Sleep Apnoea Who Has Stopped Using His CPAP — Free SCA Practice Case

Character Overview: You are Roland Pennock, a 52 year old area sales manager for a company that supplies swimming pool water treatment and filtration equipment to leisure centres, hotels and holiday parks. You drive about 30,000 miles a year in a company car, often leaving at 5 in the morning to reach the far end of your patch. Half your pay is commission. You live with your wife Harriet, who works part time at a veterinary reception, and your son Jago, who is 16 and doing his GCSEs. You are friendly, chatty and a bit of a joker, but you deflect with humour when something worries you, and you go quiet when you talk about the car and the job. You were told two years ago that you have severe sleep apnoea. You think of yourself as fit for work and do not want to be seen as an invalid. You are at home today, working from your kitchen table.

Opening Sentence: "Morning, doctor. It's about my sleep apnoea machine. The mask leaks like a colander, it whistles, Harriet can't stand the noise, so I've stopped using it. I'm absolutely shattered, so I was hoping you could sort me out a better mask."

History if Asked (Data Gathering Phase)

• ●How it was diagnosed: "Two years ago. Harriet noticed I kept stopping breathing in my sleep and I'd fall asleep in meetings. I did a test at home, then saw the sleep clinic, and they said it was severe. They gave me the machine and a full face mask."
• ●How it went at first: "Brilliant for the first six months. I felt like a new man. Then the problems started and I used it less and less."
• ●The mask problem: "It leaks around the bridge of my nose and the air blows into my eyes. It whistles, and my mouth is dry when I wake. I grew a beard about sixteen months ago and it got worse after that. I've tightened the straps as far as they go and it still leaks."
• ●The noise: "Harriet says the hiss and the whistle wake her up. She's started wearing earplugs and sometimes goes to the spare room. She hasn't been nasty about it, but I can tell she's fed up."
• ●When he stopped: "I was using it a few nights a week for months, and I've not touched it at all for about three months."
• ●Help he sought: "I rang the helpline once and left a message. Nobody called back. I've not been seen since the first six months. I don't know who to go back to."
• ●Daytime sleepiness: "I fall asleep watching telly every evening. After lunch I struggle to keep my eyes open in meetings. I wake up with a headache and I'm never refreshed. I'm snappy with Jago, and my concentration is poor."
• ●Snoring and breathing pauses: "Harriet says the snoring is back to how it was and that she sees me stop breathing and then snort. I get up to pass water twice most nights."
• ●Driving and sleepiness: Gating note: Roland first says he gets "a bit drowsy on long drives". He gives the full account only when asked directly whether he has nodded off, had a near miss or needed to pull over. "Yes, all right. I've nodded off at traffic lights twice in the past month. The last time a horn woke me. Three weeks ago on a dual carriageway I drifted onto the rumble strip and that frightened me. No crash, no one hurt. I've stopped in lay bys for ten minute naps."
• ●How he copes: "Four or five coffees and an energy drink or two in the afternoon. I open the window and put the radio up."
• ●Other causes: "No sleeping tablets, no new medicines, no restless legs, no sudden collapse when I laugh, no shift work. I've put on about 8 kilos in the past year. I feel a bit flat and I'm less interested in things, but I'm not depressed and I have no thoughts of harming myself."

Ideas, Concerns, Expectations

Gating note: Roland does not volunteer any of these. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: He thinks the machine is the problem, not him. He believes the tiredness is long hours and early starts and that caffeine and fresh air will see him through. He assumes that once the mask is fixed he will be fine straight away. "If I get a mask that fits, I'm sorted. It's the kit that's rubbish."
• ●Concerns: His main worry is losing his licence and, with it, the company car and his commission. He has been hiding the problem from work. Underneath, the rumble strip frightened him, and he has thought about what could have happened. He admits this only if the doctor is warm and unhurried. "If I can't drive I can't do my job. And that moment on the rumble strip, I keep thinking about it."
• ●Expectations: He wants a new mask sorted quickly and wants to carry on driving. He has a colleague who takes tablets to stay alert and wonders if he could have some. He hopes the doctor will not report him. "A mask that works, and maybe some of those wake up tablets my colleague has. And I'd rather this stayed between us."

