Monthly Archives: March 2013

An Early Mo(u)rning For Jayhawk Nation

 

As any student or alum of a blue blood basketball college–Duke, Kentucky, Indiana, North Carolina, Kansas–knows, summer, fall, and winter really serve but one purpose:  to prepare for March Madness, the NCAA Men’s Basketball Tournament.  During this time of year, late March to early April, 68 of the best men’s college basketball teams in the United States punch their cards to the “Big Dance,” in the hope of their one shining moment, a chance to be national champion.

I’m an 8-year Jayhawk, having gone to college and medical school at the University of Kansas.  I was a senior undergraduate when our basketball team–led by Danny Manning–claimed the national title in 1988.  It was truly an unforgettable experience:  the height of uncontrollable joy and complete elation, a party that lasted for three straight days and nights.  Differences and conflicts between people and between groups on campus simply evaporated as hundreds of thousands from Lawrence to Kansas City poured out of their homes, dorms, and workplaces to celebrate together, to hug and high-five perfect strangers, to be in the moment.  For weeks following that win over Billy Tubbs’ Oklahoma Sooners, a collective rapture unified us, making us whole in our exultation and the love for our school.  That intoxicating sensation transcended mere sports:  it was a pure happiness, the way you wanted things to be forever, the way you hoped your life would be like when you grew up, whatever it was your future held.  That feeling is perhaps what I would imagine being jacked up on crack or heroin must be like.  When you’re there, in that moment, you know that it’s unrealistic to expect such ecstasy to be sustainable, it’s so epic and so intense.  But you hope against hope that life could feel this way, if not forever, then at least again.  Some time again.

It is with this hope of recapturing that bliss that every year we Kansas Jayhawks look forward to our autumn ritual, Late Night in the Phog, to usher in the new men’s basketball season and all the hopes and expectations that go with it.  Long after graduation we look forward to watching every game, at Allen Fieldhouse, on television, or online, and cheering on our guys.  We watch the AP and USA Today polls every Monday morning for upward movement in our rankings.  We closely follow our main man, head coach Bill Self, as he clears a path for each year’s kids with grace and confidence.  And as Selection Sunday draws nearer and nearer, our heads fill with a heady mixture of excitement and anxiety, anticipating seeds, matchups, and karma in an annual quest for our holy grail:  the national title.  No matter what your station in life, no matter how happy you might be at home or at work, there is still that other happiness you crave, that sensation more powerful than any street drug.  Your team is the only key that opens the door to that happiness.

It is the proclivity of the Jayhawk to combine hope with expectation, at least an expectation to be a worthy contender, and with class.  But becoming national champion is hard.  Very hard.  And statistically unlikely.  So for us, when it comes to the final result of the national tournament, there are really only two options:  complete elation with a championship or utter devastation when our team falls short.  Since my senior year at KU, that complete elation happened once again, in 2008, thanks to Mario Chalmers and his now-legendary game-tying 3-pointer against the Memphis Tigers:

To witness a true Jayhawk championship court-stormin’, forward to 4:00 in this clip, again taken from Allen Fieldhouse:

And so it was that Jayhawk Nation went into the 2013 national tournament with its usual high hopes, Kansas the #1 seed in the south region.  When we lost in overtime to the Michigan Wolverines 48 hours ago in the Sweet Sixteen, it was full-on, crushing, world-coming-down heartbreak.  Without dwelling on details here, a healthy lead dissipated gradually during the final 3 minutes of regulation play, forcing us into overtime due in part to an incredible Michigan 3-pointer with seconds left, kind of a Mario Miracle in reverse.  We had been winning virtually all game long until the very end of regulation.  It’s tough to take, this idea that just one more point, one less missed opportunity, one more free throw, and the outcome could have been very different.  Jayhawkers around the country reeled in shock.  Only now am I starting to recover from it.

I’ve spent this past weekend nursing my emotional wounds and dealing with another transient but inevitable element of my own special method of mourning:  sleep maintenance insomnia.  I’ve been awakening around 4:30 a.m. for the past 2 days.  Yes, I’ve been following my own advice and getting out of bed to minimize the frustration.  The phenomenon of early-morning awakening is a very common clinical element in situational and characterologic depression.  I know me, and I’ve been through enough NCAA tournaments to know my tendencies:  I’m as blue as can be for 2-3 days after a tournament loss, and then life’s demands and thoughts of next year’s season gradually take over to help me climb out of my funk.  I can already feel that happening today, so I think tomorrow will be a better morning.

