All In A Night’s Work
How you interact with patients before their overnight studies can have a dramatic impact on the outcomes.
We have all had those patients who arrive resembling a train wreck waiting to happen. While they complete their paperwork, we sit in the tech room dreading whatever might await us in the night ahead. But have you ever tried to put yourself in the patient’s place? It is likely they are apprehensive and uncertain of what awaits them as well. The closest ideas most of them have of treatment for a sleep disorder are a mattress with a programmable firmness setting or a nasal spray advertised to cure their snoring. It is not uncommon for them to be in denial as to whether they even have a problem in the first place. Many patients believe that drinking an extra cup of coffee or taking an over the counter herbal supplement is all the “treatment” they really need.
Many patients arrive at the sleep center with no idea as to why they are in a strange place with a strange person who wants to wire them up for sound. For some, it is the prompting of a spouse that brings them in. Others are there for a simple screening prescribed by their physician. Fortunately for us, there is that small but ever-growing section of the population that arrive as educated consumers. They know why they are there and what to expect throughout the night; however, most of our patients still arrive asking questions like “How do you expect me to sleep with all of that stuff on?” I am sure that we all wished we had a dollar for every time we have been asked that one. Much of this is due to the way people have been conditioned to view sleep.
As awareness of the role that sleep disorders play in our lives becomes more prevalent, the field of polysomnography continues to grow by leaps and bounds. Our patient base has begun to look more like a cross-section of the general populace. We are encountering more and more people who express a desire to “feel better.” I am sure that you share my enthusiasm for this change in attitude. I appreciate the fact that people no longer think that all I do is “just watch people sleep.” Now, people are intrigued. They understand that they no longer have to feel chronically tired. They have learned there is treatment for the malaise and fatigue they experience throughout the day.
As sleep technicians, we understand that changing people’s preconception of sleep is an uphill battle. But how do we straddle the line of educating without diagnosing? How do we contradict a patient’s belief in the nature of their problem or even convince them that there even is a problem? How can we change the manner in which someone has been conditioned to view sleep for years? We have all heard things like “snoring means that you are getting a deep night’s sleep.” My personal favorite is “My husband only snores on his side, so I just nudge him over onto his back.” I usually think about how sweet it is that someone would rather have their beloved simply not breathe so they can get a full night’s sleep themselves. If they only knew. But you cannot say anything—you just have to nod and smile.
So, what happens as you test these patients and discover that they appear to have sleep apnea? What if it is so severe that they need to be tested on PAP therapy? How do we convince a patient of the benefits of PAP therapy without giving them information about their “yet to be” diagnosed disorder? A solution to these questions proves to be very difficult to find. As sleep technicians, we know how important it is to intervene. Even though our primary objective is to improve the quality of a patient’s sleep, we have repeatedly seen the secondary benefits of PAP therapy. We know that PAP therapy can help to eliminate sleep-disordered breathing and sometimes correct cardiac arrhythmias; however, we are not at liberty to express these thoughts to our patients. We are not diagnosticians. We are not physicians, we are the clinicians. Our job is only to perform the test to the doctor’s specifications; herein lies our greatest challenge.
How do we convince someone who has “nothing wrong” with them to try a machine that could improve their overall quality of life? I have always found that general education is key, but educating the patient can be a difficult task. When so many patients are convinced that a problem does not even exist, a sleep technician can often feel two steps behind where they would like to be. Because of this, it is essential to think on your feet.
So how do you accomplish this gracefully and professionally? You have already assumed that your night is going to be a difficult one, just from a clinical standpoint. Additionally, the patient often cannot accept the fact they are experiencing a sleep problem.
As sleep technicians, we know that their sleep will improve if they are tested correctly with various levels of PAP; however, is it really necessary for the patient to understand all of the technical pieces involved? Do they need to grasp the technology behind PAP therapy? It is my belief that the key to success is the way in which you “set the stage” for the night. Much of this can be accomplished during the hours you spend with your patient before they fall asleep or, more specifically, the time of the setup.
During the hookup process, sleep technicians have the opportunity to spend some quality time with their patients. It has been my experience that most people are basically friendly. I also learned that many people try to spend their time telling me what is not wrong. I usually handle this type of situation by avoiding a direct response to those issues. I would prefer to focus on what I am doing with the hookup and how it relates to the testing that the patient is having done. Remember, these patients are at their most vulnerable. They are in a situation that they do not fully understand, that they may not want to be in, that they really have no control over, and then you are going to watch them sleep. How would you feel? Remember that how you initially approach your patient will usually determine how compliant the patient will be with long-term treatment.
