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Page 1© American Academy of Sleep Medicine
American Academy of Sleep Medicine
SLEEP,
ALERTNESS, and
FATIGUE
EDUCATION in
RESIDENCY
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
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
Page 4
Objectives1. Recognize universal need for adequate
sleep2. Review risks of sleep deprivation3. Consider methods to promote
alertness when sleep-deprived4. Consider methods to reduce risk of
fatigue-related errors5. Identify methods to recover from sleep
deprivation6. Review preventive measures
Page 5
Humans need adequate sleep
Adequate means both duration and quality
Page 6© American Academy of Sleep Medicine
American Academy of Sleep Medicine
Time
9 PM9 AM 9 AM
SleepWake
Sleep Homeostatic drive (Sleep Load)
Circadian alerting signal
Alertness level
3 PM 3 AM
Human Circadian Rhythm is fairly consistent
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 Mustafa and Strohl, unpublished data.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
© 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.
Page 9
Sleep deprivation is hazardous to others
© 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
Page 11
Sleep deprivation is hazardous to you
“Dan, moments before he fell asleep at the wheel”
© 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
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
Adverse Health Consequences by Average Daily Hours of Sleep*
0
10
20
30
40
50
60
<4 hrs 5-6hrs >7 hrs
Hours of Sleep
Perc
ent
% Reporting SignifWt Change
% Reporting MedUse to Stay Awake
% ReportingIncreased AlcoholUse
*Baldwin and Daugherty,1998-9 Survey of 3604
PGY1,2 Residents
© 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.
© 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
Page 16
“Alertness management” strategies
Caffeine
Exercise
Light
Napping
Medication
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
Page 18
Exercise
Stretch, run in place, or do jumping jacks
Walk briskly from house to car, car to hospital
Page 19
Light
Best: full-spectrum light (e.g. sunlight)
Any bright light helps
Page 20
Napping
20-45 minutes
Up to 2:00
(allows REM + restorative sleep)
BUT longer naps > risk of sleep inertia
Page 21
Medication
Modafinil
ONLY IF PRESCRIBED by your personal physician
Page 22
And watch out for these
MicrosleepsSleep inertiaCircadian lowsIsolationSelf-deceptionHigh risk jobs
Page 23
Microsleeps
“Faceplants”,or “nodding off”
Sleeper often unaware
Alert your colleagues!
Response: thank colleague; exercise; talk
Page 24
Sleep Inertia:
10-120 min of grogginess, cognitive slowing, decreased vigilance after awakening.
Worsened by sleep deprivation
Page 25
Circadian lows
12-4 a.m.
12-4 p.m.
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)
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.”
Page 28
High-risk jobs
low stimulation + high need for vigilance
© 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).
© 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).
Page 31
Recovering from sleep deprivation
On average, two nights’ recovery sleep (approx 9 h) needed
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
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
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.com
• Relaxation techniques: http://www.learningmeditation.com/room.htm
• GASnet.org (fatigue in residency video): http://www.gasnet.org/videos/
Page 35
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