Risks associated with lack of sleep and improper rest – both the immediate fatigue-related accidents and the long-term health risks – cannot be overlooked. The threat of serious accident, injury and harm increases as one is unable to rest or sleep properly. Recent warnings by the European Union Aviation Safety Agency (EASA) in its report entitled ‘Possible Risks Emerging During Summer 2023’ have recommended more robust safety risk management processes for air operators to include better planning of rosters and frequent review of schedules to ensure that staff and crew are not overworked or fatigued through the appropriate use of biomathematical models – such as InterDynamics’ FAID Quantum. Explaining how FAID Quantum works, Peter Page, Managing Director at InterDynamics said: “FAID Quantum incorporates an unsurpassed sleep predicter. By inputting the hours of work activity, that precludes sleep opportunity, it then predicts length and timing of sleep and then determines the Karolinska Sleepiness Scale (KSS) score based upon the likely sleep.

“This biomathematical model’s rich and insightful assessment and outputs supports enlightened discussions, personal sleep improvements and informed company fatigue management.”

At the heart of the risk management process, EASA also recommends ‘fostering a positive safety culture’ at all levels of an organization. These warnings came with the acknowledgement that 2023 was going to be a busier summer than had been experienced in the last few years, and that operators should be prepared.

How well rested are you?

Do you think you got enough sleep in the past week? Can you recall when you last woke without an alarm, feeling refreshed and not needing caffeine? Would you like to be getting more sleep? Considering how you answered those questions:

• How will your tiredness affect your primary role today?
• How will your team interactions be influenced or changed?
• How could patient or aircraft safety deteriorate because of your fatigue?

78 per cent of UK ambulance service personnel reported poor sleep quality, and most shift workers reported severe fatigue

If you are concerned that you are alone, it’s not just you: sleep issues are common. Concerns regarding sleep are a glaring omission in most of today’s health and performance conversations, and missing from many safety risk management systems. A recent report published by the aviation safety management consultancy Baines Simmons titled ‘A fatigue survey of European Pilots’ used data collected from 6,893 responses from pilots across Europe in July 2023 to gauge their levels of fatigue and the overall flight safety risks associated with it. The findings are damning where, despite the warning from the European regulator, the majority of pilots in seven major countries felt that fatigue risk was either ‘mostly not well managed’ or ‘not well managed’ by their organizations. The country with the worst outcome in the report was the UK, with 72 per cent stating that fatigue risk was either ‘mostly not well managed’ or ‘not well managed’. Of the other European countries where fewer than half were dissatisfied with the management of fatigue risk, the country whose pilots fared the best was Switzerland, but even then, it was still very nearly a third of pilots who felt that fatigue risk management fell short and was ‘mostly not well managed’ or ‘not well managed’. If this wholesale poor management of fatigue is left to carry on, then it won’t be long before the most serious of consequences are seen.

This is not a problem for European pilots alone: a paper by researchers at the University of East Anglia reported that 78 per cent of UK ambulance service personnel reported poor sleep quality, and most shift workers reported severe fatigue. Additionally, 70 per cent of staff in East of England Ambulance Service arrived for work with inadequate rest and half of respondents said they were trying to improve their alertness at work.

In the USA, the Centers for Disease Control and Prevention (CDC) has classified sleep disorders as a public health epidemic. The CDC states that a third of US adults get less than the recommended amount of sleep, linking the effects of this to a wide range of medical issues, including type 2 diabetes, heart disease, obesity, and depression, as well as accidents at home and work.

A third of US adults get less than the recommended amount of sleep, linking the effects of this to a wide range of medical issues, including type 2 diabetes, heart disease, obesity, and depression

Advising how organizations can manage their fatigue risk, Page said: “There are three components to fatigue risk assessment:

• Risk profile of hours of work: Determine the fatigue exposure based upon the sleep opportunity provided by the hours of work – we use FAID Quantum to conduct an hours of work fatigue diagnostic
• Risk profile of individuals: Determine the risk profile of personal aspects (health, sleep disorders, secondary activities, family circumstances, sleeping facilities, commute times, corporate and personal support systems and more) – we use a targeted online questionnaire to survey staff
• Risk profile of the job type/role: Determine the fatigue-related hazards in the work place – we facilitate formalized Fatigue Hazard Analysis workshops.”

Getting the right amount of sleep

“The shorter your sleep, the shorter your life.” So says Prof Matthew Walker in ‘Why We Sleep’.

