Federal Spotlight: HRSA

Helping EMS Responders Cope with Pediatric Fatalities

Source: http://www.ems.gov/newsletter/september2015/pediatric_fatalities.html

The emotional and psychological stress of encountering a pediatric fatality is unimaginable for those who haven t experienced it, and difficult to overcome for those who have.

To assist both families and EMS providers that are faced with such a tragedy, the Health Resources and Services Administration (HRSA) has funded a grant to develop effective tools and practices for EMS providers to handle the psychological and emotional effects experienced by themselves and families when a child fatality occurs outside of the hospital.

The project, called Compassionate Options for Pediatric EMS, or COPE, is one of six Targeted Issue grants that focus on research to improve pre-hospital pediatric outcomes, which are awarded by HRSA, an agency within the U.S. Department of Health and Human Services. Diane Pilkey, RN, MPH, the HRSA project lead for COPE, says the grant will help EMS providers manage the significant stress that comes with these kinds of events.

"The stress has led some EMS providers to leave the field," Pilkey said. "In the [hospital emergency department] setting, there is usually a support system available for families at the time of death, but this is much less likely if the death occurs in the field."

Mary Fallat, MD, division director of pediatric surgery at the University of Louisville, is leading the project. For nearly three decades, Fallat has been involved in the care of pediatric trauma patients, with particular interest in the care these patients receive before they arrive at the hospital. Her involvement in EMS began with the HRSA-funded Emergency Medical System for Children (EMSC) program; she has served as a dedicated program director of the EMSC Partnership Grant to Kentucky since 1996. Earlier this year, U.S. Transportation Secretary Anthony Foxx appointed Fallat to the National EMS Advisory Council.

The COPE grant is a natural extension of a concept Fallat has been researching for years, in which EMS providers treat victims of cardiac arrest on the scene, rather than "scoop and run."

Fallat contributed to another initiative in which, she said, she "led a multi-organizational literature review to try to better define some guidelines for terminating resuscitation on children who are trauma victims out of the hospital, as many states are primarily rural and long distances from trauma centers."

Those guidelines, published last year in the journal Pediatrics, emphasize the need for family-centered care to be included in the decision-making process for deaths that occur outside of the hospital. When children die outside of the hospital, EMS providers are often the ones on the scene handling these incidents. Appropriate training and resources are imperative in order for EMS providers to offer the best care and communicate appropriately with families and other responders.

The COPE team plans to develop a mobile app to train EMS providers to better handle pediatric accidents and deaths. The app will provide videos and a variety of other tools and resources to help EMS providers console grieving parents and also care for themselves in dealing with the sorrow and stress that remains after leaving the scene.

The COPE project is supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency Medical Services for Children (EMSC) Targeted Issues grant program, Grant No. H34MC26204 for $849,246. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Compassionate Options for Pediatric EMS (COPE)

Project Director: Mary E. Fallat, MD.

PROBLEM: EMS providers are often the first to comfort shocked and grieving parents of a child victim of fatal trauma or illness in an out-of-hospital (OOH) setting. Our pilot studies suggest that overwhelmed first responders feel inadequately prepared for these encounters, which can have a profound effect on EMS providers. This predicates the need for a national, compassionate EMS resource to improve interactions with panic-stricken families and provide EMS self-care strategies.

The COPE project team has been working for 3 years through HRSA on an EMSC Targeted Issues grant. Earlier in our project, we compiled an extensive reference library, completed Kentucky statewide focus groups with EMS, interviewed bereaved parents about their past experiences, and requested input and support from national EMS educators and administrators. Working alongside a web developer, we created the 1^st edition of a mobile App prototype aimed at EMS use for education or debriefing. The app includes simulation videos, teaching moments, and local & national resources. Funding allocated for an Android platform; we hope that development in an IOS platform will take place in the near future. The app prototype was launched first in Kentucky, then nationally through a website.  Our aim was to obtain feedback - what was helpful and what was unhelpful. The information that was gathered will be important to make future updates to the app prototype. The HRSA grant timeline has ended and we are working to find a sponsor or collaborator to sustain our work. We currently do not have a way to maintain and update the App; this website has been constructed by KBEMS to allow access to our educational materials for EMS providers.

