Dr. Carlos Roberts says: "I Am I Because You Are You"

 

Carlos Roberts, M.D.

“It’s okay, I’m right here. You are going to be doing this delivery,” said the midwife to the third-year medical student as she calmly reassured him. The student was on-call on the first day of his first clinical rotation. He was “happy to be there,” sure. But, at the time, he had “zero interest” in obstetrics. He listened to the expert, however, and with steady coaching he performed the delivery. As he saw “a human” emerging from the mother’s body, as he saw “life born of life,” at that moment, Carlos Roberts knew what he was going to do as a doctor.

On a cold day in mid-February, the expected winter storm stayed to the south of York and Dr. Carlos Roberts stopped by as promised to tell me his winding story. Carlos is from Trinidad and Tobago, a warm Caribbean two-island nation just off the coast of Venezuela, part of the West Indies. He traces his lineage to the East Indies, to India, along with about forty percent of the population of Trinidad. 

How was that? The island, claimed by the Spanish, was sparsely populated into the late 18th century. In 1777 Spain lured French planters from nearby islands to immigrate to Trinidad, and to bring their African slaves (mostly men)  with them. In 1797 Spain surrendered to the British (without a fight) and Trinidad became a British crown colony. The population then consisted of about 2,000 white individuals, 4,500 free people of color, 1,000 Amerindians, and 10,000 African slaves.

Map of the West Indies, with Trinidad the southernmost
 and considered part of South America (from nationsonline.org)

When the British abolished slavery in 1833, the slave owners were deprived of their major workforce and there was a need to find cheap labor to harvest the sugarcane, a back-breaking task. The solution was to coax individuals from India to be employed for a specified period of time (at least five years) and for low wages as indentured servants. 

They were promised that after the end of their tenure, they could receive return passage to India or they would be granted a small piece of land. The long journey from India was dangerous, the work conditions on the island were harsh, and the illness and death rates were high.  

Carlos said that his paternal great-great-grandparents were persuaded to be shipped to Trinidad from India under the indentured servant program. After their years of required service were completed they chose the offer of land, and they raised a very large family.  

While Carlos knew that his father’s background was fully East Indian, his mother’s story was “a little bit unknown.” That is, until recently. By testing his own DNA, he found that his mother’s line is British, Irish, Scottish from her white mother, and Nigerian plus other African countries, from her not-white father. So Dr. Roberts is half-East Indian and half-other. He is, as he said, “mixed.” .

His father’s mother was traditional and did not approve of her son marrying a non-Indian. His father’s father, on the other hand, was welcoming.  Carlos told me that his Indian paternal grandmother “never once in her entire life,” never once, called him by his name; she always called him “Boy.“ You see, unlike his two sisters and his brother, he looked “different.”  There was awareness of "other."

But there was an unusual twist to the racial hierarchy in Trinidad. Because the (white) British (on top) feared an uprising of the much more numerous (black) African slaves (on the bottom) after their emancipation, the (brown) Indian indentured workers (placed in the middle) were automatically installed as officers of the law to help maintain the order, to prevent an uprising by those below. A defined order was set by color: white, brown, black. There a racial ordering.

Ethnic Makeup of Trinidad and Tobago
(from Encyclopedia Britanica)

Considering race and caste: In his study of capitalism and slavery, the economics of the island plantations, Eric Williams, noted historian and the first Prime Minister of Trinidad and Tobago, concluded that racism was a consequence of slavery. He saw that "white servitude was the historic base upon which Negro slavery was constructed...(as) unfree labor in the new world was [at various times] brown, white, black, and yellow; Catholic, Protestant, and pagan.” In Tobago before 1833, (as in the American colonies from 1619 until 1865) “the money which procured a white man’s services for ten years could buy a Negro for life” (Willams, p.19); cheaply-purchased slaves from Africa made good economic sense. But the human cost was enormous.

Let's get back to our story. The “mixed” Roberts family lived in Port-of-Spain and they were of “humble means,” said Carlos. His father, like many in the large extended Indian family, was a civil servant, a city hall clerk. He was “a stickler for education.” Success was “becoming a professional,” a doctor, an attorney, or an engineer. The younger of his two sisters, an engineer, was the first in the family to get a college degree. His other sister studied accounting. Carlos was the first to become a physician.

Once he decided that he wanted to be a doctor, the next question was: “How do I do that?”

Besides being a good student with a true photographic memory, he was a talented sportsman. In fact, he represented Trinidad and Tobago in field hockey at the Central American and Caribbean Games. The strong team won a silver medal at the 1993 games in Ponce, losing to powerhouse Cuba in the finals.  Maybe, he thought, maybe he could parlay his athletic skills (he excelled in soccer, too) into a ticket to college in the States, and then on to medical school.

