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Sleep Disorders (transcript)
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(ANNOUNCER)  
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an Association of independent Blue Plans committed to better knowledge leading to better, more affordable health care for consumers.

[clock ticking/heart beat]

[music]

(Dr. Peter Salgo) 
Welcome to Second Opinion where each week our health care team solves a real medical mystery. When we close this file in half an hour, you'll not only know the outcome of this week's case, you'll be better able to better take charge of your own health care. I'm your host Dr. Peter Salgo and our story today concerns Gretchen. Now you've already met our special guests who are joining our cast of regulars, Primary Care Physician Dr. Lisa Harris and health reporter Christine Rogers. No one on this team knows this case so let's get right to work and talk about Gretchen. Gretchen is a 55-year-old nurse who presented at the Emergency Room after being in a car accident. She reports having fallen asleep at the wheel, that's what she said, while driving home from her night shift. She suffered some lacerations. Mark you're in the Emergency Room. What do you want to do?

(Dr. Mark Hyman)    
Well I see that all the time. Shift work causes us to have disordered sleep cycles.

(Dr. Lisa Harris)   
Yeah we can talk about shift work, but I want to make sure that she hasn't been drinking or using any other drugs.

(Peter)  
I can tell you that they did some blood work in the Emergency Room. Her toxicology screen, Lisa they did it.

(Lisa)    
Thank you.

(Peter)  
It was negative; there's nothing in her blood. She has no real significant history from the Emergency Room physician's perspective; that is to say nothing that would have indicated other than she fell asleep at the wheel.

(Lisa)    
If she had some minor lacerations, her vitals are stable, her tox screen is negative, her labs are okay, they're going to tell her to call your Primary Care and follow up.

(Peter)  
That's exactly what they did. They said, you know go to your Primary Care Physician in 5 days which is when we want you to have your sutures taken out. What's the big deal? Everybody has fallen asleep right? Harley you've fallen asleep at odd times. You've had problems doing shift work; working nights.

(Harley Howard)    
That's correct.

(Peter)  
Falling asleep at inappropriate times?

(Harley)     
Very rarely and very rarely whenever I drive. In fact if at any time if I felt as though I was going to be a hazard, I would pull over for a few minutes.

(Peter)  
So you were afraid of falling asleep?

(Harley)     
Oh definitely.

(Dr. Peter Salgo) 
Why? What was it that was troubling you?

(Harley)      
I think probably just falling asleep and not waking up. I had it happen many years ago in Salinas where I fell asleep and it was after working a night shift and I woke up on the wrong side of the freeway looking at a truck coming at me and that woke me up real quick.

(Peter)  
Let me ask a more profound question if I could for the sleep experts here. Why do we sleep? What is it about sleep that the human body needs?

(Dr. Michael Yurcheshen)   
No one really knows the answer to that.

(Peter)  
I was afraid you were going to say that.

(laughs)

(Michael)    
No one really knows. I mean there are some theories that it has to do with memory consolidation, there are some theories that it has to do with restorative properties, but all we know for sure is the body really does need sleep.

(Donna Arand)  
And if you don't sleep you get sleepy during the day and we're now finding out that sleep is part of a healthy lifestyle that includes diet and exercise as well.

(Peter)  
But we've all heard the phrase sleep depravation. We don't know why sleep is good. Can you tell me why not sleeping is bad?

(Mark)     
Having sleep depravation is a huge problem. It affects your ability to think, it affects your mood, it affects your digestion, it affects your appetite, it affects your weight, and it affects diseases like high blood pressure and heart disease. It's something that's prevalent in our society that most of us are not facing and dealing with. We're just going to Starbucks and trying to, you know, medicate ourselves into awake and alertness which is really counterproductive.

(Peter)  
But isn't that very American, I think or at least certainly western industrialized society? Sleep is unnecessary, if you're sleep you're weak and only the strong survive on 1 hour of sleep or cat napping during the day.

(Michael)    
Right. There are increasing pressures in society to get less sleep because we have so many other demands on our time from work to family to you know, hobbies and other responsibilities.

(Christine Rogers) 
We don't leave work at work anymore either do we? I mean you bring it home; you have your laptop computer, your cell phone, your Blackberry, I mean you have all these things really that get in the way sometimes I think of probably getting appropriate sleep.

(Donna)   
 And you're right. Sleep loss, nowadays the research shows that it is linked to obesity, which is also a national health crisis as well.

