Sleep 2023.03.15 Flynn-Evans
March 19, 2023ID9697
To CiteDCA Citation Guide
- 00:00And now I have the great pleasure
- 00:03of introducing today's speaker,
- 00:04doctor Erin Flynn Evans.
- 00:06Doctor Evans is a research psychologist
- 00:08at the NASA Ames Research Center
- 00:11in California, where she leads
- 00:12the Fatigue countermeasures lab.
- 00:14She holds a PhD from the University
- 00:16of Surrey, UK, and an MPH from
- 00:18Harvard School of Public Health.
- 00:20She was also certified as an
- 00:23RPSGT from 2002 to two 2012.
- 00:26Prior to joining NASA,
- 00:27she was an instructor in medicine
- 00:29and the Division of Sleep Medicine.
- 00:31Brigham and Women's Hospital and
- 00:33Harvard Medical School and also as a
- 00:36pivotal team in the duty our changes.
- 00:38Doctor Roslyn Evans has extensive
- 00:41research experience examining the
- 00:42short and long term effects of sleep
- 00:45loss and circadian desynchrony in
- 00:47occupational settings including
- 00:48among astronauts, airline pilots,
- 00:50physicians and other shift workers.
- 00:53She's involved in both lab based
- 00:55and field based research.
- 00:56Her lab based research has focused
- 00:58on examining the effects of light
- 01:00and circadian neuroendocrine.
- 01:01And neurobehavioral responses in
- 01:03humans and how these outcomes relate
- 01:05to the development of countermeasures
- 01:07for shift work or field research has
- 01:10involved integrating these measures of
- 01:12fatigue and associated countermeasures
- 01:13into complex operational setting.
- 01:15And she has also received the
- 01:17NASA Honor award for her research
- 01:19and for her management,
- 01:21along with the NASA Superior Accomplishment
- 01:23award. She's also very active
- 01:25with the American Academy of Sleep
- 01:27Medicine and Sleep Research Society.
- 01:29She's a member of their extensive.
- 01:31Extrinsic circadian rhythm
- 01:33disorder guidelines,
- 01:34task force and Public Safety Committee.
- 01:36She also serves as a member of
- 01:39the Impairment Advisory Board
- 01:40and the National Safety Council
- 01:41with her very unique experiences
- 01:44of working with the astronauts,
- 01:45pilots and her work on circadian disruptions,
- 01:47shift work and fatigue mitigation.
- 01:49It is with great delight and
- 01:51enthusiasm that I would like to
- 01:52hand it over to doctor Flynn Evans
- 01:54to share her experiences with us
- 01:56and thank you again for joining us.
- 01:59Oh, well, thank you so much for that
- 02:02introduction, Dr. Papa. That was.
- 02:06I feel, I hope I can live
- 02:08up to that introduction.
- 02:10That was amazing.
- 02:11So thank you so much for the
- 02:14invitation to speak today.
- 02:16I I did speak actually a couple
- 02:19of years ago to this group,
- 02:22and during that talk I discussed
- 02:26my work in Space Flight,
- 02:29studying sleep and circadian
- 02:30rhythms and astronauts.
- 02:32So this is a little bit different.
- 02:33And today I'll be talking
- 02:34about some of the other.
- 02:35Work that we do specifically around
- 02:38managing sleep loss and circadian
- 02:40misalignment and shift work,
- 02:42so I don't have any.
- 02:45Financial relationships with
- 02:47ineligible companies and I am sure
- 02:50I'll leave this here for a moment so
- 02:53you can text for your CME credit.
- 02:57And hopefully. That's enough.
- 03:00All right.
- 03:01So to begin,
- 03:02you may wonder just why someone from NASA
- 03:06is here to speak about best practices.
- 03:10Firstly,
- 03:10alas and circadian misalignment
- 03:12and shift work.
- 03:13And so I thought I'd just start with a
- 03:16couple of slides describing what NASA
- 03:18does and then where I fit into that puzzle.
- 03:21So I'm sure that you've heard
- 03:23of Johnson Space Center,
- 03:24where we have Mission Control for astronauts.
- 03:26I'm sure that you've heard
- 03:27of Kennedy Space Center,
- 03:28where we do many of our
- 03:30launches and landings.
- 03:31For our space missions,
- 03:32but we actually have 10 centers at NASA and
- 03:36these centers all have distinct functions.
- 03:39We have some,
- 03:40we have Goddard Space Center,
- 03:42which is focused on
- 03:44astrophysics and astronomy.
- 03:46We have Glenn Research Center,
- 03:48which is focused on aeronautics,
- 03:49Langley Research Center.
- 03:51We have JPL,
- 03:52which I'm sure you've also heard of,
- 03:54where we do most of the Mission
- 03:56Control work for our Mars Rovers.
- 03:58And then I work up here in the California.
- 04:01Bay Area at NASA Ames Research Center.
- 04:04And you know, I'm probably biased,
- 04:07but I do think our center is the best,
- 04:09especially for research because it
- 04:12operates much like a university campus.
- 04:15So we are a government agency,
- 04:17but we are sort of the the research
- 04:19test bed for all of the work that
- 04:22happens around the rest of the agency.
- 04:24So we have people at NASA Ames who
- 04:26are doing work in molecular biology,
- 04:29who are doing work in materials.
- 04:31Engineering.
- 04:32And then in human systems integration,
- 04:35which is where my lab falls.
- 04:37And in my lab,
- 04:39my lab is the fatigue
- 04:41countermeasures laboratory.
- 04:43I didn't name it,
- 04:44and I'll get in a minute into what,
- 04:47how I feel about the word fatigue.
- 04:49But in my lab,
- 04:50we do Space Flight research again.
- 04:52That's what I spoke about
- 04:53a couple of years ago.
- 04:54And then we also do aeronautics work
- 04:57and mission operations support and with
- 05:00aeronautics and mission operations.
- 05:03Much of the work that we
- 05:04do here is both research.
- 05:06So we do studies to characterize
- 05:09problems and to better understand how
- 05:12people cope with the types of shift
- 05:16work schedules that they have to do.
- 05:19And then we also deploy countermeasures.
- 05:22And so sometimes that's a very
- 05:24formal process where we're
- 05:25doing a research study in step testing
- 05:27the effectiveness of a countermeasure,
- 05:29but sometimes that's just taking the
- 05:31knowledge that we've learned from a study.
- 05:33And deploying the countermeasure
- 05:36broadly across a particular population.
- 05:39And so the majority of what I'm going to
- 05:42talk to you about today really is based on
- 05:45the work that we do in these two areas.
- 05:48So overall today, I just want to
- 05:51quickly cover shift work biology.
- 05:53I only have a couple of slides here.
- 05:55I know I'm talking to a a Sleep
- 05:57Medicine group.
- 05:58And so I think that you're all very
- 06:01knowledgeable in this area already.
- 06:04But to make sure we're on the same page,
- 06:06I'll cover a couple of basics and
- 06:08then I'll talk about some of the
- 06:10short and long term health outcomes
- 06:11that are associated with shift
- 06:13work and I'll spend the majority
- 06:15of time talking about mitigations.
- 06:17So what is fatigue risk management,
- 06:20how do we implement it and how can
- 06:23that potentially be translated
- 06:25to patient populations?
- 06:27Much of the work that I'll talk about
- 06:30today comes from a task force that I
- 06:33was involved in that was sponsored by
- 06:35the American Academy of Sleep Medicine
- 06:38and the Sleep Research Society.
- 06:40This was an amazing group of
- 06:43researchers and clinicians that came
- 06:45together with the ultimate goal of
- 06:48trying to understand how the length
- 06:51of a shift would impact alertness,
- 06:54performance, health, and safety.
