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5 evidence-based countermeasures for EMS fatigue

A successful fatigue risk management system is an organizational approach to improve sleep health and self-recognition of fatigue


Recognize that poor sleep and fatigue are threats to EMS safety

Photo/Air Mobility Command

Updated Aug. 2, 2017

By Daniel Patterson, Matthew Weaver, and Francis X. Guyette

Our first article, “Studying sleep: Health and fatigue in EMS” provided a brief overview of sleep health and fatigue and called upon EMS clinicians and administrators to:

1. Recognize that poor sleep and fatigue are threats to EMS safety

2. Get involved in research that can help us better define the problem and test solutions for the safety of our clinicians and patients

In this article, we discuss fatigue risk management and highlight some (not all) evidence-based countermeasures for fatigue mitigation in the EMS the workplace.

Fatigue risk management system

A fatigue risk management system (FRMS) or a fatigue risk management program (FRMP) is defined as “A scientifically based, data-driven, addition or alternative to prescriptive hours of work limitations which manage employee fatigue in a flexible manner appropriate to the level of risk exposure and the nature of the operation.”[1]

For a FRMS or FRMP to be successful, it must have a strong leader or senior manager who is accountable for day-to-day oversight, adaptation, and improvement of the program. There should be fatigue management policies developed collaboratively by employers, workers, and all stakeholders. Workers and administration should receive education and training in sleep health and self-recognition of fatigue.

Administration should adopt a process that promotes reporting fatigue without fear of penalty or reprisal. A process for investigation of events potentially related to fatigue is important for evaluation and improvement. It is optimal that individuals or groups outside the organization lead evaluation or audits of an agency’s FRMS or FRMP program. Both the organization’s leadership and workers (clinicians) must share responsibility for development, implementation, evaluation, and improvement of the FRMS or FRMP.[1]

Managing fatigue in the workplace – especially the EMS workplace – is a challenge. Our understanding of EMS work-related fatigue is limited.[2] We understand that EMS clinicians are vulnerable to fatigue, inadequate sleep, and poor recovery from shift work.[3]

EMS Fatigue countermeasures

While the nature of EMS work is unique from many other occupations, fatigue can be mitigated with a number of evidence-based strategies. There is no “one-size fits all” approach to fatigue management and no single strategy will fully eliminate the threat of fatigue in the workplace.[4] Numerous individual-level, environmental factors, social factors, scheduling and work-related factors, as well as many other known or latent factors must be considered when developing an FRMS or FRMP.[4] What works for an air medical service in the northeastern U.S. may not work for a third-service, ground-based EMS system in the western or midwestern U.S. Use the following five strategies to mitigate fatigue:

1. Promote Adequate sleep for EMS Providers

Regardless of the components of an FRMS or FRMP adopted, the top strategy should be universal; adequate sleep. There is no substitute for adequate, good quality sleep. Insufficient sleep has been identified as a direct cause of vehicle crashes, errors that harm patients, worker injury and reduced productivity of the workforce.[5, 6] Adequate sleep is key to health and wellness. There is individual variability in how much sleep each worker may need, but at least seven hours per night should be encouraged.

Other person-level countermeasures supported by evidence include the following:

2. Encourage Naps and rest breaks

Taking naps or rest breaks during shift work. Numerous studies of shift workers support use of short-duration naps (e.g., 20-30 minutes) during scheduled shifts.[7-11] Actual sleep may not be needed, and the act of resting with one’s eyes closed in a quiet location can be beneficial.

Extended naps on duty may result in sleep inertia – that groggy feeling immediately after awakening.[12] Sleep inertia can last minutes or even hours after waking and impact cognition/performance.[12] Administrators and clinicians should discuss use of naps as part of an intra-shift countermeasure to fatigue.

3. increase Physical exercise

Alertness can be elevated with physical exercise such as stretching, walking, jogging in place, and other activities that increase the heart rate and body temperature.[13, 14] Clinicians should consider use of physical exercise when feeling sleepy on duty. Exercise can help thwart perceived feelings of sleepiness and help maintain alertness – to some degree.

Exercise is not a panacea for fatigue or sleepiness. Prior research shows that exercise may alleviate perceived sleepiness and improve wakefulness by increasing body temperature, yet cognitive performance may not return to levels associated with being well-rested.[15] In short, you may be more “awake” after a bout of exercise, but you may not perform at your best mentally or physically. Again, there is no substitute for adequate rest and sleep.

4. limit Caffeine consumption

There is considerable research linking improvements in alertness with consumption of caffeine.[16] Despite benefits, clinicians should exert caution and avoid over-consumption of caffeinated beverages – including energy drinks. Seizures and cardiac dysrhythmias have been linked to over-consumption of caffeinated energy drinks.[17, 18]

One approach to consider is to have a cup of coffee and immediately take a short nap (i.e., 20 minutes) – since caffeine takes about 30 minutes to kick in, and sleeping too long may lead to sleep inertia.[12] This two-pronged approach can work – especially for those working night shifts.[19] With anything, use caution, and don’t forget, your best strategy is to obtain adequate rest and sleep!

5. engage in Mental exercise

Engaging in conversation (talking) with partners to stay awake and alert when feeling sleepy is a type of mental exercise. The simple act of talking with your partner while on duty can help support alertness.[20]

There is no question that individual EMS clinicians face numerous challenges managing their own sleep health. Employers also face challenges filling schedules and ensuring continuous availability of EMS care.

We offer these strategies for fatigue mitigation because the issues are complex, and as we have said before (and affirmed by others in different industries),[4] there is no single “one-size-fits-all” solution for fatigue risk management in the EMS setting. The mitigation of fatigue in the workplace must be a shared responsibility between the clinician and employer.[1] EMS must support a culture of safety where clinicians arrive to work well rested and employers support employees to report fatigue without hesitation.

