Exposure to critical incidents in a cohort of US emergency medical services providers:

career frequency, perceived difficulty with coping, and association with burnout and stress
Lori L. Boland, MPH; Russell N. Myers, BCC; Pamela J. Mink, PhD; Karl M. Fernstrom, MPH; Kai G. Hanson, MS; William M. Spinelli, MD
Allina Health Emergency Medical Services, St. Paul, Minnesota, USA

BACKGROUND

RESULTS

 tudies of exposure to critical incidents (CI) in emergency

S
medical services (EMS) responders have largely focused on
police officers and firefighters
Exposure to CI has not been well-studied in US ambulance
workers

OBJECTIVES
 ssess CI exposure in a cohort of US ambulance personnel
A
Measure coping difficulty associated with specific types of CI
Explore the association of CI exposure with burnout and stress

METHODS
Setting & Design
Large ambulance service in Minnesota
Cross-sectional, 165-item electronic survey
Distributed to all employees (n=400) in September 2012
Measures
Critical Incident History Questionnaire (CIHQ)
Developed in law enforcement, modified for this use in EMS
A
 sks about frequency and coping difficulty (severity) of
29 CI (Figure 1)
Maslach Burnout Inventory (MBI) used to assess
professional burnout
Cohens Perceived Stress Scale (PSS) score range 0-14,
higher values indicate more stress

Figure 1: Format of the 29-item CIHQ

During your career as a paramedic/EMT/dispatcher, how
many times have you.
Never

10-20 21-50

51+

Been seriously injured

Been present when a
fellow paramedic/EMT
was seriously injured
Been threatened with a
gun or other weapon

In your opinion, how difficult would it be for paramedics/

EMTs/dispatchers to cope with this type of incident?
Not at all

A little bit

Moderately

Quite a bit

Extremely

Been seriously injured

Been present when a
fellow paramedic/EMT
was seriously injured
Been threatened with a
gun or other weapon
Score =

 = 217 survey responses (54%; Table 1)

N
CI involving children received 7 of the top 10 mean severity
scores (Table 2)
Mean frequency of exposure to CI was negatively correlated
with mean severity rating (Table 2)
43% of respondents report having been threatened with a
gun/weapon while on duty (Table 3)
Median CI recalled increased with years as EMS provider
(Table 4)
Burnout and perceived stress were not strongly associated
with cumulative exposure to CI (Table 5)

Table 1: Demographic characteristics of survey respondents

Variable
Age categories

Gender

Years as EMS provider

Primary response setting

N=217

Male

Female

Threatened with gun or other weapon?

43%

50%

33%

Assaulted by a patient?

68%

73%

60%

Table 4: Median number of CIs recalled in EMS career, by

quartiles of years in EMS
Years in EMS

Median # (IQR) of CIs recalled

Overall (0.5-30)

154 (59, 267)

Quartile I (6)

58 (20, 155)

Quartile II (7-12)

146 (66, 226)

27% (58)
20% (43)
25% (54)
27% (57)

Male
Female

60% (131)
40% (84)

Quartile III (12-24)

154 (80, 236)

= 1 year
2-5 years
6-10 years
11-20 years
>20 years

3% (6)
18% (40)
23% (50)
24% (51)
32% (70)

Quartile IV (25-30)

287 (194, 419)

Metro
Non-Metro or Rural

70% (152)
30% (64)

Table 5: Prevalence of burnout and mean perceived stress

score by quartiles of total # of CI recalled

Mean Reported Career Frequency

3.46 Encountered recently dead body
28.5
3.25 Seen someone dying
26.5
3.20 Made a death notification

18.0

3.15 Encountered a suicide victim

14.8
3.12 Encountered adult badly beaten
14.0
Encountered mutilated body or human
9.3
Encountered child sexually assaulted
2.99
remains
Encountered a SIDS death
2.93 Encountered child severely injured
8.9
Encountered child severely injured
2.75 Encountered adult sexually assaulted
7.1
Present when paramedic seriously injured
2.74 Exposed to AIDS/life-threatening diseases 6.6
Threatened with a gun or other weapon
2.71 Elderly person severely abused/neglected 5.9
Trapped in life-threatening situation
2.66 Encountered a SIDS death
4.8
Response involving persons known to
4.8
Response involving persons known to crew
2.63
crew
Been seriously injured
2.62 Responded to MCI
4.4
Been in a serious motor vehicle accident
2.58 Encountered child accidentally killed
4.2
Elderly person severely abused/neglected
2.52 Encountered patient severely burned
3.9
Exposed to life-threatening toxic
3.8
Had life endangered in a large-scale disaster 2.50
substance
Exposed to life-threatening toxic substance 2.33 Been assaulted by a patient
3.6
Exposed to AIDS/life-threatening diseases
2.30 Encountered child severely neglected
2.7
Encountered adult sexually assaulted
2.24 Encountered child sexually assaulted
2.5
Encountered patient severely burned
2.23 Responded to large-scale disaster
2.4
Responded to large-scale disaster
2.17 Encountered child badly beaten
1.7
Encountered mutilated body or human
2.16 Threatened with a gun or other weapon
1.7
remains
Encountered adult badly beaten
2.09 Trapped in life-threatening situation
1.4
Responded to MCI
2.04 Been seriously injured
1.1
Made a death notification
1.99 Present when paramedic seriously injured 0.8
Been assaulted by a patient
1.99 Encountered murdered child
0.6
Encountered a suicide victim
1.96 Been in a serious motor vehicle accident
0.4
Had life endangered in a large-scale
0.3
Seen someone dying
1.64
disaster
Made mistake that lead to injury/death of
0.2
Encountered body of someone recently dead 1.45
patient

Pearson correlation between mean severity and mean frequency = -0.72 (p< 0.001)

111024 1214 2014 ALLINA HEALTH SYSTEM. TM A TRADEMARK OF ALLINA HEALTH SYSTEM.

Overall

By Provider Gender

18-29
30-39
40-49
50+

Table 2: Critical incident types (n=29), ranked by mean

severity score and mean reported career frequency
Mean Severity Score*
Encountered murdered child
Encountered child badly beaten
Made mistake that lead to injury/death of
patient
Encountered child accidentally killed
Encountered child severely neglected

Table 3: Proportion of respondents who report having been

threatened with a gun/weapon, or assaulted by a patient
while on duty

Total # CI Recalled

Burnout

Perceived Stress

Quartile I (0-59)

11% (5)

3.8 (2.7)

Quartile II (60-154)

24% (11)

5.1 (3.3)

Quartile III (155-266)

15% (7)

5.3 (3.2)

Quartile IV (267-658)

22% (10)

5.2 (3.3)

Results are expressed as mean (SD) or percent (n)

LIMITATIONS
 4% response rate
5
Accuracy of recall of CI not examined
Terms threatened or assaulted not defined

CONCLUSIONS
Pediatric CI are particularly distressing for EMS responders
and the experience of being assaulted by a patient or
threatened with a gun or other weapon is disturbingly
common. Cumulative frequency of exposure to CI was not
strongly associated with burnout or stress in this cohort, but
studies should continue to explore how CI influence the
psychoemotional wellbeing of ambulance workers in the US.