EMS folks—whether staff, supervisory or executive—can always be counted on to say one of two things, or sometimes both.
First, from the field staff, “We always put the interests of our patients first.” Second, from the gold badges, “Our people are our most important assets.”
Really? Making ethical, rather than expedient, decisions is a constant challenge. There are always competing pressures—some internal, some external.
Recently, I challenged EMS executives to take a high ethical path when it comes to meeting response performance requirements, and the ensuing discussion was both interesting and enlightening. This month I’d like to challenge both executives and those at the tip of the spear (the field EMTs and paramedics), whose interpersonal skills, decision-making capability and clinical expertise can make or break an EMS organization, to another uncomfortable discussion: the EMS work schedule. Specifically, except in specific circumstances, it’s time for the 24-hour (or longer) shift to go away.
The science is all over the place. Excessive consecutive work hours, without adequate, quality sleep intervals, is bad for the patients, and it’s bad for providers too.1 Depending on whether you’re willing to accept evidence from other disciplines (e.g., medicine and law enforcement) we know the following:
• Fatigued drivers are as bad as intoxicated or texting drivers. They have more accidents.2–3
• Fatigued EMTs and paramedics crash ambulances, commit more clinical errors and experience more injuries.
• Fatigued shift workers are more likely to get killed or injured on the way home.4
It goes on and on, but the science is pretty clear. Being a fatigued worker, or employing fatigued workers, is a bad thing. But we continue to do so. Why?
• It’s cheaper, in many environments, to use 24-hour shifts. Certainly, this is so in the fire service, where there’s a specific exemption in the Fair Labor Standards Act that doesn’t require payment of overtime after 40 hours, but it’s also true in some non-fire environments.
• It takes less people to staff a 24-hour shift (24–48s use six full-time employees (FTEs) although 12-hour shifts require eight FTEs). Quality, qualified EMTs and paramedics aren’t like bananas found growing on trees and in bunches. It’s hard to find and keep sufficient good employees.
• Some employees like working a schedule that gives them 20 days per month off, at least on paper. This may provide more time with the family or an opportunity to work another job. Or these providers may have an opportunity to sleep away another 10 days getting caught up from the fatigue of a too-busy 24-hour shift.
Now let’s look at the ethics of this.
But before I do, let me say that I understand. Although I work in a great EMS agency with outstanding public support, money doesn’t grow on trees, and the budget has remained flat or has contracted over the past few years, more or less the same as most everybody else’s. And I also recognize that this isn’t a single-dimension discussion. There are places where the EMS units are very quiet—where a unit may not run a call for days. I’m not talking about those places. If crews have quiet days and often sleep most of the night, then 24s of any variety may be just your cup of tea. Fine. Go for it. No ethical issues to contend with. For the rest of us …
Every EMS agency that I know of has a policy that you don’t drink alcohol at work or come to work when you’ve been drinking. Some specify limits, some specify hours since, but pretty much everybody expects medics to be fully sober when at work. Many (some are slow to keep up with technology) have similar policies involving talking on cell phones and sending text messages while driving or doing patient care. All of those activities result in performance degradation that’s often benchmarked against alcohol intoxication.5
Similarly, fatigue has been so benchmarked. At the 19th hour without sleep, an individual’s driving performance (and by implication their clinical decision-making skills) are degraded similarly to an individual who has a blood alcohol content (BAC) of .10—at or over the legal limit in most states. So if our units are sufficiently busy that staff aren’t guaranteed to get at least five uninterrupted hours, and those same staff actually sleep for those five hours (I’ve never been one who could sleep on command; I need a few hours to wind down from the past call first), are we institutionalizing working while impaired? What are the ethical implications of that decision? If that doesn’t bother you, what are the potential legal and financial consequences?
Adding icing to the cake … when a member of the ambulance crew shows signs of fatigue, what do we do? Typically, we make the partner of the fatigued/impaired medic (assuming that they are in better shape) drive. So we assign patient care, instead of driving, to the impaired crew member? Not so nice an idea, when you look at it that way.
OK, bosses. If you know this, and you’re ethical leaders, why do you build, allow or maintain 24-hour shifts? Is it the right thing to do? And how will you explain it to the media, and the family of the deceased, when something bad happens because an employee is working while impaired by fatigue.
And you guys and gals—staff medics and union leaders—if patient care is our first concern, how can we justify insisting that bosses allow us those schedules? Is the “time off” really worth it? In candid conversations, I hear, “Well, maybe not.”
“I’m so tired when I get home after a 24-hour shift that I have to sleep for 12 hours to get right, and by then the day is shot,” is not an uncommon statement.
“I have to work two or three jobs just to make ends meet! If I don’t work 24s, I won’t be able to do that!”
This is another difficult argument to contend with. Just like low, entry-level requirements, that response makes the problem worse, not better. If there weren’t such a ready supply of medics willing to work for abysmal wages, then salaries would rise. Working three jobs to pay the bills just enables employers who don’t pay living wages.
The existence of 24-hour shifts, and the continuation of the practice in agencies for which they were once viable, is a disaster waiting to happen, and it poses huge ethical dilemmas for both labor and management. Many agencies have avoided that disaster, by luck if not by design. As it is often quoted, “Luck is not a strategy.” Who’s going to stand in front of your headquarters and answer the hard questions from the TV reporters about why your agency uses a known, dangerous practice. Who answers about why your agency allows trusted medics to work longer than truck drivers may drive or pilots may fly? Who’s going to explain to the spouse of the injured or killed medic, or the family of the victim or patient who’s killed or injured by a medic impaired by fatigue?
If you’re a labor leader, you need not be negotiating contract provisions that are dangerous to your members. Remember what we said at the beginning: Our patients’ well being is the most important consideration. If you’re a management representative, you need to advocate (strongly, and in writing) for the funding, FTE allocation and whatever else you need to move your organization to a more viable staffing model. Your people are your most important assets. It’s unethical to act otherwise. Just saying.
1. Patterson PD, Weaver MD, Frank RC, et al. Association between poor sleep, fatigue and safety outcomes in emergency medical services providers. Prehosp Emerg Care. 2012;16(1):86–97.
2. Auto Insurance Rates. (2012). Managing Driver Fatigue. In Auto Insurance Rates. Retrieved Apr. 23, 2012, from www.autoinsurancerates.com/managing-driver-fatigue.html.
3. NOVA. (2002). Driver Fatigue—An Accident Waiting to Happen. In NOVA. Retrieved Apr. 23, 2012, from www.science.org.au/nova/074/074key.htm.
4. Student National Medical Association Inc. (Feb. 18, 20011). What Medical Student Should Know about Fatigue, Patient Safety and Resident Wellness. In Journal of the Student National Medical Association. Retrieved Apr. 23, 2012, from http://jsnma.org/2011/02/what-medical-students-should-know-about-fatigue....
5. Austin M. (June 2009). Texting While Driving: How Dangerous Is It? In Car and Driver. Retrieved Apr. 23, 2012, from www.caranddriver.com/features/texting-while-driving-how-dangerous-is-it.