Downtime after critical incidents in emergency medical technicians/paramedics.

Effective workplace-based interventions after critical incidents (CIs) are needed for emergency medical technicians (EMT)/paramedics. The evidence for a period out of service post-CI (downtime) is sparse; however it may prevent posttraumatic stress disorder (PTSD) and burnout symptoms. We examined the hypothesis that downtime post-CI is associated with fewer symptoms of four long-term emotional sequelae in EMT/paramedics: depression, PTSD, burnout, and stress-related emotional symptoms (accepted cut-offs defined high scores). Two hundred and one paramedics completed questionnaires concerning an index CI including downtime experience, acute distress, and current emotional symptoms. Nearly 75% received downtime; 59% found it helpful; 84% spent it with peers. Downtime was associated only with lower depression symptoms, not with other outcomes. The optimal period for downtime was between <30 minutes and end of shift, with >1 day being less effective. Planned testing of mediation of the association between downtime and depression by either calming acute post-CI distress or feeling helped by others was not performed because post-CI distress was not associated with downtime and perceived helpfulness was not associated with depression. These results suggest that outcomes of CIs follow different pathways and may require different interventions. A brief downtime is a relatively simple and effective strategy in preventing later depression symptoms.

The critical incident inventory: characteristics of incidents which affect emergency medical technicians and paramedics.

BACKGROUND: Emergency medical technicians (EMTs) and paramedics experience critical incidents which evoke distress and impaired functioning but it is unknown which aspects of incidents contribute to their impact. We sought to determine these specific characteristics by developing an inventory of critical incident characteristics and testing their relationship to protracted recovery from acute stress, and subsequent emotional symptoms. METHODS: EMT/paramedics (n = 223) completed a retrospective survey of reactions to an index critical incident, and current depressive, posttraumatic and burnout symptoms. Thirty-six potential event characteristics were evaluated; 22 were associated with peritraumatic distress and were retained. We assigned inventory items to one of three domains: situational, systemic or personal characteristics. We tested the relationships between (a) endorsing any domain item and (b) outcomes of the critical incident (peritraumatic dissociation, recovery from components of the Acute Stress Reaction and depressive, posttraumatic, and burnout symptoms). Analyses were repeated for the number of items endorsed. RESULTS: Personal and situational characteristics were most frequently endorsed. The personal domain had the strongest associations, particularly with peritraumatic dissociation, prolonged distressing feelings, and current posttraumatic symptoms. The situational domain was associated with peritraumatic dissociation, prolonged social withdrawal, and current posttraumatic symptoms. The systemic domain was associated with peritraumatic dissociation and prolonged irritability. Endorsing multiple characteristics was related to peritraumatic, acute stress, and current posttraumatic symptoms. Relationships with outcome variables were as strong for a 14-item inventory (situational and personal characteristics only) as the 22-item inventory. CONCLUSIONS: Emotional sequelae are associated most strongly with EMT/paramedics' personal experience, and least with systemic characteristics. A14-item inventory identifies critical incident characteristics associated with emotional sequelae. This may be helpful in tailoring recovery support to individual provider needs.

Identifying, describing, and expressing emotions after critical incidents in paramedics.

For paramedics, critical incidents evoke intense emotions and may result in later psychological difficulties. We examined 2 ways to deal with emotions after critical incidents: (a) identifying emotions, and (b) describing and expressing emotions, and their association with recovery from acute stress and psychological symptoms. We surveyed 190 paramedics, examining how impaired capacity to identify and describe emotions (alexithymia) and voluntary expression of emotions during contacts with others in the first 24 hours after the incident were associated with recovery from acute stress and current symptoms of PTSD, depression, burnout, and somatization. Overall alexithymia was not associated with recovery, but the component of difficulty identifying feelings was associated with prolonged physical arousal (χ(2) = 10.1, p = .007). Overall alexithymia and all its components were associated with virtually all current symptoms (correlation coefficients .23-.38, p < .05). Voluntary emotional expression was unrelated to current symptoms. Greater emotional expression was related to greater perceived helpfulness of contacts (χ(2) = 56.8, p < .001). This suggests that identifying emotions may be important in managing occupational stress in paramedics. In contrast, voluntary emotional expression, although perceived as helpful, may not prevent symptoms. These findings may inform education for paramedics in dealing with stress.

Attachment insecurity, responses to critical incident distress, and current emotional symptoms in ambulance workers.

