Management of Suicide Risk

As an EMS professional, you will have to manage patients with suicidal thoughts or actions. You may get called out for sudden irrationality and suicidal thoughts. You may get called out for intentional overdoses. You may get called out for self-inflicted gunshot wounds. These are all VERY high-stakes and highly stressful events for everyone involved. Our goal in these cases is the same as in all the others, preserve life and quality of life in our patients. Position yourself as an advocate for the patient's highest self. Make a connection. Help somebody.

Risk Factors: Understanding the major risk factors associated with suicide 

The most common underlying psychiatric disorders linked to suicide include:

1. Depression: Untreated or inadequately treated depression is the leading cause of suicide, accounting for 90% of suicide attempts.

2. Bipolar disorder

3. Alcoholism or other substance abuse

4. Schizophrenia

Note: 95% of those who complete suicide have a psychiatric diagnosis.

The secondary assessment in suicidal ideation is identifying symptoms associated with suicide can help in early intervention. Use open-ended questions and conversational techniques to assess:

1. Previous suicide attempt: This is the strongest single predictor of suicide.
2. Verbalized or written ideation or defined lethal plan of action
3. Alcohol and substance abuse
4. Chronic pain
5. Feelings of purposelessness, anxiety, agitation, hopelessness, or feeling trapped
6. Sleep disturbances: either insomnia or hypersomnia
7. Social withdrawal
8. Anger and/or aggressive tendencies
9. Reckless behavior or engaging in risky activities
10. Dramatic mood changes
11. History of trauma or abuse
12. Major physical illnesses (e.g., cancer, CHF)
13. Job or financial loss
14. Relationship or social loss
15. Easy access to lethal means
16. Lack of social support and sense of isolation
17. Certain cultural and religious beliefs
18. Male gender
19. Age between 25 and 44 or 65+

Consider these risk factors and symptoms as pieces of a puzzle. The more pieces you have, the clearer the picture of suicide risk becomes.

As an EMS professional, your role isn't to provide psychiatric treatment but to recognize the signs of suicide risk and ensure the patient's immediate safety while arranging for appropriate professional help.

Management of Patients with Suicidal Ideations or Attempted Suicide

Dispatch: "You are dispatched emergency traffic to a call from a female reporting her 40-year-old husband has been expressing suicidal thoughts, and she is worried about him. He has a history of depression and recently lost his job. She states that he's currently at home and not violent."

Step 1: Scene Safety Upon arrival, ensure the scene is safe. Request law enforcement backup if there's any indication of violence or threat. People who don't care about their own lives may not care about yours either. Your first duty is to ensure you and your team go home safely to your family at the end of the shift. You should always be recalculating your safety on the scene and have a plan and an escape route if things go bad. Keep any means of suicide or harm away from your patient.

Step 2: Initial Assessment
Next, approach the patient calmly and respectfully, introducing yourself and explaining your role. Assess his immediate physical condition, ensuring adequate airway, breathing, and circulation, and assessing mental status. Then, proceed to search for immediate life threats like stab wounds or recent toxicological ingestions if the patient has already taken any extreme measures. While examining, look for any signs of self-harm or substance use. Treat poisonings or self-inflicted trauma per protocol.

Step 3: Communication
Engage the patient in conversation, using open-ended questions to encourage him to share his feelings. Avoid judgmental or confrontational language. Your goal is to build trust and rapport while showing empathy and understanding. Do not be aggressive in an attempt to "control" the situation or let the patient know "how it's going to be." Our best results come from our professional and personal attention and care. Explain to the patient that you're a medical provider and get sent to help people. Let them know you are there to help and keep them safe. You are a medical professional and an advocate who will help the patient get the help they need.

Step 4: Suicide Risk Assessment
Suicide risk is a spectrum. You may have patients who are only mildly depressed. You may arrive to find that the patient is so suicidal that they've already done damage to themselves or tried to end their life. Based on the patient's responses, assess his suicide risk. Key factors would include his verbalized intent, any specific plan to execute the suicide, actual physical access to the lethal means, and his mental state. If the patient admits to having a plan and the means to carry it out, this would significantly elevate his suicide risk. Never dismiss anything as "attention-seeking" or cast a cry for help in a bad light. Not everyone can express what they are going through, and you may have to take significant context clues from their behavior. Err on the side of caution for yourself, your team, and the good of your patient.

Step 5: Intervention If the patient is at immediate risk, try not to leave him alone unless the scene becomes unsafe for your team, and you must evacuate rapidly. If necessary, try to engage additional resources, such as a mental health crisis team or law enforcement. Even if the patient is not at immediate risk but is still expressing suicidal thoughts, transport the patient to the hospital for further evaluation and treatment. People can feel like they are at the bottom of a well, and there is no way they can escape. You need to get these patients to definitive psychological and physical care. For this time, you are this patient's advocate. Use calming and reassuring tones. Minimize stimulation. Don't feel the need to over-talk or solve anyone else's psychological problems.  There are people more qualified to help with that than us at the hospital, and we need to get the patient safely to those people.

Step 6: Documentation Finally, document all findings and actions taken in a detailed patient care report, ensuring to include the patient's statements, observed behaviors, and any physical signs related to his suicide risk.

Remember, every situation is unique, and this is just one example of how a call might be handled. The key is to remain calm, empathetic and focused on the patient's safety while ensuring you get them to the necessary support and resources.

In conclusion, managing suicide risk is a complicated and emotional, but necessary part of EMS work. You can make a significant difference in your patient's lives with the right knowledge and skills.