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Maximal tachycardia and high cardiac strain during night shifts of emergency physicians

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International Archives of Occupational and Environmental Health Aims and scope Submit manuscript

Abstract

Purpose

To compare tachycardia and cardiac strain between 24-hour shifts (24hS) and 14-hour night shifts (14hS) in emergency physicians (EPs), and to investigate key factors influencing tachycardia and cardiac strain.

Methods

We monitored heart rate (HR) with Holter-ECG in a shift-randomized trial comparing a 24hS, a 14hS, and a control day, within a potential for 19 EPs. We also measured 24-h HR the third day (D3) after both shifts. We measured perceived stress by visual analog scale and the number of life-and-death emergencies.

Results

The 17 EPs completing the whole protocol reached maximal HR (180.9 ± 6.9 bpm) during both shifts. Minutes of tachycardia >100 bpm were higher in 24hS (208.3 ± 63.8) than in any other days (14hS: 142.3 ± 36.9; D3/14hS: 64.8 ± 31.4; D3/24hS: 57.6 ± 19.1; control day: 39.2 ± 11.6 min, p < .05). Shifts induced a cardiac strain twice higher than in days not involving patients contact. Each life-and-death emergency enhanced 26 min of tachycardia ≥100 bpm (p < .001), 7 min ≥ 110 bpm (p < .001), 2 min ≥ 120 bpm (p < .001) and 19 min of cardiac strain ≥30% (p = .014). Stress was associated with greater duration of tachycardia ≥100, 110 and 120 bpm, and of cardiac strain ≥30% (p < .001).

Conclusion

We demonstrated several incidences of maximal HR during shifts combined with a high cardiac strain. Duration of tachycardia were the highest in 24hS and lasted several hours. Such values are comparable to those of workers exposed to high physical demanding tasks or heat. Therefore, we suggest that EPs limit their exposure to 24hS. We, furthermore, demonstrated benefits of HR monitoring for identifying stressful events.

ClinicalTrials.gov identifier: NCT01874704.

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Abbreviations

BMI:

Body mass index

CD:

Control day

D1:

Day 1

D2:

Day 2

D3:

Day 3

EPs:

Emergency physicians

HR:

Heart rate

HRR:

HR reserve

RCC:

Relative cardiac cost

VAS:

Visual analog scale

References

  • Astrand PO, Saltin B (1961) Maximal oxygen uptake and heart rate in various types of muscular activity. J Appl Physiol 16:977–981

    CAS  Google Scholar 

  • Baldwin PJ, Dodd M, Wrate RW (1997) Young doctors’ health–I. How do working conditions affect attitudes, health and performance? Soc Sci Med 45(1):35–40

    Article  CAS  Google Scholar 

  • Biswas R, Samanta A, Saha P (2011) Cardiac strain of confectionery worker in relation to heat exposure during regular work shift. Indian. J Occup Environ Med 15(3):120–126. doi:10.4103/0019-5278.93202

    Article  Google Scholar 

  • Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape L (2011) Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Nat Sci Sleep 3:47–85. doi:10.2147/nss.s19649

    Google Scholar 

  • Calcagnini G, Ramacci CA, Germano G, Ottalevi A, Ciavarella M, Mennuni M, Ferrucci A, Tomao E (1982) Tachycardia in the pilot. Effects of the alertness state and of helicopter flight. Riv Med Aeronaut Spaz 47(1–4):65–77

    CAS  Google Scholar 

  • Chandola T, Britton A, Brunner E, Hemingway H, Malik M, Kumari M, Badrick E, Kivimaki M, Marmot M (2008) Work stress and coronary heart disease: what are the mechanisms? Eur Heart J 29(5):640–648. doi:10.1093/eurheartj/ehm584

    Article  Google Scholar 

  • Chen KY, Yang CM, Lien CH, Chiou HY, Lin MR, Chang HR, Chiu WT (2013) Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci 10(11):1471–1478. doi:10.7150/ijms.6743

