The Case for Mandatory Sleep Apnea Testing, Part 3: The Need for Universal Testing and Treatment

In Part 1 of this series, we learned that an eye-opening study of 517 Australian truck drivers found that 45% of them possessed Obstructive Sleep Apnea (OSA) — while only four of those 45% knew of it before being tested for it. We learned that the criteria for “screening” to identify those likely to have OSA likely catches most of them, but hardly all of them. We learned that, currently, FMCSA regulations govern only one aspect of driver fatigue (the duration of the shift), while the Administration recently issued an Advanced Notice of Proposed Rulemaking (APRM) only for OSA “screening” — effectively ignoring “the other 60% — where a large, aerobically-fit “false positive” would be ensnared in the net while some skinny, jumpy, heavily-caffeinated and poorly-nourished driver who rarely exercised, but experienced regular “sleep debt,” would likely fall through the cracks. It seem almost obvious that most catastrophic accidents are the result of drivers who were transitioning into sleep or who had fallen fast asleep for a significant period of time — not from one experiencing an occasional one- or two-second microsleep.

            In Part 2 of this series, I argued that simply screening for OSA was not enough. Since about 40% of all commercial drivers likely have it, 2 1/2 times the proposed effort would subject all of them to testing. We also learned in Part 2 that relatively inexpensive, portable equipment for testing individuals for OSA is already available. And we learned how much ground a 45-foot motorcoach traveling at 60 mph would cover during a single second of an OSA-induced “microsleep,” coupled with the additional ground it would cover during a driver’s almost miraculous, instant recovery from it to (a) normal reaction time and distance and (b) braking distance — i.e., under unrealistically perfect conditions (the driver awakened immediately alert, recognized the problem immediately, and slammed on his or her brakes). So I argued that testing merely those who meet superficial screening criteria is not enough.

            In this third and last installment, I will address some of the problems of treating individuals with OSA even after this condition is detected. And I will include evidence that even mandatory OSA testing of all drivers lies far short of what is needed to address the problem, and that far more important factors are being ignored.

Adventures in False Diagnosis and Elusive Cures

            Possessing an abnormally-long sleep/wakefulness cycle literally since childhood, I myself possess none of the classical symptoms of OSA. Yet just to rule it out, my regular doctor recently suggested that I undergo a test for OSA, which I did. The greedy, overpaid “specialist” analyzing my test results informed me that I had a low level of OSA, and recommended I purchase a treatment machine — followed by a series of costly visits, all of which I did and all of which failed to improve anything. Only after finding a doctor who would even let his staff tweak my machine between visits months apart, I learned that I did not have OSA at all. Instead, my “sleep lab” experience produced OSA-related symptoms brought about the thick the haze of medication I take to simply fall asleep (and which rarely lets me sleep through the night without my taking yet more of it to fall back to sleep again).

            My present sleep specialist’s treatment goal is for me to learn how to create a “transition” between my frantic daytime schedule (compressed partly because of the additional hours I waste sleeping due to my medication) and some magical state that will help me lull myself to sleep more quickly, and with less medication. Yet no doctor and no treatment can address the “Elephant in the Room” — my abnormally long sleep/wakefulness cycle. My treatment regimen is as hopeless as if it tried to make me taller or reverse my increasing hair loss.

Constraints Lying Beyond Our Industry’s Control

            During my four decades as a public transportation professional, I have found it to be a frustrating theme that the causes of a great many of our community’s problems lie outside of the transportation field, and almost completely beyond our control. An illustrative handful include the steep, parabolic decline in drivers’ salaries in real-dollar terms, the impact of mega-acquisitions on safety, and the extraordinary commercial and institutional resistance to measures that would keep drivers alert and awake. Many of the largest of our nation’s motorcoach services do not possess a shred of a fatigue management program, relying instead on fatigue-oriented driver education — when it is well recognized that drivers are incapable of detecting their own fatigue. But every one of these dynamics reflects the extremes in our distribution of wealth.

            At the personal level, this latter dynamic has made the effective treatment of my sleep symptoms nearly impossible. This is largely because “specialists” earn a fortune for a slew of 15-minute “consultations” during which time they perform a procedure or tweak the setting of some medical device. But there is not a dime in having their technicians adjust the settings of this same device. As noted, a more honest doctor concluded that I did not have OSA at all.  Nevertheless, I wasted almost an entire year simply finding this out. And no practical remedy lies in sight.  The problem — and the point of this article  — is that I cannot possibly be the only one with such problems.

