Imagine this scenario: It is 5 a.m., your fourth night in a row, and this one is a doozy—a pediatric cardiac arrest followed by a rapidly deteriorating head bleed, capped off with some rotten toenail fungus.
Caffeine is paradoxically causing you to feel more tired. The three-day sleep deficit is catching up. And then Ms. X pops up on the tracker board. You know her well—chronic pain, undertreated psychosis, substance misuse, and homelessness.
Her ED visits run the gamut from drug-seeking to florid psychosis to the occasional physiological emergency. This morning, she is here with a simple request—a meal, some warmth, and a taxi voucher. But you don't see the simplicity. You seethe with annoyance at her and at the broken system that has her in your ED.
You are not feeling generous, and you want to toss her out. Compassion and altruism seem absent from your emotional reserves. But in a moment of insight, you wonder, “Why is that?”
Data have consistently suggested that America is an underslept nation. Survey data from the Centers for Disease Control and Prevention from 2017 to 2018 estimated that more than 30 percent of U.S. working adults sleep six or fewer hours a night. (MMWR Morb Mortal Wkly Rep. 2020;69:504; https://bit.ly/3R6a48j.) This is less than the minimum number of seven hours recommended by the CDC, and perhaps this deficit contributes to our collective angst and irritability.
New research also suggests that sleep deprivation is associated with more selfish, less altruistic tendencies. A fascinating study found evidence of this on individual and population levels. (PLoS Biol. 2022;20:e3001733; https://bit.ly/3dDEAZh.) Sleep deprivation for a single night was associated with decreased willingness to help others (strangers and familiars); functional MRI imaging revealed decreased activation of the social cognition network.
Subjects in another test twice completed a questionnaire from the Self-Report Altruism scale a week apart. Half of the group started as the rested cohort, while the other half had been kept awake for 24 hours. We know what that feels like!
The following week, the two groups switched places, which allowed each participant to serve as his own control. The questionnaire asked them to indicate how they would respond to social scenarios at that moment using a five-box vertical Likert scale ranging from “I would definitely help” to its opposite. One of the hypotheticals had participants encounter a stranger struggling with her grocery bags. Would the study subject stop to help?
You can guess how this played out. Rested participants were more likely to lend a helping hand, and sleep-deprived ones were more likely to let the woman fend for herself. It's easy to translate this to the ED. We are at our helping best when starting a day shift fully rested—“I'd be happy to get you a blanket, call your daughter, refill your blood pressure meds.” But our helpfulness reserves can be flagging as much as our energy when seeing our last patient after a series of night shifts—“Call your own daughter; let her get you a stinking blanket.”
These investigators observed a significant drop over a 16-year period on a population level (an adjusted 10%) in the amount of charitable donations made the week after daylight savings time started that was not present in states without daylight savings or in the week following its end. Even an hour's disturbance in sleep reduces our altruism.
The answer is we need more and better sleep. Sleep is good medicine for us and our patients. Easy to say, but how to actualize? There are, of course, common tricks of the trade—regular exercise, blackout curtains, hypnosis, and 4-7-8 breathing patterns. Unfortunately, many sleep aids, while not likely to be harmful, have not proven beneficial, which was the conclusion of systematic reviews of two popular slumber supplements, white noise and valerian. (Sleep Med Rev. 2021;55:101385; 2007;11:209.)
What if we have our pineal gland call Dr. Melatonin? Melatonin once seemed like a clever way to market placebo to long-distance travelers, but the evidence has evolved, and melatonin is now recommended by the American Academy of Sleep Medicine for daytime sleep for night-shift workers with shift work disorder. Recent evidence suggested that it may be helpful in other populations, such as middle-aged people suffering from insomnia. Sound familiar? (Sleep Med. 2020;76:113; https://bit.ly/3Lz2OjU.)
Another solution is to mitigate the pesky effects of natural light on shift workers by attempting to flip the pancake on sleep patterns. Melatonin production by the pineal gland is regulated by the light-dark cycle, so it makes sense that its same effects may be achieved by carefully regulating our light exposure. (Sleep Med Clin. 2015;10:435; https://bit.ly/3f8j5Ak.)
Practically, this means that shift workers should manipulate their light environment as much as possible. Getting off as the sun is rising? How about some sunglasses that block blue light for the drive home? Waking up at 11 a.m. after a few hours asleep? Adjust those blackout curtains. Waking at 9 p.m. before the night shift? Break out the natural light and reset your circadian phase.
You don't need to work summer shifts in Scandinavia to make this feasible. If you shop for a light, look for something that provides an exposure to around 10,000 lux with minimal UV light.
Back to Ms. X. Luckily for you and her, the morning team, well rested and (mostly) energetic, arrives just in time to infuse some altruism into this situation. She will get her meal and voucher and a pat on the shoulder on the way out the door, and you will head home for some restorative rest.
Dr. Vinsonis an emergency physician at Kaiser Permanente Sacramento Medical Center, a chair of the KP CREST (Clinical Research on Emergency Services and Treatment) Network, and an adjunct investigator at the Kaiser Permanente Division of Research (https://www.kpcrest.net). Dr. Ballardis an emergency physician at San Rafael Kaiser, a past chair of the KP CREST Network, and the medical director for Marin County Emergency Medical Services. Follow him on Twitter@dballard30. Read his past articles athttp://bit.ly/EMN-MedClear.