 COPE Publications:

The COPE research group has received publisher permission to make available on this website the pdf of each article that was published as a result of the COPE grant, as well as two articles that provide background information.

1. Barbee AP, Fallat ME, Forest R, McClure ME, Henry K, Cunningham MR. EMS perspectives on coping with child death in and out of hospital setting.  Journal of Loss and Trauma 21(6):455-470, 2016. doi: 10.1080/15325024.2015.1117929  pdf
2. Fallat ME, Barbee AP, Forest R, McClure ME, Henry K, Cunningham MR. Family centered practice during pediatric death in and out of hospital setting. Prehosp Emerg Care 18:1-10, 2016. doi: 10.1080/10903127.2016.1182600 pdf
3. Calhoun AW, Sutton ERH, Barbee AP, McClure B, Bohnert C, Forest R, Taillac P, Fallat ME. Compassionate options for pediatric EMS (COPE): Addressing communication skills. Prehosp Emerg Care early online 1-10, 2017. doi: 10.1080/10903127.2016.1263370  pdf
4. Barbee AP, Antle BF, Fallat ME, Forest R, McClure ME. EMS treatment of families in an ambiguous out-of-hospital child death: the role of attribution errors. J Loss Trauma 22(7):564-576, 2017. doi: 10.1080/15325024.2017.1358572 pdf

Related publications:

1. Jordan KA, Fallat ME. Prehospital resuscitation decisions in cases of traumatic cardiopulmonary arrest: assessing the risk of legal liability and the impact of TOR guidelines. Journal of Legal Medicine 36(2):159-213, 2015. doi: 10.1080/01947648.2015.1121073 pdf
2. American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, national Association of EMS Physicians, and American Academy of Pediatric Committee on pediatric Emergency Medicine (Fallat, ME, lead author). Withholding or Termination of Resuscitation in Pediatric Out-of-hospital Traumatic Cardiopulmonary Arrest. Published jointly in the following publications: Pediatrics 133(4);e1104-e1116,2014. Annals of Emergency Medicine 63(4):504-515, 2014. pdf

Communicating with Families: https://youtu.be/EobQdpLq-jM

Suicide by Overdose: https://youtu.be/uT0NXz8Q8cE

MVC with Child Fatality: https://youtu.be/7BNCOuX8BEQ 

SUID/SIDS: https://youtu.be/ybWslqeIu5U 

Secondary Trauma Prevention: https://youtu.be/RwIijIqI8qA

First Responder Support Network:    http://www.frsn.org

The mission of the First Responder Support Network (FRSN) is to provide educational treatment programs to promote recovery from stress and critical incidents experienced by first responders and their families.

Resource for First Responders:   http://safecallnow.org

Safe Call Now provides public safety employees, all emergency services personnel and their family members nationwide with a simple and confidential way to ask for help.

International Society for Traumatic Stress:   http://www.istss.org

ISTSS Mission Statement: ISTSS is an international, interdisciplinary professional organization that promotes advancement and exchange of knowledge about traumatic stress. This knowledge includes: Understanding the scope and consequences of traumatic exposure.  Preventing traumatic events and ameliorating their consequences. Advocating for the field of traumatic stress.

The Trauma Center:   http://www.traumacenter.org

The Trauma Center is a program of Justice Resource Institute (JRI), a large nonprofit organization dedicated to social justice by offering hope and promise of fulfillment to children, adults, and families who are at risk of not receiving effective services essential to their safety, progress, and/or survival.

National Center for PTSD:   http://www.ptsd.va.gov

http://www.ptsd.va.gov/professional/provider-type/responders/working-with-trauma-survivors.asp -  Working with Trauma Survivors: What Workers Need to Know:

National Center for PTSD is dedicated to research and education on trauma and PTSD. We work to assure that the latest research findings help those exposed to trauma. Emergency responders can benefit from the page on early Intervention.

