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Why Do Hospitals Hate Sleep So Much? (motherjones.com)
689 points by curtis 3 months ago | hide | past | web | favorite | 509 comments

I recently had a family member in the intensive care unit (ICU) for over a month in Austin, Texas. I quickly learned my main contribution would be protecting her sleep when I saw she hadn't slept in days because of the constant interruptions. She went from reasonable and compliant in taking her medication, to extremely irritated and noncompliant with the doctors. Of course I could see this was due to sleep deprivation, but when I kept bringing this up to the doctors and nurses, they gave me blank stares and didn't seem to believe or care. When they started suggesting another surgery due to her not improving, I nearly lost my sanity. Ultimately, I had to become a very vocal and unpleasant protector of her sleep - if a nurse came in, I quickly took him/her outside the room and asked what they were planning and whether it was absolutely necessary. This annoyed them quite a bit and they hinted that they could have me removed. It was one of the worst experiences of my life. Just being in the ICU for a month with a loved one is hard enough, but having to battle the staff to protect something so basic as SLEEP so she could recover, made it a true nightmare. Something is truly broken if trained medical staff see sleep as optional - the data and science behind sleep is so compelling, and they don't understand these basics? Desperately frustrating...

You were dealing with doctors and nurses, right?

One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week. And the other group are typically on shift rotas so their sleep patterns are permanently disrupted.

I'm going to call it for them being oblivious to the sleep requirements of ordinary human beings, because these professions are self-selecting for sleep-dep survival traits; only people who can work insane hours make it through hospital medical training, and only people who can take shift work in their stride make it as hospital nurses.

(Also, my observation of hospital doctors is that anyone you see on a ward outside core office hours is relatively junior, i.e. aged about 22-35. Senior consultants and professors work normal hours like everybody else. As for the nurses ... my understanding is that ICU nursing burns them up.)

(Source of observations: former hospital pharmacist here, who just got a refresher course c/o a relative who spent three months on an acute stroke ward this fall.)

>One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week.

I would argue this is the source of injury and death to the patients that needs to be addressed rather than powered through in some sort of macho hazing ritual. Anecdotally a very tired doctor is allegedly how my wife lost her mother.

I used to work in hospital IT at a level 1 trauma center from 2004-2006. While I was there, an article was released which studied the relationship between time on shift and errors made by staff. As I recall (and it has been 10 years) the findings were:

* Through roughly 9 hours, the error rate was about the same. Say, x%

* In the 10th hour, the error rate increased. Say x + y%.

* In hours 11 and 12, the amount the error rate increase doubled the 10th hour's increase. So x + 2y%.

* In hours 13 and 14, the amount the error rate increase quadrupled the 10th hour's increase. So x + 4y%.

* In every subsequent hour studied, the error rate increase doubled again. x + 8y% in hour 15, x + 16y% in hour 16.

I want to say the study went to 18 hours, but I don't recall if it was 16 or 18 at this point. The paper made the recommendation that shift lengths should be limited to 10 hours maximum.

Every health care professional I spoke to about the article (resident doctors and nurses, maybe 10 overall, mostly in the ER) said the same three things:

1. They had personally witnessed someone make an error they could attribute to tiredness.

2. They themselves had never made a mistake due to tiredness.

3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.

2. They themselves had never made a mistake due to tiredness.

3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.

I think those two items and the tribal knowledge that handoffs are more dangerous to the patient helps the overwork model persist. Sounds like it's past time the medical industry prove that handoffs are more dangerous to patient outcomes. Doctors are trained to be problem owners and problem solvers, but that doesn't make them good team players. And lowering handoffs also limits oversight and prevents second guessing which is great if you're convinced you're always right, but clearly doctors are not always right and patients often pay the price.

Medicine is a conservative field - unfortunately that also includes ignoring anything harmful to their cult aspects even if it is trivially obvious like "wash your hands" after doing a damn autopsy before delivering a baby. Or yes infants can feel pain - not using anesthesia because the control isn't fine enough to not have a better chance of killing them is a grim but justifiable thing initially but inexcusable once it becomes possible to do so safely.

And the sleep deprivation and hazing "I did it so everbody else must too!" is definitely a cultic thing.

I use cult very deliberately to point at the reasoning being entirely irrational and social as opposed to underlying value. And also because actual cults use slerp deprivation.

Peter Attia (MD) had a podcast episode where he talked about being a resident and how it almost killed him (asleep while driving) and was bad for patient.

Also explained that the guy who created the residency program was a cocaine addict who rarely slept, and since then all doctors have to try to follow his crazy schedule for no good reason..

My girlfriend is a second-year OB/GYN resident (which is a 4 year program) and while that field's residency is less insane than some other specialties like ER, she still works 12 hour shifts Mon-Fri (6a-6p on paper but generally 6-7:30), one 24-hour weekend shift a month, and one 12-hour weekend free clinic shift a month. This is on top of the "extras" that are not work but are required to graduate the residency programs. Weekly rotating presentations to the rest of her group (4 other second-year residents so one ~45 minute presentation every 4 weeks), research, generally keeping up with the state of the art in her field, etc.

So she's only "scheduled" for ~67 hours a week averaged throughout the month, but realistically it is in the 85-90 range.

It's easy to see how a more demanding or emergent field could seriously select for folks who are more able or willing to work on less sleep.

Yeah. I mean, I get that hospitals are 24-hour operations that need doctors & nurses available at all times. So some people are going to get the crap end of that stick and have to do night shifts. But is it really necessary for them to work 80+ hours while they're at it? It seems like there's enough people trying to be doctors that you could cut that down to a healthier 40 hours+ 15 hours on call if it's really necessary to. Heck, even 50 hours.

Here in the UK, the way I heard it from a friend who was doing their pre-med, is that there was a built-in cost incentive: hospitals paid doctors who were on-call at one third of their regular hourly rate for out-of-hours on-call coverage. (That's not regular hourly rate plus a third; that's one third of normal wages for hours after the first 40.) So the hospital administration had a solid reason to work their interns and house officers into the ground rather than hiring extra junior doctors.

The original rationale was that the "on call" hours were not supposed to be busy and the duty doctors could spend most of them sleeping in a bunk or studying: but by the late 1980s (when I heard about things) they were working more or less constantly through their shifts.

The EU Working Hours Directive was supposed to fix this by banning workers from putting in more than about 50 hours a week without very specific protections being enforced, but one of the first things the UK's Conservative government did in 2010 was to stop enforcing this.

I wonder how much of it is financially motivated in this way and how much is the inertia of this hazing-style culture. From what you've said, I'm sure hospitals would object to a change out of financial self-interest, but it seems the ingrained culture stops the issue from getting a big push to begin with.

I know labor unions (sometimes rightfully) get a bad rap, but it seems this is exactly the type of abuse they were designed to stop. There are some [0] but the rate is low, less than 15%, and there's a sort of self-censorship style of pressure against pushing harder for them.

[0] https://www.theatlantic.com/business/archive/2017/02/doctors...

But Doctors have a very strong labor union, which tends to advocate FOR this system. Probably even though the AMA represents residents, doctors who have succeeded in the residency system have more sway within it.

I'm in the US. After some searching, I can't find any information about most doctors having unions. I found one that appears to mostly work with California doctors, but that was about it. Either way, I was speaking about residents, who don't have particularly strong or ubiquitous unions. Again, that's in the US. Other countries may vary.

I was being tricky here but I mean the AMA.

It controls a great deal about doctor's education and working conditions. It does not collectively bargain, so it's not strictly a union. But it's more powerful than most unions at this point. So a glib, "maybe doctors should get a union to represent them" answer to poor working conditions for residents doesn't really make sense. They already have a powerful organization that should represent them.

I think that there is at least some group of physicians who really think that poor working conditions for residents improves patient outcomes and doctor training.

That is very true, the AMA is not formally a union, but it does exert a significant level of control and influence in standardizing the practices of doctors.

As for patient outcomes, I'd love to see a study of them for the roughly 15% of residents that have a union and very modest work place improvements, compared to outcomes for the rest of residents. You're right, many doctors do seem to "feel" the traditional method is superior, but I'd like to see hard data.

I know I've seen some before, I think The Atlantic had an article about it in the past year.

I found this paper: http://www.acgme.org/Portals/0/PDFs/Position%20Papers/Commit...

It's citations have some hard data. Maybe the most interesting part for me was this:

"There exists instead a widespread belief that physicians can be trained to defy the biology of sleep and that safeguards are in place so that patients and residents are not harmed by work schedules that are unheard of in any other workplace, let alone a hospital. That belief is most evident today in the FIRST and iCOMPARE studies that set out to prove that there is no difference in patient outcomes from residents who work 16 or 30 hour shifts. The principal investigators were so convinced that no harm would come of these experiments that they determined it wasn’t necessary to obtain informed consent from either patients or residents in the hospitals where the studies were conducted. This determination has been widely disputed and is now under investigation by the Office of Human Research Protections."

The counter argument that I have heard is that patient handoffs are where a disproportionate number of errors occur. Increasing the number of shifts means that more patients in the ED or on the floor will have care fragmented between providers, making it more likely that results will not be followed up or that changes in a patient's status will not be recognized.

I don't know at what point the errors from sleep deprivation exceed the errors from patient handoffs. People seem to take different views depending on what side of the work hours debate they fall on.

This would be easy to do a controlled experiment to compare.

> It seems like there's enough people trying to be doctors

Not in the US. The doctor per pop count is very low.


I think the key word in the sentence is trying to be doctors. The doctor per pop count in very low because med schools have super low acceptance rates[1]. That would probably be the best place to implement some sort of reforms if we want more doctors.

[1] https://www.accepted.com/medical/med-selectivity-index

There are plenty of people trying to be doctors, but there aren't enough programs to train them at the moment.