1993 CAC Games men's field hockey results (from Tudor Krastev)

So he was excited when he was offered a scholarship to Bloomsburg University. Tuition was covered, but room and board were not. His father said he couldn’t afford that, and young Carlos reluctantly gave up that opportunity. 

So he stayed in Trinidad after high school and worked in a public library and at the Carib Brewery, biding his time. It was “a challenge to get a visa” to come to the States. He took advantage of the chance to travel as a member of the national hockey team for a tournament at Drew University in Madison, New Jersey.   

While here on the visa in 1995 he stayed with his uncle in Brooklyn, home to many immigrants from T and T. So Carlos called around to the schools that had offered him scholarships before. He took winding bus rides to Bloomsburg (the bus caught on fire on the return trip to New York) and West Chester, both in Pennsylvania. And he looked at St. Francis and St. John's in New York. He was accepted to St. John’s on a soccer scholarship after a trial as a walk-on, but he could go only if he could pay his own way for the first year. Of course, he could not. Another disheartening setback.

Friendly Nostrand Avenue restaurant in Trinidadian Brooklyn
(from Museum of Food and Drink)

But he was not about to give up, no, he would not return to Trinidad and Tobago; he would make it work “somehow.”

He needed to stay in the States. His uncle’s wife was “a wonderful lady” who taught at Hunter College. Her mother had advanced ovarian carcinoma and Carlos helped take care of her. As an essential caregiver, he was allowed to extend his visa.  He did odd jobs and worked as a laborer for a few years swinging a heavy sledgehammer and knocking stuff down. And he waited. 

Things began to look up after he started working as an assistant to the owner of a small New York real estate company. And as he made enough money for college he could enroll at St. Francis in Brooklyn Heights. His boss recognized his potential and offered to pay his tuition if he worked full-time. So Carlos got up early, took classes until noon, studied on the train, and did real estate until nine or ten at night. 

He was on track and sailing along when he got a surprise call from the soccer coach at historically-black Lincoln University in Missouri. A team member had recommended him to the coach.  On this sole recommendation, Carlos was offered a scholarship; no try-out needed. But he was now comfortable in New York; what should he do?

He told his Trinidadian girlfriend, Kesha Baptiste (now his wife), of his dilemma and she felt that he needed to get out of New York.

Kesha

How did Carlos end up with such a “brilliant” girlfriend? He said that he and Kesha met once at home on the island, but they “didn’t click,” and nothing happened. Then one day in New York after a messy soccer session his buddy said he wanted to visit a friend. Carlos, all muddy, drove the company truck to this friend’s house. They knocked on the door, and Kesha (who was studying at Juniata and was visiting her mother) answered. Well, wouldn’t you know, Carlos was immediately attracted to her, and she was attracted to him. 

The visitors stood at the door a while, then left, at which point the smitten one simply told his pal that the girl in the doorway was going to be his wife. His unbelieving friend said, ”You don’t have a chance in hell.” But Dr. Roberts knew better. He had already seen the image of her face in his mind’s eye one day when he was sensing that it was time to get married.

Kenny Sattuar

So Kesha, the wise girlfriend, encouraged Carlos to make his next career move. Hearing this, his real estate mentor in Rosedale, Kenny Sattaur, was disappointed. He had seen potential; Carlos was a “hard worker,” and might be “the next real estate mogul.”  But the idea of being a physician had always been the young man’s “passion“ and he needed to move on. 

What did Mr. Sattaur do then? He decided to celebrate! He took Carlos and Kesha to Ruth Chris’s on Long Island, where Dr. Roberts had his first-ever steak. And then (wait for this...), Kenny then said he would continue to pay Carlos his weekly wage for the next year as he went to Lincoln to finish his college degree.

So, Carlos moved on. He studied hard and played soccer in Jefferson County, Missouri. It was “a very interesting place,” he said, with some irony. During the last game of his first season, he tore his ACL and needed surgery. He did quite well in his studies and qualified for an academic scholarship. He took this and gave up his athletic ride so the coach could build the program by recruiting another good player; someone else could be given a chance.  

Carlos recovered from surgery and continued with the team. One day they played against Missouri University in Rolla. To say it kindly, the small (and 87%-white) town between Springfield and St. Louis was not very progressive.  The home team was all white, as were their vocal supporters. During a throw-in, he heard a spectator shout, “Why don’t you go back to the cotton fields and pick cotton?”

