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Awakening From Denial: Acknowledging the Crisis of Sleep Apnea

As Originally published by Natioanl Bus Trader, November 2012.

By: Ned Einstein
Tel: 212-766-1121
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For decades, multiple sources cited the commonly-accepted statistic that only an estimated four percent of all individuals possessed a medical condition known as Obstructive Sleep Apnea (OSA). OSA is largely the result of certain physical characteristics and lifestyle habits that reduce the flow of oxygen into one's lungs while asleep. These characteristics result in lowered blood oxygen levels throughout one's normal night's sleep, and lower the quality of that sleep such that the individual is fatigued through much of the day. For purposes of motorcoach transit, and long-haul trucking, recently studies have increasingly acknowledged an almost astonishing percentage of professional drivers with Sleep Apnea compared to the general population.

Of those physical and lifestyle conditions that contribute to this problem are obesity (including an abnormally thick neck and even a short mandible) and other structural characteristics of one's neck and throat and their sub-elements These problems are further compounded by lifestyle choices like alcohol and caffeine consumption, and many prescription and non-prescription drugs -- not to mention our obscene intake of sugar and high fructose corn syrup which, directly or indirectly, further impede the body's ability to maintain a consistent level and quality of sleep. During the night, individuals with Sleep Apnea commonly snore, and their sleep is often considerably more restless than normal. The point is, the incidence of Sleep Apnea is not dramatically higher among drivers than the general population simply as a coincidence. Interestingly, even apart from Sleep Apnea, fatigue levels among professional drivers compared to the general population are dramatically higher, much of it related to the irregularity of drivers' shifts' start and end times from day to day, and the "disassociation" from their normal circadian rhythms this inversion in sleep-wakefulness cycles creates.

But the deteriorated quality of one's sleep is hardly the major problem with Sleep Apnea victims. The real problem - and why I consider the glacial pace of our addressing it to comprise a crisis -- is that, during their wakeful hours, individuals with this affliction, and who experience periods of fatigue in general, are not only less alert, but prone to irregular, intermittent bouts of "microsleeps" - effectively "black-outs" lasting only a few seconds, but during which time these victims are effectively fast asleep. This problem is not likely to manifest itself during one's involvement in intense activity - such as combat, sports competition or even exercise. Instead, it rears its ugly head during periods of quiet and monotony - a common environment in which long-haul truckers and motorcoach drivers not only find themselves, but find themselves for extended periods of time, much less during those hours when their bodies would normally be asleep even without any sleep disorders. The efforts of our industry's lobbying organizations, nearly a decade ago, to exempt motorcoaches from changes to the Hours-of-Service regulations that would have minimized such problems - changes enthusiastically endorsed by the U.S. trucking industry - helped cement this precarious phenomenon into place.

For even one out of every 25 motorcoach driver - never mind every motorist - to possess this problem - known for years but which triggered virtually no institutional or regulatory responses - is nothing short of inexcusable, especially in the context where major institutions such as the National Transportation Safety Board and Federal Motor Carrier Safety Administration have for years voiced their belief that roughly half of all catastrophic motorcoach accidents were fatigue-related. Of course, the inertia of our response to these beliefs is hardly surprising in a society where it took decades of frenetic advocacy to require the installation of seatbelts in common automobiles. However, some shocking new discoveries have suddenly drawn attention to the magnitude of risks involved by our failure to address this issue - particularly the dramatically-exaggerated understatement of the problem's depth, statistically.

Before exploring the new data, and certain organizations' recent responses to it, it must be pointed out that, for years, Sleep Apnea has been not only diagnosable, but treatable. Unfortunately, while losing weight, exercising and making other lifestyle modifications can often alleviate this condition, the medical industry's alternative has been to sleep with a somewhat grotesque mask that simply opens the throat's airway passages during sleep. One can imagine one's reluctance to wear such a device to bed, especially with a spouse or girlfriend, as this paraphernalia is not exactly a romantic or sexual turn-on.

Better Data and Mixed Reactions

While concern about Sleep Apnea has been growing significantly this past year, interest exploded when the results of a recent Australian study was released. That study of 480 truck drivers [535 candidates are considered a scientifically "random sample" and the legitimate foundation for drawing scientific conclusions] found that close to half of them possessed this disorder. I do not have a stereotype of "Aussies" as a continent full of fatties with thick necks. If any nations are close to this, they are Britain and the United States, where one half and one third of their entire populations, respectively, are classified as having some degree of obesity. Regardless, Sleep Apnea is far less likely to be a problem in Africa or the Orient, where obesity is rare (Sumo Wrestlers excepted). But it a whopping problem here.

