Sleep Apnea and the Sword Swallower
Polysomnography (PSG), commonly known as a sleep study, is a test in which multiple (poly) recording leads are attached to the patient in order to record (graph) sleep (somn) patterns. The use of PSG to study sleep was introduced by a group of innovative clinicians at Stanford University in the 1970s. They brought the world's attention to obstructive sleep apnea (OSA), now recognized as a very common condition.
I was introduced to OSA in a lecture by Dr. William Dement, who almost single handedly invented the specialty of sleep medicine. In the lecture he showed dramatic video of affected patients. In OSA, the upper airway becomes lax and intermittently obstructs respiration during deep sleep. The patient awakens many times during the night because of respiratory obstruction. Because of these sleep interruptions, nocturnal sleep is of poor quality, leading to fatigue and excessive daytime sleepiness. A cardinal symptom is obstreperous snoring. Many people snore, especially men. But in OSA the snoring reaches the point where the bed partner wears earplugs, or goes to sleep in another room, or banishes the patient to the sofa. Affected patients are usually overweight men with short, thick necks.
The patient before me in 1980 was a poster child for OSA: obese, with a short, thick neck and a small chin, unable to stay awake. History from his wife confirmed obstreperous snoring and excessive daytime sleepiness. PSG was then only available in a few university medical centers. Small town America had to make do.
Though we generally credit Dement for alerting the world to the existence of OSA as a syndrome, Charles Dickens described it the Pickwick papers in Joe the Fat Boy, who would “go on errands fast asleep,” and snore as he sat at a table. And medicine for years recognized an obesity-hypoventilation entity called Pickwickian syndrome.
A CPAP machine is a device that blows a steady stream of air into the throat to prevent it from collapsing during inspiration, preventing respiratory obstruction. Home CPAP machines, now the standard, first-line treatment for OSA, had not yet been invented.
On seeing an OSA patient these days, a PSG would be done to confirm the diagnosis and determine the optimal CPAP pressure, after which the patient would be fitted with a CPAP device for home use. None of this technology existed when I saw my Pickwickian man. None of the other modern therapies for OSA, such as oral appliances and surgery had yet been developed. The only treatment available was tracheotomy, a hole cut into the lower neck, an irreversible, disfiguring procedure.
In casting about for some way to treat the patient short of tracheotomy I had an idea. When I tell my wife I have an idea, she occasionally says “Luuceee,” using the tone and inflection Desi Arnaz used to address Lucille Ball on the I Love Lucy show when Lucy would tell Desi she had an idea. Many of Lucy's ideas were quite harebrained, and many episodes of the show revolved around the consequences when Lucy would try to put one of her ideas into action.
What followed with this patient might have qualified for an episode on the Lucy show.
An oral airway is a hard rubber or plastic device used for temporary control of the airway, as for resuscitation efforts before placement of an endotracheal tube, or brief periods when a patient may be unconscious and need breathing support. Many sizes are available, pediatric and adult. The usual adult airway is about 4 inches long and is curved to fit along the tongue and press it down into the floor of the mouth, preventing the back of the tongue from interfering with airflow into the lungs. The front of the airway protrudes slightly from between the lips and is often taped in place.
The gag reflex is an involuntary contraction of the muscles of the mouth and throat when a foreign object is inserted into the back of the throat. Most people have experienced the activity of the gag reflex, such as when a doctor inserts a tongue blade to examine the throat. If the tongue blade goes in too far, the patient gags. We sometimes deliberately cause gagging to check for the integrity of the reflex. It is not usually possible to voluntarily suppress the gag reflex, the response is automatic and involuntary.
But some individuals learn to suppress the gag reflex under certain circumstances, and can then tolerate the presence of a foreign object in the throat. If I could train the patient to suppress his gag reflex, then perhaps he could learn to insert an oral airway at bedtime, tape it in place and be able to sleep without respiratory obstruction. But how could he learn to suppress the gag reflex? What sort of people learn to control their gag reflex. There are the obvious erotic implications, but I was not about to go there. Under what other circumstances do people learn to suppress the gag reflex, I thought.
Aha, sword swallowers.
