south african paramedics lived experience of critical incidents: an interpretative phenomenological
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SOUTH AFRICAN PARAMEDICS LIVED EXPERIENCE OF CRITICAL INCIDENTS:
AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS
by
JUSTIN ADRIAN SCOTT
MINOR DISSERTATION
Submitted in partial fulfilment of the requirements for the degree
MASTER OF ARTS IN CLINICAL PSYCHOLOGY
in the
FACULTY OF HUMANITIES
at the
UNIVERSITY OF JOHANNESBURG
Supervisor: Professor Christopher R. Stones
Date: February 2013
Acknowledgments
I would like to thank the following people for their contributions towards this study:
My supervisor, Professor Christopher R. Stones, for his patience, sharing his
knowledge and providing valuable guidance.
The participants in this study, for their cooperation and willingness to share their
experiences with me.
Erica Ortlepp, for her generous emotional and financial support, without which I
would never have been able to follow my dream of completing this degree.
My family and friends, for their constant support and encouragement.
Abstract
South African paramedics are thought to be exposed to a high number of critical
incidents as compared to paramedics elsewhere (Ward, Lombard & Gwebushe, 2006).
Therefore, South African paramedics are at particular risk of suffering from negative effects
associated from the exposure to critical incidents. This study aimed to gain an in-depth
understanding of the meaning which paramedics attach to the experience of “critical
incidents” (Mitchell, 1983). This information may be beneficial for those working in
Emergency Medical Services in South Africa to further understandings of paramedics’
experience of work related trauma.
Five paramedics, sourced from both public and private ambulance service, between
the ages of 27 and 36 years old, who have had between 8 to 12 years of working experience
were interviewed regarding their lived experiences of critical incidents. The semi-structured
interviews were transcribed and analysed based on the Interpretative Phenomenological
Analysis (IPA) framework suggested by Smith and Osborn (2008). The analysis of each of
the participant’s transcripts provided four master themes, some of which are supported by
superordinate themes. The master themes are: 1) Experiencing the trauma of critical
incidents, 2) Experiencing in the “World” of EMS, 3) Intrinsic factors and active attempts of
coping with stress, and 4)Personal consequence of being a paramedic.
For most of the participants, their narratives highlighted that the organisational
variables were considered to be more important than the nature of the critical incidents they
experienced. Critical incidents were deemed traumatic as there was a disparity between the
participant’s expectations of what was expected and what they were confronted with in
“reality”. In addition, the participants described forming an emotional bond with their
patients or the patient’s family, which added to their distress. The participants’ narratives
emphasised the importance of the role of the EMS organisation in influencing their
experiences. Despite employing a number of coping strategies to mediate the effects of
organisational as well as critical incident stress, the participants reported experiencing long-
term negative psychological symptoms that have impacted on their personal and familial
lives. These findings support the growing body of knowledge that demonstrates that
organisational variables play an important role in either mediating or exacerbating post-
trauma outcomes.
Table of Contents
CHAPTER 1: INTRODUCTION .......................................................................................... 1
1.1 Introducing the Paramedics World ............................................................................... 1
CHAPTER 2: LITERATURE REVIEW .............................................................................. 5
2.1 What is a Critical Incident?.......................................................................................... 5
2.2 Consequences of Critical Incident exposure ................................................................. 7
2.2.1 Critical incident stress ....................................................................................... 7
2.2.2 Post Traumatic Stress Disorder (PTSD). ........................................................... 8
2.2.3 Burnout ........................................................................................................... 10
2.3 Interventions arising from Critical Incident research .................................................. 11
2.3.1 Critical Incident Stress Debriefing (CISD) and Critical Incident Stress
Management (CISM). ..................................................................................... 11
2.3.2 For and against CISD/CISM ........................................................................... 12
2.4 Is it really all about Critical Incidents? ....................................................................... 13
2.4.1 Organisational stressors. ................................................................................. 13
2.4.2 Risk of violence and injury. ............................................................................ 14
2.4.3 Compassion fatigue. ........................................................................................ 14
2.5 The Paradox .............................................................................................................. 15
2.5.1 Compassion Satisfaction. ................................................................................ 15
2.5.2 Posttraumatic Growth. .................................................................................... 15
2.5.3 Salutogenesis. ................................................................................................. 16
2.6 Coping with Critical Incidents ................................................................................... 17
2.6.1 Dissociation or emotional detachment. ............................................................ 18
2.6.2 Black humour. ................................................................................................ 19
2.6.3 Substance abuse. ............................................................................................. 21
2.6.4 Support systems. ............................................................................................. 21
2.7 Help-seeking behaviour amongst ambulance personnel.............................................. 23
CHAPTER 3: METHODOLOGY ....................................................................................... 24
3.1 Interpretative Phenomenological Analysis ................................................................. 24
3.1.1 Sample. ........................................................................................................... 25
3.1.2 Data collection ................................................................................................ 26
3.1.3 Ethical considerations. .................................................................................... 27
3.1.4 Analysis. ......................................................................................................... 27
3.1.5 Trustworthiness............................................................................................... 28
3.1.6 Reflexivity ...................................................................................................... 29
3.1.7 Self reflexivity ................................................................................................ 29
CHAPTER 4: INDIVIDUAL ANALYSIS AND DISCUSSION OF THE PARTICIPANTS’
EXPERIENCE OF CRITICAL INCIDENTS .................................................... 33
4.1 Introduction: James’ EMS work experience ............................................................... 33
4.1.2. Analysis and Discussion of James’ lived experience .............................................. 34
4.1.2.1 Experiencing the trauma of Critical Incidents. .............................................. 34
4.1.2.2 Experiencing in the “World” of EMS. .......................................................... 36
1. EMS is a subculture. ................................................................................... 36
2. Negative experiences of the EMS organisation. ........................................... 36
3. Meaningful work environment. ................................................................... 39
4.1.2.3 Intrinsic factors and active attempts of coping with stress ............................. 40
1. Perceived need to be in control of the environment...................................... 40
2. Active attempts at reducing stress................................................................ 41
4.1.2.4. Personal consequences of being a paramedic. .............................................. 43
4.1.2.5 Summary. .................................................................................................... 44
4.2 Introduction: Paul’s EMS work experience ................................................................ 46
4.2.1 Analysis and Discussion of Paul’s lived experience ................................................ 47
4.2.1.1 Experiencing the trauma of Critical Incidents ............................................... 47
4.2.1.2 Experiencing in the “World” of EMS. .......................................................... 48
1. EMS is a subculture. ................................................................................... 48
2. Negative experiences of the EMS organisation. ........................................... 49
3. Meaningful work environment. ................................................................... 51
4.2.1.3 Intrinsic factors and active attempts of coping with stress ............................. 51
1. Perceived need to be in control of the environment ...................................... 51
2. Active attempts at reducing stress ................................................................ 52
4.2.1.4 Personal consequences of being paramedic. ................................................. 53
4.2.1.5 Summary. .................................................................................................... 54
4.3 Introduction: Sarah’s EMS work experience .............................................................. 56
4.3.1 Analysis and Discussion of Sarah’s lived experience .............................................. 56
4.3.1.1 Experiencing the trauma of Critical Incidents ............................................... 56
4.3.1.2 Experiencing in the “World” of EMS ........................................................... 57
1. EMS is a subculture. ................................................................................... 57
2. Negative experience of the EMS organisation. ............................................ 58
3. Meaningful work environment .................................................................... 58
4.3.1.3 Intrinsic factors and active attempts of coping with stress ............................. 60
1. Perceived need to be in control of the environment ..................................... 60
2. Active attempts at reducing stress................................................................ 61
4.3.1.4 Personal consequences of being a paramedic. ............................................... 63
4.3.1.5 Summary. .................................................................................................... 64
4.4. Introduction: André’s EMS work experience ............................................................ 66
4.4.1 Analysis and Discussion of André’s lived experience ............................................. 67
4.4.1.1 Experiencing the trauma of Critical Incidents. .............................................. 67
4.4.1.2 Experiencing in the “World” of EMS ........................................................... 69
1. EMS is a subculture. ................................................................................... 69
2. Negative experience of the EMS organisation ............................................. 70
3. Meaningful work environment. ................................................................... 72
4.4.1.3 Intrinsic factors and active attempts of coping with stress. ............................ 72
1. Perceived need to be in control of the environment ...................................... 72
2. Active attempts at reducing stress ................................................................ 73
4.4.1.4 Personal consequences of being a paramedic ................................................ 75
4.4.1.5 Summary. .................................................................................................... 76
4.5. Introduction: George’s EMS work experience .......................................................... 78
4.5.1 Analysis and Discussion of George’s lived experience ............................................ 79
4.5.1.1 Experiencing the trauma of Critical Incidents. .............................................. 79
4.5.1.2 Experiencing in the “World” of EMS ........................................................... 81
1. EMS is a subculture .................................................................................... 81
2. Negative experience of the EMS organisation ............................................. 81
3. Meaningful work environment .................................................................... 83
4.5.1.3 Intrinsic factors and active attempts of coping with stress. ............................ 84
1. Perceived need to be in control of the environment...................................... 84
2. Active attempts at reducing stress................................................................ 85
4.5.1.4 Personal consequences of being a paramedic ................................................ 86
4.5.1.5 Summary ..................................................................................................... 88
4.6 Integrated overview of the participants master themes ............................................... 90
4.6.7 Experiencing the trauma of Critical Incidents .................................................. 90
4.6.2 Experiencing in the “World” of EMS .............................................................. 92
4.6.3 Intrinsic factors and active attempts of coping with stress................................ 94
4.6.4 Personal consequences of being a paramedic ................................................... 96
CHAPTER 5: DISCUSSION .............................................................................................. 98
5.1 Overview. .................................................................................................................. 98
5.2 Discussion of the Master Themes .............................................................................. 98
5.2.1 Experiencing the trauma of Critical Incidents. ................................................. 98
5.2.1 Experiencing the “World” of EMS. ............................................................... 100
5.2.2 Intrinsic factors and active attempts at coping with stress. ............................. 103
5.2.3 Personal consequences of being a paramedic ................................................. 106
CHAPTER 6: CONCLUSION. ......................................................................................... 108
CHAPTER 7: LIMITATIONS AND RECOMMENDATIONS ......................................... 111
REFERENCES ................................................................................................................. 113
APPENDICES .................................................................................................................. 126
1
CHAPTER 1: INTRODUCTION
Research conducted on emergency medical workers has focused mainly on the effects
of exposure to traumatic scenes, and the resultant negative psychological symptomology
(Donnelly & Siebert, 2009; Holland, 2008; Jonsson & Segesten, 2004). Studies have also
investigated coping methods employed by emergency medical workers (Kirby, Shakespeare-
Finch & Palk, 2011) as well as the positive growth (Shakespeare-Finch, Smith, Gow,
Embelton & Baird, 2003) that emergency medical workers have experienced whilst
performing their duties. Compared to elsewhere in the world, South African paramedics are
thought to be exposed to the highest amounts of traumatic scenes (Ward, Lombard &
Gwebushe, 2006). Few studies have been done in South Africa focusing on paramedics lived
experience of traumatic scenes or critical incidents (Mitchell, 1983). This study aims to gain
an in-depth understanding of the meaning which South African paramedics attach to the
experience of “critical incidents” in order to add to the growing body of knowledge in this
field.
In order to explore in detail the paramedic’s subjective experience of critical incidents it
is important to gain an account of the experience as well as examine the participant’s world in
which this experience is embedded. The following section provides a brief introduction into
the “world” of paramedics in South Africa.
1.1 Introducing the Paramedics World
In order to introduce and contextualise the reader to the “world” of paramedics in South
Africa, the following topics will be briefly discussed: 1) The varied contexts in which
paramedics operate, 2) the prescribed training paramedics are required to undergo, 3) the
specific duties paramedics are required to perform, and 4) the working environment in which
paramedics operate.
Paramedics operate in a variety of contexts where there may be a need for emergency
medical assistance. These contexts may include the following: the event management arena,
such as local sporting events or concerts; pre-hospital settings such as public and private
ambulance services; law enforcement or military settings; as well as within the hospital
environment providing support to hospital staff.
2
Emergency care practitioners in South Africa are classified into three main skill levels.
They are graded according to their level of training they have received. The training courses
offered are short term in nature and require the practitioner to complete a number of practical
and academic hours before being eligible to complete the next level of training. The first
level or entry level is Basic Life Support (also known as Basic Ambulance Assistant), in
which the individual is trained to provide basic emergency care. The higher the level of
training, the more advanced the practitioner becomes in providing emergency care. The
second level is known as Intermediate Life Support (also known as Ambulance Emergency
Assistant) and the third level is known as Advanced Life Support (also known as Critical
Care Assistance). Currently the training of emergency care practitioners is being overhauled
by the professional board for health care practitioners, the Health Professions Council of
South Africa (HPCSA). The short course qualifications are to be replaced by a more
intensive four-year National Diploma in Emergency Medical Care at a recognised tertiary
institution. In order to practice as an emergency care practitioner, once qualified, the
individual must be registered with the governing body, the HPCSA. Once a practitioner is
qualified and registered it is then incumbent on the practitioner to ensure that his or her skills
remain up to date with the industry’s standards and norms through the completion of
Continuous Professional Development (CPD) points.
Within the Emergency Medical Services (EMS) the term ‘paramedic’ or ‘medic’ is
often used generically for all levels of emergency care practitioners; however, professionally
the title paramedic is reserved for the individual who has completed the highest form of
training, which is Advanced Life Support. For the purposes of this research the terms
paramedic, emergency worker and ambulance worker will be used interchangeably to refer to
all levels of emergency medical workers.
In brief, the duties of the paramedic are to firstly respond to the emergency call.
Thereafter, the scene is assessed to ensure safety of the practitioner as well as that of the
patient. The paramedic will then begin to assess whether the use of more specialised
treatment is required, or whether more paramedics are required to assist in treating other
patients. Then the paramedic is required to ‘stabilise’ the patient, after which the patient is
transported to an appropriate facility such as a hospital or a clinic. On arrival at the hospital
the paramedic is required to ‘hand the patient over’ to the attending doctor or nurse.
Paramedics are trained to respond to a variety of medical and non-medical emergencies, such
as cerebral vascular accidents (CVA), myocardial infarctions, asthmatic attacks, maternities,
3
motor vehicle accidents (MVA), gunshot wounds, stabbings, assaults, etc. Many of the
emergencies that paramedics attend are chaotic, horrific and gruesome in nature. Paramedics
are required to deal with dismembered bodies, traumatic injuries sometimes involving
children, as well as having to notify family members that their loved one has passed away.
Paramedics are also required to interact with not only members of the public, but also a
variety of other emergency service workers such as the police, fire-fighters and paramedics of
other services.
The working environment, in which paramedics are involved, is often dangerous as
well as uncomfortable. Dangerous situations may include the following conditions:
Paramedics are often called to assist patients who may be trapped in vehicles, and while they
are treating the patient, fire-fighters may be using various lifesaving equipment (e.g. Jaws of
Life), to free the patient from entrapment within the vehicle. Whilst fire-fighters are trying to
extricate the patient from the vehicle, the paramedic often will be inside the vehicle treating
the patient. This in itself is a dangerous position to be in, due to the heavy machinery
involved in extricating the patient, which may cause injury due to the possibility of breaking
glass or metal splintering. At other times paramedics may be called to attend to a shooting
victim where the police have not yet arrived on the scene to ensure the safety of the
emergency medical support staff, yet paramedics are expected to help those in need. This
situation can be especially dangerous as the perpetrators may still be on scene or in the area.
Apart from the dangers faced at emergency scenes, paramedics are required to respond to the
scene as quickly as possible. This may mean driving at high speeds through traffic, as well as
having to pass through red traffic lights. This can put the emergency crew at an increased
risk of being injured or even killed in a motor vehicle accident. Paramedics’ working hours
are often long, usually consisting of a 12-hour shift, which is often extended in the case of an
emergency. Paramedics are required to work day and night shifts, weekends as well as public
holidays. Irrespective of weather conditions, paramedics are required to provide assistance in
conditions that may vary from extreme heat to freezing temperatures. Although the
perception may be paramedics have an exciting occupation, they are often required to wait
for long periods of time before being dispatched to an emergency; thus their working day
may consist of long periods of boredom to periods of extreme mental and physical stress.
All levels of paramedics from Basic Life Support (BLS) to Advanced Life Support
(ALS) practitioners are exposed to the stressors of the emergency scene. Therefore a BLS
paramedic may respond to a scene where the patient has been stabbed multiple times, the
4
responsibility of the BLS paramedic would be to stabilise the patient according to his or her
level of training. Whilst this medical intervention is being performed, if required, the BLS
paramedic will call for ‘back-up’ from an ALS paramedic who will arrive on scene and
provide more advanced treatment. Particular emergencies require immediate advance
treatment, when this occurs, the ALS paramedic would be dispatched first, and he or she
would then treat the patient and call for an ambulance to transport the patient. Most
ambulances are crewed by BLS and ILS paramedics; therefore both the BLS and ILS
paramedic would be exposed to the stressors of the emergency scene.
The following chapter will discuss the paramedic’s exposure to stress at emergency
scenes, the consequences of stress as well as subsequent interventions introduced to reduce
the effects of stress. It will also consider other sources of stress within the working
environment, the positive effects of working with the injured, as well as coping mechanisms
employed to combat the effects of stress.
5
CHAPTER 2: LITERATURE REVIEW
As discussed in the previous chapter all levels of paramedics are exposed to emergency
scenes, which could be interpreted by the paramedic as stressful. The term “critical incident”
is given to emergency scenes that paramedics interpret as stressful (Mitchell, 1983).
2.1 What is a Critical Incident?
The term “critical incident” was initially coined by Mitchell (1983, p. 36) and is used to
describe “Any situation faced by emergency 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.” Mitchell (1983, p. 36) provided a number of examples
of events that may overwhelm emergency services personnel’s coping abilities: “(1) the
serious injury or death of an emergency team member in the line of duty, (2) the serious
injury or death of a civilian resulting from emergency service operations, (3) cases charged
with profound emotion such as the death of an infant, (4) cases that attract unusual attention
from the news media, (5) a loss of life after a prolonged rescue effort, (6) serious physical or
psychological threat to the rescuers, or (7) incidents that surpass the normal coping
mechanisms of personnel”.
Yet Mitchell’s definition seems to be broad and has come under some criticism in that
any event could be considered to be a ‘critical incident’, thus making it difficult to measure or
identify what incident could be considered as critical (Donnelly & Siebert, 2009).
Researchers have thus attempted to provide more clarity on what “specific events”
emergency personnel consider to be critical incidents. Alexander and Klein (2001) found that
the most distressing incidents included: 1) Child victims, 2) the patient is known to the
ambulance personnel, 3) the ambulance personnel feel helpless at the scene, 4) critical
injuries, 5) delayed support from colleagues, and 6) incorrect information regarding the
address of the patient or the medical status of the patient. Other incidents that have been
deemed critical include dealing with seriously ill patients, psychiatric patients, the immediate
family and friends of a patient and the handling of dead bodies (Donnelly & Siebert, 2009).
Although attempts have been made to find a correlation between the type of critical incident
experienced and the subsequent psychological symptomology expressed this has not been
successful (Donnelly & Siebert, 2009).
6
In an effort to provide greater clarity regarding the term ‘critical incident’ researchers
have differentiated the term from similar terms such as traumatic event and crisis. Green
(1999) states that a critical incident refers to an event which occurs within the work context,
where as a traumatic event can occur within any context. A work context event for a
paramedic would therefore be responding to and managing medical emergencies, such as
responding to a shooting and providing medical treatment to the patient. With regards to the
term crisis Flannery and Everly (2002) indicate that a crisis can be considered to be a
response to an event which has disrupted a person’s normal coping mechanisms, resulting in
impaired functioning. A ‘critical incident’ however should be considered to be a catalyst or
stimulus that may lead to a response which interrupts the individual’s functioning (Flannery
& Everly, 2002). Thus not all ‘critical incidents’ may lead to impaired functioning.
Mitchell’s (1983) definition describes a ‘critical incident’ as having three basic
elements, which are: 1) the event, for example, a motor vehicle accident (MVA); 2) the
emergency personnel’s reaction, such as horror; and 3) the emergency personnel’s
performance, which may deteriorate due to the inability to concentrate resulting from the
horror that he or she experiences. Later research indicated that as a result of the interactions
of the three elements, there is a fourth component, namely the ‘meaning’ that the emergency
personnel ascribe to the event, which influences cognitive, affective and behavioural
functioning (Burns & Rosenberg, 2001).
Ortlepp and Friedman (2001) state that the meaning an individual ascribes to a critical
incident could be influenced by a number of factors. Firstly, the characteristics of the event
itself, for instance, if there are serious injuries, death or suffering, the physical location of the
event, are there family members of the patient present etc. Secondly, the characteristics of the
emergency worker, such as his or her experience within the EMS field, level of training,
personality traits, age, gender, etc. Thirdly, the patient or patients who are involved in the
actual event influence the emergency worker, for example, some aspect of the patient may
remind the paramedic of a friend, family member or aspects of him or herself.
The emergency worker could over-identify with the patient which could increase the
empathy the emergency worker experiences. The emergency worker thus forms an
attachment to the patient. Research indicates that emergency personnel who form an
emotional “bond” with their patients are more vulnerable to the effects of stress (Kirby, et al.
2011; Regehr, Goldberg & Hughes, 2002). What may also further compound the above
7
situation is that compared to other emergency services such as police or fire-fighters,
paramedics spend more time with the patient, which could make it difficult to depersonalise
or detach from the situation, increasing the chance of forming an attachment to the patient
(Marmar, Weiss, Metzler, Ronfeldt & Foreman, 1996).
It should be noted that a critical incident can either be due to a singular event or the
result of a series of events (Donnelly & Siebert, 2009). An example of this could be where a
paramedic has to deal with a number of seriously injured patients from unrelated events, such
as a motor vehicle accident and then having to respond to a patient who has been stabbed
multiple times within a short period of time. In South Africa, the exposure to critical
incidents which paramedics face is considered to be among the highest in the world (Ward,
Lombard & Gwebushe, 2006). This is not surprising as the second leading cause of death in
South Africa is due to violence and injury which is twice that of the global average (Seedat,
Van Niekerk, Jewkes, Suffla, & Ratele, 2009). It therefore stands to reason that South
African paramedics are more likely to suffer from the negative effects of exposure to critical
incidents than their American and European counterparts.
The inability to “function at either the scene or later” is a possible indication that the
individual’s coping mechanisms are insufficient to deal with a particular traumatic event
(Everly, Flannery & Mitchell, 2000). This may lead to the development of negative
psychological symptomology such as Post Traumatic Stress Disorder or Burnout.
2.2 Consequences of Critical Incident exposure
As indicated earlier, there are a number of negative consequences that may arise due to
the exposure to critical incidents. The negative consequences that will be explored here are
Critical Incident Stress, PTSD, and Burnout.
2.2.1 Critical incident stress. The stress reaction from exposure to critical incidents is
known as critical incident stress (Regehr & Bober, 2005).Critical incident stressors can be
differentiated from chronic stressors. Donnelly and Siebert (2009) state that chronic stress
refers to daily stressors that tend to be long-lasting and enduring, such as poor pay, lack of
support from colleagues, continuous risk of being exposed to infectious diseases or possible
injury. Critical incident stressors, however, are considered to be acute in nature, in other
words the paramedic is confronted with sudden and unexpected exposures to scenes that are
often horrific, tragic and chaotic (Van der Ploeg & Kleber, 2003). As a result of this the
8
paramedic may develop the following cognitive, physical, affective and behavioural signs
and symptoms: feelings of anxiety or irritability, poor concentration, avoidance of triggers
that may remind the paramedic of the critical incident, withdrawing from others or inability
to be by him or herself, feelings of being overwhelmed by daily routine activities, insomnia
or the displacement of feelings of anger, guilt and powerlessness onto others at work or at
home. (Caine & Ter-Bagdasarian, 2003; Workers Compensation Board of British Columbia,
n.d.). If left untreated critical incident stress may result in the development of serious
psychopathology such as Acute Stress Disorder, Post Traumatic Stress Disorder (PTSD),
Depression and poor coping mechanisms such as substance abuse (Mitchell, 2004).
2.2.2 Post Traumatic Stress Disorder (PTSD). Traditionally, Emergency Services
Organisations have taken the stance that those individuals who are employed to respond to
various emergency situations are immune to the psychological effects of the traumatic events
to which they bear witness (Regehr & Bober, 2005). This assumption may have stemmed
from the fact that emergency workers are trained to respond to a variety of traumatic events
that include serious injuries and death (Alden, Regambal & Laposa, 2008). Although
ambulance personnel are trained to deal with the medical challenges of a variety of
emergency situations, the literature suggests that paramedics are still at risk of developing
PTSD or symptoms of PTSD resulting from exposure to critical incidents (Donnelly &
Siebert, 2009; Holland, 2008; Jonsson & Segesten, 2004; Laposa & Alden, 2003; Smith &
Roberts, 2003; Svensson & Fridlund, 2008).
Of the other psychological disorders that may manifest as a result of exposure to critical
incidents, for example depression or other anxiety disorders, PTSD has been the most widely
studied long-term outcome amongst the paramedic population group (Donnelly & Siebert,
2009). This may be due to the specific nature of the work carried out by paramedics, which
exposes them to more critical incidents than the general population (Young & Cooper, 1997).
According to the Diagnostic and Statistical Manual of the American Psychiatric
Association (DSM-IV-TR), the essential feature of PTSD, is the development of specific
symptoms due to either being directly involved, being witness to or being vicarious exposed
to an extreme traumatic stressor such as threatened death, serious injury or other threat to
one’s physical integrity, or the death of, injury to or other threat to another person’s physical
integrity (APA, 2000). The exposure to such an extreme traumatic stressor causes the
individual to experience extreme fear, helplessness or horror (APA, 2000). The DSM-IV-TR
9
(APA, 2000) categorises PTSD symptoms into of three main clusters, the first being,
intrusive or re-experiencing symptoms, where the individual relives the traumatic event
through recurring thoughts, dreams or flashbacks (Regehr & Bober, 2005). The second
symptom cluster, namely avoidance symptoms, involves the individual making persistent
efforts to avoid stimuli that may serve as a reminder of the traumatic event; the individual
may also have difficulty remembering important characteristics of the event (Bogaerts et al.,
2008). The third symptom cluster is that of arousal, were individuals typically display
symptoms of difficulty in falling asleep or maintaining sleep, anger, irritability, hyper-
vigilance or exaggerated startle responses (Jones & Kagee, 2005). If the duration of the
abovementioned symptoms last for more than two weeks, a diagnosis of Acute Stress
Disorder can be made (Bogaerts, Daalder, Van Der Knaap, Kunst, & Buschman, 2008). In
order for a diagnosis of PTSD to be made, symptoms must be present for more than one
month (APA, 2000).
A review of the literature indicates that the prevalence of PTSD amongst ambulance
personnel tends to be within the region of 20% and 21% (Bennett, Williams, Page, Hood &
Woollard, 2004; Donnelly & Siebert, 2009; Shakespeare-Finch et al., 2003; Smith & Roberts,
2003; Sterud, Ekeberg, & Hem, 2006). This is considered extremely high, especially when
compared to that of the general population which ranges between “one and three percent”
(Shakespeare-Finch et al., 2003, p. 58). However there is some discrepancy, as some studies
indicate that the prevalence of PTSD is much lower; for example, in a recent study done in
Hawaii only 4% of the 105 participants met the clinical criteria for PTSD (Mishra, Goebert,
Char & Dukes, 2010). Similarly, research in Brazil found that the rate of PTSD amongst the
234 ambulance workers was 5.6%, which is significantly lower than that of their North
American and Western European counterparts (Berger et al., 2007).
An important factor to consider is that the literature suggests that the more critical
incidents individuals are exposed to, the greater their risk of developing PTSD (Bennett et al.,
2005). Research conducted in Japan found that paramedics who were older and more
qualified reported higher levels of stress, and were therefore more susceptible to PTSD
symptoms than those who were younger and less qualified (Okada, Ishii, Nakata, &
Nakayama, 2005). However, again there is some discrepancy as not all individuals who are
exposed to a large amount of critical incidents will develop PTSD, which may suggest that
other factors play a role in the development of PTSD (Bogaerts et al., 2008). An example of
this was found in Brazil where the prevalence of PTSD was low compared to that of other
10
emergency workers in Europe. It was speculated that characteristics of the sample group
played a role; for example, factors such as high morale and perceived high socio-economic
status may have acted as a buffer-effect against PTSD (Berger et al., 2007).
2.2.3 Burnout. Burnout is recognised as a potential long-term consequence resulting
from repeated exposure to critical incidents (Crabbe, Bowley, Boffard, Alexander, & Klein,
2004; Van der Ploeg & Kleber, 2003; Vanheule, Declercq, Meganck, & Desmet, 2008).
Apart from the exposure to critical incidents other occupational factors may play a role in the
development of burnout. These occupational factors, such as time pressures, emotional
demands of the occupation, perceived work load and patient-related stressors, such as
interactions with patients, play a role in the development of burnout (Cicognani, Pietrantoni,
Palestini & Prati, 2009). Burnout symptoms amongst ambulance personnel have been
reported to be as high as 20-36% (Halpern, Gurevich, Schwartz & Brazeau, 2009b). A recent
study of ALS paramedics in Johannesburg, South Africa, found that 30% of the participants
met the criteria for Burnout whilst 63% of the participants displayed symptoms of Burnout
(Stassen,Van Nugteren & Stein, 2012)
Burnout is a term used to describe a syndrome in which an individual experiences
emotional exhaustion, depersonalisation and reduced personal accomplishment (Kovács,
Kovács & Hegedűs, 2010). Emotional exhaustion refers to the individual’s inability to
provide emotional support to others; depersonalisation relates to the individual presenting
with a negative and pessimistic attitude towards work and patients; and reduced personal
accomplishment refers to the individual’s feelings of being inadequate in performing work-
related tasks (Montero-Marín & García-Campayo, 2010). Thus emotional exhaustion,
depersonalisation and reduced personal accomplishment may not only have a negative impact
on work performance but also on the mental health of the individual. Burnout has been
linked to psychological distress such as depression and anxiety, including cognitive deficits
in non-verbal memory and attention (Peterson et al., 2008). Burnout has also been linked to
somatic complaints as well as poor coping strategies such as substance abuse (Hooper, Craig,
Janvrin, Wetsel & Reimels, 2010).
As discussed, paramedic’s exposure to critical incidents may result in the development
of significant psychological pathology. For this reason, the emergency medical industry has
introduced a number of interventions to reduce or prevent the development of psychological
disorders such as PTSD.
11
2.3 Interventions arising from Critical Incident research
Through the research of critical incidents two important interventions have emerged in
assisting emergency personnel after being exposed to critical incidents. These interventions
are known as Critical Incident Stress Debriefing (CISD) and Critical Incident Stress
Management (CISM). CISD and CISM have been the standard interventions offered to
emergency workers in Europe and America (Bledsoe, 2003; Halpern et al., 2009a). The aim
of these interventions is to provide psycho-education regarding stress reactions to critical
incidents, as well as the prevention of the development of PTSD and other pathological
symptoms that may emerge as a result of exposure to critical incidents (Jeannette & Scoboria,
2008).
2.3.1 Critical Incident Stress Debriefing (CISD) and Critical Incident Stress
Management (CISM). Although the descriptions of CISD and CISM given below are
discussed separately, it should be noted that CISD has been incorporated from a standalone
intervention into one of the eight elements of CISM (Pia, Burkle, Stanley & Markenson,
2010).
Critical Incident Stress Debriefing was developed by Mitchell (1983), specifically for
emergency personnel (Campfield & Hills, 2001; Jeannette & Scoboria, 2008). Mitchell
(2004) states that CISD is a tool designed to assist homogeneous groups after exposure to the
same critical incident. The aim of CISD is to assist the group members in the processing of
emotional reactions brought about by the exposure to critical incidents, in order to normalise
these reactions, as well as to prepare the group members in coping with future critical
incidents (Smith & Roberts, 2003). The debriefing process is usually implemented between
24 and 72 hours after the critical incident (Campfield & Hills, 2001). The debriefing process
may last up to two hours (Smith & Roberts, 2003). CISD consists of seven phases, namely 1)
introduction phase, 2) fact phase, 3) thought phase, 4) reaction phase, 5) symptom phase, 6)
teaching phase, 7) re-entry phase (Pia et al., 2010). Mitchell and Everly (1996) describe the
phases as follows: The introduction phase consists of the trained facilitators introducing
themselves as well as describing the debriefing process; the fact phase provides the group
members an opportunity to provide a brief description of the incident; the thought phase
explores each member’s initial thoughts during the incident; the reaction phase focuses on
the emotional reactions towards the incident; the symptom phase requires the facilitators to
elicit information from the group members regarding the way the incident has had an impact
12
on their lives. The facilitators are therefore searching for any possible signs or symptoms of
distress; the teaching phase is a psycho-education phase in which the facilitators provide
information regarding typical stress reactions which the group members may be
experiencing; the re-entry phase is a summary of the debriefing process as well as a final
opportunity for group members to address any concerns or to ask any final questions.
Mitchell (2004, p. 4) warns that “Under no circumstances should this group crisis
intervention tool be considered psychotherapy or a substitute for psychotherapy”.
Critical Incident Stress Management (CISM) is considered to be a more comprehensive
and multifaceted crisis intervention programme which is mindful of the various stages of
crisis, namely the pre-crisis, acute crisis and the post-crisis stages (Everly et al., 2000).
According to Flannery and Everly (2004), psycho-education is provided in the pre-crisis
stage, regarding the possible negative behavioural and emotional responses towards critical
incidents, thereby improving coping skills. The acute crisis stage entails providing
individual, group, family and/or organisational crisis interventions that may be required
following the occurrence of a critical incident. Post-crisis interventions include the provision
of a variety of resources that could assist the individual or group in the recovery process, for
example being referred to a psychologist for specialised treatment. As with CISD, CISM is
aimed at reducing the negative emotional responses that may arise from exposure to critical
incidents, thereby reducing the risk of the onset of PTSD (Everly et al., 2000).
CISM consists of eight elements, namely: 1) pre-crisis preparation; 2) demobilization;
3) defusing; 4) critical incident stress debriefing; 5) individual crisis intervention; 6) pastoral
involvement; 7) family or organisational crisis intervention/consultation; 8) follow-up referral
and evaluation for possible psychological assessment and treatment (Pia et al., 2010).
The debate regarding whether or not CISD and CISM are effective in reducing critical
incident stress and/or preventing PTSD symptomology seems largely inconclusive.
2.3.2 For and against CISD/CISM. A number of studies have been conducted
indicating that CISD/CISM has been successful in reducing the presentation of PTSD
symptoms in individuals exposed to critical incidents (Campfield & Hills, 2001; Everly et al.,
2000; Everly, Flannery & Eyler, 2002). However, others have indicated that CISD/CISM is
ineffective and that there is no evidence that the participants of CISD/CISM have reduced
PTSD symptoms or that the intervention program has prevented the development of PTSD
13
(Bledsoe, 2003; Devilly, & Cotton, 2004; Fawzy & Gray, 2007; Pia et al., 2010; Wei &
Szumilas, 2010).
Fawzy and Gray’s (2007) response to Everly et al. (2002) statistical review of CISM
point out a number of problematic factors regarding the intervention. They point out that the
normative course of exposure to traumatic experiences for traumatised individuals is to
display a variety of PTSD symptoms, yet for the majority of these individuals the stress
symptoms will dissipate over time. Therefore they question the efficacy of studies that show
a reduction in PTSD symptomology, as these studies don’t take into account the longitudinal
course of trauma symptoms. Additionally, the authors state that there are a number of
methodological problems regarding research showing CISM to be effective; for example:
there is no standardised definition of CISM, implementation of the intervention was done at
varying times after the trauma, and the assessments used lack reliability and validity. Pia et
al. (2010) conducted a comprehensive review of existing CISD and CISM studies spanning
over a period of 44 years. According to the authors, there is a “lack of convincing scientific
evidence” that either CISD or CISM is effective in either reducing or preventing the
development of PTSD (Pia et al., 2010 p. 130). The authors indicated that there is some
evidence that CISD/CISM may even be harmful to participants, as the interventions may
interfere with normal post traumatic resilience mechanisms (Pia et al. 2010).
