MD Roundtable – Sleep Deprivation

Sleep Deprivation

Folks, welcome to the MD Roundtable for tonight. I’d like to introduce you to your lead medical director. This is Dr. Donna Phillips.

Dr. Phillips has been with us for several years now, and I’ve known him, I’d agree, for a whole good portion of my EMS career, and I’ve been in EMS now for, how many years, 38 years. So, Dr. Phillips and I have been in EMS for forever. He was a paramedic before he was a doc.

He’s been an emergency physician for, what, 35 years? Thirty-three. Thirty-three? Thirty-three. Oh, close.

And he and I- Got in EMS for 43 years in emergency. Oh, geez. There you go.

You beat me there. So, Dr. Phillips also has served on the Texas Department of State Health Services Medical Directors Committee and GTAC, which is our Governor’s EMS and Trauma Advisory Council. That’s where I kind of got to know him many years ago.

And then I worked under him as a medical director for a while, too, back in the old days of Parker County EMS. So, he and I have known each other a long time. He’s been with us as the lead medical director for about two years? I think so.

And then before that, he was associate medical director. He and Dr. Frank kind of flipped back and forth, I think. So, I wanted you to have a good idea of who this is.

This is the man that most likely will be doing for you paramedics your paramedic graduate scenario summative exam. And so, it’s good to kind of get to know him and how he thinks. And his lectures are always good and really kind of very interactive.

And you will be expected to interact for your credit tonight. So, I’ll be watching you and kind of taking notes on who is interacting. And you can’t just sit in the shadows and lurk.

So, when you want to ask a question, you can unmute your microphone or answer a question. And then re-mute your microphone again to avoid the outside noises from coming in to bother everybody else. But do participate.

Learn. We got a great topic tonight that is one of those that really, yeah, we were talking about this before. I have worked 96-hour shifts.

I don’t remember much of the last two days. So, it’s something we don’t really need to see. So, Dr. Phillips, I’m going to turn this over to you.

Okay. So, first off, I think everybody that’s been in EMS probably for more than 10 years has probably worked 24-hour shifts and some 48-hour shifts. And as one particular paramedic in the Fort Worth area was said about, at one time I saw him wearing one particular uniform and I knew that he was with two agencies.

And then he came in wearing a third uniform. And I was like, Paul, I didn’t know that you worked for them. And one of the other firefighters that happened to be there at the time said, oh, you don’t know him, mentioned his name, said, you don’t know him that well.

He’s actually homeless. He just goes from firehouse to firehouse. And, you know, sometimes it kind of seems that way.

And, you know, we’ll talk a lot about why we end up in some of those situations at times. So, you know, this is one of these things where I don’t think that you’re probably going to see anything on a test about this, but at the same time, this is part of you taking care of yourself. And I’ll relate some personal information later on during the lecture as well.

So first off, I actually love despair.com. They’re humorous, but at the same time, they sometimes carry a little nugget of wisdom. So just because you’ve always done it that way does not mean it’s not incredibly stupid. And so this was, this was my screensaver at one of the hospitals because they kept saying, well, that’s not the way that we do things here.

And I would say, well, there’s other ways to do things. And they’re like, oh no, you have to do it our way. So anyway, that’s, that’s kind of my take on tradition.

So let’s talk a little bit about what is sleep deprivation. First off, there’s several different conditions and several different definitions, but basically it’s somebody that’s getting inadequate or insufficient sleep over a long period of time. And when they consistently fail to obtain the amount of sleep that they need.

Another definition that I found was anytime that you’re without sleep for at least 24 hours, well, that’s pretty much everybody in EMS. Then there’s acute sleep deprivation, which is no sleep or reduction for at least one or two days. Then there’s chronic sleep insufficiency or sleep restriction.

When that individual routinely sleeps less than the amount required for optional functioning. I think that that’s probably by definition, just about everybody in EMS because it seems that all of us only get like four or six hours of sleep and nobody really ever gets the full amount of sleep that they really need. And then there’s sleep insufficiency.

That is another version of the, of all of these, but it’s either because of reduced total sleep time or fragmentation of sleep or by brief arousals. Well, that’s like the definition of us. If we’re on 24 hour shifts and we’re, you know, you lay down to sleep and it seems like as soon as your head hits the pillow and you start to drift off, then there go the alarms.

So, you know, this is actually a big problem and we’ll come around to, to how this, how important this is becoming. So I’m one of those old guys. I have said, suck it up.

We all do this. And it’s been seen as part of the culture and a rite of passage, but it’s also BS, very frankly. It impacts on neurocognition.

So you’re not, your mood is depressed and off your executive function, which is all of how you operate, how you think and how you behave your skills, your dexterity, that’s executive function. And then cognitive performance or how you think, your thought processes, all of those things are degraded when you have sleep deprivation and it accumulates over time. This is not something that, that you can just say, Oh, you know, I’ll add a couple of hours here and there and I’ll be all right.

And it disrupts the hippocampal function in your brain, which is where memory consolidation occurs. Obviously that’s kind of an important thing for us to have. Now, James welcome.

You do need to rename yourself with your class name. So if you wouldn’t do that, there should be three dots in your little screen and pull that down. And it’ll have rename up there.

