The Southeast and Gulf Coast states breathed a sigh of relief as the 2009 hurricane season came to an end with only one tropical storm making landfall. Regrettably though, Southern California was battered with numerous wildfires that caused three line-of-duty deaths. As we prepare for the 2010 hurricane and wildfire seasons, we as managers and leaders should start questioning how many hours our employees can or should work before fatigue sets in, and determine how to limit or prevent that from happening.

Emergency-response personnel carry out their duties within an ever-changing and often time-unforgiving environment composed of a set of distinct elements. First, there is the emergency itself — whether it is a wildland fire in the Northwest or Southwest, a tornado in the Midwest, or a hurricane in the Southeast or Gulf Coast — which imposes certain exigencies upon the responders. Second, social structures exist that are governed by the rules and associations — both internal and external — of the responding entities. An emergency response, therefore, takes place within a context of prescribed behaviors, expectations and value judgments that are sometimes in conflict with each other. Third, there is technology that must be understood in order to accomplish group goals. Should this fail to occur, the entire emergency environment may be impacted. Clearly, a breakdown in any of these elements could result in worker injury and might heighten responder stress, fatigue and general well-being.

Olin L. Greene, former U.S. Fire Administrator, recognized that stress is one of the most vexing occupational hazards facing the modern fire service. Additionally, he opined that it is important to recognize exactly how stress can adversely affect our health, job performance, career decision-making, morale and family life. But could Greene have foreseen the coming of numerous hurricanes and other natural disasters, the acts of terrorism and the weapons of mass destruction — and the additional stress these would apply to the fire service community — when he was fire administrator?

Fatigue is a growing issue in the workplace. It is estimated that fatigue results in $8.5 billion dollars in accident damage, $79.9 billion in lost productivity and $28.3 billion in associated health-care costs. Some will argue that workplace fatigue holds true for any profession to some degree; however, fatigue becomes a critical factor for emergency responders who must make split-second decisions that can affect the lives of civilians, as well as their colleagues.

Fatigue goes by many names — among them exhaustion, lethargy, weakness, weariness, lack of spirit, listlessness and burnout — and takes many forms. It can be both physical and mental. Physical fatigue, i.e., muscle weakness or "lack of strength," is a direct term for the inability to exert force with one's muscles to the degree that would be expected given the individual's general physical fitness. Mental fatigue, on the other hand, can manifest itself either as somnolence (decreased wakefulness) or as a general decrease of attention, not necessarily including sleepiness. It also may be described as a decreased level of consciousness. In any case, this can be dangerous when performing tasks that require constant concentration, such as: firefighting, conducting search and rescues, driving an apparatus or treating emergency medical patients.

Fatigue primarily is caused by lack of sleep. However, fatigue is more than just feeling tired or drowsy - it is normal to become tired through physical or mental effort. Rather, fatigue significantly affects a person's ability to function. The most common effects associated with fatigue are:

• Desire to sleep;
• Lack of concentration;
• Impaired recollection of timing and events;
• Irritability;
• Poor judgment;
• Reduced capacity for effective interpersonal communication;
• Reduced hand-eye coordination;
• Reduced visual perception;
• Reduced vigilance;
• Slower reaction times.

Additionally, fatigue can affect one's health. Gastrointestinal disorders and upper-respiratory infections are the most common health problems related to fatigue. While the most common factor that causes upper-respiratory illnesses or infections associated with fatigue is an increase in stress, which weakens one's immune system, the body rhythm for digestion is designed for food to be eaten during the day regardless of whether an individual is working or resting. This can cause problems when heavy or fatty foods are eaten at some point in the night. The most common complaints include bowel-habit changes, digestive complaints and increased risk of peptic (stomach) ulcers. We all are guilty of having something heavy or fatty in the middle of the night, especially after responding to a fire or emergency medical call, because we just cannot fall asleep. Our mindset is that we can sleep better on a full stomach. We have mom to thank for that belief.

Furthermore, the effects of fatigue increase with age. It has been confirmed that people over 50 years of age tend to have lighter, fragmented sleep. This can prevent them from receiving the recuperative effects from a full night's sleep, and can make them more likely to become fatigued.

