Posts Tagged ‘tobacco’

Lower blood pressure with deep breathing

July 5, 2017

It’s a technique, and I don’t mean to brag

But when the smoker lights the first fag

And breathes deep and slow

Though the smoke is the foe

They’re champs at that very first drag.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I see a good number of people with high blood pressure, some better controlled than others. If the pressure is too high, I repeat the reading.  A second round of measurement less than 5 minutes after the first will give a falsely elevated reading.

Most of those with hypertension (a blood pressure greater than 140/90) smoke tobacco and drink more than healthy amounts of alcohol. I point out to the smokers that they have a valuable tool, that they didn’t realize they had.

I was still working for the Indian Health Service when I had a conversation with the worst nicotine addict I ever met. She had quit 4 packs per day about 10 years prior.  Half the relaxation of the cigarette, she said, is the deep breathing technique that goes to taking the first drag.  Every meditation system in the world stresses the deep breathing that all smokers have taught themselves.

Breathing can change blood pressure a lot. The FDA approved a device to teach people to slow their breathing down; the studies showed it safe and effective for blood pressure control.

So I tell the patient to pretend they’re taking the first puff of the day, to breathe slow and deep, and I breathe with them.

I repeat the blood pressure measurement after 6 deep, slow breaths, and almost always the top number drops by 30 points and the bottom by 15, good enough for most people. Whether the improvement is adequate or inadequate, I tell the patient to breathe slow and deep for 20 minutes a day, whether in one chunk or twenty.  For those current smokers, I point out that they could get half the calming effect of tobacco just by doing the breathing exercise that they already know how to do.

+=+=+=

I had call last night. With light traffic in the ER I managed to get back to the hotel early, but I got called back at 10.

As far north as we are, I walked to the hospital with the setting sun in my eyes. Forty-five minutes later, I walked back in the twilight, thinking that I should have brought the bear spray with me.  I crossed the highway with literally not a single vehicle moving.

Tagalog, flu, and a staff meeting

February 14, 2017

The patients still suffer the flu,

And I know just what I can do

Though to prevent what they’ve got

We’ve a pretty good shot

But I’m hoping for some drugs that are new.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Most sick people want to get well, and even more don’t want to be around strangers. I’m filling in for a doc whose patients love her.   They won’t come in until they feel sick or worried enough, and I haven’t had time to build a reputation in the community.

I attended one patient every half-hour from 9:00 till 11:00. I ran 5 lab tests, and ordered one x-ray.  Half the patients got prescriptions, half of them got advice because pharmacologic management would have been a good deal more dangerous than helpful.  With the unseasonably warm weather, I advised two to get over the counter Flonase for allergies. Another patient got a simple 5-day prescription that may very well save a life.  One patient has me puzzled and awaiting labs.

I exhausted my very meager Tagalog vocabulary on one person (who gave me permission to write this), prompting my patient to ask me if I’d lived in the Philippines. I explained that the most educated immigrant minority in this country are the Philippino, with a disproportionate number of doctors, nurses, and pharmacists.  Of course I’ve had colleagues from that country.  And, inexplicably, on the North Slope of Alaska, the Tagalog speakers dominate the taxicab business..

Three patients smoked; for each one I held my forefingers 18 inches apart and said, “On a scale of 1 to 10, how ready are you to quit smoking?” No matter what number they came up with, I asked, “Why not 2?” but had to explain that the doctors had already told them the bad things about tobacco, and I wanted the patient to tell the doctor something good about it.  One patient shook her head and said, “You’re good.”  I had to admit that I’d gotten the technique from an educational CD.

We had our monthly med staff meeting from 12:30 to 2:00. They announced my successful vetting (in the trade, we call it credentialing).   We went over changes in the Emergency Medical System (EMS), and talked about criteria for blood transfusions.

The flu came up briefly; the annual epidemic started about 3 weeks ago. It’s weakening but it’s still going.

I had no patients on the schedule after 2:00, and I started reading the handbook that HR gave me. I had two patients after 430, finishing at 6:00 sharp.  I walked out with all my work done.