One thing’s for sure, a lot of Jayhawks slept poorly this past weekend.  But here’s to a new morning, a new Late Night in the Phog, and a promising 2013-2014 season.  Looks like Kentucky will be the team to beat next year, but we will continue to cultivate our high hopes.  Go get ’em, Hawks!

 

R.I.P., Phil Ramone

The music world lost a giant today.  Legendary sound engineer and music producer Phil Ramone passed away this morning.  He was 72.

Ramone was born in 1941 in South Africa and raised in Brooklyn, New York.  He became a naturalized American citizen in 1953.  In 1958 he co-founded A & R Recording, a recording studio in New York.  He subsequently became known as an innovative music engineer and producer, and he went on to produce music for dozens of seminal artists from many important genres, from jazz (John Coltrane, Stan Getz) to rock and roll (Elton John, Bob Dylan) to blues (B.B. King) to R&B (Aretha Franklin) to folk rock (James Taylor, Peter Paul and Mary).  He also produced classical music, broadway musicals, large-scale concerts, music for television shows, and movie scores.

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I met Mr. Ramone in early 2011 when he dropped by a recording session at Avatar Studios in Manhattan.  He was incredibly warm and welcoming, brimming with soft-spoken humor and wonderful stories.  We took a break for a couple hours and sat in a semi-circle around him in the control room as he regaled us with stories of coming up in New York, gaining prominence in his field, working with Paul McCartney, producing for Billy Joel (coincidentally, the subject of my blog entry from yesterday), and navigating around the music industry.

So much of the music I love exists because of Phil Ramone.  I hope he’s still making music somewhere.

What a Young Billy Joel Fan Can Teach Us

I was the tender age of 12 when Billy Joel released his groundbreaking album, 52nd Street, in 1978. His songs were all over the radio, and I fell in love with them. When his tour stopover in Wichita, Kansas was announced, I begged my parents to go. After some inter-parental discussion and to my great disappointment, it was determined that I was too young to attend the show. As consolation, Mom took me to Musicland in Towne East Square and picked up the 52nd Street LP for me to take home and enjoy. And boy did I enjoy it. I played both sides over and over, memorizing every word. “Zanzibar” remains one of my favorite songs of all time. Imagine my surprise and delight when, upon finally seeing a live Billy Joel concert several years ago here in Seattle, he performed that obscure but wonderful piece from 52nd Street; it felt like he played it just for me.

(In the unlikely event that you’re interested, I eventually wore my parents down, and my very first rock concert ended up being Kiss in 1979, a year after 52nd Street was released.)

I am but one of many millions who have loved Billy Joel’s songs over the years. Recently, during a Q and A with Joel at Vanderbilt University, a freshman named Michael Pollack stood up and asked if he would be willing to be accompanied by him on piano on “New York State of Mind,” his favorite song. Joel granted him his wish, much to everyone’s delight, and the musical result was . . . well . . . incredible. Inspiring. Please click on the video above to witness the performance.

There’s a lesson or two to be learned from this brief event, one which I’m sure Michael will never forget. This world is getting smaller, but the number of people inhabiting it is getting bigger. How are today’s young people to survive and succeed with so much competition surrounding them? It’s no longer sufficient to be good at what you do. You have to have guts now. Billy Joel, in his typical east coast nonchalance, said of Michael, “guy’s got chops!” No disagreement there; he killed it on the piano, as you can see. But another quality Michael possesses is just as crucial, if not more so: guy’s got cajónes too. Big ones.

The favor Michael asked of Joel was asked for honestly and audaciously. No one outside his friends, family, and teachers would know who Michael is today if it weren’t for that moment of boldness and risk. It paid off.

We are at a societal turning point here in the United States. Health care is in a major crisis. Regulations, ever-declining reimbursements, minimal autonomy, increasing overhead and malpractice premium costs, mounting paperwork and administrative hassles: it’s becoming more and more difficult for doctors to find success and happiness in their work. This isn’t a whine or a call for sympathy; it’s just factual. My concern is, in a time in which doctors are retiring early or just plain quitting, who of our young citizens will choose medicine as a career in the future? Why should they go through the hassle and put in all that money, time and effort for so little in return?

I’ve been asked recently by high school and college students if I would recommend medicine as a career. My answer was that it really depended on who they are, based on honest self-assessment. There’s a definite analogy I see between the qualities of a successful and happy future doctor and those of Michael Pollack, the Vanderbilt freshman pianist:

1. You have to have passion. You have to really want it, and for the right reasons.

2. You have to be good.

3. You have to have the audacity to work aggressively to get what you need or want, because in today’s way of the world it’s no longer given to you or made easy.

