Tip of the Month – April 2025

Paramedic resilience strategies; recognizing and managing burnout

The demanding nature of paramedic work, with its long hours, high-stress situations, and frequent exposure to trauma, makes burnout a serious concern within the profession. Recognizing the signs of burnout and adopting effective resiliency strategies is essential for maintaining well-being and ensuring paramedics can continue delivering the high-quality care that communities depend on

Paramedics experiencing burnout often report feeling less empathy or compassion towards those that they help, which can manifest as irritability, frustration, detachment, cynicism, or a lack of motivation to provide the best care possible. Recognizing these changes in emotions early is crucial in order to address them before they become overwhelming.

When paramedics recognize themselves becoming burnt out, the following are some strategies that can be employed to build resiliency:

• Establish strong support networks: Lean on colleagues who understand the unique challenges of the job. Having a supportive team can provide a sense of camaraderie and emotional relief.
• Prioritize Self-Care: Taking care of your physical and emotional health is essential. Ensure you are getting adequate amounts of sleep, nutrition, and exercise. Even small self-care practices like stretching, meditation, or brief mindfulness breaks at work can have a positive impact on your well-being.
• Establish boundaries/Maintain Work-life balance: Learn to say “no” or set limits when needed. Avoid overcommitting yourself both off and on the job. Make sure that your personal life is given enough time and attention. Spending quality time with loved ones, pursuing creative hobbies, or enjoying outdoor activities are all vital for recovery and long-term resilience
• Seek Help: If burnout symptoms persist, consider seeking help from a counsellor or therapist who specializes in trauma or stress-related conditions

Listed below are several resources available to paramedics in Northwestern Ontario who think they may be experiencing burnout or other stress-related injuries.

By recognizing the signs of burnout early and actively implementing resiliency strategies, paramedics can not only preserve their mental and emotional well-being but also continue to thrive in their demanding roles, ensuring both personal health and the quality of care they provide to their communities.

March 2025 Tip of the Month: Identifying Intimate Partner Violence (IPV) in Prehospital Care

Recognizing the Signs of IPV

Intimate partner violence (IPV) is a significant issue across Canada, and Northwestern Ontario is no exception. Studies indicate that up to 35% of women in the region will experience IPV in their lifetime, with higher rates reported in rural and remote communities. Certain Indigenous populations face even greater vulnerability due to unique socio-economic and systemic factors.

As frontline healthcare providers, paramedics are often the first point of contact for victims of IPV. Your ability to recognize and respond to IPV is critical for patient safety and well-being.

1. Recognizing Common Presentations

IPV victims may present with:

· Unexplained or inconsistent injuries (e.g., bruises, fractures, lacerations).

· Injuries in various stages of healing.

· Vague, non-specific complaints (e.g., headaches, abdominal pain, anxiety).

· Injuries to areas typically covered by clothing, such as the abdomen, chest, or back.

· Behavioral signs, including nervousness, avoidance of eye contact, or reluctance to provide details about injuries.

2. Observing Behavioral Cues

· A controlling or overly attentive partner insists on speaking for the patient.

· The patient appears fearful, anxious, or depressed when discussing their injuries.

· The patient hesitates or resists answering questions when their partner is present.

3. Using Open-Ended and Non-Judgmental Questions

Creating a safe and private environment allows patients to disclose abuse. Consider asking:

· “Can you tell me what happened today?”

· “Do you feel safe at home?”

· “Has anyone hurt you or made you feel afraid?”

4. Utilizing the HITS Screening Tool

The HITS (Hurt, Insulted, Threatened, Screamed) tool is a simple, validated screening method to assess IPV. Patients rate four questions on a scale of 1 to 5 (Never to Frequently):

· Hurt – "How often has your partner physically hurt you?"

· Insulted – "How often has your partner insulted or talked down to you?"

· Threatened – "How often has your partner threatened you with harm?"

· Screamed – "How often has your partner screamed or cursed at you?"

A score of 10 or higher suggests a potential IPV case, warranting further assessment and intervention. The brevity of this tool makes it especially useful in prehospital settings.

5. Identifying High-Risk Factors

Certain factors increase the urgency of IPV intervention:

· Strangulation – A strong predictor of future lethal violence.

· Pregnancy-related injuries.

· Multiple EMS calls for vague complaints in a short timeframe.

6. Documenting Accurately

· Record verbatim statements from the patient.

· Describe visible injuries and behavioural cues objectively.

· Avoid assumptions—stick to observable facts.

7. Referral and Reporting

• Hospital Triage: Communicate any IPV concerns to your receiving facility
• Self-Referral Support Services: IPV survivors can access support services independently. Referring patients to available programs and treatment centres can connect them with vital resources.
• Mandatory Reporting: If there are children in the home aged 16 or under, paramedics have a legal obligation to report suspected IPV to child protective services.
• Resource and Support Links:
  • Ontario Government: IPV Support Services
  • Sexual Assault/Domestic Violence (SADV) Treatment Centres – A list of treatment centres by location.
  • 211 Ontario – Enter your location to find local shelters, crisis lines, and other community services.

