Deemed untreatable

Regarding dementia patients, when my mom was alive & in mid-stage Alzheimer's I tried EVERYTHING to get her license pulled. DMV said go to police who said go to her Dr. Unfortunately her Dr. would not get involved. After a bad near miss I had my BIL remove a part from her engine so the car would not start. I tried taking the keys, but she called a locksmith, not once but three times! People with Alzheimer's should not drive, their judgment is impaired, but she had a wimp of a Dr. who would not get involved.

Drs. have an obligation to report unsafe drivers, whether a CDL holder or an Alzheimer's patient. Unfortunately not treating OSA makes a driver unsafe. Some infractions don't seem to make sense, but I'm learning a lot lately about DOT rules & regulations.

Has anyone else noticed that the OP hasn't uttered another peep?

old dude wrote:Has anyone else noticed that the OP hasn't uttered another peep?

I noticed.
I also noticed that he last visited the forum today at 1:43 PM...so he has likely read what has been said and has chosen not to respond. I suspect he didn't hear what he was wanting to hear but maybe I am wrong. I hope so. I hate to see anyone give up until the forum members have had a chance to try to help. You guys/gals are awesome good if someone will just give it a try.

It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.

[quote="jencat824"]It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.[/quote

Your statement presumes that CPAP can help everyone which is simply not the case.

Perhaps thier doctor understands that CPAP can only treat critical closing pressure issues, saw that the issues here were not that, and made the proper call.

Todzo wrote:

jencat824 wrote:It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.

Your statement presumes that CPAP can help everyone which is simply not the case.

Perhaps thier doctor understands that CPAP can only treat critical closing pressure issues, saw that the issues here were not that, and made the proper call.

It absolutely will NOT help anyone if they DON'T USE IT (or use it effectively).
And, that's the situation we have here with the OP.......non-compliance.


Den

.

Todzo wrote:

jencat824 wrote:It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.[/quote

Your statement presumes that CPAP can help everyone which is simply not the case.

Perhaps thier doctor understands that CPAP can only treat critical closing pressure issues, saw that the issues here were not that, and made the proper call.

Most people who fail, do so because they had trouble with adjusting to the machine and/or the settings were not optimal AND the doctor / DME didn't help them fix it.

Of the people who come here struggling, most have success because they do get help here.

You keep making it sound like people will naturally fail, so that gives them an excuse not to even try. But most people WILL succeed if they get useful help. Instead of discouraging them, try helping them!

I really do believe that Gfm was being quiet honest when he told us that CPAP caused him to be more tired during the day than when he did not use it.

CPAP can help with critical closing pressure however nonanatomic features play an important role in 56% of patients with OSA[1]. Indeed:

37% had a low arousal threshold

36% had high (respiratory control) loop gain

28% had multiple nonanatomic features.

Both low arousal threshold and high respiratory control loop gain are likely to be directly related to the stress level in the persons life. So if you tell a person “try harder” you may be hindering not helping them to adapt to CPAP therapy. You need to find ways to reduce the stress levels.

The pressure of CPAP tends to exacerbate the high respiratory control loop gain issues.

The noise, facial discomfort, and pressure changes while using CPAP tend to exacerbate the low arousal threshold issue.

So yes for some it does seem to make things worse. Many find it unusable. It is simply not an answer for everyone.

If feedback from the data is used, if EERS[2] is used when dealing with gain issues, if there is a constant pursuit of metabolic health through learning to eat and move well, and with a bit of TCM and eucapnic breathing included I have found that even those with respiratory gain issues can do pretty well. But it takes a lot of time and effort to get there and I cannot say that these things will work for everyone by any means.

We need to get real about what CPAP is and is not.

[1] http://www.atsjournals.org/doi/abs/10.1 ... 2IGGaZ3_FW

[2]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

Todzo wrote:

jencat824 wrote:It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.

Your statement presumes that CPAP can help everyone which is simply not the case.

No, actually jencat's answer is an accurate reading of current DOT regulations for CDL holders who are required to have a medical clearance card to maintain their license. Right now the DOT insists that a trucker who has been diagnosed with OSA be put on CPAP; and the trucker must be able to document that s/he is in compliance with therapy (which is defined as the typical insurance standard of using the machine at least 4 hours a night for at least 70% of the nights in the last 30 days) whenever the DOT asks for that documentation. After a quick google search, it also seems as though it may be possible to get certified after surgery for OSA if a follow up PSG is done 3 months or so after surgery and the after surgery AHI is below 5; it's not completely clear, but it looks like the certifying doc can also require future follow-up PSGs to confirm the OSA has not returned after surgery.

