An Underserved Population: Rates of PTSD Among Rural EMS

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Nicole E. Cressley, M.A.

The estimated lifetime prevalence of PTSD among American adults is 8.7%, with women more likely than men to develop the disorder at some point in their lives (APA, 2013). The likelihood of developing PTSD is based on many factors, including the type of traumatic event and the characteristics of the individual (Lukaschek et al., 2013). PTSD is associated with serious physical and psychological consequences, and can result from numerous types of traumatic events (Atwoli, Stein, Koenen, & McLaughlin, 2015). The highest likelihood of developing PTSD is related to events involving interpersonal violence or military combat, and multiple exposures to traumatic events increase the risk for PTSD, putting populations like military personnel and first responders at a higher risk (Kilpatrick et al., 2013; Walker et al., 2016). 

Brittany E. Canady, PhD

First responders include police personnel, firefighters, and ambulance personnel (Gonzalez, 2016; Regambal et al., 2015). These are the individuals who immediately attend to a scene of an accident, a crisis, or some other emergency. In comparison to research focusing on other first responder populations, the current literature fails to address ambulance personnel specifically. Emergency Medical Technicians (EMTs) and Paramedics are collectively referred to as Emergency Medical Services (EMS) personnel. Despite the fact that this subgroup spends the most time and is in the closest contact with injured survivors and relatives of the deceased, they are far less studied than firefighters and law enforcement (Marmar et al., 2006). 

April Fugett-Fuller, PhD

An even more specific subgroup worthy of clinical focus would be rural EMS workers. Generally, less is known about PTSD development and treatment in rural populations compared to urban counterparts (Erickson, Hedges, Call, & Bair, 2013). Rural communities are not immune to traumatic events. In fact, in rural areas, motor vehicle accidents have been estimated to be two-to-three times more likely to result in fatalities than in urban areas (Zwerling et al., 2005). Similarly, the rates of intimate partner violence have been shown to be significantly higher in rural areas compared to urban areas (Peek-Asa et al., 2011). To further complicate these issues, it is estimated that a third of the time, rural EMS workers know the victim on the scene they are responding to (D’Andrea et al., 2004). Because of such unique issues, it is essential to consider the specific effects on rural EMS workers, which is what the present study sought to focus on.  

Rural EMS workers throughout Pennsylvania and West Virginia were contacted through professional electronic listservs. A total of 437 participants finished an online survey comprised of demographic information, the Life Events Checklist for DSM-5 (LEC-5), the PTSD Checklist for DSM-5 (PCL-5), and the Barriers to Accessing Mental Health Care (BACE) Survey. On average, participants were 39 years old (SD = 12.3) with 16 years of service as an EMS worker (SD = 11.8). Most (68.7%) participants were male, and 31.3% were female. This demographic compares adequately to national averages of EMS personnel, with 68% male and 32% female (U.S. Department of Labor, 2016). This sample was limited in racial diversity, as 95.4% of participants were white. However, 82.1% of Pennsylvanians and 93.6% of West Virginians are white (U.S. Census Bureau, 2017). The largest group (43.2%) of participants were paramedics, 39.6% were EMTs, and the remaining 17.2% were in the “other job title” category. These responses included supervisory roles, directors, RNs, 911 dispatchers, ambulance drivers, and dual firefighter/EMS workers.  

On average, participants scored a 24.6 on the PCL-5 (SD = 19.5), with a score of 33 indicating a provisional PTSD diagnosis. Of the 437 completed PCL-5s, 35% were clinically significant, receiving a score of 33 or higher. Of the 35% with clinically significant scores, 96% endorsed at least one traumatic experience on the LEC-5 as “part of my job.” No differences emerged between the PCL-5 scores for males (M = 24.21, SD = 16.7) and females (M = 25.52, SD = 17.6; t (416) = -.733, P = .643) in this sample. 

Only 418 participants completed the BACE. The average BACE score was 65 (SD = 15). Scores range from 20-100, with higher scores indicating higher perceived barriers to treatment. Out of the 418 respondents, 36.1% endorsed personal financial difficulties as a significant barrier in their communities. Following that, the items most highly endorsed as a significant barrier were: feeling embarrassed or ashamed to seek help (35.4%); worrying about help-seeking affecting their employment (33.2%); worrying about perceptions from family and friends (32.8%); and reluctance to acknowledge a problem exists (28.9%).  

