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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Alaska Airlines Cargo Worker Falls Asleep in Plane Cargo Compartment

Here’s a recent story from right here in my home base of Seattle, Washington:

Six days ago, as Alaska Airlines flight #448 took off from SeaTac International Airport, passengers heard someone pounding from below the cabin.  A cargo worker was trapped in the cargo compartment of the now airborne Boeing 737.  This as-of-yet unidentified man, an employee of contractor Menzies Aviation, called 911 upon realizing he was trapped in the belly of the plane.  Upon learning of the presence of someone in the compartment, the pilot turned around for a hasty but safe emergency landing back at SeaTac.  No one was injured.

 

Turns out that this man had fallen asleep in the cargo compartment and he later awakened to find himself–and the plane–airborne and on its way to Los Angeles.  The Federal Aviation Administration is investigating the incident, and by report the man is on administrative leave; furthermore, according to an Alaska Airlines spokesperson he has been “permanently banned from ever working again on an Alaska Airlines operation.”

It’s not clear from the news reports why the contractor was asleep in the cargo compartment; by report he passed a drug test subsequent to the event.  However, this incident took place around 2:30 in the afternoon on a Monday.  From a physician sleep specialist’s perspective, here are some important potential reasons for someone to end up snoozing in the wrong place at the wrong time:

Irregular sleep schedules, which could be related to a wide variety of causes, from insomnia to some late weekend nights to flip-flopping work shifts (it’s not yet clear if this man’s particular work scheduling involved occasional or recent night-time work).

Chronic sleep deprivation.  Most adults require 7.5-8 hours of sleep per night regularly to feel fully rested during the day, and the most common cause of sleepiness in the U.S. is sleep deprivation.

Undiagnosed and/or untreated sleep disorders.  There are about 100 sleep disorders, ranging from breathing disorders (such as obstructive sleep apnea) to movement disorders (such as periodic limb movement disorder).  Commonly associated with excessive daytime sleepiness, these intrinsic sleep disorders often can persist for many years before coming to the attention of a healthcare provider.

I should note here that it’s not necessarily abnormal to feel a little sleepy or “let down” in the mid-afternoon.  Our natural tendency to become slightly drowsy or fatigued during that time of day is called the “circadian dip” or “circadian low;” it also provides the reasoning for the “siestas” commonly found in some cultures.  However, warningless sleep attacks and irresistible urges to sleep during that time suggest that more than just the circadian low may be at work.

 

Though I understand that Alaska Airlines does not permit people to “sleep on the job,” my real concern here is why this person experienced a sudden sleep attack or felt compelled to take a nap in the compartment in the first place.  I hope that this gentleman has been or will soon be properly evaluated in this regard.

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.

Why Sleep Center Accreditation is Important

Long time no see, everyone!  This past week has been very full, limiting my abilities to write until now.  One important event of this week was an American Academy of Sleep Medicine (AASM) re-accreditation site visit for a sleep center that I medically direct.  I am pleased to report that the facility remains a fully AASM-accredited sleep center.

To most, medical facility accreditation may not mean much, or anything at all.  AASM accreditation does mean a lot, however, to clinicians and staff for whom it is important to maintain a distinction for utilizing accepted medical and procedural standards of care regarding the diagnosis and management of patients with sleep disorders.  The AASM is the primary governing body that develops and maintains national standards of care in sleep medicine, establishing benchmarks for quality of work done by physicians and in sleep centers based on sound, published scientific data.  As such, AASM accreditation should be important for patients as well:  though there are certainly plenty of excellent sleep centers that are not accredited, it is reasonable to presume that one’s care in an AASM-accredited sleep center is generally more likely to be in keeping with established and accepted national standards of care as compared to in an unaccredited facility, particularly one that’s been around for many years without any intention to obtain accreditation.

AASM accreditation requires adherence to specific standards and guidelines for clinical work and management, diagnostic testing, and operational procedures.  It is a rigorous process, one that involves a detailed application, demonstration of maintenance of education and certification, ongoing adherence to AASM practice parameters, and site visits and inspections.  Plus, rules and standards change all the time in medicine, so accreditation forces us to keep up, stay current, and continue to do our best caring for patients in this ever-changing modern world.  Finally, and importantly, accreditation also means that a sleep center’s physicians are able to deal with all sleep-related problems, not just the easy stuff.

