Pilot fatigue survey: exploring fatigue factors in air medical operations

A preliminary framework for managing sleep inertia in occupational settings

Sleep inertia, the temporary period of impairment experienced upon waking, is a safety hazard that has been implicated in serious work-related incidents resulting in injuries as well as the loss of life and assets. As such, sleep inertia warrants formal management in industries where personnel are required to undertake their role soon after waking (e.g. emergency services, engineers, and health care). At present, there is a lack of practical, evidence-based guidance on how sleep inertia could be formally managed at an organizational level. We propose a preliminary framework for managing sleep inertia based on the translation of research findings into specific work procedure modifications/control mechanisms. Within the framework, work procedure modifications/control mechanisms to manage sleep inertia are organized into three levels: (1) modifications/controls that eliminate the chance of sleep inertia, (2) modifications/controls that reduce sleep inertia severity, and (3) modifications/controls that manage the risk of errors during sleep inertia. Practical considerations, limitations, and areas of further research are highlighted for each modification/control to help determine how readily each control measure could be implemented by industries at present. A guide for organizations to use this preliminary framework of sleep inertia management is put forward, as well as the next research priorities to strengthen the utility and evidence base of the framework. This paper is part of the Sleep and Circadian Rhythms: Management of Fatigue in Occupational Settings Collection.

Psychophysiological models of hypovigilance detection: A scoping review

Hypovigilance represents a major contributor to accidents. In operational contexts, the burden of monitoring/managing vigilance often rests on operators. Recent advances in sensing technologies allow for the development of psychophysiology-based (hypo)vigilance prediction models. Still, these models remain scarcely applied to operational situations and need better understanding. The current scoping review provides a state of knowledge regarding psychophysiological models of hypovigilance detection. Records evaluating vigilance measuring tools with gold standard comparisons and hypovigilance prediction performances were extracted from MEDLINE, PsychInfo, and Inspec. Exclusion criteria comprised aspects related to language, non-empirical papers, and sleep studies. The Quality Assessment tool for Diagnostic Accuracy Studies (QUADAS) and the Prediction model Risk Of Bias ASsessment Tool (PROBAST) were used for bias evaluation. Twenty-one records were reviewed. They were mainly characterized by participant selection and analysis biases. Papers predominantly focused on driving and employed several common psychophysiological techniques. Yet, prediction methods and gold standards varied widely. Overall, we outline the main strategies used to assess hypovigilance, their principal limitations, and we discuss applications of these models.

Sleep Patterns of Pilots: An Objective Assessment

Objectives Circadian dysregulation (jetlag), sleep loss (extended wakefulness), sleep deprivation (acute or chronic), fatigue (exhaustion), preexisting medical and mental conditions, and medication use can all affect the cognitive and behavioral performance of commercial aircraft pilots. This study evaluated the sleep habits of pilots and copilots flying short-haul flights in the Gulf region. Methods This cross-sectional study examined Airbus A320 pilots and copilots for one of Saudi Arabia's commercial airlines. Data such as age, sex, body mass index (BMI), employment position, work experience, flight hours, and rest time were collected. Each participant completed the Epworth Sleepiness Scale (ESS) for daytime sleepiness, the Pittsburgh Sleep Quality Index (PSQI), and the Fatigue Severity Index (FSI). Actigraphy equipment was used to perform objective sleep evaluations. Results Twenty-four participants were included. Actigraphy showed that 66.7% had an irregular sleep pattern and that 41.7% had poor sleep efficiency. We found that 12.5% had daytime sleepiness, 33% had poor sleep quality, and 29.2% had fatigue. We found a significant negative correlation between years of experience and time in bed; however, there was no significant difference in sleep time or sleep efficiency between pilots with different levels of experience. Conclusions We found that pilots and copilots are at risk of irregular sleep patterns, poor sleep efficiency, poor sleep quality, daytime sleepiness, and fatigue. This study emphasizes the need to instigate measures to minimize these risks.

