Hung Out With My Dad Last Night . . . In My Dreams

I wasn’t planning on writing about what I’m going to share today, but your dreams come upon you when they do.  My father appears in my dreamlife now and then, perhaps once a month or so.  Though sometimes he is a silent, peripheral character somewhere in the background of the strange moving pictures that are my dreams, there are times in which he plays a starring role, such as he did unexpectedly last night.  I awakened briefly from deep non-REM sleep around 3 a.m. this morning and fell back to sleep, and then my movie promptly started.  Here’s what happened.

It’s the dead of night.  Everything is still.  I’m walking down a dimly lit, gently sloped paved driveway carved through a wooded thicket, tall green trees on either side.  It’s a casual, peaceful walk, which I’m taking with my dad, who strides next to me on my right.  We’re having a conversation.  He tells me, in his characteristically direct and blunt manner, that I need to stop walking with my hands in my pockets.  “It doesn’t look good to do that,” he tells me.  I consider his words.  I’m a little taken aback by this reprimand; I don’t put my hands in my pockets anyway, and they aren’t even in my pockets now!  But he’s my dad, and one thing I’ve always known is that he cares for me more than anything and just wants the best for me.  I assure him that I will do my best to keep my hands out in the open.

We enter a home.  It’s not our home, but it feels like it should be, and we enter it as if it is.  The hallways are dark.  We approach the light at the end of the main hall.  It’s the kitchen, small and modest, reflecting the home’s rustic nature, darkened wood throughout, including the furniture and walls.  Dad and I walk instinctively toward the rectangular dinner table inside.  The only light in the room emanates from the small chandelier above us.  It shines like an orange halo around the table, creating a hazy effect on the rest of the kitchen.  I stand behind what must be my designated chair near the wall; Dad stands behind his near the kitchen entrance opposite me.  We look down at the mounds of white rice on plates at the table.  There is a plastic bottle of furikake (a Japanese seasoning made of sesame seeds and dried seaweed bits) on the table.  Still standing, Dad takes the bottle, shakes some seasoning on his rice, and slips the bottle in his right pants pocket.  I watch this and laugh, asking him why he’s putting the furikake in his pocket.  He answers that he wants to bring it with him on his upcoming trip to New York, sheepishly pulling it out and placing it back on the table.  It’s news to me that he will be traveling soon.

I look to my right, where the kitchen counters and sink are.  There’s Mom.  She is facing away from us and toward the counter, cutting up vegetables.  Dad walks over to her.  They are silent together as Mom continues her work.  I follow and slowly wedge myself between them.  “I wish you wouldn’t go,” I tell Dad plaintively as I stand snuggling with my parents, feeling the warmth of both of them close to me.  “Please don’t go.  Please, Dad.  Don’t go.”  Mom smiles silently as I speak, looking down at her cutting board.  I understand that Dad doesn’t have a choice; he has to go away.  Nonetheless, it is satisfying to tell him his presence is wanted, needed.  I am the only person or thing that disrupts the silence in the room.  There is increasing desperation and welling emotion as I continue to implore him not to leave.  

That’s when I awakened abruptly, about 5:30 this morning, wondering how it felt so real, the surroundings, the house, the immediate presence of my dad, when in my real waking life I know that what happened in the dream could never actually happen.  But for the short, precious time I convened with my dad last night, it did happen.  It was real in the moment.

It’s been a rather emotional morning for me.  This sudden, raw conversion back to reality upon awakening overwhelmed me with sorrow, as it does every time Dad costars in my dreams.

Who knows where all this comes from.  I don’t put my hands in my pockets, as a general rule.  I did, however, gently reprimand one of my boys last week for having his hands in his pockets on the court just before the start of his team’s basketball game, telling him he needs to have his hands out and ready for play.  Dad, who lived to 81, lived his entire adult life with remnants of his old war survival mentality; he would take wads of napkins from fast food restaurants, for example, and stuff them in his pockets to take home in the event of a future napkin shortage in the house.  I think the biggest message, though, is how much I miss my dad every day.  Cancer took him from us almost three years ago.  A dream like this reminds me of how much of a presence he still is in my life and the lives of those in my family, especially my mom.  I have photos, videos, and countless memories, of course, but my abilities to interact with him through those media are limited, if not impossible.  As sad as I am awakening from such dreams, I am comforted by knowing that somehow, until the day I die, I will always at least have this one way, however vague and unpredictable, of still interacting with my father from time to time.  It’s kind of a tragic gift, isn’t it, to dream like this.

