I woke up abruptly and looked at the clock. It was 4:30 AM, a bit early for my normal routine, but something had pulled me out of a deep sleep—what was it? I quickly realized that my heart was the culprit, beating at 150 to 180 bpm as opposed to my normal 65. My surprise quickly turned to fear but then subsided when my heart rate returned to normal after a few minutes. This episode repeated itself enough that my wife said, “We are heading to urgent care,” where they took an EKG and said, “We are sending you to the emergency room.” I was diagnosed with mild atrial fibrillation and advised to reduce my caffeine and alcohol intake, increase exercise, and reduce stress. Then the doctor asked me a question: “How are you sleeping at night?” Before I could answer “fine,” my wife piped in, “Terrible! He snores, he kicks, he wakes me up all the time and he doesn’t even seem to know it! It’s been that way for 30 years!”
The doctor explained that one of the factors that can impact heart health is Obstructive Sleep Apnea (OSA) and recommended I undergo a sleep study. Six weeks and two studies later, I now hook up to a CPAP machine each night and take a pill for Restless Leg Syndrome (RLS). And although I have not convinced my spouse that the CPAP machine is the same decibel as an expensive white-noise maker, we are both sleeping better, and I have had no further heart episodes. And I thought giving up caffeine would be the hard part!
For someone who has spent the past decade studying sleep and fatigue, this episode caused some deep introspection. Why had I not seen this? Why had no one in the medical community asked me about it while I was on active duty? What are the risks of this condition? Is there a chance that my OSA is associated with a lifestyle spent standing rotating watches and shift work? Did I have OSA prior to joining the Navy? I also realized that several of my friends in the same peer group (surface warfare, O-6, retired) had experienced similar “odd” cardiovascular events—ranging from waking paralysis to stroke (including one death) to a complete blackout. A recent LinkedIn post I shared that included a picture of my wired-up mug drew more than 10,000 views and many comments about how other service members had been diagnosed with this condition on retirement or separation—and how much of the treatment had improved their lives.
They also cautioned me that it would be almost impossible to prove that it was “service related,” which came as a bit of a surprise. There is a mountain of research for both civilian and military communities that documents long-term health implications of irregular shift rotations, sleep deprivation, and the stress of military service. The research shows the “five and dime” watch—the rotating three-section watch schedule that was once common on board Navy ships—and the phenomenon “circadian scarring” (discussed further in the following paragraphs) from non-circadian watch rotations can impact the body’s natural clock for years and even for life.
Show Me the Money?
One LinkedIn commenter opined, “You’re not interested in an academic discussion, you just want the money!” You are mistaken, sir. This issue is not about the money. It is about caring for veterans with sleep injuries incurred during service to their country. Under current VA guidelines, a diagnosis of OSA is likely to result in a 50 percent disability compensation finding (this determination is currently being reevaluated). This percent disability is the “break point” that changes the nature of payment from a percentage of the pay being tax-free, to an additional payment over a lifetime of retirement. The magnitude of this change can realistically be hundreds of dollars per month for a retiree.
Would it result in higher costs? Likely, but saving money by consciously avoiding a diagnosis of a known condition seems disingenuous. More important, it is quite possible this condition places ships and sailors at risk today, and places veterans at risk of other expensive and life-threatening health issues—mental and physical—for a lifetime. There is also abundant research tying sleep deprivation to mental illness and even suicidal thoughts. So, I thought to myself, maybe now is the time to close the loop on this widespread problem.
It is easy for companies—and even the military—to adopt a “fire and forget” approach to the workforce. Service members volunteer for a life of service and sacrifice that often includes working conditions that have documented long-term health implications. As the employer against imposing these conditions on its workforce, does the Navy not owe it to them to ensure the effects are diagnosed, treated, and compensated? Experience also indicates that the fears of career impact are largely unfounded. For example, while the Federal Aviation Administration (FAA) regards untreated OSA as a disqualifier, more than 5,000 pilots are currently certified and flying while receiving OSA treatment. Of course, there are follow-ups and checks and balances in place for treatment compliance. Further research of medical requirements did not show any programs in which treatable OSA was a disqualifier for any program or service.
Evidence—Anecdotal and Scientific
A short literature review turned up some meaningful statistics and findings by some of the most respected experts in the field:
- According to Vincent Mysliwiec, “Military service frequently results in shift work. Despite this, few studies have assessed the acute and chronic effects of shift work on service members. . . Shift workers are at increased risk of cardiovascular disease, cancer, metabolic syndrome, and diabetes.” The RAND study, Sleep in the Military, was the first to comprehensively assess the prevalence and impact of sleep problems of U.S. service members and review the organization’s policies and programs related to sleep. This study found that “only 37 percent of service members sleep the recommended seven to eight hours per night, and nearly half the sample had clinically significant poor sleep quality.”
- Timothy Monk coined the term “circadian scarring” and found that “when sleep is measured polysomnographically, there appears to be a sleep scarring associated with a working life involving shift work. Compared with retired dayworkers, retired shift workers are more likely to achieve less sleep and spend a greater percentage of the night awake. . . Prior exposure to shift work would appear to be related to currently reported sleep problems during retirement.”
