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

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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


2. Negative experiences of the EMS organisation. ........................................... 49



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


2. Negative experience of the EMS organisation. ............................................ 58

3. Meaningful work environment .................................................................... 58


1. Perceived need to be in control of the environment ..................................... 60


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




2. Negative experience of the EMS organisation ............................................. 70


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



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


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.

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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).

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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...”

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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...”

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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


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


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


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


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



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


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


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


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



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



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



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


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


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


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


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



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




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


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


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



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


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



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.

1

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

2

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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……………………………

South African paramedics lived experience of critical incidents: an interpretative phenomenological

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