Dead Tired

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.

“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.

The authors of the IAFC report note the dangers of long work hours: that they’re linked to stress, injuries and deterioration in performance; that alertness drops after 10–12 hours; that fatigue when driving home after a long shift could increase crash risk.⁸ But they also note the popularity of 24-hour shifts, and that some departments have even moved to 48s.

Delving into the ramifications of all this isn’t easy. “Not many people will be willing to admit things like medication errors or significant patient care mistakes,” observes Loscar. Even if they do, causation is often far from black and white. Was that goof a function of being tired, rushed, distracted or careless? How little sleep is too little for a given individual performing a given task?

Vehicle crashes are easier to identify, and the sleep status of drivers, should we ever choose to, wouldn’t be difficult to track. Who knows what we might find? For drivers, sleep deprivation can degrade performance as surely as alcohol. In one study, drivers awake for 17–19 hours performed worse than those with blood alcohol levels of .05%.⁹ Another found that at 24 hours awake, performance equated to a BAC of .10%.¹⁰ Particular to EMS, a 2008 look at characteristics of EMTs involved in ambulance crashes found an association with sleep problems.¹¹

Nationally, in a 2009 poll by the National Sleep Foundation, 1.9 million drivers had crashes or near-misses due to drowsiness in the preceding year.¹² A look at drivers in sleep-related crashes found them more likely to work multiple jobs, night shifts or other unusual schedules.¹³ The American Academy of Sleep Medicine says one in every five serious motor vehicle injuries is related to driver fatigue,¹⁴ and it has endorsed legislation declaring drivers awake for 22 of 24 hours impaired.

Unforgettable

There are lots of numbers to this issue. Behind them, it’s important to remember, are real people.

Today, more than half a decade after the crash that killed his partner, Rick (a pseudonym) doesn’t relish reliving the details, saying only, “It was a bad day.” He’s more comfortable talking about what preceded the event and what came after, personally and professionally, for a young EMS provider living a worst-case scenario.

“I think, among employers and employees, there’s a lack of awareness of how dangerous it can be not being properly rested,” he says. “Our profession attracts certain personalities and begets a certain lifestyle… We go from job to job and don’t really think about how we need to slow down sometimes and pace ourselves, and give ourselves time to sleep. I think we forget sometimes that we’re human and need to recharge our batteries. And sometimes our employers forget that too. You get scheduled for a double shift or go from one job to another… It’s taxing.”

The short version of Rick’s story is that he was working on just a few hours of poor sleep. Driving, nearly at his destination, it caught up with him. The resulting crash injured him, though not critically. It killed his partner.

The consequences, personal and professional, were imaginably severe. Rick’s employer offered no counseling or grief resources. He went on leave, then resigned. For a year, he says, he was simply numb. Counseling sought on his own brought no relief. Hoping to elicit a positive from the catastrophe, he went back to school, but even with the upgraded resume, EMS jobs proved hard to find. The accident shadowed him, on his driving record and among the EMS community in his area.

Rick still works in the field now, though. Still, also, deals with his consequences.

“I feel I lost everything that day,” he says. “You think your whole life is going to be some way, and in a split second, all that changes. It’s changed my life, obviously. It will follow me everywhere I go. But there are the consequences to what I did, and I understand that. And those have included not only my losses, but the guilt of hurting somebody I cared about.”

One especially insidious effect of chronic sleep deprivation is that it diminishes the ability to recognize the very impairments it causes.¹⁵ In other words, the sleep-deprived person isn’t going to be vigilant to his own degrading performance. “I thought I was fine,” notes Rick. “Just like any other day, no problem, had my Red Bull, doing my job.”

There’s a certain risk, then, in relying on sleep-deprived or fatigue-impaired providers to take themselves out of commission. That’s why some bosses are trying to help them.

Downshifting

In their preface to the IAFC paper, then-president James Harmes and Safety, Health and Survival Section chair I. David Daniels wrote that, “Some will suggest there is a correlation between shift schedules and sleep deprivation. The reality is there is correlation between the amount of sleep one gets and their overall level of performance. For those who are deprived, it really doesn’t matter why they are deprived.”

The second sentence is indisputably true, but the third is debatable. Does it matter if the deprivation is a direct function of the job, and we’re posing jeopardy to our own people and patients? That was the fear down in Texas a few years ago when Austin-Travis County EMS put the sleep issue under a microscope and set out to fix it.

