Falling asleep in the OR, especially during 24's - tips?

[propofabulous]

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I had absolutely zero problems during CA-1 year with fatigue, but I was only doing 24 hour call once a week, and because I prioritized my sleep I was alway able to get 7-8 hours on non-call days. I still prioritize my sleep and get 7-8 on non-call days, but as a CA-2 now doing anywhere between q2-q4 24 hour call, the chronic sleep deficit has been building and I've recently been struggling to fight off sleep during cases.

I imagine this is a common issue in residency with the hours we work and the call frequency. If I find myself dozing off, my only options are to stand up and move around, or try to find something stimulating on my phone (this rarely works). I drink coffee in the morning, but wonder if I should start using a second caffeine boost in the afternoon, and a third caffeine boost around hour 16 to get through the last 8? Any develop a good system for dealing with 24's and combatting sleepiness in the OR? Dealing with sleepiness during 24's is par for the course, but with the build up of the sleep deprivation it's gotten to the point where I am struggling on non-call days as well. The obvious solution is not to have residents work 24 hours straight, but that is a completely different issue, and I'm just trying to survive.

 

[DrGasPasser]

Not trying to be a smart ass, but are you otherwise healthy? That is to say, make sure that OSA, poor nutrition, ETOH, adequate exercise, etc are not a problem.

 

[abolt18]

I had absolutely zero problems during CA-1 year with fatigue, but I was only doing 24 hour call once a week, and because I prioritized my sleep I was alway able to get 7-8 hours on non-call days. I still prioritize my sleep and get 7-8 on non-call days, but as a CA-2 now doing anywhere between q2-q4 24 hour call, the chronic sleep deficit has been building and I've recently been struggling to fight off sleep during cases.

I imagine this is a common issue in residency with the hours we work and the call frequency. If I find myself dozing off, my only options are to stand up and move around, or try to find something stimulating on my phone (this rarely works). I drink coffee in the morning, but wonder if I should start using a second caffeine boost in the afternoon, and a third caffeine boost around hour 16 to get through the last 8? Any develop a good system for dealing with 24's and combatting sleepiness in the OR? Dealing with sleepiness during 24's is par for the course, but with the build up of the sleep deprivation it's gotten to the point where I am struggling on non-call days as well. The obvious solution is not to have residents work 24 hours straight, but that is a completely different issue, and I'm just trying to survive.

Personally, caffeine up to 3 times on an overnight shift for me if there's no down time. Other than that, same thing. Stand up, keep busy messing around with your monitor or vent and different settings.

 

[nimbus]

q2-4x24hr call is brutal. Is that all OR time? We only had those type of shifts during our ICU months where there was usually some rest time and sleep time built in even though we were in house.

And yes more coffee.

 

[propofabulous]

Not trying to be a smart ass, but are you otherwise healthy? That is to say, make sure that OSA, poor nutrition, ETOH, adequate exercise, etc are not a problem.

Good question, but I am! No issues with OSA, nutrition above average, minimal alcohol, exercise 2-3x/week. I believe it is more a product of chronic sleep deprivation as I didn't have this issue last year and nothing else has changed except my call schedule.

 

[propofabulous]

q2-4x24hr call is brutal. Is that all OR time? We only had those type of shifts during our ICU months where there was usually some rest time and sleep time built in even though we were in house.

And yes more coffee.

All OR time. Damn, really? How frequently would you guys take 24 hour in house call in the OR's, and would you actually get to sleep during those? Our OR's run through the night so we typically don't get to sleep. ICU is guaranteed no sleep.

I was under the impression that q4 24 was normal (equates to ~7 calls a month). q2 unfortunately happens when we are understaffed.

 

[propofabulous]

Personally, caffeine up to 3 times on an overnight shift for me if there's no down time. Other than that, same thing. Stand up, keep busy messing around with your monitor or vent and different settings.

Think I'm leaning towards this. I'll give it a shot

 

[deleted162650]

Sublingual ephedrine.

 

[UscGhost]

Caffeine..pushups...hard to fall asleep standing up

 

[Mikkel]

It's ok to close your eyes during a case as long as you are still "continuously monitoring" the patient. "Quiet wakefulness" is not as good as actual sleep, but you'll feel a little recharged after lulls in the case.

