At first, he excused his fatigue as a symptom of advancing age, expanding girth or the rigors of his grinding schedule.
There were nights when Del. Howard "Pete" Rawlings struggled to stay awake during the tedious drive home from Annapolis. Or the time the Baltimore Democrat drifted off while dining with friends at an elegant restaurant in Manhattan.
"He just nodded off," said his wife, Dr. Nina Rawlings, a pediatrician who implored him without success to see a doctor. "I was just glad I was sitting next to him. I kept bumping his knee."
But when Mr. Rawlings fell asleep in his chair during a crucial meeting last fall of the Governor's Commission on School Funding, he began to suspect a deeper problem. A colleague who witnessed his public doze begged him to get help. Mr. Rawlings relented.
With that, he was on his way toward a diagnosis of obstructive sleep apnea, a nighttime breathing disorder that afflicts millions of Americans, including many who have no idea why they drag through the day regardless of how long they sleep at night.
Those afflicted frequently stop breathing for 10, 15 and sometimes 20 seconds at a time, each time snapping out of it with a gasping reflex that disrupts their natural sleep cycles. Usually, the gasp doesn't wake them up -- but their rocky sleep deprives them of the rest they need.
In the year since his diagnosis, Mr. Rawlings has been rejuvenated.
His treatment, a mask called a CPAP that forces oxygen into his airway during sleep, has expanded his lung capacity, raised his blood-oxygen levels and stoked him with more energy than he has enjoyed in years.
He also has shed more than 50 pounds with a low-calorie diet, reducing not only his waistline but excess tissues in his throat that may have contributed to his apnea.
News of his transformation so impressed officials at the Liberty Medical Center, a hospital in his district, that last month they dedicated their new sleep disorders unit to him despite the fact he was treated elsewhere.
A brass plaque bearing his likeness will soon be placed on the wall of the fourth-floor unit.
Mr. Rawlings, 57, was honored because he is a sleep-science success story who is well-known to the community, said hospital president Everard O. Rutledge. And he's been a good friend to Liberty Medical Center, helping it obtain a $2 million appropriation for its Urban Medical Institute, a program of
preventive medicine and primary care aimed at its largely African-American constituency. Mr. Rutledge said the sleep center fits squarely into Liberty's emphasis on treating the basic problems that can hinder a person's ability to function.
"We were filling what we believed was a void," Mr. Rutledge said. "People are saying, 'Why am I constantly tired, listless? Why am I having fits of depression?'"
Obstructive apnea is the most common problem treated at sleep centers such as Liberty's, but they diagnose other afflictions as well. These include restless leg syndrome, a condition in which people are kept awake by involuntary and sometimes painful leg spasms. Another condition is central apnea, on-and-off-again breathing that has a neurological rather than a respiratory cause.
Mr. Rawlings didn't expect any drama when he showed up at his doctor's office, the day after he decided to explore the reasons for his fatigue. Two routine tests, however, showed that oxygen levels in his blood were alarmingly low, and that raised fears of a dangerous heart condition.
Quickly, his doctor called an ambulance to deliver him to the emergency room at the University of Maryland Medical Center -- just a block away. In a calmer moment, he could have walked the distance in less than five minutes.
"Here, I'm a politician, and I think I'm healthy except for being tired, and I'm concerned about my public image, and here they strap me down and send one of those life-support ambulances," he said. "They're pushing me out of the building onto Paca Street, and I'm thinking: 'I just know somebody's going to recognize me.' "
Somebody did, of course, and called his wife.
Happily, specialists determined that he did not have an underlying heart or lung ailment, even though his lungs weren't inflating as far as they should. "They believed it was correctable once they found the problem," he said.
Doctors said it was worth exploring the possibility that a sleep disorder was preventing him from drawing enough air at night. They referred him to the sleep center at the Johns Hopkins Bayview Medical Center for evaluation.
