January 1, 2013  

At war with fatigue

Weave sleep into your ops plan or give the enemy an advantage

F atigue in war is as old as war itself, and somehow has become an ennobling virtue when endured. Many classical texts express admiration for the man who is seemingly impervious to fatigue. Alcibiades extolled Socrates: “All this happened before he and I went on the expedition to Potidaea; there we messed together, and I had the opportunity of observing his extraordinary power of sustaining fatigue.” Suetonius wrote of Caius Julius Caesar: “He was perfect in the use of arms, an accomplished rider and able to endure fatigue beyond all belief.”

Even within the memory of our own national history, an interesting and telling example occurred early in the career of Gen. Robert E. Lee. During the Mexican War, Gen. Winfield Scott hailed then-captain Lee for daring physical feats of courage beyond any other soldiers he knew at the battles of Contreras and Churubusco. Lee maneuvered for 36 hours without sleep, crossing the Pedregal River twice at night to lead U.S. forces to strategic positions. During the assault on Mexico City, Lee was awake for at least 56 hours and could not keep upright in the saddle due to sheer exhaustion. Garnering praise from Scott, Lee received a third brevet promotion to colonel and likely developed a belief that he could pull off extraordinary feats during prolonged periods of sleep deprivation — and it served him ill at the Battle of Gettysburg. Here’s how Michael Shaara framed Lee’s thoughts in his historical novel “The Killer Angels”: “Let us attack and let it be done. I am extraordinarily tired.”

Field commanders have long recognized the effects of uncompensated fatigue. In “The History of the American Revolution,” David Ramsay tells of Gen. Thomas Sumter’s retreat in South Carolina in 1778: “The retreating Americans, having been four days with little or no sleep, were more obedient to the calls of nature, than attentive to her first law, self-preservation. Sumter had taken every prudent precaution to prevent a surprise, but his videttes were so overcome with fatigue, that they neglected their duty.”

Some effects of fatigue have been known since antiquity: slowed reflexes, poor judgment, “fuzzy head” and short temper. More are coming to light through modern research: disruption to effective learning, impaired physical and psychological healing and microsleeps — brief periods of complete unconsciousness that we’re not even aware of. Yet fatigue without compensatory sleep persists as an acceptable and sometimes necessary component of war.

Exactly why is an enigma; perhaps it is built into the mantra of “mission first,” although the very mission is at risk of compromise. For instance, here’s an opening scene from the war in Afghanistan (AFJ, November 2011): “Shortly after 9 p.m. on Dec. 6, 2001, machine-gun fire erupted on the perimeter of Camp Rhino, Afghanistan. Capt. Mike Flatten, an Air Force officer from the 21st Special Tactics Squadron, lay in his one-man tent, too exhausted to move. The senior airfield authority, Flatten had been awake for nearly 24 hours, orchestrating hundreds of sorties through the landing zone (LZ), enabling Naval Task Force 58 (TF 58) to amass combat power to assault Kandahar, the Taliban’s spiritual center.” Fortunately, the operation was successful, but it could very well have been teetering on the edge — we will never know. Was it a calculated risk or dumb luck?

We also continue to “train” how to fight in acute and chronic sleep debt. An Army Ranger argues (AFJ, December 2011), “One of the most difficult aspects of Ranger School is dealing with the sleep deprivation; I believe we averaged about three hours a night. Shorter periods — up to several days — of sleep deprivation are appropriate in training to mentally prepare soldiers for such a possibility in combat. However, the months of deprivation currently prescribed in Ranger School can degrade soldiers’ ability to consolidate memory, or learn, in the course.” Then he makes a far-reaching conclusion: “Taking this possibility of brain damage into consideration, further scientific research should be done on the effects of this practice to determine if sleep deprivation should be curtailed to benefit Rangers’ long-term health and to maximize the Army’s return on its investments.” We will revisit this statement at the end of the article.

