Time to prevent train collision and derailments caused by untreated obstructive sleep apnea (OSA)

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Time to prevent train collision and derailments caused by untreated obstructive sleep apnea (OSA)
Posted by Bkeppen on Monday, May 07, 2018 10:09 AM

Who says we don't a regulation to prevent more train collisions and derailments caused by train crews with untreated obstructive sleep apnea (OSA)? It certainly isn't the public.

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Posted by tree68 on Monday, May 07, 2018 3:56 PM

If there's big money to be made detecting and treating the condition, the regs will follow.

I don't mean to demean the condition - it surely exists - but if you're a hammer, everything looks like a nail.  Next thing you know, everybody will be diagnosed with it.

When I was a kid, they were going to cure cancer in "our" lifetimes.  Too many people are making money off treating it now to have that happen.

 

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Posted by Euclid on Monday, May 07, 2018 4:24 PM

If this goes forward, I don't believe that everyone will be diagnosed with OSA.  But everyone will have to be tested if they work a nighshift.  The testing is worrisome because a person's job is at stake.  If I was in this position to be tested, I would not necessarily trust the diagnosis. 

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Posted by selector on Monday, May 07, 2018 4:59 PM

A few thoughts:

Pilots even suspected of having sleep apnea (three different kinds) must have a wakefulness test. It's a long, boring test that encourages the loafing mind to drop off.  If one does drop off.......

The trucking industry is starting to come to terms with sleep apnea.  The rails, if they aren't currently, will soon follow.

I was fully asymptomatic.  Or thought I was.  I was on the phone to Revenue Canada last summer and felt my heart flutter.  An hour later, still fluttering, I was hooked up in emerg.  Diagnosis was paroxysmal atrial fibrillation.  

Over the next four months I underwent many forms of imaging, including MIBI stress test (you can look it up), echo cardiogram, and x-ray.  They were all very positive...I mean encouraging.  Whew.  Cardiologist says, okay, now the last thing is to put you through a sleep lab for a polysomnography.  A month after that event, I went to see the psychiatrist/sleep specialist about the results where I learned that I have 'severe' sleep apnea.  I had no daytime sleepiness, no falling asleep at red lights, no irritability (wife begs to differ), no headaches...just the AFib.  "So," sez the shrink, " I guess we know why you have the AFib."

I am now five months into treatment with a straight PAP machine (no bi-level or expiration pressure support).  I am also on apixaban and metoprolol for life.

We learn that truck/car drivers drive through a crosswalk and mow down several people, or they cross the centerline and cause a head-on, or they end up engine-first deep into a store or restaurant.  When the investigation is complete, the person found lying on their back in the hotel room three hours past their appointment had not brought their CPAP machine and hadn't used it.  They had slept poorly, or dangerously, perhaps the night prior to entering the hotel, and the night just past.  This happens more than one might think.  Ask the EMTs.

I won't go on, but this isn't a 'if you build it they will come' type of problem.  This is an ethical way of dealing with a growing health problem.  If you think treating cancer is expensive, ask a physician how costly atrial fibrillation is.  You'll get an earful.  Then ask the hospital administrator and co-pays how they feel about AFib.

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Posted by Semper Vaporo on Monday, May 07, 2018 5:13 PM

I LOVE my CPAP machine!  No more migraine headaches in the morning.

Semper Vaporo

Pkgs.

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Posted by tree68 on Tuesday, May 08, 2018 10:37 AM

If it's a problem, it deserves a solution.  The question is, is it the top problem?

From the post in the #2 thread, eleven deaths have been attributed to OSA in the past 17 years.  I can't find SOFA data in the time I have available right now, but I submit that more railroaders may have been killed in switching accidents in that time.

There is also the overall fatigue factor - the irregular (at best) schedules of mainline railroading are a contributor to the problem, as attested by many here in the past.

Perhaps the biggest factor is simply cost.  Someone has to pay for these tests, and the resulting treatment thereof.  

Resmed.com provides the following information:

resmed.com

■ 1 in 5 adults has mild OSA

■ 1 in 15 has moderate to severe OSA

■ 9% of middle-aged women and 25% of middle-aged men suffer from OSA

Faced with the possibility that between a fifth and a quarter of your crewmembers may have OSA, and one in fifteen may have a severe case, that potentially puts a heck of a strain on your manpower pool.

