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Cases with a Twist: When Exhaustion Equals Errors


Sooner or later even the most “normally quiet” shift turns into a nonstop, back-to-back, crazy-busy nightmare of a day. In this month’s case, our crews start their rural-based 24-hour shift expecting to get their usual morning nap, a sit-down lunch and dinner, and be tucked in by 10 p.m. watching the evening news. In fact, they are so sure this will be a “typical” slow shift in “the boonies,” they both stayed up late the night before, one working a second job, the other nursing a sick child.

However this Tuesday in December offers an entirely new experience for both crew members. The ambient temperature is below zero and for call after call, the crew drags the stretcher through slowly accumulating snow and slush. As they eat ED cookies and gas station sandwiches when they can, things finally seem to slow down at 1 a.m.

Both crew members want to believe their day is  finally done. They drift off into a deep sleep in the cab of the ambulance, parked in the bay, not even bothering going to their beds.  

Unfortunately, just one hour later, the tones go off again. This time they are dispatched to a “stat” transfer from the local community hospital to the level 1 trauma center, a two-hour drive away. Dispatch information indicates the head-injured patient is intubated and on a vent with three IVs on pumps.

“Is air available?” the crew asks over the radio. But before the dispatcher answers with the expected “Negative…bad weather” response, their cell phones start vibrating. Text messages from their peers taunt them: Trying to get out of the transfer again? What’s the matter, don’t remember the vent training in your academy? Need your beauty sleep? and, from their union steward, They better give you critical care pay for this one.

As they start on the call, the paramedic, with six months on the job, begins looking up protocols for ventilator settings, as his EMT partner tries to call their dispatcher. “You know we aren’t a critical care crew, right?” he asks. “Yes,” the dispatcher answers, annoyed, “just go to your call! They asked for the closest rig ASAP.”

This patient has a documented head bleed and GCS on scene of 5. The patient was intubated at the referring facility and a mannitol drip initiated per the orders of the receiving neurosurgeon. The crew is reassured by the ER staff: “We can’t send anyone, we are at minimum staff, but you will be fine. The pumps are all fully charged.”

The ED staff even help load the stretcher in the open garage as a number of cables and IV pumps are clamped to the stretcher. “It’s so darn cold,” a nurse says.

En route things seem to go well with the ventilator and the patient remains hemodynamically stable.

“Are you awake?” the paramedic asks his EMT partner as he feels the ambulance fishtail on the icy road.

Receiving no response, he assumes his partner is concentrating on the road. The IV pump repeatedly alarms.

“How do I silence this thing?” the paramedic keeps asking his partner.

“I’ve got my window open so I don’t fall asleep,” he yells back, “it’s not bothering me!”  

Have you figured out the twist in this case yet? Here is a hint…you may want to look up the temperature at which mannitol crystalizes in an IV line.

The IV pump was not alarming because of a typical air bubble or low battery, as the crew assumed. Approximately 20 minutes out from the receiving facility, the patient, having received no mannitol, began to seize. It was on arrival at the trauma center that the crew and trauma center staff noted that the patient received almost none of the mannitol and there were crystals in the IV tubing.

The bad patient outcome in this case is not clearly attributed to any error the crew made. It is determined the cerebral edema worsened throughout the transport.  

On the drive home the crew wakes up in a cornfield, wondering what has just jarred them awake. The crew members had fallen asleep and the paramedic drove the ambulance off the road.

Not wanting to get in trouble, they don’t radio for help, but wait for assistance. They are lucky to be found by a passing farmer who takes an interest in the odd sight of an ambulance in a cornfield and pulls them back onto the road.

The only trouble this crew gets into is when an eager new supervisor sends them a written reprimand for an unusually long return to their service area. To this day, the ambulance service leadership is unaware of the event.

The crew members smile to each other when the mechanic replaces an axle and wonders why these guys don’t slow down for the speed bumps and train tracks!


This case illustrates several serious and standard dangerous practices in our profession. Long hours under stressful conditions, unpredictable work schedules and low pay (leading providers to work multiple jobs) all contribute to the possibility of dangerous levels of sleep deprivation.

Exhausted crews, afraid to ask for a safety break, afraid to refuse a call they are not trained or equipped to handle, and afraid to report errors from fear of discipline, combine into a “perfect storm” of errors.

Here these errors involved both ambulance operations and clinical outcomes. One could also argue that the lack of critical care training contributed to this error, but it should be noted that all ALS providers in this service are trained on the use of IV pumps and ventilators. As a result, this paramedic should have recognized that the IV pump alarm error was valid and worked to rectify the problem.

It is well documented that poor sleep and fatigue can reduce focus and attention, impair central nervous system function and have a net negative impact on cognition, reaction time and overall health. Numerous studies have also identified a strong association between poor sleep, fatigue and poor safety outcomes.

This case also illustrates how some of our cultural expectations, peer pressure and a sense of duty, can resultin errors that lead to serious consequences.

