What you should know before your first ED shift

October 13, 2021September 25, 2021 ~ iEM Education Project Team ~ Leave a comment

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed thing you should know before your first emergency department shift. Dr. Ana Paula Freitas, Dr. Gregor Prosen, Dr. Joe Bonney and Dr. Rasha Buhumaid were the guest speakers of this episode. Dr. Dr. Arif Alper Cevik was the hosts of this session.

Dr. Ana Paula Freitas, Dr. Gregor Prosen, Dr. Joe Bonney and Dr. Rasha Buhumaid shared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.

Want More on ED shift work?

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed thing you should know before your first emergency department shift. Dr. Ana Paula

iEM Education Project Team October 13, 2021

The emergency department is open 24/7, meaning that most ED physicians experience shift work. Shift work means that service is provided around the clock, whether

Brenda Varriano, Canada November 30, 2020

Things You Should Know Before Your First ED Shift

I recently posted a question to the Twitterverse: “Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be

Ibrahim Sarbay, Turkey July 13, 2020

Sleep and Shiftwork

November 30, 2020December 2, 2020 ~ Brenda Varriano, Canada ~ Leave a comment

The emergency department is open 24/7, meaning that most ED physicians experience shift work. Shift work means that service is provided around the clock, whether it be night or day. Though shift work is almost always part of the job description for an ED doctor, it may not always favour the wellbeing of the physician. Inspired by a classmate, who adopted the sleep cycle of an ED early on in his M1 year, I wanted to discuss the science of sleep, the impact of shift work and how can we improve sleep hygiene when shift work is part of our job.

Basic Science of Sleep?

Sleep is part of every human being’s existence, as we could not live without it. Even though we have limited recollection of what happens during sleep, the process is quite complex. First, sleep latency is the time needed to fall asleep. Second, sleep is broken down into four stages that we oscillate through 4-5 times a night. The time it takes to go through all stages in a sleep cycle is approximately 90-120 minutes. The four stages we must pass through are called stage 1, stage 2, stage 3 and rapid eye movement (REM) sleep, respectively. Stage 1 through 3 is collectively called non-rapid eye movement sleep (NREM).

Stage 1 is the lightest stage of sleep and the first one we enter from wakefulness and is characterized by theta waves (4-7 Hz) on an EEG. Stage 2 is a deeper sleep and the period where we spend most of our time sleeping. It is characterized by theta waves, sleep spindles and k-complexes. Finally, stage 3 is known as slow-wave sleep, where delta waves predominate the EEG (0-4 Hz). Finally, after the three NREM stages, we enter REM sleep. REM is the deepest stage of sleep, despite the EEG activity being the closest to waking state. It is during REM sleep that we experience vivid dreams and have low muscle tone.

So why is sleep important?

First, there is a growing body of evidence that slow-wave sleep is when we store memories. Therefore, through proper sleep, we can consolidate memories, increasing retention of what we had learned the previous day. Moreover, sleep is important in our ability to regulate our emotions and respond appropriately to different circumstances. In addition, when we get proper sleep, we are more like to be in a positive mood, which can impact our patient interactions. Furthermore, sleep is important in immune regulation and the ability to fight off infection. Finally, sleep helps with muscle recovery and favours protein anabolism (growth). I personally believe that muscle recovery is important given the time spent on one’s feet during an ER shift. This theory of sleep and muscle recovery has been supported in sports medicine literature, and I am intrigued to see if this evidence also existed for ED Physicians and other medical specialities that are more physically demanding.

Shift work in health care workers

So, what happens when we don’t sleep? First, shift work and lack of proper sleep increase levels of fatigue and errors made by health care workers. This can have profound implications on patients, especially in the ED, where the severity of presentation is often greater than in other clinical environments. This is also alarming, given that shift workers tend to have a reduced total amount of sleep. This reduced amount of sleep most commonly impacts stage 2 NREM sleep and REM sleep, thus reducing the quality of sleep, in addition to the duration of sleep. This reduced sleep quality is worse in shift workers on a rotating shift schedule, compared to a nighttime or daytime only worker.

