It was a clear, crisp winter day as I stood in full dress uniform directly in front of Tom’s casket. Hundreds of his fellow paramedics and firefighters from around the state had come to honor this dedicated public servant who had given much of his life to his fire department and the community he grew up in. His death was sudden, untimely and difficult to understand.
The expressions of sorrow, devastation and loss on the faces of his wife and children would forever be etched in my mind. Our families had vacationed together since we had attended the academy 20 years before. He seemed to have it all: a dream job, loving family, nice house and the respect and admiration of his fellow workers. He loved being a paramedic for the fire department.
As tears froze on my face, I searched for answers. How could I have missed the signs–his pain, suffering and depression? I never acknowledged his subtle cries for help. I wasn’t there for my best friend before he took his life.
Suicide Statistics
Every year, 34,000 people will die by suicide in the U.S., and another 500,000 will be seen in the emergency department for treatment of self-inflicted injuries. Ninety Americans take their lives daily, and many experts believe that suicide deaths are widely underreported and that the extent of the problem is much larger. No culture, religion, gender, profession, degree of wealth, success or fame is invulnerable. Every 15 minutes, another life is lost, and the emotional toll on friends and families is overwhelming and eternal.
Suicide is a complex problem that is difficult to understand and hard to predict. Mental suffering leading up to death is private and can be inexpressible. The choice of death is rationalized as the only solution to intolerable psycholog-ical pain.
Those suffering often feel a narrowing of choices, with death seen as the only logical answer to escape the pain. Suicide is rarely spontaneous. Rather, it often results from the effects of it wearing on a person’s ability to cope over a long period of time.
Suicide affects both genders, but men are four times more likely to complete it. A previous history of suicide attempts or a family history of suicide increases the risk, and substance abuse and alcoholism are factors in 30% of such deaths. Mental health disorders, such as schizophrenia, mood disorders and depression, can also increase the risk.
Depression is the leading psychiatric diagnosis associated with people attempting suicide. More than 60% of people who die by suicide suffer from major depression. Treatment for depression is highly effective, but many people never seek help prior to their death.
Although there are no official statistics on attempted suicides, it’s generally estimated that 25 attempts occur for each completed suicide. Most individuals who are suicidal exhibit warning signs, such as social isolation, expression of a plan and access to lethal means or methods. These are important indicators, and suicide ideation or self-reported thoughts of engaging in suicidal behavior can be a precursor to an attempt. Dramatic mood changes, withdrawing from society, uncontrollable anger, recklessness and hopelessness are also signals.
Effects on First Responders
First responders interact with suicidal people on a regular basis. Responding time and again to attempted and completed suicides can be emotionally disturbing and requires dangerous rescues or body recoveries.
Responders may carry intrusive sights, sounds, smells and memories of these violent and often gruesome deaths with them for their whole careers. The grief and sorrow expressed by the surviving family can “splash over” onto emergency personnel, causing critical incident stress.
“Each one of these suicides leaves a small mark on your soul,” says Monte Fleming, a captain with Littleton (Colo.) Fire Rescue (LFR). “You just can’t help but feel sorry for each of these families knowing the reality they face.”
LFR has been responding to suicides in its community for many years. Colorado has the sixth highest suicide rate in the nation. On Oct. 29, 2007, a man took his life with a handgun on the front lawn of Littleton’s Firehouse 13.
The man was no stranger to the crew. Five months earlier, he had attempted suicide using carbon monoxide, and Littleton’s crews had resuscitated him. He’d written a suicide letter and collected his important personal belongings for whoever would find him.
An incident in Denver involved a 36-year-old woman who jumped to her death from the back of a moving ambulance during a routine patient transfer. On a busy highway, she removed her cot straps and jumped from the back door after distracting the EMS provider. Her family sued the company for damages.
EMS providers deal with a great amount of emotional stress from the traumatic events they’re exposed to while on the job. Photo courtesy Wayne Zygowicz
Most EMS providers have little or no training in suicide crisis intervention. Few standardized training programs or response guidelines address what to do or say to someone attempting suicide or how to support the surviving family of those who have completed suicide.
In 2001, the U.S. Department of Health and Human Services released the National Strategy for Suicide Prevention, Goals and Objectives (NSSP). This document was a milestone in suicide awareness, prevention and education.