When I start my hookup, I explain what I am doing, starting with the ABCs of signal pathway. I do this on a level that my fourth-grade daughter would understand. By doing so, I find that this ensures all patients will have some level of understanding. Try to visualize this in the abstract. Suppose you were presented with a problem from chapter 10 of an algebra book. Would you be able to successfully solve the problem without learning chapters one through nine? By the same token, how could we expect an ordinary layperson to be able to understand the complex wording and explanations necessary to explain sleep medicine? Generally, I find that following the “keep it simple stupid” method is the safest way to approach this.
First, I show them the equipment I will be using all night. I compare the screen to a lie detector machine. In this way, they are able to relate to something tangible. I then explain each electrode and how each works by relating them to the screen output. I will also explain how things are read; while stressing the differences from patient to patient, I make a statement about a physician’s eye being crucial to the accurate interpretation of the recording. This usually precludes any questions about results the next morning. Further into the conversation, I relate how it may be necessary to interrupt their night’s sleep to test them with an apparatus that will assist the interpreting physician in comparing and contrasting their sleep quality. This is usually when the patient declares that “Nothing is wrong.” My standard response is “Do you snore?” The answer is almost always some derivative of yes, such as “My wife says I do.” With that response, I explain how this apparatus might help with the sounds of snoring and how PAP works.
By this time, the hookup is usually just about complete, so I then let the patient try on different masks. By letting the patient hold the mask up to their nose, they are able to experience a low flow of air while maintaining control of when the mask comes off. This usually accomplishes two goals: the patient is more relaxed and is more receptive to the idea of trying PAP. At this time, I usually put an educational video in the VCR, which explains why PAP is important. After that, it is lights out. The patient is usually calm and has learned everything that they are going to need for a successful night.
So, as your patients fall asleep, you begin to realize that your initial thoughts about their conditions were true. With each 30-second epoch, you may see about 10 seconds of sleep followed by harsh arousals. But they are not really asleep, right? They described how it usually takes a few hours to fall asleep, their only admission of a problem. This goes on for a couple of hours, their heart rate gradually increasing and then steadily decreasing with each respiratory event.
Of course, during this time, the patient is sweating, causing all of the electrodes to come off. By now, you have heated up your dinner three times in the microwave although you have yet to taste it because every time you try to, the patient calls to use the restroom.
Eventually comes split time. You set up everything to get the patient ready to go. They insist that they will never fall asleep, but you ask them to be patient and just give it a try.
In a matter of minutes the patient is sound asleep. You start increasing pressure to eliminate those harsh apneas and obnoxious snores. After about an hour, the patient is in REM or delta rebound. Provided you followed your laboratory’s protocol correctly, your patient may stay there for a prolonged period of time. It is about 3 am and your patient is sleeping soundly on their back, something they swore they could never do. Now you are yawning, but that comes with working the night shift. You do not have a problem with your sleep, right? Me neither.
Finally, it is time for the lights to come on. You are proud that your patient slept so well, when, according to them, they did not really have a problem. Anxious to talk to your patient, you ask them how they slept. They insist that they never fell asleep. Upon explaining that hours have passed since you were last in the room and that they have not had to use the bathroom, they reluctantly agree that maybe they did sleep. They get up, and you notice that they have more color in their face than the night before. You complete the clean-up procedure and your patient is feeling great. But they still insist that they do not have a problem with their sleep.
A few weeks pass, and the patient has not slept quite as well as that night they spent in the sleep laboratory. The doctor informs them of the results, and they are shocked that they actually stopped breathing while asleep. Now, they are anxious to get the “C-PACK” machine and to get back to the quality night’s sleep they thought they had left behind back in their thirties. Partially due to diligent efforts, your patient will eventually have an increased quality of life. This is why we are all in health care, right?
How you interact with your patients during the few hours that you spend with them can dramatically impact the rest of their night. In treating your patients, you have successfully contributed to improving their quality of life.
Don J. Fahy, RPSGT, is the clinical relations administrator for SleepCare Centers Inc, an independent management company, and an instructor for the Mid-Atlantic School of Sleep Medicine, both located in Mount Laurel, NJ.