Stress and salivary cortisol in emergency medical dispatchers: A randomized shifts control trial
Identifieur interne : 002978 ( Pmc/Corpus ); précédent : 002977; suivant : 002979Stress and salivary cortisol in emergency medical dispatchers: A randomized shifts control trial
Auteurs : Sarah Bedini ; François Braun ; Laurence Weibel ; Michel Aussedat ; Bruno Pereira ; Frédéric DutheilSource :
- PLoS ONE [ 1932-6203 ] ; 2017.
Abstract
Stress at work is a public health concern. Phone operators in emergency medical dispatch centers are particularly at risk. We aimed to demonstrate that the most stressful time for emergency medical dispatchers is the shift when they receive emergency incoming calls, with cortisol as a biomarker of stress. For each emergency medical dispatcher, we measured outcomes over a control day and during three types of shift:
Url:
DOI: 10.1371/journal.pone.0177094
PubMed: 28505199
PubMed Central: 5432068
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PMC:5432068Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Stress and salivary cortisol in emergency medical dispatchers: A randomized shifts control trial</title><author><name sortKey="Bedini, Sarah" sort="Bedini, Sarah" uniqKey="Bedini S" first="Sarah" last="Bedini">Sarah Bedini</name><affiliation><nlm:aff id="aff001"><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Braun, Francois" sort="Braun, Francois" uniqKey="Braun F" first="François" last="Braun">François Braun</name><affiliation><nlm:aff id="aff001"><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>SAMU-Urgences de France, Paris, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Weibel, Laurence" sort="Weibel, Laurence" uniqKey="Weibel L" first="Laurence" last="Weibel">Laurence Weibel</name><affiliation><nlm:aff id="aff003"><addr-line>The CARSAT Alsace, Strasbourg, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Aussedat, Michel" sort="Aussedat, Michel" uniqKey="Aussedat M" first="Michel" last="Aussedat">Michel Aussedat</name><affiliation><nlm:aff id="aff001"><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Pereira, Bruno" sort="Pereira, Bruno" uniqKey="Pereira B" first="Bruno" last="Pereira">Bruno Pereira</name><affiliation><nlm:aff id="aff004"><addr-line>University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Clinical Research Direction, Clermont-Ferrand, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Dutheil, Frederic" sort="Dutheil, Frederic" uniqKey="Dutheil F" first="Frédéric" last="Dutheil">Frédéric Dutheil</name><affiliation><nlm:aff id="aff005"><addr-line>Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Preventive and Occupational Medicine, WittyFit, Clermont-Ferrand, France</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff006"><addr-line>Australian Catholic University, Faculty of Health, School of Exercise Science, Melbourne, Victoria, Australia</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28505199</idno><idno type="pmc">5432068</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5432068</idno><idno type="RBID">PMC:5432068</idno><idno type="doi">10.1371/journal.pone.0177094</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">002978</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002978</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Stress and salivary cortisol in emergency medical dispatchers: A randomized shifts control trial</title><author><name sortKey="Bedini, Sarah" sort="Bedini, Sarah" uniqKey="Bedini S" first="Sarah" last="Bedini">Sarah Bedini</name><affiliation><nlm:aff id="aff001"><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Braun, Francois" sort="Braun, Francois" uniqKey="Braun F" first="François" last="Braun">François Braun</name><affiliation><nlm:aff id="aff001"><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>SAMU-Urgences de France, Paris, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Weibel, Laurence" sort="Weibel, Laurence" uniqKey="Weibel L" first="Laurence" last="Weibel">Laurence Weibel</name><affiliation><nlm:aff id="aff003"><addr-line>The CARSAT Alsace, Strasbourg, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Aussedat, Michel" sort="Aussedat, Michel" uniqKey="Aussedat M" first="Michel" last="Aussedat">Michel Aussedat</name><affiliation><nlm:aff id="aff001"><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Pereira, Bruno" sort="Pereira, Bruno" uniqKey="Pereira B" first="Bruno" last="Pereira">Bruno Pereira</name><affiliation><nlm:aff id="aff004"><addr-line>University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Clinical Research Direction, Clermont-Ferrand, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Dutheil, Frederic" sort="Dutheil, Frederic" uniqKey="Dutheil F" first="Frédéric" last="Dutheil">Frédéric Dutheil</name><affiliation><nlm:aff id="aff005"><addr-line>Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Preventive and Occupational Medicine, WittyFit, Clermont-Ferrand, France</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff006"><addr-line>Australian Catholic University, Faculty of Health, School of Exercise Science, Melbourne, Victoria, Australia</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Stress at work is a public health concern. Phone operators in emergency medical dispatch centers are particularly at risk. We aimed to demonstrate that the most stressful time for emergency medical dispatchers is the shift when they receive emergency incoming calls, with cortisol as a biomarker of stress. For each emergency medical dispatcher, we measured outcomes over a control day and during three types of shift: <italic>Incoming emergency call</italic>, <italic>Dispatch</italic> and <italic>Re-assessment</italic>. The pattern of shifts was randomized. Saliva was sampled every 15 minutes for 2 hours, i.e. 6 consecutive times, starting 15 minutes after the first life-and-death incoming emergency call between 2 and 5 pm during three types of shift. We measured saliva cortisol every 2 hours over a control day, from 7am to 9pm. Perceived stress was assessed by a visual analog scale. We recruited 22 phone operators aged 36.4+/-10.8 years old (14 