The cost to mitigate the issue may well exceed the costs accrued because of it.

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Posted by azrail on Tuesday, May 08, 2018 2:40 PM

OSA is related to body weight. We seem to be getting fatter thus more cases of sleep apnea.

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Posted by selector on Tuesday, May 08, 2018 4:31 PM

azrail

OSA is related to body weight. We seem to be getting fatter thus more cases of sleep apnea.

 

Yet, here is one instance where the chicken/egg paradox is very much to the fore.  Does weight gain necessarily raise one's measurable AHI (apnea/hypopnea incidence/hr)?  No.  Can it?  Yes. 

Does apnea, in all its varieties, lead to weight gain?  No.  Can it?  Yes.  Just like it can lead to kidney disease, heart arrhythmias, hypertension, and so on.

There is a strong correlation, but not a definitively causal relationship between each of these, not one with compelling and replicated empirical evidence.  In fact, much of the evidence people refer to is of the 'post hoc' kind, and that kind has problems far to often.

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Posted by jeffhergert on Tuesday, May 08, 2018 5:40 PM

For those diagnosed with sleep apnea and using the CPAP machine, our railroad requires documentation that the employee uses it at least 70% of the time.  Otherwise, you'll be pulled from service.  

I'm sure the railroads love the idea that the problem with fatigue is undiagnosed sleep apne among their employees.  It moves the focus away from line ups where you expect to go to work around one time, only to have the actual call move up, or back, 8 to 12 hours.  Better yet, have line ups with ghost trains.  Symbols that don't have power or cars assigned that are towards the top while active trains that are close are buried way down the list.  Or maybe don't even show up on the line up and are called out of the blue. 

Even if the line ups are fairly decent, there's also the issue of not properly staffing extra boards, pool assigned employees are forced off their regular assignment for a vacancy in the yard or other extra board protected job, the only notice being the phone ringing unexpectedly.  

What are they going to blame for fatigue when they get everyone who meets the criteria hooked up to the machine?  I'm sure they will still find some way to blame it on the employee. 

Jeff 

PS.  I just noticed in my home terminal a vacancy on the midnight yard engine, bulletined for 5 days.  So for about the next 5 to 6 days I have to watch the extra board to see if they'll be someone to take the vacancy or will they start forcing the 1st out pool employee, and where I'm at on my pool board.

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Posted by rvos1979 on Tuesday, May 08, 2018 6:03 PM

azrail

OSA is related to body weight. We seem to be getting fatter thus more cases of sleep apnea.

Tell that to a relative of mine, he is skinny as a rail, and has severe sleep apnea.......

It doesn't just affect us fat people........

Randy Vos

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Posted by charlie hebdo on Tuesday, May 08, 2018 8:08 PM

selector

 

 
azrail

OSA is related to body weight. We seem to be getting fatter thus more cases of sleep apnea.

 

 

 

Yet, here is one instance where the chicken/egg paradox is very much to the fore.  Does weight gain necessarily raise one's measurable AHI (apnea/hypopnea incidence/hr)?  No.  Can it?  Yes. 

 

Does apnea, in all its varieties, lead to weight gain?  No.  Can it?  Yes.  Just like it can lead to kidney disease, heart arrhythmias, hypertension, and so on.

There is a strong correlation, but not a definitively causal relationship between each of these, not one with compelling and replicated empirical evidence.  In fact, much of the evidence people refer to is of the 'post hoc' kind, and that kind has problems far to often.

 

Correlation Does Not Imply Causation as the cliche goes, which is mostly true.  On the other hand, one can examine causation beyond experimental designs by using more sophisticated designs and stats, such as LISREL. Hill's Criteria is used in medical research, for example.

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Posted by Bkeppen on Tuesday, May 08, 2018 8:30 PM

All of the other issues you raise are valid concerns that contribute to fatigue, however, if you have to deal with all those issues and you have moderate to severe sleep apnea, you are a safety risk to yourself and others. The compliance standard is a minimum of four hours per night, 70% of days. In other words, four hours per night in 7 out of ten days. Not a difficult standard to meet. Railroads are required by the 2008 Rail Safety Improvement Act to address those other factors, but FRA has dropped the ball on that as well. Bottom line, have run trains myself, I do not want to be out there meeting trains on single track or CTC territory who have moderate to severe sleep apnea.

