Sleep, Fatigue, and the Provider

So but you all sleep fatigue in the provider so our guest speaker today dr. sue Jenkins agra comes to us from Duke University Medical Center where he is associate professor and department of pediatrics he is director of the pediatric neurology sweet medicine program and program director for the pediatric neurology residency program I have to say that is all right eat it I really tried to finally landed at Q because it's a little bit sure what we need which of the rivals 50 minutes apartment with you along with it so that is that person softener completed his undergraduate work at UNC Chapel Hill his medical degree at Duke his pediatric residency at chapel hill TX neurology residency a new beginning and then he went back to Chapel Hill to complete his sleep and fellowship and then in 2012 Duke won that rivalry and got him to sign on his faculty and yes Department EMS pediatric neurology department so go do it doctor the Tucker has published numerous articles written book chapters and presented at probably tomorrow he's primarily on had loved seeing sleep he's written five books one on sleep and the other for an opportunity medical student and residency candidate achieve their goals they're very cold today after photographer is here to talk about about Hollywood recognize the signs and symptoms of sleep deprivation and fatigue shows how serious it is in operation suggestion that production I am thrilled to be here everybody hear me okay right now you should talk fairly loud I'm not talking about sleep I'm I don't have it like a disclosure slide but my main disclosure is I'm a bit of like a sleep evangelist like I I go around I'm like preaching about how great sleep is then so I'm always excited to talk to anybody else willing to listen about sleep and how it affects our lives we have lots of objectives we're gonna get a little bit into sleep science I know this is noontime you guys are you know eating lunch and so I won't delve too much into the science behind sleep physiology but going through it actually helps us understand a few of the sleep disorders and sleep problems I'll talk about later we're gonna talk about the range of normal sleep talk about what happens when were sleep-deprived figure out ways to recognize and sleep issues and how to treat them and then if all goes well at the Enna's presentation I'm hoping that I may be able to change some of your perceptions and and beliefs about about sleep so I use like to start with the definition of sleep and I love this definition because it comes out of a book that was written by a surgeon any certain surgeons in the audience that they know okay great so I can find with surgeons a little bit this is a book written in the 1800s and it says what is sleep sleep is the intermediate state between wakefulness and death wakefulness being regarded as the active state of all the animal intellectual functions and death is out of there total suspension and for many years and this is what we thought sleep was here's kind of a you know kind of in-between you how they do anything just a step away from death your brain is kind of quiet and it was it into the 1920s when we invented the e we when they invented the EEG that people realize they're a whole host of things going on but with sleep you go through sleep cycles you're praying at certain times is actually so active that it looks actually like the wake brain and so this definition thankfully has changed for most of us most some surgeons still believe this they don't like to speak very much but for most of us the definition has changed this is a definition a reversible behavioral state of perceptual disengagement from and decreased responsiveness to the environment so we know we're not we're not completely unresponsive while we sleep so this is oh okay sure sauce try to stay back here we're not completely unresponsive because things that you do while you're asleep even thing is going on an environment you can sometimes incorporate into the sleep state so if you've ever had that that dream or the fire alarm is blaring in a set to your alarm clock you know you've incorporated some that auditory stimuli into your sleep state as adults we toss and turn on the bed throughout the night but we never fall off of the bed you do as a kid without an adult because you maintain some spatial understanding of where you are so we're not completely unresponsive and of course it's a reversible state thankfully why do we sleep when the first question is like to answer it there's no one there's no one answer to this question there are lots and lots of reasons why we sleep and these are just a few the other things that are out there a few other theories one it restores our bodies because we have a lot of wear and tear that we do to the machine that is our body throughout the day and so when you sleep it's a time for your muscles account relaxed repair you secrete growth hormone during the deepest stages of sleep so it kind of helps your body restore itself now energy conservation you don't need to be awake for 24 straight hours to take care what your body needs to survive you know you don't have to be a wake - you have to eat etc so you can serve some calories they're learning we do a lot of learning while we sleep we encode many of our short-term memories into our long-term memory stores lots of studies show that you know pulling all-nighters etc are terrible for your recall the next day because you do encode a lot of your memories when you learn when you're sleeping we also unlearn lovak sleep so you probably don't remember what you had for dinner five nights ago unless it was something just super amazing and you know you you made it yourself because you get rid of those memories you don't need to you don't need to know all that information otherwise you just clogged up your brain with tons and tons of memories you don't need so we actually unlearn a lot while we sleep as well and the last thing I'll mention although this is not a comprehensive list of what why we sleep but the last interesting thing that we've recently discovered is that sleep also plays a role and actually scrubbing your brain cells clean when you're asleep the interstitial fluid they CSF that surrounds your brain cells the channels that allow those that fluid to wash over yourselves increases by about 40% so it's like the floodgates gonna open up on your sleep and it bathes your Bloods your brain cells in the suit of spinal fluid and it actually cleans away a lot of toxic proteins that are being built up during the day and in particular beta amyloid has been found in the animal model this is a mouse model to be cleared away during sleep beta amyloid plays a role in in Alzheimer's disease and we think neurodegenerative disorders and so it's so you sleep is actually scrubbing your brain cells clean and getting rid of toxic proteins so another fascinating reason of obviously I love this quote it's from an evolutionary biologist if sleep does not serve an absolutely vital function it's the biggest mistake that evolution has ever made right because for eight hours you're doing nothing to please promote your survival you're not mating you're not getting calories you're a sitting duck for predators right so if you're a rabbit or something out in the Sahara then you're just sitting there and the lion could just walk up to you and eat you while you're asleep so it doesn't make sense that we'd have this time where we're such at a disadvantage for survival unless they played our huge function in helping us while we were awake to promote our survival so so sleep is gotta be important it's conserved rights and served among species so we talk about why we do sleep I don't we sleep apply them on important question to ask why don't we sleep well there's a lot of stuff going on we have very active lives work family and sleep it's hard to balance it's not really a priority right in most people's lives unfortunately that there's a there's a sleep in America poll that that happens every year and they they gave folks option of five things and say what do you prioritize most in your life and interesting the fitness and nutrition came up at 35% which was kind of surprising 27% said they prioritize work the most 17% said they prioritize hobbies and interests 10% said sleep 9% says social life these only five choices they have but you know we beat out a social life but it's still pretty low when it comes to overall priority list and allow that has to do with our cultural perceptions regarding sleep and I love this this is a straight I have an admissions packet from Duke it says basically there are 3 s's in your life study socialize and sleep at Duke you get to pick two of them most of us give up sleep apply now do you can city vanishes right I mean this is kind of like look how cool we are we don't sleep you know we sit around there you know the no shoes on wicker furniture this is a place to be and I actually when I saw this I emailed the admissions department I said why are you promoting not sleeping at our school I kind of take offense to this as a sleep doctor and they're like okay we're change it we'll take it out and I haven't seen this since this is a cultural regarding sleep you know it's it's kind of it's