Part of the strategy was to implement training for key gatekeepers of society: teachers, clergy, nursing home staff, primary healthcare providers, mental healthcare professionals, police officers and emergency medical personnel.
The thought behind this was that these people have daily, face-to-face contact with large numbers of the community, so they should be trained to identify at-risk suicidal behavior. NSSP recommended suicide awareness training that EMS agencies incorporate into basic educational and training curriculums.
Communications specialists should also be well trained to interact with suicidal callers. All suicidal situations are volatile, and every threat should be taken seriously. The dispatcher should determine the exact location of the caller if unknown. Every effort should be made to build a rapport with them.
The dispatcher should gather as much information as possible and talk specifics, such as whether the caller has the means, method and a plan to take their life. The conversation should focus on the reality and finality of the caller’s potential decision while also bringing positive reinforcement into the discussion.
Responses to threats of and attempted suicides should be handled cautiously by first responders, allowing law enforcement to first stabilize the scene. Introduce yourself and state the reason for your presence while observing the person’s body language and hand position. Take charge of the situation and avoid physical confrontations by not violating the individual’s personal space. Establish a rapport by using good listening skills. Show compassion and understanding, and don’t be judgmental. Always show empathy and respect for the person and their situation, no matter how bad it appears.
Assess lethality by questioning the person directly about a suicide plan, means and method of injury. Look for a suicide letter or indications that the person has made final arrangements. Everyone who threatens suicide should be transported for physical and psychological evaluation.
During transport, evaluate for evidence of injury, previous suicide attempts and signs of depression or substance abuse. Before leaving the scene, responders should encourage the family to remove all lethal means from the home, especially firearms and medication, prior to the person’s hospital discharge.
Suicide Scene Safety
All completed suicides should be considered a crime scene, and immediate access should be restricted from family and pets. The body and surrounding environment shouldn’t be disturbed unless it’s necessary to declare death. Confirm the identity of the deceased, and note the position and manner of death. Medical control should be consulted as local protocol requires.
A detailed patient care report should include time of death given by medical control, environment conditions, body position, location of weapons, types of injuries, presence of a suicide letter and any information that will aid in the investigation.
Efforts to support the surviving family should be a priority. You should realize the effect your words and actions can have on them, and you should ensure that they’re not further traumatized. Introduce yourself, and assign a crew member to assist the family as needed. Validate the family’s personal loss and support their immediate needs. Help survivors mobilize their own support network, such as family, friends and clergy. Prepare survivors for what will occur when law enforcement investigators and the coroner arrive.
You should also be sure to leave a business card, so the family can contact you later if necessary, and a suicide resource brochure with important telephone numbers and websites.
In the Line of Duty
The effect of suicide on society is substantial. It’s estimated that each suicide intimately affects a minimum of six people who may suffer subsequent mental health problems, guilt, pain and personal agony–sometimes those people are the emergency responders.
The effect of emergency work on EMS providers is difficult to measure because most don’t talk about their feelings and generally aren’t the type of people to voluntarily seek help. Stress is expected in a profession where death, disfigurement, long shifts, sleepless nights, poor nutrition, dangerous working conditions and guilt (e.g., “Did I do everything possible to help this patient?”) are constant companions.
It’s no surprise that mental-health issues emerge as a critical factor in performance, retention and quality of life for EMS providers, but consistent occupational mental health statistics within the EMS and fire service remain elusive.
What isn’t obscure is that suicide completion among EMS providers could be more prevalent than previously thought. For example, in 2009, the Chicago Fire Department had an above-average number of suicide attempts and completions among its members. Since December 2009, the Phoenix Fire Department alone has experienced four suicide completions. Are these departments a microcosm of a larger, more widespread problem nationwide?
The number and availability of mental-health programs for fire and EMS providers are limited and restricted by a culture of “machismo,” which implies that it’s a sign of weakness to seek help for mental-health issues. Additionally, the popular mental health model of Critical Incident Stress Management (CISM), developed by Jeffrey Mitchell, PhD, in the 1980s, is considered controversial by a number of researchers.
Resiliency Education
EMS providers and firefighters exposed to traumatic events can develop stress-induced thoughts, dreams and behaviors, which may lead to post traumatic stress disorder (PTSD). CISM, once thought to minimize these problems has been shown to have controversial results.
