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34International Annual Edition of Applied Psychology : Theory, Research, and Practice Volume 4, Issue 1, 2017.
TRAUMA, FAMILY, AND EMERGENCY MEDICAL SERVICES: AN AUTOETHNOGRAPHY OF A RIDE-ALONG EXPERIENCE
Amanda C. DeDiego
University of Wyoming, Casper, WY, USA adediego @uwyo .edu
Lauren Moret
University of Tennessee, Knoxville, TN, USA lmoret@utk.edu
Abstract
Emergency Medical Services personnel include Paramedics and Emergency Medical Technicians. These individuals serve the community by providing crisis intervention services for medical emergencies. In reaction to critical incidents representing vicarious trauma, Emergency Medical Services personnel experience high rates of compassion fatigue, burnout, and Post Traumatic Stress Disorder. The bond among Emergency Medical Services personnel is strong and provides a natural support for coping with vicarious trauma. Thus, workers prefer to depend on co-workers for emotional support and separate home life from the world of emergency services. This autoethnography explores the journey of a researcher and counselor who observes her paramedic significant other in the field. Through her ride-along experience she gains insight as to what happens when the home life and work life of Emergency Medical Services personnel collide.
Key words: emergency medical services; paramedic; vicarious trauma; burnout; autoethnography
We were relaxing on the couch in the morning when he came home from work. I asked how his shift was and he mentioned he worked a bad car accident during which the driver died. A few moments later, my friend called me in a panic. She reported her sister had died in a car accident the day before. I asked my partner the
ISSN 2313-4097
name of the woman in the car accident who died during his shift. The realization that my friend's sister was the anonymous woman in the car accident my partner had worked hit us like a ton of bricks. Then my friend asked if my partner was working the day her sister died. In that moment, my partner could no longer separate his work and home lives, and for both of us we lost of the ease of ability to be emotionally detached from the anecdotal stories about the anonymous bodies on which he worked.
Emergency Medical Services (EMS) workers including paramedics and emergency medical technicians (EMT) provide support and care for individuals seeking help during emergencies [1]. Despite the appreciation of patients and their families, EMS often feel overlooked and under-recognized for their work [2, 3]. Over the course of a career in EMS, exhaustive shifts of 12+hours, which when coupled with exposure to repeated trauma, lead to high rates of work-related stress leading to posttraumatic stress disorder (PTSD) and divorce for EMS personnel [4, 5]. Strong stigma prevents first responders, including EMS, from seeking mental health supports [6, 7]. I am a counselor, and the partner of a paramedic. My partner has been in EMS for seven years. Having seen the impact of this career on him and our life, I am motivated to use my skills and resources as a counselor and researcher to advocate for this community to improve wellness. In pursuit of this goal to gain further insight to EMS culture, and to inform advocacy, this autoethnography explores an observation experience, which represents the combining of my worlds and merging of identities as counselor, researcher, and partner.
As a counselor educator and the partner of a paramedic, I have seen the impact of the EMS work environment, despite my partner's desire and attempt at keeping his work and home lives separate. As EMTs and paramedics prefer to separate home and work, family members of EMS workers rarely get to experience the work EMS environment. Risking the comfort of my ignorant bliss, I infiltrated my partner's world of work through a unique opportunity as a researcher-in-training and conducted
a ride-along experience to observe my partner in the field providing a rare look inside the work experience for EMS spouses. A ride-along experience entails accompanying EMS personnel during a shift and riding in the ambulance to observe personnel in the field [8]. While studying counseling practices as a doctoral student in a counseling education program and wondering what goes on in my partner's work life, I decided to use a class ethnographic observation assignment to contribute to my explorations and observe my partner at work. This autoethnography describes my first experience of observing my partner in the field.