And, yes, the DOT rules and regulations DO inadvertently encourage truckers who think they have OSA, but who are adamant about not wanting to use a CPAP, and who are not significantly obese to simply not report their sleep problems to the doc who signs their medical certification. However, if it can be proved that a trucker has lied about their medical problems/symptoms on the forms that are filled in prior to the exam, the trucker could be in serious legal trouble.

I am about to express an extreme viewpoint. When I feel strongly, I tend to rant. Here goes.

Anyone with very-severe OSA who says he is not tired or sleepy during the day and drives fine has about as much credibility as a long-term drunkard who tries to defend against a DUI charge by saying he can hold his liquor. It is an empty argument and one he is in no position to make, when it comes to judgment with life-and-death matters. The issue becomes one of how to preserve the life of the OSA-sufferer and the lives of those in the vehicle with him and in the vehicles around him when he drives.

People with untreated, very-severe OSA often consider themselves great sleepers, since they can often fall asleep at the drop of a hat and may never remember waking up at night. By that measure, they sleep a straight eight hours and are getting great sleep, seemingly better than most. But much like those drunkards who think they're nicer guys and smarter when on the sauce, they're wrong.

And just as a drunkard may have to go through the DTs before he comes out the other side of it, a person with very-severe OSA may have to go through weeks and months of so-called "bad sleep" as an adjustment period to using CPAP. The body/brain may rebel against the PAP for a while before giving in to the treatment and realizing it has no choice but to adapt to it.

I couldn't sleep longer than an hour or two for several nights when I first started PAP therapy. Once my body experienced a full uninterrupted sleep cycle for the first time ever, it woke me up all proud of itself and declared it was through sleeping. I had no choice but to start my day at 2:00 in the morning there for a while. It took weeks before my body learned it could go ahead and start another sleep cycle without waking me up. Then I went through a phase of my body/brain having me remove the mask several times a night, since it still didn't trust the feel of plastic and cloth near my head. It knew I had a sleep problem, and it assumed the plastic and cloth must be part of the problem, not the solution. If I hadn't understood what was going on, I could easily have jumped to the conclusion that PAP was hurting my sleep more than it was helping it. In one sense, at first, it was.

The good people at this forum helped me understand that I just needed to strap in and hang on for the ride at night and wait for my therapy to start doing its job after the full adjustment period. Then I would be in position to drive safely again. And that's much of why I didn't crash and burn in a fireball and kill anyone with me or around me, as I surely would eventually have done had I not stuck with the treatment and had I insisted on continuing to drive long distances at highway speeds. Looking back now, I am amazed that I thought micro-sleeps at the wheel were normal. I thought everyone nodded off and drove in a daze like me. I thought I was more alert than most. After all, I reasoned, I never ran off the road or had a near miss. But my ideas of alertness while driving have certainly changed a lot now, because I know better. One almost-near-nod and I pull off at the next exit for a break and decide what to do from there. It only takes a split second to die or to kill when hurtling through space in a several-ton hunk of metal.

I am not putting down people who need to fight an addiction. I am only making the comparison that helping them should not involve allowing their lives or the lives of others to be at risk out on the road in some sort of deadly mistaken-kindness scenario. Much as someone with an addiction-related impairment shouldn't be allowed to risk lives on the road, people with an untreated, severe sleep disorder may need restrictions put on them if they don't choose to restrict themselves, because part of the problem may be their inability to recognize how impaired they are.

Let's be safe out there.

robysue wrote:

Todzo wrote:

jencat824 wrote:It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.

Your statement presumes that CPAP can help everyone which is simply not the case.

No, actually jencat's answer is an accurate reading of current DOT regulations for CDL holders who are required to have a medical clearance card to maintain their license.

So DOT is depending upon CPAP to keep us all safe.

I now know I need to contact DOT and my Representatives and Senators. This is not acceptable. We are not safe!!!!!!!!!!!

Todzo wrote: . . . contact DOT and my Representatives and Senators . . .

Hope one of them is able to help you, Todzo.