Other studies "closer to home" have mirrored the Australian study's findings. Most interesting, recently studies have found that 28% of truck drivers suffer from "Obstructed Sleep Apnea" (OSA) compared to only about six percent of the general population. Clearly, driving large vehicles is the poster boy for dangerous sedentary jobs. Unfortunately, driving a large vehicle is not only mentally and physically exhausting, and filled with stress (which further contributes to fatigue), but often compounded by bad diets, and where fatigued drivers are among the least likely members of the population to engage in physical exercise. Yet OSA is only one of 70 different sleep disorders noted by Mary Parrish, Vice President of Transportation Safety of the sleep discovery management firm Fusion Sleep.

Expounding further on these dangers, Ms. Parrish noted that the real issue is not so much the failure to diagnose and treat sleep disorders in their early stages, but that the failure to diagnose and correct this condition leads to not only an increase in overall fatigue, but to a host of other medical problems, such as type II diabetes and high blood pressure. Yet despite these extraordinary revelations, and an outburst of rhetoric about its importance (including a genuine expression of concern from Anne Ferro, the FMCSA Administrator), not only does the FTA (the FMCSA's USDOT sister organization) have no formal medical standards for transit operators (many transit operators drive either split shifts, but often "night" and "owl" period shifts), but even the FAA does not provide any guidance regarding these risk factors to its pilots. Historically, only the freight rail industry has been deeply involved in programs to screen out OSA-vulnerable motormen and other railroad personnel, and otherwise engage in what is known in other modes as "bio-sensitive driver assignment" (matching one's shift to his or her natural sleep-wakefulness cycle). Otherwise, the other sectors have effectively been "asleep at the switch" - and, as noted, at least one industry, our own, has fought against efforts to address these problems at the institutional levels - while they were applied universally to the nation's trucking industry, which encompasses roughly 99 percent of the commercial vehicles regulated by the FMCSA. At least the revised Hours-of-Service regulations help keep our packages safe.

This past May, 2012, at a two-day Sleep Apnea and Trucking Conference sponsored jointly by the American Trucking Association and Federal Motor Carrier Safety Administration, the NTSB recommended that all modes begin identifying their drivers possessing high risks for sleep disorders and guiding them to medical treatment, effectively renewing its campaign to broaden the use of sleep disorder screening across all modes of transportation as part of a long-term effort to reduce the obvious risks.

In response, regulatory responses have been, in my opinion, relatively impotent. The FMCSA's Ferro acknowledged that "the challenge is to develop- screening and treatment options that are affordable and accepted by operators," yet claims that among operators, sleep apnea is a highly sensitive issue. What can she be talking about? Other than the suggestion that a percentage of Sleep Apnea victims live largely on a diet of soda pop and Nachos -- perhaps a mild embarrassment likely to be obvious to many casual observers anyway -- I find it puzzling how this issue could be remotely sensitive. If anything, the failure to address it aggressively is the height of insensitivity.

Truthfully, it would not be fair to single out the failures to address this issue only in the United states. At the European Respiratory Society's recent Annual Congress in Vienna, it was noted that commercial truck drivers are often reluctant to report symptoms of Sleep Apnea due to their fears of endangering their employment. Endangering themselves by increasing the risks that they might fall asleep at the wheel, much less endanger fellow motorists, pedestrians and bicyclists seemed to matter less. So worried by the loss of employment have these truckers been that they have actually downplayed their degree of sleepiness, compared to other patients in the "control group," in several studies.

Change through Liability

As in so many other improvements in safety, changes in dealing with the Sleep Apnea crisis is beginning to come from the litigation environment. This past January, 2012, a State-of-Texas trucking company acknowledged that Sleep Apnea played a role in a highway death involving one of its truck drivers, and reached a $3M settlement with the driver's family. Evidence that would otherwise have been introduced at trial would have shown that the trucker had refused to treat his previous diagnosed condition, and that his employer failed to provide follow-up monitoring, much less any follow-up care.

The shame of it all is that while this settlement may quickly become commonplace, it was actually novel when it recently occurred. While I have often argued that the "industry standard" is what a "reasonable and prudent" driver and/or company or agency would do, so few current motorcoach or trucking companies bother to examine the presence of Sleep Apnea that finding it to be the cause of an accident has often led to verdicts in favor of the defendants! ("How could we have known?") The Texas case, and the plethora of studies and acknowledgments about the risks of undiagnosed and untreated Sleep Apnea, are likely to change this position very quickly. Further, given the number of drivers and accidents to whom and which it applies, these studies and settlements could radically change the transportation landscape as a liability matter. The FMCSA website estimates that almost one-third of commercial drivers suffer from Sleep Apnea alone. And this statistic does not factor it the army of drivers often significantly fatigued who do not even possess this disorder. Partly in response to this warning, the growing notoriety of catastrophic motorcoach accidents, increasing expressions of alarm and burgeoning lawsuits, more and more companies are beginning to implement sleep health assessments, diagnosis and treatment programs.