women and 8 men). Cortisol values were higher during the <italic>Incoming emergency call</italic> shift than during the <italic>Dispatch</italic> (p = .04) and <italic>Re-assessment</italic> (p = .04) shifts. The increase in cortisol levels was greater in men than in women (p = .009). There were no differences between control values and those of the three shifts. The kinetics of cortisol increased with greater perceived stress overall (p < .001) and for each type of shift (<italic>Incoming emergency call</italic>, p = .02; <italic>Dispatch</italic> p = .03; <italic>Re-assessment</italic>: p < .001). The kinetics of cortisol in response to incoming emergency calls was greater when the call was an absolute emergency (p = .03), and also tended to further increase when a subsequent absolute incoming emergency call was received (p = 0.07). In conclusion, the incoming emergency call shift carries particular risk for dispatchers, who have greater perceived stress and a greater increase in cortisol levels.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Bhui, Ks" uniqKey="Bhui K">KS Bhui</name></author><author><name sortKey="Dinos, S" uniqKey="Dinos S">S Dinos</name></author><author><name sortKey="Stansfeld, Sa" uniqKey="Stansfeld S">SA Stansfeld</name></author><author><name sortKey="White, Pd" uniqKey="White P">PD White</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ronda, E" uniqKey="Ronda E">E Ronda</name></author><author><name sortKey="Alvarez Dardet, C" uniqKey="Alvarez Dardet C">C Alvarez-Dardet</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bejean, S" uniqKey="Bejean S">S Bejean</name></author><author><name sortKey="Sultan Taieb, H" uniqKey="Sultan Taieb H">H 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28505199</article-id><article-id pub-id-type="pmc">5432068</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0177094</article-id><article-id pub-id-type="publisher-id">PONE-D-16-42705</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Biochemistry</subject><subj-group><subject>Hormones</subject><subj-group><subject>Lipid Hormones</subject><subj-group><subject>Hydrocortisone</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Biochemistry</subject><subj-group><subject>Hormones</subject><subj-group><subject>Steroid Hormones</subject><subj-group><subject>Hydrocortisone</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Critical Care and Emergency Medicine</subject></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Saliva</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Saliva</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Physiology</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Saliva</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Physiology</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Saliva</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Biochemistry</subject><subj-group><subject>Biomarkers</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Health Care Providers</subject><subj-group><subject>Medical Doctors</subject><subj-group><subject>Physicians</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Population Groupings</subject><subj-group><subject>Professions</subject><subj-group><subject>Medical Doctors</subject><subj-group><subject>Physicians</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Mental Health and Psychiatry</subject><subj-group><subject>Psychological Stress</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Psychology</subject><subj-group><subject>Psychological Stress</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Social Sciences</subject><subj-group><subject>Psychology</subject><subj-group><subject>Psychological Stress</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Physical Sciences</subject><subj-group><subject>Mathematics</subject><subj-group><subject>Probability Theory</subject><subj-group><subject>Statistical Distributions</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Primary Care</subject></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Stress and salivary cortisol in emergency medical dispatchers: A randomized shifts control trial</article-title><alt-title alt-title-type="running-head">Stress and cortisol in emergency medical dispatchers</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Bedini</surname><given-names>Sarah</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib><contrib contrib-type="author"><name><surname>Braun</surname><given-names>François</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Weibel</surname><given-names>Laurence</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Aussedat</surname><given-names>Michel</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Pereira</surname><given-names>Bruno</given-names></name><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Dutheil</surname><given-names>Frédéric</given-names></name><xref ref-type="aff" rid="aff005"><sup>5</sup></xref><xref ref-type="aff" rid="aff006"><sup>6</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>The Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Ars-Laquenexy, France</addr-line></aff><aff id="aff002"><label>2</label><addr-line>SAMU-Urgences de France, Paris, France</addr-line></aff><aff id="aff003"><label>3</label><addr-line>The CARSAT Alsace, Strasbourg, France</addr-line></aff><aff id="aff004"><label>4</label><addr-line>University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Clinical Research Direction, Clermont-Ferrand, France</addr-line></aff><aff id="aff005"><label>5</label><addr-line>Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Preventive and Occupational Medicine, WittyFit, Clermont-Ferrand, France</addr-line></aff><aff id="aff006"><label>6</label><addr-line>Australian Catholic University, Faculty of Health, School of Exercise Science, Melbourne, Victoria, Australia</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Atkin</surname><given-names>Stephen L.</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>Weill Cornell Medical College Qatar, QATAR</addr-line></aff><author-notes><fn fn-type="COI-statement" id="coi001"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con"><p><list list-type="simple"><list-item><p><bold>Conceptualization:</bold> SB LW MA.