American Helicopter Emergency Medical Service Pilots Report to Work Despite High Rates of Sleepiness

OBJECTIVE

Previous studies on helicopter emergency medical service (HEMS) pilots found a positive correlation among fatigue, nodding off in flight, and accidents. We sought to quantify the amount of sleepiness in HEMS pilots using the Epworth Sleepiness Scale (ESS).

METHODS

An anonymous survey was sent via the National EMS Pilots Association emergency medical services listserv including demographics, the ESS, and subjective effects of fatigue on flying. Statistical analyses were performed using the t-test and analysis of variance.

RESULTS

Thirty-one surveys were returned. Twenty-one (65%) reported an ESS > 10, indicating excessive daytime sleepiness. Twelve (39%) reported nodding off in flight; 20 (65%) indicated that they should have refused to fly, but only 14 (45%) actually did. En route was the most likely phase of flight to be affected by fatigue (23 [74%]), whereas takeoff (2 [7%]) and landing (2 [7%]) were the least likely to be affected.

CONCLUSION

Many HEMS pilots in this small study reported excessive daytime sleepiness. Most respondents indicated that they should have turned down a flight because of fatigue. More research is necessary to quantify the burden of fatigue among HEMS pilots.

Sleep and Sleepiness Measured by Diaries and Actigraphy among Norwegian and Austrian Helicopter Emergency Medical Service (HEMS) Pilots

The study examined sleep and sleepiness among shift working Helicopter Emergency Medical Service pilots from Norway (Norwegian Air Ambulance; NAA) and Austria (Christophorus Flugrettungverein; CFV). Both pilot groups (N = 47) worked seven consecutive 24 h shifts. Sleep was assessed by diaries and actigraphy while sleepiness was assessed by the Karolinska Sleepiness Scale, all administered throughout the workweek. The results indicated that all pilots had later bedtime (p < 0.05) and wake-up time (p < 0.01) as they approached the workweek end, but no change during the workweek was evident regarding wake after sleep onset, time in bed, total sleep time, or sleep efficiency. The NAA pilots had later bedtime (p < 0.001) and wake-up time (p < 0.001), spent more time awake after sleep onset (p < 0.001), more time in bed (p < 0.001), slept longer (p < 0.01), and had lower sleep efficiency (p < 0.001) compared with the CFV pilots. The sleepiness levels of all pilots were slightly elevated on the first workday but lower on the following workdays (day 2p < 0.001, day 3p < 0.05). For both pilot groups, no major change in sleep or sleepiness parameters throughout the workweek was detected. The NAA pilots reported somewhat more disturbed sleep but obtained more sleep compared with the CFV pilots.

Fatigue in Aviation: Safety Risks, Preventive Strategies and Pharmacological Interventions

Fatigue poses an important safety risk to civil and military aviation. In addition to decreasing performance in-flight (chronic) fatigue has negative long-term health effects. Possible causes of fatigue include sleep loss, extended time awake, circadian phase irregularities and work load. Despite regulations limiting flight time and enabling optimal rostering, fatigue cannot be prevented completely. Especially in military operations, where limits may be extended due to operational necessities, it is impossible to rely solely on regulations to prevent fatigue. Fatigue management, consisting of preventive strategies and operational countermeasures, such as pre-flight naps and pharmaceuticals that either promote adequate sleep (hypnotics or chronobiotics) or enhance performance (stimulants), may be required to mitigate fatigue in challenging (military) aviation operations. This review describes the pathophysiology, epidemiology and effects of fatigue and its impact on aviation, as well as several aspects of fatigue management and recommendations for future research in this field.