- 06:56But as we.
- 06:57Really got into this as our working
- 07:00group met.
- 07:01You know we we were scheduled
- 07:02I think for 8 hours a day.
- 07:04We ended up being at the ASM offices
- 07:07for something like 12 hours a
- 07:09day because we had lots and lots
- 07:11of discussion about this topic.
- 07:14We really came to the conclusion,
- 07:16which I think probably will
- 07:18resonate with many of you,
- 07:19that when it comes to shift work the
- 07:21answer is almost always it depends
- 07:23because you can't really apply A1 size
- 07:26fits all recommendation or strategies.
- 07:28Every population to every occupation,
- 07:31you really have to look at the
- 07:34characteristics of a work group,
- 07:36the characteristics of the
- 07:37individuals within that work group,
- 07:39and then the potential consequences of any.
- 07:43Accidents or incidents that may come from.
- 07:47Excessive sleepiness within a population.
- 07:50And so this.
- 07:52Article is really, you know,
- 07:56a nice, I think,
- 07:57summary of what I'll talk about here
- 08:00it I'll give you the Cliff notes.
- 08:02The article goes into more detail
- 08:04on all of these topics if you're
- 08:07interested in further reading.
- 08:09So to begin shift work,
- 08:11it is a term that can be very
- 08:14difficult to define.
- 08:15I think we all sort of know what
- 08:17shift work is,
- 08:17but when it comes to putting down
- 08:19a definition,
- 08:19if you ask 20 people,
- 08:21you'll probably get 20 different definitions.
- 08:24I just grabbed this from dictionary.com,
- 08:26but I I really actually like this definition,
- 08:29which is just a system of employment
- 08:31where an individual's normal work
- 08:32hours are in part outside the
- 08:34period of normal day working and
- 08:36may follow a different pattern
- 08:37and consecutive periods of weeks.
- 08:39And I like this definition in
- 08:41particular because I think a lot of
- 08:43times when we think about shift work,
- 08:45many people are thinking about
- 08:47night work or rotating shift work.
- 08:49And in reality, we have many people in
- 08:52many different occupations who have to
- 08:54work what many would classify as day.
- 08:57But where those shifts start maybe
- 08:59at 5:00 in the morning or where maybe
- 09:01those shifts end around midnight,
- 09:03you know, is that really a daytime?
- 09:06You know, it's partly daytime,
- 09:07but it's really kind of shifted.
- 09:09Outside of what the normal human
- 09:12diurnal pattern would allow,
- 09:14you know with a sort of entrained
- 09:16circadian rhythm.
- 09:17So when I talk about shift shift work,
- 09:20I am thinking more globally about these
- 09:23more nuanced types of shifts as well.
- 09:26And then, you know,
- 09:28just thinking about shift work
- 09:30and what the issues are,
- 09:33you know, first I think you know,
- 09:35you need to understand the biology
- 09:37of shift work.
- 09:38So what is happening in the body when
- 09:41we're working against our biological clock?
- 09:43And then what are the consequences that
- 09:47follow misalignment between our sleep
- 09:49wake timing and our circadian timing?
- 09:52For example,
- 09:53what are the consequences
- 09:55of peripheral misalignment?
- 09:57Peripheral clock misalignment and then,
- 10:01you know, finally,
- 10:01what can we do to mitigate that?
- 10:03We're probably never going to
- 10:05eliminate shift work.
- 10:06We're going to continue to have people who,
- 10:09you know, demand to have their
- 10:11packages shipped overnight.
- 10:12We're going to have people,
- 10:14you know,
- 10:14who want to travel to Europe.
- 10:16You really have to have pilots
- 10:17who are able to fly overnight
- 10:19to be able to accomplish that.
- 10:21And so in thinking about shift work,
- 10:25what we're really trying to do is mitigate.
- 10:28The consequences of shift work
- 10:29both in the short and long term,
- 10:31so that we can continue to
- 10:35operate in this 24 hour society.
- 10:38Now I know probably everyone here
- 10:40is familiar with the two process
- 10:43right model of sleep regulation,
- 10:45but I, I you know,
- 10:46I think it's really important to just
- 10:48start with the basics and thinking about
- 10:52how shift work influences our bodies.
- 10:54So of course we have the homeostatic Dr.
- 10:58which I've plotted here in light blue,
- 11:01which in an untrained individual of course
- 11:03builds up over the course of the day
- 11:05and then we have the circadian drive for.
- 11:08Make, which is in the darker blue,
- 11:10which sort of counteracts
- 11:12that homeostatic Dr.
- 11:13and then with shift work,
- 11:15you know, of course we all know the
- 11:18consequences of shift work are,
- 11:20you know,
- 11:21we continue to stay awake potentially
- 11:23through that biological night.
- 11:25Certainly that's the case for night work.
- 11:28And we may have a much elevated homeostatic
- 11:31sleep pressure happening at that time.
- 11:34And then when shift workers then
- 11:35try to sleep during the day,
- 11:37even though they may be going to sleep.
- 11:38The time when they have a very
- 11:40high sleep pressure,
- 11:41they're sleeping at a time
- 11:43when the circadian drive to
- 11:45be awake is opposing their ability to sleep.
- 11:47And so of course that leads to sleep
- 11:51fragmentation and potentially and
- 11:53typically sleep of insufficient duration.
- 11:55And so that compounds the problem because not
- 11:58only do we now have a circadian misalignment
- 12:01issue with sleep with shift work,
- 12:03we also have a sleep loss
- 12:06problem with shift work.
- 12:07And then, you know, of course it gets worse.
- 12:10You know, I, I'm sure many of you are
- 12:12working on a peripheral oscillator
- 12:14systems and are probably much more
- 12:16knowledgeable about, you know,
- 12:18each of these individual areas.
- 12:20But I am. But really when it
- 12:23comes to circadian Physiology,
- 12:25we're not just thinking
- 12:26about the sleep wake cycle.
- 12:28You know,
- 12:29the sleep wake cycle is important
- 12:31and we want to make sure that
- 12:33people who are engaging in shift
- 12:35work are able to get enough sleep.
- 12:37To manage their awake time,
- 12:40we want to make sure that they're able
- 12:42to stay alert during their awake time.
- 12:44But we also have these downstream clocks,
- 12:48all these peripheral oscillators and
- 12:50virtually every body system that
- 12:52are receiving information from the
- 12:54Super cosmetic nucleus that are,
- 12:56you know,
- 12:57then coordinating other aspects of
- 12:59biological function which can lead to
- 13:02symptoms that are not always clinical,
- 13:04sometimes subclinical symptoms
- 13:05that can make shift.
- 13:07Workers, you know,
- 13:09Colin Stack or or feel
- 13:11uncomfortable or or in,
- 13:13you know the worst case scenario over
- 13:16years of shift work can lead to chronic
- 13:19conditions and and clinical conditions.
- 13:22And so we have to think about the
- 13:24big picture when we're thinking
- 13:26about shift work and mitigations,
- 13:28you know,
- 13:29promoting alertness and performance on the
- 13:32job and sleep at home is really important.
- 13:36But I think we also have to think.
- 13:38This future of how do we ensure that
- 13:41shift workers health is preserved to
- 13:43the best that it can be as they're
- 13:46engaging in potentially a life of shift work?
- 13:50So breaking that down a little bit more,
- 13:54you know when I think of these
- 13:57longer term consequences on the
- 13:59short term I'm thinking of.
- 14:01You just what are the immediate effects?
- 14:04You know what what are we dealing with on a
- 14:07given shift during a given sleep episode?
