Train accident
Re: Train accident
The PSG testing would be pre-emptive, not because the drivers are reporting that they're tired. Many may be reluctant to seek treatment for fear of losing work time or ultimately their jobs. I'm talking about passing a medical in order to get/keep a bus/truck/train license, not treating the ones who complain.
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Re: Train accident
I'm talking about being helpful to people by making a cheap fix available to them without their having to jump through expensive medical hoops.
And PSG, just as you pointed out, won't catch most of the things that can make people very sleepy and tired on a very regular basis. That makes it a very expensive but ineffective test if one has the unreachable goal of making sure sleepy people never drive.
Unless you mandate a PSG every night, you have no idea how well people sleep, for any number of reasons.
Instead of punishing people with certain conditions by labeling them unfit to be hired, let's be helpful by making it easy for people to get simple, inexpensive treatments that might actually improve things and save lives.
I would rather my driver have an untreated 5-10 AHI (many of them aren't even sleepy) than that he be someone who spends every night drinking and partying until 2:00 am, and there is no test for that. But I would also like the 30 AHI dude driving me to be able to try a machine without risking his career with a medical-test result going on his permanent record.
And PSG, just as you pointed out, won't catch most of the things that can make people very sleepy and tired on a very regular basis. That makes it a very expensive but ineffective test if one has the unreachable goal of making sure sleepy people never drive.
Unless you mandate a PSG every night, you have no idea how well people sleep, for any number of reasons.
Instead of punishing people with certain conditions by labeling them unfit to be hired, let's be helpful by making it easy for people to get simple, inexpensive treatments that might actually improve things and save lives.
I would rather my driver have an untreated 5-10 AHI (many of them aren't even sleepy) than that he be someone who spends every night drinking and partying until 2:00 am, and there is no test for that. But I would also like the 30 AHI dude driving me to be able to try a machine without risking his career with a medical-test result going on his permanent record.
Re: Train accident
I'm not certain, but I'm pretty sure every transit corporation is union and provides benefits, so I don't think there are many expensive hoops for the drivers.
A PSG catches all of the medical concerns, which is the point. I didn't say that it won't catch most things, I said it will catch anything medical, the only things it won't catch are behavioral. We are talking the legal and moral liability of someone who we trust with our lives when we board a train or bus, so as much care should be made as possible to rule out any medical causes of EDS. Sure, a PSG might delay a person being treated with a PAP, but a PAP isn't the only treatment for sleep issues, it's not going to help someone with RLS or sleep-maintenance issues.
There is no reason that both cannot be done, but some people are just unfit to drive for a living, such as those with narcolepsy
A PSG catches all of the medical concerns, which is the point. I didn't say that it won't catch most things, I said it will catch anything medical, the only things it won't catch are behavioral. We are talking the legal and moral liability of someone who we trust with our lives when we board a train or bus, so as much care should be made as possible to rule out any medical causes of EDS. Sure, a PSG might delay a person being treated with a PAP, but a PAP isn't the only treatment for sleep issues, it's not going to help someone with RLS or sleep-maintenance issues.
There is no reason that both cannot be done, but some people are just unfit to drive for a living, such as those with narcolepsy
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Re: Train accident
PSG won't catch narcolepsy, I don't think. (I think it takes an MSLT, although I ain't no pro.) It will also not ascertain how sleepy and tired you are during the day.
Many drivers are not union.
OSA as a medical condition is only a medical condition for the lower AHI people if they are sleepy from the events. If the events don't make them sleepy, they aren't considered to have OSA. PSG is not a cut-and-dried test like taking a blood test for a disease you either have or don't have. There is a LOT of gray area with OSA and other sleep conditions. That is something that makes sleep testing different from many other tests. The sleepiness/tiredness has to be self-reported. So you could have one dude honestly say he was sleepy (although for some other reason, in reality) and get labeled someone who must be treated, when another dude with the exact same PSG results could say that in his subjective judgment he is not all that sleepy, and he would be considered OSA-free. It is much the same with limb-movement conditions, etc.
