Stress and Sleep Deprivation in EMS

Stress seems like it should be a four-letter word with the negative connotation that it holds. Visions of stressed-out, exhausted responders running calls all through the night come to mind, one call after the other, devoid of emotion. It seems that to have a career in public safety means simply accepting the nasty side effects of stress and fatigue, but it does not have to be this way. There are simple and effective techniques you can practice to limit and even reverse the effects of fatigue and stress.

Strange as it seems, not all stress is bad. There is good stress and bad stress. Good stress helps your mind and body prepare for an event, tests, sports and running calls. Exercise is good stress: Your body grows and becomes stronger when you stress it. Stress becomes bad when the stress mechanism and stress response do not shut off. Remember the sympathetic vs. parasympathetic nervous system--flight or fight? In the early days, if a caveman was challenged by a tiger, there were two options: run or fight. If he survived the encounter, the natural response was to rest and heal, thus resetting the stress response. In today's busy public safety world, the stress response looks like Figure 1.

Today, the stress mechanism functions just as it did in the days of cavemen. The problem is that the stress response does not discriminate a real threat from a perceived threat. Does this scenario sound familiar? You’re sitting in heavy rush-hour traffic when you get a call for a shooting. You feel your blood pressure skyrocket, and your mind races as the red lights and traffic threaten your ability to reach the scene. You arrive at the call, where media and bystanders seem as menacing as the sabertooth tiger appeared to your caveman ancestor. Your heart pumps faster as blood rushes to the large muscles in preparation for your mad dash to the trauma center. You make it to the ER, and now it is time to calm down and write your report, but your supervisor is calling and the media are asking questions. You notice your breathing getting heavier, and you start to feel a little queasy. Your mind begins to race and, unlike the caveman whose primitive mind was focused solely on life and death, you find it hard to focus on your report when your mind is bombarded with myriad scattered thoughts. You make it through the call and, after a less-than-nutritious fast-food snack and a soda, you check back in, ready for the next call. The problem here is that the caveman was under stress in relatively short spurts in an average day, while EMS responders face an onslaught of figurative sabertooths that keep the stress response on at all times.

Compounding the effects of stress is sleep deprivation. Unfortunately, fatigue and public safety are married, and the more tired you become, the less your body is able to deal with stress. It’s a vicious cycle. Many of the diseases we treat in EMS are a direct result of stress and fatigue. When the two get going, the body is unable to heal, immunity decreases and markers of total body inflammation increase. The body simply cannot rest and rebuild when circadian rhythms are frequently disrupted. For example, you may work the night shift five nights in a row, followed by two days off. During the two days off, you resume normal daytime (diurnal) activity with family or friends. This disrupts your previously adjusted circadian rhythm, and you must readjust your sleep-wake pattern when you return to work. Without a constant sleep-wake pattern, biological rhythms remain out of synch.

Generally, mood cycles and physiological processes, like the fluctuation of hormone levels, play significant roles in sleep routine. These factors are, in turn, altered by frequently changing sleep habits. So there may be complications for a shift worker who suffers from seasonal affective disorder or depression. Spending nights awake and days asleep may intensify the effects on a person with a psychiatric disorder.

The February 15, 2005, issue of American Family Physician noted that shift work has been associated with cluster headaches. The consequences of disturbing natural circadian rhythms have also been investigated. In 1986, a study by Knutsson et al. found that shift workers who had worked for 15 years or more were 300% more likely to develop ischemic heart disease. In 1987, working the night shift first became associated with higher rates of cancer. This may be due to alterations in circadian rhythm, as melatonin, a known tumor suppressant, is generally produced at night and late shifts may disrupt its production. The International Agency for Research on Cancer, part of the World Health Organization, has listed night work as a "probable cause" of cancer since December 5, 2007.

Now that we are absolutely certain our career is hazardous to our health, there are some very simple steps we can take to protect us from stress and fatigue.

First and foremost is stress management. Stress management takes many forms, including regular exercise, hobbies, good nutrition, relaxation techniques and general awareness of what triggers stress. We can combat the effects of stress through improved fitness, staying hydrated, eating healing foods and yes, breathing. The more stressed we are, the more rapid and shallow we breathe. You could say that many of us are borderline hypoxic on a daily basis.

At this point, there should be no doubt that sleep deprivation and altered sleep patterns will negatively affect you. The good news is that the same techniques to reduce and deal with stress also work with fatigue. The better your physical condition, hydration and nutrition, the easier it is for your body to deal with fatigue. Napping, which is not a problem for most responders, is a fantastic way to counter fatigue. The only caveat is that naps should not be longer than 45 minutes. If you nap too long, your body may get confused and try to take you into a deep sleep, which will confuse your sleep-wake cycle more than it already is. Anyone who has responded to a call at 4 a.m. after waking from a deep sleep can attest to this feeling.

Since stress is part of life, and almost part of a job description for public safety, with fatigue a close second, we can help ourselves to be well. I challenge field responders to exercise three days a week, stay well hydrated, and eat smart and healthy. Nap when able, and get good sleep when you can. I challenge administration to 'bend the rules' a bit to enable a culture of wellness to take root and to give employees a chance to make good food choices and the opportunity to exercise. Together we can create a public safety culture of wellness, both physically and mentally. We just need to get out of our own way.

Bryan Fass is the author of "Fit Responder," a comprehensive wellness plan for the first responder (www.fitresponder.com) and the Fit Responder Blog ((www.fitresponder.wordpress.com). Bryan has a Bachelor's Degree in Sports Medicine and is certified as a licensed athletic trainer and a strength and conditioning specialist. He was a paramedic for over eight years, and has authored four books regarding fitness, wellness and human performance. Bryan is available for consulting and speaking on Public Safety Fitness Testing along with Fitness, Wellness and Injury Prevention Programs. Contact him at bryan@firepoliceemsfitness.net.