Sleep deprivation is so much a part of EMS, it’s worn like a badge of honor. Back-to-back shifts? Bring it. Working more than one job to make ends meet? That’s how we do it. However, increasing scientific evidence indicates that fatigue is the leading cause of medical errors in the field. Medical professionals are beginning to call fatigue the number one problem facing EMS. Our hero complex is staring down renewed concerns regarding the safety of our patients, the legal liabilities of our employers and the longterm health effects on our bodies and it’s flinching.
Skills that are essential to EMS responders: critical thinking, multi-tasking, fine motor function and rapid response, are all affected by fatigue. Although a burst of adrenaline will provide the ability to mobilize for that big call, magically transforming Grumpy the Dwarf into a superhero, the problem is that, more often than not, its Grumpy who shows up for the less critical calls. Science shows that it’s those gray-area calls where prehospital providers are getting in trouble.
Worse yet, when we are over-tired, our compassion and empathy are often the first to go. A recent study by researchers at the University of Pittsburg, published in Prehospital Emergency Care, clearly links sleep deprivation of EMS responders to increased rates of injuries and medical errors.(1).
Researchers evaluated the sleep quality of EMS responders from a variety of agencies across the U.S. to assess physical and mental fatigue. Over the same period of time, they examined safety outcome data to determine provider injury, medical errors, adverse events and safety-compromising behaviors, such as excessive speeding.
The researchers classified more than half of the respondents as fatigued. After controlling for variables, the results showed that fatigued respondents were 1.9 times more likely than non-fatigued respondents to be injured on the job; 2.2 times more likely to commit a medical error or adverse event; and 3.6 times more likely to be involved in a safety-compromising behavior. The most common errors were protocol deviation, dropping patients and medication errors.
Half of the respondents work regular shift lengths of 24 hours. The majority reported working between six and 15 shifts per month. One-third said they worked for more than one EMS agency. Interestingly, more than seven out of 10 respondents identified themselves as overweight or obese.
The study relied on self-reporting and additional research is needed to determine how much fatigue plays a factor. However, in light of increasing litigation involving both medical errors and drowsy driving, it's important for EMS managers and supervisors to be aware of information and mitigation techniques regarding the effects of sleep deprivation.
The Physiology of Sleep
Adequate daily sleep is essential for humans to perform optimally and remain healthy. The sleep-deprived suffer a laundry list of effects including moodiness, impaired vigilance, depression, faulty short-term memory, increased appetite, problems with communication, decreased performance and episodes of microsleep. Microsleep is a period of sleep which may last for only a fraction of a second or up to 30 seconds. For the sleep deprived, it can occur at any time, typically, without substantial warning. It is extremely dangerous when it occurs in situations that demand constant alertness, such as driving a motor vehicle.
In addition to the number of hours of sleep, humans physically and behaviorally function best when following a 24-hour cycle called circadian rhythms. These rhythmical processes are coordinated to allow for peak activity during the day and low activity, or restfulness, at night. Typically, the body takes cues from the environment, such as clocks, social activities, the sun, and meal times to keep the various rhythms on track. When a person’s rhythms get out of phase with their activity pattern, they can feel fatigued and disoriented.
Chronic sleep loss is associated with health issues, musculoskeletal problems, increased body weight and diseases, including cardiovascular disease and cancer. The International Agency for Research on Cancer has determined that shift work that involves circadian disruption is considered a Group 2A carcinogen and “probably carcinogenic to humans.”2 Group 2A means that the conclusion is based on limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals.
“The bottom line is that if people don’t get seven to eight hours of continuous sleep, there does appear to be an increase in metabolic syndrome,” says Kerry Kuehl, MD, Dr.P.H. co-director of the Human Performance Laboratory, Division of Health Promotion & Sports Medicine at the Oregon Health & Science University, in Portland, Oregon. Metabolic syndrome is a given set of symptoms that include elevations in blood pressure, cholesterol and glucose levels that are known to increase the risk of developing cardiovascular disease and diabetes.
Impact of Sleep Deprivation
In a comprehensive report funded by the International Association of Fire Chiefs and the U.S. Fire Administration, Kuehl and fellow researcher Diane L. Elliot, MD, FACP, FACSM, documented the effects of sleep deprivation in firefighters and EMS responders.3 They noted that safety is a huge issue for fatigued workers. “Sleep debt does accumulate and increases error rates,” Kuehl says. Add to this the likelihood of critical incidents and life-threatening events, and the opportunity for both injury and medical errors multiplies.