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Posted by selector on Wednesday, May 09, 2018 10:34 AM

I foresee a series of adjustments in the standards for compliance and treatment, and even in the diagnostics.  There is a lot of me-tooing in the industry and medical community about sleep apnea, and a dismayingly large range of quality of care resulting from assessment, measurement, interpretation, treatment, and then follow-up for those who lose weight, have other conditions ameliorated over time, or who worsen for some reason.  It's all over the place, and probably mostly driven by insurance industry standards.  For example, some insurance schemes require the full polysomnography and a least 30 days of titration results with a set minimum compliance level.  Some will give permission for, and will reimburse subsequent CPAP equipment purchases, only after an in-home overnight oximetry.

Business could use more systems-thinking in their decision-making.  Few people can, or elect to, think in those terms when dealing with human factors.

PS- Do robots develop sleep apnea?

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Posted by zugmann on Wednesday, May 09, 2018 10:37 AM

Bkeppen
All of the other issues you raise are valid concerns that contribute to fatigue, however, if you have to deal with all those issues and you have moderate to severe sleep apnea, you are a safety risk to yourself and others. The compliance standard is a minimum of four hours per night, 70% of days. In other words, four hours per night in 7 out of ten days. Not a difficult standard to meet. Railroads are required by the 2008 Rail Safety Improvement Act to address those other factors, but FRA has dropped the ball on that as well. Bottom line, have run trains myself, I do not want to be out there meeting trains on single track or CTC territory who have moderate to severe sleep apnea.

Man, even the forums have commercials anymore.

 The opinions expressed here represent my own and not those of my employer or any other railroad, company, or person.

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Posted by zardoz on Wednesday, May 09, 2018 8:44 PM

selector
Do robots develop sleep apnea?

How about Darth Vader? "He's more machine than man" (Obi-Wan Kenobi)

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Posted by zardoz on Wednesday, May 09, 2018 8:51 PM

Euclid

If this goes forward, I don't believe that everyone will be diagnosed with OSA.  But everyone will have to be tested if they work a nighshift.  The testing is worrisome because a person's job is at stake.  If I was in this position to be tested, I would not necessarily trust the diagnosis. 

 

Coming soon to a bedroom near you: Big Brother watching you sleep.

 

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Posted by BaltACD on Wednesday, May 09, 2018 9:03 PM

Euclid
If this goes forward, I don't believe that everyone will be diagnosed with OSA.  But everyone will have to be tested if they work a nighshift.  The testing is worrisome because a person's job is at stake.  If I was in this position to be tested, I would not necessarily trust the diagnosis. 

The effects of sleep apena hit in daylight too.  EVERYONE will need to be tested, not just nightshift employees, and I would also no trust the diagnosis.

         

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Posted by Euclid on Thursday, May 10, 2018 7:49 AM

BaltACD
 
Euclid
If this goes forward, I don't believe that everyone will be diagnosed with OSA.  But everyone will have to be tested if they work a nighshift.  The testing is worrisome because a person's job is at stake.  If I was in this position to be tested, I would not necessarily trust the diagnosis. 

 

The effects of sleep apena hit in daylight too.  EVERYONE will need to be tested, not just nightshift employees, and I would also no trust the diagnosis.

 

I am not sure about that.  It used to be believed that shift work sleep disorder was caused by working rotating shifts.  Now it is believed that shift work sleep disorder can be caused by simply working a night shift only.  As you say, the effects of shift work sleep disorder can manifest during the daytime.  But can you get shift work sleep disorder if you only work days?

In any case, I would not be surprised if eventually it will come down to a decision to test everybody regardless of when they work or if they work.

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Posted by BaltACD on Thursday, May 10, 2018 9:18 AM

Euclid
 
BaltACD
 
Euclid
If this goes forward, I don't believe that everyone will be diagnosed with OSA.  But everyone will have to be tested if they work a nighshift.  The testing is worrisome because a person's job is at stake.  If I was in this position to be tested, I would not necessarily trust the diagnosis. 

The effects of sleep apena hit in daylight too.  EVERYONE will need to be tested, not just nightshift employees, and I would also no trust the diagnosis. 

