Tuesday, December 23, 2014

To Sleep on Duty, or Not to Sleep on Duty...That is the Question...

Flying at 3 am  is different than working in a hospital at 3 am.

Long ago, I showed up at a HEMS base in the early morning to teach an AMRM class. I went around back, found an open door, and walked in quietly finding on-duty clinicians napping in recliners. There were no beds for them at that base. It brought back memories of "the rule" for many hospital-based programs with clinicians working 12 hour shifts.

No Sleeping On Duty...

One can imagine how this rule got started. When helicopters were all hospital-based, the medical staff worked for the hospital, and were peers of the clinicians working in-house. As no ED, ICU or floor nurses are permitted to sleep on duty, why would a flight-crew be permitted to sleep? Even the appearance of being treated preferentially could cause problems for the flight program. If word got out that leadership was letting aircrew members sleep, other staff on night shift might demand the same treatment.

This is a case of safety taking a back-seat to politics, perceptions, and appearances. The nature of flight duty on night shift is completely different than that of working in-house. Sitting around and waiting is different than walking around and talking to people in a busy health-care environment.

Some leaders will read this and consider forcing flight crews to work in-house while not on a flight, but the truth is - that option degrades the quality of the program and the morale of the staff. Flight crew members are special; they volunteer for hazardous duty, they take on much more responsibility than a typical in-house clinician. They are expected to be "better." They should be treated that way or they will end up leaving.

When your experienced staff leaves, it costs money for training, orientation, and mistakes. How much better and simpler things will be if we look at every policy and rule from an operational standpoint - and remember that often, what's best for your staff is what's best for your company. You don't want just any clown taking care of sick people in your helicopter.

Morale and training costs are not the main reason that flight crews working a night shift should be permitted to take naps. The real reason is that you - Mr. or Ms. Manager - don't want to be the person explaining to the media why you are hosting a memorial service.

In 2009 I was the pilot of the last aircraft in this memorial-flight line-up. My second. We can go a day, We can go a month. Can we go a full year without a HEMS helicopter crash? It's not up to me... It's up to you!

The NTSB and the FAA have done research on aircrews and fatigue. So has Dr. Mark Rosekind, currently leading the NHTSA and an expert on fatigue. Fatigue is a hidden factor in many of our mishaps. Fatigue affects mood, performance and judgement.

The nature of flight operations at night are completely different than taking care of patients in a hospital setting. Especially the empty-leg back to base after dropping a patient at a distant facility - the leg in which bad things happen most often. Crews get "up" for the patient-care portion of the flight, then they struggle to stay alert on the way home. If this return trip occurs at the nightly physiologic low-point - typically between 2:00 am and 4:00 am - then your crew will be as sharp as a bowling ball.

Fatigued crews lose the mental-edge that prevents loose latches, cowl-strikes, tail-rotor strikes, open fuel-caps, objects dropped from aircraft in flight, still-connected cords and cables, and -  God-forbid - mid-air collisions. Surely you remember a time when you were wide awake at work, and almost fell asleep on the drive home. Well now imagine that it's your pilot falling asleep, and the crew is sleeping with him.

Flying at 3 am  is different than working in a hospital at 3 am.

As Dr. Mark noted in his research, when you are tired, "any sleep is better than no sleep." Maybe you don't want to provide beds in bedrooms, comfortable recliners in a quiet dark room will suffice...

In the interest of safety, it should be the policy of your flight program that crews are permitted to nap on night shift. Even crews working 12 hour shifts. They are probably doing it anyway, and forcing them to break a rule to do what comes so naturally creates cognitive dissonance and emotional discord.

safe flights...


