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Stress and the effects of air transport on flight crews
StTransport ress Effects Air Flight Crews and the
of
on
Brenda J. Hickman, RN, BSN, FNP, and Ruby Mehrer, RN, BSN, CMTE
edical flight crews often hear from other nurses and paramedics not involved in air transport, “You’ve got an easy job…sit around and wait for a flight, then maybe only go out 3-4 times a shift. I work much harder than that in the ED!”
M
Trying to explain why air ambulance crews’ work is so challenging is not an easy task. Perhaps some of the difficulty comes from a lack of knowledge of the physiologic and psychologic stresses of flight. Flight medicine is truly a unique form of patient care, and to educate others, we must first understand the concepts with which we are dealing. The stress of caring for critically ill patients in addition to unusual environmental factors can be physically and mentally taxing on the flight crew. Stress can be defined as the psychologic or physiologic discomfort that re-
6
sults from environmental phenomena that exceed coping abilities.1 These environmental phenomena, when related to flight medicine, include noise and vibration, oxygen deprivation, and fatigue. Stress can arise from an individual’s perception of environmental stimuli as damaging, threatening, or challenging. 2 Sapolsky 3 sees stress as “the way our bodies react to a threat…the fight or flight response.” Coping with this stress is also different for every individual. Coping can be viewed as ways of dealing with threats to psychologic integrity. 4 Coping methods to manage stress continually change and adapt over time. This article covers the psychologic and physiologic effects of critical air transport on flight crews. A comprehensive literature review of stress and air transport is included, as well as information from an informal survey of crew members of LifeFlight Eagle Air Ambu-
lance in Kansas City, Mo. This article aims to explore the work environment of air medical personnel in an effort to deal with stress and educate others.
Background of Air Transport Air transport began with stressful situations. The first known air transport of critically ill patients occurred in 1870 in Paris when 160 wounded soldiers were flown by hot air balloons over enemy lines.5 The first flight nurses, known as nurse-stewardesses, appeared in 1930. It was not until Laurette M. Schimmoler and a group of interested nurses formed the Emergency Flight Corps in 1933 that research and development of aviation nursing began. The current use of helicopters to transport critically ill patients began during the Korean and Vietnam wars and involved army medics. Today, more than 280 air medical programs, including international services,
Air Medical Journal 20:6
belong to the Association of Air Medical Services (AAMS), which estimates that more than 500 air medical programs exist throughout the United States.6
Literature Review of Physical Stress Eight classic flight stresses exist: fatigue, vibration, noise, barometric pressure, decreased partial pressure of oxygen, thermal changes, decreased humidity, and gravitational forces.7 The combination of these stresses are unique to flight crews and act in a cumulative manner. Personnel involved in air medical transport are regularly exposed to a variety of conditions not encountered by nonflight personnel. Nurses working in the controlled environment inside hospitals occasionally may experience one or two of these stresses, but they are not an expected part of their shifts on a daily basis. Because these eight stresses can be interrelated, they will not be addressed in depth separately but will be approached in a general manner. Flight crews experience fatigue in a more rapid and encompassing way than their counterparts on the ground. Although fatigue is identified as a separate stress of flight, it is also the end product of the other seven. In addition, fatigue is a component of psychologic stress, which will be discussed later. Vibration, a major flight stressor, involves multiple systems because it mimics shivering. A study involving healthy men who were exposed to heat and whole body vibrations found resultant vasoconstriction, which in turn impairs the cooling mechanism of vasodilatation.8 Many flight programs choose to wear long-sleeved Nomex flight suits that protect during flash fires. However, during the warmer months of the year, Nomex material can increase body temperatures significantly by trapping heat. The increase in basal temperatures coupled with the decrease in cooling mechanisms as a result of vasoconstriction may lead to heat exhaustion and dehydration. Vibration also has been shown to be responsible for orthopedic problems. Several studies of helicopter pilots revealed as many as 80% reported back November-December 2001
pain with radiologic abnormalities.9 Posture may be partly responsible for the high incidence of back pain, but the evidence is clear that vibration is a huge factor. The studies were particularly relevant because pilots are required by the Federal Aviation Administration (FAA) to undergo intensive physical examination at the beginning of their careers. Any pre-existing orthopedic problems very likely would be discovered at this initial evaluation. Furthermore, long-term, whole-body vibration has been found to adversely affect women. Various studies have found correlations between long-term exposure to vibration and disorders of female reproductive systems, such as
