Operations

Workplace Fatigue Creates Dangerous Risks for EMS Employees

Issue 1 and Volume 40.

I entered EMS late in my career—I started in clinical sports medicine and rehabilitation before stepping into my paramedic shoes. This means my very first 24-hour shift occurred when I was almost 30 years old, and that’s old in EMS years.

I clearly recall being so fatigued at the end of the shift that simple tasks became hard and drug calculations became almost impossible. I don’t even remember my drive home.
Starting a shift at 6 a.m. means many providers will be up at 4:30 a.m. just to get to work on time. Add in a late call and many 24-hour shifts turn into a solid 28-hour day.

Safety is a big buzzword in EMS, but are we really a safe culture? If personnel are your department’s most valuable asset, they need to come first. Too many chiefs talk a good game about how they invest in their workforce, but hold a mirror up to that and you’d realize it’s just lip service. In the 2012 JEMS.com article “Studies Prove 24-Hour Shifts Unsafe: Another ethical dilemma for EMS leaders,” Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, aptly stated these points:

>> Fatigued drivers are as bad as intoxicated or texting drivers. They have more accidents.
>> 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.

So why, if 24-hour shifts are so detrimental to our safety, do they continue? Kirkwood explains, “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.”1

If safety is so important, then why hasn’t EMS followed the lead of motor carriers , physician residency programs and airline pilots? Long-haul truckers, for example, as of July 2013, have an 11-hour daily driving limit and a 14-hour workday limit.2

Their work provisions also:

>> Limit the maximum average workweek for truck drivers to 70 hours, a decrease from the previous maximum of 82 hours;
>> Allow truck drivers who reach the maximum 70 hours of driving within a week to resume if they rest for 34 consecutive hours, including at least two nights when their body clock demands sleep the most—from 1–5 a.m.; and
>> Require truck drivers to take a 30-minute break during the first eight hours of a shift.

Table 1, below, shows the recommended changes for federal work hour limitations.3

Pilots are now limited to 30 hours of flying in any consecutive days with a minimum of 11 hours rest in a 24-hour period prior to nine or more hours of scheduled flight time.

Medical residents are now recommended to limit their time to 80 hours per week averaged across four weeks. Plus, no more than 24 hours on with a six-hour transition, followed by a 24-hour rest period.

Of concern, however, is that EMS workers outside of air medical have no recommended maximum and no predetermined rest guidelines for post shift. Complicating that matter is when many responders pick up overtime shifts or have a second job working for another department. What safeguards are in place to stop that responder from working 48 or more hours straight? This employee’s problems become that of the entire department, because at this point they’re a huge liability.

Injury

EMS is consistently rated as one of the most dangerous professions in the U.S., with risks including soft tissue injuries, vehicle crashes and assaults. A study showed that between 1992 and 1997, 114 EMTs and paramedics were killed on the job—more than half of them in ambulance crashes. That’s an estimated 12.7 fatalities per 100,000 EMS workers, making it close to the death rates for police (14.2) and firefighters (16.5) in the same time period, and more than twice the national average for all workers.6

Soft tissue traumas from lifting and moving patients and equipment is a major driver in the financial stress of both departments and providers, and it’s the one we can control the most. A 2012 study surveyed almost 550 EMTs and found 18% reported an injury when severely fatigued and 90% reported safety-compromising behavior due to fatigue.7

There are two primary reasons why fatigue should be avoided to prevent injuries:

1. Fatigue, particularly from shift work, will have a negative impact on hormone levels and hormone fluctuations. A recent study in the Endocrine Society’s Journal of Clinical Endocrinology and Metabolism found that shift work at a young age is associated with elevated long-term cortisol levels and increased body mass index (BMI).10 Long-term elevated cortisol levels lead to increased abdominal obesity, hypertension, diabetes and cardiovascular risk. A high BMI, coupled with comorbidity factors, will drastically increase a provider’s risk of trauma on the job.

2. Ergonomic risks increase. As you fatigue and cortisol levels increase, your body goes through some interesting changes. You consume less water and, since you’re awake longer, you naturally dehydrate quicker. The more dehydrated you become, the less flexibility you will have. As dehydration progresses, the vertebral disks lose volume and their ability to deal with the stresses of the job.

As you continue to fatigue and dehydrate, your tendons and ligaments become less pliable and your joints lose their ability to deal with external forces. How many times have you seen or personally felt the jolt in your knee when stepping out the back of the truck too fast?

