1. Page 1 © American Academy of Sleep Medicine American Academy of Sleep Medicine S LEEP, A LERTNESS, and F ATIGUE E DUCATION in R ESIDENCY

2. Page 2 The official requirement Faculty and residents must be educated to recognize the signs of fatigue, and adopt and apply policies to prevent and counteract its potential negative effects. –ACGME Common Requirements 2004 VI, A3

3. Page 3 © 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 The REAL requirement

4. Page 4 Objectives 1. Recognize universal need for adequate sleep 2. Review risks of sleep deprivation 3. Consider methods to promote alertness when sleep-deprived 4. Consider methods to reduce risk of fatigue- related errors 5. Identify methods to recover from sleep deprivation 6. Review preventive measures

5. Page 5 Humans need adequate sleep Adequate means both duration and quality

6. Page 6 © American Academy of Sleep Medicine American Academy of Sleep Medicine Time 9 PM 9 AM Sleep Wake Sleep Homeostatic drive (Sleep Load) Circadian alerting signal Alertness level 3 PM 3 AM Human Circadian Rhythm is fairly consistent

7. Page 7 © American Academy of Sleep Medicine American Academy of Sleep Medicine Epworth Sleepiness Scale Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002 Residency and sleep deprivation

8. © American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Needed vs Sleep Obtained Myth: “ I’m one of those people who only need 5 hours of sleep, so none of this applies to me.” Fact: Individuals may vary somewhat in their tolerance to the effects of sleep loss, but are not able to accurately judge this themselves. Fact: Human beings need 8 hours of sleep to perform at an optimal level. Fact: Getting less than 8 hours of sleep starts to create a “sleep debt” which must be paid off.

9. Page 9 Sleep deprivation is hazardous to others

10. © 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

11. Page 11 Sleep deprivation is hazardous to you “Dan, moments before he fell asleep at the wheel”

12. © American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Loss and Fatigue: Safety Issues 58% of emergency medicine residents reported near-crashes driving. -- 80% post night-shift -- Increased with number of night shifts/month Steele et al 1999 50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10pm and 6am. Parks 2000

13. © American Academy of Sleep Medicine American Academy of Sleep Medicine Adverse Health Consequences by Average Daily Hours of Sleep* *Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents

14. © American Academy of Sleep Medicine American Academy of Sleep Medicine Drive Smart; Drive Safe AVOID driving if drowsy. If you are really sleepy, get a ride home, take a taxi, or use public transportation. Take a 20 minute nap and/or drink a cup of coffee before going home post-call. Stop driving if you notice the warning signs of sleepiness. Pull off the road at a safe place, take a short nap.

15. © American Academy of Sleep Medicine American Academy of Sleep Medicine Drowsy Driving: What Does Not Work Turning up the radio Opening the car window Chewing gum Blowing cold air (water) on your face Slapping (pinching) yourself hard Promising yourself a reward for staying awake

16. Page 16 “Alertness management” strategies Caffeine Exercise Light Napping Medication

17. Page 17 Caffeine Time use judiciously e.g. before circadian low point Onset: 15 - 30 min Effects last 3-4 hours But, sleep-disruptive: if possible, d/c 3-4 hours before planned sleep

18. Page 18 Exercise Stretch, run in place, or do jumping jacks Walk briskly from house to car, car to hospital

19. Page 19 Light Best: full- spectrum light (e.g. sunlight) Any bright light helps

20. Page 20 Napping 20-45 minutes Up to 2:00 (allows REM + restorative sleep) BUT longer naps > risk of sleep inertia

21. Page 21 Medication Modafinil ONLY IF PRESCRIBED by your personal physician

22. Page 22 And watch out for these Microsleeps Sleep inertia Circadian lows Isolation Self-deception High risk jobs

23. Page 23 Microsleeps “Faceplants”,or “nodding off” Sleeper often unaware Alert your colleagues! Response: thank colleague; exercise; talk

24. Page 24 Sleep Inertia: 10-120 min of grogginess, cognitive slowing, decreased vigilance after awakening. Worsened by sleep deprivation

25. Page 25 Circadian lows 12-4 a.m. 12-4 p.m.

26. Page 26 Isolation: sleepiness predicts underestimates of level of sleepiness and overestimates of alertness; residents in 1 study did not perceive themselves to be asleep almost half of the time they had actually fallen asleep (Howard et al, 2002)

27. Page 27 Self-deception “If I can just get through the night (on call), I’m fine in the morning.” “I’m better off ‘toughing it out’, napping just makes me feel worse.” “I get used to night shifts right away; no problem.”

28. Page 28 High-risk jobs low stimulation + high need for vigilance

29. © American Academy of Sleep Medicine American Academy of Sleep Medicine Adapting To Night Shifts Myth: “I get used to night shifts right away; no problem.” Fact: It takes at least a week for circadian rhythms and sleep patterns to adjust. Fact: Adjustment often includes physical and mental symptoms (think jet lag). Fact: Direction of shift rotation affects adaptation (forward/clockwise easier to adapt).

30. © American Academy of Sleep Medicine American Academy of Sleep Medicine How To Survive Night Float Protect your sleep. Nap before work. Consider “splitting” sleep into two 4 hour periods. Have as much exposure to bright light as possible when you need to be alert. Avoid light exposure in the morning after night shift (be cool and wear dark glasses driving home from work).

31. Page 31 Recovering from sleep deprivation On average, two nights’ recovery sleep (approx 9 h) needed

32. Page 32 Preventive measures Sleep ahead: Optimize your sleep environment –Cool, dark, quiet Practice good sleep hygiene –Presleep relaxation, reduce alerting stimuli, make bed a cue for sleep

33. Page 33 © American Academy of Sleep Medicine American Academy of Sleep Medicine In Summary… Sleepiness and fatigue can’ t be eliminated in residency, but can be managed. Recognizing sleepiness and fatigue in yourself and your colleagues is the 1st step Practice alertness management strategies regularly Don’t overlook recovery periods If self-management isn’t working, talk to your seniors and/or program director

34. Page 34 For further information Hauri Peter & Linde, S. No more sleepless nights. NY: Wiley, 1996. Sleep problems: Sleepquest (William Dement MD). http://www.sleepquest.comhttp://www.sleepquest.com Relaxation techniques: http://www.learningmeditation.com/room.ht m http://www.learningmeditation.com/room.ht m GASnet.org (fatigue in residency video): http://www.gasnet.org/videos/ http://www.gasnet.org/videos/

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