Although this article only covers individuals who are at risk for attempting suicide or who have made a suicide attempt, medical professionals may be surprised to learn that, according to 2002 data, suicide is the 11th ranking cause of death in the United States (N=31,655). ₄ Although suicide is commonly associated with young adults; in actuality, people of all ages kill themselves, and the elderly are actually at greatest risk:

• College Students: Suicide is the second leading cause of death among college age students. In 2004 alone, it was predicted that more than 1,000 college students would kill themselves 5

• Young People: “Suicide is the third leading cause of death among young people ages 15 to 24. In 2001, 3,971 suicides were reported in this group,” according to Anderson and Smith. 6

• Men: “Suicide is the eighth leading cause of death for all U.S. men” Anderson and Smith, 2003. 7 “Males are four times more likely to die by suicide than females,” CDC, 2004 8

• Elderly: “Suicide rates increase with age and are very high among those 65 years and older.” 9 “Elderly have rates of suicide close to 50% higher than that of the nation as a whole (all ages).” 10

• According to 2002 data, 5,548 adults over the age of 65 committed suicide, which is a rate of 15.6% per 100,000 population. 11

Laura Fochtmann, M.D., a Professor in the Departments of Psychiatry and Behavioral Sciences, Pharmacological Sciences, and Emergency Medicine at Stony Brook University School of Medicine in Stony Brook, New York, pointed out that “these demographic features [which are for people who complete suicide] differ from those of the typical individual who attempts suicide. For example, those making a suicide attempt are more likely to be younger and more likely to be female than those who die by suicide. ₁₂

“The biggest thing for EMS professionals to understand is that suicide is associated with mental illness [including drug and alcohol dependency] and that they are doing the patient a service by getting these people into an evaluation,” said Dr. Jacobs.

Morton Silverman, M.D., a psychiatrist who is the Senior Advisor to the Suicide Prevention Resource Center, said, “Keep in mind, that most mental illnesses, as well as suicidal behaviors, are treatable.”

Here are some information about the relationship between mental illness (including alcohol and chemical dependency) and attempted suicide and death by suicide. This information is copied from the American Association of Suicidology's (AAS) fact sheet “Suicide in the U.S.A.”: ₁₃

• “Psychological autopsy studies reflect that more than 90% of completed suicides had one or more mental disorders.”

• “Approximately 60 percent of those who die by suicide had a diagnosable depression.”

• “The risk of suicide [death by suicide] in alcoholics is 50 to 70 percent higher than the general population.”

• “The vast majority of individuals who are suicidal often display cues and warning signs.”

According to “Suicide in the USA,” ₁₄ “Individuals may display one or more of the problems or ‘signs' detailed below. The following list describes some of the potential factors of risk for suicide [both attempted suicide and death by suicide]. If observed, a professional evaluation is strongly recommended.

• Presence of a psychiatric disorder (e.g. depression, drug or alcohol, behavior disorders, conduct disorder [e.g., runs away or has been incarcerated])

• The expression/communication of thoughts of suicide, death, dying or afterlife (in a context of sadness, boredom, hopelessness, or negative feelings)

• Impulsive and aggressive behavior; frequent expressions of rage

• Increase use of alcohol or drugs

• Recent severe stressor (e.g. difficulties in dealing with sexual orientation, unplanned pregnancy, significant real or anticipated loss, etc.)

• Family instability; significant family conflict.”

In addition to the above-mentioned potential risk factors, Dr. Fochtmann, noted, (as did Dr. Berman previously) that “prior suicide attempts place an individual at higher risk for later suicide attempts or suicide.”

Some people who have attempted suicide, according to Dr. Fochtmann, “are in the midst of a crisis (such as the loss of job or break up of a relationship) that is superimposed on one or more risk factors such as a mood disorder or use of alcohol or other substances. The important point is that the more risk factors that exist, the more the patient's risk would be increased.”

