Prioritizing Sleep,
Fighting Fatigue
Paul Nystrom, MD Faculty, Hennepin County Medical Center Department of Emergency Medicine Assistant Chief Medical Director, Hennepin EMS Medical Director, Edina Fire & Police Medical Director & Officer, Plymouth Police
These opinions and ideas are mine and do not
represent the opinions/policies of HCMC or PPD.
I mention specific names/brands because I believe they have value.
Today’s Agenda
•
Discuss the evidence related to
fatigue in EMS & 2018 EBGs
•
Highlight the importance of sleep &
downsides of less sleep
•
Discuss what happens when we sleep
•Talk about better sleep strategies
Less Sleep
•
Is less sleep and/or poor sleep a
problem?
•
What’s the usual advice?
•What’s our culture?
Personal Attitudes
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Sleep is for the weak
•
Napping is for lazy people
•
FOMO- Fear Of Missing Out
Systemic Attitudes
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Sleep is for the weak.
•
Napping is for lazy people.
•
Sleep on your own time.
Kirk Parsley, MD (SEAL)
•
TEDx Reno
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We think we are immune
•
We pride ourselves on sleep
deprivation
Pilots have work hour restrictions.
Truckers have work hour restrictions.
ATCs have work hour restrictions.
Medical residents have work hour restrictions.
EMS is Behind the Curve
• US commercial motor vehicle/transportation • Energy production
• Manufacturing industries • Commercial aviation
• Military
• Air traffic control • Hospitals/residents
The Beginning of EBGs
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“The need for fatigue risk management in
the EMS setting is compelling.”
•
“Shiftwork is here to stay and we will never
completely eliminate the fatigue problem.”
•
2013-2015: NEMSAC & NHTSA launched
development of Evidence Based Guidelines
for fatigue risk management tailored to EMS
Prehospital Emergency Care
February 2018 Supplement
•
Fatigue Risk Management in High-Risk Environments: A Call to Action•
Evidence Based Guidelines for Fatigue Risk Management in EMS: A Step in the RightDirection Toward Better Sleep Health
•
Absence and Need for Fatigue Risk Management in EMSSystematic Review Methodology for the
Fatigue in EMS Project
•
7 Systematic Reviews 1. Survey instruments 2. Shift duration 3. Caffeine 4. Naps 5. Fatigue training 6. Biomathematical models 7. Task loadSummary
•
“Although we are not yet able to
recommend an optimal pattern of
shift schedules for EMS workers, we
do know enough to make some
general recommendations for
optimizing sleep health.”
Sleep Characteristics
“RU SATED”
•
Regularity•
Satisfaction•
Alertness•
Timing•
Efficiency•
DurationGoals to Work Toward
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Regularity- “irregularly irregular” is bad•
Work and sleep at the same time each day•
Shifts should be strung together•
Satisfaction- enough time but not too much•
Alertness- requires adequate sleep at nightGoals to Work Toward
•
Timing- sleep is best at night•
Operational naps 0200-0500 if possible•
Efficiency- ideally a solid block with few awakenings•
Inversely proportional to time in bed•
High efficiency cannot compensate for inadequate total sleep timeEvidence Based Guidelines
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Strength of Recommendation:
•Weak/Not Applicable
•
Quality of Evidence:
•Low/Very Low
•
Exception: Strong recommendation
Not Surprising, Right?
If you’ve seen one EMS
system…
…you’ve seen one EMS
system.
Too Many “Buts”
• Shifts <24 hrs better than >24 hrs (BUT that
leaves a lot up in the air)
• Caffeine is a performance enhancer BUT screws
up sleep
Too Many “Buts”
• Fatigue training is good BUT exact training is
unclear
• Biomathematical modeling interventions are a
good idea BUT only one study existed.
• Reducing task load sounds good BUT the
Evidence Based Guidelines
1. Survey your people for fatigue
2. Shifts <24 hrs
3. Access to caffeine
4. On duty naps
Rotating Shifts*
•
Easier to adjust flying west than east•
Biological clock is slightly more than 24 hrs•
Easier to rotate day to evening to night•
Not vice versaNow What??!
What is the Risk?
•
18 hrs awake = performance at 0.05 BALLess Sleep & Health
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Higher rates of heart disease, hypertension•
Higher rates of infection, allergy & asthma•
Higher rates of sexual dysfunction•
Higher rates of depression/anxiety, anger, irritabilityLess Sleep
•
Clearly linked to metabolic disease
•
Often disregarded and overlooked
•
More important than Nutrition?
