SGEM#399: I’m So Tired – Emergency Medicine and Fatigue

Date: March 28, 2023 Reference: Fowler et al. Objective assessment of sleep and fatigue risk in emergency medicine physicians. AEM March 2023 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You arrive at 7am to relieve your colleague after a night shift. You find her at the desk, asleep with her face on the keyboard, patient documentation half finished. As she tries to wipe the drool out of the keyboard, you ask how she has been sleeping recently. She confides that she is worried that fatigue might be impacting her care of patients. Background: This might come as a surprise to some listeners, but emergency physicians are frequently tired. Realistically, this episode may not require a background section. All emergency physicians are intimately aware of the impacts of shift work and the resultant poor sleep. However, as we struggle to cope with our constant exhaustion, we may lose track of the many detrimental effects of poor sleep. Our sleep schedules impact our overall health. Shift work is associated with increased rates of cancer, cardiovascular disease, and accidents. (Knutsson 2003) I imagine many of us know of a doctor who has been in a car accident when driving home from work. However, for most clinicians, it isn’t the personal risk that bothers us. The big concern is that fatigue impacts the care we provide for our patients. Even moderate levels of fatigue can impact performance similarly to being intoxicated with alcohol. (Dawson 1997) Industrial studies indicate errors increase by as much as 30-50% on night shifts. (Akerstedt 2010) Evidence is somewhat limited in medicine. We have mostly studied residents and how badly we treat them, while ignoring the plight of staff physicians. But there are numerous studies tying fatigue to clinical errors, impaired cognition, reduced empathy, and increased interpersonal conflict. Clinical Question: What is the percentage of time that emergency physicians spend in a fatigued state? Reference: Fowler et al. Objective assessment of sleep and fatigue risk in emergency medicine physicians. AEM March 2023 Population: A convenience sample of emergency physicians from a single academic emergency department. Intervention: Sleep periods were recorded with actigraphy, using a commercially available device that measures wrist movement. Comparison: None Outcome: A “Readiscore” fatigue score was measured before and during clinical shifts. This score consists of 3 factors: sleep quality, sleep duration, and sleep efficiency (total sleep time divided by total time in bed). This is an SGEMHOP and we are pleased to have two of the author on the show. Lauren Fowler PhD Dr. Lauren Fowler is a Professor of Neuroscience at Wake Forest University School of Medicine who teaches medical students not to be afraid of the Neuroscience module. Much of her work focuses on physiological variables related to circadian desynchronization and how fatigue affects healthcare worker cognition, empathy, burnout, and perceptions. She is also studying sleep, fatigue and cognition in cancer survivors (breast and prostate), with the aim of improving cancer survivor sleep to minimize detrimental effects of sleep loss on cognition, pain perception, and quality of life. Dr. Emily Hirsh Our other guest is Dr. Emily Hirsh. She is an Associate Professor of Emergency Medicine at the University of South Carolina School of Medicine Greenville. She also serves as the Director for Faculty Wellbeing in the Department of Emergency Medicine. She survived severe burnout, left academic medicine for a while, completed a two-year fellowship in Integrative Medicine, and then realized that she wanted to help transform the health care system into one that truly cares about the people that work within it, so that they can live their unique, noble desire to care for patients and be able to do so sustain...