Monday, March 8, 2010

How Do You Sleep?

One of the more common, non-emergent complaints I hear in the ER is about sleeping, or the lack thereof. Although the patient is usually being seen for a more serious, emergent issue, if their sleep is not solid, they tend to skillfully bring it up regardless of what else is going on.

"Maam," I said, "it appears by your EKG that you are having a heart attack."

Despite chest pain so intense that my patient was clutching her chest, she still stammered, "But what can we do about my sleep?"

Or, imagine my elderly male patient in the midst of a stroke, with the left half of his face drooping, his speech slurred, and drool sliding down his chin. "I shant schweep adt nichte."

"Pardon me, sir, but what did you just say?" I asked.

Thankfully, the nurse starting his IV understood him. "He said, 'I can't sleep at night.'"

See what I mean? I've even had a patient share her insomnia issues during a pelvic exam. Maybe if she had slept more and fooled around less, I wouldn't have had to do this exam for her itchy, malodorous discharge in the first place.

Barring the situational, temporary reasons (for example, a death in the family), sleep disorders are typically viewed as chronic, long-term illnesses and, as such, should be treated by one's family doctor. Sleep studies may be necessary, and there are several options of treatment to prescribe, all requiring close follow-up. All reasons for me not to treat a patient for this disorder. I will, in a pinch, prescribe a few days worth of medication for a patient if their daily life is being severely affected, but that's about it.

Several years ago, after some prompting by my wife, I underwent a sleep study. It seems that I was having bouts of snoring and gasping for air in my sleep, per my wife. I'm not sure how she knew this, seeing that her head hits the pillow and a six-to-eight-hour coma immediately follows. But yes, she insisted, this was happening. So I took her word for it and pursued the testing.

I arrived at the sleep lab suite around 7:30 p.m, nervous and not sure what to expect. After checking in, I was shown to a huge bedroom, professionally decorated, with a queen-size, pillow-top bed beckoning for my company. "Come, Jim" it whispered to me, "come and let me wrap my big, down-filled arms around you." I think I heard the 40-inch TV calling, too, but I could have been imagining that.

After the tech showed me to my private bathroom, I changed into some appropriate sleepwear. You might be asking yourself--what's appropriate? I'm going to let your imagination answer that question. Just be aware, though, that they videotape you through the night as you sleep. And then post that video on YouTube. Just joking. Suffice it to say, I would suggest that one wear more than just the usual home sleepwear. And newer, too. Please, on behalf of all the sleep-lab techs in the world, don't show up in a stained, big-daddy Hanes t-shirt. Or tighty-whiteys. Or a moth-eaten thong. Or nothing at all. Especially nothing at all!

After changing, I climbed into bed. Soon, the tech came into the room. I was nervous, obviously, and likened this anxiety to how a 60 year-old fat, balding guy must feel while lying in his hotel bed, waiting for his prostitute to arrive.

The tech, a nonchalant, easy-going guy, explained the whole process to me. "First, we 'll attach these electrodes to your head, then your chest and finally your arms. After that, we'll leave you alone. You can do whatever you want--watch TV, read a book, whatever--until around 10 p.m. If you aren't sleeping by then, we'll ask you to turn off everything. Don't forget," he continued, "besides monitoring you, we'll be watching you on video." He pointed to the cameras in the upper corners of the room while he spoke. "Any questions?"

No questions, but just a silent prayer. "Dear God, I beg of you, keep me from scratching myself or making a fool of myself tonight. Amen." I added a bargain for good measure. "Oh, and if you do, God, I promise to give every ER patient a turkey sandwich, a warm blanket, and unlimited lemon pudding during the next week."

The tech left the room. I looked around, all this comfort surrounding me, and all I could do was think "How the hell am I going to sleep with all these wires hooked up to me?"

