep Medicine American Academy of Sleep Medicine “Patients have a right to expect a healthy, alert, responsible, and responsive physician.” January 1994 statement by American College of Surgeons Re-approved and re-issued June 2002

10 Case ● 7 o’clock on Saturday morning, the colleague you are replacing seems particularly tired. He briefly recounts another “night from hell.” He is a little more disorganized than usual in detailing some of the night’s cases and transfer of care issues. ● He’s 51, and been an anesthesiologist for 21 years. At the end of the conversation he says to you, “I’m not sure how much longer I can keep doing these nights.” And could you write him a script for “a few Imovane”? 10

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Surgery Ann Surg.Ann Surg Aug;250(2): Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients. Privette ARPrivette AR, Shackford SR, Osler T, Ratliff J, Sartorelli K, Hebert JC.Shackford SROsler TRatliff JSartorelli KHebert JC Source: Department of Surgery, College of Medicine, University of Vermont, Burlington, VT 05401, USA. a significant reduction in mortality rate in the postrestriction period (pre: 1.9%; post: 1.1%, P = 0.002)

Surgery J Surg Res.J Surg Res Oct;163(2): Epub 2010 May 6. Acute care surgery performed by sleep deprived residents: are outcomes affected? Yaghoubian AYaghoubian A, Kaji AH, Ishaque B, Park J, Rosing DK, Lee S, Stabile BE, de Virgilio C.Kaji AHIshaque BPark JRosing DKLee SStabile BEde Virgilio C Source: Department of Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA. Over the 7-y study period, 2908 LC and 1726 appendectomies were performed. Appendectomies were performed laparoscopically in 73% of cases in patients for both time periods. There were no differences in rates of overall morbidity and mortality for operations when performed in nighttime compared with daytime.

© American Academy of Sleep Medicine American Academy of Sleep Medicine Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-call (two studies) Taffinder et al, 1998; Grantcharov et al, 2001 Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns Lingenfelser et al, 1994 Pediatrics: time required to place an intra-arterial line increased significantly in sleep- deprived Storer et al, 1989

Sleep ● Most of us need 7 to 8 hours per day. ● The circadian drive for wakefulness − zeitgebers ● The homeostatic need for sleep

© American Academy of Sleep Medicine American Academy of Sleep Medicine Interaction of Circadian Rhythms and Sleep Time 9 PM 9 AM Sleep Wake Sleep Homeostatic drive (Sleep Load) Circadian alerting signal Alertness level 3 PM 3 AM

© American Academy of Sleep Medicine American Academy of Sleep Medicine Conceptual Framework (in Residency) Primary Sleep Disorders (sleep apnea, etc) Fragmented Sleep (pager, phone calls) Circadian Rhythm Disruption (night float, rotating shifts) Insufficient Sleep (on call sleep loss/inadequate recovery sleep) EXCESSIVE DAYTIME SLEEPINESS

Warning Signs of Fatigue ● Falling asleep during presentations ● Restless and irritable ● Checking your work repeatedly ● Inflexible thinking ● Difficulty focusing on the care of your patients ● Decreased compassion

Caution! ● Sleepy people underestimate their sleepiness and overestimate their alertness...and possible impact on performance American Academy of Sleep Medicine

Impact of Lack of Sleep ● Patient care and safety ● Personal health and family life ● Professionalism ● Career longevity [>50]

© American Academy of Sleep Medicine American Academy of Sleep Medicine Impact on Professionalism “Your own patients have become the enemy…because they are the one thing that stands between you and a few hours of sleep.”

Personal health at risk Resident study demonstrated increased association with weight gain, self-medication and increased use of alcohol with increased hours of work and decreased hours of sleep. Baldwin and Daugherty

Fatigue is a family affair The fallout of disrupted sleep can affect all members of the family in the homes of physicians who take call from home. Alberta On Call Study O’Beirne, Gorsche and Wedel, 1999

Career Ecosystem Personal Professional Organizational Taken from G. Hirsch, MD Strategic Career Management for the 21st Century Physician

Shared Responsibility ● Fatigue management is a shared responsibility – individual, colleagues and the organization ● student, resident, or MD, hospital, and health region ● Can you help create a climate where it is okay to talk about it?

© American Academy of Sleep Medicine American Academy of Sleep Medicine Alertness Management Strategies

© American Academy of Sleep Medicine American Academy of Sleep Medicine Myth: “I’d rather just “power through” when I’m tired; besides, even when I can nap, it just makes me feel worse.” Fact: Some sleep is always better than no sleep. Fact: At what time and for how long you sleep are key to getting the most out of napping.

