All posts by The Trauma Pro

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Fatigue Week II: Sleep Quality and Fatigue in Prehospital Providers

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EMS providers across the country are assigned to a variety of schedules, ranging from shift work to continuous 24 hour service. Overnight duty, rotating schedules, early awakening and sleep interruptions are common. Unfortunately, there are not many studies on the effects of fatigue on EMS. I did manage to find an interesting study from last year that I’d like to share.

A group of about 3,000 providers attending a national conference were surveyed using 2 test instruments (Pittsburgh Sleep Quality Index (PSQI) and Chalder Fatigue Questionnaire (CFQ)). The PSQI measures subjective sleep quality, sleep duration, disturbances, use of sleeping meds and daytime dysfunction. The CFQ measures both physical and mental fatigue.

Only 119 surveys were completed, despite the fact that a $5 gift card was offered (not enough?). The most common certification was EMT-Basic (63%) and most had worked less than 10 years. Most were full-time, with most working 4-15 shifts per month. The following demographics were of interest:

  • Self-reported good health – 70%
  • Nonsmokers – 85%
  • Moderate alcohol or less – 62%
  • Overweight or obese – 85%

A total of 45% reported experiencing severe physical and mental fatigue at work, and this increased with years of experience. The sleep quality score confirmed this fact. Also of interest was the incidental finding of a high proportion of overweight or obese individuals. Sleep deprivation is known to increase weight, and increased weight is known to increase sleep problems, creating a vicious cycle.

Bottom line: This is a small convenience study, but it was enough to show that there is a problem with fatigue and sleep quality in EMS providers. Federal law mandates rest periods for pilots, truck drivers and tanker ship personnel. The accrediting body for resident physicians has guidelines in place that limit their time in the hospital. Prehospital providers perform a service that is just as vital, so it may be time to start looking at a more reasonable set of scheduling and work guidelines to protect them and their precious cargo.

Reference: Sleep quality and fatigue among prehospital providers. Prehos Emerg Care 14(2):187-193, April 6, 2010.

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Fatigue Week: Sleep Deprivation Changes The Way We Make Risky Decisions

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I’m kicking of Fatigue Week today, where I’ll be dealing with the issues surrounding lack of sleep. As you all know, trauma professionals are expected to perform even if they have not had adequate sleep. This can occur with certain shift schedules, long periods of work, or due to call schedules and duration of call. What do we really know about the effects of sleep deprivation on us?

Today, we’ll talk about decision making. Neuroscientists at Duke looked at how we approach risky decisions when we are sleep deprived. A total of 29 adults (average age 22) were studied. They were not allowed to use tobacco, alcohol and most medications prior to sleep deprivation, which lasted for 24 hours. They were given a risky decision making task (a controlled form of gambling), and two other tests while in a functional MRI unit to watch areas of brain activation.

The researchers found that, when well rested, the subjects had a bias toward avoiding loss in the gambling test. After a single night of sleep deprivation, this shifted to pursuing gain. The MRI also showed an increased activity in the reward anticipation parts of the brain. Overall decreased vigilance was noted, but this did not correlate with the shift away from risk avoidance.

Bottom line: Sleep deprivation appears to create an optimism bias. Fatigued individuals act like positive outcomes are more likely and negative consequences are less likely. One of the most common and important things that trauma professionals do is to make decisions that may affect patient outcome (e.g. choose a destination hospital, intubate, order and interpret a test, move to the operating room, choose a specific operative procedure). We all have a set of thresholds that help us come to the “right” decision based on many variables. It appears that a single night of sleep deprivation has the potential to skew those thresholds, potentially in directions that may not benefit the patient.

Reference: Sleep deprivation biases the neural mechanisms underlying economic preferences. J Neuroscience 31(10):3712-3718, March 9, 2011.

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How Significant is Pneumomediastinum in Children?

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Pneumomediastinum seen on chest x-ray after blunt trauma always attracts attention. Possible sources may be related to very serious injuries to the aerodigestive tract. When seen in children, it causes considerable anxiety, which usually results in a very detailed workup and lots of imaging.

Children’s Hospital of Boston looked at the National Trauma Data Bank, as well as 19 years worth of their own records to see whether all the attention is justified. They found 193 patients in the NTDB that met their criteria, and most were in their late teens and had other significant injuries. Of the 17 with isolated pneumomediastinum, none had any other significant injury.

When reviewing their own patient records, they found 18 with pneumomediastinum, and all but one was seen on plain chest x-ray. Most were transferred to the hospital from referring centers, and had been involved in sports-related mechanisms. Half had undergone studies in addition to a chest x-ray before transfer. All were discharged home without any surgical interventions.

Bottom line: Pneumomediastinum is rare in children, even older ones. If associated with significant aerodigestive injuries, it was never an isolated occurrence. Other signs or symptoms were present. Pediatric patients presenting with an isolated pneumomediastinum can be safely observed, using chest x-ray and physical examination alone. More sophisticated studies (CT, barium studies) are not indicated.

Reference: Clinical outcomes and diagnostic imaging of pediatric patients with pneumomediastinum secondary to blunt trauma  to the chest. J Trauma, epub, 2011.

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Image Sources for the Trauma Professional’s Blog

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I’ve had some questions about where I come up with some of the images I post in this blog. I have a number of sources, including the good old internet as well as my own personal collection. If I do use my own images, I strictly follow these guidelines:

  • They are not related to patients I have taken care of at Regions Hospital.
  • They are at least 10 to 15 years old. If more recent, I will have obtained a consent for it.
  • They are anonymous. There is no identifying information whatsoever.

In order to avoid any confusion in the future, I will provide source info for any images I post.

Thanks, and keep reading!