Proceed With Caution

Josh McFadden

Under no circumstances should the phrase “I’m going to kill myself” not be taken seriously. It’s no doubt a genuine topic of concern when someone calls 911 with this threat.

Whether from a first- or second-party caller, when a suicide attempt has been announced or attempted, quick, decisive, and effective action is needed. Is it any wonder that hotlines have been established around the world where people struggling with suicidal thoughts can receive support and reassurance? But when the situations escalate, you, the dispatcher, play a critical role in ensuring the safety and well-being of the suicidal person and any bystanders.

Both the Medical Priority Dispatch System^™ (MPDS®) and Police Priority Dispatch System^™ (PPDS®) address suicide attempts. MPDS Protocol 25 combines Suicide Attempt with Psychiatric and Abnormal Behavior, while PPDS Protocol 127 is titled Suicidal Person/Attempted Suicide. Unfortunately, these behaviors and tendencies are prevalent across the world.

Numbers don’t lie

A quick look at recent statistics from Mental Health America reveals startling information about suicide and mental health. Perhaps most alarming is that suicide is the eighth-leading cause of death in the United States. In fact, suicide accounts for more than 1 percent of all deaths in the country. Each year, 30,000 Americans die by suicide. That number could be much higher considering unsuccessful suicide attempts in the U.S. are around half a million annually.¹ The American Foundation for Suicide Prevention reports that men die from suicide 3.5 times more often than women.²

People who attempt suicide are prone to try it again. As many as 40 percent of people who ultimately commit suicide had been unsuccessful in previous attempts. People are 100 times more likely to attempt suicide again within a year of the previous attempt.³ Suicide rates rise with age as well. Suicide rates are highest in older people, with 40 percent of suicide victims over the age of 60. After age 75, the suicide rate is three times higher than the U.S. average. After age 80, white males in the U.S. are six times more likely to commit suicide than the average person.⁴

As for determining what leads people to commit suicide, alcohol and other substance abuse is a major factor. About 20 percent of all suicides involve people who have alcohol dependency. In addition, those who commit suicide often suffer from a mental disorder. Depression is the most common among these, as 70 percent of victims suffered from this illness.⁵

Understanding the methods by which people take their own lives is important for dispatchers. According to the Centers for Disease Control and Prevention, most men commit suicide with firearms (59 percent). For women, the most common method is poisoning.⁶ The CDC also reported that in 2013, 494,169 people in the United States were treated in emergency departments for self-inflicted wounds.⁷

Warning signs

Research indicates a number of risk factors for suicide. Some of these common signs to look out for include the following:

• Verbal suicide threats such as, “You’d be better off without me” or “Maybe I won’t be around”
• Expressions of hopelessness and helplessness
• Previous suicide attempts
• Daring or risk-taking behavior
• Personality changes
• Depression
• Giving away prized possessions
• Lack of interest in future plans

Uncomfortable issues

Even though data clearly shows suicide is a significant problem and the number of people attempting suicide is increasing, it’s not a topic that gets a lot of attention and focus during dispatcher training courses. According to statistics from Public Safety Training Consultants (PSTC), suicide is discussed for less than 30 minutes in most POST-approved dispatch academies. For every one successful suicide, there are 50 other people calling 911 or suicide prevention hotlines before or during a suicide attempt.

“People don’t want to talk about things that stress them, especially in professions where stressful situations happen all the time,” said Jim Marshall, a mental health clinician and 911 Training Institute Director.

Talking to someone threatening suicide isn’t something one should take lightly. Establishing rapport with a suicidal caller is important, but Marshall said effectively handing the call requires rigorous training through a course supported by research-driven processes for assessing the caller’s risk.

“Managing suicide calls takes knowledge of the science behind mental health issues and a conscious process on the part of the dispatcher to manage (his or her) stress response,” he said.

Recognizing the physiological impact, such as “gut reaction,” can turn the “I can’t get close to this caller” ambivalence into “I can do this.” It’s a matter of the dispatcher balancing empathy with detachment. In other words, the dispatcher can assist the caller while, at the same time, manage his or her own well-being. That ability to push toward a connection, rather than over-distancing for the sake of self-protection, can provide a buffer to keep the person from falling off a cliff.

“Yes, the dispatcher’s primary job is to ensure the safety of the caller and all those on scene, but equally important is building a life bridge of empathy,” Marshall said. “By doing that, you’re showing the caller you can listen carefully. You’re trying to help the person choose life, instead of death, as a solution while waiting for the field responders to arrive. They know they are truly being heard and cared about.”

Marshall also highly recommended a direct approach to the call.

“Now is not the time to indirectly ask about intent,” he said. “While you may be afraid that asking, ‘Are you thinking of killing yourself?’ will increase the risk, the research doesn’t support this. You can ask the question. A caller is apt to feel more understood if asked directly.”

