Traumatology: An International Journal © 2013 the Author(s)

2014, Vol. 20, No. 1, 1– 8 1085-9373/14/$12.00

DOI: http://dx.doi.org/10.1177/1534765613496646

Development of a Critical Incident Stress Inventory for the Emergency

Medical Services
Elizabeth A. Donnelly and Michael Bennett
University of Windsor

In this study, a mixed-methods approach was used to develop an inventory of critical incidents for
emergency medical service (EMS) personnel. Data were collected from a probabilistic sample of EMS
personnel (N ⫽ 1,633) via an online survey. Quantitative responses captured the frequency of exposure
to 29 critical events, self-reported stress related to exposure, demographic characteristics, and posttrau-
matic stress symptomatology (PTSS). Respondents reported exposure to all of the stressors in the
inventory. Critical incident exposure and the resultant stress were significantly (p ⬍ .01) correlated with
PTSS. Qualitative feedback captured previously unidentified critical incidents unique to this population,
allowing for greater elucidation of existing items and the identification of additional items that could be
included in the inventory. Findings point toward the importance of considering cumulative critical
incident exposure and resulting self-reported stress when assessing the impact of critical incidents for
EMS personnel.

Keywords: critical incident stress, mixed methods, trauma, posttraumatic stress, emergency medical
services

People who work in the health and helping professions often
face intense and at times, traumatic work experiences. Those in the
emergency medical services (EMS) are particularly susceptible to
traumatic exposure, as they are routinely called to respond to
events that are gruesome, tragic, or otherwise traumatic. Any event
in which an individual “experienced, witnessed, or was confronted
with an event or events that involved actual or threatened death or
serious injury, or a threat to the physical integrity of self or others”
(Diagnostic and Statistical Manual of Mental Disorders, 4th ed.,
text rev.; DSM–IV–TR; American Psychological Association
[APA], 2000, p. 218) would be considered a traumatic exposure.
These events have the potential to be critical incidents for first
responders, defined as “. . . any situation faced by emergency
service 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). Early conceptualizations of critical incidents in the emergency
services included exposure to incidents involving the injury or
death of a responder or of a civilian as a result of emergency
operations, cases charged with profound emotion, cases that attract
This article was published Online First July 23, 2013.
Elizabeth A. Donnelly and Michael Bennett, School of Social Work,
University of Windsor, Ontario, Canada.
The authors would like to gratefully acknowledge the support of Gregg
Margolis, NREMT-P; Greg Gibson; and the National Registry of EMTs for
their support for this project. The authors received no financial support for
the research, authorship, and/or publication of this article. The authors
declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Correspondence concerning this article should be addressed to Elizabeth
A. Donnelly, School of Social Work, University of Windsor, 401, Sunset
Avenue, Windsor, ON Canada, N9B 3P4. E-mail: donnelly@uwindsor.ca
attention of the news media, a death after a prolonged rescue
effort, physical or psychological threat to rescuers, or incidents
that surpass normal coping methods (Mitchell, 1983).
Although this conceptualization gives a sense of what might
constitute a critical incident, it is difficult to identify or quantify
incidents that “surpass normal coping methods” or cases that are
“charged with emotion.” Subsequent research efforts have at-
tempted to identify other events that might be considered critical,
including cases that involve injury and death of children (Clohessy
& Ehlers, 1999; Gallagher & McGilloway, 2008; Haslam & Mal-
lon, 2003; Regehr, Goldberg, & Hughes, 2002), response to
acutely ill or seriously injured people (Alexander & Klein, 2001;
Beaton, Murphy, Johnson, Pike, & Corneil, 1998; Clohessy &
Ehlers, 1999), being threatened or assaulted (Mock, Wrenn,
Wright, Eustis, & Slovis, 1999; Pozzi, 1998; Suserud, Blomquist,
& Johansson, 2002), treating family, friends, or those known to the
individual (Alexander & Klein, 2001; Haslam & Mallon, 2003;
Jonsson, Segesten, & Mattsson, 2003), or having to deal with dead
bodies (Bennett et al., 2005; Clohessy & Ehlers, 1999). The
conceptualization of critical incident exposure includes primary
and secondary traumatization; responders may develop patholog-
ical reactions to having either their personal safety directly threat-
ened, or from secondary exposure as witness to another’s tragedy
or trauma. Although critical incident exposure has been identified
as problematic for all types of emergency responders (law enforce-
ment, fire/rescue, and EMS), the three types of responders serve
distinct roles, and may be exposed to different types of critical
incidents. Although an instrument is available to assess critical
incident exposure in police (Weiss et al., 2010), no extant effort
has been made to try and create an instrument that assesses critical
incident exposure and critical incident stress in EMS.
The lack of a tool to assess critical incident exposure for EMS
personnel is troubling, as exposure to such incidents has been
linked to negative psychological reactions, including posttraumatic