- 14:10And then in the long term, you know,
- 14:13what are the potential consequences
- 14:15in a person's life?
- 14:17Are they going to be able to?
- 14:20Maintain work for you know,
- 14:22their entire.
- 14:24You know, we're typical working lifespan.
- 14:27Are they going to make it to retirement
- 14:29able to work or are they going to
- 14:32develop some sort of chronic condition
- 14:33that is going to prevent the,
- 14:36that's going to take them out of
- 14:38the workforce prematurely.
- 14:39We need to protect against these
- 14:41things as well and certainly
- 14:42against like say premature death.
- 14:46There are many consequences of shift
- 14:48work both in the short and long term.
- 14:50But I just want to hit on a couple of
- 14:53them here, just as probably a reminder.
- 14:56So in my lab, I think probably the
- 14:58biggest focus that we have is on
- 15:00this reduced cognitive function
- 15:01in the short term on the job.
- 15:03Again, the populations that I work with,
- 15:06you know, specifically,
- 15:08you know, the astronauts,
- 15:10pilots and then people who are
- 15:11working on different missions at
- 15:13NASA really want to know how can I?
- 15:15Stay awake and alert on the job and
- 15:19particularly because, you know,
- 15:20many of the occupations that I work
- 15:22in are safety sensitive occupations.
- 15:25You know,
- 15:26the management in those groups
- 15:28want to make sure that everyone
- 15:30is going to stay safe and that the
- 15:32populations of people who say who
- 15:35are traveling around the country on
- 15:37airplanes are also going to stay safe.
- 15:39So we're really concerned about
- 15:40making sure that, you know,
- 15:42sleepiness is managed,
- 15:44that accident risk is reduced.
- 15:47But we also have other short term
- 15:49conditions that are made that maybe
- 15:51you know garner less attention
- 15:53but are equally important.
- 15:55So you know in the short term
- 15:56we we see increased burnout and
- 15:58poor behavioral health,
- 16:00so increased risk of depersonalization
- 16:03among hospital employees towards patients,
- 16:06increased risk of anxiety and depression.
- 16:08And then again kind of going back to
- 16:10something you mentioned previously,
- 16:12we also see an increase in
- 16:14subclinical conditions.
- 16:15This can lead to more sick calls.
- 16:16Long shift workers,
- 16:17so GI distress,
- 16:18headache,
- 16:19reduced immune function all come in
- 16:22the short term with insufficient
- 16:24sleep and circadian misalignment.
- 16:27And then in the longer term we have,
- 16:29you know,
- 16:30some pretty serious consequences that
- 16:32can come with years of shift work.
- 16:34Again,
- 16:34I'm sure there are people on this
- 16:36call who are working in this space.
- 16:38I know many of my current and former
- 16:41colleagues who work on individual
- 16:43aspects of of these long-term
- 16:45investigating these long-term.
- 16:47Conditions,
- 16:48but we see increased risk of
- 16:50metabolic disorders.
- 16:51Um vascular events and then cancer.
- 16:54And prior to coming to NASA,
- 16:56one of the cancer was an area
- 16:58that I worked on.
- 16:59So I.
- 17:01Examined how years of shift work influenced
- 17:07an individual's risk of prostate cancer.
- 17:10There are many other people who are
- 17:13working on examining the associations
- 17:15between breast cancer and shift
- 17:18work and as well as other cancers.
- 17:21But hormone dependent cancers
- 17:22seem to have the strongest links,
- 17:24and at this point,
- 17:26the World Health Organization has
- 17:27labeled shift work as a probable
- 17:29carcinogen based on the evidence
- 17:31that's been done.
- 17:32In this area,
- 17:33so I think it's also important for
- 17:35shift workers to understand that
- 17:38there are long-term consequences
- 17:40that can come in conjunction with
- 17:42their choice to engage in shift work.
- 17:46So shifting gears a little bit.
- 17:51Now I'm going to start to get into,
- 17:54you know, what the mitigations are,
- 17:56what are the things that we can do
- 17:59to help people stay more alert on the job,
- 18:02to help mitigate some of those short-term
- 18:04consequences and then hopefully mitigate
- 18:06some of the long term consequences as well.
- 18:10And to do this, I'm going to
- 18:11talk to you about the framework
- 18:13of fatigue risk management.
- 18:14But before we can talk about
- 18:16fatigue risk management,
- 18:16we need to define fatigue.
- 18:18And so fatigue, you know.
- 18:21Similar to shift work is something that I
- 18:24think everyone kind of has a definition for,
- 18:27but most people will have
- 18:30a different definition.
- 18:31And so I personally really
- 18:34hate the term fatigue.
- 18:36When I came to NASA and my lab was
- 18:39called the Fatigue Countermeasures
- 18:41Laboratory before I arrived,
- 18:43I wasn't particularly excited
- 18:45about that and I explored
- 18:46trying to change the name,
- 18:48but it was sort of.
- 18:51Prevented from doing so.
- 18:52We're strongly encouraged not to
- 18:54do so by some of the other people
- 18:57who work at NASA. So we kept it.
- 18:59But now I just try to make sure that
- 19:01whenever I'm working with the population,
- 19:03I'm defining fatigue.
- 19:04Because in my lab,
- 19:06we're not talking about fatigue as a
- 19:08side effect of some medical condition.
- 19:10We're not talking about physical fatigue.
- 19:13We're talking really about what
- 19:15I've put on the screen here.
- 19:18This comes from the International
- 19:20Civil Aviation Organization.
- 19:22So it is very aviation focused,
- 19:24but I I think that the key
- 19:27is that we're talking about.
- 19:29Reduced mental or physical performance
- 19:31capability resulting from sleep loss,
- 19:33extended wakefulness,
- 19:34circadian phase or workload.
- 19:36And in my lab we we definitely
- 19:38don't focus as much on workload.
- 19:40We do incorporate it into
- 19:42the studies that we do,
- 19:43but I'm most focused on the,
- 19:47you know the the physiological
- 19:49touch points that we targets
- 19:51that we can potentially change.
- 19:53And so it's really about sleep
- 19:55and circadian rhythms in the end
- 19:57when when I'm thinking about.
- 19:59To you in using the word fatigue.
- 20:01So what is fatigue risk management?
- 20:04Well,
- 20:04fatigue risk management is a formal
- 20:08process that has been developed
- 20:12and shaped over many years,
- 20:13particularly in safety
- 20:16sensitive organizations,
- 20:17to provide workers in a given occupation with
- 20:21tools and resources to manage their fatigue,
- 20:25so to manage their sleep loss and to
- 20:27manage their circadian misalignment.
- 20:30And fatigue risk management is.
- 20:33You know,
- 20:34it's much more than just giving
- 20:36someone a tip.
- 20:37Sheet Tigers management is typically a.
- 20:43Within an organization,
- 20:44a sort of separate work group,
- 20:47so there are people who are designated
- 20:51as fatigue risk managers who will collect
- 20:55data continuously to characterize risk
- 20:58in the organization as they see the,
- 21:02you know,
- 21:03see risk arise as a result of maybe
- 21:06a particular type of work activity
- 21:10affecting people in a negative way.
- 21:13Well,
- 21:14maybe try to implement some countermeasure
- 21:17or schedule change and then we'll reassess.
- 21:20And this is just continuous and iterative,
- 21:23trying to make sure that as fatigue
- 21:26hotspots pop up, they're managed.
- 21:27And then in addition to that,
- 21:30fatigue risk management program really
- 21:33needs to provide education to workforce.
- 21:36So it's not just about a single
- 21:40strategy or a single, a single.
