Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Sleep quality and fatigue among prehospital providers

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Even though many in EMS will tell you that EMS stands not for Emergency Medical Services, but for Earn Money Sleeping, sleep deprivation is a problem for many in EMS, many in medicine, and many in other fields. I am a night person, much more awake and alert at 2 AM, than at 8 AM.

In spite of this, some early to bed, early to rise EMS administrators demand that employees adapt their schedule to the personal preferences of the administrator. This is not only an irrational attitude, but demonstrates such a lack of awareness of what others experience, that working in any patient care setting would be contraindicated.

Sleep deprivation produces impairments in central nervous system (CNS) activities from the most basic functions, such as appetite and temperature regulation, to higher functions, such as memory and vigilance. Sleepiness has been linked to increases in unintentional incidents such as motor vehicle collisons and occupational injuries.3–5 [1]

We should not hesitate to give partial credit to those who insist on having everyone else adapt to their schedules.

Shift workers also tend to have to rely on sleep-inducing agents. A survey of emergency medicine residents revealed that 46% used some kind of sleep agent, including alcohol, benzodiazepines, and muscle relaxants, to fall asleep.8 [1]

About half of residents, not just EMS personnel, but there is no problem that needs to be addressed. Just gulp down some coffee and put on your war face.

There is some unintentional humor in the study. Probably due to lack of sleep.

We collected 119 completed surveys. Subjects were 54.0% female, and the largest age group was 40 to 49 years (39.3%; Table 1).[1]

I do consume chocolate to ward off irritability. Maybe that is the 54% of me that is female. Those 40 to 49 years old were the largest group – by weight or volume or something else? I would ask the same about the 54% female, but I know when to not comment. OK, maybe not. 😳

a moderate proportion of subjects reported employment at multiple EMS agencies (34.2%).[1]

While not the only factor, I would expect that this strongly correlates with sleep deprivation and the resultant negative effects.

I am surprised at the low rate of people working multiple EMS jobs, maybe a lot of them have real jobs work outside of EMS.

The majority of subjects were overweight or obese (84.6%) based on body mass index (BMI).[1]

Sleep deprivation produces impairments in central nervous system (CNS) activities from the most basic functions, such as appetite and temperature regulation, to higher functions, such as memory and vigilance.[1]

No connection.

one-fifth reported being told that they have weight problems (22.7%).[1]

More than 4/5 are obese, but only 1/5 have had a doctor notice this.

Nearly half of the subjects (44.5%) reported experiencing severe fatigue while at work (Fig. 2). The proportion of subjects with severe fatigue increased with years of experience (p < 0.0001),[1]

A global score >5 suggests poor sleep quality.[1]

At least this is something that we learn to adapt to, so it should be less of a problem with increased time on the job.

Or not. Maybe the increasing problems at over 20 years indicates an amount of time in EMS that causes more significant damage.

How much of what we do works out as a feedback loop that compounds problems as if we had heart failure?

Image credit.[2] Click on the image to make it larger.

We know the simple treatments for heart failure – high doses of NTG (NiTroGlycerin) and CPAP (Continuous Positive Airway Pressure).

Maybe the solution to sleep deprivation is something equally simple, such as taking naps or being permitted to sleep when not treating patients.

Even though we have known for decades that NTG and CPAP are the best treatments for acute exacerbation of heart failure, few of us seem to use these treatments. When we do use them, we use homeopathic doses of NTG and we make excuses for not using CPAP.

Will there be any faster adoption of sensible approaches to sleep deprivation?

Will people in EMS be able to make enough to not have to work other jobs?

Federal law limits work hours for many sectors of the transportation industry, including commerical pilots (eight hours of flight time per 24 hours), shipboard personnel on tankers (15 hours per 24 hours), and long-haul truck drivers (14 hours per shift, with a maximum of 11 hours driving).29–31 [1]

Will we only respond to rules set by others?

The mature thing to do would be for us to act first.

One of the reasons I work at my current job is the bosses allow the employees to sleep at any time – as long as calls are covered and other work is accomplished during the shift.


[1] Sleep quality and fatigue among prehospital providers.
Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D.
Prehosp Emerg Care. 2010 Apr 6;14(2):187-93.
PMID: 20199233 [PubMed – indexed for MEDLINE]

Free Full Text at PubMed Central with links to Free PDF Download

[2] Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed – indexed for MEDLINE]

Free Full Text PDF

Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, & Hostler D (2010). Sleep quality and fatigue among prehospital providers. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14 (2), 187-93 PMID: 20199233



  1. Sleep deprivation, perhaps more accurately, CULMULATIVE sleep deprivation is just one more contributing factor to the litany of assaults EMS providers go through on the road to burnout.

    Even I, who have been focusing on issues of burnout in my blogs, hadn’t been quite up with this assault on our senses and sensibilities. Perhaps I didn’t give it due credit. When you showed the cycle that sleep deprivation perpetuates, I got to thinking of shock and how it is a symptom complex of the progressive degeneration of functional activites of the organs, cascading to a final crash and burn.

    The same is true with burnout, and here you’ve taken a look at perhaps one of the most important straws that break the camel’s back. As always, thanks!