1
2 DONNELLY AND BENNETT
stress symptomatology (PTSS; Bennett et al., 2005; Clohessy &
Ehlers, 1999; Corneil, Beaton, Murphy, Johnson, & Pike, 1999;
Ward, Lombard, & Gwebushe, 2006), depression (Boudreaux,
Mandry, & Brantley, 1997; Regehr et al., 2002), and burnout
(Alexander & Klein, 2001). Negative reactions to critical incident
stress may occur as a result of a single event or the cumulative
result of series of events (Corneil et al., 1999). Multiple traumatic
exposures may contribute to a cumulative traumatic experience
increasing vulnerability to posttraumatic stress (Beaton, Murphy,
Pike, & Jarrett, 1995; Bryant & Harvey, 1996; Donnelly & Siebert,
2009; Halpern & Maunder, 2011). Beyond the linkage between
posttraumatic stress and critical incident exposure, other identified
risks include negative attitudes toward patients (Cydulka et al.,
1989), increased leaves from duty (Regehr, Goldberg, Glancy, &
Knott, 2002), decreased job satisfaction (Boudreaux et al., 1997),
and early retirement (Rodgers, 1998). Critical incidents do not just
impact responders, their family members also report that their
work impacts a number of facets of family life (Regehr, 2005;
Roth & Moore, 2009).
Given the ambiguity of what constitutes a critical incident and
the risk of negative reactions to critical incident exposure, the
development of an instrument to assess the impact of critical
incident exposure was needed. Conceptually, critical incidents fit
the definition of life events as “objective occurrences of sufficient
magnitude to bring about a change in the usual activities of most
individuals who experience them” (Dohrenwend, Krasnoff, Aske-
nasy, & Dohrenwend, 1982, p. 336). Due to the fact that exposure
to a critical incident is a discrete event, creating an inventory of
stressful events using a checklist approach is a preferable approach
to measurement (Turner & Wheaton, 1995).
One challenge that complicates measuring critical incident
stress is differentiating the frequency of stress exposure from the
individual appraisal of perceived stress that results from the expo-
sure and from the presence of a symptomological stress reaction
like posttraumatic stress (Bovin & Marx, 2011; Pearlin, 1989).
Although many individuals may be exposed to a stressor their
reaction may vary. For EMS personnel, no one event may be
critical to all responders. In assessing critical incidents, first it is
necessary to ascertain if the exposure has occurred. However, it is
not just the exposure that is of concern; it is the individual
responder’s unique response to that exposure that may lead them to
develop a pathological reaction like posttraumatic stress. Thus, it is
important to assess the individual responder’s exposure to the
incident, the responder’s report of the impact of the event, and the
presence of symptoms of a pathological stress response like post-
traumatic stress.
Having identified a need to create an instrument that can assess
the impact of critical incidents, this article discusses development
of an instrument that is specifically intended to assess frequency of
exposure and associated stress level for EMS personnel. Using a
mixed-methods approach, the goal of this research was two-fold:
1. To create a critical incident inventory that would identify
the most common and most stressful critical incidents
using quantitative and qualitative data collection meth-
ods.
2. To assess if exposure to critical incidents and stress
caused by critical incidents correlated significantly to
PTSS (e.g., reexperiencing the event, avoidance of stim-
uli associated with the event, and/or persistent
hyperarousal).
Method
Participants and Procedure
A sample of EMS personnel was invited to participate in a
confidential, online survey using commercially available survey
software (www.snap.com). In the United States, responders are
trained at different levels—Emergency Medical Technician–Basic
(EMT-Basic) receive basic training in managing medical and
traumatic injuries and paramedics are the most advanced caregiv-
ers, and receive training in anatomy, physiology, and advanced
medical skills (Bureau of Labor Statistics, 2011). The National
Registry of EMTs (NREMT) provided a probability sample of
12,000 currently registered responders, equally split between
EMT-Basic and paramedics. The response rate was 13.6%, result-
ing in an N of 1,633 respondents. This study was approved by the
Florida State University Institutional Review Board.
Measures
This inventory was conceptualized as having two facets, assess-
ing (a) frequency of exposure to the critical incident and (b) the
perceived stress resulting from the exposure. To assess for fre-