Further, most chronically fatigued workers don’t even realize how tired they are or how their lack of sleep is affecting their work. “You lose the ability to recognize that you are fatigued. That’s when problems occur,” Kuehl says. It has been well documented that being awake for 18 consecutive hours produces impairment equal to a blood alcohol concentration of 0.05%. Staying awake for 24 can cause the same impairments as a person with a blood alcohol concentration of 0.096%, which is over the legal limit in this country.(4)
Driving is a primary function of an EMS responder and a sleepy driver is a dangerous driver. The National Highway Traffic Safety Administration estimates that fatigue is the primary cause of 100,000 motor vehicle crashes each year. (5) Driving home after a long shift–or two–is equally as hazardous. A study of medical interns determined that driving home after working a long shift more than doubled the chance of a crash.(6)
As an increasing number of employees live farther from work, drowsy driving is a concern for both EMS providers and their employers, who may be found liable for crashes caused by fatigued workers.
Kuehl says that EMS responders have a higher risk of morbidity and mortality because of the hours they keep and the work they do. “It’s not healthy to fight nature,” he says. “If you are going to burn the candle at both ends in shift work, you’re going to pay for it.” However, there are strategies that can help lessen the effect.
Overall, the best way to avoid chronic sleep deprivation is to live a healthy lifestyle. Get proper rest, exercise, eat right and hydrate. “There are really no secrets,” Kuehl says. He also recommends avoiding tobacco products, including chew.
Often tired workers turn to over-the-counter drugs, caffeine and energy drinks as a quick fix. Kuehl says these should not be used on a regular basis, as they are generally not healthy. One of the most effective ways to help refresh a fatigued worker is to allow them to take a short nap at work. “Power naps” or “maintenance naps,” ranging from 20 to 45 minutes, can be helpful in improving alertness and reducing potential errors. NASA has found that planned naps by pilots on long flights improved alertness during landing.
Active social lives, a second job, school and a busy family life can affect how fatigued an employee is at the start of his or her shift. “Some people come in tired,” Kuehl says. He suggests involving the workers and their families in education efforts on the effects of shift work and strategies to help counter those effects. Developing a peer support system has also been found to be effective.
Employers can assist employees by providing the following:
• Educate workers about the dangers of drowsy driving. Provide alternative means of getting home or provide a place for workers to nap before driving home.
• Provide opportunities and facilities for exercise breaks. Moderate physical activity increases alertness.
• Consider fixed shifts. They tend to cause less disruption of circadian rhythms than rotating shifts.
• Offer sleep disorder screening.
• When filling a vacation spot, schedule as far in advance as possible in order to allow for adjustments to sleep schedules.
• Be alert for potential substance abuse.
• Consider limiting the number of consecutive shifts an employee can work.
Kuehl emphasizes that collecting data on fatigue is difficult. “The biggest problem with sleep deprivation data is the variety of shifts, the number of calls, and the variety of tasks,” he says. It’s important for agencies to look at their own data, examining issues such as the geographic area covered and number of calls in order to determine the best schedules for safety, operations and employee morale.
Next month, we will examine the legal ramifications of job-related sleep deprivation and discuss shift schedules that optimize efficiency and minimize the effects of fatigue.
Resources for Information on Managing Work Hours
American Lung Association
Information about shift work, especially drivers and sleep apnea issues.
Circadian Technologies, Inc.
Founded in 1983, international research and consulting firm that assists companies with their extended hour and shift work operations.
Division of Sleep Medicine at Harvard University
Well-known group involved in public education; policy, clinical and basic research, and education of medical personnel.
National Institute for Occupational Safety and Health
Plain Language about shift work, including work schedules, health and safety issues and management strategies.
National Sleep Foundation
Dedicated to improving public health and safety by achieving understanding of sleep and sleep disorders. Specific strategies for healthcare professionals.
Shiftwork Solutions LLC.
International organization that assists with schedules.
Stanford Center for Human Sleep Research
Involved in design and conduct of studies of sleep disorders, including newer drug therapies to maintain alertness.
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. IARC 2007. Press Release N°180. IARC Monographs Programme Finds Cancer Hazards Associated with Shift Work, Painting and Firefighting. Retrieved February 2, 2012 at www.iarc.fr/en/media-centre/pr/2007/pr180.html.
3. Elliot DL, Kuehl KS. Effects of Sleep Deprivation on Firefighters and EMS Responders. Final Report 2007. Retrieved February 2, 2012 at www.iafc.org/sleep.
4. Falleti MG, Maruff P, Collie A, et. al. Qualitative similarities in cognitive impairment associated with 24 h of sustained wakefulness and a blood alcohol concentration of 0.05%. J of Sleep Research. 2003;12(4):265–274.
5. Lyznicki JM, Doege TC, Davis RM, et al. Sleepiness, driving, and motor vehicle crashes. JAMA.1998;279(23):1908–1913.
6. Lockley SW, Landrigan CP, Barger LK, et al. When policy meets physiology: The challenge of reducing resident work hours. Clin Orthop Relat Res. 2006; 449(8):116–127.