Texting Drivers? Ask Tracy Morgan About Drowsy Drivers

I do a fair bit of driving.  I live in Seattle, home to long, crazy commutes.  You see a lot of stuff on Puget Sound highways:  multi-lane weavers, left-lane cruising taxi drivers, packs of wheelie-popping crotch-rocketers, hyper-caffeinated road-ragers.

Something that I see more and more of these days:  a Prius ahead of me, starting to hug those lane-dividing lines, slowly moving further and further to one side, followed by a quick correction back to the center of the lane, and then followed by another slow drift to the lane’s outer boundaries.  Then it rolls over some of those turtles on the side of the highway before it corrects yet again. I speed up to get away from this car and its impaired driver.  I look over as I pass, and sure enough:  the young driver is staring at his or her lap, poking furiously at a smart phone while putting everyone on the road at risk.

 

Everyone has seen these drivers on the road in recent years.  But another, more insidious problem has long lurked on our roads, something much less obvious than but just as dangerous as texting drivers:  drowsy drivers.  According to the National Highway Traffic Safety Administration, roughly 100,000 motor vehicle accidents are reported to occur due to driver sleepiness/fatigue in the United States every year.  Those are just the reported accidents; there are likely thousands more that occur every year that are not reported.  A 2005 National Sleep Foundation poll revealed that 60% of American drivers reported driving while drowsy at least once in the previous year, and 37% fell asleep behind the wheel at least once in the previous year.

These basic statistics should make you concerned, not just because there are so many drowsy drivers out there, but because of how casually so many people routinely drive while sleepy.  They flirt with disaster every day by doing so.

Around 12:55 a.m. one late night in June 2014, a Wal-Mart truck crashed into a van carrying, among other people, the actor and comedian Tracy Morgan, killing one van occupant and critically injuring Morgan.  Earlier this week the National Transportation Safety Board announced its conclusion that driver fatigue likely played a role in the accident:  the truck driver reportedly had driven 800 miles throughout the night prior to the accident, and had been awake for more than 28 hours straight.  The driver, Kevin Roper, now has been charged with vehicular homicide.

What to do with truck driver fatigue is a difficult, complex, and emotionally and politically charged issue.  Work hours, industry culture, the need to “get there on time,” and financial issues all contribute to the debate regarding how to improve safety on our highways.  From a clinical perspective, however, I can tell you that a great many people–truck drivers or not–simply don’t sleep as long as their bodies require.  The substantial majority of adults require around 7-8 hours of sleep per night, and let’s be honest with ourselves, many of us don’t get that much on an average night.  One of the most common causes of daytime sleepiness is chronic sleep deprivation, which is associated all sorts of long-term and short-term consequences, from poor work performance to medical problems to fall-asleep car crashes.

For those who struggle to stay awake during the day and find themselves nodding off while they are driving despite getting proper amounts of sleep per night, consider informing your doctor and consider a sleep medicine evaluation.  There are many potential causes of excessive daytime sleepiness, including many sleep disorders.

Final word, which at this point is painfully obvious:  regardless of the cause, never drive if you’re drowsy!  Spare yourself the tragedy of injury and death, as well as the guilt stemming from having caused a fall-asleep car crash.

Have a safe weekend, everyone.

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Bus Driver Falls Asleep at the Wheel and Causes a Huge Series of Crashes

Recently a Michigan bus driver was involved in a horrendous accident, in which his bus plowed into a total of eight cars.  Take a look at this surveillance video:

You can see the driver calmly driving at the beginning, and then suddenly slamming his brakes as he sees that his vehicle is about to crash into another.  He pulls over to the shoulder and slow down, but he takes out car after car as he decelerates.  Amazingly, there was only one bus passenger onboard, and she was not injured; however, multiple people in the other vehicles were hurt.  This 65 year-old driver, who reported that he felt that he had probably fallen asleep behind the wheel, now faces charges for having caused this accident.

Unfortunately, similar accidents (though usually not this dramatic) occur on American roads every day.  It is estimated about 100,000 car accidents are reported every year in this country due to driving while drowsy or fatigued.