(Peter)  
Can you, for me define sleep depravation?

(Michael)    
The proper amount of sleep that somebody needs is the amount that they need to function during the day well and not be sleepy. There are some kind of rough estimates from just what we see, you know, children, infants basically sleep 18 hours a day then into adulthood, you know, elderly patients or older patients get 6 or 7 hours of sleep but they don't always feel well rested either.

(Lisa)    
What it really gets down to is the quality of sleep so if people are getting quality sleep, it makes a difference. We were talking about elderly; I mean they may be lying in bed for 7 hours and not feeling rested. They may lie in bed for 4 hours and wake up feeling totally rested. There is some data to show that sleep times for pediatrics is changing, certainly that children that are in middle school to high school actually need more sleep than the kids that are in elementary school. What I want to know, we keep talking about sleep depravation; we don't know what her sleep was like and we don't know if there is a reason that she was staying awake above and beyond that. Did she have acid reflux, did she have asthma, and did she have sleep apnea?

(Dr. Peter Salgo) 
What is good sleep? I asked him 2 questions that were unanswerable. Do you have an answer for this one?

(laughs)

(Peter)  
That is by the way the grin on his face. It's not his question.

(Donna)   
Well the American Academy of Sleep Medicine recommends everybody get 7 to 8 hours of sleep in general. When you talk about sleep depravation, you're right, it, you know, it varies from individual to individual but generally if people are getting 6 hours or less, we figure that they're probably a little sleep deprived. The quality of sleep is absolutely important as well, you know.

(Mark)     
The real question is what is it that affects our sleep and causes us to sleep poorly because one thing is not sleeping from shift work and the other thing is all the habits we have that affect our sleep. You know we live on drugs. The 4 top drugs sold in America are all sold in supermarkets; caffeine, nicotine, alcohol and sugar and they all affect our sleep.

(Peter)  
We're going to stop just for a moment and sort of sum things up with just where we are right now. Sleep I think it is fair to say from what I've heard allows the body to repair. It is critical to good health, whatever the specific affects of lack of sleep, good sleep is a critical thing for your good health and lack of good sleep can cause problems. Can we all agree on that?

(Michael)    
Agreed.

(Peter)  
Even the 2 of you? Good so let me tell you more about Gretchen. Remember she had the car accident, she was sown up and now it's 5 days later. What do you want to know now?

(Lisa)    
I want to know what her pattern; her daily life pattern is like. What time does she go to work, what time does she get up and what does she do in between.

(Peter)   
All right here's what I've got for you. She works a rotating shift at the hospital and has been doing that for 20 years so this is not something new. She's mid menopausal, she's been gaining weight, and her blood pressure is beginning to climb. She's been started on a Beta-blocker for her blood pressure.

(Lisa)    
Oh great.

(Dr. Peter Salgo) 
She has been separated for 2 years; she lives alone. She occasionally drinks wine, wakes up at night with nightmares and can't get back to sleep. But I can tell you what she denies. She denies Diabetes, seizures, other head trauma, she does not smoke, she admits she nods off occasionally at work and then because she's so worried about her sleep, she's taking Melatonin which she got from some kid at the health food store. What's this Melatonin stuff all about?

(Mark)     
Well it's just one of the things people use over the counter to help them with sleep. Everybody's trying to self medicate.

(Peter)  
What's the theory behind Melatonin?

(Mark)     
Well it helps to stimulate the sleep cycle in the brain.

(Michael)    
Melatonin is a hormone that your body naturally produces in the Pineal Gland, which is in the brain. In the evening time there is a spike in Melatonin and we know that that is critical in regulating Circadian Rhythms, in other words the rhythm that is responsible for us sleeping at night and being awake during the day.

(Peter)  
Are there any other Nutracuedical that people are using that you think have any value?

(Mark)     
Well I think you know the biggest problem I think is a Magnesium deficiency in this country and it causes a lot of things that can make us tight and make us stressed and it's really the relaxation mineral. So Magnesium at night can be powerful.

(Dr. Michael Yurcheshen)   
Of what you've listed, there are at least 6 or 7 different things that are definitely interfering with the quality of her sleep.

(Peter)  
Okay.

(Michael)    
That includes alcohol use, Melatonin, the shift work that you said is rotating, stress in her life from the separation of her spouse and drugs; Beta blocker as you mentioned, can actually contribute to insomnia.

(Peter)  
Now that you've got this history, is there anything you'd like to know, any laboratory work you feel you need? I've got some numbers if you'd like them.

