Prioritizing Sleep for First Responders

By Dena Ali

On June 28, 2023, Dena Ali had the opportunity to sit down with Dr. Matthew Walker, a leading expert in sleep science. Dr. Walker is a neuroscience and psychology professor at the University of California, Berkeley, and founder and director of the school’s Center for Human Sleep Science. Below are his responses to some of our most pressing concerns surrounding sleep health for first responders.

• Sleep: A Missing Link to Cancer Prevention
• Sleep Risks Associated with Shift Work and How to Mitigate Them
• Addicted to Awake: Sleep Deprivation in the Fire Service
• I’ll Sleep When I’m Dead

The conversation was a breath of fresh air. While Dr. Walker has concerns with shift work, on several occasions, he expressed gratitude for our work and his understanding of the need to have responders available 24/7 despite the negative consequences to our longevity.

1. What are your thoughts on our schedules? Currently, many fire departments mandate a 56-hour workweek. Which schedule is optimal?

The optimal shift is the one that has a longer duration of recovery to gain some flexibility to get back at least some of the sleep that was lost. Additionally, you want a schedule that limits transitions, so of the ones described, 24/72 is optimal, followed by 48/96, 24/48, and finally, the On/off/on/off/on/4-off. The goal is to find something as consistent as possible.

2. How is rapid-eye-movement (REM) sleep maximized if it’s necessary for brain health?

In a typical normal night of sleep, the first half of that night will be dominated by deep, non-rapid eye movement (NREM) sleep. As you push through to the second half of the night, those sleep cycles, which last about 90 minutes in humans, will keep repeating, from NREM to REM and then again. However, the ratio of NREM to REM changes in the 90-minute cycle as you move through the night. So if you want to get a jump start on your workday and wake up after only six hours, you have lost 25% total sleep, but you have lost 80% total of your REM sleep, which is critically important dream sleep.

3. What is the relationship between post-traumatic stress disorder (PTSD) and REM/dream sleep?

What we discovered is that sleep—particularly dream sleep and REM sleep—offers a form of overnight therapy, and dream sleep acts almost like a nocturnal soothing balm that takes these difficult, painful, traumatic experiences and just starts to shave off the sharp edges, so that you come back the next day and those memories are no longer as emotional. They don’t feel like they’ve got that painful sting anymore. So in that sense, it’s not time that heals all wounds; it’s time during dream sleep that provides this emotional convalescence.

4. So, the big lesson for first responders is developing good routines, because once you’re sleep deprived, you’re gonna be more likely to struggle, and more likely to have PTSD. If we can develop good habits early in our career and make sure we are getting a full night of sleep after difficult calls and difficult events, will we be more likely to be able to process trauma?

Start emphasizing the importance of sleep in your young trainees, because, based on the evidence, everything I know, sleep is perhaps your greatest immunization against mental ill health that will come by way of the types of experiences and challenges that you face. You must start Investing in sleep as best you can, by building sleep in as one of the priorities in your life. But we often forget that sleep is non-negotiable Sleep gets squeezed like vice grips and becomes the neglected stepsister in the health conversation.

5. I’m grateful specifically for your work, because around the time your book was published, Jocko became huge for emergency responders, and everybody was reading his books. Every morning, he posted a picture at 03:45, and first responders felt they had to start getting up early. Then your book came out with a different view. 

Firstly, I completely respect the gentleman; my goodness, what a human being. The second thing is that there is an alternative perspective to his, which would be mine. It’s at the polar end. The third thing I note is that he is very clearly an extreme morning type, and to argue that everyone should be that way is a total fallacy.

Here’s why. There are different chronotypes…morning, evening, or somewhere in between. You can go online and take the morningness-eveningness questionnaire (M-E-Q). It’s about a three-minute test that will tell you which of the three types you are. You don’t get to decide; it is physically impossible to change your chronotype.

6. Can you describe how sleep flushes the brain of toxins?

Your body has a cleansing system, and it’s called the lymphatic system, but we didn’t think the brain had one. About eight years ago, a research scientist, Maiken Nedergaard, from the University of Rochester, made three stunning discoveries:

• First, the brain has a cleansing system. It’s called the glymphatic system, named after the glial cells in the brain that make up this sewage network.
• She found that it’s specifically during sleep, and deep, NREM sleep, that it kicks into high gear and flushes the brain of all metabolic detritus. In other words, wakefulness is low-level brain damage from a biochemical perspective, and sleep is your sanitary salvation.
• The third thing that she discovered, and she found all of this in mice, is that two pieces of metabolic detritus that sleep will wash out of your brain are the culprits that underlie Alzheimer’s disease.

• Does the specific time matter concerning NREM and REM sleep?