</p></list-item><list-item><p><bold>Data curation:</bold> SB LW.</p></list-item><list-item><p><bold>Formal analysis:</bold> FD BP.</p></list-item><list-item><p><bold>Funding acquisition:</bold> SB LW MA FB.</p></list-item><list-item><p><bold>Investigation:</bold> SB.</p></list-item><list-item><p><bold>Methodology:</bold> SB LW.</p></list-item><list-item><p><bold>Project administration:</bold> SB MA FB.</p></list-item><list-item><p><bold>Resources:</bold> SB FD FB.</p></list-item><list-item><p><bold>Software:</bold> FD BP.</p></list-item><list-item><p><bold>Supervision:</bold> SB.</p></list-item><list-item><p><bold>Validation:</bold> SB.</p></list-item><list-item><p><bold>Visualization:</bold> SB FD BP.</p></list-item><list-item><p><bold>Writing – original draft:</bold> SB FD.</p></list-item><list-item><p><bold>Writing – review & editing:</bold> SB FD LW.</p></list-item></list></p></fn><corresp id="cor001">* E-mail: <email>sarah.bedini3@gmail.com</email></corresp></author-notes><pub-date pub-type="epub"><day>15</day><month>5</month><year>2017</year></pub-date><pub-date pub-type="collection"><year>2017</year></pub-date><volume>12</volume><issue>5</issue><elocation-id>e0177094</elocation-id><history><date date-type="received"><day>26</day><month>10</month><year>2016</year></date><date date-type="accepted"><day>19</day><month>4</month><year>2017</year></date></history><permissions><copyright-statement>© 2017 Bedini et al</copyright-statement><copyright-year>2017</copyright-year><copyright-holder>Bedini et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:href="pone.0177094.pdf"></self-uri><abstract><p>Stress at work is a public health concern. Phone operators in emergency medical dispatch centers are particularly at risk. We aimed to demonstrate that the most stressful time for emergency medical dispatchers is the shift when they receive emergency incoming calls, with cortisol as a biomarker of stress. For each emergency medical dispatcher, we measured outcomes over a control day and during three types of shift: <italic>Incoming emergency call</italic>, <italic>Dispatch</italic> and <italic>Re-assessment</italic>. The pattern of shifts was randomized. Saliva was sampled every 15 minutes for 2 hours, i.e. 6 consecutive times, starting 15 minutes after the first life-and-death incoming emergency call between 2 and 5 pm during three types of shift. We measured saliva cortisol every 2 hours over a control day, from 7am to 9pm. Perceived stress was assessed by a visual analog scale. We recruited 22 phone operators aged 36.4+/-10.8 years old (14 women and 8 men). Cortisol values were higher during the <italic>Incoming emergency call</italic> shift than during the <italic>Dispatch</italic> (p = .04) and <italic>Re-assessment</italic> (p = .04) shifts. The increase in cortisol levels was greater in men than in women (p = .009). There were no differences between control values and those of the three shifts. The kinetics of cortisol increased with greater perceived stress overall (p < .001) and for each type of shift (<italic>Incoming emergency call</italic>, p = .02; <italic>Dispatch</italic> p = .03; <italic>Re-assessment</italic>: p < .001). The kinetics of cortisol in response to incoming emergency calls was greater when the call was an absolute emergency (p = .03), and also tended to further increase when a subsequent absolute incoming emergency call was received (p = 0.07). In conclusion, the incoming emergency call shift carries particular risk for dispatchers, who have greater perceived stress and a greater increase in cortisol levels.</p></abstract><funding-group><funding-statement>Recipient of the first prize of clinical research grant from the Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Metz, France. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><fig-count count="5"></fig-count><table-count count="0"></table-count><page-count count="15"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are within the paper and its Supporting Information files.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are within the paper and its Supporting Information files.</p></notes></front><body><sec sec-type="intro" id="sec001"><title>Introduction</title><p>Stress at work is a public health concern [<xref rid="pone.0177094.ref001" ref-type="bibr">1</xref>,<xref rid="pone.0177094.ref002" ref-type="bibr">2</xref>,<xref rid="pone.0177094.ref003" ref-type="bibr">3</xref>,<xref rid="pone.0177094.ref004" ref-type="bibr">4</xref>]. Emergency medicine is a field where stress is constant [<xref rid="pone.0177094.ref005" ref-type="bibr">5</xref>,<xref rid="pone.0177094.ref006" ref-type="bibr">6</xref>,<xref rid="pone.0177094.ref007" ref-type="bibr">7</xref>]. An emergency, by definition, requires a rapid response with no possibility of predicting the workload [<xref rid="pone.0177094.ref008" ref-type="bibr">8</xref>,<xref rid="pone.0177094.ref009" ref-type="bibr">9</xref>]. Phone operators in emergency medical dispatch centers are particularly at risk because they must assess the gravity of the situation without seeing patients, a judgement that requires experience [<xref rid="pone.0177094.ref010" ref-type="bibr">10</xref>]. They must localize the victims as quickly as possible and deal with aggressive and violent behavior from patients and their relatives, excessive alcohol consumption and road accidents sometimes involving young children [<xref rid="pone.0177094.ref011" ref-type="bibr">11</xref>]. Stress in emergency medical dispatchers can lead to work-related exhaustion with various physical and psychological symptoms [<xref rid="pone.0177094.ref012" ref-type="bibr">12</xref>], and delayed decision-making due to misjudgment of the seriousness of the patient’s condition [<xref rid="pone.0177094.ref013" ref-type="bibr">13</xref>]. All these factors contribute to increased sick leave [<xref rid="pone.0177094.ref014" ref-type="bibr">14</xref>] and an increased turnover of phone operators owing to their premature departure to other less