Moreover, in some studies of ER workers, the duration of sleep, especially REM, is less during the day then at night. So even if one believes they are still getting sleep, it may be of reduced quality. Some explanations for this diminished REM sleep during the day is the body’s natural response to a light-dark schedule and the release of melatonin, the sleep hormone. Melatonin is the sleep hormone, which often rises at nighttime when it is time to go to bed. Sunlight inhibits the release of melatonin, signalling our bodies that it is time to be awake. So, even if one tries to sleep in a dark room, the walk home from a shift or exposure to hospital lights may confuse the circadian clock, diminishing sleep quality. Finally, other studies have reported that shiftwork could increase cardiovascular disease risk, blood pressure, increase levels of stress and cause gastrointestinal issues. In women, shiftwork can cause fertility problems, such as premature birth and low-birth-weight infants.

How to combat some of the negative effects of shiftwork

Individual Strategies

There are many things we can do to manage our sleep quality and scheduling. For example, our sleep environment can be adjusted to maximize our sleep quality. Strategies can include the use of earplugs and ensuring a dark room devoid of as much light as possible. Additionally, sunglasses can be worn to and from a night shift, to avoid daylight, which may signal to our body the biological start or end of a day.

Organizational Strategies

While some of the individual strategies may be useful to improve sleep hygiene with a shift work schedule, I also believe that some strategies should be implemented at the institutional level. For example, there is a body of literature which discusses that shifts longer than 12 hours are the most detrimental to sleep quality and a physician’s health. Moreover, the duration and timing of a break during a shift could help reduce some of the symptoms of shift work. Longer breaks during a shift are favoured, though the reasons why the longer breaks are better for sleep hygiene are unknown. Finally, scheduling strategies should be implemented. A paper by Burgess, has suggested that shifts be organized in a clockwise manner. For example, on performs a morning shift, then evening shift and a night shift etc. Moreover, morning shifts should not start earlier than 8:00 A.M. to favour our natural circadian rhythm. Issues with this approach are that multiple physicians work in an emergency department, many with families and different lives, which may prefer different schedules. Another issue is when a physician is sick, and another substitutes in. This could throw off the sleep schedule of both the physician cancelling and substituting the shift. Furthermore, is there an ideal number of days between shifts? Should this change with physician age knowing how melatonin levels decrease and the body becomes less resistant to stressors with ageing. While there are currently no gold standards with sleep regulation and shiftwork, we should at least be aware of why this is important and be mindful of our practices. It is easy to neglect our health in favour of our careers, something I have been all too familiar with and hope to improve.

Conclusion

I would like to end this article with a few comments about sleep. While the published literature may not tell a complete story due to the publication bias, there are a few things we can take away. Sleep is essential for our health and mental wellbeing. Shiftwork cannot be avoided, and, if self-care is not practiced, lack of sleep can have detrimental effects on our body and wellbeing. The impact of shiftwork on everyone can be different. Therefore, individual strategies to advocate for personal health is important. Organizations have a role in fostering an environment that supports good sleep habits and employee health. Finally, medical schools and residency programs should incorporate time to educate students on sleep hygiene and hopefully, inspire students to be agents of change in their own hospitals, thus fostering wellness practices. I look forward to joining you next time while I talk about imposter syndrome in medicine.

References and Further Reading

Burgess P. A. (2007). Optimal shift duration and sequence: recommended approach for short-term emergency response activations for public health and emergency management. American journal of public health, 97 Suppl 1(Suppl 1), S88–S92. https://doi.org/10.2105/AJPH.2005.078782
Dall’Ora C, Ball J, Recio-Saucedo A, Griffiths P. Characteristics of shift work and their impact on employee performance and wellbeing: A literature review. Int J Nurs Stud. 2016;57:12-27. doi:10.1016/j.ijnurstu.2016.01.007
Dattilo M, Antunes HK, Medeiros A, et al. Sleep and muscle recovery: endocrinological and molecular basis for a new and promising hypothesis. Med Hypotheses. 2011;77(2):220-222. doi:10.1016/j.mehy.2011.04.017
Gruber R, Cassoff J. The interplay between sleep and emotion regulation: conceptual framework empirical evidence and future directions. Curr Psychiatry Rep. 2014;16(11):500. doi:10.1007/s11920-014-0500-x
Halson SL, Juliff LE. Sleep, sport, and the brain. Prog Brain Res. 2017;234:13-31. doi:10.1016/bs.pbr.2017.06.006
Ibarra-Coronado EG, Pantaleón-Martínez AM, Velazquéz-Moctezuma J, et al. The Bidirectional Relationship between Sleep and Immunity against Infections. J Immunol Res. 2015;2015:678164. doi:10.1155/2015/678164
Kuhn G. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. 2001;37(1):88-98. doi:10.1067/mem.2001.111571
Marshall L, Helgadóttir H, Mölle M, Born J. Boosting slow oscillations during sleep potentiates memory. Nature. 2006;444(7119):610-613. doi:10.1038/nature05278
Paller KA, Voss JL. Memory reactivation and consolidation during sleep. Learn Mem. 2004;11(6):664-670. doi:10.1101/lm.75704
Qureshi, S., Karrila, S., & Vanichayobon, S. (2018). Human sleep scoring based on K-Nearest Neighbors. Turkish Journal of Electrical Engineering & Computer Sciences, 26(6), 2802-2818.
Sack RL, Lewy AJ, Erb DL, Vollmer WM, Singer CM. Human melatonin production decreases with age. J Pineal Res. 1986;3(4):379-88. doi: 10.1111/j.1600-079x.1986.tb00760.x. PMID: 3783419.