In the service’s busy urban stations, widespread overtime and short sleep hours were so rampant that it began to worry leaders.

“While we were fortunate not to have any catastrophic events related to things like driving,” says ATCEMS Chief of Staff James Shamard, “we were concerned with how busy it was getting, both for the safety of our staff and for their ability to provide the same quality of medical care in hour 23 and 24, if they’ve been up all day and night, as they did in hours 1 and 2 of their shifts.”

The service sought help from Circadian, a global consultant on shift work and fatigue risk management, to measure and help fix the problem. How bad were things? ATCEMS found 60% of its surveyed employees in the field were working at least 60 hours a week, and 57% had worked more than 48 consecutive hours within the past month. A third said they’d gone 27 consecutive hours or more without sleep during the past week. More than half admitted nodding off at work at least several times a month. In urban stations, just 2% reported getting seven hours of sleep or better during 24-hour shifts, and 51% reported getting less than two.

The core feature of the resulting solution was a defined unit-hour utilization threshold that, when exceeded, resulted in switching busy units from 24- to 12-hour shifts. The service also developed hybrid schedules combining regular 24s and 12s in slower and busier stations, and transitioned personnel from 56-hour workweeks to 48. It additionally implemented minimum not-at-work time between shifts.

To inform this all scientifically, ATCEMS employees spent time wearing personal activity monitors and logging their sleep, food intake and other activities to help provide detailed biodata on which to base change.

“The process looked at workload and activity compared to people’s circadian rhythms, and at microsleep [brief periods where the brain of a sleep-deprived person shuts down, like a blackout] and at what point people are fatigued,” says Shamard. “With the data from the activity monitors, you could see the periods of microsleep and where people were. So a lot of the schedule design and way we did things recognizes there are certain things inherent to humans that we cannot manage. There are things we can help manage; we just had to build schedules that reflected that there are certain points where people get tired, and we have to work around that in a way that keeps them safe.”

Now employees bid for shifts and stations based on tenure every six months, which gives them set schedules half a year at a time. Varied schedule options accommodate varied personal lives, and the system is continually refined through feedback. Giving workers some control over their own schedules has been good for satisfaction, Shamard says, and even if shorter-tenured employees don’t get their preferred shifts at first, they know they ultimately will.

That’s important because, frankly, people like their 24-hour shifts. In a recent EMSWorld.com poll, that was the preferred shift of 40% of respondents. Even if 24s are relentlessly busy and less safe, eliminating them won’t win a lot of friends.

When he became general manager of Alameda Co. AMR, Taigman was concerned about a handful of 24s that persisted in his jurisdiction’s periphery. “It was clear right off the bat,” he says, “that some people were working too much, and it wasn’t safe.” Of five, he scrapped three.

The decision was enormously unpopular, so Taigman called affected personnel to an informal meeting at a local pub and invited them to vent.

“Many of these folks had been on these shifts for better than 20 years—their whole lives were set up around them,” he says. “I basically told them, ‘I know I’ve ruined your lives. I’ve disrupted everything from child care to school to your other jobs and everything you have lined up. This is your opportunity to yell at me and tell me how awful I am. Say anything you want, and I’ll listen. You won’t change my decision, but I’ll listen to everything you have to say.’”

First, though, he told them a story about a young EMT he’d met at a consulting job some time before. The kid was 18 and had been on the job for two weeks. He’d just finished a busy 24 in which he’d been awakened for calls five times after just a few minutes’ light sleep. Driving home afterward, like Rick, he fell asleep at the wheel. He ran a stop sign and killed a 16-year-old girl.

“This kid was taking all the blame himself,” Taigman says, “and I’m thinking, What’s the contribution to this situation of the systems we’ve set up? Do those of us who design and lead EMS systems have some responsibility for this?”

He told this all to the angry mob in Alameda. He told them, as their leader, his obligation was to take care of patients and take care of them. He told them he never wanted to visit them in a hospital, or to face the family of a patient dead because of a fatigue error in driving or medical care. Then he opened the floor.

“The room was quiet,” Taigman says. “Finally, one of the more outspoken guys just said, ‘You made that really hard to argue with.’”