Don't do it during times that actually matter, but I doubt you would ignore critical events, no matter how tired you are.

 

[Shimmy8]

Exercise more than 3x/week. Track sleep with an app, see if you’re actually getting good sleep.

Caffeine around 2-3 PM. Don’t eat a big meal for dinner.

If in OR and tired:
-Walk around the OR and talk to people.
- Pushups or air squats in the OR.
-Shock yourself with nerve stimulator.

 

[Nivens]

One of my coresidents used to chew this super-caffeinated gum made for the military. I think he got it on amazon. You could try that.

 

[Beeftenderloin]

Personally, caffeine up to 3 times on an overnight shift for me if there's no down time. Other than that, same thing. Stand up, keep busy messing around with your monitor or vent and different settings.

Only 3 cups of coffee?

 

[deleted875186]

Q2-4 day 24 call for 2 years straight is terrible, unless your able to catch some sleep overnight. If your up every call 24hrs, unfortunately I think it’s iust the call schedule getting to you.

My personal opinion, if you find yourself dozing off, your attending or someone else needs to give you a break to either get a coffee or do a power nap or something.

 

[abolt18]

All OR time. Damn, really? How frequently would you guys take 24 hour in house call in the OR's, and would you actually get to sleep during those? Our OR's run through the night so we typically don't get to sleep. ICU is guaranteed no sleep.

I was under the impression that q4 24 was normal (equates to ~7 calls a month). q2 unfortunately happens when we are understaffed.

Not normal for us, definitely not. Anywhere between 0 and 4 weekday overnight shifts in a month is normal, and those shifts are either 16h for CA2 or 3 and 19h for CA1. Likely to have one weekend per month of OR time and one weekend per month in the ICU (ICU is moonlighting if a weekend). Those are 4 total 12 hour shifts, but days more likely than nights.

Also, it's pretty typical that I'll get at least 1-2 hours of sleep on an overnight shift. I'd say 80% of the time.

 

[Ronin786]

It's ok to close your eyes during a case as long as you are still "continuously monitoring" the patient. "Quiet wakefulness" is not as good as actual sleep, but you'll feel a little recharged after lulls in the case.

Don't do it during times that actually matter, but I doubt you would ignore critical events, no matter how tired you are.

Maybe as an attending. All it takes as a resident is a nosy circulator to see your eyes closed and that's your ticket out of residency. I would go into the sub sterile and splash water on my face. Also, ask a co-resident to get you a 15 minute break if you're dozing. You literally cannot doze off as a resident. I know people who got too comfy in a cold spine case, found to have fallen asleep and were fired.

 

[jope]

I never had to resort to it, but I knew a couple coresidents (Gen Sx and Emerg) during my training that were on occasionally on modafinil for a soft diagnosis of "Shift Work sleep disorder" from a walk-in clinic. It seemed to work for them without any obvious side effects.

They are now attendings and don't require it.

 

[deleted162650]

Get eyes tattooed on your eyelids?

 

[vector2]

Please dox your program so future residents can be warned not to rank there. Don't get me wrong, all residents need to have exposure to a fatiguing in house call every now and then because those situations inevitably come up when you're a call taking attending, but in your case... you have no reading time and you're not learning sht doing busy q2 24h OR calls, not to mention that that kinda schedule is also a nice recipe for a serious drug error.

 

[deleted875186]

Maybe as an attending. All it takes as a resident is a nosy circulator to see your eyes closed and that's your ticket out of residency. I would go into the sub sterile and splash water on my face. Also, ask a co-resident to get you a 15 minute break if you're dozing. You literally cannot doze off as a resident. I know people who got too comfy in a cold spine case, found to have fallen asleep and were fired.

Or you will be seen dozing off and people will be suspicious your diverting fentanyl or something.

 

[pgg]

It's ok to close your eyes during a case as long as you are still "continuously monitoring" the patient. "Quiet wakefulness" is not as good as actual sleep, but you'll feel a little recharged after lulls in the case.

Don't do it during times that actually matter, but I doubt you would ignore critical events, no matter how tired you are.

This might be the single worst piece of advice I've ever read on SDN.