I don't argue with the principle of medical screenings for people with lives in their hands. My only point is that when it comes to driving we ALL have many lives in our hands. And if it can be mandated that taxi drivers must "pass" a PSG or prove effective "treatment" for their sleepiness, there are two likely outcomes, in my opinion--(1) there will be great expense from enforcing that ridiculous policy and (2) soon it will become a mandate for people to qualify for regular licenses to drive.
Putting someone's career on the line based on subjective judgment-calls deduced from one night of data is a scary prospect, I think. Many serious sleep conditions are intermittent enough that very frequent repeated PSGs would be the only way to attempt to use PSG as a pre-emptive enforcement tool in a vain attempt to keep sleepy people off the road.
I vote for helpful over enforcement, myself.
That said, your opinion is the more common one, I believe, and you express it well. I am only arguing the minority opinion that I hold in this particular matter.
Many drivers are not union.
OSA as a medical condition is only a medical condition for the lower AHI people if they are sleepy from the events. If the events don't make them sleepy, they aren't considered to have OSA. PSG is not a cut-and-dried test like taking a blood test for a disease you either have or don't have. There is a LOT of gray area with OSA and other sleep conditions. That is something that makes sleep testing different from many other tests. The sleepiness/tiredness has to be self-reported. So you could have one dude honestly say he was sleepy (although for some other reason, in reality) and get labeled someone who must be treated, when another dude with the exact same PSG results could say that in his subjective judgment he is not all that sleepy, and he would be considered OSA-free. It is much the same with limb-movement conditions, etc.
I don't argue with the principle of medical screenings for people with lives in their hands. My only point is that when it comes to driving we ALL have many lives in our hands. And if it can be mandated that taxi drivers must "pass" a PSG or prove effective "treatment" for their sleepiness, there are two likely outcomes, in my opinion--(1) there will be great expense from enforcing that ridiculous policy and (2) soon it will become a mandate for people to qualify for regular licenses to drive.
Putting someone's career on the line based on subjective judgment-calls deduced from one night of data is a scary prospect, I think. Many serious sleep conditions are intermittent enough that very frequent repeated PSGs would be the only way to attempt to use PSG as a pre-emptive enforcement tool in a vain attempt to keep sleepy people off the road.
I vote for helpful over enforcement, myself.
That said, your opinion is the more common one, I believe, and you express it well. I am only arguing the minority opinion that I hold in this particular matter.
Last edited by jnk on Wed Apr 09, 2014 10:45 am, edited 3 times in total.
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chunkyfrog
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Re: Train accident
I wonder if a blood test would help narrow down job or license candidates,
then a PSG for those who fail the blood test --lowering the cost and eliminating "fat profiling".
High stress hormones or low nutrient levels could indicate a possible sleep disorder, (and often do)
eliminating the need for self-reported symptoms.
Back in the day, food service workers had to take a blood test to rule out a curable "social disease".
Random drug tests are often the norm for many high risk occupations--they just need to test for more than dope.
then a PSG for those who fail the blood test --lowering the cost and eliminating "fat profiling".
High stress hormones or low nutrient levels could indicate a possible sleep disorder, (and often do)
eliminating the need for self-reported symptoms.
Back in the day, food service workers had to take a blood test to rule out a curable "social disease".
Random drug tests are often the norm for many high risk occupations--they just need to test for more than dope.
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Re: Train accident
A PSG will catch narcolepsy as well as significant sleep deprivation by measuring the REM latency. If there is too much of a deviation from the norm (90-120 minutes) they'd follow it up with the MSLT which is specifically designed to gauge EDS (medically) and diagnose narcolepsy. Feeling "sleep" or "tired" and actually being medically sleepy or tired are different things, as feeling sleepy or tired without being medically diagnosed as having EDS could simply be psychological.