He did not get upset with the players on the field or the crowd, but it suddenly occurred to him that his mother had been making a derogatory comment as she would say to him: “You need to shut your cotton-pickin’ mouth.”

Carlos had never experienced overt racism before; connecting it in his mind with what his mother said hurt terribly.

He felt overt racism again in a match in Kentucky. The Lincoln goal-keeper, Dustin Carney, was upended by an opposing player. No red or yellow card was thrown. Carlos, as the captain of the team, approached the official and asked why this obvious infraction wasn’t carded. The official looked away and spat on the ground. A melee of sorts ensued and the game was called. The naked complicity of those charged with ensuring fairness on the pitch, keeping a level playing field, was too much for Carlos to bear. Institutional racism.

Mara Aruguete, PhD

Despite the few racially charged incidents, he said he got “a tremendous education” in Missouri.  His research mentor was psychology professor Dr. Mara Aruguete. She took him under her wing and they published several papers together on the effect (or non-effect) of race on the patient-physician encounter. She helped him get into medical school and they still stay in touch.

The acceptance to medical school, the hoped-for letter, the letter saying, “We are pleased…” is anxiously awaited by all eager applicants, and Carlos Anthony Roberts was no exception. His dream was to go to historically-black Howard University, the alma mater of the previously-mentioned Eric Williams. Yes, going to Howard would be nice.

So he applied to several schools and waited. He was happy enough when he received the acceptance from Lake Erie Osteopathic Medical School. But he heard nothing from Howard, his first choice. As he was waiting he had to send LECOM fifteen hundred dollars to hold his spot in the class. Carlos didn’t have fifteen hundred dollars. He went to Dr. Aruguete; he needed advice from his advisor.

Her immediate answer: “I’ll write you a check now. You don’t have to pay me back.”  With gratitude, Carlos immediately went to the bank, deposited the gifted check, wrote his own and mailed it to Erie, and headed home. When went through his mail (you guessed it) the acceptance from Howard was sitting there. He put a stop to the mailed-in check and returned the money to Dr. Aruguete.

Unbeknownst to our protagonist, Kesha, who, like Carlos, was in the States on a temporary student visa, had quietly entered the Green Card lottery. She received notice that she was one of the winners the day after Carlos got his news from Howard. Timing. (Of those who apply each year, less than 1% receive a card.)

Borat's Permanent Resident Green Card

While this medical school application-stuff was going on in Jefferson City, Missouri, Kesha was studying for her Master’s in public health in St. Louis. She traveled back and forth on weekends. When they decided that it was time to get married Carlos feared that his “traditional” mother might discourage him, so he chose not to tell his parents of his intent. 

So, in 1998 they had a small wedding on campus. They bought a cake and boxed wine from Walmart, her mother’s friend made Kesha’s dress, Kesha’s mother cooked the food, Carlos rented a Tuxedo for a day, and his roommate and co-captain of the soccer team made the VHS video (complete with unwitting commentary). In attendance were his older sister’s son and a cousin from Trinidad whom he had bumped into while at St. Francis.“It was an amazing day,” said Dr. Roberts.

After Lincoln University in Missouri, he went to Howard in D.C. where he “met a lot of great people,” including the steady midwife who helped him with his first delivery at Prince George’s Hospital. As he considered a specific course in medicine, he thought about going into orthopedics because of his sports background. But after he nodded off, actually fell asleep, during one of the operations with hammers and saws, a hip replacement, he let that idea go. Dr. Roberts said he preferred more intricate and complex surgery, and his experience during his first rotation guided him to obstetrics and gynecology.

Founders Library at Howard University in the spring
(from Howard University)

After D.C., he returned to Missouri to start his OB/GYN internship and residency at St. Louis University. He thought he could be with his wife; she finished her MPH and they both liked the city. However, Kesha was not done. She followed her own path and she was, by then, at Johns Hopkins in Baltimore working on a Ph.D. in cardiovascular epidemiology. 

While 800 miles apart, they wanted to start having kids.  So when Kesha called him one Thursday night during his internship to announce that she was ovulating, Carlos went into action.  

The National Pike in 1850: From Baltimore to St. Louis (by 1838)
The first national road and the most heavily traveled road
in America at the time (from heraldstandard.com)

He rearranged his call schedule so he didn’t have to be back until Sunday and rushed to book the cheapest flight possible on Friday evening to BWI. He used Priceline.com. He and Kesha spent the weekend together and their first child was conceived, with a little help from William Shatner, alias Captain Kirk (help for the flight, that is, not the conception).

(There is good evidence that women are most fertile the five days before ovulation since it takes a while for the sperm to find the egg. Maybe some men have more athletic spermatozoa, more determined swimmers. Who knows?)