Going Batty: The Challenges and Opportunities of Using Drones to Monitor the Behaviour and Habitat Use of Rays

The way an animal behaves in its habitat provides insight into its ecological role. As such, collecting robust, accurate datasets in a time-efficient manner is an ever-present pressure for the field of behavioural ecology. Faced with the shortcomings and physical limitations of traditional ground-based data collection techniques, particularly in marine studies, drones offer a low-cost and efficient approach for collecting data in a range of coastal environments. Despite drones being widely used to monitor a range of marine animals, they currently remain underutilised in ray research. The innovative application of drones in environmental and ecological studies has presented novel opportunities in animal observation and habitat assessment, although this emerging field faces substantial challenges. As we consider the possibility to monitor rays using drones, we face challenges related to local aviation regulations, the weather and environment, as well as sensor and platform limitations. Promising solutions continue to be developed, however, growing the potential for drone-based monitoring of behaviour and habitat use of rays. While the barriers to enter this field may appear daunting for researchers with little experience with drones, the technology is becoming increasingly accessible, helping ray researchers obtain a wide range of highly useful data.

Sleep inertia: current insights

Sleep inertia, or the grogginess felt upon awakening, is associated with significant cognitive performance decrements that dissipate as time awake increases. This impairment in cognitive performance has been observed in both tightly controlled in-laboratory studies and in real-world scenarios. Further, these decrements in performance are exaggerated by prior sleep loss and the time of day in which a person awakens. This review will examine current insights into the causes of sleep inertia, factors that may positively or negatively influence the degree of sleep inertia, the consequences of sleep inertia both in the laboratory and in real-world settings, and lastly discuss potential countermeasures to lessen the impact of sleep inertia.

Sleepiness among personnel in the Norwegian Air Ambulance Service

Abstract

Purpose To examine the effects of shift work and extended working hours on sleepiness among pilots and Helicopter Emergency Medical Service (HEMS) crew members in the Norwegian Air Ambulance.

Methods

This field study investigated sleepiness during 3 consecutive weeks: the week before work, the work week, and the week after work. The pilots and HEMS crew members (N = 50) kept a wake diary during all 3 weeks and completed reaction time tests during the work week.

Results

The overall sleepiness scores were low during all 3 weeks. When comparing the 3 weeks, the lowest sleepiness levels were found for the work week. There was a small difference across work days, in which subjective sleepiness scores were highest the first duty day. No change in the reaction time tests was evident during the work week. The crew members reported being most sleepy at midnight, compared to all the other timepoints over the course of a duty day. Regarding workload and total work time, having larger workload was associated with lower sleepiness scores, while having higher total work time was associated with higher sleepiness score, both compared to the medium category.

Conclusions

The findings indicate that the work schedules and setting for this distinct occupational group do not seem to negatively affect the sleepiness levels.

Evaluation of a New Helicopter Crew Transport Fatigue Assessment

Fatigue in air ambulance crews leads to decrements in performance and situational awareness that may contribute to aircraft accidents and patient care mistakes. Fatigue assessments completed by flight crews can give early warning when fatigue is accumulating. Countermeasures can then be implemented to improve performance and increase safety. No validated air ambulance fatigue assessment currently exists that incorporates transport-specific factors. The objective of this study was to validate a flight fatigue assessment that accounts for air transport-specific factors. Flight crewmembers from multiple air ambulance programs participated and completed assessments. Results were analyzed to determine if the assessment captured or predicted fatigue levels of crewmembers. When used to measure crewmember fatigue, the assessment was shown to consistently and reliably confirm accumulating fatigue and correlated with crew-reported levels of fatigue. A predicted fatigue scale was created to help crewmembers objectively identify their fatigue level. Used consistently, the transport fatigue assessment should increase awareness of accumulating fatigue. With awareness, crewmembers are better equipped to justify and take advantage of opportunities to mitigate their fatigue, increase crew coordination, enhance safety, and improve patient care.

Occupational Stress in Helicopter Emergency Service Pilots From 4 European Countries

OBJECTIVE

Working conditions are known to affect motivation, well-being, and ultimately work performance. Helicopter emergency medical services (HEMS) pilots' work is highly demanding and safety critical, but virtually no published data on occupational stress and strain symptoms in HEMS pilots are available. We investigated work stressors and resources and their association with work engagement, subjective well-being, and energy levels in European HEMS pilots.

