Self-Imposed Stress

A transport team member's self-imposed stresses can greatly influence physi­ologic performance during medical transport. Most of these stresses may be applicable to the flight crew and transport team members; their application to pediatric patients may be limited.

Self-imposed stresses may greatly influence physiologic response during air or ground medical transport. Therefore, having a clear understanding of these factors is important for optimal transport safety and patient care. The acronym “DEATH” may be helpful to remember the components: drugs, exhaustion (fatigue), alcohol, tobacco, and hypoglycemia (diet/dehydration). However, another way to approach the self-imposed stresses is by way of a personal evaluation. The FAA Advisory Circular on Aeronautical Decision Making suggests that pilots “preflight” themselves as carefully as they pre­flight their aircraft to assess their physical and emotional readiness to fly. Each member of the medical team should undertake the same process as a way to evaluate his or her self-imposed stresses and to determine whether “I’m safe.” The letters in “I'm safe” correspond to: illness, medication, stress, alcohol, fatigue, and eating. This simple personal checklist (Table 11.5) con­tains all of the elements common to impaired performance and can easily be committed to memory by each team member.

Table 11.5: “I'm Safe" Checklist

Illness

The best rule is not to fly when ill, but this is not always possible.

Fever, headache, malaise, pain, or other distracting symptoms may get in the way of judgment, memory, alertness, and ability to concentrate. Any ill­ness that is serious enough to require medication may also be serious enough to consider not flying (or doing ground transports). Respiratory infections, seasonal allergies, sinus problems, pharyngitis, ear problems, or gastrointes­tinal tract distress may be exacerbated during flight by the changes in atmo­spheric pressures and altitude.

Medication

Prescription and nonprescription medications and the medical conditions for which they are taken may interfere with performance, perception, deci­sion making, and motor skills. Transport team members must be aware of the adverse effects, overdose reactions, allergic responses, and synergistic effects of medications they are taking.

Although there are known potential adverse effects of medications, every individual may respond differently to the same medication. If a label warns of adverse effects, team members should consider waiting twice the recommended interval to be certain that they are “safe.” An obvious con­sideration is to avoid taking any new medication while on duty or before a transport.

FAA regulations prohibit pilots from performing crewmember duties while using any medication that may adversely affect their facul­ties and impact safety. Considering the important safety role the medical team plays, common sense would dictate the same approach for the entire transport team.

Stress

The effects of stress are often difficult to recognize. It is this inability to recognize stress that may be hazardous in aviation and during transport.

Failure to manage stress often leads to eroded judgment, errors in decision making, decreased work performance, inattention, degraded com­munication skills, preoccupation, and complacency. Other common signs and symptoms of stress include anxiety, irritability, impulsiveness, aggres­siveness, emotional or physical isolation, problems concentrating, and dif­ficulty remembering important things. An individual may also experience diarrhea, indigestion, frequent urination, headaches, grinding teeth, cold sweats, increased smoking or overeating, and alcohol or drug use or abuse.

Top stress producers include emotionally upsetting events, the death of a family member or close friend, a separation or divorce, the loss of a job, or financial problems. However, in transport medicine, daily events may result in varying stressors to the pilot and medical team. Encountering bad weather, night operations, scene transports, performing an instrument approach in poor conditions, flying in high density traffic area, flying in a back-up aircraft, and flying in unfamiliar areas are all examples of potential stressors. Equipment malfunctions, the critical nature of the patient, and interpersonal conflicts with other team members may also result in stress for the pilot and medical crew. The other elements of “I'm safe” (illness, medica­tion, alcohol, fatigue, and eating), if present, will also play a significant role in individual stress.

The best treatment for undue stress is prevention. It is better to avoid getting into situations that are likely to overwhelm the team's ability to cope. This is not always possible, because stressors often come from outside sources that may be beyond an individual's control.

Alcohol

The effects of alcohol ingestion are increased by altitude. Ingesting one alcoholic beverage at 10 000 ft is equivalent to ingesting 2 or 3 times as much at sea level. Similarly, the effects of tobacco are magnified during flight. The carbon monoxide by-product of smoking at sea level may result in mild hypoxia similar to that seen at an altitude of 8000 ft.

FAR 91.17 regulates the use of alcohol and drugs by pilots. Among other provisions, this regulation states that no person may act or attempt to act as a crewmember of an aircraft within 8 hours after the consumption of any alcoholic beverage, while under the influence of alcohol, with a blood alcohol content of 0.04% or greater, or while using any drug that adversely affects the person's faculties in any way contrary to safety.

Because of variation in individual metabolism of alcohol, an excellent rule to follow is to allow at least 12 to 24 hours between “bottle and throttle” for pilots as well as medical team members.

Fatigue

Fatigue is one of the most treacherous hazards to flight safety and patient care. All transport team members, aircraft pilots, and vehicle drivers should avoid exhaustion and fatigue to prevent errors in judgment, poor attention span, and decreased work capacity and performance.

Concerns and controversy regarding fatigue in health care providers has received a great deal of attention in recent years and also was a concern for aircraft pilots and teams that use resident physicians. As a result, pilots are regulated by the FAA with regard to maximum duty hours. FAR Part 135 requires a pilot to have a minimum of 10 hours of uninterrupted rest within every 24-hour period. “On-call” time, when the pilot is required to carry and respond to a pager, is counted as “duty time” and cannot be included in the minimum 10 hours of required rest. Similarly, in July 2003, the Accreditation Council for Graduate Medical Education (ACGME) developed work limits for resident physicians and fellows. ACGME revisions effective July 2011 limit resident physicians to a maximum of 80 hours per week (averaged over a 4-week period) and 24 hours on duty at a time for postgraduate year-2 residents and above. Residents are required to have a minimum 8 hours off between scheduled duty periods, at least 14 hours free of duty after 24 hours of in-house duty, and 1 day off every week.

Unfortunately, the medical transport community remains divided regarding duty time and fatigue, and there are no uniformly accepted work rules. Many dedicated teams routinely work 24-hour shifts, and some team members may work several jobs or shifts back to back. Systems should be in place to audit duty time and to ensure the availability of backup personnel in case of fatigue.

Eating

A properly balanced diet and adequate hydration represent the final self­imposed stress and element to ensure that “I'm Safe.” An inadequate or improper diet can result in nausea, headache, lightheadedness, dizziness, errors in judgment, and loss of consciousness. Precautions should be taken to avoid the development of hypoglycemia and dehydration.