Before interacting with patients who have attempted suicide, keep in mind that their behavior may be unpredictable. Dr. Jacobs said, “Many of these patients can be intoxicated and unpredictably violent.”

Patty Hesse, EMT-I, the Assistant Chief of the Oxford Fire/Rescue in Oxford, Maine, also commented on these patients' behavior. She has worked in this field for 16 years. Additionally, Ms. Hesse has been an instructor for the “Maine Youth Suicide Prevention Program” http://www.maine.gov/suicide since the program began five years ago. “The program's goals are to reduce the incidence of fatal and non-fatal suicidal behavior among Maine youth aged 10-24 and to improve youth access to appropriate prevention and intervention services,” according to Cheryl DiCara, the Program's Coordinator. The program, a priority initiative of the Maine Children's Cabinet, is supported by Departments of Health and Human Services, Education, Public Safety and Corrections.

Ms. Hesse said, “You never know what to expect with these patients. They may be very calm, or they could be very angry... That's why it's important to keep the situation on a very calm level.”

Nels Sanddal, M.S., REMT-B, is the President of Critical Illness and Trauma Foundation and the Director of the Rural Emergency Medical Services and Trauma Technical Assistance Center in Bozeman, Montana. Additionally, he volunteers as an EMT with the Gallatin River Ranch Volunteer Fire and Rescue Squad in Manhattan, Montana.

Sanddal said, “Even though the patient may be exhibiting erratic behavior, a compassionate and professional demeanor can go a long ways towards building trust and stabilizing the situation.”

Another very important factor to keep in mind is that “firearms remain the most commonly utilized method of completing suicide by essentially all groups,” according to “Suicide in the U.S.A.” ₁₅

Firearms are used in 55 percent of instances in which people kill themselves, but “far less frequently” in attempted suicides, according to Dr. Berman. For example, Dr. Fochtmann noted, “for the year 2002, the CDC reported 3,295 nonfatal firearm injuries due to self-harm, which corresponds to an age-adjusted population based rate of 1.15 injuries per 100,000 persons. In contrast, in that same year there were 17,108 suicide firearm deaths, corresponding to an age-adjusted population based rate of 5.91 per 100,000 persons. ₁₆

Here are some ideas that responders may wish to keep in mind before arriving on the scene: empathize with the patient, respect the patient, and take all suicide threats seriously.

Dr. Silverman suggested that EMS professionals recognize that the individual is in “extreme psychological pain.” “Just the recognition that the individual is emotionally suffering and physically hurting is important. Once you recognize that the individual is in psychological pain, you can approach them with a certain degree of understanding, and you can talk to them in a calm and supportive manner, recognizing that they may not be catching every word. You will start your interaction in a different place, on a different level.”

Mr. Sanddal said, “When death looks better than life, you are at a place that very few of us have ever been, and we shouldn't be quick to judge, and we shouldn't just blow this whole issue off as—‘they are just crazy folks and there is nothing we can do for them.’ There are things we can do... Anything we can do to prevent a suicide is worthwhile.”

Another factor responders may wish to keep in mind before arriving on the scene is--respecting the patient. Dr. Berman previously mentioned that one of the factors that decreases the risk for subsequent suicidal behavior is if the patient is “treated with respect and is engaged in a caring way” by professionals. “Don't blame the patient, adopt a moral stance, ... or make statements that make the patient feel guilty,” Dr. Berman said.

Similarly, Dr. Silverman said, “You don't want to in any way to demean the individual, suggest they failed, or say something like: ‘you don't know how to do this right 'or ‘you must be crazy to have done this.’”