2.4 Is it really all about Critical Incidents?
Research has indicated that exposure to the actual event itself, that is the critical
incident, may not be the sole reason for emergency service workers developing traumatic
symptomology. Factors such as organisational stressors, risk of injury and/violence and
compassion fatigue may also play a vital role (Cicognani et al., 2009).
2.4.1 Organisational stressors. The impact of organisational stressors on the
paramedic should not be ignored. Bennet et al. (2005) found that organisational stressors
contributed more towards the levels of depression and anxiety experienced by paramedics
than the stress associated with critical incidents. Similarly, other studies have indicated that
paramedics found dealing with managerial or organisational problems (Halpern, et al. 2009b),
administrative tasks, the lack of support from superiors, low remuneration and the imbalance
between family and work life (Nirel, Goldwag, Feigenberg, Abadi & Halpern, 2008) to be the
most stressful aspects of their profession.
14
2.4.2 Risk of violence and injury. Research regarding the risk of violence being
perpetrated against ambulance personnel is limited. However, some studies indicate that
ambulance personnel are concerned with the possibility of being victims of violence (Aasa,
Brulin, Angquist & Barnekow-Bergkvist, 2005; Svensson & Fridlund, 2008). This concern is
not unfounded, as illustrated by both local and international findings.
In South Africa a survey conducted in 2003 by the Work Trauma Foundation, which
included ambulance personnel, technical assistants and hospital personnel, indicated that
around 75% of the participants involved in the survey experienced situations where weapons
were used to threaten them (Smith, 2003). Specific examples of violence perpetrated towards
EMS personnel have also been highlighted in the media. In 2004 two paramedics were
sexually assaulted, and the ambulance they were using was stolen (Oellermann, 2005). More
recently, in 2010, two responding paramedics were sexually assaulted (Tromp, 2010).
Internationally, research indicates that both physical violence and verbal threats of
violence may not be that uncommon. In a recent study conducted in Sweden, within a 12-
month period, 66% of the 134 respondents experienced some form of violence or threat of
violence, reportedly, the patient was the perpetrator in most cases (Petzäll, Tällberg, Lundin
& Suserud, 2011). A pilot study conducted in Australia reported that within a 12 month
period 87.5% of the 242 participants reported experiencing some form of violence ranging
from verbal abuse to sexual assault (Boyle, Koritsas, Coles & Stanley, 2007). In the United
States 90% of the 331 participants indicated that they experienced physical violence during
the course of their duties, 71% considered this to be ‘part and parcel’ of their job (Pozzi,
1998)
Other factors that place EMS-personnel at greater risk of injury are needle-stick injuries
(Sterud et al., 2006), exposure to infectious diseases (Regehr & Millar, 2007), and the risk of
being involved in a motor vehicle accident due to high speed driving as well as going through
red traffic lights (Donnelly & Siebert, 2009; Maguire, 2002).
2.4.3 Compassion fatigue. Emergency workers may not be affected by the actual
critical incident itself but rather from assisting patients who are suffering (Cicognani, et al.
2009). In this case, the paramedic experiences secondary traumatic stress or compassion
fatigue. According to Figley (1995, p. 7), compassion fatigue is “the stress resulting from
helping or wanting to help a traumatized or suffering person”. Compassion fatigue refers to
what happens to individuals who are consistently involved in assisting those who are
15
suffering, and as a result are exposed to the suffering themselves (Berzoff & Kita, 2010). An
example of this could be dealing with rape victims where, although the paramedic was not
present during the incident, he or she through treating the patient’s wounds not only
witnesses the physical injuries of the victim but is also subjected to the psychological impact
of the actual assault. This in turn could cause the paramedic to develop similar emotional
reactions of trauma as the patient he or she is treating.
Although compassion fatigue and burnout may present the same symptoms, such as
feelings of helplessness, isolation, depression and anxiety, burnout refers to a variety of
chronic work-related stressors, whereas compassion fatigue is the reaction from the exposure
to trauma in which another individual has been directly involved (Conrad & Kellar-Guenther,
2006). As a consequence of feeling of helpless, isolated, depressed and anxious due to the
cumulative exposure to “others” trauma, the paramedic may respond by disinvesting in his or
her ability to show compassion or care for the patients that he or she provides medical
treatment to (Berzoff & Kita, 2010).
2.5 The Paradox
Reducing the experience of being a paramedic to being only filled with horror and
negativity would be incorrect, as many paramedics view their occupation in a positive and
fulfilling light.
2.5.1 Compassion Satisfaction. In light of the above, there seems to be a paradox
regarding paramedics’ reactions towards traumatic or critical incidents. Not all paramedics
may respond towards critical incidents negatively. Rather, they may respond towards these
stressful events in a positive light as they find their work and duties rewarding and fulfilling
(Young & Cooper, 1997). The term used to describe the satisfaction gained by individuals
from working with traumatised or suffering persons is known as compassion satisfaction
(Cicognani et al., 2009). The benefits of compassion satisfaction include increased levels of
hope, resiliency and positive growth (Hooper et al., 2010).
2.5.2 Posttraumatic Growth. As indicated, apart from experiencing satisfaction in
assisting those who are traumatised, an additional positive outcome due to being exposed to a
traumatic event is known as Post-traumatic Growth (PTG) (Shakespeare-Finch et al., 2003).
PTG is defined as those positive cognitive and affective changes resulting from the exposure
to a traumatic event which has challenged previously held beliefs regarding self-concept, how
16
the individual views and interacts with others, as well as the individual’s concept of the future
(Paton, 2005). PTG, therefore does not only refer to having overcome the traumatic event,
but also to the individual having grown from the experience and thereby moving to a higher
level of functioning (Kirby et al., 2011). With regards to the prevalence of PTG amongst
ambulance personnel, Shakespeare-Finch et al. (2003) indicated that of the 498 participants,
98.6% had experienced at least one positive change resulting from exposure to a traumatic
event. The authors remind us that although paramedics may experience PTG it does not
exclude the presence of negative post traumatic responses (Shakespeare-Finch et al., 2003).
It therefore seems natural to ask the following question: How do some paramedics and other
emergency workers remain healthy and enjoy their occupation, despite continuous exposure
to critical incidents and other occupational stressors?
2.5.3 Salutogenesis. In an attempt to provide some clarity on this phenomenon it is
perhaps prudent to briefly explore the theory of Salutogenesis. Aaron Antonovsky
conceptualised his theory of Salutogenesis in 1979 emphasising the importance of
understanding how individuals are able to move towards healthy living, and the maintenance
of health and growth in the face of adversity (Becker, Glascoff, & Felts, 2010). Antonovsky
hypothesised that individuals are able to achieve this through problem-solving and the ability
to use available resources at their disposal; he termed this as having a sense of coherence
(SOC) (Eriksson & Lindström, 2006).
In essence, SOC is comprised out of three variables namely: 1) comprehensibility, 2)
manageability and 3) meaningfulness (Lindström & Eriksson, 2005). Antonovsky (1987, p.
19) defined SOC as “a global orientation expressing a person's pervasive and enduring
feeling of confidence that (1) the stimuli deriving from one's internal and external
environments in the course of living are structured, predictable and explicable; (2) that the
resources are available to one to meet the demands posed by these stimuli; and (3) that these
demands are challenges worthy of investment and engagement.”
It is important to note that a strong SOC is not a specific coping style, but rather the
individual’s ability to make sense of a potentially stressful situation and then be able to select
and employ a variety of resources in order to manage and create meaning from the particular
stressor (Van der Colff & Rothmann, 2009). The resources selected and employed by an
individual is known as general resistance resources; these may be cognitive (e.g.
intelligence), biological (e.g. physical strength), material (e.g. available finances), emotional
17
(e.g. emotional intelligence) and social resources which may include family support,
community support and cultural beliefs (Griffiths, Ryan & Foster, 2011). The individual who
has a strong SOC is thought to have a greater ability to withstand the negative effects of
stress, and has a greater positive perception of mental health than those with a weak SOC
(Suominen & Lindstrom, 2008).
Few studies have been conducted on the relationship between the critical incident
stress, SOC and the possible outcomes of such a relationship within the paramedic population
group. However, one study reported that paramedics who have a high SOC reported less
post-traumatic symptoms (Jonsson, Segesten & Mattsson, 2003). In South Africa, research
regarding the emotional well being of emergency workers stated that those with a low SOC
had increased symptoms of burnout than those with a high SOC (Naudé & Rothmann, 2006).
2.6 Coping with Critical Incidents
As reported previously, paramedics who have a high SOC have the ability to choose
and make use of resources to manage particular stressors they are confronted with (Van der
Colff & Rothmann, 2009). The following section will discuss ways of coping and strategies
which paramedics make use of in order to cope with critical incidents.
Research regarding the abilities of individuals to adjust to traumatic events has long
been the subject of much study and debate. Much interest has been directed towards
emergency workers, as this population group is continuously subjected to traumatic stressors
as part of the normal occupational duties. Although arguably the majority of research has
focused on the psychopathology within this population group, a number of studies have
investigated how emergency workers cope with traumatic events (Beaton, Murphy, Johnson,
Pike & Cornell, 1999; Cicognani, et al., 2009; Holland, 2011; Kirby et al., 2011; Palmer,
1983; Scott, 2007). Due to the uniqueness of this population group it is argued that the
coping mechanisms employed by emergency workers should not be compared to that of the
general population (Cicognani et al., 2009). Before reviewing the literature regarding the
coping mechanisms of paramedics, it is important to understand the term coping.
Researchers have indicated that there are maladaptive and adaptive ways of coping.
This implies that the effectiveness of the coping strategy depends on the context or the
circumstances in which it is used (Kirby et al., 2011). According to Littleton, Horsley, John,
and Nelson, (2007) research into maladaptive and adaptive coping strategies has been
18
developed into two main theories. The first theory, states coping strategies are considered to
be either problem-focused or emotion-focused. The second theory views coping strategies as
approach-focused or avoidance-focused.
Problem-focused coping consists of active steps towards removing, evading or
diminishing the impact of the stressor (Carver & Connor-Smith, 2010). In a case such as this,
paramedic may for instance feel that his or her training is inadequate when dealing with
cerebral vascular aneurism patients; the paramedic then attends courses so as to improve his
or her knowledge. The paramedic has therefore taken direct steps towards removing the
stressor he or she was experiencing. Emotion-focused coping entails reducing the emotional
distress that is caused by the particular stressor (Littleton et al., 2007). A paramedic may
want to reduce the associated distress connected to a particular traumatic call; in order to
achieve this, he or she may employ negative mechanism such the abuse of substances, for
instance, alcohol or narcotics, or he or she may use positive mechanisms such as physical
exercise. The paramedic therefore attempts to suppress the negative emotions he or she is
experiencing resulting from exposure to critical incidents.
Approach-focused strategies are targeted towards dealing with the stressor or the
associated emotions (Carver & Connor-Smith, 2010). On the other hand, avoidance-focused
strategies consist of efforts towards trying to escape the stressor or the negative emotions
connected with the stressor (Kirby et al., 2011). As indicated earlier, context is important, as
researchers indicate that problem-focused coping is more adaptive in situations where the
stressor is controllable, whereas emotion-focused is more adaptive when the stressor cannot
be controlled (Littleton et al., 2007). Approach-focused coping is considered to be more
adaptive than avoidance-coping (Carver & Connor-Smith, 2010).
A number of specific coping strategies are used by paramedics to mediate the effects of
stress arising from critical incidents. The following specific coping strategies will be
discussed: dissociation, black humour, substance abuse and support systems. Additionally,
help-seeking behaviour by paramedics will be discussed.
2.6.1 Dissociation or emotional detachment. Dissociation or emotional detachment is
often seen as a maladaptive way of coping with trauma. The term peritraumatic dissociation
refers to the “derealization, memory disturbances, depersonalization, and altered body-image
and time sense experienced at the time of the trauma” (Laposa & Alden, 2003 p. 50). By
dissociating from the traumatic event, the paramedic is in danger of inhibiting the cognitive
19
process used to integrate emotional and cognitive reactions to the trauma into general
memory scheme, which would allow the paramedic to interpret the event as being less
traumatic (Bennett et al., 2005). Previous studies have highlighted the link between
dissociation and the development of PTSD symptoms amongst emergency workers (Alden et
al., 2008; Laposa & Alden, 2003; Maia & Ribeiro, 2010; Marmar et al., 1996).
However, ‘mild’ forms of dissociation can be adaptive as it allows the individual to
cope with the presenting stressor (Levin & Spei, 2004). Regehr (2005) refers to the ‘mild’
form of dissociation as a process of emotional numbing. For paramedics, this is a technique
that is often used, by which they view the injured person from a professional standpoint, in
other words as a patient rather than as an individual who is suffering (Kirby et al., 2011).
One of the ways paramedics achieve emotional numbing is to cognitively focus on the next
step in treatment, thereby “blocking out” the potentially upsetting emotions and cognitions
associated with a particular scene at hand (Regehr et al., 2002). The advantage of this
particular coping mechanism is that it provides the paramedic with some structure during a
chaotic event, as well as enabling the paramedic the ability to respond to others, for example
fellow colleagues or family members of the patient, in an effective manner (Somer,
Buchbinder, Peled-Avram & Ben-Yizhack, 2004).
Although there seems to be a beneficial aspect to the use of dissociation or emotional
numbing during the traumatic event itself, there are negative consequences to the pervasive
use of this coping mechanism. As one paramedic stated “You almost treat your spouse like
another call . . . there is a [emotional] deficit there.” (Regehr & Millar, 2007 p. 56). Regehr
(2005) indicates that emotional numbing may decrease the individual’s ability to seek
assistance from others, and also lead to family members viewing the relationship with the
paramedic as being negative as the paramedic is emotionally unavailable.
2.6.2 Black humour. Paramedics often use humour during the course of their work.
According to Alexander and Klein (2001), 71% of the ambulance personnel that took part in
their study used humour as a form of coping; of those participants, 84% found this to be
helpful in coping with critical incidents. Typically, this form of humour is referred to as
“Black Humour” (Halpern et al., 2009b; Scott, 2007).
20
An example of black humour would be:
At a particularly gruesome accident where a person was run-over multiple times
on the highway, the paramedics were required to ensure that all body-parts were
removed from the scene. A paramedic picked up a shoe which still had the
deceased’s foot inside, turned round to his partner, stating “I guess he won’t be
needing this anymore!” and the other paramedic replied “The shoe or the
foot?”, after which both of them laughed.
To the general public this may seem particularly inappropriate and insensitive, and
could be viewed in a negative light. Yet the use of humour has been linked to two forms of
coping strategies, namely emotion-focused coping and problem-solving coping (Abel, 2002;
Moran & Massam, 1997). Emotion-focused coping refers to efforts made by the individual to
minimise or reduce the emotions related to the traumatic event, whereas problem-solving
coping refers to the active response employed by the individual towards the traumatic event
(Plana, Fabregat & Gassió, 2003). According to Abel (2002), humour can be used as a
method of emotionally distancing oneself from the traumatic event. By emotionally
disengaging from a distressing scene, the paramedic is then able to manage the overwhelming
emotional reactions associated with a particular scene, which in turn assists the paramedic in
being able to cope with and continue with the particular task at hand (Scott, 2007).
Additionally, the use of humour has been found to increase the likelihood of individuals to
consciously seek for alternative ways in solving problems with which they are faced (Abel,
2002). The paramedic might not necessarily experience less stress, but rather has an
increased ability to cope with the negative effects of stressful situations (McCreaddie &
Wiggins, 2008).
On an interpersonal level, it has been noted that humour increases emotional well-being
(McCreaddie & Wiggins, 2008) and feelings of shared experience, thereby increasing the
perception of camaraderie as well as communication amongst paramedics (Halpern et al.,
2009b). This is particularly important, considering that paramedics are often required to
work long shifts together, as well as being dependent on each other’s expertise when
providing medical care to patients. Yet Halpern et al. (2009b) noted that there is a draw-back
to the use of black humour, as it may isolate the paramedic from other forms of social
support, such as family and friends, who may respond to black humour with disgust or
awkwardness.
21
Apart from the psychological benefits of humour, it is also thought to have a positive
impact on physiological functioning by having a relaxing effect on the body, as well as
reducing blood pressure levels and improving immune functioning (McCreaddie & Wiggins,
2008; Moran & Massam, 1997;). Reduced levels of blood pressure as well as improved
immune functioning may not be immediately beneficial in an emergency situation, but may
however play an important role in mediating the effects of burnout through the reduction of
stress levels (Scott, 2007).
2.6.3 Substance abuse. Of particular concern for emergency services organisations is
the abuse of substances such as alcohol among its work force, as a form of coping. It is well
known that the abuse of alcohol can lead to impaired functioning, which endangers not only
patient care but also the emergency workers’ own safety (Bacharach, Bamberger & Doveh,
2008). As indicated previously, the stress reactions resulting from exposure to critical
incidents include PTSD like symptoms such as anxiety, irritability, avoidance of particular
triggers, heightened arousal etc. (Caine & Ter-Bagdasarian, 2003). It is thought that in an
attempt to suppress both the physiological and psychological effects of critical incident
exposure, some emergency workers self medicate through the use of substance abuse
(Bacharach et al., 2008). Although the use of substances is a concern, it does seem to be
recognised by emergency workers as a short-term coping strategy rather than a long-term
coping method (Regehr & Millar, 2007).
Rates of alcohol and substance abuse within emergency services seem to be high.
According to Donnelly and Siebert (2009) review of the literature regarding occupational risk
factors faced by emergency medical responders, the rate of alcohol and substance abuse may
be reported to be as high as 40%. The authors state that there seems to be a link between
substance abuse and critical incidents, chronic stress and PTSD (Donnelly & Siebert, 2009).
Interestingly, this finding was not replicated in South Africa. It was observed that alcohol
abuse is high amongst South African emergency service workers, yet there does not seem to
be a specific link between alcohol abuse and critical incident exposure (Ward et al., 2006).
2.6.4 Support systems. Psychosocial support for the EMS worker may come from
the following sources, the organisation and fellow colleagues, as well as family and friends.
Social support has been identified as an important mediator against the effects of both acute
stressors such as critical incidents as well as chronic stressors such as burnout (Aasa et al.,
22
2005, Cowman, Ferrari & Liao-Troth, 2004; Donnelly & Siebert, 2009; Regehr, 2005;
Shakespeare-Finch, Smith & Obst, 2002).
Despite the abundance of research regarding the importance of social support,
numerous studies have indicated that paramedics still perceive too little support is being
given to them from their employers (Murphy, Beaton & Pike, 1999; Regehr & Millar, 2007;
Ward et al., 2006). As discussed earlier, EMS organisations often provide support in terms of
structured interventions such as CISD and CISM. Yet the efficacy of these programmes has
come into dispute, for a variety of reasons ranging from methodological issues of particular
studies supporting CISD/CISM, to incorrect understanding of the course of PTSD
symptomology (Bledsoe, 2003; Devilly & Cotton, 2004; Fawzy & Gray, 2007; Pia et al.
2010; Wei & Szumilas, 2010). Although having a formal support system in place could be
advantageous as well as perhaps conforming to the Occupational Health and Safety laws of a
particular country, other informal forms of organisational support may also be beneficial in
mediating posttraumatic stress.
Halpern et al. (2009b) noted that informal support from supervisors could be
beneficial, for example, acknowledgement of a critical incident occurring and, showing
concern regarding the well-being of the staff. Being available to listen to the emergency
medical workers experience of a particularly distressing call was found to be beneficial in
assisting emergency medical workers deal with particularly distressing calls. Research has
also indicated that those who perceive the work environment to be collaborative, and have a
sense of camaraderie, and teamwork are also less likely to develop burnout (Argentero &
Setti, 2011). Therefore the relationship between the paramedic and his fellow colleagues is
important in mitigating the possible development of posttraumatic psychopathology.
The use of storytelling is often used as an informal means of debriefing amongst
paramedics (Tangherlini, 2000). After a particular call or during slow periods, paramedics at
times discuss the various aspects of a particular critical incident. According to Tangherlini
(2000), storytelling has a number of advantages: firstly it allows for the expression of a wide
variety of emotions, and secondly, through the retelling of the event, even if it has been
embellished, paramedic’s gain a sense of mastery over a situation in which they may have felt
powerless. Through the use of storytelling, the paramedic is able to examine the horrific
nature of specific scenes, and their own reactions to it; through this they achieve a sense of
closure (Tangherlini, 2000).
23
Exposure to traumatic events can have both a beneficial and negative effect on
attachment with important “others”. McFarlane and Bookless (2001) indicated that
individuals who share the experience of being exposed to traumatic events can intensify
individual attachments, thereby creating a closer bond and increasing camaraderie. This, as
indicated earlier, is an important factor for EMS workers. However, increased attachment
between colleagues can be seen as a threat by family members, as the family has not shared
the experience of the trauma and may feel excluded, which may create tension which has a
negative impact on familial relations (McFarlane & Bookless, 2001). Regehr (2005) points
out that another factor to consider regarding this is that paramedics searching for familial
support may transfer the traumatic feelings and emotions associated with a particular scene
onto their family, which again could cause marital discord as well as cause family members
to harbour negative feelings regarding the relationship between themselves and the
paramedic. Yet perceived familial support seems to have a beneficial impact on the health of
the EMS worker. This was pointed out by Regehr, Goldberg, Glancy and Knott (2002) in
their study which indicated that those who have higher perceived social support took less sick
leave days than those who felt that they did not have the required emotional support from
their families.
2.7 Help-seeking behaviour amongst ambulance personnel
An important aspect to consider is the likelihood of ambulance personnel to seek help
from professionally trained individuals such as psychologists or psychiatrists. In Norway it
was found that ambulance personnel are less likely to seek professional help than the general
population (Sterud, Hem, Ekeberg & Lau, 2008a). This may be due to paramedics priding
themselves on their emotional resilience and that the admittance of vulnerable feelings may
result in them becoming stigmatised (Halpern et al., 2009a). The use of formalised
debriefing strategies is at times viewed with suspicion from paramedics. Tangherlini (2000)
noted that paramedics felt that the use of CISD was a form of “surveillance” used by the
organisation, and that continuous use of CISD could have a negative effect on their standing
within the organisation.
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CHAPTER 3: METHODOLOGY
The epistemological stance of qualitative approaches places emphasis on gaining an
understanding of the meaning individuals attach to behaviour and experiences (Fossey,
Harvey, Mcdermott & Davidson, 2002). The researcher strives to reveal the “complexity and
nuances” of participants’ lived experiences (Coyle, 2007, p. 10), with an understanding that
multiple meanings exist within the social world (Hayhow & Stewart, 2006). This stance is in
stark contrast to quantitative approaches which aim to provide causal explanations
(Hjelmeland & Knizek, 2010). The quantitative researcher seeks objective ‘truths’ through
the acceptance or rejection of a particular hypothesis (Crabb & Chur-Hansen, 2009). As the
following study is focused on trying to understand the meaning which paramedics attach to
the experience of critical incidents, a qualitative approach was deemed appropriate. The
methodological approach used in this research is Interpretative Phenomenological Analysis
(IPA) (Smith, 2004).
3.1 Interpretative Phenomenological Analysis
IPA is characterised by the following theoretical perspectives: phenomenology,
hermeneutics and idiography (Smith & Eatough, 2007).
IPA’s association with phenomenology is rooted in its detailed exploration of the
participants’ lived experience (Smith, 2004), the aim of which is to uncover the meaning
participants attach to a particular experience (Pringle, Drummond, McLafferty & Hendry,
2011). Therefore a subjective view of the participant, rather than an objective viewpoint of
the researcher, is fundamental, as the participant is considered to be the ‘expert’ (Giorgi &
Giorgi, 2008).
IPA regards the researcher as central to the process of accessing and interpreting the
participants’ lived experience (Biggerstaff & Thompson, 2008; Smith & Osborn, 2008). IPA
therefore diverges from descriptive phenomenological approaches (Pringle et al., 2011),
where the researcher is required to ‘bracket’ his or her own assumptions, experiences and
knowledge regarding the specific phenomenon being studied (Willig, 2008).
Direct access to the participants’ lived experience is considered not to be possible, as it
is complicated firstly, by the researcher’s own world view and secondly, by the interactions
between the researcher and the participant (Willig, 2008). From a hermeneutic stance, IPA
25
considers the interpretation of the lived experience as undergoing a “double hermeneutic”
process (Smith & Eatough, 2007, p. 36). This hermeneutic process may be viewed from two
vantage points. Firstly, whilst the participant attempts to make sense of a particular
experience, the researcher is trying to make sense of the participant’s meaning making.
Secondly, the researcher takes an empathic stance towards being on the “side” of the
participant; then a critical questioning stance is taken when analysing the text (Smith &
Osborn, 2008). The ‘critical questioning stance’ should not be mistaken as an “interpretation
of suspicion” (Pringle et al., 2011, p. 3), but rather as a beneficial tool used for in-depth
analysis so as to capture the participants’ world view (Biggerstaff & Thompson, 2008).
IPA is idiographic in nature as opposed to nomothetic, the specific is studied rather than
the universal (Eatough & Smith, 2008). IPA’s idiographic nature is reflected in two ways;
firstly, it focuses on a specific event and secondly it focuses on a specific participant (Larkin,
Watts & Clifton, 2006). In order for the researcher to gain detailed information regarding the
specific, in-depth interviews are conducted with a small number of participants, which allows
for detailed examination of the data in which differences and similarities emerge (Brocki &
Wearden, 2006). IPA researchers generally search for a homogeneous sample (Smith &
Osborn, 2008), which is achieved through purposeful sampling (Reid, Flowers & Larkin,
2005).
3.1.1 Sample. This research study involved the interviewing of five paramedics. The
participants for the study have been sourced from ambulance service in both private and
public services, as these participants are more likely to be exposed to critical incidents than
paramedics who for instance, are working within the event management field. This is due to
the working context as both private and public emergency services are more likely to receive
and respond to more emergency calls as they service a greater number of people in a wider
variety of contexts, for example domestic accidents, medical calls, assaults, motor vehicle
accidents, etc. Paramedics who work at a particular event, for example a soccer match, are
only present for the duration of the event; also, the likelihood of a critical incident occurring
is minimised due to stringent safety and security measures being put in place by the event
management itself.
26
The participants recruited were all paramedics between the ages of 27 and 36 years old,
who have had between 8 to 12 years of working experience within the paramedic field. The
table below lists the characteristics of each of the participants.
Table 1.
Characteristics of Participants
Name Age Years of Experience Qualification
James 27 8 ALS
André 28 8 ILS
Paul 35 10 ALS
Sarah 36 9 ALS
George 36 12 ALS
3.1.2 Data collection. Each participant was contacted by the researcher prior to making
an appointment with the participant. An overview of the research was given, and once the
participant was informed of the research topic and agreed in principal to be interviewed, an
appointment was arranged at a time and place which was convenient for the participant. On
the day of the interview, an informed consent form was provided to each participant
explaining the purpose of the study (see Appendix 3)
Data was collected from the participants through conducting semi-structured
interviews. This form of data collection is considered by IPA researchers to be an effective
way of collecting data from participants, as semi-structured interviews allow the researcher
and participant to engage in a discussion, as well as allowing for the modification of initial
questions, so that the researcher can probe and investigate interesting and important
responses which may arise from the participant (Smith & Osborn, 2008).
The interviews lasted for a period ranging from 60min to 90min each and interviews
were recorded in an unobtrusive manner. The recording was then transcribed verbatim by the
author.
The following questions were used to assist the researcher in prompting the participant
to discuss their experiences regarding critical incidents.
1. Why did you become a paramedic?
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2. Describe an incident which for you was critical? (Describe thoughts, feelings and
emotions at the scene and after the call)
3. How or what did you do to cope?
4. Describe any perceived negative consequences resulting from the critical incident?
5. Was any support offered?
3.1.3 Ethical considerations. It was explained that participation in this study is
voluntary, and that the participant was able to freely withdraw from the study at any stage.
Permission to record the interviews was also sought from the participants. It was also
explained that the transcripts may be viewed and analysed by the researcher’s supervisor.
Identifying information, such as names, places, dates etc., was changed to ensure
confidentiality and anonymity. All of the participants signed the informed consent form.
The researcher was aware of the possibility that participants may experience anxiety or
emotional distress resulting from the retelling of their experiences of critical incidents. To
ensure that this did not occur, the researcher remained alert during the interview process for
any signs of anxiety or distress; if this was observed the interviewer halted the interview
process and checked with the participants if they would prefer to withdraw from or continue
with the interview. If the participant requested that the interview be stopped, this would have
been done immediately. In the unlikely event that a participant expressed acute emotional
distress as a result of reliving a critical incident, a referral list of suitable psychological
services was available to be provided.
3.1.4 Analysis. As indicated by Smith and Osborn (2008, p. 66), “meaning is central”,
and the aim of analysis is to understand the complexity and content of those meanings, rather
than to record the frequency with which they occur. Analysis of the transcripts was based on
the framework suggested by Smith and Osborn (2008). It is important to note that the
framework is not prescriptive, rather it is a “way of doing IPA” which can be adapted
according to the researchers “personal way of working” (Smith & Osborn, 2008, p. 67).
The first transcript was read a number of times, significant or interesting data was
recorded in the left margin. These initial recordings focused on similarities, differences,
contradictions and amplifications.
28
Thereafter the right-hand margin was used to record emerging themes that captured the
essential quality of the text. These themes tended to be more abstract and psychological in
nature. It should be noted that the link between the theme and what the participant reported
should be evident to ensure the trustworthiness of what has been captured.
The themes were then recorded on a separate sheet of paper; connections were made
between the themes. As connections were made, some of the themes were clustered together,
others became superordinate concepts. Again the themes were checked against the
participant’s responses to ensure trustworthiness of the data.
Next a table of themes was produced to identify which themes most strongly capture
the participant’s narrative. These clusters are then labelled to form superordinate themes.
The superordinate themes were checked for connections and clustered together to form
master themes. Once the analysis of the first transcript was completed, the above process
was repeated for the remaining transcripts.
Thereafter a final table of master themes is produced. Once that was achieved the
themes were reported in narrative form. Extracts from the transcripts were used to support
the narrative.
3.1.5 Trustworthiness. Validity and reliability are criteria used to evaluate the
scientific value of quantitative research in psychology, yet these criteria are not meaningfully
applicable to qualitative research (Willig, 2008). The reason for this is the differences in the
aims of qualitative and quantitative approaches, including the differences in sampling
methods, and sample sizes, as well as the differences in frameworks according to which they
operate (Kitto, Chesters, & Grbich, 2008). Qualitative researchers tend to refer to the
‘trustworthiness’ or the quality of the research instead of validity or reliability (Cohen &
Crabtree, 2008).
Trustworthiness of qualitative research should be assessed by its credibility, rigour and
transferability (Kitto et al., 2008). Credibility pertains to how well the analytic process,
including the emergent data answers the research question (Graneheim & Lundman, 2004).
This is demonstrated by ensuring that the interpretations resulting from the analysis is
supported by quoting the participants’ words (Smith & Osborn, 2008). Additionally,
credibility may be enhanced by ensuring that other researchers as well as participants are in
agreement with the emergent themes resulting from the analysis (Willig, 2008).
29
Rigour refers to the meticulousness and suitability of the research method used (Kitto et
al., 2008). This may be addressed through the transparency in which the research was
conducted, that is, how well the research paper describes the methodological and
interpretative process (Fosey et al., 2002). This allows the reader to judge for themselves the
quality of the research being done (Hale, Treharne & Kitas, 2008).
Transferability refers to how well the results of the study are able to inform or add
value to other contexts (Graneheim & Lundman, 2004). Brocki and Wearden (2006) caution
against the generalisation of interpretations resulting from IPA and other qualitative studies,
as the data that emerges from these studies are specific to small sample groups which are
grounded in a specific context. It is however argued that “commonalities across accounts and
‘analytic commentary’ can lead to useful insights which have wider implications” (Pringle et
al., 2011, p. 21). Additionally, Smith, Flowers & Larkin (2009) encourage researchers to
consider theoretical transferability rather than empirical generalisations; the reader should be
able to draw links between his or her own experiences, the IPA analysis and the existing
literature which allows for contributing towards the broader context.
3.1.6 Reflexivity. The dilemma, with which researchers are faced throughout the
research process, is the impact of the relationship between the researcher and what is being
researched and how this interaction may have has an impact on the results or findings of the
study (Larkin et al, 2006). IPA acknowledges that the researcher’s knowledge, beliefs and
world view are a necessary function of making sense of the participants’ experiences (Fade,
2004). However, it is still necessary for the researcher to maintain a reflexive attitude by
actively acknowledging his or her own world view (Willig, 2008). The following section
attempts to provide the reader with some insight into the researcher’s world view and
experiences.
3.1.7 Self reflexivity. I have been conscious of my own experiences as a volunteer
BLS paramedic and was concerned about the impact and possible prejudices that these
experiences may have had on the material presented in this minor dissertation.
My six years of work experience within EMS has exposed me to the context in which
paramedics are immersed; this experience has therefore in some way informed me of the
questions that I would ask, and influenced my interaction with the participants in this study,
as well as the interaction I have had with the theory and literature. Therefore it was deemed
30
necessary to provide the reader with some insight into the process and journey that I as the
researcher have taken whilst undertaking this minor dissertation.
My own experience as a volunteer BLS paramedic has influenced me towards my
decision and desire to do research into the field of paramedics and emergency medicine. I
was fascinated and naturally curious by how the men and women in the EMS service are able
to cope with the enormous amount of stress resulting from working in a field in which they
are confronted with horrific scenes on a daily basis. Perhaps, whilst formulating my research
question, I wanted to understand and make meaning of my own experiences working within
the EMS field. Cognisant of the fact that each individual’s experience of a particular context
or event may differ from my own, I became increasingly interested in the paramedics
“experience” of stressful events.
Whilst conducting my literature review, I became aware of the fact that a significant
amount of research has been conducted on paramedics’ stress and the resulting consequences
of that stress; however, very little research has been conducted regarding their “lived
experience” of this phenomenon. Wanting to gain access to the “lived experience” of the
paramedic led me to the methodological approach of which this minor dissertation has made
use. IPA has allowed me to explore the paramedics’ “lived experience” of critical incidents,
whilst acknowledging that I the researcher’s experiences should not necessarily be
“bracketed”, but rather be used as an important tool in order to make sense of the
participants’ experiences.
Having worked within the EMS field and having made a number of acquaintances
throughout this time, one would naturally consider the task of finding participants for this
study a particularly easy task. However, it was deemed necessary to find participants that I
have not met or worked with, in order to reduce the likelihood of any of my own
presumptions, regarding how and what the participant was experiencing during the narration
of his or her experience, to come at play, due to past interactions. The questions asked in the
semi-structured interviews were formulated with the aim of extracting the participants’ lived
experience, whilst attempting not to be directive or prescriptive, due to my own experiences,
thereby allowing the participants’ voice to be heard during the interview.
One of the challenges that I was confronted with regarding this particular method of
research, is that obtaining the participants’ “lived experience”; that is, not only their
descriptions of the event but also their thoughts, feelings and emotions regarding the event. I
31
experienced this as particularly challenging as I found that this sample group to be naturally
defensive and guarded. Despite this, I feel that two factors assisted me in this process, the
first being my training in psychology (albeit limited), and the second being that the
participants were aware that I have worked in EMS, which may have provided them with
some sense that I might “understand” the experiences and challenges which they have faced.
Of the participants that were interviewed, I found James’ interview to be the most
expressive and detailed. I was struck by his frankness and honesty during the interview
process and felt that we had built a natural rapport. I felt I was able to relate to his
experience; reading through his transcript reminded me of times when I myself experienced
helplessness and empathy towards patients who had no hope of being saved no matter what
interventions was administered. I was also struck by his loneliness at work; despite being
part of the EMS fraternity he still felt isolated.
I experienced Paul as guarded and defended. I felt that he used the interview space to
discuss his substance abuse and subsequent recovery, which frustrated me as I wanted to
discuss his experiences with critical incidents. However, I was aware of the fact that the
interview process is the participant’s opportunity to express his or her own experience.
Therefore, my own agenda and need for “specific” data is just that: my own need.
My interaction and subsequent impression of Sarah could be summed up in one word:
“professional”. I felt that she was the epitome of what a professional paramedic should be. I
was also struck by her ability to separate or perhaps compartmentalise her career from her
private life, having the ability to leave the horrors of work at work and not take them home
with her, due to her concerns regarding how this may impact her interaction with her family.
I was also impressed by her enthusiasm and commitment in treating patients.