Then there’s also the sleep fragmentation, which to me is probably the biggest problem with, with anybody EMS or if I’m working in a, in a freestanding or a critical access ER, sleep fragmentation is a big issue. So I’m going to throw a few of these in here in and out. And yeah, they’re, they’re kind of very negative and depressing, but you know, I like this one.

What optimists call objectivity when they don’t like the message. So Bryce says critical access versus freestanding. So freestanding ERs can be put up anywhere and they are not associated with the hospital necessarily.

They don’t have hospital beds, a critical access hospital. On the other hand is a federally designation designated facility. They cannot have more than 25 inpatient beds.

They have to average no more than 96 hours for per stay. So in other words, if you have a patient that stays more than 96 hours, you better have some others that offset it, that you get out in 24 or 48 hours. They are remote.

There’s mileage designations based on primary and secondary roads. The secondary road is defined by the government as being a two lane road and one lane each way. Whereas a primary road is defined as a four lane road.

And they cannot be within a certain mileage of other hospitals. The difference is, and why those are important is their billing purposes. Regular hospitals bill based on diagnostic related groups and critical access hospitals bill and get paid 101% of their actual cost for that patient.

So that’s, that’s kind of been the difference between those. So that could be a topic in itself. So let’s talk about the effects of sleep deprivation.

So there’ve been studies that have shown that being awake for only 18 hours will make you impaired to the point that you’re pretty much the same, not necessarily all of the same functions, but some of the functions are depressed to the same level as somebody that’s got a blood alcohol of 0.05. And the, and once you get to 24 hours of sleeplessness, you’re the same as a 0.1. And keep in mind that for driving 0.08 is the limit for driving. So if you think about it, yeah, somebody that hasn’t slept for 24 hours, they’re as dangerous on the road as a drunk driver. And this could be you if you’re in a very high volume system and you, you don’t get to sleep during that 24 hour shift.

Now then stretch that to your secondary job at another place. Sleep inertia. I had not heard this particular term I’ve experienced it many times.

It’s an impairment in alertness immediately upon awakening. It seems to be worse during the first 30 minutes after you wake up and especially from a deep sleep, but it may take up to two hours to really fully wake up. And so obviously if you were deep asleep and you get woke up for a call, you know, are you really fully alert and awake and ready to make those decisions that you need to make, whether you’re in the driver’s seat of the vehicle or in the back trying to make clinical decisions? This is this.

I hope that you’re seeing that this can be a real problem for us if we’re not aware of it. So there’s also evidence that says that poor sleep and fatigue results in deficits in motor and cognitive function, trust in decision-making. That means you might not trust your partner and they may not trust you.

The public may not trust you. You may end up with poor safety outcomes. We’ll cover those in a little bit more detail in a few slides.

And there’s growing concern that extended shifts over 12 hours may contribute to fatigue and ultimately negative patient and or provider safety outcomes. And so once again, we’re going to, we’re going to talk about those in a little more detail a little bit later on, but understand that more and more there is pressure that is coming downstream, like a, like a trickle on a river that is probably going to impact some of these issues that we’re talking about right now. So again, deficits in cognition and physical functioning.

You get poor sleep quality, poor recovery from work, unhealthy body weight, elevated cardiovascular risk. You have a higher risk of diabetes, disruption in the circadian rhythms and overall poor general health. So these things, and when I was in your shoes so many years ago, yeah, I was, I was Superman.

Everybody was, you know, there was no way that this stuff was really going to affect me and it did. And so, you know, I, I developed a lot of these things. And so I’m trying to get my health back at this point.

And so while you’re still young in this profession, as another reason that I want you to hear this stuff from me is that I want you to try to get yourself healthy enough that you don’t need our own services. So this comes from a website called sleepcareonline.com. And they actually have a section for first responders. Obviously they’re out to sell something.

I’m not saying that they’re fantastic. It’s a good information site. And so that’s why I’ve stolen some of their website, but it can have an effect on first responders, both on and off duty, poor decision-making on the job, impaired driving abilities.

And they say, especially going to emergency events. And I have seen this with my own eyes back when I first started in EMS. One of the folks that I worked with, he wasn’t my partner fell asleep as they were going to a call.

He and his partner both fell asleep on the second half of a 48 hour shift and they rolled the ambulance. Thankfully they weren’t hurt. But yes, it, this has been around since the 1980s increases the likelihood of becoming injured on the job.

And when we’re talking about that, what we’re talking about is while you’re on a scene, you know, you can do things that are unsafe without realizing that they’re unsafe, or you may walk into something and not realize that it’s a hazard. And so, you know, I’ve heard of people that have accidentally stepped out into traffic, not thinking about it. So these are things that can be incredibly dangerous for us.

There’s an increased risk of fatality and difficulty in coping with relationships off duty, especially if they’re not first responders as well. I think that any of us that have been in this for any length of time, either knows it with our own family within our own family, or we know somebody that we work with that has gotten divorced, has had kids that have had some issues growing up. You know, there are so many ways that this can affect us that we don’t really think about.

And especially when you’re young, like you guys are and increased health problems, especially long-term. So we’re talking about diabetes, high blood pressure, heart disease. I know that my boss, when I first started this, smoked, drank coffee nonstop, drank alcohol all the time, not at work, but he ended up with many heart problems and ended up dying of heart failure.

