Volume 41
July - 2023
By: Diana Trumble, MD
Cover: Without Light
I started this on a road-trip while looking for my first attending job. Finished it during my first year where I spent the year as a nocturnist. At this time, it represents moving to the next step, finishing one thing and starting another.
Sleep and Shift Work - Part 1: WHat is Sleep? What Are the Problems with Shift work?
By: Jonathan Warren, MD
Sleep. That sometimes elusive state of non-consciousness that is so important for our health (in a variety of aspects) as well as our well-being. As Dr. Walker (a prominent sleep scientist) says, sleep is the “swiss army knife of health.” Today, let’s do a deep dive and learn more about what sleep is, why we need to do it, and how we can best support good sleep practices.
To start, sleep is a crucial function of our body to rest and repair both emotionally and physically. With complex metabolic and hormonal processes, sleep can affect memory consolidation, emotional regulation, mood, hormonal balances, immune health, and cardiovascular health. Using the glymphatic system, our body removes toxins from around the brain (including beta-amyloid)1 and elsewhere, insulin, ghrelin, and leptin are working with growth hormones to regulate our glucose and hunger.2 Reasonably, it makes sense that when you get poor sleep, there is an increased risk for Alzheimer dementia3, coronary artery disease, obesity4, diabetes, and nearly every psychiatric disease.
IntroductionSo let’s start with the basics of sleep. Sleep is a period of non-wakefulness where our body rests and prepares for its next period of wakefulness. Sleep is broken up into cycles which define sleep architecture. As we travel through a sleep cycle, we encounter four different levels of sleep. N1 sleep sometimes has dreams that are less vivid and most frequently is when people may perceive that they “continue to be awake” throughout the night. N2 sleep is where we spend about 50% of our time and is when breathing, heart rate, blood pressure, and temperature all begin to drop. It is a restful state for our physical body. N3, or deep sleep, is where our body steps in to begin to regulate itself. During this 25% of our sleeping night, we release growth hormone, allow for physical restoration, and contribute most to fighting that grogginess in the morning. We tend to have the most deep sleep (N3) in the first half of our night. In the second half, the time that would be in this period is replaced with REM sleep, or dream sleep. It is called this because of the rapid eye movements associated with it and is when our body is paralyzed. This period is crucial for focus, concentration, mood5, and pain perception. During this period, our brain works through complex problem solving, prunes synaptic connections for memory consolidation6, and allows for disconnection from emotional stressors. While all cycles are important, it’s found that REM sleep is crucial for longevity, with even a 5% reduction in REM sleep resulting in a 13% increase in mortality.7 In between these cycles, we have brief periods of wakefulness where we wake up, change position, but frequently don’t register it as having happened.
Before we dive into the consequences of shift work and what we can do to combat its deleterious effects, it’s important for us to define a few of the features of what drives our sleep. In our body, there is a constant push and pull between varying processes that guide us into wakefulness or sleep. One such force is our internal circadian rhythm. Timed to be 24.5 hours, it is affected by exposures to sunlight, temperature, and melatonin, which maintains it as a 24 hour response. Melatonin is produced by the pineal gland after being exposed to darkness for about 2-3 hours. While it does not induce sleep, it prepares the body and initiates pathways to allow sleep to occur. It has no true effect on the generation of sleep. Finally, sleep pressure is the final piece of the puzzle. An accumulation of adenosine and other metabolites within the brain over the course of the day drives the body via a complex pathway into sleep. In general, these factors result in a human average of 7.5 to 8.5 hours of sleep but like all things, this is a bell curve and people may lie to either side of it. Beyond this, there is a need to discuss sleep efficiency, which is referred to as the amount of time spent in N3 and REM sleep.
Shift Work and Sleep DeprivationPhysicians working shift work frequently report sleep of less than 6 hours per day.8 Unsurprisingly, the deprivation of sleep leads to a multitude of chronic health effects. Indeed, the World Health Organization has recognized shift work as a Class 2A carcinogen with increased risks for breast and prostate cancer.9,10 Sleep deprivation has been associated with a number of chronic health effects including obesity11, increased hunger12, cardiovascular disease13, cancer14-16, diabetes17, and poor reproductive outcomes.18
Beyond health effects, we can see this effect on a daily level as well. Microsleeps from excessive sleep pressure results in reduction of cognitive function, focus, short term memory, and critical attention.3 Communication decreases19, there is delayed reaction time3, and decreased physical strength.20 This excessive sleepiness can lead to up to a 400% increase in errors.21 Even more frightening, these extended shifts or rapid cycling with being awake for 24 hours is equivalent in physical performance to a blood alcohol of 0.1% (for reference, the legal limit is 0.08%).22
Now, we realize this only provides the background to why we sleep and provides some terrifying data regarding the effects of sleep deprivation. Come back next week as we take an evidence-based dive into how we can best improve our sleep efficiency and sleep latency.