My initial thoughts regarding André, was that he was “immature”, I felt that during the
interview he presented the typical “facade” that paramedics present to the public. He struck
me as an aggressive, “no-nonsense” and at times a narcissistic individual. However, as the
interview progressed I revised my initial impression of André. I began to realise that the
“facade” he presented to me was perhaps his attempt at hiding his vulnerability, and as the
interview progressed I was able to gain a better understanding of him, his experience of
working within EMS, and the difficulties he has had to face.
32
I experienced George as guarded and concrete in his narration of his experiences within
EMS and that of critical incidents. However as the interview progressed a good rapport was
established with him. George impressed me as a somewhat complex individual with a variety
of inconsistencies which at times made it difficult to understand his experiences in EMS and
in particular with critical incidents.
33
CHAPTER 4:
INDIVIDUAL ANALYSIS AND DISCUSSION OF THE
PARTICIPANTS’ EXPERIENCE OF CRITICAL INCIDENTS
In this chapter, each of the five participants shall be briefly introduced and an analysis
of their experience of critical incidents will be presented. The major themes derived are
shown in Appendix 1. For pragmatic purposes, the themes and quotes that appear are most
characteristic of the key words and quotes appearing in Appendix 1. It should be noted that
although the focus of this research is on the lived experience of the participants it proved
difficult to capture their responses at this level as the participants tended to speak more
generally. However, as the interviews progressed it became possible to be more focused on
the experience itself rather than on abstract, generalised statements.
4.1 Introduction: James’ EMS work experience
At the time of the interview, James was 27 years old and had 8 years experience within
the EMS field. James has had a lifelong interest in working within the medical field. He
explained to the researcher that he could not see himself as sitting behind a desk and
prescribing medication to patients, therefore he decided that he was more suited for the
paramedic environment. Once James had matriculated, he enrolled at Wits Technical
University in order to obtain his diploma in Emergency Medical Care. However, he did not
manage to pass his first year of studies, and then decided to enrol for the short courses in
order to realise his dream of becoming a paramedic. James then completed the BAA and
AEA courses, after which; he decided to reenrol for the Emergency Medical Care diploma,
which he managed to complete in 2004 and qualify as a paramedic. James describes himself
as an outgoing, empathic person who enjoys “living on the edge”. He stated that he is able to
build relationships with others easily, and added that he considers himself to be kind and
considerate towards others. With regards to his EMS working history, he has been employed
in both the private sector and in the public sector.
James described a number of critical incidents that he felt had an impact on him.
However, the main critical incident that he experienced to be the most important was an
experience that occurred in 2007. Whilst working night shift he was asked to respond to
three separate incidents involving burns patients in one night. Two of the patients had died
on scene, when he arrived however one patient was still alive when he arrived on the scene;
34
he had to treat this patient even though he realised that his efforts were in vain, as the patient
would die later due to the seriousness of his injuries.
4.1.2. Analysis and Discussion of James’ lived experience
4.1.2.1 Experiencing the trauma of Critical Incidents. James’ traumatic experience
of critical incidents has been divided into the following themes: his sensory experience,
which includes his sense of sight, smell, touch and sound of the critical incident; his sense of
helplessness experienced at the critical incident; his experience of empathy for the patient he
was treating, and the post critical incident consequences.
1. Sensory experience. James felt that for him a key aspect of a critical incident was
the sensory experience he had to endure. As described by his quotes, all his senses were
assaulted by the horror of patients being burnt to death.
Sight:
“...we went into have a look at the patient and he was lying face up on the floor
burnt beyond all recognition and there was like chunks of meat dripping off
him like unburnt burnt chunks of meat flesh fresh flesh...”
“...there was bits of skin peeling off in the insides of his ears and the insides of
his nose...”
Touch:
“...when you touched him it was like touching a flippen cow that has been
standing in the sun that got backed that thick leathery skin...”
“...to touch his skin I mean you touch normal people’s skin it’s soft, his skin
was like touching a brick wall, it was hard it was leathery it was not cold but
not hot but not warm if you know what I’m saying it was different...”
Smell:
“...and the smell of that was terrible...”
“...and the smell the smell of that particular patient...”
Sound:
“...to hear him in he’s writhing in agony...”
James was particularly horrified by the last burns patient he had to treat, as he felt that all
of his senses were involved.
35
“...so you can basically take all your sense into the last one, sight, smell, touch
hearing, taste no really...”
2. Sense of helplessness. James felt a deep sense of helplessness in trying to treat his
last burns patient, as he knew that no matter what interventions he administered, the patient
would still die.
“...he had full thickness burns so he was going to die regardless of what you
did he was going to die...”
“...myself personally I just had a very strong feeling of helplessness like I know
what needs to be done but I just can’t do it and you kind of know what’s going
to happen to him inside you know with burns that nature and that extent you
are going to die regardless to what anyone is going to do to you...”
3. Empathy. James was able to empathise with the burns patient who was in a severe
amount of pain.
“...if you put up a drip on this patient under normal circumstances it’s going to
be painful because you[‘re] sticking a needle into skin... you going to feel it
when you burnt to that extent it’s going to be even more painful...”
4. Post critical incident consequences. James identified a number of negative
consequences related to his experience of critical incidents. He described symptoms of re-
experiencing the critical incidents. James added that he developed an aversion to treating
burns patients, and wanted to avoid going to work.
“...for months afterwards I could smell it on my uniform...”
“...it affected me actually showering because I associated that running water
with the water of the fires so I couldn’t shower and from that day forth I can’t
actually stand with my eyes closed in the shower my eyes have to be open...”
James explains his aversion to treating burns patients and wanting to avoid going to work.
“...as I say it’s just I can’t if I go to any burns patient instantly I become
apprehensive...”
36
“...I didn’t want to go back to work, I actually thought of changing
professions...
4.1.2.2 Experiencing in the “World” of EMS. James begins his description of his
experience in the “world” of EMS by highlighting the differences between paramedics and
non-paramedics. He then discusses the negative aspects of the EMS organisation followed by
what he finds meaningful in his occupation.
1. EMS is a subculture. James experiences working as a paramedic as different from
other occupations outside of the EMS field. This is due to others perceptions that being a
paramedic is comparable to that of being in a television show.
1.1 The TV show
“...to them it’s all glory I mean they watch Gray’s Anatomy and ER and when
red, when Code Red was on TV, they watched all of that, it was a thrill for all
of them because they get to see it but they don’t realize that you don’t finish it
the moment the TV series finishes..”
“...I have to see it, I got to live it, and I got to deal with it, and I can’t just turn
the TV off if I don’t like what I see...”
In a sense paramedics are expected to be “superhuman”, and are not allowed to be able
to be affected by the horror that may confront them in the carrying out of their duties.
“...you’ve got to be able to not let it affect you to the extent that it affects other
people...”
2. Negative experiences of the EMS organisation. James experienced a number of
additional stressors related to working for the various EMS organisations. The stressors he
identified were inherent occupational stressors, a lack of support from the organisation and
the feeling of being isolated at his place of work.
2.1 Inherent occupational stressors. James felt that the responsibility of being an
Advanced Life Support paramedic was stressful.
“...as an ALS paramedic you have now reached the top, and you are it... you
need to make sure that everyone on scene is doing the right thing, you need to
37
make sure the scene is safe, you need to make sure that the base runs smoothly,
you need to be able to be there for your crew...” “... it’s a lot of extra stress
being an ALS paramedic as opposed to being an ILS and BLS paramedic...”
His responsibility includes managing general office administration as well as servicing
a large district.
“...general office environment of being at work, you know you’ve got
deadlines, you know you’ve got performance cards to do, you know you’ve got
statistics to do, you’ve got stock to order and if it doesn’t get ordered you start
running out of stock you start getting stressed because you don’t have the
required equipment to treat your patients...”
“...myself personally I cover a very large district working at Joburg I covered
a very large area working at “A” and that in itself places a lot of stress and
demand on you as an individual...”
Other aspects of the work environment that James felt were stressful included
responding to calls, as well as having to interact with the families of patients.
“...going to the call as a big stressor because you driving a vehicle at a high
speed, you’ve got traffic you’ve got pedestrians, you’ve got the vehicle itself
and an accident can happen so quickly...”
“... I mean the family is in a state of need they phone an ambulance because
someone in their house is sick or dying or what not, and you take 5 min to get
there but for them it feels like 5hours, the minute you get there you get
screamed at or shouted at why did it take you so long to get here and then by
some unlucky charm or unlucky chance you land up doing a declaration at the
call and the family now is angry because you took so long to get there...”
The possibility of dying due to the inherent dangers of the occupation is an additional
stressor for James.
“...when I first started off in this industry I used to make sure that I never left
work, I mean never left home having had an argument with someone because
you never know if you never gonna see that person again and then that guilt
38
that person is going to have to live with for having an argument. I’ve seen it
and I don’t wish to do it to my family...”
The risk of being held accountable for medical negligence.
“...in the back of your mind always is two words: medical negligence, medical
negligence, you miss-treat a patient, you miss-diagnose something you don’t do
something, you can be held liable for medical negligence and lose your licence,
and take me for example I’ve got nothing to fall back on, medicine is my life...”
2.2 Lack of organisational support. As discussed by James it is evident that he
experiences a large part of his occupation as stressful. It was then asked by the researcher if
James felt he received adequate support from the organisation he works for.
Researcher: “Do you think you get enough support from, I’m not saying peers
or colleagues but rather the organisation?”
James: “No... I don’t”
James elaborates further.
“...I worked for “A” for 13 months in those 13 months we cried for about 10,
11 months to get a counsellor in, and it was like brushed under the carpet to
say ja ok you know like we will get someone in, kind of thing, and it didn’t
really materialise until the last 2 to 3 months that I was working there...”
2.3 Seeking help is a weakness. Asking for help within the EMS when in psychological
distress may be construed as a sign of weakness, an inability to confront and manage the
horrific images that you are confronted with.
“...a lot of people say oh I’m too[weak] if I see a psychologist then I’m weak
kind of thing but a strong personality in that but you got to handle what you
see, we see blood, guts and gore, we don’t see a controlled environment like a
hospital...”
39
Initially James labelled himself as being “weak” when he realised he needed help.
“... I became weak, if you know what I’m saying, I became exactly what
everyone’s perception was of you if you look for help within the EMS...”
2.4 Isolation at work. At the time of the interview, James felt isolated from his work
colleagues adding to his sentiment that he feels there is not enough support within the
organisation.
“...I feel very isolated there because they are all firemen and I’m an
ambulance driver...”
“...yes although I’ve made friends with the guys at work I still feel isolated, like
that’s your job that’s my job and don’t interfere so I don’t think there’s
support at in the work place...”
3. Meaningful work environment. Despite the horrors and the difficulties involved in
emergency work, James is able to gain meaning in his work environment resulting from three
aspects. Theses aspects: are his enduring interest in medicine, an ever-changing working
environment and job satisfaction.
3.1. Enduring interest in medicine. James describes his interest in becoming a
paramedic as a lifelong interest and a passion of his. This is important for James, as he feels
that one should not make an impulsive decision to become a paramedic.
“...medicine is something that has always interested me and ummm as far back
as I can remember right back from school days...”
“... [it has to] be a passion of yours, it can’t be as I said like wake up one day
and decide to be a paramedic...”
3.2 Ever-changing working environment. James explains that his occupation is
continuously changing and evolving, thus keeping him interested in his chosen field.
“...you see a whole lot of things that’s not the same you will never have two
cases that are the same so it keeps you on your toes, it keeps you focused, it
keeps your mind going all the time and also its an ever changing environment
where there is new technology, new procedures get brought in so it’s not a
stagnant environment...”
40
3.3 Job satisfaction. His passion for his occupational choice is further reinforced
through the satisfaction he gains from his working experience particularly when he is able to
gain a sense of accomplishment through making a difference in someone’s life.
“...it makes me feel good, it makes me realise why I’m in the industry I am in
and it makes me realise what my purpose is...”
“...it gives me a sense of accomplishment, like man I did a good job, pat myself
kind of thing, now that’s the reason why I’m doing what I’m doing...”
4.1.2.3 Intrinsic factors and active attempts of coping with stress. In this section
James discusses what he considers to be important intrinsic factors that paramedics are
required to have in order to function effectively in a chaotic environment. He also describes
the coping mechanisms that he employs in order to manage the stress resulting from critical
incidents as well as the inherent demands of the occupation.
1. Perceived need to be in control of the environment. Within the paramedic field
there is a “need” to be in control of not only the scene you are confronted with, but also of the
way one conducts oneself within the EMS “world.”
1.1 Attributes of a paramedic. For James, in order to be able to work within the EMS
field, one is required to have certain innate abilities or attributes.
“...you got to have a very strong personality you got to have strong
determination and you got to be able to have that whole like empathy kind of
thing behind you and you got to be kind and considerate, but those are like
very broad words to use because anyone can be kind and considerate but it’s
got to be an in-born thing it’s be a passion of yours...”
1.2 Psychological hardiness. He explains that these abilities are essential as an
individual requires psychological hardiness due to the demands of the occupation.
“The emergency field its very demanding its very strenuous, it’s very taxing so
there’s a lot that gets put on you and you got to be able to with stand it...”
“...after having sought the help I realised at the end of the day it made me a
stronger person...”
41
1.3 Personal strength. Despite James’ initial thoughts that he was weak when he
required help, he was able to reinterpret his help seeking-behaviour as being “strong” rather
than being “weak”.
“...it takes a lot of guts and you’ve got to be really strong to actually stand up
and to say look I need help...”
2. Active attempts at reducing stress. James described a number of strategies he
employs in an attempt to combat the stress he experiences due to the demanding nature of
being a paramedic.
2.1 Closing the book. One of the strategies that James utilizes is what he refers to as
“close the book”, that is, attempting to come to a personal resolution that there was nothing
further he was able to do for the patient he was treating.
“...at the end of the call if you stand back and say was there anything that I
could have done differently if the answer is no you have to close that book and
leave it closed and once its closed you should never open it again...”
“...if you can close that book, you won’t deal with it if you know what I’m
saying you won’t live with it for the rest of your life...”
If he is unable to “close the book” by himself, James states that it is important to him to
talk or debrief to others about his experience.
“...you need to talk about it to get to that point where you can close it and
forget about it basically because you can’t let it you can’t take it home with
you can’t let it affect you to that state as hard and callous as that sounds you
actually have to forget about it...”
2.2 Informal debriefing with colleagues and family. James describes two types of
informal debriefing of which he makes use. Firstly, he speaks to his colleagues; secondly, he
discusses some calls with his family members. With his colleagues he discusses the various
calls on an informal basis.
“....we all just sit there and joke and laugh and like someone will just crop up
and say something about a call and you say you know I had a call like that
similar to that you know and you talk about and half an hour later you order
42
another cup of coffee and then half an hour later you all go on your merry way
kind of thing it’s like a debriefing without you even knowing you debriefing...”
James explains that he only discusses some cases with his family or friends particularly
if there is some feature of the call that may remind him of his own home life or family.
“...I’ve mentioned one or two cases to family or friends but that’s like if I do
that it’s close to home if you know what I’m saying like I mentioned to my
mom, my gran is 82, I mentioned to my mom last year sometime that I did a
really hectic declaration where it was I declared some lady’s mother who was
in the region of the late 70’s...”
His reason for discussing only some calls with his family or friends is that he feels they
may not be interested, or that they would not understand how he feels or what his job entails.
“...with friends and stuff I prefer not to talk about things because it makes you
look all morbid you know, they’ve got their job, their profession they[‘re] not
necessarily interested in what you want to do so why must you palm it off on
them if you know what I’m saying...”
“...take my sister for example she doesn’t understand... she’s got a lot of
unanswered questions and she doesn’t actually understand...”
2.3 Relaxation as a means of coping. James reported that for him it is important to have
a hobby or partake in a “brainless” activity in order to “escape” and reduce his stress levels.
“...there’s days where I come home from work and I just watch TV, cartoons
because its brainless information, it’s not even information, its brainless
activities...”
“...you just shut down completely so get a hobby do something brainless and
just chill...”
“... I’ve got two [hobbies] I build puzzles in case you haven’t noticed the
amount of puzzles around the house and I play piano... those are my two
hobbies...”
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2.4 Black Humour. James explains that at times humour is used as a means of coping.
He feels that this is a means of being able to discuss a call without letting others know that
you are distressed.
“...that’s a personal coping mechanism for a lot of people because in a way it
looks like you, in a way myself what I think and feel about that is in a way you
are talking about it but in a roundabout way not letting people know that it
affects you...”
2.5 Psychological treatment: the last resort. Due to the trauma James was experiencing
from his exposure to critical incidents, as well as familial pressure, he came to the realisation
that he required psychological treatment to assist him in alleviating the negative symptoms he
was experiencing.
“...it got to the stage where it affected me actually showering because I
associated that running water with the water of the fires so I couldn’t shower
and from that day forth I can’t actually stand with my eyes closed in the
shower my eyes have to be open...”
“...then when it got to that stage that’s when I decided that I actually needed
to go see someone about it.”
In addition to having suicidal thoughts, members of his family began to highlight his
negative behaviour and exert pressure on James to seek assistance.
“Ja my mom said to me something along the lines like you[‘re] really not the
same you used to be your attitude stinks and that kind of stuff and she actually
went as far as saying to me certain of her friends have noticed a change in
my...”
“...after what my mom had said I had two choices one I can attempt suicide fail
and have a criminal record or two I can go seek help, and I went to go and
seek help. ..”
4.1.2.4. Personal consequences of being a paramedic. James’ experience of being a
medic has had an influence on his personal life in a number of ways. He feels that his
interaction with his family has suffered, as well as his psychological functioning.
44
“...[it’s] had a detrimental effect on my family life and my personal life is,
from everything as a whole, taking EMS and studying at that stage and
everything as a whole, I did become very deeply depressed it got to a stage
where I was actually thinking of killing someone, ok someone in my family...”
1. Family life affected. He further describes how his mood and behaviour affected his
family life.
“... I’d come home grumpy, in a bad mood, I would be very short shout a lot
for something small and insignificant and ummm just like vent my anger on
everyone and anyone...”
“...you then become so uptight or I’d become so uptight that I’d slam the door
shut and just go on a screaming tangent...”
2. Depression. He explained how he became withdrawn and began to have thoughts of
suicide and homicide.
“...I’d find myself being very withdrawn just coming home and going to my
bedroom and watching TV or going to play on my computer or something not
really socialising much and if I do it it’s on a very short and abrupt basis...”
“...I did become very deeply depressed, it got to a stage where I was actually
thinking of killing someone ok someone in my family...”
“...I was suicidal and that’s not me, that’s... I’ve never been suicidal in my life
I’ve never been depressed in my life either....”
4.1.2.5 Summary. James’ lived experience of critical incidents centred on witnessing
and treating burns patients. This critical incident was experienced and relived through his
sense of touch, smell, sight and hearing. James described feeling helpless in not being able to
assist his patient and empathised with the amount of pain the patient was enduring. As a
result of his critical incident experience, he described symptoms of re-experiencing the
critical incident and avoidance in treating burns patients; additionally he wanted to change
occupations.
Contextualising James’ lived experience of critical incidents begins with his perception
of the EMS world. He perceives others as viewing his occupation as a television show which
is filled with action and heroism. However, as he explains, his experience is “reality”, a
45
reality that he is unable to switch off or change by switching the channel; this is what makes
EMS different from other occupations for him. He is forced to deal with what he sees whilst
he is performing his duties as a paramedic.
Apart from the critical incidents that James experienced, he highlighted that there were
inherent stressors to his occupation. The responsibility of being “in charge” as an Advanced
Life Support Paramedic and managing general office administration as well as servicing a
large district is experienced as stressful. James identified two specific factors that he felt was
stressful when dealing with an emergency call. This included having to drive at high speeds
to the emergency scene, as well as having to interact with the patient’s family, particularly if
the patient had died. He felt that there is a constant possibility of him dying, due to the
dangerous nature of responding to and working in emergency situations. Coupled with this,
James felt that he was under constant threat of being held accountable for his medical
interventions and feared being sued for medical negligence. He reported that there was a lack
of organisational support in assisting him in managing his stress. According to him the
inability to successfully manage the environment and occupational stress in EMS work is
often viewed as being “weak” by EMS colleagues. Yet, having had to ask for assistance
when he was unable to cope with his occupational and critical incident stress James was able
to reinterpret his experience as being “strong”. James added that as a paramedic, he felt
isolated as he was unable to interact with other EMS professionals due to the differences in
occupation’s.
James’s ability to find meaning in his working environment stems from his long-term
interest in medicine, the continuous changing environment and the satisfaction he gains from
assisting others. James acknowledged that his personal and family life has been affected by
the stress he has encountered in performing his duties as a paramedic. He stated that he
became withdrawn and depressed, which had an impact on his interaction with others in his
family. James revealed that his depression became so severe that he had thoughts of suicide
and homicide.
James stated that it is important to have certain innate abilities and psychological
hardiness in order to manage the stressful environment he is exposed to.
James described three strategies he employs in attempting to reduce stress. He added a
fourth strategy when he realised that his normal coping mechanisms were not alleviating his
psychological distress. James refers to the first strategy as “closing the book”, a mental
46
exercise in which he critically evaluates his performance in his management of a patient.
This reduces the emotional aspects James may have experienced in emergency calls, by
focusing on the “technical” features in patient treatment, allowing him to “forget” the
emergency call as well as the patient. James’ second active strategy towards reducing stress
is to informally debrief with colleagues, family and friends. Debriefing with colleagues
entails discussing similar experiences in an informal setting, whereas debriefing with family
members or friends was usually only employed when an emergency call reminded James of
some aspect of his family. He was hesitant to discuss his experiences with family and
friends, as he felt that they may not understand how he feels or what his occupation entails.
James explained that the strategy of using humour within EMS allows the paramedic to
discuss certain features of an emergency call without appearing vulnerable or “weak”. At
home he reported that he enjoys partaking in “brainless” activities or involving himself in his
hobbies in order to reduce stress. Although not part of his repertoire of active attempts
towards reducing stress, James, along with members of his family, came to the realisation
that he required psychological assistance from a psychologist to assist him in alleviating the
psychological distress he was experiencing.
As discussed earlier, James revealed that his occupation as a paramedic has had a
negative impact on his personal and family life. James explained that he became depressed
and had thoughts of suicide as well as homicide. His interactions with his family suffered as
he became withdrawn and angry.
4.2 Introduction: Paul’s EMS work experience
Paul is a 35 year old married male with 10 years experience as an ALS paramedic
within the EMS field. Paul explained that he was attracted to working within the EMS field
as he wanted to assist others. He began his training as a paramedic by enrolling in short
courses. Paul practiced as a Basic Life Support Paramedic for five and a half years before
enrolling in the Intermediate Life Support course. After two years as an ILS paramedic Paul
studied further in order to complete his Advance Life Support course. Later he attempted to
further his career in medicine by studying to become a medical doctor; however, he was
unable to accomplish this due to his addiction to substances. Paul described himself an
adrenalin “junkie” who at times is easily stressed. He has worked as a paramedic in both the
private and public sector.
47
Paul was unable to identify a specific incident during his work experience which he
considered to be critical, stating that for him many of the incidents have merged. However,
he recalled a recent incident, during which he was off-duty, which he experienced as critical,
involving a pedestrian being hit by a motor vehicle.
4.2.1 Analysis and Discussion of Paul’s lived experience
4.2.1.1 Experiencing the trauma of Critical Incidents. Paul felt that he was unable to
recall one specific emergency scene or event that he could describe as a critical incident. He
revealed that in his experience the emergency calls tended to merge, and added that he feels
that he does not find much traumatic. When asked if he had experienced a traumatic incident
recently he referred to an event that occurred whilst he was off-duty.
1. Critical incidents merge. Paul explained that his experience of critical incidents
tended merge adding that was due to him repressing his memories.
“...it’s difficult to say... sometimes... purely because they all tend to merge into
one...”
“...to some extent there is a large degree of repression and that’s why I say
they all merge into one, it’s because you do repress those memories...”
2. Don’t find much traumatic.
“...I don’t know the odd thing is that I gotten to the point on the road where I
don’t find much traumatic any more you know ummm I certainly in the
beginning some of the more messy of the calls got to me you know...”
3. Off-duty traumatic incident. Paul describes the incident that he found traumatic
whilst off-duty.
“...I can sort of think of one that just happened recently... for that for me was
traumatic... purely because I was involved in it... I was off duty... in the sense
that I saw a girl get hit by a car right in front of me and then her body landed
in front of my car and I had to slam on brakes and she went under my car but
amazingly I only drove over her bag I stopped the car and I was only that far
from her head... ummm... that for me was traumatic...”
48
He adds that when trying to get assistance for the patient, he became frustrated by the
questions the emergency call taker asked him. Paul was then able to empathise with the
public’s frustration.
“I’m sorry but I’ve phoned “A” for an ambulance a while back then I realised
ok so this is actually what the public has to deal with...”
“...Is the person on medical aid? they’ve been hit by a fucken car I’ve tried
asking them but their heads caved in... what just send me a fucken ambulance...
you know... I don’t know whether he is on medical aid...”
4.2.1.2 Experiencing in the “World” of EMS. Paul’s descriptions of the EMS
“world” centred on his experiences belonging to a “brotherhood”, the inherent difficulties of
his chosen profession and the lack of support he received from the EMS organisation he
worked for. He added that despite the negative experiences of his profession he feels that his
occupation is meaningful to him.
1. EMS is a subculture. Paul explained that the experiences paramedics share exclude
“outsiders”. He felt that paramedics view councillors or psychologists with “a great degree
of suspicion”.
1.1 The “brotherhood”. Paul describes his experience of the EMS world as a
“brotherhood” in which members share “intense” experiences. The experiences they share
set EMS members apart from others.
“...the other things that sort of stand out for me is um... far greater sense of
brotherhood... than you would find in any other job. And I think it’s purely
because of the intensity of the shared experience...”
“...an intense kind of experience it tends to exclude the outside and it creates
very much a sub-culture within EMS...”
1.2 Suspicious of outsiders. He experiences EMS personnel as suspicious of others,
particularly counsellors who do not have an EMS background.
“...they don’t take kindly to interventions from outside... you know like
counsellors and psychologists that sort of thing... especially if they don’t come
from an EMS background they always feel a great degree of suspicion...”
49
Paul feels that a possible reason for this suspicion towards others, is that they do not
understand the demands of being a paramedic.
“...I can kinda sum up the attitude I think its kinda like you don’t know jack-
shit about this job, you don’t know us, you don’t know what we deal with... you
know.. so screw you and... um we cope with this everyday...”
He added that perhaps this is related to a fear that “outsiders” are able to see through
the facade created by paramedics.
“...perhaps it’s a fear of seeing through the facade...”
“...think it’s the facade that ummm the job is more difficult than they let on...”
2. Negative experiences of the EMS organisation. Paul experienced the inherent
occupational demands as stressful and felt that the organisations he worked for did not
provide enough support.
2.1 Inherent occupational stressors. Paul describes how he found the working
conditions and inherent job stressors as “difficult”.
“...I used to find the working circumstances themselves more difficult more
stressful...”
He points to factors such as shift work, non-emergency calls and lack of growth as
contributing towards his stress.
Shift work:
“...what I found most stressful working in the emergency services is uhhh the
hours...” “...the hours are tough especially the weekends...”
“...I found [that] quite hard because you continually having to try shift your
body clock between days and nights, days and nights the whole time and that I
found wore me out, I really found that that wore me out...”
Non-emergency calls:
“...one of the stressful parts of the job is the large volume of bullshit calls...as
we call them... you know... again you’re typical... I stuffed my toe, I’ve got
50
stomach pain... uh... you know I got flu... that sort of nonsense uhhh... basically
where we serve as a taxi service to get patients to hospital...”
Lack of occupational growth:
“...the other difficult part is the absolute lack of career opportunity what I
always say to people who want to do this like when you were saying consider it
as a career it’s not a career it’s a job and it’s a young man’s job...”
2.2 Lack of organisational support. Paul feels very strongly about the lack of support he
has received from the various organisations he has worked for. He highlights that the support
provided to paramedics is outsourced. Paul adds that being referred to the outsourced
company is often viewed as a punishment, as well as a quick fix solution.
“Being sent to ICAS was seen as always some kind of punishment... you
know... ohhh ja you’ve been unproductive at work... you know you[‘re]
bringing your personal problems to work fuck off to ICAS and go sort yourself
out.. you know... and I think the company sees it more of a fix it... you know...
we’ve got this here to more to cover our ass... you having shit go to ICAS and
go sort yourself out in 5 secs five sessions and come back fixed...”
He feels that the organisations do not care about their employees; he feels hurt by this as
he has given a lot of himself to the organisation.
“...as a human being they couldn’t, they don’t care about you in the slightest...
if you... and I mean I’ve seen it with the guys... they will chew you up and spit
you out...”
“...I got fuck all support from “A”. fuck all... ummm as is said it is a little bit
difficult you know I gave them a lot of my life...”
As result of this Paul prefers to draw his support from his colleagues.
“I draw my support from... people around me I don’t think you could turn to
the system for support at all whether you are in private or public, or whether
you are a freelancer whatever you cannot turn to the system be it the HPCSA
or the company you work for cause there is fucken no support...”
51
3. Meaningful work environment. Paul is able to find meaning in his work
environment due to the varied environment and job satisfaction.
3.1 Ever-changing working environment.
“...it’s such an exciting varied working environment...”
He explains further:
“...no two days are the same... and um the other phrase that comes to mind... is
that it is long periods of boredom interrupted by short periods of sheer fucking
terror...”
“...It’s not even so much as terror as it is like excitement and the potential for
terror... you know... umm... but you will go from things being very relaxed and
easy going.. you get a call and you don’t know what you going to... and there’s
that thrill that bit of excitement...”
3.2 Job satisfaction. This is achieved when he is able to use his skills to assist others
and make a difference in their lives.
“... [when] your skills are required...”
“...where you can arrive and make a difference where you can do
something...”
“...There is something very satisfying in giving part of yourself to be of help to
someone else...”
4.2.1.3 Intrinsic factors and active attempts of coping with stress. Paul discussed
the importance of learning from previous experiences in order to pre-empt what to expect at
an emergency scene. He describes various strategies he has employed in order to cope with
organisational stressors.
1. Perceived need to be in control of the environment. Paul was able to gain a sense
of control in his environment by learning to cope with what he saw whilst performing his
duties as a paramedic. In addition he relies on the experiences he has gained from working as
a paramedic.
52
1.1 Learning to cope.
“...the difficulty of the job never lay in the types of things that we saw... you
know because you can learn to cope with that... you know uh and sometimes
it’s difficult but you can learn to cope with that...”
1.2 Previous experience. When responding to an emergency call, Paul mentally runs
through previous experiences he has had.
“...I’m also thinking about what is the area I’m going to, what is it like, what
sort of calls do we do in this area...”
“...have I done calls there in the past, and have they been big calls or not...”
“...where’s the nearest fire station in case I need to call for a cut out...”
“...which is the ambulance that’s been sent with me, who are the guys on the
ambulance, what is their level of competence.”
2. Active attempts at reducing stress. Paul views peer debriefing as his main attempt
at reducing stress. He has abused substances to assist him in coping with his emotions. It is
important to note that the abuse of substance was not directly linked to coping with critical
incidents, but rather as a result of attempting to deal with familial, occupational and academic
stress. It was included in the analysis, as the researcher felt that to exclude this information
would not allow the reader to gain a holistic view of Paul’s lived experience.
2.1 Informal peer debriefing. Paul explains that peer debriefing is done in an informal
setting either around coffee or when the ambulances need cleaning after an emergency call.
“...for me peer debriefing is always the key just talking about it amongst your
friends afterwards... going for coffee and having cigarettes just chatting about
it amongst yourselves.”
“...what we do is always clean the vehicles together and while we [‘re] doing
that we also talk about what’s happened...”
Paul described how informal debriefing assists him.
“...just to be able to, to talk about it... and if you talk about and talk about it
and talk about it enough for me I find that’s how I find a place for it in my
head you know and it’s not even anything formal...”
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2.2 Structured internal peer debriefing. When asked by the researcher if Paul though a
“formal” debriefing programme would assist paramedics, he had the following to say:
“...I think it would be more productive if it came from someone from within
and perhaps if those people had a little bit more training, maybe even on how
to identify people who have a major problem who need intervention...”
2.3 Humour. Paul stated that humour is a “staple” in the EMS world and felt that the
use of humour encouraged paramedics to discuss events without appearing vulnerable.
“...black humour is like, ok we, that’s just a staple, I mean I’m the first one to
be telling the most revolting of colour jokes you know...”
“...you know what it does it breaks tension and gives people a chance to
talk...”
“...you know they getting it out they talking about it, but in a way that doesn’t
make them look vulnerable, they can be vulnerable without coming across that
way...”
2.4 Substance abuse. Paul explained that he abused opiates as a means of dealing with
emotional pain resulting from the stress he was experiencing in his personal, occupational
and academic life.
“...the specific thought process that had occurred to me was that morphine
works so well for physical pain I wonder if it works for emotional pain... and
the problem was Justin is that it did... and for six hours umm it did work for
emotional pain...”
“..I was at med school at the time, so I was just burning the candle at both
ends, because I was also working the road on the weekends for extra cash, I
was working from Friday to Monday and I was just exhausted. And plus I just
had a whole lot of personal shit you know my mother and my wife where at
each other’s throats...”
4.2.1.4 Personal consequences of being paramedic. Paul reported that his personal
life has been affected by his occupation as a paramedic. He revealed that he has experienced
recurrent dreams of dismembered bodies for a number of years, and added that his wife finds
it difficult that he is not available when she needs his support.
54
1. Recurrent dreams. Despite Paul stating he is unable to recall a specific critical
incident, he admits that his occupation as a paramedic has had an effect on him.
“I have had recurrent dreams, now that you mention it, for years I have had
recurrent dreams about dismembered bodies...”
“...body parts and pieces all over the place sometimes I’m walking through
them sometimes I’m driving through them, sometimes at the mortuary,
sometimes at a car accident you know, but that’s been sort of a recurrent thing
for me for years so you can’t say that it doesn’t affect you at all, I mean I’m
not that naive.”
2. Wife does not understand. Paul reported that his marriage has been affected, as his
wife finding it difficult when he is required to work shifts and is unable to assist her when she
needs emotional support.
“...my wife found my working on the road to be very hard for her the hours in
particular being away on nights and weekends, and I think a lot of spouses
found that hard.”
“..if she was battling like if she wanted to commit suicide or if she felt that she
had a seizure or whatever the case maybe she wanted me to come home, she
couldn’t understand sometimes that no I’m actually busy on a call I can’t come
home now you know... that she found difficulty...”
4.2.1.5 Summary. Paul was unable to recall a specific incident which he would
describe as critical. He explained that in his experience critical incidents have merged,
adding that he no longer experiences emergency scenes as traumatic. Paul was able to recall
an incident which he experienced as traumatic yet this was whilst he was off duty. He
reported that he was able to empathise with the public’s frustration when they phone an
emergency centre for assistance. Paul later revealed that he does experience some negative
consequences resulting from his occupation as a paramedic, stating that he has recurrent
dreams of “dismembered bodies”.
Paul described his experience working in EMS as sharing “intense” experiences with
his fellow colleagues; also stating that this experience tends to excludes outsiders from the
EMS “brotherhood”. He states that paramedics are suspicious of outsiders, particularly
counsellors. Paul explains the reason for this is that “others” do not understand the
55
experiences that paramedics have to deal with on a daily basis. He added that the suspicion
may be a defence which prevents others from recognising that paramedics struggle to cope
with the difficulties of the occupation.
Paul stated that he has had negative experiences whilst working for EMS organisations
specifically “working circumstances” and lack of organisational support. He found that the
“working circumstances” are stressful listing shift work, non-emergency calls and lack of
occupational growth as his main stressors. Paul felt very strongly that the organisations he
worked for provided minimal support and felt hurt by this as he had given them “a lot” of his
life to them. He reported that he prefers to obtain support from his peers.
His experience as a paramedic is meaningful as he finds his occupation exciting and
varied. Paul describes his working experience as alternating between periods of boredom and
excitement. He adds that he experiences satisfaction when he is able to use his skills and
make a difference to another person’s life.
Paul stated that he has learned to “cope” with what he sees and experiences whilst
performing his duties as a paramedic. He is able to deal with uncertainty through relying on
his previous experiences; for example, when responding to a particular emergency he tries to
recall what he has previously responded to in that area. Coupled with this, Paul attempts to
pre-empt what resources he may require before arriving on scene.
