The effect of a night shift nap on post-night shift performance, sleepiness, mood, and first recovery sleep: A randomized crossover trial.

OBJECTIVES: This study aimed to test the effect of a 30-minute nap versus a 2-hour nap opportunity taken during a simulated night shift on performance, fatigue, sleepiness, mood, and sleep at the end of shift and during post-night shift recovery. METHODS: We conducted a randomized crossover trial of three nap conditions (30-minute, 2-hour, and no-nap) during 12-hour simulated night shifts. We tested for differences in performance, fatigue, sleepiness, mood, and sleep during in-lab and at-home recovery. Performance was measured with the Brief Psychomotor Vigilance Test (PVT-B). Subjective ratings were assessed with single-item surveys. RESULTS: Twenty-eight individuals consented to participate [mean age 24.4 (standard deviation 7.2) years; 53.6% female; 85.7% Emergency Medical Services clinicians]. PVT-B false starts at the end of the 12-hour night shift (at 07:00 hours) and at the start of in-lab recovery (08:00 hours) were lower following the 2-hour nap versus other conditions (P<0.05). PVT-B response time at +0 minutes post-recovery nap was poorer compared to pre-recovery nap for the no-nap condition (P=0.003), yet not detected for other nap conditions (P>0.05). Sleepiness, fatigue, and some mood states were lower at most hourly assessments during the in-lab recovery period following the 2-hour nap condition compared to the other conditions. Sleep during recovery did not differ by duration of night shift nap. CONCLUSIONS: A 2-hour nap opportunity versus a 30-minute or no-nap opportunity is beneficial for performance, alertness, and mood post-night shift. No differences were detected in sleep during recovery.

Effect of Short versus Long Duration Naps on Blood Pressure during Simulated Night Shift Work: A Randomized Crossover Trial.

OBJECTIVE: Blunting of the sleep-related dip in blood pressure (BP) has been linked to numerous cardiovascular outcomes including myocardial infarction. Blunting of BP dipping occurs during night shift work and previous research suggest that a 60-min or longer on-shift nap is needed to restore normal/healthy BP dipping. We sought to determine the effect of different durations of napping on BP during and following simulated night shifts. We hypothesized that the greatest benefit in terms of restoration of normal BP dipping during night shift work would be observed during a longer duration nap versus a shorter nap opportunity. METHODS: We used a randomized crossover laboratory-based study design. Participants consented to complete three separate 72-hr conditions that included a 12-hr simulated night shift. Nap conditions included a 30-min and 2-hr nap compared to a no-nap condition. Ambulatory BP monitoring was assessed hourly and every 10-30 mins during in-lab naps. Blunted BP dipping during in-lab naps was the primary outcome. Goal enrollment of 25 (35 with attrition) provided 80% power to detect a mean difference of 5 mmHg in BP between nap conditions. RESULTS: Of the 58 screened, 28 were consented, and 26 completed all three 72-hr conditions. More than half (53.6%) were female. Mean age was 24.4 years (SD7.2). Most (85.7%) were certified as emergency medical technicians or paramedics. The mean percentage dip in systolic BP (SBP) and diastolic BP (DBP) did not differ between the 30-min and 2-hr nap conditions (p > 0.05), yet a greater proportion of participants experienced a 10-20% dip in SBP or DBP during the 2-hr nap versus the 30-min nap (p < 0.05). For every additional minute of total sleep during the 30-min nap, the percentage of SBP dip improved by 0.60%, and the percentage of DBP dip improved by 0.68% (p < 0.05). These improvements approximate to a 6% per minute relative advancement toward normal/healthy BP dipping. CONCLUSIONS: Restoration of a normal/healthy dip in BP is achievable during short and long duration nap opportunities during simulated night shift work. Our findings support the hypothesis that BP dipping is more common during longer 2-hr versus shorter 30-min naps. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04469803. Registered on 9 July 2020.

Are Short Duration Naps Better than Long Duration Naps for Mitigating Sleep Inertia? Brief Report of a Randomized Crossover Trial of Simulated Night Shift Work.

