Whether you’re in training or practice, working overnight is incredibly challenging. The weight of responsibility for keeping patients alive is a lot to carry. If you’re like me, the thought of getting paged or missing a page can keep you from falling asleep. Not to mention all the moments (most of them) you are actually delivering patient care.
If you get any rest at all, it is often fragmented.
I believe that sleep deprivation is a poor tool for learning, and destroys the health of trainees. We must protect the health of physicians, nurses, and students as much as possible.
The World Health Organization has named shift work a probable carcinogen. We know that sleep deprivation more than doubles a person’s risk of cancer, due to its effects on the immune system. Sleep deprivation also increases the risk for Alzheimer’s dementia, heart disease, diabetes, anxiety, and depression, among others. I’ve experienced much sleep deprivation in my training, and I worry about the risks to my health. I’m sure you do too.
This is my guide to best support your health as much as possible when working on call or night float. Remember that you are human too, that you are deserving of the health you strive so hard to bring to your patients. Please keep advocating for yourself and those coming after you.
Here are some strategies that have helped me, (and please remember that while I’m a doctor, I’m not your doctor. Talk to your doctor before taking any medications!)
Sleep and Fatigue:
· Rest when you can. Even if that means putting your feet up and closing your eyes. This helps you have a moment of peace among chaos.
· On call, when you do have a window to sleep it is normal to feel anxious and be unable to actually fall asleep despite being tired. Try not to be frustrated with yourself. It is hard to suddenly detach from the busyness of the day and fall asleep. The only thing that works for me is acceptance. I tell myself, “If I fall asleep, wonderful. If another patient needs me before I drift into sleep, I will do my best. I accept what is to come of this night.” This allows me to relax and actually fall into sleep.
· Use caffeine judiciously. It can decrease non-REM sleep, i.e., deep sleep. When this happens, you wake up feeling tired even if you’ve had a 7 or more period of time asleep. The half-life of caffeine is 6 hours, so try to drink your last cup of caffeine at least 12 hours before trying to fall asleep. If you’re working night float, this means having an early evening coffee or tea, and switching to herbal later on.
· When the night is done, don’t drive home if you’re overly exhausted. Instead, take a nap in the call room, use a car service, or call a loved one. Too many trainees have died or have had lifelong injuries from driving while tired. Please protect yourself and others.
· To help you sleep during the day, keep your bedroom cool (68 F or less). Use a sleep mask and blackout shades. Try not to look at screens an hour or more before you want to fall asleep. Silence your phone. Wear earplugs if you need to. Tell your loved ones what time you plan to wake up, and that you will reach out to them after that time.
· Melatonin can help if you have trouble falling asleep, with a few caveats. Take only a small dose (0.5-3 mg), because taking too much can suppress your body’s ability to produce its own melatonin.
· If you have young children, it helps to call/text your partner when you arrive home to allow you to sneak upstairs and sleep. In our house, my husband tells my daughter he is taking the trash out. I then come inside when he does, without her noticing, and sleep. If you’re a parent, let go of any guilt about sleeping. Your children need you to rest. They need you to be in good health for decades to come.
Eat to Nourish
· When you are sleep deprived, recognize that your hunger hormones are dysregulated. You will have more ghrelin and feel hungrier. Your leptin is reduced, making you not feel as full after eating. For this reason, you’ll have all sorts of cravings at all hours.
· It helps me to bring my own healthy food and eat when I can. Depending on my energy levels, this is sometimes a meal I’ve cooked early in the week, a jar of nut butter, and an assortment of whole fruits and veggies. I often throw whole avocados, bell peppers, apples, pears, and fresh berries into my bag. I always have a lunch bag with utensils to cut the produce. I eat the other fruit (peppers included) by biting into them.
· Bring a mug and a water bottle. Keep yourself hydrated. I bring herbal tea in my lunch bag and have a cup in the evening and early morning if I can.
· If you have the ability to eat with your team, or to eat by a window or garden, do so. This can help build community and give you a moment of rest.
