D-oing it all Night (not like that…)

il_340x270.1028664201_i3xlWorking with diabetes can be a challenge at times, trying to smooth out hypos and hypers during the working day, but all of this difficulty ramps up a level at night where there are usually fewer colleagues around, your body is struggling to work out why you’re doing stuff at 3am and you’re eating at all the wrong times.

Luckily, Beth, a doctor, and Tom, a nurse,  have put together some tips from their experiences of working busy nightshifts in hospitals. As always, what works for some might not work for you – but we can all be found on Twitter if you want to talk more about any of these issues.

Lots of folk work nightshift – factory workers, post office folk, 24hr shop folk, airline staff, carers, paramedics.

I’m a doctor. Lots of this is going to be about doing medical night shifts – but lots will also be applicable to other nightshift workers.

I worked night shifts for 6 years. I learnt a lot over that time about managing my diabetes on nightshift; but this post comes with a warning: YDMV, but also YSMV!

For those to whom the first doesn’t make sense, it stands for “your diabetes may vary”. We know that what sets things well for one PWD is sometimes not good at all for another. I’m a doctor, but this post is not medical advice: we are all different. So, on to the second acronym: YMSV – your shifts may vary. As in, they may be different from mine, but also many of us work shifts that are totally different on one night from the next.

When I first did night shifts, I had no pump, no DAFNE training, almost no carb counting training, no libre (I have one now, and I love it!) and support that went as far as a grand total of “your blood sugars are going to be crap”. No, I’m serious, that’s what the doctor said in clinic as a grand total of advice about starting work (including night shifts). That was it.

My first couple of sets of nights (9years ago) were relatively hellish. And by hellish, I mean working so hard for 14 hours that you forgot you might need the loo EVER and only realised when half way home that you really needed to go because you hadn’t been since you left home the previous evening. But only some of them were like that. On other rotations, I got time to eat “lunch” (or whatever you want to call it. Doesn’t usually feel like a midnight feast) AND go to the toilet! And check my blood sugar. And panic because I didn’t really have a clue what it was doing. I found out pretty fast that the second night of the run would be worst. I could leave home, having bolused “normal” amount for my dinner, with BG of 8. By 2 am I would have BG of 18, and if I corrected I usually crashed horribly to a hypo in the early hours.

I told myself everyone felt as sick as I did – I knew everyone felt sick on nights. Then one night I worked with a diabetes registrar (a doctor on their way towards being a diabetes consultant). A nice, sensible diabetes reg. I had crashed from 17 to 3 in the space of a few hours, and he looked at me and asked if I was ok. I said yeah, my sugar is low but it’s fine – everyone feels sick on a night shift, right? He muttered something about the rest of the world not feeling THAT sick. But there was nothing for him to do. I was doing my job with the illness I had and the tools I had.

When I was an FY2, I did DAFNE. I got a better grip on carb counting. That made some difference. I learnt I could treat a hypo on the post-nights ward round with an endocrine consultant leading the round, without them noticing. I also learnt that nights really made the next week or so pretty awful.

Then I got a pump. One of the reasons I found nights so tough became clear: my morning basal requirements are more than twice my evening requirements. I have an awful dawn phenomenon. Jetlag is a bad plan. Nights are tricky.

I can do nights, now. Theoretically. I mean, I know I can. I know that when I put my diabetes first (and I have to on nights to be well enough to do my work) I can have great sugars. It’s a LOT of work, and the associated fatigue led me to problems with hypos I wasn’t waking up for, and so now I’ve stopped working night shifts. I do know what I need to do (for me) on nights though:

Tips from my night shifts – YDMV, YSMV.

Sleep. No really. My level of fatigue was such that I could sleep in til 11, get up til 1 pm and go back and sleep through until my first night shift starting at 9 pm. Not being sooo tired at the start helps. So, if you can: sleep all day before you start.