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Things You Should Know Before Your First ED Shift

July 13, 2020July 19, 2020 ~ Ibrahim Sarbay, Turkey ~ Leave a comment

I recently posted a question to the Twitterverse:

“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”

I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.

Imagine that a new Emergency Medicine resident asked you for advice before the FIRST SHIFT. What would be your FIRST ADVICE? (The answers will be used for a blog post- Pls RT to spread) @EBMgoneWILD @EM_Educator @EM_RESUS @emcrit @Damian_Roland @FOAMpodcast @ssuner @FOAMedinburgh
— İbrahim Sarbay (@ibrahimsarbay) July 3, 2020

Core

Enjoy being on the frontline by helping patients who are seeking your help in their most difficult time. This is a great privilege and responsibility that we should never forget.

Arif Alper Cevik (@drcevik) Tweet

Never forget what a privilege and responsibility it is that people don’t know you ask for your help on the WORST DAY OF THEIR LIFE.

Amal Mattu (@amalmattu) Tweet

In the Emergency Department, you may be worried about 'why am I here?' one day, but you may think that you are doing the best job in the world another day. Now you have a lifetime which every day and every patient is different. Love your profession EVERY WAY, glorify knowledge and skill, and always be at peace with your job.

Başak Bayram (@basakdr) Tweet

Education

Never be afraid to say, "I don't know." It's why you're here to be taught. If you already knew everything, then you wouldn't need residency.

Justin Hensley, (@EBMgoneWILD) Tweet

Trust yourself as if you know everything, try to learn as if you know nothing.

@cear_slan Tweet

Want to get smart? Do 2 things: 1) Read up on at least 1 patient every shift. 2) Ask lots of questions to residents, attendings and consultants.

Amal Mattu (@amalmattu) Tweet

Feel free to ask me (or another senior) about anything (/everything). When I was at that stage I wish I’d asked more. I suspect some people think asking is a sign of ignorance or weakness. Actually, it helps us to be safe & to appreciate other perspectives.

Rick Body (@richardbody) Tweet

This is the Emergency Room; this is the lion’s den; first, you have to protect yourself, and you will do this with your knowledge. So don't think ‘I'll practice, I'll fill my knowledge gap in 3-5 months', sit down, and read the textbook.

Göksu Afacan Öztürk (@Goksu_Afacan) Tweet

First compel yourself to read at specific points, and gradually you will find your appetite for reading. You are the one primarily responsible for your education!

@ChannelAziz Tweet

Never feel shy to ask or say I don't know. It's your chance to make mistakes and learn, share the knowledge you have and don't keep it to yourself.

Lara Sulaiman (@Dr_Lara) Tweet

Of course, you cannot know everything, but you can start learning.

Ozlem Guneysel (@oguneysel) Tweet

80% of “KNOWLEDGE” is "INTEREST"

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Resilience

The Emergency Medicine career is a marathon, not just the first few years of residency. Don't waste your energy inordinately for things you can't fix. Invest in the future self.

Can Özen (@cozenmd) Tweet

When you dance with the bear you can't stop until the bear wants to stop.