I am not sure about that.  It used to be believed that shift work sleep disorder was caused by working rotating shifts.  Now it is believed that shift work sleep disorder can be caused by simply working a night shift only.  As you say, the effects of shift work sleep disorder can manifest during the daytime.  But can you get shift work sleep disorder if you only work days?

In any case, I would not be surprised if eventually it will come down to a decision to test everybody regardless of when they work or if they work.

Evidence suggests that sleep apena is linked with obesity - do obese people work during daylight hours?  We also have annecdotal evidence that sleep apena also affects 'bone skinny' people, therby establishing a case that sleep apena can affect anyone.  The matter of working day or night then becomes moot.

I have not been diagnosed with sleep apena.  During the bulk of my career that I worked nights - my day's sleep was 5-6 hours.  Now that I have been retired my nights sleep is 6-7 hours.  I can fall asleep anytime I desire - day or night.  

         

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Posted by edblysard on Thursday, May 10, 2018 12:12 PM

Not fair at all, Aimee does the same thing, no matter when or where, she can close her eyes and be out in under 10 seconds...Sad

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Posted by tree68 on Thursday, May 10, 2018 8:59 PM

Euclid
Now it is believed that shift work sleep disorder can be caused by simply working a night shift only.

I had an uncle who worked straight mids.  He always looked beat...

LarryWhistling
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Posted by Convicted One on Thursday, May 10, 2018 9:39 PM

tree68
- but if you're a hammer, everything looks like a nail.  Next thing you know, everybody will be diagnosed with it.

I know what you mean.  The symptoms and cited causes appear a little bit too "tailor made" to suit the chronic complainers, if you ask me.

"Okay, since you are fat, and smoke, and snore, and are sometimes irritable,  and won't voluntarily give up those things that are causing it, we're just going to label it a disease and hold your ability to earn a living over your head until you do comply"

Unfortunately I snore like a lawnmower. And on more than just one occassion I've been blessed to have well meaning samaritans try and convince me that I MUST  have sleep apnea, and should go get something done for my own good, when I know for a fact that their true motive is to just get a hose tethered to my face so they won't have to listen to me snore.

I mean I NEVER,  ever wake up feeling any shortness  of breath, or desperate to breathe, and so long as I get in bed early enough for at least 5 hours of sleep, I feel well rested each morning.

But since some aspect of my existance happens to fit a mold which others would like to alter, eventually they are going to find their reason.

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Posted by BaltACD on Thursday, May 10, 2018 11:01 PM

tree68
 
Euclid
Now it is believed that shift work sleep disorder can be caused by simply working a night shift only. 

I had an uncle who worked straight mids.  He always looked beat...

I prefered a straight 3rd trick schedule - while it takes some time to get used to it, once you are, you get the amount of sleep you need.  Getting used to it CAN BE A BEAR!

Swapping around tricks either in regular relief assignments or on extra boards totally wrecks any knind of repeatable schedule.

Some official positions I worked had a month daylight and a month nights.  Just as you were getting accustomed to the night schedule you were off of it.

         

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Posted by Euclid on Friday, May 11, 2018 8:03 AM

The common belief used to be that the main problem from working nights was not getting enough sleep.  The problem with rotating shifts was that they include working nights plus they are harder to get used to than working any one time shift. 

Now, the latest medical determination is that the problem is working third shift and less of a problem working second shift.  So shift work sleep disorder is only caused by working second or third shift to any extent.  it is not caused by insufficient sleep, but rather is caused by interruption of the circadian rhythms.

Not getting enough sleep is a separate problem that is not caused directly by the shift time, but is more likely with night shift work because the daytime is generally more disruptive to sleep. 

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Posted by Eddie Sand on Saturday, May 12, 2018 1:41 AM

Although I actually worked in or around the rail industry for only or a few months, I spent most of my 45-year career working non-traditional hours -- probably because I have the "lighthouse keeper" personality common to introverts, and try to avoid the politicized nature of most large-office jobs. So I think I can attest to the point that changing between shifts can be more stressful than working consistently at non-typical hours, particularly when going onto a late-night assignment with limited rest.

