SLEEP!

[epsilonprodigy]

I'm on surgery and I love it. I don't mind getting up early from sn "attitude" standpoint, but I have developed a real problem with sleep deprivation. As it stands, our hours let us have 5-6 hours of sleep per night MAX- that's assuming you go home and take a shower plus study 20-30 min. Recently I have noticed that I can and will (unintentionally) sleep through just about anything. This has nearly caused me to be late twice. I also notice that I get extremely dizzy and faint when I'm mid-call and haven't slept for close to 24 hours. So far I've managed this with lots of caffeine and trying to wiggle my toes or bite my tongue to try to stay alert. The other day, however, I felt dangerously close to passing bout in the OR to the point where I seriously considered asking permission to step out. I need to fix this! I have a great work ethic and actually enjoy putting my nose to the grindstone, but I have to find a way to tolerate this and stay in control of my sleep! I am terrified to sleep on call bc I can't use my home alarm clock (which buzzes repeatedly while basically shining a floodlight on me, lol. Don't think my call buddies would be fans.) this issue must be fairly common...suggestions?

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[Brain Bucket]

The way I deal with it is caffeine, mixed with caffeine, in a supersaturated solution of caffeine.

 

[Mad Jack]

I'm really worried about how the sleep deprivation is going to treat my epilepsy. I'm betting "not good."

What the hell would the school do with a guy that has seizures secondary to sleep deprivation? I haven't had one in years, but I've also been very careful with my sleeping habits- 5-6 hours a night at least. They might be gone for good (I'm hoping my brain dealt with the defective neurons) but what if it's just been my sleep schedule that's saved my ass? Curious how people deal with the lack of sleep, and if I can apply any of the strategies normal people use to keep myself from ending up a patient at the tail end of a shift. Hopefully some good advice pops up in this thread.

 

[colbgw02]

Sleep is a crutch. You don't need it.

 

[Apoplexy__]

I'm on surgery and I love it. I don't mind getting up early from sn "attitude" standpoint, but I have developed a real problem with sleep deprivation. As it stands, our hours let us have 5-6 hours of sleep per night MAX- that's assuming you go home and take a shower plus study 20-30 min. Recently I have noticed that I can and will (unintentionally) sleep through just about anything. This has nearly caused me to be late twice. I also notice that I get extremely dizzy and faint when I'm mid-call and haven't slept for close to 24 hours. So far I've managed this with lots of caffeine and trying to wiggle my toes or bite my tongue to try to stay alert. The other day, however, I felt dangerously close to passing bout in the OR to the point where I seriously considered asking permission to step out. I need to fix this! I have a great work ethic and actually enjoy putting my nose to the grindstone, but I have to find a way to tolerate this and stay in control of my sleep! I am terrified to sleep on call bc I can't use my home alarm clock (which buzzes repeatedly while basically shining a floodlight on me, lol. Don't think my call buddies would be fans.) this issue must be fairly common...suggestions?

This is insane. I can't believe your attendings actually put a med student on that schedule. I'm sorry, OP.

If in your situation, I would probably seriously consider talking to my doctor to see what he thinks about modafinil or another stimulant.

 

[Wordead]

This is insane. I can't believe your attendings actually put a med student on that schedule. I'm sorry, OP.

If in your situation, I would probably seriously consider talking to my doctor to see what he thinks about modafinil or another stimulant.

Modafinil and other stimulants have questionable effects on seizure disorders I believe, might be hard to find someone who will prescribe it.

That sounds like a pretty normal surgery rotation schedule to me...

 

[SouthernSurgeon]

This is insane. I can't believe your attendings actually put a med student on that schedule. I'm sorry, OP.

I'd say I averaged 5-6 hours per sleep a night on medicine, peds, OB, and surgery as an M3 (excepting days off of course). That's not necessarily a malignant schedule.

 

[J ROD]

I'd say I averaged 5-6 hours per sleep a night on medicine, peds, OB, and surgery as an M3 (excepting days off of course). That's not necessarily a malignant schedule.

I call it a good night's sleep.

 

[Mad Jack]

I'd say I averaged 5-6 hours per sleep a night on medicine, peds, OB, and surgery as an M3 (excepting days off of course). That's not necessarily a malignant schedule.

5-6 hours isn't bad at all.

 

[SouthernSurgeon]

5-6 hours isn't bad at all.

