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By David Page, MS, NRP, & Will Krost, MBA, NRP EMSWORLD.com | APRIL 2016 13 we are at minimum staff, but you will be fine. The pumps are all fully charged." The ED staff even help load the stretcher in the open garage as a number of cables and IV pumps are clamped to the stretcher. "It's so darn cold," a nurse says. En route things seem to go well with the ventilator and the patient remains hemodynamically stable. "Are you awake?" the paramedic asks his EMT partner as he feels the ambulance fishtail on the icy road. Receiving no response, he assumes his partner is concentrating on the road. The IV pump repeatedly alarms. "How do I silence this thing?" the paramedic keeps asking his partner. "I've got my window open so I don't fall asleep," he yells back, "it's not bothering me!" Have you figured out the twist in this case yet? Here is a hint…you may want to look up the tem- perature at which mannitol crystalizes in an IV line. The IV pump was not alarming because of a typi- cal air bubble or low battery, as the crew assumed. Approximately 20 minutes out from the receiving facility, the patient, having received no mannitol, began to seize. It was on arrival at the trauma center that the crew and trauma center staff noted that the patient received almost none of the mannitol and there were crystals in the IV tubing. The bad patient outcome in this case is not clearly attributed to any error the crew made. It is deter- mined the cerebral edema worsened throughout the transport. On the drive home the crew wakes up in a corn- field, wondering what has just jarred them awake. The crew members had fallen asleep and the para- medic drove the ambulance off the road. Not wanting to get in trouble, they don't radio for help, but wait for assistance. They are lucky to be found by a passing farmer who takes an interest in the odd sight of an ambulance in a cornfield and pulls them back onto the road. The only trouble this crew gets into is when an eager new supervisor sends them a written repri- mand for an unusually long return to their service area. To this day, the ambulance service leadership is unaware of the event. The crew members smile to each other when the mechanic replaces an axle and wonders why these guys don't slow down for the speed bumps and train tracks! Discussion This case illustrates several serious and standard dangerous practices in our profession. Long hours under stressful conditions, unpredictable work schedules and low pay (leading providers to work multiple jobs) all contribute to the possibility of dan- gerous levels of sleep deprivation. Exhausted crews, afraid to ask for a safety break, afraid to refuse a call they are not trained or equipped to handle, and afraid to report errors from fear of discipline, combine into a "perfect storm" of errors. Here these errors involved both ambulance opera- tions and clinical outcomes. One could also argue that the lack of critical care training contributed to this error, but it should be noted that all ALS provid- ers in this service are trained on the use of IV pumps and ventilators. As a result, this paramedic should have recognized that the IV pump alarm error was valid and worked to rectify the problem. It is well documented that poor sleep and fatigue can reduce focus and attention, impair central nervous system function and have a net negative impact on cognition, reaction time and overall health. Numerous studies have also identified a strong association between poor sleep, fatigue and poor safety outcomes. This case also illustrates how some of our cultural expectations, peer pressure and a sense of duty, can resultin errors that lead to serious consequences. D r o w s y D r i v i n g An estimated 1 in 25 adult drivers (aged 18 years or older) report having fallen asleep while driving in the previous 30 days. Drowsy driving was estimated to be responsible for 72,000 crashes, 44,000 injuries and 800 deaths in 2013. Up to 6,000 fatal crashes each year may be caused by drowsy drivers. Individuals who snored or usually slept 6 or fewer hours per day were more likely to report falling asleep while driving. I n i t i a t i v e A d d r e s s e s E M S F a t i g u e R i s k s On February 2, 2016, the National Highway Traffic Safety Administration (NHTSA) officially announced its new initiative with the National Association of State EMS Officials (NASEMSO) to develop voluntary fatigue risk management guidelines and resources tailored to EMS. The project is a collaboration between NHTSA, NASEMSO and content experts from multiple institutions, including the University of Pittsburgh Department of Emergency Medicine and Carolinas HealthCare Department of Emergency Medicine. Dr. Daniel Patterson of the University of Pittsburgh Department of Emergency Medicine will serve as the project's principal investigator. Individuals and organizations can provide comments or questions for consideration by the Expert Panel at surveymonkey.com/r/ Fatigue-in-EMS. Resources and self-assessment tools are available at emsfatigue.org. Source: cdc.gov/features/ dsdrowsydriving/