Over the following weeks, as they reordered their other affairs, at least some of the affected workers adjusted and did, in fact, start getting more sleep. Some ultimately embraced the change; others didn’t. But the system, Taigman says, is safer for everyone as a result. And while Alameda County and AMR have since parted ways, the county maintained fatigue-management criteria in its RFP for a new provider.

Liability Risks

Other departments have moved to cut long shifts too, but that may not be feasible for everyone. And in any case, you can’t control what people do during their off time. So for services concerned with provider sleep deprivation and potential liability, what’s to do? What’s the risk, and what offers protection?

As always, it’s difficult to generalize about EMS legal matters, because state laws can differ. But in some places, a sleep-deprived employee’s fatigue-related error may well pose his organization legal jeopardy.

“In probably almost every state, the employer is going to be liable for the acts of the employee,” says veteran fire and EMS attorney Bradley Pinsky, a partner in the New York firm of Scicchitano & Pinsky. “Allowing somebody to have worked to the point of exhaustion, where their senses and abilities are diminished, could amount to negligent supervision.”

There’s a straight line from sleep loss to increased mistakes to increased legal risk. To be sure, many states offer degrees of immunity to people acting in emergency situations, and frequently those protect providers who make medical errors, at least barring extreme negligence. But they may not extend to the organization that turns a foggy, sleep-short provider loose in the field.

It might not even matter why that provider is foggy and sleep-short. Say it’s not from your service working him 20-plus hours, but that he skipped sleep for a second job, then reported to work for you exhausted. You could still be on the hook for fatigue-related mistakes he makes under your authority.

“Immunity offered for medical negligence frequently does not extend to the employer’s negligence in making a person so tired, or allowing a person to be so tired, that they committed a medical error,” says Pinsky. “That’s true in a lot of areas: If an employer hires somebody they know or should have known to not be a good EMT or firefighter, they’re liable for the negligent hiring. It’s along the same lines here—they’re not going to be covered. We’ve seen that in other medical fields, with hospitals and residents. It amazes me that fire and EMS employers have not learned from the issue of residents, because hospitals and states dealt with this long ago.”

For more on that, search the name Libby Zion. Meanwhile, as an employer or boss, the way to think about sleep deprivation is as an impairment. If it can harm performance as surely as drugs or alcohol, treat it like drugs or alcohol in policy, and prohibit working under its influence.

To protect yourself, then, a few best practices: It’s good to eliminate busy 24s. To the extent you keep them, you must let providers sleep (some services don’t). It’s good to provide minimum time off between shifts. But to guard against sleep-skipping for second jobs, Pinsky recommends phrasing a policy more broadly.

“If you have a policy like, ‘You have to have had at least 7 hours of sleep in the last 24,’ you would not permit someone to work who had not slept that much, continuous or not,” he says. “I recommend that policy for that very reason: Because I don’t know what you’ve been doing in your off hours.”

This will protect an organization—but, it should be noted, shift risk to the employee. Someone who responds or works in violation of written company policy may well forfeit their immunity and benefits if something goes wrong.

EMS World Readers

Results of unscientific polling of visitors to EMSWorld.com on their sleep habits:

How much sleep have you averaged per 24-hour period in the last week?

8+ hours                           9%

6–8 hours                        35%

4–6 hours                        44%

Less than 4 hours             12%

How often do you work on less than eight hours’ sleep?

Never                                  1%

Occasionally                       14%

Frequently                          49%

Always                               36%

What is your preferred shift length?

8 hours                                 11%

12 hours                               45%

24 hours                               40%

Other                                    4%

Have you ever made a fatigue-related error in patient care or vehicle operation?

Not that I’m aware of    50%

Yes, but rarely             46%

Yes, regularly                4%

Facing the Issue

There are lots of numbers to this issue. Behind them, it’s important to remember, are real people.

Today, more than half a decade after the crash that killed his partner, Rick (a pseudonym) doesn’t relish reliving the details, saying only, “It was a bad day.” He’s more comfortable talking about what preceded the event and what came after, personally and professionally, for a young EMS provider living a worst-case scenario.

“I think, among employers and employees, there’s a lack of awareness of how dangerous it can be not being properly rested,” he says. “Our profession attracts certain personalities and begets a certain lifestyle… We go from job to job and don’t really think about how we need to slow down sometimes and pace ourselves, and give ourselves time to sleep. I think we forget sometimes that we’re human and need to recharge our batteries. And sometimes our employers forget that too. You get scheduled for a double shift or go from one job to another… It’s taxing.”