    Article  Google Scholar 

  • Christou DD, Seals DR (2008) Decreased maximal heart rate with aging is related to reduced {beta}-adrenergic responsiveness but is largely explained by a reduction in intrinsic heart rate. J Appl Physiol (1985) 105(1):24–29. doi:10.1152/japplphysiol.90401.2008

    Article  Google Scholar 

  • Costa G (2003) Shift work and occupational medicine: an overview. Occup Med (Lond) 53(2):83–88

    Article  Google Scholar 

  • Costa G, Berti F, Betta A (1989) Physiological cost of apple-farming activities. Appl Ergon 20(4):281–286

    Article  CAS  Google Scholar 

  • Dugan J, Lauer E, Bouquot Z, Dutro BK, Smith M, Widmeyer G (1996) Stressful nurses: the effect on patient outcomes. J Nurs Care Qual 10(3):46–58

    Article  CAS  Google Scholar 

  • Dutheil F, Boudet G, Perrier C, Lac G, Ouchchane L, Chamoux A, Duclos M, Schmidt J (2012) JOBSTRESS study: comparison of heart rate variability in emergency physicians working a 24-hour shift or a 14-hour night shift—a randomized trial. Int J Cardiol 158(2):322–325. doi:10.1016/j.ijcard.2012.04.141

    Article  Google Scholar 

  • Dutheil F, Trousselard M, Perrier C, Lac G, Chamoux A, Duclos M, Naughton G, Mnatzaganian G, Schmidt J (2013) Urinary interleukin-8 Is a biomarker of stress in emergency physicians, especially with advancing age—the JOBSTRESS* randomized trial. PLoS One 8(8):e71658. doi:10.1371/journal.pone.0071658

    Article  CAS  Google Scholar 

  • Estryn-Behar M, Doppia MA, Guetarni K, Fry C, Machet G, Pelloux P, Aune I, Muster D, Lassauniere JM, Prudhomme C (2011) Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study. Emerg Med J 28(5):397–410. doi:10.1136/emj.2009.082594

    Article  CAS  Google Scholar 

  • Frank JR, Ovens H (2002) Shiftwork and emergency medical practice. CJEM 4(6):421–428

    Article  Google Scholar 

  • Garet M, Boudet G, Montaurier C, Vermorel M, Coudert J, Chamoux A (2005) Estimating relative physical workload using heart rate monitoring: a validation by whole-body indirect calorimetry. Eur J Appl Physiol 94(1–2):46–53. doi:10.1007/s00421-004-1228-9

    Article  Google Scholar 

  • Garman AN, Corrigan PW, Morris S (2002) Staff burnout and patient satisfaction: evidence of relationships at the care unit level. J Occup Health Psychol 7(3):235–241

    Article  Google Scholar 

  • Gellish RL, Goslin BR, Olson RE, McDonald A, Russi GD, Moudgil VK (2007) Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc 39(5):822–829. doi:10.1097/mss.0b013e31803349c6

    Article  Google Scholar 

  • Genovesi S, Zaccaria D, Rossi E, Valsecchi MG, Stella A, Stramba-Badiale M (2007) Effects of exercise training on heart rate and QT interval in healthy young individuals: are there gender differences? Europace 9(1):55–60. doi:10.1093/europace/eul145

    Article  Google Scholar 

  • Goldstone AR, Callaghan CJ, Mackay J, Charman S, Nashef SA (2004) Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation. BMJ 328(7436):379. doi:10.1136/bmj.37985.371343.EE

    Article  Google Scholar 

  • Gordon F (2002) Shift work for specialist registrars in acute medicine: more questions than solutions. Clin Med (Lond) 2(1):41–42

    Article  Google Scholar 

  • Grant CC, Janse van Rensburg DC (2013) The contribution of preintervention blood pressure, VO2max, BMI, autonomic function and gender to exercise-induced changes in heart rate variability. Br J Sports Med 47(9):575–578