Certifications Levels of EMS
The National EMS Scope of Practice Model describes the tiered licensure levels of EMS personnel [9]. Basic Emergency Medical Technicians (EMT-B) and Advanced Emergency Medical Technicians (AEMT) represent the most basic levels of training in emergency care focusing mainly on comfort and safety for patients with non-life threatening issues during medical transport, including administering some intravenous medications and oxygen at the more advance level. EMT-Bs and AEMTs mainly focus on providing basic lifesaving (BLS) services for the community for stable patients who are not in imminent harm of death or disability. The highest level of certification is Paramedic, my partner being a paramedic with a critical care designation. Paramedics oversee the work of EMT-Bs and AEMTs to direct patient care when responding to emergencies in the community. Paramedics focus on invasive procedures necessary for life-threatening medical emergency transport, known as advanced lifesaving (ALS) services often working in a team with other EMT-Bs, AEMTs, and paramedics [10, 11].
Work-Related Stress in EMS
EMS personnel experience some of the highest levels of work-related stress known among professions, over time leading to emotional distress, burnout, and poor job satisfaction [10, 11]. Responding to medical emergencies can often entail bearing
witness to severe trauma, mass casualties, or incidents in which a patient is dying or dead [12]. Additionally, as the communicator between the field and the hospital [13], EMS personnel must make quick, difficult ethical decisions in patient care balancing directives from doctors with emergent patient needs [14]. EMS personnel frequently experience critical incidents, defined as impactful traumatic incidents, on a regular basis [15, 16]. Long work hours and high demand environment often yield high rates of burnout and work related stress for EMTs and paramedics [17]. Because of these factors, the high stress EMS work environment impacts psychological and physiological well-being leading to high occurrences of mental health issues including PTSD [18].
EMS personnel typically work twelve to twenty-four hour shifts with a primary responsibility of responding to emergency medical calls and transporting patients [19]. My partner has worked in EMS as a paramedic for five years. He worked twenty-four hour shifts for five years, and at one point working forty-eight hour shifts for three grueling months. Recently, he transitioned to part-time work of six-hour shifts in the evenings during the week. Being young and without children, he has volunteered to work on holidays so co-workers with children can be home for Christmas and Thanksgiving. His rolling schedule means his "weekends" or scheduled time off from work may not always occur on Saturday and Sunday, which is when I typically have time away from the office. As a result, we have learned to be flexible in our holidays, travel, traditions, and activities.
Time from family add to common work-related stressors in EMS. In addition to extended time spent away from family, this high-demand work environment leaves little time for attention to personal needs including eating, sleeping, and personal hygiene, as well as poor health habits [19]. Beyond having minimal time for personal needs during work, the EMS work environment is physically taxing. Paramedics and EMTs must perform physically demanding tasks such as lifting patients and carrying heavy equipment. While scene safety is vitally important [19], working in EMS carries additional inherent risk of personal harm including threat of personal assault
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on scene, threat of exposure to communicable disease, and providing invasive medical care in the back of a moving vehicle without a seatbelt [19]. Over the years, I've worried about my partner's well-being at work; worrying about him hurting his back lifting stretchers, being exposed to communicable diseases in the field, or being harmed by aggressive bystanders or patients in the community. Several times, he has come home with shoulder, wrist, or back pain from lifting heavy stretchers during a busy shift.
EMS personnel often feel helpless to prevent frequent death of critical patients, low perceived impact in the outcome of emergencies in the community, and low perceived control and support within their agency regarding management and supervisors [17]. Feeling helpless and exhausted in a demanding work environment while coping with the high stress inherent in EMS work yields serious long-term effects of frequent exposure to critical incidents and maintaining poor health habits. Knowing the demanding work environment for EMS, I have struggled over the years with the best way to support my partner. He chooses to separate his work life and home life. Thus, I do not often hear stories about his calls at work, or things he experiences in the field. I do experience the impact of his career serving the community. When he sacrifices sleep to working calls all night, we sacrifice our time together so he can sleep on his day off. He becomes irritable and restless, which tells me he had a bad shift, although I rarely know the details of what happened at work. I often feel helpless in how to help him. Being familiar with current research regarding EMS, and considering my knowledge as a mental health counselor, I am aware of long-term implications of a career in EMS. I worry about the risk of PTSD and work to be proactive to avoid becoming a divorce statistic.