Frank W. Nagorka, J.D., EMT-P, emphasized the importance of taking all suicide threats seriously. Mr. Nagorka is a partner in the law firm Mora Baugh Waitzman & Unger, LLC, in Chicago, Illinois. He frequently represents EMS operations. Additionally, he has worked as an EMT-P for 21 years. Currently he works in Cicero, Illinois, as a paramedic for the fire department and in Chicago for MASE (Medical And Safety Enterprises), a company that provides EMS at public events and private venues. Mr. Nagorka has spoken nationally and internationally at EMS conferences. Additionally he is on the adjunct faculty at various teaching institutions. Pulse Productions, now Thomson Delmar Learning, sells videotapes that feature Mr. Nagorka's presentations on various medical-legal topics. In his previous position as the Assistant Corporation Counsel for the City of Chicago, Mr. Nagorka's primary responsibility was the defense of the Chicago Fire Department, 9-1-1, and assorted safety services.

Mr. Nagorka said, “... Always, always take seriously a threat to kill themselves. The moment you don't take the threat seriously is the moment you will have a problem.”

Similarly, Dr. Berman said, “It may not seem like the patient wanted to commit suicide from the EMS professionals' perspective; however, the patient may have wanted to kill themselves. Therefore, it is very important to take seriously whatever the person says.”

Dr. Fochtmann expanded on this idea and noted, “For example, someone in a suicide attempt may have taken four aspirins. Medical personnel would not see that as particularly serious from a medical standpoint. However, the individual taking the aspirin may have been absolutely serious about killing themselves when they made this attempt. Anyone who has made a suicide attempt is in a state of emotional crisis that is very, very serious to them.”

Dr. Fochtmann continued, “You can't draw any correlations between actual medical severity and their [the patient's] intention. It is their intentions that tend to be more correlated with the patient's eventual risk of killing themselves.”

In general, for many calls involving attempted suicide, Mr. Nagorka said the police would be dispatched with the ambulance. The police will secure the scene. While waiting for the scene to be secured, Mr. Nagorka waits on the periphery of the area and turns off the ambulance's lights. “You don't want to interfere with the police,” he said

After the police have secured the scene, Mr. Nagorka said that EMS professionals should take a number of safety precautions.

The patient may be suffering from medical abnormalities. According to Mr. Sanddal, the treatment will be dictated by the physiologic condition of the patient, beginning with the ABC's.

Dr. Fochtmann explained, “With a patient who presents with what looks like a behavioral presentation, you shouldn't assume that it's just a psychiatric problem. It may be possible for someone who has an underlying metabolic problem to behave in an unusual fashion or for someone to think a person is suicidal and call EMS. [For example, someone might call 9-1-1 if] a patient is wandering around confused in the middle of the traffic. The patient might not be actually thinking of killing themselves; instead, they might be confused because of a low blood sugar.”

Dr. Fochtmann emphasized that “you have to make sure that there is not an underlying medical condition contributing to the [psychiatric] problem. You have to be just as attentive to physical abnormalities [as mental health abnormalities] and, in some instances, more attentive to physical abnormalities because the person with a psychiatric presentation may not tell you everything they know, or they may be less able to give you a clear cut history of what is going with them, what their past medical history is, and what medications they may or may not be taking on a regular basis.”

In addition to an underlying medical condition, Dr. Fochtmann noted that “there may be an unrecognized physical complication of an actual suicide attempt that the patient may or may not be telling you about.”

Keeping in mind that the patient may not provide a complete history, Dr. Fochtmann emphasized, “it's really important to get as much history as possible from other people to be able to pinpoint other possible physical causes of their symptoms that you might not have picked up otherwise.”

Mr. Nagorka reiterated the importance of assessing for physical problems such as metabolic imbalance, low blood sugar, and/or polypharmacy when evaluating these patients.

Dr. Silverman suggested, “looking for signs to aid in determining whether the individual is at increased risk for suicide.” He said that some of the questions EMS professionals may ask are the following:

1. Is the patient under the influence of a drug? Is their speech slurred? Are they lethargic?

2. Did the individual state that their intent was to die?

3. Can the person assure you what they would do if they should feel suicidal in the future? Whom would they call? What would they do to avoid acting in a self-destructive manner?”

Mr. Nagorka said that emergency professionals may wish to consider looking for pills. If the pills are in the bottle, look at the date of the prescription. “If the bottle is empty, and it's a sedative, one can draw a reasonable conclusion that the person attempting suicide may have taken those pills, and you can then alert the physician to that possibility,” he said.