Safety Strategies

Strategies that mitigate sleep deprivation-related errors include:

  1. Individual awareness of the impact of sleep deprivation. What does it take for an individual to become sleep deprived? This is a highly subjective and variable metric.
  2. Napping. In many systems napping is frowned upon before the close of normal business hours (before 1700), but this arbitrary regulation may need to be re-evaluated, especially in high-volume systems.  A 15–20-min safety nap has been shown to refresh and not cause the grogginess associated naps that last 1–2 hours and wake a person in the middle of a sleep cycle. See an IAFC video on sleep deprivation at
  3. Identification of those at risk for sleep cycle disturbances. This involves screening for sleep apnea and other sleep disorders.
  4. Education for families. It is often difficult for non-EMS/fire providers to appreciate the strain shift work has on an individual. Establishing global sessions for families may help them better understand the importance of sleep during off-duty time.
  5. Share the wealth. If possible, alternating calls, especially long transports, may provide more down time for crew rest.
  6. No-go rule. While this may be counterintuitive and violate the principles of traditional EMS operations, it is worth discussing in your service.  Allowing individuals the opportunity to call in backup or refuse a run based upon their ability to function is important.  If the provider feels they are incapable of focused thought and cannot function, there needs to be a system established to protect our patients; this would obviously require rigorous thresholds and be subject to significant scrutiny so it is not an abused process.

CRM Tips: Identify Probability for Error

The air medical world has a “no-go” rule.  This rule has been established as a non-punitive way for a crew member to voice concern over safety and abort (or refuse to accept) a mission. In EMS this could be invaluable. How many times have you felt so exhausted that you were praying for a mindless run? If you’ve found yourself in that scenario, consider a no-go if the option is available. In the flight service, no-gos are not typically abused and highly effective.

See the checklist available from Mayo Medical Transport and published in the new NAEMT safety course textbook available at

Initiative Addresses EMS Fatigue Risks

On February 2, 2016, the National Highway Traffic Safety Administration (NHTSA) officially announced its new initiative with the National Association of State EMS Officials (NASEMSO) to develop voluntary fatigue risk management guidelines and resources tailored to EMS.

The project is a collaboration between NHTSA, NASEMSO and content experts from multiple institutions, including the University of Pittsburgh Department of Emergency Medicine and Carolinas HealthCare Department of Emergency Medicine. Dr. Daniel Patterson of the University of Pittsburgh Department of Emergency Medicine will serve as the project’s principal investigator.

Resources and self-assessment tools are available at

Sleep Hygiene for Shift Workers

The promotion of regular sleep is known as sleep hygiene, which can be a challenge for shift workers. The following is a list of tips that can be used to improve sleep:

  • Avoid working a number of night shifts in a row as you may become increasingly more sleep-deprived over several nights.
  • Avoid frequently rotating shifts.
  • If possible, avoid long commutes that take time away from sleeping.
  • Keep your workplace brightly lighted to promote alertness.
  • Limit caffeine.
  • Avoid bright light on the way home from work.
  • Stick to a regular sleep-wake schedule.
  • Use blackout blinds or heavy curtains to block sunlight when you sleep during the day.


Report Events

Help identify errors and near-miss events that affect the safety of EMS providers and patients by reporting anonymously at Data collected will be used to develop policies, procedures and training programs.


1. CDC. Unhealthy sleep-related behaviors—12 States, 2009. MMWR Morb Mortal Wkly Rep. 2011;60(8):233–238.

2. Costa G. The impact of shift and night work on health. Appl Ergon, 1996;27(1):9–16.

3. Dorrian J, Tolley C, Lamond N, et al. Sleep and errors in a group of Australian hospital nurses at work and during the commute. Appl Ergon, 2008;39(5):605–613.

4. Elliot DL, Kuehl KS. Effects of Sleep Deprivation on Fire Fighters and EMS Responders. Final Report to IAFC. Portland, OR: Oregon Health & Sciences University, Portland, OR, 2007.

5. Fisman DN, et al. Fatigue increases the risk of injury from sharp devices in medical trainees: results from a case cross-over study. Infect Control Hosp Epidemiol, 2007;28(1):10–17.

6. Flo E, Pallesen S, Mageroy N, et al. Shift work disorder in nurses—assessment, prevalence and related health problems. PloS One, 2012;7(4).

7. Lamond N, Dawson D. Quantifying the performance impairment associated with fatigue. J Sleep Res, 1999;8(4):255–262.

8. Lockley SW, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf, 2007;33(11 Suppl):7–18.

9. Moore-Ede MC, Richardson GS. Medical implications of shift-work. Annu Rev Med, 1985;36:607–617.

10. The National EMS Advisory Council (NEMSAC). Fatigue in Emergency Medical Services. Report of the Safety Committee, May 2012.

11. Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D. Sleep quality and fatigue among prehospital providers. Prehosp Emerg Care,  2010;14(2):187—193.

12. Prevention CDC. Perceived insufficient rest or sleep among adults—United States, 2008. MMWR Morb Mortal Wkly Rep, 2009;58(42):1175–1179.

13. 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 Jan–Mar 16(1) 86–97.

14. Ricci JA, Chee E, Lorandeau AL, Berger J. Fatigue in the U.S. workforce: prevalence and implications for lost productive work time. J Occup Environ Med, 2007;49(1):1–10.

David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.

Will Krost, MBA, NRP, is a fourth-year medical student and a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.

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