quency and stress reactions related to critical incident exposure,
the Critical Incident History Questionnaire (CIHQ; Weiss et al.,
2010) was adapted for this population. Originally developed for
work with police officers, the original CIHQ identifies 34 critical
incidents and asks about number of exposures. In addition, it asks
“[i]n your opinion, how difficult would it be for police officers to
cope with this type of incident?” (Weiss et al., 2010, p. 736).
To adapt the CIHQ for EMS personnel, it was revised in several
ways. First, the language was changed so that it is consistent with
EMS terminology. Second, items that did not directly apply to
EMS were removed from the inventories and items were added
that reflect the extant data about stressors in EMS. For example,
although no item initially existed in the CIHQ asking about re-
sponding to a call involving friends and family, that event has been
identified in the literature as a significant stressor, especially in
rural areas (Alexander & Klein, 2001; Beaton et al., 1998; Bennett
et al., 2005; Clohessy & Ehlers, 1999; Jonsson et al., 2003).
The first iteration of the adapted CIHQ was included in the
small pilot study of North Carolina EMS personnel, resulting in
further revisions. For example, two items, asking about the re-
sponder making a mistake causing the injury or death of a co-
worker or bystander were not endorsed at all and were removed
from the inventory; the questions were replaced with an item
asking about a mistake causing the injury or death of a patient.
Other items were combined (e.g., threatened with a gun and
threatened with another weapon became threatened with a gun or
other weapon). This second iteration of the inventory was then
reviewed by key informants, all of whom were active EMS per-
sonnel, for face validity.
The adapted version of the CIHQ identified 29 stressors specific
to emergency medical responders. The adapted instrument concep-
tualized critical incident exposure as a “major life event” (Reyn-
 CRITICAL INCIDENT STRESS INVENTORY FOR EMS
olds & Turner, 2008) and therefore participants were asked to
report lifetime exposure to each stressor. Because respondents
were asked to report if they had ever been exposed to an event,
there was the possibility of recall bias, especially if an event had
been experienced repeatedly. The decision was made to collapse
multiple exposures into one response option, because it was judged
that the recall of the exact number of events, especially events that
occurred more than 10 times, over an extended period might be
limited. Therefore, respondents were asked to report the frequency
of exposure as 0 ⫽ never, 1 ⫽ once, 2 ⫽ twice, 3 ⫽ 3 times, 4 ⫽
4 times, 5 ⫽ 5 times, 6 ⫽ 6 times, 7 ⫽ 7 times, 8 ⫽ 8 times, 9 ⫽
9 times, 10 ⫽ 10 –20 times, 11 ⫽ 21–50 times, and 12 ⫽ 51⫹
times. These categories are consistent with the original CIHQ. It
must be noted that the decision to collapse the repeated exposures
into one response option may lead to an underreporting of critical
incident exposures.
If respondents reported ever having been exposed to the critical
incident, respondents were asked to rate their subjective experi-
ence of stress during the past 6 months to each incident on a
7-point Likert-type scale, with 0 ⫽ no stress at all, 3 ⫽ some
stress, and 6 ⫽ a lot of stress. If respondents reported never being
exposed to a critical incident, they were not asked about their level
of stress associated with that critical incident. Respondents were
asked about stress over the past 6 months, because the authors
wanted to try and capture stress that may have preceded the onset
of a pathological reaction. Respondents were asked about post-
traumatic stress symptoms during the past 30 days, therefore the
decision was made to expand the time frame for critical incident
stress beyond 30 days. Some evidence indicates that the effects of
a stressful event may last up to 6 months after the exposure (Turner
& Wheaton, 1995). Therefore, if respondents reported being ex-
posed to a critical incident, they were then asked how much stress
that exposure had caused them during the past 6 months. To create
overall critical incident stress exposure and stress scores, responses
were summed. Respondents were also asked an open-ended ques-
tion about what other events they considered critical incidents.
To assess if there was a relationship between critical incident
exposure, critical incident stress, and posttraumatic stress, post-
traumatic stress was measured using the Posttraumatic Stress Dis-
order (PTSD) Checklist (PCL; Weathers, Litz, Herman, Huska, &