Additionally, Mr. Nagorka said responders may wish to consider looking for a note. If you find one, bring it with you to the hospital, he said.

Similarly, Dr. Jacobs also said that responders may wish to consider looking for pills, notes, a rope, and “any other evidence that a person has made or contemplated a self-destructive act.” Dr. Jacobs recommended that EMS professional should bring any items that may be helpful in evaluating the patient, such as a note or empty pill bottle to the hospital.

Mr. Sanddal noted, “Anything taken from the scene should also be documented and catalogued. In the event that the person should die, there will be a death scene evaluation.”

EMS professionals may have to manage the other people at the scene. Ms. Hesse said, “If possible, while assessing the patient, try to clear the room of family members unless they are having a calming affect on the patient. Keep the police or another EMS responder in the room with you for safety. Try to get the patient out to the ambulance as soon as possible. This may not be easy because they are scared of what will happen to them.”

When first speaking with the patient, Dr. Berman said that responders may wish to consider doing a quick assessment of the individual's ability to understand so that “your explanations and the wording you choose have the potential to be understood [by the patient].”

Furthermore, Dr. Silverman suggested that responders may wish to consider trying to determine the best way to approach the patient “ by picking up cues from the setting, from others who may be present, or by quickly assessing the patient's demeanor, facial expressions, and body language.” He noted that some patients may be relieved if EMS professionals establish a sense of control and authority; whereas, this may frighten other patients.

Keep in mind that the patient may be very afraid and having fearful thoughts such as “Who are all these strangers?” “Will I be committed to a psychiatric hospital?” said Dr. Silverman. To help calm the patient, he suggested that EMS professionals may wish to consider calmly and slowly explaining the following: “who they are, why they are there, how they were called, how they can help, what they need to know from the patient, and what their [EMS Professionals'] responsibilities are.”

Dr. Jacobs said that EMS professionals may wish to consider asking several direct questions about suicide such as the following:

• “Have you ever considered suicide?

• If you have, for how long?

• If you haven't made an attempt, have you been rehearsing an attempt?

• Have you tried to commit suicide before?”

Dr. Jacobs said that these questions may be followed up by asking, “What are you considering?” And then finally say: “We would like to help you. We would like you to go to talk to someone and be evaluated.”

Some EMS professionals may be surprised that experts recommended asking direct questions. Mr. Sanddal explained why this was critical: “There have been a lot of misconceptions that if we [EMS professionals] talk about suicide somehow we are promoting it and putting ideas into people's heads that weren't already there, but the reality is that clinical studies show that if you talk about it, people are more apt to give you useful information.”

Additionally, Dr. Jacobs, who had served for ten years as the Director of Psychiatric Emergency Service at the Cambridge Hospital, in Cambridge, Massachusetts, emphasized that EMS professionals “shouldn't promise that the patient will or will not be admitted [to a psychiatric hospital]. Don't say, ‘just come down to the hospital and talk to someone, they won't keep you.’ Don't make any promises one way or another.” This is very important, Dr. Jacobs said, because if EMS professionals tell the patient that they won't be admitted and then the hospital staff needs to admit them, this may create a lot of unnecessary problems for the hospital's staff.

Similarly, Dr. Berman said, if the patient does feel hopeless, don't try to counsel the individual or offer “false hope.”

When the patient arrives at the hospital, Mr. Nagorka hands his report to the Emergency Department. Then he speaks with the attending Emergency Department physician. Mr. Nagorka explained, “I don't offer conclusions; rather, I offer specific factual details. Yes, factual details will be in the report, but the physician may have questions—and need additional information to make an appropriate diagnosis--that I would be able to answer by having a brief dialogue with him... For example, there have been circumstances where I thought there may have been carbon monoxide poisoning and that would explain the mental status changes. By alerting the physician to my suspicions, the appropriate tests could be ordered and treatment provided.”