Eight classic flight stresses exist: fatigue, vibration, noise, barometric pressure, decreased partial pressure of oxygen, thermal changes, decreased humidity, and gravitational forces.7
menstrual disturbances and uterine position anomalies.10 Research also noted increases of miscarriages and stillbirths associated with vibration. Degenerative spine changes, were more prevalent in workers associated with whole-body vibrations, such as in helicopters, as evidenced by the study involving the group of pilots. Another factor affecting flight crews is the constant loud noise of the aircraft engines and other sounds associated with flight. Although hearing protection is worn during flights, it is only partially effective. Topf,11 in a literature review of hospital noise, found that individual coping does not control for stress produced by sound. She discovered a positive correlation between noise-induced subjective stress
and emotional exhaustion, burnout, and headaches. Physiologic changes in the endocrine, cardiovascular, and auditory systems and sleep disturbances have been seen in individuals exposed to high noise levels. 12 Specifically, a adrenocorticotropic hormone is released from the pituitary gland and stimulates the secretion of corticosteroids. Changes in barometric pressure can result in decreased partial pressure of oxygen, producing hypoxia. Several forms of hypoxia include hypoxic, hypemic, stagnant, and histotoxic.7 When oxygen fails to be delivered to the cells, the body is compromised. Flight crews often exhibit fatigue, especially when affected by stagnant hypoxia. During this phenomenon, extreme environmental temperatures, prolonged sitting in a cramped space, and restrictive clothing and straps result in blood pooling in dependent regions.7 Cardiac output does not meet tissue demands, and the body’s compensatory mechanisms respond with vasonstriction.13 The result of this cascade is fatigue. Gas laws are involved in the body’s physiologic responses and relate to the stresses of flight. During flight, crews often experience pain or discomfort from the expansion of gas normally found in the gastrointestinal (GI) tract. As the aircraft ascends, barometric pressure decreases, and gas can escape from intestinal fluids (Boyle’s and Henry’s laws).7 The pressure from the expanded gas can cause breathing to become difficult as a result of pressure on the diaphragm and can lead to hyperventilation or even syncope in extreme cases, such as when a vasovagal reaction is triggered. Nausea and vomiting are not uncommon. Other consequences of flying related to gas laws include barotitis media (blocked ears), barosinusitis, and barodontalgia (tooth pain). These conditions are exacerbated with the changing barometric pressure as the aircraft ascends and descends.
Literature Review of Psychologic Stress The physical effects of flight are real and often extensive for air medical per7
sonnel. However, physiologic reactions are only part of the picture. Psychologic factors also are involved. In a study14 of urban firefighters and paramedics, not all 173 rated the intensity of a stressful experience the same. The emergency workers were asked to rank 33 actual or potential duty-related stressors. Individual response specificity accounted for the differences in rating the stress intensity. Another study15 involving volunteer ambulance workers looked at the effect of CPR calls on emergency workers. The study suggested that even this basic emergency care produced some degree of stress. Perhaps future studies looking at job responsibilities and training could explain differences in perception of stressful situations. Another study 1 6 found that paramedics displayed negative organizational attitudes and negative patient attitudes relative to their stress. At the same time, they had less somatic illness than hospital employees who are less likely to express their stress but have more physical illness. Similarly, rescue workers from the Hyatt Regency Hotel walkway collapse in Kansas City were studied.17 Problems reported from exposure to the incident included sadness and depression. Forty-five percent of the 54 workers studied thought that talking about the incident was the most helpful way of dealing with the experience.
or family member. As with the crew survey, a 5-point Likert scale was used. Again, twenty-seven surveys were disbursed with a return of 15 (56%).
Results Notable differences in stress perception were found between the age groups. Forty-five percent of Xs disagreed that air medical work was more stressful than hospital work. However, Xs were neutral when asked whether air medical work was more stressful than ground EMS (33% agreed, 33% neutral, 33% disagreed). Comparatively, 72% of BBs agreed that air medical work was more stressful than hospital work but disagreed that it was more stressful than
In addition to the psychologic stresses, flight crews must contend with physical pressures specific to air transport, including vibration, noise, altitude changes, and fatigue.
