Effects of Sleep Deprivation on Fire Fighters and EMS ... - NAEMT

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<strong>Effects</strong> <strong>of</strong> <strong>Sleep</strong> <strong>Deprivation</strong> on Fire Fighters and EMS Responders Wildland fire fighters have the Wildland Fire Safety & Health Reporting Network, SAFENET, which is a method for reporting and resolving safety concerns encountered in wildland fires. Reviewing the last three years <strong>of</strong> reported events (2003 to 2006), communication issues were the leading category contributing to reported incidents. Of 494 incidents (2003 to 2006), 38 appeared related to human perceptual errors, including fatigue (Bailey, 2007). Fatigue was a clear contributor in six <strong>of</strong> the serious accidents, three <strong>of</strong> which resulted in rollover vehicle crashes. Fatigue when driving can lead to poor judgement, inattention, vehicle wandering and falling asleep at the wheel. Wildland fire fighters <strong>of</strong>ten travel to and from worksites in 15 passenger vans, which when loaded with occupants become top heavy and prone to rollovers. The most notable fatigue-related incident was when eight crew members were killed in a traffic accident after spending the previous 11 days fighting a forest fire. The crew had been demobilized the previous evening. Weather was sunny and dry, and the crew had been on the road about three hours when the crew driver attempted to pass a semitrailer on a downhill left-hand curve, in a marked no-passing zone. The van struck an oncoming semitrailer head on. This particular patch <strong>of</strong> road is known for frequent accidents. Alcohol may have played a role in the incident (http:// www.ohsu.edu/croet/face/incidents.cfm). SAFENET (http://safenet.nifc.gov/) was developed on the recommendations <strong>of</strong> the Wildland Firefighter Safety Awareness Study. SAFENET is a component <strong>of</strong> the National Interagency Fire Center and reports can be submitted anonymously by anyone, although it is recommended that the first line supervisor complete the SAFENET form. It is a tool and format to identify and remedy safety concerns <strong>of</strong> wildland fire fighters. 4.7 Work Hours and EMS Responders As mentioned, EMS responders’ work a wide variety <strong>of</strong> types <strong>of</strong> jobs with different work structures. As demands for emergency medical services have accelerated, increases in work load and employee dissatisfaction have resulted in changes in shift structure. Those occurrences have allowed prospective assessment <strong>of</strong> different work formats. At one site, EMS personnel changed from 24 to 12 hour shifts, using a rotation with 3 days <strong>of</strong> 12 hour shifts, 2 days <strong>of</strong>f, 2 days <strong>of</strong> 12 hour shifts, 3 days <strong>of</strong>f. With the 12 hour schedule, both at 2 months and at 1 year, employees perceived that they were more productive and felt better, with less family and social disruption from their work. Interestingly, an index <strong>of</strong> emotional exhaustion decreased immediately after the change, and although other indices remained improved with the reduction in shift duration, the emotional exhaustion dimension returned to baseline after one year (Boudraux et al., 1997). The city <strong>of</strong> Austin changed EMS staffing to distribute shorter shifts to the busiest sites. They reported their staff survey findings that led to the change. Prior to the change when 24 hour staffing still was in effect, most paramedics felt the demands for overtime were excessive, and one-third reported working more than 24 hours without sleep in a single week . The majority felt that 24 hour shifts resulted in a decrement in their abilities, and most (72%) reported that 12 hours was the maximum time that it was safe to take calls at the busiest stations (http://www.austinchronicle.com/ gyrobase/ Issue/story?oid=oid%3A388475). 55
<strong>Effects</strong> <strong>of</strong> <strong>Sleep</strong> <strong>Deprivation</strong> on Fire Fighters and EMS Responders The relationship between sleep deprivation and decreased performance is well established (Jewett, 1997). Being awake for 18 hours produces impairment equal to a blood alcohol concentration (BAC) <strong>of</strong> 0.05 (Dawson 1997; Falleti 2003). A recent analysis <strong>of</strong> U.S. workers involving more than 110,000 job records over 12 years, controlled for age and occupation, revealed an almost linear increase in injuries with the number <strong>of</strong> hours worker per day (or per week) (Dembe at al., 2005). Working 12 hours per day was associated with a 37 percent increased hazard rate, and 60 hours per week increased injuries 23 percent. Fatigue-related ambulance crashes may be a means to identify effects <strong>of</strong> long work hours among EMS responders. Although no complete national count <strong>of</strong> ground ambulance crashes exists, the number can be approached using the National Highway Traffic Safety Administration Fatality Analysis Reporting System. Over a ten year period (1991 to 2002), the factor most related to EMS crash fatalities was not wearing a restraint, and most crashes occurred during emergency runs when arousal and vigilance would be anticipated to be high (CDC, 2003). Thus, with those data, unlike vehicle crashes in general, fatigue did not appear to be a major factor in crashes. Obtaining work-related injury information on paramedics/EMTs is problematic. The Census <strong>of</strong> Fatal Occupational Injuries is the repository for information on fatal work-related injuries. However, that database does not have a specific listing for EMS personnel. There is a website memorializing EMS personnel (National EMS Memorial Service at www.nemsms.org/honorees/) who have died in the line <strong>of</strong> duty, but that record is not complete. Review <strong>of</strong> entries from the last two years revealed 34 deaths, with the majority (21) relating to helicopter and plane crashes. Of the 17 surface vehicle crashes, 5 related to commuting to or from work, but details relating to time <strong>of</strong> day and fatigue were not reported. A death not listed in that site, which appear related to fatigue and resulted in a policy change, is presented on page 48. The pre-hospital EMS continuum includes the emergency room. Discussions <strong>of</strong> emergency room staffing patterns generally compare 8 versus 12 hour work lengths, as busy shifts longer than 12 hours are associated with unacceptable fatigue and recognized decrements in performance (J<strong>of</strong>fe, 2006). The 12 hour threshold for declining performance <strong>of</strong> critical tasks has been confirmed in other studies <strong>of</strong> medical personnel (see Section 3). Twelve consecutive hours also is the maximum duration that the Institute <strong>of</strong> Medicine recommends nurses work during a 24 hour period (Scott et al., 2006). Medical air transport teams include a pilot(s) and EMS personnel. Flight regulations require 12 hour shifts for pilots, and both 12 and 24 hour shifts are common staffing patterns for non-pilots in the air medical community. During certain times, pilots may be called into longer service. German medical transport helicopter pilots’ physiological pr<strong>of</strong>iles were studied during prolonged shifts, necessitated by longer summer daylight hours and more motor vehicle crashes with victims needing air transport. Findings indicated that pilots working longer hours accumulated significant fatigue, and the results led to an enforced eight hour uninterrupted sleep opportunity each day (Samel, Vejvoda & Maass, 2004). 56
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Effects of Sleep Deprivation on Fire Fighters and EMS ... - NAEMT

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