He soon found himself lying in a quiet room, electrodes and motion detectors attached to various points on his head and chest. In another room, technicians tracked his breathing and sleep patterns, heart rate, eye movements and chest expansions on a bank of computer monitors.
Conclusive proof
The usual routine is to sleep through the night, and to receive an analysis the next day.
"I must have been asleep for about an hour when they rushed into the room and flipped on the lights," Mr. Rawlings said. "Their monitoring had been conclusive. I had sleep apnea, a severe case."
Monitors showed that he stopped breathing for stretches of 10 to 15 seconds -- and as often as twice a minute.
This prevented him from sliding through the first three stages of sleep to reach "rapid eye movement," a stage that is both rich with dreams and essential to restful slumber. The four stages should unfold in cycles of approximately 90 minutes, but they get disorganized when sleep is interrupted.
"In obstructive apnea, there's a big struggle to breathe," said Dr. Mai-Chi Nguyen, co-director of the sleep centers at Liberty and Howard County General Hospital. "There can be tremendous chest movements. But there's no airflow in the nose."
Overweight men and women are most likely to develop sleep apnea, she said. When excess fat is deposited in the throat, the airway folds in on itself. "And when they sleep, their muscle tone is diminished. The already narrow airway becomes narrower."
Facial abnormalities such as a low-set jaw or a large tongue can also impede breathing -- but these represent a minority of cases.
"Probably all of us have a little bit of an apnea problem," said Dr. Edward W. Schaefer, a pulmonary specialist who also co-directs the two sleep centers. "When it gets prolonged, it can be classified as an illness, a disease."
The Association of Professional Sleep Societies estimates that as many as 20 million Americans have this condition, but many probably have minor cases that do little harm.
In serious cases, oxygen deprivation can cause irregular heart rhythms and hypertension, Dr. Schaefer said. Neither happened to Mr. Rawlings. But his lungs became so accustomed to their nighttime battle for air that they got into the habit of opening partway -- during the daytime as well as night.
There was a solution.
For several months, he never went anywhere without a portable tank that delivered pure oxygen through a tube that snaked up his sleeve to his nose. During the legislative session, it became an object of curiosity -- "Are you all right?" people would ask -- that sparked many discussions about the condition and its treatments.
Improved lung capacity
Once his lung capacity improved, he was able to stop using the tank.
At night, he has a separate treatment, and this will continue indefinitely. The more elaborate CPAP -- continuous positive airway pressure -- delivers forced air from a table-top compressor to a plastic mask that fits over his nose. The pressure is constant and just strong enough to keep the throat from relaxing to a closed position.
Mr. Rawlings said he quickly got used to the claustrophobic feeling produced by the tightly fitting mask. Any remaining discomfort is minor, easily outweighed by the benefits of a good night's sleep.
"The sleepier the patient is during the day, the more likely they are to stick with the CPAP mask," said Dr. Nguyen. Most patients are able to tolerate it, she said, and for them the treatment is almost universally effective.
Medical insurance
The cost of a diagnosis and treatment can approach $4,000 at Liberty. This includes two nights in the sleep laboratory, doctors' fees and the purchase of the sleep mask and compressor. Depending on the extent of coverage, medical insurance may or may not pay the cost.
Mr. Rawlings said he may be able to rid himself of the mask altogether if he loses more weight. With less tissue in the back of his throat, he might be able to breathe correctly without mechanical assistance.
For now, he can rejoice in his renewed energy and his steadily shrinking waistline. Last month, just before the Democratic primary, he tipped the scales at 295 pounds. It was the first time he had dipped beneath 300 in more than a decade.
Perhaps there's no better witness to his transformation than his wife. For many years, Dr. Rawlings said, the household laundry has been a shared responsibility. But last year, he began to slip. He'd start the job, but would often leave the finished product in a rumpled heap atop the drier.
"Now, the man is doing all three stages -- washing, drying and folding. I asked him, 'Do we have a ghost in the house?' No clothes on top of the drier. He's actually been folding it up and putting it away," she said. "That's energy."