Stress load of emergency service: effects on the CAR and HRV of HEMS emergency physicians on different working days (N = 20)

  • Katja PetrowskiEmail author
  • Benedict Herhaus
  • Christian Schöniger
  • Mark Frank
  • Jaroslaw Pyrc
Original Article



The occupation of the emergency physicians (EPs) of helicopter emergency medical services (HEMS) can be characterized as a high-strain occupation (Karasek in Adm Sci Q 24(2):285–308., 1979). Therefore, the aim of this study was to measure and compare the stress load of the EPs of HEMS on duty on air ambulance workdays and on 2 control days.


In this field study (within-subjects design), hormonal, physiological, and self-perceived stress levels of 20 EPs [3 females, 17 males; mean age (M) = 44.95 years, SD = 4.80, 95% confidence interval (CI) (42.71, 47.19)] of HEMS, were recorded on different test days. Measurements of the cortisol awakening response (CAR) and the heart rate variability (HRV) were performed while on duty on the air ambulance and during workdays at the outpatient clinic as well as at home on days of rest.


There were significant differences in the CAR (area under the curve with respect to ground F(2,38) = 12.81, p < 0.001) between the 3 test days with the highest values on the workday at the outpatient clinic [M = 81.24; 98.75% CI (61.24, 101.24)] and not on the air ambulance day [M = 61.82; 98.75% CI (45.18, 78.46)] or on the day of rest [M = 52.96; 98.75% CI (38.17, 67.76)]. In addition, the HRV parameter SDNN [F(2,38) = 6.369; p = 0.004] presented significant differences between the 3 test days with lower levels on the day at the outpatient clinic [M = 101.44; 98.75% CI (83.50, 119.38)] in contrast to the air ambulance day [M = 120.16; 98.75% CI (100.02, 140.30)] and to the resting day [M = 123.79; 98.75% CI (106.49, 141.10)]. Furthermore, there were significant differences in the HRV parameter LF/HF [F(2,38) = 6.215; p = 0.005] between the 3 testing days with the highest values on the workday at the outpatient clinic [M = 8.69; 98.75% CI (6.29, 11.09)] compared to the air ambulance day [M = 6.54; 98.75% CI (4.50, 8.57)] and the day of rest [M = 6.43; 98.75% CI (4.57, 8.29)].


Compared with the standard values and previous studies, EPs of HEMS have an increase in hormonal reactivity in the morning and a lack of recovery of the ANS. It can be concluded that—with respect to the psychobiological stress model by McEwen and Lasley (The end of stress as we know it, National Academic Press, Washington, 2003)—work-related stressors persist too long or the stress response is exaggerated (allostatic load) due to chronic stress induction and lack of recovery.


Stress load Cortisol awakening response (CAR) Heart rate variability (HRV) Emergency physicians (EPs) Helicopter emergency medical services (HEMS) 



Autonomic nervous system


Area under the curve


Area under the curve with respect to ground


Area under the curve with respect to increase


Cortisol awakening response


Emergency physicians


The European Society of Cardiology


Helicopter emergency medical services


Power in high-frequency range 0.15–0.4 Hz


Heart frequency


Heart rate variability




Power in low-frequency range 0.04–0.15 Hz


Luminescence immunoassay


Mean value


The North American Society of Pacing and Electrophysiology


International Society of Psycho-neuroendocrinology


Primary appraisal secondary appraisal


Root-mean-square successive differences


Standard deviation of all NN intervals


Trier Inventory of Chronic Stress



This study was funded by the Roland Ernst Foundation Project “Identification of stressors due to organizational structures in airborne and ground-based emergency service”.

Compliance with ethical standards

Ethical approval

The study protocol was approved by the local Ethics Committee of the Medical Faculty of the Technical University of Dresden, Germany (No#EK348092011).

Informed consent

All participants signed the informed consent.

Conflict of interest

The authors have no conflict of interest to disclose.

Supplementary material

420_2018_1362_MOESM1_ESM.docx (19 kb)
Supplementary material 1 (DOCX 18 KB)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Katja Petrowski
    • 1
    • 2
    Email author
  • Benedict Herhaus
    • 2
  • Christian Schöniger
    • 1
  • Mark Frank
    • 3
    • 4
  • Jaroslaw Pyrc
    • 5
  1. 1.Department of Psychotherapy and Psychosomatic MedicineUniversity Hospital Carl Gustav Carus Dresden, Technische Universitaet DresdenDresdenGermany
  2. 2.Medical Psychology and Medical Sociology, Clinic and Policlinic for Psychosomatic Medicine and PsychotherapyUniversity Medicine MainzMainzGermany
  3. 3.Department of Emergency MedicineCity Hospital GörlitzGörlitzGermany
  4. 4.DRF Stiftung Luftrettung gemeinnützige AG, Air Rescue Base DresdenDresdenGermany
  5. 5.University Center for Orthopaedics and Traumatology, University Medicine Carl Gustav Carus DresdenDresdenGermany

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