Why is drowsy driving so prevalent?  Well, there are several reasons:

1.  Daytime sleepiness can be a chronic issue that may not have resulted in substantial consequences for you . . . until you wreck your car.  In other words, if you have felt sleepy during the day for years, but have never been in a wreck, you may fool yourself into believing that you may never get into an accident due to falling asleep, which, of course, is completely faulty reasoning.

2.  Daytime sleepiness is not usually “painful,” per se–unless you’re in an accident because of it–and may not be viewed as an actual problem.  If you’re used to falling asleep peacefully in front of the TV every day, you may view that tendency as just a harmless “thing you do” instead of a potential concern or medical issue.

3.  Lots of people are chronically sleep-deprived, such as due to working several jobs, and so sleepiness may be viewed as just an inevitable component of everyday life.  This doesn’t make daytime sleepiness normal!

Ironically and tragically, because sleep disorders such as obstructive sleep apnea are becoming a substantially public policy issue because of their tendencies to cause fall-asleep car crashes, some professional drivers may choose to delay or even completely forego a medical evaluation for such problems for fear of losing their jobs or to spare themselves the hassle.

Bottom line:  excessive daytime sleepiness can kill you if you’re behind the wheel or operating machinery.  It’s better to pull over, rest, stop work, whatever it takes, than to keep on driving if you’re sleepy.  It’s just not worth it to keep going, man.  Imagine being the guy in the video.  And if you’re excessively sleepy during the day despite proper amounts of sleep at night, I strongly recommend seeking medical attention for this brutal problem.

 

Help Your Child Sleep Well While “Back to School”

All you parents know what’s right around the corner, if it hasn’t already happened: the start of the new school year! At least for us in the Pacific Northwest, school doesn’t start for another week, so we have one more glorious week of sun and freedom before the beginning of fall classes.  But for many of you elsewhere, school has already started in earnest.

 

One of the many concerns parents have as they transition back into the school year is how their children’s sleep habits will change. Many of us know the drill, from our children’s experiences or our own: all the staying up late on weekends, sleeping in ’til noon on Saturdays and Sundays, the Herculean effort necessary to get out of bed in the morning, especially on Mondays. Though this ritual is very common, particularly for teenagers, the stress and conflict arising from this chronic problem can wreck your family life, not to mention your grades.

This pattern, called delayed sleep phase, arises from the adolescent brain’s natural tendency to cycle its sleep-wake rhythms in a timing scheme that is longer than the 24-hour day. Many of us recall what it was like to be younger and wanting to stay up later and sleep in later if given the chance. The problem with this tendency is that children and teenagers usually engage in activities (i.e., school) that obligate them to entrain their sleep-wake behavior to the 24-hour clock. This conflicts with their biological inclination to go to bed later, resulting in sleep deprivation which makes it more difficult to awaken early in the morning and be awake and alert for classes. Friday night comes ’round, they stay up late, sleep in big-time on weekend days, and then find it impossible to fall asleep early Sunday night because their body clock’s sleep-wake phase has now been delayed from all the sleeping in, so all the sleep debt and sleep deprivation then roll into the new school week, perpetuating the cycle.

There is ongoing controversy about what can and should be done to improve this problem for young people and their families. Though some schools around the country have options of starting classes later in the day, many or most of us parents are obliged to ensure that our children are out of bed and ready for school at times earlier than what they, and their body clocks, “want.”

So what can be done? We can’t change our kids’ brains, though sometimes it’d be great if we could, right? Here are a few tips to help weary parents get their kids sleeping better as we kick off this new school year. As you will see below, these recommendations may be quick to read and absorb, but whether they are easy is another matter. The unfortunate reality is that making these sleep problems substantially better likely will be difficult, at least at first, requiring communication, motivation and insight from the child and patience and support from the parent.  Ready? Here goes.

