Why do we sleepwalk?

Note: Originally written for tiny medicine. Click on the link below to watch the animated version of this blog post

Sleepwalking or somnambulism is when a person acts out activities in their sleep. These activities can range from simple activities like walking and eating to complex activities like driving.

A normal sleep cycle consists of NREM sleep and REM sleep.

NREM sleep consists of 3 stages.

Stage 1 – Stage of falling asleep and drowsiness

Stage 2 – Stage of light sleep

Stage 3 – Stage of Deep sleep. This is the stage where the body repairs itself and releases hormones and therefore during this stage the brain is particularly resistant to awakening.

Stage 3 is followed by REM sleep. This is the stage in which dreaming occurs.

Sleep walking is a disorder of arousal that can be classified under the umbrella term parasomnia. It occurs due to partial awakening from stage 3 of NREM sleep. The sleepwalker is in a transient state between sleeping and wakefulness. Here the motor system becomes activated, but consciousness remains clouded. As consciousness is clouded sleepwalkers generally have no recollection of their actions upon waking. Contrary to popular belief sleepwalkers are not acting out their dreams when they are sleepwalking as dreaming occurs in REM sleep.

During a sleepwalking episode, a person generally has a glassy eyed expression which gives you the feeling that the person is looking right through you coupled with a blank look. Sleepwalking episodes can range from a few seconds to half an hour. Some people may go back to bed and sleep on their own or some like in my case may wake up confused while still out of bed.

Studies have revealed that people who sleepwalk have higher levels of excessive daytime sleepiness and insomnia symptoms. But it is not proven whether these symptoms are a result of sleepwalking or a result of an underlying factor affecting sleep that increases the risk for both sleepwalking and daytime drowsiness

A family history of sleep walking, stress, sleep deprivation, drugs such as antihistamines, stimulants and medical conditions like nighttime asthma, restless legs syndrome, nighttime seizures are said to cause sleepwalking.

On its own sleepwalking does not pose any real danger. But the injuries one can sustain when he/she trips, falls, or collides whilst sleepwalking can be dangerous. I dread to think of what would have happened that day if my head had not banged on the roof. I would probably not be alive today to tell the tale. Therefore, measures such as keeping doors and windows locked and keeping sharp and harmful objects locked away should be taken in order reduce safety risks.

Sleepwalking is generally easy to diagnose with the history and medical symptoms. However, a sleep study and EEG can be used to determine if any medical condition is causing a person to sleepwalk.

This condition is common in children especially between the ages of 5-12 years. Most grow out of it as they grow older. Probably explains why I have not had an episode of sleepwalking in the recent past.

Until it resolves spontaneously certain measures can be taken to prevent sleepwalking. Simple lifestyle changes like sticking to a sleep schedule, having a relaxing bedtime routine, and improving overall sleep hygiene generally helps. In addition, cognitive behavior therapy and anticipated awakening technique can be used. In sleepwalking secondary to certain medical conditions treating the underlying cause should do the trick. Finally, when other treatments have failed medicines like benzodiazepines and antidepressants can be prescribed.

Looking for the silver lining

A week ago, our clinical training was halted for the second time since the advent of our dear friend Corona. I guess you could say it’s time to get out the dalgona coffee and start brushing up our moves for tik tok videos. On a more serious note, as Sri Lanka is on the brink of a third wave I’m really struggling to find the silver lining. Besides the fact that my extroverted personality doesn’t like being caged, the thing that bothers me the most is when will I graduate?

If not for corona this would have been my 5^th and final year but with there being no date for the recommencing of clinical training on the horizon and with the country’s situation only worsening, I really can’t imagine when I will be done with medical school.

Initially my natural reaction was to get angry at the universe and sulk. Then it was to find a scapegoat and although there were many contenders for this position, I ultimately realised that it didn’t make me feel any better.

Sometimes you just got to accept that things really are out of your control and things don’t always go according to plan. Sometimes you just have to make the best of the cards that have been dealt to you. Sometimes you just got to accept that there isn’t a silver lining.

Forceps, needle holder and suture material – First time suturing

Just like how the memory of me assisting a surgery for the first time or my first clinical appointment ever or even the time I witnessed a child being delivered for the first time are memories that are etched on my mind. Last week I was fortunate enough to experience two new firsts to add to my list; suturing during an operation for the first time and performing a proctoscopy examination for the first time. Of the two I must confess that the former was my favourite but I was equally happy and excited that i was able to do both.