stressful professions [<xref rid="pone.0177094.ref015" ref-type="bibr">15</xref>]. Objective measurements of stress are therefore needed to develop evaluable preventive strategies of stress management [<xref rid="pone.0177094.ref016" ref-type="bibr">16</xref>,<xref rid="pone.0177094.ref017" ref-type="bibr">17</xref>,<xref rid="pone.0177094.ref018" ref-type="bibr">18</xref>]. To identify stress at a biological level, cortisol is the historical biomarker which can now be assessed easily and pain-free from saliva [<xref rid="pone.0177094.ref019" ref-type="bibr">19</xref>,<xref rid="pone.0177094.ref020" ref-type="bibr">20</xref>,<xref rid="pone.0177094.ref021" ref-type="bibr">21</xref>,<xref rid="pone.0177094.ref022" ref-type="bibr">22</xref>,<xref rid="pone.0177094.ref023" ref-type="bibr">23</xref>]. To our knowledge, only one study has used objective measurements to assess stress in emergency medical dispatchers [<xref rid="pone.0177094.ref006" ref-type="bibr">6</xref>]. The authors observed higher levels in the phone operators than in controls but did not compare levels at different shift times. In addition, although it is known that cortisol levels are related to perceived stress and acute mental stressful events [<xref rid="pone.0177094.ref019" ref-type="bibr">19</xref>,<xref rid="pone.0177094.ref020" ref-type="bibr">20</xref>,<xref rid="pone.0177094.ref021" ref-type="bibr">21</xref>,<xref rid="pone.0177094.ref022" ref-type="bibr">22</xref>,<xref rid="pone.0177094.ref024" ref-type="bibr">24</xref>], they did not investigate the specific effect of incoming emergency calls. Finally, the increase in cortisol levels in response to stress is greater in females [<xref rid="pone.0177094.ref025" ref-type="bibr">25</xref>] and in non-experienced workers/individuals [<xref rid="pone.0177094.ref019" ref-type="bibr">19</xref>,<xref rid="pone.0177094.ref020" ref-type="bibr">20</xref>,<xref rid="pone.0177094.ref021" ref-type="bibr">21</xref>,<xref rid="pone.0177094.ref022" ref-type="bibr">22</xref>].</p><p>From these observations, we hypothesized that 1) cortisol levels are a relevant biomarker of stress in emergency medical dispatchers during the <italic>Incoming emergency call</italic> shift 2) cortisol levels are related to perceived stress and 3) are able to identify stressful events (severity of incoming emergency call or effects of a subsequent absolute incoming emergency call) and 4) are related to sociodemographic variables such as gender and experience.</p><p>Thus, the aims of our study were to obtain objective assessments of stress by measuring saliva cortisol levels during the various shifts worked by emergency medical dispatchers, and to investigate the independent associations between perceived stress, severity of incoming calls and other variables.</p></sec><sec sec-type="materials|methods" id="sec002"><title>Methods</title><sec id="sec003"><title>Participants</title><p>Participants were phone operators working in the emergency dispatch center of the Mercy Regional Hospital Centre (CHR) of Metz-Thionville, France. Participants were recruited in May 2014 and we obtained complete data by October 2014. We recruited both men and women to better represent the whole team of medical dispatchers. Exclusion criteria were psychiatric disorders including depressive symptoms > 8 on the Hospital and Anxiety Scale [<xref rid="pone.0177094.ref026" ref-type="bibr">26</xref>], recent extraprofessional life stress event (such as death of a near relative, divorce) [<xref rid="pone.0177094.ref027" ref-type="bibr">27</xref>], alcohol consumption > 3 drinks per day for men and > 2 for women [<xref rid="pone.0177094.ref028" ref-type="bibr">28</xref>], endocrine disorder [<xref rid="pone.0177094.ref029" ref-type="bibr">29</xref>], oral contraceptive [<xref rid="pone.0177094.ref025" ref-type="bibr">25</xref>,<xref rid="pone.0177094.ref030" ref-type="bibr">30</xref>] and pregnancy [<xref rid="pone.0177094.ref031" ref-type="bibr">31</xref>], any medications used to modulate inflammatory diseases taken over the previous three months (corticosteroids, anti-inflammatory drugs, immunomodulatory drugs) [<xref rid="pone.0177094.ref032" ref-type="bibr">32</xref>], intensive sports > 3 hours per week of intense physical activity [<xref rid="pone.0177094.ref033" ref-type="bibr">33</xref>], and any current illness/infection [<xref rid="pone.0177094.ref034" ref-type="bibr">34</xref>] at the time of measurements (feeling feverish sensations or having hyperthermia above 38.5°C) [<xref rid="pone.0177094.ref035" ref-type="bibr">35</xref>]. The protocol was approved by the Human Ethics Committee of the University Hospital of Nancy, France (Clinical Trials identifier NCT02075424). The study was explained to the phone operators, who provided their written informed consent. We did not exclude non-menopausal women because basal cortisol levels do not differ during the menstrual cycle [<xref rid="pone.0177094.ref031" ref-type="bibr">31</xref>]. In addition, studies involving work stress and cortisol levels in acute care settings have mainly involved women [<xref rid="pone.0177094.ref036" ref-type="bibr">36</xref>,<xref rid="pone.0177094.ref037" ref-type="bibr">37</xref>,<xref rid="pone.0177094.ref038" ref-type="bibr">38</xref>,<xref rid="pone.0177094.ref039" ref-type="bibr">39</xref>].</p></sec><sec id="sec004"><title>Work description of an emergency medical dispatcher</title><p>The same phone operator alternated three types of shifts.</p><p><bold>- Incoming emergency calls</bold>: Dealing with emergency calls is considered to be the most stressful situation. The phone operator is the first to answer incoming calls and must evaluate the severity of the situation and choose from among the following courses of action: absolute emergency situation immediately requiring a mobile intensive care unit (MICU); relative emergency situation that needs to be first managed by phone by an emergency physician to decide the best option; relative emergency situation that can be managed on site by a primary care physician; no emergency situation and transfer the call to a general practitioner primary care physician for advice.