METHODS

Cross-sectional questionnaire data were collected consecutively from 72 European HEMS pilots (24 Western European and 48 Eastern European, mean age = 51.9 years). We examined the stressor, resource, and strain symptom levels by age group and region of origin and the association of stressors and resources with work engagement, well-being, and energy.

RESULTS

Although the responses differed notably between the Eastern and Western European pilots, their overall profile was quite favorable. At the same time, those stressor/resource variables, which on average had the most favorable ratings, were the most strongly associated with (reduced) well-being and energy.

CONCLUSION

On the whole, the HEMS pilots' perception of their work situation appears to be positive, and they are highly engaged in their work. The pilots' strong identification with their work should be taken into account in pilot mental health support systems.

Aspects of work and sleep associated with work ability in regular aviation pilots

OBJECTIVE:

Analyze the association of work organization and sleep aspects with work ability in regular aviation pilots.

METHODS:

This is a cross-sectional epidemiological study with 1,234 regular aviation pilots who worked domestic and international flights, affiliated with the Brazilian Association of Civil Aviation Pilots. Data collection employed online questionnaire. We compared proportions using Pearson's Chi-squared or Fisher's exact hypothesis tests. Then, we conducted Poisson analysis, with robust variance, to test factors associated with moderate or low work ability.

RESULTS:

The prevalence of moderate or low work ability was 43.3%. We found that self-perception of insufficient sleep (PR = 1.29; 95%CI 1.06–1.57), increased perception for fatigue (PR = 1.51; 95%CI 1.24–1.84), more than 65 flight hours per month (PR = 1.22; 95%CI 1.01–1.46), less than 10 days of time off per month (PR = 1.27; 95%CI 1.04–1.55), and frequent operational delays (PR = 1.23; 95%CI 1.02–1.48) were factors associated with moderate or low work ability.

CONCLUSIONS:

Work organization was a determining factor for decreased work ability, especially concerning aspects related to rest and its influence on the sleep of pilots.

A Preliminary Review of Fatigue Among Rail Staff

Background: Fatigue is a severe problem in the rail industry, which may jeopardize train crew's health and safety. Nonetheless, a preliminary review of all empirical evidence for train crew fatigue is still lacking. The aim of the present paper is, therefore, to provide a preliminary description of occupational fatigue in the rail industry. This paper reviews the literature with the research question examining the risk factors associated with train crew fatigue, covering both papers published in refereed journals and reports from trade organizations and regulators. It assesses the progress of research on railway fatigue, including research on the main risk factors for railway fatigue, the association between fatigue and railway incidents, and how to better manage fatigue in the railway industry.

Methods: Systematic searches were performed in both science and industry databases. The searches considered studies published before August 2017. The main exclusion criterion was fatigue not being directly measured through subjective or objective methods.

Results: A total of 31 studies were included in the main review. The causes of fatigue included long working hours, heavy workload, early morning or night shifts, and insufficient sleep. Poor working environment, particular job roles, and individual differences also contributed to fatigue.

Conclusion: Fatigue in the rail industry includes most of the features of occupational fatigue, and it is also subject to industry-specific factors. The effect of fatigue on well-being and the fatigued population in the railway industry are still not clear. Future studies can consider associations between occupational risk factors and perceived fatigue by examining the prevalence of fatigue and identifying the potential risk factors in staff within the railway industry.

Working hours associated with unintentional sleep at work among airline pilots

OBJECTIVE

Tto identify factors associated with unintentional sleep at work of airline pilots.

METHODS

This is a cross-sectional epidemiological study conducted with 1,235 Brazilian airline pilots, who work national or international flights. Data collection has been performed online. We carried out a bivariate and multiple logistic regression analysis, having as dependent variable unintentional sleep at work. The independent variables were related to biodemographic data, characteristics of the work, lifestyle, and aspects of sleep.

RESULTS

The prevalence of unintentional sleep while flying the airplane was 57.8%. The factors associated with unintentional sleep at work were: flying for more than 65 hours a month, frequent technical delays, greater need for recovery after work, work ability below optimal, insufficient sleep, and excessive sleepiness.

