Archive for the ‘Sleep physiology’ Category

In praise of Beds R Us, Warkworth, Rodney District, New Zealand

April 30, 2011

The pain of an uncomfortable bed

Is a thing that fills me with dread

     Trying to make do

     Is like an ill-fitting shoe.

Get something better instead.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  On assignment on the North Island of New Zealand, I’m living in an apartment attached to the clinic where I work in Matakana, north of Auckland.

When we arrived at the doctor’s residence in Matakana, a simple flat attached to the clinic, we became aware of the mattress’s deficiencies.  Still, looking ahead to a couple of weeks, we figured we could live with it or make do with improvisations.

First we bought a sheet of plywood at the lumber yard (here called a timber yard) next door, and had it cut to 140×200 cm.  We carried it on our heads, but when we arrived we became aware of a strong chemical stink. Not a problem, we thought, if we just leave the board outside till the smell evaporates. 

We moved the mattress off the box spring and tried sleeping on the box spring, which constituted a slow torture.  Neither of us could stay asleep more than six hours.  Three nights later we moved the mattress out to the living room (here called the lounge); the speed of the torture increased.

No matter what we did, every spring poked at me through inadequate padding.  My trochanteric bursitis, quiescent since I stopped marathoning in the early ‘80’s, reawakened. 

At about the same time we realized the hopelessness of trying to continue with the mattress, we decided to extend our stay in Matakana.  By then we hadn’t slept well in a couple of weeks, and my back, bad to start with, had me walking like a pretzel in the morning.

I emailed the office manager, saying that Bethany and I had decided to buy a new mattress.  As we couldn’t take it with us in our carry-on, we planned to leave it, and would the practice pay for half?

Bethany handled the matter with a quick trip to Beds R Us in Warkworth, Coast to Coast Medical Care refused to let us pay anything, and when I made the seven step commute home from the clinic that afternoon, the goods had been ordered and finances arranged.

When we went to bed Thursday evening, ecstatic waves of relief washed over us.

While one night on a bad mattress can be shaken off like a pebble can be shaken out of a shoe, after two weeks an uncomfortable bed becomes a parasite on the daylight hours, draining energy and sapping resilience.

I’ve written a lot about the importance of good sleep in this blog.  Bethany and I tried to remember a worse mattress, and we couldn’t.  But we still appreciate the quality of the new mattress every time we lay down.  In the long run, everything else an accomodation has to offer becomes irrelevant in the presence of an uncomfortable bed, but a person doesn’t realize that without experiencing a bad one.

Contrast is the essence of meaning.

On pushy recruiters, sleep deprivation, and our tendency to sabotage our own happiness

November 3, 2010

The price that you pay can be steep

For the nights that you spend without sleep.

     The abuse that you take

     While you’re staying awake

Can lead you to rage and to weep.

I deal with a lot of recruiters for the locum tenens agencie that find short-term work for doctors.  The level of professionalism varies a good deal.   When I started this year of going walkabout, I wanted to experience good recruiters and bad; today I dealt with the worst.

Pushy people can be trusted to be pushy; they cannot be trusted to develop good interpersonal learning skills.  For the first time ever, I told a recruiter not to call, not to email, and to take my name off his list.

In the beginning of this process, I accepted a lot of jobs  that disappeared into a cloud of bait-and-switch smoke (see my posts from March and April).  I’ve learned a lot.  I don’t have to talk to any new recruiters; I know three good ones.

I attended a patient today who might have a lot of different diagnoses, but I suspect chronic, long-term sleep deprivation gives rise to most of the problems.  Of course I ran a lot of lab work, but I did a good deal of career counseling.

Far too many people slice years from their life expectancies for the sake of their employment, notably doctors.  We get a set of skills, acquire an exaggerated sense of our own importance, and sacrifice our sleep.  Sometimes life-and-death issues justify the sleeplessness, more often late nights result from a misplaced sense of responsibility. 

Other professions provide necessary services in the wee hours, and a lot of people work nights who don’t have to.  They effectively move to a different time zone than their families live in, sabotaging intimacy.  A predictable cascade of events follows, some physical, some sociological; most to the detriment of the person, the family and society.

An industrialist friend of my started a third shift in his plant, and I begged him not to.  What you make up in increased production, I said, you’ll lose in work-related accidents and the families of your workers will suffer.   He said that he had a lot of people asking to work nights.

I’m not working nights at all in my current position.  I walk out of the office promptly at closing time: five o’clock Monday, Wednesday, and Friday; seven on Tuesday and Thursday.  This afternoon after work I went out to the trap range with my shotgun.  I can blame my mediocre shooting on the bad wind.

Jet lag is avoidable

May 29, 2010

The problem is common, not cheap

So here’s some advice you can keep:


    Interferes with life’s mission

And steals hours of sleep.

At a social gathering today I was once again called on for medical advice.

