A firefighter paramedic was driving home from the station after leaving a 24-hour shift. Within 20 miles of his home, he left the road, rolled his car and took out a small well house. He suffered a broken wrist, and when interviewed by state troopers admitted that he’d fallen asleep at the wheel, rather than risking loss of his driver’s license due to unexplained loss of consciousness.

In another instance, a volunteer firefighter suffered a myocardial infarction while participating in a physically demanding drill. During treatment for the heart attack, doctors found severe blockages, and the firefighter was diagnosed with obstructive sleep apnea. Today he has no doubt that the sleep apnea was a contributing factor in his heart attack. After six months, and the use of a continuous positive airway pressure (CPAP) machine, he returned to work.

Defining the Risks

Several years ago, I began to notice that more firefighters were falling asleep at night wearing respiratory masks attached to small black boxes. Because of this, the customary chorale of snoring throughout the station was being replaced by the constant hum of these boxes that forced air into the masks as they slept. For some, the elimination of snoring was a medical miracle in itself — but what were the boxes really about? A little research led me to discover that the boxes were CPAP machines that were being used in the treatment of sleep apnea, a formidable intrinsic sleep disorder (ISD). Later, as the deputy chief of Stanwood Camano Fire Department (SCFD) in Washington State, I wondered whether we had been ignoring significant risks due to undiagnosed and untreated ISDs. Myriad questions immediately came to mind: Is it a problem? Who is affected? Where do we start addressing these problems in our own ranks? What are the potential health risks that stem from untreated ISDs, both to ourselves and the public we serve?

The definition of intrinsic (meaning originating from within the body) sleep disorders is broad and includes such disorders as insomnia, hypersomnia, narcolepsy, restless leg syndrome, periodic limb movement disorder, and sleep apnea. Obstructive sleep apnea is the most common sleep disorder, with disorders such as narcolepsy — excessive daytime sleepiness — being relatively rare. It is estimated that 80–90% of individuals with sleep disorders remain undiagnosed simply because people are unaware that a problem exists.

So What’s Going On?

Biologically, humans are tied to a 24-hour sleep clock called a circadian cycle. The sleep cycle has several stages, from drowsiness to deep sleep, and the average requirement for an adult is approximately seven to eight hours each night. However, firefighters and EMS workers who respond to calls at night may get much less than that and most likely would be vulnerable to what has been termed as shift-worker sleep disorder, or SWSD. Like ISDs, such disorders are characterized by sleep fragmentation and sleep debt, and have not received much attention, especially in the area of public service.

Now let’s put all of this into perspective for public safety. If you already are prone to SWSD simply due to the nature of your work and you have an untreated ISD, how much sleep are you actually getting? Those who suffer from untreated obstructive sleep apnea may technically be asleep for six hours, but their bodies only get the equivalent of maybe two to three hours of quality sleep.

There is a nationwide effort underway to provide awareness to firefighters concerning sleep deprivation and sleep disorders. One of the most comprehensive reports on sleep deprivation is “The Effects of Sleep Deprivation on Firefighters and EMS Responders,” a joint project of the International Association of Fire Chiefs and the U.S. Fire Administration. The report’s authors stressed that the discovery of sleep disorders is critical to identifying the underlying risks that contribute to serious medical problems such as cardiovascular disease.

A search of NIOSH records spanning from 1984 to 2008 found several incidents where sleep disorders or fatigue were directly or indirectly related to firefighter deaths. Moreover, fatigue was listed as a cause of numerous incidents reported through the National Firefighter Near-Miss Reporting System. Among them were instances of emergency workers falling asleep while still on duty or when driving home, workers falling asleep in the driver’s seat of an emergency vehicle while standing at a stop light, and poor decision-making on rescue, fire and EMS calls. While only four of the incident reports referred to fatigue resulting from a loss or lack of sleep, it is reasonable to ask the question: Could ISDs have been a contributing factor in the rest?