Moreover, studies indicate that women's reproductive health can be affected by fatigue. Fatigue and irregular sleep patterns have been associated with numerous negative effects for pregnant women and fertility rates. These include irregular menstrual cycles, increased risk of miscarriages, low birth weight and higher occurrences of premature births. As managers and leaders of our departments, should we allow pregnant female responders to continue working on shift, or should we place them on light duty to prevent miscarriages or a premature birth? I know that many females do not want to work light duty and have their doctors write notes stating that they can work until they deliver, but is this truly the right thing to do?

So how many hours should emergency responders work? A study by the International Labor Organization for the United Nations found that Americans work longer hours than anyone else in the industrialized world. Most European workers have four weeks of vacation and many have more than that, while U.S. workers usually have only two weeks of vacation.

Additionally, the United States is the only industrialized nation where the trend for the past 20 years or so has been to work more hours with less personnel resources. In every other country, the trend is toward more time off. Somehow, the United States misses the mark in its belief that being "results oriented," along with a "do more with less" ideology, has greater value than the physical and mental attributes of a human being. Perhaps this is why firefighters are dying at a faster rate of heart-related complications and at a younger age — some less than 40 years of age. A National Sleep Foundation study found that 40% of American adults stated that, "they are so sleepy during the day that it interferes with their activities."

Most emergency responders perform shift work, which involves working outside the normal daylight hours of 7 a.m. to 6 p.m. While most people in our society work a traditional seven- or eight-hour day, five days per week, shift workers often are scheduled in non-traditional work hours such as the early evening and the middle of the night, and endure extra-long workdays, including the fire service's traditional 24-hour shift.

Emergency responders must operate around the clock out of necessity, but they are not immune to the mental and physical consequences of sleep deprivation. Extended periods without sleep, interrupted sleep and working against the body's natural sleep cycle negatively affects performance and may contribute to workplace accidents. Employers can be held liable for accidents involving their sleep-deprived workers.

The Australian Council of Trade Unions, in its report, "Health and Safety Guidelines for Shift Work and Extended Working Hours," recommended that workers should not exceed the following maximums, other than in emergency circumstances:

• Six consecutive eight-hour shifts;
• Two consecutive night shifts;
• Two consecutive 12-hour shifts;
• 12 hours overtime per week;
• 12 hours of work per day (including overtime);
• 48 hours on the roster per week.

In emergency circumstances, a maximum of 60 hours worked in one week may be necessary. But it should not be worked on a regular basis or in consecutive weeks.

Given all of this, the question begs: where does the fire service fall regarding the avoidance of fatigue? Because of the 24-hour nature of the fire service, firefighters and other emergency responders are affected differently by the shifts they work. Shift-length decisions are based on many factors; the majority of such decisions primarily are set through collective bargaining or through administrative avenues. This primarily is done for cost containment and rarely is based on fatigue or exhaustion issues. Most firefighters work a 24-hour shift, followed by 24 to 48 hours off. In departments that have higher call volume, splitting the day into 10-hour day shifts and 14-hour night shifts is not uncommon in the Northeastern U.S.

There are many opinions on which schedule provides the best quality of life to personnel. Many employees who work 24-hour shifts often complain that the schedule limits family contact, while personnel working 10- or 14-hour duty shifts state that they have more frequent family contact opportunities, including the opportunity to eat dinner together if travel time to and from work is minimal. But, as most of us know, working 24-hour shifts with 48 hours off enables many emergency responders to work second jobs to bring in extra money to support their families. In this ever-challenging economic time — which is marked by the looming threats of layoffs, cutbacks, reduced staffing, additional zone responses and reduced paychecks — many emergency responders, already stressed by fears over whether they will be able to keep their jobs, must in some cases work two part-time jobs to make ends meet. Unfortunately, "moonlighting" promotes sleep loss quite simply by reducing the time available to sleep when we are off shift. We then go back to the vicious cycle of personnel coming to work fatigued and sleep-deprived.