Anyway, when his wife was then offered a post-doc fellowship at Hopkins she wanted to take the opportunity, but not with her husband back in St Louis; he would gladly make the effort to move closer to her program.

A friend from Howard, Tommy Kimble, was doing his OB/GYN residency at York and told Carlos that he was in luck: there was an unexpected open slot for a second-year OB/GYN resident for the upcoming year.  

Speaking of “luck,” of which Dr. Roberts seems by now to have had an unusual abundance, he feels that this is mostly “opportunity and preparedness meeting in the same space.” It is what you do with what has been given, with what has been presented.

Getting back to the meandering story: Dr. Mary McClennan, one of the faculty in St. Louis, was friends with Dr. Marian Damewood, the head of the program in York, and they spoke. Carlos had already interviewed at York and he was readily accepted as a second-year resident.

After a night on call, he drove to Southcentral Pennsylvania the next day to start the year. He and his wife bought a house in downtown York and they lived there through his residency. 

When Kesha’s water broke early one morning and she went into labor she turned to awaken her husband. He was scheduled to be on call that day; he had hoped to do the delivery, but he had to work. Yet, he might still be able to help bring his daughter into the world. But as his wife’s labor progressed there were signs of trouble. The baby’s heart rate slowed. The father’s heart rate quickened. And the more experienced Dr. Kathryn Hassinger did the complicated vacuum and forceps delivery. Their second daughter, born in 2008, had an easier time of it; she was an elective C-section baby.

Leonardo da Vinci's 1511 "first in history" 
accurate depiction of the fetus in the womb

(We see, of course, that giving birth, bringing someone into the world, is not easy. We see that women need help. That assistance is required for the survival of the species. According to Karen Rosenberg and Wenda Trevathan, “the complex twists and turns that human babies make as they travel through the birth canal have troubled humans and their ancestors for at least 100,000 years” and maybe for as long as “three or four million.” The problem stems from our upright stance, with a change in the shape of the pelvis, our big-brained heads, and the “limited motor abilities of the relatively helpless human infant.”)

After his residency Carlos wanted to do a fellowship in gynecologic oncology, a decision influenced by having cared for his aunt’s mother with ovarian cancer. So he spent an intense month at Memorial Sloan Kettering (MSK) on the Gyn service. He never got more than four hours of sleep, but it was, he said, “the most exhilarating experience.” 

Though he “didn’t enjoy end-of-life care,” he applied to MSK and Hopkins for three or four years of oncology training. These top programs were extremely competitive and Carlos was not offered a position. He was disappointed, but his residency prepared him to be a generalist, and that was “okay.” 

So he went to several of the talented mentors of his residency, Drs. Detlef Gerlach, Dennis Johnson, and Jay Jackson, and offered them his services. They didn’t have a ready-made spot for him but eventually made it work, and Dr. Roberts practiced general women’s health care for five years.  As he saw women suffering from urinary dysfunction associated with other pelvic problems, and found that he could change their lives, he decided to train further. 

Dr. Vincent Lucente

So he did a formative year-long fellowship in urogynecology with Dr. Vincent Lucente at St. Luke’s University Hospital in Allentown, a pioneer in minimally-invasive surgery for urinary and fecal incontinence due to pelvic floor disorders. 

When Dr. Roberts returned to York, he took over the urogynecology practice of Dr. Leslie Robinson.  He said that he “loves” being in the operating room (like all good surgeons) and helping women “get their lives back” as they are no longer hampered by embarrassing incontinence and related problems.

One of the most disabling of these conditions is that of a fistula, a connection, a tract, an opening, between the bladder and the vagina resulting in continuous leakage of urine. In the past, it was caused by so-called obstructed labor due to pressure of the baby’s too-big head against the bladder. It is now most often an accidental complication of surgery.       

A bit of gynecologic surgical history is needed: In 1852, American surgeon James Marion Sims (1813-1883), of Montgomery, Alabama, reported on his surgery for transvaginal fistula repair in three blacks slaves, Anarcha, Betsy, and Lucy. The slave owners lent (yes, lent) him the three young women for the period of treatment. They were kept in a shack behind his house and he subjected them to a total of 42 painful surgical procedures, all without the benefit of anesthesia, over the next four years. Only Anarcha's surgery was successful (and after 30 tries). Sims is known as the founder of urinary fistula surgery and the father of modern American gynecology. A 14-foot statue of him stood in Central Park from the 1890s until it was removed in 2018.