I imagine if med schools made it easier to get through their programs, the end result would be a significant lowering of the average pay for their profession, as more doctor's hit the job market. It sounds like it's in the best monetary interest of doctors to keep their professional supply low, allowing the demand for them to be high.

You would likely have to extend residency based on everything that you need to learn for a given specialty. Med school graduates have an average of over $180k in student loan debt - from med school alone - and resident salaries in the 2-4 year programs are mid five figures.

Given the choice, I'm not sure someone whose 4-year earning potential is capped at $60k with $200k in student loans would want to extend that to 5/6/7 years.

>You would likely have to extend residency based on everything that you need to learn for a given specialty.

I would challenge that assumption because I don't believe there's any consistent number of hours worked by residents in rotation, is there? I mean there are published schedules and then there are actually the number of hours worked which at least according to the other posters is even more than scheduled. So if there's already an element of randomness here and different doctors are getting different numbers of in-rotation hours then it's plausible hours could be made consistent and reduced, isn't it?

I believe the GP is talking about increasing the number of doctors, not their years in residency.

You learn how to do your entire specialty during residency. If you cut the number of hours, you have the same amount to learn in less time.

That's on the assumption that amount learned per hour remains constant as hours worked increases.

And that sleep deprivation has no effect on learning ability.

You may want to look into why med school is so expensive, compared to other majors.

I've always assumed that the failure rate for handing off care to another person and the rate because of long hours must go in favor of long hours. I don't have anything to back this up except the MCAT being designed to check how you perform when tired. Now with electronic records I've been wondering if long hours are still be necessary, assuming I'm right about the failure rates.

I'm sorry about your mother in law regardless.

Super intersting to see people discussing this! As someone that holds a pilots license and talks with a lot of commercial pilots about their jobs, sleep is often a hot topic of discussion. It would be illegal, not just irresponsible, for a pilot to try pull off a 120 hour work week. Why do we treat doctors differently? Their macho behaviour in my opinion is unacceptable, and likely reduces positive patient outcomes, yet it goes on?

Medicine has different concerns than piloting, though. Pilots don't have to ensure continuity of care for their passengers, and can accomplish their work in reasonable chunks. Doubling the number of patient handoffs, on the other hand, significantly increases the risk of one of the more common sources of error.

But could the increase in errors from increased hand-offs be smaller than the increase in errors from sleep-deprived doctors, nurses and patients combined with the increase in disease spread and disease progression from the effect of sleep deprivation on the immune systems of doctors, nurses and patients? Additionally, could there be benefits from getting more eyes on a patient's condition?

I've always wondered if the problem might be in the handoff procedures. Those studies about mortality in the event of a handoff always make it sound like obviously handoffs are an inherently dangerous thing, but perhaps the modern way of doing them is just poorly implemented? It feels extremely unlikely to me that absurdly long hours are the only solution.

There's just no way efficient way to capture, log, and communicate every single little detail a doctor observes while diagnosing and setting treatment for a patient. First impressions are often wrong, and little details can become significant later. Early treatment might be designed not only to address symptoms but to exclude other diagnoses.

In a plane in level controlled flight, there is very little to hand off between two type-rated pilots. Both folks understand the machine, and the machine is working the way it is supposed to. Humans work the same way! Parents "hand off" their healthy kids to schools or babysitters or relatives every day.

But imagine a plane that is in the process of crashing; it's in a dive, controls are not responding as expected, one of the engines keeps turning off. A pilot is fighting to regain control... how comfy are you with THAT pilot handing off the aircraft to another pilot in the middle of that situation?

It's a little silly as an analogy, since plane crashes tend to be resolved pretty quickly one or the other. But conceptually, just imagine a plane that is in the process of maybe crashing for 12 hours. There's a good argument for a pilot to just see that through instead of "clocking out" at 8 hours.

I think this is a rational question to ask! Often people will jump to conclusions "handoffs cause errors", and while errors are a symptom of handoffs executed poorly, it seems uncommon for people to often ask for improvements to these processes.

> Pilots don't have to ensure continuity of care for their passengers, and can accomplish their work in reasonable chunks.

Are you aware that on long haul international flights pilots do in fact rotate who is actively "flying" the plane? Flying is in quotes because most of the work is done by automation these days. I won't draw any analogies between the autopilot doing much of the work for pilots and nurses doing it for doctors because I can't actually support the statement with any data.

Yes, but that's the whole point: there's little risk in rotating pilots, whereas rotating members of the care team carries a substantial risk of key information falling by the wayside.

I see your point, but i'd love to see a peer reviewed study to back up the claim that "it's better to have over-worked doctors and nurses than to introduce more handoffs".

There's no error in hand offs. Attending doctors are detached and spend just a little time with a patient during their stay. Nurses and PAs do most of the work.

Flying a plane is way less complex than medicine. A pilot can hand off a flying plane way, way, way more easily than a doctor can hand off a patient with a complex set of symptoms and treatments.

I should also point out that the vast majority of doctors don't work 120 hours a week continuously, rather, they experience higher-than-usual clusters of working time vs. not working time. That is, they might be on rotation for 36 hours straight but then off for 36 hours or more. And some of their shifts might only be 8 hours. Residents work longer hours, but are supervised by doctors.

I know several ER docs and they all cite the dangers of patient hand-off as the main reason they continue to support long shifts.

This is the claim, but if you look at the experiments supporting it, they’re all bonkers. For example, care is no worse from doctors on 28 hr shifts vs 24. I would argue that both of these are so far from a well-rested baseline that they’re meaningless.

We know from lab experiments that performance craters way, way before that, which is why pilots, truck drivers, cops, and every other profession work shorter shifts.

All this talk is insane. I have like maybe 4 top-performing hours on my best days. The idea of working more than 8 in a life safety critical situation boggles the mind.

Many sane minds would argue that, but the ACGME is actively arguing otherwise. They are actively building rules that allow residents to work longer shifts (up to 28 hours straight) while claiming these rules improve patient safety.

Patient hand-offs between shifts tends to introduce errors. Instead of finding ways to improve hand-offs, the ACGME is simply trying to have fewer of them.

These are supposed to be some of the "top minds" in medicine and that's the best they can come up with.

That's no really addressing the problem, it's just doubling down on the mistaken notion that the treating physician is the best one to tend to the patient under any circumstance. Doctors need to learn to be team players.

There's been some study(s) which suggest that medical error is the 3rd leading cause of death. This may have been debunked so if wrong please correct me.


To be clear, you're saying that people whose job is to - quite literally - understand, diagnose, and treat hundreds (thousands?) of medical issues that they personally haven't experienced, don't have the capacity to understand that not everyone is on their same sleep schedule?

Those people spent many years learning to understand, diagnose, and treat thousands of medical issues. During that entire time, they were continuously sleep deprived as a matter of culture. Those that could not handle this environment dropped out. They're probably still sleep deprived. They may have learned about sleep's medical effects, but the personal experience of those who survived the selection process who work 120-hour weeks and have been waking patients up once an hour for years has a blinding effect on this diagnosis.

It's a bit like bringing someone from south Florida to northern Michigan this winter for some ice fishing. I understand that it's cold here, I intellectually know about, have observed the effects of, and can treat frostbite and other problems resulting from this cold - but all that would make it hard for me to intuit the problems of a visitor who was unable to control their fingers when they removed their gloves and dipped their hands into a minnow bucket to bait a hook. My fingers work fine in that bucket, everyone else on the lake is doing it, you're just going to dry them off in a few seconds and put them back in warm gloves...what's the issue?

Doctor's are notorious for not understanding their patients' experiences, and how that impacts them.

I've just witnessed this with my partner's recent bout with cancer. While her oncological surgeon completely understands, her reconstructive surgeon had no conception of what she was going through.

As someone with a father and a wife who are both physicians, yes. In both cases they started working to get into medicine in high school, pushed hard in college, and then had med school and residency.

That alone is 16 straight years of normalizing sleep deprivation. Time spent studying and working is regularly 80+ hours per week, certainly from med school onward and certainly the year spent studying for the MCAT.

If they start at 16 and finish their residency at 30 or 32, that's the only life they've ever known for all of their formative years. They cannot relate to people with a normal schedule because they have not experienced it.

The mind does funny things. They also understand that exercise and good nutrition are fundamental to health. When I worked in a hospital I normally ate in the cafeteria. The physicians had horrible diets, including the cardiologists.

Let's not even get started on how many nurses smoke.

People whose job is to treat human bodies should have enough sense not to constantly wake them up.


It's my job to create applications and diagnose problems with software, but even though I've used the software in development and testing, I do not understand the experience the same way a daily user understands the experience.

Similarly, doctors and nurses do not have significant experience in being a patient, especially one who isn't around hospitals all day.

A lot of people don't do their job perfectly.

My mom was an ICU nurse for over 20 years, and yeah, the burnout is real. My mom always said that ICU is made up of a very small number of surgery recovery patients (who quickly get moved to a different section once they're past the critical part of their recovery), and the rest is people who are just there to die (especially here in Florida, where there are a large number of elderly).

She eventually had to switch to another position, because it became too much. She said she lost a lot of her empathy for the people who had spent 60-70 years abusing their bodies, and now were just here to slowly die under her care (regardless of how good that care was). She also hated that so many people were kept alive on machines long past the point of having any life left, just to keep the families happy. She said after a while, she could tell the difference... that whatever made a person a person (the soul or whatever you believe in) was gone, and all that was left was a pile of meat being kept "alive" by the machines.

Why do doctors not get sleep? It is still the most ridiculous thing I've ever heard. Start up founders? Fine. Grocery store bagger? I don't care. BUT A PERSON IN CHARGE OF TOUCHING (inside) MY BODY? I want their Fitbit sleep records for the last month showing a consistent 7 hours of sleep.

Also apart from the Doctors, the military is also notorious for their practice of having too little sleep.

This is because their job absolutely requires performing on insufficient sleep. Combat isn't shift work.

