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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Cassandra D Howard, Col, FS, MC, TNANG 164 MDG/CC, Memphis, TN
AANGFS, Vice-President
As of: 4
Photo source: ANG Creative, Health Professions Recruiting Campaign
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Headquarters U.S. Air Force
As of: 5
Endurance Management Ground Initiative
Air Force Medical Operating Agency
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 7
Basi
c S
l eep
Ph
ysi
ol o
gy
Basi
c S
leep
Ph
ysi
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gy
Sleep or Die
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 8
Impact of Fatigue Sleep Physiology Circadian Rhythm Consequences Recognition No-Go Pills
Overview
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Impact of Fatigue
FedEx Flight 1478FedEx Flight 1478American Flight 1420American Flight 1420
Korean Air Flight 801Korean Air Flight 801China Air Flight 006China Air Flight 006
2 people injured, AC major structural damage 228 killed, AC destroyed
11 killed, AC destroyed 3 severely injured, AC destroyed3 severely injured, AC destroyed
Fatigue Related Crashes
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Impact of Fatigue
As of: 10
Major Accidents
Three Mile Island
Challenger Space Shuttle
Exxon Valdez
The Cost
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 11
The Evidence Major Accidents Annual Cost
Military Strategy Human Performance
Impact of Fatigue
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Aeromedical Causal Factors
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 13
Exploit the Enemy’s Weakness
While remembering
our own limitations
Military Strategy
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 15
0102030405060708090
100
Home Away MNF MNFHome
MNFAway
WestEast
Monday Night Football
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 16
Effect of operations on Effect of operations on sleep and circadian physiologysleep and circadian physiology
FATIGUEFATIGUE
Sleep Sleep lossloss
CircadianCircadianrhythmsrhythms
Types of Fatigue
Acute:Work induced
Chronic:Repeated sleep loss
Subjective:Stress induced
Circadian Rhythm:Shift Work or Jet lag
Causes of Fatigue
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 17
Sleep – A Vital Physiological Function Sleepiness Affects Waking Performance, Vigilance,
and Mood Sleep Loss Accumulates Into A Sleep Debt Physiological Versus Subjective Sleepiness The Circadian Pacemaker
Basic Human Physiology:Sleep & Circadian Rhythms
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 18
Stages 1 & 2 Stages 3 & 4 Physical Restoration Hormone Production Tissue Repair
Dreams Muscle Twitching Rapid Eye Movement Problem Solving Short- to Long-Term
Memory
NREM NREM SleepSleep
REM REM SleepSleep
Physiology of Sleep
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
NREM Sleep
REM Sleep
WakeWake
REMREM
Stage 1Stage 1
Stage 2Stage 2
Stage 3Stage 3
Stage 4Stage 4
2400 0100 0200 0300 0400 0500 0600 2400 0100 0200 0300 0400 0500 0600 07000700
What’s Supposed To Happen(Normal Sleep Histogram)
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Wake
REM
Stage 1
Stage 2
Stage 3
Stage 4
2400 0100 0200 0300 0400 0500 0600 0700
REM - Mental restoration
NREM - Physical restoration
Sleep Histogram
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 22
Sleep-Wake Temperature Mental Performance Hormones Digestion
Types of Physiological Rhythms
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 23
SleepSleep No SleepNo Sleep
98.698.6
96.596.5 MaximumMaximumSleepinessSleepiness
2400 0600 0900 1200 1500 18002400 0600 0900 1200 1500 1800
Body Temperature
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 24
0900 1200 1800 0000 0600 09000900 1200 1800 0000 0600 0900
HighHigh
LowLow
MaximumMaximumAlertnessAlertness
Alertness Level
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 25
After 17 hours of sustained wakefulness, performance decreased to a level similar to .05 BAC
After 24 hours of sustained wakefulness, performance decreased to a level similar to .10 BAC
Center for Sleep Research, University of South Australia,Center for Sleep Research, University of South Australia,and University of Adelaide, South Australia (Nature, 1997)and University of Adelaide, South Australia (Nature, 1997)
Fatigue, Alcohol and Performance
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Fatigue, Alcohol and Impairment
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 28
Forgetful
Poor decisions
Slowed reaction time
Reduced vigilance
Poor communication
Fixated
Apathetic
Lethargic
Bad mood
Nodding off
Fatigue Signs & Symptoms
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 29
Physiological mechanisms underlie fatigue
Just like water and food,sleep is a physiological necessity
Fatigue can havesevere consequences
Financial
Human performance
Take sleepand fatigue seriously
If You Remember Nothing Else…
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 30
Fight The Good Fight Combating Fatigue
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 31
Preventive Strategies Minimizing sleep loss Naps Good sleep habits Effects of food, alcohol, and exercise Sleep environment Circadian strategies
Fatigue Countermeasures:Personal Strategies
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 32
Preventive Strategies:Sleep Loss & Strategic Napping
Sleep Requirements and Debt Strategic Napping (Prior to Duty)
Can Acutely Improve Alertness Limit Nap: 10 - 30 Minutes Decreases Continuous Wakefulness
Some Sleep is Better Than None
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Wake
REM
Stage 1
Stage 2
Stage 3
Stage 4
2400 0100 0200 0300 0400 0500 0600 0700
• Best method to minimize fatigue• Limit to 10 or 20 minutes Try not to nap within 5 hours bedtime
• Avoid sleep inertia Disorientation and lethargy for 5-20 mins
Sleep Histogram
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 34
Preventive Strategies:Good Sleep Habits
Regular Sleep/Wake Schedule Develop/Practice Regular Pre-Sleep Routine Avoid Heavy Meals Avoid Alcohol and Caffeine Physical/Mental Relaxation Techniques No Sleep in 30 Minutes…Get Out of Bed
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 35
Preventive Strategies:Sleep Environment
Dark, Quiet Room White Noise Comfortable Temperature Comfortable Sleep Surface Large Meals & Indigestion Lack of Food