Health risks for those lacking sleep include heart attacks, strokes, impotence, arrhythmias, hypertension, decreased work performance, and long-term medical complications such as learning disabilities and memory problems. Some reported depression, anxiety, obesity, immune system problems, and an inability to manage pain. Some of these resulting issues also can lead to further problems, such as increased gastrointestinal complaints and serious cardiac illnesses. Based on this partial list of health risks, why has the fire service ignored the issue of intrinsic sleep disorders and sleep deprivation? If they were addressed, could it ultimately find a way to decrease line-of-duty deaths?

“Let’s take a half-hour during the day and get a damn nap,” said Gordon Graham, co-president of Lexipol, a risk-management company. A nationally recognized educator, Graham asks students in his classes, “Has anyone fallen asleep while on duty?” When no one raises their hand, he then asks, “Who has fallen asleep while on the way home?” Everyone’s hand goes up.

“Rarely does anyone admit to this,” especially in front of their peers and their bosses, he said. “We haven’t admitted we have a problem yet, and we’re in denial.”

In one of the more unusual schedules, Lincoln, Neb., firefighters work every other day for 13 days and then have eight days off. “Toward the end of the rotation, they are shot,” said Bttn. Chief Leo Benes, who nevertheless admitted that he likes the eight consecutive days off. While this rotation has worked well for more than 40 years, higher call volume and more advanced services are taking a toll.

“We don’t know what the answer is,” Benes said. “But we don’t want to lose anyone. These are my closest friends.”

Sleep deprivation, regardless of the cause, has been the root of many costly accidents. A disruption of sleep, no matter what the etiology, is detrimental to health and safety, and the employer can be held responsible. For example, the management of a McDonald’s restaurant in the state of Oregon allowed a visibly fatigued employee to drive home after working three shifts in a 24-hour period. The employee caused a motor-vehicle crash, killing himself and critically injuring another driver. McDonald’s was sued by the other driver and the courts found against the company, stating that management should have foreseen the potential dangers in letting the tired employee drive.

Our Own Experiment

The SCFD consists of 40 career firefighter/EMTs and firefighter/paramedics, approximately 25 part-time and 30 volunteer firefighter/EMTs, 10 support members; two mechanics, and 11 career administrative employees. Three stations, manned 24 hours a day, cover more than 47 square miles — including 57 miles of shoreline — and serve 23,000 people. The service area includes an island that is connected to the city of Stanwood by a bridge. The department is involved in water rescue, marine-based firefighting, high-angle rescue, technical vehicle rescue and hazmat response. In less than nine years, the department’s call volume has tripled. Increased responses and transport to distant hospitals, some an hour away, leaves little room for getting a full night’s sleep.

Our schedule is a Modified Detroit schedule: one day on, one day off, one day on, one day off, one day on and then four days off. At times, that leaves only 24 hours to recover from any sleep debt. Although we have part-time members, they also work nights; accordingly, these individuals fall prey to shift-worker disorders. So too do many firefighters and EMS workers.

Two years ago, the department was awarded an Assistance to Firefighters Grant, which was used to implement a wellness-and-fitness program. Preventative measures such as physical exams, job-related immunizations and health screenings have resulted in positive health changes. However, we lacked a way to easily and effectively evaluate members for intrinsic sleep disorders, as well as a method to prevent workers who were suffering from only a shift-worker sleep disorder from showing a false positive as a result of the ISD testing process. So we created our own evaluation method.

When measuring sleep disorders, the most common method is the Epworth Sleepiness Scale (ESS), a self-administered series of eight questions, each of which is designed to rate the severity of situational sleepiness on a scale from zero to three. When the scores are tallied, those that exceed 10 have been found to be effective in identifying patients with snoring, obstructive sleep apnea, or other intrinsic sleep disorders.

While the ESS has been a popular method of measuring sleepiness and sleep deprivation since its inception in 1991, the STOP (Snoring, Tiredness during daytime, Observed apnea and high blood Pressure) questionnaire was introduced in 2008, primarily to test for obstructive sleep apnea. It has been used to screen surgical patients at preoperative clinics.