At best you actually have episodes of microsleep, nothing happens, and no one notices.

At worst you fall asleep and miss something.

 

[Mikkel]

Maybe as an attending. All it takes as a resident is a nosy circulator to see your eyes closed and that's your ticket out of residency. I would go into the sub sterile and splash water on my face. Also, ask a co-resident to get you a 15 minute break if you're dozing. You literally cannot doze off as a resident. I know people who got too comfy in a cold spine case, found to have fallen asleep and were fired.

Or you will be seen dozing off and people will be suspicious your diverting fentanyl or something.

This might be the single worst piece of advice I've ever read on SDN.

At best you actually have episodes of microsleep, nothing happens, and no one notices.

At worst you fall asleep and miss something.

So I guess you guys never use your phone, or read articles, or use the computer during cases because you're afraid of the circulator.

I never recommended dozing off. Closing your eyes for a few seconds every minute while watching the monitors ain't gonna harm anyone. Do it while standing up or on a small stool if you're worried about passing out.

Sheesh, you guys sound like a bunch of henpecked husbands.

 

[pgg]

So I guess you guys never use your phone, or read articles, or use the computer during cases

Sure, but I use them with my eyes open.

What's that word? Starts with a V?

 

[GravelRider]

It's ok to close your eyes during a case as long as you are still "continuously monitoring" the patient. "Quiet wakefulness" is not as good as actual sleep, but you'll feel a little recharged after lulls in the case.

Don't do it during times that actually matter, but I doubt you would ignore critical events, no matter how tired you are.

This is the dumbest thing I’ve ever read...by far.



To OP: Q2 call is unacceptable in my opinion. I would try to get that changed or look for a new program. You are being used and abused by a program with staffing issues. No amount of caffeine or push-ups in the OR will help a practice that is both unhealthy for you and dangerous for you and the patient.

 

[Mikkel]

Sure, but I use them with my eyes open.

What's that word? Starts with a V?

You just admitted to not watching the patient's monitor during the case! I'm calling the operating room police on you for your admission of decreased vigilance.


You must be one of those homeless anesthesiologists that piss in the garbage can because the thought of leaving the operating room for 60 seconds is giving them fever dreams.

 

[Arch Guillotti]

You just admitted to not watching the patient's monitor during the case! I'm calling the operating room police on you for your admission of decreased vigilance.


You must be one of those homeless anesthesiologists that piss in the garbage can because the thought of leaving the operating room for 60 seconds is giving them fever dreams.

Dude settle down.

 

[AdmiralChz]

I was under the impression that q4 24 was normal (equates to ~7 calls a month). q2 unfortunately happens when we are understaffed.

Decidedly NOT normal. I am surprised you are keeping within work hour restrictions with such a schedule (although I suspect your program encourages you not to log properly like in gen surg). Q4 is on the bad end for programs, but is a gigantic difference between that and Q2! That’s working 24 every other day and probably forbidden by ACGME. Your program is practically begging for a medical error to occur in the middle of the night.

I would say discuss this with program leadership or your chief residents, but if you’re at a program like mine the chiefs didn’t even take call due to “all their extra duties”

It's ok to close your eyes during a case as long as you are still "continuously monitoring" the patient. "Quiet wakefulness" is not as good as actual sleep, but you'll feel a little recharged after lulls in the case.

Don't do it during times that actually matter, but I doubt you would ignore critical events, no matter how tired you are.

“Quiet wakefulness” sounds like a great way to get fired or sued, so there’s that.

You just admitted to not watching the patient's monitor during the case! I'm calling the operating room police on you for your admission of decreased vigilance.


You must be one of those homeless anesthesiologists that piss in the garbage can because the thought of leaving the operating room for 60 seconds is giving them fever dreams.

Man @pgg what have we told you about administering that homeless anesthesia again! Cmon man! Also, what’s a “fever dream”?

 

[Mikkel]

“Quiet wakefulness” sounds like a great way to get fired or sued, so there’s that.



Man @pgg what have we told you about administering that homeless anesthesia again! Cmon man! Also, what’s a “fever dream”?

People get fired and sued for using their phone during a case when nothing bad occurred? But they do get fired for closing their eyes for ten seconds?