Coping with Vicarious Trauma
The nature of EMS work exposes EMTs and paramedics to critical incidents. EMS personnel must cope with inherent anxiety and stress related to the nature of responding to critical emergencies [15]. In order to perform job-related duties despite
emotional stress, emotional avoidance is a common coping strategy for work-related stress. One way EMS personnel practice emotional avoidance with each other is through a unique, and often dark sense of humor [20]. My partner uses humor and emotional avoidance to cope with critical incidents at work, sharing unique camaraderie with other first responders. He often describes discussing dinner plans with his co-workers while transporting dead bodies or bandaging bleeding wounds. He describes routine calls as boring and annoying, whereas he prefers gruesome scenes requiring invasive procedures.
This complaint of feeling like a "taxi service," and hoping to provide more intensive and useful medical care to patents in common in EMS [11]. Over time, emotional avoidance can create conflict for EMTs and paramedics who must express empathy and compassion for patients on scene, but then avoid processing the complicated emotions following a critical event [21, 22]. My partner's apathy for certain types of calls has grown over the years as his emotional avoidance becomes more ingrained. These critical incidents involving friends or loved ones are a common source of vicarious trauma and stress for EMS [23, 24].
Individuals with careers in EMS who use emotional avoidance as a primary coping strategy can experience impairment and burnout after years of exposure to critical events without emotional processing [23]. Prolonged exposure to the high stress work environment in EMS with no constructive outlet for emotional stress creates high rates of burnout and PTSD for EMTs and paramedics [23]. To support EMS personnel in developing resilience, debriefing protocols offer an outlet to process critical incidents, however popular models of debriefing lack empirical evidence of positive outcomes [24, 25]. Evidence shows the most effective means of supporting EMS personnel is through consistent peer support to vent emotional stressors and opportunities for shared empathy among peers, modeled by supervisors [26].
My partner and I are both aware of the high rates of PTSD and burnout for EMS workers. As a counselor, I often find myself mentioning stress relieving
techniques, or sharing articles about preventing compassion fatigue, which is an early sign of burnout and PTSD [27]. I worry about my partner's health, and how his job may impact life at home in the future. We are both beginning our careers and with no children at this time, I feel as though we have coped fairly well with his work hours and job stress. However, stories about my partner's coworkers and knowledge of research literature in this field bring about concerns regarding balance of household duties when we will have children and the potential impact a stressful career in EMS will have on our future.
Camaraderie within the Profession
Long work hours, high-stress work environments, and partnership in patient care creates a strong bond among EMTs and paramedics. As a result, EMS personnel experience a high level of camaraderie within the profession [28] which becomes a deterrent from leaving the field despite work stress [11]. Using this strong connection, EMTs and paramedics prefer to depend on each other as outlets to cope with high levels of work-related stress [15]. Camaraderie and peer support at work also deter EMS workers from seeking other sources of support beyond co-workers. EMS personnel see mental health professionals as outsiders and feel seeking help beyond peer support is a sign of weakness [29].
Separation of Work and Family Life
EMTs and paramedics prefer to confide in peers at work about negative impacts of stress instead of confiding in social support at home [30]. Similar to avoiding mental health professionals, EMS workers do not often discuss work-related stress with family at home. As a result, emotional avoidance strategies used to cope with work-related stressors can often have a negative impact on personal relationships outside of work. An interview with spouses of EMS workers revealed intentional distance between the EMS community and their families at home [30]. Non-traditional work hours, impact of work-related stress over time, and high
occurrence of health issues caused by work related stress become challenges in relationships for EMS workers. As a result, EMS workers experience high rates of divorce and infidelity [29].