I think my concern with your seizure history would likely be the sometimes unpredictability of your hours - i.e. prolonged call shifts where you don't get to sleep, throwing off your day-night wake cycle by working night shifts. Definitely worth discussing with your doctor ahead of time, but hope it doesn't present an issue.



And hey, at least if you have a seizure, you're already in a hospital...

 

[operaman]

Fighting to stay awake in the OR is a rite of passage. The hardest are peds cases because they keep the OR nice and warm, and if you're scrubbed it's even warmer, and you're probably not doing as much, and zzzzzzzzzzzzzzzzzzz.

Your schedule sounds pretty normal to me too. You basically make do, drink lots of coffee, and sleep whenever you can. Chewing gum helps a lot too. Make sure you're keeping busy too.

Try and enjoy the experience and get what you can out of it. Even if you don't decide on surgery as a career, you will at least benefit from doing it early because it will make every other clerkship seem easy in comparison.

 

[Mad Jack]

I think my concern with your seizure history would likely be the sometimes unpredictability of your hours - i.e. prolonged call shifts where you don't get to sleep, throwing off your day-night wake cycle by working night shifts. Definitely worth discussing with your doctor ahead of time, but hope it doesn't present an issue.



And hey, at least if you have a seizure, you're already in a hospital...

being in a hospital is actually the biggest of my worries. I come out of them just fine if I'm left alone, but if I made it to any hospital around here they'd intubate me since that's just SOP for a person post-seizure for airway protection. And I am super claustrophobic and freak out if restrained, so I'll probably end up in the ICU in the 'wean sedation, wake up, panic, initiate sedation, repeat' cycle a lot of people land themselves in because they can't stop freaking out when they wake up.

I haven't been on meds since I was 17, and don't even have a neurologist anymore. Had one seizure when I was 22, other than that I've been fine. I might have to consult with a neurologist sometime next year and see what they think. My big trigger is sleep disturbances, so yeah, I'm with you on the night shift thing. I'd be fine working permanent nights, but rotations might be the death of me.

 

[Brain Bucket]

How common is modafinil abuse?

 

[HoboCommander]

Getting 5-6 hours sleep was the norm in all my surgery and specialty surgery rotations, and also in my medicine rotations. I routinely fell asleep in the OR while scrubbed in. Could have fell and contaminated the procedure. But I think in residency, it will be even worse to get by with less sleep. More responsibility plus it's 5-7 years instead of just 2 years with "vacation rotations" thrown in like psych, anesthesia.

 

[Apoplexy__]

That sounds like a pretty normal surgery rotation schedule to me...

I'd say I averaged 5-6 hours per sleep a night on medicine, peds, OB, and surgery as an M3 (excepting days off of course). That's not necessarily a malignant schedule.

If OP is getting weekends off, that's a different story. If he can only get 5-6 hours/night every night though, sounds like 80-100 hours/week or so...

Modafinil and other stimulants have questionable effects on seizure disorders I believe, might be hard to find someone who will prescribe it.

Yeah, I meant for OP, not Mad Jack. I feel like it would be a reasonable option (i.e. not "abuse") for someone who is so affected by sleep deprivation in his/her daily life.

 

[maniacmed]

Getting 5-6 hours sleep was the norm in all my surgery and specialty surgery rotations, and also in my medicine rotations. I routinely fell asleep in the OR while scrubbed in. Could have fell and contaminated the procedure. But I think in residency, it will be even worse to get by with less sleep. More responsibility plus it's 5-7 years instead of just 2 years with "vacation rotations" thrown in like psych, anesthesia.

Ha I almost did this today at the end of a call shift. Wonder how often that happens. And all I was doing was holding the camera for a lap appy. I can't imagine actually doing the procedure as tired as I was. Surgery is definitely not in my future.

 

[Wordead]

If OP is getting weekends off, that's a different story. If he can only get 5-6 hours/night every night though, sounds like 80-100 hours/week or so...



Yeah, I meant for OP, not Mad Jack. I feel like it would be a reasonable option (i.e. not "abuse") for someone who is so affected by sleep deprivation in his/her daily life.

Uhh for the OP "Epilepsyprodigy"?

and yeah I was in 80 hrs/week easily during my surgery rotation, closer to 100 on subIs.