In attempting to reduce his stress Paul stated he informally debriefed with his work
colleagues. He explained the benefit of informal debriefing as it allowed him to “find a place
for it in my head”. Paul highlighted the importance that any form of professional debriefing
should originate from within the EMS organisation itself. With regards to the use of humour
he stated that humour is a fundamental part of the EMS world. Paul views humour as a
means by which paramedics are able to relieve tension, while also allowing them to discuss
events without appearing vulnerable. He described experiencing emotional distress due to
familial, occupational and academic stress and attempting to cope with this trauma through
abusing substances, specifically opiates.
Paul reported that his personal life has been affected by his occupation as a paramedic.
He revealed that he has experienced recurrent dreams of dismembered bodies for a number of
years and added that his wife finds it difficult that he is not available when she needs his
support.
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4.3 Introduction: Sarah’s EMS work experience
Sarah is a 36 year old married female who has a two year old son. She has 9 years
experience as an ALS paramedic. Sarah began her career in medicine in 1995 as a nurse and
explained that she wanted to become a paramedic so that she would be able to make her own
decisions regarding to patient treatment, rather than relying on doctors for assistance. She
enrolled at a university, and completed the four year diploma necessary to qualify as an ALS
paramedic. Sarah describes herself as a mature, stable person with a dynamic personality.
She has worked in both the private and public sector as a paramedic. At the time of the
interview, Sarah was employed at a government training academy. She therefore responds to
emergency calls with new recruits; whilst providing emergency care she is also required to
train her students. Sarah discussed a critical incident involving a child who had drowned.
4.3.1 Analysis and Discussion of Sarah’s lived experience
4.3.1.1 Experiencing the trauma of Critical Incidents. Sarah discussed a critical
incident involving a child who had drowned. She described how she was hoping for an
alternative explanation or outcome to the call. Sarah reported that one of the reasons why
this incident was traumatic for her was that she empathised with the father of the victim as
she has a child of her own.
1. Children are the worst. Sarah stated that, for her, scenes involving children is the
most difficult to deal with.
“...I think for me if you had to ask me about scenes my worst scenes are those
with children, those ones are the worst.”
2. Hoping for an alternative explanation. Sarah reported that whilst on the way to the
scene as well as at the scene she was hoping for an alternative reason for the child’s
disappearance.
“...the whole way there we were just questioning are you sure she’s in the
water, you sure she hasn’t got out and gonna gotten dressed...”
“...I was querying if she had not gone home with one of the kids or something
like that...”
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Even whilst searching for the child, Sarah was hoping that the child was alive.
“...we eventually realised there was a mine shaft on the side of the
[waterfall]... and I sort of thought to myself, I just want to go look in that mine
shaft because I pray she has fallen down and she's lying at the bottom and we
can pull her out and she’s alive...”
3. Empathising with the victim’s father. Sarah experienced a significant amount of
empathy with the father of the child who had drowned. She attributes this to herself being a
parent.
“...I think the worst thing was actually pulling her out when that moment when
he [the father] realised she was dead, that was just... and being a... I’ve got a
little two year old baby... and I think that makes it...”
She reported that at one point she would have preferred being in the water looking for
the child, rather than watch the father’s suffering.
“...watching him hurt was... I’d rather have been in the water so that I didn’t
have to see him and watch him hurt...”
Sarah said that she felt “better” when she read a newspaper article that reported the
father stating he did not blame anyone for the drowning.
“...I think that must have been the hardest thing for him to write but it made me
feel a lot heck of a better because he didn’t blame anyone...”
4.3.1.2 Experiencing in the “World” of EMS. Sarah’s descriptions of her
experiences of working as a paramedic for an EMS organisation are as follows:
1. EMS is a subculture. Sarah described her experience of the EMS world as a
“clique”. She added that there is a difference between EMS and the “public”, she is often
asked to recount her worst emergency calls to satisfy people’s curiosity about death.
1.1 EMS as a clique. Sarah experiences her EMS colleagues as both supportive and at
times hurtful.
“It’s a clique it really is...”
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“..the EMS are the worst they[‘re] the first ones to stab you in the back when it
happens, but they are the first ones to support you when you need help, no
matter whether we like you or not, if you need help we are there...”
She adds that often EMS colleagues tend to isolate themselves by discussing work
experiences when socialising with others.
“...I think we have a very bad habit in that we talk our jobs, you go to a dinner
party, and if there’s more than one medic at that table you will end up talking
about medicine...”
1.2 What was your worst call? Sarah mentioned that she dislikes members of the
“public” continuously asking her about her worst emergency call’s she has responded to.
“... the one thing I hate that always happens with the public, this thing what
was your worst call ever, now I must drum up the memory of my worst call and
tell that person while I’m having dinner...”
She alludes to the public’s curiosity as being naïve in the sense that they are only
able to compare her occupation to the television programme CSI.
“...people are so intrigued by what we do because it’s gruesome and it’s
bloody and its death and its murder and its all these things that CSI is...”
2. Negative experience of the EMS organisation. Sarah stated that she struggled with
shift work particularly when she first began working in EMS.
2.1 Inherent occupational stressor. Sarah provided some insight into her experience of
shift work and the physical and social impact this had on her.
“... the shift systems I was doing, and I think it was about fifteen days where
hubby and I didn’t even have dinner together, ummm just because of calls and
I was actually exhausted I lost an incredible amount of weight, I just pushed to
the extremes...”
3. Meaningful work environment. Sarah admitted that she enjoyed the adrenaline
“rush” when she first started working as a paramedic, however, she feels that she has matured
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in her job and that her focus has changed from “lights and sirens” to patient treatment. She
reported that working as a paramedic is meaningful to her as she enjoys the dynamic nature
of her occupation as well as being able to care for others
3.1 Adrenaline. Sarah revealed that when she first started her career in EMS she
enjoyed the “high” of responding to an emergency call.
“...when you start in the service, it’s the lights, it’s the sirens, it’s the buzz, it’s
the go, it’s the high, it is and you actually crave it...”
“...it’s the whole the race to get there, it is, it’s to get there to treat the patient,
and then afterwards it’s to sit down and go wow that was amazing.”
3.2 Maturity. Sarah stated that “maturity” is a mind-set change which occurs as the
paramedic develops in his or her profession. It evolves from focusing on the experience of
the adrenaline rush whilst responding to an emergency call, to focusing on the treatment of
the patient.
“..it’s not the lights, it’s not the sirens, it’s not the adrenaline anymore... It’s
treating people its seeing them responding to my treatment.”
“...I think as you’ve matured with the job, the lights and the sirens, I don’t put
them on anymore unless I have to... It’s getting to the patient, knowing that I
have the knowledge to treat the patient, treating the patient properly to my
ability, and then sitting down and saying I did it, I managed to look after him
properly; I think it changes as you grow with your job.”
3.3 Dynamic working environment. Sarah experiences her occupation as “dynamic”
which she describes as each day being different for her. She enjoys this as she is not
confronted with the same routine each day and she feels she is continuously learning.
“The dynamic, the first thing that got me was its dynamic, you don’t go in
every single day and check cupboards and count drugs and every day’s
different, its different places, I don’t like the same old thing every single day.”
“...just being out there, different people and actually seeing a result, so
actually seeing your patient and improve whereas the patients I was treating in
the GP practice at the time it’s all give them a painkiller, give them an anti-
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inflammatory, so it was run of the mill boring stuff and I love learning so I
wasn’t learning anything anymore...”
3.4 Caring for others. As Sarah has “matured” in her occupation, she revealed that she
gains meaning from being able to assist others and knowing she has the knowledge to do so.
“... I love dealing, working with people... it’s not the lights, it’s not the sirens,
it’s not the adrenaline anymore... It’s treating people it’s seeing them
responding to my treatment... it’s the little old lady who you give some pain
killers to she turns to you and she goes I’ve been praying for an angel and
you’ve just arrived... that’s what it’s all about, it’s all about being able to help
someone in that moment they need you, and giving them the right treatment
and knowing what you[‘re] doing is right...”
4.3.1.3 Intrinsic factors and active attempts of coping with stress. Sarah described
what she thought were important innate characteristics for an individual to have in order to
function effectively as a paramedic. She also discussed various coping mechanisms she
employed to reduce critical incident stress as well as organisational stressors.
1. Perceived need to be in control of the environment. Sarah discusses her need to be
in “control” as well as the important attributes she feels a paramedic is required to have.
1.1 Need for control. Sarah’s initial reason for changing occupations to become a
paramedic was as a result of an experience she had as a nurse. She was unable to provide
treatment to a patient as the treatment regime fell outside her scope of practice. Sarah was
then forced to wait for assistance from a doctor who was unavailable at the time. Although
the patient was successfully treated, she felt that she did not want to rely on another person to
assist her with patient treatment.
“...[the] decision was made there and then that I never, I wanted my own
protocol, I wanted to be able to make my own decisions and not have to always
lean on someone else.”
1.2 Attributes of a paramedic. Sarah explains that there are a number of attributes that
individuals require in order to become successful paramedics.
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“... its maturity, but how do you define that, ummm knowledge, a dynamic
personality, because medicine does change, you need to be able to change with
it, a strong personality, confidence, competence...”
She describes paramedics as people who enjoy being in control.
“I think all of us are type-A personalities, we all like control...”
2. Active attempts at reducing stress. Sarah discussed a number of strategies that she
employs to reduce stress. She highlights the importance of engaging in a healthy lifestyle,
and said that she is able to debrief with her peers as well as with her mother. Sarah provided
some reasons regarding why she would not make use of professional counsellors or
psychological services. She also said that she is aware of the use of humour within EMS, yet
in her experience it is not commonly used at her place of work. Sarah added that her uniform
serves as a protective factor which allows her to depersonalise.
2.1. Healthy life style. A healthy lifestyle and spending time with her son allows Sarah
to de-stress.
“...if I’m frustrated there’s nothing I really do, I don’t smoke, I don’t drink, I
go to gym, live a healthy lifestyle, love playing with my child, love the
outdoors, love walking, so ja I will go outside maybe garden for a while...”
Sarah emphasises that a healthy life style is an important coping mechanism, to such an
extent that she encourages her students to live a healthy life style as well.
“...the coping mechanisms we try to get the [students] to exercise we try and
get them to eat healthy lifestyle, eat well, have a healthy lifestyle...”
2.2 Informal debriefing with peers. Sarah stated that she is able to debrief with her
peers. She explained that this occurs in two formats, the first being from an educational
stance and the second is that she feels she is able approach her colleagues to “download” and
“dump”.
“...working in this professional environment you can go to any of your
colleagues and say that call really bugged me, and I’ll download to my
colleagues...”
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“...I can sit in front of my colleague, I can dump on them for 30 minutes about
what I’m feeling, they can look at me afterwards and pass the most bizarre
comment and I feel better, they feel better, it’s off my shoulders its finished.”
2.3 Debrief with mother. Sarah also mentioned that she is able to discuss difficult calls
with her mother.
“I’m lucky in my support structure I’ve got an amazing support structure, pick
up the phone, and I said to my mom, mum I need to chat, she said a bad call, I
said ja, she says right download, and I just downloaded and she said okay, and
you know she doesn’t have to answer me or give me a suggestion she just has
to listen...”
2.4 Reasons for not using professional psychological services. Sarah stated that she
would not readily make use of professional psychological services, due to the amount of
sessions she would be required to attend. Coupled with this, she feels that she would only
like to discuss the “incident” rather than including other personal factors.
“I’m coming to you for that incident, it’s bugging me because I looked a little
girl who died, that is the problem, I don’t feel anything else is associated to
that, you might pick it up, I might not, but I don’t need to drag the vet and the
dog and the cat into it, I just want to dump for that situation and I think that’s
one of the big problems out there is , we do a lot of debriefing as a group over
an incident like this water incident we debriefed, all the people involved got
together what did we do good what did we do bad what can we improve on,
and it’s finished and it will always be there but it’s dealt with, whereas now go
and see a counsellor and I must deal with it for the next six weeks, plus
unrelated stuff that may come up and everyone has got baggage.”
2.5 Humour. Sarah stated that she is aware of the use of humour within EMS and feels
that it is used by people who are unable to express themselves. She reported that the use of
“black” humour is not a common occurrence at her place of work, due to the professionalism
of her colleagues.
“...it’s somebody who wants to say something but doesn’t know how to say it
so they put humour into it...”
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“...we all laugh at it, I think some of [us] appreciate it, some of us don’t
depending on how black it actually is... but one of the reasons why I’m so
happy here I think this academy is full of professional people...”
2.6 Professional identity as a protective factor. Sarah commented that putting on her
uniform transforms her into a different person allowing her to become “blunt to everything”.
This transformation is even evident to her husband. She later mentioned, however, that this is
not an infallible means of protection.
“My hubby says I do that, he says the minute that you put your put blue
uniform on you become a different person he says, and you put your blue
uniform on, and we can, you actually blunt to everything...”
Sarah recognises that putting on a uniform is a form of protection, however, she
revealed that at times this form of protection is ineffectual.
“...it’s a protective mechanism it is, but you still hurt believe me on that, you
do...”
4.3.1.4 Personal consequences of being a paramedic. Sarah described her experience
of being involved in a motor vehicle accident whilst responding to an emergency call. This
has resulted in her suffering from both physical and psychological difficulties. Sarah also
discussed her feeling that, due to her experience as a paramedic, she has become
overprotective of her son.
1. Car accident.
“...I think the biggest thing that happened to me was my car accident...”
2. Physical consequences. Sarah was hospitalised as a result of the car accident, and to
date she still experiences physical difficulties. This has had an impact on her ability to work
fulltime on the road.
“...I’ve had subsequent back surgery which they believe is directly related to it
from the whiplash, I was in hospital two weeks ago again with my back, I now
have total back problems which will never allow me permanently on the
road...”
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3. Psychological consequences. Sarah described the subsequent psychological
difficulties she experienced resulting from the motor vehicle accident. She revealed that she
struggled to drive an emergency vehicle due to the subsequent panic attacks as well as PTSD
symptoms she was experiencing.
“...psychologically I couldn’t get on the road again...”
“...panic attacks in the traffic, on Witkoppen Road, in the middle of traffic,
rush hour traffic realising there was a problem, then diagnosed with post
traumatic syndrome then put on anti-depressants...”
“...it’s amazing there’s still triggers to this day from that accident, yellow, the
yellow line, I don’t like you driving on that yellow line, that just triggers the
whole thing off, and that smell of burning tyres...”
4. Relationship with son influenced by being a paramedic. Sarah’s identity as a
paramedic has had an influence on her relationship with her son. Firstly, she feels that she
might be is over-protective of her son. Secondly, Sarah reports that she undergoes a
transformation when she puts her uniform on, which allows her to be blunted to the trauma
that she may be confronted with when attending to patients. Sarah is aware of the fact that
this could disrupt her interactions with her son.
“...as far as my son is concerned I think maybe just over protective, but not in
any, I just, I think any mom would do that, ummm... I’m very strict at his school
I do all the first aid training, I make sure his first aid kits are all sorted, and I
mean it’s paid off, my son choked, and one of the teachers actually did all the
right moves and sorted him out and I trained her, so I’m very, very... he
doesn’t go to anyone who doesn’t have CPR training, doesn’t have first aid...
that’s about it...”
“...if I go home in uniform and I’ve been working on the road I will literally
get in the scullery strip off, put something else on and go to my son...”
“...I have this wall apparently when I wear my blue uniform I don’t need that
with my son...”
4.3.1.5 Summary. Sarah discussed a critical incident which involved a child who had
drowned. She recounted how whilst responding to the call as well as at the scene she was
hoping for an alternative explanation for the child’s disappearance. Sarah found it traumatic
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having to witness the father’s pain and anguish from losing his daughter. She felt that a
possible reason for this is that she was able to relate to him as she has her own child. Sarah
explained how she felt “better” that the father of the drowned child did not blame anyone for
the drowning.
Sarah described her experience of working in the EMS field as being part of a “clique”.
She explained that her EMS colleagues are supportive in times of need, but at times they may
also be hurtful. Sarah stated that paramedics tend to isolate themselves from others, an
example of this, is when paramedics discuss work experiences. She pointed out that she
dislikes the public asking her what is the worst emergency call she has responded to. Sarah’s
reasoning for this is that members of the public are intrigued by “gruesome” scenes, but she
feels that their point of reference comes from programmes such as CSI.
Sarah felt that a negative feature of working for an EMS organisation is the inherent
occupational stressors, specifically shift work. She experienced shift work as exhausting and
recounted how, at times, she was unable to spend time with her husband.
Sarah was able to describe a number of occupational features that she feels are
meaningful. She explained that when she first started her career as a paramedic she enjoyed
the “buzz” and the “high” of responding to emergency calls. However as she matured in her
occupation the focus of the “adrenaline” or the “high” of responding to an emergency call
changed to having the “knowledge” and the “ability” to treat the patient. Sarah added that
she experiences her occupation as “dynamic”, as each day is different for her and she is
continuously learning. Sarah spoke passionately about treating and caring for patients
explaining that this is the reason why she is a paramedic.
Sarah’s decision to change her career from nursing to becoming a paramedic was based
on her need to make her own decisions with regards to patient treatment without having to
rely on others. She described paramedics as having “type –A personalities” which she
defined as paramedics enjoying being in control; she listed a number of attributes which she
felt was essential to have as a paramedic, yet she especially emphasised the importance of
maturity in her experience.
Sarah emphasised the importance of living a healthy life style in order to reduce stress.
She reported that, if she needed to discuss a difficult call she was able to debrief with her
work colleagues as well as her mother. Debriefing with work colleagues were approached
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from an educational stand-point or at times having the freedom to able to “download” or
“dump”. Sarah felt she was able to discuss difficult calls with her mother, as her mother
would just listen without providing any solutions or “suggestions”. She explained that
making use of “professional” psychological services was unhelpful, as she felt that she was
unable to discuss only the emergency call, as councillors would often discuss “unrelated
stuff”. Sarah felt that the time period of attending, namely six sessions with a councillor was
too long. She stated that paramedics who used “black” humour are individuals who are
unable to express their feelings. Sarah revealed that when she puts her uniform on she is a
different person. Putting her uniform on allows her to become “blunt”, however she felt that
this is not an infallible means of protection, as she still can feel “hurt”.
Sarah described that there has been a significant impact on her physical and
psychological well being due to her occupation as a paramedic. She discussed an incident in
which she was involved in a motor vehicle accident whilst responding to an emergency call.
As a result of the accident she has both physical and psychological difficulties. This included
a back injury for which she is still receiving treatment, which has reduced her ability to work
on the road. Psychological consequences included panic attacks and other PTSD symptoms.
She pointed out that she may be overprotective of her son. Linked to this, Sarah revealed that
she had used her knowledge and skills to provide first aid training to the teachers at her son’s
school and that she would not allow her son to visit friends if the parents have not had first
aid training. She added that her protective mechanism of becoming “blunt” could have a
negative impact on her relationship with her son.
4.4. Introduction: André’s EMS work experience
André is a 28-year old married male, and has 8 years’ experience as an ILS paramedic.
Directly after matriculating, André started working for a company that provided services in
the form of “stage effect lighting”. Whilst in this company’s employment, he stated that he
wanted to be able “make a difference” to others. André initially applied to join the South
African Police force; however, he did not complete the interview process. Whilst applying
for this position within the police force, the company for whom he was employed “closed
down”. André then decided to study and enrolled in the short courses in order to qualify as a
BAA paramedic. He added that his decision was also influenced by his family’s background
in medicine, as a number of family members had worked within the EMS field.
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André’s career as a paramedic began by volunteering for a private EMS company, as
well as working for an events company which required paramedics to be at certain events.
Once he had managed to gain enough experience and save enough money, he enrolled to
complete his training as an ILS paramedic. At the time of the interview, André had recently
moved from a private EMS organisation to a training collage. He is responsible for training
individuals who are interested in becoming paramedics. André is required to respond to
emergency calls and assist trainees in patient management and care.
André explains he finds dealing with emergency calls that involve children especially
traumatic. He recounted an emergency call involving a seven year old child who was
involved in a quad biking accident. André later revealed that although the call that he had
spoken of was traumatic for him, he also found the working conditions to be extremely
stressful. He felt that these working conditions and the continuous exposure towards critical
incidents led him to develop symptoms of Burnout.
4.4.1 Analysis and Discussion of André’s lived experience
4.4.1.1 Experiencing the trauma of Critical Incidents. André revealed that he
experiences emergency calls involving children as traumatic. He discussed an emergency
call that involved a seven year old child who had lost control of his quad bike, and had driven
into a brick wall. André described the child as still wearing his school uniform, without any
safety gear on. As a result of the accident, the child sustained a severe head injury.
André discussed his thoughts and feelings from when he received the call, when he
arrived on scene, and when he had completed the emergency call. He reported that he felt
that the parents were to blame for the accident, and he was angered by the parents neglecting
to look after the safety of the child.
1. Upon receipt of the call: Worst case scenario. André did not expect the
emergency call he was responding to, to be as severe as it turned out to be.
“...my first thought was that seriously can’t be that bad I mean it was a
residential area, and the streets were quiet, very, very quiet streets, one of
those very quiet sort of sleepy areas more than anything else. My first thought
was you know worst case scenario somebody’s broken an arm.”
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2. Upon arrival on scene: From curiosity to fear. André expressed his “curiosity”
and perhaps surprise when he did not find what he was expecting at the emergency scene.
“Oh ja I was expecting a car, you know the absence of the car made me sort of
got me a bit curious... ummm when I saw the kid lying there my first thought
was oh fuck...”
He then described his initial feelings of apprehension, nervousness and fearfulness. Yet
these feelings passed, as he was able to go through a process which he terms as “patient
treatment mode.”
“...apprehensive, nervous ummm very, very small amount of fear, scared of
what I might find, is probably my first thought processes there, and then they
just sort of kicked in to patient treatment mode.”
3. Immediately after the critical incident: Elation to anger. André explained that
immediately after the completion of the emergency call, he had a feeling of elation, and
added he did not think much about the call afterwards.
“...initially sort of some feeling of elation that we’ve done well, well I felt that
we’ve done well, everything has gone smoothly, managed our patient I didn’t
really think about it that much afterwards it was just another call for that day.”
He however stated that he began to feel angry whilst discussing the emergency call
with his partner on the ambulance.
“...a little bit of you know anger, especially when we discussed afterwards you
know...”
4. Blame and anger towards parents. André felt the parents were to blame for the
child being hurt in the accident. He stated that the child was not to blame, as children at that
age have not developed a “sense of danger”.
“...it’s a little kiddie of seven and a half you know it’s quite a big thing... you
know one of my thoughts, one of the things I said to the guys, you know that’s
the parents’ fault, and we had a bit of a discussion of why I thought it was the
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parents’ fault, seven years old he has no concept of danger, absolutely no
concept of danger...”
“Had the father just locked up the quad bike, you tell a seven year old time
and time again put this on put that on he’s not going to think about it, if
mommy and daddy is not home, and he wants to jump on the quad bike, then
he’s going to jump on the quad.”
When thinking back to the critical incident, André expressed his feelings of anger
towards the patient’s parents. This anger seems to have generalised towards all parents.
“...in retrospect, you know afterwards thinking about it, afterwards I was very
angry with the parents it doesn’t matter which way you slice it, it’s still the
parents fault at the end of the day...”
“...in my opinion actually the worst possible thing that could happen to them
[children] is their parents because it’s parental neglect to a large extent is the
result of many children dying...”
4.4.1.2 Experiencing in the “World” of EMS. André discussed his reasons as to why
he thought paramedics where separate from “others” as well as his experiences of working
for an EMS organisation.
1. EMS is a subculture. André stated that individuals who do not have experience
within the EMS field are unable to understand what paramedics go through when performing
their duties. Due to others not understanding he feels that paramedics are drawn to one
another. Highlighting the differences between non-paramedics and paramedics, André
expressed the anger he experiences when asked “What is your worst call?” by non-
paramedics.
1.1 They don’t quite understand. André explained that he finds it difficult to relate to
others, as they don’t understand what it is like to be a paramedic and have not had the same
experiences.
“...you can’t really relate to people, and they don’t quite understand what is
involved...”
“...it’s literally one of those you have to be there to understand kind of thing...”
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He adds that paramedics tend to “gravitate” towards each other as they understand one
another’s experiences.
“You also tend to gravitate to people who can understand you...”
“...you tend to gravitate to your own kind...”
1.2 What is the worst thing you have ever seen? André described how he is angered by
others who ask him about the worst emergency call he has had to respond to.
“...a lot of what I found a lot of the time is that, meet new people and you get
into the what do you do what do you do... and the age old question that drives
me fucken bat shit is ‘what is the worst thing you’ve ever seen?’...”
“...[I] detest that question... it’s the thing that a lot of people don’t understand
is that you don’t want those kind of questions you don’t want to talk about
work, you don’t want to tell them about the little kiddie that died the other week
because his mother didn’t strap him into his car seat...”
2. Negative experience of the EMS organisation. André felt that the organisation he
worked for provided marginal support or recognition for the work that he did. He added that
he found the lack of occupational growth; poor salary and shift work exacerbated an already
stressful environment.
2.1 Marginal support. According to André, the psychological support offered by the
organisation is outsourced, and it is up to the individual to make use of the service.
“...the support... sort of mechanism so to speak, were there in that uhhh... you
had access to ICAS service ummm... barring that, and that was more of a it’s
up to you kind of thing...”
He felt that he was unable to approach managers for assistance, as he feels that
managers are either emotionally unavailable, or paramedics simply do not trust them.
“...very few base managers that I found who actually really keep an eye on
their crew, you know, a lot of the base managers are of the old boys club, you
know the kind of guys who just suck it up and deal with it kind of thing.”
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“...they[’re] either not around their crews often enough or the crews don’t
really trust them enough to really open up to them or speak to them whatever
the case maybe...”
2.2 No Recognition. André felt that despite the effort and hard work he has put into
working for the organisation, he did not get enough recognition. He added that often he felt
the organisation was punitive in the management of paramedics.
“...there’s no recognition, there’s no ummm I think in the two years I was
there ummm I got some degree of recognition twice maybe... and that was
purely where letters from the public had been passed down to us..”
“...threats of written warnings and all the rest of that kak, no, never got
acknowledgement for anything, the only thing you got was ahhh you guys are
spending too much money or too much overtime or too much leave or... it
didn’t matter something is always wrong, you know...”
2.3 Inherent occupational stressors. André expresses his unhappiness with the limited
opportunities for growth within the organisation.
“I was very disillusioned with “A”, I was very unhappy with “A”, very
frustrated because I felt I could not really go anywhere in the company I
couldn’t move up...”
He felt that his salary was poor, and did not compensate for him missing out on his
family life due to the shifts he has had to work.
“...I mean you get paid a shitty salary, you know you work when everyone else
is kind of chilling and relaxing, you don’t have a family life that other people
have and you[’re] expected to be happy with that and you get told that your
salary is market related when it’s not, you salary is determined upon your
willingness to kiss ass...”
André explained that people do not seem to understand that he is required to work shifts
which results in him losing friends.
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“...you kind of loose some friends along the way, a lot of friends don’t
understand the shift system, don’t understand why you can’t come out jolling
this Saturday night.”
3. Meaningful work environment. André reported that making a difference in another
person’s life is the most rewarding experience of being a paramedic.
3.1 Making a difference. André explains that being able to save another person’s life is
“rewarding” and “makes up” for all the negative aspects of his occupation.
“...it just it makes up for all the bullshit and all the crap just knowing
definitively that you’ve really saved someone’s life.”
“...[I] have never encountered anything as rewarding as knowing definitively
that you’ve made a difference in someone’s life.”
4.4.1.3 Intrinsic factors and active attempts of coping with stress. André discusses
what he considers to be important characteristics for an individual to possess in order to
function effectively in a chaotic and stressful environment. Additionally, he discusses his
active attempts at managing the stress resulting from his exposure to critical incidents as well
as organisational factors.
1. Perceived need to be in control of the environment. Working in an environment
that André describes as “unpredictable” requires a paramedic to have certain attributes. He
reported that trying to create predictability and control in his environment planning is
required.
1.1 Attributes of a paramedic. André described paramedics as having “A-type”
personalities.
“...I think they call it the ‘A type’ of personality, I think, I might be completely
wrong, the assertive, the confident, bordering marginally arrogant type of
person, the kind of person who sees a problem sees a solution...”
He believes that a paramedic should be able to take control of a chaotic scene.
“...to be able to walk into chaos and go ok this is now how it’s going to happen
you can all shut up and sit down and this is what we are going to do kind of
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thing, as opposed to somebody is gonna like kind of I don’t know what to do,
you need to take charge, you need to be able to go, this is how we going to do
it, that kind of thing...”
1.2 Planning. André said that he mentally plans what he needs to do before arriving on
the scene. He considers factors such as the route he has to take, what equipment he may
need, access to the scene, and ensuring safety for himself and his partner.
“...first thought is route, what’s going to be the best route to get there...”
“...what equipment should I take in initially you know some calls it’s just the
jump bag and the oxygen, others it’s the monitor and the suction all the other
stuff that goes with it...”
“...getting in there, point of access or entry into the premises, whatever it was,
like a complex for example, generally very tight, sometime difficult where am I
going to turn around if I need to get out...”
“...safety always a big factor, what am I likely to find when I walk inside of the
house... ummm and then sort of general considerations get an idea of what’s
cooking what’s going on, sort of being aware of what the environment kind of
thing...”
2. Active attempts at reducing stress. André revealed that he has made use of
ineffective strategies to cope with stress, which include anger and alcohol abuse. Other
strategies of which he makes use are debriefing with his colleagues (ambulance partner), and
what he terms as “patient treatment mode” when on scene. André later discussed the use of
“gallows humour”.
2.1 Anger. André stated that he uses anger in order to reduce his levels of stress;
however he admitted that this may not be the best way of dealing with stress.
“...I vloek, I swear more than anything else, swear kind of throw shit around or
whatever the case maybe just to sort of get over it...”
“I get angry, bit moody and you know it’s done kind of thing... which isn’t the
right way to go about it I know...”
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2.2 Alcohol abuse. André describes how he would drink alcohol in order to help him
deal with stress.
“..I was one of them I was one of those guys who when you looked for your
answer in the bottom of the bottle...”
“...there was no such thing as going out to have a couple of drinks to enjoy
yourself, you went out and got trashed, that’s all there was to it...”
2.3 Debrief with ambulance partner. André stated that after completing an emergency
call, he will often speak to his ambulance partner about the call. These discussions revolve
around the functional aspects of the call, such as whether they could have performed better or
done something differently, rather than how they actually feel. He finds this helpful as he is
able to talk to someone who had the same experience as he had.
“...it’s more a case of you know we did well we didn’t do so well, we could
have done this better we could have done that better kind of thing, as opposed
to an actual you know how did you feel about this how did you feel about that
kind of thing...”
“...so speaking to somebody who you can relate too in that ummm you know
they can get a mental image of what the concept is or what you know what the
person was seeing what they were experiencing kind of thing...”
2.4 Patient treatment mode. André described a process he terms as “patient treatment
mode”. Through this process, he is able to concentrate on treating the patient without being
negatively affected by the fear or apprehension he may be experiencing when on scene.
“...apprehensive, nervous ummm very, very small amount of fear, scared of
what I might find, is probably my first thought processes there, and then they
just sort of kicked in to patient treatment mode.”
Which he describes “patient treatment mode” as:
“...get your shit together and treat the patient...”
2.5. Gallows Humour. André reported that humour is used as a means of coping.
“Gallows humour... to some extent its bit of a coping mechanism...”
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He feels that “gallows humour” is inappropriate; however, it is used as a means to find
humour in dealing with macabre scenes.
“...all of it is really inappropriate ummm but there’s times when I sort of
almost like got this instinct to kind of judge the mood... find something funny in
the macabre...”
4.4.1.4 Personal consequences of being a paramedic. André initially stated that as a
result of working over-time a lot he became “burnt out”. He added that this had a negative
impact on his desire to work and that his relationship with his fiancé (now wife) became
strained. André pointed out that he feels the problem was located in his inability to “switch
off” from work. He summed up his experience of burnout as resulting from not just one
critical incident or one patient but rather due to a number of critical incidents and work
stressors over a period of time.
1. Burn out. André stated that he became exhausted and eventually burnt out as a result
of working of over-time a lot.
“I was burnt out...”
“...was tired... I.... very tired from working a lot, I worked a lot of overtime...”
He reported that as a result of him being burnt out he lost his desire to work and felt
that he displaced his anger onto his then fiancée.
“I actually became one of those people who I detested in that I was one of
those people who would argue with the dispatchers and question as to why I
was being sent to a particular area...”
“I didn’t have it anymore I had no desire to work anymore, had no desire to do
calls...”
“I ended up blowing my fuse at my well then fiancé now wife, in a shopping
centre over something totally, totally irrelevant...”
2. Switching off. André felt that he was unable to separate his personal and work life
resulting in him being unable to engage in aspects other than medicine. He explains further:
“...the majority of my social life revolved around my work colleagues and there
was no real down time, in that there was no, when you[’re] not, you know
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switched off from medical thinking about something... it was more work, work,
work, work.. you know you go to a braai and you talk work, you go out for
drinks and you talk work, you know.. it doesn’t matter what you do, you talk
work.”
3. It was a progression of factors. André felt his experience of critical incidents as
well as other factors contributed towards his psychological suffering, which he termed as
“burnout”.
“...it was a progression it wasn’t something that just happened it was a
progression.. and ja it just got worse and worse and worse...”
“..you don’t get burnout from one call or one scene or one patient it’s a
progression of factors you know, this scene followed by that scene, followed by
that, followed by that you know.”
“...it’s not just one call, it’s not just one patient it’s a number of factors...”
4.4.1.5 Summary. André revealed that he experiences emergency calls involving
children as traumatic. He discussed a specific critical incident that involved a seven year old
child who had lost control of his quad bike, and had driven into a brick wall. André discusses
his thoughts from when he received this call, when he arrived on scene and when he had
completed the emergency call. On receiving the emergency call, André thought that the
emergency would not be as severe as it turned out to be. When he arrived at the emergency
scene he experienced “curiosity” and perhaps surprise when he did not find what he was
expecting. As he came to realise the seriousness of the emergency André felt apprehensive,
nervous and fearful yet he was able to control these feelings through undergoing a process
which he terms as “patient treatment mode.” Directly after completing the emergency call
André explained that he felt elated, and that initially he did not think much about the
emergency call. However later whilst discussing the emergency call with his colleagues he
became angry. His anger was directed towards the patient’s parents blaming them for their
lack of vigilance in ensuring the child’s safety. André is angered by parent’s inability to look
after their children, stating that many children die due to parental neglect.
André explained that EMS is a subculture as individuals who have had no experience
within the EMS field are unable to understand the difficulties and experiences that
paramedics undergo whilst performing their duties. He felt that the experiences that
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paramedics share resulted in paramedics being drawn to one another and excluding others.
André highlighted the difference between non-emergency personal and paramedics, by
expressing his anger when asked what his worst emergency call he has been to. He is
angered by this question, as he does not want to recall horrific emergency scenes.
André’s negative experiences of the EMS organisation he had worked for consisted of
his belief that they provided marginal support, no recognition and that certain aspects of the
occupation were stressful. He felt that the organisation did not play a sufficient role in
supporting paramedics, adding that managerial staff where either emotionally unavailable or
unapproachable. This has made it difficult for André to ask for assistance when he required
it. He explained that he felt that EMS organisation provided little recognition for the effort
he had put in to his job and that at times the management were punitive in their interactions
an managing of paramedics. André reported that he became disillusioned and frustrated with
his employers as they provided limited opportunities for occupational growth. Adding to his
frustrations was the poor salary he was earning as well as the shift work he was required to
do. He stated that his family life as well his social life was negatively impacted upon as they
do not understand that he is unable to spend time with them when he was required to work a
shift. As a result of him working shifts he has lost a number of friends.
André finds meaning in his chosen occupation through assisting others and making a
difference in another person’s life. He said that making a difference to another person’s life
was rewarding, and that it “makes up” for all the negative aspects of his occupation.
André described the paramedic working environment as unpredictable. In order to be
able to function in this environment André explained that paramedics are required to have
certain attributes. He stated that paramedics should have “A-type” personalities, that is, an
individual who is assertive, confident and is able to provide a solution to and be able to take
control in a chaotic situation. André explained that he plans ahead when responding to an
emergency call stating that he would consider what the best possible route to the emergency
call would be, what equipment he may require when on scene, as well as ensuring his and his
partner’s safety.
