Prediction of development of fatigue during a simulated ambulance work task from physical performance tests

The aims of this study were (1) to identify which physical performance tests could best explain the development of fatigue during a simulated ambulance work task, (2) to investigate the effect of height and weight and (3) to investigate in what respects these findings differ between female and male ambulance personnel. Forty-eight male and 17 female ambulance personnel completed a test battery assessing cardio-respiratory capacity, muscular strength and endurance, and co-ordination. The subjects also completed a simulated ambulance work task — carrying a loaded stretcher. The work task was evaluated by development of fatigue. Univariate and multiple regression analyses were used to investigate to what extent the tests in the test battery were able to explain the variance of developed fatigue. The explained variance was higher for female than for male ambulance personnel (time > 70% of HR_peak: R² = 0.75 vs 0.10, accumulated lactate: R² = 0.62 vs 0.42, perceived exertion: R² = 0.75 vs 0.10). Significant predictors in the models were VO₂max, isometric back endurance, one-leg rising, isokinetic knee flexion and shoulder extension strength. Height, but not weight, could further explain the variance. The high physical strain during carrying the loaded stretcher implies the importance of investigating whether improved performance, matching the occupational demands, could decrease the development of fatigue during strenuous tasks.     

The effects of a 1-year physical exercise programme on development of fatigue during a simulated ambulance work task

The aim of the study was to evaluate the effects of individually prescribed physical exercise programmes on development of fatigue during the carrying of a loaded stretcher up and down the stairs. Nineteen ambulance personnel performed the training for 1 year. Testing occurred before and after 1 year of the training. Both the training group (n = 19) and the control group (n = 15) were assessed for physical capacity and lactate concentration in blood and ratings of perceived exertion during carrying a stretcher on the stairs. When comparisons were made between those who had been training three times/week for 1 year and the control group, lactate concentration was significantly decreased. In conclusion, markers of fatigue during stretcher carrying can be reduced by the use of individually prescribed physical exercise programmes.     

The effects of a 1-year physical exercise programme on development of fatigue during a simulated ambulance work task

The aim of the study was to evaluate the effects of individually prescribed physical exercise programmes on development of fatigue during the carrying of a loaded stretcher up and down the stairs. Nineteen ambulance personnel performed the training for 1 year. Testing occurred before and after 1 year of the training. Both the training group (n = 19) and the control group (n = 15) were assessed for physical capacity and lactate concentration in blood and ratings of perceived exertion during carrying a stretcher on the stairs. When comparisons were made between those who had been training three times/week for 1 year and the control group, lactate concentration was significantly decreased. In conclusion, markers of fatigue during stretcher carrying can be reduced by the use of individually prescribed physical exercise programmes.     

Biomechanical analyses of paramedics simulating frequently performed strenuous work tasks

Firefighters performing emergency rescue functions are at an elevated risk of musculoskeletal injuries. The objective of the current study was to analyze the biomechanical stresses placed on the body based on simulations of the following strenuous and frequently performed emergency rescue tasks: (1) transferring a patient from a bed to a stretcher using bedsheets, (2) transferring a patient from the ambulance stretcher to a hospital gurney, (3) carrying a victim down a set of stairs and through a landing using a stairchair, (4) carrying a victim down a set of stairs and through a landing using a backboard, and (5) carrying a victim down a straight set of stairs using a stretcher. Postural data were analyzed using the University of Michigan's Three-Dimensional Static Strength Prediction Program and the relative risk of low back disorder (LBD) was quantified using the trunk motion model published by Marras et al. (1993, spine 18, 617-628). Peak compression values and the probabilities from the Marras et al. (1993) model indicated that the most hazardous tasks performed as part of this simulation included pulling a victim from a bed to a stretcher, the initial descent of a set of stairs when using the stretcher, and lifting a victim on a backboard from the floor. Overall, the two models were well correlated in their assessment of the task components modelled (r = 0.78). These data indicate where engineering changes to equipment regularly used by emergency rescue personnel would have the greatest impact in reducing the risk of musculoskeletal injury.     