(Dr. Lisa Harris)   
So what are your FSH, your LH and her Estradial? Do you have that?

(Peter)  
Yes, they're all normal.

(Lisa)    
And her TSH?

(Dr. Peter Salgo) 
Thyroid hormone is normal, her iron is normal, her glucose is normal, all of her kidney and liver function tests are normal and I can tell you that she had an Electrocardiogram, for better or worse, which was normal. Her Follicle Stimulating Hormone, her FSH also apparently at the time they checked it was normal. What are you going to do? Any other tests you want?

(Michael)    
I think a Polysomnogram would be appropriate.

(Peter)  
What's a Polysomnogram?

(Michael)    
That's a sleep study.

(Peter)  
Well we're going to get to that. Now Harley you had a Cardiogram. I mention the Cardiogram here because there is some debate I suspect as if to whether or not she even needed one, but yours was abnormal is that right? I seem to recall that you had a racing heartbeat.

(Harley)     
Yes I had a racing heartbeat when I was driving home from the studio at a radio station, KKLA in Los Angeles and I had a program that was live 6 days a week from midnight to 2:00. In 91 I was driving home, my wife was with me that night, or that morning and we were about oh I'd say about 10 minutes from the house and all of a sudden my heart just started racing very, very fast and I woke her up and told her something's wrong and I said I was going to go to the hospital. We went to the hospital and they hooked me up, put the pads on and measured the heart rate and it was I think it was 180.

(Peter)  
Okay. That was your pulse, your heart rate?

(Harley)     
That was the pulse at that time.

(Michael)    
That's pretty fast.

(Harley Howard)    
Pretty fast and pretty uncomfortable.

(Peter)  
Define the problem a little bit better for me. Is, is that you had rapid heat beats all the time or what was bothering you that you kept asking the doctors to help you with?

(Harley)     
Well one of the things that disturbed me was that from about 1991 up until about 2001 I noticed that there were increased moments of rapid heart beat where I would wake up from a dead sleep and I would have to go immediately to the doctor. Now sometimes it would happen and if I would just lay in the bed, my wife was usually right there and she would witness this and I would continue to breathe, I would be able to get back in my rhythm, but for the most part I was always going to the doctor and then seeing my Primary Care Physician in between these episodes and still inquiring to ask them.

(Lisa)    
And therein lies the problem.

(Harley)     
Yes.

(Peter)  
What's that Lisa?

(Lisa)    
That he's getting episodic treatment in an Emergency Room. They're not remotely interested in trying to figure out the problem.

(Dr. Peter Salgo) 
Well let's talk about Gretchen. We have the opportunity here since she's seeing her Primary Care Physician to get more of this whole story. She's already told you that she's having trouble sleeping and at least somebody put together trouble sleeping, too sleepy; hit a pole with her car, wound up in your office. Why not just give her a sleeping pill so she gets the sleep she needs when she needs it?

(Lisa)    
No.

(Peter)  
Massive no's here. Why not?

(Lisa)    
You're putting a band aid on, you know, a fungating ulcer, it's like...
(laughs)

(Michael)    
Well yeah, that's what we do in medicine. We treat the symptoms and not the causes.

(Christine)   
We want quick fixes, that's what it is.

(Harley)    
There are no quick fixes.

(Donna)    
There are side affects to sleeping pills that people don't realize.

(Donna)   
We're not addressing the cause.

(Peter)  
What are the side affects?

(Donna)   
Well first of all in her case, she's using alcohol. You don't want to combine alcohol with sleeping pills.

(Peter)  
Well tell her to stop.

(Donna Arand)  
Okay you tell her to stop and she...

(Mark)     
Drinking or taking pills?
(laughs)

(Donna)   
Preferably both and you want to get her on a regular schedule of sleep. If she takes a sleeping pill that could have a half-life of 6 hours or more, she may not give herself 8 hours of sleep and that's an inappropriate use of sleeping pills.

(Peter)  
Now the half-life is the amount of time it takes for the amount of that drug in your blood to go down by 50%.

(Donna)   
By 50% right and so sleeping pills, particularly in a shift worker can be very dangerous because these people tend not to spend 7 or 8 hours in bed; they're trying to get up and do other things like drive and also you have a chronic problem with insomnia. Insomnia for most people is not a 2 or 3-week event, it can return throughout life, it can be a chronic nightly thing and you know what are you saying? Put this person on sleeping pills for the rest of their life?

