Wake Up Call To Fleets:
The Sleep That Kills
Sleep disorder among truck drivers results in reduced productivity, absenteeism, accidents and often death.
BETTE GARBER
CONTRIBUTING EDITOR
"Now when I see a truck in a ditch, I think I know how and why it happened!"
—Walter Johnson, Dart Transit.
A driver who just logged eight hours of sleep is pulling over for naps every two hours. Another driver is worried about an increasing tendency to nod off while he's driving. An owner-operator behind the wheel of a calendar-worthy show rig wakes up parked in the median.
In these cases, the on-the-job drowsiness is being caused by a sleep disorder called Obstructive Sleep Apnea (OSA). Apnea is a Greek word meaning "without breath."
In the trucking industry, this disorder is not only contributing to accidents and near-misses, late deliveries, reduced productivity, and absenteeism, but is also effecting insurance costs and liability exposure.
No one knows exactly how many truckers have OSA — yet. But because sleep apnea most often strikes middle-aged, overweight men — common demographics of professional truck drivers — it is estimated that one-third to three-quarters of truckers experience this disorder, to one degree or another. That means millions of truck drivers could be battling excessive daytime sleepiness every day and accepting this condition as "normal." In other words, they don't know there is something medically wrong with them.
Ongoing research from prominent sleep centers at Stanford University and University of Pennsylvania clearly points to large numbers of truckers who suffer from OSA and whose performance is being impacted because of it. No research has yet defined at what level of OSA driving is actually affected. Someone with mild OSA may or may not have their driving ability impaired, however, all the research indicates that moderate to severe OSA leaves the driver seriously deprived of restorative sleep.
Not Simply Fatigue
If a driver is fatigued, it does not always follow that he has OSA.
OSA is a treatable medical condition that leaves the slumber-encumbered sufferer feeling tired all the time. Fatigue, as it is generally understood in the trucking industry, has its roots in a variety of job demands.
Contributing to this condition are lengthy driving times and driving beyond one's ability to do so safely, insufficient sleep, long waits for loading/unloading, uncomfortable sleeping conditions on the road, and disturbed circadian rhythms (upsetting the natural human clock that regulates the timing of sleeping and waking).
While these sources of fatigue can be substantially reduced by heedful management, individuals who have sleep apnea represent a special risk.
When a fatigued driver with OSA gets behind the wheel, exhausted and carrying a gigantic sleep debt from his hidden inability to sleep, it's a toxic combination that could lead to disaster.
How OSA Disrupts Sleep
In OSA the tissues in the throat relax in sleep, blocking the airway, shutting off air intake, often for a minute or longer. The brain momentarily awakens the sleeper to take a breath.
These micro-arousals happen so quickly, most OSA sufferers aren't aware they take place or how many times, yet they occur throughout the night, sometimes hundreds of times. The sound associated with this behavior is loud snoring interspersed with gasps and snorts of the sleeper fighting for air.
Continual disruptions make deep, restorative sleep impossible. The OSA sufferer wakes up feeling tired, exhausted, wornout, day after day.
Left untreated, OSA also can lead to medical complications including memory loss, high blood pressure, heart attack, and stroke.
"I was like a walking time bomb,"
— Mitch Kindle, Dart Transit Owner-Operator
According to the National Apnea Foundation, an estimated 12 million Americans and countless professional drivers, experience OSA. But only 1.5 million have been treated. Most untreated drivers are unaware they have the disorder, but are likely experiencing an unsettling feeling that something is wrong. Afraid of losing their jobs, not enough drivers are seeking the help they need.
Drivers and their carriers need to know that OSA, the most common of 80 different sleep-related disorders, is usually 100% treatable and virtually fully reversible. For most, there is no surgery, no recovery time, and instant, almost miraculous, improvement.
For the nominal cost of treatment, the carrier essentially trades in a moody, lethargic driver whose alertness, motor skills and job performance can't help but be impaired, for one who is alert, energetic, well-rested, and ready for whatever the job throws at him.
Carriers will need to play a major role in educating their drivers and reassuring those with potential OSA that treatment is in their best interest and it is safe to come forward for screening and diagnosis.
To get the ball rolling, sleep clinics like SleepQuest and consultants like Stuart Lowenthal (see What Sleep Experts Are Saying page 26) offer a full menu of help for fleets.
Lowenthal likens OSA to bad vision. Like glasses fix the vision problem, a Continuous Positive Airway Pressure (CPAP) machine does the trick for OSA sufferers.
The CPAP, a small air compression device, delivers air pressure through a nasal mask worn while sleeping. The pressure creates an "air splint" which keeps the airway open and allows the sleeper to breathe normally all night long for uninterrupted and restful sleep. The machine hooks into a 12-volt lighter plug-in or runs on household current.
The CPAP must be properly calibrated by a sleep specialist to be effective.
"I know many drivers might feel funny wearing the mask, but there is nothing funny about falling asleep at the wheel and killing yourself or others."
—Tom Adler, driver (Winter 2000 Sleep Matters)
Drivers who use it say it sometimes feels confining or claustrophobic at first, but they get over that as the results of treatment become apparent.
A driver diagnosed with severe apnea after years of fighting constant sleepiness learned through treatment that he had been getting an average 60 seconds of rest for every nine minutes of sleep. Since being diagnosed and treated, Jeff Chism has not nodded off once at the wheel in close to a million miles. (see Formerly Sleepy People page 27.)