1.  Minimize the “sleeping in” on non-school days by setting the alarm clock for reasonably similar times each day to the extent you can.  Kids hate this most of all.  Sleeping in dysregulates your body clock, causing nocturnal insomnia and daytime fatigue.  Sleep schedule dysregulation is why we have jet lag, for example.  If your child has to awaken for school at 6 a.m., say, but sleeps in ’til noon on weekends, and then tries to go to sleep early Sunday night, such abrupt changes in the brain would be the equivalent of flying from the west coast to the Bahamas, for example, and back, every week.  Regulating the wake-up time may well require a hard sell to the teenager; I’d rather the teen sleep in until 8 a.m. than until noon.  This lifestyle modification (and it’s a big one) gets substantially easier if done diligently for a couple weeks, but I won’t lie, it’ll be painful for all involved at first.  The child may need some, er, parental assistance in getting up on weekends.  A second alarm clock is also an option.  Put one alarm clock on the nightstand, and then put the second one further away, set for 2 minutes after the first clock, so that your teen will need to physically get out of bed to turn it off.  Make sure the second alarm clock is loud, and the more obnoxious the better.

2.  Don’t go to bed until substantially sleepy.  If the first step is done properly and done the same way every day, then this second step should fall naturally into place eventually, because the resulting sleep deprivation should make your teen become drowsy gradually earlier in the evening on weekends.  Force your child to go to bed too early, however, and residual insomnia results.  Taking advantage of children’s sleep needs allows them to fall asleep quickly and earlier (including on Sunday nights) and at the same time get proper amounts of sleep (which for children and teens can be 9-10 hours per night), both of which are important in physical and cognitive development and proper performance in school.

3.  Declare a curfew from light and technology.  Light exposure greatly impacts our levels of wakefulness and alertness; add to this the perceived need to always be constantly “plugged in” socially through mobile devices, and you have a recipe for “up all night.”  Shield your child’s bedroom from outside light and noise, such as with black thick curtains, particularly as these summer months continue to wane.  Start dimming your home’s ambient light several hours prior to the projected bedtime.  And, finally and importantly, I recommend laying off lit-screen gadgets (including iPads, laptops, and smart phones) 2-3 hours prior to the projected bedtime.

Now that I think about it, I’m pretty sure this last recommendation is actually what kids hate the most.  But complete these 3 steps, and utilize them consistently, and chances are your child will sleep better.

Best of luck to students and parents alike this upcoming school year!

 

Sleeping Yankees Fan Brings Up Important Point About Sleepiness

Recently 26 year-old Andrew Rector filed a lawsuit against ESPN, Major League Baseball Advanced Media, and the New York Yankees, claiming defamation stemming from broadcasted video of him fast asleep in the stands during an April Yankees vs. Red Sox baseball game.

 

Here is the video in question:

According to the filed materials, Mr. Rector was subjected to an “unending verbal crusade against the napping plaintiff” and an “avalanche of disparaging words against” him subsequent to the game.

In reporting this story, this morning’s television news programs often asked a question not terribly different from that of the commentators:  “how can anyone sleep through something as exciting as a close Yankees / Red Sox game?”

I’m not writing today to provide legal commentary.  However, this incident does bring up an important issue regarding sleep and our collective perception of sleepiness.

There has long been a widely held belief that you naturally fall asleep simply because you’re bored or inactive.  The corollary concept is that if you fall asleep when you’re not supposed to or when other people usually don’t, such as while at work or at an exciting event, you must be lazy, unmotivated, or dumb.  Over the years I’ve seen many patients whose clinic evaluations were initiated by getting fired, suspended or reprimanded for having fallen asleep on the job or in meetings.

I submit that such notions are ill-conceived and unfair.  If you regularly have proper amounts of sleep and if you are free of medications, substances, or medical conditions causing sleepiness, then you really shouldn’t be struggling to stay awake all day long just because you’re physically or mentally inactive.  It’s more accurate to say that a person who is prone to excessive drowsiness (regardless of the reason) tends to fall asleep by accident if sedentary.  The question then shifts to:  why is that person prone to being drowsy in the first place?

I mean, who knows why Rector was snoozing during the ball game?  Maybe he usually gets up at 3 a.m. to get to work, so the game was past his usual bedtime.  Perhaps he holds down two jobs.  Maybe he spent the previous night caring for a sick child.  Perhaps he has an undiagnosed sleep disorder.  Is it really right to make a judgment of a person’s character or work ethic based on a tendency to fall asleep when others are awake?

