Photo source: ANG Creative, Health Professions Recruiting Campaign
Cassandra D Howard, Col, FS, MC, TNANG
164 MDG/CC, Memphis, TN
AANGFS, Vice-President
Cassandra.Howard@ang.af.mil
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Integrity - Service - Excellence
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Headquarters U.S. Air Force
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Endurance Management
Ground Initiative
Air Force Medical
Operating Agency
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Sleep or Die
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Overview
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Impact of Fatigue
Sleep Physiology
Circadian Rhythm
Consequences
Recognition
No-Go Pills
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Impact of Fatigue
Fatigue Related Crashes
China Air Flight 006
Korean Air Flight 801
2 people injured, AC major structural damage
228 killed, AC destroyed
American Flight 1420
FedEx Flight 1478
11 killed, AC destroyed
3 severely injured, AC destroyed
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Impact of Fatigue
Three Mile Island
Challenger Space Shuttle
The Cost
Major
Accidents
Exxon Valdez
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Impact of Fatigue
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The Evidence
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Major Accidents
 Annual Cost
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Military Strategy
Human Performance
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Aeromedical Causal Factors
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Military Strategy
Exploit the Enemy’s Weakness
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Monday Night Football
100
90
80
70
60
50
40
30
20
10
0
As of:
West
East
Home
Away
MNF
MNF
Home
MNF
Away
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Causes of Fatigue
Circadian
rhythms
Sleep
loss
FATIGUE
Types of Fatigue
Acute:
Work induced
Chronic:
Repeated sleep loss
Subjective:
Stress induced
Circadian Rhythm:
Shift Work or Jet lag
Effect of operations on
sleep and circadian physiology
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Basic Human Physiology:
Sleep & Circadian Rhythms
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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
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Physiology of Sleep
NREM Sleep
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Stages 1 & 2
Stages 3 & 4
Physical Restoration
Hormone Production
Tissue Repair
REM Sleep
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Dreams
Muscle Twitching
Rapid Eye Movement
Problem Solving
Short- to Long-Term
Memory
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What’s Supposed To Happen
(Normal Sleep Histogram)
Wake
REM
REM Sleep
Stage 1
Stage 2
Stage 3
NREM Sleep
Stage 4
2400
0100
0200
0300
0400
0500
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Sleep Histogram
Wake
REM - Mental restoration
REM
Stage 1
Stage 2
Stage 3
NREM - Physical restoration
Stage 4
2400
0100
0200
0300
0400
0500
0600
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Types of Physiological
Rhythms
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Sleep-Wake
Temperature
Mental Performance
Hormones
Digestion
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Body Temperature
Sleep
No Sleep
98.6
96.5
Maximum
Sleepiness
2400
As of:
0600
0900
1200
1500
1800
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Alertness Level
Maximum
Alertness
High
Low
0900
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1200
1800
0000
0600
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Fatigue, Alcohol and
Performance
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After 17 hours of sustained wakefulness,
performance decreased to a level similar to .05
BAC
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After 24 hours of sustained wakefulness,
performance decreased to a level similar to .10
BAC
Center for Sleep Research, University of South Australia,
and University of Adelaide, South Australia (Nature, 1997)
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Fatigue, Alcohol and
Impairment
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Fatigue Signs & Symptoms
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Forgetful
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Fixated
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Poor decisions
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Apathetic
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Slowed reaction time
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Lethargic
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Reduced vigilance
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Bad mood
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Poor communication
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Nodding off
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If You Remember Nothing
Else…
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Physiological mechanisms underlie fatigue
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Just like water and food,
sleep is a physiological necessity
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Fatigue can have
severe consequences
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Financial
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Human performance
Take sleep
and fatigue seriously
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Fight The Good Fight
Combating Fatigue
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Fatigue Countermeasures:
Personal Strategies
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Preventive Strategies
 Minimizing sleep loss
 Naps
 Good sleep habits
 Effects of food, alcohol, and exercise
 Sleep environment
 Circadian strategies
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Preventive Strategies:
Sleep Loss & Strategic Napping
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Sleep Requirements and Debt
Strategic Napping (Prior to Duty)
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Can Acutely Improve Alertness
 Limit Nap: 10 - 30 Minutes
 Decreases Continuous Wakefulness
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Some Sleep is Better Than None
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Sleep Histogram
Wake
• Best method to minimize fatigue
• Limit to 10 or 20 minutes
REM
 Try not to nap within 5 hours bedtime
Stage 1
• Avoid sleep inertia
Stage 2
 Disorientation and lethargy for 5-20 mins
Stage 3
Stage 4
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0300
0400
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Preventive Strategies:
Good Sleep Habits
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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
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Preventive Strategies:
Sleep Environment
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Dark, Quiet Room
White Noise
Comfortable Temperature
Comfortable Sleep Surface
Large Meals & Indigestion
Lack of Food
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Self-Medication
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Supplements and
the Human Trend
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.
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Self-Medication
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Effects of Medications
Desired Effects – treats the symptoms
• Side Effects – other effects on the body
• Allergic Reactions
• Combined Effect – 1 + 1 = 3
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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
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Personal Strategies:
Operational Countermeasures
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Physical Activity Combats Sleepiness
 Social Interaction and Conversation
 Diet and Hydration
 Bright Lights
 Strategic Caffeine Consumption
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Strategic Caffeine Use
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15 to 30 minutes to take effect
Effects can last for up to 3-4 hours
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Chocolate
Pepsi
Coke
Mt Dew
Instant Coffee
Drip Coffee
1-35 mg caffeine
36 mg caffeine
46 mg caffeine
54 mg caffeine
40-108 mg caffeine
90-150 mg caffeine
1 oz
12 oz
12 oz
12 oz
5 oz
5 oz
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Sleep Food
•Carbohydrates
•Pasta
•Corn
•White Bread
•Potatoes
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Alert Foods
• Protein
• Nuts and Seeds
• Meats/Cold Cuts
• Peanut Butter
• Cheese
• Eggs
• Fish
• Yogurt
• Beans
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“No Go” Pills
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.
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AF guidance (vol 3)
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FS Recommendations
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<= 7 consecutive days (Sonata <=10 consecutive days)
<= 20 in a 60 day period (Sonata <= 28 in a 60 day period)
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
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Smart Phone Apps
As of:
Android
iPhone
Bedtime 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
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Summary
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Impact of Fatigue
 Sleep Physiology & Circadian Rhythms
 Consequences & Recognition
 Preventive Strategies
 Operational Countermeasures
 No Silver Bullet, No Magic Pill
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