 

[Apoplexy__]

Uhh for the OP "Epilepsyprodigy"?

??? His name is "epsilonprodigy".

and yeah I was in 80 hrs/week easily during my surgery rotation, closer to 100 on subIs.

You know, some of my classmates have complained (endlessly) about their 50 hours/week rotation.

 

[Wordead]

??? His name is "epsilonprodigy".



You know, some of my classmates have complained (endlessly) about their 50 hours/week rotation.

Hhahaah my bad. For some reason I totally thought it said epilepsyprodigy.

 

[Kaustikos]

Couple things: if you find yourself falling asleep or dozing off, then you need to scrub out. I'm not being rude, but god forbid you impact the procedure negatively. I'm not talking about falling back, I'm talking about falling to the ones performing the procedure. This is like people who don't sit down when they're gonna pass out from the site of surgery. Either step back and have a seat or move away from the patient.

On that note. Getting 5-6 hours is the norm in third year. You'll get used to it. Six hours is a blessing on surgery. You need to learn how to take power naps. If I get tired, i just either sit and out my head down or lay down for 10-15 minutes. It works very well.
Third - since when is trach and intubate SOP for epilepsy? Are you not breathing when you have seizures?!

 

[Mad Jack]

How common is modafinil abuse?

http://io9.com/372097/provigil-is-the-cocaine-of-the-twenty-first-century
^article predicting that it would be found to be addictive- there was a time when it first came out that off-label use exploded

http://content.time.com/time/health/article/0,8599,1885825,00.html
^studies on its addictive potential

http://www.huffingtonpost.com/2012/07/18/provigil-narcolepsy-drug-modafinil_n_1682921.html
^An old article on abuse. They really clamped down on the prescribing of it a couple years back because it was starting to be abused. I don't know what the current abuse environment for it is though.

I'm not sure of the current market for off-label Provigil use, but my impression is that it has been substantially reduced as compared to a few years back.

 

[Brain Bucket]

http://io9.com/372097/provigil-is-the-cocaine-of-the-twenty-first-century
^article predicting that it would be found to be addictive- there was a time when it first came out that off-label use exploded

http://content.time.com/time/health/article/0,8599,1885825,00.html
^studies on its addictive potential

http://www.huffingtonpost.com/2012/07/18/provigil-narcolepsy-drug-modafinil_n_1682921.html
^An old article on abuse. They really clamped down on the prescribing of it a couple years back because it was starting to be abused. I don't know what the current abuse environment for it is though.

I'm not sure of the current market for off-label Provigil use, but my impression is that it has been substantially reduced as compared to a few years back.

Interesting. Thanks. I was just reading this subreddit http://www.reddit.com/r/Nootropics/
Fascinating that so many people are willing to be guinea pigs.

 

[Kaustikos]

http://io9.com/372097/provigil-is-the-cocaine-of-the-twenty-first-century
^article predicting that it would be found to be addictive- there was a time when it first came out that off-label use exploded

http://content.time.com/time/health/article/0,8599,1885825,00.html
^studies on its addictive potential

http://www.huffingtonpost.com/2012/07/18/provigil-narcolepsy-drug-modafinil_n_1682921.html
^An old article on abuse. They really clamped down on the prescribing of it a couple years back because it was starting to be abused. I don't know what the current abuse environment for it is though.

I'm not sure of the current market for off-label Provigil use, but my impression is that it has been substantially reduced as compared to a few years back.

I'm not surprised. My old pcp gave me modinifil without any actual workup because I "was tired in the morning". I didn't even ask for the drug.
Nowadays I can't say how easy it is but that it's easier to get this than adhd meds like vyvanse. Way easier.

 

[Mad Jack]

Interesting. Thanks. I was just reading this subreddit http://www.reddit.com/r/Nootropics/
Fascinating that so many people are willing to be guinea pigs.

I was very curious about nootropics in undergrad. Personally I think that the idea that drugs should merely "diagnose, treat, or prevent" disease is ridiculous, and that we should be able to use them to enhance people beyond their ordinary limit. Why just be human when we could be superhuman? Only did the research on them, never took any because I was too worried about their effect on my epilepsy- messing with my brain chemistry is probably a bad idea. But nootropics are a fascinating field that I wish we'd let science play around with more. If my brain weren't so damn fragile, I'd be down to be a guinea pig myself.

