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What do we know about traumatic stress in EMS?

There is a significant correlation between operational stress, organizational stress, critical incident stress, alcohol use and post-traumatic stress

By Elizabeth Donnelly

We are becoming more aware as an EMS community that there are significant costs to our physical and mental health associated with our work. We need to continue to talk about those costs in order to increase awareness and decrease the stigma associated with asking for help.

In addition to talking about traumatic stress, we need to better understand what places EMS providers at risk for developing a work-related stress reaction like post-traumatic stress.

The quick answer is there is no quick answer.

Whether or not you develop a post-traumatic stress reaction, depression or burnout as a result of working in EMS depends on a wide variety of personal, professional and situational factors. However, researchers have made some progress at understanding what might aggravate that risk.

Stress in EMS

Ever since Jeffrey Mitchell’s seminal article in 1983, we have known that critical incidents can lead to stress reactions like post-traumatic stress.

Critical incidents have broadly been described as “any situation faced by emergency services personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later. Multiple studies have identified a relationship between critical incidents and post-traumatic stress in EMS [1].”

But is that the whole story? Are tragic, unexpected and chaotic scenes the only problem?

What about the more chronic stresses associated with EMS, the stress that is a constant day in and day out, including shift work, conflict with administration, low pay and missing your family?

In 2010, I conducted a study to see if it were possible to capture a picture of what the biggest traumatic stress risk factors were for EMS personnel. Supported by the NREMT, 12,000 EMTs and paramedics were invited to complete a survey that asked about critical-incident stress, alcohol use and post-traumatic stress symptomatology (PTSS).

Nearly one-third (30.8 percent) of survey responses came from fire-based EMS personnel. Another quarter (25.3 percent) of the responses came from private for-profit departments. The remaining responses were third-service (7 percent), private non-profit (14.6 percent), volunteer (10.2 percent) and other types (12.1 percent) EMS personnel.

Service type, as well as some of the other collected data, was not included in the article published in Prehospital Emergency Care.

We also asked about two kinds of chronic stress — organizational stress (the stresses associated with working within a specific EMS agency) and operational stress (the stress of working in EMS regardless of the service).

We found that operational stress, organizational stress, critical incident stress, alcohol use and post-traumatic stress all correlated with one other in a statistically significant way.

Statistical significance means that the observed relationship between the three factors is not due to chance; as levels of chronic stress or critical incident stress increase, there also is an increase in levels of post-traumatic stress. Interestingly, chronic stress more strongly correlated with PTSS than critical incident stress did.

While previous research has been based on the premise that exposure to critical incidents is the culprit for PTSS in EMS personnel, these findings indicate that high levels of chronic stress may also be influential on levels of post-traumatic stress. So the picture is more complicated than just debriefing after a bad call.

Even more alarming, we found that high levels of chronic operational stress in combination with high levels of critical incident stress and high levels of chronic operational stress in combination with greater alcohol use was significantly associated with higher levels of post-traumatic stress.

What does this research on traumatic stress mean for EMS providers?

What this research indicates is that the relationship between work stress and post-traumatic stress in EMS go beyond the bad calls. Being stressed out because of your workplace or because of the structure of EMS work — changing shifts, being away from your family, fatigue — is also associated significantly associated with post-traumatic stress.

While we have a better picture of what might cause a stress reaction, we still lack a good body of evidence to let us know the best ways to increase resilience and mitigate stress reactions. We need to come together as a professional and academic community to do a better job of protecting EMS personnel from work-related stress.

This may come in the form of more education, increasing access to employee assistance programs and other support services, and continuing the important dialogue started by organizations like the Code Green Campaign and #IVEGOTYOURBACK911.

In terms of research, we need to develop and evaluate evidence-based interventions to increase resilience, including best practices for developing a peer support team and disseminating stress management curricula.

While it may not be possible to prevent everyone from developing a stress reaction, researchers need to focus attention on ways to support EMS personnel before they start suffering.

Study results are described in greater detail here: “Work-related stress and posttraumatic stress in the emergency medical services

About the author:
Elizabeth Donnelly is an associate professor at the University of Windsor. She has 17 years of experience working as an NREMT in Minnesota, Florida and Michigan. She would like to acknowledge the NREMT for their support of this research. Dr. Donnelly can be reached at or

Works cited referenced:
1. Mitchell, J.T. (1983). When disaster strikes…the critical incident stress debriefing process. JEMS. Jan; 8(1):36-39.

2. Donnelly, E. A. (2012). Work-related stress and posttraumatic stress in the emergency medical services. Prehospital Emergency Care, 16(1), 76-85. doi:10.3109/10903127.2011.621044