Dr. George Robinson: To Sleep, Perchance to...Stop Breathing?

Dr. Robinson

The idea of a life in medicine was always sitting quietly in the back of his mind. But as a self-described “nerd” who nevertheless went to West Virginia University on a sports scholarship as an already-injured right-handed first-baseman, George studied accounting (with a minor in chemistry). After graduation, he joined the international accounting firm of Peat, Marwick, and Mitchell where he did auditing and tax work.

Sure, he had plenty of fun outside of the office and made lots of friends. But he said the work itself was just “shifting numbers and balancing books." This was not “terribly exciting” and wasn’t “fulfilling.” Though he admitted that it  “sounds too altruistic,” he really wanted “to make the world better.” 

So he changed direction. After six years of debit and credit, George Robinson, the future pulmonologist, critical care physician, and sleep doctor, went to medical school. He viewed the practice of medicine as his chance to have a positive impact. 

But why, perhaps, did he start with accounting? His father was a manager in a large food business and “ran plants that made stuff,” said George. Because of that, he moved the family around. His parents were living in Ohio when George came along. From Bay Village outside of Cleveland, they moved to Akron, then to Port Huron, Michigan, then to New Jersey, and, eventually to Maryland. 

George’s father, an Ohio State graduate,  wanted his two sons to go to college to be able to work for themselves, not for “the man.” You could do that as a CPA (though George didn’t) and (at least back then) you could do it as a physician. 

George’s mother, a registered dietician, also an Ohio Stater, agreed about college but gave her elder son a slightly different message. A message she carefully pinned to the back of his coat. It read: “Please Don’t Feed My Child!”  

These days, Dr. Robinson shares attending duty in the Covid-ICUs, defined areas within the York Hospital filled with patients struggling to breathe, struggling to survive. 

Sitting in my living room with his wife Diane, and more than six feet from each other, our facial coverings betray the seriousness of the moment. And as we talk, the subtle puffing out and then retracting of George’s mask with each breath suddenly reminds me of those old-fashioned ventilators with accordion bellows I’ve seen on TV. Filling up, and then deflating. Filling up, and then deflating...over and over.

(Some people, it seems, still don’t see that this viral pandemic is a nightmare. Even with December’s jump in the number of new infections daily and the deaths, so far, in early January 2021, more than 360,00 Americans. Deaths often occurring in the strained and lonely Covid wards. Deaths as weary and disheartened doctors and dedicated and overworked nurses practice the best cutting edge medicine available for this new and unpredictable disease. I don’t know what it’s going to take...) 

I asked Dr. Robinson how he was managing “on the front lines.” He quickly replied that “this is what we signed up for.” He likened it to the mid-1980s, early in the frightening AIDS pandemic, when everyone was to practice “universal precautions” to avoid any possible contact with the virus. The fine details of the transmission of the HIV virus were not fully known in the beginning and since there was no treatment there was mortal fear of contagion. 

Diane, a medical librarian, reminded us that patience is needed since understanding a new disease like HIV or Covid-19 takes time and there may be early missteps. (A much younger Dr. Anthony Fauci was already carefully leading the way at the NIH in the ‘80s.) 

To continue the military theme: George enjoys reading American history and he tells his residents on the Covid Service a story about General Eisenhower and the D-Day invasion. About the decision to order young and naive 18- and 19-year-old soldiers to land at the dangerous Utah and Omaha Beaches, a risky task that older soldiers, the “seasoned professionals,” would know to avoid. 

Soldier receiving medical treatment following the 
June 6, 1944, D-Day Invasion (from History.com)

So Dr. Robinson lets his young charges venture in to see the patients first and to report back to him, the wise seasoned professional. The residents (of which, quipped George, there is a “large supply, but only eleven of us” ) usually laugh. They usually laugh. 

But, in fact, he is careful, and said that he “feels safer in the Covid unit than most any other place in the hospital.”  (And by the way, Dr. Robinson made sure to tell me later that he really loves the residents and that teaching them is a joy.)