- 21:43Uh,
- 21:44you know,
- 21:45appointment where a plan is developed,
- 21:48typically fatigue risk management involves
- 21:51ongoing education for the workforce.
- 21:54So overall when we think about
- 21:56fatigue risk management,
- 21:57we're thinking about a dual responsibility
- 22:00between the worker and the the organization.
- 22:04It's not just that all the burden
- 22:06is on the worker and I understand
- 22:08that in a clinical setting you
- 22:10know you're really dealing with an
- 22:12individual you're not dealing with.
- 22:15An institution,
- 22:16but there may be ways that you can
- 22:19talk to patients about you know
- 22:23considering you know employers that
- 22:25are that have fatigue risk management
- 22:27programs particularly if they struggle.
- 22:29So for example in trucking there are,
- 22:33there are trucking organizations
- 22:35that have really robust fatigue risk
- 22:37management programs and
- 22:38there are those that don't.
- 22:39And so you know for patients
- 22:41who are vulnerable it it again
- 22:43may be worth a conversation.
- 22:44To discuss, uh, maybe you know,
- 22:47trying to shift to an employer that will be
- 22:50more supportive of the nature of the job.
- 22:55So how can fatigue risk management
- 22:58be used to mitigate the issues
- 23:01that we see with shift work?
- 23:03So again, these are institutional
- 23:06and individual and I'm going to talk
- 23:09about both to give you an overview
- 23:13and knowing that we can't necessarily
- 23:15implement change at the institutional level.
- 23:18There may be other ways that that
- 23:22individuals can take advantage of
- 23:25those institutional best practices.
- 23:27So at the institutional level,
- 23:30what we're really looking at are
- 23:32policies that promote sleep health,
- 23:35you know,
- 23:36policies that help reduce on the
- 23:38job sleepiness that continued
- 23:40education and training and also not
- 23:42just deployment of countermeasures
- 23:44but training on how to use them.
- 23:46So I'll talk a little bit about light,
- 23:48for example,
- 23:50you can't just deploy light boxes into.
- 23:54Workspace and expect that people
- 23:56will benefit from them.
- 23:58You have to actually have training
- 24:00so that people know what to do,
- 24:02how to use them and how to
- 24:04receive their benefit,
- 24:05and then infrastructure to support
- 24:07the countermeasure implementation.
- 24:09So, you know,
- 24:10simple example here would be nap rooms.
- 24:13You know,
- 24:14if you have an employee who like this is
- 24:16exhausted and leaning against a wall and
- 24:18catching a couple of minutes of sleep,
- 24:21that's not a particularly
- 24:23supportive environment.
- 24:24So to go through each of these
- 24:26in a little bit more detail.
- 24:29These are some examples of policies
- 24:31that the best institutions have for
- 24:34fatigue risk management support.
- 24:36So just having a fatigue risk
- 24:38management program is a first step.
- 24:41And note this is required in aviation.
- 24:43So I'm going to take you through an
- 24:46example on when we get to the end of
- 24:48this describing what is required in aviation.
- 24:50But I think aviation provides a really nice.
- 24:55Set of lessons learned that could
- 24:57be adopted in other organizations.
- 25:00Thoughtful schedule design.
- 25:01So we know,
- 25:03you know,
- 25:03we know so much about how schedules are
- 25:06best designed to minimize fatigue and
- 25:09to enhance alertness and performance
- 25:11and promote sleep even for shift work.
- 25:14And so companies that have put some
- 25:17effort into schedule design so that
- 25:19they're not just plugging in people as
- 25:22commodities wherever they need to fill time.
- 25:26But rather, um,
- 25:28designing schedules that
- 25:29work with human biology.
- 25:32And this is where bio
- 25:33mathematical models come in on.
- 25:35Bio mathematical models have matured
- 25:38to a point where many companies are
- 25:41now selling bio mathematical models
- 25:44that use the cheap process model,
- 25:47usually at the core,
- 25:49to help design schedules.
- 25:51And so by using bio mathematical models,
- 25:54you know, schedule design,
- 25:55you can scale.
- 25:57The schedule of a workforce and this is
- 26:01another area where I think aviation excels.
- 26:04Virtually every airline around
- 26:06the world uses some sort of
- 26:09bio mathematical model based
- 26:10on the two process model to
- 26:13help schedule pilots to try to minimize
- 26:16their fatigue and maximize their sleep,
- 26:19non punitive reporting of fatigue.
- 26:21So I think in many situations,
- 26:24particularly in organizations
- 26:25that don't have a robust.
- 26:27Integris management program.
- 26:29People are afraid to talk to their
- 26:32employers about their sleepiness,
- 26:34are afraid to ask for accommodations
- 26:37because there is a consequence to doing so.
- 26:41And so again,
- 26:43the best organizations actually not
- 26:45only don't punish people for reporting
- 26:49sleepiness that they don't report people
- 26:51for reporting inability to sleep,
- 26:53but they encourage reporting of that.
- 26:55And then finally on policies that.
- 26:57They all kind of measure use.
- 26:59I think every few weeks in the news we hear
- 27:02about a company that's banning napping,
- 27:05you know, well,
- 27:06I'm not sure that that's always the the
- 27:08healthiest policy with respect to sleep.
- 27:11You know, it really depends on
- 27:12the nature of the organization.
- 27:14There may be some situations where
- 27:16napping is entirely inappropriate,
- 27:18but for many organizations with 24 hour work,
- 27:21napping actually can be a very
- 27:24effective countermeasure.
- 27:25Education and training is another
- 27:28institutional touch point.
- 27:29So you know, I mentioned this previously,
- 27:32but you know,
- 27:34people do not get a whole lot
- 27:37of education about.
- 27:39Sleep or circadian rhythms and they
- 27:42get a lot of poor information online
- 27:45you know and so a you know the best
- 27:48company is the best institutions
- 27:51are going to provide modules on how
- 27:53people can manage their on the job
- 27:56sleepiness and you know this education
- 27:58and screening ideally includes you
- 28:01know sleep disorders screening with.
- 28:03Recommendations for following up
- 28:06with personal doctors as needed.
- 28:09This education should include
- 28:10how to use fatigue,
- 28:12countermeasures appropriately,
- 28:13how to manage difficult schedules.
- 28:16So again, this is a situation
- 28:18where in the aviation industry,
- 28:19we do this all the time.
- 28:21We have flights that are 19 hours
- 28:24long and we have 4 pilots who
- 28:27are flying on those aircraft.
- 28:29And so we, you know,
- 28:30can develop strategies for when
- 28:32and how people should rest.
- 28:34In order to make sure that the
- 28:36pilot crews are as loud as they
- 28:39can be during the entire flight.
- 28:41And then of course you can't
- 28:43just educate your,
- 28:45you know,
- 28:45your workforce at the lowest level.
- 28:47Management needs to be supportive as well,
- 28:49and so education and training should
- 28:52really also include management.
- 28:54And then infrastructure of course
- 28:56is something that's required for
- 28:58implementation of many countermeasures.
- 29:01And you know,
- 29:02if you are allow napping but
- 29:04have nowhere for people to nap,
- 29:05that's not going to be very useful.
- 29:08Light can be a very powerful countermeasure,
- 29:11but it may be very difficult for
- 29:13people to enhance their light
- 29:15exposure on their own.
- 29:17But changing the lighting systems
- 29:19within an environment can be a
- 29:21very effective way to promote.
- 29:23Partners in performance and there
- 29:25have been several studies that
- 29:26have shown that just changing the
- 29:28lighting in a 24 hour operation is
- 29:32very helpful in enhancing workers
- 29:35ability to stay alert on the job.