an easy kind of whipping whipping boy right it's a little target and I get it and in medicine in particular we we don't have a nice relationship with sleep then you know you can think to your own personal history and think to yourself you know when is the last time you know you went up to a colleague and you're like got that eight and a half hours last night I feel fantastic today versus oh god I really struggled I only slept four hours because I had to knock out this paper and it's grant and I'm but I'm gonna make it through this day you know you kind of where the sleep deprivation is can like a badge of honor they look how hard I'm not go look how dedicated I am to do it and I tell people try to reverse that because when you're sleep-deprived you are not your best self you're not working as well as you could you're at higher risk of injuring yourself and injuring others and so I say don't be proud of the sleep deprivation I want you to feel a little bit of shame of a sleep deprivation has my goal because it's not great for it for your body and for those around you okay that's that's really my overarching goal is talk and I may be the only one that tells you this for the stuff your life because there's not many people that are like sleep evangelist okay so I'm the only voice of reason that you may hear all right so I've got to be convincing let's talk a little bit about a science the science behind sleep I love this slide because it pretty much tells you why you feel the way that you feel throughout the day there are two main things that are going on in your brain that make you feel awake in a sleepy at different times of the day the one at the top the home is Haddix sleep drive think of the blue arrows that you see here this is over a 24-hour period 9:00 a.m. to 9:00 a.m. the next day sorry you can't see the time you're all that well and of course day and night when you sleep there are various metabolites that are less right when you're awake their various metabolites that are building up due to the breakdown of ATP etc those metabolites actually have receptors and your brain binds those receptors and it tell you how long you've been awake it tells your brain I've been awake for six hours I've been awake for eight hours etc so as the day goes on more and more those metabolites build up and imagine the bigger the blue arrow the more sleepy you should feel because you have more of those metabolites when you fall asleep your brain churns - those metabolites such that by the morning if you've slept enough you start off with the same level of those metabolites as you did the day prior completely cleaning your brain free of all the metabolites that have built up that's called the homeostatic sleep drive pretty straightforward the longer you're awake the more sleep your brain feels but that's not exactly how you feel right you don't just feel sleepier and sleepier and sleepier and then crash and that's because the second process that helps you stay awake is your circadian alerting signal it's part of the circadian rhythm I could talk to you all day about us again rhythm because it's a fascinating thing it's every living thing on this planet has its own rhythm down to unicellular organisms the circuit rhythm is a twenty-four uh flea 24-hour body clock and it does a variety of things one thing that it does when it comes to sleep physiology it produces an alerting signal but it does a whole host of other things I could take in one white blood cell out of your body analyze the proteins that are being expressed and tell you exactly where you are on your circadian day where your body clock is because even down to the cellular level we actually have translation above a good chunk of our genome in a circadian fashion more proteins at certain times a day less proteins in other parts of the day we think organ systems have their own circadian rhythm we know that the lungs likely that the the diameter of various airway passages increases in decreases at different times of the day and that might play a role as to why asthma symptoms tend to get worse at nighttime the liver metabolizes drugs differently depending on time of the day that it sees those medications so the circular them is fascinating and if you invite me back I'll talk all day about this located with them but for this it's the purpose of this lecture it's it will talk about the alerting signal the the the wakefulness that it produces for you everybody has is up and down pattern the up non pattern is similar although they can occur if you can shift the entire block of yellow arrows to left on the right and we'll talk a little bit more about that later but the main thing to know is that when you wake up in the morning the circadian rhythm alerting signal is still fairly low it starts to rev up by mid to late morning which is nice it helps you get a little bit more energy more pep in your step it takes a dip right about now around 12:00 1:00 2:00 o'clock and everybody blames lunch you know I just had a big lunch I'm sleepy but it's not the lunch that's your natural circadian rhythm it does that for everybody regardless of whether you ate lunch or not we need any lunch you're gonna feel tired right about now that's a normal part of sleep physiology we don't know why that dip exists perhaps it was an advantage winter outside all day to have a quiet time where you're taking a little nap when the Sun is at its peak right when it's really hot outside who knows but unfortunate that dip exists and we all have to kind of struggle through it and then the circadian rhythm the alerting signal revs up really nicely later on in the evening time such that it's at its peak signal right before you tend to fall asleep which is really nice because what the circadian rhythm has done for you is that it's helped keep you awake during a time where your homeostatic drive is telling you you should be getting really sleepy and it works so effectively that when you go home you may feel as awake as you'll feel the entire day in the evening hours so you may think yourself you know I'm really struggling right about now I am really trying to stay awake and listen to you but it's a struggle and yet when you go home this afternoon actually pretty good and maybe I'm not so sleep-deprived but that's because your circuit ability is helping you out that's helping you stay away and then thankfully the circadian rhythm drops rather precipitously when it's time to go to sleep it does it on its own you absolutely do anything to do it it's always running in the background in the 24-hour loop and it stays really low through the rest of the night and helps keep you asleep until morning time so those are two things that are at work helping you feel the way that you feel throughout the day and for those you that are used to those you know thirty eight thirty our 48-hour call shifts you know that when you're when you start in the morning and you have a long day you're feeling you know kind of tired you hit a wall right around 2:00 or 3:00 o'clock at night or you're like this is this call and I was really getting long and then by the time morning comes and you're right around again if you've been up for 30 hours straight or 24 hours straight you feel that sense of energy again and you can make it through rounds and that's because the circadian alerting signals kicking back in and give you that extra energy to then be you know coherent and finish to finish your day so that's the two to process model now I'm gonna go through a couple of myths that I oftentimes hear are things that you might believe yourself about sleep and try to dispel some of those myths so people often say well I don't really don't need the amount of sleep you tell me I only need six hours and I'm gonna do fine this is just a breakdown of what what folks need to feel fully refreshed and it is a range everybody has a different set point as far as their biologic sleep need but by the time you hit adulthood it's seven to nine hours it's not six to seven it's not six to eight is seven to nine hours for the average adult and if you look at huge epidemiologic studies on average the adults need about 8.1 to 8.2 to feel fully refreshed so it's more than many people believe but that's really what the science shows and unfortunately the older we get the less we're napping here in our Western society most most kids will give her their naps between ages of three and five the younger you are the more sleep you need but once you hit adulthood your overall asleep need for a 24 hour a day decrease is very very little and you really continue to need that 79 hours well into the ER your your golden years now there are exceptions so 79 hours is is where 95 97 percent of population will fall but we do have folks on the fringes that are short sleepers and long sleepers long sleepers the folks that naturally need 10 - or 11 or more hours to feel fully refreshed and unfortunately our society sleepiness is oftentimes synonymous with laziness these people are labeled as like lazy oh you don't want to get out of bed you're always trying to sleep but that's just the genetic hand they've been dealt so everybody has a different set point I try to convince my wife that I need an extra hour more than she does and that's the cinetic