Many years ago I participated in the accreditation process as an AASM site inspector.  It was a great experience; it gave me opportunities to travel and to see how other centers did things.  One of the medical directors I met during my visit told me that he looked forward to our inspection because he considered it a learning opportunity.  That remark has stuck with me ever since:  the idea that a visit from the AASM should be something not to be dreaded, like an audit or an investigation, but instead something very positive, something that allows for further growth and mastery in the field of sleep medicine.  In my career I have seen sleep centers through their own accreditation as medical director many times, and in many ways the process is fun.  I find it interesting to hear the perspective of the site inspector, pick his or her brain a little, understand how physicians around the country are handling certain complex situations, and learn how others are dealing with all the changes constantly thrust upon us in American health care.

To those who ask me how to choose where to go for their sleep medicine care, I do recommend considering exploring which area sleep centers are accredited by the American Academy of Sleep Medicine as they make their choices.  Some insurance plans and other administrative bodies require patients to get their care at accredited facilities.  I recognize that some underserved parts of the country may not have accredited centers yet, and it also always takes time for a new sleep center to obtain its accreditation, but the pathway to accreditation is quite accessible now for those sleep specialists willing to step up.

And no, the American Academy of Sleep Medicine didn’t pay me to write any of this!  Have a great evening, everyone.  Cheers!

Could Your Child’s ADHD Be a Sleep Disorder?

Attention deficit hyperactivity disorder (ADHD) has again made top news in the past couple days.  The federal Centers for Disease Control and Prevention recently released data demonstrating that 11% of U.S. school-age children have received a diagnosis of ADHD, and that almost 1 out of 5 boys in the U.S. have been diagnosed with ADHD.  6.4 million children 4-17 years of age have been diagnosed in this country, making for a 53% increase over the past decade.  Millions of prescriptions have been written for these children, often, paradoxically, stimulants such as methylphenidate and amphetamine derivatives.

 

These are stunning figures, no doubt, sparking a renewal of debate regarding potential causes and solutions.  Fingers have been pointed at the pharmaceutical industry, doctors, parents, schools, and our burgeoning quick-fix technology, with iPhones and video games cluttering the landscape of our–and our children’s–lives.  However, there is a medical disorder–a sleep disorder–whose symptoms can be very similar to those of ADHD.  This sleep problem is very real, and one that is very often overlooked.

Obstructive sleep apnea (OSA) is much more common in children than many may realize.  The stereotypical sleep apnea patient is older, male, and overweight, and a misconception that may result from this stereotype is that young children, particularly skinny ones, are not prone to developing OSA.  Not only is OSA quite prevalent in children, it is also easy to miss, in part because the daytime symptoms from OSA can be different in children as compared to adults.

For adults, the most common daytime symptom is excessive daytime sleepiness:  drowsiness, a tendency to struggle to stay awake or to fall asleep at inopportune times, no matter how much sleep is obtained at night.  Children are different.  For many kids, the primary daytime manifestations of OSA are distractibility and irritability, potentially leading to poor school performance, problems concentrating, an inability to stay on task for long periods of time, and chronic conflicts at home or at school.  Sound familiar?  Patients diagnosed with ADHD also have such symptoms.  Additional symptoms attributable to pediatric sleep apnea would include bedwetting, sleep-talking, sleep-walking, frequent sleep disruption, headaches, profuse night sweats, learning problems, depression, and retarded growth.

A big clue to possible OSA is snoring.  The snoring of a young child, particularly 8 years of age and younger, really should be brought to the attention of the child’s pediatrician.  A child’s or teenager’s loud snoring should most definitely be discussed with the doctor.  And certainly if there are witnessed breathing pauses or gasping noises, the child’s doctor needs to be alerted as soon as possible.

Tonsillectomy and adenoidectomy represent the most common form of treatment for pediatric sleep apnea.  For many children, the removal of tonsils completely solves the problem, and it’s amazing how much the child’s (and family’s) life can change for the better as a result.

So today’s pearl, reflecting these recent news from the CDC:  sleep apnea is one of the most under-recognized and under-diagnosed medical disorders for children, and can present clinically in a way that is very similar to ADHD.  If your child is snoring at night and distractible or irritable during the day, I would recommend a sleep evaluation.

Have a great day, everyone!