I’m on call this weekend. As we started rounds this morning, the conversation turned to one of our superstar residents who (uncharacteristically) was late to rounds. He was up all night and overslept after falling asleep in the wee hours of the morning. What struck me was what he told us… “I knew something was wrong when I woke up feeling good.” Being on call, and being up all night is part of medical training (and practice). And it’s not just an occasional event – we often have to do it every three or four days. It’s essentially iatrogenic jet-lag and it takes some time to learn how to manage this kind of fatigue.
Being tired after call takes two major forms: with sleep and without sleep. Depending on the type of call, the recovery is different. If you have been inundated with work, but were able to sleep, you will be physically (somewhat) and emotionally (a lot) tired. The treatment for this is play. You need to spend some time doing something that is not related to work, preferably in the company of friends. You need time to process what you have just seen and done, but, more importantly, you need to feel like you are still connected to the world outside of work. Physical activity is essential. Even if you get home late, do something to stretch and use your body. Even a 15 minute walk outside followed by 5 minutes of stretching will do the trick. If you live with a significant other, make sure you have dinner together and really talk. Put on some nice music. Call a friend. Go out to eat. Whatever you do, don’t “numb out” by drinking a beer in front of the TV set.
Being tired without sleep is a physiologically abnormal state for human beings. No matter how much the culture says you should be “tough enough” to go without sleep, it’s crazy. We are designed to sleep 7-9 hours every night and, when we don’t, we don’t function as well. There is an amazing amount of literature on the effect of sleep deprivation on performance, competence and health. Suffice it to say that we all realize we don’t want the pilot of our plane to have been up for 24 hours prior to our flight. It’s no different for a doctors.
There is literature on this problem, but these are studies that doctors don’t often review. A sleepless call night is basically a shift in your body clock i.e. jet-lag. The big difference is that the light cues are the same after call (unlike when you fly to Europe). So what have business executives and airline pilots learned about dealing with this kind of time shift?
- Stay hydrated. It may sound silly, but paying attention to drinking enough water will make a big difference. How much is enough? Enough to keep your urine clear. It is amazing how, during a busy day, you can forget to drink water. Start looking for the drinking fountains and stop for a drink when you see them. Carry a water bottle in your on-call bag and pull it out when you are doing sign outs, or taking a break. Having a bag of cut up lemons helps, too. A tall glass of ice water with fresh lemon in it is a fabulous treat in the middle of a busy night. Mild dehydration will increase your level of fatigue. Watch out for soft drinks and tea – the caffeine may give you a little kick (and there is nothing wrong with that from time to time) but, if you drink a lot of caffeine, it will really mess up your sleep cycle when you do get to sleep. Also, tea and coffee act as a diuretic, so your net hydration may be negative. Water is by far the best choice.
- Don’t skip meals. Most importantly, don’t skip breakfast. Most students and residents have to get up really early to get to work. And, most people just don’t feel like eating a big breakfast at 5:30 in the morning. Eat something before you leave the house (a cereal bar or piece of fruit, for example) and then take something more substantial for later in the morning. Even if it’s only an energy bar in the pocket of your white coat – take something and then eat it!
- Don’t go too long without food during a long shift. You need to eat something every 3-4 hours if you are working hard. You should carry at least one snack in your coat pocket such as a small bag of nuts, an energy bar, some raisins, or some dried fruit.
Probably the worst mistake people make in recovering from call is what they do once they leave the hospital. You can really help your recovery, enjoy your time off more, and return to work ready if you realize one fact: You have shifted your biologic clock by staying awake all night. If you go home the next morning (or afternoon) and sleep for 8-10 hours, you will have shifted it even more. So how do you best recover?
- No matter how tired you are, your first stop should be the gym, a park, or someplace you can work out. This does not have to be (and shouldn’t be) a hard workout. This should be a “work out the stress” workout. Don’t push yourself hard, but work up a little sweat. Even if it’s just 20 minutes of walking in a park, you will feel better.
- Treat yourself well. Take a nice long shower when you get home. Make yourself a nice meal, but not junk food. Eating a lot of protein and fat will put you in a fatigue tail-spin.
- Take a nap, but make yourself get up so you can sleep that night. 3-4 hours is usually about right. Make arrangements to have dinner with friends, if you live alone. If you have a significant other, make plans to do something together in the evening. If you want to have a glass of wine, or one beer, do so – but don’t have more than that. It will mess up your sleep and it’s not worth it.
- Don’t drink caffeine after the morning. Even though you will be sluggish in the afternoon, don’t sabotage your night time sleep with caffeine.
- Go to sleep early. In addition to being sleep deprived, you will also feel socially deprived. It’s natural to want to go out with friends when you feel this way. However, they are not as sleep deprived as you are, and they don’t have to do this again in a few days. If you’ve had a hard call, with very little sleep, you should plan to get 10-12 hours of sleep the next night. You have to get at least 8 hours. In other words, if you have to be up at 6, you should be in bed no later than 10 pm, but, as crazy as it sounds, if you can get to sleep at 8, it will be better.
In the past week I had travel arrangements go awry because my embarking flight was delayed causing me to miss a connection. The reason for the delay? The pilots were not allowed to enter the cockpit because they did not receive their FAA mandated 8 hours off the night before.
Great post and great advice! I hope your residents follow your advice. I wasn’t always wise enough to do so when I was a resident 🙂