So, you know, it’ll catch up to you eventually if you don’t do something to mitigate this. So there is actually a diagnosis and I didn’t realize this of insufficient sleep syndrome and it has criteria that you have to meet. And so the patient has to, has irrepressible daytime lapses into sleep on a daily basis.

Well, that’s me. The patient’s total sleep time can be provided through clinical history. There’s one part here, you know, sleep diaries, those sorts of things.

Okay. I know that. What is actigraphy? I had no idea.

Does anybody know what that one is? You can unmute and yell it out if you do. So what actigraphy is, is apps on your phone that measure your sleep quality. If you have a smartwatch or if you have one of the Aura rings, things like that, those are actigraphic devices and they can actually help to tell you how your sleep is.

I know the Aura ring, that’s one of the big selling points for them. Now, if you’re, if you have an Aura ring, please don’t wear that while you’re at work because I don’t want you to get your finger caught on something and end up where you’re having to count only to nine. So let’s, let’s be careful.

You know, a smartwatch that’ll break away, those sorts of things are a lot better ways of monitoring things like that. And sleep pattern is present on most days for a minimum of three months. Well, for me, this sleep pattern has been here now for about five years.

Patients have decreased total sleep time due to external factors such as alarm clocks, curtailment of sleep by somebody else, dispatch. And in the absence of such measures are generally able to sleep longer. Well, I don’t know about you, but if I don’t have things like that, if I, and since I work all nights, you know, the neighbor, somebody’s not mowing.

Yeah. I can sleep a lot longer and a lot better than I do otherwise. Kids are another one of those external factors and extending the total sleep time causes a resolution of symptoms.

Well, I haven’t really been able to do that very often. And then the symptoms may, should not be better explained by other disorders. So yes, there, there are some things.

And frankly, I think that probably most EMS providers fit that diagnosis. Any questions up to this point? These are all from despair.com. Don’t show these to your boss. So Savannah says not a question more experienced to consider maybe.

Yeah. Put yourself in preterm labor. Yes.

I totally understand that. So obviously these are things that when you go to see any primary care, you should make them aware of, Hey, I work 24 hour shifts. I work 48 hour shifts.

Yeah. It should be part of their social history, but most, most health agencies don’t ask about your sleep. And so I think that it’s really important that we probably should volunteer that information to them.

Okay. Yes, Jason, we’re, we’re going to, we’re going to get to that in just a little bit, at least not necessarily a magic bullet, but some of the proposed resolutions are, are at least aids to try to help us some of this. So is this really a problem? So how many of y’all have heard that saying 150 years of tradition unimpeded by progress.

It’s the motto of the fire service. I’ll sleep when I’m dead. I know I have.

So let’s talk about a few case studies to show that this really is a problem. An EMS worker had been on duty for over 24 hours and he was, they were in a fatal accident when they were transporting a patient and that apparently the fatigue was a, was a major factor. So keep in mind that, you know, we’re, we’re especially these days.

I was, I was marveling as I was walking into the hospital day before yesterday at how huge the ambulances have become. When I was in the EMS, one of our units at my first service was a high top suburban ambulance. I mean, it, it looked like a regular suburban that just had the high top added to it.

And then the other one was a very, very old 1970s modular ambulance that was on a heavy duty pickup chassis. You know, and by heavy duty, we meant a one ton that was a dually, you know, so what, what we’re in these days is so much bigger, so much heavier. We have so much more equipment that chances are if you’re involved in an accident, other than if you roll the thing over or go off a cliff or something, you’re probably going to be all right.

However, the people that you hit are very likely going to die. And so keep that in mind and think about how you would feel if you killed someone because you fell asleep. So next is from New York city.

And in this case, they were citing instances where their lack of sleep led to difficulty in making quick decisions and compromised care. Boston driver, EMS provider fell asleep while they were driving, resulting in a crash and been working long hours without adequate rest. And the impact caused significant injuries to both the EMS provide personnel and the patient being transported.

The incident emphasized the need for better scheduling and rest breaks. So at least sounds like Boston EMS was trying to do something about this after the fact. Chicago, an EMS worker admitted to administering the wrong medication to a patient due to fatigue.

Patient provider had been working multiple back-to-back shifts and was severely sleep deprived at the time of the incident. And so medication error led to a critical condition for the patient requiring ICU. Case underscores how cognitive impairment from sleep deprivation can lead to life-threatening mistakes in patient care.

So I’m going to take just a second to talk about something personal. And that is early April. I had a habit of traveling to my work site because I live outside of DFW, but I’ve worked currently in Tulsa.

And so I would fly in and usually I would work that same day to make the flight to be sure that I was going to get here. Even if there were delays in time to make my shift, I would leave early in the morning and would try to get here somewhere around noon and hope that I could get an early check into my hotel to be able to sleep. Well, that particular day, I couldn’t get an early check in.

I couldn’t check in until three. And then when I got into the room, I’m going, okay, I’ve only got a couple of hours that I can sleep before I have to start getting ready for work. And I’m afraid I’m going to oversleep.

So I didn’t ever, I never actually went to sleep later that night while I was at work. And this is a freestanding ER, thank goodness, but I’m the only provider that’s there. The nurses ended up calling administration because they were afraid that I was having a stroke.

They said that I had a lot of repetitive questioning that the patients were commenting about that as well. And I do not remember seeing some of the patients that I charted on. That scares the crap out of me.