Methods In this study, an informal survey of 25 statements was given to the crew members of LifeFlight Eagle Air Ambulance in Kansas City, Mo. The purpose of the survey was to ascertain individual perceptions of stress levels, coping mechanisms, and job satisfaction. The respondents were asked to indicate whether they were members of Generation X or Baby Boomers according to year of birth, with Baby Boomers (BBs) ranging from 1940 through 1960 and Generation X (Xs) from 1961 through 1980. This delineation was important to determine if similarities existed that might be explained in part by age. The survey used a 5-point Likert scale. Twenty-seven questionnaires were distributed; 16 (59%) were returned. In addition, a sixquestion survey was sent to the flight crew to be completed by a close friend 8
ground EMS (57%). Another source of stress with Xs was the irregular schedule (67%); BBs were split on the issue (43% agreed, 14% neutral, 43% disagreed). Only 22% of Xs saw noise as a stressor compared with 43% of BBs. Most of the crew did not see vibration as stress producing. Xs reported more health concerns and sleep disturbances as a result of the flight job than did BBs. All respondents agreed they used constructive coping mechanisms, such as humor and conversation with peers, to relieve job stress. Most of the crew thought the job stressed their families. Comparatively, 60% of the family members surveyed agreed the flight job was an added source of stress in their lives. However, only 27% preferred their loved one to have a less stressful job. Fifty-three per-
cent of family/friends reported mood and personality changes in flight crew members, while only 34% noticed more fatigue and health-related complaints since their involvement in air medical transport. Of those respondents, 60% did not view the irregular flight crew schedule as a stressor. As with the crew survey, conversation with family/friends about the stresses of the job was used by the flight crew in 60% of the friends/family surveys.
Conclusion Physiologic and psychologic stress are very real problems in air medical transport. The literature has shown several effects of psychologic stress, including depression, somatic illnesses, burnout, and posttraumatic stress disorder on emergency workers.18 In addition to the psychologic stresses, flight crews must contend with physical pressures specific to air transport, including vibration, noise, altitude changes, and fatigue. How psychologic stress affects an individual depends on many factors, of which coping mechanisms are paramount.19 The effects of physical stress are contingent, to a certain extent, on the individual’s health status. A compromised physiologic state can deteriorate faster at higher altitudes.20 However, as the literature shows, repeated exposure to noise and vibration may cause adverse effects on health and welfare regardless of inceptive well-being. The strange flight environment (loud noise, hypoxic states, and vibration) while caring for critical patients can add stress to an already tense situation. Admittedly, the informal study of Lifeflight Eagle crew members was too small to hold a great deal of validity or reliability. But what was overwhelmingly evident was the use of other crewmembers to defuse stress. Also notable was the difference in age-related views on what produced stress and how it was exhibited. Future research is indicated on the long-term physical and psychologic effects of air transport, particularly focusing on the experience and age of crew members. An understanding of stress and its negative consequences can result in a proactive approach in developing concrete coping mechanisms. Air Medical Journal 20:6
References 1. Topf M, Dillon E. Noise-induced stress as a predictor of burnout in critical care nurses. Heart Lung 1988;17:567-73. 2. Scott DW, Oberst MT, Dropkin MJ. A stress-coping model. In: Chinn PL, editor. Developing substance: mid-range theory in nursing. Gaithersburg (MD): Aspen; 1994. p. 14-29. 3. Sapolsky RM. Best ways to reduce everyday levels of stress…bad ol’ stress. Bottom Line 2000;21(2):13. 4. Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med 1993;55:234-47. 5. Lee G. Clinical articles: history of flight nursing. J Emerg Nurs 1987;13:212-8. 6. Association of Air Medical Services. Resource guide. Alexandria (VA): The Association; 1999-2000. 7. Holleran RS, editor. Flight nursing principles and practice. 2nd ed. St. Louis: Mosby; 1996. p. 11-36. 8. Spaul WA, Spear RC, Greenleaf JE. Thermoregulatory responses to heat and vibration in men. Aviat Space Environ Med 1986;57:1082-7. 9. Hulshof C, Veldhuijzen van Zanten B. Whole-body vibration and low-back pain: a review of epidemiologic studies. Int Arch Occup Environ Health 1987;59:205-20. 10. Seidel H. Selected health risks caused by long-term, whole-body vibration. Am J Ind Med 1993;23:589-604. 11. Topf M. Theoretical considerations for research on environmental stress and health. Image J Nurs Sch 1994;26:289-93.
