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AFMOA Instructor Guidelines

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1 AFMOA Instructor Guidelines
You have the freedom to tailor this presentation to your local audience. Please read the note pages carefully. They include the details you will need to be properly prepared to present this important information. If you are using USAF official mishap data, you are required to show the AFI Disclaimer Slide. Many thanks to MSgts Doug Schmidt (Aviano AB), Mark Brandt (Lakenheath AB), and Darryl Swartz (Spangdahlem AB) for their work in creating this presentation As of:

2 AFMOA Instructor Guidelines
For Official Use Only All limited-use safety mishap investigation reports are for official, mishap prevention use only. Unauthorized disclosure of the information in the reports is a criminal offense under article 92, uniform code of military justice. See AFI , paragraphs and for restrictions. Destroy according to AFI when no longer needed for mishap prevention As of:

3 AFMOA Instructor Guidelines
For more questions or further instructor guidance, please or phone the MAJCOM points of contact: HQ: Col Susan Richardson: AETC: Col Kent Magnusson: AMC: Col Al Hartzell: AFMC: Col James Dooley: ACC: LtC Daniel Caulkins: SPACE: Maj Joe Balas: USAFE: Maj James Lasswell: PACAF: Maj Rick Fofi: AFSOC: Capt Randy McCalip: Further points of contact: LtC Don White: Capt Nereyda Sevilla: MSgt Doug Schimidt: As of:

4 Cassandra D Howard, Col, FS, MC, TNANG
Photo source: ANG Creative, Health Professions Recruiting Campaign Col Cass Howard Prior enlisted in the ANG as an Aeromedical Specialist in 1988 (128th ARW, Milwaukee, WI). Served in this capacity until 1996 achieving the rank of TSgt. (113th & 128th) Commissioned in 1996 while a 2nd year medical student (128th MDG) into MSC. Re-commissioned into Medical Corp in 1998. Transferred to 164th MDG, Memphis, TN, for combined residency in Internal Medicine & Pediatrics. Completed AMP/FS rating in 2003. Commander 164th MDG since Currently, Vice-President, Alliance ANG Flight Surgeons and life member. Cassandra D Howard, Col, FS, MC, TNANG 164 MDG/CC, Memphis, TN AANGFS, Vice-President As of:

5 Endurance Management Ground Initiative
Air Force Medical Operating Agency As of:

6 “You Must Not Needlessly Fatigue The Troops” Napoleon Bonaparte
Optional Photo As of:

7 Sleep or Die Basic Sleep Physiology As of: Title slide.
Fatigue is a major issue and will be addressed in this presentation. TRANSITION TO OVERVIEW As of:

8 Overview Impact of Fatigue Sleep Physiology Circadian Rhythm
Consequences Recognition No-Go Pills Impact of fatigue (i.e., inadequate sleep) Sleep physiology. What is fatigue? How does your body work? I have a “body clock”? Yeah, so I get tired, who doesn’t? Recognition: I can tell when I’m too tired? We are poor judges TRANSITION TO IMPACT As of:

9 Impact of Fatigue Fatigue Related Crashes China Air Flight 006
FedEx Flight 1478 American Flight 1420 Korean Air Flight 801 China Air Flight 006 2 people injured, AC major structural damage 228 killed, AC destroyed 11 killed, AC destroyed 3 severely injured, AC destroyed Source: Fatigue Management Brief by Capt Jason Susong, MD Shared by Regan Miller, Capt, USAF, PA-C, Flight Medicine, Scott AFB