And so the, the associate CMO came in at like five in the morning and, you know, told me what was going on and why he was there. And he said, I’m just going to be here. If you need anything, you’ll let me know.

And so my relief actually came in about 30 minutes early. And she was a former system medical director for the CR system. And, you know, very kind, very gracious.

And she said, you know, you just wind up what you got and I’ll pick up whatever you need me to pick up. Got to the hotel and the current system medical director called me and said, where are you? And I said, I’m at the hotel. I honestly don’t remember driving there.

And I did drive about 15 miles to get there. And she said, I’m coming to pick you up. I’ll meet you downstairs.

Took me over to the main ER and I was admitted to the hospital on an observation status to rule out a stroke. Yeah. It’s not nice to have on your chart that you had transient cognitive impairment, but that was, that was one of the diagnoses that I had turns out that is all that I had was sleep deprivation, but this has resulted in me becoming a lot more vigilant and how I’m trying to take care of myself and my own sleep hygiene.

Now see James’s comment there. Yeah. The sleep deprivation is very, very serious.

And I think especially when you mix people that have weapons, that’s a potentially even more serious problem. Cause like I said, I don’t remember treating these people. And so, um, you know, I want to try to avert that for all of you.

I never want you to have to go through that. So here’s another, this is a death. So this was about Brian Gould, his 42 year old paramedic died when he was going home from an overnight shift and his car crossed over the lanes and struck a semi head-on.

This particular service instituted a policy after that, that if a crew member gets less than four hours of uninterrupted sleep during the 24 hour shift, colleagues will take them and their vehicles home after work. So imagine you get to get a ride in your own ambulance to your house and somebody else is driving your car for you. So, um, that’s, that’s what came out of that.

Unfortunately, his wife is also a paramedic at that same service. And she was in the unit that was dispatched to his scene. Now to put a, put a real face with this, this is Brian Gould.

So, you know, these are all things that, you know, frankly, I, I would love to hear back from you guys later on if, you know, not necessarily that you’ve had situations like this, but maybe if you go into your agency and say, you know, here’s some resources and here’s one example of what happened after a paramedic fell asleep while he was driving home from a shift. And here’s what that agency did to mitigate that. So this actually comes from a publication from the National Association of EMS State Officers and our National Association of State EMS Officials, NSEMSA.

And I put the arrows there and I don’t expect you to read those, but those are all four different case reports that were in, that were used as references for this particular guidebook. And we’re going to come around to that again in just a little bit. So Dylan says damaged curb.

Yeah. Yeah. Yeah.

There’s no way for you to sleep ahead. That just does not exist. So saying, you know, you need to rest up before your shift tomorrow doesn’t really help that much.

So Dylan, what, what I would like is at the end, I’m going to give you several resources and references. And we’re talking about things like this is on the radar for the International Association of Fire Chiefs. It’s on the radar for National Association of EMS Physicians.

So get your medical director involved. NSEMSA. So the state levels are looking at this as well.

So, you know, I want you to know that there are a lot of resources out there. The CDC has an excellent resource for nurses, because this is a big problem for nursing staff as well. Not that they’re working 24 hour shifts, but they’re subject to the same problems.

And so they actually have an online training program for nurses. They can get continuing education for doing this. So, you know, I think that it’s probably time for us in EMS to have a very similar sort of thing.

Maybe not from NIOSH, which is who is the one that put out the one for the nursing staff that’s under the CDC. But, you know, I think that it’s probably time for NAMT or NAMSP. And both of them are aware of this problem.

They’ve worked together to try to come up with some solutions for nursing staff. And so I think that it’s probably time for us in EMS to have a very similar I think it’s time for us to create our own educational program for ourselves and also for leadership. But you know, there’s nothing that says that the people that are being led can’t take ideas to the leadership.

So. Here is federally mandated work hour restrictions, and this is in the NMSAC final advisory on fatigue. Hey, that’s 11 years old.

So if you, if you have an interest, this is one of the references at the end, but this tells you all the different work hour restrictions that have federal mandates on them, including for resident physicians in training. And so, you know, I think it’s probably time for those same things to be in place for physicians in general as well. So.

But this tells you all the stuff that airline pilots, you know, I think it’s safe to ask your boss, you know, Hey, would you get into an airplane that had a pilot that’s been flying for the last 18 hours straight? And he’s going to fly you and your family. I think that that’s a reasonable question to ask them. Well then why are you asking patients to get into the back of an ambulance with a crew that’s been running nonstop for 18 hours? You know, there needs to be some, some realization that this stuff is real and it really hurts people.

So. The NSEMSO recommendations, and this is from their fatigue guidebook. This is the implementation handbook.

Okay. And so it’s, it’s a lot more pages than just two, but what I’ve given you there is a summary of evidence-based recommendations. And so they’re saying that recommend using a fatigue, sleeping a survey instrument, shorter shifts than 24 hours, access to caffeine while you’re on duty.

And I have mixed feelings about that one and having opportunities to nap and education and training and fatigue related risk. So, you know, I also know that if you start talking to some of these services, if you start saying things like, well, you know, you’re probably more likely to have workers comp claims if you’re, if you’re having us work 24 hour shifts where we’re not getting to rest. You know, you really want to have your workers comp insurance rates go up.