The short version of Rick’s story is that he was working on just a few hours of poor sleep. Driving, nearly at his destination, it caught up with him. The resulting crash injured him, though not critically. It killed his partner.

The consequences, personal and professional, were imaginably severe. Rick’s employer offered no counseling or grief resources. He went on leave, then resigned. For a year, he says, he was simply numb. Counseling sought on his own brought no relief. Hoping to elicit a positive from the catastrophe, he went back to school, but even with the upgraded resume, EMS jobs proved hard to find. The accident shadowed him, on his driving record and among the EMS community in his area.

Rick still works in the field now, though. Still, also, deals with his consequences.

“I feel I lost everything that day,” he says. “You think your whole life is going to be some way, and in a split second, all that changes. It’s changed my life, obviously. It will follow me everywhere I go. But there are the consequences to what I did, and I understand that. And those have included not only my losses, but the guilt of hurting somebody I cared about.”

One especially insidious effect of chronic sleep deprivation is that it diminishes the ability to recognize the very impairments it causes.15 In other words, the sleep-deprived person isn’t going to be vigilant to his own degrading performance. “I thought I was fine,” notes Rick. “Just like any other day, no problem, had my Red Bull, doing my job.”

Living With the Night Shift

When I first entered EMS, I was like everyone else: I worked whenever they needed me. Everything was new and exciting and a learning experience, for good or for ill. As I got to know the system, eventually I gravitated toward nights. I liked the vibe, I preferred the logistics and clientele, and it’s where I made my home for the better part of 20 years. Even though I’ve moved to a day position for the last three years, I work part-time at another paramedic project—at night.

For me working nights was always a better fit. It put me against the flow of traffic, so rush hours were never an issue. Without the daytime traffic, responding to even distant jobs was less stressful. Office buildings and commercial areas are shut down, so you’re farther out of the public eye. Management across the board is absent; with less oversight there is the perception of less pressure. It seems like many true “night” people often demonstrate more independence and take things more in stride. With fewer resources available, you have to make your own solutions.

These benefits come at a cost. Not everyone can function at top speed at 4 a.m.; in fact, some folks are pretty much nonfunctional by midnight. Our system does not allow for any significant down time, so relying on it for sleep is a fool’s dream. Plus, working nights gives you one significant temptation: daytime availability. You’re off during the day, with plenty of time to go to appointments, shop, run errands—basically do everything but the one thing you really should be doing: sleeping. That’s what would really hurt me: not going to bed when I got home. I’d get a second wind, and the next thing I’d know, it was just three hours to get ready for another overnight.

When I had my kids it became even worse. Anyone who says “I will just sleep when the baby does” simply does not have a baby yet. Especially in the first few months, you sleep for an hour, get pulled awake, nod for 20 minutes, get cried awake, pass out in the chair, get screamed awake. I’m pretty sure it’s used as a template for torture in other countries. No downtime at work or home makes for one frazzled, short-tempered parent (and provider). I’ve driven home so tired that my depth perception would be way off; someone hitting the brakes hundreds of feet ahead would have me slamming mine. Or I would literally hallucinate—see things like branches or shopping carts in the middle of a highway that just weren’t there. I would find things hard to process: It would take much longer for my brain to make sense of what I was seeing or what was being said. It would be an utter lie to say my patient care was not compromised at some point.

How we learned to manage (my husband is a night guy too), both pre- and post-kids, simply was with routines and priorities. When we came home we went to bed, period. Even if it wasn’t a full day’s rest, we would dedicate the morning to letting ourselves sleep, even arranging child care around that purpose. The bedroom is quiet, cold and dark—we like our crypt. To this day there is an Army-issue OD green wool blanket covering our windows. You will not find a better shade. Nights gets harder on the body the older you get, and now I simply cannot go as long without rest. If that means cutting something short so I can go to bed early, so be it. It’s tough to admit you need to go to bed at the same time as your kids to be at your best the next day.

My best piece of advice for folks walking the edge of exhaustion most of the time? Pull over. Really. Find a rest area, lock your doors, set your alarm for 20 minutes and give in. Recognize when you are a danger to yourself and other people on the road—no destination is worth that price. I have very close friends who have suffered serious consequences because of fatigue, including one who broke their neck. Suck it up and accept that even heroes have limits.

