A paramedic on a 10-10-14-14 schedule has a busy first night with constant calls. At 5 a.m., she is treating an elderly patient with a severe hip fracture and is preparing to administer a small dose of pain medication in the form of 2 mg of morphine IV.
The patient received no relief from the pain at all, which surprised the paramedic, who attributed it to the small dose. At the hospital, her partner pulls her aside and asks why she administered magnesium sulfate to the patient.
A firefighter gets down to the end of his 24-hour shift. Normally his department is not very busy at night, but last night he was up from midnight until 6 a.m. with several nuisance fires and alarms.
On his way home he nods off at a traffic light until he is awoken by the honks of several other motorists. He makes it home but believes he may have nodded off several other times due to being so exhausted.
Good sleep
We have heard since we were children that a good night’s sleep was important for one’s health and performance the next day.
Unlike many things children are told, this is quite accurate. Sleep is a vital process that most animals need to maintain health and wellbeing. At least 7 to 8 hours is recommended for everyone for mental and physical health, immune system function and energy conservation.
The normal pattern of sleep for humans follows the circadian rhythm. This rhythm is standard wake-sleep cycles over 24 hours that not only matches daylight hours to a large degree but also one’s internal clock.
Unfortunately, up to 20 percent of the nation’s workforce does not work a schedule that is amenable to this sleep cycle. These workers include virtually all public safety workers as well as others in healthcare, utilities and transportation.
Essentially all of these shift workers have a high level of responsibility for other people or critical infrastructure and must make decisions at all times. This is not necessarily ideal for someone who is tired.
This is nothing new to us in emergency services. However, it always seems that some firefighters can handle long shifts and nightshifts better than others.
If you are one of those people who seems to have trouble being a shift worker, there are a number of ways you can try to improve the situation.
Variety of work
It is important to understand that there is an inherent difference between working a 24-hour shift at a slow fire station and working overnight on an urban medic unit. The slow station will often permit you to get sleep at night whereas the urban medic unit will not.
Unfortunately, it can actually be more dangerous at the slow station when you get the short straw and respond to calls all night long when you had no sleep during the day. At least at the busy medic unit you knew you were unlikely to get any sleep and hopefully planned for it (and slept).
The challenge is, do you nap during the day before a night at a slow station or hope and pray and tough it out if it is busy? A single busy night may be reasonable to recover from, but monitor the calls to make sure that formerly slow station is not routinely becoming more active.
Poor daytime sleep
Being able to sleep during the day can be difficult. Make sure the room is dark and the phones are turned off. Family and friends should respect this time and leave you alone. Use earplugs to block out noise from the outside.
However, setting up the first daytime sleep is just as important. If you are working a block of nightshifts and plan to not nap at all on the day before the first shift, this can be dangerous. You could be awake for more than 24 hours before you get home, and no one will be as sharp on hour 20 as they would be if they got more sleep.
In order to get sleep the first day, you need to be a little tired. I have tried two ways to accomplish this.
For many years, I would stay up until 2 or 3 a.m., then sleep for about 4 hours and get up with my family in the morning. I then would try to nap in the afternoon for 4 hours.
More recently, I have adjusted and instead of getting up at 7 a.m., I sleep straight through until 11 a.m. This larger block of sleep worked better for me. However, everyone is different — experiment to see what works for you.
Intrinsic sleep illness
Consider the possibility that there may be a medical condition that is contributing to poor sleep — namely OSA, or Obstructive Sleep Apnea. This is a condition where during the night someone has multiple periods of apnea — they stop breathing.
Often related to body habitus, it usually (but not always) is associated with being overweight. A sleep study is used to diagnose OSA, and losing weight or the use of continuous positive airway pressure at night can be used to improve the quality of the sleep.
If everything else has been considered and there is still no improvement, there is the possibility that you may be affected with Shift Work Sleep Disorder. This is associated with excessive sleepiness, insomnia during the day and unrefreshed feelings upon waking.
Treatment for SWSD or any sleep-related issues needs to be tailored to the individual. In some cases, minimizing or eliminating night shifts may be the only option.
While this may work in some areas of public safety, in many cases it may not be possible. What other options are available?
It has been shown that brief naps, 20 to 30 minutes, during downtime at work can improve safety and performance. Some employers do not permit this, and in many cases, the workload prevents this possibility. But if you find yourself with some downtime, consider lying down for a few minutes. It may not make you feel completely refreshed but it may be safer when you drive home in the morning.
Meds: Pros and cons
If your primary issue is sleeping during the day, then taking medication that improves sleep can be considered. These can include diphenhydramine (Benadryl), which is over the counter, an alcoholic beverage, or prescribed medication such as zolpidem (Ambien) or zaleplon (Sonata.)
However, in most cases, drinking alcohol or taking medications can actually adversely affect the quality of sleep and impact the performance of the next nightshift. Occasional use may be considered after discussing with your doctor, but they should not be used regularly.
Conversely, medication can be taken to help a sleepy person become more alert. One of the more common substances is caffeine, either in the form of coffee, tea or tablets.
There are some side effects, and caffeine can be somewhat addictive, just ask anyone who is forced to miss their daily cup of joe.
Amphetamines and other illegal and legally prescribed medications have been used for this purpose. However, they are much more addictive and the physical effects can actually be dangerous, so they cannot be recommended.
New medications
A new class of medication, available since 1998, has been studied for use by shift workers. Modafinil, also known as Provigil, is a stimulant with an unknown mechanism of action.
One study found that there was a small but significant improvement in performance over placebo (sugar pill). However, one-third of those taking placebo had an improvement also; so it is difficult to determine how much improvement was directly related to the drug.
Individuals who took modafinil still had sleepiness and impaired performance, and it did not facilitate adaption to a night work schedule.
Another study found that there was a decrease in the number of accidents and near misses, but there were still high rates. An additional concern is that it may be difficult to fall asleep during a nightshift, and the medication may give a false sense of security.
Overall it is believed that it may be worthwhile for the isolated need for prolonged wakefulness, but not regular night work.
A new version of the medication has come out recently as modafinil is getting ready to go off patent. Armodafinil (Nuvigil) also has been studied, and 77 percent of those who took the medication felt more alert. However, so did 57 percent of those who took a placebo. It is also quite expensive, more than $10 per pill.
Shift work and working nights is an inherent part of working in emergency services. Everyone responds differently to the stressors of this type of schedule.
It is important to prepare before a night shift by getting enough sleep before the shift, napping during the shift if tired and able to do so, and recognizing when we are too tired to continue working or drive home.
Stay safe.
This article, originally published on May 17, 2013, has been updated.