Episode 3: THE FIVE REASONS

Empowered Sleep Apnea: THE PODCAST
Episode 3: THE FIVE REASONS
All content ©2022 Empowered Sleep Apnea, LLC
www.EmpoweredSleepApnea.com

For a copy of a transcript to this episode, INCLUDING CARTOONS (how RAD is that?), click HERE.

...in this episode, our friend Robert finds himself following a White Rabbit...

       ..to find that things on the ISLE are not always as they seem...

                       ...and yet...he seems to feel comfortable at THE COFFEE HUT.

Don't miss this exciting episode, where you'll hear DAVE and ELLEN talk their way through the most challenging of all discussions--THE COFFEE HUT DISCUSSION about the FIVE REASONS TO TREAT.

Oh, yeah. And of course. You gotta have your DAD JOKE!

Our Website: https://www.empoweredsleepapnea.com
Official Blog: "Dave's Notes" : https://www.empoweredsleepapnea.com/daves-notes

To go to the BookBaby bookstore and view the BOOK, click HERE!

Transcript

 Empowered Sleep Apnea: THE PODCAST
Episode 3: THE FIVE REASONS
All content ©2022 Empowered Sleep Apnea, LLC
www.EmpoweredSleepApnea.com

For a PDF of this transcript, including cartoons (Whaaaa?!), click HERE.

00:00: Empowered Sleep Apnea BOOK promotion

Empowered Sleep Apnea: The Book is now available, in both the hardback, which is just beautiful and really showcases the art nicely, but also in e-Book form, for Apple iBook and Kindle. Are you tired of guessing? Try on some Empowerment for yourself. We’ve got just your size. Want more information? Good! Go to www.EmpoweredSleepApnea.com and click the tab that says BOOK.

…and hey!...many thanks!

00:30 Disclaimer

ANNOUNCER: Empowered Sleep Apnea is an educational podcast, which is a bit different than a medical advice show. Clinical decision-making can be complex…and even EMPOWERED PATIENTS need a partner. So, play it smart and make sure you discuss your case with your healthcare provider before making any changes to your medical treatment plan.

And now…on with the show!

01:09  Empowered Sleep Apnea. Episode 3: THE FIVE REASONS.

That night, Robert had a dream.

In the dream, he comes to awareness, standing on a rocky beach, just as the sun is coming up. 

In the way that happens in the inexplicable logic of dreams, Robert has no recollection of arriving there.

All he knows is that he is there, now. 

This thought does not trouble him.

He follows his long shadow towards the shallows, submerged coral reefs glistening with the movement of tropical fish, garish in their oranges, blacks, yellows, and blues. He has no idea how long he has been here. It could be days. It could be weeks.

This thought does not trouble him.

The water is brilliantly blue. Further out, the water is darker, and deeper. A slow mist mopes in the further distance, playing lazily on the surface of the water, vanishing into an effervescent steam, with flashes of rainbow brilliance as the warming morning sun rises.

On the horizon is an old-world wooden clipper ship, fully rigged for sail…a rainbow of flags snapping in the breeze, where gulls hover, caw-cawing to each other, and diving into the glistening sea.

The air smells of salted honeysuckle and sandalwood.

At the beginning of his journey—was it days, or weeks before this moment—

[he does not know]

he recalls that he had found, submerged in the sand near his feet, a bit of polythene plastic wrap. He nudged it with his toe, and the sand slipped away, and he was able to expose a small cardboard box, completely encased in sealed plastic wrap.

He had picked up the small package, and he had dusted it off. 

He had shrugged, as he pulled away the plastic, and opened up the box, revealing at that time a perfectly preserved hand-held dictation tape recorder.

In that wonderful, inexplicable way that ideas suddenly come to you in dreams, and you accept the idea without question or critique, Robert had become aware that he was supposed to use this recorder, to say something about his journey.

In this dream, standing on the beach now, Robert gazes at the tape recorder in his hand. His dreaming memory tells him that he has been doing this for weeks, narrating his story. And as he recalls this, he can recount distinct adventures, chronologically, just as he can recount narrating these adventures into the tape recorder.

He has an understanding that it’s for posterity. He decides that now is the time to provide a summative report on his experience so far.

Although real-life Waking Robert hates public speaking, and gets sweaty palms just recording his voicemail message, the concept of extemporaneously recounting his adventures in this mysterious place—this does not phase Dreaming Robert in the slightest.

Dreaming Robert is feeling just fine.

Dreams have a way of doing that. Making the fearsome commonplace, and the commonplace…terrifying. Robert feels a sense of duty, during this dream. He feels driven to get the story right.

After all…it’s for posterity.

He fumbles briefly with the buttons on the device, at first, not quite remembering how an antique like this is supposed to work…

…which he finds a bit odd, because he’s been using this thing for weeks!...but not quite odd enough to worry about…

After a brief inspection of the device, he ends up successfully pushing the black rectangular PLAY button at the same time as the smaller red square-shaped RECORD button, right next to it.

A steady red light comes on, next to the magic word RECORDING.

The tape heads are moving. 

Robert holds the built-in microphone to his mouth, clears his throat, and begins to speak…

05:14 Robert tells his story…

[TAPE CLICKS]

ROBERT: Um…Testing… testing. I guess it’s picking up OK. OK. My name is Robert. And I am standing on the beach of a place called the ISLE OF SLEEP APNEA. 

So far, I haven’t seen another living soul. I’ve been scouting this beach for…I don’t know how long…a few days?...maybe longer...

When I first got here, I didn’t know where I was. 

This place is clearly tropical…seemingly South Pacific Ocean…but the stars…look strange.

My little beach is about half a mile across. There’s a boat dock, but so far, I haven’t seen anyone coming or going.

Out in the Bay, there’s a magnificent clipper ship that looks to be from the mid-19th century…I haven’t seen anyone on it yet.

The beach itself is surrounded by nearly vertical rocky cliffs, and so far, I haven’t found any way to explore further inland. That is: not unless I had technical climbing gear--which I don’t!—not that I’d know how to use it anyway.