—Tracey Loscar

Sleep Tips for the Night and Shift Workers

Night-shift veteran Tracey Loscar offers the following sleep tips for night and shift workers:

• You have to recognize when you’ve hit the point where you can’t function and need to address it. That makes you a danger to your patient and your crew. If you’re so tired you can’t operate the vehicle or make a critical decision, you need to know that and step away before you mess it up.

• Know what your sleep pattern is. Everybody has a full life, but the reality is, if you want to be functional at night, you must sleep during the day. Have a routine, and whether you’re going to be a morning sleeper or an afternoon sleeper, adhere to it.

• Create a cave—a sleeping space that can keep out the ambient noise, because that’s what’s going to prevent you from getting quality sleep.

• Invest in childcare if you need to. Even though we were home, my husband and I would have a baby-sitter come over to sit with the kids, so we could get three or four hours of sleep when we were working the same schedule. It’s just too critical.

• For people who commute, pull over. If you do nothing else, pull over. If you’re nodding at the wheel, pull over. Make a phone call, get out and walk around, or call in and say, ‘Listen, I just can’t get behind the wheel.’ Because you will die, you will break your neck, or you will kill somebody else.

Sleep, Emotions & Mental Illness

The problems of sleep loss, fatigue and performance degradation are all too familiar to EMS educators, who are particularly positioned to see how they affect students.

Longtime teacher and medic Chris Nollette, EdD, NREMT-P, EMS program director at Riverside (CA) Community College and president of the National Association of EMS Educators, has seen mysterious late-term declines in otherwise good pupils.

“These were great students who were doing really well throughout the semester, but toward the final exams their grades started to plummet,” Nollette says. “When I talked with them, there was a common thread, and that was that they were staying up, cramming, and not getting sleep the nights before their exams.”

Hearing similar tales from other educators, he began researching the issue of sleep deprivation, and became increasingly alarmed as he found out more. Now he’s a frequent conference lecturer on EMS sleep problems.

He’s particularly concerned about their emotional impact. While the physical and mental impairments caused by getting too little sleep are fairly well known, it also diminishes our ability to deal with exactly the sort of complex and difficult sights and feelings EMS providers’ jobs expose them to every day. Basically, University of California sleep expert Matthew Walker told Medscape in 2007, “Even healthy people’s brains mimic certain pathological psychiatric patterns when deprived of sleep.”¹

A study Walker led that year exposed two groups of subjects—one that had missed a night’s sleep and a fully rested control—to disturbing images like mutilated bodies and children with tumors. Brain MRIs showed roughly 60% more activity in the amygdalas of the sleep-short subjects.² The amygdala governs emotional reactions, including the body’s responses to perceived danger. Basically, without sleep, those subjects were working much harder to deal with the same sights. In such situations, the brain shuts down reasoning and reverts to fight-or-flight mode. “Your amygdala,” notes Nollette, “more or less short-circuits.”

The larger implication may be that, instead of sleep problems being a common feature of psychiatric illness, as experts have long believed, psychiatric illness may be, at least in part, somehow related to sleep problems. Walker noted that brain-activity patterns seen in the healthy but sleep-deprived show similarities to those of sufferers of things like depression and PTSD.

References      

1. Anderson P. Sleep Deprivation Leads to Emotional Instability Even in Healthy Subjects. Medscape, www.medscape.com/viewarticle/564867.

2. Yoo SS, Gujar N, Hu P, Jolesz FA, Walker MP. The human emotional brain without sleep—a prefrontal amygdala disconnect. Curr Biol 17(20): R877–8, Oct 23, 2007.

What You See at Work & How You Sleep

For many people, sleep is a peaceful way to rejuvenate and prepare for another day. It provides the opportunity to rest and restore energy levels for emotional and physical well-being. But for those who experience nightmares and/or night terrors, it can be one of the most feared parts of the day.

If left unchecked, nightmares and night terrors can severely disrupt sleep patterns, which can lead to depression, anxiety and sleep deprivation, making it difficult to focus. Recurrent nightmares can also lead to insomnia.

“The mind is like a guard. It wants to protect you from noxious things,” says William Kohler, MD, director of the Florida Sleep Institute in Spring Hill, FL. “If you’re having horrible nightmares, the mind will try to keep you awake to keep the nightmares from happening.”

