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.
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.
There are generally about 30,000 deaths from car crashes each year. An analysis by the AAA shows that drowsiness is a factor in about 1/6 of them! In the early 1990’s, NHTSA looked at this problem and found only about 4% of fatal crashes were due to sleepiness.
What gives? Is everybody suddenly a lot sleepier these days? It’s actually due to the way it is reported. As you can imagine, it’s difficult to figure out if fatigue was the cause after the fact in a fatal crash. The driver certainly can’t tell you.
AAA looked at crash rates and applied information it obtained from a driver survey it administered. They found that 41% of drivers admitted to falling asleep behind the wheel at some point. And one in ten admitted to it happening in the past year. The AAA believes that their estimates are far more accurate than the lower NHTSA numbers.
Sometimes our patients tell us that they think they may have fallen asleep at the wheel. You should assume it in anyone who is driving home after a long shift, especially early in the morning.
Educate your patients about the warning signs of fatigue while driving. Everyone knows the obvious ones: droopy eyes, frequent daydreams, drifting in and out of lanes. But here are some of the not so obvious:
Difficulty remembering the last few miles driven
Restlessness, irritability or aggressiveness
Frequent scratching and rubbing
Once fatigue becomes a factor, the driver is not only a danger to themselves, but to everyone else on the road as well. The solution: pull off as soon as practical and call for assistance. Caffeinated drinks are overrated and take too long to work!
Sources: American Automotive Association, NHTSA, National Sleep Foundation
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