Near the boat docks, there’s a walking pier, and over it is a big sign that you read as you walk under it, when you’re heading towards land. It’s a big blue sign with yellow letters, and it says WELCOME TO THE ISLE OF SLEEP APNEA—Bay of Narrative Entry Point. 

If you read the sign from the other side, walking toward the ocean, the sign simply says: It Doesn’t Matter How You Got Here, You Can’t Swim Home!

(laughs)

As soon as I see somebody, I’m hoping I’ll get a chance to ask them what that means.

Now, I’ve been wandering around this Bay of Narrative, and I’ve been able to put together a few things. The more time I’ve spent here, the more I feel like I understand.

Now, first of all, my primary care physician found an abnormal heart rhythm called Atrial Fibrillation. Now I really didn’t feel it all that much, but that doesn’t matter…A.Fib can increase your risk of getting a BLOOD CLOT to the brain! 

That’s otherwise known as a stroke. So I think it’s a good thing my doc found it.

What I didn’t know then was that if you test EVERYBODY with atrial fibrillation, you’ll find that about HALF OF THEM will have Sleep Apnea.

ISLAND MAGIC: Half! Half! Half!

ROBERT (not noticing ISLAND MAGIC): …and I think it’s fair to say that I flunked that test! So, I went to see a Sleep specialist, and then, I woke up here.

Before I came here, I would  have said my sleep was fine. You know, I go to work every  day, I don’t have traffic accidents…I pay my bills…I’ve been managing pretty well, but, as I thought about it…I really don’t sleep all that well.

I get up about every two hours to pee, and I always feel like me sleep is REALLY light-stage. So, I usually wake up about an hour before my alarm goes off, and even though I’m tired, I can’t get back to sleep.

My wife Sheila says I don’t snore. But: I have to admit…she sleeps really soundly, so she’s not an ideal witness.

ISLAND MAGIC: Robert! Robert! Robert!

ROBERT: …when I wake up in the morning, though, that’s a completely different story. 

Every morning, I sound like the darn TB ward! I’m coughing, and I’m sneezing, and I’m blowing my nose…it takes me about ten minutes and a shower, to get clear. Then usually, I’m good.

Now, I never feel really great…but I pull my own weight.  I’m a systems engineer, you see? And I’m in charge of a team of seven…and there’s a lot of hands-on work, and that means I’m moving around a lot during the day, which is how I like it!

You know, I hate it when we have team meetings, especially cuz I’m the guy who has to lead them, but I have a hard time staying awake, so I have to stand up, to keep from falling asleep.

My wife…she calls me The Sandman…because…I can’t watch movies! If I try…I’m asleep! If I fall asleep…it’s over!

Get this: I fell asleep watching The Fast and The Furious…I mean…it’s a family joke.

Now, around the beach in the Bay of Narrative, there’s a stretch of boardwalk, and that leads to a garden area with lots of intertwining walkways…it’s a pretty nice place, with lots of native and tropical plants, a pretty water feature, and a place to buy post-cards, even though, so far, the window sign just says NOPE and the shop has been dark.

This place remains remarkably empty.

Throughout the gardens are benches…all of them are inscribed with different statements. Most are in fairly secluded garden rooms, surrounded by thick hedges with only one way in or out. 

The clear impression is that you’re supposed to go in there and meditate on your thoughts, in relative seclusion.

I’m heading into the garden area now and…hmmm…that’s odd.

[STATIC]

[TAPE CLICK]

ISLAND MAGIC: Robert! Robert!

[TAPE CLICK]

ROBERT: --there is a garden room…that I don’t think was here before! Um.  That’s really strange. Uh, as with the other rooms, there’s a gravel path that goes into a big octagonal clearing, it’s about thirty feet across…uh, and it’s surrounded by a dense hedge about ten feet high, but this one…was not…HERE yesterday.

Wow.

Like in the other rooms, in the center, there is a bench, and it’s situated to gaze at a lovely naturalized garden—this one has Plumeria in it—really gorgeous…now I’m getting, uh…I’m walking close enough to the bench, I can read the inscription…here we go…

ISLAND MAGIC: Read it! Read it!

ROBERT (reading): 

ALL YOUR AFFLICTIONS

ISLAND MAGIC: Yes

ROBERT (reading):

BY DAY, YOU WORRY FOR THEM

BY NIGHT…INVITE THEM

[TAPE CLICK]

ISLAND MAGIC: KEEP GOING KEEP GOING

[TAPE CLICK]

ROBERT: … … … I am now sitting in the bench. Uh, I’ve just read the inscription…uh…in a garden room that I swear was not here yesterday, and I’m looking at these beautiful flowers, and I’ve just been thinking about my medical history…

…you know, the doc told me at my 50th birthday that I had high blood pressure! And I found that really hard to believe. You know? High blood pressure? Are you kidding me? I—I was an athlete all the way through college, I- I couldn’t believe it.

She also told me that my depression screening survey score put me at the AT RISK category, um, my fasting glucose was high—not diabetic, but high…and then, of course, there’s the atrial fibrillation.

I mean. I’ll be honest.

Part of me wishes I’d never gone to that appointment.

But I’m sitting here, you know…thinking…thinking, you know?

[TAPE CLICKS]

ISLAND MAGIC: KEEP GOING! ROBERT! ROBERT! KEEP GO-

[TAPE CLICKS]

ROBERT: What IS disease, anyway? What does it mean to be UNWELL? How many of the things that bother ME…?...I mean…how many of them might be driven by a problem that’s only happening when I’m not even conscious? 

(grunts)

I keep having this vision of being visited by something…harsh and stressful during sleep, I- … I can’t quite make it out…but…somehow I wonder whether this…visitor is…I don’t know…pushing my body towards disease…you know?... DIS-EASE!

I’m just thinking about health…you know, WELLNESS…rest…recuperation…I mean…I’m thinking about it all differently now…in a different part of my brain…it feels like…

Wait a minute! WHAT THE HECK?