- 29:38And then we know that fatigue
- 29:41will never be eliminated.
- 29:42You know fatigue is something that
- 29:44goes hand in hand with 24 hour shifts.
- 29:46We're never going to be able to
- 29:49perfectly help people work at night
- 29:51as they would during the day.
- 29:54And so we need safety measures in place
- 29:57specifically for safety sensitive
- 29:59occupations that include, you know,
- 30:02clear systems for handing off work and
- 30:05cross checking shift changes happen.
- 30:08And finally on the institutional side,
- 30:12scheduling.
- 30:12So this is really the big, the big,
- 30:15you know, elephant in the room.
- 30:17This can make or break an individual's
- 30:20ability to cope with shift work
- 30:22and the lion share of scheduling
- 30:25decisions are happening on the
- 30:27institutional side of the fence.
- 30:29And so, you know,
- 30:31in optimizing schedule design, you know,
- 30:34institutions should again maybe be
- 30:36using those mathematical models.
- 30:38But, you know,
- 30:39not over scheduling people or when
- 30:42people do need to be scheduled
- 30:44for extended duty shifts,
- 30:45allowing protected time for sleep
- 30:48afterwards and recovery before
- 30:50bringing people back.
- 30:51And then in this circadian
- 30:53friendly length is, you know,
- 30:55if you're if you have people
- 30:57working overnight,
- 30:57you probably want shorter shifts than
- 30:59if you're working during the day,
- 31:01rotating shifts later rather than earlier.
- 31:04You know this has been something
- 31:07that has been.
- 31:08Known since the 1980s that humans
- 31:11do better in shifting later
- 31:13with rotating shifts.
- 31:14Yet we still see shift schedules,
- 31:16for example,
- 31:17for nurses that are shifting earlier
- 31:19that are starting at 3:00 AM.
- 31:21That doesn't make a whole lot of sense
- 31:23from the sleep and circadian standpoint.
- 31:25Minimizing the number of consecutive
- 31:28night shifts has been shown to be
- 31:31important countermeasure against fatigue,
- 31:33and then of course allowing time off
- 31:36between shifts for recovery really,
- 31:38no matter what type of shift
- 31:40a person is doing.
- 31:41So everything that I've talked about so far.
- 31:45Probably feels like things
- 31:46that are outside your control,
- 31:48particularly if you're a clinician.
- 31:51You know,
- 31:52there may be opportunities to
- 31:54do research or work with larger
- 31:57organizations to implement fatigue
- 31:59risk management,
- 32:00and if you have those connections,
- 32:02I would, you know, strongly encourage that.
- 32:06But probably more useful are the
- 32:08individual countermeasures that
- 32:10people can use to manage sleep loss
- 32:12and circadian misalignment and with
- 32:14these individual countermeasures.
- 32:16I really think of them as proactive
- 32:19countermeasures and reactive countermeasures.
- 32:21And there is some overlap between these just,
- 32:24you know, there there has to be.
- 32:27But I'm going to try to divide them
- 32:29up in these two buckets to begin.
- 32:32So we'll start with proactive
- 32:34countermeasures so, you know,
- 32:36feels a little funny putting
- 32:37us sleep hygiene,
- 32:38slide up to a Sleep Medicine group.
- 32:41We,
- 32:41I'm sure you know,
- 32:43every single person here talks about
- 32:45sleep hygiene probably every day.
- 32:47But I do want to highlight that there
- 32:49are some aspects of sleep hygiene that
- 32:51can be really challenging for shift workers.
- 32:53And having conversations
- 32:55about these specific issues,
- 32:56I think can go a long way in
- 32:59helping shift workers to manage.
- 33:01So optimizing the sleep environment,
- 33:03there have been several studies
- 33:05that have demonstrated that having
- 33:07blackout shades for daytime
- 33:09sleepiness is critically important
- 33:11in increasing the duration and
- 33:14quality of sleep that people obtain,
- 33:16you know, as with other.
- 33:17Best practices like turning off your phone.
- 33:21You know you're more likely to get
- 33:23more phone calls during the day.
- 33:25Making the environment quiet and cool.
- 33:28All of the things that we would
- 33:29normally recommend at night,
- 33:30but that are typically easier to
- 33:32achieve at night than during the day.
- 33:34Regular sleep wake timing is very difficult,
- 33:37if not impossible for shift
- 33:39workers to achieve.
- 33:40And so I think that sometimes when shift
- 33:42workers see sleep hygiene guide guidance,
- 33:44they quickly dismiss above it because they
- 33:48see recommendations they can't achieve.
- 33:50But there have been some really nice studies
- 33:54showing that maintaining a compromise.
- 33:57Day shift between your day schedule
- 33:59and night schedule can actually be
- 34:02a way for shift workers to cope,
- 34:05and so maybe if a person is a
- 34:08night worker and then they revert
- 34:11to day's during their days off,
- 34:14maybe they're keeping a very late
- 34:17shifted sleep wake schedule.
- 34:19During their days off,
- 34:21so that they're going to bed very late,
- 34:24maybe sleeping in much later than a
- 34:28typical lifetime would be in order
- 34:30to avoid that giant swing in their
- 34:33circadian time or not massive.
- 34:35Their circadian rhythm probably
- 34:36isn't shifting very much,
- 34:37but to avoid that big swing in
- 34:39their sleep timing relative to
- 34:41their circadian rhythm.
- 34:42So while shift worker may not be able to
- 34:45maintain regular sleep and wake times,
- 34:47there are some strategies
- 34:48for compromises again.
- 34:50It depends on the nature of the work,
- 34:53but there can be ways around this.
- 34:56Avoiding bright light before bed is
- 34:58another one that's really hard for
- 35:00particularly night shift workers
- 35:01because most night shift workers
- 35:03or many night shift workers are
- 35:05driving home in the light.
- 35:07And I personally wouldn't
- 35:08recommend using sunglasses.
- 35:09I know some people do.
- 35:11I think that that's a safety risk.
- 35:13You know you want the the bright light
- 35:15to help someone you know stay alert
- 35:18during their drive home so that they're.
- 35:21Getting that benefit of the countermeasure.
- 35:23But that's going to potentially
- 35:25have an acute alerting effect that
- 35:27will inhibit one's ability to sleep.
- 35:29And so perhaps,
- 35:30maybe we're talking about having a
- 35:33longer line downtime before trying to sleep,
- 35:36after being exposed to bright
- 35:37sun before sleep.
- 35:38Or maybe we're talking about taking
- 35:41public transportation home and wearing
- 35:43sunglasses so that you can minimize
- 35:45that blue light on the way home.
- 35:47So again,
- 35:48it's working with people to make sure.
- 35:50That the recommendations meet them
- 35:53where they are in their workspace and
- 35:56then lastly just communicating with.
- 35:59Family,
- 35:59household neighbors on one's
- 36:02work schedule with pilots.
- 36:05We often have them put in a note
- 36:06on their hotel room door indicating
- 36:08that they're sleeping so that
- 36:10housekeeping doesn't knock on the door.
- 36:12You know, just little things like that,
- 36:14which daytime workers probably
- 36:16don't have to do.
- 36:18They can make a big difference
- 36:20for night shift workers.
- 36:21Of course, shift work
- 36:23disorder is a big concern now.
- 36:26I am I I think you heard I'm on
- 36:29the extrinsic circadian sleep
- 36:30wake disorders task force for the
- 36:33American Academy of Sleep Medicine
- 36:36and Sleep Research society.
- 36:38And shift work disorder is one of
- 36:41the one of the disorders that we're
- 36:45examining to provide guidelines,
- 36:47clinical guidelines for
- 36:49recommendations in the future.
