Sleep Apnea & the Professional Mariner
by Capt. Doug Pine
As a professional mariner you are, I’m sure, quite familiar with the sounds of snoring coming from the cabins aboard the vessels upon which you serve. Unfortunately, at times, we must share a cabin with a snoring shipmate. I remember a time over ten years ago when the assistant engineer and I shared a cabin when I was a mate on a tug for Sause Brothers in Hawai’i. One morning he went off on me at breakfast: “Doug, I can’t get a moment’s sleep when you’re in there! You snore louder than anyone I have ever heard!” This was no surprise, as I knew that I snored. My then-wife used to kick me in my sleep to get me to roll over and stop snoring. My brother and I were famous in our family for our snoring. Next time we were in port, I walked across Nimitz Highway to the K-Mart and bought some of those strips you paste on your schnozz that are “guaranteed to stop your snoring!” I bought some sprays, too. Nothing worked. I felt bad for my cabin-mate, and stayed awake as much as I could. The A/E bitched about it until I got on a different boat that fortunately had a private berth for the Mate.
When I married my wife Kathy, she said that I snored but she didn’t mind it. I thought (and still do, by the way) that I had to be the luckiest man alive to be with a woman like that. For the first five years of our marriage I snored away happily, with no middle-of-the-night kicks and no early-morning complaints from my bed partner. As time went by I, like many of my peers, began noticing the my health was slowly but surely deteriorating. I had quit smoking cigarettes in 1999 but I had developed hypertension (high blood pressure) and was obese, lazy, and pretty much sedentary.
Then, during a pre-employment physical in 2008, I learned that I had Type 2 diabetes. Like a bucket of cold water, it was. I began changing my eating habits, started exercising, and hoping for change. Not much changed really, except I did start losing some weight. I was always tired though. I would come home from work, sit down in my easy chair to watch the news, and would be fast asleep within minutes. When I would wake my family would laugh at me for snoring away loudly as I snoozed in my chair. I just didn’t have any energy after about 2:00pm each day. On the weekends I would mostly nap, trying to build up energy for the coming work week. At this time I was running the simulation department at PMI in Seattle, a demanding and time-consuming job that, counting my commute, kept me away from home each day for over twelve hours, and often more. I was a wreck. I thought I was depressed, so my doctor put me on anti-depressant medication. So here I was, in my mid-forties, taking four different prescription medications each day, poking my finger to test my blood sugar several times a day, and taking my blood pressure twice a day. In other words, I was the poster child for the American pharmaceutical industry’s mission statement. I was in good company, yet was not comforted by that fact. I hated taking the medicine, and being tied to testing each day. It is no small thing with the Coast Guard anymore, given the new medical standards they’ve implemented with NVIC 04-08. Beware, my shipmates, beware!
At a routine visit to my dentist one day I noticed a rack card that discussed snoring. It encouraged me to ask my dentist about possible treatment for snoring trouble, so I did. Asking that question eventually changed my life. My dentist told me that there are several treatment approaches available, but it all starts with a visit to an MD, a sleep specialist. Great, I thought, another doctor-to-doctor scam to generate income and commissions. But I like my dentist, and trusted him. It took several months, but eventually I decided to follow up.
I called the Tacoma Sleep Clinic and made an appointment. When I went in I thought it would be a quick in-and-out with a return visit to my dentist for an appliance fitting. What actually happened was I had about a one hour sit down with Dr. Daniel Clerc (pronounced: claire) who proceeded to tell me all I ever wanted to know about something called Obstructive Sleep Apnea (OSA). He took a detailed medical history from me and looked inside my nose, ears and mouth. He took measurements of my various pieces and parts in there and said that, absent the results of a sleep study, he would just about guarantee that I had OSA. The most interesting moment for me that day was when he asked “Do you suffer from nightmares?” I replied that I did indeed, almost every night. “Hmm”, he said, “Interesting.”
Dr. Clerc urged me to schedule a sleep study on my way out of his office. He said it would probably save my life. That really piqued my curiosity. “Save my life?” I asked. His answer was to list for me, and give me a pamphlet that listed for me, many of the conditions that can be related to OSA. As I read through the list of deadly diseases, I occurred to me that I already had a few of them:
There are several more on that list, and all of them are killers.
Needless to say, I scheduled a sleep study. This involved going to a clinic in Tacoma to spend the night while being hooked up to about thirty different sensors that measured my brain function, respiration, temperature, eye movement, pulse, blood oxygen levels, leg muscle movement and a polygraph. Well, not the polygraph. But they might as well have done it since polygraphs measure most of the same stuff. My session would also be recorded on video and audio. The results of the study would be sent to a sleep specialist for interpretation and diagnosis. I tossed and turned a bit, not used to being wrapped in wires, and eventually fell asleep. I woke up the next morning, grumpy and tired, and headed for work. The clinic called back a week or so later and said that, based on my initial study, they wanted me to come in for another one, this time using a machine to assist my breathing.