[TAPE CLICKS]

STATIC

[TAPE CLICKS]

ROBERT: …there is…a new…opening…that has…suddenly a- appeared in this garden room. Um. I don’t know that there is any way I could have missed it. It’s about five feet across. It’s essentially a- a- a hole in the hedge—

[TAPE CLICKS]

ISLAND MAGIC: So close! So close! 

[TAPE CLICKS]

ROBERT: --and as I looked up, I watched as a little…rabbit…he’s probably no more than a few pounds…just went jumping up through that hole…and, um…I’m gonna get a little closer and see what I can see through this hole…

[TAPE CLICKS]

ISLAND MAGIC (several voices): 

--Good Job Robert! Well Done!

--Here he comes! Here he comes! Make sure he sees!

[TAPE CLICKS]

ROBERT: …ok, as I’m looking, I can just get my head through it, there’s a pathway on the other side, and, um, it looks like it leads right up to the cliffs, and then it disappears, but it looks as though there might actually be some stairs there, I’m gonna turn off the tape and see if I can get over there...

[TAPE CLICKS]

ISLAND MAGIC: Huzzah! Huzzah! Huzzah!

[TAPE CLICKS]

ROBERT (breathing hard): OK. I’ve made it through the hedge, and I found a stairway in the cliffs, and I am now at the very top. And I am at the foot of an unusual building.

It appears to be made entirely of cut stone. After climbed up the stairway in the cliffs, I found myself on this broad pasture, sloping up to a bald flat, and upon which there is this building.

So now that I’m in front of it, I can see that there are five GIANT stairs that run the entire width of the building. Each stair is sort of preposterously big, as I’m standing here, the effect is sort of cartoonish…it’s as if you’d wandered onto the set of The Incredible Shrinking Man…

…each step is high enough that I’m not gonna be able to walk up, I’m gonna have to get one knee up, and kind of CLIMB up.

And at the top of these five stairs, I can see five enormous columns, and above that is a very broad ceiling that’s about…oh I’d say about thirty feet up, above the stairs.

And, uh…it’s worth mentioning that each of these five stairs has one word on them, and I’m gonna read them from the bottom step up, the words are RISK

ISLAND MAGIC: RISK!

ROBERT: SNORING

ISLAND MAGIC: SNORING!

ROBERT: SLEEP

ISLAND MAGIC: SLEEP!

ROBERT: WAKE

 ISLAND MAGIC: WAKE!

 ROBERT: COMORBIDITIES

 ISLAND MAGIC: COMORBIDITIES!

 ROBERT: I’m gonna…I’m gonna see if I can climb up there and see if I can get to the top.

 [TAPE CLICKS]

 ISLAND MAGIC: keep going! Keep it up!

 [TAPE CLICKS]

 ROBERT (breathing hard): OK. Wow. I’ve made it to the top of the stairs. And now that I’m up here, it’s a great view…boy I can see the ocean from up here…

 On each of these columns, on the inside, it looks like there’s a different…I don’t know…a different scene…it looks like a- a- a woodcut of some kind…I’m gonna be interested to look at those in a minute…but, uh, it looks like I may have found some signs of life…

 …so at the very…uh…inside of this…building, I see what looks like a Railcar Diner, and uh, inside the lights are on, I can see the sign it says: 

 FIVE REASONS MONUMENT COFFEE HUT

 …so I’m, I’m just getting to the door here, I’ll see if I can go in and find a phone…

 [SHOP BELL TINKLES, SWEET, UNNAMEABLE MUSIC IS PLAYING]

 BARRISTA: Hey! Welcome to the FIVE REASONS MONUMENT COFFEE HUT! Doesn’t matter how you got here, ya can’t swim home! (laughs) How can I help you?

 ROBERT: Um, yeah, there’s THAT. What does that mean, anyway?

 BARRISTA: Hey, you want some coffee? Or you want a history lesson?

 ROBERT: Some coffee…I guess…house roast…um…with room for cream! Oh! And a lemon scone.

 BARRISTA: Great great great. You want the FIVE REASONS TO TREAT discussions with that? Or you just wanna dope it cold?

 ROBERT: Uhh…dope it cold?

 BARRISTA: Yeah, you know? Dope it COLD! Go it alone? By yourself? With NO KNOWLEDGE?

ROBERT: Um…I think I’ll take the discussion…with that…um…I’m not even sure if I have my wallet, how much will that be?

 BARRISTA: Well, the coffee and the scone…they’re on the house. But for the uh…for the discussion…(laughs)…wait for it…

17:12  CUE MAJESTIC THEME MUSIC

 …you’re gonna have to, uh…PAY ATTENTION! Hahhhh? Pay attention? You get it?

 DAVE: Welcome back to Empowered Sleep Apnea, the podcast where you learn about Sleep Apnea through the power of stories. I’m Dr. David McCarty, and I’m here in the studio today with Sleep Neuroscientist Dr. Ellen Stothard.

 On today’s exciting episode of Empowered Sleep Apnea: THE PODCAST, we get to accompany Robert down his own personal Rabbit Hole, and see what happens inside the FIVE REASONS MONUMENT and COFFEE HUT.

 What kind of magic happens inside those hallowed halls? 

 We’ll find out, Listeners! On today’s exciting episode of Empowered Sleep Apnea: THE PODCAST…Episode 3: THE FIVE REASONS…

 DAVE: I’m glad to be here, Ellen, it’s so good to see you again!

 ELLEN: Yeah! It’s so good to see you too, Dave.

18:19 The IMPORTANCE OF KNOWING YOUR HEADSPACE

 DAVE: Um…We have to talk about Robert; he’s having a crazy dream…

 ELLEN: Yes, he is…

 DAVE: It seems he has fallen…fallen into this world.

 ELLEN: We’ve really gone on an Alice in Wonderland kind of adventure with him, haven’t we?

 DAVE: What do you think happens next?

