Category Archives: sleep

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Bolster my courage

I am having nightmares. About clinic. Yesterday I bolstered my courage and sat down to write my dream out. What are my dreams trying to tell me? Should I extend my contract or not?

I dream that in clinic I have a male patient with his wife in the room. He is very dramatic, saying, “I am so ill, help me, help me.” He says, “I am on quercetin. You have to help me.”

He won’t tell me what his symptoms are, so I respond to what he says: “Who prescribed quercetin? What is your diagnosis?”

“Oh, you don’t want to help me,” he says. His wife just watches.

“Do you have pain somewhere? Any chest pain? Any abdominal pain? Any pain anywhere?”

“No, no, you don’t understand!” he says, “You aren’t listening!”

“I am trying to help you,” I say. “Can we reschedule you for a longer visit?” This is one of the impossible 20 minute ones. Honestly, he doesn’t look like he’s in pain. I do a quick listen to heart and lungs and feel his abdomen.

“No, I need to be in the hospital, I can’t go home!”

“I can’t put you in the hospital without a diagnosis, but we can move you to the emergency room.” Of course, the ER won’t be happy about this.

I leave the room and call the ER. The ER doctor is understandably grumpy, since I have no idea what this is about and am suspecting a psychiatric cause. “Urine drug screen,” I say. “He doesn’t smell drunk. I do not think it’s meth withdrawal.” “Make sure you do a note,” snarls the ER doctor. Good luck, since he won’t answer any questions. “How behind am I?” I ask the nurse. She just rolls her eyes. I probably have at least four or five more on the schedule. I come back to the room. Now two preteens are in the room, looking in the drawers and taking things out. Their parents do nothing to stop them.

“Please sit down now!” I say. “Put that down!”

The teens sullenly comply. The father is moaning. He has the prescriber on his cell phone. He hands it to me. I introduce myself. “What is your diagnosis?” I say. “Why is he on quercetin?” The person at the other end mumbles. “Excuse me, what did you say?” He’s gone. I say to the mother, “Please take the children to the waiting room. Sir, are you requesting that we call 911?” It would be a call saying man moaning, no idea what he’s on about. Vitals are normal, he denies chest pressure or pain, he doesn’t have an acute abdomen, his oxygen level is fine, no fast heart rate, no fever. Drama.

I wake up, thinking that I may have to call 911 to get the wife and kids out and I have to have someone monitor him while I see other patients and we just don’t have enough staff and I am ready to just cancel the rest of the afternoon. If I were in a hospital, I could call security, but we are a satellite small clinic.

So… what the heck is THIS dream about? And do we really get patients like this? Yes, but not often and I haven’t had any like this here. I think it’s funny that this dream has so much detail, down to the supplement that the man is taking as well as the clinic room. I usually work in room 1 and 2, but this was in room 5.

To be continued.

For the Ragtag Daily Prompt: bolster.



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Marijuana update

https://newsroom.heart.org/news/marijuana-use-linked-with-increased-risk-of-heart-attack-heart-failure

Marijuana is still illegal at the federal level, but some states have legalized it. I agree with legalization but I don’t think of it as benign or safe at all. It’s clear that it can be addictive. A study of teens (with parental consent and where they paid the teens to try to quit for a month) showed that the teens that smoked daily had real trouble stopping, even when quite motivated. The U of WA Pain and Addiction telemedecine said that about half of daily users have “overuse syndrome” and have trouble quitting.

I worked with two people who were trying to quit. The big issues for them in quitting were insomnia and anxiety. Marijuana can suppress both anxiety and help with sleep. However, our brains do not really like that sort of daily interference. The neurons can remove receptors from the cell walls if they are feeling overwhelmed. It is like trying to listen to music with ear plugs. You turn the music up. The drug is the ear plug: when the earplugs are gone, the music is way too loud. We can’t really “turn the music down”, so it is not much fun letting the neurons recover.

