An EMS Emergency: Sleep Deprivation and Fatigue

There is a growing concern that EMS providers are putting themselves and others at risk because of fatigue.

In March 2015, the National Highway Traffic Safety Administration (NHTSA) referenced a study in which 50% of EMS workers surveyed suffered from fatigue and are substantially more likely to be injured on the job, commit medical error or perform a safety-compromising behavior.

A typical shift length in EMS is 24 hours, but in high volume EMS systems, leaders are integrating a combination of 8, 10, 12 and 16-hour shifts. Due to lack of manpower, some EMS systems require mandatory overtime. To further complicate things, most EMS workers have one full-time job and at least one part-time job to make ends meet.

Adequate sleep is key to health and wellness. At least seven hours per night should be encouraged. Concerns of fatigue in EMS operations are consistently underappreciated. Prehospital providers have alarming rates of illness, depression, PTSD and suicide, yet the industry waits for additional studies to re-diagnose the known underlying issues. 

Much like military and aviation combat, EMS fits a similar scheduling mold as the dynamics of public emergencies. EMS crews routinely experience the same stressors as aviation pilots, but most agencies are not willing to incorporate proven cross-industry strategies of military and aviation crew duty times and rest requirements.  

The military has come up with solutions for the EMS fatigue epidemic, so there is no need to recreate the wheel with studies that have already been exhausted by the military. Whether it is due to unanticipated growth and increase in call volumes, budget restraints or lack of manpower, federal standardization of EMS regulations and operations are well overdue. 

A National Sleep Foundation poll found 20% of pilots report making mistakes due to fatigue, and this percentage doubles in drivers of a ground vehicle. In a study from a recent article from the Association for Psychological Science, “F-117 pilots deprived of one night of sleep were tested on precision instruments. Not only did pilot errors on those instruments double after one night of sleep loss, pilots reported feeling depressed and confused.” 

Additionally, studies also show that drivers who have been awake for 18 hours operate their vehicle similarly to drivers who have a blood alcohol concentration (BAC) of 0.05, and drivers who have been awake for 24 hours operate their vehicles equivalent to drivers who have a BAC of 0.10. 

While adequate sleep is preferred, EMS workers often times have immediate, long and unscheduled shifts. For those longer, oddly timed working hours, here are a few things EMS teams can consider to prevent fatigue issues in their critical workplace:

Speak Up

First and foremost, employers and clinicians need to foster open communications. There should be an open environment in the workplace where an employee can call a supervisor and say, “I’m having serious difficulty staying awake and alert.” That way, team members can watch out for each other. Departments can even post a safety message about the hazards of sleep deprivation and urge employees to speak up. 

Employees might be unlikely to take a stand due to fear of retaliation and lack of support from leadership. Historically, if the EMS service doesn’t fall under the fire department, the employee has little bargaining power due to lack of an established union or professional organization to support the employee. Unions have great influence on industry regulation and standardization and a lot of power in regulating staffing ratios, duty time requirements and competitive compensation.  

Physical Exercise

Alertness can be elevated with physical exercise, such as stretching, walking, jogging and other activities that increase the heartrate and body temperature. When clinicians start to feel sleepy while on duty, they should consider participating in some type of physical exercise to thwart perceived feelings of sleepiness and help maintain alertness.

However, it’s important to keep in mind that exercise doesn’t address all elements of fatigue. While it may alleviate perceived sleepiness, the cognitive performance may not return to levels associated with being well-rested. Notably, there is not a substitute for sufficient rest and sleep.

Caffeine Consumption

There is considerable research linking improvements in alertness with consumption of caffeine in moderation. A 75mg serving of caffeine— the amount found in approximately one small cup of coffee or a cup of espresso— leads to both increased attention and alertness. According to a report by the European Food Safety Authority (EFSA), a cause and effect relationship has been established between the consumption of caffeine and increased alertness. There is also some evidence from the study that suggests potential benefits of coffee and caffeine in night shifts. But be warned: Consumption of caffeine can further disrupt the ability to go to sleep when there’s finally the opportunity. This continues the cycle of fatigue. 

Rest Breaks

Taking naps or rest breaks during shift work is another great way to improve performance. Studies have shown use of short-duration naps of about 20 to 30 minutes can make all the difference. Actual sleep may not even be needed; merely the act of resting with one’s eyes closed in a quiet location can be beneficial.

Nutrition

Spacing out smaller meals throughout the day helps regulate blood sugar and helps increase energy. EMS professionals are known for eating on the go. Avoiding processed or fatty foods, sweets and foods with refined white carbohydrates is ideal for maintaining energy, because these foods don’t contain enough nutrients and are easily digested and absorbed. This leads to an energized feeling at first followed shortly by a feeling of sluggishness.

Conclusion

Because of the nature of their job, EMS clinicians face numerous challenges managing their sleep health. Employers also face challenges filling schedules and ensuring continuous availability of EMS care. It is not only the length of typical EMS shifts which is in question, but the intoxicating mix of call volume per shift, the complexity of calls and the lack of required rest.

Unfortunately, there is not a one-size-fits-all solution for fatigue risk management in the EMS setting.

The top strategy should be adequate sleep every day. The alleviation of fatigue in the workplace must be a shared responsibility between the clinician and employer. Higher compensation to eliminate the need for a second job, a larger workforce to avoid the expectation of mandatory overtime and the shortening of shift length are great starting points. The EMS industry must support a culture of safety where clinicians arrive to work well-rested and employers support employees to report fatigue without hesitation.

Danielle S. Wilson, Aero Jet Medical president and CEO, is an accomplished healthcare executive with over two decades of air medical experience. Aero Jet Medical is an all-inclusive provider of worldwide air ambulance transport services. The company provides patients with clinical excellence and operational expertise. In addition to Aero Jet Medical, Danielle is also the president and CEO of parent company United Medevac Solutions. United Medevac Solutions provides a full range of aviation specialty programs, healthcare supplementation and emergency response for the federal government, the Department of Defense and private sector organizations. Self-termed a “global nomad,” Danielle has a passion for exploring new cultures during her extensive world travels.