 ELLEN: Well, I was gonna ask you why do you that it so identifies with Alice in Wonderland…why not another cartoon?

 DAVE: I think it’s a- It’s a personal thing! For me, anyway, getting to the right place in your mind…where you can absorb this information…that’s the real ticket. And so for me it’s always been like this trip down the rabbit hole…you know?...this wonderous world…THAT opens up a different part of my brain, you know?

 ELLEN: Yeah! Because when you talk to patients, you don’t want to scare them! I feel like, whenever we go out in the world, we’re like: sleeping kills, you know? If you don’t sleep well, YOU’RE GONNA DIE. If you don’t get treated, YOU’RE GONNA DIE!

 DAVE: Yeah!

 ELLEN: How do you deal with that, getting people into the right headspace?

 DAVE: It’s very difficult, because the truth of the matter is: this is a very complicated subject!

 ELLEN: MmHmm.

 DAVE: Like, when I characterize this in my Brain-Space, and I think about Sleep Apnea, I imagine this big  sort-of Cthulhu-type creature—you know with these giant arms, and tentacles, and…it’s just…it’s ENORMOUS!! 

 …and you know, everyone who works on this disorder is sort of glimpsing a different part of this beast.

 …the enormity of it, in actuality, is just mind-blowing…that being said, I can’t present Cthulhu to my patients and say HERE, THIS IS WHAT YOU HAVE!

 ELLEN: Especially not on the first visit!

 DAVE: No, no! Of course not! 

 …what I would like to do is show them around…get them to the right place so that they feel like they’ve got their walking shoes on, and they kinda know their way around…

 …that’s called AGENCY…

 …and that’s the right headspace for me, anyway, is Going On A Grand Adventure opens that just wide open for me…

 ELLEN: It’s interesting that you describe it as an ADVENTURE as a PLACE…that’s so much different than a scary monster-thing that you can’t deal with…you actually can go on an adventure and figure these kind of things out…

 DAVE: Yes! That’s a little bit easier to swallow than…Here’s Cthulhu! Good luck with that! 

 (BOTH LAUGH)

20:47. Let’s Talk FIVE REASONS

 ELLEN: Contrast that with what we’re presenting today, the FIVE REASONS TO TREAT.

 CHORUS: One, two, three! four, FIVE REASONS! One, two, three, four, FIVE REASONS!

We’ve got FIVE REASONS! We’ve got FIVE REASONS!

 DAVE: The FIVE REASONS TO TREAT is basically a salve for that existential anxiety and suffering of just not knowing where you are…

 ...unfortunately that sort of suffering really blows back…to make people give up too early…it gives people bad feelings about motivations from their providers if they don’t understand…and so they draw conclusions that aren’t necessarily true, you know—they think: Oh, you’re just trying to sell me a machine like Robert did.

 So that’s all born of just not knowing…you know…and not understanding…

 …and so the FIVE REASONS TO TREAT is really the medicine for that form of suffering…and it’s really important to take it seriously enough, that you recognize that this HAS TO HAPPEN…

 …which is why there’s a MONUMENT! (laughs)

 …like there’s no arguing with it! It’s a STONE CUT MONUMENT!

 ELLEN: It is right there in your face, and it’s HUGE!

 DAVE: Yeah! It’s huge!...it almost makes you feel like a kid, you know, crawling into the building, because you’re so small…you know?...so…in a way, it’s like: you’re in for a trip!

22:09  The Loving Guidance of THE ISLE

 ELLEN: People don’t spend time introspectively thinking about their narrative, or their symptoms…or their experiences…

 DAVE: I think that’s it!

 ELLEN: …and, that’s what I really felt, when he was there, it was as if the Island was forcing him…was setting up a better infrastructure for him to have that journey…

 DAVE: Yeah! It wouldn’t let him…it wouldn’t even let him go!

 ELLEN: Yeah!

 DAVE: …to the FIVE REASONS MONUMENT, until he kind of GOT IT…

 ELLEN: Yes.

 DAVE: You know, he had this…moment…where he’s like Oh my God, I’m thinking about things differently…

 ELLEN: Yeah.

 DAVE: …you know? What is disease? And then he’s like: Oh my God, this may all be connected! 

 ELLEN: Yeah.

 DAVE: …people feel comfortable at the Coffee Hut. It’s a place where you feel safe…and comfortable…and warm.

 …in my clinic, that safe place was when you’re sitting with me, cuz I would sit with people and make them feel comfortable…

 …but when you write it down in a book, the book becomes this horrible thing…you know? IT’S A TEXTBOOK, and it’s got…tables…and things to memorize…and…CHAPTERS…and all of a sudden, the book itself becomes almost frightening.

 I realized that a TEXTBOOK wasn’t gonna work…so what we need…is a magic place.

 ELLEN: So: it’s hard to get Dave to translate Dave The Person to Dave The Writer…

 DAVE: It’s almost like it’s an engineering problem…

 …you remember that scene in Apollo 13, where the engineer comes in and he says: We’ve got a problem…

 you remember the carbon dioxide scrubber? 

 He says: We’ve gotta fit this round cylinder into the hole for this big giant box, using nothing but THAT! 

 And he dumps a bunch of stuff on the table…right? And there’s just like—who knows what’s in there? GQ Magazines? And you know…tubes and wires and toothbrushes…

 …and, but somehow they DID IT!

 I mean: that’s the definition of engineering, right?

 ELLEN: Yep!

 DAVE: Take this, put it in the hole for THAT, using NOTHING BUT THAT. So we had to take…you know…basically Cthulhu…and put it into the HOLE for the space that was left behind when I left clinical practice…using nothing but sound waves and pen and ink…you know? 

 That’s a crazy magic trick.

 The place we have to do that is…the Coffee Hut. 

 So, tell me this, Ellen. Like, my coffee hut, when I was thinking about this, was a magic place, like a railroad car with a Wurlitzer Jukebox, and you know, it felt comfortable, and like time stands still…

 What would your Coffee Hut look like?