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Self-Medication
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
2000 B.C….Here, eat this root.1000 A.D….Roots are heathen.
Say this prayer.1850 A.D….Prayer is superstition. Drink this potion.1940 A.D….That potion is snake oil.
Swallow this pill.1985 A.D….That pill is ineffective.
Take this antibiotic.2000 A.D….That antibiotic is artificial.
Here, eat this root.
Supplements and the Human Trend
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
• Effects of Medications• Desired Effects – treats the symptoms• Side Effects – other effects on the body• Allergic Reactions • Combined Effect – 1 + 1 = 3
• Companies combine antihistamines and decongestions to off set each other
•Over-the-Counter Medications•Antihistamines = sedation, drowsiness•Decongestants = nervous, dizzy, sleepy•Cold preps = most contain alcohol
Self-Medication
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 39
Personal Strategies:Operational Countermeasures
Physical Activity Combats Sleepiness Social Interaction and Conversation Diet and Hydration Bright Lights Strategic Caffeine Consumption
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 40
Strategic Caffeine Use
15 to 30 minutes to take effect Effects can last for up to 3-4 hours
Chocolate 1-35 mg caffeine 1 oz Pepsi 36 mg caffeine 12 oz Coke 46 mg caffeine 12 oz Mt Dew 54 mg caffeine 12 oz Instant Coffee 40-108 mg caffeine 5 oz Drip Coffee 90-150 mg caffeine 5 oz
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 41
Sleep Food
•Carbohydrates•Pasta•Corn•White Bread•Potatoes
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 42
Alert Foods
• Protein
• Nuts and Seeds
• Meats/Cold Cuts
• Peanut Butter
• Cheese
• Eggs
• Fish
• Yogurt
• Beans
• Protein
• Nuts and Seeds
• Meats/Cold Cuts
• Peanut Butter
• Cheese
• Eggs
• Fish
• Yogurt
• Beans
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
“No Go” Pills
AF guidance (vol 3) <= 7 consecutive days (Sonata <=10 consecutive days) <= 20 in a 60 day period (Sonata <= 28 in a 60 day period)
FS Recommendations As little as needed (but they can help jet lag) Bad sleep is not an Ambien deficiency
Melatonin is a no-go that’s a no-go
Medication Dose Half-life Grounding
Temazepam (Restoril®) 15 or 30 mg 8.0-12.0 h 12 hours
Zolpidem (Ambien®) 10 mg 2.0- 2.5 h 6 hours
Zaleplon (Sonata®) 10 mg 1.0 h 4 hours
Ground testing required prior to operational use.
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Smart Phone Apps
As of: 45
Android iPhoneBedtime Calculator (Free)- REM cycle monitoring
Crew Alert ($29.99)- Your wildest dreams come true!
Sleepy Time (Free)- Chromotherapy
Sleep Science Alarm ($.99)- REM cycle monitoring
Sleep Watcher (Free)- Daily fatigue estimation
Fatigue Calculator (Free)- Daily fatigue estimation
Relax and Sleep Plus (Free)- Ambient noises
aSleep 3 ($.99)- REM cycle monitoring
- Chromotherapy
Sleep Now! (Free)- Ambient noises
Circadian Alarm ($.99)- REM cycle monitoring
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 46
Summary
Impact of Fatigue Sleep Physiology & Circadian Rhythms Consequences & Recognition Preventive Strategies Operational Countermeasures No Silver Bullet, No Magic Pill