The surgery in question was an inguinal hernia repair surgery and if you had read my post on my first time assisting a surgery many moons ago, I’m sure you would have noticed a parallel between the two instances as that was an inguinal repair surgery as well! Coincidence much? Anyway, moving on from the fact that whether or not the cosmic powers of the universe may or may not be working in my favour and to the matter at hand. In an inguinal hernia repair surgery after the surgical incision is made and the hernia is identified, repaired and reinforced with a mesh it’s time for the surgical incision to be closed. Now to close the incision approximately 6 stitches are required and the suture technique to be used is simple interrupted.

When the time arrived to close the incision of my patient the surgeon looked at me and asked me if I had ever sutured before.  I replied saying we were taught to suture on a pillow case during our orthopaedic rotation, but that I had never sutured on actual skin. I guess that was good enough for the surgeon because he said I will leave two sutures for you to do. I was in a dilemma. My emotions were torn between excitement that I’ll finally be able to suture and apprehension that I will screw it up.

Finally, the moment of truth arrived and the surgeon handed the suture material, forceps and needle holder to me. There was no escaping it was time for me to face the music. Needless to say, my hands were shivering but I braced myself for I knew that if I shied away today, I would never be able to do it. Of course, the skin was much tougher than your average pillow case to pass the needle through and my shivering hands didn’t make the job easier. After what felt like an eternity, I was finally done with the two sutures. They didn’t look too shabby either.

I guess who ever said you gotta face your fears to overcome them really knew what he was talking about.

Locked in syndrome

Note: Originally written for Tiny Medicine. Click on the link below to watch the animated version of this bog post.

Imagine you have a stroke or meet with an accident. The next thing you know you wake up in a hospital bed. You hear your loved ones crying and you can hear them talk. You want to talk to them and tell them you are alright. Alas, try as you may you are unable to talk or make any movement that can grab their attention. You are locked in.

Locked in Syndrome also known as pseudo coma is a condition where the patient is conscious and able to think but unable to move or communicate verbally. This means that these individuals cannot consciously or voluntarily chew, swallow, breathe or speak. However they are able to move their eyes up and down as well as blink allowing them to communicate non verbally.

As a result affected individuals are bedridden and have to rely completely on their caregiver. A special feature of this syndrome is that despite the physical paralysis the cognitive function of the patient is preserved along with normal sleep wake cycles.

Locked-in syndrome can be classified into three different clinical forms.
Pure form – This is when the patient loses control of all body movements with the exception of blinking and vertical eye movements
Incomplete form – This is when some voluntary movements other than eye movements are preserved.
Total form -This is when a complete loss of motor function occurs.

Diagnosing locked in syndrome is very difficult as most patients will be in a coma for a while before they develop locked in syndrome. The diagnosis can easily be missed if eye movement is not assessed. 50% of the time it is a loved one that notices the eye movements while talking to the patient appearing to be in a coma. Diagnosis can be confirmed from a number of tests which include MRI and EEG. An MRI will show damage in the Pons and will help us rule out damage anywhere else in the brain while the EEG will reveal normal brain activity and sleep wake cycles in those with locked in syndrome.

At present there is no specific treatment or cure available for locked in syndrome. As these individuals are not able to even breathe without support it is very important to provide supportive treatment for breathing and feeding especially early on. Currently the mainstay of treatment is physiotherapy, comfort care, nutritional support, and prevention of systemic complications such as respiratory infections.
Most people with locked in syndrome do not live beyond the early stage of the disease while some live for 10-20 more years. Although it is extremely rare to regain any significant motor function it isn’t impossible either.

A letter to my 20 -year -old self

Dear 20-year-old me,

You are about to embark on a new chapter in your life. It may not seem ideal but be patient very soon everything will fall into place. Don’t give up on your dreams. No dream is too big and you can achieve whatever you set your mind to. Remember always focus on the big picture.

You will realise that people can no longer be divided into black or white everyone is a little grey. No one is perfect at the end of the day what matters is if they have your back. Remember you can’t please everyone, there will always be someone who has an issue with the way you do things. What matters is your intentions. If your intentions are pure and good that’s what really matters at the end.

You will always be a little stuck up, a little too friendly, a little big headed for someone. You can’t win this game. As long as your close friends trust you and have your back. You good. So just be you and focus on the big picture and your dreams.

In the middle of this journey, you might feel like you are lost and things are not turning out according to your plan, keep moving forward. I’m here to tell you things get better.