- 36:51And this has been a big struggle because
- 36:55in surveys that we've done and in looking
- 36:58at the literature from meta analysis,
- 36:59we actually find that there are
- 37:01not a whole lot of people diagnosed
- 37:03with shift work disorder.
- 37:05Studies sort of suggest that somewhere
- 37:08around 20% of shift workers may be
- 37:10at risk or have shift work disorder.
- 37:13But when we actually sort of pin
- 37:15down to those who are diagnosed,
- 37:17we're not finding very many people.
- 37:19And so I think screening not just.
- 37:22It's certainly screening for all
- 37:23sleep disorders is important,
- 37:25but for that,
- 37:26especially for shift work disorder,
- 37:28so that shift workers who are having
- 37:31great difficulty coping can get a
- 37:33health and treatment that they need
- 37:35to better adjust to these schedules.
- 37:38Um,
- 37:39napping again is a long standing
- 37:42countermeasure that I'm sure that
- 37:45you're already thinking about
- 37:47using and recommending.
- 37:49But I think of napping in a couple
- 37:51of different ways.
- 37:52So this is really,
- 37:53this is the prophylactic napping.
- 37:55This is recovery napping.
- 37:56This is napping outside of the
- 37:59work environment.
- 38:00And so when a person is shifting from a
- 38:03day type of shift to a night type of shift,
- 38:07recommending a nap at a strategic time maybe.
- 38:10Late afternoon before the
- 38:11Wake maintenance zone.
- 38:12You know,
- 38:13something that could help them
- 38:15better get through that night shift.
- 38:17And then for recovery sleep.
- 38:19Helping shift workers to understand
- 38:21when to time their sleep relative
- 38:24to what they're doing next can
- 38:26be really important.
- 38:27If a shift worker is again doing a
- 38:30night shift and then sleeping all day,
- 38:34but has the next day off,
- 38:36that actually might not make a lot of sense.
- 38:39Maybe it's better for them to
- 38:40take a shorter nap.
- 38:41Be awake for more of the day
- 38:43and then go to sleep at night.
- 38:46So again,
- 38:46it sort of depends on the circumstances here,
- 38:49but.
- 38:51There have been many studies that
- 38:53have demonstrated the benefit of
- 38:55NAPS in mitigating that on the
- 38:58job sleepiness that occurs and
- 39:01if done strategically.
- 39:03Napping can be a really powerful
- 39:06tool in this bed.
- 39:08Lighting is complicated,
- 39:10and so I.
- 39:13Prior,
- 39:13both prior to coming into NASA
- 39:15and now at NASA,
- 39:16I do a lot of work on using light
- 39:18as a countermeasure for the
- 39:21populations that we work with.
- 39:23Obviously bright blue and rich light,
- 39:25just the circadian rhythm.
- 39:26So if you have a maybe a
- 39:30nontraditional work shift,
- 39:31for example,
- 39:32we work with people who are
- 39:34living on Mars time on Earth,
- 39:36so they're shifting 39 minutes later,
- 39:38they're shifting their sleep
- 39:39schedule 39 minutes later.
- 39:40Every day we can give them blue light.
- 39:43Access to the shift their sleep
- 39:45so that they're getting that blue
- 39:47light pulse sort of just before bed
- 39:49on the phase delay portion of the
- 39:51phase response curve to shift their
- 39:53sleep to keep them as aligned as we
- 39:57possibly can to that weird Mars timing.
- 40:00And of course light also just
- 40:02makes you feel more alert,
- 40:03so if you're in a dark environment.
- 40:06You're going to feel sleepier than if
- 40:07you're in a very bright environment.
- 40:09So having shift workers just use
- 40:11bright light as an acute common
- 40:14measure can be very helpful and
- 40:16has a direct effect on mood.
- 40:18But it can be complicated if you have
- 40:20somebody who's shifting all over the place.
- 40:22For example,
- 40:23our astronaut population sometimes can't
- 40:25use light as a countermeasure because
- 40:27as we're building their schedules,
- 40:29we have to shift them so much to
- 40:31accommodate mission events that we
- 40:33could end up shifting them into a phase.
- 40:36Position that is not optimal for the
- 40:38work that they have to do in the future.
- 40:41And so in those cases maybe we're
- 40:44using other countermeasures.
- 40:45So the the I guess answer to
- 40:48light here is not that it's.
- 40:51Can be deployed adlab.
- 40:52It really should be deployed
- 40:54in a very controlled way based
- 40:55on the nature of the work.
- 40:59Hypnotics and chromatics. So disclaimer,
- 41:02I'm not a clinician and we're rarely,
- 41:05you know even within Tigris management
- 41:07where I work with flight surgeons were
- 41:10rarely recommending hypnotics and chronic
- 41:12biotics because we're trying to manage
- 41:14with many of the other tools that we have.
- 41:17But particularly for Hypnotics when
- 41:19we're talking about shift work,
- 41:22we're not, have not, we don't want,
- 41:25have not exceeded our first line
- 41:26of defense because we're not
- 41:28shifting this circadian rhythm and
- 41:29if we're really trying to shift.
- 41:31Circadian rhythm.
- 41:32If somebody says doing a couple
- 41:35of weeks of night work,
- 41:37say because they work on an oil rig,
- 41:39we might, we might actually
- 41:41recommend something like chronomatic,
- 41:43like melatonin to help them adjust
- 41:45to that state more stable schedule,
- 41:47rather than having flight surgeon
- 41:49prescribe a hypnotic because the
- 41:51hypnotic is going to make them sleep,
- 41:53it's not going to necessarily
- 41:55shift their circadian rhythm,
- 41:56although there may be some benefit
- 41:58to them not being exposed to light
- 42:00at the time they're sleeping.
- 42:01It's really, really complicated,
- 42:03but largely we're really focusing
- 42:05on the other aspects of fatigue
- 42:08risk management and with the
- 42:10availability of melatonin,
- 42:11so many people just self
- 42:14administer melatonin,
- 42:16try to be very careful and cautious
- 42:18in our education to the general shift
- 42:21working workforce about not using
- 42:23melatonin because they have the
- 42:26potential to use it inappropriately
- 42:28or to make themselves more
- 42:30misaligned with that self selected.
- 42:32Use.
- 42:34And then finally,
- 42:36I'm an individual countermeasures personal
- 42:38scheduling can be a target as well,
- 42:40so sometimes.
- 42:42People have a tendency to try to job cram.
- 42:47They want more days off,
- 42:49so they'll try to get more work
- 42:52into a shorter number of days,
- 42:54and that doesn't necessarily
- 42:55align with what's best for their
- 42:57alertness and performance and sleep.
- 42:59And so having a conversation about
- 43:02how the time off will be affected
- 43:05by that type of job cramming can be
- 43:08really valuable in helping people
- 43:10understand that maybe it's better to
- 43:12spread out shifts so that you can get.
- 43:14Better sleep so that you can be
- 43:16more alert and engaged with your
- 43:18family on your days off and more
- 43:21alert and rested in going to work.
- 43:23And then there are some situations
- 43:25where individuals can choose to say,
- 43:27take more early starts or late finishes.
- 43:32Which may be better aligned
- 43:34with their chronotype.
- 43:35That should also be encouraged,
- 43:37and we do that in my work all the time.
- 43:41So shifting now to reactive countermeasures.
- 43:44Caffeine, of course,
- 43:46is probably the most common
- 43:49reactive countermeasure.
- 43:50So these are on the job countermeasures
- 43:53that one can use to combat sleepiness.
