Objectives:
After reading this article, you will be able to:
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| Percentage of adults who reported an average of less than 6 hours of sleep per 24-hour period. Source: Centers for Disease Control and Prevention, National Health Interview Survey, United States, 1985 and 2006 |
Case Study
You’re a new paramedic, you’ve been working in the field for about two years,
and you love the job. You love it so much that you pick up extra shifts. You
love being on the truck, so you help out your employer and your co-workers on a
regular basis by working one or two extra shifts weekly. Everything seems great;
you’re receiving large paychecks, and you’re rapidly learning the finesse of
being a paramedic—until one evening, while on duty, you experience a terrible
headache. Nothing seems to relieve the pain, and after a few hours you’re
beginning to feel nauseated and dizzy. You finally ask your partner to assess
your vital signs, and you discover that your blood pressure is extremely high,
202/90. Stress has just caught up with you. It’s time to start reassessing your
personal priorities and managing your own health before you are the patient.
Introduction
Stress is a natural and expected aspect of life. Everyone must learn how to
adapt their personal, physical, and psychological makeup to the stress that they
experience in their lives in order to function successfully. While not all
stressors are bad, the initial concept of stress is usually negative. This
article will focus on one of the negative stressors—sleep
deprivation—specifically in relation to the career field of emergency medicine
and the impact it has on the immediate and long-term health of its medical
professionals.
Emergency medical professionals are routinely expected to rise above and beyond their personal concerns and human weaknesses to deliver excellent, consistent care to their patients, regardless of the circumstances. It is this ideal that allows the public to trust strangers with their lives and the lives of their family members, but rarely, if ever, does the public stop to consider the personal cost to the medical professional. Therefore, the paramedic is indirectly taught, through public expectation, to put his or her personal health after the patient’s health. Also, medical professionals are often expected to place their mental and physical health after the expectations of their family, friends, and even their own employer.
It is common practice for paramedics to work 24-hour shifts, not including overtime. This totals to over 2880 hours worked annually. In most emergency medical services, 24-hour shifts are normal, with forty-eight hours off between shifts to recover. Unfortunately, many services nationwide are short of paramedics, and the available personnel work an additional twenty-four hours overtime with only twenty-four hours off for recovery. When one includes these commonly added overtime shifts, many EMS professionals may work as many as 4000 hours a year.
The average middle-income employee in the United States works a standard 40-hour work week, which totals 2080 hours worked annually. Compare this to the normal work year for an average paramedic and one finds that paramedics work an additional 800 hours a year—not including overtime shifts. This averages out to be a base 55-hour work week.
One might initially think that this average doesn’t sound overly strenuous, but consider that a paramedic works the majority of those hours in blocks of time without any type of personal break. Paramedics often work through normal meal times and are usually awakened two or three times a night for at least an hour or more each time. A paramedic is engaged to work at the convenience of a patient’s need until that need is fulfilled. A paramedic doesn’t get to stop halfway through treating a patient for rest, even if that treatment time takes an hour or two.
During the 24-hour shift, paramedics may not get the opportunity to sleep more than a few hours, if the opportunity occurs at all. Or worse, they may get to sleep only to be reawakened several times throughout the night. Nearly all career paramedics will admit that during a busy night it’s usually preferable to stay awake all night rather than be reawakened several times, due to the additional stress it creates. In addition, the awakening is done by loud, obnoxious alarms that instantly activate the sympathetic fight or flight response, which causes an immediate hormone surge in the nervous system. Yet, through this natural, heightened physical response, the paramedic must be able to think quickly and act clearly in order to make good, rational decisions because someone’s life may depend upon it.
Most medical professionals begin their careers with the understanding that their choices will create major stresses in their lives. They are encouraged, even pressured, by the system to overwork and to reduce or eliminate their personal priorities. These pressures put their health at risk directly by reducing their mental and physical rest and recuperation and indirectly by occasionally forcing them to make poor lifestyle choices.
The medical profession will always demand more than what a nine-to-five career entails. People need help at all hours; tragedies and emergencies don’t keep a day schedule. However, expecting paramedics to absorb the stress of those emergencies without detriment to their health is unreasonable.
General Stress Effects
Research suggests that possibly 60 to 90 percent of all illnesses are
stress-related, causing damage to the cardiovascular system and suppression of
the immune system.1
Stress is defined as a psychological and physiological response to events that upset our personal balance in some way.1 It is designed to be a protective mechanism, but in the present age of excessive psychological stimulation it can cause long-term harm if not managed properly. Modern man is exposed to numerous triggers that activate the system, but since the perceived stress is rarely life-threatening or the danger is very short-term, the person affected may be unable to physically use the hormones circulating in his or her system.
