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Adventures in Sleep

COPD in the Sleep Lab
August 28, 2014 10:50 AM by Penny Mehaffey

We had a COPD patient in the lab this week. This is not an unusual occurrence, but it was an exclamation point for me, given that CMS adds COPD to the list of targeted and tracked diseases this October. I thought our patient was a prime example of why COPD is so difficult to treat and why it made the list.

Upon arrival to the lab all was well, but an hour and a half later he begins to complain of SOB; he can get air in but can't move it out well. He said it was painful to breathe and he could take only short breaths. His oxygen saturation remained in the 90s. We did not make it past hook-up. Due to worsening symptoms, we called our RAT (rapid assessment team). He was assessed and taken to the ED for treatment. According to the RAT, the patient was tiring and would have gone into respiratory arrest. Fortunately for us, the MD on call with the RAT was also the patient's pulmonologist.

Interestingly, earlier the sleep tech tried to get the patient to go to the ED but he refused. He did not want to have a blood gas drawn. He thought he would be okay if he rested. Once he was in the ED, he refused the jet neb treatments. This is part of what makes COPD so difficult. These patients are hard to manage and have a host of reasons why not to comply. He was well known to the ED and had multiple admissions. His doctor stated that he really needs CPAP. He was kept in the ED's observation area for about 16 hours and then discharged home with a sleep study rescheduled.

This is a typical scenario that is played out on nursing wards all the time. I see it coming to a sleep lab near you soon, as we take on our roles with the CPAP action plans. I am glad that our tech was alert, diligent and used good assessment skills. I am glad that we had a plan in place and that she followed it. I hope we are ready for October.

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Difficult Patients in the Sleep Lab
August 21, 2014 11:15 AM by Penny Mehaffey

Difficult patients in the sleep lab are no surprise, nor are they a new phenomenon. What is new is the frequency with which they are showing up. Sometimes it feels as if the doctors are in a contest to see who can refer in the most difficult patient. 

I come from a nursing background and so I can usually handle whatever comes through the door but now I am guided by a different set of standards. The safety net is different. For instance, sleep labs traditionally do not deliver bedside nursing care. Patient's requiring this type of care or help must be accompanied by a caregiver during testing. The paradigm we practice under is difficult for those outside of sleep to understand. They think we need a nurse for everything and -- to the other extreme -- that no patient should ever be one-to-one. (What is this selective blindness that some of us in healthcare seem to get when looking at other disciplines? But I digress...) 

My point is that sleep techs will encounter difficult patients and we should be able to complete our testing while ensuring patient safety in our lab. Just this week we had a patient who was the victim of a gunshot wound in the past. She was blind and wheelchair-bound. She had a professional caregiver in the home, plus family, yet no one thought she would need any help during the sleep study or the MSLT.  

I had a hard time convincing them, too. Fortunately, I was successful and she came with her aide. I believe this is the way it is going to be. The patients we see in the lab are going to be the more difficult to care for, sicker patients. We need to keep our skills sharp, be prepared for anything and have a plan for how to care for these people. I have a partner who works with me during the day ... I think we are lucky. 

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Mask Fit Savvy
August 7, 2014 11:56 AM by Penny Mehaffey

I wish, oh how I wish, that my lab dispensed our own CPAP equipment. And not so much the CPAP machines but the masks. We do as much as we can by giving the patient the mask they are titrated with, but that's as far as it goes. Once they leave us, it's out to the big bad world of DMEs. 

Part of the life of a day tech is to perform mask fit clinics; mine are usually the one-to-one basis/trickle-in types. The person who trickled in this morning actually was a VIP who did not have his sleep study with us, but is now seeing our sleep doctor. He was seen by one of the "better" DMEs in town and was told "they could not fit him." I am shocked. He has no facial hair, nothing going on that I could see that would make him hard to fit. He prefers a full-face mask and is compliant. 

I only had to go through two masks; the second one fit most comfortably to him. It was a pretty standard model, one of the two major manufacturers and one of the top full-face models, essentially something that you should find on everyone's shelf. 