 ELLEN: Well I would definitely say that mine…the place where I can imagine conversation just flowing and…empathy…and…comfort… endless beverages and good food…around a campfire, or outside at, you know, a nice brewery…around here we have a lot of those…where we, sit outside at a truck park and you enjoy a nice cold beer with a view of the mountains…that’s when you kind of can put away the niceties with your friends, and you can get down to the meat of the stuff…

 DAVE: You’re not…lookin’ at your watch, in a place like that…

 …no matter what you do, when you’re in a clinic situation, and you’re trying to get this education across, you’ve got fifteen to thirty minutes to do it…and everybody’s aware…

 …and so it’s like tick tick tick tick tick…and it just doesn’t feel right, and it starts to feel kind of like “Eat Your Vegetables!”almost. 

 People tend to shut down, in that environment.

 The reason to sort of make it into a MONUMENTAL…ha ha ha…type of thing is because, to the patient, they need to know that this is written in stone…there are FIVE REASONS. 

 And they need to be able to decode that for themselves, because THIS is what’s going to give them agency.

 25:50 The First Reason: RISK

 The whole narrative and vocabulary lessons that we learned in the first two episodes is really preparation for the first component of this discussion, which is the discussion about RISK.

 This is the hardest of all things to talk about, because it’s so nuanced…

 ELLEN: …and do you want to say anything about how you’ve come to this discussion of risk? What you’ve learned over the time?

 DAVE: I’ve learned that not all Sleep Apnea comes pre-packaged with [TV Commercial Voice] ALL THE RISK THAT NATURE HAS TO OFFER!

 You know, so the idea is we KNOW that Sleep Apnea can increase the risk for early death. And this signal is pretty strong is certain cases.

 And that risk is fueled by an increased risk of cancer, increased risk of all-cause death, including accidents, increased risk of cardiovascular deaths, and increased risk of stroke.

OK? So all of these things are fairly well-proven.

 However, there are people who carry the diagnosis of Sleep Apnea who really don’t have any appreciable demonstrable long-term mortality risk.

 So: the question is…how do you know who is who? And how do you know if you should be using a treatment on the basis of trying to make your life longer, or if that’s not a really relevant reason.

So: the discussion of RISK is really difficult.

 ELLEN: So, I have a question about that, because, this came up to me recently in my outside life…understand that when you go to the doctor, we’ve kind of created these arbitrary—quote unquote, if you will—categories that we think link to these different areas of increased RISK…

 DAVE: Ah, yes! Labels! Labels, like Mild, Moderate, Severe…

 ELLEN: That’s something that we’ve kind of created ourselves! How do we communicate to patients that this isn’t just a Sleep Apnea problem…everybody needs to understand why they’re DOING SOMETHING that they can, in their medical care, right?

 DAVE: Yeah, yeah. The WHY. This is what this whole FIVE REASONS discussion is about. 

 So…the reason RISK is hard to describe and discuss…is…for TWO REASONS!

 Reason number one we will call The Generic Hypopnea Conundrum…remember that there are apneas, and hypopneas and RERAs.

 Well hypopneas can be classified as either obstructive or central mechanism. Remember those two distinctions? Two flavors of Sleep Apnea—obstructive and central.

 The problem is hypopneas are difficult to tell one from the other, without special equipment.

 As a general rule, the American Academy of Sleep Medicine says that it’s “optional” to characterize hypopneas as being either “obstructive” or “central.” 

 OK? 

 One of the problems, though, is that when you get older, and you get more medical problems, the central apnea physiology volume knob tends to turn up. 

 OK? 

 So the older we get, and the more medical problems we collect, and…especially here at higher altitudes…the more of these events start to become centrally-mediated.

 And all of the stuff that we understand about Sleep Apnea and risk was based upon studies that were performed on patients who are mean age of about mid-40s to mid 50’s—so middle-aged rather than older—and very little represented cardiovascular disease at the beginning…and, at sea level. 

 So, you know, stated differently, all these volume knobs for central apnea physiology are turned down.

 So the AHI results that we see with a study group like the Wisconsin Sleep Cohort—which was based on a 4% desaturation hypopnea definition…um—those AHI results show very definitively that for an AHI above 30, the long-term mortality risk is significant.

 Over 18 years of Follow Up, the rate of survival was somewhere in the neighborhood of 57%, which is quite low, as opposed to- compared to the referent group, which was about 97% survival rate. 

 So, an AHI of 30 is meaningful.

 ELLEN: But we don’t know what that AHI is necessarily made up of, right?

 DAVE: Well, we don’t! And that’s the problem, is that, on an individual basis, if you’re reporting just generic hypopneas, and you have a lot of volume knobs turned up for central apnea physiology, like age, cardiovascular disease, altitude…it’s quite possible that your hypopnea score is fueled by a lot of central apnea physiology events. 

 And those don’t seem to carry the same sort of RISK…OK?  

 The given…understanding…is that pure central sleep apnea doesn’t increase long-term cardiovascular RISK. 

 And that’s in the ICSD-3 (International Classification of Sleep Disorders, Third Edition) in the discussion on Central Sleep Apnea—primary central sleep apnea.

 So: we have to understand that on a granular level, getting into the central hypopnea burden is important.

 ELLEN: So this is kind of why we keep circling, with RISK. 

 DAVE: Yes.

 ELLEN: This is why we keep coming back to it. Because we know that we have a lot of excellent data, from well-setup studies that we trust, but we don’t know that we have all of the information…yet.

 DAVE: That’s right…that’s right…

 …with that being said, we have to take that information and put it into context on an individual scale. And that’s where we have to understand that there is some meaningful information that might be lost…i.e. central hypopnea burden—we don’t know what that is, if it’s not being reported. 

 …if the person who is caring for the person wasn’t the one who looked at the patterns, that information might disappear… 

 The EMPOWERING thing to understand is that not all hypopneas are the same…and if you’re wondering about your own personal RISK, this might be worth going back to the original study, and having a conversation with the provider who interpreted it.