Abrupt onset of vomiting and diarrhea is usually food poisoning, best managed with oral rehydration fluids like Pedialyte, Gatorade, and agua horchata (a sugared Mexican rice-based beverage).

Itchy, watery eyes with itchy watery nose and volley sneezes, without fever, indicate allergies, best managed with over- the-counter cetirizine or loratidine.

And a lot of people sleep poorly.  In short order I found myself lecturing an audience of seven about basic sleep management: nicotine, caffeine, alcohol, move the TV out of the bedroom, don’t exercise or use a computer within two hours of retiring, keep regular hours.  Don’t think your internal clock has more flexibility than it does.

The adolescents in the group do what adolescents in our culture usually do: stay up late and try to sleep in.  Things like work and school interfere with the lateness of how long they can sleep, so that, in the real world, they go around chronically sleep deprived.

Teenagers effectively move to a different time zone so they don’t have to deal with adults; no wonder they love vampire novels and films.

I explained that the internal clock can be reset forwards 2 hours a day but can only be reset back ½ hour a day.  Then I started to get to time management; the television for most Americans has taken a higher priority than sleep.

Nothing on TV merits the time it takes to watch it.  History and Discovery shows teach in an hour what can be learned in ten minutes of reading.  A half hour news show has 12 minutes of commercials and six minutes of news; weather and sports take the rest of the program .  In the final analysis if a person doesn’t have time to stay in bed till awakening rested, that person doesn’t have time for television.

I recommended two alarm clocks, one to go to sleep and one to get up.

The conversation turned to jet lag.  What should a person do who’s flying across an ocean?

Jet lag is a problem I’m really good with.  Give me the time the person takes off, the time they land, the flight duration and the time difference, and I can recommend a sequence of melatonin, zaleplon, Provigil, caffeine, hydration, exercise and meals that synchronizes the person’s internal clock with destination time within twenty-four hours of arrival. 

Four  years ago I went to Israel with a tour group.  The day after we arrived the rest of the group crashed before sundown, but, good to go, I went for a walk on the banks of the Jordan and heard the wolves howling in the Golan.  It was an intense solo experience but I would have preferred company.

If you don’t dream, you don’t grow.

May 15, 2010

It can turn you into a creep,

This business of getting no sleep

    For all those who snore

   You’ll be hurt to the core

If you’re lacking the slumber that’s deep.


There’s a tradeoff for money and time

The minutes get swapped for the dimes

    There are those who expire

     Before they retire

And the loss of the pension’s a crime



After I told a patient of my coming change of career plans, she talked about her deceased husband.  He worked hard on the railroad for almost forty years and died of a massive heart attack four months before he would have retired.  A friend of his had died three months before retirement.  She told me she would miss me as her doctor, but she understood my decision.  “You’ve worked hard,” she said, “it’s time for you to enjoy yourself.  Have a good time.”  I asked for, and received, permission to write about what she’d said.

We’ve known for a long time, observationally, that all work and no play makes Jack a dead boy, but this week the AMA daily email news confirmed that working overtime leads to heart attacks and shortens life expectancy.

The patient and I hypothesized that the railroads pay so much overtime because they know that if they work you hard enough you die before you can collect your pension.

I remembered the beginning of my Junior year in high school talking with a Senior, Jimmy Hopkins, who had worked much of the summer for the railroad.  He got straight time for eight hours, time and a half for the second eight hours of the day and double time for the next eight hours. It sounded great at the time.  Now it doesn’t sound so good.

I have a number of railroad employees in my practice and most of them suffer from sleep deprivation.  They are well paid and badly overworked, like most doctors.

We learned nothing of sleep physiology in med school.

I did a month of high volume OB in my second year of residency, an externship at Los Angeles Women’s Hospital.  One of the OB attending physicians there made some off-handed remarks about the effects of sleep deprivation.  He said, “If you’ve been up all night you’ll do OK in the morning, your natural sleep/wake hormone cycle will carry you through till about noon.  That’s when you have to start to be real careful.”

That’s all that I got taught about sleep in seven years of education.

Since then I’ve gone out of my way to read about sleep, and to try to keep abreast of the developments in sleep research.

In brief: you fall asleep, the sleep goes deeper and deeper, then gets lighter and lighter, then you go into rapid eye movement (REM), or dream sleep.  You come out of REM sleep into light sleep, and the cycle repeats.  As the night progresses, the time between REM cycles shortens.  A person will go through between three and eight cycles a night.

Each sleep cycle might have the same apparent structure, but each sleep cycle in a night is different, and you must have enough of all components to function well.  If you miss one cycle, it’s a lot like listening to your favorite song and missing one of the verses– not very satisfying.

You can postpone sleep indefinitely but REM sleep cannot be completely suppressed.  People might think they’re awake but they start to dream with their eyes open; just another way to hallucinate. 

People only make growth hormone during REM sleep.

Thus poetry in physiology: if you don’t dream, you don’t grow.