  1. Dan, i couldn't agree with this post more. I say this having worked in both arenas. 7 years in a busy level I trauma center ED and in the flight arena. And i can say this, working a long 3+ hour flight at night with a sick pt. is just as tiring as a 12 ED shift. However, there are a few things to consider when comparing the two. First, i think that the "powers that be" fail to recognize what i call "insensible flight stressors." These include low humidity, low O2 environment, high stress, high noise and relatively high pt. acuity. these things combined create an increased metabolic state in the flight crew. (pilot included). Stated plainly, we chew up all our natural glucose and were damn tired with our bodies having been in overdrive to maintain homeostasis for the duration of the flight. Now, in the hospital, the effects of being tired can range from fairly simple, like walking into the wrong pt. room to moderately bad, such as a med error. In the flight arena, the consequences can be much more dire. Walking into a tail rotor, in my opinion is a FAR greater consequence. (i know we've all been habitualized to maintaining our situational awareness, but people still get punchy, or they're new, or they're just plain tired and not paying attention) The tired flight nurse/medic is also prone to making pt. care mistakes. Ofetn the pt's we fly are of the higher acuity and thus, much more medically fragile. Medical mistakes in this pt. population have far greater consequences that giving 60 Keterolac IV instead of IM in the hospital. Furthermore, when and IF a pt. goes south in the hospital, multitudes of people rush in and the medical menagerie begins. In the aircraft, its just you and you're equally tired partner. No help. No pulling over. No flying faster. Just you and your partner.
    I guess what I'm saying is this; Nurses get tired on duty, but comparatively, flight nurses face greater fatigue factors than hospital based RN's. The consequences however are far greater for the flight team. Not only for the safety of the crew, but for the quality of care provided, the utilization of limited care providers and the reputation and quality of the flight program.
    12 hr shift or 24 hr shift? it doesn't matter. Ive also worked both types of schedules flying, and there is little difference given the topic of fatigue. (i much prefer 24 hr shifts however.)
    Flight crews should be required to rest while on duty. There duties, responsibilities and the sheer gravity of the job the volunteer for demands their full attention, not standardization of flight RN vs. Hospital RN rest requirements.

  2. "Often"
    "Their" duties....
    The "job they volunteer....."
    I failed at proof reading.........

  3. Thanks to Josh for making this blog better.

  4. Unless you have worked 7 x 12 hour shifts in a row at night in a helicopter people will have no idea what you are talking about... A 30 minute patient flight can take 3 or more hours to complete.. add to that to the hostile night environment of night flying under stressful pressured conditions... you need a nap..

  5. Unless you have worked 7 x 12 hour shifts in a row at night in a helicopter people will have no idea what you are talking about... A 30 minute patient flight can take 3 or more hours to complete.. add to that to the hostile night environment of night flying under stressful pressured conditions... you need a nap..

  6. Here is another perspective that supports the "napping is good" theory...helicopters vibrate, TREMENDOUSLY! This causes stress on the body that is, more often than not, undetected by us while in flight. This vibration causes wear & tear on your body. That is why a 30 min. flight can feel like it's been hours...you're exhausted!
    Add to that the 3-D operating environment and now your body is REALLY working OT just to figure out what the hell you're doing! 4 or 5 body systems working together with all 5 senses takes its toll after just one short flight. Getting back-to-back-to-back flight compounds this effect tremendously.
    Soooo, do HAA personnel need naps?
    YES, they do.

  7. When I had night duty, I rarely slept. I was always spring-loaded to the ready position. Instead of sleeping or even napping (at night) I spent my time checking the weather at and toward all possible locations I might be asked to go. This way I was ready to decline a flight quickly (or accept it) at the moment of notice. This meant that when I was off duty between shifts I actually went home and slept, well-rested on my return to duty. Another reason for not sleeping was so that I didn't have to react to a flight request out of a dead sleep. To be half asleep checking the weather and/or starting a helicopter and getting it off the ground safely is a rather monumental chore. If you continually check the weather you will notice changes or trends in the current conditions or forecast that will assist your decision to go or not go in a timely fashion, thus allowing the ground crews needing your services to go with plan B instead of plan A also in a timely fashion. This is how you put the patient first. I also used the theory that it is better that the patient go by ground than be in the air with me and my crew should we have to land out in the middle of nowhere due to a surprise in the weather. Ambulances are hard put to find you and drive to your location out in the middle of a corn pasture.


Tell us what you think. If you are involved in helicopter emergency medical services / air ambulances, this is your community. Please refrain from posting profanity, or comments that might be considered libelous or slanderous.