As providers lose the ability to move safely on the job (from an ergonomic and biomechanical perspective) and their abdominal/pelvic mass increases, we see a very clear correlation between postural distortions, movement abnormalities and injury rates from poor ergonomics. Much of this can be tied to fatigue as the root of the problem. Movement matters—it’s what will ultimately reduce your chance of sustaining a motion-based trauma.

Mental Health

A recent study published in The Journal of Neuroscience by researchers from the University of Bonn, King’s College London, suggests sleep deprivation leads otherwise healthy people to enter into a psychological state similar to that of schizophrenic psychosis.8

“There are a lot of physiological changes that occur with sleep,” says Timothy Morgenthaler, a consultant at the Mayo Clinic Center for Sleep Medicine in Rochester, Minn. “One of the main hypotheses is that one primary function of sleep is to help eliminate metabolic waste products of the mental processes in your brain. Sleep clears those waste products out and replenishes the energy inside brain cells.”

A recent study showed “when we don’t get enough sleep, we actually injure brain cells. There is very little doubt that our cognition suffers, and our brain does not function as well.”4

The amount of sleep needed to support human biological rhythm is typically 7–8 hours during the night. Shorter periods of sleep at other times of the day may reduce the feeling of sleepiness, but don’t help the biological rhythms associated with long-term health.

Other studies clearly show difficulties in maintaining usual relationships with a clear consequence of negative influences on relationships, marriages, and social interactions at family and social levels.9,11

Think about it: How many of you have experienced or witnessed a sort of anger or rage disproportionate to the problem at hand? Many providers react violently or disproportionately to situations that could often be dealt with differently, but their brain isn’t able to handle the stress of the moment.

Physical Health

Shift work, defined as work performed primarily outside standard working hours, has been associated with increased incidences of obesity, hypertension and insulin resistance, ultimately leading to an increased incidence of cardiovascular disease. In a study, researchers collected hair samples from 33 shift workers and 89 day workers. They found long-term cortisol levels were significantly increased in individuals working in shifts, especially in study participants younger than 40. This is the first to show working in shifts leads to changes in long-term cortisol levels, suggesting that the stress hormone cortisol might be one of the factors contributing to the increased cardiovascular risks of shift workers.5

“Our findings show that cortisol might play an important part in the development of obesity and increased cardiovascular risk for those working in shifts.”5

I’ve often wondered if there was a direct correlation to the short life span of a provider leaving the profession due to burn out, stress, pain or injury. The data sure seems to point this way, and I think you’ve observed it firsthand for years. Look at the new EMT fresh to the profession. Most of them are fit, healthy and, dare I say, happy. Throw them on the street with no education on ergonomics, nutrition, fatigue management or self-care, and after about 14–16 months, what have we created?  In many cases we have a burnt out, stressed, nutritionally compromised, now overweight and sleep-deprived “valuable asset” you’ve spent thousands of training and education dollars on. If this is your most prized asset, why did we let it get to this point in the first place?

Solutions

The obvious place to start is shift length. EMS is one of the few professions left that still has 24-hour shifts, and no one discounts the data about their risks. If our people are the most valuable asset, then an investment in them is an investment in your department’s bottom line. It will cost more at first to add additional personnel and to convert to 12-hour shifts, but the reduction in soft tissue traumas, MVCs and errors, and the improvement in employee wellness, will more than make up for it.

Well employees have reduced absenteeism; they’re at work more and call out sick less. Well employees also have reduced presentism, which means that when they’re at work they’re actually working, and generally with a better mental outlook.

Hydration is incredibly important when it comes to fatigue. We know a well-hydrated responder is less fatigued, has better mentation and makes fewer errors. The better hydrated a responder is, the less weight they’ll gain as metabolic processes function more efficiently. Concentration is also improved when well-hydrated. Responders must have access to water and water bottles, preferably provided by the employer, so that staying hydrated is as easy as filling up the bottle at the base.

If properly hydrated you should have to use the bathroom every 90 minutes, which is a good rule of thumb to follow. Sadly we see responders go half a shift without using the restroom. I just trained a department where the coffee was free and the water cost money. As a result, most of the staff drank coffee their entire shift. While there’s definitely a need for caffeine in our world, we must understand that fatigue is not lack of caffeine.