I'm familiar with what a PSG is, I've had 3 and an MSLT in the past 9 months and have gone over the textbooks. OSA is certainly NOT only a "sleepy" issue for those with low AHI, it still contributes to cardiovascular issues throughout the night, nor is OSA the only problem associated with your AHI score.
The point of mandatory testing is to deal with those people who may be undiagnosed, and unwilling to seek treatment or want to just tough it out.
It won't be mandated that all drivers be required to pass a PSG, but it should also be noted that untreated sleep issues (and even some treated, depending on the condition) can cause licenses to be revoked in some places.
Putting someones career on the line from a PSG is not a scary prospect. What's scary is allowing a bus load of people with a driver on the road who's unwilling to seek treatment for sleep issues he considers unnecessary.
You do not need to have one without the other. You can absolutely help people, AND enforce testing.
as for a blood test, seeing high stimulant use might also indicate that.... tonnes of caffeine or nicotine as a compensatory self-medication, and some drivers, particularly truckers, are known to sometimes abuse stimulants on a long haul.
I'm familiar with what a PSG is, I've had 3 and an MSLT in the past 9 months and have gone over the textbooks. OSA is certainly NOT only a "sleepy" issue for those with low AHI, it still contributes to cardiovascular issues throughout the night, nor is OSA the only problem associated with your AHI score.
The point of mandatory testing is to deal with those people who may be undiagnosed, and unwilling to seek treatment or want to just tough it out.
It won't be mandated that all drivers be required to pass a PSG, but it should also be noted that untreated sleep issues (and even some treated, depending on the condition) can cause licenses to be revoked in some places.
Putting someones career on the line from a PSG is not a scary prospect. What's scary is allowing a bus load of people with a driver on the road who's unwilling to seek treatment for sleep issues he considers unnecessary.
You do not need to have one without the other. You can absolutely help people, AND enforce testing.
as for a blood test, seeing high stimulant use might also indicate that.... tonnes of caffeine or nicotine as a compensatory self-medication, and some drivers, particularly truckers, are known to sometimes abuse stimulants on a long haul.
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Re: Train accident
An MSLT is needed for definitive diagnosis of that very rare condition, unless doc is sure of there being typical cataplexy, as I understand it.
There is no proof, that I know of anyway, of cardiovascular issues for low-AHI OSA sufferers.
Some tests are useful for enforcement. Others aren't. PSG ain't. In my opinion.
Even if someone considers there to be a difference between "medical sleepy" and "sleepy" (I don't), both can kill equally as well.
Bottom line, you can't enforce sleepiness.
Maybe we could get the airport-security TSA people involved in sleepiness screenings so they would have another equally-as-practical job to do all day: sleep-security theater. Then we wouldn't have to set up another useless enforcement agency to become the sleep police. All the plane passengers could eat popcorn and watch the pilots take their mandated pre-flight MSLTs behind a one-way mirror in the middle of the terminal waiting area before each flight!
There is no proof, that I know of anyway, of cardiovascular issues for low-AHI OSA sufferers.
Some tests are useful for enforcement. Others aren't. PSG ain't. In my opinion.
Even if someone considers there to be a difference between "medical sleepy" and "sleepy" (I don't), both can kill equally as well.
Bottom line, you can't enforce sleepiness.
Maybe we could get the airport-security TSA people involved in sleepiness screenings so they would have another equally-as-practical job to do all day: sleep-security theater. Then we wouldn't have to set up another useless enforcement agency to become the sleep police. All the plane passengers could eat popcorn and watch the pilots take their mandated pre-flight MSLTs behind a one-way mirror in the middle of the terminal waiting area before each flight!
Re: Train accident
Narcolepsy can be diagnosed a few different ways (and depends on the doctor and/or insurer). Typically for a medical diagnosis of classical narcolepsy a person must show 2 REM states on an MSLT, however this is not always accurate, as one can be narcoleptic as a result of brain trauma or multiple sclerosis, and as of about a year ago, studies have shown that a PSG showing a SOREM is sufficient in 95% of cases when narcolepsy is suspected. An observed cataplexy event is also a good predictor, but depending on the insurer, it may not be sufficient.jnk wrote:An MSLT is needed for diagnosis of that very rare condition, unless doc is sure of there being typical cataplexy, as I understand it.