I think (without much data here) that medical training pushes insufficient sleep on doctors due to on-call schedules. While hospitals have doctors, many of their specialists come from private practice or multi-specialty clinics, which rotate being on-call between then (often in 12 hour shifts). The other cause of insufficient sleep is that if a patient under care of doctor has complications, they will often be called, even if just for a consult.

Economically, this is likely efficient compared to having hospital specialists (which may end up with nothing to do many nights), but causes docs to train for worst case scenarios sleep-wise.

According to my doc cousin, it's to limit the number of patient handoffs between providers. Apparently error rates are around 5-10% per handoff, so the idea is that if the error rate from sleep deprivation is less than that, it's better to have sleep deprivation.

Yes! Sleep deprivation played a role in the two Navy crashes in the last few years.

I get terrible headaches if I sleep less than 8 hours and I'm 27. Always wanted to have more time in my day but I get no time if I can't focus or function.

I'd hope someone doing something as high risk and important as surgery would be getting as much as they need regardless of how much that is.

Regarding the U.S., the reality is that it's mostly the students (med students, residents and fellows.. you're called Doctor by residency) that are sleep deprived. After that most doctors are on normal to normal-ish cycles. But because residents and fellows are such solid profit earners for hospitals and the hospital owns their life they opt to over-work them and charge you max dollar for their time. Once the doctor is board certified (post residency or fellowship) then the power shifts back towards the doctor and they can get more normal lives.

Exceptions are specializations that are essentially emergency/urgent but even most of them are on rotations like another poster mentioned where they've shifted their own sleep patterns to match their hours.

Since watching my friends become doctors (psychiatrists, uroligists, neurointerventional readiology) and my wife become a surgeon I have started telling friends and family "If your doctor looks under the age of 35 then you should ask them the last time they slept before they start treating you.

tl;dr : hospitals straight up own the futures of their med students/residents/fellows .. so they overwork them while paying them $40-55k year, and when they aren't working they have to study for their exams.

> during pre-med training: with on-call work hours up to 120 hours a week.

Can someone please tell me why they still put medical students through this institutional hazing?

In medical school, 120 hour weeks really only exist for 4th year med students who are on sub-internships in surgical specialties like neurosurgery, orthopedic surgery, general surgery, etc. Students in those fields do 3 or so month long sub-i's at hospitals they want to do residency at. They basically function as month long interviews for those programs, and are also used to get letters of recommendation from prominent faculty in the field. People who are interested in those fields know about the hour requirements on sub-i's and in residency, and self-select in a way.

The reason resident physicians work so much is because residents make $60k working 80+ hour weeks, and the PAs or NPs who would be willing to cover the floors at night would make $150k+ working 40hrs/wk. Residents also have no collective bargaining power because of the residency match system. You can't easily leave one program and go to another because you don't like the working conditions, for example. If you want to leave, you're more or less blackballed unless you're switching fields. And you don't want to speak up about the conditions because you've got $300k in debt and a degree that's useless until you finish residency.

I'm currently in my 4th year of medical school, and I have to clarify your comment on the hours worked. We're held to the same hours limits as residents, which is 80 hrs/week averaged over 4 weeks and an average of 1 day off per 7 days. We most often come near these hours on surgical specialty rotations (like the ones you noted). However, these are completely voluntary rotations. I'm not interested in surgery, and I have no surgery rotations scheduled at all during this year. Most of this year is actually spent on residency interviews. I've been traveling to different cities in the US about twice per week since October, and will continue through the end of January with breaks for the holidays. I have no hospital duties from September–January.

The 3rd year of medical school is much tougher since we spend about 10 months of that year on rotations in the hospital. While some rotations are much lighter, others like surgery again get close to the hours limits. This is complicated by the shelf exams we take every 8–12 weeks. These require an additional ~2–3 hours/day of studying and most of a weekend day as well. Obviously, this study time is not counted towards the hours limits, but it definitely factors into fatigue and burn out.

Where do we go to change that 80 to 32? This thread is making me feel unsafe.

So the other side of this problem is resident education. The ACGME in conjunction with medical specialty boards govern the requirements for graduating from residency. There are hard requirements on how many and which kinds of procedures you need to do and patients you need to treat over the course of your residency. Residents meet those requirements with the current average 80 hrs/week and ~3–5 years of training. Moving from 80 to 32 hrs/week would likely require an expansion of training time to ~6–10 years, which residents would be absolutely against (I know I would be). I've been in school forgoing a "real job" with a salary for nearly a decade, and I'll be in my mid-30s before I become an independently practicing physician under the current system. Although the work hours are abhorrent, I don't want to add more years to my training in exchange for better hours.

So they are being taken advantage of then.

Sounds like they should just legislate away the "Residency match system."

Ironically, congress passed a law in 2004 to give the NRMP, the organization that runs the match, immunity from antitrust legislation. https://en.wikipedia.org/wiki/National_Resident_Matching_Pro...

Saying that "pre-med training" (whatever that means) consists of 120 hour work weeks is not accurate but it's probably just because we're using the wrong words.

Pre-med = college, and aside from the highly scientific work load is no different than any other college experience.

Medical school (no longer called "pre-med" by anyone) is typically 2 years of classes and 2 years of clinical rotations. The rotations are not going to be 120 hours a week but may be 60-80. But unless you go to a teaching hospital and consent to student contact (which may or may not be a requirement of treatment) no med school student is touching you.

Residency is after med school (they're full doctors now) where you train your specialty, and at least in the 4 year program I'm familiar with, their title is intern, resident, resident, senior resident for each of the four years. They have increasingly high levels of responsibility as they progress and by the 4th year they are basically oversight/management of the other residents who assist on complex cases and bring in at attending physician(s) for big stuff. Hours are typically 80+ and I'm sure you could approach 100 for very demanding or emergent specialties but it's certainly not "pre-med training" and 120 is pushing it for sure.

After you graduate residency you move to an attending, fellowship, or research position and the hours drop back down to the 60-70 range and decrease as you gain seniority.

And on top of those 60-80 hours per week you need to add all the time prepping for exams and boards, correct? That study time is work too, and that pushing up to 120 hours per week.

Nurses are a lot more than just shift change workers, and their nursing school requirements are a lot higher than you seem to believe.

I don’t think (s)he was commenting on education. I read their comment as only people who can do 12 hour shifts that may be required to occasionally be overnights followed by days, completely disrupting their sleep schedule, can make it as ICU nurses.

"Works on a shift schedule" is a shared trait between nurses and shift workers. "Has one thing in common with" is not the same as "is the same thing as".

Parent to that reply edited their post after my comment, and I can no longer edit my reply.

> intensive care unit (ICU)

There are only two reasons for someone to be in an ICU: they require a therapy no other floor will administer, or their condition/therapy requires very frequent administration/titration/observation. These two reasons frequently overlap.

Sleep isn’t optional in general. It’s optional in the ICU, because the premise is “if you don’t need this level of attention to survive, you absolutely shouldn’t be on this unit.”

That is a fair point, but if, as this story implies, by the end of the process sleep deprivation was the main impediment to the patient's recovery, and might have led to additional procedures and the problems they bring, then there would be an issue here.

I also wonder if, like 'emergency room', 'ICU' has lost some of its meaning in some places.

Wife recently spent a couple of days in hospital for surgery/recovery. She was in a normal double-occupancy room for recovery (i.e. not ICU), yet was still woken every couple of hours by someone taking vitals, drawing blood, doing respiratory checks, bringing food, etc. And the room was hardly ever really quiet because if someone wasn't there to see her, someone was attending to the person on the other side of the curtain that divided the room. She said she hardly slept.

Yes and there is an added benefit to frequent interruptions: despite all the monitoring equipement, a human assessment can go a LONG way in detecting trouble. My wife used to be an ICU nurse and her first code (CPR) in her career was when she was doing some routine stuff for the patient and noticed the color of their skin "looked different". When the patient's heart stopped beating, she was already there to get it back going, saving some precious delay.

For non-ICU stuff, yes there could be some better coordination around sleeping time, but again there's so much non-verbal stuff going on in just a physical assessment.

What would really be useful is having cleaning services and admin/billing services come at the same time (well, right after) a nurse comes, to take advantage of that interruption.

Agreed, but even the medical services aren't coordinated. I was in for 4 days earlier this year -- in addition to being woken for blood draws, I was woken on a diff schedule for meds and still a third for breathing treatments..meaning every 2 hours I was woken up 3 different times...then early am they'd come to get a breakfast order.

Nor are they going to be coordinated, because each of these services addresses a number of different units in the hospital. In order to have all of these services available for each patient in concert, we'd need to multiply the staffing by four or five fold. That holds as true for coordinating physician visits as it does for the other services.

I don't want to make it sound like it's impossible. It's not. But it is incredibly inefficient - which is why it doesn't happen - and the answer to "How can we make it happen?" is "Pay for it."

I think it is absolutely standard in that situation to at least take vitals every couple/few hours, no way around it. It's annoying to be woken up so often, but it's done for good reasons.

First observation every few hours is fine, but their is little coordination between hospital workers so people are often interrupted multiple times an hour which cuts the time for the next interruption.

That’s cost effective for the hospital but simply not viable longer term. To be clear waking someone up every 2.5 - 3 hours is very different from waking them up every 2.5 hours and another 2+ random times during the night.

As long as somone is only in the ICU for 72 hours it’s not a huge deal, but start talking a week and it’s a significant issue.

So, my partner had the option of either going home directly after surgery or spending the night in the hospital. The hospital staff wanted her to go home. She wanted to stay. (She has issues with post-surgical pain.)

If the hospital staff had sent her home, she would not be woken every two hours. The medical staff were fine with that.

It would have been perfectly reasonable for them to let her sleep; it would have been no more risk than they were advocating for.

Clearly it was optional.

> Clearly it was optional.

Unless there was some regulatory, legal, or hospital requirement that she receive a certain standard of care. They may have been fine with her sleeping through the night at home, but if she's in the hospital they need to take care of her.

