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Operating on empty: How sleep deprivation impacts medics

Insufficient sleep impacts decision-making, wellness and risk-taking, putting providers and patients at risk



For many EMS providers, sleep deprivation is not an occasional inconvenience. It is a constant battle faced on a typical 24-hour shift. What often remains unseen are the struggles that unfold behind the scenes. Imagine the intense challenge of keeping your eyes open and your mind alert, as fatigue sets in during those critical late-night hours. Picture the effort it takes to stay on course, avoiding the peril of veering off the road, while making split-second decisions and calculating dosages – all on a frayed thread of consciousness.

This relentless deprivation of sleep goes beyond mere physical exhaustion; it borders on literal torture. Such conditions pile on unimaginable stress, expose vulnerabilities and create a state of mental malleability, just like what prisoners experience under interrogation [11]. It’s a blunt comparison, but paints a true picture of the environment EMS providers face. This is what it means to be on the front lines of emergency medical services, where the fight to save lives also means battling the limits of human endurance.

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The expectation to work 24-hour shifts – originally structured with the intention of allowing some rest – rarely aligns with the overwhelming demands placed on many 911 systems today. As a result, the opportunity for emergency workers to rest is significantly compromised. This relentless pace not only strains family relationships, but also diminishes their ability to provide care with the necessary mental sharpness and decision-making acuity. Worse yet, one recent study shows that most paramedics do not understand or actively work to practice sleep hygiene [12]. Overall, the physical toll on EMS providers under these conditions is profound and warrants a deeper understanding by those who live this reality.

What happens when we’re sleep deprived?

Researchers have discovered a phenomenon called the Ego Depletion model that helps explain what happens during sleep deprivation [3]. Just as muscles become fatigued and less effective after a long workout, our brain’s ability to function starts to dwindle when we don’t catch enough sleep. This means that sleep isn’t just a physical rest period – it’s crucial fuel for our brain. Without adequate sleep, our mental energy levels drop, leading to fuzzy thinking, poor decision-making, and a harder time controlling our emotions and actions. It’s as if running on low sleep forces our brains to operate on reserve power, affecting everything from how we handle stress to how we interact with others.

The connection between being able to manage our attention (executive functioning) and control our behavior (self-regulation) is key. When we are low on sleep, our capacity for both drops. This isn’t just about feeling sleepy – it’s about our brain’s reduced capability to focus, resist distractions and hold back on risky decisions. For example, a study by Kaplan and Berman showed that failing to manage our attention well leads directly to a struggle with self-control [5]. Also concerning, a study on poor sleep quality for experienced paramedics showed a reduction in their capacity for empathy [4]. A single night without enough rest can leave us feeling mentally foggy and more likely to take unnecessary risks, posing challenges not just for individuals in high-stakes professions, but for anyone needing to make important decisions on too-little sleep [8].

Studies using brain scans have shown that when people don’t sleep enough, there’s less activity in the pre-frontal cortex, the part of the brain responsible for planning, decision-making and distinguishing right from wrong [10]. This can make it difficult to make wise decisions or resist temptations, particularly in situations where we need to think about the consequences of our actions, like choosing not to drive when we are really tired or when we need to make life-and-death decisions [2,7].

A dissertation study on sleep deprivation took a deeper dive into this issue by working to determine if a lack of sleep impairs not only our ability to stay alert but also our puzzle-solving capacities [13]. Participants were tested on tasks measuring both types of cognitive functions after a normal night’s sleep and then after staying awake all night. Also, participants were evaluated to see if coffee or naps could mitigate any negative effects.

The findings revealed that sleep deprivation significantly hindered both vigilant attention and higher-order cognitive skills. This indicates that insufficient sleep disrupts more than just alertness –it also compromises our problem-solving abilities and memory for sequences. While coffee improved alertness, it did not enhance problem-solving or organizational skills, and short naps had a negligible effect on both cognitive domains, suggesting the complexity of sleep’s role in maintaining cognitive function [13].

Other studies also shed light on the multifaceted consequences that insufficient sleep has on individuals in these roles, spanning from mental health challenges to physical health concerns, cognitive impairments and lifestyle impact. These insights underscore the critical need for targeted strategies and interventions aimed at mitigating the adverse outcomes associated with disrupted sleep.

  • Impact on mental health and physiology. Sleep deprivation is directly associated with significant mental health challenges, including heightened levels of anxiety, fatigue, confusion and depression. Additionally, it contributes to increased inflammation and changes in endocrine function, leading to impaired alertness, enhanced impulsivity and worsened emotional states [15].
  • Cognitive and safety consequences. Disrupted sleep patterns are linked to a range of cognitive issues, such as slower thought processes, increased risks of accidents, notable declines in performance and diminished decision-making skills [1].
  • Health and weight management. The challenge of weight management – an essential aspect of overall well-being – becomes significantly greater in the context of insufficient sleep, underscoring the intricate relationship between sleep quality and physical health [9].
  • Fatigue in paramedics. A pattern of consistent sleep deprivation, or reduced sleep quality, notably increases both cognitive and physical fatigue among paramedics, highlighting a critical occupational hazard within this profession [14].
  • Lifestyle impacts for paramedics. Sleep-deprived paramedics exhibit reduced physical activity during their off-hours and are more susceptible to the adverse effects of depression and anxiety, illustrating the broader lifestyle and mental health ramifications of sleep loss [6].