There is no proof, that I know of anyway, of cardiovascular issues for low-AHI OSA sufferers.
Some tests are useful for enforcement. Others aren't. PSG ain't. In my opinion.
Even if someone considers there to be a difference between "medical sleepy" and "sleepy" (I don't), both can kill equally as well.
Bottom line, you can't enforce sleepiness.
Maybe we could get the airport-security TSA people involved in sleepiness screenings so they would have another equally-as-practical job to do all day: sleep theater. Then we wouldn't have to set up another useless enforcement agency to become the sleep police.
With any apnea, not just OSA, the lowered blood-oxygen levels will increase blood pressure as a compensatory measure to some degree as well as increasing respiration, regardless of the severity of the AHI. A person can have an AHI of 10 over a night, considered mild, but if all of the events took place within one specific period, the O2 drop could be severe. My apnea was only measured around 5 on average, peaking at 15 but I still need to use it because of the potential cardiac issues that may occur (and my sleep is still just as poor).
There is certainly a difference between medically diagnosed EDS and being tired. I don't qualify as EDS, but I have the attention span of a gnat and could fall asleep anywhere provided I'm left alone for 30 minutes.
I really can't understand your stance on "enforcement". All I'm saying is that to qualify for a license driving a public vehicle, you pass a sleep assessment. This would hopefully result in saving lives. You don't need an agency to do it. On the job sleepiness is already enforced to some level on drivers, they have restrictions on how long they can go without taking a break, even if they want to continue, they cannot.
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Re: Train accident
My understanding is that SOREMs are common in moderate-to-severe OSA, thus the need to get breathing cleaned up before diagnosing something rarer.
There is still no data showing below-15-AHI people are at an elevated cardiovascular risk, as far as I know. Brief desats rarely kill. (I can hold my breath for a minute right now and not risk my life.) Prolonged desats may. Although disruption to sleep and hormone surges do their fair share of the damage, I'm sure, for the higher AHI people who have been studied in connection with CV stuff.
Better to make the docs the people who help. Enough people view them as the enemy already. In my opinion. As the fed crime pathologists say, ain't nuthin' worse than a doc with a badge.
I have truckers in my family. (I am originally from KY, after all.) So maybe that has skewed my views.
Keep on a-pappin'. And let's keep it 'tween the ditches out there.
Peace out.
There is still no data showing below-15-AHI people are at an elevated cardiovascular risk, as far as I know. Brief desats rarely kill. (I can hold my breath for a minute right now and not risk my life.) Prolonged desats may. Although disruption to sleep and hormone surges do their fair share of the damage, I'm sure, for the higher AHI people who have been studied in connection with CV stuff.
Better to make the docs the people who help. Enough people view them as the enemy already. In my opinion. As the fed crime pathologists say, ain't nuthin' worse than a doc with a badge.
I have truckers in my family. (I am originally from KY, after all.) So maybe that has skewed my views.
Keep on a-pappin'. And let's keep it 'tween the ditches out there.
Peace out.
Re: Train accident
SOREMS can occur for various reasons, alzheimers, brain trauma, and severe deprivation on the scale of 48-72 hours of being awake, in addition to narcolepsy. Things are clouded when both apnea (not just OSA) and narcolepsy are suggested, but yes, in order to perform an MSLT you need to have an AHI of less than 5 on the previous nights PSG.
A brief desat will rarely kill, yes, but we're talking about long term. Those brief desaturations add up over time increasing the patients blood pressure and risk of heart attack/stroke overnight, especially if the apnea events are concentrated in one cluster.