 ELLEN: it seems like RISK would need the most attention, right? 

 DAVE: Yes! And RISK is the whole reason for the Bay of Narrative discussion…

 ELLEN: The way that we quantify RISK is through the AHI, correct? 

 DAVE: Currently, that’s the way we do it. And…we’ll go out and just SAY: The AHI needs a lot of help, doesn’t it?

 ELLEN: Absolutely. Well, do you want to tell us how you navigate that with your patients? 

 DAVE: Yeah. So, it’s difficult. The AHI—once again, for listeners—is the Apnea-Hypopnea Index…it’s basically the numeric number of apneas plus the number of hypopneas, over the number of hours of sleep.

 ELLEN: …and so we know a lot about the apneas…we can always tell the physiology of those being obstructive or central…

 DAVE: Those are easy! Yeah, you can spot those a mile away. 

 ELLEN: But the hypopneas, not so much.

 DAVE: The hypopneas can be difficult. And there are shades of gray. And sometimes one blends into the other. And so it can be very difficult. 

 And the problem with central apnea physiology is that it’s fluid over a lifetime, too.  So, it can drive an AHI up or down, based on—kind of—your cardiac status, or what altitude you happen to be at. 

 So, it can be a real conundrum to get through.

 ELLEN: So, how can patients who are listening and people who are interested in knowing how to synthesize all this information and understand their RISK…

 DAVE: OK. 

 This is really where the rubber hits the road. 

 So, you know your AHI. You know what that number is. 

 That’s the first thing. 

 And we’ve already been through the first reason that RISK is hard to talk about, is that we have to have some idea of how many are obstructives and how many are centrals…and that means overcoming the generic hypopnea conundrum.

 33:16 Different Hypopnea Definitions

 The second thing…the second reason that RISK is hard to talk about is because there are differences in the way hypopnea is actually defined.  

 Ok? 

 There is either the Rule 1A, which is the so-called AASM rule, which is a 3% [oxygen] desaturation OR an arousal from sleep to score it…

 …or there is the Rule 1B, which is the Medicare Rule—CMS rule—which is a 4% [oxygen] desaturation.  

 The reason this distinction is important: if your AHI was scored with rule 1A—the arousal/3% rule—there are NO long-term large study data that evaluate mortality…

 [record scratching sound effect]

 …with that. So we can’t use that to fuel the discussion of RISK.

 …if it was scored with the CMS—the 4% desaturation rule—then that’s what we can use, to compare to things like the Sleep Heart Health Study.

 ELLEN: …and it’s so important that people understand that…because…it’s actually a Math Problem!

 DAVE: This is why I really don’t like using-uh-labels, for degrees of Sleep Apnea, you know it’s very traditional to say…MILD sleep apnea is an AHI of 5 to 15, MODERATE is 15 to 30, and above 30 is SEVERE…

 Those labels sort of get…I don’t know…they get hijacked… and you might have an AHI of 30 based on the arousal criteria…(in other words, the AASM or Rule 1A criteria)…but, if you use the 4% criterion, your AHI might be 6!

 If you tell that person they have SEVERE Sleep Apnea, they get the wrong idea about their RISK, based on what we know about these epidemiologic studies...

 So, for listeners…I don’t use labels like that. 

 I like to talk about the AHI, how it was defined, and then what that means to YOU. 

 After we define the AHI by the hypopnea definition, we then need to sort of…flirt with the idea that the hypopneas might be centrally-mediated 

 (putting reason 2 into perspective with reason 1). 

 Many times, we don’t need to go there. 

 If a person feels like they want to be treated…and we get ‘em on a right treatment plan…and their AHI on treatment is low, then it doesn’t matter how many were central hypopneas.

 It’s really when you have to start troubleshooting, and people are like: I don’t really want to be treated; DO I NEED THIS? 

 That’s when it’s time to start snooping around…

 ELLEN: If your study only reports generic hypopneas, if you get the treatment under control, and you’re successful, and you feel good with your provider…

 DAVE: …it doesn’t matter!

 ELLEN: …it doesn’t matter. 

 DAVE: …yeah! If everything goes smoothly, then everything goes smoothly.

 ELLEN: …but an EMPOWERED patient knows that if things aren’t going smoothly, that’s an option for them to go farther…

 DAVE: That’s right. Then we start to break it down. And we start to wonder…is this a central apnea problem?…and you know…we’ll get there… 

 In a future episode, we’ll get across the River of Decision…we’ll get over there to Treated Territory, to those so-called Complications and Competing Diagnoses. 

 Because…once you get across that River, you’re not DONE…you know?

 You’re not automatically at Pleasant Dreams Beach… (laughs)

ELLEN: Yeah. You gotta stay…you’ve gotta stay on the course…you gotta stay on The Map…

 …but if they’re having other things…there’s OTHER REASONS TO TREAT, obviously, right?...

 DAVE: Right! So let’s…so take me there!  

 This is gonna bring this whole conversation home. 

 So, for Robert, his AHI was thirty-four I think? 

 ELLEN: I think so.

 DAVE: …and his central apnea…or central physiology percentage was in the twenty-percent range…so…I think it’s fair to say that RISK is a reason to treat.

 ELLEN: Because he had A-Fib as well.

 DAVE: Yes, and…because we didn’t even talk about this, but RISK has to be taken into context with…vulnerability. 

 And Robert has sort of announced to the world that he- he’s- he’s mortal!

 You know? He’s got Atrial Fib, he’s kinda borderline diabetic, so, you know, depending on where you want to FILE these things…um…I think it’s fair to say that RISK is a REASON TO TREAT…

 ELLEN: Absolutely.

 37:04 The Second Reason: SNORING

 DAVE: OK, so the SECOND REASON TO TREAT is…SNORING!

 CHORUS: SECOND REASON! Snoring! Snoring!

 ELLEN: Yep! Snoring! 

 DAVE: And, and, and…Robert doesn’t know.

 ELLEN: That’s an interesting question…as we heard in the dream sequence…YOU’RE ASLEEP!

