June 1, 2013

Surviving the terrible night-shifts

Too tired to eatNight shifts are dreadful. Even days before starting a week of night-shifts I feel my stomach beginning to turn upside and down. Hungering for sleep in the early morning hours, I'm almost in a dreamstate, careless as a sociopath, trying to stay alert while making important decisions that my patients’ life depends on. The last hours of the night-shift are my most awkard moments as I can hardly speak correctly and the social-skills part of my brain simply shuts down. There's only one way out of it - to stay awake and finish my work. And hope for the best.

Having done about 10 years of night-shifts in the ED I have tried many different tactics to make these a little easier. It seems there are indeed some things that work better than others and I wish someone had taught me these in my first years. Therefore I’d like to share my experiences with you.

The day before

Do lots of sports! Jog, bicycle, gym... 60 minutes of physical activity gives me much more energy than a nap. Being in good physical condition in general makes the difference of being a zombie in the ED or just a tired doc.

Avoid sleeping for longer time. I’ve tried all variants - long naps in the middle of the day and just before starting the shift. I’ve found out any nap longer than 30mins makes me tired already in the first hours of the shift. It’s like these rare days when I get ‘restoration sleep’ and sleep for 10+ hours or... I feel even more tired then before hitting the bed. It is if my mind cannot wake up although my body has.
For this reason I’ve changed my tactics - more physical activity and less napping. I strive for 8 hours sleep between nightshifts but as I get older my body doesn't quite support me in this and wakes me up after 5-6 hours. When that happens I make sure I get those extra 2 hours just before the night shift but it gives me "sleep lag" as mentioned above. So I have started using melatonin right after the shift to make sure I get my needed 8h in a straight. I don't hesitate to use ear plugs and even eye mask (blindfolds) if the room isn't completely dark. I've found silicon ear-plugs to be the absolutely best as they don't heart my ears after a few hours and provide for best isolation

Deep relaxation techniques. I’m habitually impatient and find it hard to do deep-relaxation as much as I’d like to do. But when it works I’ve found even as little as 20 minutes of deep relaxation to be equal to 1-2 hours of sleep and I feel much more energetic than if I’d slept. It is if some magical reset button is pressed and I’m not only physically more energetic but also mentally, especially when I manage to meditate also.

Enjoy a good podcast. Some podcasts from ED colleagues have made me so excited that I can’t wait to start my shift. The newest EmRap or an awesomeness from EmCrit - even falling asleep to a short nap from these puts me "in the mood".
I'm not saying I start every night shift with goose-hairs... but a good podcast really helps me getting mentally prepared and reminds me I'm not the only one getting ready to stay awake a whole night. The worst night-shifts are those after being away from work for a longer time and suddenly thrown into the cage again. That’s when a good podcast while out jogging helps a whole lot.

Show up 30min earlier and start preparingI've found this to be a good way to mentally prepare my self as I really need to be as alert and energetic as possible already in the first minute.

In the lion-cage

Strive for 200% efficiency in the first hours. My most important goal is to be as highly energetic and alert as possible when I start my shift, the first hours are the true golden hours and I've found that how I work these affects the rest of the night. I want to be able to do a 1-2min check on all idle (bed blocked!) patients and see as many new as possible to start doing orders for labs, xrays etc. I write no notes in the first hours,  only jot a draft on paper and go straight on to the next patient. By doing this I can see 5-8pts in the first hour already and often ensures a few peaceful hours later in the night when my alertness sinks again (and coffee and Red Bull doesn't do it!).
Therefor my highest priority is to make sure that I start my shift as energetic and alert as possible and I never nap the hour before. Meditation or physical activity is much better for the that really important pre-hour.
Increasingly I've found it to help a lot to show up 30mins before the shift starts to get mentally prepared. I might look at the list of patients and even check some notes or just sign notes from last shift. It's all about being focused on the ED when the bomb-shells start dropping on me at 23:00!

Coffee tea or me?
Earlier I used to save coffee until I started feeling drowsy but this changed as I noticed how coffe in the last 4-5 hours makes it harder for me to sleep after the shift and also I discovered how important it is to start the shift as alert as possible. If I after 2-3 coffes in the early hours start feeling drowsy I have even added an energy drink (but one only!) for that extra kick. Tea-drinking in the night shifts is a luxury I provide my self when the stars are perfectly aligned - I'm fully energetic, the ED is not a chaos and I am working with a team I can fully rely on. Tea drinking is rare!
Remember the water - for each cup I drink one glass of cold water. It's refreshing and keeps of caffeine induced nausea especially the day after.

No heavy meals. Everyone feels tired after eating big and doing it in the middle of the night-shift is something I avoid - it’s like tying my self to an anchor. I try to eat so that I feel just about full in the beginning of the shift, when my energy is at maximum, and then eat light meals in the night. No warm meals until the final hour - they really make me tired so save these until going to sleep. I’d love to tell you I eat fruits but the truth is I’m a candy junkie and I regularly break personal records in the early morning hours of a night shift. But I've felt this is mostly a bad habit and I can do my night shifts just as well without carbohydrates so I try just to not buy them at all.

Move and stretch. This doesn’t have to be said, only reminded of! Taking 3 minutes to do a few arm bends, deep knee bends or just standing up on toes - these boost your circulation just enough to move the tired proteins away from your brain for a while. Even stretching helps.

Do power naps. When it’s as if I have zero energy left, I put all aside and do a power nap. I simply close my eyes and try to forget everything. Even as little as 5 minutes while sitting helps me to regain some energy to survive one more hour.
If my caffeine level is too high a power nap is not an option. In that case sitting down and listening to one or two favorite songs with ear-buds can help a little. Music helps my mind draft away to other dimensions. It's all about coming up to the surface and inhale just a little fresh air. To get away from the night-shift just a little bit!
When the world is sleeping...
Talk with the patients. I have a few extraordinary memories of conversations with patients in the middle of the night. After all, the night does have it's charm - the little things happening while the world is sleeping somehow have magic in them. There's something in the air that makes talking intimately easier. Patients smiling through their tears or telling about an amazing life-changing event gives me more energy than any power nap. I just have toremember to relax and listen. And so often these extra few minutes have revealed essential clues for the diagnosis and patients are much more tolerant to the tired ED doctor.


Sleeping well the day after a night-shift is not least a challenge especially as we get older. As said, I save the big warm meal until the last hour (who doesn't get tired after eating) and no coffe in the last hours. As I'm in bed I try to do anything that mentally sets my thoughts as far away from the ED as possible - watch a Youtube music video or short documentary, read the news-paper... it all helps to start drifting away to dreamland.
All in all - the more physical activity I can do the day or days before, the better my physical condition and the less sleeping-the-hours-before I do, the better I survive the terrors of a night-shift.

And then a last tip - buy yourself the best possible Crocs you can find. With firm soles providing high friction against the floor so that you can run around corners without slipping!
I’d love to have your night-shift tips - please share below!