    Article  Google Scholar 

  • Hadjiolova I, Mincheva L, Deyanov C (1994) Cardiovascular changes in operators on 12-hour shifts. Rev Environ Health 10(1):67–71

    Article  CAS  Google Scholar 

  • Holmes TH, Rahe RH (1967) The social readjustment rating scale. J Psychosom Res 11(2):213–218

    Article  CAS  Google Scholar 

  • Hunziker S, Semmer NK, Tschan F, Schuetz P, Mueller B, Marsch S (2012) Dynamics and association of different acute stress markers with performance during a simulated resuscitation. Resuscitation 83(5):572–578. doi:10.1016/j.resuscitation.2011.11.013

    Article  Google Scholar 

  • Hunziker S, Pagani S, Fasler K, Tschan F, Semmer NK, Marsch S (2013) Impact of a stress coping strategy on perceived stress levels and performance during a simulated cardiopulmonary resuscitation: a randomized controlled trial. BMC Emerg Med 13(8):13–18

    Google Scholar 

  • Jorna PG (1993) Heart rate and workload variations in actual and simulated flight. Ergonomics 36(9):1043–1054. doi:10.1080/00140139308967976

    Article  CAS  Google Scholar 

  • Kamal AA, Dammak M, Caillard JF, Couzinet M, Paris C, Ragazzini I (1991) Relative cardiac cost and physical, mental and psychological work load among a group of post-operative care personnel. Int Arch Occup Environ Health 63(5):353–358

    Article  CAS  Google Scholar 

  • Kamon E, Doyle D, Kovac J (1983) The oxygen cost of an escape from an underground coal mine. Am Ind Hyg Assoc J 44(7):552–555

    Article  CAS  Google Scholar 

  • Khaleque A (1981) Job satisfaction, perceived effort and heart rate in light industrial work. Ergonomics 24(9):735–742. doi:10.1080/00140138108924895

    Article  CAS  Google Scholar 

  • Kivimaki M, Leino-Arjas P, Luukkonen R, Riihimaki H, Vahtera J, Kirjonen J (2002) Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ 325(7369):857

    Article  Google Scholar 

  • Klasan A, Madzarac G, Milosevic M, Mustajbegovic J, Keleuva S (2013) Predictors of lower work ability among emergency medicine employees: the Croatian experience. Emerg Med J 30(4):275–279. doi:10.1136/emermed-2011-200780

    Article  Google Scholar 

  • Klonowicz T (1995) Mental workload and health: a latent threat. Int J Occup Saf Ergon 1(2):130–135. doi:10.1080/10803548.1995.11076309

    Article  CAS  Google Scholar 

  • Lee YK, Lee CC, Chen CC, Wong CH, Su YC (2013) High risk of ‘failure’ among emergency physicians compared with other specialists: a nationwide cohort study. Emerg Med J 30(8):620–622. doi:10.1136/emermed-2012-201440

    Article  Google Scholar 

  • Lesage FX, Berjot S (2011) Validity of occupational stress assessment using a visual analogue scale. Occup Med (Lond) 61(6):434–436. doi:10.1093/occmed/kqr037

    Article  CAS  Google Scholar 

  • Lesage FX, Berjot S, Deschamps F (2012) Clinical stress assessment using a visual analogue scale. Occup Med (Lond) 62(8):600–605. doi:10.1093/occmed/kqs140

    Article  Google Scholar 

  • Levesque K, Moskowitz DS, Tardif JC, Dupuis G, D’Antono B (2010) Physiological stress responses in defensive individuals: age and sex matter. Psychophysiology 47(2):332–341. doi:10.1111/j.1469-8986.2009.00943.x

    Article  Google Scholar 

  • Li CJ, Syue YJ, Tsai TC, Wu KH, Lee CH, Lin YR (2016) The impact of emergency physician seniority on clinical efficiency, emergency department resource use, patient outcomes, and disposition accuracy. Medicine (Baltimore) 95(6):e2706. doi:10.1097/md.0000000000002706

