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.

15 comments:

Silverstar said...

In my time, I have delivered papers in the middle of the night, worked as a nurse, often having to stay another shift, and worked as a police dispatcher in a small town where the phone was in my home. I am here to tell you that sleep deprivation did affect me, badly, and especially after I started to have obstructive sleep apnea. Part of my disability at this time is not being able to sleep, or getting my second wind, drowsing, and then waking entirely, not able to go back to sleep.

Devorrah said...

Being an MD seems akin to parenting a newborn, except the baby never grows up...

mark's tails said...

Nice post Sid and I whole heartedly agree. I'm wondering though if the link you have for the "case that led to the 80 hour.." is correct. Wasn't that the Libby Zion case?

Right now that is linking to here
http://www.mcclatchydc.com/detainees/story/38773.html

Did you get enough sleep last night?

Anonymous said...

I believe that sleep deprivation didn't affect you much. But the 'no-sleep' during training is the main reason I stopped considering a medical career in High School. If I loose too much sleep I get migraines. Will the medical profession always be able to afford driving away potential doctors?

Sid Schwab said...

mark's: oops. I guess I didn't properly copy the link after using that other one elsewhere. Thanks. Fixed.

M said...

It all depends on the individual. Melatonin production, biological and circadian rhythms vary across the board. Personally, I can go for about three days with occasional power naps whilst others I know become light headed without their six to eight hours each night.

Sleep is for the weak!

(Lynched)

Midwife with a Knife said...

I don't know how big a role sleep deprivation plays when I'm taking care of patients. I will say, though that I rarely feel sleepy while operating, but when I was a resident and writing orders for a patient or dictating after having been up for 24 hours, I think that may have been a fertile ground for mistakes.

When I work long past 24 hours in a row (28-36), I have near-miss car accidents not uncommonly. I do feel that there is a good justification in limiting trainees hours because working more than (a certain number of hours yet to be determined) poses a real threat to the physician's health, and I wonder why that's so seldom emphasized in talks of work-hours restrictions

Justine Hemmestad said...

Dr. Schwab,
Sleep deprivation must be something that surgeons and mothers have in common!:)

Christian Sinclair, MD said...

I saw that 60 minutes episode as well, and thought about how much I would love to study the sleep of my hospitalized patients, ICU patients and hospice patients. If I had the time.....

In finishing a recent important paper, I pulled an all nighter. My wife asked me if I was in residency again.

Thanks for the good read.

zxmaster said...

I am currently in medical school and I am leaving after this semester is over. Part of the reason is that I have realized that I function very poorly when deprived of sleep and so the prospect of crazy work hours (I live in Denmark, so it is probably not bad by American standards). I used to work as a programmer before entering medical school, and I have found that it is really true when programmers say that anything written after 12 pm is most certainly crap. I am sure it is different for different individuals, but as another commenter wrote, can the medical profession afford losing potential doctors because of such a thing ?

Anonymous said...

I have to say that sleep deprivation took it's toll on me during residency. I know that I made mistakes because I was tired. My chairman always said that we would do fine in the OR tired, and I think I did. However, I missed some of the little things because frankly, I just couldn't keep my eyes open and focussed long enough. Some of those little things became big things.

I now do in-house trauma call and while the sleep deprivation is somewhat better, I still wonder about the health effects it may have on me. I find myself struggling to lose weight and in general, my mood is worse than when I had slept better. I can't imagine it's healthy to not sleep as much as your body would like to on a regular basis.

SeaSpray said...

I really don't know how you did it. It must be the adrenaline in the OR.

But do you like the idea of 80 hour weeks and reduced training. Who is right?

Anonymous said...

I made it through the pre-hour restriction era of residency too, but it took a toll on me. I sometimes gave nurses orders that I had no recollection of the next day (luckily, they were the right orders!) Sometimes after 36+ hours, I was so tired even my teeth hurt. I don't recall being sleepy in the OR but I sure was tired when the surgery was done! I am too old for that stuff any more, I try to make sure I get enough sleep. Sleep deprivation can't be good for anyone.

Sid Schwab said...

When I was chief resident one of my attendings was famously hard to wake up, and often gave meaningless instructions on the phone. One morning when he arrived I said to him, "I did what you said, Art, but I'm still not sure the leg needed removing."
He blanched considerably before he realized I was jerking his chain.

(That story and many more are in my book.)

Anonymous said...

There seems to be a lot of discussion amongst the RRC and ACGME to propose an even shorter work week, somewhere around 56 hrs. While I'm sure that will do plenty in terms of residents getting sleep, I'm a bit more dubious of what will happen to their education. I presume surgical residency will have to be longer.