CONCLUSIONS

The occurrence of unintentional sleep at work of airline pilots is associated with factors related to the organization of the work and health.

Time to wake up: reactive countermeasures to sleep inertia

Sleep inertia is the period of impaired performance and grogginess experienced after waking. This period of impairment is of concern to workers who are on-call, or nap during work hours, and need to perform safety-critical tasks soon after waking. While several studies have investigated the best sleep timing and length to minimise sleep inertia effects, few have focused on countermeasures -especially those that can be implemented after waking (i.e. reactive countermeasures). This structured review summarises current literature on reactive countermeasures to sleep inertia such as caffeine, light, and temperature and discusses evidence for the effectiveness and operational viability of each approach. Current literature does not provide a convincing evidence-base for a reactive countermeasure. Caffeine is perhaps the best option, although it is most effective when administered prior to sleep and is therefore not strictly reactive. Investigations into light and temperature have found promising results for improving subjective alertness; further research is needed to determine whether these countermeasures can also attenuate performance impairment. Future research in this area would benefit from study design features highlighted in this review. In the meantime, it is recommended that proactive sleep inertia countermeasures are used, and that safety-critical tasks are avoided immediately after waking.

Injury and fatality risks in aeromedical transport: focus on prevention

BACKGROUND

Aeromedical transport (AMT) is a reliable and well-established life-saving option for rapid patient transfers to health care delivery hubs. However, owing to the very nature of AMT, fatal and nonfatal events may occur. This study reviews aeromedical incidents reported since the publication of the last definitive review in 2003, aiming to provide additional insight into a wide range of factors potentially associated with fatal and nonfatal AMT incidents (AMTIs). We hypothesized that weather and/or visual conditions, postcrash fire, aircraft make and/or type, and time of day all correlate with the risk of AMTI with injury or fatality.

METHODS

Specialty databases were queried for AMTI between January 1, 2003 and July 31, 2015. Additional Internet-based resources were also used to find any additional AMTI (including non-US occurrences) to augment the event sample size available for analysis. Univariate analyses of the collected sample were then performed for association between "fatal crash or injury" (FCOI) and weather/visual conditions, aircraft type and/or make, pilot error, equipment failure, post-incident fire, time of day (6 am-7 pm versus 7 pm-6 am), weekend (Friday-Sunday) versus weekday (Monday-Thursday), season of the year, and presence of patient on board. Variables reaching significance level of P < 0.20 were included in multivariate analysis.

RESULTS

A total of 59 AMTIs were identified. Helicopters were involved in 52 of 59 AMTIs, with 7 of 59 fixed-wing incidents. Comparing pre-2003 data with post-2003 data, we noted a significant decrease in AMTIs per month (0.70 versus 0.39, respectively, P = 0.048), whereas the number of fatalities per year increased slightly (7.20 versus 8.26, p = n/s). In univariate analyses, abnormal weather conditions, impaired visibility, time of incident (7 pm-6 am), aircraft model/make, and post-incident fire all reached statistical significance sufficient for inclusion in multivariate analysis (P < 0.20). Factors independently associated with FCOI included post-incident fire (odds ratio, 19.0; 95% confidence interval, 1.41-255.5) and time of incident between 7 pm and 6 am (odds ratio, 11.2; 95% confidence interval, 1.29-97.2). Weather conditions, impaired visibility, and aircraft model/make were not independently associated with FCOI.

CONCLUSIONS

The present study supports previous observation that post-crash fire is independently associated with FCOI. However, our data do not support previous observations that weather conditions, impaired visibility, or aircraft model/make are independently predictive of fatal AMTI. In addition, this report demonstrates that flights between the hours of 7 pm-6 am may be associated with greater odds of FCOI. Efforts directed at identification, remediation, and active prevention of factors associated with AMTI and FCOI are warranted given the global increase in aeromedical transport.

