Drowsy and dangerous? Fatigue in paramedics: an overview

Scott Ramey, Alexander MacQuarrie, Alyson Cochrane, Ivan McCann, C. William Johnston, Alan M Batt

DOI: http://dx.doi.org/10.32378/ijp.v4i1.175



Fatigue is a complex phenomenon that has effects on physical characteristics, cognition, behaviours, and physical and mental health. Paramedicine crosses the boundaries of many high-risk industries, namely medicine, transport and aviation. The effects of fatigue on paramedics thus need to be explored and considered in order to begin to identify appropriate interventions and management strategies.


The aim of this article was to provide an overview of fatigue in paramedics and its potential effects on various areas of paramedic practice and paramedic health, and to outline potential solutions to assess and manage the risk of fatigue in paramedics as suggested by the literature.


We conducted unstructured, non-systematic searches of the literature in order to inform an overview of the literature. An overview is a summary of the literature that attempts to survey the literature and describe its characteristics. We thematically structured the review under the following headings: defining occupational activity and health status; clinical performance and patient safety; shift length and time at work; effects on paramedic health; effects on driving abilities; fatigue risk management; and, fatigue proofing.


Fatigue should be considered in the context of overall paramedic health status and paramedic occupational activity. The nature of paramedic shift work, and the associated occupational activity place paramedics at increased risk from fatigue. Shift work may also contribute to sleep disorders among paramedics. Fatigue is associated with increased errors and adverse events, increased chronic disease and injury rates, depression and anxiety, and impaired driving ability.


The issue of fatigue in paramedicine is complex and has serious consequences for patients and paramedics. Paramedic services and paramedics need to work collaboratively to identify and action appropriate measures to reduce the effects of fatigue on the wellbeing of the workforce and mitigate its effects on clinical performance and safety.


fatigue; paramedic; EMS; mental health; physical health; sleep

Full Text:



Brown ID. Driver Fatigue. Hum Factors [Internet]. 1994 Jun 23;36(2):298–314. Available from: https://doi.org/10.1177/001872089403600210

Bartley SH, Chute E. Fatigue and impairment in man. [Internet]. Fatigue and impairment in man. New York, NY, US: McGraw-Hill Book Company; 1947. ix, 429-ix, 429. Available from: https://doi.org/10.1037/11772-000

Grant MJ, Booth A. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Info Libr J [Internet]. 2009;26(2):91–108. Available from: https://doi.org/10.1111/j.1471-1842.2009.00848.x

Bell RC. The Ambulance: A History [Internet]. McFarland & Company; 2009. Available from: https://books.google.ca/books?id=-YtlthqHmHsC

Bureau of Labor Statistics. Occupational Outlook Handbook, EMTs and Paramedics. [Internet]. 2018 [cited 2019 Feb 8]. Available from: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm#tab-3

Maguire BJ, Smith S. Injuries and Fatalities among Emergency Medical Technicians and Paramedics in the United States. Prehosp Disaster Med [Internet]. 2013 Aug 9;28(04):376–82. Available from: https://doi.org/10.1017/S1049023X13003555

Maguire BJ, O’Meara PF, Brightwell RF, O’Neill BJ, Fitzgerald GJ. Occupational injury risk among Australian paramedics: an analysis of national data. Med J Aust [Internet]. 2014 May 5;200(8):477–80. Available from: https://doi.org/10.5694/mja13.10941

Gray S, Collie A. Worker’s compensation claims among nurses and ambulance officers in Australia, 2008/09-2013/14. [Internet]. Melbourne; 2016. Available from: https://www.iscrr.com.au/__data/assets/pdf_file/0004/487552/workers-compensation-claims-among-nurses-and-ambulance-officers-in-Australia-20082014.pdf

Goodwin I. Report on Health. Report on Health 2017. Sydney; 2017.

Buzga M, Jirak Z, Buzgova R. State of physical health and fitness of paramedics in Czech republic. Wulfenia. 2015;22(3).