Method
The current autoethnography emerged from a doctoral course assignment. Within the context of an Introduction to Qualitative Research course, I had to conduct an observation in the community. The setting of the observation was my choice. My connection to the EMS community through my partner had become a research interest and presented a unique opportunity for observation. To complete the assignment I opted, with permission from my partner, and "organizational" permission from the director of my partner's EMS employer, to conduct a ride-along experience with my partner at work.
Clothed in my "professional attire," a white blouse and black pants more suggestive of a restaurant server than a medical professional, and carrying my small notebook and pen, I observed my partner and his co-worker on a BLS transport. The ride-along experience proved to be insightful for gathering information and contributing to the literature on EMS, as well as enhancing my understanding of what my partner goes through when he takes on a shift. Therefore, after securing informed consent from my partner, his co-worker, and the Institutional Review Board, I converted the field notes from this assignment into data for research.
Autoethnography
The current study is an autoethnographic account of a participant observation experience conducted within the context of a course assignment. In effort to understand the experiences of a group of people in a certain setting, researchers can join the participant in the experience to gather a more complete picture of the participant experience [31, 32, 33]. Beyond building awareness of environmental norms, participant-observer researchers immerse themselves in the experience by
engaging in the activities as appropriate [34]. The amount of participation is dependent upon the demands of the environment and the appropriateness of the researcher immersion in the experience [35]. The current study entails a participant observation of a ride-along experience with my partner within the context of a course assignment, later converted into data for research. Ethnography employs observation to gather information and gain understanding of a group of people or particular setting [36]. Culture is representative of more than ethnicity or racial identity, but incorporates interactions and belonging within a group of people [37]. As such, the culture of EMS became the focus of this ethnographic observation through ride-along experiences creating opportunity for researchers who informally identified as outsiders to gain perspective on EMS culture [38, 39]. Ride-along experiences are commonly used for EMS training, and career-exploration [38]. No current research describes the experiences of a counselor conducting a participant observation of a ride-along experience.
Through this ride-along experience, I, a family member not typically exposed to the work-related stress experiences by EMS workers, gained opportunity to observe my partner in the field. When researchers are able to experience membership within a specific cultural group and are committed to developing a greater level of understanding of social phenomena, they may choose to share experiences as a member of the cultural group through autoethnography [39]. Social scientists use narratives and reflection in the form of autoethnography offering emotional and evocative recounting of meaningful experience connected to a cultural group [40, 41]. Autoethnography serves to expand the understanding of social phenomena through use of personal experiences as data [42]. Combining observation with memory of the experience provide opportunity for narrative analysis in autoethnography [42]. Here, an examination of field notes and reflective writing of a ride-along experience yield insights to EMS culture [40].
Autoethnographic writing serves as a constructive interpretation process [37]. Writing about observation experiences from an authoethnographic perspective
enables the researcher to connect the lived experiences of the paramedics in the field to that of the researcher herself [41]. Reflexive writing examines the researcher perspective within social context connecting action, memory, and meaning [40]. Field notes recorded during my ride-along, combined with processing with colleagues following the experience, and a series of reflective writings, which began during my Introduction to Qualitative Research course created a narrative exploring of EMS culture. Member checking offered another perspective, as my partner reviewed my understandings and observations, offering further explanation as well as checking of my notes and memory of events. Analysis of this project served as a guiding exercise leading to a larger scale qualitative research project exploring EMS culture underway during the completion of this article. A narrative summary of the ride-along experience provides context of the autoethnography journey, followed by discussion and implication for practice.
Findings
Preparing for my ride along experience, I felt a depth of uncertainty regarding what I might encounter. I worried about exposing myself to my partner's other identity, his demeanor at work, and grew concerned for the things I might see with patients. I imagined dismembered bodies lying on the highway from a horrific car accident, families weeping over dead bodies. I was not quite sure what to expect and how the experience might change my connection with my partner. This uncertainty stemmed from my identity as an outsider. Despite clear inclusion through my partner and his co-worker consenting to my ride-along, I experienced a sense of infiltrating a world to which I did not belong.