A new approach, substantiated by research data, has been having a positive effect in behavioral health intervention for people experiencing the effects of traumatic situations. This new methodology focuses on a holistic, preventive process capable of being taught in a non-clinical academic setting.
The concept, termed “resiliency,” is defined as “the ability to bounce back from adverse events and cope with stressors in a healthy manner.” Research literature clearly substantiates that resilient people are far less likely to experience the effects of PTSD. In fact, not only are resilient people more capable of dealing with stress, but they also thrive and grow as a result of stressful experiences.
A resiliency curriculum, known as the Supportive Education for Returning Veterans (SERV) has been developed by Michael Marks, MD, lead psychiatrist for the outpatient PTSD clinic at the Veteran’s Administration Hospital in Tucson, Ariz., and Phil Callahan, MD, NREMT-P, a professor at the University of Arizona. The SERV curriculum has received national recognition by the Veteran’s Administration as an evidence-based program that works, producing profound results within the military veteran population.
On completion of the SERV program, veterans were less likely to develop PTSD, demonstrated improved dietary and physical fitness habits, strengthened their social support system and were more likely to remain enrolled in higher education. In fact, students successfully completing SERV resiliency education as a prerequisite to enrollment in college-level courses were 15 times more likely to remain enrolled in college compared with students who didn’t enroll in a resiliency training program.
The resiliency curriculum consists of teaching responders to identify, measure and subsequently improve their abilities to cope with home and work stress. Initially, each responder establishes a baseline of their current ability to cope with personal and professional stress. Next, the responder is taught how to improve their physiological and psychological resiliency skills.
Physiological resiliency includes the following:
- Proper nutrition, including establishing a nutritional baseline and the importance of a balanced diet based on an individual’s basal metabolic rate;
- An emphasis on the importance of physical exercise using the frequency, intensity, time spent and type of exercise (FITT principle); and
- Good sleep hygiene, with an emphasis on how to use cognitive behavioral approaches to eliminate or minimize nightmares.
Psychological resiliency teaches responders to do the following:
- Relax, using proper breathing techniques and progressive muscle relaxation;
- Change self-defeating thought patterns into positive, realistic thinking;
- Learn empathetic communication and the power of perspective; and
Know the importance of establishing–and maintaining–a strong social support system.
A significant difference between CISM and resiliency education focuses on when responders are exposed to each. The CISM process takes place after the fact, with the bad event being the trigger. Resiliency education, on the other hand, occurs at the beginning of a provider’s career, an inoculation if you will, to the horrific events all responders eventually are exposed to. Regular reinforcement of resiliency concepts then occurs after the initial training, such as the beginning of a physical fitness program or the daily practice of relaxation techniques.
Both Marks and Callahan believe the results seen thus far with veterans can transfer into the world of EMS and fire, assisting providers to minimize the effects of stress and its cumulative effects.
Currently, an advisory group consisting of leaders within the fire service, EMS and academia has been formed to determine if resiliency education can produce measurable improvements in the reduction of stress, PTSD and rates of suicides within the fire/EMS profession. Pilot testing of the curriculum for the EMS and fire service will occur later this year in at least four sites nationwide.
The resulting data will be compared to those of military veterans. If favorable, resiliency education will be expanded to organizations looking for a proven methodology to assist emergency personnel experiencing issues related to mental health.
Caring for Our Own
Suicide is treatable and preventable. As gatekeepers of society, it’s part of our fundamental mission to save these lives, especially when some of them are our own.
The first step starts with collecting accurate data on work-related stress, suicide attempts and completions to help identify trends within our industry. Good data will be difficult to acquire until we reduce the stigma surrounding help-seeking behavior and encourage our fellow responders to come forward and get the help they may need.
Development of a comprehensive suicide prevention strategy, improving access to mental-health counseling and developing a responder support network is paramount to saving our brothers and sisters.
Teamwork is the foundation of EMS. What affects one individual will likely have some influence on others, and ultimately it will affect the team’s performance. Identifying mental-health risk factors and promoting individual health and well-being through education is critical to the success and evolution of our profession.
Resources
1. American Psychiatric Association. Practice guidelines for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003; 160:(11 Suppl):1—60.