While it may be difficult to tease out one cause, such as work routine, as the root cause of OSA; other factors such as obesity, neck circumference, anatomical structures of the airways, and genetics can cause OSA. RLS, on the other hand, seems to still be a bit of a medical mystery. Furthermore, there is also strong evidence that military life—specifically the long hours—lack of workout facilities on ships and submarines, fatigue, and stress can have secondary effects such as inadvertent weight gain and poor eating habits that can lead to increased BMI and thus exacerbate sleep problems—a vicious, well-trod cycle for any service member.
Consider some experiences friends shared with me on the topic. One lieutenant who recently left the service was diagnosed with sleep apnea and asked the question, “I wonder how many of our officers of the deck and commanding officers suffered from OSA and chronic fatigue during service, resulting in impaired decision making and bad judgment, and perhaps unknowingly putting lives at risk?” In fact, one study showed that a commanding officer was essentially “legally drunk” for over one-third of a deployment because of sleep deprivation. Was OSA part of the problem?
Another friend, a retired senior chief, recounted that when he approached a corpsman about his fatigue levels, he was told “drink more caffeine” and advised that if he took a sleep test it could impact his flight pay. I have also seen some veterans scoff at the idea of the disability rating associated with OSA as “fake science” and “a scam” with the implication that to seek treatment would imply selfishness or malfeasance on the part of the service member. One retired captain shared, “I was that guy who saw all of the symptoms but ignored them because I feared that a diagnosis of sleep disorder would derail my aspirations of a career culminating in command; as a result, I may have put my entire ship at risk!”
Another important reason to focus on sleep is the relationship between sleep and mental health, including the increased risk of veteran suicide because of sleep disorders. Army Major General Gregg Martin shared that as he recovered from a diagnosed bipolar condition that effectively ended his 30-year military career, he looked back and realized that his manic depression was significantly exacerbated by a lifetime of poor sleep habits. “I now go to bed at 10 and wake up at 6; if I went back to my old ways, sleeping 2 to 4 hours a night, I know that it would cause a downward spiral in my mental health that could end very badly.” Recent research indicates that almost one in three service members may have some form of sleep disorder. If the nation is serious about reducing suicide rates among veterans, diagnosing and treating veteran sleep disorders would go a long way toward this goal.
There is still an atmosphere in the military where service members are disinclined to recognize the impact of a potential sleep disorder and subsequently fail to seek treatment because they fear the potential career implications. While this is not a scientific treatise, there is certainly strong anecdotal evidence that:
- Sleep disorders are very prevalent in the active-duty military population, and at a higher rate than with their civilian counterparts.
- Service members are reticent to seek help, either through a lack of awareness or for fear of a negative career impact, even separation.
- The military medical community is still learning the magnitude of health impacts associated with sleep disorders and may not be capable of providing the requisite counseling and training.
- The VA is not readily inclined to recognize the connection, likely because it would cost a good deal of money to treat.
- Standard sleepiness questionnaires of military personnel result in skewed data since most are so tired that their fatigue masks actual disorders.
The Way Ahead
Despite having discussed this at length in a past article that drew a parallel between fatigue and black lung disease, I went down the same route as many, doing my job while ignoring my own situation, out of fear and/or ignorance. This could be changed by a few tangible actions:
- Evaluate new accessions for existing sleep disorders, such as OSA and insomnia. Give every incoming service member a sleep quiz to determine if they are already suffering from sleep impairment. Direct a sleep test for those with a potential issue and if their BMI or neck size is over a certain number and are thus prone to OSA.
- Institute a sleep test for military members as standard practice, perhaps as part of sea-duty screening, or at certain milestones such as when returning to the department head or command pipeline. A laboratory study may be prohibitive, but there are home study options that can serve as a quick triage method to determine if a risk exists and direct a lab study.
- Educate the medical community on the operational impacts of fatigue that is induced by and/or leads to OSA and other sleep disorders and provide education on the topic to service members at various leadership schools.
- Direct a study to determine if there is a higher prevalence of sleep disorders among veterans compared with the general population, and use the results to determine if a disability rating is appropriate for those who were not tested and diagnosed while still on active duty.
While we wait for policy makers to crunch the data and make large decisions, there are steps that everyone can take now.
- Self-assess your own sleep health (or ask your spouse!). Then ask your primary care provider if your symptoms and sleep experience warrant a sleep study. It only takes one night, and although you look like Frankenstein with all the sensors hooked up to your head and body, you will have a definitive answer, can deal with the situation, and have it documented.
- Learn about sleep and sleep hygiene. There is a wealth of information about the nature of sleep, the role of sleep in promoting good health, and tips to get good sleep at home or in the shipboard environment. Be your own advocate!
- If you are heading into retirement or choosing to separate from service, demand a sleep study to ensure that a future health condition that might be related, such as heart or circulatory problems, is “service related.” Do not listen to those who call you a gold-digger or selfish—you do not write the policy, but you deserve to have it applied.
In the meantime, I have submitted my claim to the VA with fingers crossed. I fully expect that it will not be approved. And for a well-compensated, retired captain, I can live with that. However, for junior sailors and other veterans whose health is on the line, we should not accept the status quo.