Exhausted paramedics: 7 recommendations to reduce impacts of fatigue

Errors in patient care and EMS provider health concerns are raising awareness of the risks of prolonger work hours

Fatigue in EMS is a serious issue that is beginning to receive serious attention.

Recent EMS1 headlines include news of a legal settlement reached in an ambulance crash with an alleged sleeping medic, a Florida man catching medics sleeping in an ambulance, a police report of an EMT who fell asleep at the wheel in an ambulance crash, a Good Morning America investigation into tired medics, and a patient video recording their medic sleeping on the way to the hospital.

Even though there is mounting evidence that being deprived of sleep is hazardous to one's own health, as well as clinical care, many EMS providers and agencies continue to defend the practice of long shifts and unnatural sleep patterns despite the risk of causing serious injury.

(Image WFTV Channel 9 Facebook)
(Image WFTV Channel 9 Facebook)

Scope of the EMS Fatigue issue

Fatigue in transportation specialists, such as over-the-road truckers and airline pilots, has been extensively studied, resulting in federal regulations that require rest periods and define the maximum number of continuous hours a driver or pilot can perform their duties [1, 2].

However there are few studies of the impacts of fatigue upon EMS providers who may be on shift for 12 to 24 hours or more [3], despite the attention paid to it in both trade and mainstream media. Nevertheless in 2013 the National EMS Advisory Council Safety Committee issued an advisory statement on fatigue in EMS [4]. Some of the concerns NEMSAC raised included:

  • By extrapolating data from sleep deprivation and fatigue studies of other health care providers, the committee concluded that EMS workers are at greater risk of committing errors and clinical mistakes when working long hours with less than normal sleep.
  • EMS workers are at greater risk of negative health effects associated with a lack of sleep, including cardiovascular concerns and chronic fatigue syndrome.
  • There are several unique characteristics of the EMS provider population and their work conditions which may exacerbate fatigue, including weather extremes, unpredictable call volume and patient acuity, emergency lifting and moving procedures, and the tendency to work numerous jobs due to low wages.

What is fatigue?

Fatigue is generally defined as the feeling of a lack of energy and motivation that can be physical or mental [5]. While fatigue is not always the result of a lack of sleep, sleepiness is often associated with feeling fatigued. In one study, 32 percent of health care providers reported six or fewer hours of sleep a day [6].

Fatigue is associated with declines in both physical and cognitive performance. Being awake for over 17 hours appears to impact behavior similarly to having a blood alcohol content level of 0.05. Being awake for 24 hours is similar to having a BAC of 0.10 percent [7]. The national legal BAC limit for driving while impaired is 0.08 percent.

Shift work and long hours appear to be the primary cause of fatigue in health care providers [8]. For example, the rate of medical accidents or errors occurring during a shift increases from day shift to evening shift (15 percent increase) and to night shift (28 percent increase). Working a 12-hour shift increases the chances of an error by 28 percent, when compared to an eight hour shift [9].

EMS providers typically work long shifts. A survey of Nationally Registered EMS providers enrolled in the LEADS II study indicated that nearly 88 percent worked either 24- or 12-hour shifts [10].

Another study indicated that nearly half of those EMS providers studied fit a profile of being chronically fatigued. Those who were classified as fatigued were 1.9 times more likely to be injured on the job, as compared to non-fatigued providers. Fatigued providers were also 2.2 times more likely to make an error in clinical judgment or care, and 3.6 times more likely to take a safety-related risk [11].

The correlation between fatigue, shift work and shift length appears to be rooted in the body's tendencies to maintain natural wake-sleep cycles. Known commonly as the circadian rhythm, the brain is triggered to either awaken or to go to sleep based on the time of day and the associated amount — or lack — of daylight.

For most occupations that function during daylight hours, that's fine. But the need for EMS providers to work swing or night shifts, as well as work long shifts, appears to go against the sleep cycle grain.

Health hazards associated with fatigue

Being fatigued is more than just feeling tired. Shift work and long work hours are associated with a number of health risks including obesity, cardiovascular, gastrointestinal, and musculoskeletal disorders, as well as mental disturbances and adverse reproductive outcomes [12, 13, 14, 15, 16, 17]. Fatigue is also associated with a greater risk of cancer [18].

Traffic crashes due to fatigue are of particular concern. The National Highway Transportation Safety Administration estimated in 2009, that there were nearly 30,000 vehicle crashes caused by driver fatigue. Two-and-a half percent of all traffic fatalities were thought to be caused by drowsy driving [19].

A study involving medical interns indicated that driving home after a long shift more than doubled the chance of being involved in a traffic collision [20]. Another study conducted by the American Nursing Association reported that 10 percent of the respondents were involved in a vehicle crash as a result of fatigue [21].

Reducing the effects of fatigue on EMS providers

Despite the evidence that shift work and long shift hours may be significant issues for both patients and providers, the fact remains that EMS is provided around the clock, 365 days a year. Here are seven recommendations from sleep and fatigue experts that can help reduce the effects of fatigue.

1. Maintain a good state of health
Staying in shape, maintaining normal body weight and minimizing fat and sugar intake is good for you overall, It can also help reduce the feeling of being tired during periods of fatigue.