You know, you’re more likely to have us have an error that ends up as a, as a medical malpractice case. Do you really want that? You know, so sometimes you have to suggest the, the material gain is, or loss is better than the, or the gain is better than the loss materially and monetarily. I’ve felt this way sometimes.

And I hope that the mistake that I made, that I described to you that you guys will use that as a warning. So let’s talk. We’re coming to the end of some of this and let’s, and we’ll have an open discussion about what I see as some of the ways that we can address some of this, but government won’t do anything.

Well, then along came the Libby Zion case, which resulted in a law. I agree, Jane, 100%. And, and we’ll talk about that as well.

So let’s, and in fact, let’s hold where we’re at right now. So I was talking with somebody else at work about this and they were like, well, you know, what do you mean? They’re going from job to job to job? Well, most people don’t understand the pay scale that EMS has. And especially as you say, when it’s not part of the fire service or when it’s not part of a municipality.

The, the problem becomes one of, you know, you guys have bills. I understand that. I get that.

And I really do not want to cause people to suddenly not be able to pay their bills because they’re not bringing in enough income. And I think that, you know, the obvious question is, you know, the, the AMRs and those sort of agencies where they have, you know, huge budgets, you know, do they need to cut down on their admin people to some extent so that, you know, we can raise the pay rates for the field personnel to where it’s a living wage and they don’t have to go and work to other agencies where you’re working 24 on 48 off at three different places. You know, that’s to me, that’s one thing that has to be discussed and that’s definitely an elephant in the room.

You know, the, I’m sure that for some of these agencies, they don’t have benefits. And so they’re not worried about the insurance. They’re not worried about, you know, you missing out on work and, and those sorts of things.

They’re not worried about temporary disability or permanent disability insurance because they’re not paying for it. Those sorts of things should be considered standard, but you know, I’m not sure how you get to that point. I can’t get to that point in emergency medicine.

You know, there’s only a few staffing groups that offer any benefits. They say that they offer benefits, but I’m sorry, giving me $2,000 a year for CME is not really a benefit. I mean, it is, but it’s not really something that’s effective.

So yeah, I think that there needs to be a lot of discussion and it’s obviously going to be above my pay grade. It’s going to be operational rather than the medical side of stuff, but your medical director should be willing to have those discussions with the operations folks, because your medical director should be the expert there in human performance and should understand this. And if they don’t, they should be willing to read up on it so that they can speak intelligently about this, bring them the, the white paper that came out from the association of fire chiefs, you know, especially if you’re in a fire service, if you throw that at the fire chief, you know, they should be willing to at least read it.

And they, they talk about a lot of these same sort of things. Now I’m not going to get into the fire base versus, you know, third service or whatever model that people are in, because, you know, those have been around for a long time. Fort Worth is actually moving away from using system status management and MedStar, and they’re moving them under the fire department.

And so, you know, I, I think for MedStar, that’s probably a big step in the right direction because they run their people ragged. And so, you know, hopefully they will be able to hold on to personnel, but you know, the biggest expense for just about any agency is training a new person. Obviously they’re not paying for your school right now for most of you, but getting you to where you’re oriented so that they can say that you’re credentialed and you’re qualified and they have the field training officer with you and you have the time with the medical director and all of those sort of things cost a lot of money to the agency.

And especially if they’re turning over faster than the staff at McDonald’s, you know, that’s a huge expense. And if you can make it so that people want to stay, you’re not the training ground for brand new paramedics every time. And then once they get to where they’re independent, then they go and work somewhere else or they get on with the fire department.

You know, there’s, there’s got to be some incentive for the administration to understand that it’s not just the right thing to do. It’s also going to benefit them in the long run. Now, anybody else have any thoughts about that? Again, feel free to unmute your microphone.

You know, I want this to be an open discussion. So let’s talk about the Libby Zion law. And I don’t expect any of y’all to, to have heard of this particular law, but Libby Zion was an 18 year old.

She was born in 65, died in 1984. And in the New York times op-ed piece, her father wrote this and you don’t need kindergarten to know that a resident working at 36 hour shift is in no condition to make any kind of judgment call. Forget about life and death.

So yeah. Russell says, yeah, they want to hire another chief. Yeah.

So, you know, it’s kind of hard to, to, I, I have issues justifying by hiring a new chief when you don’t have fully staffed below. So, you know, the frankly I’m, I’m assuming that you, by the board, you mean your board of directors. And I think that it’s reasonable for them to listen to them, but I think that they should work really hard to try to get other voices there as well.

Now, Russell, I, I have no idea where you’re at. I don’t know if you’re in a union shop or a non-union. But, you know, I, I think that they’re probably okay.

So, you know, the unions, I think the firefighters union, they’re kind of on the fence on this, but I think if you take them stuff from the fire chiefs that that may be something, you know, just, Hey, can you take a look at this? We’re short of people, you know, staffing the trucks, you know, let’s talk about what we can do to try to get fully staffed where we’re actually meeting people. And, you know, and obviously you can’t be the one to say, Nope, this is the way it is. Okay.

But I think that giving them objective information from other sources is always a better way to say, you know, Hey, listen, can you at least read this and consider it? That’s always a better tact than saying, well, I’m right. And you’re wrong. So yeah.

Yeah. Give them the information, let them do with it what they need to. I have a feeling that if they’re already pushing to hire another chief, that’s probably what’s going to happen no matter what, even if the board didn’t necessarily, you know, feel, as you put it, set on listening to them.