There will be more to say about my dad, a great man, in future posts, in part because he had REM behavior disorder, an important sleep disorder to discuss.  For now, I need to recover from last night’s proceedings.  However painful it was to awaken, it was good to hang out with Dad again.

Image

Advertisements

Sleepy Residents: The Tricky Business of Medical Education

 

This morning one of my patients was telling me about her recent sleep deprivation; recently retired, she has been going to bed late and getting about 5 hours of sleep most nights.  I mentioned to her my own experiences in sleep deprivation, specifically when I was a resident in neurology years ago.  I explained how my frequent long work days and on-call nights resulted in frequent sleepiness and fatigue, sometimes to the point in which I dozed during lectures and grand rounds.  Her reply was, “How is that allowed, for new doctors to work such long hours? Isn’t that dangerous?”

How much and how long a resident should be allowed to work have long been a challenging issue in the realm of medical postgraduate education, and one not without controversy.  Certainly when I was training, there was a pervasive sense of machismo associated with working your white-coated tail off, as if spending every waking moment in the hospital made you superhuman, worthy of admiration and respect.  In addition, a certain culture has developed over the centuries regarding the “coming of age” of the young American doctor, “paying your dues.”  As academic institutions go, it is often difficult to break such deeply entrenched, longstanding traditions, particularly when the professors have long ago paid their dues.  The medical school where I completed my residency was built in 1797, so as one may imagine there were many time-tested, conservative traditions we were expected to follow.  Me, I found the training process and the hallowed traditions associated with it absolutely fascinating, and sometimes even thrilling, but there were times (usually around 2 a.m.) in which I really questioned why things had to be the way they were, such as being up all night every third night for months on end.

There’s another oft-overlooked reason why interns and residents have been so overworked, and it is purely economic.  In reality, a postgraduate trainee and a training hospital enter into a business partnership agreement of sorts the July following the trainee’s graduation from medical school.  The trainee needs the postgraduate education in order to become board-certified in a selected medical or surgical specialty and to practice medicine independently someday in that specialty.  The hospital system needs the trainee’s hard work, without having to pay that trainee the salary that an attending physician would command–the polite way of saying cheap labor.  There needs to be a consistent, large stable of doctors to make everything run properly at a large tertiary care center, and without interns and residents to do much the work, such large, complex institutions would simply grind to a halt, go bankrupt, or both.  And with the steadily declining margins of hospitals in recent years (and undoubtedly more to come), how much a hospital must pay for a doctor’s work becomes an increasingly important consideration.

Understand:  I don’t write any of this in a pejorative way.  Both trainee and hospital have legitimate needs and they need each other, so the relationship is forged on “Match Day” and it continues until the end of the training.  When I first found out my first-year salary as a newly minted intern–$28,500–I was overjoyed, frankly; it was better than paying to be there, like I had been in medical school.  With each subsequent year of training my salary jumped by $1000-2000 per year.  And through it all I spent countless hours in the hospital, often well over 80-90 hours per week, making my income less than minimum wage.  There was no questioning it, no raging against it; it just had to be so.  So what gets sacrificed most easily and most commonly in such a system?  The trainee’s sleep.

Certainly there is the argument that the trainee’s education would be enhanced by allowing proper amounts of sleep and off-work time, and there is clearly truth to that.  However, it takes more than that to change a longstanding, proud institution like American postgraduate medical training; there is much more to consider than the trainee’s education.  I recall a general surgery resident friend telling me once that he had fallen asleep, standing, earlier that day in the middle of a case; he just shrugged, knowing there was nothing that could be done about that until he finished his training.  I remember myself often struggling to stay awake in the middle of the night sitting in the ER writing up a history and physical, looking at the unoccupied ER bed in front of me and literally lusting for it, wishing I could curl up and get some much-needed sleep before our morning rounds.