    Article  Google Scholar 

  • Lille F, Burnod Y, Borodulin L (1981) Relationship between heart rate and sinus arrhythmia in air traffic controllers at work. Eur J Appl Physiol Occup Physiol 47(4):337–343

    Article  CAS  Google Scholar 

  • Lindeberg SI, Rosvall M, Choi B, Canivet C, Isacsson SO, Karasek R, Ostergren PO (2011) Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women. Eur J Public Health 21(2):190–196. doi:10.1093/eurpub/ckq039

    Article  Google Scholar 

  • Lopez-Gonzalez A, Sanchez-Lopez M, Rovira-Gil E, Gonzalez-Garcia A, Ferrer-Lopez V, Martinez-Vizcaino V (2015) Sex differences in the effort indicators during cardiopulmonary resuscitation manoeuvres on manikins. Eur J Emerg Med 22(1):62–65

    Article  Google Scholar 

  • Makowiec-Dabrowska T, Bortkiewicz A (1989) Relationship between perceived psychic workload and heart rate reactivity in industrial women managers. Pol. J Occup Med 2(4):397–406

    CAS  Google Scholar 

  • Manning JE, Griggs TR (1983) Heart rates in fire fighters using light and heavy breathing equipment: similar near-maximal exertion in response to multiple work load conditions. J Occup Med 25(3):215–218

    Article  CAS  Google Scholar 

  • McEwen BS (2005) Stressed or stressed out: what is the difference? J Psychiatry Neurosci 30(5):315–318

    Google Scholar 

  • McKinley PS, King AR, Shapiro PA, Slavov I, Fang Y, Chen IS, Jamner LD, Sloan RP (2009) The impact of menstrual cycle phase on cardiac autonomic regulation. Psychophysiology 46(4):904–911. doi:10.1111/j.1469-8986.2009.00811.x

    Article  Google Scholar 

  • Mulders HP, Meijman TF, O’Hanlon JF, Mulder G (1982) Differential psychophysiological reactivity of city bus drivers. Ergonomics 25(11):1003–1011. doi:10.1080/00140138208925061

    Article  CAS  Google Scholar 

  • O Hartaigh B, Gill TM, Shah I, Hughes AD, Deanfield JE, Kuh D, Hardy R (2014) Association between resting heart rate across the life course and all-cause mortality: longitudinal findings from the Medical Research Council (MRC) National Survey of Health and Development (NSHD). J Epidemiol Community Health 68(9):883–889. doi:10.1136/jech-2014-203940

    Article  Google Scholar 

  • Ogungbenro K, Aarons L (2008) How many subjects are necessary for population pharmacokinetic experiments? Confidence interval approach. Eur J Clin Pharmacol 64(7):705–713. doi:10.1007/s00228-008-0493-7

    Article  Google Scholar 

  • Pajonk FG, Cransac P, Muller V, Teichmann A, Meyer W (2012) Trauma and stress-related disorders in German emergency physicians: the predictive role of personality factors. Int J Emerg Ment Health 14(4):257–268

    Google Scholar 

  • Petrofsky JS, Focil N, Prowse M, Kim Y, Berk L, Bains G, Lee S (2010) Autonomic stress and balance—the impact of age and diabetes. Diabetes Technol Ther 12(6):475–481. doi:10.1089/dia.2009.0125

    Article  Google Scholar 

  • Pieper S, Brosschot JF, van der Leeden R, Thayer JF (2007) Cardiac effects of momentary assessed worry episodes and stressful events. Psychosom Med 69(9):901–909

    Article  Google Scholar 

  • Riggs LM Jr (1981) Emergency medicine: two points of view. A vigorous new specialty. N Engl J Med 304(8):480–483. doi:10.1056/nejm198102193040810

    Article  Google Scholar 

  • Sanderson C, Lobb EA, Mowll J, Butow PN, McGowan N, Price MA (2013) Signs of post-traumatic stress disorder in caregivers following an expected death: a qualitative study. Palliat Med 27(7):625–631. doi:10.1177/0269216313483663