Well, I read a little, I flicked through the 1000 available TV channels, and finally, around 10 p.m., I turned off the lights. There's no way, I thought to myself, that I'm going to fall asleep. I pictured my wife at home, smiling, arms and legs spread out, sleeping soundly alone in our bed. I had the bad feeling that I had been set up.

Next thing I knew, though, I was being nudged in the shoulder. "Hey," I heard, "it's time to wake up." Through groggy, squinting eyes, I peered slowly around, clearing my mind's disorientation. That's right, I reminded myself, I was in the sleep-lab and, wouldn't you know, just had my best night's sleep in about ten years.

"You did great," the new male tech said. "Let's get you up and out of here." I got up, moved to the side of the bed, and he removed all of my electrodes. I got a quick shower, cleaning all the gel off of my head and body, brushed my teeth, got dressed, and headed home. I didn't need to hear the official results, I already knew--everything would come back normal.

Yeah, well, I'd like to call a penalty--the sleep-lab guys cheated. Unlimited channels, private room with bathroom included, big pillow-topped bed with down-filled comforter, the bed all to myself--who the heck couldn't sleep within those luxuries? The wires were but a mere distraction.

Have any of you had a sleep-lab study done? Similar experiences? Would you like to share how it went? What you wore? Let me lower my voice three octaves, like the great Barry White's, to a whisper and ask again. "Hey you, yeah you, how you doin'? What did you wear during your sleep lab?"

It took me some time, but I have my sleep all figured out now. Three, no four, things work for me. One, no alcohol. It's been shown to interrupt your sleep cycles, so I cut out my nightly glass of wine. Two, a great book. Three, Tylenol PM. Just one, occasionally. And four, in a pinch, 1/2 of a 10 mg Ambien tablet. I still have half of a thirty-day supply prescribed from last November. Take it on an empty stomach and within a half-hour, I'm a little woozy. Next thing I know, I wake up and it's morning time. And life is good. Bring on the day!

This isn't medical advice, just what works for me. Sometimes, though, it works too well. After taking a Tylenol PM several nights ago (I'm in the midst of several busy ER shifts), I woke up the next morning, horrified. On the ottoman beside our bed, my laptop computer sat with the top opened. Here, after taking my Tylenol PM, I had the brilliant idea to email a few people about their kind comments left on my blog. Rereading those emails this morning, I could only laugh and send those readers a follow-up email, apologizing for the ramblings. Forgive me if you got one.

Okay, I gotta run. I feel the Tylennnnnolll PPPPPMM kkickkkkkingggg innn aaagainnnnnnnn. Seriously. As we used to say when I was younger, "Good night, sleep tight. And don't let the bed bugs bite."

As always, big thanks for reading. Next post will be Wednesday, March 10. See you then...


Jacqueline said...

So then, no sleep apnea? My dad had to do a sleep study years ago...diagnosis was sleep apnea. He wears a CPAP to bed every night now. He had been in the hospital for about two weeks already for bilateral pneumonia (almost killed him...was on a vent for a week in the ICU), so he might have worn his hospital gown...then again, he's pretty modest, so it might have been a t-shirt and shorts...I'll have to ask him.

The Tylenol pm thing is funny...that's what the doc told my grandpa to take if he can't get to sleep. I can't stand the stuff...had a weird reaction one time, so when I can't fall asleep, I just watch Roseanne for 3 straight hours....that or send random e-mails about the color of my phlegm :)

Chrysalis Angel said...

Ah, that explains it. No problem. ;)

AtYourCervix said...

I have tried the ambien. Tried 5 mg. Nuthin. Tried 10 mg. Hallucinations of the bed levitating. Slept for about 3 hrs, then wide awake again. Cut out ETOH and caffeine in the evenings (I'm an evening shift nurse, not easy to do with the coffee when I'm working....). Nothing helps.

Oh, and the hallucinations from 10 of ambien? Fuuuuunny chit! I could tell you some wacked stories.......all of bed levitations, people in the room...weird stuff. Not scary though, when it's happening.


Anonymous said...