thing she doesn't believe it it's hard to convince your bed partner even if you're a sleep expert but that's that's the nature of the genetics that's not everything but thankfully for some of you on the other side short sleep time which is very advantageous for medicine and lots of other things there are folks that may actually need only four or five or six hours to feel fully refreshed it tends to run in families because there is a genetic polymorphism associated with short sleep time these folks that can get by consistently on five or six hours to fully refreshing they wake up the don't need any caffeine they don't feel this dip at noontime and they tend to be actually very positive and energetic people and these families tend to be just very positive energetic and very productive so you may know some people like this but they are they're short sleepers a nested genetic can there are you know there are famous short sleepers Benjamin Franklin was a short sleeper Leonardo da Vinci used to practice is this thing called polyphasic sleep or he'll sleep for 90-minute cycles or three hours silently and would have a total of six hours to a 24-hour day and he thought that he cracked the code for sleep he can get an extra hour or two in his day at practicing polyphasic sleep but in actuality he's probably just a short sleeper so you can get away with six hours continuously I have medical students telling all the time that they've tried polyphasic sleep they've tried two distinct the 90 minute chunks four times a day and hopes of finding that magical hour or two and they crash and burn almost every single time because there's not a short sleeper so you can't do it Navy SEALs are actually trade out to find folks that can optimize their performance of short sleep time they are trained out to be short sleepers because you want your Navy SEALs to be able to operate in there really stressful sleep-deprived conditions and still do great so most Navy SEALs are also selected out for short sleep time McDonough is thought to be a short sleeper Bill Clinton and of course it would sleep like four or five hours but even short sleepers have their limits right this is Bill Clinton if you're getting less than what your body needs you're gonna have the effects of sleep information no matter where your setpoint is all right so how many of you feel like you maybe you needed eight hours when you were younger but now you've gotten accustomed to sleeping like six or seven hours every night and you feel like that's fine I can get by and less any takers on that you've got accustomed to less sleep we did have a few takers on that hike you'll think you can do it how people you can train your body to get off to get by on less sleep amen I've never once taken upon it well you would have been right either way don't we always how you answered because you can't get accustomed to sleep deprivation subjectively if you are sleep deprived for a long period of time it becomes your body's new normal so you begin to say oh yeah I feel fine I feel okay I'm not sleep-deprived because you forgot what wakefulness feels like sadly but objective testing shows the exact opposite I'm gonna show you some data behind that but why what happens with chronic sleep deprivation so this again goes back to blue arrows that I showed you those blue arrows that signify the your homeostatic drive the longer awake the sleep your you feel and I've condensed it over three days ups and downs depending on when you're awake and when you're sleepy and I've arbitrarily given them numbers the higher the number that the sleep here you are okay so you start off your morning on day one you start off with a level one lowest level of sleepiness as the course of the day progresses you build up those metabolites and you add 3 ok metabolites you have a level 4 sleepiness you go to bed and you decide you know what I'm gonna get up after 6 hours even though you're in you need 8 hours and so the next morning because you haven't gotten rid of all those metabolites in your brain you already start off with a little bit of a fog in the morning a little bit of sleepiness in the morning you start off at a 2 and then you build 3 on top of that just like you did the day before gonna build 3 on top of every single day so now you work your way all the way up to level of time but the end of the day you fall asleep and you decide you're gonna skimp again now you're starting off at a level 3 sleepiness these are folks I wake up with that fog they're like ah this is waking up is painful and even coffee to really get going that's because you still have a lot of those metabolites swimming around in your brain that you should have gotten rid of while you slept and this can continue to compound over time that's the of sleep debt you have to pay back which you have not given your brain and when it comes to sleep so it's a very real concept and it's all driven by the homeostatic sleep drive thankfully you don't have to pay back that debt one-for-one otherwise many of you would be sleeping the rest of your lives to pay back because of the work that you've done but you do need to have prolong time in bed consistently to overtime pay off some that sleep debt to get back to your true abilities when it comes to your brains cognitive abilities so what happens when we build up sleep debt this is probably the best controlled study that we have that that put a group of people in four different conditions four different sleep deprived conditions and this is over the course of two weeks or 14 days and what they have these folks do is at baseline before they put them in Andy's conditions they said let's see how good you are at paying attention for a long period of time a prolonged attention task it's called the psychomotor vigilance task they sat them in front of a computer they gave them a little quicker and they said every time we see a red dot flash on that screen just hit the clicker that's all you have to do and it was about over the course like 10-15 minutes there's about a hundred times at it click the button and they figure out what their baseline performance was if it took them more than half a second to click the button is considered a miss you missed that bed da and half a second is a long time when it comes to just looking at something about hitting a button to respond to it you should be able to do it in less than half a second so everybody got their own baseline measure and then they put them in four different groups and they compared their performance to their own baseline they were their own internal controls this experiment to see how much worse they performed when they are put in sleep deprived conditions so so their baseline on this graph is their their their zero scale this is the amount of times they missed compare their own baseline of zero in different sleep-deprived conditions one in group the Green Line here at the zero hours TI BTB is time and dead they allow them to have the zero hours time in bed for three straight days you can't really do this experiment more than three straight days or nights IRB is not gonna be happy with you so for three straight days they got zero sleep and after day one on average they were missing that dot about eight times more than their own baseline on day two about thirteen times more than their on baseline again attempts so if they'd missed 15 at baseline they're missing 28 and then by day three they were missing at 15 is 16 times more than their own baseline which makes sense they haven't gotten any sleep two three straight things you're gonna be doing worse make sense the other three groups they allow to do it the whole two weeks worth okay there was a four-hour time in bed group a six hour in an eight-hour the four hour time in bed group as the study progressed did worse and worse and worse compared to their own baseline such that by the end of the study at two weeks they were missing about 15 to 16 more than their own baseline which is the same performance as somebody that had been sleep deprived for three straight days it's a pretty poor performance the six hour time in bed group so I'm hopeful that nominee you're doing four hours continuously you know but six hours some of you may be doing the six hour time in bed group also continue to worsen in a linear fashion throughout the course of the study such that I've been in the two weeks they're performing at the same level so missing about 12 as somebody I've been sleep deprived somewhere between one and two straight days okay continuously so freeport performance and you can see it with these graphs here there's no signs of plateauing it's pretty linear it's a pretty linear worsening so who knows if you extend to this all the way out here to like three or four weeks how boy they would be doing they might be getting to the extent where they're they're performing just as badly somebody that have been sleeper perfectly straight days and the group that was supposed to service kind of control was the eight-hour time in bed group and their performance over time also continue to worsen slightly which could be multiple factors they could just be getting bored with the experiment certainly and the missing stuff granted but there's like the also an element of sleep deprivation