Separate Worlds
"I have chosen to infiltrate my partner's world of work, I have chosen to insert myself into his second family, and in doing so I had broken his careful balancing act to keep his work life and his home life separate as a means of coping with his job. As
a result I had also broken my chosen ignorance about the realities of his service in EMS."
This observation experience built a small bridge between two separate worlds. In my ride-along as an observer, I elected to separate myself from the experience, isolating myself in the ambulance. In a strange way, this choice offered understanding of my partner's choice to manage boundaries between his home life and work life. Typically, my partner separates his work from his home life. This conscious choice offers him the opportunity to remove himself from his patients, and the persona he must embody to properly perform his work.
Prior to this observation experience, I had little understanding of the realities of his work. My understanding of EMS was restricted to research articles and television shows. Observing my partner in the field provided some small understanding of the rigorous and demanding aspects of his career. In my observation and experiences, I could imagine spending 24 hours unable to rest in anticipation of the tones. I could see him waking up at two o'clock in the morning, venturing into the cold night and into an unknown environment to help someone he has never met. I could begin to understand the frustration of calls that did not require intensive medical interventions, creating the feeling of a glorified "taxi service" rather than lifesaving transportation. Having this connection with my partner earned me respect from other EMS professionals; especially as a counselor, EMS personnel with which I have interacted were more open and shared with me more than they likely would someone who does not understand EMS.
Knowing my connection and investment in the wellness of EMS personnel offers them some trust in me. However, the separation of home from work still left me feeling like an outsider. Field notes and reflective writing explored my point of view as an outsider, so while I was able to gain some understanding of the EMS world, I have only infiltrated a small portion of the EMS experience.
Identities as an Observer
"I meekly followed them through the hallways of the hospital, avoiding eye contact with hospital personnel, unsure of my place in the hierarchy of the medical system. Considering my paramedic escorts and attire, people assumed I had at least a basic understanding of medical care. When the nurse addressed the paramedics and asked questions regarding the patient transportation, the nurse looked at me expectedly assuming I might have something to add. I confusedly shrugged at the nurse and admitted I was present to observe and she graciously smiled, nodded, and stopped asking me questions. "
I realize my experience filtered through my identities as a counselor, a researcher, a spouse, and an outsider created a dynamic experience for me. The conversations taking place, the inside jokes between medical personnel, and the changes to my partner's demeanor in his world of work created a clear barrier between our life at home and his experiences in EMS. Considering our emergency call was routine and "boring" by most EMS standards, I wonder what may have transpired had our call been emergent. Had we responded to an ALS call, perhaps my partner would have created a clearer boundary by requiring me to ride in the front of the ambulance or stay in the ambulance instead of interacting on scene. In discussion of my experience, I share insight to the world of EMS and experience gratefulness for those willing to provide a safety net for our community in times of crisis. As a researcher, I experienced excitement for the dynamic observation I conducted. I am eager to repeat the experience and engage in further research with the EMS community.
As a counselor, I experience empathy for the stories my partner told me in the back of the ambulance on the way back to the station. I recognize early signs of burnout and contributors to PTSD in his experiences over the years. I observe emotional avoidance in his and his co-worker's interactions with the patient and the matter-of-fact manner my partner expressed in transporting the patient back to her home. In addition, I recognize a need for support, and a duty to investigate the EMS
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community further and disseminate my findings with other counselors to inform best practice. As a spouse, throughout the experience I was uncertain about how to interpret things. As an autoethnographer, I reconcile these various viewpoints and identities to gain understanding of the realities of EMS the impact on EMS professionals over time. In this respect, I gain some insight into the conflict my partner must feel in choosing to separate work from home.
Forming New Understanding
"I did not realize emergency calls could at times take several hours. It then made sense to me why my partner would get so frustrated when emergency calls would come in the middle of the night costing him hours of sleep. I could finally understand why he was often so tired when he came home from work. Emergency calls were no longer an abstract concept, but an active process of leaving the station, interacting with people on scene, interacting with a patient, and completing necessary paperwork."