The Fatigue Severity Scale (FSS) is the third-most-common questionnaire. Participants rate themselves on a scale of one to seven for each of nine statements relating to fatigue. The FSS was not designed as a tool to test for ISDs, but instead was found to be effective in testing for shift-workers fatigue, a common SWSD. It can be assumed that a member who has a qualifying ESS and/or STOP score, combined with a high FSS score, may have issues with fatigue as related to shift work, as opposed to having an ISD. In either case, follow-up with a physician would be warranted.

While these questionnaires individually were useful for their primary intents, we created the Firefighter Intrinsic Sleep Disorder Questionnaire (FISDQ) to address the sleep patterns that are attributed to the shift schedule usually worked by firefighters and EMS personnel (download at the bottom of this page). The FISDQ attempts to compensate for the limitations of the other test methods, especially in regard to SWSDs. Administered under the direction of a physician specialized in sleep disorders, this questionnaire takes into account the sleep deprivation that results from getting up during the night to respond to calls.

Within our department, 89 people — including both volunteer and paid personnel — agreed to participate. Each work 24-hour shifts, 12-hour night shifts, or some night-duty configuration. Only nine reported that they previously had been diagnosed with some type of ISD. The ESS portion of the FDISQ showed that 21% of our undiagnosed members were predisposed to ISDs, while the STOP portion showed that 37% of our undiagnosed members were predisposed for ISDs. The significance of this variance between the STOP and ESS results is unclear. Through the use of our own FISDQ, we were able to rule out fatigue associated with SWSD as a factor in erroneously high ESS and STOP scores, which increased the confidence that those testing positive actually had an ISD. This was a critical development, since there had never before been a method for differentiating between a potentially treatable ISD and simple SWSD fatigue.

By the strict and self-reported body mass index parameters, many of the study participants were at varying levels of obesity, which has been found to be a contributing factor in the development of ISDs. For some, maintaining a healthy body weight can decrease the severity of ISDs or prevent such disorders completely.

Our in-house study determined that a significant number of our members had the potential for undiagnosed sleep disorders. Sleep deprivation was affecting the safety and quality of the lives of our members. To date, there have been no deaths or injuries proven to be directly associated with sleep disorders in the SCFD’s active membership. However, both the literature review and the results of the FISDQ survey suggest that the department should consider taking steps to mitigate any future potential for such events.

Conclusion

When our study concluded, we found some possibilities for change. First and foremost, we’d like to see the wellness-and-fitness program include evaluation for intrinsic sleep disorders. We’re much more aware of how sleep deprivation and sleep disorders affect our personnel, and several members have expressed interest in following up with a practitioner. For our department, the awareness of ISDs has prompted almost half of the participants to seek follow-up with their physicians.

Encouragement to get evaluated for sleep disorders and to follow through with treatment of such disorders as sleep apnea could potentially minimize a plethora of health problems and decrease the potential for on-the-job mistakes, injury or death, while increasing shift productivity and members’ quality of life.

Further, we’re considering changing our work rotation to a 48-hours on, 96-hours off schedule, in order to minimize sleep debt. Despite a reluctance to let firefighters sleep during the day, there is a significant advantage in taking a 15- to 20-minute safety nap during daytime hours. (However, any longer has been shown to increase grogginess and lead to more mistakes.) If someone has been responding all night, they should be allowed to sleep for an hour or two before trying to drive home.

Finally, any public-safety agency where shift work is typical should be encouraged to use this information to determine whether department members are at risk for sleep disorders. A polysomnographer can answer questions, and soliciting the input and direction of a physician who specializes in sleep disorders will help with the development and interpretation of the findings.

While questionnaires are easy to administer and popular for evaluation, a definitive diagnosis should be done through an overnight sleep study — called a polysomnogram — and a physician evaluation. Considering some of these changes not only may have a positive effect on the health and safety of our membership, but also of the public we serve.

• Download the Firefighter Intrinsic Sleep Disorder Questionnaire (FISDQ).

Darin Reid is a deputy fire chief and medical services administrator for Stanwood Camano Fire Department in Stanwood, Wash., and is the operational fire chief for the city of Stanwood. He has been in the fire service for 27 years, serving as a paramedic for 23 of those years, and is in the fourth year of the National Fire Academy's Executive Fire Officer program.

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