André revealed that he has made use of ineffective strategies to cope with stress,
including anger and alcohol abuse. André described that his attempts towards to reducing his
stress levels by swearing or throwing things around, admitting that this was an ineffective
strategy to reduce stress. André explained that at times he would drink large quantities of
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alcohol to assist him in reducing his levels of stress. He reported that a more effective
strategy is to debrief with his colleagues, as he is able to speak to someone who had the same
experiences that he had. These debriefings concentrate on the functional aspects of the call
rather than what they were feeling during or after the call. André revealed that, upon arrival at
an emergency scene, he at times experiences fear, nervousness and apprehension, he
explained that he overcomes these feelings by what he terms as going into “patient treatment
mode.” This process allows André to perform his duties adequately and professionally when
tending to a patient. André was aware of the use of humour amongst paramedics describing
this form of humour as “gallows humour”, where paramedics are able to find humour when
confronted with macabre scenes. Although inappropriate, André felt that this form of
humour was a coping mechanism.
André reported that the paramedic occupation has had a negative impact on his personal
life as well as on his desire to continue working in his chosen profession. Having worked
many shifts and “over-time” André explained that he became “burnt out”. This resulted in
him having arguments with his fiancée; he added that he lost his passion to work. André
explained that his experience of “burnout” resulted from not only working overtime but also
from being unable to separate his work life from his personal life. He stated that his social
life included spending time with work colleagues thus he was unable to “switch off” from
work. André summed up his experience of negative psychological symptoms as resulting
from occupational stressors, as well as from being exposed to multiple critical incidents.
4.5. Introduction: George’s EMS work experience
George is a 36 year old male with 12 years’ working experience within the EMS field.
At the time of the interview, he had two years’ experience as an ALS paramedic. He
described his interest in becoming a paramedic as a “dream” of his. When George was a
young boy, his home was near a fire station; he would often drive past it and comment to his
mother that he was going to work at the fire station one day. His interest grew when he joined
a scouts group which made regular trips to the fire station. George later completed the short
courses in order to become an Advanced Life Support paramedic. He has worked for a
number of private organisations, as well as for government as both a paramedic and fire-
fighter. At the time of the interview, George was working for a government training centre.
He was responsible for training ILS paramedics to qualify as ALS paramedics. His students
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would accompany him on emergency calls, so that he could train them in providing advanced
emergency care to patients.
George felt that he is able to cope with the horror of emergency calls due to the support
mechanisms he has in place. Despite this, he stated that he struggles with self-doubt,
continuously wondering if he has performed competently and provided the best possible
treatment to the patient. George recalled a specific emergency call in which he treated a
patient with a septic ulcer and handed him over to the hospital staff. According to him, the
patient was doing well by the time he got him to hospital. Later that night, however, he
received another emergency call to respond to the same emergency scene. On arrival, at the
home of the patient he had previously treated, he found that the patient had passed away.
This emergency call left George with a lot of self-doubt and wondering whether he had
provided the correct treatment to the patient.
4.5.1 Analysis and Discussion of George’s lived experience
4.5.1.1 Experiencing the trauma of Critical Incidents. George considers burns
patients to be the worst emergency calls to attend to, due to the low chance of survival.
1. Burns patients are the worst. George revealed that he experiences burns patients
as the worst emergencies to manage as, despite the treatment provided, there is little chance
of the patient surviving.
“...I think burns patient is the worst because there’s nothing you can do for
them, absolutely nothing you know, you know that they are not going to make
[it], they might not see the next day they might not see the next week, especially
those burns patients, ja not good.”
When questioned as to which specific call he found to be traumatic, George discussed
an emergency call in which he was required to treat the same patient twice on the same day.
When he first responded to the call and after the initial assessment the patient was diagnosed
with a septic ulcer. Whilst on route to the hospital, George provided emergency treatment
and the patient’s condition improved. After handing the patient over to the relevant treating
facility, George continued with his shift. Later that evening, he was asked to respond to the
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same address of the patient he had treated. On arrival, the patient’s condition had
deteriorated severely and ultimately the patient died on scene.
George was initially surprised at having to go to the same address twice. After seeing
the patient on arrival, he began to question himself regarding the treatment he had provided
the patient with. Perhaps adding to George’s self-doubt and stress, he was then required to
inform the family of the patient that their son had died.
2. Novelty of the call. George expressed his surprise at having to return to the same
address twice.
“...I mean it’s hardly that you go back to the same address twice you know.”
Having treated the patient previously and seen an improvement in the patient’s
condition, George was shocked at the severity of the patient’s condition and began to
question what had happened.
“[Previously] he was fine, he was 1000%, gave him the medication on route to
hospital, everything was fine, handed him over to hospital nothing wrong... I
still showed him thumbs up and he said you know [shows thumbs up] and then
that’s one of those calls that you feel you know what you saw him in this
condition and look at him now he's much better, it was like just after 12 at
night, we went back to the same address and the guy was basically dead, and
we resused [resuscitated] the guy, that you got to think off you know, what
happened there.”
3. Questioning his ability. George began to question himself about what he could
have done differently in order to have prevented the death of the patient.
“...he just didn’t make it... so that’s one of the things you think about, it gives
you something that you did... that maybe you know could have been different or
could you have done it quicker or better type of thing.”
George stated that he went through the call in his mind over and over again to try and
assess what he could possibly have done differently.
“...analyse and reanalyse and analyse and reanalyse and you think maybe I
should have done that maybe this maybe that.”
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4. Family involvement is stressful. George empathised with the family, and felt that
having the family present as well as having to notify them that their son had passed away,
added to the stress he was experiencing.
“.. it’s not like your high income people who knows this, you tend to think what
you have and you tend to relate it to some people someway... I mean the areas
that we go to see patients in, you really kind of feel sorry for the people...”
“I think also the other thing is the family was involved as well, because the
mom and dad were right there...”
“..the main thing was I think the family, because also I had to tell them listen
hey your son didn’t make it...”
4.5.1.2 Experiencing in the “World” of EMS. George relates his experience of
working as a paramedic and his experiences of the EMS organisation.
1. EMS is a subculture. George felt that the public has no understanding towards the
experiences of what paramedics have to do.
1.1 Public has no understanding of EMS. George considers the public’s lack of
understanding regarding how the EMS functions or what they are required to deal with as the
reason why EMS may be considered to be a subculture. He added that perhaps the public is
not concerned about how the EMS functions, as when paramedics arrive on scene the
public’s expectations is for the paramedics to assist them irrespective of their level of
expertise.
“...I don’t think that the public actually knows what we deal with, what we
actually do, I think that’s the biggest thing they don’t know the difference
between what a fire-man can do, what a BAC [is], they don’t know the
difference, for them it’s I need help and whoever comes I hope can actually
help, and that’s the general, how can I put it, perspective that people have.”
2. Negative experience of the EMS organisation. George explained that working in
EMS is stressful despite; despite this he is unsure of the measures that are put in place to
assist paramedics. Although support programmes are available for paramedics, he felt that
paramedics make use of this when there are familial difficulties and not specifically for
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assistance in dealing with emergency calls to which paramedics have responded. George
finds dealing with families of patients to be particularly stressful for him.
2.1 Inadequate support: Nobody to speak to. George explained that when assistance
was given, paramedics would often not make use of it. A possible reason for this is that
paramedics could be labelled as weak by their colleagues.
“... it is a stressful environment definitely... the guys I don’t know... I think we
must have programmes in place, we always say phone the chaplain to help the
family [paramedic’s family]... you know what I mean... then you think fine
chaplains coming... run away... then you never end up speaking to anybody
about it...”
George feels that the support offered to paramedics and their families in certain
organisations is adequate, specifically if there was a familial crisis. However, he feels that
the support system available is never used for work-related trauma such as critical incidents.
“... a good support system that I see at “A”, they have a good support
system...it’s a phone call and the people arrive in 10-20 min, and I think that’s
good for the family... but like I say.. you never use it after a [emergency] call...
you get in your car and bugger off... and there you go and there’s nobody for
you to speak to...”
George offered an explanation as to why paramedics do not make use of support
systems.
“...you kind of think that somebody is weak when somebody is booked of for
stress and you think, why is [he or she] being booked of for stress? what the
hell?”
Despite the perceived conception that individuals are “weak” when making use of
support systems, George feels that being aware of the fact that a system was in place could be
helpful.
“Just knowing that there are people around that can help, you know there’s a
support structure in place, I think ummm... I mean you don’t really have to tell
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someone hey you know I need to speak to somebody, but I think what is
important...”
2.2 Inherent job stressor: The patient’s family. George reported that he experiences the
expectations of the families involved in the emergencies as stressful.
“...that expectation I think that the family put in you please you know you know
just fix the oke [the patient] up, I think that can affect it, like I said the family
are the worst, always expecting more...”
3. Meaningful work environment. George explained that his occupation is
meaningful for him as his working environment is varied. He added that making a difference
in another person’s life is also rewarding. George reported that he gains job satisfaction
through training others.
3.1 Varied work environment. George said that although he may go to similar
emergency calls, no two of them are the same.
“...you can go to two resuses [resuscitations] and it’s not the same, you can go
to two MVA's and it’s not the same ummm, you can go to a shooting now that
the guy actual is 100% and the next moment you can go to a shooting and the
guy is dead or he is almost dead... that type of stuff... I suppose it keeps it
interesting...”
3.2 Job satisfaction: Making a difference and Training others. George feels that helping
others and making a difference in their lives is important. He added that he enjoyed training
others.
“I think it’s more helping people, I think that’s the main thing... It’s just
making a difference you actually, it’s more, I’d say it’s, it’s like what I
suppose, like job satisfaction where you can see ja I actually made a
difference...”
“...looking at what the guys are doing, job satisfaction is helping them do the
right thing, that for me is more satisfying than actually...”
“...I part with knowledge that’s what I do on a daily basis, I enjoy it you
know...”
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4.5.1.3 Intrinsic factors and active attempts of coping with stress. George discusses
innate factors as well as additional coping strategies that he considers important to manage
stress that he experiences.
1. Perceived need to be in control of the environment. George described the
attributes an individual requires in order to become a competent paramedic. He reflected on
his own need for reassurance that he has provided the correct treatment to a patient, adding
that he requires more experience as an ALS in order to feel more competent and in control of
his environment.
1.1. Attributes of a Paramedic. George stated that paramedics need to have leadership
skills or “A-type” personalities.
“...you need to be able to take leadership, ummm... and I think that’s the most
important need for me actually you need to have a little bit of a they call it A
type of personality I don’t even know what it means but you need to be
assertive to a point and that type of thing, control ja, you need to have a kind
of, kind of attitude, attitude is not the exact right word, to be a person that can
do that type of stuff, to be a strong person basically.”
1.2. Need for reassurance. Being in “control”, or at least feeling in “control”, requires
confidence in one’s ability. George said that he requires reassurance from more experienced
paramedics that he has correctly managed his patient.
“..I think is what I could have done better, could I have actually made a
difference that’s what bugs me most of the time.”
“...for me I need [to] get reassurance still because I’m new in the ALS field for
me it’s like maybe I could have done that or used that drug, or how would it
have affected the outcome...”
“...did I do the right thing, you know that sometimes bugs you, bugs me for
sure, you have I wouldn’t say sleepless nights but you, you kind of go to bed
and you sleep and you wake up and you think to yourself you know maybe this
or that or whatever could have been different, that happens from time to
time...”
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1.3. Experience is important. After some self-reflection, George added that he still
required more experience, which would assist him in becoming a more skilled paramedic by
making the correct decisions when treating a patient.
“Like I say, so the main thing for me is gaining more experience and also
making a decision to do the right thing...”
“...that's the thing, for me, it will make me a better paramedic, I can say.
Cause you'll always think that experience tells you this - that's what you need
to do”
2. Active attempts at reducing stress. George reported that there are a number of
strategies that he employs to assist him with his stress. He stated that he feels that it is
helpful to discuss emergency calls with his colleagues and his wife. In addition, he feels it is
important to engage in a life style that is separate from the EMS world. He achieves this
through exercise and playing computer games.
2.1. Informal debriefing with colleagues and wife. George stated that discussing
emergency calls with his colleagues and his wife helps him to reduce his stress.
“...the guys just tell stories... but I think that’s how they cope with it, because
we can sit here the whole day and speak about it, I can tell you lots of
stories...”
“...we always used to sit for hours and just let’s speak to each other, and that
seemed to help. ..”
“...speaking to colleagues, speaking to people and speaking to my wife as well
because she's straight to the point... she doesn’t beat around the bush... that
helps as well.”
2.2 Additional coping strategies: Escaping EMS. George explained that he will take
part in activities that allow him to “escape” from the EMS world. He stated that playing
computer games and exercising allow him to achieve this.
“... I go play some flight-simulator on the computer, put myself in my own little
world, or ummm I swim often... like [in] a swimming squad... I generally go on
a regular basis and these guys don’t know anything about EMS but they[’re]
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not connected in any way... it’s a total different... I can tell them, they don’t
really they don’t care... so I think that kind of helps...”
4.5.1.4 Personal consequences of being a paramedic. George revealed that when he
initially began his career in EMS, he would go “hunting” for patients, however later in his
career he realised that there was more to life than seeing dead people. George discussed the
photo album he keeps of various emergency scenes. When looking at the pictures he is able
to recall the details of that particular call. George stated that working in EMS exposes the
individual to the “bad side of life”.
1. Wanting to see more and more. George reported that he would actively search for
patients adding that he wanted to see more and more. His pursuit towards witnessing as
much as possible later changed as he began to realise that there was more to life than seeing
dead people.
“I don’t go hunt for patients anymore that type of stuff... I used to when I
started in the service, because then you want to see more and more and more
and more, you get to a point in your life, but you know why, you know it’s
there’s more to life than actually seeing dead people everyday...”
2. Re-experiencing emergency scenes. George stated that despite being reminded of
certain emergency scenes, he was not adversely affected by this. He reported that he could be
reminded of a particular emergency call by something as simple as a piece of cloth or by
driving past the scene of the emergency. Later in the interview, he revealed that at times he
avoids areas that remind him of certain calls.
“...you can drive past a tree where someone was killed, you never forget you
always think about it but you not gonna have sleepless nights about it...”
“...a piece of clothing that can remind you of something, it’s like a trigger I
think, like when you drive past a house, for me I just avoid it, try avoid that
route sometimes if it was a really bad incident.. so ja... you never forget it’s
always in your mind...”
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Interestingly, George has kept an album of particular emergency scenes he has
responded to. He explained that the album reminded him of his past, both the good and bad
times.
“I used to keep an album of like MVA's and things like that, and then obviously
you not allowed to show it to the public but ummm... that car accident was
quite a bad car accident, you know if you look at a picture you can recall it
instantly, up to the finest set of details you can recall...”
“with the album you just take pictures, there’s pictures of everything in there,
there’s accidents and there’s good and bad times in there, like ummm, think
back to the good old days, but certainly not for the accidents and the gore
pictures and stuff...”
3. Exposed to the bad side of life. George stated that due to him being exposed to
numerous critical incidents, he had reached a point where he lost his empathy.
“...you tend to get to a point where you think you know what I’ve seen
everything, you lose your empathy, because the time I was out of service you
change as a person, you change because then you like... you like me... you
drive past a dog that’s been driven over on the side of the road and you feel
sorry for it... you know what I mean, but like I think when you in this industry
when you see it every day, all day, you don’t... stuff like that doesn’t bother
you...”
He added that he was exposed to the “bad side” of life, losing touch with the “good
side” of life.
“...you only get exposed to the bad side of life, don’t ever see the other part...”
“...the more you interact with people you actually realise but you know what
there’s more to life than actually sitting in the environment where you just wait
for bad things to happen so I think you never pick up the good things in life, I
think... you may not pick it up, but you like kind of lose touch with it you
don’t...”
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George reported that at times insignificant things would cause him to feel angry and
become aggressive towards others.
“I think change in attitude towards people... a little bit more aggressive, I can
certainly say I got, you tend to have your bad days you know what I mean... so
let’s say it was a bad day at work... ummmm... take it back home and ja
certainly more, maybe if there’s kak it will tick you off, you more irritated with
certain little things, that’s not normal, I think the only negative thing is that, I
think that for me is the bad thing...”
4.5.1.5 Summary. George stated that he finds burns patients to be the most traumatic
patients to treat, as he feels that despite the treatment provided there is a high likelihood of
them dying. When questioned as to which specific call he found to be traumatic, George
discussed an emergency call in which he was required to provide emergency treatment to the
same patient twice. The first time he treated the patient, and the patient’s condition
improved; however, when called out later for the second time, the patient died despite
George’s earlier efforts.
According to his narrative of his experience, George progressed from initial surprise at
being called out twice to the same address, to the shock of seeing the patient he initially
treated had died. It was during that time George began to question his management and
treatment of the patient. He described how he ruminated on the treatment he had
administered to the patient, wondering if he could have done something different. George
added that he empathised with the family and that having to tell the patient’s parents that their
child had died was stressful for him.
George reported that there is a divide between those that work in EMS and the public as
the public does not understand what paramedics do or what they are required to deal with.
He pointed out that perhaps this is to be expected, as when members of the public require
assistance from paramedics they are only concerned with receiving the necessary help.
George reported that working in the EMS field is stressful, yet when asked if the EMS
organisation offers any support to assist him with this stress, he was unsure regarding what
programmes are available to assist him or other paramedics. He explained that there were
programmes available to assist paramedics with familial problems, however he feels that
there is no one to talk to with regards to critical incidents. George added that even if support
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is offered, paramedics tend not to make use of this. He provided a possible explanation for
this, namely the fact that other colleagues may interpret those that do make use of the support
as being “weak”. Despite the possibility of being labelled “weak” George felt that it was
important that a support structure should be made available to paramedics. George reported
that he found interacting with families of patients as especially stressful for him.
George explained that his occupation is meaningful to him as the environment in which
he works is varied, which keeps him interested in his occupation. In addition to this, he
stated that making a difference in others’ lives and training others provides him with job
satisfaction.
George described paramedics as requiring an “A-type” personality which he defined as
an individual who is a leader, is assertive and in control. A sense of being in control requires
the individual to be confident in his or her abilities. George stated that he is still requires
more experience as an ALS, and as he lacks this experience he requires assurance from more
experienced colleagues that he has managed his patients correctly.
George commented that he is able to cope with stress because he has the opportunity to
discuss emergency calls with his colleagues as well as with his wife. In addition, he stated
that he enjoys playing computer games as this allows him to escape from the world of EMS.
Another coping strategy that George finds helpful, is belonging to a swimming “squad” along
with individuals who do not belong to EMS.
George stated that when he initially began his career in EMS, he would actively search
for patients as he wanted to see and perhaps experience more and more. However, as time
progressed he began to realise that there was more to life than seeing dead people. Despite
this, George kept an album of emergency calls to be reminded of good and bad times.
According to him, there are “triggers” that remind him of certain emergency calls. Initially,
George stated that he was not affected by these triggers, yet later he revealed that he would
avoid certain routes if the emergency call was “bad”. Having been continuously exposed to
critical incidents, George felt that he was only exposed to the “bad side” of life which he felt
caused him to lose touch with the “good things” about life as well as leading to a loss of
empathy towards others. He added that working in EMS changed his attitude towards others,
as he became more aggressive and irritable in his interactions.
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4.6 Integrated overview of the participants master themes
In the previous section, each of the five participants were briefly introduced, following
which, an analysis and discussion of their lived experience of critical incidents was presented.
The analysis of each of the participant’s transcripts provided four master themes, some of
which are supported by superordinate themes. These are:
Experiencing the trauma of critical incidents
Experiencing in the “World” of EMS
o EMS is a subculture
o Negative experiences of the EMS organisation
o Meaningful work environment
Intrinsic factors and active attempts of coping with stress
o Perceived need to be in control of the environment
o Active attempts at reducing stress
Personal consequence of being a paramedic
The following summary will provide an integrated overview of the four master themes
derived from all of the participants.
4.6.7 Experiencing the trauma of Critical Incidents. The participants were asked to
recall an incident that they experienced as traumatic. The participant’s descriptions of their
feelings, emotions and thoughts regarding the experience of critical incidents varied
considerably. Subjective accounts of lived experiences may and can be influenced by the
individual’s previous experiences of critical incidents, their coping mechanisms, and their
stance in the world.
Of the five participants, only one participant (Paul) maintained that he did not find
much traumatic. He, however, described an incident that he found traumatic when he was off
duty, recounting his frustration in having to deal with the EMS in trying to get assistance for
the patient as soon as possible. Four of the five participants (James, Sarah, André and
George) were able to recall critical incidents that contributed towards them experiencing
some form of psychological distress. However, only one of the participants (James) was able
to report that three specific critical incidents that occurred during one shift involving a
particular type of patient (burns patient), contributed towards him experiencing psychological
difficulties. These distressing psychological symptoms included re-experiencing the event, as
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well as avoiding treating burns patients. Two participants (Paul and André) feel that critical
incidents tend to merge together. One participant (Paul) maintained that he has not been
affected by the combined traumatic experiences, whilst the other (André) reported that the
continuous exposure to various critical incidents as well as work stressors contributed
towards him experiencing psychological distress in the form of burnout.
With regards to the type of patients that the participant felt were the most traumatic to
treat, two participants (James and George) found dealing with burns patients to be the most
difficult, as despite the treatment provided to these patients there is a high possibility of them
dying. Two participants (Sarah and André) reported that children were the most difficult for
them to treat. One participant (Sarah) felt this was due to her being a parent and having her
own child. The other participant (André) did not provide a specific reason regarding why
treating children was traumatic for him.
The following provides a summary of the thoughts, feelings and emotions recounted by
the participants. These were divided into three stages, namely the thoughts, feelings and
emotions they experienced whilst responding to the emergency; on arrival and during the
emergency, and after or on completion of the emergency call. It is important to note that the
attempt at categorising the thoughts and feelings of the experience of critical incidents is not
an attempt at reducing the individual participants’ experience to just three categories, but an
attempt at gaining a better understanding of the essence of the experience of critical incidents.
In addition, it should be noted that not all of the participants’ descriptions critical incidents
provided enough information to fit into these categories. The categories, regarding their
thoughts, feeling and emotions of critical incidents are as follows:
1. Whilst responding to the scene. One participant (André) was not expecting the
emergency scene to be “that bad”; however on arrival this initial thought changed. Another
participant (Sarah) had some knowledge with regards to the severity of the emergency, but
she was hoping for an alternative explanation or perhaps that the emergency call was a “false
alarm”. One participant (George) was confronted with an experience that was “new” or
“novel” to him, that is, having to respond to the same emergency scene and treat the same
patient he had already treated on that same day.
2. During the emergency. A variety of thoughts, feelings and emotions were
described by the participants; these were horror, helplessness and empathising with the pain
that the patient was enduring (James), initial apprehension, nervousness and fearfulness
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which was brought under control through a mental process called “patient treatment mode”
(André), hoping for an alternative outcome and empathy towards the father’s pain because of
losing his daughter (Sarah) and self-doubt about the ability to treat the patient, empathising
with the family and having to notify the family that their son had died (George).
3. After the emergency scene. One participant (André) described feeling elated at
having done a good job; however, these feelings later changed to anger. This anger, which
included blame, was directed towards the parents of the child he had treated. Another
participant (Sarah) felt relieved that the father of the drowning victim did not blame anyone
for the accident. One participant (George) continued to question the treatment he had
provided.
4.6.2 Experiencing in the “World” of EMS. The analysis of the data revealed that the
participants’ experience of critical incidents were embedded and influenced by two specific
contexts firstly, the context of belonging to a specific group known as “paramedics”, and
secondly, the context of the working for the “EMS organisation”.
EMS is a subculture. The participants set themselves apart from the rest of “society”,
as they felt that “others” were unable to understand the experiences and difficulties
paramedics endure and share. One participant (George) felt that this is understandable, as the
public is only interested in receiving the necessary medical assistance when they need it.
Two of the participants (James and Sarah) explained that non-paramedics are only able to
base their understanding of being a paramedic on television programmes, which are
inadequate in portraying the world of paramedics in its entirety. Two of the participants
(Paul and André) felt that the “experience” of working as a paramedic could only be “felt”
and understood if an individual was a paramedic as well, as the “experience” cannot be
conveyed to non-paramedics meaningfully through explanation.
The experiences shared by the participants and their colleagues draw them closer
together as a group, yet in doing so it has excluded non-paramedics from entering the world
of paramedics. As discussed by two of the participants (Sarah and André), “others” are
further excluded in social settings from entering the world of paramedics, as paramedics will
often discuss their occupational experiences whilst socialising. One participant (James)
reported that he also feels further isolated at his place of work; he explained that this is due to
the differences in training and qualifications at his workplace. He was trained as a
paramedic, whilst his colleagues were trained to provide fire rescue services as well as
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emergency medical treatment. Despite paramedics discussing their experiences with each
other, two of the participants (Sarah and André) often feel angered by non-paramedics’
questions regarding the worst call they have had to attend. They explained that the question
anger them as they are then forced to recall traumatic incidents that they would prefer not to
remember.
Negative experiences of the EMS organisation. The analysis of the participant’s
transcripts revealed that the participants have experienced a number of stressors related to
working in an EMS organisation. Four of the five participants (James, Paul, André and
George) feel that the organisations for whom they work do not provide enough psychological
support for paramedics. In addition, one of the participants (André) stated that the
managerial staff is not emotionally available to paramedics when he requires assistance or
support. Two of the participants (Paul and André) explained that psychological support is
outsourced to another company, and at times it is up to the individual to contact this company
for assistance. Despite reporting that the organisations do not provide enough support, the
participants generally view seeking assistance from professionals in a negative light; for
example, seeking help is a form of punishment (Paul) or seeking help could be interpreted as
being weak (James and George).
The participants feel there are a number of organisational factors that contribute
towards their stress. There of the five participants (Paul, André and Sarah) feel that shift-
work is especially stressful. One of the participants (André) explained that shift-work
negatively impacted on his time to socialise with family and friends, due to him being unable
to attend functions on weekends or evenings, when they are required to work shifts. In
addition it was noted that shift work had a physical impact on two of the participants: losing
weight (Sarah), and difficulty in adjusting their “body clock” (Paul) according to the various
shifts when required to work.
Additional occupational stressors reported by the participants included interacting with
family members of a patient (James and George), lack of occupational growth opportunities
(Paul and André), poor salary (André), the increased responsibility of being an ALS
paramedic (James), inherent dangers of working as a paramedic which could lead to death or
injury (James), and lack of recognition from managerial staff or the organisation itself
(André).
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Meaningful work environment. Despite the horrors associated with the occupation of
being a paramedic, all of the participants feel that their vocation has brought meaning and
satisfaction to their lives. Although the environment in which paramedics work is
unpredictable and at times chaotic, four of the participants (James, Sarah, Paul and George)
feel that the unpredictability contributes towards the occupation being exciting and varied.
All of the participants reported that being able to make a difference or saving a person’s life
has brought a significant amount of job satisfaction, which they feel makes up for any of the
negative experiences they associate with the occupation of being a paramedic.
4.6.3 Intrinsic factors and active attempts of coping with stress. The participants
described various means of coping with stress. These included intrinsic factors required to
bring order and predictability in a chaotic environment as well as active strategies used to
reduce the effects of stress resulting from the exposure of critical incidents and other work
related stressors.
Perceived need to be in control of the environment. The analysis of the transcripts
revealed that the participants feel that there is a “need” for paramedics to be in “control” of
the emergency scene they are confronted with, as well as regarding how they conduct
themselves within the EMS world.
Four of the five participants (Sarah, James, André and George) feel that it is important
for a paramedic to have a number of personality attributes in order to function effectively
within a chaotic environment. The list of attributes provided by the participants varied;
however, three of the participants (Sarah, André and George) described paramedics as
requiring an “A-type” personality. Descriptions of the “A-type” personality also varied; a
consistent factor mentioned by the three participants was an ability to be in “control”.
Further analysis revealed that the participants rely on a variety of strategies in an attempt to
“control” their environment, which includes relying on prior experiences of attending
emergency calls, pre-empting what they may expect at an emergency call, and having
confidence in their training. Being assertive, confident and having a strong personality were
also regarded as important attributes that paramedics are required to have in order to function
affectively.
Active attempts at reducing stress. The participants discussed a number of strategies
that they employ in an attempt to reduce stress which they experienced resulting from
occupational demands as well as from critical incidents. Informal debriefing with fellow
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colleagues was identified as the most popular means of reducing stress by all the participants.
These discussions, normally regarding an emergency call that they had attended to, are
generally done in an informal manner and setting. The content of the discussion tends to be
based on the functional aspects of the call, such as where the paramedic felt they could have
done something different in terms of patient management, and how they could improve on
their performance in the future. The participants feel that these discussions are helpful, as it
allows them to discuss emergency calls and assists them in resolving any functional
difficulties they may have experienced during the emergency call. Of the five participants,
three participants (James, Sarah and George) stated that they also discuss emergency calls
with family members as a means of coping. One of the participants (James) feels that he is
only able to discuss emergency calls that have some aspect which could be related to his
family.
Black humour was discussed by four of the five participants (James, Paul, Sarah and
André), and was revealed to be a means of coping which allows the paramedic to discuss
aspects of an emergency call without appearing to be vulnerable to his or her colleagues. The
participants feel that paramedics who use this form of coping often tend to be ineffectual in
communicating their distress. One of the participants revealed that black humour is used to
reduce tension at an emergency scene (André).
With regards to poor coping mechanisms, two of the participants (Paul and André)
revealed that they have abused substances in an attempt to reduce stress. Both of these
participants felt, however, that this was an ineffective means of coping. One participant
(André) stated that when angered by an emergency call, he sometimes expresses his anger
through aggressive means such as shouting or throwing objects in order to reduce his
emotional distress. Other means of coping include leading a healthy lifestyle, such as
exercise (Sarah and George), and engaging in activities that promote relaxation, such as
computer games and hobbies (James and George). Of interest is the fact that one of the
participants (Sarah) feels that when she wears her uniform, she is able to become a “different
person”, which allows her to depersonalise from the emergency scene. She feels that this
allows her to become “blunt”, however she feels that it is ineffective and that it has had a
negative impact on her interactions with her family members. A similar means of coping was
demonstrated by another participant (André), who reported that when confronted with
difficult scenes he goes into “patient treatment mode”.
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Four of the five participants have made use of “professional” psychological services
(James, Paul, Sarah and André); however this was not listed as a main means of coping.
Possible reasons for this have been discussed earlier. Two of the participants (Paul and
Sarah) provided some insight into what factors would assist in making psychological services
a viable means of support to other paramedics. One participant (Paul) feels that the services
offered should be made available within the organisation itself and be in the form of a
“structured” informal debriefing session. Another participant (Sarah) feels that any
assistance offered should be on a short-term basis and focus specifically on the critical
incident itself.
4.6.4 Personal consequences of being a paramedic. All of the participants reported
that the occupation of being a paramedic has had a negative impact on their psychological
functioning. Three of the participants labelled their symptomology, namely depression
(James), Burnout (André) and PTSD (Sarah). One participant (Sarah) described a specific
incident in which she was physically hurt whilst on duty, which she considers as having
contributed towards her experiencing negative psychological symptomology such as having
panic attacks, symptoms of re-experiencing the event, as well as avoidance.
The most common negative symptom shared by the participants (James, Sarah and
George) was that of “re-experiencing” previous emergency calls. This usually occurs
through the form of “triggers”, which remind the participant of a specific critical incident. As
expected, the “triggers” vary according to the experience of the participant, however a
common consequence of “re-experiencing” traumatic incidents is avoidance. The
participants try to avoid the “triggers”, for example driving a different route, avoiding
treating certain types of patients, or as in the case of one participant (James), wanting to
change occupations. Interestingly, one participant (André) kept an album of various
emergency scenes, which allowed him to recall the various emergencies he has responded to.
One participant (Paul) reported that he suffers from recurrent “bad” dreams.
Four of the five participants (James, Sarah, Paul and André) indicated that there was
some impact on their relationships with family and friends. Two of the participants (James
and André) reported that they have at times displaced their distress, resulting from the
psychological symptoms they were experiencing, in the form of anger onto their family
members. One of the participants (Paul) felt that due to him having to work shifts he was
unable to provide his wife with the emotional support as and when she required it. Another
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participant (Sarah) reported that she has become overprotective of her son, and added that
being “blunted” could have a negative impact on her interactions with her son.
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CHAPTER 5: DISCUSSION
5.1 Overview.
Despite the large number of quantitative studies conducted on paramedics specifically
focusing on the exposure to critical incidents, as well as on the possible negative outcomes of
this exposure, little research has been conducted from a qualitative perspective. In addition,
few studies have been conducted on the South African paramedics’ experience of critical
incidents. With this in mind, it was hoped that an in-depth understanding of South African
paramedics’ experience of critical incidents would add to the existing knowledge in this area.
In order to achieve this, semi-structured interviews using Interpretative Phenomenological
Analysis (IPA) were conducted, with the aim of gaining an in-depth understanding of South
African paramedics’ lived experience of critical incidents.
The master themes, as well as the supporting superordinate themes presented in chapter
four will be discussed in relation to the existing literature as presented previously in chapter
two. Although each master theme was reported separately, it is important to acknowledge that
each of these themes is related to the others; therefore connections will be made between the
various master themes and superordinate themes throughout the discussion.
5.2 Discussion of the Master Themes
The discussion of the participants’ experience will be explored by initially discussing
the participants’ experience of critical incidents, followed by their accounts of how these
experiences are embedded in and influenced by a specific context, namely the “world” of
EMS. Thereafter, the participants’ methods of coping with both critical incidents and
organisational stressors will be explored. Despite the participants’ efforts to reduce the
negative impact of being exposed to critical incidents as well as organisational stressors,
many of them reported experiencing post-traumatic symptoms which negatively impacted on
their psychological well-being, as well as on their families’ well-being.
5.2.1 Experiencing the trauma of Critical Incidents. Specific critical incidents that
the participants reported as being stressful were mentioned, included dealing with children
and burns patients. International studies indicate that dealing with child victims is considered
to be one of the most stressful incidents to be exposed to (Alexander & Klein, 2001; Jonsson
et al., & 2003; Sterud et al., 2008b). Research conducted in this country has revealed that
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South African paramedics find burns patients to be particularly stressful, more so than their
international colleagues (Ward et al., 2006).
As indicated previously, the participants’ descriptions of their feelings, emotions and
thoughts regarding the experience of critical incidents varied considerably. The experience
of critical incidents was divided into three categories in order to gain an understanding of the
essence of experiencing critical incidents. These categories, relating to the thoughts, feelings
and emotions regarding critical incidents, will be discussed in relation to the existing
literature:
Whilst responding to the scene. Each of the participants related a particular
expectation of how they thought the emergency call would be, unless the participant was
confronted with a novel experience. These expectations varied; however, the expectations
allowed them to mentally prepare for what they may be confronted with at the emergency
scene. This finding has been consistent with previous research findings (Jonsson & Segesten,
2004), and has been linked to the reduction of stress whilst responding to emergency scenes
(Svensson & Fridlund, 2008).
With regards to this study, this finding may be linked to the participants’ “perceived
need to control the environment”. By relying on previous experiences and pre-empting what
may be required at the scene of the emergency, the paramedic is trying to create structure and
predictability in his or her environment, in order to reduce stress.
On arrival or during the emergency. On arrival at the emergency scene, the
participants were met with a “reality” that was inconsistent with their previous expectations.
This evoked reactions such as horror, fear, apprehension, helplessness and self-doubt
regarding being able to treat the patient.
The above-mentioned horror, fear and helplessness are considered to be typical
reactions when exposed to critical incidents, and are viewed as the precursors to developing
severe psychological distress such as PTSD (APA, 2000). Additional emotional reactions,
such as feelings of empathy and helplessness have also been linked to paramedics’ reactions
to critical incidents (Halpern et al., 2009b). Empathy, or the ability to identify with the
suffering of the patient, has been reported to increase the psychological distress experienced
by emergency workers (Regehr et al., 2002), at times when despite the emergency medical
treatment being provided, there is nothing that the paramedic can do to save the patient. This
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evokes feelings of helplessness and has been found to be associated with feelings of self-
doubt, which heightens stress experienced by paramedics (Halpern et al., 2009b)
After the emergency scene. Of the five participants, only one participant (James) was
able to directly attribute his psychological distress to his experience of a specific critical
incident. He reported symptoms of re-experiencing the critical incident, as well as symptoms
of avoidance. As previously reported, post-traumatic symptoms resulting from exposure to
critical incidents is well documented (Bennett et al., 2005; Donnelly & Siebert, 2009;
Shakespeare-Finch et al., 2003; Smith & Roberts, 2003; Sterud et al., 2006). Additional
symptoms linked to the exposure to critical incidents have also included arousal symptoms,
such as anger (Halpern et al., 2009b; Monnier et al., 2002).