Painting by Robert Thom for the Parke-Davis
"Great Moments in Medicine" series
(Anarcha is kneeling on the table)

Urogynecologic specialists now use a variety of non-operative and minimally-invasive or robotic-assisted approaches to alleviate this devastating condition with much less trauma. (While it is relatively rare here now, it remains a major health issue in developing countries, mostly in sub-Saharan Africa.)  

Dr. Roberts said that the care for a woman with incontinence, and, in fact, of a woman through her reproductive life, and as her daughters have children, is no longer provided by a single person. He said that this now is “compartmentalized” and that there are “many more people touching that individual than in the past.” 

There are positive aspects to specialization, sure, but he is concerned that as care is fragmented we “may lose some of the doctor-patient relationship.”

He sees this relationship as a tricky one in our consumer-driven health care system. Old-fashioned paternalism is frowned upon, of course. But true shared decision-making, he thought, the collaboration between the doctor and the patient, could be likened to, perhaps, “paternalism with more information.”   

And Carlos hopes to be able to be good enough to adequately train the physicians who will someday care for his wife and two daughters. And to pass that goal on to the following generation of doctors, and so on. He said that “when you’ve been helped so much in your life you have to pay it forward.” He fears that if this doesn’t happen, medicine as we know it “will die on the vine, and that will be a miserable death.”

This sentiment led Dr. Roberts to read me something he wrote about his personal journey. He titled it “I am I Because You are You” and sent it to several of his mentors. Standing in front of a mirror looking at himself he saw his evolution as a physician. He saw himself at different ages. But as he felt the passage of time and stared at his reflection in “the mirror of life” for a while he no longer saw his ancestral biological lineage. Instead, he saw “the tapestry that has been carefully woven by those that have taken the time to inculcate the best parts of themselves” in him. He thanked them for their “munificence,” for their generosity.

These thoughts echo the South African social philosophy of Ubuntu: "I am because you are." Or as formulated in the Zulu saying: "A person is a person through other people." In our relationships with others, through intimate I-Thou dialogues, we create each other.

Dr. Detlef Gerlach

And Carlos still stays in contact with many who helped create him along the way. For example, he receives a Christmas card complete with cramped hand-written scribbles from Dr. Aruguete each year as she keeps him abreast of things in St. Louis. And after he gave up soccer a few years ago Dr. Gerlach (he’s now retired) got him “hooked” on cycling and took him to get his first bike, introducing him to the incredulous shop owner as his “son.”

Dr. Roberts encourages his daughters, like every good father does, to think critically, to read widely, and to “seek out and validate information” for themselves. (I am certain their professor-mother encourages nothing less.)

So, looking ahead, I imagine a recurring scene: Dr. Carlos Roberts quietly standing off to the side of an expectant mother in labor as he coaches a nervous student on the first day of her OB rotation: “It’s okay, I’m right here. You are going to be doing this delivery.” 

References and Further Reading:

1. Anon. Indentured Labour from South Asia (1834-1917) https://www.striking-women.org/module/map-major-south-asian-migration-flows/indentured-labour-south-asia-1834-1917.  

2. Reverby, Susan M. "Memory and Medicine: A Historian's Perspective on Commemorating J. Marion Sims." AHA Today, American Historical Association Sept. 17, 2007. (Ideas of what is acceptable, what is ethical, in medical research, in how people are to be treated, evolves.)

3. Rosenberg, Karen and Trevathan, Wenda. "Birth, obstetrics and human evolution." BJOG 2002 Nov; 109(11): 1199-1206. (Midwifery may be the very oldest "medical" profession.) 

 

4. Wilkerson, Isabel. Caste: The Origins of Our Discontents. Random House. New York, 2020. (A well-told, far-ranging, and painful story about the lasting consequences of systemic dehumanization of the "other" in India, Nazi Germany, and the United States.)  

5. Williams, Eric. Capitalism and Slavery. University of North Carolina Press. Chapel Hill, 1944.

6. Eze, Michael Onyebuchi."I am Because You Are: Cosmopolitanism in the Age of Xenophobia." Philosophical Papers, 46:1, 85-109, 2017. (A discussion of the philosophy of African humanism that stresses the importance of community, of "fellowship.") 

Male Red-winged Blackbird at Lake Williams (Spring 2021) (SC)

By Anita Cherry 4/25/21

Dr. Dominic Glorioso Shares his Life, and his Thoughts on Palliative Care

Dr. Dominic Glorioso

"The end of life." A difficult sentence for me to write, and to think about. Wondering what stranger will be there to greet me when events threaten my intactness is hard to imagine. And who will be there for the next shift. No-one knows me; how could they?

Yet, as we approach death we want others, even total strangers, to know our story. We want them to know that we mattered, to know that our one unique life meant something.