 

[Brain Bucket]

I was very curious about nootropics in undergrad. Personally I think that the idea that drugs should merely "diagnose, treat, or prevent" disease is ridiculous, and that we should be able to use them to enhance people beyond their ordinary limit. Why just be human when we could be superhuman? Only did the research on them, never took any because I was too worried about their effect on my epilepsy- messing with my brain chemistry is probably a bad idea. But nootropics are a fascinating field that I wish we'd let science play around with more. If my brain weren't so damn fragile, I'd be down to be a guinea pig myself.

I've only recently started looking into them. I share your curiosity and agree with your premise, but I'm not willing to mess with my brain until I have a better understanding of the mechanisms involved.

 

[SouthernSurgeon]

Couple things: if you find yourself falling asleep or dozing off, then you need to scrub out. I'm not being rude, but god forbid you impact the procedure negatively. I'm not talking about falling back, I'm talking about falling to the ones performing the procedure.

This is like people who don't sit down when they're gonna pass out from the site of surgery. Either step back and have a seat or move away from the patient.

Yup. You get no points for bravery. If you feel bad or like you're going to pass out - scrub out. No one will judge you. Go to the bathroom, slap some water on your face, drink a coke, and come back.

Falling back is bad too, because then the nurses and anesthesiologist have to take care of you instead of the patient.

Third - since when is trach and intubate SOP for epilepsy? Are you not breathing when you have seizures?!

I'm assuming he means if its a prolonged seizure that doesn't break?

I've never seen a post-ictal patient get tubed for being post-ictal. But I imagine if someone doesn't come out of it they'd intubate for airway protection?

 

[dozitgetchahi]

Modafinil isn't extensively abused. Misused, perhaps, and prescribed inappropriately - but not abused. In this sense, it's similar to dronabinol. The potential for a 'high' is minimal and you'll never find people spending their last cent and walking the streets because they blew everything on it.

IMHO it has much less justification for being C-IV than does tramadol, which as far as I can tell is an extensively and enthusiastically abused opioid that until recently was totally uncontrolled.

 

[Kaustikos]

Yup. You get no points for bravery. If you feel bad or like you're going to pass out - scrub out. No one will judge you. Go to the bathroom, slap some water on your face, drink a coke, and come back.

Falling back is bad too, because then the nurses and anesthesiologist have to take care of you instead of the patient.



I'm assuming he means if its a prolonged seizure that doesn't break?

I've never seen a post-ictal patient get tubed for being post-ictal. But I imagine if someone doesn't come out of it they'd intubate for airway protection?

Yeah,
Nurses/anesthesia aren't a fan of that. lol

I guess I didn't understand his comment about SOP. I've never seen post-ictal get intubated either. It must be pretty bad if you need to do that. I always thought post ictal patients were just confused but capable of breathing/etc. Seems like a very serious thing that would warrant further workup.

 

[michaelrack]

How common is modafinil abuse?

very rare... I have never seen it and I am a sleep doc who also moonlights at a psych ward on weekends.

Provigil and seizures: http://www.ncbi.nlm.nih.gov/pubmed/22420936

Stimulants and seizures: http://www.ncbi.nlm.nih.gov/pubmed/18065271

 

[operaman]

My guess is modafinil use/abuse is probably more prevalent than we realize, though not nearly at the level of more well known drugs of abuse. It is not picked up by routine urine drug screens so that may lower the numbers. You can obviously pick up anything on GC/MS, but that's pretty expensive and probably not used unless you are specifically looking for it.

 

[swoopyswoop]

I don't get why you guys are sleeping 5-6 hours a night. I've done surgery and medicine so far and I sleep at least 7. Then again, I will choose sleep over studying... so there's that...

 

[Psai]

I don't get why you guys are sleeping 5-6 hours a night. I've done surgery and medicine so far and I sleep at least 7. Then again, I will choose sleep over studying... so there's that...

this is my life

 

[Kaustikos]

I don't get why you guys are sleeping 5-6 hours a night. I've done surgery and medicine so far and I sleep at least 7. Then again, I will choose sleep over studying... so there's that...

Troll more. Even if I get out at a decent hour, I still prefer 5-6 hours sleep. It's how I function. Also, it's not just studying. Sometimes you don't get out until after 7. And I have other things to do like work out, eat, etc.