Recognizing these multi-faceted impacts, it becomes imperative to explore and implement measures designed to safeguard the health and efficacy of EMS providers. Strategies such as incorporating restorative naps during shifts, moderating caffeine intake for optimal alertness and revisiting shift structures for feasible adjustments hold promise. By prioritizing interventions that support the maintenance of cognitive function and decision-making capacity, we not only invest in the well-being of EMS providers, but also ensure a higher standard of care for those they serve.


1. Banks, S., Landon, L. B., Dorrian, J., Waggoner, L. B., Centofanti, S. A., Roma, P. G., & Van Dongen, H. P. (2019). Effects of fatigue on teams and their role in 24/7 operations. Sleep Medicine Reviews, 48, 101216.

2. Barnes, C. M., Schaubroeck, J., Huth, M., & Ghumman, S. (2011). Lack of sleep and unethical conduct. Organizational Behavior and Human Decision Processes, 115(2), 169-180.

3. Baumeister, R. F., Muraven, M., & Tice, D. M. (2000). Ego depletion: A resource model of volition, self-regulation, and controlled processing. Social Cognition, 18(2), 130-150.

4. Guadagni, V., Cook, E., Hart, C., Burles, F., & Iaria, G. (2018). Poor sleep quality affects empathic responses in experienced paramedics. Sleep and Biological Rhythms, 16, 365-368.

5. Kaplan, S., & Berman, M. G. (2010). Directed attention as a common resource for executive functioning and self-regulation. Perspectives on Psychological Science, 5(1), 43-57.

6. Khan, W. A. A., Conduit, R., Kennedy, G. A., & Jackson, M. L. (2020). The relationship between shift-work, sleep, and mental health among paramedics in Australia. Sleep Health, 6(3), 330-337.

7. Killgore, W. D., Balkin, T. J., & Wesensten, N. J. (2006). Impaired decision making following 49 h of sleep deprivation. Journal of Sleep Research, 15(1), 7-13.

8. Nilsson, J. P., Söderström, M., Karlsson, A. U., Lekander, M., Åkerstedt, T., Lindroth, N. E., & Axelsson, J. (2005). Less effective executive functioning after one night’s sleep deprivation. Journal of Sleep Research, 14(1), 1-6.

9. Papatriantafyllou, E., Efthymiou, D., Zoumbaneas, E., Popescu, C. A., & Vassilopoulou, E. (2022). Sleep deprivation: effects on weight loss and weight loss maintenance. Nutrients, 14(8), 1549.

10. Schnyer, D. M., Zeithamova, D., & Williams, V. (2009). Decision-making under conditions of sleep deprivation: Cognitive and neural consequences. Military Psychology, 21(sup1), S36-S45.

11. Sharuk, D. N. (2022). No Sleep for the Wicked: A Study of Sleep Deprivation as a Form of Torture. Maryland Law Review, 81(2), 694.

12. Shriane, A. E., Russell, A. M., Ferguson, S. A., Rigney, G., & Vincent, G. E. (2023). Sleep hygiene in paramedics: What do they know and what do they do? Sleep Health, 6(3), 321-329.

13. Stepan, M. E. (2019). Testing the role of vigilant attention as a mediating process for cognitive deficits due to sleep deprivation. [Dissertation] Michigan State University. Available from ProQuest Dissertations & Theses Global; Psychology Database.

14. Sumińska, S., Nowak, K., Łukomska, B., & Cygan, H. B. (2021). Cognitive functions of shift workers: Paramedics and firefighters–an electroencephalography study. International Journal of Occupational Safety And Ergonomics, 27(3), 686-697.

15. Thompson, K. I., Chau, M., Lorenzetti, M. S., Hill, L. D., Fins, A. I., & Tartar, J. L. (2022). Acute sleep deprivation disrupts emotion, cognition, inflammation, and cortisol in young healthy adults. Frontiers in Behavioral Neuroscience, 16, 945661.

Bram Duffee, PhD, EMT-P, is the host of the vlog and podcast “EMS Research with Professor Bram.” He is an Institutional for Social Innovation Research Fellow at Fielding Graduate University and an Assistant Professor of Communication at Kennesaw State University. He is co-author of the book “Hypnotic Communication in Emergency Medical Settings: For Life-saving and Therapeutic Outcomes.” To connect with him or participate in a research study on first responder stress, visit