These unused hormones will remain in the vascular system causing damage instead of being utilized by the organs and muscles for increased performance and endurance. The more often this stress response is activated, regardless of whether it is needed, the more difficult it is to stop. Instead of leveling off once the crisis is over, the stress hormones, heart rate, and blood pressure remain elevated.1 Repeated activation of the stress response takes a heavy toll on the body; prolonged exposure increases one’s risk of heart disease, obesity, infection, anxiety, depression, and memory problems.1 The repetitive exposure to emergency activation alarms, especially during sleep time, is a prime example of this long-term problem. Other major work stressors are generally considered to be: job dissatisfaction, exhausting workload, sleep deprivation, insufficient pay, office politics, and conflicts with supervisors or co-workers. Chronic stress or severe acute stress can affect even the most well-adjusted person, causing that person to lose the ability to adapt.
Sleep Deprivation
The primary health deficit in emergency medicine is sleep deprivation.
According to sleep experts, not getting enough rest leads to serious safety and
health consequences. Dr. James Herdegen, M.D., the medical director of the Sleep
Science Center at the University of Illinois at Chicago, states that sufficient
sleep amounts to approximately eight hours a day.2 Getting less than that can
lead to impaired math skills, thought processes, or memory, which can create
hazards for workers performing various at-risk duties. Sleep deprivation can
also cause poor decisions, indecisiveness, accidents, and even death.
Dr. Sean Drummond, a researcher with the Department of Defense, conducted a study to determine the impact of sixty-four hours of total sleep deprivation on brain function, the course of brain recovery once normal sleep is resumed, and the effects of the deprivation during different periods of the day.3 As the hours of deprivation increased, other areas of the brain not usually accessed responded in an effort to compensate for the lack of sleep. As the time without sleep continued beyond thirty hours, these regions also began to fail, resulting in the brain becoming impaired and unable to function properly, and causing decision-making to become difficult and faulty; this further increased risk factors leading to poor decisions. Dr. Drummond’s study concluded that there is a limit to the brain’s ability to compensate for total sleep deprivation; as time increases, individuals can keep fewer pieces of information active, and multi-tasking and complex problem-solving become more difficult. Attention and working memory also become impaired, according to his study.
Impaired Moral Decisions
Another study, conducted by William D.S. Killgore, Ph.D., and colleagues at
the Walter Reed Army Institute of Research, focused on twenty-six healthy adults
who made judgments about the “appropriateness” of various courses of action in
response to three types of moral dilemmas on two separate occasions—at baseline
and again following fifty-three hours of continuous wakefulness.4 Compared to
baseline, sleep deprivation resulted in significantly longer response latencies
(suggesting greater difficulty deciding upon a course of action) for moral
personal dilemmas.4
This suggests that continuous wakefulness has a particularly debilitating effect on judgment and decision-making processes that depend heavily upon the integration of emotion with cognition. Dr. Killgore also stated that the results further support the hypothesis that sleep loss is particularly disruptive to the ventromedial prefrontal regions of the brain, which are important for the integration of effect and cognition in the service of judgment and decision-making.4 This study shows that sleep deprivation can have serious consequences for medical professionals, due to a change in the leniency or permissiveness of response style rather than an actual decline in “morality.”4 Dr. Killgore’s results suggest that when medical professionals are sleep deprived, they appear to be slower in their deliberations about moral personal dilemmas relative to other types of dilemmas.4 These same personnel may have more difficulty reaching morally-based decisions under emotionally charged circumstances and may be prone to choosing courses of action that differ from those that they would have chosen in a fully rested state.4
This is of particular concern in the emergency field setting. Paramedics have fewer on-site support systems, work in uncontrolled settings with numerous distracting non-medical personnel and bystanders, and take full responsibility for all medical decisions made in a very short amount of time under the worst of physical and mental conditions. Paramedics with normally strong moral direction have only to make one poor moral decision due to sleep deprivation and a chain of tragedy may ensue, often ending the patient’s life and the paramedic’s career.
Effects of Shift Work
Dr. Herdegen examined sleep deprivation among medical professionals and found
that those who work at night have a higher rate of motor vehicle accidents or
near misses.2 Shift workers in other careers are also usually at higher risk
for many health problems, such as peptic ulcers, hypertension, and
cardiovascular disease, and they also face increased risk of making workplace
errors. Shift work may disturb medical professionals’ circadian rhythms and even
cause them to get less sleep overall, even when the opportunity for sleep is
provided.