Maximal manual stretcher carriage: performance and recovery of male and female ambulance workers

The effects of a maximal duration stretcher carriage on heart rate (HR), lactate concentration, hand steadiness and hand-grip strength were studied up to 72 h post-exercise in 17 male and 15 female military ambulance personnel. Using both hands for transport, the participants walked on a treadmill ergometer at a speed of 4.5 km/h. Force measurements at the handlebars yielded mean loads of 245 N (25 kg) on each side. Each step on the treadmill induced additional force oscillations with peak forces up to 470 N corresponding to 130% (women) and 98% (men) of maximal voluntary contraction (MVC). In the males the maximal transport time was about twice the time in women (mean +/- SD: 184 +/- 51 s vs. 98 +/- 34 s). These differences had no significant effect on HR and lactate values. The same applies to hand steadiness, which showed only a transient deterioration immediately after exercise. In contrast to these parameters, substantial differences were seen in hand-grip strength recovery. Immediately after exercise, maximal hand-grip strength decreased by 150 N (25% MVC) in the males vs. 50 N (14%) in the females. Irrespective of gender, individuals with larger hand-grip strength and longer carriage durations (range 120 s-280 s) showed the slowest strength recoveries (up to 72 h) as compared to 1 h of recovery in participants with short transport durations (range 27 s-120 s). These findings suggest that the increasing number of eccentric strains during uninterrupted stretcher carriage induces cumulative muscle damages that may require some days for complete recovery.     

Postural analysis of paramedics simulating frequently performed strenuous work tasks

Paramedics who perform emergency rescue functions are highly susceptible to musculoskeletal injuries. Through an interview and survey process firefighters, many of whom are cross-trained paramedics in a consortium of 14 suburban fire departments, identified and rated tasks that were perceived to be both strenuous and frequently performed. The objective of the current study was to describe the working postures and the forces applied as firefighter/paramedics (FF/Ps) simulated specific roles within the following tasks identified by the survey: (1) transferring a patient from a bed to a stretcher using bedsheets, (2) transferring a patient from the ambulance stretcher to a hospital gurney, (3) carrying a victim down a set of stairs and around a landing using a stairchair, (4) carrying a victim down a set of stairs and around a landing using a backboard, and (5) carrying a victim down a set of stairs using a stretcher. Ten two-person teams of FF/Ps participated and were videotaped to obtain postural data for the upper and lower extremities as they performed each role in the simulated two-person tasks. Trunk postures were obtained using lumbar motion monitors. Static hand forces were estimated using a hand-held dynamometer at the most physically demanding points for each role within each task. The postural and force data were averaged across subjects performing identical roles to quantify the postures assumed by the FF/Ps at the most strenuous moments during task performance. Based on these analyses we concluded that: (1) when transferring victims from a bed to a stretcher the FF/P on the bed was able to maintain an upright and more stable posture by standing as opposed to kneeling, (2) an interface board should be used to reduce the frictional forces when transferring victims from a bed to a stretcher or from a stretcher to a gurney, thereby reducing the need to lift the victim with flexed torsos and/or shoulders, and (3) equipment and training that encourages the FF/P in the leader role to walk facing forward during victim transport, especially when descending stairs, potentially results in safer transit.     

Biomechanical risk assessment during field loading of hydraulic stretchers into ambulances

The process of loading a stretcher into an ambulance is known to cause a high incidence of back injuries among paramedics. This study aimed to assess the forces at L5/S1 during real-life stretcher loading activities and to determine the variables that contribute significantly to these forces. Analyses involved 58 paramedics (111 shifts) and 175 stretcher loading activities. Estimates of compression and shear forces at L5/S1 were calculated using the 3DSSPP program. Seventy-one percent of loading activities exceeded the safe loading level of 3.4 kN compression force at L5/S1 (mean: 3.9 kN, min–max: 2.1–7.0 kN). About 92% of the variance can be predicted from a combination of several variables, notably hand load (mean: 0.72 kN/number of paramedics) and back sagittal flexion (mean: 32°). Recommendations to reduce the risk of back injuries are proposed with regard to stretcher and ambulance loading design as well as training in stretcher lifting for paramedics.Relevance to the industryThe results of this study suggest that ambulance stretcher manufacturers should make ergonomic design changes to reduce the physical strain on paramedics’ backs during the process of loading a stretcher into an ambulance. Other preventive measures (e.g., training) must be formulated and applied to reduce the risk of back musculoskeletal disorders during the loading of stretcher patients. For instance, training should focus on back posture, teamwork and equipment/patient positioning on stretchers.     