November-December 2001
12. Falk SA, Woods NF. Hospital noise-levels and potential health hazards. N Engl J Med 1973;289:774-80. 13. Wagner-Browne L, Bodenstedt R. Flight physiology. In: Air medical crew national standard curriculum. 1st ed. Pasadena: ASHBEAMS; 1988. p. 82-95. 14. Beaton R, Murphy S, Johnson C, Pike K, Corneil W. Exposure to duty-related incident stressors in urban firefighters and paramedics. J Trauma Stress 1998;11:8218. 15. Myles G, Levine J, Ramsden F, Swanson. The impact of providing help: emergency workers and cardiopulmonary resuscitation attempts. J Trauma Stress 1990;3:305-13. 16. Hammer JS, Mathews JJ, Lyons JS, Johnson NJ. Occupational stress within the paramedic profession: an initial report of stress levels compared to hospital employees. Ann Emerg Med 1986;15:536-9. 17. Miles M, Demi M, Mostyn-Aker P. Rescue workers reactions following the Hyatt hotel disaster. Death Educ 1984;8:315-31. 18. Boudreaux MA, Mandry C. The effects of stressors on emergency medical technicians (part II): a critical review of the literature, and a call for further research. Prehosp Disas Med 1996;11(4):76-82. 19. Steptoe A. The links between stress and illness. J Pychosoma Res 1991;35:633-44. 20. Kennedy MG. Dealing with violent patients in flight. J Emerg Nurs 1991;17:295-8.
Brenda J. Hickman, RN, MSN, FNP, and Ruby Mehrer, RN, BSN, CMTE, are flight nurses with LifeFlight Eagle in Kansas City, Mo. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 74/1/120082 doi:10.1067/mmj.2001.120082
9
of
on
Brenda J. Hickman, RN, BSN, FNP, and Ruby Mehrer, RN, BSN, CMTE
edical flight crews often hear from other nurses and paramedics not involved in air transport, “You’ve got an easy job…sit around and wait for a flight, then maybe only go out 3-4 times a shift. I work much harder than that in the ED!”
M
Trying to explain why air ambulance crews’ work is so challenging is not an easy task. Perhaps some of the difficulty comes from a lack of knowledge of the physiologic and psychologic stresses of flight. Flight medicine is truly a unique form of patient care, and to educate others, we must first understand the concepts with which we are dealing. The stress of caring for critically ill patients in addition to unusual environmental factors can be physically and mentally taxing on the flight crew. Stress can be defined as the psychologic or physiologic discomfort that re-
6
sults from environmental phenomena that exceed coping abilities.1 These environmental phenomena, when related to flight medicine, include noise and vibration, oxygen deprivation, and fatigue. Stress can arise from an individual’s perception of environmental stimuli as damaging, threatening, or challenging. 2 Sapolsky 3 sees stress as “the way our bodies react to a threat…the fight or flight response.” Coping with this stress is also different for every individual. Coping can be viewed as ways of dealing with threats to psychologic integrity. 4 Coping methods to manage stress continually change and adapt over time. This article covers the psychologic and physiologic effects of critical air transport on flight crews. A comprehensive literature review of stress and air transport is included, as well as information from an informal survey of crew members of LifeFlight Eagle Air Ambu-
lance in Kansas City, Mo. This article aims to explore the work environment of air medical personnel in an effort to deal with stress and educate others.