Sports physicals and good horses

July 30, 2016

Out here they have nothing to hide

They think it’s important to ride

The unified force

Comes down to a horse

They’re cowboys and cowgirls, bona fide.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Thursday the construction noise had become intolerable. I put on my shooting muffs, and stepped out the side door.  The worker operated an electric jackhammer, not a drill, detaching a concrete lip from the foundation.  I waited till he had hacked off a chunk, stopped his machine, and repositioned.

“Excuse me,” I said, “Um, any idea how much longer you’re going to be?”

“Almost done, probably by lunch,” he said.

“Do you have hearing protection?”

“Yeah, “he said, “In the truck.”

“Take it from me,” I said, “If you want to be able to hear the voice of your grandchildren, protect your ears.”

I had a productive day, between outpatient and inpatient I attended 14 people.

Sports physicals, required by school districts, don’t save lives and don’t prevent injuries. On average, less than once every two years I detect a problem during a pre-participation exam that I can do something about.  Still, the visit goes quickly, and I get to educate the kids.  As the athlete sits on the exam table I ask what sports.

Here in western Nebraska a lot of the students start their list with rodeo. Ranching and wheat dominate the agricultural sector.  People rely on horses for work and for play.  Ranch work goes much easier with a good horse and good roping skills.  People favor quarter horses for their intelligence and speed.  So when the kid says rodeo, I ask, “Do you have a good horse?”

Sometimes the face lights up and the grin follows, and I infer, that, indeed the horse is a quality animal. And sometimes the answer comes back, “Pretty good.”

Patient flow slowed to a negligible trickle on Friday; I attended three times more people in the hospital than in the clinic, where I only saw one.

I greatly enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person leaves.

The insurance credentialing process has cleared me for 4 insurances but not for the majority. I do not understand why, because I had full credentials when I worked here in January.

So I had a slow week, and I would have preferred more patients. All in all, I saw entirely too much drama and irony in for form of patients paying the ultimate piper for their dance with tobacco.

 

Mail the patient in a cardboard box.

March 15, 2016

The ER doc said with a growl

“Should I cry fish, fair or foul?’

For after the collision

How do I make a decision

About a Boreal Owl?”

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

 

At morning rounds on Monday we gathered to go over the cases from Friday and the weekend. Including the doctors and the representatives from Mental Health, Pharmacy, Nursing, Physical Therapy, and Social Services, I counted 15.

Drama and irony run rampant in those stories, and, as always, drugs and alcohol provided the majority of the good stuff. But the best patient had been brought in after a collision with a car, and still had a pulse, and was eventually identified (with the help of the internet) as a Boreal Owl.  The calls flew back and forth, and the experts agreed that the best course of action included punching holes in a cardboard box and send the owl via mail.  Which is perfectly legal.

I hope HIPAA doesn’t apply to wild animals.

In general I don’t like prescribing controlled substances, and, when I do, I prescribe in small numbers. Though I dislike the benzodiazepines (a family which includes Valium, Xanax, Ativan, Miltown, and Klonipin) the most, I acknowledge they have their uses.  In fact, I would have difficulty caring for inpatient alcohol withdrawal without them.  I find few other uses for them, such as claustrophobia for an MRI or fear of flying, but I in fact found a reason to prescribe 6 pills of one (but I won’t say for what or for whom).

I decided a long time ago that I’m a lousy judge of character. Too many people have fooled me too many times.  So I ask for a urine drug screen on everyone who asks me for a controlled substance, and even a few who don’t.  I find about 50% surprises.

As everywhere, drug seekers come to the facility hoping to get substances with which to get high or to resell. As it turned out today I did a lot of physical exams for people wanting to get into drug or alcohol rehab, and I was able to pick the diagnosis of Health Seeking Behavior.

And today the people wanting to quit tobacco outnumbered the ones who wanted to continue.

February 24th, 2015, a day that will live in infamy

March 3, 2015

When it comes to the drug they call pot
What is it good for? It’s not.
But they were quick on the draw
To pass a new law
And speed up the memory’s rot.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Marijuana use runs rampant across the US.

In the early part of the year I asked a patient, a single parent of five and a major pothead, if they would hire a babysitter who got stoned every day, and we agreed that any intoxicant impaired ability to care for children.

My first Monday back brought me to contact with patients running into problems as a direct result of their marijuana abuse.

