Over their careers paramedics experience critical incidents that can negatively affect their emotional health, resulting in post-traumatic stress disorder (PTSD) and/or depression. They are at greater risk for PTSD than the general population (10% vs. 1.3%–3.5%) and other rescuer groups,1 likely due to frequency of exposure, workplace pressure, and contact with victims.2 Suicidal thoughts, plans, and attempts are also highest in paramedics.3
Despite all this, the mental health of paramedics is studied less often than in other first responders, and few preventive methods have been suggested.2 For nearly two decades (1983–2001) Critical Incident Stress Debriefing (CISD)4 was the intervention of choice for first responder groups after critical incidents; however, beginning in 1995 the empirical basis for using CISD was called into question.5,6 Evidence indicated debriefing could be harmful,7 and a meta-analysis and Cochrane review concluded CISD was ineffective in preventing PTSD.8,9 It became clear new approaches were needed.
Social support is a robust resilience factor after trauma.10,11 Greater perceived social support is associated with less PTSD in first responders,12 and a review of work-related PTSD in first responders and others specifies social support from colleagues and managers as a preventive factor.13 This aligns with others who have identified support from superiors as being of special value to first responders.14–16
Stigma is an important barrier to receiving support. The American and Canadian armed forces have put considerable effort into tackling stigma against seeking help for symptoms of PTSD,17 which has yielded insights that may be useful to paramedics. One emphasis has been to identify the range of reasons why veterans eschew help. These include not knowing their symptoms can be treated effectively and a preference to be self-sufficient rather than relying on health professionals. Thus, preventive measures that accommodate self-care may reduce barriers to social support.18
Development of a Post-Critical Incident Prevention Tool
Our purpose was to develop a post-critical incident tool that would address needs identified in an assessment. This is in line with accepted approaches that allow knowledge users to lead the way.19
Given the paucity of evidence to guide tool development, our process included a mixed-methods assessment of the perceived needs of paramedics and supervisors. We engaged partners at stages of both idea formulation and dissemination, engaged target knowledge users (paramedics and supervisors), and identified the strategies and main messages of the tools.
We worked with a public municipal sole provider of ambulance-based emergency medical services in an urban center. In our jurisdiction the term paramedic is used to describe all ambulance workers. In our system more than 1,000 paramedics transport more than 200,000 patients a year to hospitals. Over the last several years, leadership and the union that represents employees recognized the need for developing strategies to prevent and respond to PTSD after incidents.
For the project we formed a steering committee that included representation from paramedics, EMS leadership, and the union. EMS leadership agreed to devote a portion of the paramedics’ dedicated continuing education time to the project.
Engagement of Knowledge Users
Paramedics and supervisors shaped the development of the tool from the onset in semistructured focus groups and individual interviews. Based on their input we identified the importance of the workplace immediately after a critical incident, and particularly supervisor support, as key themes.20 While peer support was identified as important, especially from work partners, supervisor support was emphasized, perhaps because it mitigates the loss of self-esteem and feelings of professional incompetence often evoked by critical incidents.21
Paramedics indicated there were barriers to accessing support, especially an organizational culture of stigma and fear of being overwhelmed by emotions.20,21 Importantly, although paramedics fear paying attention to their emotions on the job may impair their functioning,22 there is evidence that identifying feelings after a critical incident is helpful.23,24 Paramedics also pointed to a time-off period after a critical incident (downtime) as feeling helpful and were willing to accept help in the form of an educational tool provided at their workplace by their organization.
Based on the results of these qualitative interviews, we conducted a retrospective quantitative study of critical incidents and their consequences for paramedics and identified nonemotional markers of risk. We found that if three nonemotional components of the acute stress reaction25—insomnia, irritability, and social withdrawal—persisted two days beyond a critical incident, there was at least double the risk of subsequent symptoms of PTSD and depression.26 Physical symptoms of panic also predicted these outcomes, even if they didn’t persist.26 Paramedics were less adept at describing emotions than people in the community,27 which reinforced the value of emphasizing nonemotional triggers for intervention and identified a potential target for change.
An alternative way to identify higher-risk critical incidents without relying on paramedics reporting emotional distress is to focus on the characteristics of the incidents themselves. Over the years paramedics have suggested certain types of incidents that can be critical—for instance, crib deaths.28,29 In the quantitative study characteristics of critical incidents significantly associated with delayed recovery from symptoms of acute stress reaction and with later PTSD symptoms involved aspects of the person rather than the situation or organization: pre-incident state of mind (e.g., fatigue, prior stressors), appraisal of the incident (e.g., surprised by the call, feeling of not doing a good enough job), as well as the emotional experience of the incident (e.g., feeling overwhelmed, helpless, unappreciated).27 We included these elements in the tool.
