Table 1.

Review table.

References	Study aim	Country	Study type	Methods	Sample	Findings and recommendations	Limitations	Theme
Skogstad et al. (9)	To investigate the prevalence of PTSD among first responders, including EMS responders, after the 2011 terrorist attacks in Norway.	Norway	Quantitative cross-sectional study	Questionnaire	A purposive sample of 238 first responders, including 89 paramedics.All were male. Most of the participants' (60/89) ages ranged from 30 to >50 years old. 84/89 of the EMS group had >5 years of experience.	The study found very low prevalence of PTSD among all participants, including the 89 EMS providers. Effective training and preparedness may have led to the positive psychological results. Recommendation: Future research among this group to identify what made EMS providers resilient and able to overcome psychological challenges.	1. Most of the participants were men, which could have resulted in them not reporting some symptoms that could make them feel weak. 2. Absence of some emergency responders may have resulted in bias. 3. Long time between the first and second questionnaires, which may have affected the results.	Low prevalence of mental health challenges among emergency responders.
Yip et al. (10)	To investigate the mental and physical health issues among emergency responders, including EMS providers, after the response to 9/11 attack.	USA	Quantitative observational cohort study	Retrieve data from the electronic health records of FDNY Bureau of Health Services (BHS).	A purposive sample of 2,281 medical records (recorded in 2013) of EMS providers who responded to that 9/11 attacks. N = 1,795 M N = 486 F Age range (30–42 years). Years of experience not mentioned.	The study found that, after 12 years, some EMS providers were still having: - PTSD (n = 159, 7.0%) - Depression (n = 380, 13.7%) - Harmful alcohol use (n = 68, 3.0%) Recommendation: Continuous psychological monitoring and treatment of EMS providers.	The authors did not have access to participants' physical and mental information before 9/11 or information from databases other than FDNY-BHS.	EMS providers' vulnerability to mental health challenges. EMS providers' vulnerability to long-term health challenges. The need for mental health awareness programs.
Hsiao et al. (11)	To identify the prognostic factors that could have led to PTSD among EMTs who responded to the 2016 Taiwan Earthquake.	Taiwan	Quantitative longitudinal study	Two questionnaires were distributed 1 month and then 6 months after the disaster.	Voluntary sampling of 38 EMTs. All were male. Median age (35 years). Median years of experience (13.5 years).	Psychological challenges can develop immediately after the disaster response and remain high for 6 months and more. The total scores showed that N = 19/38 reported PTSD after one month and N = 13/38 reported PTSD symptoms after 6 months. Recommendation: Psychological challenges should be clarified before disaster response. Short- and long- term counseling stress management programs.	1. The sample size was small and consisted of only men. 2. Using a self-report questionnaire rather than a clinician's diagnosis could have affected the value of the study. 3. No information showed whether the EMTs had other missions during the 6 months.	EMS providers' vulnerability to mental health challenges. The need for mental health awareness programs.
Smith and Burkle (12)	To get EMTs' and paramedics' reflections on the long-term impact of mental health challenges after response to the 9/11 attacks.	USA	Qualitative phenomenological	Face-to-face interviews	Purposive & snowball sampling of 54 EMS providers. N = 18 paramedics. N = 36 EMTs. N = 42 M N = 12 F Age range (39–68 years). Years of experience not mentioned.	Most of the participants reported long-term mental health challenges, such as guilty feelings, anxiety, and nightmares due to responding to the 9/11 attacks. N = 24 of the participants were not provided with psychological support by their employers. N = 43 reported PTSD symptoms (50% did not seek support). N = 8 reported anxiety. Recommendation: Continuous psychological monitoring of EMS providers after disasters.	1. Influence of assumptions. 2. Sampling bias due to the small sample number. 3. Lack of clinician's diagnosis of participants.	EMS providers' vulnerability to long-term health challenges. The need for mental health awareness programs.
Motreff et al. (7)	To assess the long-term impact of PTSD among first responders, including EMS providers after Paris 2015 attack.	France	Quantitative	Questionnaire	Purposive sampling of 614 first responders, including 230 EMS providers (mentioned as first responders' health professionals). N = 148 M N = 82 F Mean age (43 years). Years of experience not mentioned.	Between 8 months and 1 year after responding to the 2015 Paris attack, n = 10/230 (4.4%) had PTSD symptoms, n = 24/230 (10.4) had partial PTSD symptoms. Lack of psychological awareness was associated with PTSD symptoms. Recommendation: Systematic education about the potential mental health challenges associated with disaster response.	Small sample number.	EMS providers' vulnerability to long-term health challenges. The need for mental health awareness programs.
Yacout et al. (1)	To investigate levels of PTSD and burnout among paramedics following COVID-19.	Egypt	Quantitative descriptive exploratory	Questionnaire	Purposive sampling of 68 paramedics. All were male. Mean age (40 years). Most of the participants (69%) had work experience >10 years.	n = 23/68 (33.8%) had emotional exhaustion, and n = 19/68 (27.9) had high levels of emotional exhaustion. Participants reported different degrees of burnout syndrome and PTSD. Recommendation: Continuous screening of paramedics to evaluate psychological challenges associated with the EMS profession Mental health and stress management awareness programs are needed. A plan to support paramedics' mental health.	Not reported	The need for mental health awareness programs.