Seems to me that a young man or woman possessing these three elements should be able to weather the current health care storm and carve out a satisfying, fulfilling career in medicine. If any of the three are missing, however, the happiness factor will plummet, I can promise you. A missing link or two may be why there is so much unhappiness and dissatisfaction among doctors right now.

I want people to go into medicine in part, admittedly, for selfish reasons. I want a quality physician to be willing to care for me when I am old. Doesn’t everybody?

So to those kids and teens considering becoming a doctor: do it if you really want it. If you really want it, and if you know it, and if you know what you’re getting into, then go for it. And go for it hard. Not obnoxiously or unethically, but boldly. It takes audacity now to make it in this world. If you ever want a reminder of what that quality looks and sounds like, click on the video again.

Have a great weekend, everyone!

What About Naps?

Thank you, everybody, for your recent inquiries.  I’m happy to help!

The other day I was asked about daytime naps:  “is it better to take a nap when you are feeling really tired that day or try to go to bed earlier instead and skip the nap?”  In order to best answer the question, it’s important to know what is causing you to want or need the nap in the first place.

 

The science of sleep regulation is quite complex.  Sleep intensity is mediated by what is called the homeostatic mechanism of sleep, the specifics of which are beyond the scope of this blog entry.  Simply stated, the principles of sleep homeostasis dictate that sleep deprivation results in a compensating increase in intensity and duration of sleep, and excessive sleep (such as related to a daytime nap) reduces the inclination for sleep.  Taking a nap during the day implies daytime sleepiness, so let’s explore why one may be sleepy during the day.

One of the most common causes of daytime sleepiness is simple sleep deprivation.  If you’re getting 5 hours of sleep per night, for example, when your body needs 8, then likely you will not need to take a nap during the day any longer if you then gradually increase your sleep time to 8 hours per night, because by satisfying your body’s natural sleep needs consistently you should eventually feel substantially more awake and alert throughout the day.

Another common cause of daytime sleepiness is insomnia.  If you get less sleep at night because you’re awake a lot in bed, an obvious consequence would be feeling fatigued and drowsy during the day.  The problem is that taking a nap during the day can cause or worsen insomnia, particularly if the nap is prolonged and/or taken in the mid-afternoon to early evening; you tend to get a “second wind” and feel more awake and alert later than what you desire, resulting in further sleeplessness at night.

Finally, you could be sleepy during the day due to a problem with the quality (as opposed to the quantity) of your sleep.  Numerous sleep disorders can cause substantial drowsiness during the day even if you get your 8 hours per night:  obstructive sleep apnea, upper airway resistance syndrome, periodic limb movement disorder, and narcolepsy to name a few.  A good general rule to follow:  if you regularly get 7-8 hours of sleep per night and you’re consistently struggling to stay awake during the day when 7-8 hours per night used to satisfy your sleep need in the past, and if the sleepiness can’t be explained by some other factor (like medications or alcohol), you may want to see a specialist like me.

OK, synthesizing this down, then, here are my personal primary clinical concerns about napping:

1.  If you nap because you’re sleep deprived, there is often residual sleepiness between the time you awaken in the morning and the time your nap starts.

2.  If you nap due to insomnia, a vicious cycle can develop:  the nap can cause or worsen the insomnia, which then reduces your nocturnal total sleep time, which then makes you feel more sleepy during the day, which then makes you want to nap more.  In extreme cases people’s bedtime schedules can be completely turned around due to this problem, such that they become essentially nocturnal, sleeping throughout much of the day and remaining awake all night.

3.  Taking a nap to sustain you for the rest of day may “mask” concerns for an occult sleep disorder.

Bottom line here:  if the nap doesn’t cause difficulties falling or staying asleep at night, and if you don’t have substantial daytime fatigue or sleepiness prior to the nap, and if you’re confident you know the reason why you need the nap in the first place (such as staying up too late the night before), then I think there’s probably not much of a problem with taking that nap.  However, if you find yourself unable to stay awake during much of the day, if you are substantially sleepy during the day despite getting proper amounts of sleep, or if you are having mounting insomnia in this setting, there should be further concern about what is happening.

I’ll add several additional points before Sleep Help Desk closes for today.  First, naps can be intentional (i.e., laying down with the intention of taking a nap) or unintentional (such as falling asleep by accident in front of the television).  Second, if you doze off on the couch at 10 p.m. before you go to bed, that’s still a nap!  That late-night nap can cause difficulties falling back to sleep once you do go to bed, so try to avoid dozing off in the evening until you’re in bed intending to sleep.  Finally, to answer the original question posed to me above, I suggest not going to bed too early if you choose to not take the nap.  If you go to bed way earlier than usual, you can still have insomnia even if you’re sleep deprived, because your body clock “wants” regularity nonetheless.  The idea is to gradually increase your total sleep time such that you reliably get proper amounts of sleep every night.

