Tuesday, July 26, 2016

AMRM 101.... Managing fatigue


"The nurse was restocking the drug bag after landing. The crew had just completed a patient transfer from a rural facility to a major metropolitan hospital.  He knew what supplies had been used, or at least he knew what supplies were supposed to be used, and as he inventoried the drugs, one that was supposed to be consumed wasn't. Worse, one that was not supposed to be gone was. The patient had been given the wrong medication. He immediately went inside his base and called the receiving hospital. "Hello, I just flew in Mr. Doe. I am afraid we may have made a mistake with his meds..."

The FAA and the NTSB have identified fatigue as a silent partner in most of the fatal accidents we suffer in HEMS. In recognition of this fact, the study and discussion of fatigue has been included in the list of required topics for Air Medical Resource Management and Crew Resource Management training. As it turns out, fatigue can be factored into many of the mistakes and mishaps we experience. If your mouse is tired, you don't need a better mouse trap.

From advisory circular 00-64...

(3) Fatigue Countermeasures. The term “fatigue” has been used to describe many
different experiences: sleepiness, physical tiredness, inability to focus mentally, time on duty,
types and number of missions, prolonged stress, and other factors. The effects of fatigue, which
concern the operational community, are those that affect crew member alertness and
performance. This type of fatigue stems primarily from sleep loss, circadian rhythm disruption,
lack of fitness, inadequate food and fluid intake, and the interaction of these physiological

From CFR part 135...

§ 135.330 Crew resource management training.
(a) Each certificate holder must have an approved crew resource management training program that includes initial and recurrent training. The training program must include at least the following:...
(6) Effects of fatigue on performance, avoidance strategies and countermeasures;

The flight paramedic finished his good-byes and climbed into his truck for the hour-long ride home. It had been a long and a good shift, with a pilot and nurse he enjoyed working with. The three of them seemed to click together as a team, and they had completed four flights! The workload and activity had helped him feel okay through out the day and night, although he did struggle a bit completing the last of the charts. Charting had kept him from resting, and he had considered the need to close his eyes for a bit. But his base needed every flight, and he had willingly done his part to make the flights happen. He was a member of a team, and the team needed him.

He departed the secondary road and eased onto the interstate highway for the long, boring ride to the city. As he rode along, cruise control set and cool air flowing, he began to feel drowsy. "Thank goodness this didn't happen last night" he thought to himself, and sat up straight in his seat. He turned on the radio, and set the volume up higher than normal. He stretched his neck and head left, then right. He took a deep breath and flexed his hands. "Come on dude. You can do this. Wake up!" 

Ten minutes later he was struggling to stay awake. He was too comfortable, and too relaxed. He thought, "twenty more minutes and I am home." He checked his side and rear mirrors, no traffic. Just him and a long ribbon of smooth concrete. His eyes drooped. His breathing and heart rate slowed. He was no longer concerned. His eyes drifted shut and a peaceful, wonderful sleep came upon him. 

The white Ford pickup truck drifted from it's lane. It veered increasingly right, rumbled across the wake-up strips, and dove into the drainage ditch. At this juncture, the stage was set. Nothing was going to change the outcome...

HE WOKE UP! "OH CRAP." The front-end of the truck plowed into the ditch, and mud, water and weeds flew up across the hood and windshield.  And then he was in the trees...

One of the realities of modern life is that we try to squeeze more out of every resource available. Any unused  margin of capability is viewed as a wasted opportunity to increase personal or professional gain. When our schedule is maxed out, it's easy to forego a  good night's sleep.

We cram more requirements into a given time-period. We accept more demands on ourselves. We expect more from others.  And thanks to "the social normalization of deviance," we take this abnormal and unhealthy situation in stride without much thought.

The problem with this lifestyle? This business ethos? This way of living and working?

Well, we are still human. We must contend with human factors. Humans don't work well when tired...

If you are a supervisor, and you don't think fatigue in your employees means anything to you, study this chart. You may see it again someday in a court room...

Managing fatigue requires commitment from both employee and employer....

As managers of the human resource that is "us" we have a moral and ethical obligation to pay due diligence to our own personal fatigue state. As HEMS team members, we operate in an extremely high-consequence world. Society and gravity hold us to a high standard when it comes to any negligence or lack of preparation for our duties.

Let's consider 24-hour shifts for medical flight team members. After initial resistance, the Commission on Accreditation of Medical Transport Systems (CAMTS) got on board with 24-hour shifts, with stipulations.

In case you have forgotten, here's what CAMTS standards have to say about 24 hour shifts.

01.07.00 STAFFING
The service must have written operational policies to address each of the areas listed below:
01.07.01 Scheduling and individual work schedules demonstrate strategies to minimize duty-time fatigue,
length of shift, number of shifts per week and day-to-night rotation. (See References for circadian rhythm,
Fatigue Risk Management System (FRMS) and other fatigue studies.)
1. On-site shifts scheduled for a period to exceed 24 hours are not acceptable under most circumstances.
The following criteria must be met for shifts scheduled more than 12 hours.
a. Medical personnel are not required to routinely perform any duties beyond those associated
with the transport service. (emphasis added)
b. Medical personnel are provided with access to and permission for uninterrupted rest after
daily medical personnel duties are met.
camts.org Commission on Accreditation of Medical Transport Systems
10th Edition Accreditation Standards
c. The physical base of operations includes an appropriate place for uninterrupted rest.
d. Medical personnel must have the right to call “time out” and be granted a reasonable rest
period if the team member (or fellow team member) determines that he or she is unfit or unsafe
to continue duty, no matter what the shift length. There must be no adverse personnel
action or undue pressure to continue in this circumstance.
e. Management must monitor transport volumes and personnel’s use of a “time out” policy.