    Article  Google Scholar 

  • Sandvik L, Erikssen J, Ellestad M, Erikssen G, Thaulow E, Mundal R, Rodahl K (1995) Heart rate increase and maximal heart rate during exercise as predictors of cardiovascular mortality: a 16-year follow-up study of 1960 healthy men. Coron Artery Dis 6(8):667–679

    Article  CAS  Google Scholar 

  • Savonen KP, Lakka TA, Laukkanen JA, Rauramaa TH, Salonen JT, Rauramaa R (2007) Effectiveness of workload at the heart rate of 100 beats/min in predicting cardiovascular mortality in men aged 42, 48, 54, or 60 years at baseline. Am J Cardiol 100(4):563–568. doi:10.1016/j.amjcard.2007.03.061

    Article  Google Scholar 

  • Savonen KP, Lakka TA, Laukkanen JA, Rauramaa TH, Salonen JT, Rauramaa R (2008) Workload at the heart rate of 100 beats/min and mortality in middle-aged men with known or suspected coronary heart disease. Heart 94(4):e14. doi:10.1136/hrt.2007.123471

    Article  CAS  Google Scholar 

  • Schmitt L, Regnard J, Desmarets M, Mauny F, Mourot L, Fouillot JP, Coulmy N, Millet G (2013) Fatigue shifts and scatters heart rate variability in elite endurance athletes. PLoS One 8(8):e71588. doi:10.1371/journal.pone.0071588

    Article  CAS  Google Scholar 

  • Schmitz GR, Clark M, Heron S, Sanson T, Kuhn G, Bourne C, Guth T, Cordover M, Coomes J (2012) Strategies for coping with stress in emergency medicine: early education is vital. J Emerg Trauma Shock 5(1):64–69. doi:10.4103/0974-2700.93117

    Article  Google Scholar 

  • Schneider SM, Hamilton GC, Moyer P, Stapczynski JS (1998) Definition of emergency medicine. Acad Emerg Med 5(4):348–351

    Article  CAS  Google Scholar 

  • Simpson RJ, Graham SM, Florida-James GD, Connaboy C, Clement R, Jackson AS (2010) Perceived exertion and heart rate models for estimating metabolic workload in elite British soldiers performing a backpack load-carriage task. Appl Physiol Nutr Metab 35(5):650–656. doi:10.1139/h10-053

    Article  Google Scholar 

  • Steptoe A, Fieldman G, Evans O, Perry L (1996) Cardiovascular risk and responsivity to mental stress: the influence of age, gender and risk factors. J Cardiovasc Risk 3(1):83–93

    Article  CAS  Google Scholar 

  • Streiner DL (2015) Best (but oft-forgotten) practices: the multiple problems of multiplicity-whether and how to correct for many statistical tests. Am J Clin Nutr 102(4):721–728. doi:10.3945/ajcn.115.113548

    Article  CAS  Google Scholar 

  • Tomas T, Wichrowski A (1983) Evaluation of the workload of weavers based on the analysis of cardiac function and changes in heart rate. Med Pr 34(1):47–52

    CAS  Google Scholar 

  • Uchino BN, Uno D, Holt-Lunstad J, Flinders JB (1999) Age-related differences in cardiovascular reactivity during acute psychological stress in men and women. J Gerontol B Psychol Sci Soc Sci 54(6):P339–P346

    Article  CAS  Google Scholar 

  • Ueshima K, Yamashina A, Usami S, Yasuno S, Nishiyama O, Yamazaki T, Nakao K, Nishimura T (2009) Prognostic value of myocardial perfusion SPECT images in combination with the maximal heart rate at exercise testing in Japanese patients with suspected ischemic heart disease: a sub-analysis of J-ACCESS. Ann Nucl Med 23(10):849–854. doi:10.1007/s12149-009-0315-8