even this group because eight hours time in bed is not equate to eight hours time asleep none of us are asleep 100 percent of the time when we're laying in bed and so they were likely slowly sleep for private themselves as well then also seemed to increase in a somewhat linear fashion again this it can be lots of other factors but interesting to see that you know there is no plateau effect when you comes to objective testing this same group they have them subjectively say how sleepy they fell and the four to six out of four and the six hour time in big group didn't have much differences and over time their their reports plateaued to the point they're saying now I don't feel that much worse than I did a few days prior so they didn't feel sleepy er and yet their brains we're kind of getting slower and slower which is a bad combination right if you think if you're fine but you're really not doing so so great so that's a fun little an interesting study and that's great you may say but I have the magic potion right you can just caffeinate your way out of sleepiness so let's talk a little bit about what caffeine does these are blue arrows again we keep going back to the blue arrows because it all goes back to the sleep science the blue arrows you're building up that drive on a normal day from in the morning tonight you build up that drive nicely well I told you that one of the substances that it's building up is adenosine from a breakdown of ATP we have adenosine receptors in our brains the denison receptors bind that aid to that adenosine and tell tell you about how long you've been awake caffeine actually prevents then Essene from binding the adenosine receptors that's what it's doing it's just playing a trick on your button in your brain saying you actually haven't been awake that long after all there's not that much to then it seemed floating around it's just a temporary trick the caffeine plays it doesn't do anything to get rid of that sleep drive I wish it did but it doesn't dissipate the sleep drive your dentist scene is still there floating around just waiting until your body turns to that caffeine which it does eventually and that's ready to bind to those receptors so nothing tricks the brain nothing tricks a brand new brain always knows okay your brains very smart it always knows and then once you're by turns to that caffeine you kind of end up at the same place you would have anyway right you end up with a pretty high homeostatic drive and this is this is mostly true by tell people depending on when you consume the caffeine you might still have some caffeine in your system when you're going to bed at night so if you're consuming in the late you know afternoon evening we turn through about half the caffeine in our system every four to seven hours that's the like for caffeine so even caffeine that you drink in the morning there's likely a little bit of it still floating around in your system and it's time to sleep at night so something too something to think about when I did my sleep fellowship I was also treating adults then some of the most elderly of my patients would come and say I just can't sleep at night I feel really Restless the older you get the slower you tend to metabolize caffeine and the first thing I did was I'd cut their two cups of coffee in the morning out of there there's their routine I said let's just switch to decaf just just humor me on this let's switch to decaf let's see what happens they come in the next visit better like it was my morning caffeine I was keeping me up at night I can't believe it and they do great so so caffeine is not as benign as we may think so medical training right we have just this love-hate relationship when it when it comes to to sleep and I'd like to take you a little bit through the historical perspective on this to figure out why exactly sleepiness and working so hard and sacrificing sleep is seen as such an occlusal element to our medical education William Osler the founder of the father of modern modern medicine he started the first residency program at Hopkins and William Stewart Halsted was also him in Hopkins they were two of the big four that started you know Hopkins education William Stewart Hall said was in charge of surgery program he heavily influenced William Osler who started the first medicine program and William motors model kind of then permeated throughout you know medical training because they started residency modern residency William Shorthouse ed was a workhorse he was a surgeon he was a workhorse he made contributions to like a surgical world that you wouldn't believe and he expected the same of his residence you work you work you work and so that's back then residents in the Hopkins program were residents right and it continued many programs you were resident at the hospital that's why they called your residence so you lived there and you stay there day and night if you could find somebody to take care of your patients on Sunday afternoon you got to leave the hospital or Sunday afternoon and if you didn't do that you're in the so this was there were you know no duty hours rules back then so they expected a lot and William Stewart Halsted is kind of his his his push for for contributing for working sacrificing sleep was well known and we think he heavily influenced William Osler but dr. Halstead had a little bit of a some help when it came to his his work ethic he was addicted to cocaine he was known to be addicted to cocaine it wasn't illegal back then so to his credit and he got addicted because he volunteered to be a part of an anesthesia experiment where he got a little taste and then couldn't stop but he used cocaine for likely the majority of his career and that may have driven some of this work ethic now we're all expected to have a same work ethic but using cocaine is frowned upon so I truly believe that someone like the ethos behind the medical training and working so hard probably has its start in cocaine this is my perspective I wanted to do a little something with you guys is I want to calculate all your own sleep numbers there is an up worth sleepiness scale it's a subjective scale so I'm gonna have each of you do this on your own you'll have to share your number I'm gonna walk you through eight different scenarios and I want you to in your head calculate your chances of dozing off in each of those scenarios you can give each scenario one of four scores a zero one two or three depending on the chances of dozing off a zero means no chance of going off at all the one is a slight chance to as a moderate chance and three is a high chance that you doze off and by doze off I don't mean like a full-fledged nap and you're you know drooling I just mean like you're kind of like doing everyone you know done odd kind of a thing what are the chances that you might have that experience in these these scenarios they've got to write it down fine if you want to keep tracking your head no problem so scenario one is if you're sitting and reading give yourself a score zero one two or three okay zero is no chance when is a mile chance to is a medium chance three is a high chance and I'll keep adding it to the next scenario okay so that's scenario one sitting and reading scenario two watching television what are your chances of dozing off scenario and again you can have to average it you know it depends on which show you're watching right I mean if you're watching you know some paint dry you're gonna but on average what your chances of just sing around your family watching TV oh the chances you'll doze off scenario three sitting in acting in a public place like this for example couple you should have answered shrieks I've seen you doze off I'm just kidding so zero one two or three sitting and active in a public place scenario for if you're a passenger in a car for an hour without a break what are the chances let me know if I'm going too fast scenario five laying down to rest in the afternoon when circumstances permit again if this doesn't happen to you just imagine that it has happened to you what are your chances of dosing scenario six sitting and talking to somebody and keep adding up the scores as you're getting them scenario seven is sitting quietly out for lunch without alcohol alcohol is critical there and then the last scenario is if you're in a car that stopped in traffic for just a few minutes the question doesn't specify whether you're driving or not but there's probably intentional so you'll have to decide whether you drive you're not but a car that's stopping traffic just a few minutes everybody got their score now we're going to see what those scores mean okay so the interpretation this is this is a widely used scale when it comes to research for sleep and clinically if you score between zero and seven it's unlikely that you have abnormal sleep or you're abnormally sleepy as eight to nine on this scale based on the metrics they have they feel like it's an average amount of daytime sleepiness ten to fifteen you may be excessively sleepy depending on a situation you may want to consider seeking medical attention and in sixteen to twenty is you are excessively sleepy and should strongly consider seeking medical attention and let me put that also in the medical frame of reference here this