With the edibles and THC vs the other one, it’s even more confusing. I had many patients taking edibles or tinctures to sleep. Some said, “Oh, it’s CBD, so it doesn’t make me high. So it is not addictive.” We do not know it that is true. With opioids, people can have opioid overuse syndrome without ever getting high, just from being on pain medicine as directed. And marijuana does not have only CBD and THC. There are over 300 different cannabinoids in the plants, and CBD and THC are just two of them. I have no idea if the edibles and tinctures have the other 298 or more and what they do to the cannibinoid receptors in our brains alone or in combination.

I don’t want to have any overuse syndrome: alcohol, opioids, gambling, marijuana, whatever. I know I can get off caffeine in 24 hours, though it involves an awful headache. I am nearly off coffee now, because my body only likes coffee when I have pneumonia. I quit coffee from 2014 to 2021 and now am quitting again.

The two studies in the article look at people who do not smoke tobacco and who are using marijuana. They are seeing an significant increase in heart disease, heart attacks, sudden death and congestive heart failure. Congestive heart failure is pump failure, where the heart does not pump correctly. This is a major problem, as you might guess.

Be careful out there.

I took the photograph at Fort Worden last week on a day where both the wind and the tide were howling.

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Naps

Naps are for the very young, then we forget
or scorn naps for years. We think of those who nap
as old when we are 8 or 10 or 20, still wet
behind the ears. Once we climb down from the laps
of those who try to teach us about the whirled
and we’ve mastered running free, we fight the time for bed.
My son would cry right before the pearled
evening would close his eyes, fighting sleep with dread.
He might miss a fun filled happening. We run
fast and learn until we reach an age or illness where we tire
and fall asleep in day on a couch in spite of sun.
Wake climbing out of sleep like from the ocean or swampy mire. Our children now make fun of us, they fill the gaps,
as we have reached the age where we once again need naps.

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I took the photograph from a train in 2017, going from Edmonds, Washington, to Chicago.

For the Ragtag Daily Prompt: nap.

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Imprecation

imprecation

damnation

what a nation

what a notion

needs some lotion

or a potion

to awake

not be baked

by booze or sun

just no fun

we’re on the run

after the clock

time in hock

where are our socks?

get up woke

or you’ll get a poke

job loss no joke

worry re banks

sink or sank?

money there give thanks

worry heaps

til back asleep

falling deep

imprecation

what a nation

__________________

For the Ragtag Daily Prompt: imprecation.

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I was looking for a song with imprecation. I did not find one, but there is an infernal Texas horde (aka a band) named Imprecation. The band’s new album, Damnatio Ad Bestias will be the first since 2013’s Satanae Tenebris. Here:

https://music.youtube.com/watch?v=yYOPr4SSSEo&list=OLAK5uy_mRyE2ZBb8s_LYFam77uMP76ayELbYtVd8
I did listen to a little. Maybe Elwha or Sol Duc is into infernal Texas death metal. Now, is Sol Duc begging me to keep it on or turn it off in the photograph?
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Perchance to dream

I have been dreaming regularly since mid-January, nightmares. The cause is my sleep apnea machine. I got it in December, but two days before I flew east to my son’s for Christmas. I did not take it with me. I delayed getting back for nine days to visit an ill friend in Michigan and help out. On January 11, I took the class on how to use the machine.

My initial “mask” was the “nasal pillow” one. I go to sleep by slowing my breathing and using the Zen Buddhist and Jon Kabat Zinn’s body scan to relax. However, if I slow my breathing, the CPAP will start to blow pressure when my breath out drops below a certain volume. Then I was breathing against pressure and it woke me up. Also I would sometimes open my mouth, which lets the air out and the machine instantly increases pressure and is much noisier.

I got another mask within ten days. This is a face mask. It did not have one strap around the head, but four. The hose is attached to the top of the head. The main pressure point is where the four straps meet right at the back of the skull.