Ambulance workers are exposed to critical incidents that may evoke intense distress and can result in long-term impairment. Individuals who can regulate distress may experience briefer post-incident distress and fewer long-term emotional difficulties. Attachment research has contributed to our understanding of individual differences in stress regulation, suggesting that secure attachment is associated with effective support-seeking and coping strategies, and fewer long-term difficulties. We tested the effect of attachment insecurity on emotional distress in ambulance workers, hypothesizing that (1) insecure attachment is associated with symptoms of current distress and (2) prolonged recovery from acute post-critical incident distress, coping strategies and supportive contact mediate this relationship. We measured (1) attachment insecurity, (2) acute distress, coping and social contact following an index critical incident and (3) current symptoms of post-traumatic stress, depression, somatization and burnout and tested the hypothesized associations. Fearful-avoidant insecure attachment was associated with all current symptoms, most strongly with depression (R=0.38, p<0.001). Fearful-avoidant attachment insecurity was also associated with maladaptive coping, reduced social support and slower recovery from social withdrawal and physical arousal following the critical incident, but these processes did not mediate the relationship between attachment insecurity and current symptoms. These findings are relevant for optimizing post-incident support for ambulance workers.

Symptoms and responses to critical incidents in paramedics who have experienced childhood abuse and neglect.

BACKGROUND: Mental and physical symptoms are common in paramedics, which may relate to high work stress, including critical incidents. As previous trauma is a risk factor for psychological symptoms after exposure to critical incidents, the prevalence of childhood experiences with abuse and neglect and paramedics' adaptation to critical incidents may be important. METHODS: 635 paramedics were surveyed regarding childhood experiences of physical, sexual or emotional abuse as well an index critical incident from the past, acute stress responses to that event and current mental and physical symptoms. A comparison group of 159 female hospital-based healthcare workers completed the same survey of childhood abuse and neglect in a separate study. RESULTS: 232 paramedics (36.5%) responded. Among these, physical, sexual or emotional childhood abuse was reported by 38.4%. Female paramedics reported significantly more emotional and physical abuse and neglect than female hospital workers. Paramedics who reported childhood abuse or neglect more frequently experienced signs of acute stress immediately following the index critical incident and for the following 2 weeks. Childhood abuse and neglect were associated with significantly higher scores for depressive symptoms, physical symptoms and burnout, and a higher prevalence of 'cases' scoring above thresholds of clinical significance. CONCLUSION: Childhood abuse may be more common in paramedics than in other healthcare workers, at least in women. Childhood abuse and neglect is associated with acute stress responses to critical incidents and to current physical and mental symptoms. These results are based on a low response rate and may not be generalisable.

Identifying risk of emotional sequelae after critical incidents.

BACKGROUND AND PURPOSE: Ambulance workers could benefit from a method for early identification of incidents likely to result in long-term emotional sequelae. There is evidence that persistence of some measures of anxiety beyond the first week after an incident is associated with sequelae. In this study we test the hypothesis that persistence of self-identifiable components of the acute stress reaction as early as a few days post-incident is associated with sequelae. METHOD: 228 ambulance workers volunteered to complete surveys on occurrence and persistence of physiological, behavioural and emotional responses to an index critical incident in the past, as well as symptoms of depression, post-traumatic stress, somatisation and burnout at the time of the survey. Data were analysed for associations between duration of each reaction and present symptoms. Using cut-off scores for the outcomes, we tested the RR of high scores in each of three situations: occurrence of the reaction, persistence of reaction beyond one night and persistence beyond 1 week. RESULTS: Prolonged duration of all five acute stress reaction components was associated with all four outcomes, with the strongest associations being with post-traumatic stress and depression symptoms. The occurrence of physical symptoms of arousal is an immediate predictor of long-term sequelae. Three other components--disturbed sleep, irritability and social withdrawal--provide potential indicators of long-term emotional sequelae as early as 2 days post-incident. CONCLUSION: Four easily identifiable responses to a critical incident can potentially be used for early self-identification of risk of later emotional difficulties. These findings should be submitted to prospective testing.

The capacity to be an analyst: A contribution from attachment research to the study of candidate selection.

In this paper the author discusses how the study of candidate selection, once a topic of vibrant research, has unfortunately languished. Certain qualities were thought to characterize the successful candidate. However, they were never successfully operationalized nor empirically tested. Possibly because of this lack of empirical data, selectors today have difficulty articulating their criteria and are relying on intuition. In order to provide a more rational basis for contemporary selection, the author looks to the attachment literature. This makes sense because attachment theory shares some basic assumptions of contemporary psychoanalysis. The Adult Attachment Interview (AAI) is a research tool that predicts the ability of a parent to convey attachment security. It is scored by attending to how a person speaks about his early attachment experiences. The AAI appears to tap into similar qualities to those selection researchers have sought in their candidates. Further, the scoring method of the AAI appears to be similar to the last attempt by selection researchers to operationalize them. Given these similarities, the author recommends an empirical study using the AAI to operationalize these qualities in analytic candidates. The study would test their importance for success in the training program, thus offering selectors some empirical grounding for their choices.