OBJECTIVE: We sought to test the effects of different duration naps on post-nap cognitive performance during simulated night shifts. METHODS: We used a randomized laboratory-based crossover trial design with simulated 12-hr night shifts and each participant completing three conditions of 72 hrs each (Clinicaltrials.gov; registration # NCT04469803). The three conditions tested included no-nap, a 30-min nap opportunity, and a 2-hr nap opportunity. Naps occurred at 02:00 hrs. Cognitive performance was assessed with the Brief 3-min Psychomotor Vigilance Test (PVT-B). Four PVT-B measures include: reaction time (RT in milliseconds (ms)), lapses (RT > 355 ms), false starts (reactions before stimulus or RT <100 ms), and speed (1,000/RT). The PVT-B was performed at the start of the simulated night shift (19:00), end of shift (07:00), pre-nap (02:00), and at 0 mins, 10 mins, 20 mins, and 30 mins following the 30-min and 2-hr nap conditions. Simultaneously, participants reported subjective ratings of fatigue and other constructs. RESULTS: Twenty-eight (15 female), mostly certified emergency medical technicians or paramedics, consented to participate. For all three conditions, looking within condition, PVT-B lapse performance at the end of the 12-hr simulated night shift (at 07:00) was poorer compared to shift start (p < 0.05). Performance on PVT-B speed, RT, and false starts were poorer at shift end than shift start for the no-nap and 30-min nap conditions (p < 0.05), but not for the 2-hr nap condition (p > 0.05). Compared to pre-nap measures, performance on the PVT-B assessed at 0 mins post-nap showed significant performance declines for lapses and speed for both the 30-min and 2-hr nap conditions (p < 0.05), but not at 10, 20, or 30 mins post-nap. After waking from the 2-hr on-shift nap opportunity (at 0 mins), participants rated sleepiness, difficulty with concentration, and alertness poorer than pre-nap (p < 0.05). Participants in the 30-min nap condition rated alertness poorer immediately after the nap (at 0 mins) compared to pre-nap (p < 0.05). CONCLUSIONS: While sleep inertia was detectable immediately following short 30-min and long 2-hr nap opportunities during simulated night shift work, deficits in cognitive performance and subjective ratings quickly dissipated and were not detectable at 10-30 mins post-nap.

Reply to Letter: Merigo et al., "De trop" meta-analyses and systematic reviews in cardiopulmonary resuscitation - A way to rapidly improve authors' citation index at a price of real science.

Merigo and colleagues argue that the meta-analyses and systematic reviews published in scientific journals in recent years is excessive, and that the primary goal is often more author-centric rather than to advance science. We agree that author benefits are not trivial, but some are foundational and important, especially for trainees. Trainees learn how to judge the quality of published evidence and create a comprehensive understanding in a selected topic, allowing for skill acquisition and a strong base for later work. This can stoke a future career and better insights by many, starting with the people who create these pieces.

Examining the prevalence and health impairment associated with subthreshold PTSD symptoms (PTSS) among frontline healthcare workers during the COVID-19 pandemic.

The COVID-19 pandemic has increased healthcare workers' (HCWs) risk for posttraumatic stress disorder (PTSD). Although subthreshold PTSD symptoms (PTSS) are common and increase vulnerability for health impairments, they have received little attention. We examined the prevalence of subthreshold PTSS and their relationship to physical health symptoms and sleep problems among HCWs during the pandemic's second wave (01/21-02/21). Participants (N = 852; 63.1% male; Mage = 38.34) completed the Short-Form PTSD Checklist (SF-PCL), the Cohen-Hoberman Inventory of Physical Symptoms, and the PROMIS Sleep-Related Impairment-Short-Form 4a. We created three groups with the SF-PCL: scores ≥11 = probable PTSD (5.5%); scores between 1 and 10 = subthreshold PTSS (55.3%); scores of 0 = no PTSS (39.2%). After controlling for demographics, occupational characteristics, and COVID-19 status, HCWs with subthreshold PTSS experienced greater physical health symptoms and sleep problems than HCWs with no PTSS. While HCWs with PTSD reported the greatest health impairment, HCWs with subthreshold PTSS reported 88% more physical health symptoms and 36% more sleep problems than HCWs with no PTSS. Subthreshold PTSS are common and increase risk for health impairment. Interventions addressing HCWs' mental health in response to the COVID-19 pandemic must include subthreshold PTSS to ensure their effectiveness.

2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care.

INTRODUCTION: Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel. OBJECTIVES: We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel. METHODS: We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing. CONCLUSIONS: This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.

Recommendations for Improving the Quality of Prehospital Evidence-Based Guidelines.

Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. Guideline developers and end users could be better informed by efforts across medical specialties to improve the quality of guidelines, including the use of specific criteria that have been identified within the highest quality guidelines. In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.

The Emergency Medical Services Sleep Health Study: A cluster-randomized trial.

