Early in my career, I was assigned to the Antietam Station in the heart of downtown Hagerstown, Maryland, about an hour west of Washington, D.C. The two ambulances assigned there are the busiest medic units in the city. In 2022, each unit ran nearly 3,600 calls.
Parking outside the station and walking up the street to the open bay door at shift change, the oncoming crew was greeted by the off-going crew, who would be sitting on the front steps or in the bay with coffee or energy drinks, yawning as they had never been to bed. [At the end of this article, download a sleep tracker to measure fatigue]
Stay alert: Vigilance and quick decision-making
In 2007, the International Fire Chiefs Association released “Effects of Sleep Deprivation on Fire Fighters and EMS Responders,” highlighting that humans have limits to their abilities, and adequate daily sleep is needed to perform optimally and be healthy.
The report notes long work hours are often associated with chronic sleep loss, which may result in decreased ability to think clearly and feelings of depression, stress and irritability. Chronic sleep loss is associated with a general increase in health complaints and musculoskeletal problems, higher body weight, a greater risk of obstructive sleep apnea, and heightened levels of cardiovascular disease and cancer.
We know there are consequences to operating with fatigue. The National Highway Traffic Safety Administration estimates that in 2017, drowsy driving led to at least 91,000 crashes, resulting in roughly 50,000 injuries and 800 deaths.
More than 90% of law enforcement officers reported being routinely fatigued, and 85% reported driving while drowsy in a National Institute of Justice Journal study.
For first responders, the danger of falling asleep at the wheel isn’t the only problem with fatigue and sleep deprivation. Our alertness, movement, strength, memory, reaction time and perception all diminish as our body begins the work of shutting down to fight for rest.
I spoke with Dr. Ben Lawner, associate professor at University of Maryland School of Medicine, who said “The literature is clear that a lack of sleep correlates with impaired cognitive and motor function.” He noted published studies indicate that a lack of sleep can induce effects similar to intoxication with alcohol.
Sleep deprivation is linked with increased errors in tasks requiring alertness, vigilance and quick decision-making. Quick decision-making and operating efficiently has life-or-death consequences for first responders, whether they’re pursing an armed suspect, searching for victims in a basement fire or performing a surgical airway.
Protect your sleep
Public safety professionals do not have regular business hours. Instead, crews work 24/7/365, and many leave one job just to go to another, making sleep schedules more difficult.
However, preparation is not a new term for first responders. Much of our jobs are preparing for the worst and then operating at that level or scaling it back. For us to function at our maximum abilities at work, we must be well rested. This starts the night before our shift. The Mayo Clinic offers these six steps for better sleep:
- Stick to a sleep schedule. Set aside no more than 8 hours for sleep.
- Pay attention to what you eat and drink. Don’t go to bed hungry or after over-eating.
- Create a restful environment. Keep your room cool, dark and quiet.
- Limit daytime naps.
- Include physical activity in your daily routine.
- Manage worries.
A public safety guide to getting better sleep
I spoke with International Fire Chiefs Association Internal Director of Safety, Health and Survival Scott Kerwood, who noted while first responders coming on duty shouldn’t be consuming alcohol, screen time is an issue. Too many of us pull out our phones on the way off to bed and they are the first thing we look at upon waking. “Bed is meant to wind down and relax to get refreshed for when you get up,” Kerwood said. “Remove TV from bedrooms; walk away from computers, phones and screens.”
Leadership initiatives to combat fatigue
There are a number of factors public safety leaders can control that impact the amount of fatigue personnel experience, including:
- Competitive pay/annual raises
- Work schedules that promote time off to relax and refresh
- Maintaining adequate staffing levels
- Minimizing the number of mandated shifts for employees
- Knowing the signs and symptoms of fatigue
- Offering assistance to members that are fatigued
In many EMS jurisdictions across the country, medical directors and agency leaders have limited the number of hours that clinicians can work in a row. In many departments, the maximum number of hours that can be worked is 48 hours without a 12-hour break.
“It is important to have policies in place to protect your personnel,” Kerwood said, noting leaders must be diligent to see how much their staff is working.
Frederick County (Maryland) Division of Fire and Rescue Services (FCDFRS) Chief Thomas Coe shared his department has a policy in place that addresses working consecutive shifts without breaks.
FCDFRS provides fire, rescue and EMS services from 26 stations throughout the county for nearly 280,000 residents. The county provides mutual aid assistance to Washington, Carroll, Howard and Montgomery counties in Maryland, as well as neighboring counties in Virginia, West Virginia and Pennsylvania.
“We do not allow employees, under normal circumstances, to work greater than 48 hours in a row,” Coe said. “Once they reach the 48-hour mark, then they are required to have a 12-hour rest period prior to coming back to work.”
“Critical care transport teams have rigid policies with respect to fatigue. Driving greater than 16 hours is prohibited in certain ground agencies,” Dr. Lawner said. The Commission on the Accreditation of Medical Transport Systems (CAMTS) requires services implement fatigue mitigation tools and have provisions for rest during certain long-distance transports. CAMTS also encourages a “time out,” which puts a stop to any mission when there are concerns about fatigue that could negatively impact transport.
“I think we can take some pages out of the aviation industry here. There is a strict focus on maintaining vigilance, alertness and ensuring adequate crew rest,” Lawner said. “Pilots ‘time out’ after specific intervals and are, quite simply, not permitted to operate airplanes when they work beyond established time intervals.”
As a Maryland EMS Medical Director and Critical Care Medical Director, Lawner encourages crews to take a time out if they feel unsafe to continue driving, because the consequences of an ambulance crash are quite simply too profound.
Shifts should be determined on a department basis. But it is important to have longer periods of time off for personnel to recover mentally and physically before returning to work.
“Coffee, tea and exercise have been associated with mildly improved alertness and can supplement reasonable shift schedules. There is no singular solution, but certain best practices can be extrapolated from successful industries to maintain crew safety,” Lawner added.
How tired are your people? You won’t know until you ask. As part of the annual NFPA 1582 physical, Kerwood’s department has a questionnaire about sleep and sleep deprivation to help evaluate their members’ fatigue level.
Fill out the form below to download a sleep tracker to share with your staff to measure fatigue.