Based on the current diagnostic criteria for PTSD, occupational exposure constitutes a traumatic event (APA, 2013). This acknowledgment of the potential for traumatic events via occupational exposure has been justified in the present study, with most participants endorsing at least one traumatic event occurring as part of their job. Participants in the current study tended to endorse multiple traumatic events as part of their job, consistent with prior research that demonstrates multiple exposures in first responder populations increase their risk for developing PTSD (Walker et al., 2016). Thus, participants in the current study would appear to be at elevated risk of PTSD due to the types and number of events to which they are exposed as a function of their rural EMS work.  

When examining rates of PTSD symptoms in the present sample, this elevated risk is evident; 35% had clinically significant PCL-5 scores. Prior studies have estimated the lifetime prevalence of PTSD among first responders at nearly one-third (Walker et al., 2016). Interestingly, the risk associated with EMS work appears to outweigh gender differences typically found in rates of PTSD diagnosis (APA, 2013). Although women are likely to experience intimate traumatic events in their lifetime, the LEC-5 revealed that the exposure to traumatic events as a part of the work of an EMS provider did not differ based on gender. Males and females appear equally susceptible to the development of PTSD in this role. It is therefore clear that serving as a first responder, and particularly as an EMS worker, substantially and independently increases risk of PTSD.  Access to appropriate mental health care and resources to enhance resiliency and coping skills are essential to protect this vulnerable population.  Despite this increased need, several barriers may limit access to this much-needed care. 

In the current study, personal financial difficulties emerged as the most commonly cited barrier to mental health treatment. The average annual wage for EMTs and paramedics in Pennsylvania is $33,200 and is $28,320 in West Virginia, and both states are below the national average of $36,700 (U.S. Department of Labor, 2017).  With 35% of the respondents reporting clinical levels of PTSD, there are likely other mental health issues occurring or co-occurring. EMS personnel are an extremely at-risk population who are traditionally underpaid and overworked in rural areas (Stamm et al., 2007). 

While the current study identifies multiple risk factors associated with elevated rates of PTSD in EMS workers and substantial barriers to accessing treatment in this population, it is important to consider the key protective factors in rural areas which can be mobilized to assist in prevention and intervention strategies. Often, resilience is conceptualized from an individual standpoint, rather than a systemic one (Shaw et al., 2016). However, resiliency is highly dependent upon one’s social environment, and rural cultures share characteristics that may be particularly beneficial. A unique component of Appalachian culture is the collectivist nature of the communal bonds which serve as a protective factor for mental health (Wagner, 2005). 

While there are higher levels of adverse situations in Appalachia, individuals tend to report adequate well-being (Hamby, Grych, & Banyard, 2018). This resiliency could be due to the ability for Appalachians to find the meaning in a tumultuous situation. Higher levels of generativity are also quite common in rural areas. Generativity is the need to contribute to the younger generation, and this directly relates to the role of kinship ties as a protective factor for rural and low-income populations (Ostbye et al., 2018; Taylor, 2010). 

These protective factors should be used to mitigate the elevated risk for rural EMS personnel. Approaching prevention and intervention efforts from a systemic standpoint could be particularly powerful, rather than placing the expectation on the EMS provider to seek their own support. Their occupational environment puts them at a high risk for adverse mental health outcomes, so that system should be incorporating more protective factors towards prevention. Rural EMS populations should be approached from a collectivist standpoint, meaning that intervention strategies should be targeted at the group rather than the individual. With generativity in mind, peer support programs could be beneficial for this population. 

Finding the meaning in an adverse situation can be highly beneficial. For EMS providers, a sense of meaning can certainly be tailored to their occupational experience through peer support. Focusing on the positive aspects of what they do can be a helpful way to cope with adverse situations and doing so with a peer reinforces a sense of shared meaning, addressing the need for social cohesion and kinship bonds.  Because of the increased risk for this population, additional opportunities should be developed for better protecting EMS personnel and enhancing access to treatment. 


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Nicole Cressley, M.A. is a fourth year Psy.D. student at Marshall University. She is interested in health psychology and the complexities of trauma exposure.  

Brittany Canady, PhD is an Assistant Professor at Marshall University. She is board certified in clinical health psychology.  

April Fugett-Fuller, PhD is a Professor and Assistant Director for the Center of Teaching and Learning at Marshall University.