Stress response in Swedish ambulance personnel during priority-1 alarms


ambulance personnel
heart rate
stress response

How to Cite

Karlsson K, Niemelä P, Jonsson A, Törnhage C-J. Stress response in Swedish ambulance personnel during priority-1 alarms . Australasian Journal of Paramedicine [Internet]. 2020Aug.13 [cited 2020Sep.29];17. Available from:


Ambulance personnel consider themselves as being healthy, but studies show they often suffer from stress-related illnesses. However, research on the causes of these stress-related illnesses is limited. This study aimed to examine the stress response of Swedish of ambulance personnel during priority-1 alarms.

During 90 priority-1 alarms salivary cortisol concentrations were measured at alarm and after end of alarm, and heart rates measured every 15 seconds. Thirteen men and six women participated in the study. A questionnaire with background data was collected. Non-parametric statistical tests were used.

Elevated heart rate (median +34.7%) was associated with the actual priority-1 alarm, and during the alarm for women. Median salivary cortisol concentrations at alarm and after end of alarm (14.0 and 14.2 nmol/L respectively) showed non-significant differences. There were individual non-identical responses to the alarms. Alarms concerning traffic accidents, fast track and children generated the highest cortisol concentrations. The stress response showed non-significant differences in age, gender or level of education. Salivary cortisol concentrations and response were lower in the afternoon shift (2pm to 8pm).

The alarm causes increased heart rate at the group level but with individual different responses. Predefined fast track schedules and traffic accidents appear to generate measurable stress. Cortisol concentration follows normal diurnal variation of cortisol regarding time point for priority-1 alarms. Time of day does not affect the heart rate


Hegg-Deloye S, Brassard P, Jauvin N, et al. Current state of knowledge of post-traumatic stress, sleeping problems, obesity and cardiovascular disease in paramedics. Emerg Med J 2014;31:242-7.

Steptoe A, Kivimäki M. Stress and cardiovascular disease: an update on current knowledge. Annu Rev Public Health 2013;34:337-54.

Huang Y, Xu S, Hua J, et al. Association between job strain and risk of incident stroke: a meta-analysis. Neurology 2015;85:1648-54.

Heikkilä K, Nyberg ST, Theorell T, et al. Work stress and risk of cancer: meta-analysis of 5700 incident cancer events in 116 000 European men and women. BMJ 2013;346:f165.

Nirel N, Goldwag R, Feigenberg Z, Abadi D, Halpern P. Stress, work overload, burnout, and satisfaction among paramedics in Israel. Prehosp Disaster Med 2008;23:537-46.

Wiitavaara B, Lundman B, Barnekow-Bergkvist M, Brulin C. Striking a balance - health experiences of male ambulance personnel with musculoskeletal symptoms: a grounded theory. Int J Nurs Stud 2007;44:770-9.

Aasa U, Brulin C, Ängquist KA, Barnekow‐Bergkvist M. Work‐related psychosocial factors, worry about work conditions and health complaints among female and male ambulance personnel. Scand J Caring Sci 2005;19:251-8.

Jonsson A, Segesten K. Daily stress and concept of self in Swedish ambulance personnel. Prehosp Disaster Med 2004;19:226-34.

Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med 2002;40:625-32.

Bounds R. Factors affecting perceived stress in pre-hospital emergency medical services. Calif J Health Promot 2006;4:113-31.

Socialstyrelsen. Socialstyrelsens föreskrifter (SOSFS 2009:10) om ambulanssjukvård. 2009.

Herlitz J, WireklintSundström B, Bång A, et al. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med 2010;18:48.

Grønkjær LL. Nurses’ experience of stress and burnout: a literature review. Klinisk Sygepleje 2013;27:15-26.

Yang Y, Koh D, Ng V, et al. Salivary cortisol levels and work-related stress among emergency department nurses. J Occup Environ Med 2001;43:1011-8.

Boudreaux E, Jones GN, Mandry C, Brantley PJ. Patient care and daily stress among emergency medical technicians. Prehosp Disaster Med 1996;11:188-93.

Backé EM, Kaul G, Klußmann A, et al. Assessment of salivary cortisol as stress marker in ambulance service personnel: comparison between shifts working on mobile intensive care unit and patient transport ambulance. Int Arch Occup Environ Health 2009;82:1057-64.

Millán EM. Occupational stress among health care professionals specialising in acute medicine. Emergencias 2007;19:151-3.

Berland A, Natvig GK, Gundersen D. Patient safety and job-related stress: a focus group study. Intensive Crit Care Nurs 2008;24:90-7.

LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T. Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care 2005;9:439-44.

LeBlanc VR, Regehr C, Tavares W, et al. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med 2012;27:369-74.

Hellhammer DH, Wüst S, Kudielka BM. Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology 2009;34:163-71.

Törnhage CJ, Alfvén G. Children with recurrent psychosomatic abdominal pain display increased morning salivary cortisol and high serum cortisol concentrations. Acta Paediatr 2015;104:e577-80.

Karlsson K, Niemelä P, Jonsson A. Heart rate as a marker of stress in ambulance personnel: a pilot study of the body's response to the ambulance alarm. Prehosp Disaster Med 2011;26:21-6.

Karlsson K, Persson Niemelä P, Jonsson A, Törnhage C-J. Stress response in swedish ambulance personnel evaluated by Trier social stress test. Journal of Health and Environmental Research 2019;5:14-23.

Törnhage C-J. Reference values for morning salivary cortisol concentrations in healthy school-aged children. J Pediatr Endocrinol Metab 2002;15:197-204.

Pruessner JC, Kirschbaum C, Meinlschmid G, Hellhammer DH. Two formulas for computation of the area under the curve represent measures of total hormone concentration versus time-dependent change. Psychoneuroendocrinology 2003;28:916-31.

Fekedulegn DB, Andrew ME, Burchfiel CM, et al. Area under the curve and other summary indicators of repeated waking cortisol measurements. Psychosom Med 2007;69:651-9.

Puri K, Suresh K, Gogtay N, Thatte U. Declaration of Helsinki, 2008: implications for stakeholders in research. J Postgrad Med 2009;55:131.

Lundberg U. Stress hormones in health and illness: the roles of work and gender. Psychoneuroendocrinology 2005;30:1017-21.

Verma R, Balhara YPS, Gupta CS. Gender differences in stress response: role of developmental and biological determinants. Ind Psychiatry J 2011;20:4.

Committee NAoEMTP-HTLS, Trauma ACoSCo. PHTLS: prehospital trauma life support. Jones & Bartlett Publishers; 2010.

Alexander DA, Klein S. Ambulance personnel and critical incidents: impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry 2001;178:76-81.

Öberg M, Vicente V, Wahlberg AC. The emergency medical service personnel's perception of the transportation of young children. Int Emerg Nurs 2015;23:133-7.

Dorn LD, Lucke JF, Loucks TL, Berga SL. Salivary cortisol reflects serum cortisol: analysis of circadian profiles. Ann Clin Biochem 2007;44:281-4.