Mostly hemp excess happens in the context of abuse of other drugs, usually tobacco and alcohol. All three contribute to poor memory, seizures, depression, loss of restful sleep, low testosterone levels (both sexes), low sex drive (both sexes), lowered resistance to infection, poor pain tolerance, social isolation, and irresponsible parenting.

Recently I had a heart-to-heart talk with couples in the maelstrom of dysfunction; the medical problem that brought them in stemmed directly from marijuana abuse. I correctly guessed that both had cold, controlling, distant mothers, and exciting, generous-to-a-fault fathers who failed to follow through on promises and brought repeated disappointments. They readily admitted that each could tell me everything wrong with the other and neither had much of a handle on their own failings. I pointed out that drug abusers can’t exist without enablers, and the cycle can be hard to break because it has roots more than a generation old.

I took a step back and talked about myself. The vast majority of med students, 70%, come from chemically dependent households and most of the rest had other sources of dysfunction in their nurturing families. I skipped the details of my upbringing, but I told them about Alanon and the Adult Children of Alcoholic Parents movement, which use the same 12 steps as Alcoholics Anonymous, and how I went to meetings for 7 years. Every strength is a weakness, every weakness is a strength; it all depends on what you do with them. We agreed that their current approach didn’t work. I replaced a benzodiazapine tranqulizer with Dilantin (most common use=seizure or migraine, but a good second or third choice for almost everything), recommended 12 step meetings for both, and called in Behavioral Health Services.

I learned more about human behavior in dysfunctional families from Alanon than I had from med school.

My last patient requested a back-to-work slip, which I cheerfully supplied. But in the process I uncovered alcohol and marijuana excesses; I accepted at face value the patient’s assertions, and said, “Let me be the first to tell you that nicotine, alcohol, and marijuana will make any medical problem worse and none of them better.”

I could more easily believe that the weed wiped out memory than that all previous docs had missed the chance to educate the patient.

During my two weeks off, the state of Alaska legalized marijuana on February 24th, a date that will live in infamy for those with intact memories, but the pot heads will promptly forget.

I suspect that those in power prefer an apathetic electorate with a poor memory.

Contrast and meaning at a gun show: a doctor weighs in on gun control

February 3, 2013

Don’t be too quick on the draw,

Is there a statistical flaw?

When it comes to a gun,

Let people have fun,

Just enforce existing law.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The US has lots of firearms and lots of firearms deaths; in the current gun control debate, a lot of statistics have been thrown back and forth.  When listening to the statistics, one must remember to think critically.  The question has arisen if firearms deaths constitute a public health issue.

Tobacco remains the big killer in our country.  Close to 450,000 people die per year from tobacco, 10% of them from passive smoking.  Thus on the day of the Sandy Hook killings more children died from passive smoking than died from bullets. 

Effective legislation should decrease the death rate from firearms, rather than regulate for the sake of regulation.  In our country, lightning kills about as many people as succumb to high-capacity clips. 

While in Barrow, I met a number of people who guarded their whale camp with assault style firearms.  Certainly if I lived in polar bear and wolf country, I would want a lot of firepower. 

As the number of firearms in the country increases, the number of deaths from firearms decreases.  This trend has remained steady for more than 20 years. 

The vast majority of firearms deaths in our country occur in the demographic of young minority men aged 15 to 25 who have not been accorded equal protection under the law.  Made outlaws by our society, they behave as outlaws; they shoot each other.

Prohibition should have taught us that passing laws without providing for enforcement does more harm than good; people learn to disrespect the law.

Accidental firearms deaths happened fewer than 200 times per year, despite our 300,000,000 guns.

If we really want to do something about saving lives, we would increase the taxes on tobacco by a dollar a pack per year, indefinitely.

I helped staff a gun show earlier today.  While there, a number of people spontaneously remarked to me about how they’re doing after their cancer surgeries.   One fellow admitted he smoked 3 to 4 packs a day until breathlessness during a golf game drove him to give up his cigarettes.  Shortly thereafter, he was diagnosed with lung cancer.

As hundreds of people browsed through the show’s offerings, ordinary rifles, shotguns, pistols, and revolvers, a few stepped outside to smoke.  The real public health problem contrasted with the much maligned “assault rifles,” (which really are weapons whose biggest failing is in aesthetics).  Contrast is still the essence of meaning.