Keane, 1993), a 17-item scale that provides a continuous measure
of PTSS as well as a cutoff diagnostic of PTSD (scores ⬎ 50);
responses are recorded on a 5-point Likert-type scale. The military
version of the PCL, the (PCL-M), was used because it is not
grounded in one traumatic exposure and the frequencies of trau-
matic exposures in the emergency services are similar to those
experienced by the military. The military cutoff of 50 was used,
rather than the civilian cutoff, as it was judged that EMS person-
nel, by virtue of the repeated exposure to trauma in the workplace,
would be more analogous to military personnel than civilians.
Respondents were asked about stressful work experiences rather
than stressful military experiences. In this study, the PCL-M was
used continuously to assess PTSS rather than dichotomizing the
results, as even subclinical levels of posttraumatic stress can result
in impairment (Zlotnick, Franklin, & Zimmerman, 2002). In this
sample, the PCL-M behaved reliably (␣ ⫽ .926).
Respondents were also asked demographic questions including
their gender, race/ethnicity, level of training, and how busy they
thought their primary service was (1 ⫽ not at all busy, 2 ⫽
3
occasionally busy, 3 ⫽ moderately busy, 4 ⫽ frequently busy, 5 ⫽
very busy). Respondents were also asked about the length of time
they had worked in EMS; for purposes of analysis, the median
length of service (6 years) was used to dichotomize responses.
Results
Quantitative Results
Results were summed to create a cumulative critical incident
exposure and stress scores. Overall critical incident stress exposure
scores ranged from 0 to 239 (M ⫽ 59.80, SD ⫽ 45.74) and critical
incident stress scores ranged from 0 to 146 (M ⫽ 28.83, SD ⫽
25.52). Posttraumatic stress scores ranged from 17 to 81 (M ⫽
29.67, SD ⫽ 11.24). As seen in Table 1, respondents reported a
significant amount of variability in exposure to critical incidents,
critical incident stress, and PTSS by demographic characteristics.
Males reported more critical incident stress exposure (p ⬍ .001)
and critical incident stress (p ⬍ .01) than women, but there were
no significant differences in levels of posttraumatic stress. No
significant differences were identified by race. Paramedics re-
ported significantly higher rates of critical incident exposure (p ⬍
.001), critical incident stress (p ⬍ .001), and posttraumatic stress
(p ⬍ .001) than EMT-Basic. Those with more than 6 years of
experience reported far more exposures to critical incidents (p ⬍
.001), critical incident stress (p ⬍ .001), and more PTSS (p ⬍ .01)
than those with less than 6 years experience in the field. Finally, as
the business of the service increased (how busy the respondent
reported being at work), so did reported rates of critical incident
exposure (p ⬍ .001), critical incident stress (p ⬍ .001), and PTSS
(p ⬍ .001).
Table 2 presents comparisons of the mean frequencies of expo-
sures and mean reported levels of stress during the past 6 months
to each of the critical incidents in the inventory.
The five most frequently reported exposures involved watching
someone die, encountering the body of someone recently dead,
making a death notification, encountering an adult who had been
badly beaten, and responding to a scene involving someone known
to the crew. The five critical incidents that caused the most stress
were closely tied to the most frequently reported critical incidents.
Critical incidents that caused the most stress were watching some-
one die, making a death notification, encountering an adult who
had been badly beaten, encountering a child who was severely
neglected or in dire need of medical attention because of neglect,
and responding to a scene involving someone known to the crew.
As the second goal of this research was to assess if critical
incident exposure and critical incident stress were related to PTSS,
bivariate correlation was utilized to assess if critical incident
exposure and critical incident stress had a relationship with post-
traumatic stress. Critical incident exposure (r ⫽ .250, p ⬍ .01) and
critical incident stress (r ⫽ .393, p ⬍ .01) were correlated with
PTSS. To assess if critical incident exposure and critical incident
stress had independent relationships with PTSS, partial correla-
tions were utilized. Controlling for levels of critical incident stress,
critical incident exposures retained a significant correlation with
PTSS (r ⫽ .078, p ⫽ .005) and controlling for exposures, critical
incident stress also retained a significant relationship with PTSS
(r ⫽ .322, p ⬍ .001). Regression analyses exploring the relation-
4 DONNELLY AND BENNETT