Sleep inertia during a simulated 6-h on/6-h off fixed split duty schedule

Sleep inertia is a safety concern for shift workers returning to work soon after waking up. Split duty schedules offer an alternative to longer shift periods, but introduce additional wake-ups and may therefore increase risk of sleep inertia. This study investigated sleep inertia across a split duty schedule. Sixteen participants (age range 21-36 years; 10 females) participated in a 9-day laboratory study with two baseline nights (10 h time in bed, [TIB]), four 24-h periods of a 6-h on/6-h off split duty schedule (5-h TIB in off period; 10-h TIB per 24 h) and two recovery nights. Two complementary rosters were evaluated, with the timing of sleep and wake alternating between the two rosters (2 am/2 pm wake-up roster versus 8 am/8 pm wake-up roster). At 2, 17, 32 and 47 min after scheduled awakening, participants completed an 8-min inertia test bout, which included a 3-min psychomotor vigilance test (PVT-B), a 3-min Digit-Symbol Substitution Task (DSST), the Karolinska Sleepiness Scale (KSS), and the Samn-Perelli Fatigue Scale (SP-Fatigue). Further testing occurred every 2 h during scheduled wakefulness. Performance was consistently degraded and subjective sleepiness/fatigue was consistently increased during the inertia testing period as compared to other testing times. Morning wake-ups (2 am and 8 am) were associated with higher levels of sleep inertia than later wake-ups (2 pm and 8 pm). These results suggest that split duty workers should recognise the potential for sleep inertia after waking, especially during the morning hours.

Fatigue in Air Medical Clinicians Undertaking High-acuity Patient Transports

Abstract Background. Fatigue is likely to be a significant issue for air medical transport clinicians due to the challenging nature of their work, but there is little published evidence for this. Objective. To prospectively assess the levels and patterns of fatigue in air medical transport teams and determine whether specific mission factors influenced clinician fatigue. Methods. Physicians and flight nurses from two intensive care interhospital transport teams routinely completed fatigue report forms before and after patient transport missions over a 4-month period. Data collected included subjective ratings of fatigue (Samn-Perelli and visual analog scale), mission difficulty and performance. Multivariate hierarchical logistic and linear models were used to evaluate the influence of various mission characteristics on post-mission fatigue. Results. Clinicians returned 403 fully complete fatigue report forms at an estimated overall return rate of 73%. Fatigue increased significantly over the course of missions, and on 1 of every 12 fatigue reports returned clinicians reported severe post-mission fatigue (that is, levels of 6 or 7 on the Samn-Perelli scale). Factors that impacted significantly on clinician fatigue were the pre-mission fatigue level of the clinician, night work, mission duration, and mission difficulty. Poorer self-rated performance was significantly associated with higher levels of fatigue (r = -0.4, 95% CI -0.5 to -0.3), and for the 6-month period leading up to the study clinicians reported a total of 22 occasions on which they should have declined a mission due to fatigue. Conclusions. These results suggest that clinicians undertaking interhospital transports of even moderate duration experience high levels of fatigue on a relatively frequent basis. In the unique and challenging environment of air medical transport, prior fatigue, long or difficult missions, and the disadvantageous effect of night work on normal circadian rhythms are a combination where there are minimal safety margins for clinicians' performance capacity. Fatigue prevention or fatigue resistance measures could positively affect air medical clinicians in this context.

Have restricted working hours reduced junior doctors' experience of fatigue? A focus group and telephone interview study

OBJECTIVE

To explore the effects of the UK Working Time Regulations (WTR) on trainee doctors' experience of fatigue.

DESIGN

Qualitative study involving focus groups and telephone interviews, conducted in Spring 2012 with doctors purposively selected from Foundation and specialty training. Final compliance with a 48 h/week limit had been required for trainee doctors since August 2009. Framework analysis of data.

SETTING

9 deaneries in all four UK nations; secondary care.

PARTICIPANTS

82 doctors: 53 Foundation trainees and 29 specialty trainees. 36 participants were male and 46 female. Specialty trainees were from a wide range of medical and surgical specialties, and psychiatry.