Evidence-Based Practice

Research indicates that up to 40% of women treated by EMS have experienced IPV, yet it frequently goes unrecognized. The HITS screening tool has been shown to improve IPV identification and facilitate early intervention in prehospital care.

Your Role in IPV Recognition

By applying these guidelines, paramedics can play a critical role in identifying IPV and ensuring that victims receive the support they need. Early recognition and appropriate action can make a life-saving difference.

ALL the ECGs presented this week have a final diagnosis of Pulmonary Embolism (PE)!

Before we begin the review, take a moment and refresh yourself as to where the various leads are with respect to the anatomical location of the heart. I specifically want you to notice that aVR, V1, and lead III are on the right side of the heart.

ECG findings in Pulmonary Embolism

• Sinus Tachycardia
  • You don’t need tachycardia to have a PE. Tachycardia is seen in only ~30% of patients, but signals increased oxygen demand
• Atrial and ventricular dysrhythmias
  • SVT, atrial fibrillation, atrial flutter, etc.
  • SVTs (AVNRT, AVRT, atrial and junctional tachycardias, etc.) are an independent predictor of subsequent clinical deterioration
• ECG Signs of RV strain
  • Rightward axis (look for large S wave in lead I)
    • S₁Q₃or S₁Q₃T₃(not sensitive or specific)
  • Conduction delays and repolarization abnormalities
    • New RBBB or incomplete RBBB
    • Look for tall R waves in V1
  • New T-wave inversions
    • Right precordial leads (V1-V4)
    • Inferior leads (II, III, aVF)
    • New T wave inversions in the anteroseptal leads +/- inferior leads should be considered a sign of acute pulmonary hypertension or PE until proven otherwise
  • ST-segment elevations or depressions (mimics ischemia)
  • ST-segment elevation in rightward leads (V₁, V₂, aVR, III)

• Co, et al. J Emerg Med 2017 (PMID: 27742402) – identified the most common ECG changes in patients with known PE when comparing their ECGs with previous ECGs
  • 285 PEs diagnosed on CTA (62% segmental, 20% in main pulmonary artery, 8% saddle)
    • No ECG changes ~ 24%
    • T wave inversion ~ 34%
    • T wave flattening ~ 30%
    • Sinus tachycardia ~ 27%
    • Rightward axis ~ 11%
    • ST segment changes ~ 9%
    • S₁Q₃T₃~ 4%

ECG 1

This shows the classic S1Q3T3 finding, which is neither sensitive nor specific per PE and present only probably about 4% of the time. More importantly, we see ST elevation in leads aVR, V1 and lead III.

ECG 2

Here again, we see S1Q3T3. There is also STE in aVR and widespread STD. You may recall that we have mentioned this pattern before, and it can be seen with critical ACS, however, it is also seen in other conditions whereby the heart is put under stress such as sepsis, profound GI bleeding, and PE!

ECG 3

This ECG shows deep TWI (T wave inversion) in both anterior (V1- V4), as well as inferior leads. This is PE until ruled out!

ECG 4

Here we see an incomplete RBBB, we also see SRE in aVR, V1, and lead III. There is also T wave inversions in the precordial and inferior leads. All of these findings point towards PE as the diagnosis.

ECG 5

Here we see S1Q3T3 again, and certainly, the S wave is deep in lead 1. But also note the significant STE in aVR V1, V2 and lead III.

ECG 6

This ECG is essentially a normal sinus tachycardia with no other specific findings to suggest PE and this is often what we see.

Welcome to the Final Week of ECG Reviews!

This week, we present six ECG examples from patients who all shared the same final diagnosis. Each patient presented with some form of chest pain and shortness of breath.

While historical and clinical clues may provide valuable context, we’re keeping those details undisclosed for now. Your challenge is to analyze the ECGs carefully and determine common patterns or findings that might hint at the underlying diagnosis.

Key Areas to Focus On:

• T waves: Are there signs of ischemia, hyperacute changes, or repolarization abnormalities?
• Territories: Which areas of the myocardium appear affected? Consider anterior, inferior, lateral, or posterior involvement.
• Intervals: Assess for prolonged PR, widened QRS, or QT abnormalities that could provide diagnostic clues.

Your Task:

1. Review the provided ECGs.
2. Identify common patterns across all cases.
3. Consider potential underlying causes based on ECG findings alone.
4. Formulate your working diagnosis before next week’s reveal.

Next week, we will provide detailed explanations and discussion on these cases.

Good luck, and we look forward to your interpretations!

ECG 1

ECG 2

ECG 3

ECG 4

ECG 5

ECG 6