Implications for the Commercial Vehicle Industry

            Extrapolating from my own experiences to the world of U.S. public transportation, it should be clear that merely determining who has and does not have OSA is not so simple. The real challenge, in our society and our economy,  lies in treating it.

            From the FMCSA’s and FAA’s joint ANPRM and other sources, I learned that three months after a pilot has been diagnosed with OSA, he or she can return to flying — even if treatment for OSA has not yet even begun. Parallel to this, our passenger rail trains occasionally derail at nearly triple the speeds at which they should be traveling — when measures to prevent this are as old as railway technology itself (i.e., flagmen, dead man switches and switch tracks).  But in our society, adding another motorman to the locomotive is unthinkable. Instead, AMTRAK cannot afford costly digital “positive train control.” So we have none.

            When we combine such dynamics with the problems of treating drivers or motormen with OSA, it is easy to see why we have the catastrophic accidents we do. And we can see why one of our largest intercity motorcoach carriers — with drivers operating the same shifts or pairs of shifts day after day –experienced four catastrophic accidents this past year alone.

Slim Odds but Good Baby Steps       

            In this environment, it is easy to see why things are likely to get worse rather than better. 13 years ago, with the chance to regulate shift inversion out of existence in commercial vehicles (as the Canadians did shortly afterward),  our industry representatives lobbied against regulations to limit it at the scheduling and driver assignment levels, arguing instead that all we needed were “fatigue management programs.” Hundreds or  thousands of motorcoach passengers have died or been mutilated by that decision. So now, more than a decade later, we are being offered a shot at another meaningful partial solution — “screening” drivers for OSA.  In fairness, screening alone would likely take a huge bite out of our cascade of catastrophic accidents if (a) the screening identified those likely to have the condition, (b) those individuals were administered testing, and (c) they were treated. Of course, as my own experiences demonstrate, even with inexpensive diagnostic equipment available, actual treatment can be a goose-chase for the most persistent and dedicated driver. One could argue from this scenario that screening for OSA is of limited value. But clearer thinking suggests that, instead, more should be done. We should test everyone.

            Focused solely on OSA, the latest proposed rulemaking also makes no distinction between drivers who awaken naturally (to operate shifts compatible with their natural sleep cycles) compared to those jolted awake by an alarm clock — so that they can operate a shift when, at least part of the time, their bodies should be sound asleep. Similarly the rulemaking overlooks different types of drivers — including the fact that “early-risers” are excellent candidates to assign to shifts with pre-dawn start-times, while “late risers” would have little difficulty safely operating “night “and “owl” service. Other notions in the rulemaking, such as the claim that OSA diagnosis can be effectively “done by any physician,” are as ignorant as they are dangerous. In other words, while admittedly a commendable step, the rulemaking’s focus on “screening” omits the consideration of the fundamentals of sleep that facilitate driver fatigue when not properly managed. Nor is any consideration given to issues like monitoring or privacy — much less the time often needed between diagnosis and successful treatment. Should a driver or motorman still struggling with this transition even be allowed to operate a vehicle — much less a pilot allowed to fly a plane?

Embracing Opportunities Where We Can Find Them.

            Knowing all the failures, loopholes, ignorance, disinterest, institutional resistance and economic/commercial problems still before us, are we actually debating the significant baby step that screening for OSA would accomplish? Are we so shortsighted or pound-foolish that the FMCSA and FAA have not even considered the mandatory testing of all vehicle operators among the choices in their rulemaking?

            I recognize that money does not grow on trees. Government is sometimes slow or reluctant to act. And it often serves as an institutional puppet to much stronger powers with far greater resources and more genuine control over policy-making. Only two years ago, Congress literally forbid the FMCSA from issuing the rulemaking it recently released advanced notice of. So it would be naive to think that these two administrations (the FMCSA and FAA) can eliminate the tragedy of catastrophic accidents in one swoop. But despite their limitations, the regulations proposed would offer a significant promise of almost certainly reducing the level of mayhem. And if they form a slippery slope to even stronger, more diverse and more stringent regulations in the future, this is a slope we should welcome and embrace.

            The FMCSA and FAA should be applauded for their institutional courage in bringing this rulemaking to the forefront. We would be foolish to not push it as far as it can go.

Publications: National Bus Trader.