Reviewing ambulance design for clinical efficiency and paramedic safety

This study aimed to review the layout of the patient compartment in a UK ambulance for paramedic efficiency and safety using: (1) link analysis; (2) postural analysis. Paramedics were observed over 16 shifts (130 h) carrying out a range of clinical tasks. The most frequently occurring clinical tasks were checking blood oxygen saturation, oxygen administration, monitoring the heart and checking blood pressure. Access to the equipment and consumables to support these tasks had been designed for the attendant seat (head end of the stretcher), however, a link analysis found that paramedics preferred to sit along side the stretcher which resulted in increased reach distances. The higher frequency tasks were found to include over 40% of working postures which required corrective measures. It was concluded that future ambulance design should be based on an ergonomics analysis (including link analysis and postural analysis) of clinical activities.     

Standard and alternative methods of stretcher carriage: performance, human factors, and cardiorespiratory responses

Transporting a casualty on a stretcher is a common task for medical and military personnel. Stretchers are usually carried by hand, but distributing the load to other parts of the body may have advantages. To examine alternative carriage methods, 11 soldiers walked on a treadmill at 4.8 km/h while performing two-person carries of a stretcher containing an 80-kg manikin. In separate trials, soldiers carried the stretcher using: (1) hand carriage, (2) shoulder straps, (3) a specially designed harness that allowed load shifting between the hips and shoulders (hip-shoulder system), and (4) a clip that fitted on the belt of standard military load carrying equipment (LCE) and placed the stretcher mass mainly on the hips. With each system, subjects walked until volitional fatigue or 30 min. While walking, expired gases and heart rates were obtained and subjects rated their perceived exertion (Borg Scale). At the conclusion of all four trials, subjects rated each system on a number of subjective measures. Results showed that average (+/- SD) carriage times were 2.7+/-1.4, 14.5+/-8.3, 25.4+/-8.1, and 21.7+/-9.9 min with the hand, shoulder, hip-shoulder and LCE systems respectively (p<0.01). Hand carriage resulted in considerably more cardiorespiratory stress (higher heart rate and minute ventilation, p<0.05) than the other three systems, but there were few consistent differences among the other three systems. Perceived exertion in the upper body was less with the hip-shoulder and LCE systems than with the other two systems (p<0.05). Subjects preferred the hip-shoulder and LCE systems overall and for specific subjective characteristics such as comfort, ease of use and stability (p<0.01). These data indicate that moving the stretcher load from the hands and placing that load on the shoulders and/or hips results in improved performance, reduced cardiorespiratory stress and favourable subjective evaluations. Further developmental work should focus on the hip-shoulder and LCE systems.     

Experimental validation of a subject-specific maximum endurance time model

This study aimed at experimentally validating a subject-specific maximum endurance time (MET) model. Thirty health participants (15 males and 15 females; Age: mean = 21.5 years, SD = 1.6 years) volunteered to conduct an isometric elbow flexion task until exhaustion. The endurance times of each participant were measured under relative exertion levels ranging from 30% MVC (Maximum Voluntary Contraction) to 70% MVC at 10% intervals. Assessment of the model showed that the intensity–endurance time relationship for each studied individual could be well fitted by the subject-specific MET model (R² > 0.89). The fatigue rates identified from the model fitting were normally distributed (Mean = 0.96 min^?1, SD = 0.29 min^?1). In addition, the fatigue rates of the male group were significantly higher than the female group. The subject-specific MET model can be used to predict the MET for individual workers, and further support physical task design, based on the fatigability data of a targeted worker population.