(Dr. Michael Yurcheshen)   
It's a much easier thing to put somebody on a pill or a tablet than to get them to change lifestyles and habits.

(Lisa)    
That's true.

(Peter)  
Well I want to tell you what happened with Gretchen first because actually her doctor offered her a sleeping pill, but Gretchen said because I'm a nurse; she said I don't want to be groggy at work. I don't want a pill. Then, good for Gretchen is what I heard over here. Somebody, her doctor said why don't you go to see a psychologist who specializes in sleep problems. Donna what do you think of that?

(Donna)   
I think that's an excellent idea.

(Dr. Peter Salgo) 
I knew you'd think that.
(laughs)

(Peter)  
Walk me through this. What would it involve going to see a Sleep Psychologist? What is Gretchen looking at?

(Donna)   
Well it could be as few as 4 to 6 treatments with a psychologist who has training in Cognitive Behavioral Therapy. The first appointment they would sit down with her and talk about her misconceptions about sleep and insomnia and the affect it's having on their life. A lot of people feel that, you know their whole life is coming unglued because they can't sleep at night; they lost their job because they couldn't sleep at night, and they had a wreck because. There are so many misperceptions about it that really then it increases the stress level and the need to get good sleep so the rest of my life is fixed and that doesn't happen.

(Mark)     
So you have to not care about sleeping and then you can sleep?
(laughs)

(Mark)     
That sounds fine.

(Donna Arand)  
Well you've got to take the stress off of I've got to sleep because no one can make themselves go to sleep naturally, not even the best sleepers know how we fall asleep or when we do it, in fact the only way we know we've been asleep is because we wake up.

(Lisa)    
But I'm still a little worried that there may yet be some other underlying medical problems there and I probably would, if she had refused a sleeping pill, which I wouldn't; have done or couldn't change her shift; a Polysomnogram would have been the next thing that I would have done.

(Peter)  
She's coming to see you. That's your daily work. What on earth is this Polysomnogram?

(Lisa)    
I want to know what's going on when she sleeps.

(Peter)  
I promised you we'd get there.

(Michael)    
You're right, it's my minute.

(Peter)  
It's more than a minute; take all the time you need.
(laughs)

(Michael)    
So this is a sleep study and it basically is used to find out disorders of people's sleep. It's not really used in cases of insomnia so if we're thinking that this is a problem with insomnia, either Primary Insomnia or insomnia due to something else, or it's shift work, we diagnose that basically on the basis of history.

(Peter)  
So if you're going to do a sleep study, what actually do you measure during the time? She comes to you right?

(Michael)    
Correct.

(Dr. Peter Salgo) 
And sleeps in your laboratory while she's observed.

(Michael)    
Correct.

(Peter)  
So what parameters are you observing?

(Dr. Michael Yurcheshen)   
We watch any number of parameters. At the very least we watch eye movements, we measure brain waves with EEG leads on the head, we monitor cardiac rhythms with a couple of cardiac leads, some limb movements, effort from the chest and the abdomen and flow through the nose or the mouth of air and also blood levels of oxygen.

(Peter)  
What is it telling you?

(Michael)    
We're trying to find out information of what, if anything is disrupting sleep at night.

(Peter)  
Is it insomnia if you stop breathing and you have sleep apnea.

(Michael)    
No.

(Donna)   
No.

(Michael)    
No that's not insomnia. That is sleep apnea by definition.

(Mark)     
You sleep great once you fix it.
(laughs)

(Michael)    
It is the cause of disrupted sleep, but insomnia tends to refer more to people who have difficulty maintaining sleep or initiating sleep and a lot of patients with sleep apnea aren't even aware that they have it.

(Peter)  
Harley do you have one of these?

(Harley)     
Oh yeah. What began to happen was each episode became progressively worse; the one thing that I will never forget and I'm thankful that it was done is the horrific nightmares that I've had in all those years. The nightmares of death; it was always death and I would always wake up choking, strangling for air. My wife was in such a terror about it because each episode would happen unpredictably. You'd just get up and you'd have to go the hospital.

(Peter)  
Now you did go to a sleep clinic?

(Harley)     
Eventually after that last episode where they had to shock the heart back into rhythm.

(Dr. Peter Salgo) 
Tell me about what the sleep test was like.

(Harley)      
The next morning...

(Peter)  
Yeah, you woke up.