 

[Armadillos]

Like others have said, it all about prioritizing whats important to you, if sleeps important you can get it. I dont think I got less than 7hrs of sleep two days in a row at any point during ms3, if I had to get up crazy early I just went to sleep crazy early.

My spouse and I actually sat down and talked and decided we would rather have less time to hang out if it meant I would always be in a good mood b/c I was well rested

 

[Mad Jack]

I'm assuming he means if its a prolonged seizure that doesn't break?

I've never seen a post-ictal patient get tubed for being post-ictal. But I imagine if someone doesn't come out of it they'd intubate for airway protection?

Maybe they were just super intubation happy at my hospital. If a guy rolled in with altered MS post-GM seizure, they'd intubate in the ED every single time unless their GCS was 8+ for "airway protection." We didn't have a lot of GMs on the floor, so I don't know how they'd approach them up there. I've never been intubated after rolling into a hospital after a seizure, so I was kind of shocked that a place as prestigious as where I was working would be some intubation happy. If I ever woke up intubated after a seizure I'd be pissed.

 

[evilbooyaa]

Troll more. Even if I get out at a decent hour, I still prefer 5-6 hours sleep. It's how I function. Also, it's not just studying. Sometimes you don't get out until after 7. And I have other things to do like work out, eat, etc.

He's not trolling. I sacrificed working out, eating, and studying for sleep all the time. Rare were the days I got home at 9pm and had to be in at 4am the next day. If I got home at 8 and had to be in at 4am, I usually would just grab a quick bite and then pass out. Some days were come home, take off clothes, fall onto bed, bam it's 3:30am. I studied and read about future procedures during any downtime during the day.

 

[swoopyswoop]

He's not trolling. I sacrificed working out, eating, and studying for sleep all the time. Rare were the days I got home at 9pm and had to be in at 4am the next day. If I got home at 8 and had to be in at 4am, I usually would just grab a quick bite and then pass out. Some days were come home, take off clothes, fall onto bed, bam it's 3:30am. I studied and read about future procedures during any downtime during the day.

Yup, not trolling. Sleep > all else. Actually, sleep = food > all else.

 

[Doctor Bob]

Maybe they were just super intubation happy at my hospital. If a guy rolled in with altered MS post-GM seizure, they'd intubate in the ED every single time unless their GCS was 8+ for "airway protection." We didn't have a lot of GMs on the floor, so I don't know how they'd approach them up there. I've never been intubated after rolling into a hospital after a seizure, so I was kind of shocked that a place as prestigious as where I was working would be some intubation happy. If I ever woke up intubated after a seizure I'd be pissed.

That facility is an anomaly. Intubation isn't standard for seizures. Unless they are persistently apneic, unbaggable, and the seizure isn't breaking with hefty benzos... well then they buy themselves an ET tube. And if they get a little hypopneic/apneic from all the benzos? HOB to 30 degrees, drop in an LMA, and wait for them to be more arouseable.

 

[alpinism]

We had pretty standard hours on my surgery rotation, but I still could have managed 7 hrs per night if I really needed it.

Wake up at 415am, pre round at 5am, leave the hospital by 8pm most days, home at 815 = 8 hours to eat/study/sleep

I usually only slept 6hrs a night, but that was due to reading up on the next days cases, studying for the shelf, working out, then relaxing for an hour.

The only way only could have 6hrs MAX to sleep most nights is if you're at the hospital way over 80hrs per week or you have an hour drive to the hospital every morning.

Not saying its not possible, just highly unlikely on a M3 rotation.

 

[DermViser]

I'm on surgery and I love it. I don't mind getting up early from sn "attitude" standpoint, but I have developed a real problem with sleep deprivation. As it stands, our hours let us have 5-6 hours of sleep per night MAX- that's assuming you go home and take a shower plus study 20-30 min. Recently I have noticed that I can and will (unintentionally) sleep through just about anything. This has nearly caused me to be late twice. I also notice that I get extremely dizzy and faint when I'm mid-call and haven't slept for close to 24 hours. So far I've managed this with lots of caffeine and trying to wiggle my toes or bite my tongue to try to stay alert. The other day, however, I felt dangerously close to passing bout in the OR to the point where I seriously considered asking permission to step out. I need to fix this! I have a great work ethic and actually enjoy putting my nose to the grindstone, but I have to find a way to tolerate this and stay in control of my sleep! I am terrified to sleep on call bc I can't use my home alarm clock (which buzzes repeatedly while basically shining a floodlight on me, lol. Don't think my call buddies would be fans.) this issue must be fairly common...suggestions?