DAVE: Yeah! 

 ELLEN: All these things will happen when you’re asleep! How can you be a reliable witness? 

DAVE: Yeah, I mean…maybe you can’t! And some people sleep through it, you know? I mean: does it matter? Some people ask me this…Does it matter?…I mean…I’m not waking myself up, and I SLEEP ALONE…it doesn’t matter, right?...

 And I tell ‘em: NO…it DOES MATTER…

…and you know why?...

 …because snoring is trauma…

…it’s like working a jackhammer on the back of your throat, all night long…

 …so there’s evidence that links THE INTENSITY AND DURATION OF SNORING with… carotid…that’s the arteries that lead blood to the brain…carotid-specific atherosclerotic disease!

 Meaning… in the carotids, but no-where else…

 ELLEN: Atherosclerotic, let’s go over that word, real quick…

 DAVE: Hardening of the arteries, with junk building up…this is the stuff that leads to stroke! The point is that SNORING seems to be a contributor to that pathogenesis, because it rattles those arteries around, and damages the lining of them…

 …so, even if you don’t KNOW you’re snoring…even if you’re not aware of it, if you’re doing it, it can be a problem!

 ELLEN: Imagine that you’re just…hitting on something—you’re hitting on your HEAD, you’re hitting on your arm…you’re hitting on anything…over and over and over again…

 DAVE: …it’s gonna damage it, right? 

 ELLEN: …it’s not like it’s gonna come out unscathed!

 DAVE: Right! This is…the trauma of life…people sort of make jokes about snoring…it’s something that’s sort of comedic…

 …the point is, though: even if you don’t snore…let’s say that, you know, somebody’s watching you all night long…you know?...and you’re not snoring at all…are you in the clear?

 People ask me that! Oh, I can’t have Sleep Apnea, I don’t snore. The truth is: there’s a thing called SILENT SLEEP APNEA…! 

 ELLEN: Absolutely…and Central Sleep Apnea doesn’t necessarily involve SNORING…

 DAVE: …doesn’t necessarily involve SNORING…so, you know…even if you DON’T snore, you’re not off the hook! 

 So…now this is why it’s a whole separate thing to inventory…and so for the people at home who don’t really know if they snore…and they sleep alone…and maybe they’re waking up with a sore throat or sneezing like Robert…

 …I call that the Aftermath of Snoring… you know? The trauma!...

 …they can use a device…there’s an APP you can get on the App Store called Snore Lab…and…it records snoring when you’re sleeping…and…it can play it back for you! 

 So, even if you’re a SNORING AGNOSTIC, you can get information from it…

 ELLEN: Absolutely. Well, and it’s amazing the technology that we have that can help us understand what’s going on when we’re not awake…

 DAVE: More data. More data. 

 …for Robert, I think he’s got SNORING equivalents…

 …I would say that his sore throat…and his sneezing and coughing…I would say that probably Sheila’s just sleeping through it…and he’s probably snoring. 

 ELLEN: Well, that’s good for her then!

 DAVE: Yeah, yeah! And the good news is that when he gets on treatment, that’s probably gonna improve—all those nasal congestion symptoms…

 
39:48 The Third Reason to Treat: SLEEP

 DAVE: THIRD REASON TO TREAT?...

 CHORUS: Third Reason! SLEEP! SLEEP! SLEEP! 

 DAVE: SLEEP…I think it’s fair to say…Robert’s not sleeping well. 

 ELLEN: How would we define not sleeping well for him?

 DAVE: His SLEEP EXPERIENCE…I would call it…the perception of light-stage sleep…

 ELLEN: He did say that in his recording... 

DAVE: …yup…frequent awakenings…frequent trips to the bathroom…

 ELLEN: …so, isn’t that normal as you get older?

 DAVE: …you know, it can be…there’s lots of reasons for it, and we’ve always sort of looked at mens’ PROSTATES as being the reason…

 …but it’s really common that frequent trips to the bathroom is because of the Sleep Apnea…we talked about that, last episode.

 In the omniscient Writer’s Eye View…we’re gonna find that Robert’s nocturia gets better, when he gets on treatment, so I’m…a little foreshadowing there!

 So, uh…I think SLEEP is a reason to treat! We can say that, right?

 ELLEN: Yeah! And: even independent of SNORING, or RISK in other situations, if you’re unhappy with your SLEEP…

 DAVE: Yup!

 ELLEN: …we should treat it! That’s what we do! When we see people in the world that have questions about their sleep and  don’t necessarily feel good about it…I make a comparison to like:  if your ARM was broken…you would go to the doctor. 

 DAVE: Yeah! You’d know!

 ELLEN: Yeah! You’d know! B

 But you don’t necessarily know if your SLEEP’s broken! 

 So we’ve gotta help people go through that conversation, to understand what actually IS good sleep for them!

 DAVE: Yeah! 

 
41:01 The Fourth Reason To Treat: WAKE

 ELLEN: So, what about his WAKE, then?

 CHORUS: it’s the fourth reason!

 DAVE: So, WAKE experience, likewise…he’s got some…problems! And even though, he’s a proud man…and he doesn’t wanna feel like he’s…you know…slacking off…and not doing his share…you know, you can hear that in his voice…

 …he’s like I pay my bills, man, and I haven’t had any accidents, I’m at work every day! 

 He’s running his team! OK? 

 So if you ask him if he’s impaired, he will tell you NO, up front…but, then, at the Coffee Hut, when we can slow down, and stop feeling defensive…

 …and stop feeling like he has to prop himself up…

 …he realizes that…I’m really not doing great…I have to stand up at meetings…in order to keep from falling asleep…I can never watch movies with Sheila…

 ELLEN: …and Sheila loves movies!

 DAVE: …it’s sort of a joke, but it’s not funny. 

 He’s missing out. You know? 

 So his WAKE experience is impaired…and we’ve helped him talk about that now…and how he knows that that’s something we can work on…

 The WAKE experience?

