I’ll Sleep When I’m Dead: Sleep Loss and Fatigue in EMS

(4 min read) When I was a new EMT all I wanted to do was work on the ambulance answering calls with my friends. So much so that I had three jobs working on the ambulance, two of them full time. 100 hours a week, every week, doesn’t last long before the body rebels.

One morning around 4am my partner and I were roused from our nap on the crew couches by the dispatch phone. We shuffled to the ambulance, rubbing sleep from our eyes, and began to respond to the emergency. On the way, I stopped at a red light to clear the intersection before proceeding with lights and sirens. The next thing I remember was waking with my foot resting on the brake an unknown amount of time later. I looked at my partner to find out why she let me stop there for so long and found her asleep as well. Things could have ended quite differently, as depicted in the news recently; we were very lucky no one was injured or killed.

Traffic accidents, whether in the ambulance or while driving home after shift, are not the only liability brought about by fatigue for EMS providers. Fatigue causes difficulty in making critical or ethical decisions, something required on every response, even the mundane. EMS providers are responsible for asking questions to get to the root of a complaint in order to deliver appropriate care. Sometimes, EMS providers are responsible to deliver interventions that include medical math or deciding to perform a high acuity procedure – these necessitate that we are operating at optimal performance and lessen the opportunity for a medical error or accident.

Per the CDC, adults should be sleeping seven or more hours per night. Not many first responders can confidently proclaim they have great sleep hygiene. Not many Americans can say they have great sleep hygiene either, one third of Americans are chronically sleep deprived. Chronic fatigue has been linked to a higher incidence of cardiac illness, hypertension, stroke, obesity, and diabetes. Fatigue has also been associated with increased propensity for depression and PTSD.

The National Association of EMS Officials (NAEMSO) has been working on the Fatigue in EMS Project and offers a myriad of resources, references, and recommendations on their site. They have recommended 5 evidence-based guidelines for leaders to reduce the incidence of fatigue at their agencies.

1. Use fatigue survey tools (checklists) to measure and monitor fatigue
2. Personnel should work shifts less than 24 hours
3. Access to caffeine as a countermeasure
4. Have the ability to nap while on duty to mitigate fatigue
5. Personnel should receive training on how to mitigate fatigue and related risks

EMS providers can manage their fatigue risk if working for an EMS agency that doesn’t have a plan in place. The following recommendations can be used to mitigate fatigue risk:

• Be consistent- this can be difficulty with an EMS work schedule, but try to go to sleep and wake at the same time everyday, even on days off when tempted to “sleep in.” Adopting a bedtime routine can help to signal to your body that it’s time to go to sleep as well.
• Maintain a comfortable sleep environment- spending 7 to 8 hours in the same place requires a certain level of comfort to rest well. A quality mattress and pillows to your preference, firm to soft, are a critical factor in falling asleep and staying asleep. Temperature in the room is also important; being too hot or too cold can wake you during sleep. For those that work night shift, a sleep mask or blackout curtains can help keep out daylight triggering the release of melatonin to your brain to inspire sleep.
• Remove distractions from your bedroom- save your bedroom for relaxing and sleep. Don’t bring your work or computer into bed with you. Co-sleepers can often cause difficulty falling asleep or cause you to wake in the night; consider alternate sleeping arrangements if this occurs chronically. If you work night shift, talk with others living in your home and educate them on why you need to sleep during the day.
• Limit caffeine use- NAEMSO recommends caffeine as a fatigue mitigation tool, but don’t imbibe too close to bedtime. Caffeine has a half-life of 6 hours and doesn’t inhibit sleep, but can affect the quality of sleep. Try to allow enough time between last use of caffeine and bedtime, usually about 6 hours.
• Utilize naps- naps won’t make up for shortened sleep or chronic fatigue, but they can be a short-term solution to improve mood, alertness, and performance. Optimal lengths for naps are either 20 minutes or 90 minutes. Naps that are too short, or too long can be an impediment to improved alertness, making the person drowsier on waking.

Like many hot topics in EMS, provider fatigue is multifaceted and not easy to solve. Personnel, staffing, financial concerns, and culture are all in the mix related to fatigue, and while we are using evidence based methods to research the issue- EMS providers and leaders must adapt the recommendations to change EMS culture and improve our service to the community and care for ourselves. Our longevity, physically and mentally, depends on it.