It would not be an easy sell in a courtroom to explain that while you checked everyone except her every 3 hours, you let her sleep through the night and there was an issue that cost her life.

Not that the physicians and nurses should have been taking that into account but the folks crafting the regulations or hospital policy very well may have.

Clearly there was an organizational reason, but those reasons had nothing to do with what she actually needed according to her physicians, which was rest and painkillers.

What you've just said supports the article's argument that hospitals are designed to prevent people from sleeping.

There is a fantastic book, "The Circadian Code," which describes this exactly. I don't know what I would have done in your situation, it sounds absolutely infuriating. It is amazing how ignorant some of the best educated people can sometimes be (including myself, I'm sure)!

To get up to speed on how dramatically sleep affects our cognitive performance, listen to this excellent interview with Matthew Walker (Professor of Neuroscience and Psychology at UC Berkeley, and Director of the Center for Human Sleep Science)



I’m always sleep deprived (typing this up at 1:30am) but I’ll watch that tomorrow. Just wanted to say, as a chronically sleep derived person I typically feel like crap, everything aches. One day I got 9 hours of sleep and I felt amazing. No aching, total clarity, just felt like a new person. I’ll probably drop dead soon, off to bed now but will watch the video tomorrow! Thanks.

I'll push this one step further: why is our entire society built around the idea that sleep literally doesn't matter?

- Elementary school starting so early all the kids are half asleep in class.

- College + Sleep? Not gonna happen.

- 24 hour construction in certain part of NYC, check!

- Most cities quiet hours are very precisely 8 hours. Hope your days start at 6:30/7:00 and you're falling asleep precisely at 11pm, and all your neighbors do the same!

- Having attention deficit? Lets start with ADHD medecine, not with a sleep study, no sir.

- Bazillion jobs requiring on call, waking people up at all manner of time, as a standard thing.

- Neighbors woke you up? Toughen up bro!

- Myth around how so many people apparently can do just fine on 5 hours of sleep.

The hospital thing is just a symptom of a society built around lack of respect for sleep. No one seems to consider it an important thing. If you're drowsy because you couldn't sleep, it's considered a minor inconvenience and little more.

My wife's background is in childhood development. Her job involves keeping up with studies in the field. I remember her talking about this issue. There's evidence that school start times should be flipped for elementary and high school students: elementary going in earlier and high school later. Teenagers need more sleep due to their brains re-wiring, so the reasoning goes.

Keep in mind that in our school district, elementary school students need to be in by 8:40 while high school students need to be in by 7:50.

Our neighborhood is setup for walking. The elementary school is a six block walk, so most people walk their kids to school. My daughter didn't sleep past 7:00 for most of elementary school. Our experience was that elementary really could have started closer to 8:00.

I'm with you on all your other points. But, I think our experience was significantly different for elementary school.

I actually went to a school corporation where this happened, about 20 years ago. I was in high school. School started at 7:38. We got up around 5:30, boarded the bus at 6:05, arrived to school at 7:00. Elementary school started at 8:55, with a similar length bus pre-schedule.

Our corporation hired a firm to do a study, found that younger children performed much better during earlier hours, and flipped the schedules. The next year, the high school started at 8:50, and the elementary school at 7:45, and the schedules have been essential unchanged since. I can't describe how much of a difference that 1.5 hours made to a 16-year old.

As a father of 3 young children, they rarely sleep past when I have to wake them for school anyway. The same is definitely not true of teenagers.

Makes a little more sense in the parent's position as well. An argument that is normally made to stop school start times from being set later is that the parents have jobs which require them to normally wake up the same time as their kids. Elementary school children obviously need this parental help in the morning much more than high school students who can even possibly get to school by themselves by driving or simply being self-sufficient enough to walk to the bus stop.

As a counter-anecdote, we have to get our kids up by 7:30 to get them to their elementary school on time, and it's a battle every single morning. Left to their own devices, they would sleep to at least 8:30.

Kids are different, and we really don't have very good ways of dealing with that in some ways...

Okay, but you don't have counter-evidence. Yes, kids are different, but YES, we also know that younger children generally desire sleep and wake earlier, and teens desire sleep and wake LATER than adults. Biologically. Why not start from there, and THEN acknowledge that everyone's different, rather than starting from the WORST principles and throw up our hands and say "we can't suit everyone, may as well screw as many people as possible!"?

Where did I suggest starting "from the WORST principles"?

What I would suggest is that there is not a Pareto-optimal solution here short of redesigning how schooling works entirely...

So, maybe they would benefit from an earlier bedtime? Not being snarky, am a parent myself.

It's possible. They are generally in bed by 8:30. We have tried experimenting with pushing it back to 8 and that did not have an obvious effect on their mornings and did make evenings a lot more miserable. Going even earlier than 8 is not really feasible given that dinner generally can't happen until 6pm.

(Our no-longer-elementary-schooler, by the way, never really had this problem. He just seems to sleep a lot less in general.... kids are different.)

Just an idea - you could try putting them to bed 15 min earlier every few days, and if they have trouble sleeping put on a short kids audiobook. Two of the most peaceful I know of from Audible are “The Tailor of Gloucester” read by Meryl Streep and “The Little House”.

Also depends on how young they are, if they are of reading age, then putting them to bed a little earlier and then allowing them to read for 15-20 minutes on their own can also be another way of calming them down.

Some of the kids mindfulness podcasts (Peace Out as an example) are also good for this kind of thing

One is of reading age, one is just about there.

The one of reading age is already reading after he's in bed. The hard part is getting him to stop and actually go to sleep.

I will look into the podcasts; thank you for the suggestion!

Scripture Lullabies is really great too - very peaceful & soothing.

Anecdotally based on my kid (n=1), stopping screen time about an hour before bedtime helps.

However, she still seems wired to fall sleep at a certain time, and we finally decided that fighting biology is a losing battle. The strategy of moving bedtime a little bit earlier each day didn't work at all.

There's definitely no screen time involved anywhere near bedtime. But yes, I'm pretty sure it would not help if there were!

> maybe they would benefit from an earlier bedtime?

One can try but you will be limited by biology: The problem is that our internal clocks are reset by daylight. You can't just shift yourself to another timezone, since your circadian rhythm will always set itself back to the respective local time. So if your brain prefers you to go to sleep and to wake up at certain points it will always be relative to "local (sunlight) time", not relative to human clock time.

If the schools are fun and a great experience, the kids would wake up at 5 for school. The schools are so boring and useless, the kids obviously find no use or interest in attending them.

The kids are very happy to _go_ to school once they've woken up enough. It's that first 20 minutes after we start trying to wake them up that are miserable.

I would think that would be because teenagers are more likely to stay up late over elementary school kids.

It's a combination of a shifted sleep schedule and teenage brains going through significant, exhausting development.

> Teenagers need more sleep due to their brains re-wiring, so the reasoning goes.

I work in the education industry, and the education experts in our company have been saying this for years.

I'm envious. My high school started at 7:17am. It was brutal.

OMG! 7:17am, that's crazy. Mine started at 8:30am, it was ok most days, especially later years as I generally enjoyed going, depending on what class was first. But 9am would have been better. (as that's when primary school started for me), which suited me really well.

I took zero hour PE to add in an extra class and mine started at 6:30 am

We had a brave school superintendent a few years ago who tried to get our local high school started at 9 a.m. instead of the traditional much earlier start. (Classes at 8 a.m., with many extra-curricular activities like band practice and swim practice at 7 a.m.) This is in the western U.S.

All the sleep-cycle research is on his side. And he was friendly, focused and persistent. But his campaign failed.

A later school start would have cut into the available daylight for after-school sports practices and events. Perhaps 30% of students participated in these, and perhaps 10% in total (or their parents!) were adamant that anything that short-changed the football team was an evil that needed to be stopped.

Still, the don't-do-it crowd was vocal and implacable. Eventually everyone else gave up. So high school students continue to get out of bed, very groggy, at a time that's too early for them, and struggle to get a grip on their morning classes. We wouldn't have it any other way.

Its always bizarre that they don't have activities involving daylight first so that school could run into the dark and nobody would care because you are indoors anyway.

Its basically that society used to require daylight to get anything done two centuries ago, and most people worked the farm by daylight, so fast forward generations and centuries and we are still structuring our lives around that - such that we are actually outside in the dark and doing our main activities indoors during the day.

Humanity is nothing if not set in its ways.

>Its always bizarre that they don't have activities involving daylight first so that school could run into the dark and nobody would care because you are indoors anyway.


Your last sentence could not be more true.

The other problem is do you have any idea of how much bureaucratic nonsense would have to be changed in order to make one simple change such as changing the schedule of a school start and stop time.

It makes you wonder how hard it is to change things that may be of higher importance than this.

My theory is that there is an eternal secret war between morning people and evening people and the morning people are winning. Resistance must be done in secret but fight back in every way you can.

And both groups don't even acknowledge the existence of 3rd shift workers. It's not even just businesses being closed or noise. As a night person even going on a walk can get you harassed by the cops or ticketed for being in a park. There's an implicit assumption, one that's been baked into law, that anyone doing things at night is up to no good.

As father of three (a 3 year old and 1 year old twins), I've found that when we only had one kid, our schedule remained basically the same. But now with three, we are somewhat forced to shift toward being morning people. With multiple, good luck getting them back down to sleep if the sun is up. By the time you succeed, the others will decide to be awake. Also morning routines take longer, so you need to start your day earlier to compensate.

I feel like a big part of it is that very young children are geared towards being early (at least from my perspective) risers. Parents end up shifting their day to account for that. And then as kids get older, their rhythms start moving to starting the day later, but by that time the parents' routine is molded around being up early.

Not sure where I'm going with this exactly, just an observation of mine.

The first rule of the resistance is that we don’t talk about the resistance with people who find 5:30am tolerable.


Cough. Timezones. Cough...

