Paramedic fatigue

For those not on Twitter, a summary of my thoughts on this recent issue: https://www.irishexaminer.com/breakingnews/ireland/paramedics-suspended-after-raising-safety-concerns-898612.html
 
This decision flies in the face of the evidence regarding fatigue and its impact on patient safety, paramedic safety, other road users and general occupational health of paramedics.
 
Paramedics should be supported when they make risk assessments regarding their fatigue levels. Fatigue affects alertness, concentration, judgement, mood and performance. This affects their ability to make safe decisions, and problem solving abilities – leading to increased risk taking, potentially manifesting in increased errors, injuries and accidents.
 
Did you know that fatigue is four times more likely to be a cause of workplace impairment than drugs or alcohol? Fatigue can also cause impairment similar to that caused by alcohol intake. We wouldn’t want drunk people driving ambulances – why let fatigued people do the same?
 
Several studies investigating ambulance crash data have pointed to fatigue as a contributory factor in many crashes. This topic is of such importance that the US has generated fatigue management guidelines: https://www.tandfonline.com/doi/pdf/10.1080/10903127.2017.1376137?needAccess=true
 
A 2005 study in France demonstrated that sleepiness (like at the end of a night shift) combined with fatigue significantly affected response times. They advised drivers to avoid driving after sleep restriction, even on relatively short trips especially if they feel sleepy.
 
A consensus statement from an international group of scientists who study human performance, safety, and prevention of accidents associated with work schedules, night activity, and inadequate sleep made the following statements . (Note no. 3 in particular):
 
  1. The 24 h society, with around the clock operational demands in all transport modes, challenges the powerful and vital need for sleep. Sleep, alertness, and performance are fundamentally linked to the 24 h biological clock.
  2. The major causes of fatigue are: (a) the time of day of the transport operation (e.g. night/early morning), (b) a long duration of wakefulness, (c) inadequate sleep, (d) pathological sleepiness (sleep apnea, etc.), (e) prolonged work hours (not necessarily operating the vehicle).
  3. Fatigue (sleepiness, tiredness) is the largest identifable and preventable cause of accidents in transport operations (between 15 and 20% of all accidents), surpassing that of alcohol or drug related incidents in all modes of transportation. Official statistics often underestimate this contribution.
  4. Underestimation of the impact of fatigue can lead to the under utilization of important countermeasures.
  5. Public and environmental safety, health, and productivity are compromised by fatigue and sleepiness, with substantial financial costs to individuals and society.
  6. Fatigue related risk may be reduced through a variety of interventions, that include education (about sleep, the biological clock, sleep disorders, fatigue countermeasures), improved scheduling of work hours, and the judicial use of strategies and technologies.
https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1365-2869.2000.00228.x
 
Fatigue has also been associated with increased injury rate among providers, increase patient care errors, and adverse events. Is this really the culture we want to promote in paramedicine? If anything we should be promoting a fatigue-reduction culture.
 
  • Encourage crews to report fatigue BEFORE something happens
  • Allow crews to nap on duty (Yes, I know right?!). A 2009 study in Japan suggested that a modified night shift (which ensured time for paramedics to take long, restful power naps) alleviated subjective fatigue, and improved physiological function which are often adversely affected by night workload
  • Monitor fatigue levels. There are tools to do this.
  • Provide education and resources on fatigue management.
Fatigue risk management is a *shared* responsibility of both the paramedics and the organisation. Fatigue management needs to be part of the organisational safety culture, and paramedics should not face consequences for highlighting risks to safety because of fatigue. https://www.tandfonline.com/doi/full/10.1080/10903127.2017.1380101
 
In the current climate of paramedic mental health, it is also worth noting that fatigue has been linked to poorer mental health in paramedics. So while perhaps not apparent, the issue of fatigue in paramedics is bigger than the immediate safety concerns.
 
These thoughts and suggestions are all supported by the literature. Happy to provide further reading if required. Will be writing more on this soon with several other authors, stay tuned.

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