</p><p><bold>- Dispatch</bold>: The phone operator manages the deployment of the different intervention teams. She or he must organize transport by calling the MICU, private ambulances or the fire department depending on the severity of the case. She or he always follows the orders of the emergency physician or the general practitioner primary care physician of the emergency medical dispatch center.</p><p><bold>- Re-assessment</bold>: The phone operator must re-assess the different interventions and list the management of each patient.</p><p>All phone operators do only one kind of shift per working day. All included EMDs had the same working schedule i.e. 7am-7pm. As the impact of night shifts on biomarkers of stress may last several days [<xref rid="pone.0177094.ref040" ref-type="bibr">40</xref>,<xref rid="pone.0177094.ref041" ref-type="bibr">41</xref>], we included in this study only shifts which did not follow a night shift (7pm-7am) over the three previous days.</p></sec><sec id="sec005"><title>Shift randomization</title><p>For each phone operator, we measured outcomes during a control day and during the three types of shifts: <italic>Incoming emergency call</italic>, <italic>Dispatch</italic> and <italic>Re-assessment</italic>. Latin squares were used to randomize first the order between <italic>Incoming emergency call</italic> and <italic>control day</italic>. The <italic>Incoming emergency call</italic> shift was always before the two other types of shifts. However, after measurements were made during the <italic>Incoming emergency call</italic> shift, Latin squares were used to randomize the pattern of shifts between <italic>Dispatch</italic> and <italic>Re-assessment</italic>. All outcome data remained blinded until the end of the study.</p></sec><sec id="sec006"><title>Main outcome: Saliva cortisol</title><p>During the <italic>Incoming emergency call</italic> shift, saliva was sampled every 15 minutes for 2 hours, i.e. 7 consecutive times (+15min, +30 min, +45min, +60 min, +75min, +90 min, +120 min), starting 15 minutes after the first life-and-death incoming emergency call between 2 and 5 pm. Sampling was then performed 7 consecutive times during the other two shifts. We began sampling at the same time for each shift. As fasting affects cortisol levels [<xref rid="pone.0177094.ref042" ref-type="bibr">42</xref>], we controlled that participants had lunch during shifts. On the other hand, to avoid contamination of salivary samples, participants were asked to fast and refrain from brushing teeth and chewing gum within the hour before the putative beginning of sampling (4pm).</p><p>As chronic stress may affect the nictemeral cycle of cortisol [<xref rid="pone.0177094.ref026" ref-type="bibr">26</xref>,<xref rid="pone.0177094.ref027" ref-type="bibr">27</xref>], we measured saliva cortisol levels every 2 hours during a control day, from 7am to 9pm [<xref rid="pone.0177094.ref029" ref-type="bibr">29</xref>]. The control day was a day-off after at least 8 days of vacation, without jet lag.</p></sec><sec id="sec007"><title>Secondary outcomes</title><p><bold>Socio-demographic variables</bold> (age, gender, and experience in the unit) were retrieved by self-reported questionnaires.</p><p><bold>Perceived stress</bold> was assessed by a visual analog scale (VAS), which is a horizontal, non-calibrated line of 100 mm, ranging from very low (0) to very high (100) [<xref rid="pone.0177094.ref043" ref-type="bibr">43</xref>]. Perceived stress was measured at the same time as the first saliva sampling during the three types of shifts.</p><p>During the <italic>Incoming emergency call</italic> shift, the severity of the calls was expressed as absolute or relative. Any subsequent absolute incoming emergency call was also recorded.</p><p>Phone operators had to report any stressful events during the control day.</p></sec><sec id="sec008"><title>Biochemical measurements</title><p>Assays were done on saliva samples, since saliva is a good alternative to steroid hormones, in particular stress hormones, including those of the HPA axis [<xref rid="pone.0177094.ref044" ref-type="bibr">44</xref>]. Cortisol levels were assayed by commercial ELISA kits (Salimetrics, State College, USA), according to the manufacturer’s recommendations (including sampling step). All samples were analyzed in duplicate. Mean values of duplicates were used to represent measured values. Sensitivity and intra- and inter-assay coefficients of variation were 0.05 ng/ml, 7% and 9.3%, respectively. The saliva kit was designed to avoid cortisone cross-reactivity [<xref rid="pone.0177094.ref045" ref-type="bibr">45</xref>].</p></sec><sec id="sec009"><title>Statistics</title><p>The sample size calculation was estimated on the basis of a previous study by members of our team [<xref rid="pone.0177094.ref006" ref-type="bibr">6</xref>] which showed a 22.8% increase in cortisol levels in emergency medical dispatchers compared with control participants. Following the recommendations of Cohen [<xref rid="pone.0177094.ref046" ref-type="bibr">46</xref>], who has defined effect-size bounds as small (ES: 0.2), medium (ES: 0.5) and large (ES: 0.8, “‘grossly perceptible and therefore large”), we decided to include 22 participants to evidence an effect-size equals 0.7 at +120min for a two-sided type I-error at 0.017 (correction due to multiple comparisons), a statistical power of 80%, and within subject variability at 0.5 (due to the experimental design).