And, and that, the, the board of directors and how they’re elected, selected, however, they’re there in there can, you have to, you have to understand that each one of those is unique and you have to understand the politics behind those. And I am not a politician. I don’t do well in those situations.

So yeah, it’s more, I, for me as a medical director, you know, I would be talking to the service director, the chief, and telling them my perspective and, and offering them that same, you know, printed information from other sources. So I hope that that helps. So anyway, back to Libby Zion in this, in this day and age, residents always were working 36 hour shifts.

I mean, not every shift, but you would come in and work 12 hours, which usually was more like 14 to 18 hours. And then you go home, but one person would be there overnight. And then they would actually work all the way through the night, 24 hours.

And then they’d work another 12 after that. And then they could go home. That was kind of standard.

And it was usually a three day rotation. You were back the next morning. So you had 12 hours off after your 36 hour shift, and then you were back for another 12.

But once again, you got to get there early and you usually stay late. So, you know, it was chronic sleep deprivation. In 1987, an intern and resident were charged with 38 counts of gross negligence or incompetence based on this young girl, college student dying.

And I know that the, I have a lecture out here on, on the MD round tables about serotonin syndrome. That was what killed this young woman was serotonin syndrome. And the, the intern and the resident made some really bad choices and there was no attending in the hospital to supervise them.

So they, they rounded up a commission, named after the leader, Dr. Bell, named it the Bell commission. And they recommended that attending physicians be present at all times in hospitals. And they also limited the work hours to 80 hours a week and 24 hours at a time, no longer than that.

And then you have to have, I think it’s 24 hours off now. So that was adopted and it’s in state regulation and their health code in New York state, a lot of other places have picked this up. And so now, and I have actually seen this, the chief residents are sitting there, you know, Hey, who’s still here.

And, you know, if there’s a resident that wants to work longer than their work hours, they send them home. That never happened when I was in medical school or residency, it just was not going to happen. So if you wanted to stay late, that was great.

That showed that you really, you know, you had initiative, you had drive, you wanted to do this and it was encouraged. And, you know, it took me a while when this first came out and it was adopted by the accrediting council of graduate medical education in 2003. And when it came out, I was like, Oh, this is horrible.

This is going to ruin medical education. I don’t really think that that’s ruined medical education. I do wish that they had said, we’re going to add a year onto every residency in order to make up for, for those lost clinical hours and patient contacts.

But yeah, that’s, that’s for the residencies to decide not for me. But I think that it’s important that you guys now, while your students begin to look very hard at your sleep patterns. I have a, I have an app on my phone that will measure my sleep every night.

It’s called sleep cycle. And so I set the time that I want it to wake me up and it listens to me as I sleep. So it’ll tell me if I’m snoring, if I’m talking, if there’s noise, if there’s dogs barking, if there’s, you know, if they hear a blender turn on and it logs all of those things.

And it gives me a percentage on my sleep. It tells me how long I was actually asleep and how restful it was. It also links to my, my Apple watch.

So it measures my oxygen saturation through the night. That may be the first sign that you have obstructive sleep apnea, which the sleep deprivation itself will encourage. So, you know, there there’s several things that you can do about this.

So one more of the fun things, and some things can not be overcome with determination and a positive attitude. And so Russell, that, that unfortunately describes sadly, how administration tends to, to react many times. They’re, they’re the lava.

And so, you know, you may have to forge another way, but closing out, these are the references and I’ll leave that up there. If you want to take a picture of it with your cell phone or whatever, but these are the references that I use. So EMS.gov has the final advisory and fatigue in EMS.

And then the SIMSO has their guidebook, the CDC, the work hour training for nurses. And then you’ve got some stuff from the national library of medicine. There’s an article there from the Washington post about what happened with Libby Zion.

And so there’s, there’s a lot of good information. There is a section. I think that national library of medicine, the next to the last one is actually an article in stat pearls, which if you haven’t heard me talk about stat pearls, I really liked them.

They have a lot of EMS content relatively. And they also offer free quizzes at the end of those articles. So if you pay for it, you can get CE hours, but you know, they’re still good for your knowledge.

And so it’s, it’s a good reference point. So I’m going to stop sharing this for a minute and let’s, let’s talk, you know, what questions do you guys have about this? And so that we can try to, you know, answer your, your questions about the sleep. I think that there are numerous resources out there that are going to tell you, okay, so for optimum sleep, you need to be sure that you go to sleep at the same time every night.

Yeah. Good luck with that when you’re on shift and you should sleep in a place where it’s cool. Well, you don’t control the thermostat.

Most of the stations that we have, you should also make sure that it’s completely dark. And once again, you didn’t get to build the place, but this is one of the first places where you can talk to your administration, whoever that is chief or Lieutenant or whoever and say, yeah, we’re working 24 hour shifts. We need to be able to nap, but we also need to be able to make it completely dark in those areas when we’re napping.

Can we get some blackout curtains if you’ve got windows? Or can we set up a sleep room for people to nap in? And this was one of the, one of the solutions that I saw as I was perusing all of this was that one place had set up a nap room and no windows and it was cool. And it was off from the rest of the, of the station. So they weren’t hearing the TV and the kitchen and those sort of things.