  • Labelling: do all your carb counting before you start night shifts. Get a marker pen and label All The Things. Be over-organised and a bit weird and have a meal plan for what you are going to eat, with pre-checked carb counts. At 4 am on your 4th night in a row, your brain needs to be able to do work, not think about carbs.
  • Low carb: I deal with my moving dawn phenomenon on nightshift partly by eating almost no carbs before I go to work. I do eat – protein, veg – just 20g carbs or less though. I imagine I would find this less of a thing if I had less of a dawn phenomenon.
  • Food to take with you: buy it before you start the run of nights. Take more than you need, and make sure you have some low carb options as well as higher carbs. You need to eat something if you can in the middle of the night, but some folk feel sick so take something easy to eat.
  • WATER or TEA: hydration is an issue if you aren’t going to sit down all night. If you aren’t going to the loo for 14hours, you probably haven’t drunk enough! Get a flask. Label it with your name. Put tea in it. Then wander the wards at 1030am after morning ward round wondering where you put it down…. If someone offers you tea, say yes.
  • Basal Insulin
    • if you are on MDI, think about when you need to take your basal. Try not to take it twice (yes, I’ve done that in post nights’ daze!!). If you are going to need to take it at work, I HIGHLY recommend setting an alarm. In receiving shifts especially, you can look up and find its 3 am and you haven’t stopped to think at all: this is a problem if you were due Lantus at 11 pm.
    • if you are on a pump and have higher requirements in morning, I suggest trying a switch over to “night shift” as far as your pump is concerned when you get home from the first night shift, not before. It makes jetlag sense…
  • Bolusing – if you have different insulin sensitivity factors at different times of day, remember those will switch if you have switched night to day. Again, second night you need to think most carefully about this – they don’t switch like a light switch, they sort of drift!
  • Clipboards and Bags: If your nightshift even *might* be in more than one ward/department, you need one. Or probably both. By clipboard, I mean the ones that are actually a box you can stash things in. Dextrose does not fit. Jellybeans do. Cereal bars do. CEREAL BARS ARE YOUR FRIENDS ON THESE SHIFTS. If you haven’t eaten for 10hours and now have to continue to stand upright on a ward round for 2 more hours, a cereal bar from your clipboard is a lifesaver. See also – when your junior colleague is crying and they are upset about something that is reasonable to be upset about but also they haven’t eaten all night. CEREAL BARS make things better. Also tea. Anyway, diversion: back to clipboards and bags: take your stuff with you. I cannot emphasise this enough if you are working in a hospital environment covering more than one ward. You do not want to get arrest-paged to the other side of the hospital without your BG machine and some food.
  • Tell at least one of your colleagues that you have diabetes if you feel able to. It helps to explain before they find you eating glucose tabs!
  • LASTLY: try and keep some check on what happens, and learn from it for next time. It’s hard when you are that tired to properly keep a check on anything but try after.
  • Side-note for the girls: periods have an affinity for night shifts. For me, this is good when day 1 is night 2: the night shift badness and the period badness (as far as sugars only, unfortunately!) cancel each other out. No, really. YDMV, but periods and night shift are… a thing.

Tom’s Experience

So, here are the musings of an Emergency Department Nurse. I’m the ED resuscitation hobbit with a munted pancreas. My thoughts will echo Beth’s to some extent. A little background about me first. I’m an ED nurse and the probable attention span issues to match it. Look, squirrel! I’ve also been type one for twenty years, for six of those I’ve been rocking a bionic pancreas. I work a particularly unpleasant rota involving a lot of nights and I also have a rigorous shift pattern. I have five shifts, early, late, nights, twilights and long days. Over the last eighteen months, I’ve had to develop patterns that reflect the demands of each shift. In addition to that, you have to be very proactive and willing to make changes on the go, this is damn easy using a pump. A small period where I had the loan of a Freestyle Libre as part of a clinical trial made my night shifts much better and easier to get a grip of.

The only minor issue I have with nights is the quantity of junk food and chocolate that nurses and all healthcare professionals seem to exist on. Oh well. Needs must. Just don’t talk to me until I’ve had my coffee.

The last little thing that always seems to get me is that at around two in the morning I suddenly become incredibly sensitive to insulin so I have to be very cautious with my correction doses. This is just the need to get to know your own diabetes and how it behaves on nights. Sadly, we can’t do much else other than trying what fits for size in regards managing diabetes on nights. Getting out of nights and day sleeping is not an issue for me, my flatmate already calls me day walker due to the large number of night shifts that I do which has reduced me to a vampiric wreck. Oh well.


Beth’s List of Nightshift Snacks!

(some low carb, some high, easy to eat, don’t go off fast, don’t need 5mins in microwave that’s not gonna happen, you can eat it when you feel sick)

  • Babybels – protein that will last ages in your bag.
  • Cereal bars ARE YOUR FRIEND
  • Carrot sticks and dip
  • Bags of kids biscuits – easy to carb count (like the chocolate animal biscuits). Also, they make you smile at 5 am
  • Pepperami sticks
  • Apples
  • Granola in a box
  • Porridge – either a sachet thing or just oats and dried milk in a pot with whatever you fancy and pour over boiling water
  • Milkshake boxes (I buy UHT ones – give you carbs and hydration at once and can be drunk whilst running down corridors!)
  • Cookies
  • Nuts
  • TEA TEA TEA (other beverages are available)

Do you have any tips or tricks to get through nightshifts? Get in touch over on twitter – @k_d85


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