I've had a few sleep studies. The last one the techs were rude (pretended one was a registered nurse -- easy to ascertain that she was not). The last one proved that I wake up all night long and CPAP makes things worse for me (I have the relatively rare central sleep apnea). The report claimed I snored all night long. However the room was about 50F and the heat was broken. The rest of the data was inconsistent with snoring. The doc pulled the tape and it turned out my teeth were chattering through the night since I was freezing. I told the doc I could have saved the insurance co $4000 as I already knew my sleep patterns were out of whack.

Ambien puts me to sleep but I wake 2-3 hrs later. Rozerem worked. The diphenhydramine in the PM meds has the opposite effect on me (and many in my family) unless I'm having an allergic reaction. Hyper like a 7 year old with cabin fever. Not a pretty sight.

Just be wary if your wife "strongly recommends" another sleep study. ;)

Katie said...

Just yesterday afternoon I wrote a few note to selves that I contemplated blogging about but opted against it. Here are some highlights:

Note to self: Do not wake up at 4am convinced you know the day of the week better than when you did when you went to bed and reset your alarm. If you must reset your alarm at 4am, check a calendar to be sure of the day or you'll be really disappointed when you wake up at 7am on a Saturday.

Note to self: If you're going to burn yourself while removing the pizza pan from the oven, don't burn the last joint on your dominant thumb. Especially if you're a writer. It makes it painful to type and awkward to hold a pencil.

Note to self: if you're going to tell the boys you're babysitting that it's a race to see who can put his pajamas on the fastest, keep in mind that some boys sleep in boxers and it's really easy to get into those... in the living room... (oh, and make sure your 22-year old co-babysitter knows he's not included in this race!)

All this to say, I'm sorry to hear about your loss of the nightly glass of wine.

<>< Katie

911RN said...

Sleep...sorry, not a problem. Have a night once in great while that I have to get all my worrying done, solve all the world's problems and may then have a hard time sleeping.Other than my zzzz's.Love a good 2 hour, middle of the day nap , as well!

Have to watch late night caffeine- sweet tea is worse than coffee, believe it or not. Don't drink enough alcohol to even say I do so rare beer/wine actually helps me relax and sleep better.Only place I can't sleep- in a car/plane-ever since I learned to drive- not a problem before that! Makes me the DD for long trips.

Sleeping pills- never tried 'em. Tylenol PM- benadryl is the sleep inducing agent- makes me feel weird and buggy when I have taken it by itself. Don't need that! Have a nurses 2 liter bladder so not bothered by night time wakings to use the facilities.

College roommates gave me the nickname SB (not my initials)....stands for Sleeping Beauty! More for the former ability, not the latter description.

Stay busy and active and luckily sleep is welcome, restful and not a problem. Just need a pillow, blankets and must be horizontal. How do people sleep sitting up- have no idea??!! Now, THOSE folks have truly mastered the lost art of effective sleeping!

Post has some great one liners and descriptions! Tighty- whiteys. Pelvic exam comments.Bald guy waiting on the prostitute.Youtube. Promising God the turkey sandwiches,warm blankets and pudding to ER pts. for an uneventful,embarrasment free sleep study performance. LOL.

Yaaaawn...think I'll go take a nap!

Rositta said...

I've had a sleep study and it wasn't nearly as pleasant as yours. For one thing there wasn't a pillow top mattress or TV with a 1000 channels, are there really that many? I found being hooked up to so many wires made it difficult to read or knit and I spent most of the night awake. The techie kept coming in and telling me to sleep, of the reasons I was there was because I couldn't sleep. It was a wasted night, I simply don't sleep well. I don't medicate for it, I just read and knit and don't fight it any more...ciao

Bibliotekaren said...

You slept well during the sleep study? Oh, aren't you the hardy one! And yeah, I don't own any PJs so I showed up with loose exercise pants and a respectable but well-worn long sleeve cotton shirt. Between the wires and clothing, I thought I'd gone to mummy-hell.