Are you interested in writing an article for Art of Emergency medicine?
Reach out to us through our contact form and we would love to work with you to make this a reality!
By: Jacob Pannaman
Wat(Temple) Jet Lin - Chiang Mai, Thailand
This picture was taken while on my honeymoon in Thailand. This specific picture was one of my favorite temples while visiting Chiang Mai, Thailand. Thinking back to this vacation keeps me motivated to continue to learn and excel as a student physician. Looking back at photos that I've taken is therapeutic for me when I'm having a bad day.
Alcohol Swab Reflections
Alcohol swab remains a divine art,
Our symbol of a brand new start.
In sterile white lies a swab of care,
With crisp spirits, it aids repair.
Disinfecting wounds, cleaning grime,
Restoring health, one patient at a time.
So let us pause and appreciate,
The humble swab, a doctor's fate.
By: Rida Jawed, MD
Often times we overlook the small things in our routines that make a huge difference in our everyday life. Celebrating the uniqueness and beauty of the minute details are what Gratitude and self- reflection is all about.
By: Andrew Thorne, MD
The Guardian of Santa Maddalena
I had planned to capture this shot long before leaving for Europe. What I didn't expect were the twists, turns, and obstacles that we'd face to get here. It's only because of the patience, ingenuity, and stubbornness of my friends that my dream became a reality. Now I not only have an epic shot of this Italian landscape, but a reminder of a hilarious adventure with some of my best friends.
The Light
By: Vincenzo Happach, DO
On the path that we started, back several years
The tail of the journey is coming near
The farther we go the closer to end
We say bye to our coresidents, colleagues, and friends
A 20 year journey comes to a conclusion
I’m still not really sure I know what I’m doin’
In just a short time will be off on our own
It feels like we just started but we’re almost full grown
Can I handle the sick, the acute and the dying?
I hope that I’m ready cause I’m sure as hell trying
No more senior resident or attending to guide in
We’re now the physicians the residents confide in.
Though we may graduate we’ll always be learning
There is no true end to our educational journey
Through years of training we work, claw, and fight
Now the end of this long tunnel, I can see the light
From the Author:
This is an overall feeling of the end of residency. It can't begin to capture the full gravity and range of emotions that go along with it but I feel the need to put something down in print on the idea that a journey of medical education I started over 20 years ago is coming to a conclusion.
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References:
1. Iliff JJ, Wang M, Liao Y, et al. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid β. Sci Transl Med. 2012;4(147):147ra111. doi:10.1126/scitranslmed.3003748
2. Food odors are more enticing to sleep-deprived brains. Published April 2, 2017. Accessed July 22, 2023. https://www.sciencenews.org/article/food-odors-are-more-enticing-sleep-deprived-brains
3. Goel N, Rao H, Durmer JS, Dinges DF. Neurocognitive Consequences of Sleep Deprivation. Semin Neurol. 2009;29(4):320-339. doi:10.1055/s-0029-1237117
4. Spivey A. Lose Sleep, Gain Weight: Another Piece of the Obesity Puzzle. Environ Health Perspect. 2010;118(1):A28-A33.
5. Della Monica C, Johnsen S, Atzori G, Groeger JA, Dijk DJ. Rapid Eye Movement Sleep, Sleep Continuity and Slow Wave Sleep as Predictors of Cognition, Mood, and Subjective Sleep Quality in Healthy Men and Women, Aged 20-84 Years. Front Psychiatry. 2018;9:255. doi:10.3389/fpsyt.2018.00255
6. Li W, Ma L, Yang G, Gan WB. REM sleep selectively prunes and maintains new synapses in development and learning. Nat Neurosci. 2017;20(3):427-437. doi:10.1038/nn.4479
7. Zhang J, Jin X, Li R, Gao Y, Li J, Wang G. Influence of rapid eye movement sleep on all-cause mortality: a community-based cohort study. Aging. 2019;11(5):1580-1588. doi:10.18632/aging.101858
8. Centers for Disease Control and Prevention (CDC). Short sleep duration among workers--United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(16):281-285.