It seems as though this scenario occurs more often than it should. Mask fit is the most important component of CPAP therapy. It's the delivery system. It has to work and work well or you have nothing.

Failure is not an option. I for one would prefer to have total control over that part of the process. 

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Ultimate responsibility?
August 1, 2014 8:52 AM by Penny Mehaffey

Problem: A patient was diagnosed with sleep apnea 5 years ago and has been treated with CPAP since. At his office visit this year he complains of poor sleep and a return of symptoms of OSA. He has gained 60 pounds and has other lung problems as well. 

His doctor orders a new sleep study since it's been 5 years. Said sleep study is promptly denied by the strategically aimed, absolute and total no-care comprehensive major government services coverage plan he has. Default request of HST denied promptly as well.  

It seems that all approvals for this scenario hinge on the download data over the last 5 years. No problem, it's a reasonable request. Patient can't locate the smart card, thinks it was lost a while back during home renovations, but, that he has not been using it for a while since "it got mold in it ." Ok, let's check with the DME, who is unable to provide documentation, and says that's most likely because patient did not keep their follow up appointments.

This is a nightmare.  You have a patient who legitimately needs something but can't prove they were ever compliant, an equipment provider who can offer no evidence either way and a hardline payor who absolutely will not approve any testing without the requested information. 

There are missing links here all along the way and it's very difficult for the person stuck in the middle who is trying to obtain what is now needed for the patient.  Did ultimate responsibility lie with the patient?  Were the rules this strict 5 years ago? Did the DME do all they should to follow up? And should it even matter? If you consider just the new symptoms only wouldn't he qualify for at the least an HST? 

Where do you think the ultimate responsibility lies?

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Being a Sleep Educator
July 24, 2014 10:32 AM by Penny Mehaffey

I want to blog today about an experience I had related to sleep in industry. I know it's been done but it is pertinent still. I took the sleep educator workshop at FOCUS this summer and thank God I passed the exam. It was a toughy. Then, as if right on cue, I was contacted by a company in our area asking for me to attend their annual employee health and safety training. I went yesterday to tour the plant and learn about what they actually do and see the work sites of their employees. This was all at the company's invitation. 

I must admit that I am very impressed by this company's approach to sleep-related issues on the job. I will be the only healthcare professional present on training day and focusing just on sleep. Safety is of upmost importance at this plant and they recognize that shift workers face a unique set of problems when it comes to being able to remain alert on the job. I toured the facility giving an eye to the work space and looking for areas where they could make changes that would make staying alert easier? I guess that's how I want to say that. This companys willingness to be proactive represents to me a novel approach. They don't just say they are concerned about safety among shift workers, but they are putting a plan into action. I am so excited to be a part of this process and to have my first official task as a sleep educator lined up. 

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Medical Marijuana
July 17, 2014 11:10 AM by Penny Mehaffey

I am curious about the opinions of my peers regarding medical marijuana. It's a hot topic lately and especially so in my area. Our governor was in for a visit last week to underscore his support of continuing research in the use of marijuana to help treat seizures in children. Our pediatric neurologist is very interested in researching cannabidiol with his severe patients. He has one child who has upwards of 60 seizures a day.  

I live in the Bible Belt and change does not always come easily or quickly here. I am in support of the research. I think the stigma attached to marijuana research is legitimate, but I also believe we shouldn't let that stop us from investigating the benefits to be derived from cannabidiol. 

Marijuana is not the first drug of ill repute to be harnessed for medicinal purposes. I think in this day and age we should be open to finding the facts or seeking the truth about this drug and how we can use it to our patients' benefit. It is, after all, a chemical just as the rest of our medications are.

The potential for, and history of, misuse for this drug is a fact, but that is true in many instances -- consider the myriad of narcotic pain medications we have today. 