Table 1
Demographic Variability in Critical Incidents and Posttraumatic Stress

Critical incident exposure Critical incident stress PTSS

n M (SD) M (SD) M (SD)

Male 1,208 64.18 (47.28) 30.07(26.37) 29.88 (11.30)

Female 418 47.65 (38.65) 25.43 (22.67) 29.09 (11.10)
t(879) ⫽ 7.09, p ⬍ .001 t(835) ⫽ 3.46, p ⬍ .01 t(1,556) ⫽ 1.22, p ⫽ ns
White 1,406 60.55 (45.20) 28.98 (25.46) 29.74 (11.27)
Ethnic minority 218 54.71 (47.65) 28.27 (25.99) 29.27 (11.24)
t(1,622) ⫽ 1.76, p ⫽ N/S t(1,622) ⫽ .38, p ⫽ N/S t(1,554) ⫽ .55, p ⫽ N/S
EMT-Basic 486 31.23 (30.06) 19.91 (20.28) 27.68 (10.33)
Paramedic 1,146 71.89 (45.89) 32.63 (26.55) 30.52 (11.51)
t(1,356) ⫽ ⫺21.15, p ⬍ .001 t(1182) ⫽ ⫺10.52, p ⬍ .001 t(973) ⫽ ⫺4.79, p ⬍ .001
⬍6 years experience 815 36.59 (31.06) 24.76 (22.57) 28.88 (10.54)
⬎6 years experience 818 82.91 (46.33) 32.88 (27.58) 30.46 (11.85)
t(1,429) ⫽ ⫺23.74, p ⬍ .001 t(1,572) ⫽ ⫺6.52, p ⬍ .001 t(1,543) ⫽ ⫺2.79, p ⫽ .005
How busy is your service?
Not at all busy 73 47.01 (49.88) 16.49 (21.38) 27.09 (10.33)
Occasionally busy 317 40.91 (36.55) 20.35 (20.70) 27.97 (10.35)
Moderately busy 564 57.10 (42.33) 28.87 (24.33) 29.38 (10.45)
Frequently busy 350 61.98 (43.16) 32.59 (26.24) 30.60 (10.46)
Very busy 324 83.11 (50.35) 35.69 (28.60) 31.43 (12.61)
F(4, 1623) ⫽ 40.45, p ⬍ .001 F(4, 1623) ⫽ 21.83, p ⬍ .001 F(4, 1556) ⫽ 5.28, p ⬍ .001
Note. PTSS ⫽ posttraumatic stress symptomatology; EMT-Basic ⫽ emergency medical technician-basic.

ship between critical incident stress and posttraumatic stress in
greater analytic detail is described elsewhere (Donnelly, 2012).
Qualitative Results
In addition to reporting frequency and level of stress associated
with identified critical incidents, respondents were asked an open-
ended question: “What other events would you consider critical
incidents?” In all, 236 respondents gave qualitative responses
describing a total of 295 stressful events. These responses were
coded and themes were developed, grouped by the type of stressor.
Some of the qualitative responses expanded on themes identified
in the quantitative measure and some were new incidents not
presently in the inventory.
Preexisting inventory items. The stressor identified in the
inventory that had the most frequent comments involved respond-
ing to a scene involving family, friends, or others known to the
crew. Twenty-eight respondents talked about responding to friends
and family members; responding to vehicle collisions involving
fatalities of friends and family; performing cardiopulmonary re-
suscitation (CPR) on a family member; and discontinuing care/
pronouncing a friend or family member dead. A variation on this
theme was noted in responses describing responding to a scene
where they encountered someone who reminded them of a family
member or friend. This variation indicates that treating someone
unknown but with whom the responders identify (e.g., responding
to a child the same age as their own) may also be considered a
source of stress. This theme has been identified in other emergency
responders; a study of police officers found that personally rele-
vant threats (threats to someone with whom the officer had a
personal relationship) were associated with higher levels of dis-
tress (McCaslin et al., 2006).
Eleven respondents discussed being called to disasters, includ-
ing responses to Hurricanes Ike, Rita, Katrina, and Gustav, re-
sponses to the Columbia shuttle disaster, the World Trade Center
attacks (1993 and 2001), and the attack on the Pentagon. Mass
casualty incidents were mentioned by eight respondents, including
responses to plane crashes, car accidents, and shootings with
multiple casualties that required attention; four respondents re-
ported encountering a child who was severely neglected or in dire
need of medical attention because of neglect.
Elaboration of inventory stressors. Of those stressors that
expanded on items extant in the inventory, by far the most re-
sponses (68 different respondents) addressed the impact of wit-
nessing the illness or death of a child. The current critical incident
inventory lists four separate stressors involving children (sexual
assault, sudden infant death syndrome [SIDS] death, badly beaten,
severely neglected). However, the qualitative responses indicated
that it might be helpful to differentiate between traumatic and
medical mechanisms of injury and death. More than half of the
responses that dealt with responses to children specified that the
mechanism of injury was traumatic; a subset of these responses
dealt with children who had been deliberately hurt or killed by
their parents or caregivers. Six individuals mentioned the stress
involved in delivering a child that was nonviable. Given the
qualitative feedback, future iterations of this critical incident in-
ventory might differentiate between medical and traumatic mech-
anisms of death in children as well as death during the childbirth
process.
Vehicle-related responses similar to the question about being in
a serious car accident included the ambulance catching fire, the
stress of maintaining control of the vehicle at high speeds (while
driving with lights and sirens), and other involved accidents related
to emergency response, specifically helicopter crashes. Three re-
spondents described being on EMS helicopters when they had
crashed or had to conduct emergency landings. The item might be
improved by asking about an accident in an emergency response
vehicle (which would cover ambulances, medical helicopters, fire
trucks, etc.).
 CRITICAL INCIDENT STRESS INVENTORY FOR EMS 5