Those people insert large, heavy metal objects into their throats and down their gullets, or at least appear to. How do they learn to do that? I need to talk to a sword swallower. How the heck do you find a sword swallower. This was not a simple proposition pre-Google.
I started by looking up circus in the yellow pages.
When I finally reached someone who knew something about the circus my first question was whether sword swallowing was an illusion, a trick, perhaps a collapsible blade. Masters of the sleight-of-hand can appear to accomplish amazing feats. Was sword swallowing some sort of magician trick? My circus insider assured me it was not, that those swords were real, that people did indeed insert them down their throats. He did not really know any details about how they learned to do it but suggested I talk with one of the practitioners of the art. How do you find a sword swallower? Find a circus and just show up? The circus guy told me that the Ringling Brothers circus was then in winter quarters just outside Sarasota, Florida.
A few calls later and I was talking to a sword swallower, a pro, a real circus performer. I explained the nature of my call and what I was trying to find out. He graciously agreed to brief me on the ins and outs of sword swallower training.
"You start with coat hangers," he explained. He went on to describe how the first stage involves inserting a straightened out coat hanger down the throat. "Isn't that difficult?" I asked. "Of course it is. But with patience and persistence you get used to it. I could walk around all day with a coat hanger down my throat and it wouldn't bother me." I tried to picture going about daily affairs with a coat hanger sticking out of my mouth, the other end deep in my gullet.
Once a trainee can tolerate a single straightened out coat hanger the ante goes up. First the coat hanger is bent to form a double strand squeezed tightly together. Then the strands are widened. Then multiple straight coat hangers taped together, adding hangers gradually until there is a large wad. Each stage takes days to weeks. But by gradually increasing the size of the object and learning how to gently maneuver it down the throat the performer learns to suppress the gag reflex.
Learners also deliberately trigger the gag reflex by putting other objects down the throat: fingers, spoons, whatever blunt object will work. By gagging over and over they desensitize the reflex. Mastering the trick is difficult and it can take years to learn to swallow a real sword. Then they try to swallow more than one; the world record is fifty-two. Why anyone would want to do this is a mystery to me.
Injuries are not rare. Severe sore throats are common from trauma to the pharynx. Such a "sword throat" is an occupational hazard. As many as a third of sword swallowers eventually suffer a laceration of the throat or a perforation of the esophagus. Major gastrointestinal bleeding occasionally occurs. The Sword Swallowers Hall of Fame lists twenty-nine deaths from sword swallowing injuries over the past one-hundred and fifty years. Sword swallowers helped physicians develop the technique of bronchoscopy in the 1930s.
George the Giant. the stage name for George McArthur from Bakersfield, Ca., set the official record for the longest sword ever swallowed, thirty-three inches. At seven feet three inches, George has a significant edge in height. He is also a fire eater as well as holding the record for most bricks broken on a man lying on a bed of nails.
After he had explained sword swallower training, I thanked him and started to say goodbye.
Then, "Let me ask you a question." There was an obvious need to hear him out. He had helped me, and I should try to help him if I could. He went on.
"I am six feet seven inches tall. Theoretically, I should be able to swallow a thirty-five inch sword and set the world record but whenever I try there is a point where I encounter resistance and the sword will not go in any further."
I tried to visualize the anatomy. Not a gastroenterologist or general surgeon, the best I could think of was that the sword was refusing to pass through the lower esophageal sphincter or impacting the lower part of the stomach.
He continued, "When I reach that point the sword just stops and won't go in any further, do you think it would be OK if I push?"
A flurry of questions flashed through my decision making centers related to the anatomy, what little I knew about swords, my medicolegal exposure and how fast he might bleed out if he did push.
I told him that pushing was a supremely bad idea and could result in disaster. When I started to explain the anatomy and the consequences of a GI tract perforation, it quickly became apparent he knew these things as well I did. The real question was what risk he was willing to take to attain sword swallower glory and only he knew the answer.
When the OSA patient returned for follow-up I told him about my sword swallower consult and how he might go about deconditioning his gag reflex and learning to sleep with an oral airway. I got him a pediatric airway to start with but he could never get the hang of it. It was simply impractical.
"Luuceee."
Only in my line of work could you start with a question about how to manage a sleep apnea patient and end up learning the world record for swallowing a sword.
