The transport environment and the nature of the industry expose transport professionals to frequent stress in both their professional and personal lives. The challenges of transport predispose these individuals to stress not commonly addressed by other professions. Continual changes in healthcare and clinical services provide a tumultuous arena for the provision of care.

Rules and laws govern transport programs and can predispose personnel to stress. Air medical transport programs must deal with rigorous federal regulations to accomplish the daily operations of the aviation programs. Interactions with pilots who are governed by the Federal Aviation Agency can produce conflicts between duty time and the ability to undertake the transport. Ground transport programs face regulations dictated by not only federal agencies but state and local governing bodies. These challenges add stress to the already demanding environment of transport medicine.

Transport professionals are often physically limited by space during the provision of patient care. Transport vehicles, whether ambulance, airplane, or helicopter, are much smaller than any hospital room and require the transport professional to be creative to provide care in such a limited environment. The lack of information about the patient’s true diagnosis, especially injury, adds additional stress to the transport team. Research has identified that limitations in the physical working environment add to individual stress. ⁴⁸ The challenges of providing care during scene transports also can produce stress for the transport professional. ^9,10

Financial considerations can also present stress to the transport team. Changes in insurance coverage, reimbursement, managed care, downsizing, and outsourcing have added challenges to the financial management of transport medicine. Today’s programs also are required to frequently examine current service lines and consider the addition of new programs, which require new training and cultural changes within the organization. The fear of restructuring and potential job loss has markedly increased stress in long-term established transport programs. Working conditions have been found to be the greatest predictor of job stress. Regulatory, physical, and financial factors continue to add to the stress of transport healthcare. ³⁵

Stress is a normal component of life. Stress is defined by Johnson²⁷ as the body’s reaction to the environment and the changes that occur. Stress occurs not solely because of an event but is dependant on the person’s reaction to the event. One must also understand that individuals react differently and what might be considered a stressor for one person does not present stress to another. Stressors in the transport environment vary between individuals, prior training, education, and experience and the resulting effects of the stressor on the person. Stressors in transport also include those produced by patients, referral agencies, bystanders and family members, and management. Stress from weather and the confines of transport vehicles may result in decision making that can prove fatal to all involved. Understanding the nuances of stress in transport is imperative to safe insightful operational decision making.

Stress is not only potentially damaging during transport but can affect individuals on a daily basis. The American Psychological Association (APA) identified that 43% of all adults have some form of adverse health effects from stress. The APA’s research also identified that 70% to 90% of all doctor visits are related to stress ailments and symptoms. Stress has been linked to the leading causes of death in adults: heart disease, cancer, accidents, suicide, cirrhosis of the liver, and lung conditions. The Occupational Safety and Health Administration (OSHA) declared stress a work hazard from the associated dangers found in the work environment. ³⁰

The negative aspects of stress were first postulated by Claude Bernard (1865) with the description of dynamic equilibrium. Dynamic equilibrium is the steady state in the internal body where balance is maintained. ²¹ Bernard noted that external changes in the environment and external factors that affect the internal balance of an organism must be reacted to and compensated for if the organism is to survive. Walter Cannon (1932) coined the phrase homeostasis to further define dynamic equilibrium. Cannon recognized that stressors are both physical and emotional and coined the term fight or flight to describe the body’s physical reaction to those stresses.

Research on the causes and long-term effects of stress began in the past 70 years. Hans Selye identified the correlation of stress with physical symptoms as early as 1936 while doing research as an endocrinologist. He identified the role of the pituitary gland in the stress response. Selye postulated that as the body continues to function under stressful situations, adaptation occurs (general adaptation syndrome) but with exhaustion that can eventually lead to death. ⁴⁰ Selye introduced the term stress and defined it as “mutual actions of forces that take place across any section of the body, physical or psychological.”²¹

Selye said, “To be free of stress is to be dead.”²⁸ However, Selye found that stress was both productive and destructive and introduced the concept of general adaptive syndrome (GAS). General adaptive syndrome is comprised of three parts: alarm, resistance, and exhaustion. ³⁹ During the alarm stage, the body releases adrenaline as a result of a perceived danger. Although the body may not be able to identify or define the threat, preparation is made to respond once the danger is identified.