2. Stay hydrated
Maintaining adequate fluid levels helps to keep all body systems functioning normally, and is an easy way to maintain alertness.

3. Avoid tobacco and stimulants
EMS providers may turn to smoking and or caffeinated beverages to temporarily feel more alert when they are fatigued. At best, these are short term Band-Aids; at worst tobacco and excessive caffeine use are associated with a variety of significant health hazards.

4. Maintain sleep schedules
If you are on night shift, try to maintain your sleep schedule even on your days off. Abrupt changes in sleep patterns can be very disruptive and can actually cause sleeplessness.

5. Rotate shifts clockwise
If your schedule rotates between shifts, rotate them in a clockwise manner. In other words, go from a day shift to an evening shift, and an evening shift to a night shift.

6. Prepare early for a change in shift
You can prepare for a new work shift by gradually changing your sleep pattern before the shift begins. For example, when preparing for a night shift rotation, consider going to bed later each night by a couple hours for the three days before the shift begins.

7. Plan your social calendar with work in mind
Staying up the entire day before a night shift due to an outing with friend and family may be tempting, but can disrupt your subsequent sleep schedule. Take work into consideration when making social plans.

With increased attention being placed on workplace fatigue, providers and agencies alike must look closely at the current shift practices. The risk to personal health and patient care is too great to continue extended work hours as the norm.


1. Federal Motor Carrier Safety Administration. Summary of Hours of Service Regulations. https://www.fmcsa.dot.gov/regulations/hours-service/summary-hours-service-regulations retrieved 2 April 2016.

2. Federal Aviation Administration. Fact Sheet – Pilot Flight Time, Rest, and Fatigue. https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=6762. Retrieved 2 April 2016.

3. Patterson PD et al. Editorial: The Shift Length, Fatigue, And Safety Conundrum In EMS. Prehospital Emergency Care 2012 Oct-Dec;16(4):572-6.

4. National EMS Advisory Council Safety Committee. Fatigue in Emergency Medical Services: Final Advisory. 2013 January. http://www.ems.gov/pdf/nemsac/2013/NEMSAC-AdvisoryFatigueJan2013.pdf Retrieved 3 April 2016.

5. EMedicine Health. Fatigue: Definition and Facts About Symptoms. http://www.emedicinehealth.com/fatigue/article_em.htm retrieved 30 April 2016.

6. Luckhaupt SE, Tak S, Calvert GM. The prevalence of short sleep duration by industry and occupation in the National Health Interview Survey. Sleep. 2010;33:149-159.

7. Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000;57:649-655. 

8. Caruso CC, Hitchcock EM, Dick RB, Russo JM, Schmit JM. Overtime and Extended Work Shifts: Recent Findings on Illnesses, Injuries, and Health Behaviors. DHHS (NIOSH) publication no. 2004-143. Cincinnati: Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; 2004.  http://www.cdc.gov/niosh/docs/2004-143/pdfs/2004-143.pdf 

9. Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and "accidents." Am J Ind Med. 2006;49:953-963.

10. National Registry of EMTs. 2015 Spring Newsletter. April 2015; https://www.nremt.org/nremt/downloads/2015%20Spring%20Newsletter%20Word.pdf.

11. Patterson PD, Weaver MD, Frank RC, et. al. Association between poor sleep, fatigue and safety outcomes in emergency medical services providers. Prehosp Emerg Care. 2012;16(1)86–97.

12. Bushnell PT, Colombi A, Caruso CC, Tak S. Work schedules and health behavior outcomes at a large manufacturer. Ind Health. 2010;48:395-405.

13. Puttonen S, Harma M, Hublin C. Shift work and cardiovascular disease -- pathways from circadian stress to morbidity. Scand J Work Environ Health. 2010;36:96-108.

14. Caruso CC, Lusk SL, Gillespie BW. Relationship of work schedules to gastrointestinal diagnoses, symptoms, and medication use in auto factory workers. Am J Ind Med. 2004;46:586-598.

15. Caruso CC, Waters TR. A review of work schedule issues and musculoskeletal disorders with an emphasis on the healthcare sector. Ind Health. 2008;46:523-534

16. Dembe AE, Erickson JB, Delbos RG, Banks SM. The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States. Occup Environ Med. 2005;62:588-597. 

17. Frazier LM, Grainger DA. Shift work and adverse reproductive outcomes among men and women. Clin Occup Environ Med. 2003;3:279-292.

18. IARC 2007. Press Release N°180. IARC Monographs Programme Finds Cancer Hazards Associated with Shift Work, Painting and Firefighting. www.iarc.fr/en/media-centre/pr/2007/pr180.html retrieved 4 April 2016.

19. NHTSA Traffic Safety Facts. Drowsy Driving, a Brief Statistical Summary. 2011 March. http://www-nrd.nhtsa.dot.gov/pubs/811449.pdf retrieved 4 April 2016.

20. Lockley SW, Landrigan CP, Barger LK, et al. When policy meets physiology: The challenge of reducing resident work hours. Clin Orthop Relat Res. 2006; 449(8):116–127.

21. American Nurses Association. ANA 2011 Health and safety survey. 2011.www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Work-Environment/2011-HealthSafetySurvey.html

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