"I'm glad I don't have to live like that anymore," Chism said. "It's a miracle I am here to tell about the many close calls I've had."
In 2000, drivers from Dart Transit, Eagan, Minn. and Star Transport, Morton, Ill., participated in the trial run of a pilot fatigue management program (See What Sleep Experts Are Saying, page 26) subsequently submitted to the Federal Motor Carrier Safety Administration for review.
Tested for OSA as part of the study, eight of the nine drivers put through the program were diagnosed and treated for sleep apnea. All would later testify that it has changed their lives.
"Everybody needs this information," said a Benton, Ill. driver who claims he is 50% more productive now. "I am sure a lot of drivers are in danger and don't know it."
With no interruptions to get in the way of restorative sleep, drivers who undergo treatment immediately feel better, as in more energetic and alert, and they become significantly more active and productive.
Sleep experts believe that drivers are likely to feel grateful for the carrier's intervention and help, and less likely to leave a company that so substantially enhances their quality of life. Not only would this improve a driver's frame of mind, but reduce the cost of retraining.
William C. Dement, M.D., Ph.D., at Stanford University noted in a press conference late last year that well-rested drivers would be less likely than tired drivers to have accidents and, if accidents declined, insurance rates would likely fall.
Not A Cheap Fix
The costs associated with treating drivers for OSA aren't cheap, but they aren't off the charts either. In "a la carte programs," initial screenings using questionnaires and take home tests, can be as low as $100 per person. It is only the drivers whose tests confirm they are truly at risk who would undergo treatment that ranges from $1,400 to $2,500. Comprehensive package programs provide education, screening, treatment, and follow-up at one price.
Treatments are usually covered by medical insurance.
Chism, an outspoken crusader for sleep testing since being diagnosed himself, offered this scenario: "What if a driver with undiagnosed OSA fell asleep and hit a school bus. The liability could put a carrier out of business, its employees out of work, all for lack of a relatively low-cost treatment. In the long run, the benefits would far outweigh the cost."
Those benefits, already enumerated above, also bring the peace of mind that comes from knowing everything has been done to make a fleet's drivers as healthy and safe as possible.
Bob Bonich, vice president, human resources at Suttles Truck Leasing, Inc., in Demopolis, Ala., was diagnosed with OSA over 20 years ago, so he was familiar with the OSA topic du jour at a NTTC seminar presented by Lowenthal. Even someone like Bonich, who knows the benefits of treating OSA, learned how widespread the disorder was in trucking. He went on to participate with Lowenthal in sleep apnea seminars to these organizations.
Today all drivers in the Suttles fleet undergo screening.
Jet Express's Jeffrey Davis, vice president, safety and human resources, decided to look into apnea after reading a research account that indicated truckers were at particularly high risk for OSA. He correctly deduced that drivers who can't get the sleep they need would have an even more difficult time if and when new, longer hours of service went into effect. His fleet now screens and treats all its drivers. The experiences of these two carriers are related in the accompanying story, Fleets Screen For Safety, page 31.
Science Of Sleep
Sleep apnea is not a new disorder, but sleep science is a relatively new area of medicine, with research only accelerating in the last decade. Testifying before the House Subcommittee on Health and Environment, Stanford's Dr. Dement stressed that sleep disorders have become one of the nation's most serious health problems.
New research is bringing OSA to the forefront of public awareness, thanks in large part to Dr. Dement and his colleagues. As more research is done on the connection between accidents and sleep-deprived drivers, you will hear even more about it.
Research results proving OSA is a clear issue for commercial drivers have been so convincing that last year the FMCSA added several "yes-no" apnea indicator questions to the truckers' medical examination form: pauses in breathing while sleeping, daytime sleepiness, loud snoring.
Labeled by some sleep specialists as too vague and open to less than truthful responses, these questions are nevertheless a signpost to the impact sleep disorder research has already made on the agency overseeing truck driver licensing.
At HDT press time, a study to determine the prevalence of sleep apnea in commercial drivers and how it affects their performance, sponsored by the American Trucking Associations Foundation and Federal Highway Administration, was about to be released. As reported in Sleep Matters, a publication of the National Sleep Foundation, the study was conducted at the University of Pennsylvania. Out of 1,400 drivers initially screened, 400 drivers were studied. Roughly 5% clearly showed severe apnea and 28% had at least mild sleep apnea.
Also, a ruling by the FMCSA was anticipated by year's end on the pilot program proposal. A pilot test can last as long as three years, although the carriers involved expect to demonstrate positive results within three months. Their objective is to show that fatigue management deserves to be an optional alternative to HOS rules.
"I now wake up without an alarm, ready-to-go"
—James Tomlins,
Star Transport
The rapidly growing demand for sleep disorders treatment has diagnostic sleep centers springing up all over the country, expanding out of universities and hospitals into private clinics. The number of accredited sleep testing facilities has risen an estimated 31% from 1999 levels.
Alternative testing options are emerging, however, that may slow this rate down. The most convenient is at-home sleep testing, a service currently being offered by clinics like SleepQuest. More cost-effective screening devices are coming into use, like a disposable SleepStrip that records breathing apneas and helps determine the next level of treatment.
Information on sleep center locations is readily available on the internet along with valuable information on OSA and sleep deprivation, as well as services for screening and treatment. Some of these sites are: www.sleepfoundation.org, www.sleepapnea.org, www.mdadvice.com, and www.medhelp.org, www.sleepquest.com and www.health-screening.com.
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