MacQuarrie AJ, Robertson C, Micalos P, Crane J, High R, Drinkwater E, et al. Fit for duty: The health status of New South Wales Paramedics. Irish J Paramed [Internet]. 2018;3(2). Available from: https://doi.org/10.32378/ijp.v3i2.109

Studnek JR, Bentley M, Mac Crawford J, Fernandez AR. An Assessment of Key Health Indicators among Emergency Medical Services Professionals. Prehospital Emerg Care [Internet]. 2010 Jan 30;14(1):14–20. Available from: https://doi.org/10.3109/10903120903144957

Hegg Deloye S. Work-related and Dietary Factors Associated with Weight Gain over the Period of Employment in Paramedics. Occup Med Heal Aff [Internet]. 2014;02(04). Available from: https://doi.org/10.4172/2329-6879.1000173

Boreham CA, Gamble RP, Wallace WF, Cran GW, Stevens AB. The health status of an ambulance service. Occup Med [Internet]. 1994;44(3):137–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7919297

Kales SN, Tsismenakis AJ, Zhang C, Soteriades ES. Blood Pressure in Firefighters, Police Officers, and Other Emergency Responders. Am J Hypertens [Internet]. 2009 Jan 1;22(1):11–20. Available from: https://doi.org/10.1038/ajh.2008.296

Hegg-Deloye S, Brassard P, Prairie J, Larouche D, Jauvin N, Poirier P, et al. Prevalence of risk factors for cardiovascular disease in paramedics. Int Arch Occup Environ Health [Internet]. 2015 Oct 6;88(7):973–80. Available from: https://doi.org/10.1007/s00420-015-1028-z

Gamble RP, Stevens AB, McBrien H, Black A, Cran GW, Boreham CAG. Physical-Fitness and Occupational Demands of the Belfast Ambulance Service. Br J Ind Med. 1991;48(9):592–6.

Karlsson K, Niemelä P, Jonsson A. Heart Rate as a Marker of Stress in Ambulance Personnel: A Pilot Study of the Body’s Response to the Ambulance Alarm. Prehosp Disaster Med [Internet]. 2011 Feb 25;26(01):21–6. Available from: https://doi.org/10.1017/S1049023X10000129

Backe EM, Kaul G, Klussmann A, Liebers F, Thim C, Massbeck P, et al. Assessment of salivary cortisol as stress marker in ambulance service personnel: comparison between shifts working on mobile intensive care unit and patient transport ambulance. Int Arch Occup Environ Health [Internet]. 2009 Oct;82(9):1057–64. Available from: https://doi.org/10.1007/s00420-009-0428-3

Caruso C, Hitchcock R. Russo. J. Schimt, J. ED, Anonymous. Overtime and Extended Work Shifts: Recent findings on illness, injuries and health behaviours. Natl Inst Occup Saf Heal [Internet]. 2004; Available from: https://doi.org/10.1109/IEMBS.2009.5333242

Ashish jha, Duncan B, Bates D. Fatigue, Sleepiness, and Medical Errors. In: Making health care safer: a critical …. 2001.

West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA - J Am Med Assoc [Internet]. 2009; Available from: https://doi.org/10.1001/jama.2009.1389

Monaco K, Williams E. Assessing the Determinants of Safety in the Trucking Industry. J Transp Stat. 2000;3(1):69–79.

van der Ploeg E. Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med [Internet]. 2003;60(>90001):40i–46. Available from: http://oem.bmj.com/cgi/doi/10.1136/oem.60.suppl_1.i40

Patterson PD, Weaver MD, Frank RC, Warner CW, Martin-Gill C, Guyette FX, et al. Association Between Poor Sleep, Fatigue, and Safety Outcomes in Emergency Medical Services Providers. Prehospital Emerg Care [Internet]. 2012 Jan 5;16(1):86–97. Available from: https://doi.org/10.3109/10903127.2011.616261

Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D. Sleep Quality and Fatigue Among Prehospital Providers. Prehospital Emerg Care [Internet]. 2010 Jun 3;14(2):187–93. Available from: https://doi.org/10.3109/10903120903524971

Donnelly E, Bradford P, Hedges C, Davis M, Socha D, Morasutti P. Fatigue, shiftwork, and safety outcomes in Canadian paramedics. Prehospital Emerg Care. 2017;21(1):119.

Harrison Y, Horne JA. The impact of sleep deprivation on decision making: a review. J Exp Psychol Appl [Internet]. 2000 Sep;6(3):236–49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11014055

Lim J, Wu W, Wang J, Detre JA, Dinges DF. Perfusion Study of the Time-On-Task Effect. Neuroimage. 2010;49(4):3426–35.

Gillberg M, Kecklund G, Åkerstedt T. Sleepiness and performance of professional drivers in a truck simulator - Comparisons between day and night driving. J Sleep Res. 1996;5(1):12–5.

Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL. The link between fatigue and safety. Accid Anal Prev [Internet]. 2011;43(2):498–515. Available from: http://dx.doi.org/10.1016/j.aap.2009.11.011

Patterson PD, Weaver MD, Hostler D, Guyette FX, Callaway CW, Yealy DM. The Shift Length, Fatigue, and Safety Conundrum in EMS. Prehospital Emerg Care [Internet]. 2012; Available from: https://doi.org/10.3109/10903127.2012.704491

Donnelly E, Bradford P, Hedges C, Davis M, Socha D, Winter E. Stress and safety in EMS: How work-related stresses and fatigue relate to safety outcomes. Prehospital Emerg Care. 2016;20(1):159.

Fletcher A, Dawson D. A quantitative model of work-related fatigue: Empirical evaluations. Ergonomics [Internet]. 2001;44(5):475–88. Available from: https://doi.org/10.1080/00140130119824

Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and “accidents.” Am J Ind Med [Internet]. 2006;49(11):953–63. Available from: https://doi.org/10.1002/ajim.20307

Scott LD, Rogers AE, Hwang W-T, Zhang Y. Effects of critical care nurses’ work hours on vigilance and patients’ safety. Am J Crit care [Internet]. 2006 Jan;15(1):30–7. Available from: https://doi.org/10.4037/ajcc2012607

Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff. 2004;23(4):202–12.

Hanecke K, Tiedemann S. Original articles Accident risk as a function of hour at work and time of day as determined from accident data and exposure models for the German working population. 2011;28(6):43–8. Available from: https://doi.org/10.1073/pnas.1524845114

Folkard S, Tucker P. Shift work, safety and productivity. Occup Med (Chic Ill). 2003;53(2):95–101.

Courtney JA, Francis AJP, Paxton SJ. Caring for the country: Fatigue, sleep and mental health in Australian rural paramedic shiftworkers. J Community Health. 2013;

Courtney JA, Francis AJP, Paxton SJ. Caring for the Carers: Fatigue, Sleep, and Mental Health in Australian Paramedic Shiftworkers. Aust New Zeal J Organ Psychol [Internet]. 2010; Available from: https://doi.org/10.1375/ajop.3.1.32

Sofianopoulos S, Williams B, Archer F, Thompson B. The exploration of physical fatigue, sleep and depression in paramedics: a pilot study. J Emerg Prim Heal Care [Internet]. 2011;9(1):Article 990435. Available from: https://doi.org/10.1017/CBO9781107415324.004

Carleton RN, Dobson KS, Keane TM, Afifi TO, Turner S, Taillieu T, et al. Suicidal Ideation, Plans, and Attempts Among Public Safety Personnel in Canada. Can Psychol [Internet]. 2018;59(3):220–31. Available from: http://proxy1.calsouthern.edu/login?url=https://search.proquest.com/docview/2108802706?accountid=35183

Vigil NH, Grant AR, Perez O, Blust RN, Chikani V, Vadeboncoeur TF, et al. Death by Suicide—The EMS Profession Compared to the General Public. Prehospital Emerg Care [Internet]. 2018 Sep 14;0(0):1–6. Available from: http://dx.doi.org/10.1080/10903127.2018.1514090

Caruso CC. Negative Impacts of Shiftwork and Long Work Hours. Rehabil Nurs [Internet]. 2014 Jan;39(1):16–25. Available from: https://doi.org/10.1002/rnj.107

Dianne L Elliot and Kerry s keuhl. Effects of Sleep Deprivation on Fire Fighters and EMS Responders. Int Assoc Fire Chiefs [Internet]. 2007;1–104. Available from: https://aams.org/toolbox/IAFC - Effects of Sleep Deprivation Report.pdf

Pannain S, Beccuti G, Van Cauter E. The connection between sleep loss, obesity, and type 2 diabetes. In: Sleep Loss and Obesity: Intersecting Epidemics [Internet]. 2012. Available from: https://doi.org/10.1007/978-1-4614-3492-4_10

Beccuti G, Pannain S. Sleep and obesity [Internet]. Current Opinion in Clinical Nutrition and Metabolic Care. 2011. Available from: https://doi.org/10.1097/MCO.0b013e3283479109

Akerstedt T. Consensus statement: fatigue and accidents in transport operations. J Sleep Res [Internet]. 2000;9(4):395. Available from: https://doi.org/10.1046/j.1365-2869.2000.00228.x

Williamson AM, Feyer A. Moderate sleep deprivation produces impairments in cognitive and motor perfor ... Heal (San Fr. 2000;649–55.