</p><p>Statistical analyses were performed with Stata software (version 13, StataCorp, College Station, TX, US). Data were presented as mean ± standard deviation (SD). A Shapiro-Wilk test was used to test the assumption of distribution normality of cortisol. For paired comparisons (according to time of first life-and-death incoming emergency call, type of shift and control day values), standard statistical tests were performed, either paired Student t-test or Wilcoxon test when appropriate. To compare the longitudinal kinetics of this parameter in the three shifts, a zero-inflated Poisson random-effects model [<xref rid="pone.0177094.ref047" ref-type="bibr">47</xref>,<xref rid="pone.0177094.ref048" ref-type="bibr">48</xref>,<xref rid="pone.0177094.ref049" ref-type="bibr">49</xref>,<xref rid="pone.0177094.ref050" ref-type="bibr">50</xref>] was used to take into account (1) between- and within-subject variability and (2) statistical distribution characterized by frequent zero-valued observations (random event containing excess zero-count data in unit time). The zero-inflated Poisson model employs two components that correspond to two zero generating processes. The first process is governed by a binary distribution that generates structural zeros. The second process is governed by a Poisson distribution that generates counts some of which may be zero. The covariates were studied according to their clinical relevance, as fixed effects with a particular attention on interaction effects. All tests were two-sided, with a type I error set at α = 0.05, taking into account when appropriate correction of type I error due to multiple comparisons.</p></sec></sec><sec sec-type="results" id="sec010"><title>Results</title><sec id="sec011"><title>Participants</title><p>We recruited 22 phone operators, out of a potential pool of 28 (<xref ref-type="fig" rid="pone.0177094.g001">Fig 1</xref>). We obtained complete data for 22 of the 22 phone operators. They were aged 36.4+/-10.8 years (14 women aged 37.9+/-10.7 years, 8 men aged 33.8+/-11.2 years). Men and women did not differ in age (p = .35) but female emergency medical dispatchers had greater experience: 86% of the women had a >5 year experience as against 25% of the men, p = .004. None of the participants were taking routine medications and none took occasional medications during the study. No participant reported not having lunch before cortisol measurements during shifts.</p><fig id="pone.0177094.g001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0177094.g001</object-id><label>Fig 1</label><caption><title>Flow chart and study design.</title></caption><graphic xlink:href="pone.0177094.g001"></graphic></fig></sec><sec id="sec012"><title>Cross-sectional analyses of cortisol</title><sec id="sec013"><title>Endpoint (+120min) between shifts</title><p>Cortisol levels at endpoint (+120 min) had a tendency (p = 0.11, effect-size 0.65) to be higher for <italic>Incoming emergency call</italic> shift (0.30±0.28 mmol/l) than for <italic>Re-assessment</italic> (0.14±0.23 mmol/l) and <italic>Dispatch</italic> shifts (0.23±0.23 mmol/l) (<xref ref-type="fig" rid="pone.0177094.g002">Fig 2</xref>).</p><fig id="pone.0177094.g002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0177094.g002</object-id><label>Fig 2</label><caption><title>Cortisol levels during control day and paired cortisol levels as from time of first life-and-death incoming emergency call, and during <italic>Dispatch</italic> and <italic>Re-assessment</italic> shifts.</title></caption><graphic xlink:href="pone.0177094.g002"></graphic></fig></sec><sec id="sec014"><title>Baseline and endpoint between control day and shifts</title><p>Paired tests showed no differences between control values and shifts (15 minutes after Incoming emergency call, Control day vs <italic>Incoming emergency call</italic>: p = .25; Control day vs <italic>Dispatch</italic> p = .66; Control day vs <italic>Re-assessment</italic>: p = .79; Control day vs <italic>Incoming emergency call</italic>: p = .25; Control day vs <italic>Dispatch</italic>: p = .66; Control day vs <italic>Re-assessment</italic>: p = .79; 2 hours after <italic>Incoming emergency call</italic>, Control day vs <italic>Incoming emergency call</italic>, p = .34; Control day vs <italic>Dispatch</italic> p = .18; Control day vs <italic>Re-assessment</italic>: p = .51).</p></sec></sec><sec id="sec015"><title>Longitudinal evolution of cortisol depending on shift</title><sec id="sec016"><title>Comparison within shifts</title><p>For <italic>Incoming emergency call</italic> shift, cortisol values did not differ from baseline (+15min) except for +90min (p = 0.02). For <italic>Dispatch</italic> shift, the kinetic seemed comparable to <italic>Incoming emergency call</italic> shift with only significant difference at +90min (p = 0.02) and a tendency at +75min (p = 0.08). For <italic>Re-assessment</italic> shift, cortisol values differed from baseline after +60min (p = 0.02) (+75min, p = 0.05; +90min, p = 0.02; and +120min, p = 0.001).</p></sec><sec id="sec017"><title>Comparison between shifts</title><p>The study of interaction measurement-time x shift confirmed these results with no difference between <italic>Incoming emergency call</italic> and <italic>Dispatch</italic> shifts (p = 0.91) and between <italic>Dispatch</italic> and <italic>Re-assessment</italic> shifts (p = 0.20). However, there was a significant interaction between <italic>Incoming emergency call</italic> and <italic>Re-assessment</italic> shift (p = 0.02).</p></sec><sec id="sec018"><title>Zero-inflated Poisson random-effects model</title><p>A zero-inflated Poisson random-effects model [<xref rid="pone.0177094.ref047" ref-type="bibr">47</xref>,<xref rid="pone.0177094.ref048" ref-type="bibr">48</xref>,<xref rid="pone.0177094.ref049" ref-type="bibr">49</xref>,<xref rid="pone.0177094.ref050" ref-type="bibr">50</xref>] showed that kinetics did not differ between the three types of shift (interaction shift position x time, p = .78). However, when all measurements were taken into account, cortisol levels were higher during the <italic>Incoming emergency call</italic> shift than during the <italic>Dispatch</italic> (p = .04) and <italic>Re-assessment</italic> shifts (p = .04) (<xref ref-type="fig" rid="pone.0177094.g002">Fig 2</xref>). There was a tendency between the <italic>Dispatch</italic> and the <italic>Re-assessment</italic> shifts (p = .095).</p><p><bold>Therefore</bold>, according to results of all those longitudinal analyses, <italic>Incoming emergency call</italic> and <italic>Dispatch</italic> shifts had a similar kinetic (p = 0.91) but with higher cortisol values <italic>for Incoming emergency call</italic> shift (p = 0.04). Moreover, <italic>Incoming emergency call</italic> and <italic>Re-assessment</italic> shifts had significant different kinetics (p = 0.02), with an increase of cortisol values for <italic>Incoming emergency call</italic> shift whereas cortisol values decreased for <italic>Re-assessment</italic> shift (p = 0.04).