 

"Accommodation to Unnatural Death": Article by E.K. Rynearson, MD

This is written for someone who has experienced the death of a friend or family member by an unnatural dying—accident, suicide, or homicide.

Coping with Loss: http://www.mastersincounseling.org/loss-grief-bereavement.html Moments of grief occur in everyone’s life. The death of a parent, partner, or especially of a child, can cause almost unbearable emotional pain, and knowing how to cope with that grief is important for ensuring that the emotional distress doesn’t lead to depression or cause deeper psychological damage.

International Critical Incident Stress Foundation: Training website:  http://www.icisf.org/get-cism-support/

The CISM Hotline provides referrals to individuals or agencies in need. We maintain a database of CISM Teams worldwide, and, while it is not available for public release, we will be happy to assist you in identifying teams in your area.

Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/  

SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

US Department of Labor:  https://www.osha.gov/SLTC/emergencypreparedness/resilience_resources/index.html

US Dept. of Labor: Federal and federalized employees involved in emergency response may be physically and emotionally impacted by this experience. Emergency response can be both rewarding and stressful, and it is important to recognize that some emotional reactions are to be expected. Support can be provided by family, friends, and consider utilizing community or faith-based organizations.

Center for the Study of Traumatic Stress:  http://www.cstsonline.org/  

The Center for the Study of Traumatic Stress (CSTS) is one of the nation’s oldest and most highly regarded, academic-based organizations dedicated to advancing trauma-informed knowledge, leadership and methodologies. The Center’s work addresses a wide scope of trauma exposure from the consequences of combat, operations other than war, terrorism, natural and humanmade disasters, and public health threats.

Training for emotional survival:   http://www.911salt.com/resources.html

SALT is a philosophy and approach designed to help agencies create an organizational culture of wellness that sustains their officers' individual wellness practices, improves officer safety, and supports community security.

Counseling team International: http://www.thecounselingteam.com/

The Counseling Team International has provided employee support services to governmental agencies, law enforcement, fire and emergency services, private industries and organizations in the State of California, as well nationwide since its founding in 1985.

Grief is this Normal?, by Diana M. Cimador Roscigno

ISBN-10: 0741445883 

ISBN-13: 978-0741445889

Helps parents verbalize the questions and the roller coaster of emotions that they

have about the unknown.

Dear Parents: Letters to Bereaved Parents, by Joy Johnson

ISBN-10: 1561230332 

ISBN-13: 978-1561230334

A collection of letters to bereaved parents written by bereaved parents and well-known leaders in the bereavement field. This is a support group in book form.

How To Go On Living When Someone You Love Dies, by Theresa Rando

ISBN-10: 0553352695 

ISBN-13: 978-0553352696

Mourning the death of a loved one is a process all of us will go through at one time or another. But whether the death is sudden or anticipated, few of us are prepared for it or for the grief it brings. There is no right or wrong way to grieve; each person's response to loss will be different.

The Grief Recovery Handbook, by James and Russell Friedman

ISBN-10: 0060915862

ISBN-13: 978-0060915865

An inspirational book that presents a proven, step-by-step recovery program that has helped thousands of individuals recover from all kinds of loss.

When Something Terrible Happens: Children Can Learn to Cope with Grief, by Marge Heegaard

ISBN-10: 0962050237

ISBN-13: 978-0962050237

Creates ways for children to explore the fright, confusion, and insecurity caused by traumatic events in their lives.

Grief Quest: A Workbook & Journal To Heal the Grieving Parent’s Heart, by Lilly Julien and I.J. Weinstock

ISBN-10: 0982932227

ISBN-13: 978-0982932223

Utilizes a unique question-based L.O.V.E. process. The questions will help parents memorialize their child.