Nightmares are vivid dreams that force you awake during REM (rapid eye movement) sleep, Kohler explains. Their disturbing subject matter is often clearly recalled when you wake up, which can then make it difficult to fall back to sleep. They can also make you afraid to fall asleep, which can lead to daytime sleepiness.

Night terrors, which are often accompanied by yelling and screaming, occur in non-REM sleep. You will have very little, if any, memory of the incident. Loved ones may try to console you, to no avail. Because people who experience night terrors can lash out, talk soothingly to them but don’t try to force them awake.

Both events are associated with emotional stress, which can be a common concern for EMS professionals. “EMTs and paramedics are involved in some very serious and horrible situations,” Kohler says. “It’s important to recognize the potential for developing nightmares and possible PTSD (post-traumatic stress disorder) when exposed to emotional and physical trauma.”

Learn to Restructure

According to information published by NAEMT, research indicates that about 5% of the population will suffer from nightmares at any given time. But for those who witness or survive a trauma, the rates are 50%–88%higher.

“Having nightmares after a trauma is quite common,” notes Michael Nadorff, a doctoral student in clinical psychology at West Virginia University. “But it isn’t always a bad sign. Some theories suggest that nightmares may be part of the natural process of dealing with a traumatic experience.”

They may work similarly to exposure therapy for treatment of anxiety, Nadorff says. “For example, if someone is anxious about heights, psychologists may slowly build up a person’s exposure to heights so he or she isn’t as afraid,” he says. “Or, if someone has a traumatic experience in a car, we can slowly expose that person to that stimulus until he or she can get back into the vehicle. It’s possible that nightmares do the same thing naturally, where they expose someone after a trauma to whatever it is they’re afraid of. The hope is that eventually the trauma will no longer strike fear in them. One thing we don’t really fully understand is why for some people, nightmares go away, but for others they remain.”

If nightmares persist at a rate of more than one a week for more than about a month, Nadorff suggests seeking treatment, which can be based on behavioral or pharmacologic therapies. One common treatment is imagery rehearsal therapy. With this treatment, nightmare sufferers are taught—when they’re awake—methods to develop pleasant imagery to create a new dream. Usually sessions are brief, and treatment can be completed in three to four visits. “You reset the imagery and the trauma,” says Kohler. “You restructure the event to try to make it less onerous.”

“It’s important to realize that if you have persistent nightmares, there are effective treatments available,” Nadorff adds. “Having a couple of nightmares after a trauma doesn’t necessarily mean you have PTSD. But if they persist, it’s worth looking into treatment. It might be a good idea to talk to someone. Medications can also be prescribed. Either way, there is treatment out there. Knowing that can be a great service in and of itself.”

Conclusion

There’s ample literature on the harm of sleep loss to the body, the mind and human performance, and much known of the diminishing returns of long shifts. Still, they’re issues that don’t often seem on the minds of EMS leaders.

“I don’t get the sense people are really aware,” says Pinsky. “Of the 400 fire departments and ambulance services I represent, I can’t tell you I’ve ever seen any have a policy that included lack of sleep as an impairment that had to be prevented. I’ve drafted them, but I’ve never seen one implemented on its own.”

Front-liners may enjoy the lifestyle benefits of their long shifts or need the paychecks of multiple jobs. Longer shifts make financial sense for systems, too; both Austin-Travis Co. and Alameda AMR had to spend to go shorter. These are decent arguments for the status quo.

With physician residents, change came from a high-profile case involving a journalist’s daughter. Following Libby Zion’s death, New York limited residents’ work hours to 80 a week, and the Accreditation Council for Graduate Medical Education adopted a similar cap soon after, which also limited shifts to 30 hours (12 in the ED) and mandated time off.

There’s no comparable body to do that for EMS, and lots of pressures in favor of days spent long on work and short on sleep. At the least, the wise provider should be educated to the dangers of sleep deficits and, whatever their circumstance, work to reduce their own risks and any danger they pose to others. And system bosses should be aware of potential liability from provider sleep impairment, whether they’re contributing to it or not. It’s no excuse for a mistake.

“As I get older,” says Nollette, “I want these people who may be responding to me to be able to get the IV in the right place, the tube in the right place, and give me the right drugs in the right order at the right dosage. I know if we don’t do something about this, there can be mistakes. I just don’t want to be one of them.”

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