Given the exponential rise of technology and the explosion of information, fighting while fatigued isn’t confined to boots on the ground. In the world of remotely piloted aircraft, with 24/7/365 operations, fatigue resulting from the shift work of telewarfare induces the risk of errant remote decision-making. The RPA milieu attracted the attention of human systems integration practitioners at the Air Force 311th Human Systems Wing and the Naval Postgraduate School. In a second report on fatigue in RPA operations, they documented no improvement in shift work fatigue found in a survey of the same squadron the year before. The report faulted a lack of adequate manpower rather than shift work design as the reason for insufficient sleep recovery.

Integrate Sleep Into War

We are not blind to the fact that combat with lack of sleep is sometimes unavoidable — that is the nature of war — but it should be the exception rather than the rule. Doctrine, concepts of operation and man-machine interfaces should protect us from presenting our enemies with any advantage whatsoever, and human performance ought to be the common thread running through it all.

In the short term, and at the tactical level, research has provided us with an arsenal of proven strategies for fighting fatigue. The question is not whether they work — they do — but how to integrate them into the logistical chaos of war.

Prevention of fatigue begins with smart scheduling incorporating sleep as a priority. Sleep is often the first thing sacrificed during war, but an honest assessment of individual off-duty time may reveal opportunities for sleep if prioritized. Informed leadership is absolutely crucial in the establishment of work-rest cycles, especially during periods of high ops tempo.

RPA operations are ripe for proper scheduling of personnel. While lack of sufficient manpower may lead to inadequate recovery time between work shifts, leaders can address this problem by thinking out of the proverbial box. Do RPA operations truly need 24/7 schedules? Since these are remotely piloted aircraft, is it plausible to strategically place ground control stations around the globe so operators only work day shifts? If 24/7 scheduling is necessary, have schedulers considered shortened night shifts (six hours rather than eight or 12) with longer day shifts (10 or 12 hours)? Are scheduled naps during long shifts, particularly the night shift, feasible?

In addition to proper scheduling, countermeasures are available to help improve alertness and performance during times when sleepiness is high, such as low-cost behavior and operational changes without the use of drugs. Like choosing exercise rather than a pill to lower cholesterol, these behavioral strategies rely on personal and group-level commitment. Standard operating procedures can include regular and frequent checks of the work, numerous breaks, lighting that promotes alertness, changes to posture and strategic use of caffeine. Adding fatigue education for leaders and workers will facilitate behavior change.

When inadequate sleep is unavoidable and scheduling and behavioral countermeasures still leave workers fatigued, sometimes the appropriate action is pharmaceutical intervention. History shows that properly managed use of prescription stimulants and sleeping aids can temporarily improve alertness and performance. Generally, there are two approaches for using pharmaceutical aids to increase alertness when work has to be done after too little sleep. One approach is to increase the amount and quality of sleep. Inability to sleep is particularly a problem for people trying to sleep during the day — usually night-shift workers. Sleeping aids can be used to help workers obtain restful daytime sleep, which will reduce sleepiness on the night shift. But sleepiness in the early morning “circadian dip” will still occur since sleeping pills do not change the body clock, although time on shift will help the body’s clock adapt to working nights.

The second approach to increase alertness is through alertness-enhancing drugs. Go-pills have been used successfully to counter fatigue during combat. The newest go-pill, modafinil, has been used in aviation operations and is becoming the prescription drug of choice. It has low abuse potential since it doesn’t create a “high” feeling; is effective in increasing alertness, and thereby performance; and is approved by the Food and Drug Administration for shift-work sleepiness disorder.

Weave Sleep Into Doctrine

At the end of the day, though, there is no substitute for sleep. In other words, sleep is imperative. How then can we weave this requirement into modern warfare? A holistic approach to fatigue starts with joint doctrine. This does two things: It gives decision-makers a distillation of experience as a guide in forming plans and policies, and it provides “best practices” at the tactical level. Thus, a common and agreed-upon framework guides fatigue management throughout training and during wartime operations in both deployed and in-garrison postures. A fatigue-management cascade flows down from joint doctrine to each service’s manpower office, training commands and research laboratories, eventually reaching the tactical-unit commander. Combatant commanders in particular will benefit from fatigue doctrine and more detailed descriptions in tactics, techniques and procedures manuals. Two examples of fatigue TTPs are the Australian Defence Force publication “Fatigue Management During Operations: A Commander’s Guide” and the U.S. Coast Guard’s “Crew Endurance Management Practices.” Failure to manage the risk of fatigue in military operations heightens the risk of unsafe acts and mission ineffectiveness or failure.