BACKGROUND: Greater than half of emergency medical services (EMS) clinician shift workers report poor sleep, fatigue, and inadequate recovery between shifts. We hypothesized that EMS clinicians randomized to receive tailored sleep health education would have improved sleep quality and less fatigue compared to wait-list controls after 3 months. METHODS: We used a cluster-randomized, 2-arm, wait-list control study design (clinicaltrials.gov identifier: NCT04218279). Recruitment of EMS agencies (clusters) was nationwide. Our study was powered at 88% to detect a 0.4 standard deviation difference in sleep quality with 20 agencies per arm and a minimum of 10 individuals per agency. The primary outcome was measured using the Pittsburgh Sleep Quality Index (PSQI) at 3-month follow-up. Our intervention was accessible in an online, asynchronous format and comprised of 10 brief education modules that address fatigue mitigation topics prescribed by the American College of Occupational Environmental Medicine. RESULTS: In total, 36 EMS agencies and 678 individuals enrolled. Attrition at 3 months did not differ by study group (Intervention = 17.4% vs. Wait-list control = 18.2%; p = .37). Intention-to-treat analyses detected no differences in PSQI and fatigue scores at 3 months. Per protocol analyses showed the greater the number of education modules viewed, the greater the improvement in sleep quality and the greater the reduction in fatigue (p < .05). CONCLUSIONS: While intention-to-treat analyses revealed no differences in sleep quality or fatigue at 3 months, per protocol findings identified select groups of EMS clinician shift workers who may benefit from sleep health education. Our findings may inform fatigue risk management programs.

Working hours, sleep, and fatigue in the public safety sector: A scoping review of the research.

BACKGROUND: The public safety sector includes law enforcement officers (LEO), corrections officers (CO), firefighter service (FF), wildland firefighting (WFF), and emergency medical services (EMS), as defined in the National Occupational Research Agenda (NORA) of the National Institute for Occupational Safety and Health (NIOSH). Across these occupations, shiftwork, long-duration shifts, and excessive overtime are common. Our objective was to identify research gaps related to working hours, sleep, and fatigue among these workers. METHODS: We used a scoping review study design that included searches of MEDLINE, Embase, CAB Abstracts, Global Health, PsychInfo, CINAHL, Scopus, Academic Search Complete, Agricultural and Environmental Science Collection, ProQuest Central, Cochrane Library, Safety Lit, Homeland Security Digital Library, and Sociological Abstracts using a range of occupational search terms and terms related to working hours, sleep, and fatigue. RESULTS: Out of 3415 articles returned from our database search, 202 met all inclusion criteria. Six common outcomes related to working hours, sleep, and fatigue emerged: sleep, fatigue, work performance, injury, psychosocial stress, and chronic disease. Nearly two-thirds (59%, n = 120) of the studies were observational, of which 64% (n = 77) were cross sectional and 9% were (n = 11) longitudinal; 14% (n = 30) of the studies were reviews; and 19% (n = 39) were experimental or quasi-experimental studies. Only 25 of the 202 articles described mitigation strategies or interventions. FFs, LEOs, EMS, and WFFs were the most studied, followed by COs. CONCLUSIONS: In general, more longitudinal and experimental studies are needed to enrich the knowledge base on the consequences of long working hours, poor sleep, and fatigue in the public safety sector. Few experimental studies have tested novel approaches to fatigue mitigation in diverse sectors of public safety. This gap in research limits the decisions that may be made by employers to address fatigue as a threat to public-safety worker health and safety.

Masking by health care and public safety workers in non-patient care areas to mitigate SARS-CoV-2 infection: A systematic review.

Objectives: Wearing a mask is an important method for reducing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in health care and public safety settings. We assess the evidence regarding masking in the workplace during the initial months of the COVID-19 pandemic (PROSPERO CRD4202432097). Methods: We performed a systematic review of published literature from 4 databases and evaluated the quality of evidence with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. We searched for observational and experimental research involving public safety and health care workers. We included articles evaluating the use of masks, versus no mask, on the outcome of SARS-CoV-2 infection. Results: Our search yielded 15,013 records, of which 9 studies were included. Most studies (n = 8; 88.9%) involved infections or outbreaks among health care workers. The majority (88.9%) used in-depth interviews of cases and non-cases to obtain self-reported use of masks during periods of exposure. One of 9 studies quantitatively assessed differences in SARS-CoV-2 infection based on use of masks in non-patient care settings. Use of observational study designs, small sample sizes, inadequate control for confounding, and inadequate measurement of exposure and non-exposure periods with infected coworkers contributed to the quality of evidence being judged as very low. Conclusions: The available evidence from the initial months of the pandemic suggests that the use of masks in congregate, non-patient care settings, such as breakrooms, helps to reduce risk of SARS-CoV-2 virus transmission. However, this evidence is limited and is of very low quality. Prospective studies incorporating active observation measures are warranted.

Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society.

CITATION: Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: (1) a recognition of the factors contributing to fatigue and fatigue-related risks; (2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and (3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.

Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society.

Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: (1) a recognition of the factors contributing to fatigue and fatigue-related risks; (2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and (3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.

Does the evidence support brief (≤30-mins), moderate (31-60-mins), or long duration naps (61+ mins) on the night shift? A systematic review.

We performed a systematic review of four databases to determine if the evidence supports a short or long duration nap during night shifts to mitigate fatigue, and/or improve health, safety, or performance for emergency services and public safety personnel (PROSPERO CRD42020156780). We focused on experimental research and evaluated the quality of evidence with the grading of recommendations, assessment, development, and evaluation (GRADE) framework. We used the Cochrane Collaboration's risk of bias tool to assess bias and reported findings using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Our search yielded n = 10,345 records and n = 44 were reviewed in full-text. Inter-rater agreement during screening was substantial (Kappa = 0.66). We retained n = 11 publications, reporting on n = 7 experimental studies with a cumulative sample size of n = 140. We identified wide variation in study design, napping interventions (i.e., timing, placement, and duration), and outcomes. We identified mixed findings comparing brief, moderate, and long duration naps on outcomes of interest. All seven studies presented serious risk of bias and the quality of evidence was rated as low. Based on the best available evidence, decisions regarding nap duration during night shift work should be based on time (post-nap) and outcome.

COVID-19 Vaccine Uptake and Intent Among Emergency Healthcare Workers: A Cross-Sectional Survey.

OBJECTIVE: Vaccine hesitancy limits population protection from SARS-CoV (coronavirus disease [COVID-19]). Vaccine hesitancy among healthcare workers (HCW) could put patients and coworkers at risk. METHODS: We surveyed 475 emergency department and emergency medical service workers from January to February 2021 to determine vaccine intent/uptake, perceived COVID-19 vulnerability, and factors associated with vaccine intent/uptake. RESULTS: Although 79% of HCWs received or had plans to receive the COVID-19 vaccine, 21% had no intent/were unvaccinated; intent/uptake was lower among females (odds ratio [OR] = 0.34) and those with a history of COVID-19 infection (OR = 0.55), and higher among those with advanced degrees (OR = 3.53) and high perceived COVID-19 vulnerability (OR = 1.99). CONCLUSIONS: This study provides a timely assessment of vaccination status among frontline HCWs and highlights subgroups who may be at high risk of exposure and transmission.

Napping on the night shift and its impact on blood pressure and heart rate variability among emergency medical services workers: study protocol for a randomized crossover trial.

BACKGROUND: There is an emerging body of evidence that links exposure to shift work to cardiovascular disease (CVD). The risk of coronary events, such as myocardial infarction, is greater among night shift workers compared to day workers. There is reason to believe that repeated exposure to shift work, especially night shift work, creates alterations in normal circadian patterns of blood pressure (BP) and heart rate variability (HRV) and that these alterations contribute to increased risk of CVD. Recent data suggest that allowing shift workers to nap during night shifts may help to normalize BP and HRV patterns and, over time, reduce the risk of CVD. The risk of CVD related to shift work is elevated for emergency medical services (EMS) shift workers due in part to long-duration shifts, frequent use of night shifts, and a high prevalence of multiple jobs. METHODS: We will use a randomized crossover trial study design with three study conditions. The targeted population is comprised of EMS clinician shift workers, and our goal enrollment is 35 total participants with an estimated 10 of the 35 enrolled not completing the study protocol or classified as lost to attrition. All three conditions will involve continuous monitoring over 72 h and will begin with a 36-h at-home period, followed by 24 total hours in the lab (including a 12-h simulated night shift), ending with 12 h at home. The key difference between the three conditions is the intra-shift nap. Condition 1 will involve a simulated 12-h night shift with total sleep deprivation. Condition 2 will involve a simulated 12-h night shift and a 30-min nap opportunity. Condition 3 will involve a simulated 12-h night shift with a 2-h nap opportunity. Our primary outcomes of interest include blunted BP dipping and reduced HRV as measured by the standard deviation of the inter-beat intervals of normal sinus beats. Non-dipping status will be defined as sleep hours BP dip of less than 10%. DISCUSSION: Our study will address two indicators of cardiovascular health and determine if shorter or longer duration naps during night shifts have a clinically meaningful impact. TRIAL REGISTRATION: ClinicalTrials.gov NCT04469803 . Registered on 9 July 2020.