Sleep & Insulin
•
Small studies restricting sleep:
•
Insulin at pre-diabetic levels
Insulin Resistance OUR UNIFIED FIELD THEORY
Hormone Disruption
•
Increased Cortisol•
High blood sugar/High insulin•
Good for “fight or flight”•
Bad when chronically elevatedGrowth Hormone (GH)
•
The Repair hormone•
Released in response to:•
Deep sleep (slow wave sleep)•
High intensity exerciseHunger Hormones
•
Ghrelin- promotes hunger•
Increased with lack of sleep•
Leptin- inhibits hungerSleep Cycles
•
5 stages•
1,2•
3,4 (Deep sleep, SWS)•
REM- Rapid Eye Movement•
Repeating pattern in 90-100 min cyclesSleep Cycles
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Stage 1: occurs only once, a transition into sleep•
Stage 2: accounts for >50% of sleep time•
REM: 20% of sleep timeSleep Inertia
•
Waking from SWS•
You are not “more tired” than before•
Proven solutions: 1. Physical activity2. Sensory stimulation 3. Caffeine
Practical
Recommendations
Sleep
Hygiene
•
Consistent routine•
Sleep alarm•
Dark•
Sleep mask, (BPH lights if awake)•
Cold•
60-66 degrees optimal•
QuietSex & Snoring
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Your bed is for sleep or sex•
Program your body to happily anticipate going to bed•
Change your environmentDon’t Waste Sleep Time
•
Screens & Technology are not your friends•
Social media•
FOMOUse the Light
•
Most powerful environmental/circadian cue•
Use light to your advantage•
Bright light early in your wake cycle•
Non-blue light before bed•
f.lux or Night Shift on screensCaffeine Effects
•
Blocks adenosine receptors in the brain•
Adenosine is usually inhibitory (downer)Caffeine = Band Aid
•
Proven performance enhancer but effects are negated by tolerance.•
Long half life impairs sleep cyclesCaffeine Dosing
•
Small, regular doses are better than large, fewer dosesEmotional Commotion
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Guard your relationships•
Don’t check email/messages before bed•
Don’t be a school kid the day after Labor Day•
Paper and pencil by the bedSleep Aids/Experiments
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Sleep aids/herbal remedies/tea•
Tetris•
Meditation/mindfulness•
Eating lateSleep Drugs
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All sleep drugs disrupt sleep architecture•
Humans don’t have Ambien receptors•
The best treatments for insomnia are behavioralInsomnia is more often a
Priority
Melatonin
•
Reasonable/safe option•
Conflicting information:•
Dose•
Timing•
DependenceTo Nap or Not To Nap?
•
Evolutionary evidence supports biphasic sleeping•
A longer period at night, shorter period 12 hrs later•
Lost with the invention of the clock and the industrial revolutionNap Benefits
1. Increase your alertness
2. Speed up your motor performance 3. Improve your accuracy
4. Make better decisions
5. Improve your perception 6. Fatten your bottom line
7. Preserve your youthful looks 8. Improve your sex life
9. Lose weight
Nap Benefits
1. Reduce your risk of diabetes 2. Improve your stamina
3. Elevate your mood 4. Boost your creativity 5. Reduce stress
6. Help your memory
7. Reduce your dependence on drugs/alcohol
8. Alleviate migraines, ulcers & other problems with psychological components
9. Improve the ease and quality of your nocturnal sleep 10. It feels good
The 20 min Power Nap
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Stage 1: 2-5 mins•
Stage 2: the first Stage 2 takes 17 mins at minimum•
Avoids SWS and sleep inertiaNaps & Nocturnal Sleep
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Naps do not adversely effect nocturnal sleep if:•
You have normal sleep•
Shorter than 2-3 hours (max 2 sleep cycles)Guard Your Sleep
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And your family & friends’ sleep•
Don’t call/text/message late except emergencies•
Email x3, Active 911 x3, ZipIt, Smart Pager, Slack, FB, FB Messenger, Twitter, Google Hangouts•
Change your phone settings•
Fetch vs. Push?Take Aways
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Acknowledge this is an issue•
Systemic and Individual•
Check out the guidelines•
Prioritize & Protect your sleepResources
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Prehospital Emergency Care February
2018 Supplement
•
Kirk Parsley- TEDx Reno
•
Take a Nap, Change Your Life-
Sara Medick
•
The Sleep Revolution-
Arianna Huffington
•
Tools of Titans-
Tim Ferriss
[email protected] @paulcnystrom
Kids & Sleep
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Sleep is essential to health•
Sleep is not punishment•
Establish good habits early•
“My kid can sleep anywhere!” is not necessarily cause for braggingKids & Sleep
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Studies confirm worse grades & decreasedproductivity in kids short on sleep
Guard Your Kids’ Sleep
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Don’t over schedule•
Phones/tablets/TVs/devices•
Model good sleep