Administration and Leadership, Columns, Training

Making the Case for EMS Work Hour Restrictions

Issue 9 and Volume 40.

Matt Rushing was 24 years old in 2008. He’d just finished an EMS shift and was exhausted after working seven days in a row.

Some time while driving home, he fell asleep and his 2005 Chevy pickup truck veered off of the roadway and rolled 30 feet down an embankment.

Matt was knocked unconscious and his vehicle came to rest on a set of railroad tracks along Texas Highway 105. While he was still unconscious, his vehicle was struck by a freight train heading westbound on the tracks, hurling his car end over end and coming to rest on its roof. Matt woke up to see the train conductor running toward his truck to check for survivors.

He suffered multiple spinal fractures, a hand fracture and lacerations. However, he survived the incident without permanent injury, finished college followed by medical school, and started as a resident in emergency medicine at Baylor College of Medicine in July.

A Shorter Shift

Ironically, Matt’s work hours as a resident are tightly controlled by the Accreditation Council for Graduate Medical Education since 2003. These guidelines place limits on the work hours imposed on resident physicians who traditionally worked a staggering number of hours, sometimes more than 120 hours in a single week.

The same residents are now limited to 80 hours per week and 24 hours in a single shift with an allowance for an additional six hours for clinical handover. Interns (first-year residents) are further limited to no more than 16 hours in continuous duty with no allowance beyond that. Emergency medicine residents are somewhat unique because they’re seeing high-acuity undifferentiated patients and are limited to 12 hours per shift and 60 hours per week.

Why this sudden change for resident physicians? Well, like Matt, there was report after report of residents crashing their cars after extended shifts and being injured and killed. There are endless reports of medical errors in the early morning hours after working more than 16 hours in a row without sleep, which has been shown to be equivalent to a 0.01 blood alcohol level in relation to cognitive impairment. There are even cases of surgical residents falling asleep during operations because they were so fatigued!

So why do 24-hour shifts remain the norm and why are 48- or even 72-hour shifts still accepted? I think part of the reason has to do with the difficulty in changing patterns of EMS institutional behavior.

Many of our EMS services start as small organizations with relatively low call volumes. With “occasional” EMS runs it makes it easy to justify 24-hour shifts because there’s a pretty good chance that at some stage during the shift the crew will have uninterrupted time to sleep. The problem, however, is that as the call volume increases and the frequency of uninterrupted sleep diminishes, we don’t change the shift length to accommodate the new normal.

Breaking It Down

There are two main and distinct areas of concern in relation to EMS: The capacity to drive an emergency vehicle, and the ability to make critical decisions and perform critical skills on patients after extended work hours.

Regarding driving, there are numerous parallels and restrictions that are federally mandated for pilots, ship personnel, truck drivers and railroad conductors. These limitations range from eight hours of maximum time at the stick for pilots per 24-hour period to 15 hours for ship personnel. If we consider the limitations on emergency medicine resident physicians, we see a pattern emerge that we shouldn’t ignore.

The patterns suggests we should have ideal shift lengths of 8–12 hours, with maximums of 16 hours in a row, with mandatory rest periods for EMS agencies where the expectation is that providers will be attending to patients for the duration of the shift. The problem is, of course, what to do in the circumstance with ambulance crews that aren’t “busy.”

I think the answer is that we utilize data to make an educated decision. If, for instance, the crew in question has some period of uninterrupted sleep for at least six hours 80% or 90% of the time, then 24-hour shifts for that individual unit makes sense. If they don’t meet this burden, personnel should be limited to 12-hour shifts, with a hard stop at 16 hours of continuous duty.

Conclusion

This industry needs to realize that, like physicians, we have to begin to protect our EMS practitioners from the harms associated with extended work hours.

Just as important, we have to protect our patients from fatigued paramedic practitioners who are more likely to make errors when they’re tired. We must also commit resources to evaluating the correlation between fatigue and errors. We must learn from the mistakes of other industries and the EMS physician must advocate for work hour restrictions and be an essential stakeholder on institutional policy regarding limitations.