As aircrew, you’ve probably had many a disturbed night’s sleep in order to go flying on rescue callouts or due to irregular shift patterns, and standby rotas. You’ll also know about human performance limitations and how important it is to be well rested. Yet this isn’t always easy to achieve. Shiftwork is inherently tiring and reduces life expectancy, and yet workers still don’t seem to be able to get the regular sleep that they should. This is not just one’s personal responsibility, but an organizational opportunity to care for their staff, either with the aid of the numerous companies that provide fatigue risk management services (training, software and other services) or through their own governance and safety processes.

During Andy Elwood’s 20-year emergency services career, there have been times when he’s been physically exhausted and mentally drained. Fatigue risk management systems protected him in Royal Air Force (RAF) military and Coastguard search and rescue operations as a winch paramedic during 24-hour shifts. However, he felt real fatigue when working on the RAF Medical Emergency Response Team (MERT) battlefield rescue helicopter over a summer tour in Afghanistan, as these protections were prone to be flexed more readily for operational reasons.

A few years ago, when asked “So how long haven’t you been sleeping well for?”, Elwood stopped in his tracks. He realized that the answer was two to three years. This was the motivator to make changes and do something about not sleeping properly. Sorting out sleeping habits and routine, Elwood was able to reset and start again – giving him the resilience to bounce back from depression and burnout. Ask yourself the same question and, if it has been going on for any significant length of time, consider what you need to do to remedy the issue.

The most common way for emergency services responders to start a conversation about how they really feel mentally and emotionally is that they’ve not been sleeping well

The most common way for emergency services responders to start a conversation about how they really feel mentally and emotionally is that they’ve not been sleeping well recently, or they don’t remember when they last got a really good night’s sleep. In many areas of the emergency services, people still aren’t comfortable or confident talking about stress or mental health, so a sleep conversation is often where it starts. Be aware of the poor sleeping narrative as a warning sign of declining mental health in yourself or your colleagues.

Sleep research in recent years has shown that sleeping well is integral to a healthy life, both physically and mentally. Often sleep is one of the first casualties when under pressure for deadlines or feeling stressed, and also when routines are broken or by staying up late on days off.

Mechanism of sleep

Quantity and, importantly, quality of sleep matters to these functions:

• Learning and memory retention
• Restocking immune system
• Managing metabolism via the glucose–insulin balance
• Weight control by regulating appetite and making healthy choices
• Reducing blood pressure and risk of heart conditions
• Flourishing microbiome in gut, strengthening the immune system and nutritional health.

It is recommended by the UK’s National Health Service (NHS), the American Heart Association and innumerable other healthcare institutions that adults get seven to nine hours of sleep per night. Rapid eye movement (REM) sleep is the crucial quality stage of sleep and Prof Walker describes REM sleep as a neuro-chemical bath, which services the brain and body. The bad news is that research from the Chronobiology and Sleep Institute at University of Pennsylvania, Philadelphia, PA, USA, shows that we can’t really fully catch up on chronic lost  sleep and we will be running on a deficit.

Rapid eye movement (REM) sleep is the crucial quality stage of sleep and Prof Walker describes REM sleep as a neuro-chemical bath

There is so much benefit from sleep that the focus in current research is ‘are there any biological functions that don’t benefit from sleep?’ and the answer from the wealth of research projects so far is ‘no’.

Our sleep drive – or need for sleep – comes from adenosine, which builds up during the day and cycles through the circadian rhythm. We tend to sleep better on a regular basis when we have an established pattern that we can mostly stick to. This is not easy to do on shift patterns in the emergency rescue world.

For someone that wakes at 07:00 hrs and gets to bed at 23:00 hrs, giving themselves an eight-hour opportunity for sleep, their sleep drive (Fig 1; shown in green) increases during the day until 23:00 hrs, when they fall asleep and the sleep drive can begin to fall again, as sleep is happening.

As this person cycles through the 48-hour period, we see that the dotted red line of the wake drive has the most rapid rise early in the morning, during the first hours of wakefulness. Prof Walker encourages us to get as much daylight as we can early in the day to feel more awake (and, similarly, you should avoid light to get to sleep, especially when coming off a night shift). During the day this wake drive falls away and when the gap between sleep drive and wake drive is largest (23:00 hrs), that is when the person is more likely to fall asleep.