Living with Loss, One Day at a Time, by Rachel Blythe Kodanaz

ISBN-10: 1938486315

ISBN-13: 978-1938486319

Offers daily encouragement to individuals and families who have recently lost a loved one. The short entries are easy to read and give realistic, practical advice to guide readers through the day. By providing tools and suggestions that offer hope, optimism, introspection, and self-discovery, this book enables readers to embrace the happy days of life with their loved one and gently guide them through their grief.

Good Grief: Healing Through the Shadow of Loss, by Deborah Morris Coryell

ISBN-10: 9781594771590

ISBN-13: 978-1594771590

A compassionate guide to the experience of loss as an essential growth process. Explores the nature of loss as a profound mystery shared by all human beings and offers sensitive and practical advice for experiencing grief and preparing for the healing journey that follows. Includes CD of the author reading selections from the text.

The Death of a Child...Reflections for Grieving Parents, by Elaine Stillwell

ISBN-10: 0879462604

ISBN-13: 978-0879462604

Filled with stories of people who have lost a child and how they dealt with the reality of that event. This collection of life-giving lessons touches on a wide range of emotions and situations that parents may encounter after the death of their child.

A Time to Grieve: Meditations for Healing After the Death of a Loved One, by Carol Staudacher

ISBN-10: 0062508458

ISBN-13: 978-0062508454

A collection of truly comforting, down-to-earth thoughts and meditations -- including the authentic voices of survivors -- for anyone grieving the loss of a loved one.

Living with Loss, Healing with Hope: A Jewish Perspective, by Rabbi Earl A. Grollman

ISBN-10: 0807028134

ISBN-13: 978-0807028131

Guides readers through Jewish funeral observances, Shiva, and beyond, and reminds all that these symbolic customs are 'about change-remembrance, letting go, and moving on.'

Children Die, Too, by Joy Johnson and Marv Johnson

ISBN-10: 1561230294

ISBN-13: 978-1561230297

For newly bereaved parents needing general grief information. Includes: Feelings, Your Other Children, Grandparents, Friends, Single Parents and Step-Parents, Taking Care of Yourself, and Searching.

Creating a New Normal After the Death of a Child, by Sandy Fox

ISBN-10: 1450230946

ISBN-13: 978-1450230940

Helps the newly bereaved as well as the seasoned griever find their way through the darkness and into the light again to a life full of happiness and new meaning.

​A Broken Heart Still Beats: When Your Child Dies, by Anne McCracken

ISBN-10: 1568382014

ISBN-13: 978-1568382012

A remarkable collection of poetry, fiction, and essays compiled by a journalist and a social worker, both of whom have lost a child. Seasoned with wisdom and experience, the words offer rare comfort and insight to those who need it most.

 

After Goodbye: How To Begin Again After The Death Of Someone You Love, by Ted Menton

ISBN-10: 1561382957

ISBN-13: 978-1561382958

Explains how to begin life again after the death of a loved one. By taking into account the most common elements of the grieving process, this sensitive guide to moving on teaches the bereaved how to work their way through the pain and back to life with touching personal accounts and honest answers to difficult questions.

 

Healing After the Suicide of a Loved One, by Ann Smolin

ISBN-10: 0671796607

ISBN-13: 978-0671796600

Helps parents take the first steps toward healing. Filled with case studies, excellent information, valuable advice, and a completely up-to-date reading list and directory of suicide support groups nationwide, this valuable book will give parents the strength and hope to go on living.

 

The Worst Loss: How Families Heal from the Death of a Child, by Barbara D. Rosof

ISBN-10: 080503241X

ISBN-13: 978-0805032413

Helps families who have experienced this to know what they are facing, understand what they are feeling, and appreciate their own needs and timetables.

 

No Time for Goodbyes: Coping with Sorrow, Anger, and Injustice after a Tragic Death, by Janice Harris Lord

ISBN-10: 1878321307

ISBN-13: 978-1878321305

Parents will find deep understanding and insight as well as detailed practical information on dealing with legal and financial issues.

 

Living With Grief After Sudden Loss Suicide, Homicide, Accident, Heart Attack, Stroke, by Kenneth J. Doka, Ph.D.