So you know, I think that there’s a lot of room for you to get very creative with your administration. They’re also going to tell you to try to always, in addition to going to sleep at the same time, try to get up at the same time every day. Obviously this can happen on days that you’re off and those are times to try to catch up on the stuff.

You should not have caffeine within an hour or two before you’re going to go to sleep. If it’s scheduled, especially on your day off, you need to not have electronics in your room. You really should not have the blue light.

It disrupts your sleep patterns. And also you want to say that your bed is only for sleep and one other activity. So, you know, those are some of the things that if you read, you know, suggestions on improving your sleep that are in everything.

And, you know, obviously at work there’s going to be a different matter and different animal completely. So I see Edward’s comment about, I’m not sure about caffeine. So here’s the problem.

Caffeine feeds you with an addiction. It’s an addictive chemical. So is sugar and it tends to go hand in hand and those can end up causing you to have metabolic syndrome that is also implicated in type two diabetes, high blood pressure, heart attacks, strokes, basically every disease of Western society.

And so, you know, the, I’m sitting here with a Red Bull, so I can’t really talk too much about it, but that doesn’t mean that it’s optimal for me. And so the caffeine is one of the strategies that you see when we have people that are chronically sleep deprived for them while they’re at work to maintain their alertness. But at the same time, you know, I’m not sure that that’s really necessarily the best thing that you can do.

And so I’ll, I’ll be upfront and I’ll confess I rely on caffeine way too much. And I think that there are several resources if you’re interested that you can get that talk about metabolic syndrome and how you can help yourself with those things that it doesn’t cost anything to do. You’re going to eat anyway, pick the right foods.

You know, you’re going to drink fluids to hydrate yourself, pick the right ones. You know, so it’s not really that you don’t have to go out and buy an app. You don’t have to buy somebody’s plan.

It’s more a matter of you can educate yourself and figure out those things. And there’s a Dr. Robert Lustig. He’s a pediatric endocrinologist and, and he has a lot to say about caffeine and how it affects our brain.

And so I would, I would encourage you to look up any of his books and resources because he has, he has a biochemical background to be able to tell you, you know, why it’s not necessarily the best idea. Let’s see, Meyer must’ve gotten the memo about 24 is not being the best for health. Well, good.

I’m, I’m glad for that. And I understand why a lot of people want to do those because you get the hours really fast and you get paid more potentially. So I also worked at one place where the, the federal government allowed them to take us off of the clock.

If we were not on calls after 11 PM, they, we weren’t on the clock, we couldn’t leave, but we weren’t on the clock until we got a call. Then they would put you back onto the pay clock. And, um, so, you know, there, there’s pluses and minuses to it.

Um, and up all night clause. I’m, I’m intrigued by this Russell. Um, I can tell you a little more if you want on it.

It’s, it’s in our union contract. It’s, uh, basically, if any station gets a call or our tones are dropped, even if they’re accidentally dropped between midnight and 6 AM, uh, we are allowed to sleep instead of normally we have to be up at seven 30. We’re allowed to sleep until nine 30.

Uh, or if we’re up, if we’re truly up all night, like on a fire or for, you know, a really, really long call. I work at the Lake of the Ozarks. So we have a lot of boat wrecks overnight that take quite a long time finding victims and such.

And we’ll, they’ll cancel everything the next day. Uh, so we can rest now. Just curious.

Do you get paid? So if you get off, off your shift at seven 30, but you can sleep in until nine 30, are you on the clock or off the clock until nine 30? Sorry. So let me, let me clarify. We worked 48.

Ah, so it’s, uh, it’s truly, it’s just for that second, that second day. Um, you’re not paid any additional, uh, we’re allowed to, I mean, our station’s really laid back. So if we did have a long night and I’ve done it a couple of times, cause I, I live two hours from where I work.

If we’ve had a long second night, uh, I’ll stay and sleep in for a couple extra hours just so I can safely make that drive home. I’m not paid for those extra hours. We get off at seven 30 in the morning, but, uh, but they’re, they allow us to, you know, to hang out.

Well, and, and I think that the solution that the, the Colorado agency had for the worker that, uh, crashed going home is a good, good policy. The problem is when they’ve got workers like yourself, where it’s two hours, you know, they can’t take the unit out of service for two hours to allow the, the paramedic to drive your vehicle while the, the ambulance driver or whoever’s driving that day, whoever the driver is drives you and your car back to your house. They can’t take them out of service for four hours.

Right. Yeah. So that wouldn’t work where we’re at.

Most of our employees live an hour plus away. Right. And Dylan, absolutely.

You know, um, I frankly, I don’t count stuff. Um, you know, other than my sleep hours, um, and the whole thing about a balanced diet. Um, there’s some politics involved in that, that really more and more, we’re finding is not being held up by the science.

Um, when, when we study it, we’re seeing that it’s not necessarily true what we’d been being told all these years. Um, I’ll give you a, for, for instance, um, probably it’s going to say that you need to have vegetable oils and margarine, um, in August, and you can Google this and I encourage you to Google. It’s a free article.

Um, JACC, journal of the American college of cardiology, August, 2020, and saturated fats. And so let me give you my, my 32nd version of what that paper says. It says we messed up back in the seventies and eighties.