The docs are the people who help. "Failing" a PSG wouldn't invalidate a license so long as treatment is made available, and monitored for compliance. The doctors wouldn't be enforcing anything, it would be the DMV, which they already do in many cases where there's untreated sleep issues contributing to EDS. Remember that many people with any form of apnea or sleep disturbances have been undiagnosed for years, and don't know how bad they've gotten until they start receiving treatment. It's entirely about helping the drivers, and saving the lives of the passengers in turn.
My apnea, as I said, is only mild to moderate, but I'm 35 and I've never been behind the wheel because of my sleepiness. A coworker hit 65 on his AHI at his last PSG and he was driving untreated. I know several narcoleptics who still drive
A brief desat will rarely kill, yes, but we're talking about long term. Those brief desaturations add up over time increasing the patients blood pressure and risk of heart attack/stroke overnight, especially if the apnea events are concentrated in one cluster.
The docs are the people who help. "Failing" a PSG wouldn't invalidate a license so long as treatment is made available, and monitored for compliance. The doctors wouldn't be enforcing anything, it would be the DMV, which they already do in many cases where there's untreated sleep issues contributing to EDS. Remember that many people with any form of apnea or sleep disturbances have been undiagnosed for years, and don't know how bad they've gotten until they start receiving treatment. It's entirely about helping the drivers, and saving the lives of the passengers in turn.
My apnea, as I said, is only mild to moderate, but I'm 35 and I've never been behind the wheel because of my sleepiness. A coworker hit 65 on his AHI at his last PSG and he was driving untreated. I know several narcoleptics who still drive
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chunkyfrog
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Re: Train accident
My diagnosed AHI was only 13, and I have "kissed" a few curbs (before treatment only)
I had also fallen asleep at my desk (almost daily!)
The AHI = 15 is not always a reliable cut-off.
Perhaps what we really need is a driving simulator with misc. sensors to detect diminished mental activity.
Safe driving is a responsibility--unsafe drivers need to ride or walk.
I had also fallen asleep at my desk (almost daily!)
The AHI = 15 is not always a reliable cut-off.
Perhaps what we really need is a driving simulator with misc. sensors to detect diminished mental activity.
Safe driving is a responsibility--unsafe drivers need to ride or walk.
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Re: Train accident
Same here.chunkyfrog wrote:My diagnosed AHI was only 13, and I have "kissed" a few curbs (before treatment only)
I had also fallen asleep at my desk (almost daily!)
The AHI = 15 is not always a reliable cut-off.
Perhaps what we really need is a driving simulator with misc. sensors to detect diminished mental activity.
Safe driving is a responsibility--unsafe drivers need to ride or walk.
Dunno about diminished activity, but in theory it's possible, the neurosky EEG chips are cheap enough to make a bluetooth device for a cell phone pretty easily.. and I remember that there are, or at least were, a few products to watch for rubbernecking as someone starts nodding off... though for public vehicles, I still like the idea of a random alarm going off every hour or two to check response time.
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Re: Train accident
No doubt about it Sleep Apnea places people at risk and reduces productivity!chunkyfrog wrote:My diagnosed AHI was only 13, and I have "kissed" a few curbs (before treatment only)
I had also fallen asleep at my desk (almost daily!)
I think our current ways of measuring Sleep Apnea need a major update. How about some tests to determine executive functioning and basic reflex times?chunkyfrog wrote:The AHI = 15 is not always a reliable cut-off.
Several years ago I simply let the drivers license laps and got an ID. I will consider getting another license after I stay up on a bicycle (trails and off road) for six months running.chunkyfrog wrote:Perhaps what we really need is a driving simulator with misc. sensors to detect diminished mental activity.
Safe driving is a responsibility--unsafe drivers need to ride or walk.
You are so right! None of us has the right to risk the lives of others.
That includes the doctors who need to find the Sleep Apnea before it takes the train off the tracks!!!!!
May any shills trolls sockpuppets or astroturfers at cpaptalk.com be like chaff before the wind!