9. Erren TC, Falaturi P, Morfeld P, Knauth P, Reiter RJ, Piekarski C. Shift Work and Cancer. Dtsch Ärztebl Int. 2010;107(38):657-662. doi:10.3238/arztebl.2010.0657
10. Module 3. Diseases and Shift Work (Continuted), Cancer | NIOSH | CDC. Published April 2, 2020. Accessed July 24, 2023. https://www.cdc.gov/niosh/work-hour-training-for-nurses/longhours/mod3/19.html
11. Antunes LC, Levandovski R, Dantas G, Caumo W, Hidalgo MP. Obesity and shift work: chronobiological aspects. Nutr Res Rev. 2010;23(1):155-168. doi:10.1017/S0954422410000016
12. Spiegel K, Tasali E, Leproult R, Van Cauter E. Effects of poor and short sleep on glucose metabolism and obesity risk. Nat Rev Endocrinol. 2009;5(5):253-261. doi:10.1038/nrendo.2009.23
13. Puttonen S, Härmä M, Hublin C. Shift work and cardiovascular disease - pathways from circadian stress to morbidity. Scand J Work Environ Health. 2010;36(2):96-108. doi:10.5271/sjweh.2894
14. Bonde JP, Hansen J, Kolstad HA, et al. Work at night and breast cancer--report on evidence-based options for preventive actions. Scand J Work Environ Health. 2012;38(4):380-390. doi:10.5271/sjweh.3282
15. Conlon M, Lightfoot N, Kreiger N. Rotating shift work and risk of prostate cancer. Epidemiol Camb Mass. 2007;18(1):182-183. doi:10.1097/01.ede.0000249519.33978.31
16. Schernhammer ES, Laden F, Speizer FE, et al. Night-shift work and risk of colorectal cancer in the nurses’ health study. J Natl Cancer Inst. 2003;95(11):825-828. doi:10.1093/jnci/95.11.825
17. Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2015;72(1):72-78. doi:10.1136/oemed-2014-102150
18. Frazier L, Grainger D. Shift work and adverse reproductive outcomes among men and women. Clin Occup Environ Med. 2003;3:279-292. doi:10.1016/S1526-0046(03)00034-7
19. Pilcher JJ, McClelland LE, Moore DD, et al. Language performance under sustained work and sleep deprivation conditions. Aviat Space Environ Med. 2007;78(5 Suppl):B25-38.
20. Reilly T, Piercy M. The effect of partial sleep deprivation on weight-lifting performance. Ergonomics. 1994;37(1):107-115. doi:10.1080/00140139408963628
21. Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003;26(2):117-126. doi:10.1093/sleep/26.2.117
22. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294(9):1025-1033. doi:10.1001/jama.294.9.1025
This Months Featured Artists:
Andrew Thorne, MD
Andrew is an emergency medicine physician practicing in Los Angeles with a passion for wilderness medicine and capturing the beauty of the outdoors.
Diana Trumble, MD
I've been crocheting for over 20 years. In medical school, I starting selling some items and doing more than just your typical grandmother's crochet. Now I focus on the repetition of the patterns and creating beauty from a ball of yarn in the midst of residency in a pandemic. Find more of her work on Instagram.
Jacob Pannaman
I am a Medical Student currently on emergency medicine rotation. Being able to capture moments in time forever and share it with loved ones is something that I've always loved to do.
Rida Jawad, MD
I am Resident Year III at Emergency Medicine department at Aga Khan University Hospital. I have a passion for writing since childhood and being a strong believer in stoic philosophy, I cherish every opportunity to write from my heart and soul. Entering medicine 13 years back, my writing has become even more heartfelt and deep over the years.
Vincenzo Happach, DO
I graduated from Des Moines University College of Osteopathic Medicine in 2013. I spent 7 years as an active duty US Navy Medical officer, 5 of which were as an Aeromedical Officer. I'm currently an Emergency Medicine PGY-3 at the Piedmont Macon Medical Center Emergency Medicine Residency. See more of his work on instagram.
You can learn more about the artists featured in this and other volumes at our contributors page!