Administration and Leadership, Columns, Training

Making the Case for EMS Work Hour Restrictions

Issue 9 and Volume 40.

Matt Rushing was 24 years old in 2008. He’d just finished an EMS shift and was exhausted after working seven days in a row.

Some time while driving home, he fell asleep and his 2005 Chevy pickup truck veered off of the roadway and rolled 30 feet down an embankment.

Matt was knocked unconscious and his vehicle came to rest on a set of railroad tracks along Texas Highway 105. While he was still unconscious, his vehicle was struck by a freight train heading westbound on the tracks, hurling his car end over end and coming to rest on its roof. Matt woke up to see the train conductor running toward his truck to check for survivors.

He suffered multiple spinal fractures, a hand fracture and lacerations. However, he survived the incident without permanent injury, finished college followed by medical school, and started as a resident in emergency medicine at Baylor College of Medicine in July.

A Shorter Shift

Ironically, Matt’s work hours as a resident are tightly controlled by the Accreditation Council for Graduate Medical Education since 2003. These guidelines place limits on the work hours imposed on resident physicians who traditionally worked a staggering number of hours, sometimes more than 120 hours in a single week.

The same residents are now limited to 80 hours per week and 24 hours in a single shift with an allowance for an additional six hours for clinical handover. Interns (first-year residents) are further limited to no more than 16 hours in continuous duty with no allowance beyond that. Emergency medicine residents are somewhat unique because they’re seeing high-acuity undifferentiated patients and are limited to 12 hours per shift and 60 hours per week.

Why this sudden change for resident physicians? Well, like Matt, there was report after report of residents crashing their cars after extended shifts and being injured and killed. There are endless reports of medical errors in the early morning hours after working more than 16 hours in a row without sleep, which has been shown to be equivalent to a 0.01 blood alcohol level in relation to cognitive impairment. There are even cases of surgical residents falling asleep during operations because they were so fatigued!

So why do 24-hour shifts remain the norm and why are 48- or even 72-hour shifts still accepted? I think part of the reason has to do with the difficulty in changing patterns of EMS institutional behavior.

Many of our EMS services start as small organizations with relatively low call volumes. With “occasional” EMS runs it makes it easy to justify 24-hour shifts because there’s a pretty good chance that at some stage during the shift the crew will have uninterrupted time to sleep. The problem, however, is that as the call volume increases and the frequency of uninterrupted sleep diminishes, we don’t change the shift length to accommodate the new normal.

Breaking It Down

There are two main and distinct areas of concern in relation to EMS: The capacity to drive an emergency vehicle, and the ability to make critical decisions and perform critical skills on patients after extended work hours.

Regarding driving, there are numerous parallels and restrictions that are federally mandated for pilots, ship personnel, truck drivers and railroad conductors. These limitations range from eight hours of maximum time at the stick for pilots per 24-hour period to 15 hours for ship personnel. If we consider the limitations on emergency medicine resident physicians, we see a pattern emerge that we shouldn’t ignore.

The patterns suggests we should have ideal shift lengths of 8–12 hours, with maximums of 16 hours in a row, with mandatory rest periods for EMS agencies where the expectation is that providers will be attending to patients for the duration of the shift. The problem is, of course, what to do in the circumstance with ambulance crews that aren’t “busy.”

I think the answer is that we utilize data to make an educated decision. If, for instance, the crew in question has some period of uninterrupted sleep for at least six hours 80% or 90% of the time, then 24-hour shifts for that individual unit makes sense. If they don’t meet this burden, personnel should be limited to 12-hour shifts, with a hard stop at 16 hours of continuous duty.

Conclusion

This industry needs to realize that, like physicians, we have to begin to protect our EMS practitioners from the harms associated with extended work hours.

Just as important, we have to protect our patients from fatigued paramedic practitioners who are more likely to make errors when they’re tired. We must also commit resources to evaluating the correlation between fatigue and errors. We must learn from the mistakes of other industries and the EMS physician must advocate for work hour restrictions and be an essential stakeholder on institutional policy regarding limitations.