At this point, I gaze at his tan starched-looking fabric mask again, looking for the creases, the laugh lines, at the corners of his eyes that tell of a smile.  But with our faces half-covered, it’s much harder to read people now, increasing our “distance” from one another beyond the recommended six feet.

As I started writing this story more than a month after our interview, trying to get to know who Dr. Robinson was, I wanted to tell him that things were underway. So I casually sent him a text. He quickly texted back to tell me that his story had changed; he had contracted Covid-19! My heart sank. I anxiously called him. As he answered I could hear his breathing. He said calmly, with that matter-of-fact doctor voice I’ve come to know from my husband, that he had a cough and was fatigued. 

But he was upbeat (that’s George, I guess), and said that he was taking care of patients remotely. No need for time off for the general, for the seasoned warrior. Diane, I learned, was sick, too, with the same symptoms. (Ironically, the first vaccines for Covid-19 would become available in just a few weeks.)    

The Covid-19 ICU is a new twist in critical or intensive care medicine. It is claimed that the world’s first intensive care unit was set up in Copenhagen in 1953, one year after the polio pandemic that hit that city especially hard. There was one, just one, iron lung in the entire city, and adults and children were dying daily of respiratory failure. Dr. Bjørn Ibsen decided to use positive pressure ventilation, instead of the negative pressure of the bulky iron tank, for a young girl seemingly about to die. In six-hour shifts, medical students took turns squeezing the rubber bag attached to her tracheostomy. Twelve-year-old Viv Ebert survived. A new idea was born. 

Tending to Dr. Ibsen's patients (from nature.com)

What about intensive care in the US? A sort-of ICU was created in 1954 at Chestnut Hill Hospital outside of Philadelphia to allow short-staffed nurses to closely watch over a group of their sicker patients. But Dr. Peter Safar in Pittsburgh is given credit for developing the first real ICU in the States in 1958. The first critical care residency was established in 1963, also in Pittsburgh; the first board exam in the new specialty was offered in 1987.

These days, Dr. Robinson, in his role as an experienced pulmonary/critical care practitioner, needs to figure out what to do for his patients with Covid-19 who have trouble breathing. Some need only supportive care without supplemental oxygen, some need low-flow nasal oxygen, some need high-flow nasal oxygen with assisted ventilation, and some need a mechanical ventilator. Some patients, we learned, are periodically flipped from being on their backs to their belly, from supine to prone, to aerate different parts of their lungs (an old technique that is easier on the nurses now, said George since all of the rooms are fitted with cranes).

(An interesting historical tidbit, recounted in a story recently by newspaperman Gordon Freireich: The first-ever report of the use of supplemental oxygen for a patient with pneumonia to be published in a professional journal appeared in 1885. An astute 23-year-old doctor, only a few years out of medical school, wanted to make other “country practitioners” aware of the treatment. The patient, 16-year-old Frederick Gable, survived. The physician, Dr. George Holtzapple, of Loganville, was a staff member at the York Hospital.)   

Painting of Dr. Holtzapple delivering oxygen to Frederick
on March 6, 1885, and a plaque marking the event
(from the "York Daily Record")

In addition to the life-threatening respiratory problems, Covid patients may develop acute cardiac complications, kidney failure, liver damage, blood clotting abnormalities, and neurologic impairment with agitation, delirium, or strokes. Teamwork is required to support the patient until the body heals itself, and Dr. Robinson guides his squad steadily (and, when needed, especially now, with a dose of wry humor).  

(Another image popped into my head. As we were first learning about the spread of the novel coronavirus we were shown how showers of tiny droplets were sprayed into the air as we coughed or talked without a face covering. This reminded me of the Jewish folktale about the danger of malicious gossip: It is as impossible to repair the damage done by harsh words or outright lies as it is to put the feathers back in a pillow once they have been released and scattered to the wind. So the virus, once dispersed, cannot be recalled, cannot be gathered up and stuffed back into the "pillow.") 

Spread of aerosols and droplets on coughing or exhaling
(from ScienceDirect)

But let’s take a break from Covid and go back to tracing George’s career path. After his bleary accounting days, admitted fiscal conservative that he is, he looked around for an affordable (very affordable) medical school and decided to apply to the West Virginia program. It was a good choice. 