So back I went. While he was hooking me up to the now-familiar sensors, the technician showed me the mask and machine I would be breathing from and said he would be controlling it from his lair. So I picked a sleep number (love those sleep number beds!), watched a little TV and, after bitching a bit about the mask, fell asleep. He woke me the next morning and sent me on my way. I had gone in on a Friday night so I headed for home on Maury Island. When I got home I decided to do some yard work. Heavy stuff, tree trimming, clearing and chipping. I worked for eight hours straight and then figured it was time for my afternoon nap. Here’s where everything went sideways for me: I went in, turned on the TV, reclined in my easy chair and expected to fall asleep in moments. I waited, and waited some more, for sleep. It eluded me. I drank a beer, thinking that would push me over the edge. No sleep. Not even a yawn. So I got up and went outside and did three more hours of yard work. I had more energy on that Saturday in July of 2008 than I’d had since I was a twenty-something surfer on Maui. Kathy was as amazed as I was.
First thing Monday I called Dr. Clerc’s office. Gimme one of those machines, now! But no, one must work within the system. Two weeks for the results, two more weeks to get a machine ordered and set up. The longest month of my life, knowing that the cure was out there but not being able to get it. I was miserable. Two weeks later, I got a call from Dr. Clerc’s office. They asked me to come in for a follow-up visit for the results of my sleep study. I went in shortly thereafter and Dr. Clerc told me that I did indeed have a whopper of a case of OSA, and they would be able to fix me up without surgery. This was right around the time that television reporter Tim Russert died suddenly, and I’d been wondering if he, too, suffered from OSA, and if it had killed him. I wouldn’t be surprised if it did.
Dr. Clerc prescribed my treatment: the machine I craved. A Continuous Positive Air Pressure (CPAP) machine. This little beauty blows pressurized air into your airway when you sleep, preventing the soft tissues from collapsing and obstructing (OSA, get it?) your airway and causing apneas, which are the times when you stop breathing at night and your brain eventually forces you awake just enough to draw a breath. It is these apneas that cause all the trouble. If you’re waking up a hundred times each night, to prevent yourself from suffocating to death, you simply cannot get any good sleep. Your body will, over time, suffer terribly. In other words, a fan can save your life.
The CPAP machine is small and quiet. I use a mask that fits into my nostrils, and doesn’t cover my mouth. It even has a humidifier built in. It’s portable, so I take it to work with me. It’s the easiest cure I’ve ever taken. I’ve been using CPAP for just over a year and, during that time, I’ve lost forty pounds. I’m not taking prescription medications anymore. None. My blood pressure is normal. My blood sugar is normal. I’m not depressed. My energy level is up. I exercise. At my last eye exam I read one line better than I’d ever done before. Oxygen is an essential element, and when you get enough of it your body responds in positive ways. What a concept. Most intriguing to me: I no longer have the nightmares. I used to wake screaming in the night from horrible nightmares, and they scared the heck out of my wife. The last one I had was one night when I didn’t use the machine. They’re gone.
I wanted to share this story with my fellow mariners, especially those whose employers still see fit to force them to work a six-on/six-off watch rotation. The two-watch system alone is a huge threat to a mariner’s health. Add sleep disorders to the mix and it becomes potentially deadly. Look around you at work. How many of your peers suffer from hypertension, diabetes and obesity? How many of your shipmates snore? How many live sedentary lives? How many have died within a year or two of retirement? We all know them. That was me not too long ago. My diagnosis of OSA, and the treatment with CPAP, has changed my life for the better, and more than likely has extended it by many years.
Many of us in the maritime industry, like it or not, are stuck in the two-watch system. We owe it to ourselves to maintain our health as best we can under these difficult work hours. Quit smoking if you haven’t. Switch to decaf. Drink lots of water, and try to get at least five hours of sleep during one of your off-watch periods. It’s a challenge, to say the least. I don’t believe that the two-watch system will disappear in my lifetime, so I’ve decided that, for me, it isn’t worth it. I won’t work another six-and-six boat unless I have to in order to feed my family. But I’m at a point in my career where I have the luxury of making that choice. If you can’t make that choice for yourself do everything you can to preserve your health so you’ll be around for your family for many years to come.
I did an interview with Dr. Clerc for this article, and his answers follow:
Doug: What do you estimate is the number of people in the United States with OSA?
Dr. Clerc: It is conservatively likely somewhere between 5 to 15% of the entire population, some estimates are higher (20%) = 15 to 60 million people).¹
Doug: Of these, how many have been diagnosed and treated?
Dr. Clerc: Possibly 10 to 15 percent.
Doug: What can be the long term impact on the health of those with untreated OSA?
Dr. Clerc: In terms a layman can understand: It can kill you.²
Doug: How does treatment of OSA impact the lives of those treated?
Dr. Clerc: From a clinical perspective there is very often a complete resolution of clinical complaints. The associated medical conditions are known to be improved: less cardiac problems, improved depression, improved diabetes control, decreased sleepiness, and a generalized improvement in cognitive function.
Doug: Is treatment complicated and difficult to comply with?