There are 20 or so states that have legalized medical marijuana. It has been demonstrated to have medical benefits for AIDS/HIV, Alzheimer's disease, arthritis, asthma  and breathing disorders, Crohn's disease, epilepsy/seizures, glaucoma, hepatitis C, migraines, multiple sclerosis/muscle spasms, nausea/ chemotherapy side effects, pain, psychological conditions and Tourette syndrome. Let's try and think clearly and objectively about this research and not limit it based on the stigma it currently carries.
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Challenged by BRPT Exam
July 10, 2014 11:34 AM by Penny Mehaffey

I mentioned before that I attended the FOCUS spring conference in Florida. My main goal for that event was to attend the sleep educator workshop presented by the BRPT. I must say I thoroughly enjoyed the workshop and I did learn a lot; it was worth every penny spent. 

Now, I am tasked with passing the associated exam. I attempted it a day or so ago and am disappointed to say that I did not pass on my first try. I had heard that this was the case with a lot of students, but you never think it will be you.  Fortunately, the BRPT has extended the deadline for testing and has allowed a third attempt at the exam...

I guess I fell into the trap of thinking that since I've been in sleep long enough, I should know this stuff; I did not expect to have any trouble with the test. I mean, I'm a smart girl. Boy, was that notion a mistake. The exam is very challenging.  And since I am not handling stress very well right now, I wanted to sit down and cry and have a big ol' hissy fit when I saw my score. But I didn't. 

I'm taking a deep breath and planning to retest this weekend. In retrospect it was probably a bad idea to try to do the test while I was at work even though my boss promised not to bother me. Still, I was interrupted about 25 times. That's my fault. I am really glad now for the extra time to test and for the third attempt. Looks like I may need it too. Good luck to everybody taking this exam, and remember, nothing worth having ever really comes easy. 

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Independence Day
July 3, 2014 10:36 AM by Penny Mehaffey

I hope you all have a safe and fun time as our nation celebrates another birthday. I'd like to suggest that we take time to think of freedom as it relates to our health today. We have open access to doctors in our country and readily available medications, equipment and medical supplies. We have volumes of information streaming in from multiple media. We have hospitals, urgent care centers, primary care centers and retail walk-in care centers on almost every corner.

Yet, we don't take care of ourselves. This frustrates me to no end. We have for the most part access to safe places to walk or exercise ... gyms and parks and school playgrounds, church programs and support groups that lag by the wayside. And let's just skip the endless access we have to food.

Are we so rich that we don't see it? Are we so overloaded with information that we are unable to sort through the fodder and pull out what's right for us? What can we do?  I say exercise your independence. You have the right and responsibility to be in charge of your healthcare and your body.

Exercise your rights: exercise and take your medicines every day, check your blood sugar and blood pressure and bombard your physician with those numbers. Dust off that CPAP machine and liberate the treadmill from the pile of clothes that now oppresses it. Put on your tenny shoes (southern speak for sneakers) and take a little walk. Turn off the television and go to bed, you owe it to yourself to get a good night of sleep every night. Encourage your patients to do the same. 

I believe motivation -- or the lack of it -- is the main culprit. And I know it's hard to stay motivated day after day; sometimes it feels almost impossible. But it's worth it.  There's only one you and we have only one shot at this life. Let's do it right!!

Enjoy your Fourth of July and be careful not to get carried away while celebrating.
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Cancer and Sleep Woes
June 26, 2014 10:10 AM by Penny Mehaffey

I was thinking about an article I saw a while back about cancer patients and the sleep disturbances and cognitive loss that they experience. I have read before that CPAP was helping to improve memory and function during the day for some patients. I have a wonderful sister-in-law, who is a breast cancer survivor. I remember talking with her about this very thing when she was going through chemo and radiation. 

She said that at times it felt like her brain was on fire. She was fortunate that she happened to live in a village where there was a major cancer research and treatment center. She received excellent care and it was very inclusive in that they treated mind, body and soul with traditional medicine and holistic therapies. 

Cancer patients have a host of sleep issues, pain, insomnia, anxiety, respiratory disturbances, hot flashes.  The article I read reported that some improvements in response to therapy and alleviation of some symptoms was achieved when CPAP was used. I totally believe this. I am a proponent of CPAP. I love mine and my husband's. I think the majority of us could benefit from a little CPAP. 