    Article  Google Scholar 

  • van Kruijsdijk RC, van der Graaf Y, Bemelmans RH, Nathoe HM, Peeters PH, Visseren FL (2014) The relation between resting heart rate and cancer incidence, cancer mortality and all-cause mortality in patients with manifest vascular disease. Cancer Epidemiol 38(6):715–721. doi:10.1016/j.canep.2014.09.004

    Article  Google Scholar 

  • Vrijkotte TG, van Doornen LJ, de Geus EJ (2000) Effects of work stress on ambulatory blood pressure, heart rate, and heart rate variability. Hypertension 35(4):880–886

    Article  CAS  Google Scholar 

  • Vyas MV, Garg AX, Iansavichus AV, Costella J, Donner A, Laugsand LE, Janszky I, Mrkobrada M, Parraga G, Hackam DG (2012) Shift work and vascular events: systematic review and meta-analysis. BMJ 345:e4800

    Article  Google Scholar 

  • Wong del PL, Chung JW, Chan AP, Wong FK, Yi W (2014) Comparing the physiological and perceptual responses of construction workers (bar benders and bar fixers) in a hot environment. Appl Ergon 45(6):1705–1711. doi:10.1016/j.apergo.2014.06.002

    Article  Google Scholar 

  • Zeier H (1994) Workload and psychophysiological stress reactions in air traffic controllers. Ergonomics 37(3):525–539. doi:10.1080/00140139408963668

    Article  CAS  Google Scholar 

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Acknowledgements

We express our sincere gratitude to all emergency physicians of the Department of the Emergency Department of the University Hospital of Clermont-Ferrand, France, who participated in this study.

Author contributions

FD has participated as main investigator. FD, GB, CP, AC and JS contributed to the conception of the protocol. FD, GB and FM contributed to data analysis. FD and FM drafted the manuscript. All authors revised the manuscript and added substantial inputs. All authors read and approved the final manuscript. FD and FM takes responsibility for the integrity of the data analysis.

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Authors and Affiliations

  1. University Hospital of Clermont-Ferrand (CHU), Occupational and Preventive Medicine, F-63000, Clermont-Ferrand, France

    Frédéric Dutheil, Gil Boudet & Alain Chamoux

  2. University Hospital of Clermont-Ferrand (CHU), Emergency department, F-63000, Clermont-Ferrand, France

    Frédéric Dutheil, Christophe Perrier, Farès Moustafa & Jeannot Schmidt

  3. Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, F-63000, Clermont-Ferrand, France

    Frédéric Dutheil & Pascal Huguet

  4. Australian Catholic University, Faculty of Health, School of Exercise Science, Melbourne, VIC 3065, Australia

    Frédéric Dutheil & Geraldine Naughton

  5. WittyFit, F-75000, Paris, France

    Frédéric Dutheil

  6. University Hospital of Toulouse, Anesthesiology and Intensive Care Unit, F-31000, Toulouse, France

    Fouad Marhar

  7. Université Grenoble Alpes, CNRS, Laboratory of Cognition and NeuroPsyhology (LPNC), F-38000, Grenoble, France

    Martial Mermillod

  8. Institut Universitaire de France, F-75000, Paris, France

    Martial Mermillod

  9. Saudi Electronic University, College of Sciences and Theoretical Studies, Riyadh, 13316, Saudi Arabia

    Foued Saâdaoui

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  1. Frédéric Dutheil
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  2. Fouad Marhar
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  3. Gil Boudet
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  11. Jeannot Schmidt
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Correspondence to Frédéric Dutheil.

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Funding

This work was funded by the Association of Emergency Physician of Clermont-Ferrand (ASMUC). The funding source had no role in the design, conduct, or reporting of the study.

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The authors declare that they have no competing interests.

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Dutheil, F., Marhar, F., Boudet, G. et al. Maximal tachycardia and high cardiac strain during night shifts of emergency physicians. Int Arch Occup Environ Health 90, 467–480 (2017). https://doi.org/10.1007/s00420-017-1211-5

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