01-09-2015, 06:55 AM
(This post was last modified: 01-09-2015, 07:33 AM by DocWils.)
(01-08-2015, 08:34 PM)Ghost1958 Wrote: 62 percent would be BAD I take it.
That would be qualified as an event or worse, depending on when it happens and the length and frequentness of the desat event.
(01-08-2015, 08:46 PM)TyroneShoes Wrote: I thought daytime sleepiness was not directly connected to anything (as far as sleep apnea goes) other than if you are being strangled 30-90 times an hour all night long every night, that you are partially roused from sleep each time and never really get quality sleep.
Sure, that will desat you if the apnea is long enough, just like holding your breath will desat you naturally, but being desatted is what partially wakes you and gets you to struggle for air, which is what directly interrupts your sleep and lowers its quality.
Or do I have that all wrong?
Not wrong, just not complete. The relationship between daytime sleepiness, apnoea events and O2 desaturation is a bit more complex, as is gradual organ damage from the frequent desats (okay, don't freak out - it is all a slow and gradual problem which is largely addressed and rectified by CPAP - once the therapy is in action, much of the damage is reversed over time). So, yes, your daytime sleepiness is largely due to sleep deprivation effects. And yes, it is the loss of O2 that causes the sleep deprivation via the sudden waking. But the picture is not as simple as one thinks - most explanations for lay people revolve around "lies to children" types of explanations - deeply simplified that gives a good understanding of the basic ideas while being wrong or incomplete in almost every way. Your understanding is more or less correct but incomplete and simplified. However, the basics are correctly in place, just that the whole thing is more complex and intertwined. For instance, the stress on the heart not only leads to heart problems, but also contributes, over the long term, to daytime sleepiness by changing the natural ebb and flow of the blood pressure and other mechanisms. A lot of it is so subtle and complex that even now we don't have a complete picture down to the molecular level. And I expect we never will in my lifetime. We know that continual O2 desaturations lead, through various mechanisms, to a variety of problems, and daytime sleepiness is part of the picture, not only from sleep deprivation itself, but also from knock-on effects of frequent desaturations, which puts your body into a type of defensive mode that will feed into the sleep deprivation mechanism in a sort of feed-back loop (lies to children again, I am afraid - the anatomical mechanism is well understood, but way too long winded to go into here, unless you want to read a few pages of detailed medical jargon).
However, it is unnecessary to consider these subtleties, because the main mechanism to daytime sleepiness in relation to SA is the interrupted sleep of the apnoea events, and part of method of measuring the severity of the event is the desaturation of O2 in the blood. For most purposes that understanding is sufficient and for a basic understanding of the broad effects of SA it is more than enough.
So, that was a very long-winded way of saying "yes, but". Forget the whole thing or it will give you a headache. It sure gives me one.
That was such a great explanation. Thank you very much.
And the "lies to children" concept is brilliant, and gives me a way to characterize more clearly in my mind something I see multiple times a day. For example, not to be overly cynical, but sleep docs do it by reflex, so that they can see more patients for shorter sessions and collect more dough for the same amount of work done.
I now get excited when Doc replies to any post. Its almost Pavlovian.
Tyrone, your doc doesn't do it to make more money, but because the technical explanations are hard for lay people to understand and their eyes glaze over, which makes them not hear the important, often life saving information contained in it. So we have learned (as have all scientists) to find a more easily digestible way to communicate these concepts. Between us we use all sorts of wonky jargon and can go on for HOURS (ugh!), but a ton of it is shorthand which no one outside of their speciality understands.
However, we are also bound by insurance rules, which means we have to see so many patients per day in so around 15 minute (more or less) divisions. Some take more, some take less so it evens out, but it means we can give less time to patients than we would like to. And most of us are so over booked we have no choice. We don't earn more that way, and we work a LOT harder than if we stuck to fewer patients for longer time periods.
When I was first suspected of having apnoea, I had to read up in order to get to grips with something I understood superficially from medical school, and believe me I encountered a ton of shorthand and jargon that I simply didn't understand, having never used it in orthopaedics. It took me about a week to get up to speed, and that is WITH a medical background. It has taken me another year to fully understand the subtleties of the branch (and I find it interesting, even if it isn't exactly rocket science, but since thoracic surgery was my first interest even though ortho won over in the end, I find this quite interesting indeed). The basic mechanics behind it is easy to explain in a lies to children sort of way, and even outline in a less lies to children format if one takes a bit longer, but the subtleties behind the whole thing, how the various parts work, the short and long term effects interact with each other and the spider's web of causality in the whole thing is still an evolving branch that crosses over many disciplines, including mine, and that makes the fine detail extremely hard to explain even in the medical world, let alone to the lay people. And yet the basic stuff of the mechanics of it isn't rocket science, nor is the measurement methodology. It is all the little things that make this an interesting branch of medicine. Or, as one colleague murmured to me in in a lecture a few weeks back, "beats hell out of proctology". Yep, sure does.
01-10-2015, 05:26 PM
(This post was last modified: 01-10-2015, 05:35 PM by TyroneShoes.)
I am not trying to imply that all docs are doing the least they can get away with so they can get paid by more patients, but I am sure there is a large contingency that do; there seems to be a large contingency that do this in every profession, and in everyday life...you can hardly get away from it. And I don't think any of us are happy that Big Insurance encourages this also. But it does. When Eisenhower stated "beware the military-industrial complex", he was right, even if no one listened. Money talks, motivates nearly everyone, and runs everything.