is a study that looked at various different subjects a normal population they scored about a six insomniacs because they have a hard time falling asleep scored about two sleep apnea scores about a 12 if you have sleep apnea if your medical resident you score about a fifteen worse than sleep apnea and then narcolepsy who are just about as sleepy as you can get score about an eighteen so medical residents are somewhere between sleep apnea narcolepsy when it comes to level of sleepiness which many residents reply believe this was right before the first duty hours iteration but I'm sure that much of this actually still still stands because duty hours hasn't really done what we're hoping to do when it comes to increasing sleep time so why do why are we so sleepy in the medical field plenty of reasons you know you're on calls you don't have time to sleep you have fragmented sleep because you're getting paged the night you can have circadian rhythm to certain disruptions if you're asked to do night flow and your your body clock is lined up completely differently that causes problems with sleep and then you can have a primary sleep disorder like sleep apnea insomnia this is a this is a hip mcgrann this takes you to the various stages of sleep over the course of entire night it's daram stage 1 stage 2 3 & 4 we actually now combined into like stage 3 as deep sleep but you should go through cycles every 90 minutes the first part of the night you're supposed to spend a lot of good time in deep sleep second probably night a lot more time these black bars are REM sleep that's how a normal night should look in an ideal situation if you were to get 10 pages of the course at night you're fairly evenly spaced this is how you hit the ground will likely look your spending really any hardly any time at deep stages your REM sleep is very fragmented and you're just having a poor overnight quality of sleep and then BOOM morning rounds hits and you're you have to go and be coherent so it really destroys your sleep architecture and the normal cycles that you're supposed to be getting through so what does that result in it a deprived resident or faculty or any secret live human being it affects almost everything that you do okay if you have a sleep problem it worsens just about every other social psychiatric medical condition that you can imagine so a workplace becomes difficult your mood and performance are strongly linked to how well you sleep your professionalism can take a little bit of a hit if you're sleep-deprived relationships at home of course can be a problem your overall health and well-being driving safety which we'll talk a lot more about in just a bit it can be a big issue for our trainees and then learning you don't learn as well winter secret project who's at risk what are the most the specialty is most likely to report experiencing sleep deprivation probably no surprise in your surgery they've count they've carved out an exception to duty hours rule for neurosurgeons they can make it to work 80 hours just was not enough to get the job done so they have a higher like duty hours limit so neurosurgery is actually number one reporting signs of sleep deprivation general surgery is number two orthopedic surgery the number three we see a little bit of a trend here the people that are standing over you while your body is split open are the ones that are the most sleep deprived which is great and said but then some that might surprise you neurology comes in at number 4 will be Gy a and 5 and actually Pediatrics comes in a number six for sleepiness so I give this talk to my Pediatrics department every year I remind them that you know even in Pease where we think the schedule is not as taxing turns out it is if you say that's great you know we are a self-selected root for medicine right we likely function fine off asleep reparation we can stop perform at our best and unfortunately the data again shows that that's not quite true this was a fun little study where they had folks tracking a little a moving object on the screen with the mouse just to see how they could track it and they established the person's mean performance and they let put that as a level one and then they look to see how that performance changed the longer they were awake so after about 21 22 23 hours their performance began to suffer such that they were doing about 6 percent worse 94% of what they were doing at their own baseline ok and one and then they gave them the interestingly their performance actually then started to improve back to like the 29 hour mark and this is all due to that the robust effective your circadian rhythm that kicks back in in the morning time so fascinatingly you know it shows that yeah you suffer but the secatur them kind of helps you out your plight might be not getting back to 100% if you're awake for that long but it does kind of help you the next morning but you can see that this is this is a problem right yeah when you're up for 20 to 23 straight hours you're performing at about 94% of what your baseline is on this motor tracking task they then gave these subjects alcohol and they were checking the blood alcohol content of different levels and then seeing where they perform on this tracking tasks and at around 0.08 which is you know the legal driving limit they're performing at about 94% of our baseline the same performance they have in there there are secret prior for about 21 22 23 straight hours so sleepiness can in some ways mimic the deficiencies you experience when it comes to this specific task as alcohol does to your brain and there are lots of studies that show that sleepy driving does have the same risks in certain situations as wrong if you're a resident that reports sleeping less than five hours how do you compare to those reporting sleeping more than five hours per night these are odds ratios for a whole host of bad things that can happen and this is that this was kind of a nice paper that they sent out surveys - it was over 5,000 residents across all different specialties they got about 3,000 responses that shows that they really are at risk if they're reporting a minimal sleep and that same study they also have them bend into different amounts of sleep and how they experience their training program so whether there are reports of stress their reports of how well they learned the self impairment and feeling belittled and humiliated by their superiors the more sleep you got the better they felt they did with learning and the less they reported all these bad things stress is self impairment and feeling belittled and humiliated an opposite is true for folks has slept really little they had poor scores across the board I know when I'm sleepy that's another thing that people often say well I know when I'm unsafe to do a procedure at once safe to get behind the wheel these are some of the warning signs that may make you think well maybe your are a little bit more sleepy than you think if you fall asleep at a conference on rounds you know I tell people that if you're falling asleep during my talk and you think I'm boring you you shouldn't necessarily fall asleep you should just sit there bored if I'm boring you that's what we do when we're bored you actually fall asleep when you're bored you to sit there bored if you're falling asleep it's a sign that you have a problem with the quality or quantity of your sleep it's pretty clear and simple so if you find yourself dozing off from the day when you don't want to be it's not because you're bored it's because you have a problem with your sleep if you're fearing irritable with staff colleagues family and friends maybe it's not everybody else maybe it's you and how that could be the problem if you have to check your work repeatedly if you have difficulty focusing on the care of your patients and if you feel like you just don't care apathy is when those early markers of like sleep deprivation just you just start feeling like you don't really care so much the more you don't have that wants to go out there and take care of your patients residents are unfortunately subjected to lots of like sleep experiments this is another experiment on residents when it came to sleepiness the MS LT the multiple sleep latency test is a daytime test we use to objectively determine how sleepy you are and what we have folks do is that different at two hour intervals so 10 a.m. noon to 4 & 6 we have subjects come into the sleep lab we hook them up to an EEG put them in a nice dark room but I am in a comfortable bed and say I'll bet her lights off I want you to go to bed as fast as you can let's see how fast you fall asleep and you do five naps and you average how long it took them to fall asleep those five names if it takes them under 8 minutes to fall asleep on average it's considered pathologic sleepiness that's not what cutoff for pathologic sleeping if it takes some more than 10 minutes to fall asleep during the day that's considered normal and between 8 and 10 minutes is kind of a grey zone but we're not quite sure whether it's you know pathologic or not so what they did is they had residents go through the snap test to figure out how on average where they fell when it came to the different naps and so and they had a divvied out by by the time the