How “normal” is it to sleep through something exciting or otherwise stimulating?  In my younger years (prior to practicing sleep medicine), and in the setting of chronic sleep deprivation, I routinely slept through fire alarms, tornadoes, tornado alarms, neighborhood car crashes, earthquakes, and parties next door.  I slept through important lectures, grand rounds, and meetings due to not getting enough sleep.  Your ability to stay awake and your ability to arouse from sleep in response to a stimulus depend on a number of factors, including your age, how much sleep you usually get, how regular your sleep schedules are, how much sleep you happened to get the previous night, and what stage of sleep you happen to be in when the stimulus occurs.

I’m not saying it’s OK to sleep through important events, of course.  Here are my main points today.  If you are finding yourself falling asleep in inappropriate times, places, and circumstances, and particularly if your professional and personal lives suffer as a result:

1.  Work to identify the reason(s) for the sleepiness.  Often an underlying cause may be obvious and right under your nose, like getting 5 hours of sleep each night.  We are creatures of habit, though, so lifestyle choices that lead to chronic sleep deprivation may not feel like problems if you’ve engaged in them for a long time.

2.  If there is a specific lifestyle choice that is causing your sleepiness, make a change, even if the change is uncomfortable or inconvenient.

3.  Strive to get proper amounts of sleep (which for most adults is 7.5 – 8 hours per night) on a regular basis to the extent possible.

4.  Should you remain prone to falling asleep despite proper amounts of sleep and after excluding other potential causes, discuss your sleepiness with your doctor; your drowsiness may suggest the presence of an undiagnosed sleep disorder.  You may want to consider an evaluation at an accredited sleep center.

Stay healthy and awake this summer, everyone!

Final thing:  shout-out to my friend Doug, man, you’re an inspiration.

Sleep Well This Summer!

 

Shortly I’ll be on a plane to Wichita, Kansas, for my high school reunion.  Every time I step foot on Kansas soil a flood of great memories returns:  Friday night football games, Knolla’s Pizza, midnight movies, parties, Bionic Burger, the River Festival, Galaga, and, especially around this time of year, the all-important beginning of summer.

 

Where I grew up, summer was all about crowded public swimming pools, Dairy Queen Hot Fudge Brownie Delights, baseball, mowing a huge yard all day every Saturday, hay fever, washing dishes at a restaurant by day, dragging Douglas by night, and listening to the Police and Marillion in my little green 2002.  It was also about hanging out with my friends, and to be perfectly honest I often didn’t sleep as much as I should have.  What did I know?  Sleep deprivation and sleeping in were pretty common during the sweltering, humid summer months of my teenage years.

Sleep often suffers in the summertime.  So before I depart I will leave you with some quick, easy tips to make your sleep easier, better, and more enjoyable during these hot summer months.

1.  Keep your bedroom dark, quiet, and cool.  Insulate your room and windows from noise and light to the extent that you can.  It’s a tough time for many of us financially, but if you are unable to sleep because the room is hot, use your air conditioning; sleeping well is worth the money spent on utilities.  If you can’t fix your hot, light, loud bedroom, try sleeping in the basement.

2.  Strive to keep your sleep schedules regular.  School’s out; loved ones are visiting; the neighborhood BBQ is in full swing; you’re off on a family vacation.  There is always the temptation to party late, sleep in, and not set your alarm clock during the summer.  Your body clock doesn’t care about any of that, however.  A common cause of insomnia and daytime sleepiness is dysregulation of sleep schedules.  Continue to awaken around the same time every morning (if you don’t have to awaken at any one specific time, you would do well to choose a preferred awakening time and stick with it), including on weekends and non-work days.

3.  Mind your late-night alcohol.  Alcohol has sedative effects for the first couple hours after you ingest it.  However, after several hours it tends to be a sleep disrupter.

