Was Heath Ledger Snoring? Or Was It Something Worse?

There’s only one way to feel about the sudden death of Heath Ledger–what a tragic loss of youth, life, and talent. While we may never know what actually happened, the story about his death raises some important opportunities to learn, and, hopefully, prevent future deaths like this. First point: the medicines that were found in his apartment are a very dangerous combination of pills that can all depress your urge to breathe. Some commentators seem to be downplaying this physiologic fact, even though we should all be aware of it for our own safety. In particular, Valium is the wild card pill–that’s one of the many reasons it’s not commonly prescribed in this country. Valium (or diazepam, its generic name), can last anywhere from 36 hours to several days in your bloodstream. Not only does it hang around forever in your blood (in drug years, that is), but it also, while it’s hanging around, blocks your body from breaking down and clearing out similar drugs–like the sleeping pills and Xanax that were reportedly in Mr. Ledger’s room. That means, if Valium is in your blood, you get much worse, whopping bad side effects from the other pills, even if you take a normal dose. So you could take a Valium on Friday, then pop two Xanax on Saturday, have a glass of wine with dinner, take two Ambien Saturday night, and, depending on your liver, not wake up Sunday morning. Yes, it can be as easy as that. The second tragic factor about what might have happened with Mr. Ledger is the report that, less than three hours before he was found dead, his housekeeper heard him “snoring.” Healthcare professionals across the nation have all probably given a sad shake of the head at that news. Here’s why: “Snoring” is often how non-medical people describe something that emergency room workers would recognize as early airway obstruction. When someone has their urge to breathe suppressed by drugs, it tends to happen is stages. One of the first signs that something is deeply wrong is that the person is unable to do something that we in medicine call “protecting your airway.” Protecting your airway is something that you do, even in your sleep. You have the subconscious urge to cough, to gag, to rustle around. But most of all, protecting your airway means you have the muscle tone in your throat and mouth to keep your breathing tubes open and air flowing freely. Could a trained healthcare provider hear the difference between snoring and early airway obstruction? Generally, yes. Not so much for a housekeeper. Here’s what we’re going to do for our Doc Gurley Health Ledger memorial. In honor of this fine actor, we’re going to review some tips on how to tell if someone is too far gone to protect their airway. So, for anyone who ever had to go home after a procedure with new pain meds, for anyone who worries that their buddy is waaaay too plastered and might not be breathing right, for anyone who just wants to know that the homeless person under the blanket is still breathing, here are some Doc Gurley practical tips on the difference between “snoring” and airway obstruction.
1) Sure, people snore. Especially guys. Hey, don’t look at me, I don’t snore. Okay, well, not enough to wake myself up anyways. The “snoring” that is the hallmark of airway obstruction is a bit different from what most people do. For one thing, it is rougher, harsher, more gurgly. If that sounds too vague, keep this in mind: when you are losing the ability to protect your airway, your breathing tubes actually get floppy. That means the “snore” can last all the way through the inhale, and then all the way through the exhale. Most healthy people don’t snore that way. Another tip: If you see the chest working, but no sound of breathing, and then, with a sudden jerk of the chest, the snore begins, that’s a sure sign of airway obstruction. A few of you (especially the wives/partners/husbands of champion snorers) may be saying, hey, that’s my bedmate. He/she does that all the time. If so, get in to see your doctor and ask for an evaluation for sleep apnea. Until you’ve been thoroughly cleared by a sleep study, that’s not a normal way to snore.

2) A skipped breath is a very bad sign. Snore, snore, snore, pause…pause…pause, and then, with a sort of gasp, or even a weak gurgle, snore. Don’t even think about it–just call 911.

3) Extra credit pop quiz! Who knows how many times we should be breathing a minute? Any civilians out there know the answer? Here’s an important number to remember–anything less than 12 (or certainly 10!) breaths a minute is abnormal. Even if someone seems to be “snoring” normally, but they’re only breathing 6-8 times a minute, call 911.

4) When people are sedated, we mistakenly think of them as being asleep. That’s not true. With the kind of drugs that Mr. Ledger had in his apartment (and with narcotics and other depressants) what someone experiences as drug levels creep up is more like being put into a coma, or close to death–a kind of suspended, very abnormal, state. Someone who is losing the urge to breathe lies too still. In normal sleep, we all shift and rustle. Maybe not constantly, but pretty regularly. If we didn’t we’d end up with bedsores, even on a soft bed. When someone has a snore you’re worried about, eyeball their movements. If they are just melted onto the bed (or ground), no twitches, no shifts, no nothing–that’s not a good sign. Especially if they look like they’re in an abnormal, uncomfortable position. Sometimes you can even see the redness along a cheek where there has been too much pressure for too long as the drug levels (sedatives, narcotics, alcohol) creep up in their bloodstream.

5) Here’s the most heartbreaking part of the Heath Ledger story (and it is, sadly, a scenario that is played out too many times across the country)–why the heck do we not go ahead and shake the guy? Sure, you might find an annoyed person snarling at you. But here’s the thing–we’re talking about breathing. About dying. If you know you want to be a Good Samaritan and shake someone you’re worried about, but it just seems too awkward or embarrassing, work on your story in advance. If it’s your boss (and you’re a housekeeper) how about waking someone up with “I made you some tea?” Or, if it’s the homeless guy and you’re kind of worried about how he’ll react, how about sacrificing a dollar and then wake him up with “hey, buddy, someone left you this and I think you better put it away before it gets taken?” I can promise you, however, that if someone is groggy enough for their breathing to worry you, they probably won’t even remember you waking them. These things tend to go one of two ways–you shake them, you wake them, you can barely get them to sit up, and then you watch them or call someone to watch them until they’re normal (or end up in the emergency room). Or, you shake them, you realize you can’t wake them, and you call 911–before they stop breathing.

6) Finally, if you’re worried about someone’s breathing, never leave that person face down on a bed (or sidewalk). At least get them to roll onto their side. If you see someone’s actual mouth/nose/face smashed under an arm or a pillow or even literally pressed against the mattress–that is a sure sign something is abnormal. It is shockingly easy to smother when you’re heavily sedated. That’s what “protecting your airway” is all about. If someone sleeping normally starts to smother, they wake up gasping. We’ve probably all had that experience where we’re getting over a cold/flu and we wake bolt upright, hacking up a lung just because a little speck of phlegm broke loose. Someone who is sedated can’t do that.

Preventable deaths somehow seem so much more heartbreaking. I think I’m going to get me a box of tissues and rent Brokeback Mountain this weekend. I offer my heartfelt condolences to his family and friends.

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