</p></sec></sec><sec id="sec019"><title>Longitudinal evolution of cortisol levels depending on participants’ characteristics</title><sec id="sec020"><title>Gender</title><p>When all measurements were taken into account, cortisol values were greater for men (p = .009) (<xref ref-type="fig" rid="pone.0177094.g003">Fig 3</xref>). Subgroup analysis showed that this difference was only observed during the incoming emergency call shift (p = .002) (<italic>Re-assessment</italic>, p = .075; <italic>Dispatch</italic>, p = 0.73). The study of group x gender interaction confirmed this result (p = .04).</p><fig id="pone.0177094.g003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0177094.g003</object-id><label>Fig 3</label><caption><title>Stress response of cortisol depending on gender during the incoming call shift.</title></caption><graphic xlink:href="pone.0177094.g003"></graphic></fig></sec><sec id="sec021"><title>Age</title><p>There were no age-related differences in kinetics.</p></sec><sec id="sec022"><title>Experience in the EMD unit</title><p>An experience-related effect was observed (p = .01) but seemed to be dependent on gender. This was confirmed by multivariate analysis with experience and gender as covariates (p = .21).</p></sec><sec id="sec023"><title>Perceived stress</title><p>The kinetics of cortisol levels increased with greater perceived stress, overall (p < .001) and for each shift (<italic>Incoming emergency call</italic>, p = .02; <italic>Dispatch</italic>, p = .03; <italic>Re-assessment</italic>, p < .001).</p></sec><sec id="sec024"><title>Severity of incoming emergency call</title><p>The kinetics of cortisol levels in response to incoming emergency calls was greater when the call was an absolute emergency (p = .03 vs relative absolute incoming emergency call). In particular, participants dealing with an absolute emergency tended to have greater values of cortisol during the last four measurement times compared to workers who had no absolute emergency calls (p = .09) (<xref ref-type="fig" rid="pone.0177094.g004">Fig 4</xref>).</p><fig id="pone.0177094.g004" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0177094.g004</object-id><label>Fig 4</label><caption><title>Stress response of cortisol depending on severity of life-and-death emergency oncoming call.</title></caption><graphic xlink:href="pone.0177094.g004"></graphic></fig></sec><sec id="sec025"><title>Subsequent absolute incoming emergency call</title><p>In phone operators who had a first absolute incoming emergency call, the kinetics of cortisol values tended to increase when there was a subsequent absolute incoming emergency call (p = .07) (<xref ref-type="fig" rid="pone.0177094.g005">Fig 5</xref>).</p><fig id="pone.0177094.g005" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0177094.g005</object-id><label>Fig 5</label><caption><title>Effects of a subsequent absolute incoming emergency call after beginning of measurements.</title></caption><graphic xlink:href="pone.0177094.g005"></graphic></fig></sec></sec></sec><sec sec-type="conclusions" id="sec026"><title>Discussion</title><p>The main findings to emerge from our study are that cortisol is a relevant biomarker of stress in emergency medical dispatchers, with higher values being recorded during the <italic>Incoming emergency call</italic> shift. Cortisol values were linked with perceived stress and identified stressful events (severity of incoming emergency calls or effects of a subsequent absolute incoming emergency call). We also observed relationships between cortisol levels and sociodemographic variables such as gender and experience.</p><sec id="sec027"><title>Cortisol is a relevant biomarker of stress</title><p>In our study, the relationships between cortisol levels and perceived stress confirmed that cortisol is a relevant biomarker of stress in the workplace [<xref rid="pone.0177094.ref022" ref-type="bibr">22</xref>]. Emergency medical dispatchers are particularly at risk of stress because of the combination of witnessing medical distress [<xref rid="pone.0177094.ref006" ref-type="bibr">6</xref>] and the constraints of a call center [<xref rid="pone.0177094.ref051" ref-type="bibr">51</xref>]. There are usually strenuous demands by the employers and not much flexibility allowed for the employees [<xref rid="pone.0177094.ref051" ref-type="bibr">51</xref>]. Chronic stress can lead to basal hypocortisolism characterized by a flattened cortisol rhythm with dramatically smoothed production of glucocorticoids [<xref rid="pone.0177094.ref052" ref-type="bibr">52</xref>]. In our study, the nictemeral cycle of cortisol on the control day was normal. Chronic stress at work can also lead to hyporeactivity [<xref rid="pone.0177094.ref053" ref-type="bibr">53</xref>]. However, we report here for the first time that the <italic>Incoming emergency call</italic> shift is the most stressful period, with phone operators having higher cortisol values than at other times when calls had already been dealt with and decisions already made without any direct contact with callers. In contrast, in some patients with post-traumatic stress disorders a stressful event induces hyporeactivity [<xref rid="pone.0177094.ref054" ref-type="bibr">54</xref>]. This confirms that our phone operators reacted to stressful stimuli but did not experience a biologically overloaded stressful experience. Identifying stressful events may be crucial for safety practice.