4.  If you’re a night shift worker, get thick black curtains for your bedroom windows and wear dark sunglasses on your way home from work in the early morning.  Remember:  it’s light out early in the morning and late in the evening when it’s summertime, so your brain can be tricked into making you feel more awake and alert if there is bright light exposure around the time that you should be sleeping.

5.  Avoid late-night exercise.  The release of stimulatory hormones when you exercise hard can last for several hours, causing insomnia.  I recommend that you stop heavy aerobic activity 2-3 hours prior to your projected bedtime.

6.  Take care of yourself.  Don’t sacrifice your health for all that summertime fun.  Obviously, anything that causes physical discomfort can be a detriment to your sleep.  Avoid sunburns and dehydration.  Use nasal sprays or see your doctor for those seasonal allergies.  Minimize hangovers.  Don’t overextend yourself.  And, as I will probably see firsthand this weekend, it’s best to remember you’re not in your 20’s when you’re, uh, no longer in your 20’s, just ’cause it’s summer.

Utilize these simple suggestions and chances are you likely you’ll be able to avoid a . . .

“Why is My Mouth So Dry With CPAP Use?”

I must have struck a chord with yesterday’s post on dry mouth, given the responses I’ve received.  Dry mouth is a very common symptom associated with sleep.  So let’s continue this topic, but with a little twist.  Do you awaken with your mouth feeling dry during a night of CPAP use?

As mentioned briefly yesterday, obstructive sleep apnea (OSA) is a sleep disorder of breathing associated with episodic collapse of your upper airway while you are sleeping; sleep disruption, gasping sensations at night, witnessed breathing pauses during sleep, substantial snoring, and daytime sleepiness are common clinical features of this very prevalent but under-recognized medical illness.  CPAP (continuous positive airway pressure) is a primary form of treatment for OSA.  CPAP is an electronic device which pressurizes room air and gently sends it down the throat via a mask to keep the airway open all night.  If properly used, CPAP stops the snoring and breathing pauses, deepens your sleep dramatically, and therefore makes you feel much better and more awake and alert during the day.

 

Some still think of CPAP use as a primitive, invasive, or unavoidably uncomfortable medical therapy based on what they’ve seen or heard a decade or more ago; this is unfortunate, in part because many people end up foregoing medical evaluation and treatment for their sleep apnea for many years based on an erroneous perception of what their treatment may be like.  There are now dozens of mask interfaces available, each with different sizes; the CPAP devices themselves are much smaller and quieter than they used to be, with lots of bells and whistles to make them more comfortable and easier to use.  If used properly and if you are willing to use it, CPAP can be an absolute game-changer; untreated sleep apnea can wreck your life, and proper treatment can dramatically turn things around.

Having said that, though, there are lots of potential ways for CPAP use to go wrong, causing people to have difficulties using it or to stop using it altogether.  I will write about these problems more in later posts, but one problem some CPAP users may have is dry mouth.  The majority of CPAP users don’t have substantial problems with this, but if this is relevant to you or someone you know, read on.

Presuming that your dry mouth isn’t caused by one of the problems I wrote about in yesterday’s post, and if the dry mouth started or became much worse after having started CPAP, most likely this symptom is caused by oral leak or oral breathing.  Your jaw muscles naturally tend to relax when you fall asleep.  In some cases, the lower jaw (mandible) may then drop slightly due to gravitational forces.  If you are using a nasal mask (i.e., a mask that covers your nose but NOT your mouth) or nasal pillows (i.e., soft prongs which are placed gently at the entrance of your nostrils), and if the mouth opens a little, then air from the CPAP device may then divert and escape out of your mouth.  This is obviously a problem.  The air dries your saliva, first of all, causing you to awaken more from sleep with that uncomfortable, parched, “Sahara desert” feeling in your mouth.  Just as importantly, though, if air is leaking out of your mouth and escaping into the open space instead of going down your throat the way it should be, then you aren’t being adequately treated because your airway may again be predisposed to collapse due to insufficient air pressure.  So due to sleep disruption and inadequate treatment, oral leak can lead to a perception that CPAP doesn’t work because you may still feel sleepy during the day despite CPAP use.

