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Article #67

SUMMARY

Note: This is an overview article rather than a primary research report, but the main issue here seems important and timely enough to warrant its inclusion here. Pulmonary physicians have to become familiar with the effects of severe sleepiness on behavior, now that it has been associated with a sevenfold increase in risk of motor vehicle accidents. People in general have a 24-hour daily cycle of changing alertness and performance, with two low points, in the early hours of the morning and in the early afternoon. These times show increased tendency to sleep, to performance impairments (such as reading errors by factory workers), and even to timing of disease-related deaths. There is also a "forbidden zone" of decreased tendency to sleep in the early evening. Other factors which increase sleepiness--such as sleep deprivation, sedative drugs, and sleep apnea--superimpose their effects on the daily cycle. Thus, the patient with sleep apnea will be most vulnerable to sleepiness in the early morning and afternoon. The author feels such research findings should be integrated with public policy. In safety-sensitive jobs, people with disorders of excessive sleepiness "should be identified and treated or excluded." Other measures he suggests for industry include public education about sleep, special concern for individuals working alone, extra performance checks at high-risk times of day, use of fitness-for-duty tests, and preplanned naps in the work periods. With respect to driving privileges, the author notes key features of the American Thoracic Society's position. Brief summary of that position includes: acknowledgement of high risk for driving accidents in sleep apnea patients with EDS who have some history of accidents; the need to warn such a patient and discuss immediate ways to reduce risk; prompt start of treatment with close monitoring of compliance and effectiveness; no restriction of driving for sleep apnea patients without accident history; doctors to follow state laws in determining which patients to report to authorities; criteria for reporting should include not only the previously mentioned factors but also whether the patient is treatable, whether he will accept treatment, and whether he will restrict driving. The author notes the updating of a California law to require reporting of "every patient...diagnosed as having a disorder characterized by lapses of consciousness" to include specifically sleep apnea and narcolepsy. Lawyers have supported doctors following this rule strictly, with or without the patient's knowledge. But some doctors delay this to give time for adequate treatment, which may be defensible if it is the prevailing standard of care. Consistent failure to report, however, may result in suspension of physician licenses.

COMMENTS

Before I started to do literature research on this issue, I had sleep apnea with EDS ineffectively treated, despite my compliance, for several years. I don't recall any accidents for most of this time, but I did notice often getting so sleepy during a one-hour commute that my car would veer into another lane, drawing honks of alarm. When I finally did have an accident it was so minor--letting my brake pedal up while standing in a line of traffic and gently bumping the car ahead of me, causing no injury or damage--that no police report resulted. However, when I mentioned this to my sleep doctor, I learned that the Pulmonology Society's policy required him to insist I stop driving until my EDS cleared up. Without thinking it through, I acquiesced. At that point I wasn't working so had no need to commute. I lived within walking or bicycling distance of stores and libraries. My wife, I thought, could drive me where I needed car transportation, such as to appointments, some of which were 60 miles away. But I hadn't realized the burden it would place on my wife, with a full-time job, to have to do all the errands that required a car. Most of my many medical appointments, even in our home city, required a driver. These needed scheduling in relation to her days off, which thereby got consumed. Our stress level rose at a time already quite stressful for many reasons. How much worse would this be for a patient who wanted--had--to continue working at a job, maybe inaccessible by public transportation? How difficult would it be to find a new job if you had to explain your reason for moving? Most patients with sleep apnea should be quite treatable. Perhaps it is even useful to have some pressure applied to compel them into treatment. But being treatable does not mean that within a short time after diagnosis, the symptoms will be fully controlled. In fact, not only may the illness itself take many months of adjustment to work most effectively, the limited availability in time of sleep clinic appointments, sleep lab assessments, and sleep study readings, may all add to the delay. Meanwhile, many patients may not be financially secure enough to stop working for months without catastrophic effects. Finally, consider how many jobs may be called "safety-sensitive." We might start by thinking of technicians in nuclear power plants, airline pilots and air traffic controllers, drivers of trucks, buses, and taxis, policemen, and so forth. But where actually would the list end? I recently heard of a judge who was fired for falling asleep at the bench...

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