I  believe the cancer patients were being treated with behavior modification and sleep aids. But I wonder how they would respond to mild CPAP. I'm thinking about the soothing hum of the device as it gently delivers the low pressure and the rhythmic sound of their breaths as they breathe in and out. CPAP could be incorporated as part of the breathing exercises for relaxation.

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Expanding Sleep Resources
June 19, 2014 10:08 AM by Penny Mehaffey

There are a lot of good resources available to us today that even 10 years ago we did not have.  I encourage you to read the various e-magazines and periodicals and keep up with what's happening in sleep. There is constantly new and exciting research being published and changes going on in government that greatly affect us. 

I have some very saavy people attending our  AWAKE  support group who show up with a lot of good questions and suggestions. I am proud of them for investing in learning about their sleep problems in this way and for bringing what they've learned to the group. (This must be how teachers feel when the light goes on in the student's brain.)  It's a good thing. 

This week of interest to me was an article comparing CPAP to oxygen and CPAP to exercise. The benefits of regular use of CPAP come as no surprise to those of us who work in sleep, but it is nice to see it in black and white and now almost on a daily basis. The report said that in patients with OSA who have a cardiovascular risk, CPAP proved more beneficial than giving oxygen at night. The same held true of CPAP versus exercise. Obese people with elevated CRP levels who wore CPAP at night had results that were similar to a weight-loss intervention in reducing the inflammatory maker -- very interesting.  Check it out on MedPage Today; it's full of research  and continuing education information.

 

 

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Sleep Study 101
May 29, 2014 9:59 AM by Penny Mehaffey

There's a conversation going on in LinkedIn revolving around this question: Does a sleep study require a doctor's order? It's been an interesting feed to follow. You would think that this is a no-brainer, right?  It's a medical test, so it requires a physician's order.

But what's curious to me is why so many people even ask this question. I mean, they don't ask if they need an order for an x-ray  or a lab test, so what's going on here? Is it a lack of understanding about what a sleep study is, fueled by all the media information available? Is it a lack of respect for the discipline of sleep medicine and thinking that "it's just a sleep study, I don't need an order for that"?

Or is it just a simple question. I take several calls a week for this question. My feeling is that people in general have several motivations. I think the biggest is financial. Let's face it, copays aren't what they used to be and if you add up all the required visits that are now associated with having a sleep study, it could be a car payment. 

And that's only for diagnostics; we won't even talk about CPAP. I think the requirements we have to adhere to seem more like barriers to care for the patients. This was my comment to the feed.  All the new requirements imposed on us by all the insurers make us look like part of the problem. I want to be an advocate for my sleep patients, not an obstacle to overcome. 

I confess I feel very frustrated by the current environment in which we must operate and I don't trust insurers to have the best interest of my patients at heart, yet my hands are tied.

What to do?

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Hurray for FOCUS 2014
May 22, 2014 12:32 PM by Penny Mehaffey

Well, we have another FOCUS meeting behind us.  nd what a great meeting it was: action packed, star studded and uber-educational.  Hats off to everyone involved in putting this first-class event together. The meeting was held at the Coronado Springs resort at Disney World, near Orlando, Fla. It's an idyllic setting, as is everything at Disney.

I attended the Sleep Educator workshop and I am very excited about this area of practice. I was encouraged by the talks relating to insurance regulations and projections relating to where sleep is going. It was encouraging to hear positive directions for our field -- not just the usual doom and gloom. 

The CSE is actually a program of and by the BRPT. It and an Asthma Educator workshop occurred the day before the FOCUS conference started. If you have not attended an educational meeting this year, I highly recommend this one as there is typically a meeting in the fall as well.  You can find an organized listing of meetings and conferences right here at ADVANCE  as well as on the BRPT web site. It is money well spent and an investment in your professional self.