From personal experience over 17 years flying HEMS; I can tell you that management is pretty good at "monitoring transport volumes," but not so good at offering "a time out policy."

If your company requires a crew member to notify two or three levels of management before calling a time out, then you don't really have a time-out policy. You have something written in a book that says you have a policy, but your real policy is that your employees get their butts in that helicopter, no matter how tired they may be. If you tout your company's CAMTS certification, but don't adhere to the standards in good faith, then your company is CAMTS certified in name only.

Hidden factors of 24 hour shifts...

"The aircraft was in cruise flight when the nurse asked, "are you sure the weather is good enough for us to do this flight?" As this was the second time the question had been raised, the pilot determined that something was up. Something that had nothing to do with weather. He said, "guys, I checked the weather. It's way good. But if  you don't want to go, tell me and I will turn around. 


What this pilot didn't know was that the nurse in question was tired. She desperately needed sleep. But because she was the proximate cause of her own fatigue she couldn't ask for a rest. Since she only worked on the helicopter every fourth day, she took advantage of her free time and took another job in a local hospital. The demands of two full-time jobs - and her personal life - left her without enough time to rest. She anticipated catching up on sleep at work, But when the work load was steady throughout a 24-hour shift and she didn't get a chance to nap she came up short. And snappy.

Fatigue effects mood, performance, and judgement. (Dr. Mark Rosekind)

Humans are subject to two circadian (circa - around, dian - day) lows in each 24 hour day. These occur, roughly, between 2 AM and 4 AM, and then again between 2 PM and 4 PM. It is during these hours that we have the most difficulty with our mood, performance, and judgement. If we are well rested we can work through these circadian lows. If we are fatigued, then we have two impediments to overcome. And things go wrong.

Policy and schedule should allow crews to rest during circadian-low periods, unless a patient-flight is at stake. This is when our bodies need to rest, and when our performance is most degraded.

It's true, safety-naps increase safety. 

Crews working an extended shift should take advantage of any rest-opportunity during these low periods. Turn off the TV, shut down facebook (or this blog), and close your eyes.

We as individuals have an obligation to do our part by showing up for work rested and ready. The company should not need a policy that you do not work another job for 8 or 10 hours before reporting for work. You should know this yourself. You are going to be flying a helicopter or taking care of sick people who trust you with their lives. Don't violate this trust.

If I am making you angry without cause, I apologize. If I am making you angry because you recognize yourself in these anecdotes, get angry, then fix the problem.

If you are scheduled to work a 24 hour shift tomorrow, then today should be protected, when it comes to work-load, stress-inducing activity, diet, and drinking. Do drink water. Alcohol? Not so much, if any.

Sidebar: After I volunteered to serve in the 160th Special Operations Aviation Regiment, I was sent to SERE (Survival, evasion, resistance, and escape) school. As part of SERE, I was captured and held in a prison camp. I was made to stay awake for three days. As part of the torture regimen I was forced to drink liter upon liter of water. What I didn't know then, but I do know now, is that drinking so many liters of water helped my body cope with the demands placed upon it. If you are subject to a fatigue-causing scenario, drink water until you can't take any more. If you are using caffeine to mitigate fatigue, fair enough, but follow it with water...

"Without adequate hydration, bodies can experience more muscle soreness, the need for longer recovery times and less desire to push oneself – in short, dehydration can make you feel less motivated to achieve at any activity. As little as 3 percent or more loss of body weight due to dehydration can cause as much as a 10 percent drop in performance level. One study of athletes found after limiting fluids for 15 hours, 92 percent felt tired, had lapses in memory and difficulty concentrating."  text courtesy truelemon.com

Finally, lets consider the role of the company-leadership in controlling fatigue for employees working 24-hour shifts. Let's go back to the CAMTS stipulation that crews shall not be required to perform any duty beyond those associated with medical transport - flying sick people and charting medical treatment.

Dear supervisor, leader, manager,

If you require your flight team, during a 24 hour shift, to perform ancillary duties not directly related to the care and transport of sick people, such as public-relations visits, teaching classes, or EMS nights-out... then you are NOT in compliance with the CAMTS standards.

And you are a contributing factor in the medical-errors made by your employees. You are a contributing factor when your employee falls asleep on the drive home after working a 24 hour shift. You are a contributing factor in your employee's degradation of mood, performance and judgement.

You are either part of a problem, or part of a solution...

You have every right to ask your people to come to work ready, rested and able. And you have a responsibility to avoid subjecting them to any extra fatigue or stress.

You owe it to them and the souls they care for...

Our world is more litigious than ever before. Take care.

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