Practitioner Summary: Ergonomists have extensively used MET models in physical fatigue assessment and physical task design. A subject-specific MET model could be used to predict the MET at individual levels, and also to support work design for a target worker population, based on the fatigability data distribution obtained from sampled workers.     

Maximal manual stretcher carriage: performance and recovery of male and female ambulance workers

The effects of a maximal duration stretcher carriage on heart rate (HR), lactate concentration, hand steadiness and hand-grip strength were studied up to 72 h post-exercise in 17 male and 15 female military ambulance personnel. Using both hands for transport, the participants walked on a treadmill ergometer at a speed of 4.5 km/h. Force measurements at the handlebars yielded mean loads of 245 N (25 kg) on each side. Each step on the treadmill induced additional force oscillations with peak forces up to 470 N corresponding to 130% (women) and 98% (men) of maximal voluntary contraction (MVC). In the males the maximal transport time was about twice the time in women (mean ± SD: 184 ± 51 s vs. 98 ± 34 s). These differences had no significant effect on HR and lactate values. The same applies to hand steadiness, which showed only a transient deterioration immediately after exercise. In contrast to these parameters, substantial differences were seen in hand-grip strength recovery. Immediately after exercise, maximal hand-grip strength decreased by 150 N (25% MVC) in the males vs. 50 N (14%) in the females. Irrespective of gender, individuals with larger hand-grip strength and longer carriage durations (range 120 s–280 s) showed the slowest strength recoveries (up to 72 h) as compared to 1 h of recovery in participants with short transport durations (range 27 s–120 s). These findings suggest that the increasing number of eccentric strains during uninterrupted stretcher carriage induces cumulative muscle damages that may require some days for complete recovery.     

Standard and alternative methods of stretcher carriage: performance,human factors,and cardiorespiratory responses

Transporting a casualty on a stretcher is a common task for medical and military personnel. Stretchers are usually carried by hand, but distributing the load to other parts of the body may have advantages. To examine alternative carriage methods, 11 soldiers walked on a treadmill at 4.8 km/h while performing two person carries of a stretcher containing an 80-kg manikin. In separate trials, soldiers carried the stretcher using: (1) hand carriage, (2) shoulder straps, (3) a specially designed harness that allowed load shifting between the hips and shoulders (hip-shoulder system), and (4) a clip that fitted on the belt of standard military load carrying equipment (LCE) and placed the stretcher mass mainly on the hips. With each system, subjects walked until volitional fatigue or 30 min. While walking, expired gases and heart rates were obtained and subjects rated their perceived exertion (Borg Scale). At the conclusion of all four trials, subjects rated each system on a number of subjective measures. Results showed that average (±SD) carriage times were 2.7±1.4, 14.5±8.3, 25.4±8.1, and 21.7±9.9 min with the hand, shoulder, hip-shoulder and LCE systems respectively (p<0.01). Hand carriage resulted in considerably more cardiorespiratory stress (higher heart rate and minute ventilation, p<0.05) than the other three systems, but there were few consistent differences among the other three systems. Perceived exertion in the upper body was less with the hip-shoulder and LCE systems than with the other two systems (p<0.05). Subjects preferred the hip-shoulder and LCE systems overall and for specific subjective characteristics such as comfort, ease of use and stability (p<0.01). These data indicate that moving the stretcher load from the hands and placing that load on the shoulders and/or hips results in improved performance, reduced cardiorespiratory stress and favourable subjective evaluations. Further developmental work should focus on the hipshoulder and LCE systems.     

Perceived fatigue after mental work: an experimental evaluation of a fatigue inventory

The aim of this study was to investigate the perceived fatigue after mental work and to test the Swedish Occupational Fatigue Inventory (SOFI). Twenty male and 20 female participants worked with proof reading (2 x 90 min) and a vigilance task (2 x 60 min). After each task session, perceived fatigue was rated with the SOFI and Borg's CR10O-scale. In addition, physiological reactions were registered; blood pressure, heart rate, heart rate variability and muscle activity in corrugator supercilii, as well as measures of performance: reaction time, number of pages read and number of proof errors found, number of detected signals. As expected, the highest ratings were obtained on Lack of energy, Lack of motivation and Sleepiness, particularly after the vigilance task. High ratings after both work tasks were also found on the CR10-scale. Men and women did not differ significantly with respect to their ratings. No clear-cut physiological reactions were found to correlate with ratings of fatigue. The results indicate the validity of the mental dimension of the SOFI.     

