Save Lives — Let Doctors Sleep!

When I was a very junior neurosurgical resident in France, I always thanked my lucky stars I had not overused coffee.  Mme. M., who ran the cafe below my apartment throughout the first part of my studies, which were mostly classroom, had an Italian espresso machine and little demitasses (half-cups) of potent brew — so potent that I could not consume more than one in the morning.  Arabica, fragrant, and aromatic, it was a true joy.

After I moved closer to the hospital center, I heard for the first time the expression “pump yourself full of coffee.” (se pomper pleine de cafe)  It was foul tasting stuff, consumed in an infinity of Styrofoam cups, and strong — really strong.  There were rumors that it came from the same “common market supplier” as the wine, which was supposed to also be from a a mixture of common market (it had not yet become the European Union) countries.  All the food was free, as we were government employees.

Nobody ever figured out where the coffee had come from.

There was an open bar 24/7, about as well outfitted as Mme. M’s.  I was afraid to be in the same room with it.  I am delighted to report that I never saw anyone use it on an on-call night.

This is the place I could access a small bed — iron tubes for headboard and rails, mattress probably stiffened with starch.  The joke, which may well have been true, was that it was Napoleonic non-issue, meant for a barracks.

After the first night I lay upon it sleepless, answering a beeper that whenever it rang told me to call the operator and they would tell me who to call, my then-young back was killing me and I was fighting tears.

My supervisor in neurosurgery, handsome and authoritative and scary, greeted me the next morning.  He had a half-smile when he greeted me with a cursory “Bonjour, Mademoiselle Goldstein” (I was not yet officially to be addressed as Mlle. Docteur), “comment ca va?”

I told him, “It was my first night on call, lots of business in the emergency room, I have a sore back and no sleep from the famous Napoleonic non-issue bed, and I am sure I have a lot of work today and of course it will get done.”

He smiled, something he rarely did, at least to me.  “This is the most important part of surgical training.  A surgeon must be both strong and smart.  A surgeon must be able to make sound decisions after about four days of work with no sleep.  Then you will know you are becoming competent.”

There was no answer to this macho kind of belief, and I knew better than to answer him back.

Many times, when I was in neurosurgery in both France and Canada, I was scrubbed into operations that took over twenty hours.  New nurses came on, fresh looking, at every shift.  Doctors did not change.

Back when almost all doctors seemed male and almost all nurses were female, I thought this was a “macho” thing, pure and simple.  A fair amount of the guys were on prescription stimulants.  Some told me that they were jealous I only needed coffee.

This is also the time I learned the (French resident’s prayer, which must exist somewhere in English. “May they not die while I am on call.”  (“Qu’ils ne meurent pas quand je suis de garde.)

I remember the original reporting of the Libby Zion case. This young woman died while in the care of sleepy trainees in a New York Hospital.  I believe it was from “serotonin syndrome,” a drug interaction problem which even now the author of the article has discovered most physicians don’t know about.

I diagnosed it recently, in a mild form, in a psychiatric outpatient, when I was covering for a colleague, who, when he returned from his absence, barged into my office and asked, “how the hell did you know about that one?”

Most docs don’t seem to know about drug interactions – at least it seems that very few check them regularly.

I’m the obsessive type — I keep internet access to drug interaction sites on the screen of my computer when I see patients — especially if they are on free samples or things from multiple pharmacies.

I did not have to check this one, I knew and it was flagrant and the patient (who started college soon afterward) said I had changed her life.  The doctor who barged into my office said I was going to consult on all of his regular patients who were doing “rotten.”  I did, and there were lots of things besides serotonin syndrome.

Sad to say – that is the norm for institutional medical treatment. I have since left that region — he is counting the days to retirement.  In general, it is a good idea to practice preventive medicine, if for no other reason than to avoid medication errors and hospital-acquired infections and the like.

Here is another reason.  I actually once told a “frequent flier” (hospital jargon for “frequent emergency room user”) to ask any trainees who were assigned to care for her how long it had been since they had any sleep and to try to get a fresh one.  She said it was impossible — she could never get any care if she held out for this.

Please don’t think I’m sexist — this idiot practice of seeing how long a resident can function without sleep — associated with errors and deaths — continues, even when not all the medical doctors are male.

Sometimes I think that the U.S., just like England, has so lowered the social acceptability — not to mention the pay — for medical doctors that it is an “easier” profession for females to enter.

I remember when I was a resident in France, an obviously erudite and cultivated female physician from the U.K. told me not to come practice in the U.K. unless I wanted a pay cut from France. She was a fully qualified specialist but was paid so little she did not think it was worth it to maintain her own flat away from the family homestead – a necessity for nipping of to get a little shut-eye instead of going all the way home when you were on call constantly.

Why does this horrible “sleepless doctor” tradition continue despite serious ramifications and serious efforts to change?

The answer is a common one: “Tradition.”

I hear a lot of people tell me they have to continue the job they have done all their life, because it is all they know how to do.  It never occurs to them to ask what else their skills could be used in.

I heard someone say that in an assembly line he operated the same machine that his father had before him, and loved it, and even though he was quite ill, he had never wanted to do anything else, and would not. Maybe, maybe, someone can see beauty in spiritual or symbolic traditions, although sometimes I worry about those, too.

Criticizing tradition and custom puts one on shaky ground. “It simply is not done!” or “That’s just the way it is done.”

Please don’t look for logic.

People are harmed – or die – because doctors don’t get enough sleep.  Why not give them sufficient sleep?

Tradition.

I grew up among traditional people – mainly Jewish traditions.  Most seem puzzling to non-Jews.  The traditions of many of my Christian friends seem puzzling to me.  Ask why these things are practiced and you will see eyes glaze over as if you’ve overloaded one of those robots in Science Fiction movies – “Does Not Compute!  Does Not Compute!” as smoke comes sizzling out of their ears.

There’s no reason – it’s just our custom.

Medicine and doctors do not seem to be smart enough to abandon this useless tradition of forced insomnia that can easily kill people. Medicine and its practice seem to have become stupid beyond tolerance.

I am glad I saw the article referenced above. Don’t quote custom or tradition as reasons. Stupidity, which can apply to a profession, to its educational system, as well as to individuals, is the only reason.