Background of Air Transport Air transport began with stressful situations. The first known air transport of critically ill patients occurred in 1870 in Paris when 160 wounded soldiers were flown by hot air balloons over enemy lines.5 The first flight nurses, known as nurse-stewardesses, appeared in 1930. It was not until Laurette M. Schimmoler and a group of interested nurses formed the Emergency Flight Corps in 1933 that research and development of aviation nursing began. The current use of helicopters to transport critically ill patients began during the Korean and Vietnam wars and involved army medics. Today, more than 280 air medical programs, including international services,
Air Medical Journal 20:6
belong to the Association of Air Medical Services (AAMS), which estimates that more than 500 air medical programs exist throughout the United States.6
Literature Review of Physical Stress Eight classic flight stresses exist: fatigue, vibration, noise, barometric pressure, decreased partial pressure of oxygen, thermal changes, decreased humidity, and gravitational forces.7 The combination of these stresses are unique to flight crews and act in a cumulative manner. Personnel involved in air medical transport are regularly exposed to a variety of conditions not encountered by nonflight personnel. Nurses working in the controlled environment inside hospitals occasionally may experience one or two of these stresses, but they are not an expected part of their shifts on a daily basis. Because these eight stresses can be interrelated, they will not be addressed in depth separately but will be approached in a general manner. Flight crews experience fatigue in a more rapid and encompassing way than their counterparts on the ground. Although fatigue is identified as a separate stress of flight, it is also the end product of the other seven. In addition, fatigue is a component of psychologic stress, which will be discussed later. Vibration, a major flight stressor, involves multiple systems because it mimics shivering. A study involving healthy men who were exposed to heat and whole body vibrations found resultant vasoconstriction, which in turn impairs the cooling mechanism of vasodilatation.8 Many flight programs choose to wear long-sleeved Nomex flight suits that protect during flash fires. However, during the warmer months of the year, Nomex material can increase body temperatures significantly by trapping heat. The increase in basal temperatures coupled with the decrease in cooling mechanisms as a result of vasoconstriction may lead to heat exhaustion and dehydration. Vibration also has been shown to be responsible for orthopedic problems. Several studies of helicopter pilots revealed as many as 80% reported back November-December 2001
pain with radiologic abnormalities.9 Posture may be partly responsible for the high incidence of back pain, but the evidence is clear that vibration is a huge factor. The studies were particularly relevant because pilots are required by the Federal Aviation Administration (FAA) to undergo intensive physical examination at the beginning of their careers. Any pre-existing orthopedic problems very likely would be discovered at this initial evaluation. Furthermore, long-term, whole-body vibration has been found to adversely affect women. Various studies have found correlations between long-term exposure to vibration and disorders of female reproductive systems, such as
Eight classic flight stresses exist: fatigue, vibration, noise, barometric pressure, decreased partial pressure of oxygen, thermal changes, decreased humidity, and gravitational forces.7
menstrual disturbances and uterine position anomalies.10 Research also noted increases of miscarriages and stillbirths associated with vibration. Degenerative spine changes, were more prevalent in workers associated with whole-body vibrations, such as in helicopters, as evidenced by the study involving the group of pilots. Another factor affecting flight crews is the constant loud noise of the aircraft engines and other sounds associated with flight. Although hearing protection is worn during flights, it is only partially effective. Topf,11 in a literature review of hospital noise, found that individual coping does not control for stress produced by sound. She discovered a positive correlation between noise-induced subjective stress
and emotional exhaustion, burnout, and headaches. Physiologic changes in the endocrine, cardiovascular, and auditory systems and sleep disturbances have been seen in individuals exposed to high noise levels. 12 Specifically, a adrenocorticotropic hormone is released from the pituitary gland and stimulates the secretion of corticosteroids. Changes in barometric pressure can result in decreased partial pressure of oxygen, producing hypoxia. Several forms of hypoxia include hypoxic, hypemic, stagnant, and histotoxic.7 When oxygen fails to be delivered to the cells, the body is compromised. Flight crews often exhibit fatigue, especially when affected by stagnant hypoxia. During this phenomenon, extreme environmental temperatures, prolonged sitting in a cramped space, and restrictive clothing and straps result in blood pooling in dependent regions.7 Cardiac output does not meet tissue demands, and the body’s compensatory mechanisms respond with vasonstriction.13 The result of this cascade is fatigue. Gas laws are involved in the body’s physiologic responses and relate to the stresses of flight. During flight, crews often experience pain or discomfort from the expansion of gas normally found in the gastrointestinal (GI) tract. As the aircraft ascends, barometric pressure decreases, and gas can escape from intestinal fluids (Boyle’s and Henry’s laws).7 The pressure from the expanded gas can cause breathing to become difficult as a result of pressure on the diaphragm and can lead to hyperventilation or even syncope in extreme cases, such as when a vasovagal reaction is triggered. Nausea and vomiting are not uncommon. Other consequences of flying related to gas laws include barotitis media (blocked ears), barosinusitis, and barodontalgia (tooth pain). These conditions are exacerbated with the changing barometric pressure as the aircraft ascends and descends.
