How can EMS providers protect themselves from fatigue?

The EMS1 Advisory Board reacts to second-degree homicide charges brought against EMT Crystin Keys after a fatal ambulance crash


By EMS1 Editorial Advisory Board

A Puckett EMS driver has been charged with second-degree homicide and failure to maintain a single lane after the ambulance she was driving allegedly weaved off the road and hit a tree, killing patient Tony Patterson.

EMT Crystin Keys, who was five weeks pregnant at the time of the crash, sustained multiple injuries. Her attorney said she was suffering from extreme exhaustion and was avoiding caffeine to keep her baby healthy. Keys turned herself into police and was booked and released on bail.

Fatigue mitigation is an ongoing challenge in EMS, requiring collaboration between providers and leaders to ensure providers are properly rested. (Photo/CDC)
Fatigue mitigation is an ongoing challenge in EMS, requiring collaboration between providers and leaders to ensure providers are properly rested. (Photo/CDC)

EMT Keys is not the first EMS provider to suffer fatigue while behind the wheel of an ambulance. In 2013, an EMT and his passenger sustained minor injuries in a crash after he fell asleep at the wheel. In February 2017, a N.Y. state EMS provider fell asleep while transporting a patient who was killed in the crash.

Fatigue mitigation is an ongoing challenge in EMS, requiring collaboration between providers and leaders to ensure providers are properly rested.

We asked EMS1 Advisory Board members to react to the charges Keys faces and to answer this question, “What’s your advice to EMS providers to protect themselves from fatigue?”

Many encouraged providers to implement sleep quality improvement strategies, as others pointed to underlying issues, like education and salary, at the root of the problem, requiring advocacy from the top down.

Here are the replies from EMS1 Advisory Board members. Read what they have to say and add your response to the question in the comments below.

Chris Cebollero: EMS leadership more culpable than providers

I am not so sure that this is a provider issue. Our EMS providers are working to make ends meet, pay bills and put food on their tables. There needs to be more responsibility from EMS leadership on this topic, specifically, rules that govern maximum allowed hours worked, with corresponding rest periods.

Second, there has to be a program put into place where a provider can call out for mandatory downtime for a couple of hours. There are many factors that cause an individual to not be as alert and aware as they should be. As leaders, we have to be cognizant of how our providers are meeting their driving responsibilities.

EMS leaders have to come to the realization that if we are allowing providers to work unlimited hours, shift after shift, we are even more culpable than the provider behind the wheel if an accident occurs.

Ann Marie Farina: Prioritize adequate, quality sleep

I think providers need to be willing to stand up for themselves and also need to accept that it isn't always possible to live a "normal" life and work EMS. Adequate sleep needs to be prioritized above nearly everything else when working nights and other unusual shifts.

I've worked nights and it is miserable trying to have a social life and schedule doctor’s appointments, but there are ways to still get adequate sleep while dealing with those issues.

We need to be focusing on both sleep length and sleep quality. Sleep quality can be improved though using the "quiet time" feature on your phone, using blackout curtains, and using apps like Twilight that reduce the amount of blue light your phone puts out. Meditation can help with stress reduction and allow people to fall asleep faster. If people are having issues sleeping due to nightmares, there are several good options that can improve the situation without affecting their ability to work.

Ryan Greenberg: Practice mind body care

We speak so often about ensuring the safety of ourselves and our patients. When we do skill stations, the first thing we say is "scene safety, BSI," but what do we do to ensure we are safe to enter the scene, to ensure the provider is in a safe mindset to ensure they can perform without an issue? 

Long shifts, long transports and in – many systems – down time for crews spent in areas that are not idea for resting add to the stress and fatigue of EMS professionals. 

We need to change the culture. 

We need to manage PTO in better ways to increase patient and provider safety. Some organizations allow crews to bank PTO or they buy it out. My opinion is this leads to some unsafe practices both emotionally and physically for our staff. PTO is designed to allow staff (in some cases, force staff) to take some time to themselves, have a mental break and sleep in from time to time. When we have polices that offer staff money for PTO time it can have a negative effect as staff may be less likely to use the PTO when they are overtired or not feeling 100% and not in the right mindset to treat patients.

Putting a system in place that encourages staff to take a break from work while still getting paid helps with some of these issues. In our agency, we allow staff to bank up to 1.5 of their annual PTO time and after that, they must use it. We feel using your PTO is a good thing for mind and body and for our families who often don't see us for days at a time. 