Ambulatory blood pressure monitoring among emergency medical services night shift workers.

OBJECTIVES: Higher 24-hour blood pressure (BP) and blunted BP dipping during sleep and night-time hours are associated with adverse health outcomes. Night shift work may affect 24-hour BP and dipping patterns, but empirical data in emergency medical services (EMS) clinician shift workers are sparse. We implemented ambulatory blood pressure monitoring (ABPM) in EMS workers to characterise BP during night shift work versus a non-workday, and sleep versus wake. METHODS: Participants worked night shifts. Hourly ABPM and wrist actigraphy (to measure sleep) were collected during two 24-hour periods, one scheduled night shift and one non-workday. Blunted BP dipping was defined as a BP decrease of <10%. RESULTS: Of 56 participants, 53 (53.6% female, mean age 26.5 (SD 7.5) years) completed the study. During daytime sleep on a workday, 49.1% of participants had blunted systolic BP (SBP) or diastolic BP (DBP) dipping. During night-time sleep on a non-workday, 25% had blunted SBP dipping and 3.9% blunted DBP dipping. Blunted SBP or DBP dipping occurred among all participants who did not nap during the night shift or who napped <60 min. Blunted SBP dipping occurred in only 14.3% of participants who napped 60-120 min. CONCLUSIONS: During night shift work, the BP dipping of EMS shift workers is blunted; however, most who nap for 60 min or longer experience a healthy dip in BP. The potential health consequences of these observations in EMS clinicians warrant further study.

Accidental hypothermic cardiac arrest and extracorporeal membrane oxygenation: a case report.

BACKGROUND: Accidental hypothermic cardiac arrest, an involuntary drop in core body temperature resulting in cardiopulmonary arrest, is linked to 1500 deaths annually. We highlight the challenges with the treatment of accidental hypothermic cardiac arrest and describe improved preparations necessary for an integrated health system to care for similar patients. CASE REPORT: Emergency medical services (EMS) were dispatched to a 34-year-old female who had been missing for several hours during a January snowfall. The patient was found unconscious over an embankment. The patient was found with a weak carotid pulse and two empty bottles of clozapine, an atypical antipsychotic. The EMS crew extricated the patient, performed a rapid trauma assessment, passive rewarming, and airway management. During transport, the patient suffered a ventricular fibrillation cardiac arrest, received defibrillation, and advanced life support measures. Resuscitative efforts continued in the emergency department while the treatment team addressed environmental exposure, assessed for traumatic injury and toxicologic exposure. On emergency department (ED) arrival, the patient's core temperature was 24°C, and despite aggressive resuscitation, the patient remained in cardiac arrest. The ED care team used extracorporeal membrane oxygenator (ECMO) and successfully resuscitated the patient with extracorporeal cardiopulmonary resuscitation. The patient achieved full neurologic recovery 15 days post-ED arrival. CONCLUSION: This case highlights the importance of early recognition of accidental hypothermic cardiac arrest by EMS clinicians, rapid transport to a tertiary facility, and the timely application of active rewarming and in-hospital ECMO. Accidental hypothermic cardiac arrest is a reversible state; prompt and correct treatment allows for a high probability of a favorable neurologic outcome.

Should public safety shift workers be allowed to nap while on duty?

Fatigue and sleep deficiency among public safety personnel are threats to wellness, public and personal safety, and workforce retention. Napping strategies may reduce work-related fatigue, improve safety and health, yet in some public safety organizations it is discouraged or prohibited. Our aim with this commentary is to define intra-shift napping, summarize arguments for and against it, and to outline potential applications of this important fatigue mitigation strategy supported by evidence. We focus our discussion on emergency medical services (EMS); a key component of the public safety system, which is comprised of police, fire, and EMS. The personnel who work in EMS stand to benefit from intra-shift napping due to frequent use of extended duration shifts, a high prevalence of personnel working multiple jobs, and evidence showing that greater than half of EMS personnel report severe fatigue, poor sleep quality, inadequate inter-shift recovery, and excessive daytime sleepiness. The benefits of intra-shift napping include decreased sleepiness and fatigue, improved recovery between shifts, decreased anxiety, and reduced feelings of burnout. Intra-shift napping also mitigates alterations in clinician blood pressure associated with disturbed sleep and shift work. The negative consequences of napping include negative public perception, acute performance deficits stemming from sleep inertia, and the potential costs associated with reduced performance. While there are valid arguments against intra-shift napping, we believe that the available scientific evidence favors it as a key component of fatigue mitigation and workplace wellness. We further believe that these arguments extend beyond EMS to all sectors of public safety.