The dreams started. Nightmares every single night. About being trapped and trying to escape. An octopus grabbing me by the skull. One dream about trying to rescue a man from a building that was under attack or going to blow up and he kept saying, “But I’m not READY. I have to PACK.” I’m arguing, “You can get more stuff! We have to go! We’ll get killed if we stay! Come on, I am here to rescue you.” He keeps looking for his stuff because he can’t believe that a 5 foot 4 female could actually be a heroine and there to rescue me. Dumb male. I wake up and laugh. Even men in my dreams have little respect for me. That is a pretty sad illustration of my lifetime experience with the other gender.

Anyhow, to have the insurance pay for the stupid sleep apnea machine, I needed 21 out of 30 days with more than 4 hours on the machine. And I have to do this within 3 months of getting the machine. I got it in December, remember? So I was motivated and hella grumpy with it. At least twice a night I would wake up from a nightmare and rip the darn thing off my head. The cats do not like it when it hisses.

I took to using it during naps too. Since I was NOT sleeping well on it, I was sleeping longer. Nine or ten hours a night, at least three or four OFF the machine. Pretty pathetic.

Last week I had my visit where I am blessed and the insurance will now pay for the machine. I begged a little to talk to the mask guy. They said no at first and then yes. He gave me another octopus headdress. This one also goes around the back of the skull, but the hose is hanging from the front. That means the weight is more in front.

It still took three or four days before I got to four hours on the new one. It works better and I am not dreaming about escape rooms twice a night. Phew!

The interview to have the machine paid for was pretty amusing. The insurance wants me to say I am sleeping better to qualify for the machine. I answered that I was sleeping longer. There are a bunch of questions. Mostly I could be positive except for the “are you waking up less?” “No, more.” “More? Why?” “Because the octopus has me by the head or I am dreaming I am trapped.” I had the nurse laughing at my answers, but I still qualified.

Anyhow, if I can invent a different mask that doesn’t feel like an octopus, I could probably be a gadzillionaire. I think I will look at some bondage stores, seems like they have various masks that could be adapted. Then they could do double duty and I will be a double gadzillionaire!

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For the Ragtag Daily Prompt: dreams.

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sleep and defiance

Oh, gosh, CNN is making everyone panic about sleep again: https://www.cnn.com/2022/11/08/health/sleep-deprivation-wellness/index.html

Don’t buy it. It used to be 8 hours. Now they are saying 7 in this article. SLEEP AT LEAST 7 HOURS OR YOUR BRAIN WILL MELT.

Nope. The media likes us to panic because it sells papers and gets shares. Don’t buy the hoopla.

After all, I took call at night for 30 years and my brain has not melted. (Ok, if you disagree, post your own blog, heh, heh.) Starting third year of medical school. Sometimes it was every third night, sometimes every fourth. We were often up and awake and working for much of the night and then through the next day. If we had to be ready for rounds at 8 am, we had to be there earlier to see the patients, check the lab work, check any studies, drink a gallon of coffee and then be coherent on rounds, where the faculty physician might quiz us about the nineteen causes of high potassium. Uh. Taking too much potassium is one. Kidney failure, diabetic ketoacidosis, etc, etc.

I made up the number nineteen.

Anyhow, I was a sleep rather than eat person. If we got a break, I would go to sleep and skip food. The bad rotations were obvious because my weight would drop. We’d meet for “nutrition rounds” in the morning. I would skip lunch, hoping to have it at home post call, but the list might have things added even as I ran around checking things off. At last I would stop for lunch at 2 or 3 or 4 because my brain was no longer functioning.

Doesn’t sound very healthy, does it?

Here is a post on sleep from 2015: https://drkottaway.com/2015/01/08/sleep/. I sent a copy to our sleep specialist and he liked it.