Literature Review of Psychologic Stress The physical effects of flight are real and often extensive for air medical per7
sonnel. However, physiologic reactions are only part of the picture. Psychologic factors also are involved. In a study14 of urban firefighters and paramedics, not all 173 rated the intensity of a stressful experience the same. The emergency workers were asked to rank 33 actual or potential duty-related stressors. Individual response specificity accounted for the differences in rating the stress intensity. Another study15 involving volunteer ambulance workers looked at the effect of CPR calls on emergency workers. The study suggested that even this basic emergency care produced some degree of stress. Perhaps future studies looking at job responsibilities and training could explain differences in perception of stressful situations. Another study 1 6 found that paramedics displayed negative organizational attitudes and negative patient attitudes relative to their stress. At the same time, they had less somatic illness than hospital employees who are less likely to express their stress but have more physical illness. Similarly, rescue workers from the Hyatt Regency Hotel walkway collapse in Kansas City were studied.17 Problems reported from exposure to the incident included sadness and depression. Forty-five percent of the 54 workers studied thought that talking about the incident was the most helpful way of dealing with the experience.
or family member. As with the crew survey, a 5-point Likert scale was used. Again, twenty-seven surveys were disbursed with a return of 15 (56%).
Results Notable differences in stress perception were found between the age groups. Forty-five percent of Xs disagreed that air medical work was more stressful than hospital work. However, Xs were neutral when asked whether air medical work was more stressful than ground EMS (33% agreed, 33% neutral, 33% disagreed). Comparatively, 72% of BBs agreed that air medical work was more stressful than hospital work but disagreed that it was more stressful than
In addition to the psychologic stresses, flight crews must contend with physical pressures specific to air transport, including vibration, noise, altitude changes, and fatigue.
Methods In this study, an informal survey of 25 statements was given to the crew members of LifeFlight Eagle Air Ambulance in Kansas City, Mo. The purpose of the survey was to ascertain individual perceptions of stress levels, coping mechanisms, and job satisfaction. The respondents were asked to indicate whether they were members of Generation X or Baby Boomers according to year of birth, with Baby Boomers (BBs) ranging from 1940 through 1960 and Generation X (Xs) from 1961 through 1980. This delineation was important to determine if similarities existed that might be explained in part by age. The survey used a 5-point Likert scale. Twenty-seven questionnaires were distributed; 16 (59%) were returned. In addition, a sixquestion survey was sent to the flight crew to be completed by a close friend 8
ground EMS (57%). Another source of stress with Xs was the irregular schedule (67%); BBs were split on the issue (43% agreed, 14% neutral, 43% disagreed). Only 22% of Xs saw noise as a stressor compared with 43% of BBs. Most of the crew did not see vibration as stress producing. Xs reported more health concerns and sleep disturbances as a result of the flight job than did BBs. All respondents agreed they used constructive coping mechanisms, such as humor and conversation with peers, to relieve job stress. Most of the crew thought the job stressed their families. Comparatively, 60% of the family members surveyed agreed the flight job was an added source of stress in their lives. However, only 27% preferred their loved one to have a less stressful job. Fifty-three per-
cent of family/friends reported mood and personality changes in flight crew members, while only 34% noticed more fatigue and health-related complaints since their involvement in air medical transport. Of those respondents, 60% did not view the irregular flight crew schedule as a stressor. As with the crew survey, conversation with family/friends about the stresses of the job was used by the flight crew in 60% of the friends/family surveys.