And we told you to eat these things, get rid of all the seed oils, get rid of all the vegetables, get rid of vegetable shortening, get rid of margarine, the fats that you should be eating. And this is in the article include lard, which is from a pork tallow, which comes from beef or geese and butter, real butter. And also they say that whole eggs are not bad for you.

And they even have an infographic that says unprocessed red meat does not cause heart disease or diabetes. So, you know, even the heart doctors are coming around to this sort of stuff. Um, so I would encourage you to, to Google that for yourself.

You know, I, I tell everyone all the time, you know, don’t trust me completely verify it for yourself. That’s why I gave you these references so that you can verify these things. Um, but yeah, I, I, I think that, you know, trying to achieve balance and stuff is good.

Um, that said my balanced diet is that I’ve been doing carnivore now since summer of 2019 and I only eat one meal a day. And so, you know, I’m not sure that, that anybody would say that that’s balanced other than people that are doing the same sort of thing, but I, I had ballooned myself up to 250 pounds and I had sleep apnea and high blood pressure. And now I’m down to one 73, the last time that I weighed and I still like sleeping with the CPAP because it’s a lot easier to fall asleep.

Um, but, and, but yeah, do I really need it when I’m sleeping and I don’t have it on my sleep tracker doesn’t tell me that I’m snoring any more than, than I do. So I still snore sometimes with the CPAP. So, you know, I think that there’s a lot to be said for trying to get yourself healthier in, in however you can.

And so, you know, if you have questions about those sorts of things, I’m more than happy to talk about the metabolic health and stuff. Um, so let’s see. Yeah.

PTSD does affects everybody’s sleep patterns. I know for many years, I still will sometimes have some nightmares about some of the calls that I had. Um, and yeah, I’m, I’m right there with you on four or five hours.

Now I’ve got another little demon that wakes me up pretty much every night called my prostate. Yeah. And so, yeah, some people do require background noise and, and I get that and that’s not necessarily a bad thing.

In fact, the sleep tracker that I use actually has that built into it. Um, you can import your own, they have theirs, you can buy theirs. I’ve got a bunch of free ones.

So yeah, look at, look at all those options and whatever tends to give you the best sleep overall, that’s obviously the best route for you. Um, and some people actually function well with four or five hours sleep every night. And they always have.

And, and I wouldn’t say that I envy those people, but you know, I have known some of those people and I would like to say that I’m one of those, but I’m really not. So yeah, we have to know our own limitations. Yeah.

Three kids under five. Definitely. I get that.

Um, and, and so my strategy when my kids were like that was that, you know, nap every chance that you get. And when I got remarried and we had two grandkids that had, they still live with us and that’s been eight years now. Yeah.

Nap every chance I get. So I, and, and I still encourage you if you get a chance and you don’t have anything else to do, by all means, you should go and nap. Um, a couple of other things that, that they recommend to try to help with your sleep hygiene and stuff is get outside, go outside into the sunlight, get real sunshine.

Um, I’m not sure about the whole grounding thing, you know, walking around barefoot for a while. Hey, you know, if it helps you, it helps you. That’s great.

Um, they encourage mindfulness training and stuff. And, and, um, um, Dr. Lustig said, you know, that at least the, when they do some controlled trials, it does seem to help people’s fatigue in their sleep. So, you know, it’s, I think that that’s something to at least look at.

Um, you know, I’m not saying go all Zen Buddhist or anything, but, you know, at the same time, you know, what’s going to hurt to sit and just concentrate on your body for a few minutes. Um, he talked about eating a raisin over 10 minutes, one raisin and taking 10 minutes to do that. Um, you know, I, I think that there’s something to be said for it.

Um, it’s not part of my routine as yet, but you know, he highly recommends it. So, you know, and he is a scientist and he says that he backs all of the things that he says up with science. So, um, youngest is seven weeks old.

Yep. Definitely. I remember those days.

Um, one of our, one of our nurses has a, um, six month old now and she works nights and she was looking at the baby camera. And she said, I don’t understand why when, when I’m not there, baby will sleep through the night. When I’m there, the baby’s up all night long.

So, you know, I, I get the frustration. Um, I wish that I had a miracle solution to all of these problems, but unfortunately like so many things in life, the, the solution depends on so many different parameters. Anything else? Yeah, I hear you, Russell.

I definitely understand that. Yeah. I hate to say it this way, but I think that it’s probably good that you and your wife are both in EMS because I think that that, that fosters an understanding of, you know, Hey, listen, I had a horrible shift and yeah, I, I just need to sleep.

I get that. Anything else? And at the same time, Russell, I’m sure that, um, the, the slides with the paramedic that got killed on the way back to his home, uh, probably resonate with you more than others as well. So, you know, especially with his wife being one of the responders, Mr. Gould.

Ah, so not in the same service. All right. Well, Jane, I think that that’s, it’s been an interesting, um, journey to navigate some of these items to, you know, extract just a little bits here and there and wish that we could spend more time talking about it.

But, um, yeah, I think that we’ve beaten the proverbial horse as it were. This was a great discussion. Thank you so much, Dr. Phillips.

And for those of you who weren’t here earlier, I just added a, um, another session with Dr. Eshelbach for a week from tomorrow night on Tuesday night in case you need another one of the roundtables. Dr. Phillips, um, I’ll be seeing you in the advisory council meeting room or at least your post and, uh, everybody, I hope you have a good night. All right.

Good night, everyone. Thank you. Thank you.