On a personal basis, I have no use for the black rifles with pistol grips, bayonet lugs, and the capacity to accept 30 round magazines.  But I’m glad I know people who like them.  They keep the government honest.

Weekend rounds in vignettes

August 5, 2012

This morning I rounded on nine

Three of them now feeling fine

It’s only a slip

That can fracture a hip

An ankle, a neck, or a spine.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

I rounded on nine hospital patients this morning.  The oldest 86, the youngest 19, all of them had more than one diagnosis.  I can’t give identifying information about specific patients because of confidentiality, but drama and irony fill the stories of the people who fill the hospital beds.

Schizophrenia makes a person more susceptible to disease, and the disease process is worse for having schizophrenia on board.  Most schizophrenics smoke, and a frightening number acquire insulin dependent diabetes.  They face problems at the time of discharge, if they can’t take care of themselves and lack financial resources, though most have government-funded insurance.

Anyone unable to care for themselves, with no money or insurance, represents a problem for the hospital.  A lot of nursing homes would go bankrupt if they kept more than one non-paying patient, and some couldn’t afford even one.  Nonetheless, the attending physician has to round on those patients, and has to deal with Utilization Review, a committee that politely and professionally asks why the patient has to stay in the hospital at a frightful cost.

Everyone who smokes knows they shouldn’t, and most intend to quit, but I get a lot of business from people who don’t quit soon enough.  Contrary to popular belief, most smokers die of heart disease and emphysema rather than lung cancer. 

Some people arrive in this world with bad diseases that they didn’t ask for.  Some give up hope at a young age, and bring me a lot more business than those who decide the make the best of a bad situation and take care of themselves as best they can.

Mathematical ability dissolves in alcohol, nobody can count after they’ve had more than two.  Which leads people to think that alcoholics lie, when in truth they’re just lousy estimators.  Continued alcohol use with hepatitis C, viewed by many doctors as an active death wish, leads to cirrhosis and a horrid, stinking death, frequently accompanied by dementia.  The combination affects a disproportionate number of people too young for Medicare, and, again, discharge becomes problematic.

The elderly come to the end of their road with or without dementia; their mental status has little to do with how much their families love them.  Whether beloved or not, the drama of the hospital scene transcends culture and language.

Though most alcoholics smoke, not all smokers drink.  The two most addictive drugs in our culture usually go hand in hand, and the presence of other mental or physical disease brings layer on layer of irony and problems, some of which can’t be solved. 

Bones break, most fractures don’t require hospital care, but while a person heals from a fracture they tend to get illnesses requiring hospitalization, which complicates the fracture care while the fracture care complicates their other problems.

Fourteen hours of a zoo of a day.

February 17, 2011

I don’t do this because of the pay,

Going straight into the fray

     From eight until ten

     Like the old headless hen,

It’s been a zoo of a day.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

I’m writing this after fourteen continuous hours of caring for sick people trying to get better, sick people trying to stay sick, well people pretending to be sick, and a few well people just wanting to go back to work.

I tried to take care of five people who came out and said they didn’t trust me, then tried to bully me into narcotics prescriptions.  I pointed out to them that if they really didn’t have confidence in my judgment they wouldn’t accept anything I would prescribe, and the only thing they should take from me is an arrangement to see another doctor.

A recurring theme today, just like an episode of a TV doctor show, involved a schizophrenic with a horrendous medical problem that cannot be dealt with on the North Slope.  We discussed the patient at morning rounds, I made several calls to Anchorage and received varying combinations of arrogance and sympathy from the Big City.

I placed a cast with the advice to the patient for prompt follow-up if the cast got too tight.  Which it did.

Influenza and post influenza problems saturated the walk-in clinics.  People slip on the ice and sometimes break things, but mostly just hurt for a couple of weeks.  I explained to a lot of people that if it didn’t hurt bad enough to come in for the first five, six, or eight days that they didn’t narcotics today, and they should expect to be sore for several days.

The Inuit smoke a lot of marijuana, which has marginal legality here.  But they smoke it now like hippies smoked it in the sixties and a lot of folks haven’t been unstoned for decades.  Some of them hunt stoned.  I see health problems related to cannabis abuse.

Instead of eating dinner, I waited twenty minutes to talk to a pediatrician at ANMC (Alaska Native Medical Center) because the phone operator didn’t read the call schedule correctly.