The worse part was the Tech was a young sexy man with an intriguing accent. And, there I was in my middle-aged frumpdom all wired up!

Diana said...

I had a study done at the age of 13. Mine wasn't nearly as fancy. They made me stay awake for 24 hours prior, including my poor mother to ensure I didn't cheat. I then went to the office (during the day), and was given a standard exam type table to sleep on. They hooked me up to the wires, and let me sleep for an hour. I think I was ripped off!

Nowadays, I may pay good money for a place like yours! My 21 month old son, still wakes up 2-4 times a night to eat! GAH!

On a side note- You should sign up for a twitter account. Another med blogger I follow does.

Sandra said...

I am waiting for a sleep study to be set up because I do snore.

Tylenol PM is my sleep aid of choice, too, but I have to make sure I have 8 hours to sleep or I will get up groggy.

Anonymous said...

Great topic! My husband had a sleep study. He said he slept the same at the lab as he does at home, i.e. lots of snoring and gasping for breath. While sleeping on his back his oxygen saturation fell to 50%. On his side it improved. What really helped him to sleep better and feel more rested was the CPAP machine the sleep specialist prescribed. It was like a new lease on life.

As for me, I usually sleep very well. My secret is exercise. I do cardio and resistance work and I really push myself hard. I not only get the endorphin rush but also I sleep like the dead at night. I believe exercise is the key to a good night's sleep.

Anonymous said...

That test sounds out of control—how can they actually report those results? It sounds like a hotel with really good housekeeping...I guess you had to pay for that, being in the US...shame.

When I'm experiencing insomnia, I try having a hot bath a couple hours before— don't drink 2 hours before- it's true— and I try to go to bed an hour earlier than I have been if I find it hard to sleep. Technology- computers, email etc., can cause me to stay awake, so try to cut this out an hour as well.

I've tried meditation too, and it is great- body scan, lake meditation, mountain meditation etc., and there's one with ocean sounds that is good- mimics delta waves during REM sleep.

Sleep medication can often cause daytime drowsiness, making insomnia worse. It has to be a personal choice, guided by communication with your GP.

Just like the reader, AtYourCervix, Tylenol makes me have strange lucid dreams no matter when I take it— Unicorns baby— Unicorns~!!

Tanya said...

No glass of wine every evening? You can't do that here in California-I'm pretty sure there's a state law against it...

Stephany said...

There are so many horror stories with Ambien sleep walking/and even sleep sex, not kidding. Can you believe you had to email people re: Tylenol PM "drunk emailing"? LOL

I think benedryl works the same w/out the pain killer! (or weird side effects)

Anonymous said...

Complained to my internist that I was tired all the time - he sent me to a sleep specialist for a sleep study. My experience was very similar to yours with the exception that the "bedroom" I was in had more of a clinical feel than yours did - it sounds like your room was more like a nice hotel room. Had the same kind of easy-going tech, don't remember what I wore, got all wired up and was surprised that I fell asleep easily. Dx: sleep apnea and I now use a cpap machine. And 1 mg of Klonopin before bed.

June Cleaver said...

Man, compared to your experience, my sleep study sucked. Well, mine sucked even not comparing it to your's.

My husband works in the hospital where I had my study done and had told me about the nice rooms and big comfy beds, etc. Of course, when I went to have mine done, they were remodeling so I got the economy room.

For the record, I wore some light cotton capri pants/pajams and a t-shirt. I got a standard hospital room 9and even that was on the small side) and a mostly standard hospital bed. I was lucky enough to get one of the randomly inflating beds which, oddly, I find kind of comfortable. Maybe it's because of my back issues and the inflating/deflating helps avoid putting pressure on the same spots all night. Anyway, there was a tv in my room but I wasn't allowed to watch it. I was told I could bring a book to read but I was allowed to do that either :( I had a hard time falling asleep because they had me ready for bed at 9:30. My natural sleep patterns have always been staying up very late (like until 2 or 3 am). I finally got to sleep at 10:30 or 11 and slept....ok. I kept having crazy dreams. Then the tech came in at 4:30 and woke me up.