I think sleep is losing the war against staying awake, both in the morning and the evening. As a morning person, I often have a hard time participating in social activities when I'm trying to get to sleep by 9-10pm.

The trouble is that by the time the evening people get going, the morning people have already defined the world's schedules.

It's because they keep getting the worm.

And it's a known biological fact that during teenager years the circadian rhythm is affected and normal sleep is pushed later in the night. Having teens wake up early is literally fighting biology and can't but have negative results on their health, education, socialization, etc.

Sure, I barely remember high school seeing how I was half asleep most of it. There was not a day when I did not fall asleep in class early in the morning. I remember having to fake like I was looking down to pick something up just so I could sleep.

I had a math teacher surreptitiously call the office and report that I was a drug user, due to my falling asleep at his 10:30 class. I always felt extremely drowsy 3-4 hours after rising. Now I wonder if it’s related to how I have been diagnosed with celiac disease, which has caused extreme fatigue 2-4 hours after eating in my adult life.

How many desks in high school did I drool on while sleeping I wonder?

I remember trying to sleep in between classes. Like, I would close my eyes and touch the wall in the hallway so that I could "sleep" while I was walking to my next class.

I had the same problem in college. Classes started at 0830 but for me it was still too early. I was always falling asleep and after a while I just stopped attending.

I just started attending the sections of the same class that started at 930, except on test days. The professors knew I was doing it, but didn't seem to mind.

The Elementary school comment rings so true. We have to get my seven year old up at 6:15 to get to school at 7:30. That's if we take him, if he caught the bus he would have to be AT the stop by 6:15. Every day is a battle against exhaustion. On the days that school is delayed due to weather and he can get up naturally at maybe 7:30, he is so much better. He feels better, his attitude is more positive, and he does so much better with learning.

Why does the school bus pick him up more than an hour before school starts? That seems ridiculous.

Sounds like my experience growing up in a rural area. My high school was on the other side of our county, so I was the first person on the bus every morning, 60 minute ride each way.

Kind of off topic, but a fun story: Growing up, we were the last kids off our bus and the ride took an hour. The silly thing was, there was a different bus that drove past our literally five minutes after school got out. Eventually they figured it out and switched the route we were on, but by then we were old enough to not ride the bus most of the time.

For me it was often 90 minutes to get home, but about 30 minutes into the trip we would drive right by my house. Problem was, it was on the other side of the street, and they wouldn't let me cross. This was in middle school, on a street that I crossed by myself all the time.

While on subject of school buses, my driver would not let me cross the street on the way home, so even though I was the first stop, I’d have to wait until we looped all the way around to the end. My stepdad had to scream down their throats and they finally caved, I came home an hour earlier. Talk about the stupidity of that situation!

Just realized I wrote basically the same comment as you. I wish my stepdad had yelled at them! It didn't even occur to me that I could complain.

Oh it didn’t occur to me right away either. This was in middle school and I was not the smartest cookie, so I must have wasted at least 5 trips before the revelation occurred.

Small town America. The high school I attended in 9th grade was a 30 minute drive away if there was no traffic and first bell was at 7:00 AM. It also served 2-3 small towns in the area. I took the bus before I could drive, and my bus stop was one of the first on the route that had to pick up kids from all over the place because we didn't have a lot of busses. So in order to get me to school on time for 7:00 AM, I got picked up at 5:45 AM.

Jeez... couldn’t they spend a couple bucks more for extra service?

Now that’s in essence the whole problem with tax cuts and privatizations: public service is cut to the bone, and privatized ones maximize their profits together with the citizenry’s inconvenience.

For this and most questions regarding school schedules, consider the point that the timing is for the convenience of the adults who need to go l get to work / back home / other tasks, not the children. A school system that puts kids first would start by 9am but how would society cope with that ?

> A school system that puts kids first would start by 9am but how would society cope with that ?

Do it like daylight savings time. Have everything start two hours later, all year. The issue for the kids is time related to sunrise, not time related to when the parents go to work.

> The issue for the kids is time related to sunrise, not time related to when the parents go to work.

Is that what it is? I thought it was total sleep duration. Do you have a link explaining more?

> I thought it was total sleep duration.

They're related. If you go to sleep at the same time (relative to actual-midnight) and get up an hour before school, you get more sleep when school starts later.

Or else what difference would any of it make? If all you did was start school at 9:30 instead of 7:30 and then kids used that to go to bed two hours later, nothing has changed. But when people go to sleep (and are inclined to wake up) has a lot to do with daylight.

If you go to sleep at the same time (relative to actual-midnight) and get up an hour before school, you get more sleep when school starts later.

That still doesn't seem all that helpful. If my high school had started at 10 instead of 8, I'd be out of class at 5:30 instead of 3:30, done with fencing practice at 8 instead of 6, etc. I'd finish the night's homework two hours later, and finishing that was already well past sundown even on the original schedule. A later start time wouldn't have been an opportunity to stay up later -- it would have been an obligation to stay up later.

The only way you'll be getting more sleep is by doing less non-sleep. You can't add hours to the day. What you can do is to arrange the sleeping hours so that they're the ones that come more naturally to more of the people in that age group.

The total lack of unscheduled time is an independent problem.

Our middle schools start at 9:15am and society copes just fine.

8:45-9 is the standard school start time in the UK at least.

To pick up the other kids on a long route.

> To pick up the other kids on a long route.

The obvious problem then being that the routes are too long.

You have to wonder if there isn't some kind of carpool incentive the school could give to parents to get rid of 90-100% of buses. How many stay at home parents with 9-passenger vehicles would be willing to make $500/month by filling their minivan with other kids when they deliver their own kid as they were going to do regardless?

Cheaper than buses, kids spend less time sitting in vehicles because there are 8 kids instead of 30, fewer vehicles (and especially fewer huge diesel buses) on the road because those parents were driving their kids anyway.

I actually did the math on this in my district. Based on the cost data they published, it costs (roughly) $1.5-2/ride on our school bus system. Allowing 20 minutes for pick up and drop off, no current ride-sharing system I know about would be cost competitive, but its a relatively close thing.

RE carpooling, this probably cost competitive but their are other factors that make this harder than you think. Buses are allowed exemptions to booster seat rules, minivans aren't- do you leave the van full of car of booster seats all day? Do kids carry their own? My kindergartener still has issues buckling their self in in a crowded car, that really pushes up pickup/drop off time spent. How do you get kids to school if the primary driver is sick or has car trouble? Who is liable for accidents? Do you randomly drug/alcohol test your parents?

None of these are insolvable, but they also aren't easy.

School busing in the era of autonomous vehicles gets a lot more interesting- you could have much smaller and efficient pick up routes. However, I think it will take (US at least) society a while before they are willing to leave 4-8 children alone in a car for 30 minutes a day. It just takes a couple 5th graders fighting in a car before the district decides supervision is needed.

> Buses are allowed exemptions to booster seat rules, minivans aren't

Buses are allowed exemptions for pragmatic reasons, not safety reasons. Whatever the rule is, it should be the same for both, in which case there is no relative advantage. If you're not willing to allow it for a minivan, why are you willing to allow it for a bus? (This also doesn't apply to high school students who don't need them anyway.)

> How do you get kids to school if the primary driver is sick or has car trouble?

How do you do it when the school bus driver is? You maintain some level of reserve and you send someone else.

> Who is liable for accidents?

The insurance company. The better question is who pays for the insurance, but considering that the school would already be paying for it for a school bus, it still doesn't appear to be any disadvantage for the school either way.

> Do you randomly drug/alcohol test your parents?

They're voluntarily choosing to drive someone else's kids for money. If you want to do that and they don't, they don't get put on the roster and don't get paid. It seems like the only real question is whether (or how often) it's worth the cost given the expected probability of drug abuse in your parent population.

> no relative advantage

Speed doesn’t kill, change in speed kills.

With significant mass at play, a bus in a collission doesn’t change speed as suddenly as a car, thus passengers experience less G force.

The rule does appear to relate to weight, and safety reasons:


Notable quote:

> Federal agencies like the National Highway Highway Traffic Safety Administration (NHTSA) have long maintained that even without seat belts, school buses are the safest mode of transportation for children. Between 2005 and 2014, NHTSA reported 1,191 crashes involving school buses or other vehicles functioning as school buses. That makes up less than 1 percent of the 331,730 fatal collisions in those 10 years. Among the 133 people who die each year on average in related crashes, only 11 are bus passengers or drivers.

However, that doesn’t help when the bus collides with an immovable object, so the rules are being reconsidered.

> Buses are allowed exemptions for pragmatic reasons, not safety reasons.

No, buses are safer, period, even without seatbelts. Occupants of bigger vehicles have much better outcomes in auto collisions, and buses are some of the biggest vehicles on the road.

Also, most school buses don't do much freeway driving... Not having a seatbelt in 25 mph collision is one thing. Not having a seatbelt in a 70 mph collision is lethal.

> No, buses are safer, period, even without seatbelts. Occupants of bigger vehicles have much better outcomes in auto collisions, and buses are some of the biggest vehicles on the road.

By causing much worse outcomes for occupants of the other vehicle or pedestrians in the same collision. Not really something you want to have around your schools and homes where your kids may be the pedestrians or occupants of the other vehicles.

It's also no help for single-vehicle collisions, which are nearly two thirds of auto collisions. 12 ton bus vs. 2000 ton overpass, overpass wins.

In addition to the unfortunate high center of gravity that increases the probability of rollovers (which are especially likely to cause injury without seatbelts).

> Also, most school buses don't do much freeway driving... Not having a seatbelt in 25 mph collision is one thing. Not having a seatbelt in a 70 mph collision is lethal.

Which is a reason why statistics make school buses appear safer than they actually are -- a minivan picking up the same kids would be on the same roads with the same traffic speeds, even if the "average" minivan would be on different roads traveling at higher speeds.

That may even be a good basis for the rule -- car seat required if traveling more than 35MPH.