Yes, you're weak if you can't manage on 5-6 hrs of sleep. Man up. (j.k.). Now you know why you REALLY have to love Surgery (and can't see yourself as doing ANYTHING else) in order to get thru 5 years of General Surgery training.

 

[Kaustikos]

Yes, you're weak if you can't manage on 5-6 hrs of sleep. Man up. (j.k.). Now you know why you REALLY have to love Surgery (and can't see yourself as doing ANYTHING else) in order to get thru 5 years of General Surgery training.

Yeah,
No one in my circle understands how someone like me who isn't a morning person enjoys surgery. lol
But I don't understand why people say its the worst in terms of time commitment. My friend is doing her medicine subI and works the same total hours on average.
I guess I enjoy not having to tell the autobiography of every new admit including their favorite Beatles album.

 

[swoopyswoop]

I was much more exhausted during my medicine month at the VA than my surgery month on transplant surgery... and sleeping less.

 

[Kaustikos]

I was much more exhausted during my medicine month at the VA than my surgery month on transplant surgery... and sleeping less.

**** the VA. Things crawled to a snails pace during medicine. I was volunteering to see patients 3-4 times a day because I was so bored. The patients probably wanted to file a restraining order against me for talking to them so much.

 

[swoopyswoop]

We were always EXTREMELY busy, mostly doing non-medical things because the nursing staff/ transport / any ancillary service would just not do them.

 

[neusu]

Ha! I can't count how many times I have fallen asleep standing up looking through a microscope, while scrubbed in post-call, watching a hand on attending doing a spine case. Nod off only to be woken up by your face hitting your eye pieces and the attending yelling at whomever bumped the scope. Painful.

One week a while ago, on a horrible stretch (patches of sleep, an hour here, maybe 2 there), I was scrubbed in a 540 degree spine, leaded up, room was a billion degrees because it was a trauma, I was sitting on a stool because we were doing a spin to check our hardware alignment and fell asleep. The circulator had to nudge me to wake me up!

 

[mimelim]

Ha! I can't count how many times I have fallen asleep standing up looking through a microscope, while scrubbed in post-call, watching a hand on attending doing a spine case. Nod off only to be woken up by your face hitting your eye pieces and the attending yelling at whomever bumped the scope. Painful.

One week a while ago, on a horrible stretch (patches of sleep, an hour here, maybe 2 there), I was scrubbed in a 540 degree spine, leaded up, room was a billion degrees because it was a trauma, I was sitting on a stool because we were doing a spin to check our hardware alignment and fell asleep. The circulator had to nudge me to wake me up!

You know I'm a reasonably hardcore guy, but that just sounds dangerous...

 

[Kaustikos]

You know I'm a reasonably hardcore guy, but that just sounds dangerous...

Yeah...
If I feel tired, I at least move away from the patient and pretend to look at the CT or whatever. Or even step back and stretch.
I dunno, make something up like you randomly got something in your eyes or something. I just don't see how it's smart to feel like you should stand there and nod off.

 

[Lawgiver]

gosh, posts like these make me feel sorry for all those poor cells being abused in the name of learning. hope things change.

 

[Kaustikos]

gosh, posts like these make me feel sorry for all those poor cells being abused in the name of learning. hope things change.

I dunno. Like, the interns and residents bitch but they seem content with it overall. I think part of it is knowing it sucks and expecting it.

 

[DermViser]

http://io9.com/372097/provigil-is-the-cocaine-of-the-twenty-first-century
^article predicting that it would be found to be addictive- there was a time when it first came out that off-label use exploded

http://content.time.com/time/health/article/0,8599,1885825,00.html
^studies on its addictive potential

http://www.huffingtonpost.com/2012/07/18/provigil-narcolepsy-drug-modafinil_n_1682921.html
^An old article on abuse. They really clamped down on the prescribing of it a couple years back because it was starting to be abused. I don't know what the current abuse environment for it is though.

I'm not sure of the current market for off-label Provigil use, but my impression is that it has been substantially reduced as compared to a few years back.

Doesn't the military use Modafinil to keep soldiers awake?