Trivia question:  who is the famous person napping in the photograph above?  Write me with your answer!

Cheers, everyone!  Keep your questions coming!

“Why Do I Wake Up at the Same Time Every Night?”

I’ve been asked recently by a friend why she finds herself awakening at 2 a.m. virtually every morning.

Many people have experienced this phenomenon, a tendency to awaken at least briefly around the same time every night. There may be many potential reasons for this, ranging from your pet to a need to urinate or a spouse coming to bed for sleep later than you. The expression of certain hormones in your brain throughout the night might play a role.  However, for many people, these brief awakenings may also be related to your brain’s natural rhythms for sleep.

To describe human sleep physiology as simply as I can, human sleep is very dynamic. We sleep in cycles, called ultradian cycles, in which lighter stages of non-REM (called stage N1 and N2) sleep are followed by deeper forms of non-REM (formerly called stage 3 and stage 4 sleep, but now called stage N3, or slow wave) sleep and then, to varying degrees, rapid eye movement (REM, stage R, or dream) sleep. In general, the amount of deep non-REM sleep we have per cycle is highest during the first one-third of the night’s sleep, and the amount of REM sleep we have per cycle gradually increases as the night progresses (which explains why we tend to remember our dreams most around, say, 4-6 a.m.). Exactly how and why we have been designed neurologically to sleep in this way are a mystery. A typical human adult’s ultradian cycle lasts for about 90-110 minutes. Generally it’s most difficult to awaken fully from N3 sleep, and it’s quite easy to awaken fully from REM sleep. This explains why you often feel very groggy if you’re awakened abruptly during the first 2-3 hours of sleep, but may find yourself awakening easily and quickly from a dream later at night.

The primary point I want to make with all this is that between these ultradian cycles, there are normally and naturally periods of arousal from sleep. There can be several of these brief arousals in a typical night.  In children, adolescents, and young adults, these arousals are generally very brief, perhaps lasting for only several seconds; these awakenings are not usually enough to remember, in part because younger people tend to have a lot of slow wave sleep), leaving you with the feeling that you are sleeping uninterrupted all night long, even though you have likely in reality aroused several times. Once you reach middle age, however, such as your 40’s and 50’s, the tendency to recall these arousals from sleep can gradually increase, and the duration of the typical arousal from sleep may gradually increase as well. This may explain why some people remember awakening, say, at 3:30 a.m. on the dot every night. Finally, when you become elderly, in your 70’s and 80’s, say, still more frequent awakenings may occur due to the naturally increased sleep disruption that occurs as your brain becomes more brittle with age.

Why is this all important? Because some people freak out over a spontaneous recalled arousal from sleep in the middle of the night, and this substantial concern or annoyance can generate enough worry or frustration to actually cause persistent wakefulness subsequent to that arousal, potentially triggering chronic insomnia.

Take-home point here: if there is a brief awakening around the same time most nights, and there is no specific symptom or problem that causes the awakening, and if there aren’t substantial problems falling back to sleep, and if there is minimal sleepiness during the day, my sense is that the awakening is probably not much to worry about. If there are substantial problems associated with the awakenings, however, it may be worthwhile to bring that to a doctor’s attention.

Have a great evening, everybody, and sleep well!

Insomnia . . . For Wichita State and Gonzaga

I am and always will be a Kansas Jayhawk.  But my first awareness of college basketball was thanks to Wichita State University, the very school whose team just advanced to the Sweet Sixteen of this year’s NCAA men’s national college basketball tournament by trouncing top-seeded and top-ranked Gonzaga last night.

Wichita State was an integral part of my childhood.  My dad was a professor there for decades, teaching criminology, editing the journal he founded, The International Journal of Comparative and Applied Criminal Justice, and solidifying his legacy in the field of administration of justice.  I also took math, literature, and computer science classes there in the summer while I was in high school.  And, importantly, WSU’s infamous basketball coach, Gene Smithson, lived three doors down from us.  Growing up, we looked up to him and the young men he coached–particularly Antoine Carr and Xavier McDaniel, who subsequently became nationally recognized professional basketball players.  Smithson popularized (and perhaps even invented) the term “MTXE”–“mental toughness, extra effort.”  I live by this phrase every day.