About the Authors

Daniel Patterson, PhD, NRP, is a nationally registered paramedic, senior scientist and associate director of emergency clinician and patient safety research in the Department of Emergency Medicine at Carolinas HealthCare System Medical Center in Charlotte, N.C. His research focuses on fatigue, sleep, and other factors that affect the health, safety, and well-being of EMS clinicians and their patients.

Matthew Weaver, PhD, EMT-P, is a paramedic and an NIH T32 post-doctoral research fellow in the Division of Sleep Medicine at Harvard Medical School. His research focuses on the health and safety of the EMS workforce and the patients they treat.

Francis Guyette, MD, MS is an associate professor at the University of Pittsburgh, Department of Emergency Medicine and medical director of STAT MedEvac air-medical system. His research focuses on treatment of the acutely ill and injured in the prehospital setting and health and safety of EMS professionals.


1. Lerman SE, Eskin E, Flower DJ, George EC, Gerson B, Hartenbaum N, Hursh SR, Moore-Ede M, ACOEM: Fatigue risk management in the workplace. J Occup Environ Med 2012, 54(2):231-258.

2. Patterson PD, Weaver MD, Hostler D, Guyette FX, Callaway CW, Yealy DM: The shift length, fatigue, and safety conundrum in EMS. Prehosp Emerg Care 2012, 16(4):572-576.

3. Patterson PD, Buysse DJ, Weaver MD, Callaway CW, Yealy DM: Recovery between work shifts among Emergency Medical Services clinicians. Prehosp Emerg Care 2015, 19(3):365-375.

4. Caldwell JA, Caldwell JL, Schmidt RM: Alertness management strategies for operational contexts. Sleep Med Rev 2008, 12(4):257-273.

5. Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL: The link between fatigue and safety. Accid Anal Prev 2011, 43(2):498-515.

6. Lombardi DA, Folkard S, Willetts JL, Smith GS: Daily sleep, weekly working hours, and risk of work-related injury: US National Health Interview Survey (2004-2008). Chronobiol Int 2010, 27(5):1013-1030.

7. Bonnefond A, Muzet A, Winter-Dill AS, Bailloeuil C, Bitouze F, Bonneau A: Innovative working schedule: introducing one short nap during the night shift. Ergonomics 2001, 44(10):937-945.

8. Garbarino S, Mascialino B, Penco MA, Squarcia S, De Carli F, Nobili L, Beelke M, Cuomo G, Ferrillo F: Professional shift-work drivers who adopt prophylactic naps can reduce the risk of car accidents during night work. Sleep 2004, 27(7):1295-1302.

9. Petrie KJ, Powell D, Broadbent E: Fatigue self-management strategies and reported fatigue in international pilots. Ergonomics 2004, 47(5):461-468.

10. Sallinen M, Harma M, Akerstedt T, Rosa R, Lillqvist O: Promoting alertness with a short nap during a night shift. J Sleep Res 1998, 7(4):240-247.

11. Smith-Coggins R, Howard SK, Mac DT, Wang C, Kwan S, Rosekind MR, Sowb Y, Balise R, Levis J, Gaba DM: Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med 2006, 48(5):596-604.

12. Tassi P, Muzet A: Sleep inertia. Sleep Med Rev 2000, 4(4):341-353.

13. Harma MI, Llmarinen J, Knauth P, Rutenfranz J, Hanninen O: Physical training intervention in female shift workers: I. The effects of intervention on fitness, sleep, and psychomatic symptoms. Ergonomics 1988, 31(1):39-50.

14. Harma MI, Llmarinen J, Knauth P, Rutenfranz J, Hanninen O: Physical training intervention in female shift workers: II. The effects of intervention on the circadian rhythms of alertness, short-term memory, and body temperature. Ergonomics 1988, 31(1):51-63.

15. Matsumoto Y, Mishima K, Satoh K, Shimizu T, Hishikawa Y: Physical activity increases the dissociation between subjective sleepiness and objective performance levels during extended wakefulness in human. Neurosci Lett 2002, 326(2):133-136.

16. Ker K, Edwards PJ, Felix LM, Blackhall K, Roberts I: Caffeine for the prevention of injuries and errors in shift workers. Cochrane Database Syst Rev 2010, 12(5).

17. Trabulo D, Marques S, Pedroso E: Caffeinated energy drink intoxication. BMJ Case Rep 2011.

18. Seifert SM, Seifert SA, Schaechter JL, Bronstein AC, Benson BE, Hershorin ER, Arheart KL, Franco VI, Lipshultz SE: An analysis of energy-drink toxicity in the National Poison Data System. Clin Toxicol (Phila) 2013, 51(7):566-574.

19. Schweitzer PK, Randazzo AC, Stone K, Erman M, Walsh JK: Laboratory and field studies of naps and caffeine as practical countermeasures for sleep-wake problems associated with night work. Sleep 2006, 29(1):39-50.

20. Rosekind MR, Gander PH, Gregory KB, Smith RM, Miller DL, Oyung R, Webbon LL, Johnson JM: Managing fatigue in operational settings. 1: Physiological considerations and countermeasures. Behav Med 1996, 21(4):157-165.

The National Association of EMS Physicians (NAEMSP) is an organization of physicians and other professionals partnering to provide leadership and foster excellence in the subspecialty of EMS medicine. The NAEMSP promotes meetings, publications and products that connect, serve and educate its members, and acts as an advocate of EMS-related decisions in cooperation with organizations throughout the country.