The Dangers of Too Little Sleep

Sleep is essential to basic human functions like your appetite, temperature regulation, memory, and awareness.¹ Sleep impacts all aspects of your life, from mental and physical health to financial and spiritual well-being. Additionally, the sleepier you are, the more likely occupational injuries and accidents are to occur.¹ 

As EMS providers, most of us know what it feels like to not get a sufficient night of sleep, but what effects does it really have on us? Let’s break down the science of sleep, the issues that arise in EMS work from insufficient and irregular sleep, and what that means for the communities we serve. 

Sleep Science

Sleep is a state of altered consciousness with biometric signs such as decreased pulse, decreased blood pressure, and slowed breathing.² Your brain continues to work and is actively processing information.² 

To understand sleep better, researchers have defined different stages of sleep: non-REM (NREM is divided into three levels, N1, N2, and N3) and REM (rapid eye movement). Throughout the night we cycle through these stages from NREM to REM, with NREM stages corresponding to the depth of our sleep.² For example, our deepest sleep is found during the N3 stage, when we are hardest to wake. The N1 stage is typically when people are still responsive to their senses while falling into a deeper sleep.² Think of it this way: NREM equals a still brain in an active body; REM equals an active brain in a still body. Dreams, muscle atonia, and rapid eye movements all occur during REM sleep.²

For adults, as the night goes on, bouts of REM sleep get longer and longer.² Allowing our bodies to sleep for longer periods of time gives it the amount of REM sleep we need to feel fully rested. Without adequate REM sleep, we develop a sleep debt, something that cannot be fully reversed once it’s happened.¹ While many of us fall victim to thinking a nap can make up for lost sleep, naps cannot fully reverse our sleep debt. For those of us who regularly get insufficient sleep, that deficit is here to stay. 

In addition to the stages of sleep, researchers focus on Process S (the sleep-wake homeostatic process) and Process C (circadian rhythms).^2,3 Process S works to encourage sleep the longer you are awake and encourages being awake the longer you are asleep.^2,3 Seems straightforward, right? But now throw in the circadian rhythms, or Process C. This is your internal clock that regulates the sleep-wake cycles, secretion and production of hormones, and temperature in your body.^2,3 It is largely controlled by the suprachiasmatic nuclei (SCN), situated in the hypothalamus.² Circadian rhythms operate on a 24-hour period, with light being the ultimate sign to our bodies for optimal sleep/wake times.⁴ When it’s dark our body produces melatonin—the hormone catalyst for sleep.⁴ The more we are exposed to light, the less our body encourages sleep.⁴

Processes S and C do not operate in isolation. In fact, they work together in almost every capacity. As Process S nears the top boundary of Process C, sleep is triggered in the body. The opposite happens as Process S reaches the bottom boundary of Process C.³ In monophasic circumstances this cycle happens twice for every circadian cycle. For humans, we usually experience polyphasic conditions, where these dual cycles occur more often with continual sleep.³ 

Problems for EMS Providers

For EMS providers, shift work and rotating schedules are just two aspects of an incredibly dynamic job. Many times providers have interrupted sleep while on night-shift duty; we may wake up earlier than our circadian clocks would like us to; and some of us never have a set schedule, and as a result our sleep is misaligned with our work hours.² Circadian rhythm disruptions come with myriad health risks, like sleep disorders, cardiovascular disease, and diseases with an immunological component.¹ Research has also found that providers on shift-work schedules have increased rates of heavy drinking, job stress, and poor psychological health as opposed to those with more regular sleep-wake schedules.¹ 

Working more than 24 hours at a time is not uncommon but poses substantial safety and care risks.^5,6 In many situations an EMS provider will get little to no sleep during a 24-hour shift.⁷ In fact, one study showed those working 24-hour shifts reported the highest levels of fatigue and fair/poor health.⁸ Working these long shift hours puts the EMS provider at higher risk for cognitive and motor impairments, sometimes to the same extent as being intoxicated.^1,8

Perhaps the most detrimental effect from lack of sleep for EMS providers is fatigue. Fatigue is defined as a ”subjective, unpleasant symptom which incorporates total body feelings ranging from tiredness to exhaustion, creating an unrelenting overall condition which interferes with an individual’s ability to function to their normal capacity.”⁶ 

With the danger of adverse events like ambulance crashes, EMS providers need to be aware of the risks associated with working while sleep-deprived and fatigued.⁷ In fact, it is estimated that more than half of EMS providers report severe fatigue, both mentally and physically.^1,6,8 Some providers acknowledge the feelings of dread and guilt with going into work while fatigued but do it anyway for many reasons.⁸ EMS providers often feel the burden of being short-staffed, needing the money to pay for necessities, and having a strong passion for helping others that often comes before their own well-being, including obtaining healthy sleep.⁷

These factors all add up to increase the chance an EMS provider experiences dysynchrony, the misalignment of our circadian rhythms to the environment.^1,2 In other words, EMS providers are at risk of largely insufficient sleep, misaligned sleep-wake patterns, and overall poor sleep quality. Variable schedules, long shifts, financial needs, and a passion for helping others put many EMS providers in a position to ignore the health risks of insufficient sleep. 