Love,

Your older and wiser self

Reflection on my psychiatry rotation

As the time for me to bid adieu to my psychiatry rotation draws closer, I really cannot for the life of me figure out where all the time went. From a Covid scare, to spending every waking moment with my friend who stayed with me in the hostel, to pushing the limits of our taste buds with the different cuisines we ordered in for dinner and finally getting the COVID vaccine, you could say that it was an eventful month.  I sure am going to miss it but perhaps what I am going to miss the most is the rotation itself. Not only did we get the opportunity to work under 4 amazing consultants, but we had some interesting patients. There were two patients in particular who made our stay in ward 6B eventful and interesting: David and Mary.

David was a 24-year old with alcohol dependence syndrome. He had stayed in the ward for so long that it had become his home. The rest of the patients were his “Homies” and I got the feeling that he felt he was responsible for the people as well as the things in the male side of ward 6B. He would look after the other patients and sometimes answer on behalf of them when we were taking history from them. He was also a pro at giving his own history (because so many people had taken his history) in fact he had written all the points down on a paper so that it would be easy for him to tell his history and at the end would tell us any points that we had missed out on.   

Mary was the patient diagnosed with OCD and bipolar who I mentioned in my previous blog post. We became firm friends with her within the first week, and since then we were assured of an enthusiastic greeting and compliments every time we walked into the female ward. She was also very interested in learning and would come and listen to the ward class and sometimes have a more enthusiastic face than some of my colleagues. Once my friend was reading about schizophrenia in the ward and Mary crept up from behind and started reading it along with her and then went on to discuss schizophrenia with her!

Between Mary and David our stay at ward 6B was interesting to say the least. Honesty when I started the psychiatry rotation, I was a little skeptical but now 4 weeks later I think it is one of the best rotations that I have done so far.

Note: Name and identification details have been changed to protect the privacy of the patients.

Bipolar disorder,electro convulsive therapy, personality disorders – 1st week of psychiatry rotation

The moment I stepped foot into the ward I had an inkling that this rotation was going to be different from the 18 other rotations I had done so far and boy was I right. For starters at the centre of the ward a carrom board surrounded by cushioned chairs was placed, the windows had grills and we didn’t have to carry our stethoscopes. But perhaps the most striking difference was the fact that  our consultant started pointing out everyone’s dominant traits 15 minutes into her class giving us the feeling that we were taking part in an extremely long personality assessment.

During our first week we met 3 interesting patients. One was diagnosed as having both obsessive compulsive disorder and bipolar disorder, the other schizophrenia and the third one was a heroin addict who wanted to get sober. The patient with OCD and bipolar disorder was really interesting to talk to. She was over talkative and highly energetic  (probably attributing to the bipolar disorder, as patients are energetic and over talkative during a manic episode). She loved telling us her story and we really enjoyed talking to her and getting to know her.

It was not only the patients that were interesting, we also learnt interesting things about humans in general. 

Like for instance that all of us have hints of one or more personality disorders. Not the full blown version but one or two traits. This is why many of us feel like we have a personality disorder when we read the description of a certain disorder. That’s perfectly normal as long as it doesn’t hinder your daily activities you don’t have a personality disorder and you needn’t worry.

Apparently most doctors have a ghost of an obsessive compulsive personality for their job requires them to be perfect and have everything in an orderly manner. I must say that I agree with this because my medical school friends and I exhibit traits of obsessive compulsive personality. For example I actually took out my clinical record book to count how many rotations I had done so far to include in the introduction of this post for I had this compulsive need to include the correct number even though I knew there was no harm in using an approximate number.

Another interesting topic we learnt was electroconvulsive therapy. Although we had heard about it before we didn’t know that it was a pretty popular treatment. In our first week alone, 2 patients received electroconvulsive therapy.

Unfortunately thanks to pop culture portrayals when one thinks of psychiatry immediately images of violent uncontrollable behaviour flashes into one’s mind.  While this is true it only represents a minute fraction and extreme cases. Psychiatry is actually much more than that and it’s really sad that people view it in such a negative manner and family members try to sweep these things under the carpet.

Law of laughter

Have you heard about the law of laughter? Chances are that you already have. If you have not well, you can learn it from me and spare yourselves the embarrassment that goes along with learning this valuable lesson. Now I know what you are thinking. How can a medical student teach a lesson that is even remotely close to humour and laughter right? I mean after all yes, you can say it medical students are boring and yes, it is also true that the only humour we know is the humerus bone.