In 2003, Accreditation Council for Graduate Medical Education (ACGME) limited work duty hours went into effect, reducing the maximum amount of time allowable for postgraduate training work.  Among the policies was a call for an “80-hour weekly limit, averaged over 4 weeks, inclusive of all in-house call activities.”  I trained in the early- to mid-nineties, so this change came too late to benefit me and my brethren.  I deeply appreciate all of my postgraduate medical training, and I remain very grateful for having had it.  I do believe strongly, however, that I would have learned more, and would have been happier, had I been allowed more sleep per night on average.

I lead a very busy life; it’s hard, in fact, to find someone with a crazier life than me.  However, I get my 7-8 hours most of the time (I’d be a hypocrite if I didn’t, right?).  I find that proper sleep allows me to maintain my very busy life and to enjoy it.  And, importantly, I know that most everybody can get their 8 hours if they allow it.  Unless, perhaps, you happen to be a young doctor in training.

Is Snoring “Normal?”

 

Millions of Americans snore substantially. The ubiquity of snoring is pervasive in our culture; TV and radio shows depict people snoring for a laugh, or simply to demonstrate they are sleeping. For many, there is a simple one-to-one relationship between snoring and sleeping, such that it seems like you’re supposed to snore when you’re asleep.  It’s almost like it’s an inevitable part of the human condition.

Well, the problem is that snoring is not necessarily “normal.” On the most fundamental level, snoring is just the noise resulting from vibration of soft tissues in your throat while you breathe during sleep.  However, there is the potential for health effects with longstanding log-sawing.  Nonetheless, it’s very common for people to blow off concerns for their snoring.  Some potential reasons:

1. It’s so common. Millions of people in the U.S. are obese too, but that fact doesn’t make obesity normal, either.
2. You’re not awake to hear the snoring. By definition you don’t snore unless you’re sleeping, and you’re unaware of what is happening while you are asleep, so frequently people don’t think they snore, even when their spouses or bed partners complain bitterly about their nightly snoring noises.

Through the years I’ve heard all sorts of comments from incredulous loud snorers dragged into my clinic by angry spouses (usually wives, but husbands too). Some examples, often resulting in a dirty look or a punch in the arm by the spouse:

“Well, SHE snores loudly too!”
“She has a tendency to exaggerate things.”
“I don’t have that.”
“It’s really not a problem. She’s just making it a problem.”
“I’m telling you, I don’t snore. I don’t remember ever snoring.”
“Nobody has ever told me I snore except for HER.”

One time a man came to see me with his wife, who pulled out her iPhone and played back some audio of his intolerable snoring, only for him to reply, in all seriousness, “That wasn’t really me.”

On another occasion, a gentleman visited me in my clinic and told me when first sat down to talk, “I’m here as a birthday present for my wife.”

There are some very real reasons to take snoring seriously:

1. Marital and relationship discord. I’ve had patients actually get divorced in part because of the snoring, not necessarily because of the noise itself, but because of the spouse’s frustration in not being believed or taken seriously. That’s extreme, of course, but think about the millions of bed partners whose sleep is constantly disrupted by loud, open-mouthed snoring in close proximity. It would be maddening, right?  Many have to sleep elsewhere in the house or time their bed schedules just right to minimize prolonged awakenings.  Slowly, insidiously, this problem can wreck a whole family’s quality of life.
2. Loud snoring is often associated with obstructive sleep apnea.  Sleep apnea is a breathing disorder in sleep, in which one’s upper airway actually collapses or closes episodically during sleep.  This is a medically dangerous problem, associated with an increased risk for heart disease, early stroke and heart attack, hypertension, and sudden cardiac death.  Though you don’t need to snore loudly to have sleep apnea and you don’t have sleep apnea just because you snore loudly, often sleep apnea and loud snoring can go hand in hand, and the snoring can be a tipoff for your doctor to a problem with your breathing.
3. Snoring itself may be associated with medical problems. This is the subject of intense research at the moment, but there are suggestions now in the medical literature that snoring may be an independent risk factor for metabolic diseases and cardiac problems.

How can you tell if your snoring is loud? Loudness is a relative term; I’ve had patients who delayed medical evaluation for years, for example, despite very substantial snoring, because the spouse is hard of hearing and unaware of the snoring and breathing pauses during sleep. Some general benchmarks that suggest loud snoring:
1. If it can be heard in other rooms, or other floors, of the house. I’ve had patients whose neighbors next door or ACROSS THE STREET (no joke) called them to complain of their snoring.
2. If it regularly awakens the bed partner from a sound sleep.
3. If it is louder than an ordinary, casual conversational voice.

