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Randomized Controlled Trial
. 2025 Jul 1;33(1):113.
doi: 10.1186/s13049-025-01373-8.

Effect of cold environments on technical performance and perceived workload and stress during advanced medical procedures: a randomized controlled simulation study

Giulia Roveri  1   2 , Lorenzo Gamberini  3 , Erika Borotto  4 , Frederik Eisendle  1   5 , Luigi Festi  6 , Hermann Brugger  1 , Giacomo Strapazzon  7   8   9 , Simon Rauch  1   2 ; EMEX investigators
Affiliations
Randomized Controlled Trial

Effect of cold environments on technical performance and perceived workload and stress during advanced medical procedures: a randomized controlled simulation study

Giulia Roveri et al. Scand J Trauma Resusc Emerg Med. .

Abstract

Background: Advanced medical procedures in prehospital settings are often performed in hostile environments, where cold temperatures may impair manual and cognitive performance. Although such procedures are essential in mountain rescue missions, the effects of cold conditions on their execution and associated workload and stress are unknown.

Objective: This randomized controlled simulation study evaluated differences in performance, perceived workload, and stress during the execution of three advanced emergency medical procedures under cold (- 20 °C) versus control (+ 20 °C) ambient temperatures. Additionally, the study examined the influence of operator experience on these outcomes.

Methods: Thirty-six members of the International Medical Commission for Alpine Rescue participated in a crossover study conducted at the terraXcube environmental simulator in Bolzano, Italy. Participants performed orotracheal intubation via videolaryngoscopy (OTI-VLS), mini-thoracostomy, and front-of-neck airway (FONA) procedures under both temperature conditions. Time to procedure completion, number of attempts, and perceived workload and stress (using the NASA Task Load Index and Visual Analogue Scale) were measured. Operators were categorized into high or low experience groups based on self-reported prior procedure frequency.

Results: Time to complete the procedures tended to be longer in cold conditions for all procedures, with the largest difference observed for OTI-VLS (14 s, p = 0.076). Success rates exceeded 90% on the first attempt under both conditions. Perceived workload and stress increased significantly in cold environments across all procedures, especially for less experienced participants. Experienced operators completed OTI-VLS and mini-thoracostomy significantly faster and reported lower stress and workload levels compared to their less experienced counterparts.

Conclusions: While cold environments had low impact on procedural time, they significantly increased perceived workload and stress among rescue personnel. Experience mitigated these effects, emphasizing the importance of tailored training programs to enhance both technical and non-technical skills in challenging conditions. While this study has explored the impact of temperature, it would be valuable to investigate how other environmental factors, such as wind and rain, might affect clinical actions.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the Ethics Institutional Review Board for Clinical Studies of Bolzano (protocol number 80–2023). Competing interests: The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Time to complete each procedure (in seconds) in control and cold environments for the overall study population. Abbreviations: OTI-VLS: orotracheal intubation using videolaryngoscopy. Mini-thoracostomy: mini-thoracostomy with chest drain insertion. FONA: front-of-neck airway with the Scalpel-Bougie technique. Notes: Colored points are single observations. Boxplots show medians, interquartile ranges, and whiskers indicate min and max values. The violin plot details the distribution of observed times, with wider sections indicating higher frequency
Fig. 2
Fig. 2
Levels of workload and stress across the procedures in control and cold environments for the overall study population. Abbreviations: OTI-VLS: orotracheal intubation using videolaryngoscopy. Mini-thoraco: mini-thoracsotomy with chest drain insertion. FONA: front-of-neck airway with the Scalpel-Bougie technique. NASA-TLX: Nasa Task Load Index; VAS: Visual Analogue Scale. Notes: Boxplots show medians and interquartile ranges; whiskers indicate min and max values; points are outliers. * p < 0.05 (Wilcoxon Signed-Rank test)
Fig. 3
Fig. 3
Time to complete each procedure (in seconds) in control and cold environments. Comparison between high- and low-level experience clinicians. Abbreviations: OTI-VLS: orotracheal intubation using videolaryngoscopy. Mini-thoraco: mini-thoracostomy with chest drain insertion. FONA: front-of-neck airway with the Scalpel-Bougie technique. Notes: Boxplots show medians and interquartile ranges; whiskers indicate min and max values; points are outliers. * p < 0.05 for Experience effect in bivariate ANOVA. The interaction between Experience and Temperature showed no significant effect on any variables
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