Regarding the homeless anesthesiologist comment, check out the bathroom break topic here: How often should I ask for bathroom break?

I think the last thing this profession needs is doctors using the operating room as their personal bathroom. You WILL get sued for that if a patient gets a bad surgical infection and the circulator says you pissed in a garbage can. Try defending that in court.

 

[AdmiralChz]

I think the last thing this profession needs is doctors using the operating room as their personal bathroom. You WILL get sued for that if a patient gets a bad surgical infection and the circulator says you pissed in a garbage can. Try defending that in court.

What about pooping in the garbage can? I had some rough Mexican last night.

 

[Beeftenderloin]

All OR time. Damn, really? How frequently would you guys take 24 hour in house call in the OR's, and would you actually get to sleep during those? Our OR's run through the night so we typically don't get to sleep. ICU is guaranteed no sleep.

I was under the impression that q4 24 was normal (equates to ~7 calls a month). q2 unfortunately happens when we are understaffed.

Not only is this abnormal but Q2 isn’t even ACGME compliant, duty hours aside.

 

[osumd]

If your program is acgme accredited, q2 24h is a duty hour violation. It should be reported

 

[Mikkel]

What about pooping in the garbage can? I had some rough Mexican last night.

That's ok, but cleanup can be tough. Just have the circulator do the usual nurse stuff for you, they're used to that s***.

 

[Shimmy8]

I’m sure this guy/girl is just having a bad run of a few q2 24 hr shifts every month or so. I certainly did.

NOT q2 for weeks, but a week before vacation or working a holiday I’d have 3-4 q2 shifts pop up couple times a year.

 

[GravelRider]

People get fired and sued for using their phone during a case when nothing bad occurred? But they do get fired for closing their eyes for ten seconds?



Regarding the homeless anesthesiologist comment, check out the bathroom break topic here: How often should I ask for bathroom break?

I think the last thing this profession needs is doctors using the operating room as their personal bathroom. You WILL get sued for that if a patient gets a bad surgical infection and the circulator says you pissed in a garbage can. Try defending that in court.

So who is going wake you up if that 10 seconds turns into 10 minutes? It is just really terrible advice to tell someone who is already sleep deprived and sleepy in the OR to “just close your eyes.” Better advice would be to call someone in to give you a break while you take a nap for a little while in the call room.

 

[deleted162650]

I had some rough Mexican last night.

What was her name?

 

[Mikkel]

So who is going wake you up if that 10 seconds turns into 10 minutes? It is just really terrible advice to tell someone who is already sleep deprived and sleepy in the OR to “just close your eyes.” Better advice would be to call someone in to give you a break while you take a nap for a little while in the call room.

If he's worried about dozing off, then either do it while standing up or while sitting in a stool/chair with no back.

If he's falling sleep standing up then this is a safety issue that needs to be addressed by acgme or the hospital administration. Constant Q2 call when up for 24 hours is inhumane and violates labor laws.

 

[San Marzano]

It's ok to close your eyes during a case

Wrong.

 

[Mikkel]

Wrong.

You don't blink, you don't read, you don't chart. I applaud your ability to never stop looking at the monitor.

 

[Dexmetaketapropofol]

Ahh, don't miss those days. We used to do Q3-4 24hr in my residency with elective cases in the night. I had 2 tricks that worked for me:

1. O2 nasal cannula with whatever flow rate to keep me awake. The hyperoxia helped and I felt more wakeful.
2. Some type of 30 second exercise. Throw a blanket on the floor throw on gloves and do pushups, use the chair to work on the triceps, bring an elastic band for biceps. Either the brain has to be active or the body has to be active. If one starts to shut down, the other will follow in severe boredom.

Anyways, it got me through the residency calls. The cardiac fellowship calls were intense cases enough I wasn't ever bored. Good luck!

 

[pgg]

You don't blink, you don't read, you don't chart. I applaud your ability to never stop looking at the monitor.

You've got more strawmen and diversions here than in the political threads. 🙂

 

[Mikkel]

You've got more strawmen and diversions here than in the political threads. 🙂

They're just comparisons. Eyes looking at the inside of your eyelids for 10 seconds is not much different than studying a journal article or looking at your phone for extended periods of time.