Impact on our Communities 

A 2012 study found 90% of EMS respondents believed their behaviors compromised the safety of themselves and their patients within the last three months.⁸ Those working long shift hours had the highest rate of believing they put the safety of themselves or others at risk. Respondents who were reported as fatigued were five times more likely to report believing safety had been compromised. It should be a standard that the first patient a provider sees on their shift receive the same level of care as the last patient, which cannot happen when sleepiness and sleep deprivation are part of the scene. 

Moreover, this study documented that medical errors or adverse event (AEs) are more likely with poor sleep.⁸ Specifically, there was a 40% occurrence for one or more medical errors/AEs in the past three months, with EMS providers ages 17–25 in the highest group. Reports of a medical error or AE were 50% more likely when combined with poor sleep than with good sleep. 

While little research has focused on the association between fatigue and medical errors in EMS, there has been considerably more for the in-hospital environment.¹ Physicians in training who work regular 24-hour shifts make five times as many serious diagnostic errors, are 50% more likely to get into a motor vehicle accident, and make 36% more serious medical errors compared to someone working a 16-hour shift.⁵ We know the hospital setting has a myriad of control factors when providers make decisions—alerts before sending orders, more time to make judgement calls, and the benefit of a full team to converse with. EMS providers conversely make split-second decisions in moving vehicles, with less-prominent alerts to our care decisions. Knowing the amount of control in a hospital setting is much more defined than the EMS environment, it is crucial this relationship be explored for greater insight on the damage we may be doing to ourselves and our patients. 

Conclusions

With this new knowledge about sleep and its relationship to our physical/mental health and the impact that has on our communities, change needs to happen. According to the National Sleep Foundation, the adult person should get an average of 7–9 hours of sleep each night.⁹ Working in EMS, providers are responsible for performing at the highest standard due to the high stress and high-risk nature of the work. Battling fatigue while also working complicated patients in complicated environments is a recipe for medical errors and adverse events. 

It’s disheartening to know federal law limits how long people work in most aspects of the transportation industry, like commercial pilots (limited to eight hours of flight in a 24-hour period), but there remain no guidelines or restrictions for EMS providers.^1,8 Looking to the future, regulations for shift hours on a federal level and more discussion around feelings of fatigue while at work will encourage providers to speak their truth about the safety of themselves and others on shift. 

By making sleep a more common subject in the workplace for EMS providers, we hope to normalize a sufficient night’s sleep, improve the overall well-being of providers, and be able to give all patients the same high-quality level of care. 

References

1. Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D. Sleep Quality and Fatigue Among Prehospital Providers. Prehosp Emerg Care, 2010; 14(2): 187–93.

2. National Institute of Neurological Disorders and Stroke. Brain Basics: Understanding Sleep, www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep.

3. Borbély AA, Daan S, Wirz-Justice A, Deboer T. The two-process model of sleep regulation: a reappraisal. J Sleep Research, 2016; 25(2): 131–43.

4. Blume C, Garbazza C, Spitschan M. Effects of light on human circadian rhythms, sleep and mood. Somnologie, 2019; 23(3): 147–56.

5. Lockley SW, Barger LK, Ayas NT, 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): 7–18. 

6. Barger LK, Runyon MS, Renn ML, et al. Effect of Fatigue Training on Safety, Fatigue, and Sleep in Emergency Medical Services Personnel and Other Shift Workers: A Systematic Review and Meta-Analysis. Prehosp Emerg Care, 2018; 22(sup1): 58–68. 

7. Bardinelli JA, Roarty J, Goldstein S. EMS Disordered Sleep and Work Schedule. StatPearls [Internet], 2020 Dec 12; https://www.ncbi.nlm.nih.gov/books/NBK470349/. 

8. 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; 16(1): 86–97.

9. Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s updated sleep duration recommendations: final report. Sleep Health, 2015; 1(4): 233–43.

Katherine Benoit, BA, NREMT, is an EMT for Athens County (Ohio) EMS.