Exercise
· When you’re home with a short window of time, I recommend maximizing the time you can sleep over waking up early to exercise. Try instead to incorporate activity as possible into your call day or night shift.
· If you feel motivated, set a timer for 30 minutes on your phone, put on music or an audiobook, and go up and down flights of stairs. If you get paged after five minutes, stop and address the page. When you’re able, restart the timer and climb again. For me, sometimes this pause would be a few minutes, or hours later. I also bring an extra undershirt and undergarments if I get sweaty to change into later. Celebrate any activity you get, even if you don’t hit 30 minutes.
· If you enjoy yoga, you can bring a yoga mat, or use a hospital blanket to do some stretching throughout the night. I found this harder to do if on call with a group, but more possible in a call room or solo in a team room.
· Some hospitals have gyms, and this is a good option if it is very close to where your patients are. Make sure you have good cell/pager reception there. I have not often utilized hospital gyms due to reception issues or being too far from sick patients.
· When you face a busy call or night float shift, give yourself grace for these times. You are likely doing plenty of walking, and this certainly counts.
Reducing Stress
· Being on call is very stressful. So is night float. Working odd hours and taking care of sick patients is stressful. It will likely evoke many complex emotions, especially when patients decompensate or die.
· After a code or difficult experience, talk about it with your team. Debrief. If you are leading the team, take a moment to check in with everyone and provide support.
· Recognize that fatigue increases the chance you will make a medical error, and this will happen at some point in your career. Be sure to give yourself time and space to process this, and to talk to someone. This helps.
· I highly recommend using a meditation app to learn the gift of meditation. This practice allows me to acknowledge my thoughts and emotions without reacting strongly to them. It has helped me as I perform procedures to reduce anxiety. It also helps me fall asleep and can keep me from spiraling into negative self-talk or anger.
· Music in the team room can reduce stress, if only for 30 minutes. Jazz, guitar, and piano are some of my favorites. Appropriate times to play music are when your level of work is manageable and your co-workers are okay with it.
· Make your commute as enjoyable as possible. Snacks, sturdy slippers, good music, audiobooks, and podcasts all help.
Social Connection
· Being in medical training can be isolating. When on call or on night float, it can be even more difficult to connect with the people you care about. Recognize that these are often short periods of time and easier stretches will come.
· When I’m on night float, it is not unusual for me to go days without seeing my family. I leave home before they arrive, and come home after they’ve left in the morning. For me, video chats in the evening help, if only for five minutes. My husband and I will often talk during my evening and morning commutes. This helps.
· In the hospital, try to connect with your co-workers and patients. This connection is protective for you, and for them. To connect with colleagues, eat meals together, get to know each other, laugh together. When I was an intern on night float, my co-intern and I would see every cross-cover patient together. In this way, we supported each other and had the added benefit of doubled overnight learning.
What to Wear
· Comfortable scrubs, short or long-sleeve undershirt based on preference, compression socks, tennis shoes or clogs.
· Bring a fleece or jacket, as your body temperature drops overnight, with a peak low core body temperature at 2-3 a.m.
What to Pack
· Healthy food, a mug, and a water bottle (see above)
· An extra undershirt, undergarments, and socks. If on call, bring a regular pair of socks to sleep/rest in.
· Overnight toiletries: toothbrush, toothpaste, facewash, lotion, etc. I typically bring a washcloth and towel, although these are often provided by the hospital.
· If you plan to shower, bring flip flops and soap.
· Slippers are great for call rooms and a small comfort from home.
· Keep an on-call bag packed during the year, much easier than packing every shift.
Final Tips
· Be kind to your nurses. Remember it isn’t their fault they are paging you at 4 a.m. They are either advocating on behalf of a patient who needs help or communicating some aspect of a hospital protocol. Anger directed towards nurses is hurtful and unproductive. Always be kind.
· Your compassion will likely fade throughout your 24+4 hour calls as you become increasingly exhausted. Try to be as caring as possible with your admissions coming in the early morning. Take a moment to reset before you enter each patient’s room.
· Even when you’re exhausted, try not to rush sign out. Make sure the morning team understands the important aspects of patient care overnight.