Todzo wrote:

robysue wrote:

Todzo wrote:

jencat824 wrote:It would indeed be sad if the OP chooses not to take advantage of all the folks here who want to help. We can help, but cannot offer the OP an 'easy way out' kind of fix. I'm learning more about the DOT this week than in all my research attempts put together. For the OP there is only yes, I'll comply with therapy & take advantage of this wealth of knowledge to help me do so. Or, no I don't really need a CDL, I'll find another line of work.

Hope the OP see's this.

Your statement presumes that CPAP can help everyone which is simply not the case.

No, actually jencat's answer is an accurate reading of current DOT regulations for CDL holders who are required to have a medical clearance card to maintain their license.

So DOT is depending upon CPAP to keep us all safe.

I now know I need to contact DOT and my Representatives and Senators. This is not acceptable. We are not safe!!!!!!!!!!!

Honestly, with the sleep testing being done in the lab rather than the home such that they have to use sleeping aids just to facilitate enough sleep to test, with titration being done in the same place, and with the doctors not even using the data that the machine takes to properly monitor what is going on it is no wonder so many find CPAP unusable and/or ineffective not even looking at the nonanatomic causes CPAP cannot treat and may make worse!

Even the resource here is constantly bantered by shills, trolls, sockpuppets, and astroturfers who keep people away and confused.

I think we need to move toward vigilance monitoring as a reasonable way to handle this.

Todzo wrote:
I think we need to move toward vigilance monitoring as a reasonable way to handle this.

No matter what you or the OP think should be different, the OP must deal with the regulations as they are NOW.

I am certainly not an expert on the DOT rules since I do not have a vested interest in them one way or another (other than I drive on the same roads).

So, this is just my own personal observation and "OPINION".

My city has an East - West Interstate and a South - North Interstate where the South - North Interstate ends at the intersection with the East - West Interstate but the South - North divided highway continues through the City & beyond.

The East - West Interstate has AT LEAST 2 accidents per month (sometimes 1 a week) involving 18 Wheelers where that driver was at fault. At least 50% of them result in 1 death, sometimes more deaths. In EVERY case the accident was caused by the inattention of the driver of the 18 Wheelers. Now whether they fell asleep or something else was the cause, the point is that these accidents are NOT being caused by anyone other than drivers of 18 Wheelers.

Further, the South - North Interstate that continues through the city only as a divided Federal Highway (no longer an Interstate once it gets into the City) has even more accidents than that involving 18 Wheelers. But the speed limit on that section is much less than on the Interstate part, so the accidents are not as severe (in a lot of the cases, but not in all of them).

There was 1 accident a couple of months ago where an 18 Wheeler plowed into a vehicle stopped at a stop light on that section. Killed all 5 occupants of the vehicle. He was on a section with a 55 MPH speed limit & the investigation showed he was speeding & never even slowed down before hitting the vehicle. Inattention on the part of the 18 Wheeler driver was cited as the cause of the accident.

There have been some major lawsuits filed & major damages collected because of these numerous accidents. Yet, they continue to happen.

The trucking companies pay the damages & move on, but never seem to do anything to try to address the problem of WHY these accidents continue to happen.

So, now the "gubment" steps in & tries to regulate what no one else seems to want to address. Now that has happened, everyone must live with those regulations until something better comes alone.

I am often driving on both Interstates, so I personally welcome those regulations. And believe me, I am not a proponent of government regulation.
These regulations may not solve the problem(s), but they make it a little less dangerous.

Todzo,

I just can't figure out where you are coming from. From reading your many posts, it seems clear to me that you do think doctors should be responsible for preventing people with untreated OSA from running around driving large eighteen wheelers and commuter trains (See (A)), and that people with untreated OSA really don't know just how bad their cognitive skills and reaction times can be affected by the untreated OSA (See (B)). But at the same time when a trucker who is required to treat his/her now diagnosed OSA complains of having problems adjusting to the one DOT-approved therapy for his/her condition, you also seem to think it unfair that the trucker either has to figure out a way to make CPAP work or give up his/her CDL. (See (C).)

And that's contradictory in my opinion: You can't have it both ways. You can't say docs are responsible for getting truckers and train engineers with OSA off the roads until their condition is treated and at the same time tell the truckers and engineers who run into problems with PAP that PAP doesn't work and they should not have to comply with therapy.