Asked how the physicians usually respond, Mr. Nagorka replied, “Not only are they responsive, they are writing down the things I told them.”

Dr. Jacobs said that it is not uncommon for these patients to change their mind and suddenly say that they feel fine and that they would never attempt to kill themselves or that they were just joking when they said they were going to kill themselves: “People in suicidal crisis can be emotionally labile and provocative. They may try to talk ER professionals out of bringing them for help either because of their intent to act on their suicidal impulses or their beliefs that they are hopeless and not worthy of help. When people come to the hospital after having made a suicide attempt, it is not uncommon for them to say: ‘I'm fine, let me go.’ So certainly they will also say this to EMS, and EMS needs to understand that this phenomenon can occur.”

What can EMS professionals do if the patient still refuses to go to the hospital? According to U.S. law, do patients have this right?

Dr. Fochtmann noted, “Although the laws vary from state to state, someone who has shown evidence of dangerousness to him or herself or to others as a result of a mental disorder can generally be taken for an emergency assessment upon authorization by a physician. This is true even if the individual objects to transport.”

Mr. Nagorka said: “What EMS providers should do very early in the game is call medical control... The physician is qualified by the mental health code of every state to make a determination of whether a person can be brought to the hospital for a mental health assessment and possible confinement pursuant to the Mental Health Code of the state for a certain period of time for psychiatric evaluation.”

Another expert who mentioned problems that may occur with this population is William Bake, M.P.H., E.M.T.-P, a Research Specialist for the National Association of EMS Educators and a part-time paramedic in Pittsburgh, Pennsylvania, with 16 years experience in pre-hospital care.

Mr. Bake said, “No matter how depressed the patients may present or how hopeless the patient may present, the EMS professionals should never take it personally. The patient may inadvertently attempt to bring the EMS professional into their live and make them feel bad as well. For instance, a patient may say ‘there is just so much wrong, you wouldn't understand.’ A portion of the EMS professional's job is attaining a basic understanding of the problem. This is necessary for appropriate patient care. However, by hearing the surface problems, an EMS professional may become too involved. If this happens, try your best to remain non-judgmental, show sympathy, and stay calm.”

A number of individuals reported to Dr. Silverman that people at the scene had made inappropriate remarks. Dr. Silverman emphasized that these individuals did not specify who these first responders were, and thus, they may not have been emergency medical services personnel. These remarks included the following: “I've seen other people who tried to do this. And your attempt is not very successful.”

Ms. Hesse reported that she had heard some inappropriate remarks: “You are going to have that. It is human nature--that would be your first response because you can't imagine somebody wanting to do that. I have heard people say, ‘Why did you do that? It is pretty stupid.’” She noted that responders who complete the Maine Youth Suicide program no longer have this perspective.

Similarly, Mr. Nagorka said that it is “not uncommon that inappropriate remarks are made.” Asked why this was the case, Mr. Nagorka replied, “I don't think that EMS providers are sufficiently trained in dealing with mental health emergencies... Because of this lack of training, I think sometimes EMS providers are uncomfortable around someone who presents in an acute state of mental illness.”

Like other medical professionals, EMS professionals, themselves, may face increased risk of suicide. However, it is beyond the scope of this article to offer in-depth information about this topic.

Liz Lipton, MA, a freelance journalist for more than 10 years, has written about podiatry, emergency medicine, psychiatry, law and technology. Having earned a Master of Arts in Journalism from New York University, she was the assistant editor for the New York State Psychiatric Association's Newsletter, The Bulletin from January 2003 to July 2005 and before that a freelance contributor to Psychiatric News from 1999-2002. She is a consultant for I/O Test, Inc., a full systems integration and consulting firm. She won the 1999 Sidney Gross Investigative Journalism Award from New York University Journalism Department, and the 2000 Print Award from the Mental Health Association of Ulster County. To view samples of her writing, visit her Web site http://www.hvinet.com/lizlipton or Google her name “Liz Lipton.”