- 43:56And I think the big problem with caffeine,
- 43:58like with melatonin,
- 43:59people can just grab it whenever they want,
- 44:01and many people don't understand
- 44:03how to use caffeine effectively.
- 44:06So little and often is the
- 44:08best recommendation,
- 44:09about 50 milligrams an hour,
- 44:10which equates to about a week.
- 44:11Of coffee or tea and trying
- 44:13to recommend that people avoid
- 44:15habitual use as much as possible,
- 44:17especially shift workers.
- 44:20And then avoiding caffeine
- 44:23within six hours of sleep.
- 44:26Unless required by job demands so
- 44:28that we minimize the impact of
- 44:32caffeine on subsequent sleep and
- 44:34then other stimulants like Modafinil
- 44:37certainly can be prescribed.
- 44:39There are some studies that
- 44:40support the use of Modafinil for
- 44:42some shift working situations,
- 44:44but of course that should be done
- 44:46in a very as needed basis with
- 44:49oversight of the physician because
- 44:50the use of these stimulants is
- 44:53really going to depend on the nature
- 44:55of the job and the type of shift.
- 44:57The person is doing.
- 44:59On the job napping as a countermeasure,
- 45:03you know this is sort of this
- 45:04is your safety valve.
- 45:05This is the way that a person who's
- 45:08at work and now suddenly feeling
- 45:10that excessive sleepiness can
- 45:12relieve some of that sleepiness.
- 45:15And so having nap rooms, you know,
- 45:18in hospitals we have call rooms,
- 45:20but using them during the day for Naps
- 45:21to release sleepiness is a good idea.
- 45:23In other occupations,
- 45:25just getting that and and napping
- 45:27vironment in place is important.
- 45:29And we in this area have in
- 45:33some parts of the world,
- 45:36pilots can actually nap in the cockpit,
- 45:38can of course have only one
- 45:39pilot at a time came out,
- 45:41the other has to be awake and focused.
- 45:44But when we have a pilot
- 45:45napping in the cockpit,
- 45:46there's huge risk of negative consequences
- 45:50associated with sleep inertia.
- 45:52So we recommend that pilots
- 45:53limit their nap in their cockpit
- 45:56seat to 40 minutes maximum,
- 45:58and that they're we tell them
- 45:59they're not allowed to take.
- 46:00The controls of the aircraft
- 46:02until 20 minutes have passed from
- 46:04the time that they've woken up,
- 46:06and during that time they have
- 46:07to come back into situational
- 46:08awareness with their copilot.
- 46:10So this is an example of a
- 46:12situation where napping can be used,
- 46:14but has to be used in a very prescriptive
- 46:17manner in order to maintain safety.
- 46:19And then caffeine naps for short breaks,
- 46:23like if a person has a lunch break and
- 46:25has an opportunity to have a little
- 46:28bit of caffeine and then a very short nap.
- 46:31That caffeine can mitigate
- 46:32the impact of sleep inertia,
- 46:34and that can be a very powerful
- 46:36countermeasure for getting
- 46:37through the rest of the shift.
- 46:39Exercise and activity breaks are another
- 46:41on the job countermeasure that can be used.
- 46:44I wanna emphasize there's,
- 46:45you know,
- 46:45evidence for this but it's limited.
- 46:47You know the the best countermeasure we
- 46:49would lose would target sleep systems.
- 46:50Circadian systems exercise seems
- 46:53to have short term benefit,
- 46:57so short stretch breaks during long surgeries
- 46:59and operating rooms seem to be beneficial.
- 47:02That's probably not sleep related.
- 47:05You know,
- 47:06you're you're not getting a huge benefit.
- 47:08There has been one study at NASA
- 47:11by Laura Barker and colleagues
- 47:13that used blue enriched light in a
- 47:16break room with exercise machines
- 47:19that mission controllers could
- 47:21access during night shifts.
- 47:24And they found that.
- 47:27With this.
- 47:29This exercise break paired
- 47:31with the light on the mission
- 47:33controllers had better alertness
- 47:34and performance on the job
- 47:36after a bit of exercise.
- 47:38But of course this isn't a replacement
- 47:40for sleep, so it's really important
- 47:41to educate the workforce on that.
- 47:43And then finally, you know,
- 47:45this is just a hypothetical.
- 47:48We really don't know anything
- 47:50about countermeasures that will
- 47:51reduce risk in the long term.
- 47:53And there's a recent study that suggested
- 47:56that limiting eating to daytime may prevent.
- 47:59Some of that internal misalignment
- 48:02that comes with glucose intolerance
- 48:04with nightwork.
- 48:06This is very early.
- 48:07This was a lab study.
- 48:08We don't know how this actually
- 48:10translates to the real world or
- 48:12this long term consequences.
- 48:13These are areas that I think are
- 48:15really important for study in the
- 48:16future because we have no idea if
- 48:18the countermeasures that we're using
- 48:20to mitigate the short-term impacts
- 48:22are healthy in the long term.
- 48:25So just to wrap up,
- 48:26I'm going to take a couple slides here
- 48:28to tell you about an implementation
- 48:30example that we've done in my lab.
- 48:32So in aviation,
- 48:34I mentioned previously,
- 48:35you know,
- 48:36obviously safety is #1 and there are
- 48:40lots of regulations in place to make
- 48:43sure that pilots are set up for success with.
- 48:48Their work hours,
- 48:49with a number of hours they have
- 48:51to have off in between shifts.
- 48:53The number of pilots who have to be
- 48:55in the cockpit at any given time,
- 48:57airlines are all in the US,
- 48:58are also required to have a
- 49:00fatigue risk management program
- 49:02with that ongoing education
- 49:04with countermeasure deployment.
- 49:05And you know that that's again
- 49:08an iterative process that's
- 49:10constantly evolving and shifting
- 49:12based on the nature of the work.
- 49:15And with this we can test
- 49:17countermeasures to see how effective
- 49:19they are for future deployments.
- 49:21So we did a study using luminet glasses,
- 49:24which are light emitting glasses with
- 49:26pilots who were flying early starts.
- 49:29So basically these pilots were
- 49:32working for five days in a row.
- 49:35Um flying starting around 5-6 in
- 49:37the morning and we gave them these
- 49:40luminet glasses in addition to
- 49:42all of the other benefits that
- 49:45they get from the fatigue growth
- 49:47management program to help attempt
- 49:49to shift their circadian rhythm
- 49:52and to enhance their alertness in
- 49:54going into that room they start
- 49:56and we compared that to a placebos.
- 49:59This was a randomized crossover
- 50:01trial within participants and we
- 50:03were very fortunate that this
- 50:04airline let us change.
- 50:05Balance schedules so that we can be
- 50:08very quasi experimental about it.
- 50:10And in the control condition,
- 50:12they didn't have any light.
- 50:13They just had these inner safety glasses,
- 50:15but we didn't tell them that they were inert.
- 50:17And you know,
- 50:18very quickly what we found was that
- 50:21they wore both of the glasses for
- 50:23the prescribed number of minutes,
- 50:2525 minutes in the morning before
- 50:27they went to work.
- 50:28And.
- 50:29We found small but positive effects,
- 50:34so we saw small improvements in
- 50:36weight so and small improvements
- 50:38in sleep efficiency.
- 50:40And we also saw a very small
- 50:43but significant positive
- 50:45improvement in sleepiness.
- 50:47So this is, you know again is this.
- 50:51You know, going to make a huge splash and is
- 50:53everybody going to use light glasses now?
- 50:56But this is just one additional
- 50:58countermeasure that may be useful for
- 51:01especially people who are struggling to
- 51:03deal with those early starts in aviation.