> By causing much worse outcomes for occupants of the other vehicle or pedestrians in the same collision. Not really something you want to have around your schools and homes where your kids may be the pedestrians or occupants of the other vehicles.

This has nothing to do with whether or not bus riders need to wear seat belts.

> It's also no help for single-vehicle collisions, which are nearly two thirds of auto collisions. 12 ton bus vs. 2000 ton overpass, overpass wins.

> In addition to the unfortunate high center of gravity that increases the probability of rollovers (which are especially likely to cause injury without seatbelts).

You're making buses sound like deathtraps. And yet, per passanger-mile traveled, they, despite lacking seatbelts, are two orders of magnitude safer then personal automobiles. [1] 0.11 deaths/billion miles, versus 7.3 deaths.

Buses, the way we currently use them, are much safer then cars. This isn't even a point of debate.


You are right in "the way we currently use them", but that doesn't make buses inherently as safe as you imply. Buses get professional, trained drivers, subject to substance abuse testing and rest laws, consistently driving the same route. In the resource you shared, it looked like professionally driven cars (presumably mostly taxis and town cars? from 2000-2009) also had dramatically lower death rates, although they didn't give the deaths/passenger mile number.

All kinds of liability problems with that. School bus drivers are presumably vetted and trained to deal with not just getting from point A to point B, but dealing with students along the way.

School bus driver "vetting" is checking their driving and criminal record and "training" is essentially how to operate a large vehicle. The first could still be done, the second doesn't apply.

And the liability issues all seem to go the other way, don't they? Buses are less safe (they don't even have seatbelts), problematic incidents involve a larger number of students, the buses are more officially associated with the schools, etc. And actual parents obviously have better incentives to make sure their kids are safe than someone who is only doing it for a paycheck.

In 9th grade, my bus driver let an obviously angry man onto the bus.

Some kids threw peanuts out the window and into his car. He followed us to the next stop and pounded on the door. She courteously opened the door and in he came, shouting the whole way.

The awkwardness was compounded when I realized I had known this man for 10 years.

I don’t have a very high opinion of bus driver training.

Where I grew up the high school was a 45 minute drive away. We would get picked up an hour early so there was a little leeway in case of traffic.

Same, in Indiana. High school started at 7:45, bus picked up at 6:45.

more schools are consolidated these days. In some places, one large school serves 3 counties. I don't know why.

It's more expensive to run three schools. And if those three schools don't each have enough students, they're going to be underfunded as funding is largely based on the number of students.

So the problem starts multiplying.

1. Can't afford supplies, facilities, etc.

2. Can't afford to be properly staffed.

3. The school is invariably going to be under-performing and we've decided as a society that if your school isn't performing well we're going to penalize it by cutting funding, which exacerbates the funding problem.

4. You've got all sorts of people, fiscal hawks, tax payers, etc who don't really want to pay for education, let alone pay for half empty schools and all that overheard. No one really wants to subsidize a ghost town...

So the result is school districts that are too small to make sense being combined together to try and pool their resources and maintain quality and efficiency.

So if you live out in super rural or low population density areas, and families aren't churning out children like they're old school farmers or Catholics, then this is the sort of reality you'll have to deal with.

Traffic? Traffic at that time of day can be crushing. Arounds here, anyway.

A lot of elementary schools start early because of parent pressure to start early, because parents need to get their kids to school so they can get to work themselves.

We are lucky that our school district provides before and after school programs since my daughter's elementary school doesn't start until after 9:00 AM.

I don’t see a lot of evidence that elementary schools have started classes earlier as more households have relied on both parents working. I _have_ seen an increase in after-school programs to make up the gap between school letting out and parents getting off of work.

The battle to get up early is about as old as time. We aren’t that far removed from an agrarian-based economy, and farm work has always required very early rising (my father grew up raising dairy cows: he was fond of reminding us as children that the cows don’t care how tired you are).

“Early to bed and early to rise” is not a modern day mantra, but I fear we’ve kept the wake up call constant while continuing to push how long we stay up. I don’t know how to fix it: if your kid is in an after-school program until 6, comes home to eat dinner, and then still has to do homework... I don’t see how an early bedtime is even possible.

>I don’t see a lot of evidence

Have you actually looked? Ask some parents and see what replies you get.

I’m a father of three. I’ve had my kids in schools in four different cities. If we’re playing anecdotes, growing up my elementary school started at 8:00. My kid’s have had school start around 7:45. I don’t think that 15 minutes is the issue.

Continuing our story time, as a child a very small number of my classmates were part of after-school programs. Kids today are much more scheduled and for far later into the day. I grew up wandering the streets and maybe had baseball practice one day a week with a game on Saturday. I was home from school around 3:30, had homework done by 4:30-5:00, ate dinner around 5:30, and was put to bed (in elementary school) by 8.

I remember the thrill of having my bed time pushed to 9 around 8th grade. Bed time was 10 in high school except for weekends.

Very few people rode the bus to school: most had a parent drop them off.

This game changes significantly when both parents work. If both parents have to be in the office by 8, kids have to take the bus. Which means they have to get up very early. If both parents work until 5, then kids have to be in after-school programs. They’ll get home by 6-ish and have to fit in dinner, homework, and whatever activities they need to put on their resume to get into college.

You forgot my favorite. In California (and probably other states), the building codes for apartment sound proofing are much weaker than for condos.

If you wanted to sleep, you shouldn’t have chosen to rent. Your landlord couldn’t be expected to pay $1000’s [1] extra to build your apartment, after all.

(1) https://www.remodelingexpense.com/costs/cost-soundproof-insu...

I hear this claim thrown around a lot, but I've never seen the legal code pointing to a difference in minimum standards for apartments vs condo. Section 25 (http://mlacoustics.com/projects/multifamily/CA.noise.final.p...) treats them the same.

Do you know where the differing laws are?

Counterpoint: regulations like these are part of what leads to an affordability crisis. It all adds up.

I don't have anything backing this up, buty personal experience is that NIMBY is partly because of the lack of proper building code. People are TERRIFIED of neighbor noise, most of which could be dealt with with better insulation.

My best semester in college I managed to have a schedule of classes that started at 2pm and finished by 8pm.

Pretty sure it's the only time in my life where I've literally slept as much as I wanted...and felt great.

My exams were regularly scheduled at 09:00 in the morning. I would regularly gasp when reviewing the errors I made, wondering how drunk I must have been to make such gross ones. Indeed I was drunk... from sleep deprivation. I wonder how much has this affected my overall performance as a student and later as a professional...

Same. My dorm-mates were confounded that I was getting straight "A" grades and seemingly always sleeping.

Because civilizations are built and ruled by Type A people, who usually sleep less and get up super early, they are known to die younger though.

And %3.3 people have DSPS, who are just simply labelled as sleazy.

To add to your list, a big one for me is the ritualization of coffee. Can't focus until you've had a cup!

Which is honestly a lot like not being able to calm down until you've had a cigarette. Doesn't seem to be a problem for those who just never do it.

School starts early because most adults have to get to work by 8:30 or 9, and they need to drop off their kids early enough to drive potentially a considerable distance to that work after the drop off.

The school thing is a challenge. If the parents have to be at work 8-5 plus time to drive there, the kids have to be up at the same time so they can be dropped off either at school or a day care setting to be put on a bus later. If the parent has a longer drive to work, the child must get up that much earlier. I don't really know how to solve this problem.

Our school district has a before school program starting as early as 7:00 so kids that need to be can be dropped off early, but most kids arrive much later. Classes don't start until 9:00 at our school.

Isn't that the same thing though? It's a very common problem without an easy solution.

Kind of the same, but at least it gives parents options. Most kids arrive just before classes start, instead of forcing everybody to get there really early.

One theory I've heard is that sleep deprivation is used as part of conditioning techniques. Doctors are conditioned to tolerate things most people would not (cutting people open, touching diseased people, dealing with people dying) and sleep deprivation may be one way in which their minds are made malleable. The same with grad students and soldiers. This may be one of the primary methods by which society makes young people behave the way it wants them to; mess with their minds, then tell them what to do, and repeat it long enough until they keep doing it on their own.

> Elementary school starting so early all the kids are half asleep in class.

The primary purpose of K-12 education these days is to keep kids locked up so their parents can go to work. If Mom and Dad have to be at work at 8, as is often the case, the kids have to be at school before 8. Teenagers, who naturally sleep in later than younger kids, would be better served starting school at 9, but because our society still infantilizes teenagers and young adults, we can't systemically trust them to fend for themselves in the mornings.

This isn't to say that K-12 schools are entirely unconcerned with actual education, but it has to accomplish this goal within the constraint of keeping children locked up.

> College + Sleep? Not gonna happen.

Wait, what? I slept so much in college. Way more than at any other point in my life. You schedule your own classes and aren't actually in class that much, gives you plenty of time to sleep.

Probably depends what you study and at what rate. Alot of students work fulltime in addition to studying fulltime, which basically puts sleep and eating secondary or even tertiary. Socializing isn't on the radar for many.

Working full time and going to school full time is basically having two full time jobs... that would clearly hinder sleep.

The statement, however, said college means no sleep. That is a bit disingenuous to say that was meant to imply the person was working full time.

That would be like saying "living in an apartment means no sleep!" because you lived in an apartment above a 24 hour bowing alley.

Fair enough, but I understood your comment to mean that college was a "point in [your] life" that had ample time for sleep. I was just pointing out that that point in many people's lives has less sleep due to college, not more.

My workload in college was insane. For one of my semesters I had zero social life and slept a day out of two, one out of three near the end. It was awful. I didn't have a job and lived with my parents who handled food too. Not many people made it through. Was a shitty community college. I would have had an easier time at MIT, heh.

I worked 3 jobs, was on the newspaper, ran track, and took a full course load on top of commuting home when I could -- I probably slept more than I do now but it was def not enough!