Descriptions and statements provided by the participants, specifically those pertaining
to critical incidents, were often abstract and general. Several factors may have contributed
towards this phenomenon. Firstly, previous research has indicated that paramedics are often
unwilling to express their emotions, due to the difficulty of identifying their emotions, shame
at feeling distressed, and concerned about the associated stigma that may result from
expressing their distress (Halpern, Maunder, Schwartz & Gurevich, 2011). Secondly,
research has indicated that the exposure to critical incident stress may not be as significant as
initially thought. Organisational stressors (Bennet et al., 2005) such as lack of support, low
remuneration, and administrative tasks (Nirel et al., 2008) have been found to contribute
significantly towards the distress experienced by paramedics. As reported by the participants
in this study, organisational stressors did indeed contribute significantly towards their
experiences.
5.2.1 Experiencing the “World” of EMS. The analysis of the data revealed that the
participants’ experience of critical incidents were embedded in and influenced by two
specific contexts; firstly, the context of belonging to a specific group known as “paramedics”,
and secondly, the context of working for the “EMS organisation”.
EMS is a subculture. An interesting factor that emerged from the analysis of the
transcriptions is that all of the participants identified themselves as belonging to a specific
group, namely paramedics. The participants highlighted this distinction between themselves
and “others” by reporting that “others” are unable to understand the experiences that
paramedics endure. The distinction is further clarified by some participants having
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mentioned being angered when asked to share their experiences (critical incidents) with
others not belonging to the world of paramedics. Other instances of this phenomena occurs
in social settings when group members tend to discuss “work” experiences in social settings,
further isolating or excluding them from “others”.
To best understand the reason for this clear distinction and how it is related to the
experience of critical incidents, it may be best to briefly review the social identity approach,
which includes both social identity theory and self-categorisation theory (Hornsey, 2008).
The dynamics of group processes and intergroup relations is not the focus of this study,
however due consideration should be given to it, as membership to a specific group
influences individuals’ identities in terms of how they think, act and perceive the world
(Haslam, Reicher & Levine, 2011). When an individual belongs to a group, the individual is
said to develop a shared social identity with other members of this group (Van Dick &
Haslam, 2012). The participants’ shared identity was highlighted specifically with regards to
their shared experiences of critical incidents. They felt that others, or individuals outside of
the group, were unable to understand the experiences they have shared with fellow group
member, that is their work colleagues. As a result of their shared identity, and the fact that
others do not understand their experiences, the participants reported preferring to seek help or
assistance from their own colleagues.
According to authors Haslam and van Dick (2010) this behaviour is understandable, as
seeing oneself as sharing a social identity with other person’s increases the probability that
support will be offered between group members, and that the support offered will be received
in a positive light and perceived as helpful. If, however, the individual does not share a social
identity with the other person, the likelihood of support being provided will reduce, and any
support offered could be misinterpreted and perceived as unhelpful (Haslam & van Dick
2010). This was particularly evident with some of the participants indicating their mistrust of
outsiders, particularly psychologists. A negative result of belonging to the paramedic group
with its inherent mistrust of others, is that it limits the paramedic’s options of seeking
assistance from others outside of the group.
Negative experiences of the EMS organisation. Most of the participants related
negative experiences and perceptions of the EMS organisation. Factors such as minimal
support offered and shift work were the most prominent issues highlighted by the
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participants. Other factors that contributed towards the participants’ dissatisfaction of the
organisation included low remuneration, and the lack of occupational growth opportunities.
The participants’ reports regarding the lack of organisational support are in line with
international findings (Regehr et al., 2002; Sterud et al., 2008; Van der Ploeg & Kleber,
2003). Similarly, low remuneration and lack of occupational growth has also been reported
as contributing towards emergency workers’ stress (Donnelly & Siebert 2009; Halpern et al.,
2009b). In addition, inherent occupational stressors such as shift work have been widely
reported to have a negative effect on emergency workers’ psychological as well as physical
well-being (Pisarski, Bohle & Callan, 2002; Van der Ploeg & Kleber, 2003; Ward et al.,
2006).
The role of the organisation and its influence on emergency workers’ psychological
well-being has increasingly become an important area of research. This is due to findings
that suggest that despite the constant exposure to critical incidents, the organisation itself
might be the greatest contributor towards the distress experienced by emergency services
personnel (Regehr & Millar, 2007). There is further support for this opinion, as studies have
reported that “organisational variables have been demonstrated to have more of an impact on
post-trauma outcomes in emergency service organisations than the nature of the event per se
and it has been argued that they account for more post-trauma and crisis variance than
individual difference variables” (Shakespeare-Finch, 2007 p. 363).
Linking to the previous section regarding group dynamics and their influence on help-
seeking behaviours, the EMS organisation has developed a culture that stigmatises the
expression of feelings of vulnerability, which, reportedly, is one of the most important factors
preventing emergency workers from accessing support when affected by critical incidents
(Halpern et al., 2009a). These findings suggest the organisation has a significant role to play
in buffering the effects of critical incidents and other organisational stressors. As indicated
by Argentero and Setti (2011), when an individual belongs to a specific group which
nourishes a sense of community and the perception of working together as a team, the
individual is less likely to experience the effects of burnout.
Meaningful work environment. Despite the difficulties and the challenges that the
participants are faced with, the participants felt that certain aspects of their occupation does
provide them with meaning and satisfaction. Being able to make a difference in someone’s
103
life was reported to be the most important factor that brought the participants satisfaction.
The participants felt that the satisfaction attained from making a difference in someone’s life
made up for the difficulties they were faced with. As discussed previously in chapter two,
this phenomenon is termed compassion satisfaction (Cicognani et al., 2009), which has
shown to increase levels of hope, resilience and positive growth (Hooper et al., 2010). The
benefit of compassion satisfaction are that it provides the individual with a buffer against the
negative effects of stress (Wee & Myers, 2003), lowering the risk of developing burnout
(Jacobson, 2006).
An additional factor which the participants felt provided them with job satisfaction, was
that they considered their occupation to be “varied”. They explained that each call and day
was different, which makes the occupation exciting. This is perhaps a “cognitive reframing”,
from turning an occupation which is experienced as unpredictable and chaotic into an
occupation that is varied and exciting. Cognitive reframing has been linked to positive
growth, as the stressor is perceived to be controllable (Paton, 2005).
5.2.2 Intrinsic factors and active attempts at coping with stress. The participants
described various means of coping with stress. These included intrinsic factors required to
bring order and predictability to a chaotic environment, as well as active strategies used to
reduce the effects of stress resulting from exposure to critical incidents and other work related
stressors.
Perceived need to be in control of the environment. The need for control over the
environment is related to bringing order and predictability to an occupation which is often
unpredictable and chaotic. The participants discussed the need for the individual to have an
“A-type” personality, or to have the intrinsic ability to be in control of an environment which
is often chaotic, for instance at an emergency scene. Additionally, the ability to learn from
previous experiences was important, as this allowed the participants to pre-empt what they
could be faced with at an emergency scene. This enables the participants to be mentally
prepared for the emergency scene.
This particular coping strategy has been noted in other studies (Jonsson & Segesten,
2004), and has been shown to reduce stress (Svensson & Fridlund, 2008). However, as
indicated in this study, the ability to pre-empt what may occur is not always successful,
104
especially if the paramedics’ expectations of what to expect at an emergency scene are at
odds with the “reality” of what they find at the scene.
Active attempts at reducing stress. The following mechanisms were identified by the
participants in an attempt to reduce stress resulting from the exposure to critical incidents as
well to other occupational stressors: social support from colleagues and family members,
black humour, substance abuse, a healthy life-style, dissociation, and use of professional
psychological services.
Social support for the participants was reported to be the most important means of
coping with stress. All of the participants reported speaking to their colleagues about critical
incidents. Research from previous studies has indicated that this form of support is one of the
most typical means of support used by paramedics and other emergency workers (Alexander
& Klein 2001; Maia & Ribeiro, 2010), and it has been shown to mediate the effects of stress
(Donnelly & Siebert, 2009; Pisarski et al., 2002). Although not a main means of social
support, some participants reported discussing their experiences with family members,
particularly if there was some connection between the patient and the paramedic’s family.
This seems to be consistent with other research studies (Halpern et al., 2009a; Regehr et al.,
2002). A possible reason as to why paramedics’ familial support is not a main means of
support is that emergency workers tend to compartmentalise their work and family-life, in
order not to traumatise their family members (Halpern et al., 2009a; Hyman, 2004;
Shakespeare-Finch et al., 2002).
The majority of participants described the use of black humour as a coping mechanism
which allows the paramedic to discuss the critical incident without appearing vulnerable. In
addition, it relieves tension at the emergency scene. Previous studies regarding emergency
workers and their use of humour are in agreement with the above finding (Alexander &
Klein, 2001; Scott, 2007).
Previous research done both internationally (Donnelly & Siebert, 2009) and locally
(Ward et al., 2006) indicated that there is a high prevalence of substance abuse amongst
emergency workers. Two of the participants revealed that they have abused substances in an
attempt to cope with the stress they were experiencing. The stress that the participants were
experiencing was not necessarily related specifically to critical incident exposure, but rather
due to a combination of this exposure and to occupational stressors. This finding may be in
105
agreement with previous research done in South Africa which indicated that there is no
specific link between substance abuse and exposure to critical incidents (Ward et al., 2006).
This finding suggests that other factors such as occupational stressors do, however, play an
important role in South African paramedics’ experience of stress.
Two of the participants (Sarah and André) related that they found the process of
dissociation or emotional numbing Regehr (2005) to be a means of coping. One participant
(André) referred to the emotional numbing as “patient treatment mode” which allows him to
focus on treating the patient without being affected by upsetting emotions related to the
traumatic emergency scene. The other participant (Sarah) discussed her ability to become
“blunt”, when she wears her uniform, which allows her to perform her duties without being
overwhelmed when confronted by difficult scenes.
Both of these “mild” forms of dissociation have been reported in past studies (Kirby et
al., 2011; Regehr et al., 2002), and are considered to be adaptive as they allow the paramedic
to cope when confronted with traumatic scenes (Levin & Spei, 2004). One of the participants
felt that this form of coping could have a negative impact on her interpersonal relationship
with her family, therefore on returning home after work she immediately changes out of her
uniform. Research has indicated that pervasive use of emotional numbing could have a
negative impact on the paramedic’s relations with others, as he or she could be experienced
as being emotionally unavailable (Regehr & Millar, 2007).
Additional coping strategies included living a healthy life style as well as partaking in
activities that promote relaxation. These strategies have also been implemented by
paramedics elsewhere, and are considered to be important strategies in order to reduce the
negative consequences of prolonged exposure to critical incidents and organisational stressors
(Beck, 2011).
As previously discussed in this section, the participants have indicated their hesitation
in making use of professional psychological services. Internationally, it has been found that
emergency services workers are less likely to make use of professional psychological services
than the general population (Sterud et al., 2008a). This study has revealed that all of the
participants have made use of professional psychological services, despite their reservations.
As indicated earlier their reservations regarding the use of psychological services could be
due to the perception that they may be stigmatised against at their workplace (Halpern et al.,
106
2009a). Two of the participants indicated that if any psychological services are offered, these
should be made available within the workplace rather than being outsourced to another
company. In addition, the service offered should be structured as an “informal” debriefing
session and focus specifically on the critical incident.
Internationally, EMS organisations have implemented such a programme, namely
CISM. Despite the controversy surrounding the programme regarding its effectiveness in
reducing or preventing PTSD symptoms (Fawzy & Gray, 2007), there seems to be a need for
such a programme in South Africa, to assist paramedics in managing the emotional
repercussions resulting from critical incidents. As highlighted earlier, there is a need for this
programme to be tailored to assist paramedics and other EMS workers in managing
additional stressors such as organisational stressors.
5.2.3 Personal consequences of being a paramedic. As discussed previously, the
participants have made use of a number of coping strategies to assist them with the emotional
distress resulting from exposure to critical incident as well as to organisational stressors.
However, the participants have revealed that they have had negative experiences resulting
from performing their duties as paramedics, which have had an effect on their own mental
well-being as well as on their families and friends.
As reported previously, the most common post-traumatic symptom reported by the
participants was that of “re-experiencing” previous emergency calls. Re-experiencing or
intrusive memories of previous critical incidents have been widely reported and discussed by
previous international studies (Argentero & Setti, 2011; Bennet et al., 2004; Clohessy &
Ehlers, 1999). One of the typical behavioural reactions reported upon exposure to critical
incidents, is that of avoiding stimuli which may remind the individual of the traumatic
experience (Bogaerts et al., 2008). As reported by the participants, efforts were made to
avoid “triggers” that reminded them of particular distressing emergency calls they have
attended.
The resultant stress experienced by paramedics from exposure to critical incidents as
well as to organisational stressors, has also reportedly had a negative effect on their families.
The participants’ accounts related incidents of displaced aggression onto family members, as
well as being generally emotionally unavailable to them. Authors, Van der Ploeg and Kleber
(2003) reported that, in their study, exposure to critical incidents led not only to the
107
physiological and psychological distress experienced by the paramedics themselves, but also
to a negative impact on the family of the paramedic. Similarly, Reghr et al. (2002), reported
that exposure to critical incidents led to emergency workers being emotionally distant and
interacting aggressively with family members. This highlights the need for effective
programmes to be put in place by EMS organisations to reduce the stress experienced by
paramedics, as negative interaction with family members could not only increase stress levels
experienced by paramedics, but also could lead to a decrease in support offered by family
members.
108
CHAPTER 6: CONCLUSION.
In summary, the majority of the participants reported experiencing critical incidents,
but as expected, their subjective accounts of critical incidents varied. However, there was
some common ground in their all experiences. Whilst responding to the emergency call, the
participants described undergoing a process of mental preparation. This process allows the
participant to be prepared for the scene they are about to confront. However, on arrival, their
expectations regarding the specific scene they would be confronted with were in these cases
not met. The disparity between what was expected and the “reality” of the emergency scene
led to a variety of feelings, such as, fear, horror, helplessness, apprehension and self-doubt.
In addition, the participants described empathising with either the patient or the patient’s
family, thereby increasing the distress the participant was already experiencing.
Subsequent to the critical incident, only one participant attributed severe negative
psychological symptomology as resulting from the experience of a specific critical incident.
The participant described experiencing PTSD symptoms, such as re-experiencing the critical
incident, and avoidance symptoms. Despite the other participants having experienced critical
incidents, their descriptions did not include specific negative psychological symptoms
resulting from these events.
The participants’ accounts of critical incidents was embedded and influenced by their
belonging to a specific context, namely the “world of EMS”. The “world of EMS” plays a
significant role in the participants’ lives, specifically in three areas, the first being identifying
and belonging to a specific group, namely the paramedic group. A positive aspect of
belonging to this group is the ability to elicit support from other group members, which has
been identified as an important coping mechanism for the participants.
The second area is the role of the EMS organisation. As identified by the participants,
the EMS organisation contributes significantly towards the stress that the participants have
experienced. Specific stressors identified include the following: the perceived lack of
support, low wages, and lack of growth opportunities as well as inherent job stressors such as
shift work. An area of concern is the influence which belonging to the paramedic group as
well as to the EMS organisation has on help-seeking behaviours of the participants. The
perception of being stigmatised against if help were to be sought, could limit the participants’
ability to cope with both acute and chronic stressors.
109
The third area of influence identified by the participants, is the positive “meaning”
that this occupation brings to the participants’ experience of “being” a paramedic. The
participants felt that the experience of making a difference in an individual’s life brings them
immense job satisfaction. Many felt that experiencing compassion satisfaction “made-up” for
all of the negative aspects that they experienced in their occupations. In addition, the
participants felt that the occupation is varied and exciting.
As discussed by the participants, their occupation is considered to be highly stressful.
Bearing this in mind, the participants identified a number of innate as well as active coping
mechanisms used to buffer the effects of stress experienced. The participants mentioned that
the paramedic should have the innate ability to “control” a chaotic environment. Specific
coping mechanisms employed by the participants included eliciting support from colleagues
and family members, dissociation or emotional numbing whilst treating patients, black
humour and living a healthy life-style. Two participants revealed that they have abused
substances in an attempt to cope with the stress they have experienced.
Despite the reservations expressed by the participants regarding the use of
professional psychological services, the majority of the participants have at some stage made
use of these services. However, some of the participants would prefer to have a service that
1) deals specifically with the critical incident, 2) are short term in duration and 3) available at
their place of work. This highlights the need for South African EMS organisations to
consider the implementation of programmes such as CISM, tailored to meet the specific
needs of South African paramedics.
The participants employed a number of coping strategies in an effort to mediate the
effects of organisational and critical incident stress, theses included the following: Social
support from colleagues and family members; black humour; substance abuse; living a
healthy life style; dissociation and use of profession psychological services. Although the
participants identified a number of strategies used to cope with the organisational and critical
incident stress they experience, the participants still described experiencing chronic negative
psychological symptomology. The most common of these is intrusive thoughts regarding
critical incidents, which are brought about through “triggers”; a consequence of this is that
the participants displayed avoidance-behaviours in order to prevent the re-experiencing of
particularly distressing critical incidents. Additionally, the participants reported that their
families were negatively affected by the critical incident stress as well as by the
110
organisational stress they themselves have experienced. The participants related that they
have often interacted aggressively with family members. A consequence of this is that
aggressive interactions could lead to a reduction in familial support available to paramedics,
and increase the stress levels the paramedic is currently experiencing.
Having discussed the findings of this study, the following chapter will consider the
study’s limitations and recommendations.
111
CHAPTER 7: LIMITATIONS AND RECOMMENDATIONS
This chapter will consider the limitations as well as recommendations arising from this
study. A number of limitations could be highlighted with regard to the characteristics of the
sample group. The study’s sample group comprised five participants, four males and one
female, all of whom were white. They were sourced from a specific region, Gauteng, South
Africa. In addition, the participant’s length of experience within EMS fell within a specific
time frame, namely, between eight to twelve years of experience.
In light of the above, the following limitations should be considered:
1. The results of this study should not be generalised to the rest of the EMS population
as studies conducted in other regions and with different lengths of experience within
EMS may differ.
2. The characteristics of the sample group excluded the possible impact of factors such
as gender and racial groups on the lived experiences of critical incidents.
3. An additional factor that should be considered is how the level of training of the
paramedic; that is BLS, ILS and ALS, may influence the experience of critical
incidents.
With regard to the participants’ narratives and descriptions of critical incidents, the
following limitations should be considered:
1. This study focused on the lived experience of critical incidents; however the
participants’ narratives and descriptions of critical incidents were generalised.
2. Narratives and descriptions of critical incidents encompassed additional experiences
such as their experiences of the EMS organisation rather than specifically focusing on
critical incidents.
Having considered the limitations and the findings of this study, the following
recommendations are made:
1. Further research should be conducted regarding the role of South African EMS
organisations in buffering or mediating the effects of critical incident stress.
112
2. Research should be conducted on the adoption and implementation of “on site”
psychological support offered to paramedics. The programme should be able to deal
with both critical incident stress as well as organisational stressors.
3. Training of managerial staff in providing emotional support to paramedics.
4. Emphasis should be made on training paramedics in identifying stress reactions and
the implementation of coping strategies.
5. Future research should perhaps consider the role of gender and racial groups and their
possible influence on critical incident experiences.
113
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APPENDICES
Appendix 1: Master Theme Tables: James;
: Paul;
: Sarah;
: André;
: George.
Appendix 2: James’ Transcribed Interview. The decision was taken that due to space
constraints only one transcript would be included. It should be noted, that in
order to track the themes, the page numbers on the transcript are displayed
according to that found in the Master Theme Table.
Appendix 3: Copy of Informed Consent.
127
Appendix 1: Master Theme Tables:
1. James
2. Paul
3. Sarah
4. André
5. George
James
Master
Theme
Superordinate
Theme
Theme Label Quote/Keyword Page & line
number 1. Experiencing the Trauma of Critical Incidents
Experiencing the Trauma of Critical Incidents
Sensory Experience burnt beyond all recognition/ chunks of meat dripping of him unburnt burnt chunks of meat flesh, flesh, flesh died in crawling position bits of skin peeling in the inside of his ears and nose terrible smell the smell of that particular patient leathery like a cow baked in the sun/touching of his skin was thick, his skin was so thick couldn’t put a drip up touching his skin was like a brick wall, leathery, not cold, not hot, not warm, it was different still talking to us hearing him writhing in agony you can hear it, see it, smell it take all your senses into last one, sight, smell, touch, hearing, taste
3: 83; 4: 84; 4: 88; 93-94 4: 84; 100 4: 92-93; 95 6: 148-151 4: 91; 6: 151 6: 151-152; 156-157
Sense of helplessness he was going to die regardless of interventions with burns that severe internal damage is worse so he will die regardless of intervention felt helpless because he couldn’t do anything sense of helplessness very strong feeling of helplessness cause he was alive sent me over the edge last patient was still alive
4:96 6: 154-155 4: 94-95; 99 6:152-153 4: 90-91 6: 148
Empathy he was in pain in back of mind putting up a drip on a burns patient is more painful than normal
4: 94; 97-99
James
Post Critical incident consequences
Re-experiencing the incident Aversion to Burns Patient (Work Performance) Avoidance (wanted to avoid work) Dissociation amnesia subsequent burns pt gone through it before (treating burns pt) seen many burns patients before which never affected me not the first patient seen like that told lecturers and psychologists that he had previously treated burns patients without adverse affect
6: 160-165 4: 104 5: 119 3: 73; 74; 4: 109; 101-102 5: 121 6: 153 7: 173 173-174 4: 106-108;110; 5: 115 3: 76; 77 4: 85 5: 134-136
2. Experiencing in the “World” of EMS.
EMS is a subculture
The TV Show friends think it’s a TV show fill of glory and thrill they don’t realise it doesn’t finish the moment the TV series finishes you have a choice what you want to see you can change the channel in my job I don’t have a choice can’t turn the TV off, have to see, live and deal with it it doesn’t go away it stays there (image stays with you)
13: 343-344 13: 345-346 13: 348-349 13: 350-351 13: 353 14: 358-359
James
Negative experience of working for the EMS organisation
Inherent occupational stressors
everything as a whole EMS and studying Responsibility as ALS (stress) Possibility of death (stressor)/ Going to call (stressor) Medical negligence (stressor general office admin is also stressful I cover a large district which places allot of stress and demand on you scene stress is high as there is less staff/with more staff you are not overworked and overtaxed/have someone in your hour of need Family of the patient
23: 622-623 11: 283-285 18: 470-474 18: 475-485; 18: 485-488 19: 518-520 20: 525-527 17: 460-465 18: 466-468
Lack of organisational support
no I don’t (answer regarding if enough support from organisation) I don’t think there’s support at in the work place
15: 406-407 16: 431-432
Seeking help is a weakness
others see seeking help as weakness I became exactly what everyone’s perception was of you if you look for help within the EMS If you seek help you considered weak/you can’t cope kind of thing something insignificant that affected me showing problems could be a sign of weakness I became weak can hide things well considers it a flaw lifelong use of mask no one knew what was going on (explanation): you’ve got own problems I’ve got mine still keep problems to self to this day people don’t need to know about it/no one knows about it therefore it doesn’t make it weak
3: 65-66 22: 580; 583-584 22: 585-586 7: 187-190 22: 579 7: 180 181 181-182 183 186 26: 701-703
Isolation at work feels isolated at fire dept as they are all fireman and he works on the ambulance/I don’t fit in because I’m not a fireman I’ve been employed to work on a little yellow bus not a big red lorry
16: 426-430
James
I still feel isolated, like that’s my job and don’t interfere I don’t really get along well with the crew
20: 534
Meaningful work environment
Enduring interest in medicine
lifelong interest “in born” passion passion Can’t just wake up and decide
1: 2 3: 58 12: 303 2: 53 3: 58-59
Ever changing working environment
(not the)same thing over and over not the same/No two cases are the same Ever-changing/New technology/New procedures Not a stagnant environment Not a controlled environment
1 : 3-4 15 16-17;20-21 17-18 3: 67-68
Job Satisfaction a good call ran well from beginning to end where all your basis are covered within the deadline the results you were expecting are the results you get in retrospect it was a good call because you identified the problem, knew the consequences, did something to rectify it and the results were positive use your mind studied to treat the good stuff not the bad stuff accomplish something for the benefit of others I turned his whole life around gives me a sense of accomplishment what my purpose is I enjoy my job enjoy getting down and treating patients
14: 372 14: 373 14: 373-374 14: 382-15:384 15: 394 402-403 397 14: 380 15: 403 15: 400 12: 309 12: 304
3. Intrinsic factors and active attempts of coping with stress
Perceived need to be in control of the environment
Attributes of a Paramedic
Interpersonal skills young on the edge Adrenaline junky strong personality/determination Empathic, kind, considerate Non-restricted personality/Adaptable and outgoing
1: 7-8 11 12 2: 55 3: 56-57; 12: 305-307
Psychological Hardiness
Emergency field is demanding, strenuous and taxing you got to stand it Can’t let it affect you Recognise strengths, Seek help if need be Handle seeing blood, guts gore
3: 61; 62; 62-63; 63-65; 67;69-70
James
Personal strength strong willed so stuck it out after seeking help I realised it made me stronger it takes a lot of guts, you’ve got to be really strong and stand up and say I need help
7: 174 22: 586-587 27: 720-721
Active attempts at reducing stress
“Closing the Book” you block it out if answer is no then “close the book” (if effort for different outcome possible) if you close the book at the end of the call and there’s nothing you could have done differently leave it closed never open it again if it comes up talk about it so you can close it and forget about it have to forget about it you have to close the book between work, home and friends if you can close that book you don’t have to live with it for rest of your life if the book isn’t closed its an unread chapter without realising it you’ve dealt with it and closed the book (informal debriefing)
12: 317 11: 274-275 12: 318-321 12: 321-322 12: 324 13: 331-333 14: 367-368 14: 368 22: 601
James
Informal Debriefing with colleagues and family
doesn’t have to be on a formal basis informally at base generally talking about it even if you sit around in a joking way sitting in a public place you start talking a whole lot more, a whole lot easier we would all sit round the table at the coffee shop the crowd grew at the coffee shop in the mornings it was a ritual someone would say something about a call you would say I had a similar call it’s like a debriefing without you even knowing you debriefing it was wonderful it really was talking to someone helps/relives it subconsciously it affects you where you can’t think about it you have to talk about it once you’ve spoken about it, it becomes easier to deal with (Debrief with family) if it’s close to home only things close to home are mentioned went home told mom it was bad as the mother was roughly the same age as the gran missed granddad so it really touched home spoke to mom stating she had children, what had the child done to deserve that (suicide case involving mother and daughter) you can’t take it home with you I prefer not to talk about things because it makes you look morbid not necessarily interested so why palm it off on them sisters does not understand medical industry/she doesn’t understand my mom and a few of my friends understand
8: 200-201 201 203 22: 594 22-23: 602-604 23: 607; 612-613 23: 606 (ritual) 23: 609 610; 612 23: 613-614 8: 200 12: 317-318 25: 681 9: 218-219 237 9: 226-228 229-230 9: 242-243 12: 323 13: 333-334 13: 335 13: 336-341 13: 341-342
Relaxation as a means of coping
believes having a good cry gets it out getting a hobby I build puzzles and I play piano (hobby) brainless activity like watching cartoons you shut down completely (numbing) get a hobby, do something brainless and just chill (numbing)
8: 195-196 27: 726; 28: 736-737 27: 728-729; 733-734 734
Black humour black humour is a personal coping mechanism it’s a personal coping mechanism you are talking about it in a roundabout way other people see it as very undignified
20: 541; 546 20: 542-543 21: 565
James
if you speak to my sister about death they still have to have dignity so it depends on the person you talking to and the type of humour they have she wouldn’t understand (sister) can’t do it in front of family not in front of the family
566 21: 573-574 21: 572 21: 548; 552-553
Psychological treatment the last resort
sought psychological assistance through university saw a psychologist I got sent to a psychologist it was a clinical psychologist when it got to that stage decided needed to see someone (unable to shower with eyes closed) I then decide after what my mom had said I had two choices it was difficult to come to the realisation
3: 73-74 4: 102-103 23: 624-625 625 6-7: 162-165/168-169 26: 692-697 22: 585-586
4. Personal consequences of being a paramedic
Personal consequences of being a paramedic
Family life affected home life is affected it’s had a detrimental effect on my family your family picks it up you come home and you make home life hell I’d come home grumpy in a bad mood I would be very short, shout allot for something small and insignificant vent my anger on everyone and anyone your fuse becomes very short it got to a stage where I was actually thinking of killing someone in my family
8: 192 23: 621; 24: 650; 652-653 25: 667 667-668; 668 673 23: 623-624
Depression I became very deeply depressed yet again reached the stage where I was suicidal coming home and going to my bedroom and watching TV or play on my computer (withdrawal) I seriously thought of suicide Realise a lot is getting to you was not using medication at time as considers self not usually depressed that’s not me I’ve never been suicidal I’ve never been depressed in my life either I’m not a depressed person/ I’m not one for medication/I’m not a depressed person by nature
23: 623 24: 632-633 25: 674-675 26: 694 26: 685 7: 176 24:633 634; 649-650
Paul
Master Theme Superordinate
Theme
Theme Label Quote/Keyword Page & line
number 1. Experiencing the Trauma of Critical Incidents
Experiencing the Trauma of Critical Incidents
Critical Incidents merge
it’s difficult to say.. sometimes.. purely because they all tend to merge into one. you know I’ve had the odd time where I’ve, where I’ve felt that ummm.. ja this is really sad or whatever the case maybe but it’s hard for me to say.. for example that it’s all built up absolutely, that’s bullshit, they do effect you, you just don’t, to some extent there is a large degree of repression and that’s why I say they all merge into one, it’s because you do repress those memories
5: 200-201 6: 213-215 13: 602-604
Don’t find much traumatic
I don’t know the odd thing is that I gotten to the point on the road where I don’t find much traumatic any more you know ummm I certainly in the beginning some of the more messy of the calls got to me you know I have literally seen so much shit that most people would consider traumatic..
5-6: 206-208 6: 212-213
Off duty Traumatic Incident
Personally involved / Off duty Empathy with public
5: 202-206 5:137-141
2. Experiencing in the “World” of EMS
EMS is a subculture
The brotherhood it’s an intense kind of experience it tends to exclude the outside and it creates very much a sub-culture within EMS Protective Proud of subculture Have to earn place Brotherhood Intensity of the shared experience
2: 68-69
2: 70 2: 70-71 2: 71-72 2: 65 2: 66-67
Suspicious of outsiders
they don’t take kindly to interventions from outside.. you know like councillors and psychologists that sort of thing especially if they don’t come from an EMS background they always feel a great degree of suspicion Outsiders don’t understand the demands of the job Fear of seeing through the facade they are not interested in hearing some outsiders opinion it may be wrong or right its neither here not there, they are not going to listen to them,
2: 73-74 / 6: 241-242
2: 74-75
2: 77-79 2: 80 / 2: 82-83 / 3: 86 10: 425-427
Negative experience of the organisation
Inherent work stressors
I mean I used to find the working circumstances themselves more difficult more stressful. shift work lack of growth Non-emergency
6: 222-223 12: 481-482 / 12: 483 / 12: 489-492 / 12: 493-497 5: 190-192 12: 497-499 / 12: 499-501 / 12: 501-503 3: 117-120
Paul
Lack of Organisational Support
ICAS Seen as a punishment As a quick fix but as a human being they couldn’t they don’t care about you in the slightest. Used kind of the just the lack of support from the system/ cannot turn to organisation I got fuck all support from (organisation) .fuck all
6: 242-243 6: 246 6: 243-244 / 6: 248-249 / 6: 249-250 7: 256-257 7: 257-258 / 7: 259-260 / 7: 261 / 7: 263-264 10: 415-417 10: 390
Meaningful work environment
Varied work Environment
the fact that its such an exciting varied working environment no two days are the same long periods of boredom interrupted by short periods of sheer fucking terror It’s not even so much as terror as it is like excitement and the potential for terror you will go from things being very relaxed and easy going.. you get a call and you don’t know what you going to.. and there’s that thrill that bit of excitement also what drew me was the adrenaline Adrenaline junkies Anticipation when receiving a call
1: 4-5 2: 61 2: 63 4: 146-148 1: 4 3: 99 5: 182 / 5: 187 / 5: 189
Job Satisfaction
skills required making a difference what first attracted me to EMS, was uh partly is that calling, that altruistic side There is something very satisfying in giving part of yourself to be of help to someone else
3:111 / 3: 116 3: 113-114 1: 2 1: 3
3. Intrinsic factors and active attempts of coping with stress
Perceived need for Mastery/control of the environment
Learning to cope the difficulty of the job never lay in the types of things that we saw.. you know because you can learn to cope with that you know uh and sometimes it’s difficult but you can learn to cope with that
6: 215-216 6:216-217
Previous Experience Route/Previous calls done in area Available resources Competence of staff on ambulance
4: 151-156 5: 175-177 5: 179-180
Active attempts at reducing stress
Informal Peer debriefing
for me peer debriefing is always the key just talking about it amongst your friends afterwards.. going for coffee and having cigarettes just chatting about it amongst yourselves.. and that was always something I used to do on my shift with my guys that sort of thing what we do is always clean the vehicles together and while we doing that we also talk about what’s happened if you talk about and talk about it and talk about it enough for me I find that’s how I find a place for it in my head you know not formal
6: 219-221
6: 233-234
6: 239-240
6: 240-241
Paul
Structured internal peer debriefing
I think it would be more productive if it came from someone from within and perhaps if those people had a little bit more training, maybe even on how to identify people who have a major problem who need intervention ummm... that would be, that would be valuable if they can at least identify people who need intervention and can run a basic peer debriefing session itself For me I think what might work would be ummm... peer debriefing that is a little bit more structured you know ummm I think that if you dealing with guys who maybe are interested in for example maybe a peer debriefing course something like that, that might be put together I think that is right you need to get the right person, because not ALS paramedics... because you think ALS would be the most logical choice but not all ALS are that way inclined and not all of them have the people skills for it they really don’t I think it’s more likely to be received if it comes from within , if it comes from within
10-11: 428-432 10: 423-426 11: 438-440 11: 441-442
Humour it’s a staple breaks tension encourages talking talking without being vulnerable emotional release I think there is a time and a place for it you know not in front of public after call at base
11: 450-451 11: 457 11: 460-461 / 11: 464 11: 463-464 11: 452 11: 452-455 11: 455-456
Substance abuse Burning the candle at both end/personal problems Never developed healthy coping dealing with emotional pain
7: 284-287 7:289-290 9:307-309/9:354-356/9:361-363
4. Personal consequences of being a paramedic
Personal consequences of being a paramedic
Recurrent dreams I have had recurrent dreams, now that you mention it, for years I have had recurrent dreams about dismembered bodies body parts and pieces all over the place sometimes I’m walking through them sometimes I’m driving through them, sometimes at the mortuary, sometimes at a car accident you know, but that’s been sort of a recurrent thing for me for years so you can’t say that it doesn’t affect you at all, I mean I’m not that naive
16:607-608 16:611-614
Wife does not understand.
my wife found my working on the road to be very hard for her the hours in particular being away on nights and weekends, and I think a lot of spouses found that hard like if she needed like if she was battling like if she wanted to commit suicide or if she felt that she had a seizure or whatever the case maybe she wanted me to come home, she couldn’t understand sometimes that no I’m actually busy on a call I can’t come home now you know.. that she found difficulty
14:570-571
14: 577-580
Sarah
Master
Theme
Superordinate
Theme
Theme Label Quote/Keyword Page & line number
1. Experiencing the Trauma of Critical Incidents
Experiencing the Trauma of Critical Incidents
Children are the worst I think for me if you had to ask me about scenes my worst scenes are those with children, those ones are the worst there was a young girl who had fallen into the waterfall at the botanical gardens and she hadn’t surfaced
4: 116-117 4: 122-123
Hoping for alternative outcome
the whole way there we were just questioning are you sure she’s in the water, you sure she hasn’t got out and gonna gotten dressed i was querying if she had not gone home with one of the kids or something like that and I sort of thought to myself I just want to go look in that mine shaft because I pray she has fallen down and she's lying at the bottom and we can pull her out and she’s alive
4: 124-125
4: 127
5: 156-157
Empathising with victims father
the father was on the scene, and at one stage he got very, very aggressive, which it’s understandable it’s his daughter in there. And ummm I think the worst thing was actually pulling her out when that moment when he realised she was dead, that was just... and being a, I’ve got a little two year old baby... and I think that makes it.... watching him hurt was... I’d rather have been in the water so that i didn’t have to see him and watch him hurt the interesting thing that made me feel better he released an article in the newspaper a couple of days later to say that in his religion they can’t blame, they not allowed to blame I think that must have been the hardest thing for him to write but it made me feel allot heck of a better because he didn’t blame anyone
4: 133-136
5: 158-159
4: 141-143
4: 143-144
2. Experiencing in the “World” of EMS
EMS is a subculture
EMS as a clique It’s a clique it really is First ones to stab you in the back First ones to provide support Easily labelled by other paramedics Talking Shop (medicine)
10: 404 10: 405-406 10: 406-407 10: 407-409 / 10: 416 11: 425-426
What is your worst call? the one thing I hate that always happens with the public, this thing what was your worst call ever I must drum up the memory of my worst call and tell that person while I’m having dinner Rather not talk about it Don’t want to remember Others intrigued by death/blood
11: 427-428
11: 428-429
11: 429-430 / 11: 441-443 / 11:
448-449 11: 431 11: 431-433 / 11: 436 / 11: 443-
445
Sarah
Negative Experience of the Organisation
Inherent occupational stressor
Shift Exhausted
12: 471 12: 468-469 / 12: 472-747
Meaningful work environment
Adrenaline I like the adrenaline it’s the lights, it’s the sirens, it’s the buzz, it’s the go, it’s the high Crave the adrenaline it’s the whole the race to get there
1: 23 2: 29-30 2:30 2: 32
Maturity I think as you’ve matured with the job the lights and the sirens I don’t put them on anymore unless i have to. I think as you mature you realise that, the speed well is maturity actually saying I’m fine I can deal with it, or is maturity saying you know what that was a nasty one I need to talk. I have the maturity to turn to someone and say you know what i felt it on that call i went wrong, this went wrong, that went wrong what would you have done teach me, I love learning so for me that’s it’s not the lights, it’s not the sirens, it’s not the adrenaline anymore.. It’s treating people its seeing them responding to my treatment.. I think I’m lucky that I’m an older paramedic stable older person
2: 34-37
2: 31 8: 299-300
12: 479-483
9: 353 9: 356-357
Dynamic working environment
the first thing that got me was its dynamic, you don’t go in every single day and check cupboards and count drugs and everyday’s different, its different places, I don’t like the same old thing every single day I was treating in the GP practice at the time it all give them a painkiller give them an anti-inflammatory so it was run of the mill boring stuff different people Learning
1: 21-26
1: 27
Caring for others Care for people it’s the little old lady who you give some pain killers to she turns to you and she goes I’ve been praying for an angle and you’ve just arrived... that’s what it’s all about, it’s all about being able to help someone in that moment they need you, and giving them the right treatment and knowing what you doing is right
12: 476-477 12: 483-486
3. Intrinsic factors and active attempts of coping with stress
Perceived need to be in control of the environment
Need for Control decision was made there and then that I never, I wanted my own protocol, i wanted to be able to make my own decisions and not have to always lean on someone else.
