James' World 2

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During residency, I worked hospital shifts that could last 36 hours, without sleep, often without breaks of more than a few minutes. Even writing this now, it sounds to me like I’m bragging or laying claim to some fortitude of character. I can’t think of another type of self-injury that might be similarly lauded, except maybe binge drinking. Technically the shifts were 30 hours, the mandatory limit imposed by the Accreditation Council for Graduate Medical Education, but we stayed longer because people kept getting sick. Being a doctor is supposed to be about putting other people’s needs before your own. Our job was to power through.

The shifts usually felt shorter than they were, because they were so hectic. There was always a new patient in the emergency room who needed to be admitted, or a staff member on the eighth floor (which was full of late-stage terminally ill people) who needed me to fill out a death certificate. Sleep deprivation manifested as bouts of anger and despair mixed in with some euphoria, along with other sensations I’ve not had before or since. I remember once sitting with the family of a patient in critical condition, discussing an advance directive—the terms defining what the patient would want done were his heart to stop, which seemed likely to happen at any minute. Would he want to have chest compressions, electrical shocks, a breathing tube? In the middle of this, I had to look straight down at the chart in my lap, because I was laughing. This was the least funny scenario possible. I was experiencing a physical reaction unrelated to anything I knew to be happening in my mind. There is a type of seizure, called a gelastic seizure, during which the seizing person appears to be laughing—but I don’t think that was it. I think it was plain old delirium. It was mortifying, though no one seemed to notice.

No matter what happened to my body, I never felt like it was dangerous for me to keep working. I knew I was irritable and sometimes terse, and I didn’t smell the best, but I didn’t think anything I did was unsafe. Sleep experts often liken sleep-deprived people to drunk drivers: They don’t get behind the wheel thinking they’re probably going to kill someone. But as with drunkenness, one of the first things we lose in sleep deprivation is self-awareness.

It’s this way of thinking—that you can power through, that sleep is the easiest corner to cut—that makes sleep disturbance among the most common sources of health problems in many countries. Insufficient sleep causes many chronic and acute medical conditions that have an enormous impact on quality of life, not to mention the economy. While no one knows why we sleep, it is a universal biological imperative; no animal with a brain can survive without it. Dolphins are said to sleep with only half their brain at a time, keeping partially alert for predators. Many of us spend much of our lives in a similar state.

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Mauricio Alejo

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