And we want them to know the long version. The version that only we can tell. We need a witness to hear the story filled with words, and with commas, semicolons, ellipses, and periods. And the one with blank, wordless spaces. The slivers of empty space that help tell the full story. 

In these quiet private wordless spaces, the life of a human being and its meaning is created. You see, we need, in the end, before it’s all over, to be known as who we actually were, not just who others thought we were. But maybe, just maybe, we won’t be surrounded by strangers in a cold hospital room. And maybe our suffering will be softened.

The deeply emotional and complicated end-of-life issues are particularly relevant for physicians who specialize in hospice work and so-called palliative care. Dr. Dominic Glorioso is one of those physicians who chose this path (or did it, as we will see later, choose him?). I asked him to tell me his story.

His first Internal Medicine job after medical school and residency was in Pensacola, Florida, as he accompanied his wife Dr. Barbara Caton for her Navy posting. His second job, fulfilling his three-year Public Health obligation, was in Paterson, New Jersey. He started there in 1989. He said that “there was a lot of HIV” as the pandemic was developing. He worked mostly with a poor inner-city population and almost all of those with HIV/AIDS were IV drug users. Sadly, he reminded me, “HIV was a death sentence.”

The well-known AIDS quilt memorializes those who have died over the years due to the HIV virus. With morethan 48,000 panels, is felt to be the largest community art project in history.

The massive AIDS Memorial Quilt displayed in D.C.
 (from NIH/Wikipedia)

The well-regarded infectious disease specialist at St. Joseph’s Hospital was Sister (Dr.) Mary Christine Reyelt (1946-2008), a Catholic Sister of Charity. She needed help and she asked Dr. Glorioso to assist her in the care of her terminally-ill patients who were suffering. Suffering due to unremitting pain, severe depression (with social stigma and isolation), striking weight loss, and abject fear.   

At that time “everything (for pain) was Demerol and Vistaril IM,” said Dominic. There was very little written about how to control pain in patients who were opiate abusers, so he had to teach himself symptom control in this trying setting. And he realized that he had to be better at communication to be able to help his patients effectively.

After his three-year public health obligation was met he could leave. But he signed up for more, and he spent a total of eight years in Paterson and (for a short while) nearby  Denville. Dr. Glorioso told me that it was at St. Clare’s Hospital in Denville that Karen Ann Quinlan, the young girl in a persistent vegetative state, with no hope of recovery, had first received care. Her sad case resulted in a landmark 1976 New Jersey Supreme Court decision that, in part, triggered the "right to die" movement and led to the formation of ethics committees in hospitals around the world.

Sure, the work in New Jersey was intense but “it was fun, in a sense,” he said. And he learned a lot. When he was leaving Paterson he told Sister Reyelt that he would miss taking care of AIDS patients. She quietly assured him that there will always be patients in need. Thus, the seed of his future work in palliative care was planted.

Paterson, itself, was a bit foreign to Dom. He was raised in the suburban town of Lansdale, just outside of Philadelphia. After Catholic high school, he went to LaSalle, a small private Catholic school in the city, west of North Broad Street. He graduated in 1978 and then went to the Philadelphia College of Osteopathic Medicine, on City Line. Paterson, N.J., "the cradle of the industrial revolution in America" (according to Wikipedia) was very densely-populated and mostly non-white. So Dominic was immersed in an entirely different culture than he was accustomed to.

The 77-foot Great Falls of the Passaic River in Paterson
 (from Naturalatlas.com)

He said that he was “one of only two Caucasians” in a staff of 60 or 70, including about a dozen physicians. He said that as you got to know the people, “there was no Black or white, just people you were working with.” Reflecting on this, he felt that “everyone should be in a minority at some time in their life.” 

       

What was Dominic's background before that? All four of his grandparents grew up in Southern Italy before emigrating to the US through the (contract labor) patrone system. His parents were both born in the outskirts of Philadelphia and they raised their sons in the strong Italian immigrant community of Lansdale. His parents were factory workers and “pushed” Dominic and his brother to pursue higher education. Dominic listened, and he and his twin, Thomas, were the first in the family to go to college.

His father, Dominic Sr., served in WWII and received a Purple Heart.  His mother Angeline was, according to her family, “a wonderful cook.” His father died at 87 on December 11, 2006; his mother passed away at 85, ten weeks later. They were both residents in a nursing home. (I wonder, was his mother’s death due to Takotsubo, the broken heart syndrome? Or, in Italian, morire di crepacuore?)