Nurettin Özgür Doğan (@DrOzgurDogan) Tweet

Calm down. Every shift eventually ends.

Mustafa Ercan Günel (@mercangu) Tweet

Rest and eat, whenever you get the opportunity. The Emergency Room is like a HIIT, you need to slow down first to speed up.

Burcu Yılmaz (@Burcu_Yilmazzz) Tweet

If you are a parent, sleep when the child sleeps.

@pekinipeklisi Tweet

Empathy

Don’t judge patients or consultants without walking a mile in their shoes.

Amal Mattu (@amalmattu) Tweet

Think of every patient as your relative. Balance your professional authority with your kindness.

@damkmiyenses Tweet

Communication is important. Tell the patient and one of his/her relatives what you already did and what you plan to do, and ask if there is anything they want to ask.

Altuğ Kanbakan (@prothemanes) Tweet

Peter Rosen once said, “Nobody woke up this AM decided to ruin your day.” Happiness is YOUR choice. Be happy, stay positive.

Amal Mattu (@amalmattu) Tweet

Remember, when you see a patient in the middle of the night who requests you to apply his/her prescribed topical cream on his/her back because –apparently- he/she can’t, that person is the joy of the night.

@dogu6 Tweet

Follow up on your patients. This will reinforce your learning. Call patients at home to see how they’re doing. They will love it, and it reminds you of why you chose this profession.

Steve Richards (@srichmd) Tweet

Remember to acknowledge that you most likely are a stranger to your patient. It only takes a few minutes to reassure someone that you are there to help them through their ER experience as a team. We tend to forget this in the busy ER.

Anél Pelser (@PelserAnel) Tweet

Values

Nobody expects you to know much (yet). But it is expected you to be 100% reliable. Never EVER EVER EVER lie. If you don’t know something or you don’t do something, be honest.

Amal Mattu (@amalmattu) Tweet

Your attitude to this advice will determine your path through our specialty. The blindingly following advice will bring as much peril as ignoring it all. Emergency Medicine requires you to consider impacts on patients, professionals & the populations - no one approach fits all.

Damian Roland (@Damian_Roland) Tweet

Never EVER EVER EVER be arrogant. You will be wrong many times in your career. Learn humility NOW.

Amal Mattu (@amalmattu) Tweet

What I like most about emergency medicine is how it allows us new perspectives every day. In the pandemic, we are treating the same disease all the time, but each patient and their family brings a different story, and every time I feel more humble in the face of life, the disease, and the future. Being in a LIMC country can be so challenging, so painful to treat and suffer along with inequalities and lack of resources... But we have the opportunity to be our best, as I said yesterday to my residents: we don’t have the best hospital, but we can be our best and give the patient what they may not have in the best hospital: treatment with dignity and respect and love. For me, being able to show my patients that I care, and receiving their gratitude has been undoubtedly the only possible prevention of Burnout. So I would say: Our specialty is beautiful, the opportunity for growth is vast, but it takes humility and perseverance to complete this journey.

Jule Santos (@julesantosER) Tweet

Never allow senior residents of other departments to treat you as if you are their junior.

Dr Erdi Kadir Y. (@DrEKYacil) Tweet

Our fingers are not equal, and so are the attendings whose hands you train on are not the same nature. There is the gentle one who loves you and there are critics who believe that development comes only with criticism and a dose of pain. Your job is not to try to classify them but to do what is required of you and to benefit from everyone.

@ChannelAziz Tweet

We want you to be the brain of a machine in which none of its cogs can work properly. Sometimes, even if you don't know how to swim, you will find yourself in the ocean surrounded by the waves, but most of the time, in the hardest moments, you will find a huge army with you. Welcome...

Barış Murat Ayvacı (@emresuspack) Tweet

If you think a senior is wrong about something, give him evidence, but don’t be obstinate...

Ali Kaan Ataman (@erdrkaan) Tweet

You may be untutored, but never be uninterested. Because knowledge definitely comes to those who have interest.

Mustafa Ipek (@dr_mustafaipek) Tweet

Appear weak when you are strong and strong when you are weak. Look weak when strong; look strong when weak. Also don't forget to look at vital signs 😉

Osman Avşar Gül (@mefisto_avsar) Tweet

Don’t be a d*ck.

Rob Rogers (@EM_Educator) Tweet

Enjoy your junior days, qualify for your senior days.