 

So I have to say I was very pleased with WSU’s win over the Bulldogs last night.  As a Kansas native now living in Washington state, I empathize with both teams and their fans.  Nobody with ties to either school slept very well last night.

Here’s the Wichita State Shocker in bed.  You just watched your team pull down the heretofore #1 ranked college basketball team in the country.  Only now that you’re in bed are you processing what this huge upset means for you and your fellow Wu-Shocks.  It’s pure rapture.  You’re in the Sweet Sixteen in a year of absolute mayhem in men’s college basketball.  There’s no clear, inarguable favorite to take the title like there was last year.  It’s anybody’s tournament; any team can win it all.  This year it might, just might, be the Shockers!  Your head is buzzing from all this emotion and mental racket.  You imagine the improbable run to the championship game, a buzzer-beating final shot that clinches the title, the ticker-tape parade down Douglas Street.  How are you gonna sleep with all that adrenalin running through your brain?

Here’s the Gonzaga Bulldog in bed.  You’ve become tired of the pundits and analysts saying that Gonzaga became #1 by default.  You’ve just heard Dick Vitale on ESPN predicting loudly that “the Shockers are gonna shock the nation.”  Sure, your school is in the West Coast Conference, but you’ve had some wins against quality non-conference teams this season, and going into the Big Dance you know the Bulldogs now have the chance to prove the nay-sayers wrong.  And then . . . crushing, unmitigated defeat–in the third round.  It’s like someone ran over your dog and then sped off.  You feel helpless and in despair, left with the bitter reality of the loss.  You go to bed truly in mourning, knowing the mourning will only continue upon awakening the next day.  How can you hope to sleep tonight, knowing that any temporary rest will bring only minimal reprieve and solace?

Man, I’ve gone to bed both ways every late March and early April for years.  I know exactly how it feels.  And the fact is that all of us have, basketball fan or not, for one reason or another, throughout our lives.  Why?  Because we’re human.  We have emotions, hopes, dreams.  We put ourselves at risk emotionally by daring to hope in the face of adversity or unfavorable statistics.  When the risk pays off, the elation is something you will savor for the rest of your life.  But when you lose, well, that’s also something you remember forever.

It is part of the human condition for these emotional peaks and troughs to affect your sleep.  As such, everybody is susceptible to at least some occasional transient insomnia.  Usually the insomnia burns off as its trigger fades into the background of your life.  However, in some cases the sleeping problem can persist as dysregulation of bedtime schedules and mounting frustration over the insomnia set in and worsen.  It’s at this point that people start to schedule appointments to see guys like me.

Bottom line here:  anything you think about that is of emotional importance–whether good or bad–can cause at least transient insomnia.  Just ask Shocker and Bulldog fans.

I’m hoping that I won’t be going to bed tonight like the Zags did last night.  KU is playing Roy Williams and his Tarheels.  MTXE, baby, and Rock Chalk Jayhawk!

 

My Recurring Nightmare . . . Read If You Dare

Many people have recurring nightmares, and I’m no exception. The science of this phenomenon is still very young; there is little understood of why dreams recur, or indeed why or how we dream at all. As I mentioned in yesterday’s entry, the prevailing dream research indicates that a majority of dreams have negative or unpleasant content or connotations. As such, unfortunately, having bad dreams over and over is quite common.

I thought I’d indulge a little today and describe my own recurring dream. I’ve had this same dream once or twice per year for the past two decades or so. There’s no monsters, no bad guys, no bogeymen, but it’s absolutely terrifying nonetheless, every single time. Without fail I awaken abruptly at the same point in the dream, drenched in sweat, sometimes literally yelling out in horror. Are you sure you want to join me on my journey back into Hell? Read on.

I’m back in college at the University of Kansas. I’m an underclassman. I’m two-thirds through the fall semester. I’m on an old green and biege campus bus. It’s a bright, beautiful, crisp Kansas autumn morning. The sky is brilliant blue, and white early morning light shines effortlessly through the windows, warming my face. I’m in the back. Nondescript fellow students surround me, sitting and standing silently. I close my eyes, relaxing, taking in the cold smell of diesel and giving in to the comforting, slow side-to-side sway of the bus as it snakes slowly up Naismith Drive into the main body of the campus.

After a couple minutes of reflection, my thoughts turn to the activities of the day. I recognize that I am still enrolled in a course that I need to cancel. It’s an upper-level calculus course, and I haven’t bothered to go to a single class. I haven’t studied a thing for it and I haven’t even shown up for any of the tests. I know, therefore, that I must be failing it. I’m not worried, however: I’ve known all along this semester that I can cancel the class without consequence or penalty, as long as I cancel prior to the deadline. I don’t remember which exact day is the last day I can cancel the class without an “F” showing up in my transcript, but I’m sure the cancellation date is still some time in the future. Or is it?