The only good part was the insanely hot sleep tech; a gorgeous black man with a Caribbean accent and incredible smile. Oh, and I did at least get to bring my own pillow.

Leslie said...

I only have one issue with sleep...finding time to do it! Oh yeah...that and waking up. I hate the waking up part.

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Celeste said...

"I've even had a patient share her insomnia issues during a pelvic exam. Maybe if she had slept more and fooled around less, I wouldn't have had to do this exam for her itchy, malodorous discharge in the first place."

As busy as you are, you still make time to judge.

Christine said...

Funny - I went to the doctor today about my hip pain and managed to sneak in the sleeping issue. Going to try trazadone. We'll see how it works.

Earl Grey said...


Strike a nerve, did he?

coulrophobic agnostic said...

Sleeping pills don't do a freaking thing for me, and most medications that "cause drowsiness" don't either. Occasionally benadryl will know me out if I haven't taken it in a while.

If left to my own devices I'll be up all night and sleep until early evening. I don't drink alcohol or caffeine. No idea why I'm like this, but my dad was the same way.

My lower back/leg pain keeps me up if I lie in bed for more than fifteen minutes or so and can't sleep, which doesn't help. There doesn't seem to be any reason for it. I've had the leg pain since toddlerhood - it started in my ankles, and over the years moved upward so that it's from my ankles to just above my waist. Incredibly annoying. And the 40 lbs I gained back while my dad was sick didn't help...nor does the fact that I'm still binge eating and barely moving. Wish I could figure it out, because sometimes I'll be close to finally falling asleep and it starts up...

Sondra said...

I had a sleep study done (wore my cotton print nightie -- the only "appropriate" night attire I own) and learned that although I don't have sleep apnea, my upper respiratory tract does begin to constrict, causing me to wake up a bit about 20x/hr. For the second sleep study to set up the CPAP, I had the worst time falling asleep, and the room was waaaayyy to warm for me (my house is at 60 in the winter).
Now I have a heck of a time sleeping because of the CPAP, and I just found out that there is a good chance that my insurance company is going to withdraw payment for the CPAP machine because I'm not using it for at least 4 hours per sleep period (which is daytime for me). It's really frustrating because no matter how hard I try, I just can't stay asleep with the CPAP on. And I really need to be able to get some uninterrupted sleep in order to work a 12-hour night shift.
I really, really hope that my insurer will be reasonable and give me more time to adjust. Maybe a different style mask would help (I'm using the nasal pillows now).
Glad your sleep study was good!

Celeste said...

@Earl Grey: I just think it's interesting that somebody who professes to be so upset over somebody making snap judgements that he's a hick for wearing a John Deere cap, is pretty quick to judge that somebody with a vaginal infection is a slut.

Cal said...

My dad really needs to have one of these sleep studies done. We are all sure he has some serious sleep apnea issue, but he is convinced that he is just fine, but he is permanently exhausted during the day.
I sleep fine, except when I was pregnant when out of nowhere I would wake up at about 2 am and just stare at the ceiling for a couple of hours. I am convinced it is training for when the baby arrives.
The first night one sleeps alone, it is bliss, and like you said, you imagined your wife all stretched out with the bed all for herself! Then you miss the other warm body next to you the subsequent nights.

StorytellERdoc said...

Celeste and my fellow readers

I rarely respond in my comment section about other comments, but feel I must address Celeste's snappy comments.

Without sharing too much information about the patient Celeste alludes to, she admitted to having multiple partners. So it was NEVER a judgement on my part, nor a "quick one" at that. It was a fact, admitted by the patient and brought up by her as a question as to why she might not be sleeping. And besides, a judgement based on good background information is much different that a predjudice based on no viable background information. I think you were heading there, Celeste, with your snappy comments and not knowing the whole story.