day they took the naps if they allow them this this line here is you know how many minutes on average it took for each nap after they had an extended period to sleep in okay they did pretty well they stayed above like this this is the eight-minute cutoff here for every Napa temp on average it took him more than more than eight minutes for this for this group the square boxes here are just their baseline well they're just a regular day where they they went in there and took a snap test they were consistently below the 8 minute mark just on average for so residents on average as their baseline are pathologically sleepy it's not surprised and then post call of course they did a little bit worse they were actually even more sleepy than they were at their at their baseline all that makes sense residents are sleepy people that's what this study shows but the interesting part isn't after every nap attempt they ask the resident hey when you're in there for the last 20 minutes did you fall asleep during that map you know you should you should know right it's your brain you are they're arresting you should know you closely did you fall asleep and so out of all the residents out of all the naps on 90 episodes the residents actually walked out of that room after 20 minutes and said nope I was awake the whole time I know I was away I fell asleep and they were wrong based on our EEG which doesn't lie they were wrong 76 percent of the time they're like I didn't fall asleep and they actually fall asleep which is scary right they're fall asleep don't know it which is scary when it comes to again being a surgeon or driving at home not knowing how sleepy you are or not even knowing that you fell asleep is a really concerning thing so a fascinating study so you don't really know if you take the general population so how sleepy are we and and the thing I like to focus on are things that put its most at risk of problems which is driving is the most dangerous thing you guys are going to do today the general population in America reports about 60% of adult drivers say that they've they've driven while feeling drowsy within the past year more than 1/3 say they've actually fallen asleep behind the wheel at some point in their lives and of those that say that they've not at all 13% of them say they do it once a month once a month but we were on the road with a bunch of zombies actually believed because three or four percent of people say that they're doing this every month which is frightening this is the general population we're not even talking about our sleep-deprived residents who are much more sleepy than the general population the highway the National Highway Safety Administration they conservatively estimate that a hundred thousand police report crashes are due to fatigue and sleep this number continues to increase with more detailed and more specific studies that we have and it causes lots of deaths lots of injuries and it's not just limited to cars Exxon Valdez oil spill was thought to be related to fatigue third mate that was at the wheel and when the issue happened there have been a couple of commuter train derailments up north that are blamed on the driver actually falling asleep one of them had untreated sleep apnea fell asleep and went around a curve at 70 miles per hour and killed multiple people and this is a picture of Maggie this is where Maggie's thought comes from she was in her 20s driving in New Jersey when somebody that had been awake for 24 straight hours fell asleep behind the wheel crossed the median hit her head on and killed her in New Jersey before this accident happened if you kill somebody when you were asleep behind the wheel it was a misdemeanor and you had like a thousand dollar fine or something now because this law was passed if they can prove you've been awake for 24 straight hours and you get an accident due to your fatigue then you are charged with vehicular homicide that comes with the up to ten year jail sentence and about a hundred thousand dollars in fines so this is in a law in New Jersey but it's a state-by-state kind of a decision and most states don't have drowsy driving laws but it's very interesting because you know what I gave us talk and Rutgers in New Jersey at night and I told them I said you know how do you guys deal with this because when you're charting in a medical induct chronic medical record they can easily prove out that you've been awake because you're always charging you always you know look easily glorious and go back and prove it and they didn't even know about the law it's not didn't nobody tell us about that so it's it's good it's it's something I'm hopeful I'm hoping there'll be more of a push because I think this is the kind of legislation we need to really open up people's eyes to the fact that you know sleepiness is dangerous and we got to be held accountable at some point for a residents when it comes to vehicles stuff a lot more dangerous than the general population this is a Mayo training they asked their residents during your training your three or four years here what happened in eleven percent of the report that they were involved in a car crash forty three percent said had a near-miss motor vehicle crash twenty percent said they fell asleep while driving seventeen percent they fell asleep got stopped in traffic so of course it's a real problem this is just one training institution but sleeping its behind the wheel as a problem and every time I give this talk you know I when I give it in front of like a group of residents I always have one person come up to me like share up just the saddest stories and these are young healthy people like one of my good friends I gave his talk to that doll neurology team at Duke and she came up to me she goes I have a friend who was a resident we just had a child so a resident that has just had a child is probably the highest risk of injury out of any human being on the planet I think this poor woman I decided to take a lunch break to drive home to see her child fall asleep behind a wheel car accident cervical spine injury and now she's quadriplegic and confined Toby like just the saddest cases and it's completely preventable and avoidable so that's why I really drive home the message you got to be safe behind the wheel so important duty hours I am NOT a duty hours expert okay so we're not I'm not gonna delve into the duty hours debate but I will tell you that we thought this was gonna help people sleep more and it's not really doing that Duty hours just because we limit the amount of time the hospital does that equate to more sleep time unfortunately so this it's not that it's not the answer to getting more sleep because you can do whatever you want to when you're at home right and residents opt to you know they they have Netflix and smartphones and lots of things that are vying for their attention and and limiting their sleep so now what can you do to become an expert sleeper let me give you some practical tips that you can hopefully use yourself you can tell your trainees you can tell your family about step one we'll do it step by step the four steps the first step is practicing good sleep hygiene sleep hygiene is anything that's in your environment or behaviors that can help or hurt your sleep so the steps to good sleep hygiene are one developing a routine everybody benefits from routine you talk about you know look kids having routines adults should have nighttime routines it should happen about twenty or thirty minutes prior to bed you the same way every single night before you get sleep you avoid bright lights you try to stick with it no matter what day of the week it is and try to at the same time this works on a subconscious level because your brain begins associated the steps of your routine with impending sleepiness and sleep opportunity so you naturally start to actually feel sleepy during a nighttime routine so it helps everybody you an avoid light we'll talk more about the details barring that but you in short your brain can't tell the difference between artificial light and sunlight then sunlight is really what drives your circadian rhythm and tells your brain hey you should be feeling sleepy at certain times so if you have light close to your face at nighttime or bright lights from your TV your brain actually diminishes the amount of melatonin secretion and pushes back your bedtime for you so you want to have the weight light now it's not as simple as just avoiding all light because brightness does play a role if you have to be exposed like it's you know it for example you're looking at patient records you're on call and it's all you know electronic medical record the brightness of light is important the brighter the light the more likely it is to affect your melatonin secretion and you know we're measuring light brightness and Lux so this room is probably about 250 300 Lux if you go outside right now it's probably about fifty thousand to a hundred thousand looks like nothing beats like the brightness from the Sun but Lux all the way down to fifty Lux has been shown to be able to suppress melatonin to a certain extent from your body from your brain a smartphone turned up its maximum brightness up your face can produce up to 400 Lux of luminescence so can certainly