I wonder now when that deadline is. I’ve got a couple minutes of ride time before the bus drops me off at Hoch Auditorium, so I casually open up my light grey nylon backpack and retrieve my “timetable,” the KU academic semester catalog that describes all the courses and schedules. I look for the deadline to cancel courses. Finally I find the date in bold letters near the bottom of the page. $#!@ me, the deadline was YESTERDAY!

My heart pounds relentlessly now as I take in what this means. I’m on the verge of panic. I’m trying to keep it together, but I can’t see straight. There is an explosion of manic thoughts in my head. I’m going to fail this course now even if I start going to class faithfully and ace every test. An “F” in my undergraduate transcript will immediately put an end to my hopes to go to medical school. I want to scream, but I don’t want to attract attention. I fidget nervously in my seat, wishing the bus would move up the hill a little faster, but it’s crawling. I’m going to have to miss my class now; I have to stop off at Strong Hall, KU’s main administration building, and find some authority in front of which I can plead my case. All the while, I am thinking of what kind of alternative career plan I can come up with that might still provide me a good and happy life. Will an engineering school accept me with an “F?” Pharmacy school? A chemistry post-graduate program, perhaps? These thoughts make the bus feel like it’s going one mile per hour.

 

Finally I’m dropped off at Strong Hall. My panic and adrenalin send me flying out of the bus and storming down the concrete walk toward the front door of the building. I blast my way inside, unable to think clearly about where to go. I run, out of breath, to a counter built into the wall on the left in the front foyer. There’s an older woman behind the counter; large, imposing gold-colored steel bars separate her from me as I rush over, blustering incoherently that there was some mistake, I need to cancel my calculus course immediately, please please don’t put a failing grade on my transcript. She stares at me, blankly and silently, as I jump up and down like a maniac. I don’t know if she understands what I am saying, but looking at her impassive face one thing is starkly apparent as I blather on: whatever my problem is, she could . . . not . . . care . . . less.

It is at this point in which I awaken suddenly, sitting up bolt upright in bed, sweating and tachycardic, thanking God it was a dream. I’ve had this same dream dozens of times now. Its theme, sequence and outcome are virtually identical each time, but each time it feels new, the horror absolutely fresh.

As you can see, there are no monsters in my nightmare—just me and my own stupidity and foolishness. I feel some vague anxiety even now just thinking about it. The terror and dread come from a place completely different from some rated-R slasher flick: where innocent aspirations and diligent work intersect harshly with reality. This experience never actually happened to me, blowing off a course that I couldn’t get out of. I suppose the recurring nature of the dream exposes some of my deepest personal fears: watching helplessly as the prospects for my future slip through my hands, and loathing myself for getting myself into trouble due to my own irresponsibility. I think it also suggests part of what drives me to be the person who I strive to be every day.

Write me with your recurring dreams. I’m curious to know of them. What are they, and how do they affect you?

Nightmares vs. Night Terrors

Hello everybody!  I’m writing this brief entry tonight to address something a lot of people, particularly parents of young children, can be confused about:  the difference between nightmares and night terrors.  I’ve heard people use these terms interchangeably, but they represent entirely different clinical entities.  Herein I provide a simple distinction between the two.

 

Night terrors–also known as “sleep terrors” or “pavor nocturnus“–are very memorable for parents.  Here’s a typical scenario.  Your child goes to bed the way she usually does at night.  Later that night, suddenly, from her bedroom comes a loud, blood-curdling scream that scares the hell out of you.  You jump out of bed and run to your daughter’s bedroom.  You find her sitting up in bed, appearing awake and dazed, eyes wide open in fear.  She may or may not respond to you.  She appears distressed and freaked out, sweating and breathing hard; she may move her arms and legs nonspecifically but frenetically as well, compounding your concern as you observe her.  She seems panicked and inconsolable, almost possessed.  After several minutes, though, she calms down, lies down again, and returns to sleep.  The next morning, when you ask her about the event, she tells  you she has no idea what you’re talking about:  she recalls nothing of what happened.

Here’s a nightmare.  You hear your child crying or crying out for you in the middle of the night.  You enter his room.  He’s clearly awake and clear-headed, and answers your questions appropriately and quickly.  He may hug you for comfort.  You ask him what happened.  He tells you he had a terrible dream; a monster was out to get him, for example, or he was about to be pushed off a cliff by someone mean.  He has good recollection of what he was dreaming about.  After some reassurance, he eventually feels comfortable enough to return to bed, and the following morning he may or may not recall the full details of the disturbing dream, but he does remember that he had a terrible dream that caused him substantial distress.