This observation experience illustrated knowledge and academic understanding of first responder experiences. Even in the routine call I observed, I gained understanding the demanding and arduous nature of a career in EMS. As an EMS significant other, I recognize early signs of burnout and contributors to PTSD from my partner's experiences over the years. My partner shared a story about when he was eating dinner at a fast food restaurant in uniform. Halfway through a 24-hour shift and taking a short break on the way back to the station after a long day of calls, he was eating quickly in anticipation of the "tones" sounding, requiring them to leave for another call. A man came up to his table and complained about his tax dollars being wasted paying people to eat fast food on the clock. This lack of appreciation coupled with intense pressure and vicarious trauma from calls often lead to burnout, compassion fatigue, and possibly PTSD [23].
During my ride-along, I observed emotional avoidance in my partner and his co-worker's interactions with the patient and the matter-of-fact manner my partner
expressed in transporting the patient back to her home. There was juxtaposition in the enthusiasm of the EMS personnel regarding my interest in experiencing their work environment and my uncertainty in being there. This reflects the common struggle in coping with work-related stress and vicarious trauma, while separating work and home for EMS personnel [29, 30]. Observation is a powerful tool for gaining understanding of experiences, especially with populations with a strong camaraderie. This experience helped form new understandings of the demands of my partner's work environment and his desire to separate work from home.
Implications and Limitations
In conducting my ride-along, I disrupted the typical social structure, including my partner's successful separation of work and home family experiences. This was significant for me in experiencing my partner interacting with his "other" EMS family and executing his responsibilities as a player in the world of EMS. As a counselor, I recognize a need to support and a duty to investigate the EMS community further, disseminating my findings with other counselors and EMS leadership to inform promising practices for personal and professional health in our mutual fields.
The purpose of autoethnography is to gain understanding from experience through reflection, as such, the goal of the current study is not to generalize my experience to represent those of others. However, while my experience was unique to my family and me, the reflections following the ride-along experience offer some implications for EMS and family members of EMS. Findings resulting from reflection yield beneficial implications for EMS and mental health. In reconciling my identities as a researcher, significant other, counselor, and educator I found appreciation for the struggle EMS personnel face in coping with vicarious trauma and separating work and home life. My infiltration of my partner's world of EMS yielded insight for me, which translates into implications for the mental health and trauma fields.
As a counselor, spending time with EMS personnel in their work environment and showing openness to their experiences created an avenue for dialogue and sharing. If counseling professionals were able to connect more with EMS and demonstrate an interest in learning more about the EMS world, they may be able to better support the vicarious trauma experienced in emergency response, and stigma associated with seeking mental health supports could be lessened. Extending more effective and better-received emotional supports to EMS could be improved if more counselors sought opportunities for crisis cross training within EMS.
As a significant other, I experienced first-hand the strong divide between the camaraderie of the EMS family and the families of EMS personnel at home. EMS personnel intentionally separate experiences at work from home life [29]. My feelings of infiltration illustrated this division. Further, EMS personnel typically use emotional avoidance to manage the stress of crisis work [6]. My partner and his coworker describing the "boring" routine calls, and wishing for more exciting trauma-related emergency calls demonstrates the compassion fatigue and emotional avoidance often experienced by those experiencing vicarious trauma.
There is a lack of research about EMS and these observations highlight the importance of further research and clinical focus on supporting EMS to prevent burnout and PTSD. This experience serves as a catalyst for future research of EMS culture and vicarious trauma, but also exemplifies the need for best practices in mental health services addressing vicarious trauma and better connection between first responders and mental health practitioners.
References
[1] David, G., & Brachet, T. (2009). Retention, learning by doing, and performance in emergency medical services. Health Services Research, 44(3), 902-925.
[2] Blau, G., Eggerichs-Purcell, J., & Bentley, M.A. (2012). Testing the impact of emotional labor on work exhaustion for three distinct emergency medical service (EMS) samples. Career Development International, 17(7), 626-645.