It is based on your chronotype. So, if you’re a night owl and you’re going to bed at 01:00 a.m., that’s perfectly normal and natural for you, and you will start your sleep cycle naturally and get your deep sleep appropriately. Different stages of sleep do different things for your brain and your body at different times of night. If there was any one stage of sleep that wasn’t necessary, trust me, during the course of evolution we would have stripped out that stage of sleep. We have all of these stages of sleep because all of them are nonnegotiably necessary.

8. How does sleep contribute to learning and memory?

Sleep is critical for learning and memory in three different ways.

1. You need sleep before learning to prepare your brain. The memory structures in your brain are almost like a dry sponge ready to initially soak up that information, and if you have not slept sufficiently, your brain cannot effectively imprint those memories into the circuits of the brain.
2. You need sleep after learning. Deep sleep takes those individual memories and hits the save button.
3. Deep sleep strengthens individual memories, but during dream/REM sleep, the brain starts to stitch and associate all of that new information with your back catalog of stored information. So during dream sleep, we go to sleep with the pieces of the jigsaw, but we wake up with the puzzle complete.

9. The next question is two-part question. For first responders, we will run a call in the middle of the night and when we get back, we can’t fall back asleep. So, how do you fall asleep?

Another problem  for a lot of us is that, on our days off at home, we wake up at 02:30 or three and toss in turn and cannot go to sleep.

What you described in the first situation is what happens when you’re adrenalized, which is your heart rate is jacked up, and you’ve got a large amount of adrenaline that’s released from your adrenal glands.

Sleep happens when we switch over from the fight-or-flight branch over into the parasympathetic nervous system, which is very difficult to just get into. Here are some of the things that will help.

• Warm bath or hot shower.
• Surround yourself in darkness,
• Try relaxing exercises. Breathing techniques are fantastic. Meditation.
• Other ways to wind down are reading a book, listening to a podcast, or anything that does not activate your mind.

In terms of your second question, middle-of-the-night awakenings are hugely difficult, and it’s a big problem as we get older, but it’s a huge problem in a career where you’re trained to be what we call hypervigilant throughout the night. The common sleep recommendation is that after 20-30 minutes of being awake, don’t stay in bed, because quickly your brain learns that this thing called my bed is this place where I’m awake. That’s a bad association to make, so you need to break that association. The recommendation is: get up, get out of bed in dim light, just do something relaxing, and only when you’re sleepy and there’s no time limit should you return to bed.

10. What are your thoughts on supplements like magnesium sulfate, especially for the tactical athletes, zinc, and tart cherry juice?

I’ve researched a lot about supplements and the first thing I would note is that anything online that suggests it is the Holy Grail of perfect sleep is absolute nonsense. If there was some special supplement out there that promoted exceptional sleep, I will guarantee you that the pharmaceutical companies would have discovered it 20 years ago and would be making billions of dollars of profit from it. There is no magic bullet in the supplement world for sleep. Do not be fooled. It’s big business. That’s not to say that there aren’t some supplements that may help with sleep a little bit.

If you are stressed out and you feel as though you’re in that “wired but tired” phenomenon, there are two supplements that have been shown to reduce the cortisol response. The first is called ashwagandha; it’s been shown to benefit sleep because it lowers your fight-or-flight response, and shifts you over into that more passive, quiet branch, which helps with sleep. The other compound that’s got some evidence is glycine.

11. I found first responders like to supplement with melatonin, and for the men, they like to supplement with testosterone, not realizing that their testosterone is low because they don’t sleep enough.

Certainly, as we get older, there is a time and a place for hormone replacement therapy. Embrace that, because when you have low T in mid to late life, lots of things don’t go your way in terms of health, including sleep, so normalizing testosterone can certainly help that. But if you’re young and you should be in a state where you can produce plenty of natural testosterone but it’s low, you should ask yourself what’s going on with my sleep. A healthy, young male who limits their sleep five hours for five nights will have a level of testosterone which is that of someone 10years their senior. I can take a healthy guy and I can age him by a decade in terms of his testosterone, just by limiting his sleep for one week.

12. A lot of first responders are at more risk for concussion and traumatic brain injury. Any thoughts about concussion insomnia?

I would say there is very clear evidence that almost 80% of individuals with concussions will lead to some kind of short-term sleep disruption.

We’re now interested in evaluating people with concussions and It may be that sleep, even in the first week, is ultimately critical. Sleep is the single most effective thing you could do in a hospital setting to reset the health of your brain and your body.

13. How detrimental is it to stare at your phones at night?

A study comparing people who read on an iPad compared to those who read a book in dim light found that the people who read the iPad had significantly less total sleep, significantly less dream sleep in particular, and third, the peak levels of melatonin were delayed by somewhere between two to three hours.

