“Without enough sleep we all become tall two-year-olds”

“Without enough sleep we all become tall two-year-olds” 
—JoJo Jensen, Dirt Farmer Wisdom, 2002

Many physicians are required to do overnight or multiple days of call to ensure patients have access to care when needed. I am midway through another 48-hour call shift for our obstetrical clinic as I write this Comment. For all of us who do multiday overnight call, we understand the importance of sleep to our personalities and our performance. However, we also understand that there are different types of sleep for physicians on call.

Yesterday I was fortunate as there were only a few deliveries and assessments that took me back and forth to the hospital. I had breakfast and lunch at the normal hours, and while dinner was a bit off schedule, I did have time to eat. At 9:00 p.m. I was called back to assess an abnormal fetal heart tracing. Although the situation improved in the 10 minutes it took me to arrive, leaving the hospital was not an option. After watching the tracing for another hour, I decided to try to grab a few minutes of sleep in our breakroom. 

Our breakroom is only 6 years old. A luxury. Before we built this room, I slept in my car or in a chair in the operating room doctors’ lounge. The room is partially lit from the hallway, and the continuous high-pitch hum of the fan makes the room too cold to immediately drift off. Plus, I can hear the nursing staff grabbing supplies from the storage closet next door. Still, it’s better than my car. I am slightly on edge because I am concerned about the patient; however, I also recognize that my body and mind need sleep for me to function at my best. This is the shallow sleep—drifting in and out, answering numerous phone calls from the ward and case room about other patients, and waiting for my patient’s situation to progress or to declare an emergency. Several other patients come in and out of the hospital for assessment and pain management in their labor processes. This sleep feels like body rest, but the mind is not really recharging as I subconsciously process all the possible scenarios ahead. 

Things progressed well and the mom-to-be began pushing, but 3 hours later, despite her best effort, we had to proceed to a cesarean section birth. Once the baby was successfully delivered and the mother safely out of her first hour postpartum, I could put my head back down. I call this resolution sleep—sleep that is slightly deeper and more restful that comes at the resolution of prolonged or complicated cases. 

When my phone rings again, I feel like I was completely out. According to my Fitbit, I had 3 hours and 11 minutes of sleep overnight; however, the sleep-wake division looks suspiciously like a seismograph.

I am hoping to get a few more hours this afternoon before the nighttime rush starts again, which is sleep that I call pre-sleep. It is different from the first two types of sleep as there is nothing really worrying on my mind, yet it is still difficult to get into a truly deep sleep phase.

The final type of sleep I call blanketed sleep—sleep that feels like you are under a down comforter in front of a cozy fire in the middle of a snowstorm. I will get this type of sleep the evening after I am off call, after I have gotten through the 4 to 5 hours of patients booked in my office and caught up on the many nonclinical tasks required to keep my family practice office running. I will have handed over all my clinical duties and could safely turn off my phone, although many of us never do. The percentage of my REM sleep during this time is certainly higher during those hours than on the nights preceding, and I know I will wake up refreshed and ready to start the process again. 

I do not believe there has ever been a truly comprehensive study of the cumulative impact of sleep disruption that on-call physicians experience over the course of a lifetime. I am not even certain there would be a way to accurately study this topic. What I do know is that this chronic sleep disruption is just one of the many sacrifices physicians make every day to keep our health care system viable and sustainable. Thank you all, and sweet dreams.
—Kathleen Ross, MD
Doctors of BC President