10 Impact of Fatigue The Cost Major Accidents Three Mile Island
Challenger Space Shuttle The Cost Exxon Valdez Three Mile Island: Nuclear plant accident [1979] occurred at 4:00 a.m. The accident was the worst commercial nuclear plant accident in US history -- occurred in the early morning hours of March 28, The following year, the NRC reported: Studies indicate that with fatigue, especially because of loss of sleep, an individuals detection of visual signals deteriorates markedly, the time it takes for a person to make a decision increases and more errors are made, and reading rates decrease. Other studies show that fatigue results in personnel ignoring some signals because they develop their own subjective standards as to what is important, and as they become more fatigued they ignore more signals. [5] The last part is particularly disturbing because it suggests that well-founded procedures and layers of emergency equipment can be defeated by weary workers discounting warning signs. Other: Chernobyl 1:23 AM; Bhopal 12:40 AM Challenger Space Shuttle: The Chronicle article goes on to state, quoting the panel report, that fatigue may also have contributed "significantly" to the disputed decision by NASA and Thiokol officials to launch the Challenger in cold weather -- despite strong evidence that the O-ring booster seals were ineffective. The panel said "certain key managers obtained only minimal sleep the night before the teleconference" in which the fatal decision was made. Furthermore, a study of 2900 workers' timecards in the weeks before that showed an "unusually high amount of overtime”, during which time there were five aborted launches and two actual launches. Exxon Valdez: What happened? At four minutes past midnight, on March 24, 1989, the Exxon Valdez, loaded with 1,264,155 barrels (53,945,510 US gallons) of North Slope crude oil, ran aground on Bligh Reef in the northeastern portion of Prince William Sound. About one-fifth of the total cargo, 11.2 million gallons, spilled into the sea. Why did it happen? The NTSB determined that the probable cause of the grounding was: failure of the third mate to properly maneuver the vessel because of fatigue and excessive workload; the failure of the master (Captain Joseph Hazelwood) to provide a proper navigation watch because of impairment from alcohol; failure of Exxon Shipping Company to provide a fit master and rested, sufficient crew for Exxon Valdez; the lack of an effective vessel traffic service because of inadequate equipment and manning levels, inadequate personnel training, and deficient management oversight; and the lack of effective pilotage services. What did it cost? Damage to Exxon Valdez ~$25 million; lost cargo ~$3.4 million. $2.1 billion plus for clean-up Exxon must make 10 annual payments totaling $900 million for injuries to natural resources and services, and for the restoration and replacement of natural resources. TRANSITION TO OPERATIONAL FATIGUE Major Accidents As of:

11 Impact of Fatigue The Evidence Military Strategy Human Performance
Major Accidents Annual Cost Military Strategy Human Performance Fatigue has been found to be a cause in several significant accidents, with significant costs. What is the cost? Annual Cost: *Vehicle Accidents ($37.9B); Public Transportation ($720M); Home Accidents ($2.72M); Disabling Injuries (2.5 mil); Deaths (24,318) *$12.5 billion in diminished productivity and property loss Military personnel and accidents: Use any example: SFS SSgt falling asleep while driving home after a “hard’ 12 Airman… self-imposed stress (out all night) As of:

12 Aeromedical Causal Factors
Source: Fatigue Management Brief by Capt Jason Susong, MD Shared by Regan Miller, Capt, USAF, PA-C, Flight Medicine, Scott AFB

13 While remembering our own limitations
Military Strategy While remembering our own limitations We attempt to exploit the enemy’s weakness and outmaneuver and outperform the enemy. TRANSITION TO OUR OWN LIMITATIONS Exploit the Enemy’s Weakness As of:

14 While remembering our own limitations
Military Strategy We must remember, like our enemy, we are human…susceptible to fatigue and decreased performance…from a demanding OPSTEMPO TRANSITION TO COMPARISON OF MONDAY NIGHT FOOTBALL While remembering our own limitations Exploit the Enemy’s Weakness As of:

15 Monday Night Football Monday Night Football:
Traveling across time zones results in a disruption of our natural biorhythms (circadian rhythms), which can have a significant impact on athletic performance. Each of us is influenced by a 24-hour "biological clock" that is located in the hypothalamus in the brain. This internal timepiece effects our physical and mental functions -- including strength, flexibility, reaction time, sleep-wake cycle, and mood. These functions (and consequently athletic performance) typically peek in the late afternoon and are at their lowest point late at night and early in the morning. Several studies of professional baseball, basketball and football teams have demonstrated just how much the disruption of biorhythms by travel affects performance. The latest, and most striking, of these studies involved the National Football League (NFL). This research, which was reported recently in Sleep, the official publication of the American Sleep Disorders Association, looked at the performance of West Coast and East Coast teams during Monday Night Football. It found that the overall home and away winning percentages of the West Coast and East Coast teams were about the same over the last 25 years. However, West Coast teams won far more (65%) of the Monday Night games. And they won by more points than East Coast teams (15 points vs. 9 points per game average, which is significantly better than predicted by the Las Vegas point spread). Explanation. The explanation proposed for this win/loss difference is that West Coast teams have a "circadian advantage" over East Coast teams. That is: Monday Night Football games begin at 9:00 p.m. Eastern Standard Time. Gave the three-hour time difference between coasts, West Coast Teams traveling East start playing at 6:00 p.m. "their time". On the other hand, East Coast teams traveling west start playing at 9:00 p.m. -- and frequently play to 12:00 midnight -- "their time".   This late hour is close to the point where the biological clock of the East Coast players has about wound-down. Consequently, their performance potential is at a low point, and this is reflected by the outcome of the games. Patrick J. Bird, Ph.D. , Keeping Fit, Column 596, 1998 TRANSITION TO FATIGUE As of:

16 Effect of operations on sleep and circadian physiology
Causes of Fatigue Sleep loss Circadian rhythms Types of Fatigue Acute: Work induced Chronic: Repeated sleep loss Subjective: Stress induced Circadian Rhythm: Shift Work or Jet lag FATIGUE Fatigue is really a catchall term for a variety of different subjective experiences. For example, physical discomfort after overworking a particular group of muscles, concentration difficulties during a monotonous task, difficulty appreciating potentially important signals following long or irregular work hours, or simply difficulty staying awake. In the context of ... operations, ... fatigue becomes important if it reduces efficiency or otherwise impairs ... performance. Subjective fatigue can be affected by motivation or by the amount of stimulation coming from the environment. However, there are 2 systematic physiological causes of fatigue (and poorer performance)—sleep loss and circadian rhythms—both of which are affected by ...operations. It is also important to note that inadequate rest can result in sleep loss and circadian disruption, and can therefore be a source of fatigue in its own right. Circadian Rhythm Disruption is critical The specific determinants of work-related fatigue are: -The time of day of work and breaks -The duration of work and breaks -Work history in the preceding seven days -The biological limits on recovery sleep TRANSITION TO SLEEP LOSS AND CIRCADIAN RHYTHMS Effect of operations on sleep and circadian physiology As of:

17 Basic Human Physiology: Sleep & Circadian Rhythms
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 Just like water and food, sleep is a vital physiological need. In fact, you are able to do without food for a longer time than you are able to do without sleep. Sleep debt Banking sleep and Sleep Debt Poor judges of our level of sleepiness and subsequent alertness Our biological clocks TRANSITION TO TYPEES OF SLEEP As of:

18 Physiology of Sleep NREM Sleep REM Sleep Stages 1 & 2 Dreams
Physical Restoration Hormone Production Tissue Repair Dreams Muscle Twitching Rapid Eye Movement Problem Solving Short- to Long-Term Memory It is widely believed that sleep is a time when the brain and the body shut off and then re-engage upon awakening. Actually, sleep is a highly complex physiological process during which the brain and body alternate between periods of extreme activity and quiet, but are never “shut off.” Sleep is composed of two distinct states: NREM, or non-rapid eye movement, and REM, or rapid eye movement, sleep. These two sleep states are as different from each other as they are from wakefulness. During NREM sleep, physiological and mental activities slow (e.g., heart rate and breathing rate slow and become regular). NREM sleep is divided into four stages, with the deepest sleep occurring during stages 3 and 4. There is usually very little mental activity during NREM stages 3 and 4. If awakened during this deep sleep, an individual may take sometime to wake up and then continue to feel groggy, sleepy, and perhaps disoriented for 10–15 minutes. This phenomenon is called sleep inertia. REM sleep is associated with an extremely active brain that is dreaming, and with bursts of rapid eye movements (probably following the activity of the dream); during REM sleep, the major motor muscles of the body are paralyzed. If awakened during REM sleep, individuals can often provide detailed reports of their dreams. Over the course of a typical night, NREM and REM sleep occur in a cycle, with about 60 minutes of NREM sleep followed by about 30 minutes of REM sleep. This 90-minute cycle repeats itself throughout a typical sleep period. However, most deep sleep (i.e., NREM stages 3 and 4) occurs in the first third of the night, and REM periods are shorter early in the night and then become longer and occur more regularly later in the sleep period. Overall, about 25% of sleep time is spent in REM sleep and about 50% is spent in NREM stage 2. TRANSITION TO SLLEP HISTOGRAM As of:

19 What’s Supposed To Happen (Normal Sleep Histogram)
Wake REM Stage 1 Stage 2 Stage 3 Stage 4 REM Sleep This graph portrays a typical night of sleep for a normal adult. It exemplifies the sleep architecture discussed on the previous slide: REM (indicated by darkened bars) and NREM alternating throughout the period; most deep sleep occurring in the first half of the sleep period; and REM periods becoming longer and more regular later in the sleep period. NREM Sleep: Stages 1 & 2; Stages 3 & 4; Physical Restoration; Hormone Production; Tissue Repair REM Sleep: Dreams; Muscle Twitching; Rapid Eye Movement; Problem Solving; Short- to Long-Term Memory EMPHASIZE: To understand the problem of inadequate sleep, we should understand what sleep is. There are four stages of sleep starting with about 10 minutes of REM (rapid eye movement) sleep where the mind is active (dreaming) and the smaller muscles twitch. During the next three stages the mind and body slow down. After minutes, we return to REM. People go through this cycle several times through the night and an interruption of any stage (i.e., the hotel maid waking you up to see if you need the room cleaned, or a phone call from dispatch to tell you that they have received your fax) will render that whole cycle ineffectual. TRANSITION TO CIRCADIAN RHYTHM NREM Sleep

20 Sleep Histogram REM - Mental restoration NREM - Physical restoration
Wake REM Stage 1 Stage 2 Stage 3 Stage 4 REM - Mental restoration Source: FAA Pre-Flight Safety Briefing NREM - Physical restoration

21 Circadian Rhythm Circa = Approximately or about
Dian = 24-hour period or a day Over evolutionary time, the daily cycles in the physical environment (produced by the Earth’s rotation) have become hard-wired into our neuronal circuitry in the form of a biological clock in the suprachiasmatic nucleus of the hypothalamus. However, since the beginning of the industrial revolution, we have developed a cultural environment in which there is ever-increasing pressure for round-the-clock operations and services. The expedient (but incorrect) assumption that we can and do function equally at any time of the day or night underlies many activities in our society, from medical diagnosis and treatment to many hours-of-service regulations. When people live alone in environments from which all possible time cues have been carefully excluded (deep caves, underground bunkers, or specially designed apartments), they begin to live “days” that are generally longer than 24 hours. Regardless of how long someone’s subjective “day” becomes in a time-free environment, however, the circadian clock still enforces an approximately 25-hour cycle in many functions. Some people even develop “days” as long as 50 hours with, for example, 36 hours of wakefulness followed by 14 hours of sleep. The circadian clock can be thought of as analogous to the conductor of a symphony orchestra. Many different systems in the body, down to the level of individual cells, are capable of generating circadian rhythms independently, just as the members of an orchestra must each be capable of playing their own part. However, if they are not all synchronized appropriately, the harmony rapidly degenerates into cacophony. TRANSITION TO TYPES OF PHYSIOLOGICAL RHYTHMS As of:

22 Types of Physiological Rhythms
Sleep-Wake Temperature Mental Performance Hormones Digestion Influence on Body Systems The SCN also plays a role in the circadian system by triggering a neuroendocrine response in the hypothalamus, which then acts on the pituitary. This last pathway profoundly influences other parts of the body, including the endocrine, immune, cardiovascular, and urinary systems. Rhythms in most of these systems have a simple waveform similar to that of body temperature, which is highest in the early evening and lowest right before waking in the morning. A plot of urine volume, for example, shows a cyclic pattern very similar to that of the body's temperature [4]. Some of the hormones thought to be influenced by the circadian system are growth hormone, prolactin, thyrotropin, and testosterone. One endocrine event clearly under the influence of the clock is the release of the hormone ACTH. The SCN triggers the hypothalamus, which activates the anterior pituitary to release ACTH, causing the adrenal glands to release cortisol and aldosterone. A plot of cortisol concentration in blood plasma shows a characteristic peak in the very early morning (around 6 AM) with a trough right before bedtime. Similarly, aldosterone level is constantly high throughout the night and low throughout the day[4]. Activity of the immune system, as represented by the number of lymphocytes, also seems to peak in the late evening and is lowest a few hours after the cortisol peak in the morning[5]. The timing of the endocrine and immune systems are clearly intermeshed. It is known that aldosteone and cortisol suppress the immune system, while melatonin appears to enhance it. TRANSITION TO BODY TEMPERATURE CHANGE As of:

23 Body Temperature Sleep No Sleep 98.6 96.5 Maximum Sleepiness
Circadian Rhythm Factors (Body’s Natural Clocks): light, hormones, core body temperature, level of physical activity, average heart rate, etc. Trough Period: Early Morning and Mid-Afternoon An important feature of the circadian temperature rhythm: temperature reaches a minimum during normal daily sleep period, and begins to rise well before individual awakens. This spontaneous rise in temperature is not the result of increased physical activity. It reflects the action of the circadian clock, which is envisaged to drive a cyclic variation in the setpoint of the temperature-regulating system. In general, changes in heart rate closely paralleled the changes in the level of physical activity. As expected, by the end of a normal day you feel more fatigued and report less activity. We cannot, as yet, reset our circadian rhythms at will, as we do our wrist watches. However, this is the aim of most circadian countermeasures. It may take days to weeks for all rhythms to synchronize to a new time zone. Shift workers are rarely, if ever, fully adapted to one work/rest schedule before they switch back to normal daytime activity and nighttime sleep on their next days off. In the case of rotating shift workers, going back to work then means trying to adapt to yet another work/rest schedule. Two different approaches have developed for scheduling rotating shift workers. With rapid rotations (changing hours of work every few days), circadian adaptation to any one work/rest pattern is minimal, and workers revert easily to being day-active on their days off. This approach is more common in Europe. With slower rotations (changing the hours of work every 1–2 weeks), the circadian clock has more time to synchronize to a given work/rest schedule. Sleep and performance are thus expected to improve progressively, at least until the next day off. This approach is generally preferred in the United States. Troughs: 3-5 AM & PM. Increase your awareness and vigilance. Avoid boring tasks if possible & afternoon meetings. TRANSITION TO ALERTNESS LEVEL 96.5 Maximum Sleepiness As of:

24 Alertness Level Maximum Alertness High Low
Peak: Around Take advantage with scheduling critical tasks if possible. TRANSITION TO FATIGUE, ALCOHOL, AND PERFORMANCE Low As of:

25 Fatigue, Alcohol and Performance
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 Most of us maintain a 17 hour day. TRANSITION TO ALCOHOL INDUCED SLEEP Center for Sleep Research, University of South Australia, and University of Adelaide, South Australia (Nature, 1997) As of:

26 Fatigue, Alcohol and Impairment
Source: FAA Pre-Flight Safety Briefing

27 Alcohol-Induced Sleep
Wake REM Stage 1 Stage 2 Stage 3 Stage 4 Directly to the coma state. How much alcohol? Hangover effects: hours later (even with a .00 BAC) TRANSITION TO FATIGUE SIGNS AND SYMPTOMS

28 Fatigue Signs & Symptoms
Fixated Apathetic Lethargic Bad mood Nodding off Forgetful Poor decisions Slowed reaction time Reduced vigilance Poor communication What have you seen (symptoms) in the base population, your coworkers, you. Forgetful: medical, dose/amount; tool accountability Poor decisions: risk management Slowed reaction time: breaking Reduced vigilance: SF at post; FOD Poor communication: sender & receiver; tail #, HAS # Fixated: on something unimportant; loss of good scanning Apathetic: “not important” Lethargic: overall slowness Bad mood: take it out on the family (and friends); fights; attitude toward pilot Nodding off: monitoring equipment; on post; in the HAS Work Related Fatigue = Consequent Changes In: -Alertness -Reaction time -Hand-eye coordination -Communication -Decision making TRANSITION TO INTERIM SUMMARY As of:

29 If You Remember Nothing Else…
Physiological mechanisms underlie fatigue Just like water and food, sleep is a physiological necessity Fatigue can have severe consequences Financial Human performance Take sleep and fatigue seriously People are generally NOT lazy (slackers) and whiners We/You can’t change OpsTempo and remove the stress of fatigue, but we/you can reduce fatigue’s impact (negative outcomes associated with fatigue) We/You can’t just “gut it out”. Sleep is a physiological need, just like food and water. What works for some may not work for all. You may not like tuna fish, coffee, chocolate (coffee candy), etc. No quick fix: For every complex problem there is a simple solution…and it is usually wrong. TRANSITION TO COMBATING FATIGUE As of:

30 Fight The Good Fight Combating Fatigue
My intent is to provide a few simple (practical) tools for you to use to defend yourself against the negative effects (and potential negative outcomes) of fatigue. TRANSITION TO PERSONAL STRATEGIES As of:

31 Fatigue Countermeasures: Personal Strategies
Preventive Strategies Minimizing sleep loss Naps Good sleep habits Effects of food, alcohol, and exercise Sleep environment Circadian strategies OVERVIEW -Quality at least, if you can’t also get quantity -Napping strategy -Practice, practice -Self-Imposed Stress -Sleep hygiene -Adjusting body clock(s) TRANSITION TO SLEEP LOSS AND NAPPING As of:

32 Preventive Strategies: Sleep Loss & Strategic Napping
Sleep Requirements and Debt Strategic Napping (Prior to Duty) Can Acutely Improve Alertness Limit Nap: Minutes Decreases Continuous Wakefulness Some Sleep is Better Than None Sleep requirement (~8 hrs); Sleep Debt (`1.5 hrs/night) Strategic Napping can be useful for shift workers and night week An extensive scientific literature clearly demonstrates the effectiveness of naps in improving subsequent alertness and performance. One important consideration when napping close to a duty period is to minimize the chances of going into deep NREM sleep (stages 3 and 4). If awakened out of deep sleep, an individual may continue to feel groggy, sleepy, or disoriented for 10–15 minutes. This phenomenon is called sleep inertia. Therefore, if taking a nap before a duty period, limiting its duration to 30 minutes or less will decrease the chances of having significant amounts of deep sleep. A brief nap can be an important way to decrease the length of continuous wakefulness. It is usually much better to get some sleep than none at all. When you nap at times other than immediately before a duty period, then the nap can be longer. In this case, a nap longer than 2 hours is likely to get an individual through at least one NREM/REM cycle. Strategic napping can be an extremely effective countermeasure in improving subsequent alertness and performance. Some individuals call these “power” naps. In flight operations, “NASA naps” have been demonstrated to be an effective acute fatigue countermeasure. A planned, brief nap is an operational strategy that reduces physiological sleepiness. Addresses the “afternoon window” of sleepiness ( ) and mental restoration (REM sleep). Naps: During Duty? Commander’s/Supervisor’s call TRANSITION TO GOOD SLEEP HABITS As of:

33 Sleep Histogram Best method to minimize fatigue
Wake REM Stage 1 Stage 2 Stage 3 Stage 4 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

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 Impact of changes in sleep-wake schedules and behavior during weekends versus weekdays The following recommendations are generally considered important for maintaining good sleep habits. They apply to everyone. First, keep a regular sleep and wake schedule as much as possible. At home before trips, try to keep sleep time protected and minimize other responsibilities. A regularly practiced pre-sleep routine can be used to teach your mind and body that it is time to relax and fall asleep. A set of cues can be established to condition pre-sleep relaxation and can then be used anywhere and anytime before going to sleep. It is important to avoid work or worry in the bedroom and to prevent the association of the bed with activities contrary to relaxation and sleep. Going to bed hungry can delay falling asleep. Eating a heavy meal also can disrupt sleep, for the stomach is busy digesting food. If hungry or thirsty at bedtime, eat a light snack or have a small quantity of something to drink. As previously mentioned, alcohol should be avoided immediately before going to bed because of disruptive effects on sleep. Caffeine consumption should also be limited. Caffeine in coffee, tea, and colas can prevent sleep onset and disrupt subsequent sleep. Some individuals are sensitive to the caffeine in chocolate, and even a chocolate dessert after dinner is enough to interfere with their sleep. Many mild pain relievers also contain caffeine; read the label for ingredient information. Be sure to stop caffeine intake several hours before planned bedtime. A variety of mental and physical relaxation techniques are proven to promote sleep onset and good sleep. Appendix B describes some of these techniques in more detail. Like any skills, these techniques can be practiced; then they can be used in a wide range of applications, essentially anywhere. If unable to fall asleep in 30 minutes, don’t lie in bed trying to fall asleep. Instead, get out of bed and engage in some activity conducive to relaxation and sleep. TRANSITION TO SLEEP ENVIRONMENT As of:

35 Preventive Strategies: Sleep Environment
Dark, Quiet Room White Noise Comfortable Temperature Comfortable Sleep Surface Large Meals & Indigestion Lack of Food Disruptive environmental factors should be minimized. Sleep in a dark, quiet, temperature-controlled room, and on a comfortable sleep surface. Laboratory studies suggest that regular exercisers may have increased amounts of NREM stages 3 and 4. However, exercising too close to bedtime can disrupt subsequent sleep. Although physically tiring, exercise elevates heart and breathing rates (and body temp.), and is generally activating physiologically. Usually, it is not possible to immediately wind down and fall asleep after exercise. A balanced diet and regular exercise are critical components for overall good health. White Noise: Low level continuous noise to block-out other noised. i.e. fans, air conditioner, etc… Lifestyle: You have control; when given the opportunity, sleep; have and implement a plan TRANSITION TO OPERATION STRATEGIES As of:

36 Self-Medication Source: FAA Pre-Flight Safety Briefing

37 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. Source: FAA Pre-Flight Safety Briefing

38 Self-Medication Effects of Medications
Desired Effects – treats the symptoms Side Effects – other effects on the body Allergic Reactions Combined Effect – = 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 Source: FAA Pre-Flight Safety Briefing

39 Personal Strategies: Operational Countermeasures
Physical Activity Combats Sleepiness Social Interaction and Conversation Diet and Hydration Bright Lights Strategic Caffeine Consumption One of the most successful techniques for combating sleepiness is physical activity. Chewing gum is also quite effective. Engage in conversations with others and be sure to participate verbally. Communication and sense of humor (loss of humor: key stress indicator) Nutrition (“eating on the run”): important to eat at regular intervals; the brain is fat tissue; fat tissue does not store energy; the brain’s energy source must be replenished. Exercise; maintain a balanced diet; drink plenty of fluids and stay hydrated. Bright Light: normal lighting = 500 LUX; to suppress melatonin production = 2,500 LUX Caffeine can be consumed strategically to acutely increase alertness. Determine the potential periods when caffeine could be used. Usually takes 15–30 minutes to take effect and then lasts for up to 3–4 hours. Strategic Napping: A planned, brief nap is an operational strategy that reduces physiological sleepiness. Is this even possible in your squadron? Strategic Caffeine: Caffeine, a stimulant, can be consumed strategically to acutely increase alertness. It is best not to continually consume caffeine before, during, and after duty. Instead, determine the potential periods when caffeine could be used to combat a specific period of sleepiness (e.g., 3–5 A.M. or 3–5 P.M.). Avoid using it when already alert, for example, when just beginning a daytime duty period or immediately after a nap. Though affected by several variables (e.g., body size, previous food intake), caffeine will usually take 15–30 minutes to take effect and then last for up to 3–4 hours. Therefore, continually consuming caffeine throughout a shift could interfere with subsequent sleep. Stop caffeine consumption far enough in advance of a planned bedtime so that it will no longer be active. Be sensible about nutrition. Whenever possible, maintain a balanced diet. Obviously, operations can interfere with regularly scheduled, balanced meals. Try to carry appropriate snacks as needed. Drink plenty of fluids and stay hydrated. Remember, it is very easy to become dehydrated. TRANSITION TO COMMON CAFFEINE AMOUNTS As of:

40 Strategic Caffeine Use
15 to 30 minutes to take effect Effects can last for up to 3-4 hours Chocolate mg caffeine oz Pepsi 36 mg caffeine 12 oz Coke mg caffeine 12 oz Mt Dew 54 mg caffeine 12 oz Instant Coffee mg caffeine oz Drip Coffee mg caffeine oz Caffeine, a stimulant, can be consumed strategically to acutely increase alertness. It is best not to continually consume caffeine before, during, and after duty. Instead, determine the potential periods when caffeine could be used to combat a specific period of sleepiness (e.g., 3–5 A.M. or 3–5 P.M.). Avoid using it when already alert, for example, when just beginning a daytime duty period or immediately after a nap. Though affected by several variables (e.g., body size, previous food intake), caffeine will usually take 15–30 minutes to take effect and then last for up to 3–4 hours. Therefore, continually consuming caffeine throughout a shift could interfere with subsequent sleep. Stop caffeine consumption far enough in advance of a planned bedtime so that it will no longer be active. Be sensible about nutrition. Whenever possible, maintain a balanced diet. Obviously, operations can interfere with regularly scheduled, balanced meals. Try to carry appropriate snacks as needed. Drink plenty of fluids and stay hydrated. Remember, it is very easy to become dehydrated. TRANSITION TO FOOD As of:

41 Sleep Food Carbohydrates Pasta Corn White Bread Potatoes
Theory “Elevating serotonin levels with a diet rich in carbohydrates may induce sleep; and elevating the catecholamine levels with a high protein meal may promote wakefulness” “High carbohydrate meals can increase the levels of tryptophan. Tryptophan is associated with the behavioral changes of increased brain serotonin and possibly melatonin (serotonin is a substrate for melatonin); therefore, increase serotonin from carbohydrates may promote sleepiness and night time adaptation. ”We suggest that foods rich in carbohydrates (legumes, pastas, potatoes, etc) be consumed before sleep periods. Simple carbohydrates (sugars) can provide a short lived boost in alertness, but are frequently followed by a rebound of alertness as blood glucose levels fall. ”High protein meals (or meals rich in tyrosine) may promote wakefulness by enhancing catecholamine activity, and foods such as meats, dairy products, eggs, etc., are suggested for the meal after awakening. “Specific meals and the proper timing for those meals can positively affect mission performance.” As of:

42 Alert Foods Protein Nuts and Seeds Meats/Cold Cuts Peanut Butter
Cheese Eggs Fish Yogurt Beans Theory “Elevating serotonin levels with a diet rich in carbohydrates may induce sleep; and elevating the catecholamine levels with a high protein meal may promote wakefulness” “High carbohydrate meals can increase the levels of tryptophan. Tryptophan is associated with the behavioral changes of increased brain serotonin and possibly melatonin (serotonin is a substrate for melatonin); therefore, increase serotonin from carbohydrates may promote sleepiness and night time adaptation. ”We suggest that foods rich in carbohydrates (legumes, pastas, potatoes, etc) be consumed before sleep periods. Simple carbohydrates (sugars) can provide a short lived boost in alertness, but are frequently followed by a rebound of alertness as blood glucose levels fall. ”High protein meals (or meals rich in tyrosine) may promote wakefulness by enhancing catecholamine activity, and foods such as meats, dairy products, eggs, etc., are suggested for the meal after awakening. “Specific meals and the proper timing for those meals can positively affect mission performance.” As of:

43 in Military Operations
Optimize Sleep Dark, cool room “Warfighter Sleep Kit” AMMO Alertness Management in Military Operations or Source: Fatigue Management Brief by Capt Jason Susong, MD Shared by Regan Miller, Capt, USAF, PA-C, Flight Medicine, Scott AFB

44 Ground testing required prior to operational use.
“No Go” Pills Medication Dose Half-life Grounding Temazepam (Restoril®) 15 or 30 mg h 12 hours Zolpidem (Ambien®) 10 mg h 6 hours Zaleplon (Sonata®) 1.0 h 4 hours Ground testing required prior to operational use. 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 Source: Fatigue Management Brief by Capt Jason Susong, MD (Shared by Regan Miller, Capt, USAF, PA-C, Flight Medicine, Scott AFB) GROUND TESTING REQUIREMENTS: Testing against all 3 agents recommended If member declines, document in writing and note ASIMS Flyer in duty status No-Go Pill Form, Part 1 completed: Only test ONE agent at a time PRIOR to testing (member must be in a duty status) AF Form 1042 completed to DNIF member No-Go Pill Form Part 2 completed: AFTER no-go pill testing completed PRIOR to returning to flying status Only after the minimum GROUNDING TIME (PER AGENT) has passed Update DD Form 2766 (Adult Preventative & Chronic Care Flow) form indicating ground test results Use 1042 to Return to Flying Status (RFTS) at he completion of ground testing. If side effects reported, complete FDA Form 3500 (FDA Med Watch Program)

45 Android iPhone Smart Phone Apps Bedtime Calculator (Free)
- REM cycle monitoring Crew Alert ($29.99) - Your wildest dreams come true! Sleepy Time (Free) - Chromotherapy Sleep Science Alarm ($.99) Sleep Watcher (Free) - Daily fatigue estimation Fatigue Calculator (Free) Relax and Sleep Plus (Free) - Ambient noises aSleep 3 ($.99) REM cycle monitoring Chromotherapy Sleep Now! (Free) Circadian Alarm ($.99) As of:

46 Summary Impact of Fatigue Sleep Physiology & Circadian Rhythms
Consequences & Recognition Preventive Strategies Operational Countermeasures No Silver Bullet, No Magic Pill You make the call! As of:


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