Jerry can carriage is an effective predictor of stretcher carry performance

Carrying a casualty on a stretcher is a critical task conducted in a range of occupations. To ensure that personnel have the requisite physical capacity to conduct this task, two bilateral jerry can carries were used to predict individual performance in a four-person stretcher carry. Results demonstrated a bilateral 22-kg jerry can carry (R² = 0.59) had superior predictive ability of stretcher carry performance than a bilateral 15-kg jerry can carry (R² = 0.46). Pre- to post-carry changes in grip endurance (p > 0.05), back–leg isometric strength (p > 0.05) and leg power (p > 0.05) were not significantly different between carry tasks. There was no significant difference in heart rate (p > 0.05) and oxygen consumption (p > 0.05) between the stretcher carry and either jerry can carry. Thus, on the basis of performance correlations and physiological measures, the 22-kg jerry can carry is an appropriate predictive assessment of four-person stretcher carriage.

Practitioner Summary: This study investigated the ability of a jerry can carry to predict individual performance on a four-person stretcher carry. Performance correlations were substantiated with physiological measures to demonstrate similar physical requirements between task and test. These results can be used to set physical employment standards to assess stretcher carriage.     

Perceived fatigue after mental work: an experimental evaluation of a fatigue inventory

The aim of this study was to investigate the perceived fatigue after mental work and to test the Swedish Occupational Fatigue Inventory (SOFI). Twenty male and 20 female participants worked with proof reading (2x90 min) and a vigilance task (2x60 min). After each task session, perceived fatigue was rated with the SOFI and Borg's CR10-scale. In addition, physiological reactions were registered; blood pressure, heart rate, heart rate variability and muscle activity in corrugator supercilii, as well as measures of performance: reaction time, number of pages read and number of proof errors found, number of detected signals. As expected, the highest ratings were obtained on Lack of energy, Lack of motivation and Sleepiness, particularly after the vigilance task. High ratings after both work tasks were also found on the CR10-scale. Men and women did not differ significantly with respect to their ratings. No clear-cut physiological reactions were found to correlate with ratings of fatigue. The results indicate the validity of the mental dimension of the SOFI.     

Muscular fatigue and endurance during intermittent static efforts: effects of contraction level, duty cycle, and cycle time

OBJECTIVE: To determine the effects of intermittent task parameters on muscle fatigue and endurance time during static shoulder abductions, with a long-term goal of establishing relationships between intermittent task parameters and short-term performance. BACKGROUND: Effects of intermittent work on endurance and fatigue development have been reported, and certain combinations of contraction levels and duty cycles have been proposed as design guidelines. These findings, however, were not derived from systematic manipulations of the task parameters. METHOD: Prolonged (1-hr maximum) intermittent shoulder abductions were performed at different combinations of contraction level (12% or 28% of muscle strength), duty cycle (.25 or .75), and cycle time (34 or 166 s). Fatigue was measured based on reductions in muscle strength and indirectly by changes in ratings of discomfort, electromyographic (EMG) amplitude, and EMG spectral distribution. RESULTS: Contraction level and duty cycle significantly affected endurance time and muscle fatigue, and interactive effects between these parameters were observed for some of the measures. Significant effects of cycle time were found only for EMG spectral measures. CONCLUSION: Endurance time and local fatigue were dependent on the comprehensive effects of the different task parameters. APPLICATION: Design changes to reduce the occurrence of localized fatigue during intermittent work need to take into account all the task parameters simultaneously.     

Alteration of circadian rhythm in shift-working ambulance personnel. Monitoring of salivary cortisol rhythm.