The next phase, resistance, is commonly labeled the fight or flight stage. Marked physiologic events occur from pathophysiologic actions that prepare the body to flee from the perceived danger. ³⁹ The sympathetic nervous system causes:

The final stage, exhaustion, occurs when the stressor has been resisted. If ineffective means of stress reduction are used, the body returns to the alarm stage and becomes further exhausted because all resources have been exhausted. This continual exhaustion can deplete resources until death of the organism occurs.

Holmes and Rahe (1964) developed the Holmes and Rahe Schedule of Recent Experiences that awarded numeric rankings to events commonly associated with stress syndrome. These events are common occurrences that affect almost everyone during the life cycle. The most common of these events are death, divorce, loss of a job, moving, and severe illness. The research identified that stressful life events have detrimental effects and have been associated with sudden cardiac death, diabetes, pregnancy and obstetric complications, and increased risk for other diseases. ²⁶ Transport professionals often experience these events while continuing to perform in the high-stress transport environment. Transport professionals are often tasked with the added stress of illness or death of patients and the concurrent personal events of team members.

Stress can cause physical and emotional exhaustion as a short-term effect. ²⁷ The severity of the body’s response to stress is related to the type of stress, the frequency of stress, and methods of stress management used. Long-term effects include a possible relationship between stress and the development of Alzheimer’s disease. ^1,4

The body attempts to create a balance to deal with stress. The initial response to a stressor is stimulation of the sympathetic nervous system. This stimulation produces the fight or flight phenomenon. In response, the parasympathetic nervous system releases hormones to the adrenal glands to help stem the release of cortisol. The cortisol binds with the hormones for transport back to the kidney for excretion. This action helps the body reach homeostasis.

When the stress is resolved, the parasympathetic system responds in an attempt to revert to a state of relaxation. As individuals age, this process becomes more difficult and takes longer to occur. The norepinephrine released during this process helps to improve mood, helps in the creation of new memories, and increases creativity.

When a stressor occurs, the body’s systems initially react to stressful situations during the alarm and resistance phase. However, continued stress produces long-term effects on every system in the body, which leads to exhaustion. Transport professionals should be aware of these symptoms and work to recognize these effects in themselves and in others on the team.

A stressor can be defined as “anything that causes stress.”²³ Stress can result in job dissatisfaction, reduced work effectiveness, and behavioral and health changes. Stress can also be further differentiated between affective stress and cognitive stress. Cognitive stress may result from excessive mental workload. Affective stress (emotional stress) occurs when concerns exist about one’s personal life. ²³ Both types of stress can be detrimental and potentially deadly to individuals in the transport setting.

Stress is not only produced by external sources but also occurs through self-imposed stressors. The inability to manage stress effectively can many times compound stress itself. These self-imposed stressors are often listed using the pneumonic DEATH (drugs, exhaustion, alcohol, tobacco, and hypoglycemia). Drugs, both over-the-counter and prescription, can produce issues with cognition and alertness. Exhaustion from multiple transports, insomnia from stress, and the common practice among transport professionals of multiple jobs also alters cognition and can cause potentially dangerous lack of attentiveness. Alcohol, when not consumed in the work setting, causes dehydration and depressed cognition. Research has shown that after a drinking binge, an individual may need up to 3 days for full return of higher mental and reflex functions to return. ²³ Tobacco causes long-term health issues and can predispose the transport professional to hypoxia. An individual with a carboxyhemoglobin (COHb) level of 5% at a cabin altitude of 5000 ft has the equivalent physiologic altitude of 10,000 ft. ²³ Hypoglycemia caused by the unpredictable nature of transport and erratic meals causes weakness and decreased alertness or worse. All of these stressors are self imposed and are under the control of the transport individual. ²¹