  Dr. Ferimer

You see, it was there that he met Diane. She was on the faculty as one of the librarians. Though it wasn’t kosher for faculty members to date students, George's cadaver-mate, Howard Ferimer (now a pediatric critical care physician in Pittsburgh), chose to play matchmaker anyway. It took some, but not much, maneuvering and they were “sort of together” said Diane, through medical school.

As George did rotations he carefully considered the different specialties. He thought about orthopedics, but he discovered one day in the OR that he was allergic to the cement used to anchor the prosthetic parts. He thought about cardiology, but he didn’t want to “stand around all day doing caths.” He thought about ophthalmology (like his uncle) but the “Number one or number two?” stuff turned him off. He even thought about neurology. 

His decision was finally influenced by infectious disease specialist Dr. Robert D'Alessandri at WVU who, besides being an expert clinician, showed the student that “attendings actually had a sense of humor.” So George realized that he enjoyed internal medicine, and since he wanted “to do things,” he was drawn to the brand new field of critical care. 

The University of West Virginia Medical School (from UWV)

When Dr. Robinson graduated from medical school in 1987 at the age of 32 to start an internal medicine residency he wanted to move closer to his parents in Severna Park. He looked at programs at Hopkins and the University of Maryland but wasn’t happy with either one. One night in the WVU ER someone told George of a doctor who “had a great time” at the York Hospital (it was Dr. Chris Due). He decided to take a look, and Dr. Robinson told me that “the rest is history.”

Dr. Zwillich

So, George moved to Pennsylvania and brought Diane along later; while she worked in the hospital library, he did his residency and a year as Chief Resident.  After the enjoyable four years at York, he did a three-year pulmonary and critical care fellowship at Penn State Hershey. Dr. Clifford Zwillich ran the program where they saw many patients with sleep-disordered breathing problems. Dr. Robinson said that it was while he was there he “found out” he “liked sleep medicine more than anything else.” 

In fact, his personal goal, his vision, over the past 25 years in York has been to build a strong sleep program for Central Pennsylvania. He’s been inching towards that, despite a few temporary administrative setbacks.  Even as he (as someone who knows about accounting) carefully explained to those who made such business decisions how just a few more sleep-lab beds would provide them with a nice “return on investment.”

So, as we sat together we spent a lot of time talking about George’s real passion, sleep. And why we often don’t get enough. And what happens next. 

All life, it turns out, has a built-in roughly 24-hour metabolic cycle, a circadian (“about a day”) rhythm. This clock keeps us synchronized, in tune, with nature and with each other. Failing to abide by the schedule causes problems. Dr. Robinson said, for example, that disrupting this rhythm in the spring for only one hour as we switch to Daylight Saving Time and get an hour less sleep results in more car accidents, more heart attacks, more strokes, and more medical errors over the next week as we adjust. We should probably stick to Standard time, he noted. 

NEJM: Canadian study of auto accidents 
after time changes (from Vox.com)

The shifting of the cycle, whether we wake up ready to go, like young grade-schoolers, or tend to stay up late and sleep late, like most teens, for example, should be considered as school start-times are set. 

Light, sunlight, especially blue light, is the strongest natural modifier of the cycle that slowly adjusts as the length of the daylight varies through the year. Exposure to light early in the day encourages wakefulness and energy. And the gradual dimming of light toward evening is the signal for us to stop and rest, and to sleep (and to dream). 

Speaking of dreaming, narrative dreams, where there is a story, occur in the REM, or rapid eye movement, stage of sleep. This is the time when the brain waves recorded on the EEG look like waking but most of the body is essentially paralyzed, preventing us from moving. 

This stage of sleep was first identified by Eugene Aserinsky (1921-1998) in 1953 while working with the founder of sleep medicine, Dr.  Nathaniel Kleitman (1895-1999), his thesis advisor. Gene performed the first all-night recording of ocular movements and EEG activity (now standard in sleep labs). This showed that sleep was an active state, not passive, as had been assumed. (The subject of the historic recording was Aserinsky’s eight-year-old son and the paper tracing was nearly a mile long!)