However, if there is one thing medical students can do (apart from misdiagnosing patients) is teaching and explaining concepts well. So, you can rest assured if you have not already learnt the law of laughter that by the end of this blog post you will have a masters on it.

The Law of laughter goes like this.

The ability to control one’s laughter is indirectly proportional to the importance/need of controlling one’s laughter. Meaning the more important or crucial it is that you control your laughter the more difficult it becomes to control it.

Allow me to elaborate.

Back in school we had this rule where the entire school gathered in the morning for prayers before starting lessons. All the Buddhists had to assemble in the school basketball court for prayers.

One seemingly innocent morning my friend and I were lining up in the basketball court for prayers, when she told me a very funny story. It was very funny because it sent us into fits of laughter. After stifling our laughter with the greatest difficulty, we started telling our prayers like the pious children we looked but certainly were not. Now I have this tendency to replay conversations in my head in my free time like when telling my prayers for instance.

So, you can guess what happened next right?

I replayed this funny story in my head and next thing I knew I burst into laughter in the middle of prayers and then my friend who was next to me looked at me, remembered the story and burst into laughter as well. There we were in the middle of the basketball court among hundreds of students laughing out loud amid prayers.
We were lucky that our laughter was masked by the sound of everyone else praying, for now, at least. The students in our row kept giving us looks that conveyed “can you guys shush; you will get us into trouble as well”.

We needed no look, to tell us to stop laughing. We knew that if the teachers or worse the prefects saw us; it would be game over for the both of us. So, my friend and I made up our minds to stop laughing. I took a deep breath, but it was in vain. As much as I wanted to, I just could not stop laughing in fact it was only getting louder. I could feel my entire body shaking with laughter. I snuck a peek at my friend, and it was the same for her.
I tried to imagine all the worse possible scenarios that could happen to us including getting expelled, but I still could not stop my laughter.

And there in the middle of the basketball court in front of hundreds of other students my friend and I learnt the law of laughter.

Just when I started to think that things could not get any worse the head teacher in charge of prayers came to the front and told everyone to stop telling prayers. Everyone was confused. Everyone except the two of us that is.

She then started scolding us in front of everyone, but the worse part was that we still could not control our laughter so now it looked like we were mocking her. Having finally had enough of the two of us she called us to the front and demanded an explanation for our uncontrollable fits of laughter. My friend was finally able to gather her wits and told her that we were talking about a funny story just before prayers began and remembered it while telling prayers and hence burst out laughing. She was not amused at all and instead said in a sarcastic tone “We would like to know the funny story as well please share it with us.” In my head I was like oh shit. Because the story involved my friend’s boyfriend and somehow, I felt that our teacher would not find the story quite as funny as we did.

Luckily, my friend was able to come up with a censored version for her on the spot. Unfortunately, the censored version was not as funny as the uncensored one. Our teacher looked at us like we were a couple of baboons. “Was this your funny story?” she asked in a confused manner. I guess we responded convincingly enough because to our greatest relief she accepted it, most likely passing it off as having a very poor sense of humour. She then made us tell our prayers in front of everyone as a punishment. Thank god, by this time our laughter had subsided.

Any plans of this story not reaching our family was shattered by the fact that the prefects on duty made it their top priority to convey the message ASAP to our sisters. By ASAP I mean faster than the Lankan Aunty Network. Both our sisters were not at Buddhist prayers as they had duty elsewhere. You know how dear siblings can be. They will forget everything even their prefect’s duties just to witness their siblings getting embarrassed. Yes, the smug look on their faces was more difficult to digest than our teacher’s scolding and punishment put together.

I guess you could say that we paid a big price to learn the law of laughter.

Why slow fashion?

Did you know that the clothes we wear pose a threat to the environment? Did you know that the fashion industry emits more carbon than international flights and maritime shipping combined? Did you know that the fashion industry is the second largest consumer of the world’s water supply? Did you know that every second one garbage truck of clothes is either burned or dumped into a landfill? Did you know that an estimated 17% to 20% of industrial waste pollution comes from textile dyeing and fabrics finishing treatment?

Scary isn’t it? Who knew clothes could come at such a price? At the cost of Mother Nature’s health! 

So what can you and I do to stop this?