If Asked: Medical History and Medications

Gating note: Roland answers each of these plainly when the doctor asks about it.

• ●Other health problems: "High blood pressure, and that's it. I stopped smoking about ten years ago."
• ●Medicines: "Ramipril every morning. Nothing else, no sleeping tablets, nothing from the chemist."
• ●Allergies: "None."
• ●Alcohol: "Two pints most evenings and more at client dinners, perhaps 15 to 20 units a week. Wine on Saturdays."
• ●Weight: "About 104 kilos. I've put on 8 in the last year."

Social History and Lifestyle Impact

• ●Work: He drives most days for work, up to 400 miles on some trips. The company car is insured through his employer. He has not told his manager about the sleepiness, and he has not thought about whether the insurer would care.
• ●The licence: He told the DVLA when he was diagnosed, because the sleep clinic made him. His licence came back with a three year review, and the paperwork says he should tell them if things change. He has not told them he stopped the machine. He assumes he only has to say something if he crashes.
• ●Plans: Tomorrow he is due to drive about 200 miles each way to a holiday park for a pool refit meeting. He could ring the customer to move it if he had to, but would rather not. He can be seen in person on any day this week.

If Asked: Associated Symptoms

Gating note: Roland answers these only when asked. Every one is negative unless stated.

• ●If asked about chest pain, palpitations or breathlessness: "No."
• ●If asked about drinking before driving or driving the morning after drinking: "Not drinking before driving. The odd morning after a client dinner I feel rough but I'm sober."
• ●If asked about low mood, anxiety or thoughts of self harm: "A bit fed up, no more than that. Nothing like that."
• ●If asked about a stroke, seizures, blackouts or fainting: "No."

Responses to Management (The Negotiation Phase)

• ●If the doctor says he must not drive until the sleepiness is controlled and he must tell the DVLA:
  • ●Reaction: Shocked. "Not at all? I've got a 200 mile run tomorrow. Surely I'm fine if I have a coffee." He goes quiet when he hears nodding off at traffic lights counts as the same danger as falling asleep at speed. "I told them two years ago. I didn't think I needed to tell them again." If the doctor explains clearly, he agrees to stop and says he will contact the DVLA himself that day, but asks "Will they take my licence for good?" He accepts the answer that driving can restart once the condition is treated and the sleepiness has improved. If the doctor says they may have to tell the DVLA medical adviser if he carries on driving, he looks at the floor: "Right. I won't, then."
• ●If the doctor offers to sort the mask and machine:
  • ●Reaction: Eager. "Can you give me a new mask?" Once told the sleep service or CPAP provider will refit it quickly, he asks "Will they do it this week? And what about the beard? I'm not shaving it off." If options such as a different mask style, a humidifier, a quieter machine or a mandibular advancement device are explained, he says he would try a different mask first. If told it should be quick, he says "Fine, but I've left a message before and nobody rang." He asks the doctor to chase it up.
• ●If the doctor discusses stimulant tablets:
  • ●Reaction: Hopeful. "My colleague swears by them." If told they do not treat the cause and would not make driving safe, he accepts: "So the machine is the fix, not a pill."
• ●If the doctor discusses work, a fit note or telling his employer:
  • ●Reaction: Anxious. "If I tell them, I'm finished." If told he could work without driving, ring customers, work from home or have a short note, he asks "Could I do video calls for now?" He agrees to speak to his manager if the doctor explains why it matters. He asks whether his insurer needs to know: "I suppose I'd better check."
• ●If the doctor discusses alcohol, weight or lifestyle:
  • ●Reaction: Slightly defensive. Once told alcohol makes the breathing pauses and sleepiness worse, he agrees to cut down.
• ●If the doctor gives safety netting and arranges follow up:
  • ●Reaction: Wants specifics. "When can I drive again? What do I do if the mask still doesn't work?" He repeats back the plan when it is given clearly and agrees to a review in about two weeks.