One of the worst schedules I ever had to cope with was a "compressed swing" arrangement: two days on the afternoon-to-midnight, followed by two on the "day watch" (usually Saturday/Sunday) -- which wasn't that bad. But i was then expected to get a few hours rest in the evening, followed by a midnight-to-8AM ordeal. (You can't force yourself to sleep, and liquor and pills pose their own risks.) I'm given to understand that this one was at one time a fairly common practice for air traffic controllers (where it was known as a "rattler") and might have figured in a particularly ugly crash in Lexington, KY about ten years ago.

The problem has been around for years, but it appears that it's begun to get some serious attention only recently.

 

 

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Posted by rvos1979 on Saturday, May 12, 2018 7:26 AM

This has been a tough one to write.........

Being in trucking, there have been programs in the works to test for sleep apnea, and some companies have gone further in testing for and treating it.  I switched to one of those companies in 2015 (hint: they pull orange trailers), and had the opportunity to get tested. The in-home test said I was negative, but I was referred to having an overnight study done, the results of which put me in the mild-to-moderate category of sleep apnea. At one point, I had stopped breathing for something like 90 seconds, if I remember what the doctor had told me correctly. So, on the CPAP machine I went. Noticed a difference the first night, when I slept completely through the night, instead of waking up two to three times during the night. I also didn't wake up with a dry throat in the morning anymore, which was confirmed a couple months later when I fell asleep without the CPAP, and woke up with a sore throat, which lasted for two days. Yes, it is a pain to have the machine with me, I have to break it down and set it up every time I change beds (from house to sleeper, and vice versa), and some places make it interesting to set up in. My company is nice enough to provide all the equipment to us, including regular shipments of consumables (masks, hoses, filters, humidifier tanks, etc) at no charge, and I had no out of pocket costs for the sleep studies, other than lost income from the overnight study, which I had to travel to.

Unfortunately, my company is one of the rare ones that paid for all the testing and therapy, other companies force the drivers to pay for the study, and then the equipment, if their insurance will not cover it. This can amount to several thousand dollars just for the study, then add costs for machines and consumables on top of that. The older machines you had to send in the data from your CPAP when requested, my newest machine has a built in WIFI hotspot that sends the data automatically. I still have to request for a data summary every time I go to the DOT doctor to renew my medical card, compliance is required to retain CDL privelidges.

I am honestly not sure what the best way is to go about screening people for sleep apnea, I dont think the proposal of being above a certain body mass index is a good way to go, as you can be thin and have sleep apnea. It may come down that it may be required that all people performing safety sensitive jobs be screened. Some guidance would be nice, but I don't see that happening from the feds anytime soon. I do agree that the underlying issue of fatigue from a non-standard sleep schedule is also a big issue, both rail and truck. Dealing with the costs of all the testing and compliance is another problem, and I don't see any resolution in that area anytime soon either........

Randy Vos

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Posted by erikem on Saturday, May 12, 2018 10:07 AM

rvos1979

This has been a tough one to write.........

Randy,

May have been tough to write, but the effort you put into comes through.

 - Erik

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Posted by Shadow the Cats owner on Sunday, May 13, 2018 8:20 AM

My boss does the same thing as your carrier rvos1979.  Why we lost one of our founders to OSA when he passed out behind the wheel of his truck going around a curve of an exit ramp and rolled his truck about 15 years ago.  The guy was beanpole thin also and no health issues what so ever.  So the carrier on its own started a OSA treatment program.  All drivers diagnosed with it are given the same machine we supply hoses masks humdifier tanks everything needed.  But then we have such a low turnover rate it isn't funny.  I think in the last 6 months we had 20 new faces come into the office as drivers.  They are all still here. 

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Posted by charlie hebdo on Sunday, May 13, 2018 11:09 AM

A factual article link from NIH. The linkage with overweight and obese is clear.  Of course some thin people may suffer also, but weight is a strong risk factor for OSA.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021364/

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Posted by BaltACD on Sunday, May 13, 2018 12:30 PM

charlie hebdo
A factual article link from NIH. The linkage with overweight and obese is clear.  Of course some thin people may suffer also, but weight is a strong risk factor for OSA.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021364/

And all of them ate mashed potatoes.  So mashed potatoes is the causitive factor.  Birth is the leading cause of eventual death!

         

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