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.
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