diminish your melatonin secretion which is a big problem for our teenagers I see in clinic the color of light is important you law made you probably heard about blue light filters things that you can do on your phones and we you that helps so if you take the blue light spectra out that is the most offensive when it comes to your melatonin secretion the problem is all the visible spectra do it to a certain extent that can diminish the melatonin so blue a purple light and green light of the next biggest offenders a yellow orange and red are less likely to decrease melatonin but they all do it so I tell folks using the blue light filters or is a good step if you have to have a screen in front of you but ideally just turning the turning the device off is best and then timing the later you get at night the more likely it is that the brightness is going to affect your melatonin secretion and especially for young people who like to stay up well past at bedtime all that light they're consuming the later they're getting it the worse it is for your melatonin okay so some people about and then others as far as steps of it see packaging you want to avoid substances that are gonna disrupt your sleep so caffeine nicotine alcohol all of these end up actually being sleep disruptors some of these may not surprise you but alcohol you think of as oh man that helps me sleep if I have a little nightcap it makes me sleepy and it's true alcohol helps you fall asleep but your body actually ends up withdrawing from alcohol during the night with withdrawing and as you turn through the alcohol it actually fragments your sleep keeps you in lighter stages of sleep and then you wake up earlier than you would have otherwise because your body has withdrawn from that alcohol particular if you have like two three or more drinks you will wake up earlier and you will be tricked into thinking you have a little extra energy is sometimes you wake up feeling oh man after a you know hard night of drinking I got I got what pep in my step you know I feel pretty good that's not withdrawal phase where you're going from sedated to more awake but as the day goes on you realize that you actually haven't gotten to quality sleep because then you start to really struggle so alkyl Hans up being a net sleep disrupter it does not help your sleep and then I wanted to just focus a little bit on caffeine with hopes of not offending too many people here just to tell you how many milligrams of caffeine are in there substances that we typically drink because the FDA doesn't make anybody label this so they can keep it as a nice little secret but it's important to know because this is the reason why people are kind of using these substances and to put it in kind of a reference 10 grams of caffeine is a lethal dose if you can jet ingested 10 grams of caffeine really quickly you'd likely have cardiovascular shutdown and collapse and die these doses are milligrams okay it's a slightly different and milligrams not grams the clear sodas don't have any caffeine in them so you can go to town and when it comes to caffeine content probably not so great for sugar consumption but from a caffeine standpoint no problem decaf coffee they have to take out a certain percentage to label a decaf but it still has caffeine in it about five milligrams not not that much milk chocolate also not a big offender an ounce of that has about six milligrams dark chocolate is three times worse than milk chocolate so I really would to avoid that late at night time your average can of coke has about thirty five milligrams and Mountain Dew people love that buzz for Mountain Dew it's because the caffeine content with fifty five milligrams this is why Red Bull gives you wings it's the caffeine content okay it's not you know people are talk about energy drinks like I have this energy there's no you know ATP there's no energy in these energy drinks it's just gobs and gobs of caffeine and make you feel alert and awake that's all these energy drinks are the Red Bull has eighty milligrams of caffeine they put other stuff in there like taurine and all these stuff to make you feel like you're getting energy but you're really just getting caffeine Coffee has it's better than a Red Bull you know coffee gives you wings because it has 110 milligrams of caffeine in it there's still two ounces 5-hour energy shots and they've seen it if you're checking out the grocery store two hundred and seven milligrams you can drink it in like two sips and it's like two cups of coffee widely abused by by students and then straw bucks I don't know how they do it but Starbucks has found a magical way of infusing their coffee beans with with caffeine and this is this is like their house blend like Pikes Peak or something like that and again it differs based on how they're brewing it etc but on average 16 ounce of Starbucks coffee house blend has 515 milligrams of caffeine their stock price and they're in the number of their stores that has done really well over time and this is this is a reason why I mean they people love this stuff makes them feel really good that it's because the caffeine so if you drank 20 cups of straw bucks coffee really fast you would die that's a lethal dose it's 10 grams there was actually a case of a I think it was a 14 year old a few years ago who had ingested three caffeinated beverages one was an energy drink I think one was a coffee one was a soda then he died and the coroner said I can find no other reason that this child died apart from caffeine intoxication and it was only about five or six hundred milligrams of caffeine total to the child had ingested no structural heart issues you know likely the kid the child probably had an underlying propensity for everything nobody knew about but still there may be many people out there that having a propensity for everything that they don't know about and so caffeine is not a benign thing all right that wraps up sleep hygiene that's acceptable sleep hygiene number two is managing your sleep time this is again trying to change your perception about sleep many people say you know I have a certain amount of things that I have to get done today and if I don't get them done gosh darn I'm just gonna sacrifice sleep max you tell people try to reverse that that philosophy and say I have a certain amount of hours of sleep I need to get done I'm gonna work my day around that because at the end of the day I feel like you end up being a more efficient person if you get the sleep that you need you end up working better you got feeling happier so everything I think improves if you're giving yourself that but amount of time to sleep if you're gonna take a nap or something wrong with naps as long as you're not an insomniac at nighttime naps are fine I usually say stick with less than 30 minutes like a little power nap or stick with 90 minutes because that gives you an opportunity go through a full sleep cycle if you sleep some run between you you know you may wake up out of deep sleep and that's not to say that sleep still isn't good for you it'll pay off later on the day but you're gonna wake up feeling really kind of crappy with like a headache and really kind groggy because you're coming out of deep sleep so and then the find that magically finds some extra time in your day I kind of put that in here because I often time I talk to residents and young crowds and I say you know it's it's amazing you know we spend about the average adult spends three or four hours looking at their screen every day that's probably some extra time you have in your day the average teenager now is spending about seven to eight hours looking at a screen during the course of a day there there is time in your day to really you know carve out some extra time for sleep and one of the main things suspension academics is we talk about Nina email checking you know perpetually email checking there's this joke about you know academic medicine is a bunch of active the mission send the emails back and forth until one of them gets tenure he does saying sorry I Fergal and responds you know the emails was just everywhere this is kind of what we do I recommend people try to bend their email checking yeah check it once the morning check it once in the afternoon don't keep it open try not to keep it on your phone because nobody really needs that kind of access to you you know your time is important nobody needs that kind of access that you they you just respond to an email right away and should have that kind of access to your time and when you've been it you'll probably find that magically the world is not imploding if it takes you three hours to get some email and you're likely to be more productive because every time you take your focus off of your task to check an email and then come back to your task you've wasted multiple minutes just shifting your attention and it's just not good for productivity so find some extra hour in your day adjust your cicada missus this is a little bit harder to do but if you're a night owl you want to avoid late night light you want to get lots of bright lights in the morning and you want to try to keep your schedule the same on the weekdays and weekends because if you have a tendency to shift your body clock so if you have a tendency to