Interestingly, Sleep Apnea testing may soon be required for commercial truck drivers. On December 11, 2011, the Medical Review board and Motor Carrier Safety Advisory Committee of the FMCSA held a joint meeting to discuss this subject, and as a result, the committees issued a proposal that would tie the likelihood of Sleep Apnea to body mass index (BMI) and recommended that an interstate commercial driver with a BMI of 35 of higher be evaluated for Sleep Apnea. Another recommendation listed five criteria that would result in a driver being immediately disqualified from driving. While these recommendations were only stop-gap measures, a draft of the permanent regulations was expected at some point after the end of the first quarter of 2012.

Progress is also being made elsewhere - particularly in the trucking sector. Recently Sleep HealthCenters became the first multi-state provider of Out of Center Sleep Testing (OCST) to receive accreditation from the American Academy of Sleep Medicine (AASM). Sleep HealthCenters can provide OCST and treatment in almost every state by working with a network of accredited sleep centers, currently number over 200. I suspect this organization would be highly receptive to bus or motorcoach drivers and their employers requesting their services.

Remaining Behind

Much of the credit for this information should go to the schoolbus community's Dick Fischer, whose clipping-service-derived daily newsletters (sent via e-mail to subscribers free-of-charge) collected much of this information from a variety of sources. This information coming from that sector of the industry is ironic since the problem is far more serious in the motorcoach sector than in the schoolbus sector, the latter of whose drivers generally operate on split shifts (with generous opportunities for napping between them), where most drivers are "larks" or "morning people," and where the radical inversion of shift start and end times from day to day that characterize much of the motorcoach industry is almost non-existent.

As a physical transportation matter, of course, these findings have extraordinary implications: At 60 mph, a vehicle travels 352 feet in the four seconds of a typical "micro sleep." Unless the road is absolutely straight, with no dips or bumps on the shoulders, and where traffic on most high-speed roadways is almost non-existent - parts of Wyoming come easily to mind, as do the Bonneville Salt Flats - the magnitude of drivers and motorists with this condition would appear to comprise a frightening risk. Frankly, the paucity of collisions we experience given these statistics suggests, for those open-minded enough to accept it, that without considerable spiritual intervention, our highways would be the travel equivalent of mosh pits, where mayhem is not only commonplace, but expected and welcomed.

Regardless, now that our courts are beginning to hold defendant's accountable when their drivers possess untreated Sleep Apnea - instead of, ironically, using it as a legal loophole because our heads-in-the-sand approach has, in the past, treated it is as some non-accident-related surprise for which defendants were not held accountable - I expect to see a lot more emphasis on testing, diagnosis and treatment for sleep disorders of various kinds. To expect a rapid regulatory response might be unrealistic. But even if liability is one's only concern, I expect more and more motorcoach companies will begin acknowledging and responding to these changes - if only to fall in step with the positions which our courts are likely to begin adopting.

Lest any readers feel these concerns or my predicted responses are overboard, last week Republican New York City's Mayor Bloomberg succeeded in passing a law outlawing the sale of super-size bottles of soda. So the War on Obesity - a war we have been losing that has exploded healthcare costs and entitlement programs as a consequence of our lack of personal responsibility - has begun, if only by one tiny gesture at a time. But many important changes begin with such gestures. During my college years, I recall the ignorant and now-embarrassing treat of drinking at famous McSorley's Pub, New York City's only bar to which no woman had ever been admitted. And it took the appointment of Margaret Mead, in 1954, as the Director of New York City's Museum of Natural History, to immediately dismantle an obscene exhibit, in the very lobby, titled, "The Ascent of Man" - an array of statues that represented our evolution from primates to homo sapiens, and which ended with separate statues of a Black person and a White Person. Regardless, some efforts do indeed form starting points, spur inspiration, and occasionally lead to dramatic change. They also demonstrate how embarrassingly behind reality we can at times be.

I mention these idiosyncrasies not to dilute or trivialize the importance of this installment's message, but to heighten it. If such small measures like those noted above can be made to dispel the inertia blocking much-needed social change, it is hardly much to ask that we undertake and support some serious efforts to address an issue that is causing considerable mayhem and carnage, the results of which have also damaged our industry's image greatly, particularly in the past several years. We already have enough studies and corpses to document the need. It is now time to address the problem.

Ned Einstein is the President of Transportation Alternatives, a passenger transportation and automotive consortium engaged in consulting and forensic accident investigation and analysis (more than 600 cases). Specializes in elderly, disabled, schoolchildren. Mr. Einstein has been qualified as an Expert Witness in accident analysis, testimony and mediation in vehicle and pedestrian accidents involving transit, paratransit, schoolbus, motorcoach, special education, non-emergency medical transportation, taxi, shuttle, child transport systems and services...

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