Dr. Herdegen also stated that shift workers tend to get an hour less of sleep per day than day workers, which can lead to obesity or weight gain because sleep-deprived people tend to increase their caloric intake.2 According to Dr. Herdegen, research implies that a person who sleeps only four hours is hungrier, despite receiving the same amount of calories as someone sleeping eight hours.2 This increased risk for obesity can also increase the risk for diabetes and the cardiovascular diseases listed previously. Obesity can also decrease productivity and increase absenteeism. Shift workers must choose to make consistent, responsible lifestyle choices regarding diet and exercise to help counteract the risks of obesity.
Abnormal Hormone Levels
Sleep deprivation can also directly affect the basic metabolic functions,
even in otherwise healthy, young adults, reported researchers from the
University of Chicago’s Medical Center.5 The researchers had subjects reduce
their sleep hours from eight to four hours each night. Within one week, this
resulted in significant changes in glucose tolerance and endocrine function,
changes resembling the effects of advanced age or the early stages of diabetes.5
“We found that the metabolic and endocrine changes resulting from a significant
sleep debt mimic many of the hallmarks of aging,” stated Eve Van Cauter,
research professor in medicine and director of the study. “We suspect that
chronic sleep loss may not only hasten the onset but could also increase the
severity of age-related ailments, such as diabetes, hypertension, obesity, and
memory loss.”5
The subjects showed profound alterations in glucose metabolism during sleep deprivation, and during the height of their sleep debt the subjects took 40 percent longer than normal to regulate their blood-sugar levels following an injection of glucose. Their ability to secrete insulin was decreased by about 30 percent, which is an early marker of diabetes.5 Sleep deprivation also dampened the secretion of thyroid-stimulating hormones and increased blood levels of cortisol, which was especially marked in the afternoon and evening. This finding is generally found in much older subjects and is considered to be linked to age-related health problems.
After the subjects were allowed twelve hours of sleep, the abnormalities returned to the original baseline readings. As the subjects recovered more than eight hours of sleep on consecutive nights, their original baseline normal readings improved further, which suggests that even healthy, young adults require more than eight hours of sleep a night to reach a completely rested state. The researchers concluded that although the primary accepted reason for sleep is cerebral restoration, they suggest that sleep loss also has long-term consequences for peripheral function that may have adverse chronic health effects.5
Hypertension
The increased risk of hypertension has been shown to affect shift workers’
blood pressure at work, after work, and even during sleep, according to a study
completed by Ghent University in Belgium. They state that while the increase in
blood pressure is not huge, it’s enough to confer a substantial risk of heart
disease.6 The study showed that the stressed shift workers’ blood pressure was
highest on the job—5.9/3.0 mmHg higher6 than non-stressed workers—and their
blood pressure was also higher at home, including while they were sleeping. The
higher blood pressure was attributed to work-related stress called “high job
strain,” a condition where a worker is exposed to “high psychological demands”
in combination with “low job control.”6 It is suggested that the low job
control is the larger aspect of job strain and it most affects blood pressure.
Even temporary spikes in blood pressure, if occurring often enough, can damage
blood vessels, the heart, and kidneys, just as chronic hypertension causes
damage.
Symptoms of mild hypertension can be similar to general stress symptoms, such as headache, dizziness, and shortness of breath and/or chest pain or pressure, and may not be taken seriously. A person may be asymptomatic, meaning that the increase in pressure gives no physical symptoms to the person at all. The person may feel perfectly normal but the hypertension exists and is causing slow damage.
Increased Mortality
Many studies have found links between stress, lack of sleep, and a person’s
overall health, but one study may have found a link between sleep deprivation
and an increase in general mortality. Researchers followed the sleep patterns of
10,000 government workers ages thirty-five to fifty-five and tracked their
mortality rates for almost twenty years, until 2004.vii Those subjects who
decreased their sleep from seven or more hours to five or less hours a night had
a 1.7-fold increase of death in general, after all other risk factors were
adjusted.7 It is suspected that short durations of sleep raise a person’s
overall daily blood pressure. The risk of cardiovascular death is more than
double, and researchers believe it’s related to the increase in blood pressure
due to the overall lack of sleep.
Unfortunately, hypertension often is undetected, especially in younger adults. According to data from the National Health and Nutrition Examination Study, 24 percent of adults ages thirty-two to fifty-nine who slept for five or less hours a night developed hypertension verses 12 percent of those that got seven to eight hours of sleep; 30 percent of the people who developed hypertension did not know they had it.8 As previous studies have illustrated, even a slight, long-term increase in blood pressure can have serious consequences.