Is there a happy medium? How do we prevent fatigue in our emergency responders? Fatigue management is a shared responsibility between management and workers, as it involves factors both inside and outside of work. Employers are responsible for using a risk-management approach to manage fatigue. Additionally, it is the responsibility of employees to ensure that they make appropriate use of their rest days and are fit for duty.

Maintaining comfortable temperatures, controlling excessive noise and providing well-lit duty areas and dark, quiet sleeping facilities are steps that some fire agencies have taken to make the workplace more comfortable and to reduce employee fatigue. As managers/leaders of our departments, there are further steps that we should take to reduce fatigue in our employees. These include: allowing tired employees an extra hour or two of sleep, even after shift change, to help keep them awake on the drive home; modifying work schedules to better accommodate increasing alarm loads; rotating busy units/crews with slower units; and limiting the length of time personnel can be assigned to busy companies. Also, reducing responder fatigue can be accomplished via a risk-management approach: identify factors that contribute to fatigue; assess risk; decide on control measures; implement the control measures; then monitor and review.

Managers are not the only ones responsible for managing sleep deprivation and fatigue - employees need to be responsible as well. Emergency responders must take advantage of opportunities for sleep, both on- and off-duty. Sleeping areas at home should be cool (65°F-70°F). Additionally, a comfortable, good-quality mattress is a must, as are comfortable pillows and bedding. Good sleep habits are essential. Emergency responders need to get an adequate amount of uninterrupted sleep every off-duty night. Going to sleep and waking up at the same time every day, even on weekends, is important for maintaining the body's circadian rhythms. Furthermore, for 24-hour shift workers, such as emergency responders, outdoor exercise during daylight hours can help maintain natural biological rhythms and increase sleep quality off-duty.

The last approach that managers and employees should come to agreement on concerns the taking of naps during a shift. Studies have shown that napping is an effective coping strategy that can be used in anticipation of a long night or during extended operations. Taking a brief break and clearing one's mind has been shown to greatly enhance one's creativity later in the day.

There is an abundance of sleep research that substantiates the positive effect of taking regular naps. Most of the research supports the notion that mood, alertness and performance are improved with a nap of 30 minutes or less. Naps that are longer than 30 minutes tend to create sleep inertia and reduce the effectiveness of evening sleep.

There is one last thought to consider regarding emergency responder fatigue: there are federal and international regulations for seafarers, airline pilots, flight attendants, air traffic controllers, commercial truck drivers, rail workers (freight and passenger trains) and resident physicians. Is the fire and medical services sector next? Wouldn't it be easier if we look at fatigue as a serious issue and try to limit it before the federal government regulates us too?

• Read the "The Rise of Wellness in the Valley of the Sun" sidebar to learn about the development of a firefighter health center in Glendale, Ariz.

Jo-Ann Lorber is a captain in the EMS bureau for Fort Lauderdale (Fla.) Fire-Rescue Department, where she has served since 1996. Lorber holds associate's degrees in liberal arts and fire science technology, a bachelor of arts degree in public management, and a master's degree in public administration with a graduate certificate in human-resource management from Florida Atlantic University. Lorber is a 2006 graduate of the National Fire Academy's Executive Fire Officer Program and was awarded Chief Fire Officer Designation along with becoming a member of the Institute of Fire Engineers in 2008.

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The Rise of Wellness in the Valley of the Sun

For more than a decade a wellness and fitness initiative between the International Association of Fire Chiefs and the International Association of Firefighters prompted the nation's fire departments to develop firefighter health centers. Last year, the city of Glendale, Ariz., and its fire department committed to construct and equip a complete health center that now is providing annual physical examinations, as well as medical, health and wellness screenings. The health center also provides education on health hazards frequently encountered by firefighters; in the near future it will include police officers.

