medical cases as being emotionally difficult, which led to the most robust shame reactions. Shame reactions were more common when EMS providers committed selfperceived errors in patient care, whereas guilt reactions were more common when patient outcomes seemed "inevitable" despite any intervention. Common themes related to coping mechanisms included both personal mechanisms which tended to be less successful compared to interpersonal mechanisms, particularly when emotions were shared with colleagues. This reflected a perceived culture change within EMS in which sharing emotions with colleagues was seen as a departure from the "old school" where emotions tended to be kept to oneself. Feelings of inadequacy, low self-worth, and being "not good enough" were frequently identified as lingering emotions after difficult cases that were hard to move on from, corresponding to longstanding shame in these providers. Recovery and resilience varied but tended to be positively associated with a culture in which sharing with colleagues was encouraged, and personal introspection on root causes for the sentinel event.Conclusion: EMS providers often identify complex patient cases as those leading to emotions such as shame and guilt, with shame reactions being more common when a perceived error was committed. Coping mechanisms were varied, but individuals often relied on their co-workers in a sharing environment to adequately process their negative feelings, which was seen as a departure from past practices in EMS personnel. Our hope is that future studies will be able to utilize these findings to identify targets for intervention on negative mental health outcomes in EMS personnel.
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