- 51:06So overall, um,
- 51:09shift work perfects everybody's body.
- 51:12In addition to sleep,
- 51:15we have short and long term
- 51:16outcomes and of course many
- 51:18mitigations for the short term,
- 51:20but we don't really understand
- 51:22what's happening in the long term.
- 51:24As a reminder,
- 51:25here's the manuscript that I mentioned where
- 51:28most of this information is drawn from.
- 51:30And then if you have further questions,
- 51:32feel free to reach out from that.
- 51:33Thanks for your attention and I'm
- 51:34happy to take questions now if we have.
- 51:39Thank you so much Doctor Evans.
- 51:40That was a fantastic and
- 51:42a very thoughtful talk.
- 51:45I welcome everyone to ask questions.
- 51:49I don't see any question in the chat room.
- 51:52Please feel free to unmute yourself and ask.
- 51:55And hi, I have a question, Aaron.
- 51:59So one of the problems I used to see
- 52:02in practice was someone who had been a
- 52:06nurse for decades with terrible shifts
- 52:10that they in that they requested.
- 52:12I only want to work three days a
- 52:14week and their sleep was terrible.
- 52:17During that whole interval and they
- 52:19assumed that once they stopped
- 52:22working, everything would
- 52:23become normal and it didn't.
- 52:25And they were very, very difficult to treat.
- 52:28Do you have any thoughts on that scenario?
- 52:31Yeah. Oh, my goodness.
- 52:33And Professor Krieger, Barry,
- 52:34thank you for the questions.
- 52:36Very nice to see you.
- 52:39Thank you. Yeah.
- 52:41So, you know, I think Doctor Vicey
- 52:45has some work in this area looking
- 52:47at how years of shift work actually
- 52:51leads to continued disruption once a
- 52:53person stops engaging in shift work.
- 52:56And so to me, what that says,
- 52:58the target really has to be early education.
- 53:01It has to be helping.
- 53:03You know,
- 53:03I think people do that type of scheduling,
- 53:06schedule cramming because
- 53:07they're not understanding.
- 53:09The bigger long term consequences
- 53:11of their decision making and so
- 53:14that would be another to add to the
- 53:16list of long term consequences.
- 53:18You know you could have persistent
- 53:20ongoing sleep issues just based
- 53:22on years of shift work.
- 53:24I don't think there's been a lot
- 53:25of work in that area but certainly
- 53:26there's enough now that I think it
- 53:28could be added to the list as a caution.
- 53:30But again I don't think shift
- 53:31workers even realize as a as a
- 53:33you know group if you serve it
- 53:34someone should probably do that.
- 53:36If you surveyed shift workers
- 53:38I bet that you would find.
- 53:40That they didn't even realize there
- 53:41were increased risks of all of
- 53:43these long term health outcomes.
- 53:44And so I think we need to do a better
- 53:47job educating these workforces,
- 53:49particularly younger patients to,
- 53:52you know,
- 53:53help them understand how their decisions
- 53:55now may impact them in the future.
- 53:58Because I I don't know of any work that's
- 54:01been done to mitigate the consequences after,
- 54:04you know,
- 54:05after shift work has been completed,
- 54:07after the years of shift
- 54:08work have been completed.
- 54:10Thank you.
- 54:10Yeah.
- 54:12Yeah. And it's it's also harder
- 54:14for ones who go back and forth
- 54:16from you know shift night,
- 54:18night shift to day shift.
- 54:19You know, it keeps changing
- 54:20versus having a set night shift
- 54:22versus day shift routine I guess.
- 54:26Absolutely. And you know I think,
- 54:28I think we have you know there are people
- 54:31who are just victims of circumstance.
- 54:33They have no control over their
- 54:36situation and you know that that's
- 54:39that's the hardest I think.
- 54:41But when people have some control
- 54:43maybe they can choose to work four
- 54:46days instead of three and and you
- 54:48know have maybe a more a schedule
- 54:51that allows them to maybe shift
- 54:52from a day to an evening to a night.
- 54:55You know if one can.
- 54:56Bid for a schedule that allows that,
- 54:59that's better.
- 54:59You know, that's going to be
- 55:01better for their short term health.
- 55:02And you know,
- 55:03we don't know if it'll impact
- 55:04their long-term health,
- 55:05but I would hypothesize that it
- 55:07probably would be better than trying
- 55:09to cram it all in to some crazy.
- 55:12I mean air traffic controllers do create,
- 55:14they call them Rattlers where
- 55:16they work a day shift,
- 55:17have the evening off and then
- 55:18come back for the night shift
- 55:19because they don't want it.
- 55:20They want to have like 5 days off in a row.
- 55:22But that doesn't make any sense,
- 55:24you know,
- 55:25from a from a sleep health perspective.
- 55:27And so a lot of the work that we
- 55:29do with air traffic controllers
- 55:30is really just education.
- 55:32You know,
- 55:32this is how this is affecting your body.
- 55:34And then maybe even showing them
- 55:36feedback on how they're performing,
- 55:38what their alertness looks like when
- 55:39they're doing that type of shift,
- 55:40that tends to be pretty powerful too.
- 55:45I have a
- 55:46question or answer as we were talking
- 55:48you know before I change is related
- 55:50to circadian rhythm shift worker.
- 55:52You know it takes a while to happen right?
- 55:54Example the duty hour changes.
- 55:56Now in terms of adopting this
- 55:58shift work fatigue mitigation,
- 56:00what do you think you know would
- 56:02help the most for institutions to
- 56:04adopt these changes nationally,
- 56:06for example on the job napping or
- 56:08nap room or the proper scheduling.
- 56:11You know all these things
- 56:12but what's your thought?
- 56:14Yeah. Well, I mean I definitely think
- 56:16it varies, occupation to occupation.
- 56:17So as you mentioned, I worked,
- 56:19you know, I worked on the resident
- 56:21work hour studies in Boston when I
- 56:23was there before coming to NASA and
- 56:25that was really challenging because,
- 56:27you know, I don't think that you can
- 56:29just regulate these problems away.
- 56:31I don't think the answer is simply saying,
- 56:33OK, we need to just cut work
- 56:35hours and that's it.
- 56:36In a hospital system,
- 56:37I think you all know very well
- 56:39you have to engage with the nurses
- 56:41and with the PA's and with all of
- 56:43the people who are going to be.
- 56:44Peripherally affected by a work hours change,
- 56:47you might have to do rounds twice a day.
- 56:49So you're fundamentally changing
- 56:51the nature of how a work group
- 56:54has operated for a very long time.
- 56:56And to me, you know that's that.
- 56:58That's where implementation science comes in.
- 57:01You know,
- 57:01bringing in people who know how you
- 57:04know what the best practices are
- 57:06for implementing to make the change
- 57:09as effective as it can possibly be.
- 57:12Change is hard no matter what you do.
- 57:14But.
- 57:14Making sure that that change is done
- 57:16in the best possible way I think will
- 57:19help mitigate some of the reactivity
- 57:21that comes with just blanket changes
- 57:23that people end up hating.
- 57:27Right. Thank you. Two, we
- 57:31have any other questions?
- 57:41Lauren, did you have any
- 57:43question? No, no. OK.
- 57:45Thank you. Thanks, Byron.
- 57:47Thank you for a fantastic talk.
- 57:49Good to see you. Good to see you too.
- 57:52Alright. Thank you so much
- 57:54again for this wonderful,
- 57:55fantastic talk as usual.
- 57:58And well, thank you everyone
- 58:00for joining us. Thank you.
- 58:03Thank you. Take care. Bye, bye.