1: 14-16
Sarah
Attributes of a paramedic maturity, dynamic personality, strong personality, confidence, competence good support structure I think all of us are type-A personalities, we all like control
8: 318- 320
2: 67-68
Active Attempts at Reducing Stress
Healthy life style if I’m frustrated there’s nothing I really do, I don’t smoke, I don’t drink, go to gym, live a healthy lifestyle, love playing with my child, love the outdoors, love walking, i will go outside maybe garden for a while or.. just have a little bit of my space just to think eat healthy lifestyle eat well have a healthy lifestyle
6: 235-236 6: 236-237
6: 237-238
8: 326-328
Informal Debriefing with peers
you will find at this academy we will come back and say you know I had this really interesting call this what it was this is what I did, what do you guys think how we gonna change our teaching it becomes an educational thing professional environment I’ll download to my colleagues first before i go to someone professional... I can sit in front of my colleague I can dump on them for 30min about what I’m feeling, they can look at me afterwards and pass the most bizarre comment, and I feel better, they feel better, it’s of my shoulders its finished debrief in terms of what went right and what went wrong
7: 268-269
7: 270-271 5: 181-182 5: 182-183 6: 194-196
6: 206-208
Debrief with Mother Down load to mother just listen there from the beginning first person approached knows the right things to say
5: 178-180 5: 180-181 5: 186-187 5: 189 5: 189-190
Reasons for not using professional psychological services
going to professional people and they will dig up every emotion that wasn’t involved and its 6 weeks of counselling we don’t go to them because of that. if i want to down load I want to sit in front of you, i want to dump on you and if I’m feeling better i want to be able to walk out and say cheers, whereas we will see you in two days time for your next appointment dealing with the specific event only whereas now go and see a counsellor and i must deal with it for the next six weeks, plus unrelated stuff that may come up and everyone has got baggage So you can relate anything to everything, and I, you know it’s, I think that’s probably the biggest problem
6: 196-198
6: 189-199 6: 199-201
6: 203-206 6: 209-211
6:211-212
Humour unable to express true emotions macho man not common at place of work
7: 260-261 7: 261-262 7: 264-266 / 7: 266-268
Sarah
I think the people who are blunted and put on those faces are actually probably the ones who are affected the most, they don’t have someone to turn to, to talk to...
7:278-279
Professional Identity as a protective factor
different person blunted/protected put up the wall blocking
5: 162-163 / 11: 453-454 / 11-12:
454-459 5: 163-164 5: 173-174 5: 174-175
4. Personal consequences of being a paramedic
Personal consequences of being a paramedic
Relationship with son influenced by being a paramedic
overprotective first aid training at school he doesn’t go to anyone who doesn’t have CPR training, doesn’t have first aid. I’m pretty almost pedantic about it, if I go home in uniform and I’ve been working on the road I will literally get in the scullery strip off put something else on and go to my son because I don’t want for two reasons, I have this wall apparently when I wear my blue uniform I don’t need that with my son and I don’t need him exposed to anything I might have picked up,
7: 251-252 7: 252-253 7: 255-256
12:455-459
Car accident had a very bad car accident so I’m not a fast driver i think the biggest thing that happened to me was my car accident.
2: 31-32 2: 45-46
Physical Consequence I ended up in ICU along with two of the other guys in the car had subsequent back surgery which they believe is directly related to it from the whiplash i was in hospital two weeks ago again with my back, I now have total back problems which will never allow me permanently on the road I wasn’t allowed to do anything physical or get in a car for about, I think it was about two months afterwards
2: 56 2: 57-58
2: 58-59
3: 79-80
Psychological Consequences
panic attacks in the traffic PTSD Re-experiencing symptoms: sight (yellow line) : hearing(screeching tyres) : smell (burning tyres) Aversion to driving
2: 65 2: 66 3:98-99/ 3:106-107 3:106 3:100 2:59-60/ 2:62-63/ 2:68-69
André
Master
Theme
Superordinate
Theme
Theme Label Quote/Keyword Page & line number
1. Experiencing the Trauma of Critical Incidents
Experiencing the trauma of critical Incidents
Initial thoughts when received call: Worst case scenario.
Can’t be that bad My first thought was you know worst case scenario I somebody’s broken an arm you know
5: 169-171 5: 171-172
Thoughts when arrived on scene: From curiosity to fear.
I was expecting a car, you know the absence of the car made me sort of got me a bit curious when I saw the kid lying there my first thought was oh fuck apprehensive, nervous ummm very, very small amount of fear, scared of what I might find, is probably my first thought processes there arriving there and ja absolute flippen mayhem
5: 186-187 5: 187 5: 189-190
5: 172-173
Thoughts immediately after the critical incident: Elation to anger.
initially sort of some feeling of elation that we’ve done well, well I felt that we’ve done well, everything has gone smoothly, managed our patient I didn’t really think about it that much afterwards it was just another call for that day didn’t really bother me that much a little bit of you know anger especially when we discussed afterwards you know it makes me angry, it makes me very, very angry
6: 217-218
6: 218-219 6: 219 6: 220 6: 220-221
4: 156
Parents are to blame No concept of danger Child is not responsible for the accident
6: 223-225 4: 152-153/4: 161-163
Anger towards parents in retrospect you know afterwards thinking about it afterwards I was very angry with the parents it doesn’t matter which way you slice it it’s still the parents fault at the end of the day, at the end of the day the worst possible thing that could happen to a child is their parents I get very angry, I become very short with the parents in general in my opinion actually the worst possible thing that could happen to them is their parents because its parental neglect to a large extent is the result of many children dying... you know one of my thoughts, one of the things I said to the guys you know that’s the parents fault, we had a bit of a discussion of why I thought it was the parents fault, I very clearly remember the father saying to the garden afterwards you know take that thing and throw it away, in reference to the quad bike my thought ok it was a very brief passing thought my thought then was that it was too late china, it’s far too late, you know that was one of them
4: 150-151
4: 151-152
4:156-157
6: 228 4: 157-159
6: 222-223 6: 223 4: 153-156
André
2. Experiencing in the “World” of EMS
EMS is a subculture
They don’t quite understand
You also tend to gravitate to people who can understand you you tend to gravitate to your own kind you don’t really have time to socialise outside the EMS you know you can’t really relate to people, and they don’t quite understand what is involved can’t understand how you feeling because they haven’t experienced it, it’s literally one of those you have to be there to understand kind of thing
11: 441-442 11: 453 11: 438-439 11: 450-451
11: 451-452 11: 452-453
What is the worst thing you have ever seen?
a lot of what I found a lot of the time is that, meet new people and you get into the what do you do what do you do... and the age old question that drives me fucken bat shift is what is the worst thing you’ve ever seen detest that question... it’s the thing that a lot of people don’t understand is that you don’t want those kind of questions you don’t want to talk about work, you don’t want to tell them about the little kiddie that died the other week because his mother didn’t strap him into his car seat
11: 442-444
11: 444-446
11: 446-447
Negative experience of working for the EMS organisation
Marginal support Outsourced support Support dependant on own initiative Poor support from managers Unable to talk about feelings
7: 284-285 7: 289-291 7: 285-286 8: 299-300/8: 305-307/8: 323-324/ 8: 325-326/8: 300-302 6: 241-242/6: 242-243
No recognition Support from management, there’s no recognition The problem comes in higher up where you don’t get recognition never got acknowledgement for anything, the only thing you got was ahhh you guys are spending too much money or too much overtime or too much leave
10: 400 10: 416 11: 429-430
Inherent occupational stressors
Limited growth Poor Salary Shift work
8: 317-319/8: 321- 322 10: 393-397 10: 394-395/11: 439-441
André
Meaningful work environment
Making a Difference sort of I suppose its clichéd but you making a difference it just it makes up for all the bullshit and all the crap just knowing definitively that you’ve really saved someone’s life Wanting to make a difference which is a positive have never encountered anything as rewarding as knowing definitively that you’ve made a difference in someone’s life it’s an experience that I’ve only really, really felt once it’s the best feeling in the world... it really is knowing definitively that you’ve made a difference in someone’s life, knowing that you made a difference with someone’s life you’ve made a difference
1: 11-12 11: 459-460
11: 456 11: 456-458
11: 458 11: 460461 12: 475-476 12: 480-481 12: 477
3. Intrinsic factors and active attempts of coping with stress
Perceived need
to be in control
of the
environment
Attributes of a paramedic
A type of personality Taking charge confidence assertive, arrogant Solution Focused
2: 41 1: 37 1: 39 1: 34-35 2: 42 2: 42-43
Planning Route Equipment Access to premises Safety
3: 116 3: 120 3: 124 3: 123 / 4: 130-135
Patient Treatment mode then they just sort of kicked in to patient treatment mode... very brief passing sort off... get your shit together and treat the patient... so ja ummm that’s pretty much what happened...
5: 189-191
5: 193-194
Active attempts at reducing stress
Anger I floek I swear more than anything else, swear kind of throw shit around or whatever the case maybe just to sort of get over it I get angry, bit moody and you know it’s done kind of thing... which isn’t the right way to go about it I know
7: 255-256
6: 229-230
Abuse of alcohol I was one of them I was one of those guys who when you looked for your answer in the bottom of the bottle you didn’t do it slowly you did it as quickly as you possibly could there was no such thing as going out to have a couple of drinks to enjoy yourself, you went out and got trashed, that’s all there was to it
7: 265-266
7: 266-267 7: 267-268
Debrief with ambulance partner
you talk about it with your partner even then it’s more a case of you know we did well we didn’t do so well, we could have done this better we could have done that better kind of thing, as opposed to an actual you know how did you feel about this how did
6: 231 6: 233-235
6: 235-236
André
you feel about that kind of thing a coping mechanism by means of just talking about what sort of what you experienced somebody could relate to what you seen to what you experienced so speaking to somebody who you can relate too in that ummm you know they can get a mental image of what the concept is or what you know what the person was seeing what they were experiencing kind of thing relate to it in sort of an emotional level a lot of the times it’s not so much a case of looking for approval or looking for an agreement it’s just a case of talking about it as to what you saw what you did I suppose to some extent is a coping mechanism, ummm talking about it, just get it out, you know see what sort of input come from that
7: 274-276
7: 276-278
7: 278 7: 279-280
7: 281-282
Gallows humour Coping mechanism Inappropriate Finding something funny in the macabre No jokes about children
7: 249-250 7: 252 7: 253-254 7: 254-255
4. Personal consequences of being a paramedic
Personal consequences of being a paramedic
Burn out I was burnt out was tired I very tired from working a lot I worked a lot of overtime not having I mean in the 2 years I was working for Linksfield I think I took in total 4 days of leave... On the road working the whole time I didn’t have it anymore I had no desire to work anymore, had no desire to do calls I actually became one of those people who I detested in that I was one of those people who would argue with the dispatchers and question as to why I was being sent to a particular area... Couldn’t anymore... Personal Relationship affected
8: 336 9: 337 9:372-373
9: 375 9: 378-379
9-10: 379-381
9: 363 9: 337-339
Switching off Not turning off, Unable to separate work life from personal life even like I don’t know you got to like an EMS braai something like that it’s not we’re not talking about our feelings when we talk about calls its almost a pissing contest you know I did an MVA better than the one you did kind of thing, you know the patient was more severely injured than the one you did or I’ve done so many heli calls this week and you haven’t kind of thing so it’s almost a... you don’t talk about it you just kind of make jokes
9: 366 9: 366-369 / 9: 369-372 6: 243-247
It was a progression of factors
so ja it was a progression it wasn’t something that just happened it was a progression... and ja it just got worse and worse and worse you don’t get burnout from one call or one scene or one patient it’s a progression of factors you know, the scene followed by that scene,
10: 385-386
10: 391-393
André
followed by that, followed by that you know it’s a progression of things, it’s not just one call, it’s not just one patient it’s a number of factors...
10: 397-398
George
Master
Theme
Superordinate
Theme
Theme Label Quote/Keyword Page & line number
1. Experiencing the Trauma of Critical Incidents
Experiencing the Trauma of Critical Incidents
Burns patients are the worst
Burns Pt 13: 514-516 / 13: 516-520
Novelty of call Being called to same address twice 4: 147-150 / 4: 154-158 / 6: 212
Uncertainty about treatment
he just didn’t make it... so that’s one of the things you think about, it gives you something that you did that maybe you know could have been different or could you have done it quicker or better type of thing so that’s one thing I think, I mean it’s hardly that you go back to the same address twice you know what I mean [inaudible it was a difficult pt, and you kind of think well is there something else I should have done to this pt or I could have done but in the hours that went past, you kind of think but I doesn’t make sense analyse and reanalyse and analyse and reanalyse and you think maybe I should have done that maybe this maybe that
4: 154-158 / 5: 157-189
6: 224-225
Family Involvement is stressful
... I think also the other thing is the family was involved as well, because the mom and dad were right there... it’s not like your high income people who knows this, you tend to think what you have and you tend to relate it to some people someway... I mean the areas that we go to see pts in, you really kind of feel sorry for the people I think the main thing was that I think the family, because also I had to tell them listen hey your son didn’t make it..
5:194-195 5: 196-198
5: 199-200
2. Experiencing in the “World” of EMS
EMS is a subculture
Public has no understanding of EMS
I don’t think that the public actually knows what we deal with, what we actually do, I think that’s the biggest thing they don’t know the difference between what a fire-man can do, what a BAC, they don’t know the difference, for them its I need help and whoever comes I hope can actually help, and that’s the general, how can I put it, perspective that people have.
3: 95-96
3: 97-100
The negative experience of the organisation
Inadequate support: Nobody to speak to.
Chaplin-runaway counsellors -forced I don’t know put a programme In place considered weak if booked off for stress they have a good support system like that I mean it’s a phone call and the people arrive in 10-20 min, and I think that’s good for the family but like I say... you never use it after a call... you get in your car and bugger off... and there you go and there’s nobody for you to speak to... having a support structure in place Should be part of training
12: 479-481 12: 488-492 / 12: 494-496 11: 451-452 11: 458-460 12: 498-501 12: 502-503 / 12-13: 503-506 8: 300-301
George
Inherent Job stressor: The patients family
Family at scene Not good when family is there Expectations from family
5: 193-194 6: 201 / 6: 213 6: 221-222
Meaningful work environment
Varied Environment you can go to two resuses and it’s not the same, you can go to two MVA's and it’s not the same ummm, you can go to a shooting now that the guy actual is 100% and the next moment you can go to a shooting and the guy is dead or he is almost dead
2: 38-41
Job satisfaction: Making a difference and training others
making a difference you actually job satisfaction where you can see ja I actually made a difference Pt survives Training others
2: 44-45 2: 45-46 11: 429-430 2: 49-51 / 2: 55-57 / 9: 337-339
3. Intrinsic factors and active attempts of coping with stress
Perceived need to be in control of the environment
Attributes of a paramedic strong personality leadership A-Type personality-assertive/control
11: 433 / 11: 437-439 / 11: 447-
448 11: 434 11:435-437
Need for reassurance I think is what I could have done better, could I have actually made a difference that’s what bugs me most of the time you speak to colleagues, for me I need get reassurance still because I’m new in the ALS field for me it’s like maybe I could have done that or used that drug, or how would it have affected the outcome, then speaking to the guys with more experience obviously I actually realise but you know what I couldn’t have, I wouldn’t have been able to make a difference there, did I do the right thing, you know that sometimes bugs you, bugs me for sure, you have I wouldn’t say sleepless nights but you, you kind of go to bed and you sleep and you wake up and you think to yourself you know maybe this or that or whatever could have been different, that happens from time to time, you know just that reassurance that everything’s okay
4: 128-129
4: 129-133
4: 133-136
7: 262
Experience is important that's the thing, for me, it will make me a better paramedic, I can say. Cause you'll always think that experience tells you this, that's what you need to do. Like I say, so the main thing for me is gaining more experience and also making a decision to do the right thing I still need to understand and ummm understand the experience wises that you're going to get the days and you’ll be able to do something and then get the days that you can't do something.
6: 238 6: 239-240 6: 228-230
George
Active attempts at reducing stress
Informal Debriefing with colleagues and wife
Telling the Story Talking to Colleagues Talking to Wife
9: 339-341/9:353-354 7: 283-285 / 8: 290 / 7: 248-250 / 9:355-356 8: 291-293
Additional coping strategies: Escaping EMS
computer game (alone time) exercise with others Important to have support or something else in place
8: 294 8: 295-296 / 12: 461-463 8: 298-300
4. Personal consequences of being a paramedic
Personal consequences of being a paramedic
Wanting to see more and more
I don’t go hunt for pts anymore that type of stuff... I used to when I started in the service, because then you want to see more and more and more and more you get to a point in your life but you know why, you know its there’s more to life than actually seeing dead people everyday
2: 52-53
2: 54-55
Re-experience emergency scenes
I used to keep an album of like MVA's and things like that, and then obviously you not allowed to show it to the public but ummm.. [inaudible] that car accident was quite a bad car accident, you know if you look at a picture you can recall it instantly, up to the finest set of details you can recall you can drive past a tree where someone was killed, you never forget you always think about it but you not gonna have sleepless nights about it I suppose it’s the same with the album you just take pictures, there’s pictures of everything in there, there’s accidents and there’s good and bad times in there a piece of clothing that can remind you of something, it’s like a trigger I think, like when you drive past a house, for me I just avoid it, try avoid that route sometimes if it was a really bad incident.. so ja... you never forget it’s always in your mind...
2: 62-65
10: 387-388
10: 389-393
13: 507-510
Exposed to the bad side of life
loss of empathy exposed to bad side of life aggression
2: 67-70 3: 106-108 / 3: 109-113 / 3: 113-
114 9: 363-364 / 9: 364-367
128
Appendix 2: James’ Transcribed Interview.
0
Transcription: James’ interview
Date: 30/05/2011
Gender and Race: Male/White
Level of Paramedic: ALS
Years of experience: 8
Age: 27
The decision was taken that due to space constraints only one transcript would be
included. It should be noted, that in order to track the themes, the page numbers on
the transcript are displayed according to that found in the Master Theme Table.
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Justin: Maybe you can just start off by just saying why you do what you do. 1
James: All-righty ummm medicine is something that has always interested me and ummm as 2
far back as I can remember right back from school days and stuff ok but not the type of 3
medicine that entails sitting behind a desk all day listening to ten people say the same thing... 4
ahhh my nose is running I got a sore throat ja you got a cold go take some of this and go home 5
Justin: Like that Panado ad with the parrot... 6
James: Yes that’s right and one thing that I have sort of... I’ve got very good interpersonal skills 7
and umm I’m very outgoing and I can build relationships very quickly just on my personality so 8
when it was time to sit down and think of a career I looked at a whole lot of things my 9
personality my interests and that kind of stuff and medicine for me was the way to go and as I 10
said it like really interested me and I’m young and I’m kind of like on the edge of the whole 11
adrenaline junky thingy so paramedic was the way to go 12
Justin: How old... sorry how old are you now? 13
James: I’m 27 so that was the way to go, also if you look at it you see a whole lot of things 14
that’s not the same you will never have two cases that are the same so it keeps you on your 15
toes, it keeps you focused, it keeps your mind going all the time and also its an ever changing 16
environment where there is new technology, new procedures get brought in so it’s not a 17
stagnant environment where you got to work every day like accountants got to work every day 18
and count figures and go home and that is their lives, that is their sum total of their lives job 19
where as with with medicine in particular medicine law IT I’m not that kind inclined it its sort of 20
like keeps you on your toes and it’s an ever changing environment 21
Justin: And you started off as BLS? 22
James: I actually didn’t I matriculated and went straight into the Tec, wits tech and I failed first 23
year I’ll be honest I was lazy everyone says party hard, party now study later I employed that 24
approach in first year so I failed due to shear laziness and at the end of my first year I then went 25
and challenged BAA and then got my BAA then went back to first year the following year and 26
then followed through the process from there, worked as a BAA and then registered as an AEA 27
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then worked as an AEA so I’ve gone through the channels on the two different sides I’ve worked 28
independently in inverted commas as well as understudying with the tech 29
Justin: Tell me a little bit about that how was the studying and that... 30
James: Fucken awful...I kind of felt that mum the tech had it in for me, because if you look at it 31
yes first year I failed out of shear laziness I’ll be honest with you but when I got to second year 32
eventually I was in the running for top student I had the best marks in the class ummm my 33
marks was good my attendance was good yes there were a few weak areas and stuff but at the 34
end of the year when it was time to do finals I failed on my final patient simulation because at 35
the end with the way the tech works and stuff like that by the time you reach second year they 36
start bringing in third year skills and I elected not to do a third year skill in my final sim, and 37
when I challenged it they said to me ok its fine we understand your reasoning behind it because 38
you still didn’t do this kind of thing so I landed up failing the year because of that and I didn’t find 39
it necessary because as I said I was in the running for top student. So that that failed me there 40
and in third year the same thing happened I yet again I was in the running for top student I had 41
the highest marks in my drug tests and everything like that and the only thing that failed me was 42
something like four or five percent in a case study assignment, so that I had to redo the entire 43
year because of that. And when I begged and pleaded you can look at my track record you can 44
look at my academic history from my first year I’m not lazy, my second first year registration, I’m 45
not lazy and they wouldn’t under any circumstances grant me three percent four percent 46
whatever it was that I needed in order to qualify, so out of that sense it was awful, because as I 47
say it took me six years to do a three year degree or diploma and I feel I could have qualified in 48
four, two years unnecessary in my opinion 49
Justin: Yes for sure, what do you think it takes to be a medic? 50
James: What do I think? 51
Justin: Ja 52
James: Well first of all you can’t wake up and decide that you want to become a paramedic, 53
that’s not gonna work, you can do that with law, accountancy book keeping, secaterial but you 54
cant... you got to have a very strong personality you got to have strong determination and you 55
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got to be able to have that whole like empathy kind of thing behind you and you got to be kind 56
and considerate, but those are like very broad words to use because anyone can be kind and 57
considerate but it’s got to be an in born thing its be a passion of yours it can’t be as I said like 58
wake up one day and decide to be a paramedic, it’s not for everyone 59
Justin: What do you mean by a strong personality? 60
James: The emergency field its very demanding its very strenuous, it’s very taxing so there’s a 61
lot that gets put on you and you got to be able to with stand it and you’ve got to be able to stand 62
up and say right, okay that was a terrible call but I can’t let it affect me and I need to realise my 63
own strengths and that’s that’s the first thing as I was saying you need to realise that and if you 64
need to seek help, seek help and that comes into your personality because a lot of people say 65
oh I’m too if I see a psychologist then I’m weak kind of thing but a strong personality in that but 66
you got to handle what you see, we see blood, guts and gore, we don’t see a controlled 67
environment like a hospital, by the time a patient arrives there we’ve already sorted it out, you 68
see what’s a second part of it and it affects people, and you’ve got to be able to not let it affect 69
you to the extent that it effects other people 70
Justin: What would you ummm classify something that would affect you? So another words for 71
you what would affect you or has something affected you? 72
James: I actually have... its burns patients, I cannot treat burns patients, I’ve seeked 73
psychological help before with regards to burns patients and to this day I still can’t handle them 74
Justin: Maybe can you tell me of a time when you did have to? 75
James: Yup, what steered it on was, I’ve been in this industry since 2004 and you go through 76
it... you see many burns patients and they never ever effected me until 2007 when I was doing 77
one of my shifts and I was doing it in the alberton/ ekulalerni area and that particular night we 78
went to three burns call out and they were just terrible, the first one we went to if I remember 79
correctly, well I can remember correctly [laughs] the first one we went to the guy was he burnt, 80
he burnt in his house, he basically burnt to death and when we go there ummm (9:09) the fire 81
crew was putting out the fire and we went into have a look at the patient and he was lying face 82
up on the floor burnt beyond all recognition and there was like chunks of meat dripping of him 83
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like unburnt burnt chunks of meat flesh fresh flesh and the smell of that was terrible but I mean 84
it’s not the first time I’ve seen a patient like that, then the night progressed and we went to a 85
second burns patient, and this guy also burnt to death but he burnt in his house and managed 86
to get out of the house and he was like crawling along the floor to get out to where he needed to 87
go and he died in that crawling position so my assumption of that is yes he burnt but he also 88
has asphyxiation and died because of that and the third patient that we saw that night was a full 89
thickness burn 100 percent the guy was in his house and burnt and that I think that cause he 90
was still alive and I think that what sent me over the edge because he was still talking to us his 91
skin when you touched him it was like touching a flippen cow that has been standing in the sun 92
that got backed that thick leathery skin and I mean there was bits of skin peeling off in the 93
insides of his ears and the insides of his nose and he was in pain and I felt so helpless because 94
I couldn’t do anything because his skin was so thick I couldn’t put up a drip he had full thickness 95
burns so he was going to die regardless of what you did he was going to die and you kind of 96
know in the back of your head if you put up a drip on this patient under normal circumstances its 97
going to be painful because you sticking a needle into skin.. you going to feel it when you burnt 98
to that extent it’s going to be even more painful so you kind of feel very helpless in that sense 99
and the smell the smell of that particular patient, and as I said it was all in one night (11:06) that 100
we had that I mean in small doses I’ve been able to handle it but since that night I actually.. I 101
cannot and last year well when that happened I went to go see a psychologist through the 102
university I went to go and see a psychologist and we sort of helped well they had helped me in 103
those days I thought work through the problem and I’ve never treated a burns patient since well 104
I had I had I lie because in 2008 I treated a burns patient the first one sine that incident and the 105
only thing that I can remember about that call was getting out to the call and my mentor saying 106
to me I had two burns patients and the next thing I remember was stepping out of the response 107
vehicle with the fireman driving the response vehicle at hospital I don’t remember anything else I 108
know I couldn’t treat that patient and I remember saying to my mentor saying that I cannot I just 109
cannot and I don’t remember anything there but he got out of the back ambulance treating the 110
patient, and then last year as well I had another burns pt , the guy drank petrol and set himself 111
on fire, and I was the only person on scene until my ambulance got there and I think from what 112
I’ve heard I managed to handle myself quite well on that call but the minute company arrived, I 113
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left and I remember phoning the last number in my phone that phoned me and I was in a state 114
in an absolute state how I got home I actually don’t know to be honest with you I just got in my 115
car and drove and I’m friends with someone who that’s affiliated through st Johns [inaudible] 116
and she’s a trauma counsellor well she’s a Chaplin actually and when I got home my mom 117
actually phoned her, she booked me of duty for about two hours my mom phoned her she came 118
through, we spoke for about two hours and since then I haven’t treated another burns patient, I 119
actually don’t know but by that time I thought I mean 2008 and 2011 I really thought I was able 120
to handle it but as I say it’s just I can’t if I go to any burns pt instantly I become apprehensive 121
Justin: I’m gonna get back to that just now In uhhh 2007 you said that when you had those 122
three calls those three burns so there was quite a.. or the thing that stuck out for me was that it 123
was three calls so it, so another words it wasn’t just one incident... 124
James: Ja it was three separate incident... 125
Justin: So I’m just trying to find out whether or not it seems like it was like you know like one... 126
it’s like being put on top of each other if you know what I mean... so another words it just 127
became well eventually it became too much just to have that all in one night 128
James: Ja I think so... as I said like you can handle it in small doses I think it will be handled I 129
think I will be able to handle it 130
Justin: So what you saying... ja exactly that if it was just one incident then it wouldn’t really, well 131
it would have mattered but it wouldn’t really have been the consequence wouldn’t have been as 132
great as if it was as like as it was when it was one after the other after the other after the other... 133
James: Ja it’s very possible... I mean I’ve treated burns patients before and I’ve said this to my 134
lecturers and I’ve said this to the psychologist that I was seeing I’ve treated burns pt before and 135
I’ve ever had had an effect of any description towards it so why now 2008 from 2004 is four 136
years in the industry I’ve seen just about everything that you gonna see you know but I couldn’t 137
understand that.... 138
Justin: Ummm who were you working with at that time...? 139
James: I was working with A.P the paramedic on shift that night 140
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Justin: If you go back to... I mean pls tell me if you don’t want to but that particular night apart 141
from the sight you said also there’s also this is the other thing that I picked on apart from 142
obviously the sight what you saw was horrific but there was other stuff involved and I’m you said 143
one of them was smell is there anything else that... you know that made it particular or that thing 144
besides the sight and the smell anything else that you can pick on how you felt thought or heard 145
that kind of stuff.... 146
James: Well I basically said it’s your sense you can take out the hearing aspect of it for the the 147
first two that we did because the pt was dead but take that last pt that was still alive, to touch his 148
skin I mean you touch normal peoples skin its soft his skin was like touching a brick wall it was 149
hard it was leathery it was not cold but not hot but not warm if you know what I’m saying it was 150
different and then to hear him in he’s writhing in agony you can see it you can hear it and he’s 151
breathing and the smell and everything like that myself personally I just had a very strong 152
feeling of helplessness like I know what needs to be done but I just can’t do it and you kind of 153
know what’s going to happen to him inside you know with burns that nature and that extent you 154
are going to die regardless to what anyone is going to do to you the internal damage is worse 155
so the feeling a sense of helplessness as well so you can basically take all your sense into the 156
last one sight, smell touch hearing taste no really... 157
Justin: But some people even describe it as even the smell in the back of your throat you can 158
almost taste it... 159
James: For months afterwards I don’t know if it was just me but for months afterwards I could 160
smell it on my uniform and I know as I say I don’t know if it was just me but I could and not to 161
sound funny but this is probably is gonna sound funny It got to the stage where it affected me 162
actually showering because I associated that running water with the water of the fires so I 163
couldn’t shower and from that day forth I can’t actually stand with my eyes closed in the shower 164
my eyes have to be open 165
Justin: Because it brings back memories 166
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James: Ja which is weird because I mean I’m 27 I shower every day of my life [laughs] So I 167
mean it got to that stage and then when it got to that stage that’s when I decided that I actually 168
needed to go see someone about it 169
Justin: What other aspects affected you afterwards besides the showering part ummm I mean 170
the smell on the uniform ummm how did it effect you almost mentally per say that kind of stuff if 171
you can [inaudible] relationships your work that kind of stuff... 172
James: Look with work I didn’t want to go back to work, I actually thought of changing 173
professions from that but I stuck it out because I’m strong willed [laughs] and that kind of thing... 174
but home life and stuff like that I actually can’t remember to be honest with you id lie if I had to 175
tell you I’m not one that’s usually depressed I’m not one that usually goes on anti-depressants 176
and stuff like that so I wasn’t on any medication on that time... 177
Justin: Did anybody come up to you and say like hey you’ve kind of changed or anything like 178
that 179
James: Not really because that also maybe that’s a flaw of mine is I can hide things like that 180
very well I’m for years and years I’ve left this house with a mask on like [inaudible] and no one 181
knew what was going on and when my friends eventually found out they like why didn’t you tell 182
me about this because it wasn’t important you’ve got your problems I’ve got mine and that’s that 183
you know 184
Justin: So you’ve kind of kept it all to yourself, you bottled inside 185
James: Ja and I still do to this day with a lot of things 186
Justin: Would you say that is also part of being a paramedic I mean a lot of people I’m just 187
saying a lot of ummm I’m assuming here perhaps a lot of people bottle this stuff inside... like you 188
were saying earlier if you show it it could be a sign of weakness... 189
James: Yes 190
Justin: The perception is there 191
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James: Ja I think a lot of people do and that defiantly affects your home life as much as you like 192
to think it doesn’t so I think a lot of people do I’ve had crew members that have come to me and 193
spoken to me and said to me that look that was a very hectic call and I’ve had grown men cry 194
because of it and I’ve personally myself spur it on and say go for it have a good cry because it 195
gets it out 196
Justin: how would what would you say is the best way after a hectic call what would you do it 197
doesn’t have to be burns but I mean anything else uhh to kind of... you know to get rid of all 198
those feelings what would you normally do 199
James: I normally talk to someone about it maybe not on a one on one formal basis but like 200
even over a smoke and cup of coffee back at base like say oh you know I had this call kind of 201
thing and the guy was like seriously fucked, pardon my language, you know and this and this 202
and that kind of thing you know and like just talking about generally subconsciously it relieves it 203
Justin: So you would talk to your peers or your colleagues 204
James: Ja, ja and if, if I notice or depending on the type of call it is it may not affect me but it 205
may affect someone else so I will always go to the people that were with me on that call and say 206
to them id give them the option to talk if they want to they are more than welcome to if they don’t 207
it’s their choice but least they know that that the offer is there if they if they want to and I’ve had 208
one or two crew members just ignore it and I’ve had one or two crew members actually talk 209
about it because everyone’s personality is different so things effect you differently 210
Justin: Sure no defiantly... um what other ways would you say people cope or for yourself 211
ummmm besides maybe talking about it... what else I don’t know... do you talk... besides talking 212
to uhhhh peers do you talk to the family members or to friends about it at all I know you did 213
mention it that you keep it inside so ummm has that changed at all or not really? 214
James: Not really 215
Justin: ok so for you the main way of perhaps dealing with hectic calls is to actually talk to 216
peers about it 217
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James: Ja I’ve mentioned one or two cases to family or friends but that’s like if I do that it’s 218
close to home if you know what I’m saying like I mentioned to my mom my gran is 82 I 219
mentioned to my mom last year sometime that I did a really hectic declaration where it was I 220
declared some ladies mother who was in the region of the late 70’s and virtually to the day later 221
a year later I declared her father... 222
Justin: Oh my word 223
James: Virtually to the date... it was really weird and they remembered me the minute I walked 224
through the door they said you declared my mother last year and I stood back and then I 225
actually took note of the surroundings and I’m like ja I’ve been here before and I came home 226
and like said to my mom you know that was really bad because last year her mother was 227
roughly that age of my gran and now her father or her father which is... what her grans her 228
grandfather [inaudible] and I lost my granddad at a very early age and I miss my granddad so 229
like it really touched home 230
Justin: So it was a very personal aspect 231
James: Ja and to have that statement made oh like you declared my mother last year kind of 232
thing and it like makes you realise and wonder 233
Justin: Almost sound like a blame statement! 234
James: Yes 235
Justin: So holding you almost personal for the death of the granny in a weird way 236
James: In a weird way so like only things that are close to home will I mention... also kiddies... if 237
I treat a very bad kiddie case I did a suicide the other day, sorry I don’t mean to go into all my 238
cases, I did a suicide case the other day where a mother jumped out a seven storey building got 239
out the window of a seven storey building with her two year old daughter in her arms and both of 240
them were alive when I got there and half an hour later I pulled out a declaration form for both of 241
them and I mean the women was roughly my age if I had to take a guess and I was like talking 242
to my mom saying like you’ve been there you’ve had two kids at two what have they done so 243
wrong that they deserve that kind of treatment I was very angry at that mother very angry... 244
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Justin: How did you deal with that anger, besides talking to your mom? 245
James: I haven’t [laughs] I still get very angry if I think of it very angry because the kid did not 246
deserve it you know I can understand if the mother did that and did that on her own but the child 247
did not deserve it’s an innocent child 248
Justin: In terms of the emotions going back to the burns part you said you felt helpless hey ja 249
that’s right... ok ja.... ummm... you coming home how do you think it effects your mom talking 250
about this stuff? 251
James: I don’t actually know, my mom funnily enough also wanted to be in the medical industry 252
but due too, She got a hip problem so she couldn’t she can’t stand long hours and that kind of 253
stuff medicine also interests her so I don’t actually think it affect her to much she’s worked with 254
me once or twice before on the odd occasion but she hasn’t shown anything of great anxiety or 255
anything like that to cases that I’ve told her cases that she’s seen this was also for [inaudible] 256
