Dead Tired

With 24-hour shifts and multiple jobs, sleep loss is rampant in EMS.

Jokes about Joseph Hazelwood’s drunkenness persist to this day.

But officially, the early, besotted retirement for the night of the Exxon Valdez’s maligned captain wasn’t why his oil tanker hit that reef in 1989, bleeding 11 million gallons into Alaska’s Prince William Sound. Lots of things contributed, one being that the third mate left in charge, Gregory Cousins, was overworked and short on sleep. The National Transportation Safety Board concluded he may have had as little as four hours, plus a short nap, in the 24 preceding the accident.

That’s a good cautionary tale and, more broadly, a good metaphor for the problems of sleep deprivation and on-the-job fatigue as they relate to EMS. They exist. They’re likely causing problems—perhaps big ones. But they’re all mixed up with other things, difficult to quantify, variable in cause, intractable to solution, and thus typically an underrecognized and undertreated component when things go bad.

Veterans will tell you stories: “I dozed off on the way to an arrest.” “She drove to work without pants.” But not many organizations have really ever set out to break down the issue or do anything about it.

“We can’t ignore sleep and fatigue as potential problems for our field,” says Daniel Patterson, PhD, MPH, EMT-B, an assistant professor at the University of Pittsburgh who has investigated EMS sleep issues. “Medical physician educators and trainers have recognized that excessive work hours have negative consequences. We in EMS need to delve into sleep and fatigue from the perspective that either can have a potential negative impact on our workforce, patients and bottom line.”

Not Getting Enough

There’s not much mystery to sleep deprivation. The negatives of not getting enough are well documented in literature and ubiquitous in anecdote. Lack of sleep can result in inattention, confusion, memory lapses, depression, headaches, irritability and increases in blood pressure and stress. It can impair cognitive function, slow response time and decision-making, and has been associated with a wide range of illness and disease.

In the healthcare fields, sleep deprivation and fatigue are often linked to long shifts and overwork. Here too the negative effects have been exhaustively chronicled: Nurses working shifts longer than 12½ hours have shown greater risk of medical error.1,2 Physician interns working 80-hour weeks made 36% more serious medical errors and nearly six times more serious diagnostic errors than when working more limited schedules, and residents working 24 hours or more were more than twice as likely to crash driving home.3 Emergency medicine residents did worse on a standardized intelligence test after working a series of night shifts.4 When working five marathon (24+ hours) shifts in a month, first-year residents reported making 300% more fatigue-related mistakes that led to patients’ deaths, and their risk of making fatigue-related errors that harmed patients increased by 700%.5 Other studies abound.

“Sleep deprivation is linked with increased errors in tasks requiring alertness, vigilance and quick decision-making,” noted the authors of a 2007 IAFC report, The Effects of Sleep Deprivation on Fire Fighters and EMS Responders. “Long work hours often are associated with chronic sleep loss, which may result in decreased ability to think clearly and feelings of depression, stress and irritability.”

Imagine, now, how such effects might translate across the landscape of EMS, where we’re performing complex, time-sensitive medical tasks on unknown patients in distracting, uncontrolled environments, and operating big vehicles full of people and heavy equipment under immense pressure at high speeds and altitudes.

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