[3] McCann, L., Granter, E., Hyde, P., & Hassard, J. (2013). Still blue-collar after all these years? An ethnography of the professionalization of emergency ambulance work. Journal of Management Studies, 50(5), 750-776.
[4] Johnson, S., Cooper, C., Cartwright, S., Donald, I., Taylor, P., & Millet, C. (2005). The experience of work-related stress across occupations. Journal of Managerial Psychology, 20(2), 178-187.
[5] National EMS Management Association [NEMSMA] (2016). Mental health and stress in emergency medical services. Platte City, MO: Author.
[6] Halpern, J., Maunder, R. G., Schwartz, B., Gurevich, M. (2012). Identifying, describing, and expressing emotions after critical incidents in paramedics. Journal of Traumatic Stress, 25, 111-114.
[7] Rusch, N., Angermeyer, M.C., & Corrigan, P.W. (2005). Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma. European Psychiatry, 20, 529-539.
[8] Huff, C. (2017). Paramedicine programs making house calls but scope of practice under scrutiny. Annals of Emergency Medicine, 69(1), 13A-16A.
[9] U.S. Department of Transportation, National Highway Traffic Safety Administration [USDOT]. (2007). National EMS scope of practice model (DOT HS Publication No. 810-657). Available at: http://www.ems.gov/education/EMSScope.pdf (Accessed 01, December, 2017).
[10] OMeara, P., Stirling, C., Ruest, M., & Martin, A. (2016). Community paramedicine model of care: An observational, ethnographic case study. BMC Health Services Research, 16(39), 111.
[11] Chapman, S.A., Blau, G., Pred, R., Lopez, A.B. (2009). Correlates of intent to leave job and profession for emergency medical technicians and paramedics. Career Development International, 14(5), 487-503.
[12] Regehr, C., Hill, J., Goldberg, G., Hughes, J. (2003). Postmortem inquiries and trauma responses in paramedics and firefighters. Journal of Interpersonal Violence, 18(6), 607-622.
[13] Mellinger, W. M. (1994). Negotiated orders: The negotiation of directives in paramedic-nurse interaction. Symbolic Interaction, 17(2), 165-185.
[14] Sandman, L. & Nordmark, A. (2006). Ethical conflicts in prehospital emergency care. Nursing Ethics, 13(6), 592-607.
[15] Donnelly, E.A. & Bennett, M. (2014). Development of a critical incident stress inventory for the emergency medical services. Traumatology, 20, 1-8.
[16] Regehr, C., Goldberg, G., Glancy, G., & Knott, T. (2002). Posttraumatic symptoms and disability in paramedics. The Canadian Journal of Psychiatry, 47(10), 953-958.
[17] Regehr, C.D., & Millar, D. (2007). Situation critical: High demand, low control, and low support in paramedic organizations. Traumatology, 13, 49-58.
[18] Pirrallo, R.G., Levine, R., Dickison, P.D. (2005). Behavioral health risk factors of U.S. emergency medical technicians: The LEADS project. Prehospital and Disaster Medicine, 20(4). 235-242.
[19] Weaver, M.D., Patterson, P.D., Fabio, A., Moore, C.G., Freiberg, M.S., & Songer, T.J. (2015). An observational study of shift length, crew familiarity, and occupational injury and illness in emergency medical services workers. Occupational and Environmental Medicine, 72(11), 798.
[20] Scott, T. (2007). Expression of humour by emergency personnel involved in sudden deathwork. Mortality, 12(4), 350-364.
[21] Tangherlini, T.R. (2000). Heroes and lies: Storytelling tactics among paramedics. Folklore, 111, 43-66.
[22] Boyle, M.V., & Healy, J. (2003). Balancing mysterium and onus: Doing spiritual work within an emotion-laden organizational context. Organization, 10(2), 351-373.