stay up later than you should on the weekend like the average teenager instead of worried about a ten they go to bed at like 2:00 or 3:00 on the weekends and they sleep until noon if you do that you then have to readjust your body clock and shift it earlier on on Sunday night to go back to bed at 10 o'clock and you can't do that you can't adjust that quickly so if you're asking a teenager who's going about 3:00 then go to bed at 10 o'clock on Sunday night but you've asked them to do is essentially shift their body clock from Hawaii time to North Carolina or Virginia time overnight and you can't do that you know it's this is what jet lag is you can't shift your by clock that quickly and so I'm convinced that many teenagers are in a perpetual state of jet lag because of what they do to themselves over the weekend they try to catch back up to the workweek they probably get close to I need to be and then they delay themselves all over again so they're perpetually jet lag and perpetually angry upset because of it if you're an early riser feel the type of person that does not need an alarm clock you wake up the same time no matter what time you went to bed don't ignore those early signs of sleepiness your colleagues may be able to stay out at a social event longer than you and but they'll also getting able to sleep in long the next morning if you're a morning person you have that luxury you can't really sleep in your body clock wakes you up in no matter what so don't ignore those early signs of sleepiness and then you want to screen from the line steepest orders half of adults that snore have sleep apnea so that's a lot you can have restless leg those abnormal symptoms in your legs creepy crawly feeling pain that keeps you up then you can have insomnia as well so lots of other underlying sleep issues that our trainees and ourselves can experience that can prevent you from sleeping well let's uh let's skip over this here listen this is a challenge for you guys I like to end with the challenge one week try this if she can I beg you please it for one week trying to get yourself nine hours of in bed sleep opportunity it sounds crazy but if you are at eight hours sleeper you likely will be a little bit more than eight hours to start catching up so I said give yourself at least nine hours of in bed sleep opportunity if not more no caffeine after 10 o'clock and no screens for 30 minutes before sleep and just see how the week goes see how you feel that in the week I'm asking just for one week out of your life and the reason I say this is because I'm convinced that the majority of us are going through life in this semi kind of fog state because of sleep deprivation not really kind of experiencing the colors as bright as they are the birds aren't singing as nice as they're you know we're kind of walking zombies many of us are if you try this and you're like wow I actually feel that better I got should get through this whole chapter without falling dozing off and maintaining focus and attention I've become much more efficient worker and much more happy person at home it might just change your perspective on sleep so so give me a week of trying this and see what how things go alright let's wrap it up take-home points seven hours of sleep switch the average adult needs no such thing as getting accustomed to less sleep sleep plays a vital role and fatigue performance in personal safety duty hours can only do so much you got to take responsibility for your own sleep health and sleep timing alright I think we hopefully have some time for questions thank you very much for the attention just anyway appreciate it the question you can feel free to ask we know you all are on a time schedule so if any delete feel free to leave or staff Air Force I was always told that you can't compensate for a cig deficit by like sipping it all weekend and then I caught the tail after the news story on the radio the other day get out but yeah they don't like children on average over seven days over a week that matters yeah so you can't catch up to a certain extent it depends really on how much of the sleep that you've built up the average teenager has been shown that based on how badly they sleep there by themselves even sleeping on the weekends is not catching them up completely so it all depends on your individual situation how secret private you are the tricky thing is you're likely not going to be able to pay off all your sleep done quickly because even though you may want to sleep from 14 hours straight and pay everything off your circadian rhythm won't let you it's gonna wake you up in the morning at some point even if your brain still feels sleepy that alerting signals gonna kick in and wake you up so you can pay off only so much every single day and all depends on how sick to five you've been or the course of your life the the the best way to do this to test it is to think to yourself how much sleep you think you need to feel fully refreshed and then give yourself an extra half an hour of sleep opportunity and see how things go and if you are paying off sleep debt over time you'll find that you start waking up earlier and earlier and earlier and hopefully get back to what your baseline you need is so that's the best way of testing give yourself little bit extra time and then slower than your body work itself back and then it'll average out somewhere you know like eight and a half maybe maybe less I'll average out somewhere that's where you know that's what you're gonna sleep need is yes yeah I tell them to get rid of the past I actually screen for this and it's one of my questions on my clinical intake and I tell them that the pets have to be out of the room and I can and this is tough it would depend on the situation I have children autism that having a pet helps with anxiety etc it's fine always exceptions but if you have a choice close your door and keep your pet out of the room pets can be a big disruptor not just because they like to jump on your bed and wake you up etc but you know they can stoke allergy issues they can be loud and there are actually sleep training books for dogs out there because there's such a problem with like dogs not sleeping through the night so it's a problem so I tell them please out of the room and ideally a pet that doesn't make noise at night and having the location doesn't make toys away and if they can't if there's something the house they can't avoid there is gonna be some noise and having a background white noise machine can help drown out some that background noise that'll be helpful yes yeah what about infants yes kicked another ring - yeah so infants after they hit about six months of age this is kind of bread and butter in my clinic which is a parent training when it comes to sleepiness but there are effective solutions and we didn't mention this but I actually I wrote a 50/50 page like primer book on sleep problems and children particularly focusing on infants and toddlers because there are they're almost always a behavioral issue there's almost always a behavioral solution sig train is like the behavioral solution there are multiple scientifically proven ways asleep train a child but the but the the steps are actually pretty straightforward and again a few in value back I have a whole lecture on insomnia and how to take care of in some at different ages but but infants can be a challenge the American Academy attrex now recommends that the infant stay in the parent room for one year of life which the sleep doctors are gonna pull their hair out of it are you kidding me room sharing for a year that's crazy and and now we're getting more literature that shows that you probably don't need to keep them in your room that long you need to kind of get them out there longer than the room with you the more likely they are to have other sleep issues x sleep association is sort of where they need a caregiver help them fall asleep wake up in the middle of night multiple times and you'd help to fall asleep again so there's this balance between the risk of SIDS which is the AAP is trying to address and the benefits of getting adequate and and restful sleep so infant depending on your family situation I encourage you at six months and sometimes even earlier actually getting them out of the room having their own sleep location it's so funny cuz you know they'll be sleepless I kind of joke yeah when I was doing research for my book I knew all this think techniques I already finished my sleep fellowship but there's like it's three four hundred page books like you have like forever or lies with all Fant and fantastic individuals and have great techniques but like the books are like so dense and I'm like a sleep-deprived parent you know I just hadn't had my first time let me just tell me what I need to know just tell me what I need to know dr. wise be telling dr. Farb what's gonna so I just made a book at it just in this south of techniques cuz all these books that the of techniques Lee is like four lines is what the books about the publishers make them put 400 pages of stuff to sell the book it's like four lines so I just put the four lines and I thought this is what you have to do you know let's make it easy steak should be easy that's my day anything else enjoy your day you.