Quiet hour

Mr. Peterson has a pulmonary embolism--a clot in one of the blood vessels going from his heart to his lungs that threatens to keep his blood from picking up oxygen. It most likely came from somewhere lower down in his body, sliding up his vena cava and into the right side of his heart. While there isn't much that we can do about it now, we need to prevent the clot from getting bigger and new clots from getting started in the first place--he needs heparin. Because everyone responds a little differently to heparin, we have to make sure that his blood gets tested every few hours (around the clock) and adjust his dose until he is in the therapeutic range.

I am the 'night float' intern; I take care of patients like Mr. Peterson (which is, of course, not his real name) overnight while the three day teams get whatever sleep they can. It's quieter at night, and with only the occasional beeping of infusion pumps, telemetry monitors, and pulse oximeters all just out-of-sync, I'd even say it's soothing. So far I've been too terrified of something going wrong in the hospital to go to sleep, but I've become used to sleeping during the day. Not so for my patients.

I should say that I've never spent a solid amount of time in the hospital at night before this, my first month of internship. As such, I'd never really thought about how care continues through the night. I never considered that, when I ordered a test or a medication to be performed or administered 'q6h'--every six hours--patients would at some point have to be awakened from sleep during at least one of those instances. And, of course, worse for q4h orders, and so on. I just never thought about it.

Now, I am sitting in a call room and waiting for 4 am when I am to draw another tube of blood from Mr. Peterson. Just a few hours earlier overnight, I had woken him for the first tube and the result showed that I needed to increase his heparin infusion rate because his blood was still clotting too quickly, which I did. Now, I need to wake him for more blood and I know that if I don't, and his response to the increased heparin dose was not adequate, the complications could be disastrous. His clot could get bigger, or a new one could materialize and shoot up his veins through his heart and into another pulmonary artery. Pulmonary emboli can be fatal.

Often, with busy day teams trying to get through their mounds of work, little thought goes into how much sleep patients might need. I mentioned this in an off-hand comment to a colleague and he said, "Patients are always in bed and have nothing better to do than sleep!" But what about the quality of that sleep, interrupted as it is without fail for this blood pressure or that blood draw, sometimes barely an hour apart and not usually more than four or five? It's not surprising that patients--even the most positive and pleasant ones--quickly tire of being in the hospital. Insomnia and irritability go hand in hand.

Although many researchers have discussed the importance of sleep, including in critically ill patients, none have actually studied the effect of its deprivation on hospitalized patients and hospitals do a poor job of promoting good sleep hygiene. In the hospital where I work, a large academic medical center, there are signs posted at the nurses' stations telling staff and visitors that between 2 am and 3 am our patients are asleep and would appreciate quiet. Nurses, doctors, and phlebotomists walk into patients' rooms at all hours of the night for any number of reasons--urgernt or not--turn on the light, poke around, and sometimes forget to turn the light off or close the door when we leave. Alarms, chatter, and beeps puntuate the dark hum of the hospital at night, and they would certainly keep me awake. Sleep is clearly not a priority here, nor is it at any hospital where I've trained so far. How could it be? This is not a hotel; these people are sick and we are working tirelessly and at the expense of our own sleep hygiene to get them well again.

But sleep does matter. Several pre-clinical and clinical studies have shown us that deprivation of sleep, and particularly REM sleep (thought to be the most 'restful' phase of sleep, and the most fragile), affects all sorts of brain and body systems from memory and mood to the heart and general health. In one study, rats were shown to be more sensitive to pain the less REM sleep they got. In many other studies, shortened sleep cycles have been associated with obesity and diabetes--in humans. In a very recent Chinese study, also in humans, sleep deprivation increased inflammation and blood clotting--both involved in stroke and heart disease. And pulmonary embolism.

So what is the right thing to do? In Mr. Peterson's case the decision is simple: I'm going to wake him up. His life is on the line. But what about Ms. Simmons in room 436 who's getting routine (that is, not urgent) lab tests at 5 am--the time designated for AM blood draws throughout the hospital--despite having been kept awake until after midnight in our busy ER awaiting admission to the ward? No one really stops to think about how little sleep this poor sick woman has had last night and how important it might be to her recovery here. We have far too much else on our minds.

Anyway, it's time to go wake someone up. This time I have the luxury of not agonizing over the decision. It's not always this easy.