Initial guidelines for sustaining EMS provider alertness and managing fatigue in EMS operations

In this article, we address a number of organizational and environmental factors that play important roles in preventing or mitigating worker fatigue and offer guidelines for sustaining EMS provider on-the-job alertness. The special focus is on the physical environment associated with EMS work stations and ambulances important aspects of worker health and fitness.

Sleeping accommodations at the station

Crew members on 24-hour schedules need to obtain several consecutive hours of rest, and they need to attain quality sleep between runs. Locations where EMS crews await their next emergency calls, at the station, in hospital emergency parking areas, or at the pre-positioned ambulance staging point should provide adequate resting and sleeping facilities to allow this respite. No matter where they are parked the driver’s crew compartments of most ambulance vehicles do not provide suitable seats to permit taking restful naps. In many organizations, the ambulance crews that are stationed on the street are on 12 hour shifts and are prohibited from sleeping in the ambulance. The availability of quiet separate rest/sleeping areas for EMS providers vary tremendously by location. In the best of settings, some modern stations offer separate one or two-person rooms for ambulance crews to sleep. Others provide large sleeping bays containing numerous individual beds. Still others simply provide “lazy-boy” type cushioned relaxation chairs which frequently are positioned in front of large screen TV sets. Each location's management and leadership personnel, together with EMS crew members, should take inventory of site circumstances. They can work together to make improvements whether implementing simple fixes or planning out modifications for the longer term.

Environmental design factors

Physical environment considerations for enhancing the likelihood of obtaining quality sleep include: providing quality mattresses; ensuring adequate storage for crew members’ bedding; and spacing the separation among beds, including separate sleeping quarters for mixed gender crews. As a courtesy to teammates who are asleep, the elimination or attenuation of acoustical noises in the sleeping area should be addressed. These could include: miscellaneous sounds from TVs; cackling radio calls in the sleeping area; alarms; heating, ventilation and cooling (HVAC) noise control; and miscellaneous loud talking. Also, minimizing extraneous lighting that interferes with sleeping can be accomplished with blackout curtains, subdued lighting, light diffusers, and arrays of electronic power buttons that are placed out of view.

Crewmembers should be cautioned to minimize looking at electronic devices such as TVs, lap top computers, video games, IPADs, and mobile phones within an hour before attempting to sleep. The short wavelength blue light of such devices delays the brain's release of melatonin into the blood stream (our natural sleep-inducing hormone from the pineal gland, which is emitted only in darkness).

Sleep timing each day

Depending on the crew's individual work schedule, and how much down time might be available between frequent ambulance runs crews may need to carefully plan out their best times for obtaining quality sleep at the station. Recall that the body's circadian rhythm (CR) physiology impacts our level of alertness and interacts with our on-the-job performance. CR physiology also affects our ability to sleep at certain times of the day. The best times to obtain 4+ hours of sleep, and preferably 5-6 or more contiguous hours of sleep will normally be during the dark hours of the night between 11:00 p.m. and 6:00 a.m. It is recognized that for some ambulance crews night work may be episodic and unpredictable. The second best time to sleep is in the middle of the afternoon from 1:00 to 5:00 p.m.

While some stations set rules such as no daytime sleeping until mid-evening, from a physiological standpoint, this rule contradicts what the brain would like to do. To augment the core 4-6 contiguous hours of sleep, additional naps should be taken. Short power naps of 10-15 minutes taken whenever free time is available can help recharge our energy. To maintain a suitable level of alertness, the goal is to obtain an aggregate total of 7-8 hours of sleep for every 24-hour day. If one awakens from the deep stages of sleep with a need to respond quickly, there is likely to be sleep inertia which must be overcome.

Other measures

Taking frequent rest breaks from demanding tasks helps rejuvenate worker effectiveness. Judicious consumption of caffeine can help to restore alertness temporarily, but avoid caffeine several hours before bedtime. Some daytime sleepers find that taking synthetic melatonin in darkened sleep quarters can help induce sleep faster. Use of sleeping pills is discouraged and should only be used under a physician's prescription guidance with full knowledge of the importance of EMS crew members' work settings. Making up sleep debts by obtaining more recovery sleep on one's nominal weekend or on days off work is important for restoring alertness.

Sleep disorders

Workers who experience frequent bouts of insomnia may actually have a sleep disorder. Seeking professional medical evaluation and possible treatment may be called for. In today’s work force, a common sleep malady is obstructive sleep apnea (OSA), which often manifests as frequent short awakenings, loud snoring or snorting, and a restless sleep period which leaves one drowsy at work even after having been in bed for 6-8 hours. Persons who are heavy-set and with large necks are particularly susceptible to OSA, which is readily diagnosed by an overnight sleep clinic test. When OSA is treated, it can offer huge life-changing improvements.

Diet, nutrition, and physical fitness are important too

Military research has shown that eating a proper diet, getting plenty of nutrition, and maintaining high levels of physical fitness are all important for maintaining suitable overall fitness for work. Recent research verifies that these factors interact with sleep quantity and quality. High levels of fitness can help individuals maintain the highest levels of on the job cognitive alertness, quick reaction times, and clear thinking in emergency situations.

These factors affect an individual's long term health for workers who engage in continuous around the clock work schedules for long periods. Thus, taking advantage of and using the physical fitness equipment provided at the work station regularly, eating nutritious meals prepared at the station's kitchen facilities, and maintaining good sleeping habits all contribute to sustaining worker alertness on the job. An additional (positive) side effect is a safer, healthier work environment, and conducive to maintaining the health of ambulance crewmembers.

This fifth Vitals article concludes the series on EMS worker alertness and fatigue. The authors seek reader feedback on any topic covered in these short articles. They encourage reader commentary about any related topic you may wish to sound off about, or that you might wish to have expounded upon with more information. Please send your comment to Mike Szczygiel at

About the Authors:

Gerald P. Krueger, Ph.D., CPE, a research psychologist, is also a certified ergonomist who has spent much of the last 20 years examining issues of commercial driver alertness and driver fatigue (i.e., truck and bus drivers).  Jerry has published numerous articles, and taught courses for DOT on driver fatigue and health and wellness.  He also serves as an expert witness on cases of driver fatigue and driver performance.

Billy Rutherford, MS, President of American Integrated Training Systems, Inc. has managed the development of the USDOT Emergency Vehicle Operator Course (Ambulance).  Billy also managed the development of over 500 hours of Pre-Hospital Computer/Internet Based training.  He has been conducting EVOC Train-the-Trainer Courses Nationwide for over 20 years.  Billy serves as an Expert Witness on cases where there was a serious injury or death when an emergency vehicle was involved.

In an attempt to stay abreast of NHTSA progress on their research initiative, Billy Rutherford and Jerry Krueger are participating in periodic EMS stakeholders’ meetings on these important topics to all EMS providers.

This document is intended for general information purposes only, and should not be construed as advice or opinions on any specific facts or circumstances. The content of this document is made available on an “as is” basis, without warranty of any kind. This document can’t be assumed to contain every acceptable safety and compliance procedures or that additional procedures might not be appropriate under the circumstances. Markel does not guarantee that this information is or can be relied on for compliance with any law or regulation, assurance against preventable losses, or freedom from legal liability. This publication is not intended to be legal, underwriting, or any other type of professional advice. Persons requiring advice should consult an independent adviser. Markel does not guarantee any particular outcome and makes no commitment to update any information herein, or remove any items that are no longer accurate or complete. Furthermore, Markel does not assume any liability to any person or organization for loss of damage caused by or resulting from any reliance placed on that content.

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