Why we should never discount the value of sleep

“Do you snore?” has become a standard question in many internal medicine reviews. The answer is usually “What?” followed by a giggle, and “How would I know? Just a minute and I’ll ask my wife.” This is how telemedicine docs find out who else is in on the call. “Apparently I do, but only if I am on my back, and I try not to lie on my back” is one interesting answer, noting that one transitions from left to right via lying on one’s back, and one is unconscious at the time. But sometimes the response is: “Loudly. My wife moved out of the bedroom and down the corridor two years ago. Visitors comment on the walls vibrating.” Read: Tough decisions inevitable in this job Our appreciation of the value of sleep has grown over the last 10-20 years, and is now an industry into itself. Watches track sleep. Devices improve sleep disorders. Patients either hate CPAP or love it (“wouldn’t leave home without it”). And doctors know the impact of glottal obstruction of the pharynx on cardiovascular well-being: hypertension, arrhythmia, premature atherosclerosis, cardiomyopathy, and metabolic disarray. Like many of the old school, I used to associate snoring with morbid obesity, and then along comes atrial flutter in a 52-year-old mesomorph. “Hey, your AHI is 35.” “Yeah, and I have a power nap every afternoon, does me proud.” I ran a Heart Function Clinic in my local hospital for a decade. As part of the intake questionnaire, we asked about sleep (Epworth Sleep Score, Stop-Bang review), measured height and weight, and arranged for a sleep study on all patients with reduced LV function. The results were surprising. Read: The cases you never forget Many OSA patients had arrhythmia and hypertension that complicated their recovery. Intervening with CPAP or a mandibular advancement device improved LV function, over a period of several months. It wasn’t a trial powered sufficiently to be published. But it taught me the value of a broad IM approach to understanding cardiovascular dysfunction. As part of a QI push in our hospital, I got interested in implementing a H.U.S.H. (Help Us Support Healing) program on the Cardiac Ward. (2) We borrowed the program from The Cleveland Clinic. Anyone who has been an inpatient knows that silence is a scarce commodity. Nurses chattering at the desk, alarms going off, stretchers moving in and out of your room late at night, and a 6am blood draw you probably didn’t need. On top of a rational anxiety about your own health (why else would you be there?), your new friend in the adjoining bed arrested (not the cufflinks type, the flat line type) at 10 p.m. So, most hospital patients will gain from any measure that lowers decibels. H.U.S.H. was designed to do this. As part of a QI project in Nanaimo Hospital, nurses were encouraged to lower all conversations to a whisper after 9 p.m.: signs were posted and doors were closed to unnecessary traffic. We even had ‘noise level monitors’ installed (a traffic light system that showed red-yellow-green at the nursing desk so you know when conversations got a bit too loud). Here are the results: Patients slept better Stress levels fell Discharge feedback was better Healing occurred faster/LOS dropped Overall satisfaction improved (patients/staff/family) How did we manage to forget that adequate sleep quality and duration (like good nutrition, pain control, relief of anxiety and dyspnoea) make for a better healing environment? And yet the hospital ward (or sometimes corridor!) is far removed from a reassuring, peaceful and nurturing place of healing. I did my own research in the Heart Function Clinic: identifying patients with disturbed sleep (OSA) proved to be valuable. Diagnosing and treating OSA (with CPAP or a mandibular advancement device) resulted in improved ejection fraction (when combined with good HF therapy). Well, who needs the surges of adrenaline that goes along with intermittent airway obstruction? And what about physician sleep and the on-call experience? How good are we in making good decisions at 2 a.m., woken from deep sleep by a concerned nurse? “Ms. Jones is gasping, can you come straight away?” Your attempts to orient yourself and buy breathing space are logical, but unappreciated. “Eh, who is Ms. Jones, is she a cardiac or a lung patient, is she the DNR cancer patient with lung metastases in bed 7A, have you started oxygen, what are her vitals?” “I don’t know her, I’m just covering for Anne on her break…. Are you on your way?” As a resident, you expected a broken sleep. Once I remember sleeping over on the maternity wing, being the Anaesthesia back-up for epidurals. I had a nightmare - someone in the ICU (ward H7) had called me to do an urgent re-intubation on a burly chap who pulled his tube out. Being confused at 4 a.m. was distressing, so I just got out of bed and wandered over anyway. There I found a team of nurses restraining Jack Tuff. “What kept you, it’s been nearly five minutes since we called!” “Right!” I said, and with a push of Sux and a chug of Fentanyl, and Mr. Tuff became Mr. Easy. Everyone forgave my tardiness. How many times have I woken up, taken a call, and had little recollection of events the next morning? Scary when you think of it. Lastly, Lethe, the river one crosses on one’s way to the Underworld. It comes from the Greek, meaning Oblivion. (3) Some believe drinking water from the Lethe with eradicate memories from a lifetime: drinking from the Mnemosyne, the river of memory, will end the transmigration of the soul. The first modern anaesthetic (i.e., beyond opiates and mandrake root) was a mixture of sulphuric ether and orange juice, and was called Letheon. Introduced by Boston dentist, William Morton, in October 1846, it allowed Dr. John Collins Warren to operate on Glenn Abbott’s neck, without the pain and distress routinely associated with surgical intervention. (3) Attempts to patent the invention were met with disdain, of course. It’s getting late, and as Zebedee (the Magic Roundabout) once said “It’s time for bed.” (4) References: https://www.britannica.com/topic/Lethe https://prezi.com/tacm-j1vlkrt/hush-protocol/ https://www.umhs-sk.org/blog/medical-milestones-discovery-anesthesia-timeline https://en.wikipedia.org/wiki/The_Magic_Roundabout

Casebook of a Community Internist

Why we should never discount the value of sleep

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Hector Baillie

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