The Protocol in action

Protocol 25: Psychiatric/Abnormal Behavior/Suicide Attempt focuses on the type of medical assistance the caller or victim needs in the event of a suicide attempt. However, as opposed to the PPDS, different methods of an intended suicide attempt may shunt to a different protocol in order to handle the incident appropriately. Protocol 25 shunts to three other MPDS Protocols, when appropriate: Protocol 8 if the person is threatening suicide by carbon monoxide, inhalation, HAZMAT, or other toxic substances; Protocol 23 if the person is attempting a suicide by OVERDOSE; and Protocol 27 if the person has a stab or gunshot wound.

Key Questions 1 and 2 are critical. They ask, “Is s/he violent?” and “Does s/he have a weapon?” The answers to these questions will help the dispatcher code the call with the appropriate suffix, thus allocating appropriate resources and alerting responders to potential danger. Violent people may include those who are refusing help or entry, or those exhibiting frantic, irrational behavior. Police should be notified in these cases, and the appropriate suffix should be assigned. When weapons are involved, include the W Problem Suffix in the Determinant Descriptor. If the person is violent and has weapons, use Problem Suffix B.

This protocol makes special note to teach dispatchers to keep first-party callers on the line if they are violent or suicidal. In fact, Rule 3 is specific in instructing that “1^st party callers who are THREATENING SUICIDE should be kept on the line until responders arrive.” Not only does staying on the line keep the dispatcher and responders informed, but it may also help to prevent further action by the caller through constant, empathetic interaction.

In addition, it is crucial for the dispatcher to understand the difference between a “suicide attempt” and a “suicide threat.” Protocol 25 defines THREATENING SUICIDE as: “Persons who are threatening to commit suicide but have not yet done anything to harm themselves.” In this case, the call would be given the Determinant Code 25-B-3. Conversely, a suicide attempt is an act toward ending life that has been committed.

Protocol answer options for suicide attempt include jumpers; cut/laceration; near hanging, strangulation, or suffocation; and chemical suicide, OVERDOSE, and stab or gunshot wound, the latter three appropriately shunted to more specific protocols.

In Key Question 4, the dispatcher asks, “Is this a suicide attempt?” If the caller says it isn’t, the dispatcher must ask the follow-up question, “Is s/he thinking about committing suicide?” If a suicide has been attempted by cut/laceration, the dispatcher must ask where the person is cut and if there is any SERIOUS bleeding (spurting or pouring). Key Question 5 asks whether the person is completely alert. If the hemorrhage is dangerous and the caller is alert, the call must be coded as 25-D-2. DANGEROUS Hemorrhage is defined as occurring in the areas of the armpit, groin, or neck. SERIOUS Hemorrhage and MINOR Hemorrhage get separate, BRAVO-level codes. SERIOUS Hemorrhage is uncontrolled bleeding (spurting or pouring) from any area or anytime a caller reports “serious” bleeding. MINOR Hemorrhage is controlled or insignificant external bleeding from any area.

If it has been determined that a hanging, strangulation, or suffocation suicide attempt has occurred and the person is completely alert (as learned from Key Question 5), the dispatcher must ask whether the victim is having difficulty breathing. A Not alert victim always gets a Determinant Descriptor of 25-D-1; a victim that is alert without difficulty breathing in a near hanging, strangulation, or suffocation is assigned 25-B-5.

Chemical Suicide is defined as “suicide by inhaling poisonous vapors that can be created from a mixture of household chemicals.” The definition also explains that: “Often, patients will tape window and door seams shut and post warning notes to prevent harm to others, such as ‘Danger,’ ‘Toxic Gas,’ or ‘Call 911.’ The immediate area also frequently smells of rotten eggs or sulfur, but Emergency Dispatchers should not rely on this indicator alone as a warning signal.”

For obvious safety and response concerns, Case Entry Rule 6 instructs: “If the complaint description involves hazardous materials (toxic substances) that pose a threat to bystanders or responders, go to Protocol 8.” However, if the dispatcher initially selects Protocol 25, the fail-safe shunt to Protocol 8 will ensure appropriate coding and instruction for Chemical Suicide cases.

Sources

1. "Suicide." Mental Health America. http://www.mentalhealthamerica.net/suicide (accessed Feb. 2, 2017).
2. "Suicide Statistics." American Foundation for Suicide Prevention. https://afsp.org/about-suicide/suicide-statistics/ (accessed Feb. 2, 2017).
3. See note 1.
4. See note 1.
5. See note 1.
6. “Web-based Injury Statistics Query and Reporting System.” Centers for Disease Control and Prevention (CDC). 2017; Jan. 12. http://www.cdc.gov/injury/wisqars/index.html.
7. See note 6.