This is the reason my father, an Orthopedic Surgeon, told me "do not go into medicine", because he could see the future and how it would make me unhappy, as changing trends at the time in medicine were already making him unhappy.
But a lot of good people do go into medicine, and Doc Wills seems to surely be one of them.
I think my cynicism is healthier than not having cynicism, but we also have to have faith in people, and give them the benefit of the doubt. I give everyone a chance, but I also subscribe to the "fool me once..." school of thought, just for self-preservation in a predatory world.
And I also learned long ago that sometimes being completely open and frank about the details of something could be counter-productive. As an Engineer I deal with a lot of folks who have very different skill sets than that, and I often have to give them the "fairy tale" version to get a point across. It bothered me at first, until I realized that, quite ironically, it might actually be the best way to communicate what you are trying to say, so it serves the spirit of what I am trying to do even if it is not the entire, detailed story.
The fact that few readers have even reached this point in reading this post is clear evidence that generally speaking, people just can't be bothered to listen in the first place.
My dad didn't want me to go into medicine at all - he thought I could earn so much more as a banker or lawyer. Of better yet, be an airline pilot so he could travel for free. He was right, of course - doctors on the whole don't earn anything near what lawyers and bankers earn, at least not here. For all the income people seem to think we have, they don't see the outgo in the debts setting up and running a practice, so it is a bit one sided. A lot of times, any money making is done to feed the debt and get a titch ahead (a doctor going into private practice will start his practice around one million Swiss franks in debt - he'll be in his sixties before that debt is paid off, if ever, if he is around 30 when going into private practice). We get our fair share of bad apples - I have sat on several disciplinary committed in the past, but there is more padding the accounts done by spending more time with the patient than necessary than in seeing more patients, and way less work, too. The one thing the US and Swiss medicine have in common is the dealing with a myriad of insurance companies, and the masses of paperwork one has to do to keep them happy and get recompense, which is one reason I was for a single insurer at the base insurance level when it came to a plebiscite, which was, alas, defeated, despite the spiralling costs of medicine and of insurance fees here in Switzerland - the people bought the lies of the interest groups instead of the truth of how much it would reduce costs and fees by moving the general mandatory insurance to a single insurer system (this would have had no effect on the other two levels of insurance we have, which would have remained in private hands).
Anyway, thanks for the complement, Tyrone. Most people I know went into it for the right reasons, some because it was the family business (a lot of doctor's kids go into it) and some for the money, but I suspect that is rarer here than in the US for obvious reasons. I went into it because I got hurt when I was young and wanted to know what the guys in the white coats knew, and I didn't trust anyone, so I needed to be the one I could trust. I have authority issues.....
But to be honest, there are waaaaaaaaaay easier ways to make money than going into medicine in any country - to start with, it is hell just to get the degree, and then the three to four years interning and residencing, and then the six years prepping if you go into a specialty, etc, etc, etc,. Cutting off your foot and hopping across Antarctica barefoot and naked seems easier, to me, if you want to make a ton of money (of course, we can be pretty mean in medicine, and we all think that dentists are coining it like crazy with practically no medical training or hard work compared to us, and so on....). My cousin is a shrink, and I said once to her that she took the easy way out and is doing it to make money instead of practising real medicine, and she let me have it between the eyes - in the end, there are no easy options in this biz for money making. Gods know I wish there were.... maybe I should have been a proctologist...... Naaaaahhhhh.....
I think...maybe only if you really needed that money.
But then specialties don't pay more on a scale of unpleasantry, do they?
I also think if you choose a profession because it will make you lots of money, then you have abdicated the option of choosing a profession because it will be the fun thing for you to do (luckily I found a fun thing), and that is something to be pitied, unless you are among the lucky few who serendipitously choose what will be the fun thing and it coincidentally will make them lots of money.
No, specialities don't pay more based on how unpleasant they are - if that were the case, interns would be making the big bucks as would nurses, cleaning out by hand impacted bowels, etc. most of the high fees in specialities go to covering equipment costs (some of the gear can cost big big big time) and in the US, supply and demand as well (not here - our fees are more heavily regulated by the insurance industry and the government).
I have met a few doctors in the US who did do it for money or prestige, but I honestly think they are fools. Most though did it because they heard the call. This is too tough and brutal a profession to go into so lightly. You do need dedication and love of the subject to survive (it has a high enough suicide rate already, thank you). I did know a few doctors (and nurses) who emigrated to the US because the money was so much better, but a lot of them came back because the work load and conditions and quality of life was so much worse. And big city hospitals there are like war zones compared to here. One that stayed had gotten a cushy government job in Ottawa (Canada) for the ministry of Health there. in at 9, out at 3. You call that a job?
I did parts of my residency and part of surgical training in the US and was always impressed at the their facilities and the dedication of the crowd I was with, anyway, Johns Hopkins was great back then, but in a hospital situation, you get no feel for what private practice may be like there, so I can't comment too much on how they think and work, I just know what they have to deal with insurance-wise, and it is an even bigger pain that it is here. You want to know what drives up medical costs? Insurance companies and the endless mischigas we go through dealing with them. That and malpractice insurance (in the US, not here - we don't have that sort of culture).
My advice to everyone is find something that you love, whether it pays big or not, and do it. If you need more money, then get a gig on the side to make up the difference, or learn to accept a more modest lifestyle. In the end, you feel better, and that will contribute greatly to your long term health.