In people already diagnosed with hypertension, less than seven and half hours of sleep a night increased their risk of heart attack or stroke, according to a study conducted by Dr. Euguchi of Jichi Medical University. This report stated that this increased risk was more apparent in those sleepers whose shorted rest could not lower their blood pressure overnight. During this study, conducted over a 50-month period, ninety-nine heart attacks, strokes, or cardiac arrests were recorded in patients ages thirty-three to ninety-seven.9
Sleep deprivation also increases a person’s risk for an automobile accident. The National Highway Traffic Safety Administration (NHTSA) estimates that sleep-deprived drivers account for approximately 100,000 automobile accidents, 71,000 injuries, and 1550 fatalities annually. According to various studies, sleep deprivation has a higher risk of death than smoking, high blood pressure, and heart disease. Also, severe insomnia triples the risk of death in elderly men.10
Insomnia
Often, paramedics’ sleep patterns may be so disrupted that it leads to
insomnia. It is important for any symptoms of insomnia to be acknowledged early
so that proper rest and treatment can be initiated. Some of these symptoms are:
difficulty falling asleep, waking during the night or early in the morning
without outside cause, not feeling well-rested after a full night’s sleep,
daytime fatigue, irritability, depression, anxiety, difficulty focusing,
increased errors, headaches, gastrointestinal problems, and worries about
sleep. Increased risk factors for insomnia include being a woman, any person
over sixty years of age, having a mental health disorder (paramedics may fall in
the post traumatic stress area of mental health), increased stress, and night
shift work or frequent shift changes.11
How to Combat Sleep Deprivation
The obvious answer, of course, is to get more sleep. However, that’s not
usually possible in emergency medicine. One may start with the best intentions
to increase his or her sleep but work and life do not usually comply. The usual
actions and treatments for insomnia for a person with a normally-scheduled
career often don’t mesh well with an EMS career. For example, many insomniacs
are prescribed sleep medications, such as Ambien©, but this is impossible for a
paramedic to take while on duty, since it will significantly impair his or her
ability to reawaken if called. Conversely, the advice to avoid daily naps also
does not work well, since during a shift, a daytime nap may be the only sleep a
paramedic is allowed.
However, other actions may be of use, especially during off-duty time. Paramedics must strive to maintain a regular sleeping schedule while off duty. Learning relaxation techniques, such as biofeedback and meditation, will assist in reducing anxiety. Limiting time spent in bed while sleepless will also help reduce anxiety. Exposure to sunlight or a medical grade light box for thirty minutes daily during the evening can readjust a person’s internal clock. Paramedics should: make their home bedroom a comfortable, dark, cool place to sleep, removing any TVs or computers; limit caffeine, alcohol, and nicotine; exercise vigorously for at least thirty minutes daily; avoid large meals and drinks before bedtime; ensure that prescribed medications are correct; and hide the clocks in their bedroom to avoid obsessing over time.11
Conclusion
Paramedics and those supporting them need to learn when their health is more
important than any overtime shifts or their future patients’ health. Of course,
if the paramedic’s health is impacted, it will, at some point, directly affect
his or her patients, employers, family, and the public. A common personality
trait in paramedics is the arrogance in thinking that they are beyond the same
medical afflictions of the public; this, coupled with the public and
professional conditioning to put others’ needs first, can result in a very
unhealthy paramedic.
Paramedics must learn when to place their health and personal needs before the job. They must learn how to say no when asked to work too many shifts. Paramedics must learn to make healthy lifestyle choices to offset the negative influences of their career. They must learn how to find mental and physical balance in a career based on imbalance. But, while paramedics must learn to take personal responsibility for their own health, they can’t do it alone.
EMS employers must share responsibility by providing a healthy work environment in any way possible. Employers should provide an area for physical fitness, encourage healthy lifestyle choices, and, when time permits, allow daily naps without negative consequences. There is a national shortage of paramedics, which creates a greater need for empty shifts to be covered by currently overworked paramedics. Therefore, employers must do all they can to hire and retain a full staff and not place negative pressure on current paramedics to work excessive hours. Employers should monitor the physical and mental health of their employees whenever possible.
Family members and friends of paramedics can help by providing a supportive, positive home environment. They can try to be more understanding when the paramedic is exhausted and needs additional sleep during the day. Families can practice healthy lifestyle choices and encourage regular exercise.
And last, but certainly not least, the public can help by stepping outside of their personal environment and becoming involved with their community services. The public can do their best by learning about the requirements and limitations of their emergency services, and understanding that even during the most tragic of circumstances, we are only human.
Author: Heather Gaff Mewis, Copyright CE Solutions. All Rights Reserved.
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