Most of this department’s medics were overweight and injured. Six months later, the water was free and the coffee wasn’t. Most of the medics lost weight and had no new injuries. Plus, all employees stated they felt better.

Fitness is a huge component to fatigue management. Multiple studies confirm that any type of exercise, when done 3–4 days per week, will reduce the severity of your fatigue. The more fit you are and the more regimented you are with your exercise routines, the better you sleep.

There’s a reason consistent fitness is so engrained in the military and fire cultures. High levels of physical readiness equate to high levels of physical ability. High levels of physical ability mean fatigue and stress have vastly reduced negative effects on your body. This may be why the fire service has gotten away with 24-hour shifts for so long.

Departments need to make job-specific, biomechanically accurate fitness a priority. Fit employees get hurt less, are more productive and generally lead a healthier lifestyle. Give your responders access and time to exercise. Pre-shift stretching, foam rollers for tissue mobilization and simple effective station/budget-friendly equipment will empower staff to get fit and stay fit.

Education can also help with fatigue. I teach more than 200 classes a year across the country to all types of EMS departments, and the absolute ignorance of responders on how to eat properly never ceases to amaze me. Why do responders feel that energy drinks, fast food and vending machines can provide them with the ability to heal and be healthy? The reason they feel this way is because fatigue and stress make them crave these very certain foods, even though they’re all bad for them. (See Table 2 and Table 3 below.)

Instead of having a room of vending machines full of disease-causing foods, tell the vendors to only stock it with healthy choices. Get rid of or reduce the soda choices and bring healthy foods—not donuts or bagels—during meetings. Responders need to be taught how to eat on the go, how to make good food choices and how to understand the disease implications of poor eating.

Conclusion

With good nutrition and fitness as a priority for departments, the negative effects of fatigue, stress and hormone disruptions can be buffered. Food can help responders heal and promote wellness instead of disease. Nutrition and fitness should be part of all EMT curriculums.

What it takes to achieve the metrics we all desire is to grab the bus by the sirens and open our eyes to the problem. Fatigue and poor wellness/fitness go hand in hand. We can’t confront one without dealing with the other, but getting a good night’s sleep will sure help.

References

1. Kirkwood S. (April 25, 2012). Studies prove 24-hour shifts unsafe another ethical dilemma for EMS leaders. JEMS. Retrieved Nov. 20, 2014, from www.jems.com/article/administration-and-leadership/studies-prove-24-hour-shifts-unsafe.
2. Federal Motor Carrier Safety Administration. (Dec. 27, 2011.) Hours of service of drivers. U.S. Department of Transportation. Retrieved Nov. 20, 2014, from www.gpo.gov/fdsys/pkg/FR-2011-12-27/pdf/2011-32696.pdf.
3. Safety Committee INTERIM Advisory. (May 30, 2012). Fatigue in emergency medical services. The National EMS Advisory Council. Retrieved Nov. 20, 2014, from www.ems.gov/pdf/nemsac/may2012/Safety_Committee_Interim_Advisory-Fatigue.pdf.
4. Hellmich N. (June 22, 2014). If you don’t snooze, you lose, health experts say. USA Today. Retrieved Nov. 20, 2014, from www.usatoday.com/story/news/nation/2014/06/22/sleep-series-health-benefits/7299461/.
5. Costa G. The impact of shift and night work on health. Appl Ergon. 1996;27(1):9–16.
6. Maguire BJ, Hunting KL, Guidotti TL, et al. Occupational injuries among emergency medical services personnel. Prehosp Emerg Care. 2005;9(4):405–411.
7. 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.
8. Petrovsky N, Ettinger U, Hill A, et al. Sleep deprivation disrupts prepulse inhibition and induces psychosis-like symptoms in healthy humans. J Neurosci. 2014;34(27):9134–9140.
9. Grosswald B. Shift work and negative work-to-family spillover. J Soc & Soc Welfare. 2003;30(4):31.
10. Manenschijn L, van Kruysbergen RG, de Jong FH, et al. Shift work at young age is associated with elevated long-term cortisol levels and body mass index. J Clin Endocrinol Metab. 2011;96(11):E1862–E1865.
11. Hardy GE, Shapiro DA, Borrill CS. Fatigue in the workforce of National Health Service Trusts: Levels of symptomatology and links with minor psychiatric disorder, demographic, occupational and work role factors. J Psychosom Res. 1997;43(1):83–92.