Table 2
Frequency and Stress Associated With Critical Incident Exposure

Level of
stress
Number of associated
exposures with exposure
Number of responders
In the line of duty, I . . . reporting event M SD M SD

Responded to a scene involving family, friends, or others known to the crew. 1,289 3.85 3.78 2.23 2.08
Saw someone dying. 1,563 7.96 4.01 2.16 1.69
Encountered an adult who had been badly beaten. 1,356 5.59 4.46 1.61 1.64
Encountered a child who was severely neglected or in dire need of medical attention
because of neglect. 786 1.90 3.00 1.52 2.19
Made a death notification. 974 3.91 4.52 1.49 1.91
Encountered an adult who had been sexually assaulted. 1,104 3.38 3.77 1.46 1.77
Encountered a SIDS death. 748 1.63 2.70 1.35 2.10
Responded to a MCI. 944 2.37 3.28 1.34 1.82
Exposed to serious risk of AIDS or other life-threatening diseases. 800 1.53 2.67 1.32 1.92
Encountered a child who had been badly beaten. 638 1.31 2.47 1.27 2.09
Encountered a child who had been sexually assaulted. 640 1.49 2.72 1.21 2.05
Responded to an aggressive crowd or riot. 752 1.67 2.82 1.15 1.84
Saw animals that had been severely neglected, intentionally injured, or killed. 760 2.20 3.37 1.11 1.78
Encountered the body of someone recently dead. 1,548 7.97 4.08 1.06 1.44
Had to respond to a large-scale disaster. 770 1.31 2.17 1.05 1.71
Encountered a mutilated body or human remains. 881 2.64 3.67 0.95 1.57
Encountered a decaying corpse. 1,086 3.58 4.04 0.93 1.41
Was trapped in a potentially life-threatening situation. 689 0.99 2.02 0.93 1.76
Threatened with a gun or other weapon. 570 0.89 1.82 0.85 1.74
Present when a fellow EMT/paramedic was seriously injured. 538 0.67 1.32 0.78 1.59
Exposed to a life-threatening toxic substance. 511 1.05 2.43 0.74 1.50
Was seriously injured. 373 0.51 1.55 0.58 1.45
Received serious threats toward loved ones as retaliation for your work in EMS. 290 0.54 1.68 0.42 1.25
Was in a serious car accident. 282 0.26 0.72 0.39 1.24
Had my life endangered in a large-scale disaster. 225 0.30 1.09 0.34 1.17
Made a mistake that lead to the serious injury or death of a patient. 129 0.13 0.62 0.29 1.19
Was present when a fellow EMT/paramedic was killed. 93 0.08 0.36 0.14 0.83
Was seriously beaten. 97 0.09 0.43 0.13 0.74
Was taken hostage. 42 0.03 0.20 0.05 0.49
Note. MCI ⫽ mass casualty incident; EMS ⫽ emergency medical service; EMT ⫽ emergency medical technician.