The reason why it’s important to recognize the difference between these two clinical entities is because both can concern and frighten parents, particularly night terrors.  As frightening as they may be to watch, however, they are in and of themselves generally benign in nature and prognosis.

Night terrors represent a type of parasomnia (sleep-related unusual movements or behaviors) typically occurring out of deep non-REM sleep.  As such, dreams are not recalled, and the child is usually completely amnestic of the event.  Though some adults may experience night terrors, they are by far most common in children 3-12 years of age.  As scary as these events are for parents, they are usually not indicative of an underlying abnormality or medical problem, and children with night terrors usually outgrow them over time.  In some children, sleep deprivation or other reasons for going to bed particularly fatigued or sleepy may play a role in the likelihood of night terrors occurring, so make sure that your child gets proper amounts of sleep and sleeps in reasonably predictable, regular schedules night after night.

Nightmares are simply particularly unpleasant and/or frightening dreams.  They occur out of rapid eye movement (REM) sleep, and are usually recalled–and often recalled well–upon abrupt awakening from dream sleep.  For whatever reason, 2/3 – 3/4 of human dreaming is emotionally negative in nature (I had a distinctly negative dream early this morning, for example, though I wouldn’t classify it as a nightmare; hence I’m writing this entry today!).  Most people don’t need specific treatments for nightmares, and how to treat recurring nightmares is controversial.

I think I’ll write a little about recurring nightmares some time soon.  It might be cathartic for me.

Have a good evening, everybody.  I hope your dreams tonight are positive and pleasant.

A St. Patrick’s Day Anecdote

 

Long ago during my training years, a man in his early sixties—I’ll call him Karl—was admitted to our hospital service one day in mid-March. Karl had metastatic cancer, and he was dying. We on the in-service team liked him very much, remarking quietly to each other how it so often seemed to be the good ones that die early of such tragedies. Despite his terrible prognosis and physical discomfort he was pleasant–jovial, even–during morning rounds, putting everyone at ease with his polite disposition.

One day we walked into his hospital room, and he was having a tough morning, though not for physical reasons. He was really down, uncharacteristically so. We asked him what was troubling him. A little embarrassed at first, he shared that it was St. Patrick’s Day, and true to his Irish roots he normally celebrated that day with a glass (or two) of green beer. Doing so was a custom of his and his family’s for decades. He told us how unfortunate it was that he wouldn’t be able to celebrate this way this time ‘round.

Upon examining him and talking with him further, we took our leave and somberly continued morning rounds. Afterwards I stood at the nurses’ counter with my chief resident. I was post-call and yearning for sleep, so I wasn’t paying much attention to what he was doing; I was hanging around until his exit off the floor, which was tacit permission for me to go home and go to bed. He made a couple brief phone calls and wrote something in a patient chart. He slammed the chart shut, startling me, and grinning widely he proclaimed, “That oughta do it!” And he walked off, swinging his stethoscope in his hand as he disappeared down the hall.

I looked down: it was Karl’s chart. I couldn’t help it, of course. I opened it, flipped to the “orders” section, and read the following in my chief resident’s barely legible scribble:

“Administer 1 glass beer p.o. x 1. Apply green food color prior to ingestion.”

I smiled as I left the hospital that morning.

After awakening from my post-call nap I called the floor and spoke with Karl’s nurse. He had enjoyed his green ale. Several days later he went to hospice a happier man.

That was a couple decades ago. I hear that beer is still available in some hospitals. But I wonder how difficult it would be for a dying person to get it these days. The process of health care is so burdened now with endless complexities—regulations, statutes, administrations, commissions, regulations, third party payers, boards, committees, and did I mention regulations?—it seems hard to believe that underneath all of that still exists the original idea that I went into medicine for in the first place: to actually care for people, to make what is miserable less miserable, to heal, to help make life a little better, maybe lengthen it too. All this sounds so quaint and clichéic now, things one might say in a medical school interview. But isn’t it still true, what we’re all still supposed to be doing in health care? If so, does the administration of health care now really have to be such a struggle, such a fight all the damn time?

To some of those non-clinicians who have their hands in the business of health care, I would ask what they would do if charged directly with the task of making a person’s life better. What rules that they themselves created would they try to bend to grant a dying man a green beer? Or would they? A green beer would be difficult to pre-authorize.

