Dead Tired

“It can put the public at risk, put patients at risk and do physiological, emotional and psychological damage to our people doing the work,” says Mike Taigman, general manager for California’s Alameda Co. AMR and a longtime EMS consultant and educator. “It’s always kind of boggled my mind that the person who served me coffee on the airplane when I flew home last night has federal regulations limiting the amount of time they can work, but somebody tasked with differentially diagnosing pneumonia from congestive heart failure from asthma from chronic bronchitis often has nothing regulating their schedule so they can work safely.”

In fact, in EMS, there’s not been a whole lot of attention paid to the issue. “The current peer-reviewed literature on EMS provider sleep and fatigue is limited, and the perspective from which sleep and fatigue have been defined and studied varies,” noted Patterson and colleagues in a study published last year. “The basic understanding of sleep quality and fatigue in EMS providers is limited to small studies that may not be generalizable to the larger EMS population considering the variety of shift lengths and operational paradigms. A large cross-sectional study is needed to describe these issues in the EMS worker.”⁶

Step one, of course, is to quantify the problem. To that end, for their study, Patterson’s team sampled providers using instruments designed to gauge sleep quality (the Pittsburgh Sleep Quality Index, or PSQI) and fatigue (the Chalder Fatigue Questionnaire). With the PSQI, a global score greater than 5 indicates poor sleep quality. With the Chalder test, a score of 4 or more indicates severe mental and physical fatigue. Their respondents—attendees at a Pennsylvania EMS conference—produced a mean PSQI score of 9.2 (6.5 points higher than previously documented in healthy adults), and 44.5% met the Chalder threshold for severe fatigue. The results, the authors concluded, “suggest that the sleep quality and fatigue status of EMS workers are at unhealthy levels.”

An even more recent publication looking at sleep problems in EMTs found them more prevalent than in the general population, with 7 in 10 having some kind of problem. It concluded that “severe sleep problems and severe sleepiness at a level that may contribute to health and job issues are common in U.S. EMTs.”⁷

“It’s funny, because safety is the first thing we teach our students,” says Chris Nollette, EdD, NREMT-P, president of the National Association of EMS Educators and a frequent conference lecturer on EMS sleep issues. “For 30 years I’ve told them, ‘Scene safety first. Your safety. Your partner’s safety. Before you even enter.’ And then patient safety too. Yet we may have already compromised it all, just by not getting enough sleep.”

What might that compromise look like in the field? Good question. Through ongoing work with the Pittsburgh-based EMS Agency Research Network for Quality & Safety Improvement (EMSARN), Patterson and his colleagues will work to hone in on that and further questions.

“Our focus so far has been perfecting measurement,” Patterson says. “We must first be confident our measurement of sleep and fatigue is reliable and valid. Our next steps will address the association between poor sleep, fatigue and other factors—including potential precursors like working multiple jobs and outcomes like injury and medical error.”

Causes, Implications

There are different types of sleep deprivation. Acute deprivation can result from a single night’s missed sleep. Chronic deprivation can occur with insufficient sleep over multiple nights. Among night workers there are also issues of circadian misalignment (mismatched sleep/wake cycles) and difficulties in day sleeping, and among all shift workers sleep-inhibiting factors such as irregular or rotating start times. These difficulties are so pronounced that shift work sleep disorder is now a recognized diagnosis.

“A lot of people get a second wind once the sun comes up—they’re not tired anymore,” notes EMS author and educator Tracey Loscar, MICP, a night shift veteran. “Then before you know it, it’s noon, and before you know it, it’s 2, and then what’s the point of going to bed when you have to go back to work anyway?”

In EMS, other factors exacerbate the problem too. For one, many providers work multiple jobs: In Patterson’s study, 34% of respondents worked at more than one agency. Another is the prevalence of 24-hour shifts. Employees like the ample time off those provide, and they’re no problem if you get enough down time to sleep, but at a time when most services’ call volumes are rising, that can be increasingly difficult.