Haraldsson P-O, Åkerstedt T. Sleep disturbances - Greater traffic hazard than alcohol. Causes, risks and treatment. Lakartidningen [Internet]. 2001; Available from: https://doi.org/10.1109/ICMLC.2008.4620583

Dinges DF. An overview of sleepiness and accidents. J Sleep Res [Internet]. 1995 Dec;4:4–14. Available from: https://doi.org/10.1111/j.1365-2869.1995.tb00220.x

Kribbs NB, Dinges D. Vigilance decrement and sleepiness. In: Sleep onset: Normal and abnormal processes [Internet]. 1994. Available from: https://doi.org/10.1037/10166-000

Haraldsson PO, Carenfelt C, Laurell H, Tornros J. Driving vigilance simulator test. Acta Otolaryngol [Internet]. 1990; Available from: https://doi.org/10.3109/00016489009122528

Philip P, Sagaspe P, Moore N, Taillard J, Charles A, Guilleminault C, et al. Fatigue, sleep restriction and driving performance. Accid Anal Prev [Internet]. 2005;37(3):473–8. Available from: https://doi.org/10.1016/j.aap.2004.07.007

Takeyama H, Itani T, Tachi N, Sakamura O, Murata K, Inoue T, et al. Effects of a modified ambulance night shift system on fatigue and physiological function among ambulance paramedics. J Occup Health [Internet]. 2009;51(3):204–9. Available from: https://doi.org/10.1539/joh.L7040

Dawson D, McCulloch K. Managing fatigue: It’s about sleep [Internet]. Sleep Medicine Reviews. 2005. Available from: https://doi.org/10.1016/j.smrv.2005.03.002

Helmreich RL, Klinect JR, Wilhelm JA. Models of threat, error and response in flight operations. Tenth Int Symp Aviat Psychol. 1999;677–82.

Reason J. Human Factors Aspects of Safety Management Systems. In: Proceedings of the 15th Annual FAA/TC/CAA Maintenance Human Factors Symposium. London; 2001.

Steege LM, Rainbow JG. Fatigue in hospital nurses — ‘Supernurse’ culture is a barrier to addressing problems: A qualitative interview study. Int J Nurs Stud. 2017;

Dawson D, Chapman J, Thomas MJW. Fatigue-proofing: A new approach to reducing fatigue-related risk using the principles of error management [Internet]. Sleep Medicine Reviews. 2012. Available from: https://doi.org/10.1016/j.smrv.2011.05.004

Patterson PD, Higgins JS, Van Dongen HPA, Buysse DJ, Thackery RW, Kupas DF, et al. Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services. Prehospital Emerg Care [Internet]. 2018;22(S1):89–101. Available from: https://doi.org/10.1080/10903127.2017.1376137

Dawson D, Mayger K, Thomas MJW, Thompson K. Fatigue risk management by volunteer fire-fighters: Use of informal strategies to augment formal policy. Accid Anal Prev [Internet]. 2015; Available from: https://doi.org/10.1016/j.aap.2015.06.008

Martin-Gill C, Higgins JS, Van Dongen HPA, Buysse DJ, Thackery RW, Kupas DF, et al. Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services. Prehospital Emerg Care [Internet]. 2018;22(S1):102–9. Available from: https://doi.org/10.1080/10903127.2017.1381791

Dawson D, Cleggett C, Thompson K, Thomas MJW. Fatigue proofing: The role of protective behaviours in mediating fatigue-related risk in a defence aviation environment. Accid Anal Prev [Internet]. 2017; Available from: https://doi.org/10.1016/j.aap.2015.10.011

Mathew JJ, Joseph M, Britto M, Joseph B. Shift work disorder and its related factors among health-care workers in a tertiary care hospital in Bangalore, India. Pakistan J Med Sci [Internet]. 2018; Available from: https://doi.org/10.12669/pjms.345.16026

DOI: http://dx.doi.org/10.32378/ijp.v4i1.175


  • There are currently no refbacks.

Copyright (c) 2019 Scott Ramey, Alexander MacQuarrie, Alyson Cochrane, Ivan McCann, C. William Johnston, Alan M Batt

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

IJP is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) licence. Article copyright remains with individual authors. Authors grant unrestricted copyright license to the IJP. Readers may copy, distribute, build upon, reproduce, and display the work with the proper citation of the original work in this publication.

DPLA Rights statement:http://rightsstatements.org/page/InC-NC/1.0/?language=en. The IJP supports the National Principles for Open Access Policy Statement.