Sounds like the college part was only a minor contributor to the no sleep... it was doing all the other things along with it that lead to no sleep.

I've had some of the best lucid dreams I've ever had while my sleep was disrupted by living in the second story of a building smack dab in the corner of a very busy street corner during broad daylight. I had a night job so my sleep schedule was from 7am to 3pm. All in all I had half a dozen lucid dreams and one mindblowingly extreme out-of-body experience which left me breathless upon waking. I think I even had a night terror or two while I was there.

I didn't hate it. Sleeping during the day has taught me how to put a pillow over my head in order to block out all light, and now I can sleep in the brightest loudest room without trouble.

I haven't had lucid dreams since then, or if I have, they've been really really rare and extremely hard to remember. Now that I think about it... Could my lucid dreams and OOB have been triggered by smog from the traffic in that area??

>I've had some of the best lucid dreams I've ever had while my sleep was disrupted by living in the second story of a building smack dab in the corner of a very busy street corner

Though not during the day, I lived in a second floor apartment that overlooked a traffic circle that had an elevated subway stop, was a main route for ambulances going to the hospital a block away, and a crucial interchange for traffic entering/existing that part of the city. I barely slept for the first few days and then got the best sleep of my life. I rarely woke up for anything other than my nightly trip to the restroom.

Fast forward a few years and I now live in the suburbs. I've been woken up several times in the past month by the sounds of a mouse scurrying in the ceiling of an adjacent room.

Tell me about it. We have to get our high school kids up at 5am to get to school on time while the middle schoolers don't have to get up till 8am or so (school starts at 9:15).

I deadass pre-planned being asleep during my second hour of high school, after recognizing that whatever alertness I summoned in the walk, the bus, and first interactions of the day would dissipate by then. If a study hall was an option, I would take it and sleep at my desk. If it wasn't, I would still sleep at my desk and try to cold-test my way into a D.

Damn very nice summary. I do think the kids in school thing, however, is more of a symptom of our generation as parents- they love staying up late, thus keeping their kids up late. just sayin... that being said - NOT A PARENT!

When I've stayed over at friends house (who are parents) they have very strict go to bed times for their kids. THOSE darn crazy kids are up at 5 or 5:30 banging around the house full of energy.

Add time necessary to get to school when your commute isn't the best and it becomes even more fun.

I remember having to get up at 5:20 AM four days a week, to leave 20 minutes later to catch a bus at 5:58 AM to be get to high school in time for classes starting at 7:10 AM. And a teacher complaining to my parents that I often seem tired.

"Elementary school starting so early all the kids are half asleep in class"

That's the only reason I don't put my daughter on the school bus. I can save her an extra 30 minutes of sleep by driving her to the school myself.

I guess on paper going without sleep gives you some kind of competitive advantage? A company that believes otherwise could bet on giving their workers more sleep and they should gain an advantage by doing so.

People shouldn't be so beholden that they need someone else to give them sleep.

This can be done indirectly by reducing the work day from 8 hours to 6 hours, those who otherwise need to get up early to commute may have a bit more time to settle down in the evening.

And reducing the productivity of workers by 25% couldn't possibly have any bad effects. /s

In all seriousness, I've seen mentions of studies that suggest going from 8 hours to 6 does _not_ correlate with a 25% decrease in productivity, because most people aren't consistently productive for all 8 hours of a day. I know in my case, there's an extremely strong inverse correlation with productivity and how bored I am with a particular task. I'm sure I'm not alone.

Actually there was an interesting study done to show that most people in the office environment on average do 4 hours of work (actual work) and the rest is breaks, distractions, chit chat, bathroom breaks etc. I have found the 4 hour figure to be much too generous, I’d say on average people work less than 4 hours (maybe closer to 3) the other 5 are a total waste.

When I first started freelancing hourly, it was a sobering feeling to see how little of my time was actually billable for actual work. It takes random screen grabbing software to make you realize that most of the time you are not working. Of course those days have long passed for me but I’m always left to remember just how wasteful office workplaces are and how much time people waste away in their life. More than half of their working life is a total waste. Tell me, how does that make you feel? :)

I'd think so, if you're up against enough people willing to sacrifice sleep/social lives to get a job/project done faster

This assumes raw time spent guarantees faster delivery with comparable quality of work in spite of efficiency implications of low morale and insufficient sleep. I'm sure it does help to a point but I imagine there's an individual threshold where it seizes to be productive.

Most companies (not startups) don't have their employees work much more than 40 hours.

Lack of sleep is very rarely an issue with your employer.

In which fields? Financial/Law firms are routinely scrutinized because they overwork their employees, just to name a few. Doctors, EMS personnel, Police, all work more than 40 hours. There may not be mandated work hours over 40, but the culture/workload creates that environment anyway.

As others have said, sleep deprivation is the norm in certain fields like healthcare. There are also jobs where you work 40 hours but the schedules are so random that they can also screw with your sleep such as retail. And a lot of top performing companies in a variety of fields expect people to always be on.

Even with an 8 hour day plus a long commute, there are at least 14-15 hours a day left for you. If you aren't finding time in there to sleep, that's on you.

Good thing that work is literally my only responsibility as an adult. /s

Having to choose a schedule that irritates the least number of people is somewhat different than hospital staff poking and prodding people every hour or so throughout the night, don't you think?

No. My point is that I'm every bit of society we consider sleep as something you can cut as opposed to something critical. Yes my examples were different, but they have the same root cause: quality of sleep isn't considered a big deal.

Except your examples (several of them, at least) are essentially unsolvable. We can't find a time that everyone will agree on, so we collectively chose an arbitrary time that most people seem to deal with okay, and ran with it.

The hospital staff absolutely knows that sleep is important, but they have competing goals that are deemed important enough to interrupt sleep for. That seems very much different from societal-level / cultural priorities.

You might have forgotten to mention our society's addiction to caffeine... Am writing this sleep-deprived, on my fourth espresso, check. :-)

This is bullshit bravado, even when increasingly studies point out the correlation between all kinds of diseases and poor sleep.

Instead of elementary school did you mean secondary? Here elementary school starts the latest.

Dunno, don't have kids. I just know I see the little kids walking around with their parents whenever I'm unfortunate enough to have to be out that early, and I assume hundreds of 9 years old didn't all have to go to a birthday party at 7 am all at the same time.

what a good summary. so true.

> Elementary school starting so early all the kids are half asleep in class

Isn't the amount of sleep you get determined by when you go to sleep? So if elementary school kids need more sleep just... put them to bed earlier?

While I think most elementary school kids probably should be put to bed earlier (even if their school doesn't start so early), it's easier said than done. Imagine having to get home from your commute, feed your family, getting the older siblings to/from extracurriculars and then getting the elementary school ones to bed by 7:00/8:00pm.

Yeah but time is zero sum. Let's pretend school now starts at 9. Now everything is shifted by 2 hours. Extracurriculars are now 2 hours later, feeding your family is now 2 hours later, etc.

"Imagine having to get home from your commute, feed your family, getting the older siblings to/from extracurriculars and then getting the elementary school ones to bed by 9:00/10:00pm. It's easier said than done! School needs to start at 11!"

I must be missing something. How is your family life going to be less hectic after work with school being 2 hours later?

> Let's pretend school now starts at 9. Now everything is shifted by 2 hours.

(1) The school day is too long and the school year too short, anyway, so chopping two hours off the end of the day and making it up by extending the school year would be a win.

(2) Even if you don't do that, eliminating the end-of-school to end-of-typical-fulltime-work gap would be a different win.

Biological clock aside, the kids might not be able to sleep earlier. Can't go to sleep before 7 if the jack hammers are going on until 7, for example.

I spent a week in a German hospital a few years back. One thing that struck me is that they offered sleeping pills to ensure patients got a good night of sleep. Worked for me. Also didn't notice too many interruptions at night.

Another trend that I know of in the Netherlands (where I'm from) is that newly built hospitals have private rooms for all patients. These hospitals no longer have shared rooms by design. They also try to minimize hospital stays as being in a hospital exposes you to hospital infections, is expensive, and to be avoided unless explicitly needed.

That's a big difference with Germany, which is old fashioned on this front. The default attitude in Germany seems to be to keep people in a hospital much longer. In Germany you only get a private room if you need it medically or if you take private insurance.

I suspect a lot of this stuff is part cultural and part wrongly aligned incentives because hospitals just bill whatever to insurers and couldn't care less about patient comfort because their paying customer is the insurer, not the patient. The insurer cares about cost, the hospital cares about milking the insurer to the maximum of their ability. Between those two, patient comfort is not much of a concern.

The reason things have improved in the Netherlands is that they spent the last decade realigning incentives to cut cost between insurers and hospitals. People pick their own insurer (they are all private). However, all insurers are required to offer the same base packages (with extras if you want). So, people can easily switch insurance provider if they want and they do. So, insurers now compete on quality of service and cost. Which is why a lot of hospitals are actively concerning them selves with upgrading their facilities to improve customer happiness (still the insurers). Insurers are happy when their customers don't switch to another insurer and when hospitals don't waste their money.

How does that work: insurers trying to keep as many customers as possible is disjoint from the customer satisfaction a patient has when receiveing healthcare at a hospital.

As a patient I don't think about my insurer when I'm at a hospital. I just want to be treated.

It's more likely to be the opposite, where the hospitals with the better healthcare and care of the patients have to spend more money and thus get less contracts with the insurers, who have an incentive to reduce cost as much as possible. Out of the 4 hospitals I've visited for healthcare in my area, only 1 will currently be covered by insurers in their most basic plan next year, and that one is the most remote.

Basically, next year I cannot visit my regular hospitals to continue my current treatment plan without getting a more expensive basic healthcare plan (+15%, or roughly 220euro).

US is weird, you are usually stuck with whatever insurance your employer provides. If you try to buy your own we're talking $500 a month with a $3000 deductible. If your insurer doesn't cover a hospital there is no way you want to end up there. Down that path lies bankruptcy because the hospital will try to charge your insurer an arbitrary large amount who will then just hand it to you and go "Good Luck!"