 

[pgg]

They're just comparisons. Eyes looking at the inside of your eyelids for 10 seconds is not much different than studying a journal article or looking at your phone for extended periods of time.

I think where the disconnect between you and everyone else here is that everyone else seems to recognize that closing your eyes even for a short time when you're that exhausted carries an unacceptable risk of actually falling asleep.

You presented this terrible idea and then your defense of something indefensible branched out into absurdities involving peeing and pooping (again there's that weird fecal obsession), conjured fears of nurses, and comparison to active wakeful activities (which may themselves sometimes be a bad idea).

Closing your eyes to rest a while when you're so tired you post about how tired you are on SDN is foolish and reckless, full stop.

 

[Mikkel]

I think where the disconnect between you and everyone else here is that everyone else seems to recognize that closing your eyes even for a short time when you're that exhausted carries an unacceptable risk of actually falling asleep.

You presented this terrible idea and then your defense of something indefensible branched out into absurdities involving peeing and pooping (again there's that weird fecal obsession), conjured fears of nurses, and comparison to active wakeful activities (which may themselves sometimes be a bad idea).

Closing your eyes to rest a while when you're so tired you post about how tired you are on SDN is foolish and reckless, full stop.

Go read the entire bathroom topic over and then tell me that urinating and defecating in the operating room are more acceptable than closing your eyes for 10 seconds while standing up.

If he's so deathly tired that he would fall asleep standing up, then he needs to report his residency to ACGME/OSHA/hospital administration.

 

[pgg]

Go read anything I've posted on the topic and show me where I've demonstrated anything but puzzlement that people have trouble managing their bodily functions.

You're a weird dude. I think we're just going to have to agree to disagree.

 

[Mikkel]

Go read anything I've posted on the topic and show me where I've demonstrated anything but puzzlement that people have trouble managing their bodily functions.

You're a weird dude. I think we're just going to have to agree to disagree.

Read what others have written there.

Some say it's worse to leave a case for 60 seconds to piss in the bathroom, how could anyone disagree.

Some say it's worse to piss in the operating room trash can, how could anyone disagree.


You said that closing your eyes for 10 seconds is indefensible. I think it's actually defensible since you're still with the patient the whole time and you're still listening to everything around you even if your eyes aren't on the monitor. It's not like you're leaving the room for a few minutes to help a colleague with an airway disaster, or leaving the room for a few minutes to use the bathroom.

 

[chocomorsel]

This guy is a troll and just comes here to piss people off. We should all just learn to ignore him. He is clearly demonstrated narcissistic behavior. He’s been only on this site a few months. And his main goal is to rile people up.
Let’s stop falling for the troll.

 

[San Marzano]

You don't blink, you don't read, you don't chart. I applaud your ability to never stop looking at the monitor.

K

 

[DM27]

I personally have never had a problem with actually falling asleep in the OR. I have felt miserable on call and wanted to shoot myself and I have been so tired that I probably sound drunk, but I haven't had a problem where I actually dozed off in the middle of a case. When I was on call I would just get a large coffee and I slowly drink it throughout the call once I am certain I am going to be awake. It is normal to be tired and to lose focus, but it is not normal to fall asleep outside of your control.

 

[chocomorsel]

I personally have never had a problem with actually falling asleep in the OR. I have felt miserable on call and wanted to shoot myself and I have been so tired that I probably sound drunk, but I haven't had a problem where I actually dozed off in the middle of a case. When I was on call I would just get a large coffee and I slowly drink it throughout the call once I am certain I am going to be awake. It is normal to be tired and to lose focus, but it is not normal to fall asleep outside of your control.

It is absolutely normal to fall asleep if you have been doing Q2 to Q4 24 hour call. And that’s why you are drinking coffee. Our bodies have a circadian rhythm for a reason. We are made to require rest.

Let’s not perpetuate this super doctor/superhuman persona of the old days that’s an absolute fallacy.

 

[UscGhost]

Yup. Report them to the ACGME. It's the only way they will change. Similar to hospitals and JCAHO...hospital admin couldn't care less what you need unless JCAHO asks for it.

ACGME is your only ally. You are cheap labor for the residency program..so dont feel like you owe them any favors.