In response to paramedics identifying downtime as valuable, the study surveyed the amount of downtime received, if any, after an index critical incident. Downtime from half an hour up to one day was associated with lower post-critical incident severity of depressive symptoms than not receiving downtime, whereas longer downtime was associated with worse outcomes. Downtime was not associated with a difference in PTSD symptoms.30 Importantly, this study suggests an opportunity for a practical and welcome intervention immediately post-incident. Downtime was, therefore, included as a possible response to immediate post-critical incident red flags in the tool.
Translating the Knowledge
Our research made it clear paramedics’ needs went beyond a need for awareness or knowledge. The evidence suggested resilience would be more likely enhanced by supervisors providing support and offering downtime when indicated, and paramedics seeking and accepting it.
Further consultation with EMS partners identified a preferred format for a tool: small laminated cards. Laminated cards with point-form reminders of best practices are a commonly used EMS tool, and thus the format could improve uptake and might reduce stigma.
Laminated cards take two aspects of workplace culture into account. First, they recognize paramedics’ desire for control by facilitating self-identification of risk rather than screening. Second, the format respects that paramedics often mistrust outsiders, especially mental health professionals. Our EMS partners were helpful in the cards’ rollout; their audiovisual department designed the cards and filmed an accompanying educational video.
We developed the cards with attention to the principles of adult education.31,32 After a critical incident the cards encourage both supervisors and paramedics to take active steps. Creation of separate cards for supervisors and paramedics optimized the relevance of information for each and facilitated interaction, which supports behavior change. Laminated cards that are available whenever stressful calls occur support repetition of the processes of identifying risk factors and responding, which enhances learning. Finally, the cards encourage cautious, respectful speaking about emotions, which may enhance skills and, through normalization, change attitudes (i.e., reduce stigma).
We revised the cards with feedback from users over several months. Near the end of the revision process, a supervisor casually said, “I always thought that if an incident wouldn’t be critical for me, it shouldn’t be for anyone else,” and his colleagues agreed. This information resulted in our emphasizing on the supervisors’ card a finding from a study that individuals respond differently to the same incident, and listening is paramount.32
Results and Discussion
This critical incident tool for EMS consists of two laminated cards each printed on both sides, one for supervisors and one for paramedics. The supervisor cards include information on checking in after a stressful call, what to listen for, how to respond immediately, a reminder to follow up two days later, and how to respond at that time. The paramedic card includes red flags immediately after a critical incident, red flags two days after a critical incident, and what to do if red flags are observed. Most of the content of the cards follows directly from our literature review and mixed-methods studies.
Based on concerns that discussion of emotions under the wrong circumstances could be harmful, the supervisors’ card emphasizes listening carefully and recommends supervisors follow the lead of the paramedic, rather than pressure them to discuss the incident if they are uncomfortable. The tool is designed as a reminder to be used after a critical incident and can also be used in advance of anticipated critical incidents to learn what to expect.
The tool we’ve developed is based on empirical evidence and was developed in close collaboration with knowledge users. It addresses the need for rapid identification of risk factors for PTSD, circumvents resistance within the EMS community to identifying distressing feelings, and suggests short-term interventions to minimize negative impacts.
In contrast to previous interventions, particularly CISD, this tool helps personalize intervention according to need and requires no mental health professionals. It allows downtime to be provided as needed to paramedics who request or appear to need help, and for further contact with mental health professionals when required. We expect this stepped-care approach to be much less expensive to implement than CISD.
As local EMS organizations heard about the tool, they requested information, and we’ve begun dialogues about the best way to use it. We look forward to EMS organizations testing this tool and continuing to consider ways to offer their employees the best available protection from the high risks they encounter at work.
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Janice Halpern is an assistant professor in the University of Toronto Department of Psychiatry’s Division of Psychotherapies, Humanities, and Education Scholarship and a psychiatrist at Mount Sinai hospital in Toronto. Contact her at Janice.firstname.lastname@example.org.
Robert G. Maunder is a professor in the Department of Psychiatry at the University of Toronto and head of research for Mount Sinai Hospital’s Department of Psychiatry. His research collaboration explores psychosocial aspects of health and disease.
Brian Schwartz is chief of communicable diseases, emergency preparedness, and response for Public Health Ontario, as well as an associate professor in the Clinical Public Health Division of the University of Toronto’s Dalla Lana School of Public Health.