Several obstacles delayed the scheduled opening of the center. However, through a unique partnership, all issues were addressed. Chief among them was the current economic conditions. The city of Glendale Fire Department (CFD) had to establish the operating and maintenance costs for the center with no impact to the department's existing operating budget. Through many meetings and negotiations a partnership was formed that allowed the annual physical exams to be conducted at the rate all departments currently are paying, yet generated the necessary operating and maintenance revenue to satisfy the net-zero budget requirement. Credit needs to be given to the private partners that were willing to make numerous concessions in order to achieve the numbers needed, as well as Daisy Mountain Fire District Fire Chief Tom Healy, who was the principle negotiator.

Professional medical staffing and scheduling is provided by two vendors, Strength Training Inc. (STI) and Scottsdale Health Care (SHC). The program is managed through an intergovernmental agreement (IGAA) between Daisy Mountain Fire District and the city of Glendale.

The grand opening of the health center was held on Feb. 24, 2009. With its location at the Glendale Regional Public Safety Training Center (GRPSTC), the health center presents a unique public/private partnership for the city of Glendale, several other cities in the region and the local community college system.

The health center is the continuation of a partnership that began in the late 1970s during the development of the Phoenix Regional Automatic Aid System. This system provides an environment that fosters partnerships and the consolidation of resources from 25 cities for most firefighting activities in the Valley of the Sun. Development of the health center was the next logical advancement in automatic aid and local partnerships for the West Valley cities.

Our department has enjoyed the benefits of the Phoenix Fire Department's Health Center for more than 20 years. The PFD Health Center has more than 20 fire departments participating in annual physical exams, as well as industrial and modified-duty exams and rehabilitation programs. The PFD Health Center rapidly was reaching capacity, conducting nearly 5,000 annual examinations. The development of the GRPSTC facilitated the partnership that led to the opening of the Glendale Health Center, which in turn has provided some necessary relief for the PFD.

How it Does it

The health center occupies 6,200 square feet of the main building at GRPSTC. The training center was designed to create a city-like environment and to provide a realistic atmosphere for public-safety training on an 80-acre site. The health center, training administration and main classroom building encompasses 94,690 square feet.

An IGA was crafted between the CFD and the DMFD. The agreement was approved by the latter's board of directors and by the Glendale City Council on Feb. 17, 2009, and the health center opened one week later.

The IGA places a Glendale chief officer in an oversight management position for day-to-day operations. The Daisy Mountain fire chief is designated as the billing and contract administrator for the two medical vendors. This arrangement places all four entities into very specific and actively engaged roles for decision-making regarding business management and on-going operations. Any other department can join the Health Center by either a formal IGA or by establishing a contract with DMFD.

The CEO of STI, Jim Maher, once was a firefighter and fully understands the rigors of the profession. STI and Maher have assisted countless firefighters in improving their physical health for more than two decades. STI operates several successful physical therapy clinics in the Valley of the Sun and has a reputation for returning firefighters to optimum health after an injury or illness has compromised their ability to perform their basic functions. The current role of the STI staff in the health center is to perform a complete functional-movement screening, one that provides information about the firefighter's flexibility, structural stability, balance and potential for injury in certain areas. This insight enables pre-injury intervention with a fitness trainer or referral to physical therapy care if required.

SHC has been in the medical care and hospital business since 1962. It employs 6,700 staff members and physicians who represent more than 50 medical-care specialties. In 2006 it became the first multi-hospital system to be recognized in Arizona as a Magnet Health System. This achievement places the organization in the top four percent of hospitals in the nation according to their health center liaison, Jayne Ambrose. SHC's occupational/corporate health system alone logs close to 50,000 patient visits annually.

The Glendale Health Center currently provides medical evaluations and screenings through annual physical examinations that comply with the National Fire Protection Association's NFPA 1500 standard. The center processes eight patients per day — on Tuesdays, Wednesdays and Thursdays, from 8 a.m. to 5 p.m. The center is staffed with six personnel committed to daily operations and was designed to expand to a five-day-a-week schedule. At that time we plan to provide industrial care or occupational intervention, as well as physical therapy, as the center's scope is expanded to meet the evolving needs of the public-safety personnel it serves.

— Fire Chief Mark Burdick and Deputy Chief Chuck Montgomery Glendale (Ariz.) Fire Department