Oral leak is a very fixable problem.  Don’t turn your CPAP device into a very expensive doorstop because of it.  Before reading how to repair oral leak below, though, make sure you’ve determined where the dryness is; this is particularly important because people often don’t actually feel the air coming out of their mouths, because the leak happens while they’re asleep (when you awaken your muscles abruptly regain their tone and the mouth usually closes).  If the sensation of uncomfortable dryness is in the nasal passages and/or the back of the throat, but NOT in the mouth, oral leak is probably NOT the problem; I would suggest increasing the heated humidity in your CPAP device if this is the case.  However, if the dryness is clearly localized to the mouth chamber–with a pasty sensation in the mouth, for example, a feeling of having to “peel” your tongue from the roof of your mouth, dryness of the lips and teeth–oral leak is then likely the cause.

1.  If you’re using a nasal mask or nasal pillows and you like your current setup, a chinstrap is usually effective.  When wrapped gently around the head, it mechanically keeps your mouth gently closed.  It does not need to placed tightly; it should be just secure enough to be effective, but not so tight it’s uncomfortable.  People usually become accustomed to chinstrap use pretty quickly.  Many straps are made of thin neoprene.  However, particularly for my patients who are more heavyset or who have larger neck circumferences, I prefer a “deluxe” or “heavy-duty” chinstrap, which is wider and made of less stretchy material and therefore more likely to be effective.  An added bonus:  in some cases chinstrap use can be temporary; over time you may find that tendency toward oral leak has stopped after having discontinued the use of the strap.

2.  Another way of addressing oral leak is with the use of a full face mask, which covers both the nose and the mouth.  There are now many different full face masks available on the market.  Potential issues with full face masks, however:  since they’re larger masks, they may be more prone to leak than smaller masks; also, they don’t keep the mouth from opening, so you can still have some dry mouth if air continues to go in and out of your mouth (though usually substantially better).  Try increasing the heated humidity (which usually comes standard) in your CPAP device should this be the case.  But if you’re already using a nasal mask or nasal pillows and you’re comfortable with your current setup, a chinstrap usually does the trick with relative ease.

3.  Finally, as mentioned in yesterday’s post, addressing problems causing decreased airflow through the nose (such as seasonal allergies, hay fever, sinusitis, or anatomic nasal disorders) may well reduce the tendency to open the mouth during sleep.  Consider a visit to your primary care physician or an ear, nose, and throat doctor should you have symptoms that suggest such problems.

Sleep well tonight, everyone, and stay warm!

“You’re Gonna Hear Me SNORE!”

I hope your holiday season has been great so far!  And it’s not over yet!

I recognize I’m posting this video late–it aired originally during the Thanksgiving holiday–but it’s worth posting now anyway; we’re still in holiday mode, after all, aren’t we?, and lots of people eat turkey at Christmas time!  Jimmy Fallon, Rashida Jones, and Carrie Underwood gave a hilarious musical performance about Thanksgiving traditions on Late Night With Jimmy Fallon.

Please pay particular attention to what Rashida sings 1:29 into the clip.  She parodies Katy Perry’s song “Roar,” singing, “you’re gonna hear me SNORE!”

Drowsing and falling asleep in front of the television or fireplace after a big ol’ hyper-caloric meal are so common, they seem like natural components to our American holiday tradition.  The degree to which L-tryptophan in the turkey triggers an after-dinner snooze is questionable, actually.  However, there are so many reasons for sleep to take you over after a huge holiday meal:  sleep deprivation due to wrapping things up at work; family and friends coming into town; irregular work and sleep schedules; parties keeping you up late; alcohol, particularly when combined with certain medications; underlying medical problems; and undiagnosed sleep disorders.  Untreated sleep apnea, for example, may leave you both sleeping and snoring like a bear in your recliner, disturbing your house guests.

It’s always easier to say than to do, but keeping your sleep schedules as regular as possible and getting proper amounts of sleep during the holidays may well improve your levels of wakefulness and alertness during this time of year and may bring forth even more holiday cheer!  Have a great holiday week, everyone!