The inventory asked about line-of-duty injuries and fatalities for
EMS personnel; however, nine qualitative responses also dis-
cussed responding to or supporting other responders after a line-
of-duty injury or fatality involving law enforcement. Given the
high degree of contact that EMS personnel routinely have with law
enforcement, it might be useful to ask more broadly about line-
of-duty incidents in future iterations of the inventory.
Stressors not in the inventory. A number of events not in the
inventory were identified by respondents. Some of these events
dealt with the mechanism of injury, and others dealt with situa-
tional factors. Responses that involved specific clinical presenta-
tions included death or injury due to burns (28 responses), and
attempted or completed suicides (24 responses). Of the 24 respon-
dents who mentioned suicide, five mentioned responding to a
homicide/suicide, specifically of a spouse or children. Further-
more, 10 respondents stated that responding to a homicide was
stressful. Other stressful events included drowning (seven re-
sponses), and dealing with patients who are unstable and unpre-
dictable due to psychiatric or drug- and alcohol-related issues (six
responses). Although the inventory had a question about child
neglect, nine respondents mentioned that dealing with instances of
elder neglect had also been stressful. Therefore, elder neglect
should be included as a critical incident in the inventory.
Another subset of responses dealt with situational factors. Nine-
teen respondents talked about being involved in an “unsafe scene,”
a call where responders are placed in direct danger due to uncon-
trolled crowds, angry bystanders, aggressive dogs, or gunfire and
gang violence. Although not immediately dangerous, seven re-
spondents discussed the stress of having to deal with grieving or
distressed families on scenes.
While reviewing the feedback, it was noted that other responses did
not describe an event, but a feeling associated with an event. Specif-
ically, 10 respondents described situations in which they felt helpless
(e.g., being unable to extricate someone in a burning vehicle). Eight
respondents discussed situations that they felt were particularly grue-
some (e.g., decapitation, train accidents). As the purpose of this
inventory is to identify stressful events and associated stress, not to
elucidate the specific type of emotional reaction, they are not appro-
priate for inclusion into the inventory. However, it warrants mention
as it was a theme identified in the qualitative feedback.
Given the qualitative feedback, future iterations of this inven-
tory might be expanded to include the following critical incidents.
In the line of duty, I . . .
• Encountered a child that had been accidentally severely in-
jured;
6 DONNELLY AND BENNETT
• Encountered a child that had been accidentally killed;
• Encountered a child that had been murdered;
• Encountered an elderly person who was severely abused or
neglected or in dire need of medical attention because of
abuse or neglect;
• Encountered a patient who was severely burnt;
• Encountered a suicide victim;
• Encountered a drowning victim;
• Was assaulted by a patient.
Further items in the inventory may be revised; suggestions for
new language are italicized.
• Present when a fellow EMT/Paramedic or other first re-
sponder was seriously injured;
• Present when a fellow EMT/Paramedic or other first re-
sponder was killed;
• Was in a serious (car) accident with an ambulance or other
emergency response vehicle.
Discussion
The first goal of this research was to develop an inventory of
stressful events to which EMS personnel are exposed. Such an
inventory assists the assessment of the impact of critical incident
stress. The inventory was able to identify which critical incidents
were the most common and most stressful. Each item in the
original 29-item inventory was endorsed, indicating that their
inclusion in the inventory was appropriate. The collection of the
qualitative feedback indicated that although a number of incidents
were included in the inventory, some incidents could be developed
in greater detail. In addition, new incidents were identified that
should be included in the inventory. Future iterations of this survey
will be improved with the inclusion of the qualitative feedback
gathered from respondents.
Interestingly, the stressors to which respondents reported most
frequent exposure and subjectively as the most stressful were
relatively commonplace. Rather than large-scale, dramatic events,
respondents reported the most stress from seeing someone die or
someone who was recently deceased, encountering an individual
who had been badly beaten, responding to someone known to the
crew, or making a death notification. These data indicate that
relatively commonplace occurrences have more impact on respon-
dents than dramatic or unusual events. These findings indicate that
researchers and practitioners should be mindful of the danger of
the cumulative nature of “routine” stresses as much as large-scale
events. It is also interesting to note that this emphasis on com-
monplace events, in combination with the feelings of helplessness
noted in the qualitative feedback, may reflect a unique feature of
this profession. By definition, EMS personnel almost exclusively
respond after someone has gotten sick or been injured. Thus,
responding to events after the fact and the associated feelings of
helplessness may in itself be a stressor for responders.
The second goal of this research was to assess if critical incident
exposure and critical incident stress were correlated with posttrau-
matic stress. In this sample, exposure and the resultant stress were
significantly (p ⬍ .01) correlated with PTSS. Further exploration
with partial correlation indicated that although critical incident
exposures and critical incident stress have significant relationships
to PTSS, critical incident stress is a much stronger correlate. These