EEG patterns of waking and stages of sleep: 
compare waking with REM sleep.
(from Semantic Scholar)

But how does sleep itself come about? Melatonin, the sleep hormone, produced in the pineal gland deep in the brain, is geared to be released toward evening, preparing us for restful and peaceful slumber. Seems fine. But bright light late in the day, thanks to Thomas Edison and his bulb, messes things up. 

So we stay up late doing things, watching TV, or simply gazing mindlessly at our phones. And when we need to wake up early for work or for school we haven’t gotten the required seven to eight hours of sleep (needed for adults). We are tired. We yawn. We lose focus. We are irritable. We make mistakes. We should have turned down the lights earlier, but we just have too much to do. 

Sometimes, even though we go to bed early enough, fall asleep quickly, and spend eight hours apparently asleep (and our phones assure us that we slept) we are still sleep-deprived. We have a sleep debt and we are tired during the day, not fully awake. The most common cause of this, said Dr. Robinson, is the serious and increasingly recognized problem of obstructive sleep apnea (or OSA). This makes up the bulk of his sleep practice. 

What causes OSA, I asked? Here goes. Muscle tone decreases as one falls into light sleep. If the upper airway is already narrowed by enlarged tonsils, fat deposits, a large tongue, or other anatomical features, including the general (sadly) sagging of tissues with age, the partial collapse of the sidewalls of the throat that occurs during light sleep can block the flow of air. 

Partial blockage produces snoring. When complete blockage occurs breathing stops, snoring stops, and the blood oxygen level gradually falls. As a result, the brain, though busy with its sleep stuff, arouses itself to correct the problem. And the sudden reopening of the airway by expelled air is often accompanied by a loud snorting noise (often awakening the sleep partner). This cycle repeats through the night, maybe hundreds of times. Deep restorative sleep doesn’t happen. Chronic daytime tiredness results as sleep debt increases and sudden brief sleeps without warning may occur.

Where obstruction typically occurs

Yet simple tiredness, said George, is not all that happens. Not by far. Individuals with OSA have an increased risk of developing high blood pressure, diabetes, obesity, heart disease with dangerous rhythm disturbances, heart attacks or heart failure, cognitive impairment, and strokes.

It is estimated that more than 70% of individuals with OSA are obese. So, as obesity (especially central obesity) is the major cause of the pandemic of diabetes it also fuels the pandemic of sleep apnea. A vicious cycle.  

Obstructive sleep apnea said George, also greatly increases the chance of complications of surgery and anesthesia and he and his colleagues have started a program to screen patients for OSA before surgery. And since it may negatively affect the unborn fetus as oxygen levels fall in the second trimester of pregnancy he wants to identify women at risk before that happens. 

In addition, Dr. Robinson hopes to work closely with the trucking industry since falling asleep at the wheel is costly (trucks are expensive, he noted) and nearly 30% of truckers may have sleep apnea.

How is OSA treated? When it was first identified in 1965 (in Germany) it was treated with a tracheostomy to bypass the obstruction. The continuous positive airway pressure or nasal CPAP device to hold, or to stent, the upper airway, to keep it open, was devised in 1981 by Australian Colin Sullivan, said Dr. Robinson. CPAP is still the most effective treatment...but only if people use it regularly. Fitting the right mask for a patient is an imperfect art, and George believes it will be easier with new custom-made designs. Weight loss is also important if the patient is overweight and it may become easier to lose pounds as sleep improves; a virtuous cycle.

Dr. Robinson also sees individuals with other sleep issues, too. For example, he sees those with REM-sleep behavioral disorder. In this, the normal inhibition of voluntary muscle activity during REM doesn’t occur; people act out their dreams and may become violent. Fortunately, it responds well to medication. Curiously, it is sometimes a very early symptom of Parkinson’s disease. He sees other so-called parasomnias such as sleep-walking or night terrors, and there are circadian rhythm disorders. 