Agit Akgül (@DrAgitAkgul) Tweet

Patient Records

(Carefully) Fill out the patient records. What will save you from everything are these records.

@dferek Tweet

Spoken words fly away, written words remain. Record everything...

Şervan Gökhan (@servangokhan) Tweet

What is not written is deemed not done. First, protect yourself and then protect the patient. Choose a good role model.

Ozge Duman Atilla (@ozgedumanatilla) Tweet

Workup

No workup can replace a good physical examination.

Erdal Demirtaş (@Erdal_DD) Tweet

Never order a test that you won’t check the results.

Eyupkaraoglu (@drekaraoglu) Tweet

Know your tests! Know their rough sens/spec and when to trust them (and more importantly, when NOT to trust them)!! No test is 100%, and all are context-dependent!

Elias Jaffa MD MS (@jaffa_md) Tweet

Decision Making

Being efficient should never be at the expense of being thorough. You will eventually have to waste more time making things right.

Danya Khoujah (@DanyaKhoujah) Tweet

If someone brings up a concern, go to the bedside.

Sunny Elagandhala (@elegantdolla) Tweet

Think simple, make a quick decision. Determine the senior you will take as a model.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Once you suspect about a diagnosis, be sure to rule it out.

Ilker Akbaş (@ilkerakbas) Tweet

Do not forget to consider emergencies and other diseases while focusing on frequent diseases of the period, such as COVID. The most important thing that the emergency doctor needs to do is to look at the case from a wide perspective from the very beginning.

Gaziantep Acil Tıp (@AcilGaziantep) Tweet

Watch out for the last patient who came just before your shift ends.

Meltem Şahin (@onlakonusmayin) Tweet

In emergency medicine [and in life :)] the possibilities are 0% or 100% only in limited scenarios. You need to quickly learn managing probabilities, setting priorities, distinguishing acceptable and unacceptable risks. Also you need to learn reading the environment; because it usually gives many signs before the problem emerges.

Elif Dilek Çakal (@DrEDCakal) Tweet

Patient in the Resus is easy. Spotting the patient with a real emergency in minors is the tough one.

@fakuna_matata Tweet

First rule of emergency response is to ensure your own safety!

SALİH KARABULUT (@drskbulut) Tweet

When in doubt or worried about someone, talk to floor senior physicians EARLY.

Rahul Goswami (@Rahul_Goswami_) Tweet

I would say to try your best to remain open-minded and try to be aware of your biases and blindspots. This applies especially to patients with psychiatric illness and substance use disorders. If you're explaining X symptom on Y problem, always ask yourself, "Does this actually make sense?

Elias Jaffa MD MS (@jaffa_md) Tweet

The most frequently overlooked diagnosis in the emergency room is the second diagnosis! Do not limit your perspective to one diagnosis. Most frequently missed fracture in the emergency room? The second one! Remember that the patient may have a second fracture!

Mehmet Ergin (@drmehmetergin) Tweet

While assessing only isolated parts, don’t miss to assess the patient as a whole. Do not evaluate the patient on a single system, single organ basis. Emergency Medicine requires ‘holistic assessment’.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Discharging

No hospital bed belongs to you. If in doubt, do not discharge the patient.

Haldun Akoglu (@IstanbulEMDoc) Tweet

Do not discharge the patient relying on what someone else is telling you without assessing by yourself!

Emre Salçın (@emresalcin) Tweet

Do not discharge the patient after midnight: You may be tired, you may overlook something, the patient and his relatives may not find a car or money to leave, or they may try to go to the town or another city but have an accident on the road, etc. Those all happened (Not my personal experience, but I have seen them), evidence based...

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Before discharging the patient whose treatment is completed, make sure to think like that: ‘Is there any possibility that this patient will come back with a cardiac arrest before the shift ends?’ If you are hesitant, prolong the process.

@fakuna_matata Tweet

The patient at the hospital is better than the patient at home’. Do not discharge if you are not sure.

Belgin Akilli (@AkilliBelgin) Tweet

Team Play

Emergency Medicine is teamwork. Get along well with your colleagues, your nurse, your intern, your staff and your secretary. Find yourself a role model, try to be a good example for others. And enjoy the Emergency Medicine.

Melih İmamoğlu (@melihimam) Tweet