More recent studies have pushed back against this idea that it’s the blue light, and what they’ve discovered is that the blue light is not as delicate as we thought. However, the sleep disruption caused by those devices is still profound. The other explanatory mechanism is that these devices that we have in our pockets are attention-capture devices.

14. Can you elaborate a little bit more on those strategies for shift workers?

What’s the ideal shift? There is no ideal shift. We’re not a nocturnal species, and we can’t train ourselves to deal with that biologically. Psychologically, you may be able to think that’s true, but don’t forget, it took Mother Nature about 3.6 million years to put this thing called a circadian rhythm in place in human beings, to make us sleep nocturnally at night.

Try not to flip back and forth every 24 hours—on for 24 then off for 24 and so on. You don’t want to confuse your circadian system. If you can have slightly longer stretches of time when you’re on and then slightly longer stretches of time when you’re off, that’s one model that is adapted and useful.

15. What should you do on your days off to help your sleep?

Sleep is not like the bank. You can’t accumulate a debt and then start to pay it off. However, there is a different form of what I would call sleep banking. It was discovered by the Walter Reed Army Institute. This means if you’ve got two days off, and you know that you’re about to go into a 48-hour shift where you’re maybe only going to get three hours of sleep on average, the best piece of advice I can give you is, in those two nights before you go into your shift, try to sleep as long as you possibly can. Instead of paying off debt, go to the bank and build up some sleep credit.

16. Afternoon naps?

Naps are wonderfully beneficial for both the brain and the body. Naps, however, are a double-edged sword. There is a dark side to napping, and it’s the following: If you’re struggling with sleep at night, do not nap during the day.

There is an art and skill of napping. Firstly, try not to nap too late into the afternoon or in the early evening. Next, try to limit naps to about 20-25 minutes. Because if you sleep more, you start going into the deeper stages of deep NREM sleep and get a sleep hangover, and you will feel almost worse after you wake up from the nap.

16 Alcohol and THC?

Alcohol fragments your sleep, so you wake up many more times throughout the night. You don’t remember it, but the next day you kind of feel lousy, and you don’t feel refreshed by your sleep. Alcohol is pretty good at suppressing your REM dream sleep.

The problem with THC is that like alcohol, but through a different biochemical mechanism, it will also block your dream sleep.

The evidence may look somewhat promising with CBD. CBD is the nonpsychoactive component of cannabis, and in some animal studies it seems to help with increasing the duration of sleep and increasing the amount of deep sleep that you get. CBD seems to be very good at reducing your anxiety, and I can see this in your brain when we dose you with CBD. The emotional centers of your brain, called the amygdala, are dampened down in their activity.

17. Is polyphasic sleep healthy?

As adults, sleeping like a baby is the most unwise thing that we can do, which is sleeping in these ultra-short cycles. Now, that’s not to say that when you’re under extreme circumstances, when you’re profoundly sleep deprived. In that case, sleep whenever you can, within reason, under those extreme circumstances, but don’t adopt it as a lifestyle.

18. How do we better help our population of first responders improve their sleep?

There is not much sleep education throughout the emergency services, and I feel sad about that. With even just a 15-minute lecture, or posters saying here are the five tips to help optimize sleep, you could be empowered.

The second thing is a slight change in attitude. There is the sleep machismo attitude that people are almost braggadocio about how little sleep that they need. That is profoundly hurtful to you as the individual, and it’s a profoundly poor signal if you’re in a leadership position to then transmit to the next generation.

Sleep is an investment in your health. If you don’t want to live a shorter life, and you want to live a life that is largely free of disease and sickness, there is no better health insurance policy that I know of, other than this thing called sleep. And many of you have husbands and wives, many of you have kids, and they desperately want you around for as long as possible. We need to prioritize sleep.

Download the full interview as a PDF here. (352 KB)

DENA ALI is a battalion chief with the Raleigh (NC) Fire Department. She previously served as a police officer for five years. Ali has a degree from North Carolina State University and an MPA from the University of North Carolina—Pembroke, where her research focused on firefighter suicide. As a graduate student, she was awarded the 2018 MPA student of the year, and she has also received several other awards, including the NC Office of State Fire Marshal Honor, Courage, and Valor. Dena has also served as a subject matter expert at the National Fire Academy, where she assisted in curriculum review for their health and wellness curriculum. Dena is an advocate of awareness, education, and understanding of mental health disorders and suicidality. She speaks locally and nationally on these topics and is a QPR Suicide Prevention Gatekeeper Instructor. She is the founder and director of North Carolina Peer Support, where she helped to develop their statewide curriculum. She is also a founding member of the Carolina Brotherhood, a group of cyclists/firefighters in North Carolina who honor the fallen and their families annually.