[23] Streb, M., Haller, P., & Michael, T. (2014). PTSD in paramedics: Resilience and sense of coherence. Behavioural and Cognitive Psychotherapy, 42, 452-463.
[24] Tuckey, M.R., & Scott, J.E. (2014). Group critical incident stress debriefing with emergency services personnel: A randomized controlled trial. Anxiety, Stress, and Coping, 27(1), 38-54.
[25] Scully, P.J. (2011). Taking care of staff: A comprehensive model of support for paramedics and emergency medical dispatchers. Traumatology, 74(4), 35-42.
[26] LeBlanc, V.R., Regehr, C., Birze, A., King, K., Scott, A.K., MacDonald, R., & Tavares, W. (2011). The association between posttraumatic stress, coping, and acute stress responses in paramedics. Traumatology, 17(4), 10-16.
[27] Patterson, P.D., Probst, J.C., Leith, K.H., Corwin, S.J., Powell, MP. (2005). Recruitment and retention of emergency medical technicians: A qualitative study. Journal of Allied Health, 34(3), 153-162.
[28] Vogel, J.M., Cohen, A.J., Habib, M.S., & Massey, B.D. (2004). In the wake of terrorism: Collaboration between a psychiatry department and a center for emergency medical services (EMS) to support EMS workers and their families. Families, Systems, & Health, 22, 35-46.
[29] Regehr, C. (2005). Bringing the trauma home: Spouses of paramedics. Journal of Loss and Trauma, 101, 97-114.
[30] Pajonk, F., Andresen, B., Schneider-Axmann, T., Teichmann, A., Gärtner, U., Lubda, J., & ... von Knobelsdorff, G. (2011). Personality traits of emergency physicians and paramedics. Emergency Medicine Journal, 28(2), 141-146.
[31] Becker, H.S., & Geer, B. (1957). Participant observation and interviewing: A comparison. Human Organization, 16(3), 28-32.
[32] Spradley, J.P. (1980). Participant observation. New York, NY: Holt, Rinehart, and Winston.
[33] Preissle, J., & Grant, L. (2004). Fieldwork traditions: Ethnography and participant observation. In Foundations for research: Methods of inquiry in education and the social sciences. Mahwah, NJ: Lawrence Erlbaum Associates.
[34] Vogt, F. (2002). No ethnography without comparison: The methodological significance of comparison in ethnography research. In Debates and Developments in Ethnographic Methodology (Vol. 6, pp. 23-42). Oxford, UK: Elsevier Science
[35] Chang, H. (2008). Autoethnography as method. Walnut Creek, CA: Left Coast Press.
[36] Anderson, L. (2006) Analytic autoethnography. Journal of Contemporary Ethnography, 35(4), 373-395.
[37] Denzin, N.K. (2014). Interpretive autoethnography. Thousand Oaks, CA: Sage.
[38] Wolfberg, D.M., & Wirth, S.R. (2006). Do ems ride-along programs violate patient privacy? How to ensure your program measures up to HIPAA's privacy rule. JEMS: Journal of Emergency Medical Services, 31(1), 36-41.
[39] Chang, H. (2013). Individual and collaborative autoethnography as method: A social scientist's perspective. In S.H. Jones, T.E. Adams, & C. Ellis (Eds.), Handbook of Autoethnography. Walnut Creek, CA: Left Coast Press Pp. 107-122.
[40] Giorgio, G. (2013). Reflections on writing through memory in autoethnography. In S.H. Jones, T.E. Adams, & C. Ellis (Eds.), Handbook of Autoethnography. Walnut Creek, CA: Left Coast Press. Pp. 363-383.
[41] Ellis, C., Adams, T.E., & Bochner, A.P. (2011) Autoethnography: An overview. Historical Social Research, 36(4), 273-290.
[42] Denzin, N.K. (2013). Interpretive autoethnography. In S.H. Jones, T.E. Adams, & C. Ellis (Eds.), Handbook of Autoethnography. Walnut Creek, CA: Left Coast Press. Pp. 123-142.
