error or adverse event are twice as high among
fatigued EMS clinicians compared to non-fatigued clinicians.
11 Most clinicians in this
study reported poor sleep, thus the role of sleep
hours on performance is unclear.
Thomas is a paramedic with 45 years’ experience in EMS as a clinician, supervisor and
educator. When asked if EMS administrators
are aware of the issues and importance of sleep
deprivation, fatigue, health and performance,
he replied, “I think they have no clue and need
to be aware of the issues.”
Many would argue that the harder we work, the
more fatigued we become. Joe is a paramedic
in the Western U.S. He believes fatigue is a
problem when “you’re in a system that runs
back-to-back calls and have no downtime to
complete reports, to just relax, or just get out
of the ambulance.”
In general, we have a poor understand-
ing of the relationship between workload and
fatigue in EMS.
27 Our concept of workload in
EMS is fairly simple. Most would operation-
alize EMS workload as patient call volume.
Other tasks may qualify as workload or task load.
These might include inspecting, restock-
ing, cleaning, and general maintenance of
Workload may also involve completion of
paperwork, such as patient care reports. In
some places, such as dual fire/EMS systems,
Other systems may require a variety of tasks or
duties not well described, yet they contribute
to a clinician’s workload or shift-related
task load. Regardless of how we define work-
load, the type of work performed by EMS cli-
nicians differs from that of many other shift
work occupations and may contribute to feel-
ings of physical and mental fatigue. These
feelings may not be comparable to other shift
Caring for patients can be fatiguing mentally and physically. Patient care is unpredictable and stressful. The care needs and demands
vary dramatically from one patient to the next.
An interfacility transport with a patient that
requires oxygen and cardiac monitoring isn’t
the same workload as an acutely ill patient
with multi-system trauma that needs a patent airway, multiple IVs, cardiac monitoring, splinting, bandaging, full immobilization,
prolonged extrication and other interventions.
The environment, time pressures and other
factors create stress. Stress and anxiety can
lead to mental fatigue and disrupted sleep.
The nature of EMS work is complex, and
the workload is often not easy to describe to
others not familiar with EMS. Most would
agree that the job of an EMS clinician is
stressful and shifts are often filled with anx-
iety, regardless of call volume. Heightened
arousal/awareness during both low- and high-
workload periods is common.30
It’s plausible that the ambulance accidents
described at the beginning of this article were
precipitated by excessive workload, which may
have caused fatigue.
Shift duration feels like the elephant in the
room when discussing fatigue mitigation in
EMS. Extended shifts (e.g., 12-hour and
24-hour shifts) are common.
The industry appears to have three camps
of people on this issue. The first camp includes
those who are unapologetic about how much
they work. They’ll do everything in their power
to defend working as much as they want; continuously and without much rest, if necessary.
The second camp includes those who feel
they work too much and welcome restrictions on
shift duration to ensure adequate rest and recovery, time with family, adequate leisure time, etc.
The third camp might easily be comprised
of individuals who really don’t care. They work
a regular shift schedule, and if necessary, will
work overtime or additional hours to fill in
for voids in the schedule, or simply to make
some extra income.
The clinicians interviewed for this article
differ in their opinions on this issue. Joe from
the Western U.S. reports that he’s worked
every shift duration imaginable and believes
that there’s a strong correlation between shift
duration and fatigue.
However, Joe doesn’t believe that limiting
shift duration will have a positive impact on
fatigue in EMS. “Crews would supplement the
lost time with second or third jobs,” he says.
Nancy shares Joe’s opinion. “You can make
eight-hour shifts, yet that doesn’t mean you will
work less,” she says. “Even though the shifts
are shorter, you’ll work more days per week. In
EMS, we have late calls and you often have to
work beyond the end of your shift. An eight-hour shift isn’t always an eight-hour shift.”
Mike, a paramedic in the Northeast U.S. who
describes working more than 48 hours in a row
says, “I used to work a 56-hour shift. I would
work Tuesday and Wednesday as 24s back-to-back, and then I would work Thursday daylight. I can tell you it was a bad idea. It doesn’t
work out well. It’s too long. Between those two
24-hour shifts, if you didn’t have any calls, you
were fine; but if you were out on calls half the
night, you started the next 24-hour shift with
no sleep. It just seemed like a domino effect.”
A low-to-moderate dose of caffeine can be an effective countermeasure to fatigue and have a positive impact on
performance and other outcomes.