(Harley Howard)    
I woke up at 7:00 and he said you have got to see this. He showed me the charts. The oxygen levels that begin at 96% went down to 73%.

(Mark)     
Wow that's not good.

(Harley)     
Within a matter of a few hours just dropped.

(Peter)  
The amount of oxygen in your blood just dropped?

(Harley)     
Right. Big time depravation and he was showing me various parts on the charts where I would stop breathing; 30 seconds here, 20 seconds, a minute, a minute and a half, 30 seconds. It was hundreds of times throughout the evening.

(Peter)  
So you had sleep apnea?

(Harley)     
I've had obstructive sleep apnea.

(Peter)  
Can one of you docs define for us, sleep apnea.

(Michael)    
There are many different kinds of sleep apnea. The kind that you are referring to and the most common kind is called Obstructive Sleep Apnea so that happens when there is a physical obstruction in your breathing passageways that interferes with the flow of air.

(Harley)     
Yeah.

(Dr. Michael Yurcheshen)   
This is the kind that is most associated with snoring and also when people are overweight and things like that.

(Peter)  
They told you, you had sleep apnea which means you're not breathing well during sleep. What happened next? You said that there was a machine involved.

(Harley)     
Right. I was, after we looked at the chart, the first 3 words out of my mouth were hook me up.

(laughs) 

(Harley Howard)    
Hook me up. I didn't care. He said well there's going to be a big machine. I said I don't care if the machine is the size of a Samsonite; I want to get hooked up today. He gave me a huge machine that they use at the clinic. I took it home and for the first night I didn't have any nightmares.

(Lisa)   
Wow.

(Harley)     
The position I laid in that night was the position I woke up in the next day. I finally for the first time in a decade got a solid night's sleep.

(Mark Hyman) 
I want to look at that ...

(Christine Rogers) 
Did you have any problems, because you were talking about like you have headaches? Did that go away as well?

(Harley)     
The headaches went away, the nightmares went away. Within a few weeks the blood pressure dropped down to almost 50 points. Everything began to drop down.

(Dr. Mark Hyman)    
You'd lost weight too right?

(Harley)      
I lost a lot of weight.

(Peter)  
Are Harley's symptoms by the way unusual for somebody with sleep apnea?

(Donna)   
Classic.

(Mark)     
People can't lose weight when they have sleep apnea. People often have real struggles with their weight.

(Peter)  
Let's pause for just a minute over here and just sort of just sum up where we are because we've covered a lot of ground. Sleep disorders are very common and they can be very serious. There are many causes for sleep disorders that you need to work out with your team of doctors to diagnose your problem and among the things you can do is a sleep study and that's exactly what Gretchen had. Would you like to know what Gretchen's sleep study results are, because I can give them to you?

(Michael)    
Great.

(Peter)  
I thought you might like to know this. Gretchen had a sleep study, which showed that of the total potential 500 sleep minutes; she slept for about 198 of them. Her sleep efficiency was about 40%. She did not have sleep apnea she wasn't Harley. She had mild Hypopnea, no Hypoxemia and no disruptive leg movements. Can you interpret all of that?

(Michael)    
The quality of sleep that she got when she was sleeping seemed to be fine so it leads us back to where we were in our initial discussion, which is a lot of habits, and the sleep hygiene is really interfering with her ability to get good sleep.

(Donna)   
Insomnia.

(Peter)  
So what do you think her real problem is due to? What's causing her to have...?

(Mark)     
The way she's living.

(Peter)  
It's her life?

(Mark)     
It's her life.

(Donna Arand)  
It's the shift work, it's the insomnia, and it's the alcohol...

(Christine)    
The wine...

(Mark)     
Medications, right.

(Dr. Peter Salgo) 
Everything?

(Donna)   
Everything; her life.

(Michael)    
That's where the problem is.

(Peter)  
Now I'll tell her what her doctors did and told her to do. They changed her blood pressure medicine; you guys were concerned about her Beta blocker. They put her on an Ace inhibitor instead, they prescribed CBT; Cognitive Behavioral Therapy for her anxiety.

(Donna)   
Cognitive Behavioral Therapy.

(Peter)  
They gave her a sleep center follow up appointment and they suggested, but did not insist on Lunesta and they want her to change her sleep hygiene. Do you all agree with all of that or not?

(Dr. Lisa Harris)   
Well again, the issue is the Lunesta.

(Michael)    
With the exception of the Lunesta.

(Peter)  
Okay. In terms of changing her sleep hygiene, what does that involve do you think?