 

 

 

 

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Can Ambien Be Linked to Murder?
May 8, 2014 9:42 AM by Penny Mehaffey

I read with some horror an article, Murder: Another Ambien Side Effect?, by John Gever in MedPage Today.

Oh my goodness. I was aware of the bizarre behaviors reported with Ambien use: cooking while sleeping, having sex and not remembering... and driving while asleep. Still, I must admit this article shocked me. 

It also generated a lot of questions, like:  Isn't Ambien supposed to be a short-term drug, meaning you take it for a couple of weeks and then investigate other treatments?  Aren't Ambien users supposed to be followed closely by medical professionals?  If you take a medication differently than how it was prescribed, aren't you asking for trouble? 

And given all the press surrounding Ambien since it hit the market in the 1990s, shouldn't we be better at eliminating those who are not good candidates for this drug?  

I have spoken with people who self-report they have been taking Ambien "for years."  They usually don't report any strange behaviors though, they probably save those for the MD or may not be aware of any. I believe the drug and many drugs can cause us to do and say things we normally would not. Yet I have a hard time leaping to the conclusion that certain actions (murder, automobile accidents, violence) are not one's fault because of it.  And even if you know you are taking a drug that can potentially cause you to drive while asleep, what are you to do? Would placing the car keys in a hard to get to place be enough to prevent a sleeper from driving? 

This was a very interesting article; it also offered CME credit. Take a look, it's a quick read and I would be interested to hear your opinion. Has anyone had any experience with Ambien either personally or through patients, family or friends?

 

 

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Acclimating to a CPAP Mask
May 1, 2014 10:39 AM by Penny Mehaffey

There is a good discussion going on this week on the LINKED-IN network. It was started by an AlaskaSleep Clinic blogger and is titled "How Can I get used to this CPAP Mask?"

This topic remains continually relevant because acceptance and/or success with the mask is imperative to compliance with therapy. I wonder if sometimes as professionals we forget that while this may be our ten thousandth mask fit, for the person sitting in front of us, it's foreign and obtrusive.

I like to read other's blogs and am always happy -- or maybe comforted is more accurate -- when I see that techs in other labs are doing things the same as I am. Helping a patient accept that they stop breathing during sleep and convincing them that CPAP is the best treatment for them can be a struggle. But the good news is that it's a struggle that we can win most of the time. It's struggle that's worth it for the patient.

The aforementioned discussion also brings up some interesting opinions regarding alternatives to CPAP, such as oral appliances and various types of meditations or breathing techniques to help lessen the fear or stress created during the acclimation process. I am advocate of stess-relief techniques such as breathing exercises prior to sleep. We had a yoga demonstration at 2 of our A.W.A.K.E meetings, and several people dozed off and snored!

Take a look at the discussion. See what you think.

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At Long Last: Spring!
April 10, 2014 9:54 AM by Penny Mehaffey

Spring is trying so hard to manifest here in Augusta. I keep hoping it will happen any day now. The past couple of days have been so pretty, sunny and warmish-cool. My assistant Brittany texted me this morning to say that she thinks we should have a day set aside when we are allowed to call off "because it's just too pretty to work." I second that! 

Here in our area it's very warm in the sun but also very cool in the shade, maintaining a need for jackets. Our flowers are late blooming, so the "garden city" is not quite living up to it's name yet. The Master's golf tournament is underway and that, of course, is the main event in town. I guess the weather is pretty good for golfing right now. 

My son Noah, is trying to get out of Turkey and return home to start his civilian life after spending the last six years in the U.S. Air Force. He has been met with delays all along the way, and now is becoming frustrated. He's stuck in "transition limbo." I am very excited that he will be home this Saturday night.  Woohoo!! That is my main event. My birthday is next week and I could not ask for a better gift than to have my son back. I have missed him.

I hope spring comes forth for all of us very soon. We've endured the winter storms and are now ready for the renewal that is springtime. Don't give up hope, it will surely happen.
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    Adventures in Sleep
    Occupation: Sleep technicians
    Setting: Various sleep facilities
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