As my life continues on, I am increasingly grateful for what I have, who I have it with, and what I am allowed to do every day for work. I think of Karl every St. Patrick’s Day. To my readers, if you choose to celebrate a little tonight, I’d appreciate your lifting one up to Karl and cheering the greatness of life. We’re lucky to have each day we have.

Happy St. Patrick’s Day, and Happy Selection Sunday!  Lá Fhéile Pádraig Sona Daoibh!

 

Sleep Song #3: “Shiftwork” by Kenny Chesney and George Strait

One thing I’ve always loved about country music is the recurring theme of hard work. Like sweet tea, personal freedom, trucks and cutoff jeans, getting your hands dirty and proudly carrying out your duties for yourself and your family are major topics in country songs old and new. And boy, can I relate.

 

I can also relate well to the topic of this little nugget from Kenny Chesney (with a little help from “The King,” the great George Strait). Growing up I worked late washing hundreds of thousands of dishes at a restaurant, and as a medical postgraduate trainee I was expected to work not only night call but also “night float,” in which we worked all night for weeks on end.

According to the Bureau of Labor Statistics, roughly 15 million Americans work permanently at night or regularly rotate in and out of night shifts. That’s a lot of people. People work the night shift for all sorts of reasons: it often pays better, for example, or they may simply prefer the quieter work environment, or their professions or particular stations in life may leave them no choice. Regardless, many or most of these millions of people suffer from sleep problems directly or indirectly related to the timing of their work.

A primary sleep-related problem for shift workers is fatigue. The feeling of tiredness or drowsiness can be pervasive, and when experienced during work can lead to a host of negative consequences, ranging from substantially reduced productivity to major industrial accidents. Working at night can often lead to falling asleep on the job, reduced attention and concentration, and missed time from work.

Why are such problems so prevalent in night shift workers? The answer usually lies in the difference between their weekly activities and the way we are designed to sleep. Days off from work are precious to night shift workers like they are for everybody else. The problem is, on days off, most night shift workers want to be awake during the day, because that’s when family, home, social, and leisure activities take place for everybody else around them. As a result, they end up flipping their sleep schedules around abruptly, such that now they are staying awake during the day instead of sleeping during the day on their non-workdays.

Unfortunately, your brain isn’t quite that flexible. Your body clock “wants” regularity in its sleeping patterns–which the basis for the concept of “jet lag,” for example–and completely changing your bedtime schedules around by reverting suddenly back to a night-time sleep schedule on non-workdays often or even inevitably leads to sleepiness and reduced quantity and quality of sleep.

No matter how many years you’ve put in work at night, your body clock does not biologically adapt or accommodate for your work shifts if you regularly revert back to a night-time sleep schedule when you’re not working. Instead, you adapt subjectively, accepting a certain degree of fatigue as a regular component of your life, and/or inserting a nap here and there to make up for the reduced sleep, or breaking your sleep times up into 2 or 3 separate parts in a day.

There will be more to say about shift work in future posts, because it’s not only a potential medical problem, but also a major public policy issue. Bottom line: fatigue due to irregular sleep schedules stemming from night shift work is potentially dangerous, decreasing safety at work and putting people at risk.

On that grim note, enjoy Kenny’s song! The lyrics don’t delve directly into sleep issues associated with working the night shift, but the fatigue so many shift workers feel can certainly cause “’round-the-clock pain” and make you feel like a big ol’ pile of . . . shift work.

Have a great weekend, No Shoes Nation, shift worker or not!

Shiftwork
(written by Troy Jones)

Shift work, hard work, tired body
Blue collar shirt and a baseball cap
Union made

He’s hot, sweat drops, ’round the clock
Door never locks
And the noise never stops
Not all day
Work seven to three
Three to eleven
Eleven to seven

Shift work, tough work for the busy convenience store clerk
Two feet that hurt, going insane
She’s mad at some lad
Drove off and didn’t pay for his gas and he won’t be the last
‘Round-the-clock pain
Work seven to three
Three to eleven
Eleven to seven

I’m talkin’ about a bunch of shift work
A big ol’ pile of shift work
Seven to three
Three to eleven
Eleven to seven

Well I work shift work,
Ten years man, I hated that work
Then I made a break with the money I saved
It took me to the beach
To have a beer by the edge of the sea
And this ’round-the-clock place
I drank my money away
We partied
Seven to three
Three to eleven
Eleven to seven

I’m talkin’ about a bunch of shift work
A big ol’ pile of shift work
Seven to three
Three to eleven
Eleven to seven

Talking about a bunch of shift work
A big ol’ pile of shift work
Seven to three
Three to eleven
Eleven to seven

Seven to three
Three to eleven
Eleven to seven