… is practically impossible.  This is a topic that’s near and dear to my heart, as my research focuses on circadian rhythms and sleep.  As a field, I think we’ve done an excellent job communicating how disruptions of the circadian clock contribute to the pathogenesis of psychiatric disorders, neuro-degeneration, heart disease, metabolic disorders, and even cancer.  Earlier this year, I published a paper with my colleagues at Penn whose major finding was the majority of major drugs target genes/proteins that are under circadian control, indicating that time-of-day is a major influence on the efficacy of many pharmaceuticals.  Sadly, the importance of sleep and circadian rhythms has not percolated through the medical community to actually influence patient care.

Nurses:

Nurses are awesome.  I’ve met quite a few in the last few weeks, and without exception, they’re competent, hard-working, and well-intentioned.  I can’t think of another profession that’s filled so uniformly with good people, except maybe circadian biologists.  But that being said, nurses are the enemies of sleep.  For reasons never explained to me, nurses are obligated to check your vitals (BP, heart rate, O2 saturation, core temp) every 2-4 hours, regardless of whether you’re asleep or not.  Does this actually help patients?  Absolutely not.  It’s entirely defensive medicine.  They come into your room at 3am, trailing a mobile work station with an enormous 17″ monitor blasting out blue light (the ideal wavelength for resetting your circadian clock).  They make you sit up and endure their proddings, despite your protests that you are manifestly vital.  After a week in the rehab hospital, we finally realized that we could ask the nurses not to check vitals until after breakfast, and quality of life improved 100%.  Still, much better to be back at home, where people take it for granted that you’re vital.

Medications:

They put me on Keppra, which is an anti-seizure medication and has some interesting sleep effects, about which I’ll write about later on, and which may in fact become a topic for my lab to study.  I was also on enormous doses of steroids to keep my brain from swelling.  The steroids do an excellent job of abolishing sleep as well.  Also as a side effect of the steroids, my blood sugars were temporarily high, so the nurses had to stick my fingers to get a glucose measurement almost every hour.  Then insulin shots in the belly.  At all hours of the day.  Quite unpleasant.  I have new respect for my lab’s research technician, Erin Arant, who has managed her diabetes every day for her entire adulthood.  These shots were only nominally consensual: “Honey, I have to give you some insulin in your belly… “JAB!  Likewise, I had heparin shots several times daily in my belly to prevent blood clots.  These were worse — a full mL was injected, and it burns going in.  A word to the wise: if you find yourself in a predicament where you’re getting belly shots in the hospital: be brave.  Flinching makes it much, much worse.  I don’t want to seem ungrateful or take things out of perspective.  I understand well that dis-regulated blood sugars and post-op blood clots are really bad.  I just want to say that belly shots at all hours of the day, and the bright lights they bring in to make sure they do it correctly is a strong current against which your circadian clock must swim.

Screamers next door:

At both Barnes and the Rehab hospital, we had screamers in the rooms next door.  In the first case, a woman had some major psychiatric issues resulting from a prion disease.  As far as we could make out, she was convinced the nurses were trying to kill her (maybe she was getting heparin shots too?) and acted accordingly whenever they had a procedure to do.  At the rehab hospital, there was a middle-aged stroke patient who would cry all night long for her mother, which is really, really unsettling.  Basically, if you are moved by human misery (i.e. you’re a halfway decent person), hospitals are terrible places for resting and recovering.

Blood draws:

At both hospitals, routine blood draws were performed between 4-5am, I presume because that’s most convenient for the analytical lab’s workflow.  Does this help patient care?  Absolutely not.  Is it extremely disruptive for patients trying to sleep to be woken up at 4:30am to get stabbed with yet another needle?  Yes, absolutely.

Sleep and circadian rhythms are a big deal:

In those rare cases when I was able to steal a couple hours of quality sleep, I awoke with better coordination and muscle strength, less severe pain, and a better appetite.  Note well, I’m talking about healthy, normal sleep, not passing out from drugs and exhaustion in the ICU like the neighboring image.  Just as the circadian field has struggled mightily to communicate how important circadian rhythms are tICUo the pathogenesis of many different diseases, I think we as a field should endeavor to make the actual practice of medicine more consistent with the normal, healthy functioning of the circadian clock.

That is, no more pointless checking of vitals at all hours of the night, including the inevitable pulses of bright blue light.  No more procedures during the middle of the night that could safely wait until morning.  I think that by shifting medical practice to be more consistent with the interests of the circadian clock, many aspects of patient suffering could be alleviated.

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