cause I’m the first one in my family in three generations to go in to medicine three or four 257
generations to go into medicine 258
Justin: That’s quite an achievement hey, that’s really good 259
James: Ja so no one else in my family everyone in my family is desk orientated bookkeepers, 260
secretaries, accountants... 261
Justin: Ja umm tell me a little bit about what is the process of when you first get a call what are 262
you thinking what are feeling, till you get there and then afterwards, tell me a little bit about that 263
process 264
James: In my mind what happens when I get a call is I always think of the worst case scenario 265
like for instance if I get a call and its chest pain something simple I always think of it as the pt 266
has got chest pain and they are knocking on deaths door and I’m gonna need to resuss and its 267
its great when you arrive on scene and the tables have turned and the pt is sitting there and 268
talking to you and its minor chest pain and that kind of stuff so I will always I mentally prepare 269
myself for the worst case scenario, but then I also bare in the back of my mind if it’s not the 270
worst case scenario you have to do this cause then you get tunnel vision ok ummm also like 271
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breathing problems and stuff like that I I think of I think off the worst possible cases where the pt 272
is and then I treat the pt and I stand back at the end of it once I’ve handed over at the hospital I 273
think to myself quickly and briefly is there anything I could have done different ummm if the 274
answer is no, then it basically comes like a closed book if the answer is yes then I’ll keep it in 275
the back of my mind and say what could have been done differently how could it have been 276
done, when could I have done it, and then I’ll keep it in the back of my mind for the next case if I 277
get something that’s similar... 278
Justin: That almost sounds like a bit of a debriefing session in it self 279
James: Kind off 280
Justin: Thinking about what skills I could have maybe used or different skills if there was 281
anything I could have done ummm ja 282
James: Ja cause another thing especially with that I mean when you get to the stage of 283
advance life support people think that you are highly educated and that you are very 284
knowledgeable which should actually be the case but at the end of the day we are also human 285
we’ve got a very large scope we’ve got a large number of drugs that we need to carry and know 286
and there’s no ways unless you read them every single day of your life there’s no ways at the 287
end of two or three years after qualifying you going to know those drugs like you did the day you 288
qualified and people feel weak if they have to refer to their protocol book where as I carry mine, 289
it’s like my bible, I carry mine and if I’m not sure please believe me ill reference it, I I’ve done it 290
before and I’m not shy to do it now to be honest with you I don’t care what people think of me 291
having done that because it shows that I’m stronger than them I’m ready to admit defeat if I 292
need to admit defeat, I’m doubting myself I’m just making sure... 293
Justin: Ummm... you’ve mentioned in the beginning something about uhhh empathy being kind 294
and considerate 295
James: And compassionate yes 296
Justin: or compassionate, sorry, for you particularly after seeing I mean being for a number of 297
years in this industry, ummm how do you keep that because some people would say that well 298
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because you’ve seen so much you kind of loose your empathy, you know kindness that kind of 299
stuff people maybe just don’t care about other people any more 300
James: You get it don’t get me wrong I mean there are cases where you go to it and say to it 301
ahh God this is the biggest load of croc shit that I’ve ever had to deal with in my life you know 302
but for me it’s my passion, it’s what I enjoy doing as sadistic as that sounds I enjoy my job, I 303
don’t necessarily like the companies that you work for but I enjoy getting down and treating pt’s 304
and my personality comes a lot into that because I’m not a restricted person I’m adaptable and 305
I’m as I was saying earlier I don’t know if it was here or outside but I can adapt to many 306
situations and I’m outgoing I can strike up conversation with someone in the shopping queue ( 307
30:40) that I’ve never met in my life before and I have that ability to do it with pts and people as 308
well and because I enjoy my job it makes it a lot easier but as I said there are case where you 309
go to where you really tired and you know it’s going to be bullshit and you get there and you’ve 310
already got that bullshit attitude like you know what just grin and bear it’s another three hours 311
until the sun comes up and then go to the hospital kind of thing and then you treat the pt like 312
you have to treat them not because you want to 313
Justin: Ja, ja... what do you say for you to protect yourself uuhhhh in terms of like your own 314
mental health if you can call it that, how do you do that, because day in and day out you see 315
grizzly scenes... how do mentally save yourself if I can put it that way 316
James: You’ve got to block it out and if it if it affects you it to the state where you can’t think 317
seem to think about it you have to talk about it that’s what I firmly believe but if you can close 318
that book as I was saying to you at the end of the call if you stand back and say was there 319
anything that I could have done differently if the answer is no you have to close that book and 320
leave it closed and once its closed you should never open it again ok and if it comes up at some 321
stage then you need to talk about it to get to that point where you can close it and forget about it 322
basically because you can’t let it you can’t take it home with you can’t let it affect you to that 323
state as hard and callous as that sounds you actually have to forget about it... 324
Justin: Do you think other people can understand? 325
James: Understand what? 326
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Justin: This type of stuff that you see in terms of like not being in the industry itself... 327
James: I don’t think so because the question that I get asked or a question that I get asked is 328
what’s the most gruesome thing you have ever seen it drives me crazy and another statement 329
that gets made by just about everyone ask what profession [inaudible] you must see quite a lot 330
of things yes I do and you get that relationship between work and home and that’s the 331
relationship I was talking about with the book where you have to close it and yes you do and 332
that kind of stuff and to be honest with you with friends and stuff I prefer not to talk about things 333
because it makes you look all morbid you know, they’ve got their job their profession they not 334
necessarily interested in what you want to do so why must you palm it off on them if you know 335
what I’m saying , take my sister for example she doesn’t understand what industry I’m in, she 336
knows it’s the medical industry and that kind of stuff but she she asks me so do you get a lunch 337
hour... no I don’t I work from 7 to 7 and if I get a chance to eat then I eat kind of thing you don’t 338
have lunch hour like your controlled office job, yes you see it all, and she was like but now if 339
someone did this and you did that how’s it going to be together and how can you not let that 340
affect you, and she’s got a lot of unanswered questions and she doesn’t actually understand 341
where as my mom understands on the other side of the coin and a few of my friends understand 342
but a few of them don’t I mean to them it’s all glory I mean they watch gray’s anatomy and er 343
and when red when code red was on TV they watched all of that it was a thrill for all of them 344
because they get to see it but they don’t realize that you don’t finish it the moment the TV series 345
finishes... 346
Justin: Ja explain a little bit more about that... 347
James: Well you do still think about it I mean the media is broadcast is to or they trained to to to 348
broadcast the sensational aspect of things, the things that people want to see so you have a 349
choice you can either watch gray’s anatomy or not if you don’t want to watch it you change the 350
channel where as my job I don’t have a choice... 351
Justin: you have to see what you see 352
James: I have to see it I got to live it and I got to deal with it and I can’t just turn the TV off if I 353
don’t like what I see, now you have a bad day at the office you have a rip roaring argument with 354
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your boss, you come home you have a beer you have a glass of wine, whatever you want, 355
depending on your gender and you scream at your spouse and say you know my boss is a 356
bloody idiot, this and that and the next thing and by tomorrow its forgotten, whereas you go to 357
sleep at night, in your mind to got that picture of what you see and it doesn’t go away it stays 358
there... you can bring up a case maybe four five years ago and I probably remember the setting 359
of the case, like the burns patient I described, the guy was next to his shack, crawling down he 360
was wearing a blue t-shirt or blue shirt with like working pants on, black boots I can remember 361
everything the ground underneath him was wet, his right hand was further [inaudible] than his 362
left hand... 363
Justin: Is this something that you think you will have to live with for the rest of your life... 364
James: Yes and no... eventually they will fade, memories fade eventually they will fade, the 365
most important ones or the most crucial ones will stick with you but the insignificant ones fade 366
and if you can close that book, you won’t deal with it if you know what I’m saying you won’t live 367
with it for the rest of your life, so until that book is closed it will be there like an unread chapter... 368
Justin: Well just as a part of the book like the unread chapter no we are dealing a lot with the 369
morbid stuff, maybe you can tell me like a little bit about a good call, something that you felt well 370
what do you consider as a good call? 371
James: I consider a good call a call that ran well from the beginning to the end where all your 372
basis are covered everything was covered within the time deadline and the results that you were 373
expecting were the results that you saw.. I will give you a case to elaborate on that I was a 374
student and I had a case very similar to this recently after qualifying or ja, and the case was a 375
guy couldn’t breathe he had a lot of fluid in his lungs and automatically instinct kicked in I got in 376
the back of the ambulance did what I needed to do got oxygen on the pt, got an ecg on the pt, 377
got a drip up, gave drugs and within 10 to 15 minutes the guy was able to talk to me, from not 378
being able to talk to me and breathing very erratically almost knocking on deaths door with 2 or 379
3 simple drugs I turned his whole life around basically and I remember the last word before we 380
drove of the scene was my mentor turned round to his daughter you have that man to thank for 381
that... and that to me looking back in retrospect was a good call because you identified the 382
problem, you knew what the consequences where and you did something to rectify it and the 383
15
results were positive, and shortly after qualifying I had a case very similar to that where I had my 384
base manager, my branch manager, my area manager, phoning in absolutely hysteria stating 385
that my ambulance crew were on scene and they didn’t know what to do, well they did know 386
what to do but they reached what they could do and they needed further intervention, then I got 387
a phone call to say that the drip has been pulled out, and the crew (38:50) members are no 388
panicking because it was roughly the same situation, so I arrived on scene did what I needed to 389
do got a drip up gave the pt drugs and by the time we, it was here at garden city, and by the 390
time we got to Baragwaneth hospital the guy was able to string a string a sentence together, 391
where he couldn’t string two words together 10min prior, and that to me was a good call... 392
Justin: So again a number of themes there, one is to be able to use your skills 393
James: Yes and use your mind, what’s in your mind as well... 394
Justin: ja so as how do I say it, not one of those bullshit calls, but a call where you can actually 395
use your skills, and then also to know that you’ve, well you’ve saved somebody’s life 396
James: Ja accomplished something for the benefit for someone else 397
Justin: How does that feel for you inside, like what do you feel... 398
James: Myself personally it makes me feel good, it makes me realise why I’m in the industry I 399
am in and it makes me realise what my purpose id, because more often than not you get sent to 400
rubbish, and you got to treat, then you start to think to yourself why did I actually waste 6 years 401
of my life studying this if this is what in gonna treat, I studied to treat the good stuff not the bad 402
stuff, so it gives me a sense of accomplishment like man I did a good job, pat myself kind of 403
thing, now that’s the reason why I’m doing what I’m doing... 404
Justin: Do you think you get enough support from, I’m not saying peers or colleagues but rather 405
the organisation 406
James: No... I don’t... 407
Justin: Ok... Maybe elaborate a bit more on that... 408
16
James: Ok I’m gonna use just because I recently change jobs and I’ve worked for “A” and now I 409
work for the “C”, I’m going to compare them in in the two, I worked for “A” for 13 months in those 410
13 months we cried for about 10, 11 months to get a counsellor in, and it was like brushed 411
under the carpet to say ja ok you know like we will get someone in, kind of thing, and it didn’t 412
really materialise until the last 2 to 3 months that I was working there, then we got a counsellor 413
in and you could see the change, you could see the change in the guys, the moral, the 414
enthusiasm, their willingness to come to work, cause it’s not only.. when you get to that point 415
where something starts affecting you everything affects you, for example if the milk runs out at 416
work, and you like god damnit the milk is run out at work and like you know all I want is a cup of 417
coffee and I can’t even have a cup of coffee and it stresses you out even more, but... and like 418
ahhh grief you know my ambulance is dirty I’ve got to go and wash my ambulance but it take 419
work I don’t feel like washing my ambulance because the sense of pride is gone and after 420
getting that counsellor in at “A” you could see a definite change in the guys, you could see that 421
their moral was a little bit better and there was a little bit more enthusiasm to come to work... 422
Now you go to the Johburg setting the “C” sector of it, and we don’t have that there are 423
chaplains and counsellors available but by appointment, whereas “A” has got one that works at 424
the hospital now, so that’s beneficial cause any time you need to talk you can go find her, close 425
the door and talk, and like with the fire dept, myself personally I feel very isolated their because 426
they are all firemen and I’m an ambulance driver, yes the firemen work on the ambulance, they 427
rotate to work on the ambulance but they want to work on the big red lorry not on the little yellow 428
bus, and I don’t fit in because I’m not a fireman I’ve been employed to work on a little yellow 429
bus, not a big red lorry. And I... yes although I’ve made friends with the guys at work I still feel 430
isolated, like that’s your job that’s my job and don’t interfere so I don’t think there’s support at in 431
the work place 432
Justin: Do you when you work there do they tell you ok well there’s the numbers for this place 433
this place or do you have to actually sorry I’m saying numbers to the Chaplin or... 434
James: No 435
Justin: You personally have to go find that out about that yourself 436
James: Yes ja 437
17
Justin: So do you think the guys, including you make would make use of that... 438
James: I think so... 439
Justin: So if there was a problem they would get hold of the number and phone... 440
James: Yes... but the question is who do you get the number from, it becomes a [inaudible] 441
race, so from having worked at “A” and having friends outside the EMS as well ummm I’ve got 442
a couple of numbers that I use and I recommend these people to, [inaudible] people... I 443
recommend them because they the only people that I know... yes they might not be part of the 444
“C” or they might not be part of the “A”, or something like that, or they might be from a different 445
organisation for example St John there’s a lady that works at St John that’s a trauma counsellor 446
St John is an ambulance service, but she is not affiliated to johburg, she is not affiliated to “A”, 447
she’s not affiliated to “B”, so I mean a complete outsider... 448
Justin: Ja is that important for you to have somebody who’s a complete outsider or somebody 449
to be a part of the, even though St John’s is an outsider they still part they still an ambulance 450
service or there’s a medical component of it, I mean is that important or not really... 451
James: It’s not important aspect is the person needs to understand, and not understand in the 452
sense that, you can go in there and cry your tears of woe and they say it’s ok I understand, they 453
need to understand where you come from initially, and that makes a large difference whether or 454
not they are in the medical industry or not, it doesn’t matter, what matters is they need to 455
understand they need to understand where you coming from why it’s affecting you, to that 456
extent its affecting you and to be able to treat you or help you in the right direction 457
Justin: Ummm besides the lets say the scenes themselves or the medical stuff what other 458
things do you think contributes to the stress, if there are 459
James: There are I’m just trying to think of the right ways to put it... the families would be a big 460
one, but that’s more related to the scenes.. I mean the family is in a state of need they phone an 461
ambulance because someone in their house is sick or dying or what not, and you take 5 min to 462
get there but for them it feels like 5hours, the minute you get there you get screamed at or 463
shouted at why did it take you so long to get here and then by some unlucky charm or unlucky 464
18
chance you land up doing a declaration at the call and the family now is angry because you took 465
so long to get there and if you didn’t take that long my mother wouldn’t be lying dead on the 466
bed, kind of thing, so there’s blame and there’s unanswered questions and... that’s that’s for like 467
the scene thing. Then you can take going to the call as a big stressor because you driving a 468
vehicle at a high speed, you’ve got traffic you’ve got pedestrians, you’ve got the vehicle itself 469
and an accident can happen so quickly, it really can and that’s always in the back of your mind, 470
there’s when I first started off in this industry I used to make sure that I never left work, I mean 471
never left home having had an argument with someone because you never know if you never 472
gonna see that person again and then that guilt that person is going to have to live with for 473
having an argument. I’ve seen it and I don’t wish to do it to my family. So that’s also a big stress 474
and then it’s the stress of actually going to work, because you’ve got your protocols you’ve got 475
your scope and in the back of your mind always is 2 words medical negligence, medical 476
negligence, you miss treat a pt, you miss diagnose something you don’t do something, you can 477
be held liable for medical negligence and lose your licence, and take me for example I’ve got 478
nothing to fall back on, medicine is my life vie matriculated went straight into varsity, I’ve got 479
nothing else to fall back on and I’m 27 28 at the stage where I’ve now got to start setting up a 480
family, let’s just take worst case scenario, I get found to be medically negligent for something I 481
lose my licence I now have to start studying again, I’ll have no job I’ll have a family to support, 482
which which career do I go on to... people aren’t looking for companies aren’t looking for people 483
that are 50, 60 years old, they are looking for people that are 20 30 years old.. so it’s a big 484
concern of yours as well... and then like just the general office environment of being at work, 485
you know you’ve got deadlines, you know you’ve got performance cards to do, you know you’ve 486
got statistics to do, you’ve got stock to order and if it doesn’t get ordered you start running out of 487
stock you start getting stressed because you don’t have the required equipment to treat your pts 488
Justin: Seems a lot of, quite a bit of responsibility 489
James: Yes very much so... 490
Justin: From ok this is gonna sound kind of obvious, but I mean do you work as BLS before 491
hey, if I’m correct? 492
James: Yes vie worked BLS, ILS ALS... 493
19
Justin: Ok so would it be fair to say, the higher the grade the higher the stress 494
James: Yes definitely, because even if you look at it from the different practionar side of things, 495
i mean as a BLS on your little card its registered supervised practioner which means you can 496
basically do what the hell you like because someone more qualified than you is going to step in 497
and stop you, the chances of you being found medical medically negligent is slim because a) 498
your protocol is small and b) you’ve been watched then you get to the stage of intermediate life 499
support where on your card its written independent practioner so now your it for the ambulance 500
but you still got an escape route with your ALS because on the same scene your ALS will 501
watch over what you’re doing and say to you look [inaudible] you doing something wrong, let’s 502
look at it from a different avenue kind of thing, so you’ve still got that piece of mind behind you 503
but as an ALS paramedic you have now reached the top, and you are it... you need to make 504
sure that everyone on scene is doing the right thing, you need to make sure the scene is safe, 505
you need to make sure that the base runs smoothly, you need to be able to be there for your 506
crew ummm as I’ve said earlier you are very highly regarded when you get to ALS because 507
people think you are this world of knowledge and this very highly educated person whereas 508
back at the ranch you may not necessarily be I know people out there that I won’t allow near my 509
family with a barge pole.. so it’s, it’s a lot of extra stress being an ALS paramedic as opposed to 510
being an ILS and BLS paramedic... 511
Justin: So there seems to be less support in a way if you know what I mean 512
James: Yes.... 513
Justin: Ummm... what do you think the organisation could do to give you more support...? 514
James: That’s a little bit of a tough question... 515
Justin: Well whatever comes to the top of your mind 516
James: The first two things that come to the top of my mind is employ more staff and have a 517
counsellor on standby, I mean if you look at the areas that you service myself personally I cover 518
a very large district working at Joburg I covered a very large area working at “A” and that in itself 519
places a lot of stress and demand on you as an individual, and if you employ more staff it takes 520
20
the stress of of you, I mean we were talking at work the other day and the guys were saying 521
back in the days in nineteen foetsack, there were 3 ambulances and 2 response cars that ran 522
from Fairview fire station, and there were 16 to 20 people on shift a day and they had three fire 523
engines that ran from one station, now you’ve got 2 fire engines one ambulance and one 524
response car and ten people on shift, so you’re on scene stress your at work stress is incredibly 525
high whereas if you can have a lot more staff it evens the stress out a little bit because you not 526
that overworked so to speak, overworked and over taxed. And to have someone to talk to to 527
know that you’ve got someone that gonna comfort you in your hour of need... 528
Justin: Who are you able to talk to know at, you don’t have to mention names or anything, but I 529
mean is there somebody that you can talk to at Fairview or not really... 530
James: There’s only really one or two guys that will like, without sounding racist or anything like 531
that but there’s including myself four white guys on shift and one black lady all the rest are black 532
men, and there’s one white guy that I can speak to and possibly the black lady we could speak 533
to, I don’t really get along well with all the crew but those are the two crew that I get along the 534
best with.. 535
Justin: Just in terms of my research one of the besides talking to peers one of the other ways of 536
coping with stuff is uuuhhhh what they call black humour, so almost macabre jokes about stuff 537
like that.... 538
James: Ja we kind of do that too [laughs] 539
Justin: Tell me a little about that... 540
James: I think that’s a personal coping mechanism for a lot of people because in a way it looks 541
like you in a way myself what I think and feel about that is in a way you are talking about it but in 542
a roundabout way not letting people know that it affects you, so you go and say Geeezz that 543
dude was burnt to a crispy last night did you check him I mean like if you broke his toe of it 544
would have gone crack kind of a thing. I mean ja it’s terrible and it’s sick to joke about stuff like 545
that but it’s a personal coping mechanism in my opinion... 546
Justin: When, when can you do this and when cant you do it... 547
21
James: You can’t do it in front of the family [laughs] 548
Justin: There would be no appreciation there... and if there was I would be worried [laughs] 549
James: Very much so... I suppose you can do it any time provided the time and place is right, 550
back at base over a cup of coffee and cigarette or back at base at the end of hand over or if you 551
got other people in the car you can make a joke going from one case to the other but like not in 552
front of the family, it will offend them. Now I did something like that once it was embarrassing, I 553
did a declaration and it was a taxing declaration ill be honest with you and ummm we phoned 554
the mortuary van and I waited and I helped the guys load the pt, as we were loading it into the 555
back of the hearse I didn’t realise that the family had followed us out of the house and as we 556
were loading the pt into the back of the hearse, the undertakers cell phone rang, and it rang and 557
it rang and it rang and it was loud, and nit thinking twice I just turned around at the most 558
inopportune moment and I said geez your phone is ringing so loud it can wake the dead, 559
[laughs] you know, and I said it with like the straightest face as a joke, and I didn’t realise the 560
family was standing right behind me, so that was a very inopportune time, so that doesn’t 561
definitely have a time and place for anything like that, I was very embarrassed and very 562
apologetic, and all I wanted to do was stick my head into the ground 563
Justin: Ummmm... besides that do you think friends and family understand black humour? 564
James: No because they could then see it as very undignified, take my sister for example if you 565
speak of death to her she’s like they got to save their dignity and they now have passed away, 566
and that’s the end of it, that’s nothing for them, but it’s for my sister I would never go to my sister 567
and say geeez I did a crispy on the highway last night or I did this spread on the highway last 568
night and I stood on a piece of brain, because it would send her over the edge to be honest with 569
you because in her opinion that pt is dead and they should, although they died in a very 570
undignified manner they should still have the dignity they deserve, which I understand so she 571
wouldn’t understand that but let’s just take my mom for example she would, she’s got a very 572
wicked sense of humour like I do, so it also depends on the person you talking to and the type 573
of humour they have 574
22
Justin: Ummm what do you think the chances of, ok I know you’ve sort help, was it difficult for 575
you to actually look for help in terms of like, I know you came to the realisation but I mean was it 576
difficult for you to sort of look for help 577
James: Initially if I had to go back to that burns incident that I was referring to earlier when it was 578
the first time that I sought help, yes it was because I became weak, if you know what I’m saying, 579
I became exactly what everyone’s perception was of you if you look for help within the EMS 580
Justin: Ok...ummmm oh ok so you saying others people’s perceptions or even you thinking I’m 581
weak, that’s why I have to look for help... 582
James: Ja cause as I said to you like if you seek help you considered weak and like you can’t 583
cope kind of thing (58:10) but after having seeked help, ja it was difficult to to come to the 584
realisation and actually go to someone and say look you know I mean this call has affected me 585
it was something insignificant it has affected me and I need help, but after having sought the 586
help I realised at the end of the day it made me a stronger person... 587
Justin: What do you personally think would change that perception in the EMS... but just 588
because I need help doesn’t mean I’m weak you know what I mean what do you think could 589
change that perception? 590
James: Is if help was already available because you find you would that you would be speaking 591
to them without even knowing it and you wouldn’t be considered weak so if you could have that 592
available to you, if the help is more readily available and I mean yes you still have your 593
confidential times behind a close door but even if you just sit around in a joking way I mean the 594
lady that I refer to from St John’s she is really sweet lady she’s wonderful she’s brilliant, you can 595
sit next to her and say like I did a really bad call or you know I declared a kid the other night and 596
she will say one or two things only and it will put your mind at complete rest like you did all you 597
could or deep down inside the mother was probably hurting just as much kind of thing as what 598
you are now and she needed to get rid of but she never had someone to talk to, so had she and 599
then the kid would have still survived kind of thing or on those lines, she says it in the sweetest 600
of ways and without even realising it you’ve dealt with it and closed the book, and I think and I 601
mean that’s sitting in public not necessarily behind a closed door its sitting in a public place in 602
23
amongst other people you just start you find especially with her you find you start talking about a 603
whole lot more a whole lot easier and your crowd gets bigger at the end of the day. Going back 604
to “A” days it started off where she was there and you have one or two people that came and 605
that kind of thing and then in the mornings it would be this huge big ritual that we would go to 606
the coffee shop and we would all sit round the table at the coffee shop and we called her mom 607
quite literally, cause she’s old enough to be my mom and we called her mom and we all just sit 608
there and joke and laugh and like someone will just crop up and say something about a call and 609
you say you know I had a call like that similar to that you know and you talk about and half an 610
hour later you order another cup of coffee and then half an hour later you all go on your merry 611
way kind of thing it’s like a debriefing without you even knowing you debriefing and the crowd 612
grew at the coffee shop and that was like our meeting place every day, it was wonderful it really 613
was... 614
Justin: Any particular negative ways that you may have dealt or started to try and deal with that 615
particular those burns those burns pts that you saw like any negative ways that you may have 616
dealt with 617
James: In what sense? 618
Justin: Like for instance like I interviewed a particular person and I’m not saying this is for you, 619
he started drinking heavily, that kind of stuff, I don’t know if that ever happened with you at all... 620
James: Not really, but I will say one thing that’s that’s had a detrimental effect on my family life 621
and my personal life is , from everything as a whole taking EMS and studying at that stage and 622
everything as a whole, I did become very deeply depressed it got to a stage where I was 623
actually thinking of killing someone ok someone in my family and then I got sent to a 624
psychologist I think it was a clinical psychologist we worked through issues, and shortly after 625
that this particular family member of mine happened to pass away and I had deep regret and I 626
didn’t think I that it would affect me as much as it actually did it affected me very badly, because 627
of history and the thoughts, and I actually said to this person you you’ve got a telephone 628
number to phone and thank because the person on the other end of that line is responsible for 629
you standing here today and not me killing you, and it got very nasty because of that and for the 630
last 4 5 months, ok this person has been deceased for a year and half but for the last 5 months 631
24
I’ve been on a course of antidepressants, from like everything in general because I yet again 632
reached the stage where I was suicidal and that’s not me that’s I’ve never been suicidal in my 633
life I’ve never been depressed in my life either.... 634
Justin: And that was [inaudible] what you’ve been telling me seems to be not only from the 635
actual work but also, ok I’m just trying to understand it more the work itself influenced the family 636
life 637
James: Yes 638
Justin: And but then it’s kind of amalgamated in a way in terms that the work and the family life 639
increases the stress, if that makes sense and 640
James: Yes 641
Justin: does that make sense? 642
James: It does... 643
Justin: And then because of that increased the depression 644
James: Yes because... 645
Justin: Am I saying it right 646
James: You are... 647
Justin: Ok 648
James: Umm because as I said I’m not a depressed person I don’t I’m not one for medication 649
and one for antidepressants I’m not a depressed person by nature, but your family picks it up 650
that there’s something now that’s affecting you, and its work let’s be honest I mean the reason 651
why I’m on antidepressant now at the moment is because of work, and you come home and you 652
make home life hell ok and you don’t realise that you are doing it, and it affects those around 653
you and those around you will say something to so you concentrate more on trying to increase 654
the attitude or the atmosphere or better the atmosphere at home and that also places an 655
incredible amount of stress on you because you now trying to please everyone and... 656
25
Justin: Which in a way is not how you feeling so it’s false? 657
James: Exactly and you can’t please people, you have to be this is me, you either like me or you 658
don’t you know and take me with a pinch of salt if you want to I really don’t care but you 659
pleasing someone and you not pleasing them up to their expectations so you work harder and it 660
puts extra additional stress on you so they do kind of like join and amalgamate as you said... 661
Justin: It’s like a snowball affect almost... 662
James: Ja a vicious circle 663
Justin: Tell me a little bit how you thought or you think that you made home life hell in what 664
ways how did you behave or act 665
James: According to the people that brought it to my attention my attitude was a major 666
component of it, id come home grumpy in a bad mood I would be very short shout a lot for 667
something small and insignificant and ummm just like vent my anger on everyone and anyone, 668
for example, take a stupid example, and my mom says to me like do you have to leave that cup 669
in the office when you going from the office to the backyard to smoke and you passing the sink, 670
you then become so uptight or id become so uptight that id slam the door shut and just go on a 671
screaming tangent like it’s my cup and it’s my office and I’m gonna go back there later and if I 672
want coffee ill go to the office and fetch it you know and just your fuse becomes very short so 673
that’s that’s a lot of how I did it and to be social id find myself being very withdrawn just coming 674
home and going to my bedroom and watching TV or going to play on my computer or something 675
not really socialising much and if I do it it’s on a very short and abrupt bases 676
Justin: So almost isolate yourself not only family I presume friends as well... 677
James: Ja very much so... 678
Justin: So and now how’s things going now? 679
James: Much better now that I’m taking happy pills [laughs]... no but you also like find that 680
there’s certain things like once you’ve spoken about it it becomes easier to deal with and you 681
you sort of put it behind you and ok yes I’m now taking chemicals to improve my mood but still 682
much to my disapproval... 683
26
Justin: Its chemicals that would have been there anyway... 684
James: Exactly... but it makes it more manageable and you realise that you letting a lot get to 685
you that actually shouldn’t like for example the mother with the cup, like now ok cool I just go 686
fetch it and put it in the sink I’m sorry kind of thing you know just keep the peace, give it up 687
whereas before it would affect you to that extent. 688
689
Justin: So was it the family that finally said listen... you really got a problem here you really got 690
to sort it out... 691
James: Ja my mom said to me something along the lines like you really not the same you used 692
to be your attitude stinks and that kind of stuff and she actually went as far as saying to me 693
certain of her friends have noticed a change in my behaviour and at that point I’d also around 694
that time 5 months ago I had seriously thought of suicide seriously and I then decided after what 695
my mom had said I had two choices one I can attempt suicide fail and have a criminal record or 696
two I con go seek help, and I went to go and seek help... 697
Justin: Good very good 698
James: So ja I take happy pills 699
Justin: Nothing wrong at all... 700
James: I don’t think there is actually, you know what people don’t need to know about it you 701
take it in the morning no one knows about it, at least I take mine in the morning and no one 702
knows about it, and therefore it doesn’t make it weak, I know a lot of people in the EMS who 703
take antidepressants and have for years and it doesn’t change my view or perception of them at 704
all, I actually think it’s very admirable of them and I think it’s even more admirable for them to 705
admit it..... 706
Justin: It’s an interesting concept on why people think that to ask for help its weak almost... but 707
too actually to ask for help you’ve got to be incredibly strong, to actually go that far to ask for 708
help if you know what I mean.... 709
27
James: No I do know what you mean... it’s like my [inaudible] of suicide people say that suicide 710
is a cowards way out I actually disagree with that statement 100% because it’s not, can you in 711
your right mind, hold a gun to your head knowing that you gonna pull the trigger and put a bullet 712
through your brain and kill yourself... so you can’t be a coward to do that, you can’t be a coward 713
to put a rope around your neck and jump off a tree... you got to be incredibly strong to do that... 714
and strong willed when I say that and ummm... you’ve got to be incredibly incredibly down and 715
depressed in order to do that 716
Justin: And considering the fact that you know what death looks like 717
James: Yes.... 718
Justin: That makes it a whole different ball game there hey 719
James: very much so... so I completely disagree with that as you say it takes a lot of guts and 720
you’ve got to be really strong to actually stand up and to say look I need help... 721
Justin: In terms of coping we’ve mentioned a couple of things, first of all we’ve mentioned 722
debriefing with the colleagues, second we’ve mentioned about looking for help and asking for 723
help when you need it, any other ways that you think you it’s important for you to cope it doesn’t 724
matter how minuscule or anything else like that, any other ways besides talking about it... 725
James: Getting a hobby... I think that’s a good way... 726
Justin: So like down time almost... 727
James: Ja you time where like there’s days where I come home from work and I just watch TV, 728
cartoons because its brainless information, it’s not even information, its brainless activities you 729
sit and watch little hand drawn things run across the screen and scream and shout, it’s all 730
futuristic and fiction to even watch a horror movie for example its its brainless, you gonna watch 731
it you know you gonna scare your pants off and at the end of the day you sit and say well that 732
had no plot what so ever you don’t need to concentrate, really cause you just shut down 733
completely so get a hobby do something brainless and just chill.. 734
Justin: What’s your hobby, do you have a hobby or is watching TV your hobby 735
28
James: No I actually don’t like watching TV... I’ve got two I build puzzles in case you haven’t 736
noticed the amount of puzzles around the house and I play piano... those are my two hobbies... 737
Justin: Excellent... well thank you... 738
James: It’s a pleasure... 739
129
Appendix 3: Copy of Informed Consent
1
Psychology Department
Description of Research
Ambulance/Paramedic work is a unique and potentially dangerous environment.
Often they are exposed to a variety of traumatic incidents i.e. critical incidents.
Research has shown that these incidents may have a potentially negative effect on
mental health as well as physical health.
The aim of the following research is to gain a clearer understanding of what
constitutes as a critical incident as well as what coping mechanisms are utilised in
reducing stress resulting from the critical incidents.
Participation in the research is voluntary and will require you to answer a number of
questions relating to your experiences within EMS field. There are no right or wrong
answers. This should take approximately 1hr to 1hr30min.
Anonymity will be assured as your name and any other identifying details will not be
recorded. The information provided will be treated as highly confidential.
2
Informed Consent
In order to participate in this research study, it is necessary that you give your
informed consent. By signing this informed consent statement you are indicating that
you understand the nature of the research study and your role in that research and
that you agree to participate in the research. Please consider the following points
before signing:
I understand that I am participating in psychological research;
I understand that my identity will not be linked with my data, and that all
information I provide will remain confidential;
I understand that I will be provided with an explanation of the research in
which I participated and be given the name and telephone number of an
individual to contact if I have questions about the research.
I understand that participation in research is not required, is voluntary, and
that, after any individual research project has begun, I may refuse to
participate further without penalty.
Sign……………………………………… Date……………………………