ISBN-10: 156032578X

Sudden loss, death without forewarning, understandably creates special problems for survivors. Three of the most common include intensified grief, the shattering of a person’s normal world and the existence of a series of concurrent crises and secondary losses.

 

The ABC’s of Healthy Grieving, by Harold Ivan Smith.

ISBN-10: 1-59471-127-5

ISBN-13: 978-1594711275

Realistic advice on how to deal with grief day by day.

 

After the Chapters End, by Susan Hessel.

ISBN-10: 1-49593-343-1

ISBN-13: 978-1495933431

A step-by-step guide to preserving the life story of a child who has died, written by a

bereaved parent.

Ask Me…30 Things I Want You to Know, by Nan Zastrow

ISBN-10: 1-56123-198-3

ISBN-13: 978-1561231980

How to be a friend of a survivor of suicide.

 

Healing a Parent’s Grieving Heart, by Alan Wolfelt.

ISBN-10:1-879651-30-0

ISBN-13: 978-1879651302

This book offers 100 practical ideas that have helped other grieving parents understand

and reconcile their grief.

 

A Guide to Coping, by Jane Smith

ISBN-0909123445545

The death of a loved one is painful enough but when death is sudden and combined with the loss of home, community and security, as during a natural disaster like Hurricane Katrina, it doubles our pain and intensifies the grief. Mourning and recovery are more difficult for surviving family members, regardless of their age. Many survivors will be in denial of the tragedy, some for a very long time.

 

Healing After Loss: Daily Meditations for Working through Grief, by Martha Whitmore Hickman.

ISBN: 0380773384

For those who have suffered the loss of a loved one, here are strength and thoughtful words to inspire and comfort.

 ​Local Civil Assistance:   Louisville, Kentucky (Metro)

 

1. Metro Safe : (502) 574-2117​
   

 

2. Metro Police: 911 or (502) 574-7111 or 574-2111

 

3. Fire Department: Local fire districts: http://www.jeffcofire.com/links.htm

 

4. Jefferson County Coroner: Barbara Weakley-Jones: (502) 574-6262

 

5. Jefferson County Medical Examiner- Chief ME- Tracey Corey: (502) 852-5587

 

6. Utilities: http://louisville.about.com/od/movingtolouisville/ss/setuputilities.htm

 

7. Funeral Information: http://nfda.org/planning-a-funeral.html or funeralnet.com

 

8. Grief Care Information:

• http://www.hospicebg.org/grief
• http://www.griefhealing.com/
• https://www.grieflink.com/
• http://www.opentohope.com/ 
• https://www.griefwatch.com/

 

9. Support groups:

• http://www.parentsleftbehind.com/
• http://www.compassionatefriends.org/home.aspx

 

10. Counselor(s): https://therapists.psychologytoday.com/rms/county/Kentucky/Jefferson.html

 

11. Crisis Center:

• http://chfs.ky.gov/dcbs/dpp/centerandshelterinfo.htm
• http://kccrb.ky.gov/resources/confidentiality.htm

 COPE App- Family Attendant: “Help” icon- A “Family Attendant” is a third person who has completed COPE training and is available to be at the scene. Their role is to inform and console the family about what is being done in order to alleviate hysteria. This allows EMS personnel to focus on the child and to work more effectively. Family Attendants may be a firefighter, police, clergy, another EMS provider, community volunteers, etc.

Family Support Sites:

Coping With Disaster – Surviving Sudden Loss: http://mentalhealthsf.org/coping-with-disaster-surviving-sudden-loss/

The death of a loved one is painful enough but when death is sudden and combined with the loss of home, community and security, as during a natural disaster like Hurricane Katrina, it doubles our pain and intensifies the grief. Mourning and recovery are more difficult for surviving family members, regardless of their age. Many survivors will be in denial of the tragedy, some for a very long time.

Bereaved Parents of the USA: http://www.bereavedparentsusa.org

We want you to know you are not alone on your grief journey. Bereaved Parents/USA understands and cares about you and knows that we bereaved families truly share “A Journey Together”.