</p></sec><sec id="sec028"><title>Identification of stressful events</title><p>In our study, the <italic>Incoming emergency call</italic> shift induced elevated levels of cortisol, depending on the severity of the emergency call. We also observed a cumulative effect of a subsequent absolute emergency incoming call. Our results bear similarity to the increased morbidity rates described in subsequent patients after surgeons had experienced a patient’s death during emergency surgery [<xref rid="pone.0177094.ref055" ref-type="bibr">55</xref>]. In our study, the potential for residual effects of the <italic>Incoming emergency call</italic> shift need to be investigated, and the consequences of stressful events identified for both patients and phone operators. Phone operators often deal with many absolute emergencies during the same shift, which may produce substantial hypersecretion of cortisol. A succession of days with elevated levels of cortisol can lead to serious diseases such as metabolic disorders including type two diabetes, and also depression and psychiatric disorders [<xref rid="pone.0177094.ref022" ref-type="bibr">22</xref>]. The impact of night shifts can also contribute to stress and to the alteration of the nictemeral cycle of cortisol, which can also lead to an increased morbidity and mortality [<xref rid="pone.0177094.ref016" ref-type="bibr">16</xref>,<xref rid="pone.0177094.ref022" ref-type="bibr">22</xref>]. Thus, the possibility of long-term adverse effects raises the question of the management of stress at work. Further studies could investigate the length of shifts and introduce rotations during the day to reduce the impact of daily stress.</p></sec><sec id="sec029"><title>Sociodemographic variables such as gender and experience</title><p>The phone operators included in this study were representative of the overall population of emergency medical dispatchers. There was a greater increase in cortisol levels in response to stress in the men than in the women, as reported elsewhere [<xref rid="pone.0177094.ref056" ref-type="bibr">56</xref>] Another report showed that experienced individuals had a lower increase in cortisol levels and faster recovery compared to those without experience [<xref rid="pone.0177094.ref057" ref-type="bibr">57</xref>]. Although we did not demonstrate an effect of experience, that the longer experience of the female emergency medical dispatchers may have affected the results. Preventive strategies at the workplace could therefore be personalized by taking into account gender specificity and experience.</p></sec><sec id="sec030"><title>Limitations</title><p>According to the sample size estimation, the estimated size effect was around 0.7. It is interesting to observe that all results showed an effect size at 0.66 underlying the fact that we lack statistical power for the primary outcome. However, additional exploratory analyses demonstrated significant results. This study has certain limitations. The sample size was small but each individual was their own control, which limited inter-individual cortisol variations. In addition, the high participating rate (75%) limited selection bias. Cortisol values are reported to depend on season, but sampling was conducted in a limited timeframe to limit intra-individual variations. Although cortisol levels are influenced by several factors such as nutritional intake and physical activity [<xref rid="pone.0177094.ref021" ref-type="bibr">21</xref>,<xref rid="pone.0177094.ref029" ref-type="bibr">29</xref>], our study design, which included specific measurements at work, limited the potential effect of these major confounders. Saliva sampling every 15 minutes for 2 hours, starting 15 minutes after the first life-and-death incoming emergency call, were conducted only during the three types of shifts (<italic>Incoming emergency call</italic>, <italic>Dispatch</italic> and <italic>Re-assessment</italic>) and not during the at-home control day because eight measurements every two hours had already been performed to provide a nictemeral cycle of cortisol. Finally, our findings are not necessarily applicable elsewhere because organizational procedures may differ between emergency medical dispatchers. Further analyses should focus on relationships between cortisol secretion and personality traits [<xref rid="pone.0177094.ref058" ref-type="bibr">58</xref>] or other biomarkers of stress [<xref rid="pone.0177094.ref041" ref-type="bibr">41</xref>,<xref rid="pone.0177094.ref059" ref-type="bibr">59</xref>,<xref rid="pone.0177094.ref060" ref-type="bibr">60</xref>,<xref rid="pone.0177094.ref061" ref-type="bibr">61</xref>].</p></sec></sec><sec sec-type="conclusions" id="sec031"><title>Conclusion</title><p>The shift on which phone operators received incoming calls was the most stressful. Cortisol levels were highest during this period, varying with perceived stress, severity of the emergency call, and the occurrence of a subsequent absolute incoming emergency call. The increase in cortisol levels was greater in the men than in the women during this shift. Preventive strategies in the workplace could be personalized by taking into account gender specificity.</p></sec><sec sec-type="supplementary-material" id="sec032"><title>Supporting information</title><supplementary-material content-type="local-data" id="pone.0177094.s001"><label>S1 Appendix</label><caption><title>CONSORT checklist.</title><p>(DOCX)</p></caption><media xlink:href="pone.0177094.s001.docx"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="pone.0177094.s002"><label>S1 Protocol</label><caption><title>Study protocol in French.</title><p>(DOCX)</p></caption><media xlink:href="pone.0177094.s002.docx"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="pone.0177094.s003"><label>S2 Protocol</label><caption><title>Study protocol in English.</title><p>(DOCX)</p></caption><media xlink:href="pone.0177094.s003.docx"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="pone.0177094.s004"><label>S1 Database</label><caption><title>Titles of columns are written without abbreviations.</title><p>999 = missing data.</p><p>(XLSX)</p></caption><media xlink:href="pone.0177094.s004.xlsx"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material></sec></body><back><ack><p>We express our sincere gratitude to all the emergency medical dispatchers of the Mercy Regional Hospital Centre (CHR) of Metz-Thionville, Emergency department, Metz, France, who participated in this study. 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