Second, we need to change the culture to allow for us to look at one another and without judgement or consequences during a safety stop. Often in today's times we feel we have to keep up with everyone and we don't want our partners or coworkers to know we are not at 100% today. We need to be in a place where we can say "I need a safety stop" and allow our crews to pull to the side of the road and regroup to determine the best and safest course of action. 

Art Hsieh: Financial pressures a part of the problem

This continues to be a terrible situation. On the surface, the fatigue that may have caused the crash may have stemmed from a lack of restful sleep.

Falling asleep at the wheel of an ambulance is just a sign of a complex, multifaceted problem. Long hours stem from long shifts working multiple agencies, a pattern correlated with low wages, which result from a low level of training.

There’s also the general apathy by agencies and providers alike regarding personal safety. Sure, we talk (and write) about it, but how many agencies have safety stops? How many providers have put themselves out of service for fatigue, or insist on discontinuing 24-, 48- or 72-hour shift lengths?

Unless we advocate for change, it won’t happen. Financial pressures will continue to force agencies to keep the long shifts.

Kris Kaull: It’s about culture

I’ve been there. In my career, I’ve clocked off shift and drove home, only to not remember driving at all. The gradient between shift ready and exhausted happens slowly over the course of many hours. Fatigue is a system problem, and – like any of our other risks – needs to be managed appropriately. This responsibility lies on both the clinician and the organization.

At the flight service where I work, we have both governmental, FAA regulations and operational policies for the crews. FAA mandates rest time before starting a pilot’s shift and limits number of hours on duty.

Additionally, we have a policy that states a team member who identifies they are fatigued to the point of no longer being able to safely perform their assigned duties will immediately self-report to the other team members.

Dispatch is notified that the crew is out of service and the flight team member(s) immediately retreat to the private crew rest area for two hours. During that time, crew members are mandated to rest (not clean, complete paperwork, etc.). If a flight team member requests a fatigue stand-down within the last two hours of their assigned duty shift, they are still required to rest at the base even if the two-hour rest period crosses over their end of shift time.

There are no questions asked and there is no pressure for crew members to take a flight if they are tired. As with EMS, it comes down to doing the right thing. It’s about culture.

David K. Tan: Put the patients first in EMS care

Based on the information released so far, I would have to first say a charge of homicide in the second degree is egregiously, ridiculously and utterly unwarranted. Murder 2 is defined as an intentional killing that is not premeditated or planned, or a killing caused by dangerous conduct and an obvious lack of concern for human life.

The fact that Keys is a licensed EMT devoting her life to the care of others makes it nearly impossible to charge her with second-degree homicide with a straight face. Maybe involuntary manslaughter, but even that is a stretch as there must be criminal negligence causing or contributing to the death.

Was she criminal in trying to avoid caffeine with the best interests of her unborn child in mind working a job that often causes exhaustion even in the absence of pregnancy? I think not. At most, a civil action may be brought against her with a claim for wrongful death.

If it turns out she was exhausted because she was crashing from meth or cocaine, then OK, bring on the criminal charges, but it doesn’t sound like this is the case.

I think the bigger issue is fatigue and the growing trend of 48-hours shifts. I don’t know where she was in her shift or what type of schedule she works, but generally, many departments (both Fire and EMS) are moving away from 24-hour shifts to 48-hour shifts. They work the same number of shifts per month, but with half of the fuel costs.

These types of shift schedules are designed around the worker and not the patient –which is the primary problem with most departments. We don’t put patients first. It’s the same reason that we scoff at mandating paramedicine be a minimum two-year college level degree if not a four-year bachelor’s degree.

It’s a no-brainer if one considers the patient perspective first. And, if we want to pay EMS professionals a living wage so that they aren’t forced to work multiple jobs, then the requisite education must be a part of the discussion.

In the absence of these long-term reforms, EMS providers should combat fatigue by understanding that sleep debt can only be paid back with sleep. No amount of caffeine or energy drinks can substitute for sleep. Thus, as the old EMS adage goes, “Eat when you can, pee when you can and sleep when you can. Avoid staying up late at the station because “the tones will just go off anyway.” Practice good sleep hygiene, eat healthy and exercise.

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