Monday, June 16, 2008
To Sleep, Perchance...
Last night, as is occasionally the case, I watched "60 Minutes." (I love PIP. In my form of ADHD [figuratively] I rarely watch one thing at a time. I was watching the NBA finals, too.) Most of the show was devoted to sleep, and the lack thereof. It raised issues about which I've thought often over the years.
To anyone more than an occasional reader of this blog, it's well-known that I learned surgery in those bad old days before work-hour restrictions. Spending a couple of weeks straight (and in some cases a couple of months) in the hospital was the norm. Working through many nights, catching a couple hours' sleep here and there was how it was. And although I was frequently exhausted, and despite the fact that on my rare nights off I routinely fell asleep whenever I went to a friend's house, I would say then and I would now still insist that I never made a poor decision or improperly carried out an operation because of sleep deprivation. And I recognize that insisting such a thing does not make it so.
Youth has certain advantages. Back then, when I had a moment to sleep I made full use of it. Within moments of resting my head on pillow, I was out. If the phone rang, I was fully awake and firing on all cylinders instantly; heart pounding, brain sizzling. Whether I could handle the issue from the call room or whether I got up and did something somewhere, if and when I made it back to bed I was asleep again approximately immediately. Like the last canteen in the desert, I husbanded those moments of slumber with perfect efficiency. I'm pretty sure.
Past the middle of my career it was decidedly less so. A call at three a.m. (where have I heard that before?) often found me disoriented on waking. Whom are they talking about? Do I know this person? For that matter, who am I? After unscrambling my thoughts and pulling coherence together in a tug-of-war with my own brain, I'd produce some instructions and, after hanging up, lie there unable to regain unconsciousness. Unrarely, I'd think of something I should have asked, or said, and call back. Most often, sleep, like vapor, eluded me for the rest of the night.
And yet when it came to operating, no matter the time in the course of my career nor the amount of sleep or lack thereof, I say with the certainty which comes from knowing there's no way to prove it, that I always rose to the occasion in the operating room. The adrenaline, the focus, the intensity of the task at hand always cleared the mind and provided the needed clarity. Sometimes when it was over I'd feel entirely emptied of energy, trembling, nearly unable to write the orders, dictate the op note. But never, so I believe, in the act of operating.
Oh, there were times that I flagged during surgery, but it was never, I think, about sleep deprivation. When it happened (maybe twice, I'd guess) it was because the operation was so long, so difficult, so stressful that it took out of me nearly everything I had. I'd ask the circulating nurse to get me some orange juice and poke it behind my mask with a straw, a hard candy to suck on. I've considered taking a fifteen-minute break; I've wondered if I'd get to the point of asking for a replacement, but never did.
I don't doubt that sleep is an issue, even in youth, for physicians and most especially for surgeons. The medical staffs of which I've been a part allow doctors of a certain age to opt out of taking call; it makes sense, despite the resentments it sometimes engenders in the younger ones. Unlike those early days, as I aged I found that working all night made a wreck out of me the next day. Back then an hour or two seemed fully to recharge me for another eight or more. It didn't remain so for my all my active life. Still, I have a feeling -- unproven, unproveable -- that the sleep deprivation thing, especially during training, has been over dramatized. Between youth and necessity, one can rise to the occasion. So I think. In my case, anyway. So I think.
The case that led to the eighty-hour work week restrictions, so I'm told by reliable sources, was less about sleep deprivation than is generally believed. As is often the case when errors occur in training, it was (so I've heard, and can't confirm) actually about improper supervision. In no way am I disputing that sleep is an issue for physicians, in training or otherwise. Nearly all of us must work extended hours, through the night, into the next day; some more often and more routinely than others. I'm just saying that in my case I say with as much certainty as I can muster that I know of no case in which I identify lack of sleep as an issue in my operative conduct or critical thinking.
In the time leading up to my eventual retirement (if that's what it was), there was a related issue which may or may not be wrapped up in sleep as a factor. Finding myself working harder and harder, burning enthusiasm like the last briquettes in the bin, I began to worry if I'd try -- in the name of staying in bed one night, or of avoiding a difficult or depressing case -- to rationalize my way out of a situation improperly. I sensed the possibility. I had, figuratively, to slap myself in the face once in a while. And it concerned me. Was I on the edge of letting self-preservation override judgment? It figured in my decision to sheath my scalpel. Sleep, possibly, was a part of it. But it's more complicated than that.