© American Academy of Sleep Medicine American Academy of Sleep Medicine Get adequate (7 to 9 hours) sleep before anticipated sleep loss. Avoid starting out with a sleep deficit! Healthy Sleep Habits

© American Academy of Sleep Medicine American Academy of Sleep Medicine Healthy Sleep Habits Sleeping environment: –Cooler temperature –Dark (eye shades, room darkening shades) –Quiet (unplug phone, turn off pager, use ear plugs, white noise machine) Avoid going to bed hungry, but no heavy meals within 3 hours of sleep. Get regular exercise but avoid heavy exercise within 3 hours of sleep.

© American Academy of Sleep Medicine American Academy of Sleep Medicine Healthy Sleep Habits Go to bed and get up at about the same time every day. Develop a pre-sleep routine. Use relaxation to help you fall asleep. Protect your sleep time; enlist your family and friends!

© American Academy of Sleep Medicine American Academy of Sleep Medicine Napping Pros: Naps temporarily improve alertness. Types: preventative (pre-call) operational (on the job) Length: short naps: no longer than 30 minutes to avoid the grogginess (“sleep inertia”) that occurs when you’re awakened from deep sleep long naps: 2 hours (range 30 to 180 minutes)

© American Academy of Sleep Medicine American Academy of Sleep Medicine Napping Timing: -- if possible, take advantage of circadian “windows of opportunity” (2-5 am and 2-5 pm); -- but if not, nap whenever you can! Cons: sleep inertia; allow adequate recovery time (15-30 minutes) Bottom line: Naps take the edge off but do not replace adequate sleep.

© American Academy of Sleep Medicine American Academy of Sleep Medicine Recovery from Sleep Loss Myth: “All I need is my usual 5 to 6 hours the night after call and I’m fine.” Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness. Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss.

35 DWD

© American Academy of Sleep Medicine American Academy of Sleep Medicine Recognize Signs of DWD * Trouble focusing on the road Difficulty keeping your eyes open Nodding Yawning repeatedly Drifting from your lane, missing signs or exits Not remembering driving the last few miles Closing your eyes at stoplights * Driving While Drowsy

© American Academy of Sleep Medicine American Academy of Sleep Medicine Drugs Melatonin: little data in residents Hypnotics: may be helpful in specific situations (eg, persistent insomnia) AVOID: using stimulants (methylphenidate, dextroamphetamine, modafinil) to stay awake AVOID: using alcohol to help you fall asleep; it induces sleep onset but disrupts sleep later

© American Academy of Sleep Medicine American Academy of Sleep Medicine Caffeine Strategic consumption is key Effects within 15 – 30 minutes; half-life 3 to 7 hours Use for temporary relief of sleepiness Cons: –disrupts subsequent sleep (more arousals) –tolerance may develop –diuretic effects

39 Case ● 7 o’clock on Saturday morning, the colleague you are replacing seems particularly tired. He briefly recounts another “night from hell,” and is a little more disorganized than usual in detailing some of the night’s cases and transfer of care issues. ● He’s 51, and been an anesthesiologist for 21 years. At the end of the sign-over he says to you, “I’m not sure how much longer I can keep doing these nights.” And could you write him a script for “a few Imovane”? 39

References ● American Academy of Sleep Medicine promotes excellence in sleep medicine health care, education and research. ● Collaborative effort of Duke University Hospital and NC Physician’s Health Program. Learning to address Impairment and Fatigue to Enhance patient safety. ● Howard, SK. Sleep deprivation and physician performance: Why should I care? BUMC Proceedings. 2005;18: ● Owens, JA. Sleep loss and fatigue in medical training. Current Opinion in Pulmonary Medicine. 2001;7: ● Tewari, A et al. Does our sleep debt affect patients’ safety? Indian J Anaesthesia. 2011;55(1): ● Epworth Sleepiness Scale is useful to determine daytime sleepiness. ● Wilson JF. Is Sleep the New Vital Sign? Annals of Internal Medicine. 2005;142;

Other PFSP conversations ● Medical marriage —making yours better ● Dare to Care —the addicted physician and the road to recovery ● Ready or not, here comes retirement! ● Weathering the Perfect Storm —surviving a career in medicine ● Show up, stay awake— mindfulness in daily life ● Speaking in Tongues: communication in the therapeutic Tower of Babel

Questions?

Action Point Decide on one thing that you will do differently to manage your own fatigue-- before you put your head on the pillow tonight. [Evaluations]

44 The Unexpected Benefits of Showing Up

45 The Unexpected Benefits of Showing Up 1. Ginger in Dark Chocolate 2. The ABC of the ER 3. van Gogh’s bed 4. X-treme Bean Coffee w/ Guardian Weekly