This past Sunday, it appears another major accident has joined the likes of the space shuttle Challenger explosion, the Exxon Valdez disaster, and the Chernobyl meltdown as tragedies possibly related to sleep deprivation.
Sleep deprivation is not a new problem. With 45 percent of the 15 million Americans (20 percent of the workforce) engaged in shift work or nontraditional shifts and experiencing excessive daytime sleepiness, there are a staggering amount of people working when biologically they should probably be sleeping [1]. This sleepiness is causing accidents at work and accidents behind the wheel at an alarming rate. This is not surprising given the fact that these workers average five to seven hours less sleep than their non-shift worker counterparts.
Shift work disorder is a relatively new and somewhat controversial medical disorder. The diagnosis is made when an individual works a nontraditional shift, feels sleepiness as a result, and this sleepiness impacts the work life or home life in some negative way. The commuter train crash reads like a primer illustrating the finer points of shift work disorder.
For years, William Rockefeller worked as a train conductor in the afternoon. Two weeks prior to the crash, he was switched to an early morning shift (5 a.m. - 2 p.m.). Two weeks many not have been enough time to adequately adjust his circadian rhythm, as studies have shown specifically two-week periods may not be enough transition time [2]. Understand that our brains like routine, and Mr. Rockefeller's brain, for years, was in a routine whereby it was most likely soundly asleep shortly after 7 a.m., when this crash occurred Sunday. Want to see this phenomenon in action? Show up for an 8 a.m. Intro to Business Statistics lecture at a big university and look around at all of the students who all summer stayed up until 3 a.m. and slept until noon. Now forced to show up for this class, count the number of pupils nodding off during the dull lecture. This shift change is very difficult for many individuals.
As we age, particularly as we approach 50, our ability to successfully navigate shift work is compromised. As a 40-year-old doctor who has been a night owl all of my life, I sure feel it. Gone are the days I could pull all-nighters in the hospital dealing with neurology patients, go home the next day and play with my kids. William Rockefeller is 43 years old, and his age could very well have made his ability to cope with not only the shift work, but the recent schedule change very difficult.
Another independent factor making this particular shift difficult is the shift start time. Studies have shown that an independent risk factor for shift work-related problems is a first shift starting earlier than 7 a.m [3]. This 5 a.m. start time puts him right at the peak of a human's drive to achieve sleep, a factor contributing to the high amount of auto accidents at this time of day.
Another published risk factor for shift work-related difficulties is rotating backward through shifts. In other words, it is easier to move through shifts that are progressively later rather than progressively earlier [4]. This is the reason why it is easier for someone here on the East Coast to adjust to West Coast time vs. a West Coast inhabitant to fly east. Most individuals can stay up a few hours later with relative ease; it is very difficult to force yourself to fall asleep a few hours earlier.
The bottom line in relation to this issues is that our country needs to come to grips immediately with how we are going to deal with accidents related to sleepiness. We seem to have a clear understanding of what it means to drive while intoxicated. We consider this a punishable offense related to a conscious choice. What do we do about accidents related to sleepiness? Sleepy drivers pose a threat to be sure, and this threat is unique as they may as impaired as drunk drivers, yet they are less aware of their impairment.
As economic times become tighter for individuals, hours worked will become longer, and less time will be available to sleep. I see this with an increasing frequency in my own patients as more and more people seek second jobs, drive further for work, and as a result spend less time in bed. I have no idea how to solve the problems that come with less sleep. I do think the first step to solving this problem is to recognize the fact that we have a problem. So I'll say it:
Shift work and the sleep problems that can go along with it, are a huge problem.
A huge problem!
I wonder what tragic event will need to transpire for us to get serious about working on a solution. I would like to think the loss four innocent lives would provide a strong incentive to get started.
References:
1. United States Department of Labor Statistics. Workers on flexible and shift schedules.
2. Paley MJ, Tepas DI. Fatigue and the shiftworker: firefighters working on a rotating shift schedule. Hum Factors. 1994 Jun;36(2):269-84.
3. Tucker P, Smith L, Macdonald I, Folkard S. Shift length as a determinant of retrospective on-shift alertness. Scand J Work Environ Health. 1998;24 Suppl 3:49-54.
4. van Amelsvoort LG, Jansen NW, Swaen GM, van den Brandt PA. Kant Direction of shift rotation among three-shift workers in relation to psychological health and work-family conflict. J Work Environ Health. 2004 Apr;30(2):149-56.