Dominic told me an interesting side-history. He said that many Italian immigrants came to Ambler from Maida, Calabria, to work for the Keasbey & Mattison Company, manufacturer of asbestos building products of all sorts. The small community thrived and became the asbestos capital of the world. After a while, highly skilled stonemasons were brought over from Southern Italy to help build the so-called Lindenwold Castle (modeled after Windsor) for Mattison, a chemist/pharmacist, and one of the founders of the company. 

Mattison's fancy Lindenwold Castle (from Wikipedia)

After Mattison’s death in 1936, the 43-acre property was purchased by the Sisters of the Holy Family of Nazareth. It was first used as an orphanage, and then, until 2013, as a home for abused and neglected youth. It also served, said Dr. Glorioso, as the Pennsylvania Catholic boarding school setting for the 1966 Rosalind Russell/Haley Mills comedy “The Trouble with Angels.” As we speak, it is being developed into a luxury senior living complex to include independent living, assisted living, and memory units with (get this) an indoor pool, fitness center, yoga studio, two movie theaters, indoor and outdoor dining venues, bars and lounges, barbecue grills, a dog wash and dog run, an art studio, fire pits, and a putting green. (Times have changed.)

June Harding, a mesmerized Hayley Mills, and the stern Rosalind Russell
from "The Trouble with Angels" (from quintessenceblog.com)

Anyway, back to Dominic. It was one of his Lansdale Catholic teachers who encouraged him to go to LaSalle. He had an interest in medicine, so he studied biology, but he said that he “would have liked to be an English literature major.” 

And he told me that he still enjoys reading “a little of everything” both fiction and non-fiction. He recently read, and highly recommended, Isabel Wilkerson’s “The Warmth of Other Suns,” the story of the slow migration of six million Blacks from the South to the North and West from 1915 to 1970 that changed America.  

Routes of the Second Great Migration
(along the railways)  (map by Michael Siegel)

Anyway, from LaSalle, the next step was medical school. The decision about where to apply was strongly influenced by his family’s doctor, his father’s friend, Dr. Edwin “Tex” Detwiler Jr. (1946-2018).  He had trained at the Philadelphia College of Osteopathic Medicine (PCOM) and Dominic, being “familiar” with the osteopathic approach, decided to go there as well. 

Dr. Glorioso recalled that during his internship (1982-1983) at the Parkview division of Metropolitan Hospital he was taught by Dr. Alvin Greber. Dr. Greber (1933-2013) was a noted cardiologist, and Dom felt that he was “the most brilliant doctor” he ever met (though he got himself into some serious legal trouble for a while). 

John Simelaro, D.O.

Dominic stayed at PCOM for a three-year General Internal Medicine residency where he learned a lot from “the brilliant” and fun-loving and dedicated educator and pulmonologist Dr. John P. Simelaro. Dr. Glorioso was struck by the fact that Dr. Simelaro (who reminded him of “The Fonze”) and his partner Dr. Michael Venditto were “so human.” He said that they worked extremely well with the students and nurses; they connected. Dr. Glorioso lamented that it seems now that “we’ve lost our ability to communicate.”

This story about those who taught him led him to tell me that as he is serving as Associate Medical Director of Asana Hospice in Harrisburg he is also (in his mid-60s!) a Ph.D. candidate at Duquesne (another Catholic institution). He is studying bioethics and has written research papers on suffering and medical futility. He found (though he already knew) that physicians sometimes have trouble being honest and truthful with patients and families at the end of life when it seems that nothing more can be done.      

And, as has been noted, it is when “nothing more can be done” that the idea of providing palliative care is raised.

What is palliative care? According to the WHO, “it is an approach that improves the quality of life of patients and their families who are facing problems associated with a life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial or spiritual.” It addresses all of the needs of the patient. And it requires a team. 

Palliative care--Hospice or End-of-life Care--Terminal Care
(from closingthegap.ca) 

Dr. Glorioso taught himself how to do what was essentially palliative care (without the formal name) in New Jersey with the terribly-suffering and dying AIDS patients. As we saw, he was happy and stayed there for a good while. How did he make the transition to York?

Dom with his wife

It was through a friend, Dr. Steven Karp, a psychiatrist in York (now an addiction specialist in Arizona). Dr. Glorioso was recruited to help start a medical practice. Dominic visited and liked what he saw. So, in 1997, he, his physician-wife, and their two young daughters moved to Southcentral Pennsylvania. He did general internal medicine and some work in palliative care, building on his experience in Paterson. His wife joined a Family Medicine group.

In 2003 Dominic was asked to be the medical director at the local VNA hospice. And his career has been in hospice and palliative care since then.