Conclusion Physiologic and psychologic stress are very real problems in air medical transport. The literature has shown several effects of psychologic stress, including depression, somatic illnesses, burnout, and posttraumatic stress disorder on emergency workers.18 In addition to the psychologic stresses, flight crews must contend with physical pressures specific to air transport, including vibration, noise, altitude changes, and fatigue. How psychologic stress affects an individual depends on many factors, of which coping mechanisms are paramount.19 The effects of physical stress are contingent, to a certain extent, on the individual’s health status. A compromised physiologic state can deteriorate faster at higher altitudes.20 However, as the literature shows, repeated exposure to noise and vibration may cause adverse effects on health and welfare regardless of inceptive well-being. The strange flight environment (loud noise, hypoxic states, and vibration) while caring for critical patients can add stress to an already tense situation. Admittedly, the informal study of Lifeflight Eagle crew members was too small to hold a great deal of validity or reliability. But what was overwhelmingly evident was the use of other crewmembers to defuse stress. Also notable was the difference in age-related views on what produced stress and how it was exhibited. Future research is indicated on the long-term physical and psychologic effects of air transport, particularly focusing on the experience and age of crew members. An understanding of stress and its negative consequences can result in a proactive approach in developing concrete coping mechanisms. Air Medical Journal 20:6
References 1. Topf M, Dillon E. Noise-induced stress as a predictor of burnout in critical care nurses. Heart Lung 1988;17:567-73. 2. Scott DW, Oberst MT, Dropkin MJ. A stress-coping model. In: Chinn PL, editor. Developing substance: mid-range theory in nursing. Gaithersburg (MD): Aspen; 1994. p. 14-29. 3. Sapolsky RM. Best ways to reduce everyday levels of stress…bad ol’ stress. Bottom Line 2000;21(2):13. 4. Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med 1993;55:234-47. 5. Lee G. Clinical articles: history of flight nursing. J Emerg Nurs 1987;13:212-8. 6. Association of Air Medical Services. Resource guide. Alexandria (VA): The Association; 1999-2000. 7. Holleran RS, editor. Flight nursing principles and practice. 2nd ed. St. Louis: Mosby; 1996. p. 11-36. 8. Spaul WA, Spear RC, Greenleaf JE. Thermoregulatory responses to heat and vibration in men. Aviat Space Environ Med 1986;57:1082-7. 9. Hulshof C, Veldhuijzen van Zanten B. Whole-body vibration and low-back pain: a review of epidemiologic studies. Int Arch Occup Environ Health 1987;59:205-20. 10. Seidel H. Selected health risks caused by long-term, whole-body vibration. Am J Ind Med 1993;23:589-604. 11. Topf M. Theoretical considerations for research on environmental stress and health. Image J Nurs Sch 1994;26:289-93.
November-December 2001
12. Falk SA, Woods NF. Hospital noise-levels and potential health hazards. N Engl J Med 1973;289:774-80. 13. Wagner-Browne L, Bodenstedt R. Flight physiology. In: Air medical crew national standard curriculum. 1st ed. Pasadena: ASHBEAMS; 1988. p. 82-95. 14. Beaton R, Murphy S, Johnson C, Pike K, Corneil W. Exposure to duty-related incident stressors in urban firefighters and paramedics. J Trauma Stress 1998;11:8218. 15. Myles G, Levine J, Ramsden F, Swanson. The impact of providing help: emergency workers and cardiopulmonary resuscitation attempts. J Trauma Stress 1990;3:305-13. 16. Hammer JS, Mathews JJ, Lyons JS, Johnson NJ. Occupational stress within the paramedic profession: an initial report of stress levels compared to hospital employees. Ann Emerg Med 1986;15:536-9. 17. Miles M, Demi M, Mostyn-Aker P. Rescue workers reactions following the Hyatt hotel disaster. Death Educ 1984;8:315-31. 18. Boudreaux MA, Mandry C. The effects of stressors on emergency medical technicians (part II): a critical review of the literature, and a call for further research. Prehosp Disas Med 1996;11(4):76-82. 19. Steptoe A. The links between stress and illness. J Pychosoma Res 1991;35:633-44. 20. Kennedy MG. Dealing with violent patients in flight. J Emerg Nurs 1991;17:295-8.
Brenda J. Hickman, RN, MSN, FNP, and Ruby Mehrer, RN, BSN, CMTE, are flight nurses with LifeFlight Eagle in Kansas City, Mo. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 74/1/120082 doi:10.1067/mmj.2001.120082
9