Tired to Death

On January 22, 2018, an ambulance crashed in Miami County, Indiana. The ambulance was transporting a 5-month-old child who, accompanied by her mother, was being moved between hospitals when the accident occurred at approximately 3:45 AM. The driver of the ambulance failed to stop at a red light and collided with another vehicle that was already in the intersection. The crash caused the ambulance to roll over and an EMT in the patient compartment was ejected. The EMT later died of his injuries.

The driver of the other vehicle was transported to a medical facility for a non-life-threatening head injury, and neither the child, their mother, or the ambulance driver sustained injuries. A police investigation of the crash showed that the accident was a result of the ambulance driver falling asleep at the wheel.

Events like this are unfortunately not isolated incidents. In fact, in Maine from July 12th to August 4th of 2017, there were three ambulance crashes that were all triggered by the driver falling asleep while driving. Even more alarming, several research projects have demonstrated that more than half of EMS workers report being under severe mental and/or physical fatigue while working.

In this article, we will discuss some of the various factors that contribute to fatigue for the EMS professional and the potential effects of this fatigue on their job performance. We will also explain evidence-based guidelines for managing fatigue in the EMS setting.

What is fatigue?

It is important to remember that fatigue is more than just the normal feeling of being tired or drowsy after a long day exerting yourself both physically and mentally while working. When we talk about EMS workplace fatigue, we are talking about a relentless exhaustion that affects a person’s mind, body, or both, and prevents them from functioning at their normal capacity. There are numerous factors that can contribute to fatigue in the EMS workplace but those that we are going to focus on here are sleep deprivation, shift workload, long-duration shifts, and working multiple jobs.

Sleep Deprivation

The recommendation for adults is to get between seven and nine hours of sleep per 24-hour period. Unfortunately, more than half of EMS professionals admit to getting six hours of sleep or less per day. In addition, half of EMS workers report that the sleep that they do get is of poor quality. Multiple studies have found the obvious correlation between sleep and good job performance but one study specifically examining EMS fatigue and medical error found that, when compared to non-fatigued EMS workers, fatigued EMS workers were twice as likely to commit a medical error or experience an adverse event. In addition to contributing to poor job performance, sleep deprivation has also been linked to cardiovascular disease, obesity, metabolic disorder, emotional problems, and various gastrointestinal conditions.

Shift Workload

EMS is a complex, fast paced, unpredictable, and demanding field. There is a continual variety of patients whose medical conditions present with a broad range of severity. Emergency situations require that definite decisions be made and actions taken in a rapid but controlled manner. These aspects of EMS work are often what those in the profession find most appealing but, they can also be the source of considerable stress and anxiety and this can lead to workplace fatigue.

Long-Duration Shifts

Extended 12-hour and 24-hour shifts are very common amongst EMS professionals. Due to a lack of manpower, some EMS agencies also require mandatory overtime which can further lengthen work days. These long shifts can wear down even the most resilient EMS professional and can very easily contribute to EMS crew fatigue.

Working Multiple Jobs

Having more than one job is common for those who work in the EMS field. A salary survey conducted in 2016 by the Journal of Emergency Medical Services (JEMS) reported that more than half of EMS professionals have a second job to supplement their income. A 2007 study in the Air Medical Journal found that roughly 80% of air-medical crews have additional employment and that many of them begin their medical shift within 8-hours of leaving this second job. With the median pay for an EMT in 2016 found to be $15.71 per hour, many of those in EMS argue that the need for a second job is a direct result of their modest salary. Their decision to work multiple jobs can contribute to fatigue.

Addressing Fatigue

Recognizing that EMS workplace fatigue is a problem and one that is not disappearing anytime soon, the National Association of State EMS Officials (NASEMSO) generated evidence-based guidelines for addressing fatigue in EMS. They used an extensive review of the literature and a panel of experts in fields like sleep medicine, public safety, risk management, and emergency medicine, to develop recommendations in four key areas. These four areas were shift duration, access to caffeine, use of napping during shift work, and education and training.

Recommendation on Shift Duration

It is recommended that EMS workers work shifts less than 24-hours in duration. The review of evidence indicated that shifts of 24-hours or more lead to an increase in fatigue and poorer patient outcomes. The panel of experts noted that, while shortening shifts is an important part of mitigating EMS fatigue, reducing work hours is only a component in addressing this problem and should not be interpreted as the lone solution.

Recommendation on Access to Caffeine

It is recommended that EMS professionals have access to caffeine as a means to combat fatigue. The available evidence showed that the use of caffeine had a positive impact on performance and other outcomes although it did not specify an optimal dose. For those crews that spend the majority of their time deployed in remote locations, it is suggested that EMS agencies equip ambulances with coolers to store caffeinated beverages. Whether it is free or for purchase, all on duty EMS workers should have access to caffeine.

Recommendation on Napping During Shift Work

It is recommended that EMS crews have the opportunity to nap while on duty in order to help prevent fatigue. The evidence reviewed showed that actual napping, not just resting, during a shift had a positive impact on EMS performance. There are many EMS agencies that already allow EMS crews to take naps while on duty but, there are also a large number who strictly prohibit sleeping during a shift. The expert panel recommended that for those EMS crews on either extended or overnight shifts, they should be provided with the access, opportunity, and explicit permission to nap while on duty.

Recommendations on Education and Training

It is recommended that EMS personnel be educated and trained in sleep health and the dangers of workplace fatigue. This training and education should be connected to new employment orientation and ideally would be repeated every two years. The two-year reeducation and retraining is recommended because it has been shown that this knowledge and skill set decays over time.


These four fatigue mitigation strategies are supported by the best available evidence and as such, the recommendations that they make should be taken seriously. Workplace fatigue saps us our passion, our focus, and our strength. The public we serve and those we work alongside both expect and deserve our best. If workplace fatigue is truly as widespread and as deadly as it appears to be, there is no time to waste in taking real and immediate action.

Sources & More Information

Buysse DJ. Evidence-based guidelines for fatigue risk management in emergency medical services: a step in the right direction toward better sleep health. Prehosp Emerg Care. Jan. 11, 2018.

CBS News, “Police: EMT dies after ambulance driver falls asleep, crashes” https://www.cbsnews.com/news/emt-in-indiana-dies-after-ambulance-crash/

EMS World, “An EMS Emergency: Sleep Deprivation and Fatigue” https://www.emsworld.com/article/12135723/an-ems-emergency-sleep-deprivation-and-fatigue

Frakes MA, Kelly JG. Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts. Air Med J. 2007;26(1):45–49.

JEMS, “Evidence-Based Guidelines for Combatting Fatigue in EMS” https://www.jems.com/articles/print/volume-43/issue-2/features/evidence-based-guidelines-for-combatting-fatigue-in-ems.html

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.
By Jeremiah Johnson, MA, BS

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