data indicate that although critical incident exposure has an influ-
ence on PTSS, it is the subsequent critical incident stress reaction
that has much more influence on the development of PTSS.
The inventory identified significant differences in stress expo-
sures and levels of critical incident stress by gender and ethnicity;
however, the differences in levels of PTSS were nonsignificant.
Respondents who worked as paramedics, opposed to EMT-Basic,
had more years of experience, and worked at busier services.
Consequently, paramedics reported significantly higher levels of
stress exposure, higher levels of resultant stress, and higher levels
of PTSS. The finding that paramedics had higher levels of critical
incident exposure, critical incident stress, and posttraumatic stress,
then, is not surprising. Many paramedics, by virtue of their higher
level of training are more likely to have full-time employment in
EMS. Indeed, in this sample, paramedics reported working signif-
icantly more hours a week t(713) ⫽ ⫺13.34, p ⬍ .001) than
EMT-Basic. The findings that respondents with more years of
experience report higher levels of PTSS and individuals in busier
services report higher levels of PTSS is consistent with other
research that found cumulative adversity (repeated exposure to
traumatic events) is predictive of posttraumatic stress (Lloyd &
Turner, 2003).
Limitations
Several limitations of the current study must be acknowledged.
This study had a low response rate; research suggests that Internet-
based surveys have considerably lower response rates than paper-
based surveys (Nulry, 2008; Shih & Fan, 2009). Given the expan-
sive sampling frame of the present study, Internet-based
distribution of the survey was the most practical and cost-efficient
strategy for reaching this population. The low response rate to the
survey makes the findings vulnerable to nonresponse bias; there
may be unknown differences between individuals who responded
to the survey and those who did not. However, the demographic
features of this sample are similar to other large-scale studies of
EMS personnel in the United States (Donnelly, 2012); therefore,
the results could be considered comparably representative.
Paper-based surveys may yield a larger sample size in future
iterations of the study. Another methodological challenge is in
the sampling approach used to collect data. The use of proba-
bility sampling increases the external validity of the results;
however, the sampling frame used does not include every individ-
ual employed in EMS in the United States. The NREMT certifies
EMS personnel in 45 states; individuals working in Delaware,
Massachusetts, New York, North Carolina, and Wyoming may not
have been included in the sampling frame. Despite this limitation,
the NREMT is the best available sampling frame for this study, as
it includes a larger proportion of all EMS personnel in the United
States than any other source.
As this was an exploratory study, several measurement deci-
sions were made that may complicate interpretation of the results.
The decision to conceptualize critical incident stress as a “major
life event” and collapse the categories for multiple exposures was
made to minimize recall bias and is consistent with the original
measure. However, as noted earlier, the decision to collapse the
repeated exposures into one response option may lead to an un-
derreporting of critical incident exposures. Another limitation is in
the reporting of critical incident stress. Although respondents were
asked to report critical incident stress in the past 6 months and
 CRITICAL INCIDENT STRESS INVENTORY FOR EMS
PTSS in the past month, asking respondents to report critical
incidents stress and PTSS at the same time may obscure any
predictive association critical incident stress may have with post-
traumatic stress.
Recommendations for Future Research
This exploratory study has illustrated that it is possible to assess
the impact of critical incidents using a checklist approach. How-
ever, opportunities remain for greater elucidation of the concept of
critical incident stress. Future research studies should consider
folding the events identified in the qualitative data collection into
the inventory, creating a more comprehensive list of events. Fur-
thermore, future research efforts should focus on clarifying what,
if any, temporal relationship may exist between critical incidents
and posttraumatic stress by assessing if stronger correlational
relationships may be found when assessing for stress exposure and
stress reactions in different time frames. Researchers may also
choose to assess if more proximal predictors of PTSD, like peri-
traumatic dissociation (Ozer, Best, Lipsey, & Weiss, 2008), sig-
nificantly mediate the relationship between stress exposure and
stress reaction. Finally, future research efforts might utilize a
longitudinal design to measure the cumulative impact of critical
incident stress over time and how it relates to the development of
posttraumatic stress.
Despite the limitations of the study, the development of an
inventory of critical incident stressors contributes to the overall
understanding of relationships between critical incident exposure,
critical incident stress, and PTSS in EMS personnel. The qualita-
tive data collected in the current study identified additional critical
incidents that should be included in future studies utilizing this
critical incident stress inventory. These findings emphasize the
need for practitioners and researchers to consider the frequency of
exposure to critical incidents and the perceived stress resulting
from exposure. Although the current effort enhances existing
knowledge in the area of critical incidents in EMS, more research
is needed to deepen the understanding of the interactions between
critical incident exposure, critical incident stress, and posttrau-
matic stress reactions in the EMS.
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Received August 10, 2012
Revision received February 11, 2013
Accepted February 18, 2013 䡲