By increasing the shelf life of the clothes in our wardrobe and by reducing the amount of clothes we buy per year, together we can decrease the amount of clothes thrown away and in the long run reduce the clothes manufactured per year. In other words switching from fast fashion to slow fashion should do the trick. 

What exactly is slow fashion?

Slow fashion is based on 4 core principals; Conscious consumption, environmental sustainability, transparency and ethical designs and production methods. Basically it is a conscious effort to move away from excessive consumption.

On the outset this may sound boring and dull right? Aren’t sustainable clothes generally ugly?  I mean wouldn’t it be an absolute bore to wear the same thing? Wouldn’t it mean that I would no longer be fashionable?Also aren’t all these sustainable products super expensive? Not to mention the fact that I’m just one person and one person can’t make a difference right?

Wrong.

Switching to slow fashion doesn’t mean you get stuck with all the ugly and dull clothes, it doesn’t mean you end up looking like a plain Jane and finally it’s not going to break the bank. 

1. Myth – I can’t afford slow fashion without breaking the bank

Fact – Initially it may seem that sustainable clothes are much more expensive in comparison to clothes from a fast fashion company. This is because sustainable clothes are made with the aim of lasting longer as opposed to fast fashion clothes which are generally supposed to last only a few wears. Therefore the quality of sustainable clothes is superior to that of clothes belonging to fast fashion companies. Hence it stands to reason that sustainable clothes would be more expensive. However if you consider the cost per wear you will realize that in the long run sustainable clothes are in fact cheaper and that our brains are just being tricked into believing that clothes from a fast fashion company are cheaper when in reality it couldn’t be further from the truth.  

2. Myth – Slow fashion = Plain Jane 

Fact- There is a common misconception that just because the word sustainable is attached that these clothes must be dull and rusty. After all, do Emma Watson and Anne Hathaway (both leading advocates of slow fashion) dress in dull clothes and designs? Just because you switch to slow fashion doesn’t mean you have to become less fashionable or lose your sense of fashion.

3. Myth – I’m just one person, how can I make a difference

Fact- Remember how little drops of water make the mighty ocean? Without these little drops there would be no mighty ocean. Every single little drop matters. Similarly all of us have the power to help combat the negative effects of the fashion industry on the environment. Everybody’s contribution matters.

While switching from being a fast fashion consumer to a slow fashion consumer cannot be done overnight, it is worth noting that even the smallest effort towards becoming a more conscious consumer can go a long way in making a better tomorrow.

Things medical students are tired of hearing

As medical students there are certain things like for instance the smell of formalin, not always knowing an answer to a question or looking at rashes that are not easy on the eye that we get accustomed to. However, there are certain comments that we get from the non-medical population that despite the many times we hear them our body just refuses to get acclimatized to. Do not get me wrong I do understand that these comments for the most part come from a good place but that still doesn’t make it easier for us to digest it.

“You will be graduating in ……..? won’t you be so old then?”
From all the comments I have heard, this by far has to be my personal favourite. I already know that I would be older than my non medical colleagues when I finally graduate medical school and I think I speak for all medical students when I say it would do all of us a great favour if you’ll don’t take it as your personal duty to remind us about it every time we meet.

“You always have exams; you can never make it”
Sadly, this is the truth almost always we have exams or something or the other that doesn’t allow us to have a lot of free time. But when we are free, we always try to make it. We already feel bad about having to miss out on the fun but hearing it said out loud is just rubbing salt into our wounds.

“So, once you graduate you will treat me free of charge, right?”
The chances are you will be getting free medical services from your medical friend once he/she graduates. So, there is no need to voice it out. In fact, voicing it out makes us feel like that person is friends with us only for that reason.

“Which specialty do you want to specialize in?”
This question is not that bad it really just depends on who is asking it. I am certain that most people ask this question with good intention but even though it does not seem like it on the outset it is a very personal question. Think about it would you ask the same question from someone in the business field? Like for example would you ask your friend working in finance if he plans on doing an MBA? Sounds intrusive right? Secondly some medical students would not like to disclose the field they plan on specializing in. Maybe coz they are undecided, or maybe they just do not want the whole world to know until they are sure. I think that is reasonable.

“Aren’t you afraid of blood?”
Now this is something the fairer sex gets bombarded with. I honestly do not understand why anyone would even ask this question. Now, let’s see if you are afraid of heights you wouldn’t become a skydiver, now would you? So, isn’t the answer obvious?

If you are a medical student, I hope you found this relatable and if you are not well now you know what to avoid saying next time you meet your friends from medical school.