A life's work
Thursday, February 11, 2016 by Rhonda Locke
Dr Johns graduated in medicine from Monash University in 1966. He had previously graduated in science from Melbourne University, and worked as a geologist for a few years before changing his career direction. After postgraduate clinical training at the Alfred Hospital, Melbourne, he began a program of research into sleep and its disorders. As a result he was awarded the first PhD in sleep medicine in Australia in 1973. Subsequently he continued that research in the USA and England for several years.
Epworth Sleep Centre
Then in 1988 he established the Epworth Sleep Centre in Melbourne, the first of its kind in Australia. As one of the first full-time practitioners of the newly developing specialty of sleep medicine, he diagnosed and treated patients with the whole range of sleep disorders, but also maintained a program of research. A special Sleep Disorders Unit was established at Epworth Hospital where patients stayed overnight with wires attached to them, so their sleep and many different bodily functions could be monitored, a procedure called polysomnography. With a long-standing ‘amateur’ interest in biomedical engineering Dr Johns designed the new digital polysomnography equipment that was manufactured in Melbourne especially for Epworth Hospital.
One of the commonest problems that patients complained of when they came to Epworth Sleep Centre (or any other Sleep Centre around the world) has become known as excessive daytime sleepiness. As Dr Johns explained, this is “an increased tendency to become drowsy and fall asleep at times and under circumstances when the intention and expectation is to remain awake. This can be caused by a variety of different sleep disorders, such as obstructive sleep apnoea or, alternatively, by simply not spending enough time in bed to obtain sufficient sleep.”
Of all the patients with excessive daytime sleepiness Dr Johns saw at Epworth Sleep Centre, some stand out in his memory today. One was a flight engineer who had recently passed the strict medical examination they were subjected to routinely by the authorities. However, that examination did not reveal the problem this man had in staying awake during flights. He realised he was not fit to fly, and came for help. He had a sleep disorder which was diagnosed and treated, and the issue was resolved. There were other very memorable patients too, including several long-haul truck drivers who had dozed off at the wheel. Unlike some, they had fortunately survived to tell their story.
Epworth Sleepiness Scale (ESS)
Dr Johns developed the Epworth Sleepiness Scale (ESS) in 1990, and this became a world standard for measuring a person’s average level of sleepiness in daily life. As he explained, “the ESS does not provide an accurate measure of how likely a person is to become drowsy at some particular time. Whenever that tendency increases, it poses a particular problem for those people whose very lives depend on them remaining alert, for example while driving a car or any other vehicle, at times when they would otherwise be tucked up in bed asleep”.
Investigating the state of drowsiness
Twenty five years ago Dr Johns began to investigate the nature of the problem behind these stories. He explained to me, “Very little was known then about the state of drowsiness and how it interfered with driving. Researchers had largely ignored drowsiness, or confused it with fatigue, probably because appropriate methods for its investigation were yet to be developed. The methods for assessing sleep and wakefulness that were so helpful in the Sleep Centre did not provide answers to the question ‘who is now too drowsy to drive?’ To answer that question, we needed new methods for monitoring levels of alertness/drowsiness continuously in drivers. My knowledge of physiology and sleep medicine led me to believe that eyelid movements held the answer to that question. Between 1994 and 2002 eyelid movements became the focus of my ‘after-hours’ research, in addition to my full-time clinical practice.”
Dr Johns developed the prototype of a special pair of glasses with sensors attached which, with a lap-top computer and software specially written by an engineer who was contracted to help, could accurately measure multiple characteristics of every eyelid movement that occurred during blinks, using infrared reflectance oculography. That was the first step, albeit a very important one, in the development of Optalert.
Dr Johns recalls that “it was too dangerous to study drowsy drivers on public roads, so I deprived volunteers of sleep to make them drowsy, and then monitored their eye and eyelid movements in my office during the night while they performed a reaction-time task that was incorporated into the Optalert Drowsiness Measurement System (ODMS). That led to the discovery that the ‘relative velocity’ of eyelid closing and reopening movements (measured by their amplitude/velocity ratio) was intermittently reduced as one of the first signs of drowsiness. A patent was taken out to protect that new IP. That was the second major step in the development of Optalert.”
However, there was no scale of drowsiness available then that could be calibrated in terms of the driver’s crash-risk at the time. Much more research and development was needed, and that required more time and money than before.
When Dr Johns retired from his clinical practice in 2002, he decided to form a company, raise capital and assemble a team of people, including board members, business managers and others with the necessary skills and experience that he didn’t have, to develop Optalert’s technology as a commercially viable product. That was to be his ‘retirement project’.
Optalert’s JDS™“Our team developed a new scale of drowsiness, called the Johns Drowsiness Scale (JDS), which we calibrated in terms of the relative risk of ‘performance failure’ at any particular time. In practical terms, this meant that if a driver’s JDS score reached five, his risk of dying in a drowsy driving crash at the time was five times higher than it would have been if his JDS score was one or two. With patent protection of our IP, we published our results in peer-reviewed journals. This caught the attention of other researchers, particularly at Harvard Medical School, as well as Monash, Melbourne and Swinburne Universities, who carried out various experiments that independently validated our JDS. That has been another huge milestone in the development of Optalert. None of our competitors have achieved that level of independent validation.”
Looking back, Dr Johns says he is very proud of how our Company (now Optalert Holdings Pty Ltd) has succeeded in an entirely new field. “As a start-up company we had to encompass an unusually broad range of expertise in physiology and sleep medicine, psychology, hardware and software engineering, design and production, sales, marketing and customer support, all within a framework of efficient corporate and financial management. Over time, the company has had to change to meet differing demands at each stage of its development. Everyone contributed to that success, at all levels of the Company. That we have succeeded is quite an achievement, given that most start-ups fail within five years.”
Dr Johns’ role in the Company has gradually decreased, but he continues as a Board Member. And he still strives to understand the nature of the state of drowsiness from a physiological point of view in greater depth – in his (second) retirement!