When I got my flu vaccination and covid booster a month ago, it hit me pretty hard. I am sleeping as I normally do at night, for 6.5-7 hours. But I also started napping, once or twice a day. I was sleeping 11 or 12 hours total daily. I canceled pulmonary rehabilitation exercise, because it wiped me out. I was starting to feel better after three weeks, so I restarted pulmonary rehab. I promptly slept 12 hours a day again and my muscles gave me HELL.

So what in the heck IS this? Well, healing. My body is knocking me out to do repair work. It’s sending a pretty clear message that running on a treadmill is not ok right now. My immune system is busy making antibodies and is saying HEY WE DO NOT HAVE ENERGY TO SPARE FOR ANYTHING ELSE. This is sort of annoying except that having had four rounds of really bad pneumonia, the last one requiring oxygen for a year, still on oxygen to sing and for heavy exertion, I am willing to listen to my body. It is annoying, but: my mother, father and sister are dead, so even though I am struggling some, I’m not dead. It’s all relative, right?

When I had pneumonia #3 (2014) and pneumonia #4 (2021), both times part of the healing is sleeping twelve hours a day. I went back to work six months after the 2014 one and promptly slept twelve hours a night. I was seeing 4-5 patients a day and could barely do that. I went into denial about chronic fatigue, but I knew I had it. NO WAY, I AM TOUGH. Well, I am tough, but that means chronic fatigue and not dead.

I do not worry about sleeping 7 hours a night or 8 hours. I sleep when I get sleepy. Naps are fine and one gets to relearn napping after age 50 or 60 and it’s ok. If you need to stay awake after lunch, have a small lunch and no alcohol. Alcohol is not good for sleep in the long term and neither is marijuana. Benzodiazepines are worse than either. Ambien and those drugs are approved for “short term” use, meaning two weeks. Great. We don’t know what it does if you are on it for years, but some of us note that those drugs are closely related to the benzodiazepines. I think the most addictive drug is tobacco, followed by benzodiazepines and then methamphetamines. That is from asking patients and observation over 30 years. There are individual quirks though, and I have had people say, “Alcohol is no problem but the first time I was given oxycodone I wanted more.” Sometimes there is a bit of denial in those statements.

The photograph is me doing my second sleep study last week. I scored. Um, or rather, it was a positive test. Sleep apnea, darn. I am now waiting for my bipap machine. The funny bit is that I had to drive an hour to the lab. I was supposed to be there at 8. I got there an hour early because I get really tired at night. The tech let me in and wired me up. “But,” she said, “you can’t go to sleep until 9, because I have another patient and they are not here yet.” “Ok,” I said. I read for a while in the chair, put my head back and (don’t tell) fell asleep.

She came back in, did the final connections and then left. There is a ceiling camera and a disembodied voice. We tested the connections. “Flex and extend your right foot.” “Now breath through your nose.” I did and immediately fell asleep. She woke me, “Breath through your mouth now.” “Was I asleep?” “Yes.” The wires didn’t bother me much, though I had to surface part way during the night to change position.

I’ve slept sitting up in hospital meetings. I fell asleep standing against the wall in medical school. It is really a blessing to be able to fall asleep.

The year my father died, I had a terrible time falling asleep. His will was very out of date, written 40+ years before. It was a mess. His house had 13 years worth of unopened mail. I used Jon Kabat Zinn’s Mindfulness Meditation tape to fall asleep. But I used it in a rather weird way. He has a section where he says “Do NOT fall asleep.” It was a body scan. I would think, hey, you can’t tell ME what to do, and I would always fall asleep during it. So there, Dr. Kabat Zinn. Thank you.

The pandemic is enormously stressful, not to mention all of the other things. You can still relax though. What relaxes YOU? Stupid animal videos? A walk around a yard or park? Dancing in your kitchen? Knitting? Reading your absolutely most boring textbook? Put the phone and the television and the computer away at least one hour before you want to sleep and preferably two hours.

And here, to relax you, are pictures of sleep: https://drkottaway.com/2018/04/30/zzzzzz/

Blessings.