Sleep Health and First Responder Performance and Safety

In this line of work, being tired is just part of the job. Everyone says so. Here's the thing: just because it's normal doesn't mean it's healthy, and it doesn't mean it's inevitable.

Look at what the job asks. Firefighters' schedules include extended shifts and long work weeks.^[6] Calls break up the night. Rosters rotate. Overtime and court dates eat into recovery. And as I told a room of first responders in 2019, in a single day you can face more trauma than most of us do in a lifetime.

Add it up and the sleep window gets squeezed from every side. The body clock doesn't care about the roster, either. That's the key: it's not just how much responders sleep, it's when.

More common than most people think:

• Firefighters: of 6,933 firefighters in 66 US departments, 37.2% screened positive for a sleep disorder. Sleep apnea was the most common (28.4%).^[1]
• Police: of 4,957 officers in the US and Canada, 40.4% screened positive for at least one sleep disorder, most of them not previously diagnosed.^[2]
• Paramedics and EMS: in a survey of 547 workers at 30 agencies, 55% were fatigued, and average sleep quality was in the poor range.^[3]
• Medical first responders overall: across 28 studies, the pooled rate for each of shift work disorder, sleep apnea, insomnia and excessive daytime sleepiness was roughly 3 in 10. The ranges were wide.^[4]
• Canada: of 5,813 public safety personnel in a self-selected online survey, 49 to 60% in each group reported symptoms consistent with clinical insomnia.^[5]

"Screened positive" means a questionnaire flagged a possible problem. It isn't a diagnosis, and most of these surveys rely on self-report. I'm a PhD, not an MD, so if this sounds like you, that's a conversation for your doctor. The good news: a flag is information, and information is where change starts.

On some tests, performance is comparable. Not identical. After about 17 to 19 hours awake, transport workers and army personnel performed on some tests as poorly as, or worse than, they did at a 0.05% blood alcohol level.^[12] After about 24 hours awake, a hand–eye coordination task matched roughly 0.08 to 0.10%.^[13] By about 21 hours, some driving-simulator measures matched 0.08%.^[14]

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Here's what the headline leaves out. Most of those tests ran late at night or in the small hours of the morning, as the body clock heads toward its low point, so hours awake and time of day are mixed together.^[12][13] Alcohol and sleep loss also hurt different skills: on the driving simulator, alcohol did more damage to speed control and staying on the road.^[14] So think of it as a warning, not an exact equation. A tired driver is still an impaired driver.

Broken sleep counts too. In a lab study built to mimic firefighting, both a night with no sleep and a night broken by three 60-minute awakenings increased attention lapses and slowed task-switching.^[15] The good news: a long shift is a risk you can see coming and plan for.

Each finding below comes from a different study, and most rely on self-report.

• Driving: firefighters who screened positive for a sleep disorder had about twice the odds of reporting a motor vehicle crash.^[1]
• EMS: fatigued EMS workers had 1.9 times the odds of injury and 2.2 times the odds of a medical error or adverse event. The authors call it preliminary evidence.^[3]
• Police on nights: in one mid-sized urban department, injuries were 72% more frequent on the midnight shift than on days.^[9] Back-to-back night shifts carried about 4.3 times the odds of a public complaint, and about 4.7 times when court hours fell between them.^[10]
• Five nights in a row: after five consecutive night shifts, 29 patrol officers did worse on simulated driving and vigilance than after three days off.^[11]

Muscles may hold up better than minds. In simulated hot wildfire conditions, two nights with only a four-hour sleep opportunity did not change firefighters' physical task performance.^[16] The clearer risks are to attention, mental flexibility and driving.^[15][1]

That's the bad news. The good news: schedules and sleep habits can both change.

I hear it a lot: "Glenn, I can function really well on four or five hours." I'm sorry. You may feel like you're great, but you aren't your best self when you're sleep deprived.

There is science behind that. In a classic experiment, healthy adults limited to six hours or less in bed a night for two weeks performed as if they had missed up to two nights of sleep entirely. They were largely unaware of it.^[17] Like someone who has had a few drinks, a tired person is a poor judge of whether they are fit to drive. And 26.1% of surveyed officers reported falling asleep at the wheel at least once a month.^[2]

There's another important point. You might feel fit for duty right now, but that says nothing about how you'll feel 90 minutes from now. Cognitive function rises and falls with our circadian rhythms across the day,^[18] and one small early study even found shorter swings of roughly 60 to 100 minutes.^[19] So the real question isn't 'Are you fit for duty right now?' It's 'Are you fit for duty now, and for the hours to come?' That's why a quick check at the start of a shift can't be the safety system. We need objective measures built into the work, and peer support around sleep, not a public confession at the start of a shift.

Sleep and mental health travel together. Among 6,307 North American firefighters, those who screened positive for insomnia had 3.78 times the odds of emotional exhaustion, a core sign of burnout.^[20] Among Canadian public safety personnel, those who screened positive for insomnia were 3.4 to 7.0 times more likely to screen positive for a mental disorder.^[5] A meta-analysis linked insomnia in medical first responders with depression, anxiety and PTSD.^[4] These are associations. They can't tell us which comes first.

The prefrontal cortex is the CEO of the brain: reason, logic, decision-making. It's also the brake pedal. In a small study of people kept awake for a night, the amygdala, the brain's emotional center, reacted more strongly to upsetting images, and its link to that brake weakened.^[21] Picture an officer who has just ended a chase, fully charged. That's when you need the brake. Officers who screened positive for a sleep disorder somewhat more often reported uncontrolled anger toward suspects (34% vs 29%).^[2]

I said it plainly in 2019: "If we are going to address mental health, we must also address sleep at the same time." The good news is that sleep is something you can start on this week.

It's not just what you do that matters, it's when you do it. Circadian rhythms are daily biological rhythms of physiology and behavior. We all have them. Alertness follows one, with two predictable dips: the overnight low, roughly 2 to 6 a.m., and the mid-afternoon lull.

Road-safety data show the pattern. Accident risk has a clear daily rhythm with a major peak around 3 a.m.,^[22] and sleep-related crashes cluster in the early morning and again in mid-afternoon.^[23] Responders drive in those hours, on calls and on the way home. In police data, injuries on the first day back on midnights were 69% more frequent than on days.^[9]

The overnight low isn't a character flaw. It's physiology. We need to stop fighting our physiology and work with it. The core message of my Surviving Shift Work® program is to take the shift out of shift work: keep your body clock as close to a day schedule as the roster allows, rather than flipping it back and forth. For the night shift side of the story, read the best sleep schedule for night shift workers.

Now, let me be very clear. You cannot manage fatigue. The only way to manage fatigue is to get the sleep you need. What you can manage is the risk: find when your people are most exposed and put your effort there.

Every service is different, so start with a day in the life of your crew. The goal is the best sleep possible given the demands of the job.

If you snore loudly, wake up gasping, or still feel exhausted with a steady sleep window, talk to your physician. How far you take any of this is entirely up to you. More: sleep support for first responders.