Dr. Clerc: The treatments can be divided into three broad groups: surgical, medical(CPAP), and dental (oral appliances). Adjunctive treatments include weight loss, elevation of the head of the bed, and maximizing treatment of conditions like nasal allergies and congestive heart failure. Compliance with treatments is largely dependent on the person rather than the approach to care. The treatment modality is predicated upon anatomy and the severity of the OSA. With guidance by a dedicated Board Certified Sleep Specialist who will chose the correct treatment and address problems that may arise related to the specific treatment modality…compliance is related more to innate personality traits than the mode of therapy being used.
Doug: Considering professional mariners, in particular those on six hour watches who regularly get only four to five hours of sleep per day, at times in one to two hour blocks, can CPAP treatment for OSA help mitigate fatigue?
Dr. Clerc: The general concept is that if you have OSA…you have it at all times and locations. It doesn’t matter when or where you are sleeping. The CPAP should be on during sleep, even if it’s a short nap.
Doug: What are the potential long term effects on the overall health of mariners working a six and six watch rotation?
Dr. Clerc: The immediate effects related to sleepiness and fatigue related to disruption of the normal circadian rhythms. This is often related to the development of mood disorders (depression/anxiety disorder), metabolic disorders (weight gain, diabetes), and cardiovascular problems (HTN). These problems can of course persist long after return to a normal sleep schedule, but can be diminished by a health conscious individual who exercises and has a good diet and lifestyle.
Doug: What are good sleep strategies for mariners working six hour watches?
Dr. Clerc: This is an area that has gotten increased attention over the years. The question is – what happens when the normal circadian cycle is disrupted? And, is there a way to maximize function when a traditional regimen of 8 hours sleep/16 hours of wakefulness is not possible? The navy has used an 18 hour schedule…6 on and 12 off with 3 rotating shifts. Much research has been done on this. The problems arise with the use of stimulants like caffeine to stay awake and alert….but then adversely impact the ability to sleep. The ideal position is to avoid stimulants for 12 hours before desired sleep. Make the sleep environment as dark, quiet, and comfortable as possible. With 6 on/6 off scheduling…many find it useful to choose one of the 6 off time periods as the major sleep period and they try to get the most sleep – 5 hours or more during that time period….and a shorter nap during the alternate time. Other obligations….hygiene and meals also eat into the time periods. Consistency is the most important approach. Avoidance of sedatives is important and is often prohibited in environments that involve the operation of equipment.
¹ Depending on the study and the criteria being used for diagnosis (the criteria have been modified over the years and the technology being used has advanced) it is conservatively likely somewhere between 5 to 15% of the entire population, some estimates are higher (20%) = 15 to 60 million people).
- Community Based Study 30-60 yrs old (random sample of 602 employed men and women)
- OSA defined as AHI > 5 = 9% women, 24% men
- OSA defined as AHI > 5, plus excessive daytime sleepiness = 2% women and 4% men
(Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S., NEJM, 1993;328:1230)
Note the year of this study: 1993. The prevalence today is likely to be much higher.
- Our society is growing more and more obese.
- The equipment and techniques used to diagnose OSA are now far more sensitive.
- 35 – 50% of hypertension (HTN) patients have underlying sleep disordered breathing (SDB)
- >70% of drug resistant HTN patients have SDB
- Roughly 50% of patients with diabetes type 2 have underlying SDB
- 70% incidence of OSA in stroke patients
- 50% incidence of obstructive or central sleep apnea in congestive heart failure patients
- 40% incidence of SDB in coronary artery disease patients
²OSA is independently associated with:
- Cardio-vascular disease (CAD, CHF)
- Cerebro-vascular accidents
- Daytime sleepiness & impaired cognitive function
- Motor-vehicle & job-related accidents
- Diminished quality of life.
- Insulin Resistance/Diabetes
(Young T, Peppard PE, Gottlieb DJ. Epidemiology of Obstructive Sleep Apnea: A population health perspective. Am J Resp Crit Care Med.2002;165:1217-39)
(Mohsenin V. Is sleep apnea a risk factor for stroke? A critical analysis. Minerva Med. 2004 Aug;95(4):291-305)
(Harsch IA, Hahn EG, Konturek PC. Insulin resistance and other metabolic aspects of the Obstructive Sleep Apnea Syndrome. Med Sci Monit. 2005 Feb 25;11(3):RA70-75)
(Peker Y, Kraiczi H, Hedner J, Loth S, Johansson A, Bende M. An independent association between obstructive sleep apnea and coronary artery disease. Eur Respir J. 1999;13:179-184)
OSA is also associated with:
- Anxiety disorder
- Substance abuse
- Memory impairment
- Sleep fragmentation & insomnia
Editor’s Note: this is the first contribution to the Towmasters Forum from MTVA member Doug Pine, and you’ll be seeing more quality writing from him in the future. You can check out his blog, The Dullest Catch, and read about his recent harrowing experiences as captain of a U.S.-flagged fishing vessel working in the South Pacific. Doug is now safely back home in Washington.