RESULTS

Implementation of the WTR, while acknowledged as an improvement to the earlier situation of prolonged excessive hours, has not wholly overcome experience of long working hours and fatigue. Fatigue did not only arise from the hours that were scheduled, but also from an unpredictable mixture of shifts, work intensity (which often resulted in educational tasks being taken home) and inadequate rest. Fatigue was also caused by trainees working beyond their scheduled hours, for reasons such as task completion, accessing additional educational opportunities beyond scheduled hours and staffing shortages. There were also organisational, professional and cultural drivers, such as a sense of responsibility to patients and colleagues and the expectations of seniors. Fatigue was perceived to affect efficiency of skills and judgement, mood and learning capacity.

CONCLUSIONS

Long-term risks of continued stress and fatigue, for doctors and for the effective delivery of a healthcare service, should not be ignored. Current monitoring processes do not reflect doctors' true working patterns. The effectiveness of the WTR cannot be considered in isolation from the culture and context of the workplace. On-going attention needs to be paid to broader cultural issues, including the relationship between trainees and seniors.

Fatigue on the flight deck: the consequences of sleep loss and the benefits of napping

The detrimental effects of fatigue in aviation are well established, as evidenced by both the number of fatigue-related mishaps and numerous studies which have found that most pilots experience a deterioration in cognitive performance as well as increased stress during the course of a flight. Further, due to the nature of the average pilot's work schedule, with frequent changes in duty schedule, early morning starts, and extended duty periods, fatigue may be impossible to avoid. Thus, it is critical that fatigue countermeasures be available which can help to combat the often overwhelming effects of sleep loss or sleep disruption. While stimulants such as caffeine are typically effective at maintaining alertness and performance, such countermeasures do nothing to address the actual source of fatigue - insufficient sleep. Consequently, strategic naps are considered an efficacious means of maintaining performance while also reducing the individual's sleep debt. These types of naps have been advocated for pilots in particular, as opportunities to sleep either in the designated rest facilities or on the flight deck may be beneficial in reducing both the performance and alertness impairments associated with fatigue, as well as the subjective feelings of sleepiness. Evidence suggests that strategic naps can reduce subjective feelings of fatigue and improve performance and alertness. Despite some contraindications to implementing strategic naps while on duty, such as sleep inertia experienced upon awakening, both researchers and pilots agree that the benefits associated with these naps far outweigh the potential risks. This article is a literature review detailing both the health and safety concerns of fatigue among commercial pilots as well as benefits and risks associated with strategic napping to alleviate this fatigue.

An investigation of pilot fatigue in helicopter emergency medical services

Pilot error has caused the majority of helicopter emergency medical services (HEMS) accidents in the United States for almost 2 decades. Pilot fatigue may have contributed to some of these accidents. This nonexperimental quantitative study investigated the relationships between fatigue reported by on-duty HEMS pilots (the criterion variable) and consecutive HEMS pilot day shifts, consecutive HEMS pilot night shifts, age, and experience as an HEMS pilot (the predictor variables). Surveys completed by 395 on-duty HEMS pilots in the US were examined to quantify respondent fatigue with the Brief Fatigue Inventory (BFI). This study found some evidence of a statistically significant positive relationship between HEMS pilot night shift respondent BFI scores and experience as an HEMS pilot, while controlling for consecutive HEMS pilot night shifts and age. A 1-way analysis of variance suggested that the effect of experience as an HEMS pilot on HEMS pilot night shift respondent BFI scores was statistically significant. Multivariate regression analysis suggested that experience as an HEMS pilot predicted HEMS pilot night shift respondent BFI scores. Additional quantitative research is recommended to confirm the results of this study and to investigate relationships between fatigue experienced by HEMS pilots and other variables that were not considered in this investigation. Qualitative research to identify and document fatigue management strategies that are used by experience HEMS pilots is also recommended.

Ethical Challenges in Emergency Medical Services: Controversies and Recommendations

Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

BeckerTK, Gausche-HillM, AsweganAL, BakerEF, BookmanKJ, BradleyRN, De LorenzoRA, SchoenwetterDJ for the American College of Emergency Physicians’ EMS Committee. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med. 2013;28(5):1-10.