You say

Todzo wrote:I think we need to move toward vigilance monitoring as a reasonable way to handle this.

But just what the heck does "vigilance monitoring" mean in your opinion? Wide scale testing of whole groups of people by making them all go to an in lab PSG screening test? (And who's going to pay for all those sleep tests?) And if CPAP simply doesn't work for 50% of OSA paitents for the reasons you believe it doesn't work, what are you going to do with them once they're diagnosed? You've made it clear that you don't think they should be out there on the road, and yet at the same time you convey the idea that they should not be forced by the DOT to comply with CPAP therapy.

The DOT wants to make sure that drivers with diagnosed OSA problems get treatment before driving. And the AMA says "CPAP is the gold standard" and CPAP has a built in way of "vigilance monitoring" called "Usage Data". And that's why Jencat and others have pointed out to the OP that he has a choice: Either figure out a way to make CPAP work (which can be HARD) or volunteer to give up the CDL. Regulations are what they are, and if the OP is not willing (or cannot) make CPAP work, then he has no other choice but to give up the CDL.



(A) Evidence:
In OT: NYC Train Victims Sue Engineers Dx?, you were quick to condemn the guy's docs for not diagnosing OSA after the fact:

Todzo wrote:So the doctors searched diligently and found obesity, hypothyroidism, high cholesterol, low testosterone, vitamin D and B12 deficiencies, and mild high-frequency hearing loss[1]. Could the engineers last visit to the doctor May of 2013 have been looking for causes of fatigue?!

With his observable large neck size as well as the above mentioned how in the world did they not check for Sleep Apnea?

So why should not the victims of the NYC Train Crash go after the engineer's doctors?

and

Todzo wrote:If he were a truck driver obesity + large neck = Sleep test

and

Todzo wrote:

49er wrote: It does look like the doctor should have referred this guy for a sleep test. But as someone who is quite leery of doctors in general, until all the facts of the case some out, I am not willing to say this person should be sued.

And by the way, if a patient has lost the ability to complain about symptoms for various reasons, that isn't the doctor's fault. Still, one would hope they would raise the issue of sleep apnea in obvious cases like with the engineer. But whether that is cause for a suit is a whole other issue.

49er

49er this is one case where I absolutely positively disagree!!! The fact is that the patient is disabled from knowing. So the doctor must understand this and ask the right questions. Honestly, a sleep questionnaire such as the University of Maryland sleep apnea quiz (see: http://umm.edu/programs/sleep/health/qu ... leep-apnea ) takes less than five minutes. In a clinical setting STOP BANG (see: http://www.sleepapnea.org/assets/files/ ... nnaire.pdf ) can be added for further verification. It is NOT hard. It SHOULD be done!!!

If it had been done most likely the loss of peace, loss of resources, loss of health, indeed loss of life could have been avoided.

If they are sued perhaps the rest of the doctors will finally listen!!!

(B) Evidence:
Also in OT: NYC Train Victims Sue Engineers Dx?, you made the statement:

Todzo wrote:Executive dysfunction with sleep apnea is very real and very observable (although it is intermittent in character).

Self reporting cannot be relied upon, observation is limited so a compromised driver who, for that matter, can be compromised by many causes is likely to slip through.

We really need full time vigilance monitoring on those whose actions so seriously affect our lives!!

and

If your doctor observes "brain fog" they have a responsibility to obtain and check your charts!!!

(C) Evidence:
In multiple posts over the entire time we've both been around this board, you seem to adamant about spreading the word that CPAP simply doesn't work---at least for some people over and over and over. In some posts it even seems as though you believe that PAP therapy cannot work in a certain subset of people with plain old ordinary OSA (i.e. NOT complicated by CompSA issues).

You may intentionally be doing it, but the overall tone of many of your posts gives the impression that you promote a rather dubious idea that in many (most?) people OSA can be improved or corrected by breathing exercises and working with a personal trainer and dietitian for three years. You also may not intend to do it, but many of your posts also leave the impression that you believe that for many people CPAP does more harm than good:
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viewtopic.php?f=1&t=92468&p=903122&#p903122
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I have read many of the external links you keep posting as reasons to back up your beliefs about CPAP. And many of them seem to either be studies that are NOT fully relevant to the case you are trying to make OR they're small studies that do not seem to have been replicated. Either way, I don't think that you've even come close to establishing the scientific validity of many of your ideas.