ANNOUNCER: …survey says?...

 [DING!]

 DAVE: Yes! A REASON TO TREAT!

 
42:00 The Fifth Reason to Treat: COMORBIDITIES

ELLEN: OK. So that leaves us with the last one…

 CHORUS: FIFTH REASON! FIFTH REASON! FIFTH REASON!

 DAVE: COMORBIDITIES! 

 This is an inventory, right? 

 We’re looking at anything that Sleep Apnea could make worse! 

The nonspecific stressor of SLEEP FRAGMENTATION/DEPRIVATION & RESTRICTION…

 …the nonspecific stressor of RECURRENT HYPOXIA…up-and-down of oxygen levels…

 …and the fight or flight BURSTING activity…

 You know…Robert mentioned this when he was in his meditation bench…he says: I feel like I’m having a nightly visitor…

 …remember that?

 ELLEN: Yeah. That was pretty spooky.

 DAVE: It IS spooky. 

 When you have Sleep Apnea, it’s like being visited by a Warthog Nurse…who has a syringe full of ADRENALINE! 

And as soon as you fall asleep, that nurse comes in and gives you quote “treatments,” by giving you shots of adrenaline…ALL NIGHT LONG! 

 ELLEN: Whenever you’re trying to gasp for your life!...Right?

 DAVE: Yeah! Imagine…what that would do…if you got an EPI-PEN every…45 seconds…

 ELLEN: …it’s crazy…

 DAVE: …you know…it’s not gonna make you sleep better…

 …it’s gonna make you feel anxious…

 …you know—there’s all kinds of things that go along with that physiology…

 …Robert’s insight was…perhaps there’s something I’m not seeing, that I’m doing battle with in my sleep…

…medical issues that Robert’s dealing with…Atrial Fibrillation? ABSOLUTELY worse, with adrenaline surges! 

 …the depression symptoms that he’s having…SLEEP RESTRICTION does that! Right? 

 It can simulate DEPRESSION, ADHD…all kinds of syndromes of daytime neurobehavioral impairment…

 …the BORDERLINE BLOOD SUGARS…also related!  

 All of that FIGHT OR FLIGHT response overnight drives up CORTISOL levels, and that makes BLOOD SUGARS go up. 

 Which gives you all kinds of metabolic consequences…

 I think it’s fair to say…that COMORBIDITIES…are a reason to treat.

 
43:53 At last, the CARTOONS!

 [ALIEN LANDING SERVO MACHINERY SOUNDS…DING!...APPLAUSE!]

 DAVE: …and that sound is my reminder to mention…

 …the cartoons that helped inform today’s discussion. You can view any of the cartoons featured in this program by going to the PODCAST portion of our website (that’s www.EmpoweredSleepApnea.com), and click on the title of the cartoon in the Show Notes. 

 The first cartoon is one of my favorites, and it’s called The True Crimes of the Evil Warthog Nurse. Looking at this, we can understand the shudder that went down Robert’s spine, as he pondered on his meditation bench.

 The second cartoon is called Risk Management. This is one of the hardest things to talk about in Sleep Apnea is the notion of RISK…

 …and after drawing this cartoon, it helped both of us understand that the very concept of RISK is daunting…and requires extra care.

 The third cartoon is called Lovecraftian Nightmare

 …the enormity of Sleep Apnea is truly terrifying, but only if we don’t understand it. If we put our walking shoes on, and establish agency, it can become a different experience……it can become a Grand Adventure!

---------

45:04: Summing Up!

DAVE: Well, that wraps up another exciting episode of Empowered Sleep Apnea: THE PODCAST.

 In some ways, this was the most important episode of all…because it’s in this episode that we dive deep into the WHY of Sleep Apnea…

 …we’ve walked with Robert on his journey…we’ve explored the idea that the discussion about RISK is nuanced, and requires an understanding of the different defintions of hypopnea, and an understanding of the fluidity of central apnea physiology.

 …Importantly, we discovered the monumental notion that Sleep Apnea has FIVE REASONS TO TREAT. 

 Not one. 

 Not three. 

 FIVE. 

 Each and every one of us has to come to terms with how our own Narrative adds up, and whether these REASONS are meaningful for us. 

 Do you have REASONS TO TREAT? 

 Does your spouse? 

 Your parent? 

 Which ones are most important?  

 When is it time…for you…to come to the Coffee Hut? 

 Cue music! ;) 

46:21: CUE MAJESTIC THEME SONG and CLOSING CREDITS

Empowered Sleep Apnea: THE PODCAST is a production of Empowered Sleep Apnea LLC. Visit us on the interwebs at www.EmpoweredSleepApnea.com. 

The show was written and performed by David E McCarty MD, FAASM and Ellen Stothard PhD. 

 All sounds on this program were made by the performers, or were cobbled together from public-domain sounds we found lying around the house. 

 Dr. McCarty’s footwear this week is influenced by the laws of physics. 

 Dr. Stothard’s sense of humor is rinsed clean each day with Rocky Mountain snowmelt. 

 Special choral arrangements created by 25% FRED featuring Someone Else’s Problem.  

 Cartoons this week were discovered beneath the cornerstone of an ancient stone cabin in the woods.

 Tune in next time, when Robert will find himself on the bank of a deep and turbulent river, and we’ll hear the White Rabbit say this: 

 “Hey…psst…you lookin’ for pleasant dreams beach? Hey you! I’m talkin’ to you! Ain’t you ever seen a talking rabbit before?”

 Coming up next…your Sleep Medicine Dad Joke!

47:36: Sleep Medicine DAD JOKE

 DAD: Did you hear the one about the late-sleeper who decided to sleep in his garden?

 NOT DAD: Naw, I don’t think I’ve ever heard that one, Daddy-O, why don’t you go on and tell it!

 DAD: OK, OK, OK… he used to sleep in his garden, because he figured every day, he’d  wake up on THYME! 

 Get it? ON THYME?

 Ha Ha Ha Ha Ha Ha Ha!