While doctrine is a good start, alone it is insufficient. Examining the risk of fatigue through the lens of human systems integration is long overdue. Manpower, personnel and training affect fatigue in military operations. The human factors of engineering, the environment, safety, occupational health and the habitability of systems affect fatigue. But if we focus on fatigue resulting from sleep deprivation, the elephant in the room is manpower. We have already seen that a manpower shortage underlies the acute and chronic fatigue exhibited in Air Force RPA operations; tinkering with shift schedules only kicks the can down the road. In fact, the development of Predator and Reaper concepts of operation showcases the consequences of not integrating the human with the system, perhaps because the system was considered “unmanned.”

But it really doesn’t matter what system we talk about within the Defense Department — fatigue must be taken into consideration during acquisition to prevent, or at least forestall, the inevitable decline in human performance. The acquisition system, from concept development in the Joint Capability Integration Development System to writing of requirements and program management, should consider fatigue within the trade space of HSI and base decisions on sound doctrine. The ability to engage our enemies anywhere and anytime means that without foresight, fatigue is inevitable.

With joint doctrine in place, and HSI mitigating fatigue during acquisition, the performance of war fighters must still be sustained. To accomplish that, the services’ medical corps needs to embrace a new paradigm: delivering human performance to the war fighter. Going beyond traditional episodic medical care and deployment medicine, the medical corps should use a periodic health and performance assessment focused on subgroups of similar skill sets (e.g., special operations, aircrew, space operators, RPA operators, infantrymen, etc.) — and this necessarily includes mitigating fatigue. The model pivots on a human performance team that, in the case of assessing fatigue risk, advises the commander and maintains surveillance of signs of fatigue. The team can institute interventions within their medical purview, or recommend interventions more appropriately executed by the line commander. Many people automatically think of pharmaceutical aids to alertness. While effective, they are the avenue of last resort, not the first choice.

To reiterate, there is no substitute for sleep, and sleep should be the commander’s prime objective. A second reason is ethical: We just do not know the long-term effect of using drugs in a healthy population for off-label purposes.

However, that doesn’t mean we quit the pursuit of human performance enhancement. To keep a technological cutting edge, we have to preserve a research portfolio to facilitate alertness. Current research of fatigue countermeasures, both pharmaceutical and behavioral, is moving toward more fully understanding the impact of fatigue at the individual level: actual war fighter performance. While we know which countermeasures theoretically work, they need to be applied in operational conditions. War fighters and their commanders need to tell the research community what does and doesn’t work. For example, if bright lights improve performance and alertness during the night shift, but the RPA environment cannot implement this countermeasure, another solution is required.

At the same time, scientists must effectively disseminate innovation to the field. For instance, the idea of individually tailored fatigue solutions has been common in the lab for almost a decade; however, this message has not spread to the operational community. The work is there, but the communication channel is closed. Without a feedback loop between the war fighter and the scientist, research projects may fail in operational utility and needs from the field will remain unmet.

Here is a key point: Communication drives culture, which propagates solutions. The ultimate example of this concept is in the difference between how the scientific and operational communities view the need for sleep. Scientifically, sleep is a biological imperative, like the need for food to convert to energy, or blood to transport oxygen. There is no replacement for a biological imperative. The operational community treats the need for sleep as a resource to be rationed in the best times, and as a sign of weakness in the worst. There may be real, necessary reasons for each stance; however, we cannot make substantial progress toward a solution for fatigue unless we reach common ground. This demands a robust, continuous cycle of communication.

In a way, we have circled back to the Army Ranger’s question: Should sleep deprivation be curtailed to benefit Rangers’ long-term health and to maximize the Army’s return on its investments? There is an answer, and we can get to it by understanding the cultural basis of the question and then applying the tools of doctrine, human systems integration and research. If we don’t, we just might prove Albert Einstein’s famous adage: “Insanity is doing the same thing over and over again and expecting different results.” AFJ