When I finally connected to the surgeon/gynecologist/pediatrician, I received cogent, useful advice in a time efficient fashion.

Seventy percent of my business came from tobacco, alcohol, or marijuana. Twenty percent came from influenza.  Ten percent came from bad luck or overeating or both.

And I saw something I’d never, ever seen before.  I didn’t even ask for permission to write about it, even if the answer had been yes, I wouldn’t have written the details.

Snow machine excess, cold injury, and wolverines

January 19, 2011

Some people, they smoke and they drink,

Some trap the otter and mink

     But the story’s been told

     That Barrow’s so cold

You can’t open your eye if you wink.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  To avoid burnout, I’m transitioning my career, and while my one-year non-compete clause expires, I’m working in exotic locations, traveling, having adventures, and visiting family and friends.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I’ve been back on the job for less than twenty-four hours, here in Barrow.  I’ve seen several cases related to snow-machine use.

In Barrow, one avoids the terms sled or snowmobile in favor of snow machine.   The people here use them, not for recreation, but to do necessary work.  People hunt from snow machines, so that hunting injuries are almost synonymous with snow machine injuries.

Most, not all, caribou migrated south past the Brooks Range when the days grew too short.  Herds of up to five hundred remain, grazing on the tundra.  In temperatures so cold that alcohol freezes, in the Arctic night when the sun doesn’t rise and the moon doesn’t set, subsistence hunters go after them with firearms ranging from .22 magnum handguns to 7mm Remington Magnum rifles.

A lot of parkas here sport wolverine fur on the ruff. Unique in that breath frost won’t stick to its fur, hunters eagerly seek the “skunk bear.”  The creature has such a nasty disposition that it acts like a serial killer, slaughtering everything in its path for fun and eating for necessity. 

The government issued a wolverine fur-trimmed parka to a person I know (not a patient) during the cold war, for work done in the Arctic.  To this day, the nature of the work and the circumstances of issuance remain clouded in mystery.

Hunters also go after wolves; polar bears occur as targets of opportunity.

Most of my clinic load, whether in Iowa or Alaska, has to do with damage from alcohol and tobacco.  Respiratory infections, cough, asthma, depression, fatigue and malaise, hypertension, high cholesterol follow from those two substances.  Counseling people to quit, though a good idea, rarely works.

When the patients come in with fetal alcohol syndrome and fetal alcohol effect, it’s too late.  With irreparable damage I just make the best of the situation.

I won’t say where, but I attended a set of fraternal twins, one of whom had fetal alcohol syndrome and one of whom had much milder fetal alcohol effect.  Some people are more resistant to alcohol than others, and such resistance starts before birth.

If most of what I see in any clinic has to do with drinking and smoking, the majority of the remainder has to do with the unique factors of where the clinic stands.  Barrow’s air is so dry that eczema here runs an order of magnitude worse than any I’ve ever seen.  Yet most people know the cold so well that frostbite comes rarely.

The first case of frostbite here in Barrow came my way today, very shallow damage, but not to fingers or toes.

Rage, hunger, lust, and sleep.

March 8, 2010

Just thinking the beeper will beep

Will keep you from getting good sleep,

            Then hunger you must           

            There’s anger and lust

And you tend to sigh and to weep.

 

The amygdala, an almond-shaped piece of your brain, is charged with a lot of things, among them hunger, anger, sexuality and sleep.  If you mess with one, you mess with them all.  And every knows it.

If you are hungry, you can’t sleep, you’ve got a short temper, and you have no perspective on sex.

If you’re sexually deprived, you’ve got a short temper, you can’t control your appetite, and you can’t sleep.

If you’re angry, you can’t sleep, you either can’t eat or you can’t stop eating, and you have no perspective on sex (nothing kills a sexual relationship faster than anger).

If you’re sleep deprived, you can’t control your appetite, you have a short temper, and you have no sexual perspective.

I remember speaking with a medical school classmate in that stressful third year.  She’d been on call the night before and hadn’t slept well most of the rotation.  I asked her how she was, and she said, “How do you think I am?  I’m down to the limbic system level.”  Which she then detailed, graphically. 