Bottom line from tonight’s post:  loud snoring is not normal just because many people snore loudly.  My recommendation is that loud snoring be reported to one’s primary care physician. In future posts I’ll discuss what to do to help the “heroic” snorer. If a loved one is having clearly witnessed breathing pauses during sleep, I strongly recommend that the snorer see someone like me, a physician sleep specialist, for the consideration of breathing problems during sleep.

Have a great evening, all!

How to Sleep Well After the Super Bowl

Howdy y’all!  I’m still licking my wounds following the Kansas Jayhawks’ tough loss in basketball yesterday.  The only thing that makes me feel better about that is that no college team is infallible right now, including Michigan, who also lost yesterday.  The increased parity of teams this year should make for a great NCAA tournament come March.  I’ll probably have a sleep-deprived night or two during the Big Dance, and hopefully for good reasons!

 

Today America turns its attention once more to football and bids farewell to the 2012-2013 NFL season with the Super Bowl game between the San Francisco 49ers and the Baltimore Ravens.  Now personally, me, my teams are, in order, the Seahawks, the Packers, and the Patriots, so with no horses in the race I’m not feeling particularly invested in today’s game (though I am curious to see if Beyoncé actually sings during the halftime show). I’m rooting for the Ravens because I respect Ray Lewis’ longevity (he’s an ancient 37 years of age, and he’s still kickin’ it all the way to the end), I love O.J. Brigance’s heartbreaking but inspiring story (he has Lou Gehrig’s Disease, he’s 43, and he still works, serving as the Ravens’ director of player development), and I’m not a big fan of that Kaepernick arm-kissing thing.  I know a lot of people who are very emotionally invested, however, and particularly for them, as well as millions of other football fans ’round the country, there will be a high potential for subsequent problems sleeping, win or lose.  So here are a few quick tips to prevent a sleepless night tonight.

1.  Mind your timing.  The game starts at 6:30 p.m. east, 3:30 p.m. west.  Keep this in mind as you plan your bedtime routine tonight, because for most people life and work will go on tomorrow, Monday morning, as per usual.

2.  “Come down” after the game.  Whether your team wins or loses, the Super Bowl is exciting, and all of that adrenalin and dopamine has a stimulatory effect.  I would suggest not jumping into bed right after the game, particularly after a night of partying and cheering on your team.  Give yourself an hour or two to decompress from the game.  Relax, read a bit, take a hot bath or shower.  Shoving yourself into bed all hyped up will make it difficult to fall asleep quickly.

3.  Time your caffeine use.  Many people don’t realize that caffeine can last in your system for up to 8-12 hours after you drink it.  Drinking that Red Bull may enhance the excitement at your Superbowl party, but I would suggest drinking it early on, particularly if you live on the east coast.

4.  Time your alcohol use, and drink responsibly.  Alcohol can have both excitatory (owing to emotional disinhibition) and sedative effects for the first 2-4 hours after it’s consumed, but after that it tends to be a sleep disruptor.  I suggest taking it easy on the booze, man, it’s Sunday night.  I’m not in my twenties anymore, however, so understand where my words are coming from, a place of age and hard-earned wisdom.

5.  Eat early if you can.  All those buffalo wings, all that pizza . . . you’re not gonna enjoy that bubbling up your esophagus tonight.  Indigestion, heartburn, and reflux tend to happen more if you go to bed shortly after a big old spicy meal.  Give all that pub grub some time to travel from your stomach and into your intestines.  If you have to eat late, you may want to prop yourself up with a couple pillows before you go to sleep.

6.  Try to awaken at the time you usually do on Monday morning.  It may be a late night for you tonight, particularly if you live in Maryland and the Ravens win.  However, if you sleep in Monday morning, it might be difficult to fall asleep at your desired time Monday night.  We’re generally built to tolerate a night of sleep deprivation if necessary.  That’s usually preferable to a protracted bout of insomnia.

Enjoy the game, all!  Hoping for great things for the Seahawks in the 2013-2014 season.  12th Man!