The Compassionate Friends: http://www.compassionatefriends.org

The Compassionate Friends exists to provide friendship, understanding, and hope to those going through the natural grieving process.

The Dougy Center: http://www.dougy.org

Tip Sheets: Helping Children & Teens Cope with Fear After a Death: It’s common for children and teens to have an increased sense of fear and anxiety after a death. Some children and teens develop fears about places or circumstances related to the death. Fear is the body’s natural alarm for danger. When someone dies, it is natural for our bodies to be on “high alert.” Acknowledging that this is a normal reaction can help reduce children feeling overwhelmed.

Survivors of Suicide: http://www.survivorsofsuicide.com

Time heals all wounds is not necessarily true for survivors of suicide. Time is necessary for healing, but time is not enough. Shared feelings enrich and lead to growth and healing.

MISS Foundation: http://www.missfoundation.org

We can help you find support & resources after the death of a child, no matter their age or cause of death. We offer free family packets, HOPE mentor matches, support groups, counseling, and more.

Courageous Kids: https://www.peacehealth.org/shared-pages/Pages/courageous-kids.aspx?from=/sacred-heart-riverbend/services/end-of-life-care/grief-support

A grief support program for youth ages 6-17 and their caregivers. Courageous Kids believes:

• Grief is the normal response to the death of a loved one.
• Children grieve as intensely as adults, but in different ways.
• It is important for the healthy development of a child to grieve a significant loss.
• Healing from a painful loss is possible with support and acceptance.
• Children need support that is appropriate to their developmental stage. 

Coalition to Support Grieving Students: http://grievingstudents.scholastic.com

Providing support over time.

List: What to say & what not to say. Understanding what not to say will help you be more confident and effective.

How to Act: Behaviors that will increase children’s comfort, sense of safety, and ability to express themselves:

• Be present and authentic.
• Listen more, talk less.
• Avoid trying to “cheer up” students or their families.
• Accept expressions of emotion.
• Show empathy.
• Step in to stop harmful actions when safety is a concern.

Centering Corporation and Grief Digest Magazine: http://www.centering.org/

We give you support. We give you information. We give you hope. We will help support groups find the resources they need to make a difference. We support other publishers who are also reaching people.

Living with Loss Magazine: www.livingwithloss.com 

Our mission is to offer compassion and hope by providing the most current resources, information and tools for coping with life’s losses. We provide individuals, businesses and organizations the best in hope and healing, when suffering a loss associated with death, terminal illness, cancer, jobs, natural disasters, finances, divorce, mental health and physical challenges, ecumenical faith and spirituality, pet loss and military loss. 

 

​REFERENCE LIST:

Updates:

Hobgood, C; Harward, D; Newton, K; Davis, W. (2005). The educational intervention “GRIEV_ING” improves the death notification skills of residents. Acad Emerg Med, 12(4), 296-301.

doi: 10.1197/j.aem.2004.12.008

Lipton, H; Coleman, M; National Association of Social Workers. (2000). Bereavement practice guidelines for health care professionals in the emergency department. Int J Emerg Ment Health, 2(1), 19-31.

Hellberg, S. (1994). Losing the human touch. Emergency Medical Services, 23(8), 58-60.

Floren, TM. (1981). Death and dying in the emergency setting. Emergency Medical Services, 10(4), 38,40,42,45. 

Evans, S; Patt, I; Giosan, C; Spielman, L; Difede, J. (2009). Disability and posttraumatic stress disorder in disaster relief workers responding to September 11, 2001 World Trade Center disaster. Journal of Clinical Psychology, 65(7), 684-694.

Halpern, J; Maunder, R; Schwartz, B; Gurevich, M. (2012). The critical incident inventory: characteristics of incidents which affect emergency medical technicians and paramedics. BMC Emergency Medicine, 12:10.

Erich, J. (2014). Earlier than too late: stopping stress & suicide among emergency personnel. EMSworld.com/magazine, November, 38-47.

Stanley, I; Hom, M; Joiner, T. (2016). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics. Clin Psych Rev, 44, 25-44.

