Carpe Circadiem

Back when I was in Residency I once was awake for 36 hours.  Finally flopping on a very comfortable bed I looked over at the end table and saw a small green lizard.  He winked at me.  I took this as a cue to close my own eyes and to sleep for an indefinite stretch of time.

I should mention that this occurred during a high risk OB rotation in Houston Texas, so seeing a green lizard was not quite so unexpected as it would be here in Wisconsin, but for the rest of my month living there I never saw one of these critters indoors again.  To this day I am not sure whether the lizard was real.

Fast forward 28 years.

My main job these days is working ER.  12 hour shifts, 8 to 8.  Day shift is not bad, but 8pm to 8am on a regular basis is tough duty for a mid 50’s brain.

The term circadian, as it applies to the concept of an on board clock, derives from the Latin words circa (as in going around) and diem (or day).  And ER work is a big brutal boot stomp to the natural circadian cycle.  Gracious me, I am at an age where afternoon naps are rising rapidly in my esteem.

So here is how it can be done, or at least how I manage.

Rule 1.  Do not over commit.  10 to 12 shifts a month are plenty.  No more than three in a row.  At least 24 hours off before switching from day to night shift.

Rule 2.  Before night shifts always sleep between 2 and 5 pm.  If you do not fall asleep at least be lying in a comfy bed with your eyes closed.  Low grade rest is better than no rest.

Rule 3.  During the rare quiet stretch at work, lie down.  See rule 2.

Rule 4.  Keep track of sleep debt.  If you are up all night you need to find a way to sleep 8 hours in the 12 hours between shifts.  This is more important than meals.  We all carry extra calorie reserves but tired doctors are not good doctors.

These are general rules.  But since the ER is by definition an uncontrolled environment they may not be sufficient.  There are peculiar shifts of very high intensity where you have to stay on an hour or two and tidy up.  Sometimes you have to pick up an extra shift for colleagues.  And on occasions the non work world intrudes on the sleep-work-sleep patterns. 

The only thing you can really do is fluid management.

After a difficult day shift it is appropriate when safely in evening quarters, to enjoy a beer.  One.  I operate on the same principle as airline pilots, no alcohol unless you have a minimum of 12 hours and a night sleep before your next shift.  And while one beer has the salutary effect of inducing rapid somnolence, more that one has the effect of disrupting your sleep a time or two for trips to the loo.

The other important aspect of fluid management is obviously coffee.

There is no doubt that the metaphorical “kick from Juan Valdez’s mule” will give you several hours of enhanced logic ability.  But there is a point of diminishing returns, so the infusion of several cups of go-juice has to be timed properly.  Sometimes in the wee hours if you are simply waiting out test results on a minor illness it is better to operate the brain on “PowerSaver” mode and save the high voltage thinking for when it is perhaps literally a matter of life or death.

And speaking of life and death there is a state of existence somewhere betwixt the two.  After finishing a night shift it seems seductively good and proper to enjoy a mug of steaming java.  But if there is another shift looming in 12 hours you must resist.  It is better to exist in a slight state of drowsy, headachy caffeine withdrawal and get decent inter-shift sleep.  Your patience and low level suffering will be rewarded when 7pm rolls around and the pre-shift “cuppa” puts the hammer down with eye opening force!