Sleep hygiene

In order to benefit most from the sleep drive at its peak, or if you are working on shift patterns, at an appropriate length of time before you need to get up, you need to make the most of good ‘sleep hygiene’. Sleep hygiene is the patterns of behavior and environment associated with your sleep. Recommendations from leading healthcare professionals who specialize in sleep (such as Prof Walker, Dr Allie Hare, Dr David Flower, and Dr Sophie Bostock) often cover simple tips that fall roughly into the same broad categories:

• Rhythm – as seen by the earlier graph, the circadian rhythm, driven by light, can have a drastic effect on sleep drive, so make sure that you prepare the time before sleep by not having any individually bright ‘blue’ lights on, including your phone screen or TV, preferably by switching off devices at least an hour beforehand
• Routine – make a routine (as much as possible if you are working shifts) so that your patterns are similar before bed and on waking. Habit forming is a good way to work with and kick-start your circadian rhythm. Regular exercise (but not heavy physical exertion just before bed) also encourages a good sleep. The ‘World Health Organization Guidelines on Physical Activity and Sedentary Behaviour’ recommend physical activity where one of the positive outcomes on health is better sleep
• Room – your bedroom should be cool (dropping your core temperature by 1°C helps initiate sleep), dark and quiet, and your bedding should be comfortable and allow you to regulate your temperature effectively. As well as your physical space, you should make sure that you aren’t eating heavy meals, drinking caffeine (more on this to follow), drinking alcohol or smoking tobacco before bed as these can all prevent sleep or disrupt sleep patterns
• Relaxation – engage in calming activities, such as reading, mindfulness meditation, yoga, breathing exercises, a warm shower or bath, or listening to music, so that your mind is settled and you aren’t distracted by worries that could prevent you from sleeping. If it helps, keep a notebook by the bed and write any worries down, then they are there to be addressed when you wake and not keeping you from your sleep.

  Sedation is a different process on the brain and body to natural sleep, and is not a good substitute

If you do already adhere to a good sleep hygiene regimen and you still find that you are struggling to sleep, you should speak to your local healthcare provider. The NHS and the UK’s National Institute for Health and Care Excellence recommend the Sleepio app as an alternative to medication to help people with sleeping disorders. Free for residents in parts of the UK through the NHS and included in coverage of some health insurance policies elsewhere, the app uses artificial intelligence to guide users through a six-week program of cognitive behavioral therapy to decrease insomnia, with evidence from 12 randomized controlled trials that it is more effective than sleep hygiene, in-person therapy or sleeping pills. Indeed, Prof Walker, the NHS and the American College of Physicians do not recommend sleeping pills generally as the first route to solving sleeping problems, since sedation is a different process on the brain and body to natural sleep, and is not a good substitute.

Caffeine

Caffeinated drinks are prevalent around the world, including coffee (~150mg caffeine per cup), tea (~45mg), cola (~50mg) and ‘energy’ drinks(~80–160mg). Everyone reacts differently to caffeine – as with any drug, size, body weight and other factors can affect tolerance or effectiveness – and many use it to wake up and then stay awake later in the day. There are two really important points to know when it comes
to caffeine:

• Caffeine blocks the adenosine (sleep drive) receptors in our brain, which is why it helps us stay awake. The problem with this is that residual caffeine in your system can be preventing sleep even when you are incredibly tired. You may have built up lots of adenosine during the day, but your brain can’t access the drive to sleep because its receptors are blocked
• Caffeine has a surprisingly long half-life (four to six hours). This means that it lingers in our system well after we have consumed it, with 50 per cent of the caffeine remaining in our system up to six hours after drinking it, and 25 per cent after 12 hours from drinking. If you had your last cup of coffee at 14:00 hrs, you are likely to still have a quarter of that cup of coffee’s caffeine in your system at 02:00 hrs the next morning.

Effect on performance

According to a 2020 study published in BMC Public Health by Joanna Lowrie and Helen Brownlow using driver simulation, driver reaction times and lateral control of vehicles was poorer for sleep-deprived participants than for those who were intoxicated by alcohol. The study also concluded that coffee is not an effective countermeasure for sleep-deprived driving, and the driver’s ability to judge this impairment is suggested to be limited. It wouldn’t be acceptable to pilot complex aircraft, and perform the highly specialized procedures involved in rescuing and treating patients while drunk, so clearly, one should not be working or made to work while fatigued.

Fostering a positive safety culture – including an adequate fatigue risk management process – is everyone’s responsibility

Ensuring that you sleep well on a regular basis will help you to maintain your license, your registration and your career, and enable you to perform at your best as an individual and as part of your team to save lives. Conversely, not sleeping well, especially over a prolonged period, can have serious consequences for your career, your colleagues, your patients, and your health. Your sleep is important. In line with the EASA recommendations, fostering a positive safety culture – including an adequate fatigue risk management process – is everyone’s responsibility, from the bottom to the very top. If sleep and adequate rest is not already a subject at flight safety or clinical governance meetings, then try to add it to the agenda; this would allow everyone to be able to have a conversation about how your organization can work towards being safer for everyone involved. This is especially relevant for the complex sleep and work schedules/rosters for the emergency services personnel. Managing sleep and rest while off shift or even on standby is an important consideration for staff and for companies to provide the facilities and services to encourage a safe and well-rested workforce, while minimizing the exposure to hazardous fatiguing situations.