In order to investigate the relationship between internal desynchronization and clinical intolerance to shift work, a set of circadian rhythms including salivary cortisol rhythm were monitored in seven shift-working ambulance personnel. Oral temperature, grip strength of both hands, subjective assessment of drowsiness, fatigue and attention were recorded approximately every four hours except during sleep, for seven days. Self-sampling of salivary cortisol, which was suitable evaluation of endocrine rhythm in field studies, was also tried in this study. cosinor (cosine curve fitting) method and power spectral analysis were used for time series data analysis. The internal desynchronizations between rhythms of physiological variables and sleep-wake cycle were observed in shift-working ambulance personnel. The incidence of internal desynchronization seemed to be higher in intolerant subjects, although the difference between tolerant and intolerant subjects did not reach a statistically significant level. The peak time of salivary cortisol rhythm during a twenty-four hour shift was phase-advanced as intolerant to shift work showed apparently an atypical circadian pattern of salivary cortisol with an abnormal peak at 21.00 h. In this subject, the clinical intolerance to shift work seemed to be associated with internal desynchronization of circadian rhythms. The present study confirmed the internal desynchronization of the circadian rhythm in physiological rhythms like oral temperature and grip strengths, and was in favour of the hypothesis of an internal desynchronization and clinical intolerance to shift work. The clinical implication of impairment of salivary cortisol rhythm remains to be further investigated.     

Glove and gender effects on muscular fatigue evaluated by endurance and maximal voluntary contraction measures

OBJECTIVE: To investigate the effects of gender and gloves on hand fatigue, measured by the reduction in grip strength (delta MVC), the shift in time needed to reach maximal voluntary contraction (MVC; deltaTMC), and the maximal endurance time (MET). BACKGROUND: Information about the effect of gloves on muscle fatigue seems to be less plentiful than that on hand strength, dexterity, sensation, and so on. METHOD: Ten male and 10 female volunteers served as participants. A task of sustained gripping until exhaustion was used as the designated fatigue protocol. Three gloved conditions were evaluated: bare-handed and single (Cotton 1) and double (Cotton 2) cotton gloves. RESULTS: After completion of the fatigue protocol, a greater reduction in grip strength was found for men than for women in both magnitude and percentage. Male deltaTMVC was significantly greater; that is, there was more delay in time needed to reach the MVC for men than for women when the fatigue protocol was completed. MET was longer for men than for women. During gloved conditions, except for the deltaMVC, glove use did not change any of the other responses. Specifically, the gloved effect on deltaMVC depended upon gender. CONCLUSION: Men had a greater reduction in grip strength and took longer to reach the MVC than did women after the fatigue protocol. Except for decreasing the deltaMVC, whether or not gloves were worn did not change any of the other responses. APPLICATION: These data are useful for glove design, manufacture, and selection.     

Ergonomic evaluation of the ambulance interior to reduce paramedic discomfort and posture stress

OBJECTIVE: This study aims to evaluate safety and accessibility of an advanced life support (ALS) ambulance interior. BACKGROUND: The standard ambulance's interior design is unsatisfactory based on perceived discomfort and postures that constrain paramedics and medical staff, resulting in unsafe treatment of patients, mainly when being transported. METHODS: Two procedures were used to evaluate performance during a wide range of rescue tasks: a survey, based on questionnaires, interviews, and observation of paramedics performing routine tasks; and upper body and back posture analysis, based on postural considerations. RESULTS: Findings revealed that 74% of the paramedics stated that the location of the paramedic's seat is inefficient while they perform clinical procedures; 94% found the bench uncomfortable; 77% felt that the vertical distance between the bench and the stretcher is too far; and 86% needed to steady themselves when the vehicle was moving. Posture analysis showed that paramedics undergo several nonneutral back postures, including twisted back (>20 degrees) and sitting with back flexion between 20 degrees and 45 degrees. CONCLUSION: Because the interior of the ALS ambulance was found to be unsatisfactory both to paramedics and patients, alternative design issues are proposed. APPLICATION: The suggested practical layout contains four main modifications: (a) replacing the bench with two adjustable paramedic seats, (b) redesigning the medical cabinet for easy access, (c) adding an adjustable folding seat opposite the two new seats, and (d) adding a swiveling base and lifting apparatus that will accommodate the stretcher and enable better accessibility to patients by the paramedic personnel.