After additional training at Harvard, he became a strong local and national advocate for the palliative care approach to terminal illness. He feels  that “we are not taking as good care of our patients as we should (as they face death).”   He told me that for the treating physician ”it is easy to keep doing what you are doing (for their patients) until they die...avoiding the discussion of death (altogether).”  And maybe offering costly futile treatments that result in needless suffering.

  

An online article on Vox by Dr. Haider Warraich, a cardiologist, was enlightening. He noted that more care, more procedures, and more tests, simply more, doesn’t equal better care. And he said that it has been shown that patients with cancer or heart disease who receive palliative care, care that “focuses on quality of life rather than quantity of life can actually live longer.” And they may “avoid the complications associated with procedures, medications, and hospitalization.”  

Dr. Warraich believes that “palliative care can, and should be delivered to patients with serious illness alongside conventional care.” He feels that this “supportive care" (to use a less emotionally-charged word) is in everybody’s best interests, all physicians, not only the very few specially-trained palliative care experts.          

Dr. Glorioso said that “we have avoided the conversation (about death) for way too long.”  And that it is vital for us to talk to our doctors and family members about what we desire for ourselves as we approach that. We need to communicate openly before it’s too late. 

He said that with this in mind we should all have a comprehensive advance directive. Jim Towey worked with Mother Teresa in her hospice in D.C. and developed the “Five Wishes” document. This outlines who will make decisions if we cannot, what kind of medical treatment we desire, how much comfort is expected, how we want to be treated by others, and what we want our loved ones to know. (It is very popular.)

However, Dr. Eric Cassell makes the point that legal documents are no substitute for frank discussions of these issues about “things that matter” with our physician. He feels that doctors “have an absolute and unremitting responsibility to understand their patient’s aims.” (Cassell, p.242) 

Physicians, Dr. Glorioso reminds us (we’ve heard this before) need to always “focus on the person, not the disease.” This is especially necessary where there is a mortal illness.

A man and his dog

Outside of medicine? And in addition to his intense Ph.D. studies? Besides being an avid reader and being in a book club, Dominic likes to eat and is, he admitted, a “pretty good cook” (Italian dishes are preferred, but there is some French, too). He and his wife adopted an Australian Shepherd with a double blue merle gene. The handicapped dog is completely deaf and has vision defects. Training such a pet has been tricky, but a rein around the snout to quickly redirect her has allowed Dom to proudly walk her with a loose leash. 

Dominic worries whether “we are ever going to improve healthcare in this country.” He feels that “we have a lot of technology but (we are) not doing a good job about how we use it.” And the cost for society is enormous. 

Changing our ideas about old age and death and dying by truly understanding and paying attention to "what matters in the end," as Dr. Atul Gwande has written, would be a good start.  

Where we experience death is a factor in how we experience death. Most people want to die at home, said Dominic. But, according to 2017 CDC data about 30% of deaths in the US occur in the hospital (down from 40% in 2003), 30% in the home, about 22% in a nursing facility, 8% in a hospice facility, and about 10% elsewhere. 

Yet, as Gina Kolata notes in the New York Times, deaths at home, even with home-hospice assistance, may still be characterized by unnecessary suffering, both by the dying patient and the over-burdened caregivers. Dr. Glorioso said that he finds that, even with hospice, pain relief is often inadequate. 

We can do better as we compose the final words and fill in the empty spaces of our life story.   

The surgeon-author Dr. Sherwin B. Nuland (1931-2014) has written:

We have been given the miracle of life because trillions and trillions of living things have prepared the way for us and then have died--in a sense, for us. We die, in turn, so that others may live. The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life (Nuland, p. 267).

References and Recommended Readings:

1. Cassell, Eric J. The Nature of Suffering: And the Goals of Medicine. Oxford University Press. New York, 1991. (There is always something to be done to ease suffering.)

2. Frankl, Victor E. Man's Search for Meaning. Beacon Press. Boston, 2014. (There is meaning even in suffering, but not needless suffering.)

3. Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Henry Holt and Company. New York, 2014. (We can design something better.)

4. Kolata, Gina. New York Times. December 26, 2019.

5. Neumann, Ann. The Good Death: An Exploration of Dying in America. Beacon Press. Boston, 2016. (An impassioned plea for improvement.)

6. Nuland, Sherwin B. How We Die; Reflections on Life's Final Chapter. Alfred A. Knopf. New York, 1994. (A classic.)

7. Warraich, Haider. "The way we die will be considered unthinkable 50 years from now: how we treat dying people needs to change." Vox. April 3, 2019. (online)

A quiet late winter morning (SC)

by Anita Cherry 2/26/21

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