(Donna)   
That refers to her sleep habits; when she's going to bed, what she does when she's not sleeping in bed, what time she gets up, what types of things she's drinking during the day that may be stimulants such as caffeinated beverages and it also involves her daytime activities. You know, is she exercising close to bed, and is she drinking alcohol?

(Peter)  
So you don't do that? No exercising close to bed?

(Mark)     
You know the key is that we're animals. We need to follow biologic rhythms. If we don't we're going to screw ourselves up. We need to wake and sleep at the same time everyday, we need to have dark at night, we need to have quiet at night, we need to find ways to pause, you know like we used to without having tremendous activity at night with stimulating television and stimulating email and you know, sort of reading things that are disturbing to us.

(Peter)   
So we shouldn't put this show on at 11:00?

(Dr. Mark Hyman)    
No.

(Donna)    
Only if you want insomniacs to see it.

(Dr. Peter Salgo) 
What about sugar?

(Mark)     
Sugar is huge.

(Lisa)    
Get rid of it.

(Peter)  
What about alcohol? Should it put you to sleep or not?

(Michael)    
Alcohol usually helps you to get to sleep, but then fragments your sleep once you fall asleep.

(Donna)   
Alcohol is the most commonly used self-medication to put people to sleep.

(Peter)  
I can tell you that she took all this advice to heart, and I don't know because I don't have the record here, 5 or 10 years down the line how she is doing, but certainly she was satisfied that somebody actually looked at her problem and done something about it. Now I would be remiss to leave here Harley without letting people see the machine that you use to sleep at night. You've got it with you. Can I help you with any of this here?

(Harley)     
Yes.

(Peter)  
This is a C-Pap Machine?

(Harley)     
Right.

(Peter)  
Explain what you do with this.

(Mark)     
That's the new version. The old ones used to be really big.

(Harley Howard)     
Yeah and I understand the new ones are probably half this size.

(Dr. Michael Yurcheshen)   
That's right.

(Peter)  
Now this machine actually blows air...

(Harley)     
Right. It creates what's called an air splint and what it does is it keeps that air passageway open at night so that the passageway doesn't close down.

(Dr. Peter Salgo) 
So show me what you do with this. This is remarkable.

(Harley)     
These are basically nose pads here and this just goes in your mouth; you adjust it, turn on the machine...

(Peter)  
And you breathe.

(Michael)    
This is delivering pressurized air.

(Peter)  
As you breathe with this, you sleep with this. You can take it out so you can talk.
(laughs)

(Mark)     
C-Pap stands for Continuous Positive Airway Pressure so it keeps your airways open at night.

(Peter)  
Let's just take a moment here, because I don't want to let this moment pass to point out that with proper diagnosis treatment for sleep disorders can be effectively targeted like Harley had done over here with his C-Pap Machine. Now since you've been using your C-Pap Machine, how you doing?

(Harley)     
Doing great, I mean, again, to be able to sleep at night, to have a good comfortable night's sleep is wonderful. I've lost a lot of weight and am able to resume an exercise program that I have never been able to do at all.

(Lisa)     
Right, that's a key point.

(Harley)     
The key here is that this is about a lifestyle change. That C-Pap is only as good as you work synergistically with everything else you have to do.

(Mark)     
Right.

(Peter)  
It was just wonderful to hear your story and I'm delighted; I think we all are that you're doing as great as you are. Congratulations.

(Harley)     
Again I urge people who are watching this program, if you have any concerns about sleep apnea, get tested. This is for your life, this is not a joke, and this is not a game. You're gambling with your life and you're going to lose.

(Dr. Peter Salgo) 
I don't think we have anything to add to that which is a good thing because we're just about out of time too. Let me take a few moments and just sum up a few things because we've covered a lot of ground today; there's a lot to remember. Lack of good sleep causes problems. Sleep, for whatever reason, allows the body to repair. It is critical to good health. Sleep disorders are very common, some of them are very serious, some of them are life threatening and there are many causes. You need to work with your team to diagnose your problem. Now with proper diagnosis, treatment for sleep disorders can be effectively targeted; Harley is living proof. And our final message of course is this; taking charge of your health means being informed, having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

(Announcer)   
Search for health information and learn more about doctor, patient communication on the Second Opinion web site. The address is pbs.org.

[clock ticking]

[music]

(ANNOUNCER)  
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an Association of independent Blue Plans committed to better knowledge leading to better, more affordable health care for consumers.