I see a lot of illness which has been exaggerated by sleeplessness.  Diabetes, we now know, improves dramatically if sleep pattern can be normalized; CPAP treatment for diabetics with sleep apnea is the equivalent of 1000 mg twice daily of metformin.  Much, not all, of fibromyalgia comes down to a sleep disorder.  Sleep apnea makes high blood pressure much worse.

In patients with rheumatoid arthritis, sleeping poorly the night before predicts pain level better than pain level during the day predicts sleeping poorly at night.

In another state (remember, I’ve had licenses in seven states so it is not possible for the readership to identify the patients) I cared for a pair of brothers who became psychotic after doing too much speed and not sleeping for a week.  After a couple of good night’s sleep in the psych ward they were saying things like, “I can’t believe I…, I remember it and I remember how it all seemed so real.”

Then there are the correlates of depression, and you can’t have depression without sleep disturbance nor sleep disturbance without depression.  You can treat the depression till you retire but you won’t make real progress if there is a sleep disorder that needs to be treated.

If you sleep well the night after your flu shot, you get antibody levels five times higher than if you go on call and don’t sleep at all, and the antibody levels never completely catch up.

Many patients are resistant to normalization of sleep patterns because they have disordered family dynamics, and sleeping lousy keeps them from functional interaction with their families.  For those patients I recommend marital counseling, which they usually won’t accept.

Good sleep hygiene takes care of most (not all) sleep problems:

             Nicotine:  Tobacco is evil.  It also cuts down on the time you spend in Stage IV and REM sleep, the restful stages.  The effect lasts for months after you quit.

            Caffeine:  This one is not rocket science.  Caffeine is supposed to keep you up. Most people don’t realize that the effect of the caffeine persists months after the last dose, though most of the recovery is done in two weeks.

            Alcohol:  Booze puts you to sleep for four hours without the restful stages of sleep (Stage IV and REM), then you wake up and you can’t get back to sleep.  If you’ve been drinking hard your sleep EEG will not normalize for six months after your last drink.

            Television:  On a regular basis people will stay up late to watch the evening news, and go to sleep half an hour later than they would have normally.  Or they’ll stay up to watch a favorite show.  My advice is to get the TV out of the bedroom all together.  Nothing on TV is worth the time it takes to watch it.

            Meal timing:  Wait for three hours after eating before laying down.  If you’re going to have a bedtime snack, make it light with a low glycemic index.

            Exercise:  Don’t do it right before you go to bed, you’ll be too hot.

            A quiet, comfortable, safe place to sleep:  I have a friend who doesn’t sleep well if  no dog is there as a guard.  Don’t expect to sleep well in an uncomfortable bed with an abusive partner.

            Adequate sexual frequency: It’s different for each person.

            Anger management:  This is a much thornier issue.  I’ve started to advise writing for twenty minutes before bedtime, starting with the worst thing that ever happened.  Longer term anger management is best addressed with professional  counseling.

A lot of people will tell me they sleep fine because they fall asleep quickly and they stay asleep through the night but they wake up feeling rested less than half the time.  They need effective sleep.

Like many other things, sleep deprivation/loss of appetite control/anger/loss of intimacy tend to a vicious cycle; people gain weight, get sleep apnea, can’t control their hunger, gain more weight, their knees hurt, they can’t exercise, they gain more weight, they sleep worse, they’re so angry that their loved ones shrink from their short tempers, they eat more, they sleep worse, etc, etc.

Sleep problems of doctors come from frequent night-time awakenings while on call, and from vigilance.  Aside from a few years while I was with the Indian Health Service, I’ve done OB.  If you have patients after 36 weeks gestation you don’t sleep well, you’re always waiting from the call from Labor and Delivery.

Vigilance murders sleep.  Ask any mother of a newborn.  Ask any doctor on call.

Sleeping during the day after call helps but it doesn’t make up for the deficit.

As time goes on, my resilience to sleep deprivation has weakened.  Twenty three years ago if I stayed up all night with a hard delivery or a series of admissions I could sleep the next afternoon and I’d be OK the day after.  Now if I’m up all night on Monday I feel terrible till about Thursday. 

I’m on call this weekend.

Even if I don’t get called, the fact that I’m liable to be called will rob my sleep.

I’m hoping when I slow down I’ll have more down time before and after call, so that I’ll rest better more of the time.