A memorable patient: Sleep deprivation
Authors: R. Booker
Journal: BMJ (2002)

The effects of sleep deprivation are well known. For junior hospital doctors, they are not only well known but frequently experienced, and crossing the divide between knowledge and experience can be an astonishing journey.

The casualty department in the hospital where I was a young house physician many years ago had no casualty officer overnight and was covered by the house physicians and surgeons in rotation. The hospital served an area where flats and “bedsitters” accommodated large numbers of young people, many of whom were deeply unhappy and confused about life. On average three patients who had taken drug overdoses were seen in casualty each day, and we junior doctors were all too familiar with “the pump,” as the stomach washout apparatus was known.

It was about 5 am on a Monday morning, and I had been on call since 9 am on the Saturday. I had had virtually no sleep on the Saturday night and none at all on the night in question, when I was covering the casualty department as well as the wards. I was exhausted to the point where I no longer felt tired. I no longer felt anything at all. All concentration took huge effort.

The patient was a young woman, drowsy but able to tell me her name and that she had taken “lots” of unidentified tablets after a row with her boyfriend. The staff nurse was ready with the pump, and we set to work.

We were half way through when I became aware that the patient's head had come off in my hands. I registered this fact quite calmly, feeling no alarm at all, no distress, not even any surprise. I struggled to think whether I had seen this happen before. I decided I hadn't. With great mental effort, I moved on to wondering if I had ever read about it. No, I thought, I hadn't done that either.

It was when I realised the staff nurse was smiling that I returned briefly to reality. Looking down again, I saw that I was holding the patient's wig in my hands and that her head remained healthily attached to the rest of her body. The lack of alarm I had felt was now matched by lack of relief. I simply registered the fact and returned to my sleep deprived thinking: so, OK, her head was in place, it didn't matter for the moment if I didn't know how to re-attach a head. But at some stage I'd better find out, ask my registrar, read it up.

The overall memory I have of this event is one of slow, painstaking, mechanical registering of fact, requiring great effort and lacking any consequent rational thinking. I was devoid of all emotion and of any sense of involvement. Merely an observer, I felt completely detached from what seemed to me to be the reality of the situation.

Junior doctors' working conditions have improved; reasonable pay for long hours is to be welcomed, and there has been a reduction in the working week. But there is still some way to go, and exhaustion remains a problem. As doctors, we hope to learn from our memorable patients, but learning that one shouldn't be working when exhausted is only useful to those with some control over their working hours. No doubt I dealt with all sorts of other problems that sleepless night and throughout the next day, hopefully adequately, but if that was the case then it was due more to luck than to rational thinking and alertness of mind.