Narcolepsy was the first recognized sleep disorder. It is uncommon, but dramatic, with abrupt sleep attacks, sudden collapses or near-collapses due to loss of muscle tone, vivid waking dreams, and frightening episodes of momentary immobility upon awakening. The orderly sleep system, so-called sleep architecture, is disrupted as REM-sleep and waking occur at the same time. (II guess that is sort of like when I feel half-asleep.) 

Narcolepsy is probably an autoimmune disease due to damage to a small group of cells at the base of the brain that releases the wakefulness hormone hypocretin/orexin. Stimulants help the sleepiness and antidepressants can alleviate the embarrassing collapses, the cataplexy. 

Hypocretin modulates alertness through
dopamine, serotonin, histamine, etc. 
(from ResearchGate.net) 

Restless legs syndrome (RLS), a surprisingly common condition, was first described in 1685 but was“overlooked” until 1945 when Swedish neurologist Karl Ekbom wrote about it. RLS interferes with falling asleep (the legs are oddly uncomfortable and there is the urge to move them) and staying asleep (due to involuntary kicking of legs). It has genetic features and evidence of brain pathology regarding dopamine and can be mostly alleviated with medicines. Some sufferers have an iron deficiency.

I asked him about insomnia. He implied that he leaves that thorny problem and the emotional aspects of perceived sleeplessness and true insomnia mostly to the mental health team. He said, however, that cognitive-behavioral therapy (CBTi) is often useful. He was doubtful about CBD: “Show me the data,” he said. 

So, Dr. Robinson, as a pulmonary physician, noted that chronic lung disease or COPD is difficult to treat since it doesn’t improve over time. Sleep disorders, on the other hand, generally respond well to therapy. He said that he likes to help people get better and that his sleep work is very rewarding.

And as we were wrapping things up and George was talking about his outside interests, including travel with friends, Diane mentioned their special trip to Cuba.  She recalled the exquisite taste of the fish, freshly caught from the sea and then simply grilled and immediately brought to their table. For a moment they both seemed to be somewhere else; they were suddenly more relaxed, more at ease. George stretched out his long legs and Diane’s arms waved about as she spoke. I could see the smile creases at the corners of their eyes. It was an unexpected blissful remembrance of a before-Covid experience. 

George cruising in Havana, Cuba

I watched and listened. And waited for them to return to our new reality, yet looking forward to life after-Covid, when the Covid ICUs will be dark and empty and a dedicated sleep center will be up and running. When we will be able to sleep soundly again and drift into REM sleep and have pleasant dreams.

(George and Diane, you’ll be glad to know, while still easily-fatigued a few weeks after their Covid infection, are improving daily. George is back in the hospital where there are now four ICUs for Covid patients.)

References and recommended readings:

1. Aserinsky, Eugene and Kleitman, Nathaniel. "Regularly occurring periods of eye motility, and concomitant phenomena, during sleep." Science, 1953, 118, 3062, p.273-274. (A turning point in the history of sleep medicine.)

2. Dement, William C., M.D., Ph.D., and Vaughn, Christopher. The Promise of Sleep; A Pioneer in Sleep Medicine Explores the Vital Connection Between Health, Happiness, and a Good Night's Sleep. Delacorte Press, Random House. New York, 1999. (Somewhat dated, but worth reading.)

3. Freireich, Gordon. "York and the history of oxygen in medicine." York Daily Record, February 2, 2020. (Clarifying the story.)

4. Hamblin, James. The Mysterious Link Between Covid-19 and sleep. The Atlantic. December 21, 2020. (He says that "The coronavirus can cause insomnia and long-term changes in our nervous systems," and speculates that "sleep could also be a key to ending the pandemic.")

5. Jung R, Kuhlo W. Neurophysiological Studies of Abnormal Night Sleep and the Pickwickian Syndrome. Prog Brain Res. 1965;18:140–59. (First description of obstructive sleep apnea.)

6. Leschziner, Guy. The Nocturnal Brain: Nightmares, Neuroscience, and the Secret World of Sleep. St. Martin's Press. New York, 2019. (An enjoyable up-to-date read.)

Canada geese flying across the
York Heritage Rail-Trail (SC)

By Anita Cherry 1/3/21