Rotating shiftwork schedules: can we enhance physician adaptation to night shifts?

OBJECTIVES: To evaluate the effectiveness of a broad, literature-based night shiftwork intervention for enhancement of emergency physicians' (EPs') adaptation to night rotations. METHODS: A prospective, double-blind, active placebo-controlled study was conducted on 6 attending physicians in a university hospital ED. Three data sets were collected under the following conditions: baseline, after active placebo intervention, and after experimental intervention. In each condition, data were collected when the physicians worked both night and day shifts. Measurements included ambulatory polysomnographic recordings of the main sleep periods, objective performance tests administered several times during the subjects' shifts, and daily subjective ratings of the subjects' sleep, moods, and intervention use. RESULTS: The subjects slept an average of 5 hr 42 min across all conditions. After night shifts, the subjects slept significantly less than they did after day shifts (5 hr 13 min vs 6 hr 20 min; p < 0.05). The physicians' vigilance reaction times and times for intubation of a mannequin were significantly slower during night shifts than they were during day shifts (p = 0.007 and p < 0.04, respectively), but performances on ECG analysis did not significantly differ between night and day shifts. Mood ratings were significantly more negative during night shifts than they were during day shifts (more sluggish p < 0.04, less motivated p < 0.03, and less clear thinking p < 0.04). The strategies in the experimental intervention were used 85% of the time according to logbook entries. The experimental and active placebo interventions did not significantly improve the physician's performance, or mood on the night shift, although the subjects slept more after both interventions. CONCLUSIONS: Although the experimental intervention was successfully implemented, it failed to significantly improve attending physicians' sleep, performance, or mood on night shifts. A decrease in speed of intubation, vigilance reaction times, and subjective alertness was evident each time the physicians rotated through the night shift. These findings plus the limited sleep across all conditions and shifts suggest that circadian-mediated disruptions of waking neurobehavioral functions and sleep deprivation are problems in EPs.

Morningness-eveningness preferences of emergency medicine residents are skewed toward eveningness.

OBJECTIVE: To determine the morningness-eveningness (ME) distribution of emergency medicine (EM) residents. METHOD: A voluntary, modified ME questionnaire was administered to all EM residents in the United States at the time of the 1995 American Board of Emergency Medicine's annual In-Training Examination. RESULTS: Seventy-eight percent (2,047/2,614) of the surveys were returned. ME scores ranged from 24 to 76, with a median score of 49 (interquartile range 44, 56). The scores were distributed differently from those of the normal population (p < 0.001), being skewed toward eveningness. There was a correlation (r = 0.13, p < 0.0001) between resident age and ME score, with older residents being more morning-oriented. Males were more morning-oriented than females (p = 0.005), and respondents with children living at home also were significantly more morning-oriented (p < 0.001). Stepwise logistic regression showed that the influence of age, gender, and children was cumulative (r = 0.19) but accounted for only 4% of the observed variability. CONCLUSION: EM residents are distributed differently from the normal population in terms of their ME preferences, tending slightly toward eveningness. The importance of this distribution in EM residents in unknown. A longitudinal follow-up of this cohort may help to determine the association of ME preference with overall practice satisfaction, tolerance of shift work, and career longevity.

Gender-associated differences in emergency department pain management.

STUDY OBJECTIVE: To determine whether patient or provider gender is associated with the number, type, and strength of medications received by emergency department patients with headache, neck pain, or back pain. DESIGN: Prospective cohort study. SETTING: Stanford University Hospital ED PARTICIPANTS: Patients 18 years and older who arrived at the ED with a chief complaint of headache, neck pain, or back pain between February 1, 1993, and September 30, 1993. Provider participants included medical students, interns, residents, nurse practitioners, and attending physicians. RESULTS: ED administration of analgesic versus no analgesic, strength of analgesic administered, and administration of multiple medications. The study group consisted of 190 patients, 110 of them female. The patients were evaluated by 84 providers, 60 of them male. According to the providers surveyed, female patients described more pain than did male patients (P < .01) and were perceived by providers to experience more pain (P = .03). Female patients received more medications (P < .01) and were less likely to receive no medication (P = .01). Female patients also received more potent analgesics (P = .03). Linear and logistic regression analysis showed that patient perception of pain was the strongest predictor of the number and strength of medications given; patient gender was not a predictor. CONCLUSION: Female patients with headache, neck pain, or back pain describe more pain and are perceived by providers to have more pain than male patients in the ED. Female patients also receive more medications and stronger analgesics. In this study, severity of patient pain rather than gender stereotyping appeared to correlate most with pain-management practices.

Relationship of day versus night sleep to physician performance and mood.

STUDY OBJECTIVE: To document and analyze the quality and quantity of emergency physicians' sleep as a function of day and night shift work, and to compare cognitive and motor performance and mood during day and night shifts. DESIGN: Six physicians were monitored for two 24-hour periods. One period consisted of daytime work and nocturnal sleep and the second consisted of daytime sleep and nighttime work. SETTING: The emergency department of Stanford University Medical Center and physicians' homes. PARTICIPANTS: Six attending emergency physicians. INTERVENTIONS: Ambulatory polysomnographic recorders continuously gathered EEG, electro-oculogram, and electromyograph data throughout each observation period. Physicians filled out hourly mood ratings and completed a set of two performance tests five times throughout the day. RESULTS: Physicians had significantly less sleep (496.6 minutes versus 328.5 minutes, P = .02) when sleeping during the day as compared with sleeping at night. Significant performance decrements were also found. Physicians working nights were slower at intubating a mannequin (31.56 seconds versus 42.2 seconds, P = .04) and were more likely to commit errors as their shift progressed (P = .04). Physicians in both conditions were more likely to make errors during a simulated triage test toward the end of their shifts (P = .02). Subjects also rated themselves significantly less sleepy (P < .01), happier (P < .01), and more clear thinking (P < .01) when working day versus night shifts. CONCLUSION: Attending emergency physicians get less sleep and are less effective when performing manual and cognitive tests while working night shifts with day sleep compared with working day shifts with night sleep.

Mothball composition: three simple tests for distinguishing paradichlorobenzene from naphthalene.

We describe three analytical procedures that can be used to distinguish naphthalene from the less toxic mothball component paradichlorobenzene. An initial presumptive identification can be made by noting the characteristic aroma of the two substances. This can be followed by one of the three analytical tests, each of which is simple to perform, gives an answer in seconds to minutes, and is definitive enough to eliminate the need for costly additional testing at an analytical reference laboratory. These tests have as additional advantages that the endpoints are dramatic and the reagents are commonly available.

Local anesthetics.

Local anesthetics are remarkably useful agents that enhance patient comfort and improve patient compliance. Their use, however, requires an understanding of their action, proper dosages, potential risks, and treatment of reactions. We have presented the history, pharmacokinetics, action, risks of using, and ways in which agents are used to treat the most common agents, with notes on the special aspects of each agent. With the increased awareness that these are, indeed, not benign substances, we hope that serious reactions can be avoided by prophylactic measures and proper treatment in the early stages of toxicity.