One time my family was charged $1000 for an ibuprofen for a perforated eardrum at an emergency room. We never even saw a doctor because we waited 7 hours and left. It was faster to get an appointment at our personal doctor the next morning. I can't imagine what it would have cost for a severe problem like a car accident...

>> One time my family was charged $1000 for an ibuprofen for a perforated eardrum at an emergency room

This kind of maddening injustice is why I left the USA after living there for 3 years, and will likely never return even to visit.

No it is not. Hospitals need to negotiate with insurers to get bills payed. So insurers have a strong negotiation position here. In a dysfunctional market like the US where insurers have near monopolies that basically means they get to screw people over and cut cost everywhere they can. Meanwhile hospitals maximize their bills to insurers while minimizing their actual cost. Patient happiness does not factor into this as they are at their mercy.

If you fix that by giving them the possibility to take their money elsewhere, insurers are incentivized to behave a bit better. Likewise, hospitals will want to make sure they attract patients from good insurers so they keep their revenue coming in.

As a potential future patient you think about the quality of care when you shop for insurance. An insurance plan that can show you get better care when you need it for only $[small]/month is something you will consider taking, particularity if "know someone" (including a random person on the internet) who got bad service and regretted it.

Of course if you are in the US you cannot shop for insurance, the law ensures that you take whatever your employer offers.

All "public" insurers in Germany are private companies as well. They are all required to provide the same level of service and they all cost nearly the same.

There are separate private insurers that are cheaper when you're younger and more expensive as you age, but that's a parallel system and you must earn over 40k Euro/yr. to purchase that (or be a state employee for some weird reason).

Possibly this has to do with the state assurance companies who need to justify the tax ( approx 15% ), so keeping someone in hospital longer works for them.

Single time when I was in hospital, but private assured, they did everything to keep me as little as possible, even skipping an OP for a non invasive procedure, because the recovery time was inexistent.

I felt the question and answer to be a little flippant, which is fine, but hear this: Sometimes there are reasons, very genuine reasons. I've been recovering from a recent stay. I, too, was interrupted frequently - every 45 minutes in fact. After a few nods off and being woken up by a knock at the door repeatedly I asked 'why' and the staff gently explained that me sleeping for too long would be a bad idea for a few reasons:

1. My surgery affected my nervous system and thyroid; maintaining blood flow (especially in my legs) was important.

2. Knowing how I felt at the time kept the nurses informed about the dosage of medicine they should administer. Hormones and their effects can change rapidly.

3. Having a patient awake for blood draws, or an emergency, is useful. I’m not a small person; turning me over for some blood is much easier if I am awake and cooperative.

I can imagine anyone with recent head trauma shouldn’t be allowed to sleep either.

Ask your doctor (and nurses!) to keep you informed and educated about your situation. You're responsible for yourself. Medicine isn’t always intuitive, especially if you’re not yourself yet.

> 3. Having a patient awake for blood draws, or an emergency, is useful. I’m not a small person; turning me over for some blood is much easier if I am awake and cooperative.

> I can imagine anyone with recent head trauma shouldn’t be allowed to sleep either.

Well, yes, it would be enormously practical in a large number of situations if we wouldn't sleep. It would also solve a lot of problems if we didn't need to eat. Problem is, those things are biological necessaries with immediate adverse effects if we neglect them. I also believe there is a solid body of research showing the importance of sleep for recovery.

I'm not a doctor or nurse and the blood flow argument does sound reasonable - however, the other two arguments sound a lot like "it's more practical and less risky for us if you're awake", which I don't see is a valid reason. Also, by what medical school is >45 minutes of uninterrupted sleep "too much"?

I don't think all hospital patients meet all (or even any) of the three points you listed. Hospitals should wake up folks that actually need it (e.g. folks like you in your past situation), and leave those who don't need it alone to sleep.

I mostly agree. The author of the piece didn't go into much detail about their medical needs at the time - perhaps they were a high-attention patient and didn't know it? Hence my call to educate oneself about their own situation. When you're in a foreign bed/room, in some amount of discomfort, on (likely) new medicine, you probably aren't the best judge of neediness and intent. The best you can do is ask and see what you can do to make the situation better.

The author makes it pretty clear, hospital staffs should wake up patients if absolutely necessary.

"If a patient is at low risk and can go six or eight hours without a vitals check, for example, perhaps don’t do that check once every four hours." ..

"..I made a sort of handshake deal with my nurses to leave me alone between 11 and 7. This mostly worked (and was reasonable in my case since I was only there waiting for the first round of chemo to start). I also refused to allow the night nurse to draw blood at 4 am, and that was that. She never came back, and that was fine: after all, there are lots of cases where they really don’t need your counts on a daily basis. And they certainly don’t need them at 4 am. That’s merely for the convenience of doctors, who want the results back by 8 am." ...

There should be an equal call to educate hospital staff, to inform patients about their requirements, and to apply their requirements on a case-by-case basis instead of applying it to all patients regardless of needs.

> Ask your doctor (and nurses!) to keep you informed and educated about your situation. You're responsible for yourself. Medicine isn’t always intuitive, especially if you’re not yourself yet.

This mentality is fundamentally flawed. We don't allow truck drivers to drive for more than 11 hours a day because lack of sleep impairs your cognitive ability. But we're expecting patients recovering with potentially days without rest to make informed decisions?

A counter to your example...

When my youngest was born, my wife had complications with delivery due to high blood pressure. They refused to release her or the baby until two conditions were met. One was that her blood pressure was lowered and the other was that the baby put on a % of weight. Without intervention neither would have been released. I had to pull the care team aside during a group visit to ask them:

"Is high blood pressure a symptom of insomnia?" Yes

"Is a REM cycle 90 minutes?" Yes

"Have we had more than 45 minutes in recovery without your staff waking my wife?" No

They left us alone for 3 hours straight and magically her blood pressure returned to normal.

We then had to have the attending pediatrician point out to them that the medications given during labor caused water retention and that apart from the lack of weight gain, the child was 100% on track and doing extremely well.

The hospital we were at, Emory, is highly regarded but their whole system seemed to be fundamentally flawed because it didn't take into account the continuous interrupts. Or rather there was no distinction between 3 uninterrupted hours of rest and four 45 minute periods of rest.

Tangentional, but why recent head trauma shouldn't be allowed to sleep?

I had a very severe head impact couple of years back, and while I was fuzzy at the time of impact, few hours before I go to bed, it was not until the day after when, my internal functions went half way south. I am not certain if the weakening of some of my external senses immediately happened or not.

Tangentional, but why recent head trauma shouldn't be allowed to sleep?

This was dead, but it seems like a sensible question so I vouched for the comment to resurrect it.

My understanding is that with any head trauma doctors are concerned about the possibility of bleeding into the brain, and it's much easier to detect the neurological symptoms of this in a patient who is awake. But I'm not a medical doctor; someone else here may be able to provide a more in depth answer.

My mother is a doctor (in a different specialty), and this came up when we watched 10 Things I Hate About You, which repeats the myth.

You're correct; as far as the patient is concerned, it's better for them if you let them sleep. But it's easier for everyone else if the patient isn't allowed to sleep, as sleeping and dying look exactly the same.

My son managed to get himself a concussion in kindergarden once. Our doctor told us that as long as he's able answer questions normally and focus on whatever he is doing, he's fine. Let him sleep, but it's wouldn't be a bad idea to wake him up once or twice and evaluate his situation. Using the excuse that he should go to the bathroom was the least intrusive way to do this.

> sleeping and dying look exactly the same.

I do not know how many dead people you've attended to, but the ones that I have seen generally lack pulse or breathing. Both of those vitals are monitored for inpatients. And if one of those goes, the other goes too in short order.

Sleeping patients, on the other hand, usually pulse at least once per second, and breathe every six seconds or so.

there is a difference between dead and dying

What do you think "dying" means, or looks like? What signs would such a "dying" awake person display, that a "dying" sleeping person wouldn't?

Choking? Pulse goes up and breathing becomes shallow.

Cardiac arrest? Aneurysm? Torn blood vessel? Shot in the head? Stabbed in the chest? Poisoned? Spider/Snake bite? Fell off bed and broke hip? All these "dyings" are easily detected by pulse and breathing monitors.

From earlier in the comment chain:

"and it's much easier to detect the neurological symptoms of this in a patient who is awake"

In this context, I imagine neurological symptoms would be things like cognitive function, spatial coordination, memory functions, and linguistic functions.

All of those are things that are not really possible to assess while sleeping, but would be possible to assess in a patient who is awake.

Cranial bleeding can be caused by blunt head trauma, can raise intra-cranial pressure high enough to kill you, and there are only three ways to detect it: a) medical imaging scans, b) changes in patient behavior, or c) drill a hole in the skull and insert a sensor.

If the patient is sleeping, you can't use a) or b). Now, there might be an argument that everyone should get c) and lots of sleep, but drilling into a person's head is not risk-free either.

I believe the parent comments are referring to the cognitive and behavioral changes that often accompany bleeding or swelling in the brain.

Sure, if there's a real medical need to wake the patient up, they should absolutely do so. But waking the patient merely to draw blood in the middle of the night when that could just as easily be done in the morning or evening, is stupid and harmful.

Although as someone pointed out above, if the doctor gets the results in the morning because the bloods were taken overnight, they might be able to discharge the patient immediately and get a bed before lunchtime for another patient. If they wait to take bloods in the morning, the patient might be in another day for no particular reason.

Five years ago in Switzerland I could get a full blood panel from my Dr's office in the mall within twenty minutes. The blood came straight out of my arm, into the vials, and into vials went into the analysis unit.

Maybe there needs to be some investment in better analysis equipment for routine draws.

Or maybe an analysis of the analysis process to see what takes so long.

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