Carla Williams is an Indiana long-haul trucker with a tricky little problem — about the size of a tissue box.
At issue is her CPAP machine, which treats sleep apnea, a medical condition that causes drowsiness. A doctor told her she needed to use it to keep driving. But a second doctor she consulted five months later told her she had a milder sleep condition and shouldn't use it.
Williams said the machine disrupts her sleep rather than improves it, but she can't get the second doctor's opinion to override the first.
"I sleep worse — I've never had sleep troubles before," Williams said in an interview. She will keep trying to get a waiver to drop the CPAP requirement or find another job.
Williams' trouble is a symbol of a big problem in the transportation industry — how to prevent sleepy driving. Awful crashes have been caused by truck and rail operator fatigue — including a 2013 derailment that killed four people in the Bronx and the 2014 truck-limo bus collision that seriously injured comedian Tracy Morgan and killed James "Jimmy Mack" McNair. Twenty percent of the 182 major National Transportation Safety Board investigations from 2001 to 2012 found fatigue as a probable cause or contributing factor.
One cause of drowsiness is sleep apnea — when a person's breathing pauses during sleep. Most common among overweight men, it affects 28 percent of commercial truck drivers — with 10.5 percent suffering from moderate to severe forms, according to a 2002 University of Pennsylvania study. The percentage is similar to that of the general population, but is viewed as a big concern for rail and truck operators because of the danger to the public.
This spring, the Federal Motor Carrier Safety Administration and the Federal Railroad Administration are collecting public comments as a first step toward making rules on testing and treatment for sleep apnea for truck drivers and rail operators. Currently, no regulations address the subject except to say you can't drive if you have untreated apnea. A comment session was held in Chicago this month.
It's an area fraught with controversy and confusion. Right now, apnea testing and enforcement are like the Wild West, with medical examiners applying different standards for qualifying drivers and operators paying for treatment they may not need, said Scott Grenerth, a former truck driver and regulatory affairs director for the Owner-Operator Independent Drivers Association.
"You've got a mishmash," said Bob Stanton, a Batavia truck driver and co-founder of Truckers for a Cause, a sleep apnea support group. "Many in trucking call it the 'no-rule rule.'"
To drive a truck, a driver needs to have a commercial driver's license and a Department of Transportation medical card saying he or she is fit to drive.
To renew their cards, drivers need to see medical examiners, who can be doctors, chiropractors, nurse practitioners or physician assistants who have taken a training course and passed an exam. Examiners are listed on an FMCSA registry. Many are employed by large occupational health companies that work with carriers and have adopted their own requirements and apply FMCSA guidance in different ways — some more strictly than others, Stanton said.
Grenerth said some examiners have a financial interest in apnea tests and CPAP machines, and rarely recommend other options like dental appliances for mild cases. It's enough of a concern that the FMSCA put out a reminder to examiners last year that "perception of a conflict of interest is possible" if drivers are referred for costly testing at laboratories where examiners have financial ties.
The costs of testing and CPAP machines vary widely, depending on insurance coverage, Grenerth said. Some drivers pay a couple of hundred dollars, while others can pay thousands and lose days of work.
A study released Thursday by the American Transportation Research Institute found that 53 percent of drivers referred for sleep studies paid some or all of the test costs, with an average of $1,220 in out-of-pocket expenses, or about 1 1/2 weeks of median driver pay.
Drivers with severe sleep apnea are more likely to report good results from CPAP — with 84 percent reporting increased sleep, according to the study. Less than a third of drivers who had mild sleep apnea reported better sleep.
Williams was referred to take a sleep apnea test in a hotel room in Pennsylvania, where she spent a night hooked up to wires that monitored her sleep. She talked with a doctor by phone, who told her she needed a CPAP machine four hours a night, for which she paid $900 out of pocket.
CPAP — continuous positive airway pressure — increases air pressure in the throat so the airway doesn't collapse when inhaling. Williams found the machine did not help, and that the mask often slips during sleep and blows air in her eyes. So she sought a second opinion and another sleep test — this time in a hospital.
The machines can present problems for long-haul truckers who sleep in their vehicles, depending on the truck. The machine can suck power from the truck battery, which can result in the engine powering up and idling — a violation of anti-pollution ordinances in some regions, including the Chicago area. Asked if she ever got a ticket, Williams said, "I haven't gotten one yet."
Despite its problems, CPAP is the first choice of therapy for obstructive sleep apnea, and drivers who need it and don't use it could suffer worse than a loss of their medical cards, according to a March 21 study published by the American Academy of Sleep Medicine. The study, which involved 1,613 truck drivers with apnea, found that the rate of preventable crashes was five times higher among drivers with sleep apnea who failed to adhere to CPAP therapy.
"Certainly sleep apnea is a major issue. Fatigue and drowsy driving are a major cause of crashes," said Peter Kurdock, director of regulatory affairs for Advocates for Highway and Auto Safety, a coalition of property and casualty insurers, consumers and public health groups.
Grenerth said that there still is not a clear connection between sleep apnea and crashes, and it needs more study. He said the government might want to try a pilot or test program before setting national rules.
Stanton said he has benefited from CPAP. He used to think drinking a liter of Mountain Dew at lunch to stay alert was normal behavior before his 2002 diagnosis. Now he tells other drivers to get tested.
"I'd probably be dead now if I didn't get treated for sleep apnea," Stanton said.
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Judging from the varied comments from industry groups and operators, federal officials have a lot to consider before making apnea rules — what's fair to drivers and clear evidence on what will keep the public safe. It could be a year or more before any rules are in place.
Williams said she hopes that if rules are made, they are clear about drivers' responsibilities and options in case there's a dispute. She said the current situation has caused confusion and pushed some drivers into financial crises.
Rail and truck operator advocates also say the attention on sleep apnea should not blind regulators to other big causes of fatigue — poor scheduling practices that put people in control of enormous machines when they haven't slept for more than a day.
"Singling out apnea as the problem with regards to fatigue is the equivalent of putting a Band-Aid on a bleeding artery," said Joseph Ciemny, assistant Illinois legislative director of the SMART Transportation Division, which represents rail workers, speaking at the Chicago comment session.