Jonsson, A; Segesten, K. (2004). Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel. Accident and Emergency Nursing, 12(4), 215-223. 

Maguire, B; Hunting, K; Smith, G; Levick, N. (2002). Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med, 40(6), 625-632.

Mishra, S; Goebert, D; Char, E; Dukes, P; Ahmed, I. (2010). Trauma exposure and symptoms of post-traumatic stress disorder in emergency medical services personnel in Hawaii. Emerg Med J, 27(9), 708-711.

Halpern, J; Maunder, R; Schwartz, B; Gurevich, M. (2012). Identifying, describing, and expressing emotions after critical incidents in paramedics. J Traum Stress, 25(1), 111-114.

Newland, C; Barber, E; Rose, M; Young, A. (2015). Survey reveals alarming rates of EMS provider stress & thoughts of suicide. JEMS.com October, 30-34.

Hegg-Deloye, S; Brassard, P; Jauvin, N; Prairie, J; Larouche, D; Poirier, P; Tremblay, A; Corbeil, P. (2014) Current state of knowledge of post-traumatic stress, sleeping problems, obesity and cardiovascular disease in paramedics. Emerg Med J, 31(3), 242-247.

Loscar, T. (2010). The policy of truth. EMSworld.com/magazine, August.

Wheeler, J. (2010). Changing Kingdoms. EMSworld.com/magazine, February.

Declercq, F; Meganck, R; Deheegher, J; Van Hoorde, H. (2011). Frequency of and subjective response to critical incidents in the prediction of PTSD in emergency personnel. J Traum Stress, 24(1), 133-136.

Stevens, S; Alexander, J. (2005). The impact of training and experience on EMS providers’ feelings toward pediatric emergencies in a rural state. Pediatr Emerg Care, 21(1), 12-17.

Donnelly, E. (2012). Work-related stress and posttraumatic stress in emergency medical services. Prehosp Emerg Care, 16(1), 76-85.

Hobgood, C; Mathew, D; Woodyard, D; Shofer, F; Brice, J. (2013). Death in the field: teaching paramedics to deliver effective death notifications using the educational intervention “GRIEV_ING”. Prehosp Emerg Care, 17(4), 501-510.

Maguire, B; Hunting, K; Guidotti, T; Smith, G. (2005). Occupational injuries among emergency medical services personnel. Prehosp Emerg Care, 9(4), 405-411.

Smith, A; Roberts, K. (2003). Interventions for post-traumatic stress disorder and psychological distress in emergency ambulance personnel: a review of the literature. Emerg Med J, 20(1), 75-78.

Topjian, AA; Nadkarni, VM; Berg, RA. (2009). Cardiopulmonary resuscitation in children. Curr Opin Crit Care, 15(3), 203-208.

Eckstein, M; Stratton, S; Chan, L. (2005). Termination of resuscitative efforts for out-of-hospital cardiac arrests. Acad Emerg Med, 12(1), 65-70.

Mosenthal, AC; Murphy, PA; Barker, LK; Lavery, R; Retano, A; Livingston, DH. (2008). Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma, 64(6), 1587-1593.

Seibert, PS; Stridh-Igo, P; Zimmerman, CG. (2002). A checklist to facilitate cultural awareness and sensitivity. J Med Ethics, 28(3), 143-146.

Mularski, R; Curtis, R; Billings, J; Burt, R; Byock, I; Fuhrman, C; Mosenthal, A; Medina, J; Ray, D; Rubenfeld, G; Schneiderman, L; Treece, P; Truog, R; Levy, M. (2006). Crit Care Med, 34(11)Suppl, S404-S410.

Beck, B; Bray, J; Cameron, P; Straney, L; Andrew, E; Bernard, S; Smith, K. (2017). Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Resuscitation, 111(2), 14-21.

Fallat, M; Costich, J; Pollack, S. (2006). The impact of disparities in pediatric trauma on injury-prevention initiatives. J Trauma, 60(2), 452-454.

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