22 December 2006

How Do You Stay Awake?

Many times I have been asked how I stay awake and answer calls overnight. I don't have a specific "system" but I have some things that help me remain alert when I have to remain alert. Being on overnight call is physically and emotionally draining at times. You never know what will be at the other end of each page. For me, not knowing what to expect with every page is one of the more interesting aspects of medical practice.

First, let me dispel some myths. It is a myth that a resident physician in training has to go for 36 hours straight in order to learn how to deal with emergencies. I have had few emergencies when I was on my 36th hour. What may seem as an emergency when presented to a physician who is sleep deprived becomes a major annoyance. One simply cannot do their best work after 36 hours of work without rest. Medicine suffered before the institution of work hour limitations and no amount of complaining by attending physicans who were trained under the "old system" will negate that fact. Most of the times, the residents and the physicans were lucky that they didn't harm more patients because of lack of sleep.

It is a myth that every night on call is a "race against death". Most of my on-call nights are spent dealing with problems that either came in through the emergency department or were left over from other services during the day. With the 80-hour work hour limits, some services are not going to be able to take care of all of their work during the day and get their operative cases done too. It become the work of the on-call resident to finish any needed work in terms of the services that they cover. The patients that I cover overnight are MY patients during my watch. I am happy to take care of their needs and help my fellow residents.

Still, there have been times when I have been so sleep deprived that I bordered on being depressed. I am mostly affected with I am not busy but just waiting for the night to move on and for the frenatic activity of just before dawn to begin. If I am busy, the night goes by rapidly and the exhaustion doesn't hit until I am ready to hit the bed. On nights of extreme exhaustion, I go outside and take some deep breaths of air that has not gone through the HVAC system of the hospital. One of the nicest places to take some deep breaths of fresh air and survey "my kingdom" is the roof of the hospital. If the weather is rainy or misty, the cool moisture against my face is great. If snow is falling, there is a fresh, crisp, and quiet calm that is invigorating. If there is fog, there is an eerieness that is wonderful. Summer, spring, fall or winter, I can't lose on the roof.

There is a certain amount of "sleep deprivation" that you learn to live with. For me, it started in medical school when I quickly learned that I would have to be able to study regularly with less than 6 hours of sleep. The volume of material to be mastered in huge and this mastery takes time. I learned to study when I was tired and I learned to do things such as aerobic exercise that would keep me alert and make my studying more efficient. I also learned that caffeinated drinks like coffee, tea, Mountain Dew and Diet Coke, did not keep me awake but only make me more nervous. Sugar was out too as it gave me a rush but then a drop where I found myself more energy depleted.

Hydration became a goal for me. I found that I felt less tired when I was adequately hydrated. This meant keeping a bottle of water in my lab coat pocket at all times. I also kept a Brita water pitcher in my call room and kept it filled with water. As most hospitals are hot and dry, I found that I have to work to keep myself hydrated and that dehydration is the enemy of efficiency.

I always hear my pager. I don't know why I have always been able to hear the thing beeping but I have never missed a page when my pager was working properly. I also made it a habit of letting the page operator know the number to my call-room in case my pager was not working. He/she always knew how to track me down if the paging system was off. We could sign out our pages to the residents who were in the house overnight or leave a phone number where we could be reached. I just never sleep deeply at the hospital or at home so that I do not hear my pager.

When I have found myself so exhausted that I was just not interested in anything except sleep, I took a nap. First, I would take a brisk walk and then I would nap for 20 minutes in the large lounge chair in the surgical lounge. Those 20 minutes would bring me back refreshed enough to get through the rest of the night. Taking a shower worked well also. I never did morning rounds without a shower, tooth brushing and change of clothes if I had been on call overnight. There have been times that I have literally left the OR, headed for the shower and then to AM rounds. Life just works out that way.

When a nurse pages me, I have always kept a pencil and paper handy to write down the patient's name, the service and jot down the time. I keep a running tally of my calls overnight so that I know exactly when I was paged or how many times I have been paged. These tally sheets have come in handy more than one time during Mortality and Morbidity conference. My first rule has always been to "Go and evaluate the patient if I am not familiar with the problem." Most of my problems these days come from a more junior resident who needs another pair of eyes or hands in terms of evaluating their patient. I am only happy to help as I vividly remember being in their shoes. Most of the time, they have solved the problem before I get there but it is always nice to have a backup when you need a backup.

Most nurses (99.99%) do not call a resident in the middle of the night for things that are "trivial". Occasionally, I will get a call to speak with a patient's family member about the plan for the patient. If I am not the resident on service, I can only offer support and a willingness to pass along the concerns to the service in the morning. If a nurse calls, they have a problem and I appreciate the calls. The nurse is at the bedside and I am usually in the call-room. Most of these calls can be taken care of by phone but many times, I have to go and evaluate the patient. My rule is this, if I think that I "ought" to see the patient, I "go" and see the patient.

When I am on-call, I plan my evening and next morning and write down those patient care plans. I know that I am not going to be doing late cases (unless there is a dire emergency) so I get everything squared away for my service. Before I leave post-call, my junior residents and students know exactly what they need to be doing for the day. The senior on-call resident gets a list of my patients and potential problems with solutions so that they have a better idea of what has been happening on my service. I also chat with my attendings so that they know what I have planned for the day.

With the new limited work hours, we have to have excellent communication with our colleagues and with our attendings. We also have to be able to anticipate what our patients will need and make those provisions. As residents, we have to get to a higher level of efficiency faster than before when we had the luxury of more time in the hospital.

I don't think that I am getting any more sleep these days than in medical school but the work is more interesting. Gone are the days when I could go "drinking with my mates" for an evening or watching the telly for hours. I have loads to read and study most of the time. Still, there are nights when I have to fight to stay awake and fight to keep my concentration. Usually, I take a deep breath and keep on plugging away. That clock never stops and soon my work will end. It takes the same amount of time to do a job well as to do it poorly. I just cannot do anything that involves one of my patients poorly.


Jacqueline said...

awesome post. I am very far from being a doctor yet, but I can still relate. I work full-time graveyard (11p-8:30am), have a husband/toddler/dogs and go to school full-time. It's not easy, but it CAN be done, and like you I take the time to make sure it gets done well. Bravo to you doc :) Happy Holidys!

Anonymous said...

I'll try some of these....my aim is to stay awake longer and revise whilst actually learning something as opposed to feeling tired.

thanks for the tips ;)