Flipping the coin, I am surprised how Celeste feels that she knows enough about me, through several posts, to "judge" me and my approach to this patient. Where did she connect the dots to feel that I would think a vaginal infection equates to a slut? Hardly. Those are her assumptions and words. And they are wrong. That's a pretty big step she took to arrive at that statement. In fact, Celeste seems to be guilty of what she is accusing me of.

Also, in Celeste's second comment, she writes, "I think it's interesting that somebody who professes to be so upset over somebody making snap judgements that he's a hick for wearing a John Deere cap, is pretty quick to judge that somebody with a vaginal infection is a slut." Very big words and, again,very WRONG words. If you read about the John Deere hat, never once did I get "so upset." In fact, I found everything to be quite funny and interesting. If I was "so upset," I wouldn't still be wearing the hat.

Celeste's anger comes through loud and clear, and I hope she sorts through that. Being fellow humans, I will gladly absorb her anger and frustration if it spares those around her from it. I'm truly sorry she missed the meant humor of the post, and also made a wrong assumption that the John Deere cap experience made me "so upset."

Thanks for reinforcing my belief, Celeste, that I am human and will never please everybody.

A big shout-out to Earl Grey as well as the many readers who emailed me their support about these spiteful comments. Much appreciated.


Jabulani said...

StorytellER: Reading through the comments, I was about to leap onto the wagon, sword aloft ready to defend you. Then I read your comment; so picture me now: hand-on-hips wagging my sword at you saying "I was going to say that! You took the words RIGHT OUT OF MY MOUTH."

As a South African who moved to England and had to become familiar with "their ways", I'll grant that sometimes folk can misunderstand. Generally I find that asking questions can overcome that.

emmy said...

I have an appointment with the sleep doctor on April 1, and it has been interesting to read your post and the comments made here by many. Thanks for giving me a better idea of what to ask about.

emmy said...

I have an appointment with the sleep doctor on April 1, and it has been interesting to read your post and the comments made here by many. Thanks for giving me a better idea of what to ask about.

Neo said...

I'm a neonatologist in a busy NICU with 24 hour coverage. We manage this by doing a week of nights in-house at a time every six weeks or so. It can really mess with your sleep cycles (preaching to the quire on an ER doc blog!). Anyway, I recently started using the Zeo sleep coach (sort of like a portable sleep lab) and I've had some real revelations about sleep. For example, my daily naps during my week of nights are not nearly adequate enough, caffeine and alcohol after 3 pm really do affect my sleep, there is such thing as catch up sleep (and it's heavenly!), and paying attention to a few small details really can enhance the way you sleep and the way you feel during the day!

Ab incunabulis

Anonymous said...

I did the sleep study thing. My experience was very similar to yours - the bedroom setup, etc. It's funny, I had the same fears and said as much to my physician. He didn't help things much because he said, Oh, don't worry...I've seen it all. That's great, but I didn't want to add to the entertainment.

So, I show up and the sleep tech who is not only attaching the electrodes to me but was also going to be the one observing me all night was someone I went to high school with. Fabulous! I was mortified that I was going to be doing something naughty in my sleep, completely unaware and this guy would know it.

I was told I had periodic limb movement syndrome. Apparently I twitch a lot in my sleep. The answer was supposed to be medication, but I've been noncompliant. I just hate taking medication and not sure if I think the diagnosis is worth treating.

Meg said...

Hard physical exercise is the best sleep medicine. Ambien is scary stuff.

Lynn said...

My DH wore pajama pants and a T-shirt whereas he normally wears nothing to bed so I'm sure the tech appreciated it. He too was dxd with severe sleep apnea which I knew since our family witnessed his non-breathing spells for 30 seconds or more.

@Chrysalis Angel: Check into sleep attacks, hypnagogic hallucinations. Crazy stuff of which I am intimately familiar.