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A Comprehensive Approach to Stress in EMS

Today EMS providers respond to more calls per 24-hour shift than their predecessors and perform more invasive procedures with newer medications and equipment.1,2 They complete more documentation, deal with a public that’s more demanding, and have their skills and performance reviewed by medical directors who hold their licenses to function. Violence in their jobs is a constant, and shortages in many places keep their workloads and overtime high. It’s no surprise that emergency services personnel are at higher risk for stress-related disease and death than almost any other occupation in the world.3  

In some EMS systems paramedics can experience multiple traumatic events (e.g., incidents involving children, burns, gunshots, mass casualties) in a single shift. Extrapolating that, an individual could experience anywhere from 500 to more than 3,000 traumatic events during a 20-year career. Stress may also cause poor-quality service to the public4 and resulting financial costs through lawsuits from patients who felt their service was inappropriate. 

These stressors and effects are often ignored or denigrated as just part of our jobs. Rarely are they dealt with proactively, through awareness and training. But procrastination does not solve problems—it merely delays them. Something needs to be done about stress in EMS, and sooner rather than later. 

What to Do?

The solution starts with a holistic mind-set toward stress—one that encompasses understanding the nature of stress, research needs, formal training, appreciating the frequency of traumatic events, awareness of the impact of stress on employees and organizations, leadership, and mentoring.

Narrowing the scope of investigation is a more traditional scientific approach, but many factors influence what happens to humans and how they view it. These factors must be considered in their entirety, not piecemeal. There is a need to define stress in EMS, explore its depths and effects, and determine how to mitigate some of its consequences and cope with stressors holistically. 

One point of this multipronged solution would be to expand stress awareness/management to the EMT/EMT-P curriculum. Training can impose a directed sense of purpose, intent, and understanding on the capriciousness of traumatic incidents as well as reduce the emotional threats that accompany them. The goal of training is to enhance task and performance capabilities and accelerate the recovery of workers affected by traumatic events.5 Agencies must also continue the education of their members to the insidiousness of stress and promote specific methods of assisting their employees (peer support, professional intervention, etc.).

Supervisors are looked to for empathy, advice, and leadership but often receive little education or training in basic management tactics and skills, let alone the higher concepts of leadership. A more cohesive national effort is needed. Good leaders are not born with the skills required but learn their trade through education, experience, and observation. Bad leadership can unnecessarily subject subordinates to stress, causing a decrease in self-confidence and self-worth, an increase in somatic complaints, and the effects of micromanaging or abandoning their charges.6

Along with leadership development, mentorship can have a role in reducing the organizational stress of EMS. It can be formal or informal, but embracing it can improve bench strength and ease the anxiety felt by others. Mentors must be trained in their roles as much as possible to effect positive change.7

Next Steps

How do we begin to adopt these strategies?

  • Adopt a holistic approach to the problem of stress.
  • Explore a national curriculum expansion of time and content on stress education/prevention.
  • Promote social support/peer support. Social support is a buffering mechanism that mediates between psychological stressors and negative health outcomes.8 Researchers have noted that supervisors are looked at for much social support.9 Organizations should prepare supervisors to recognize and begin alleviating stress reactions as soon as they are perceived.
  • Train and utilize peer-support groups to monitor members after critical incidents. They can relate to the situations firefighters and paramedics face and offer resources their members may not be aware of.
  • Create leadership-development programs at all levels in your department.
  • Initiate and support mentoring programs.
  • Advocate for research at the national, state, and local levels.

Paramedics are at high risk for traumatic stress, and more research is needed to determine the types of disorders they may develop and how to positively deal with them. The time is right to reconnect with our old foe stress, define its boundaries in EMS, enhance education to mitigate its effects, and provide EMS workers with the tools to positively affect their personal and professional lives.  


1. Roche K. 2014 National Run Survey—Part 2. Firehouse, 

2. Roche K. 2017 National Run Survey—Part 1. Firehouse, 

3. International Association of Fire Fighters. 1998 Death and Injury Survey. 

4. Lloyd B. Addressing burnout in paramedics: Leading community risk reduction. National Fire Academy: Executive Fire Officer Program, 2004.

5. Anderson W, Swenson D, Clay D. Stress Management for Law Enforcement Officers. Upper Saddle River, N.J.: Prentice Hall, 1995. 

6. Blanchard K, Bowles S. Raving Fans: A Revolutionary Approach to Customer Service. New York, N.Y.: Harper Collins, 1993. 

7. Cox, Jr. R. The evolution of mentoring in prehospital EMS: A case study. ProQuest Dissertations and Theses Database, UMI# 3229297, 2006. 

8. Karasek R, Theorell T. The Psychosocial Work Environment. In: Karasek R, Theorell T, eds. Healthy Work: Stress, Productivity, and Reconstruction of Working Life. New York, N.Y.: Basic Books, 1990. 

9. Corneil W, Beaton R, Murphy S, Johnson C, Pike K. Exposure to traumatic incidents and prevalence of traumatic stress symptomatology in urban firefighters in two countries. J Occup Health Psych, 1999; 4(2): 131–41.

Dawn Dow, EMT-P, PhD, recently retired from a 33-year career with the Chicago Fire Department. She experienced 18 years as a Chicago street medic, 15 years as a paramedic field chief, and four years in rural healthcare. She has advanced degrees in both management and leadership.

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