2. Carney SS, Rich CL, Burk PA, et al. Suicide over 60: The San Diego study. J Am Geriatr. 1994. Soc. 1994(3);251—261.
3. Centers for Disease Control. National mortality statistics. www.cdc.gov.
4. Clark S. After suicide: Help for the bereaved. Hill of Content. Colorado Department of Public Health and Environment, Office of Suicide Prevention. Suicide Prevention. http://cdphe.state.co.us/pp/suicide/index.html.
5. Colt GH. The enigma of suicide. New York: Summit Books, 1991.
6. Conroy DL. Out of the nightmare: Recovery from depression and suicidal pain. New York: NewLiberty Press, 1991.
7. Durkheim E. Suicide. New York: Free Press, 1951.
8. Fire and Emergency Training Network. Suicidal Callers. (Available from the Fire and Emergency Training Network, 4104 International Parkway, Carrollton, Texas, 75007.)
9. Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing suicide: A national imperative. Washington, DC: The National Academies Press. 2002.
10. Lester D. Suicide prevention: Resources for the millennium. Philadelphia: Brunner Routledge, 2000.
11. Rudd MD, Berman AL, Joiner T, et al. Warning signs of suicide: Theory, research and clinical applications. Suicide and Life-Threatening Behavior. 2006; 36(3):255—262.
12. Schneidman E. Voices of death. New York: Harper & Row, 1980.
13. Schneiderman E. Comprehending suicide: Landmarks in 20th-century suicidology. Washington, D.C.: American Psychological Association, 2001.
14. Silverman MM, Davidson L & Potter L (Eds.). National suicide prevention conference background papers: Oct. 1998, Reno, Nev. Suicide and life-threatening behavior. 2001; 31 (Suppl.).
15. Suicide Prevention Resource Center. The role of the first responder in preventing Suicide. Retrieved July 18, 2008, from www.sprc.org/featured_resources/customized/pdf/first_responders.pdf.
16. U.S. Department of Health and Human Services. National strategy for suicide prevention: Goals and objectives for action. Washington, D.C: U.S. Government Printing Office, 2001.
17. U.S. Public Health Services. The Surgeon General’s call to action to prevent suicide. Washington, D.C., 1999.
18. Zygowicz WM. Development of suicide prevention strategies to reduce death and injury in communities served by Littleton Fire Rescue. Unpublished manuscript, National Fire Academy. 2010.
19. Zygowicz WM. Too close to home: Suicide at Station 13. JEMS.com. www.jems.com/article/industry-news/too-close-home.
Ryan’s Story
In every sense of the word, Ryan Cooper is a hero. It’s not something he would have chosen for himself, but his lifesaving actions are well documented. If you asked him about July 10, 2007, he would tell you, “I did what any other police officer, firefighter or paramedic would do under similar circumstances.” On that day, Ryan did what he had been doing for 15 years with the fire department; he saved lives. And because of that day, his life, as he knew it, was never the same.
On that ill-fated morning, Cooper was saying goodbye to his wife in the driveway of their Sanford, Fla., home when he heard a sound he says he’ll never forget. A twin engine Cessna, engine sputtering and smoke filling the cockpit, clipped palm trees in his neighborhood and crashed in a ball of flames, engulfing two homes.
Cooper, a Lake Mary Fire Department paramedic, without hesitation, donned bunker gear left in his truck between shifts and entered the burning homes looking for survivors. He was credited with saving a badly burned 10-year-old boy under severe fire conditions fueled by the burning aviation fuel from the downed aircraft. While he was searching the second home for a little girl believed to be in a bedroom, Cooper became lost and disoriented in dense smoke conditions. With the help of a police officer yelling his name from the front door, he was able to escape.
This usually quiet suburban neighborhood was littered with airplane parts and burning debris as arriving police cars and fire trucks rushed to the scene. Cooper was transported to the hospital for smoke inhalation and exhaustion where he spent three days in the intensive care unit. Fire people died in the tragedy–two adults aboard the aircraft and a woman and two children in the homes. Four were badly injured.
Even before he left his hospital bed, Cooper was being hounded by the media for an interview. The day after the crash, he talked with Matt Lauer on the Today Show about his terrible ordeal while recovering at the hospital. He became an instant celebrity and was hailed as a hero. He received hundreds of cards, letters and e-mails from around the world thanking him for his bravery and courage. The city of Sanford passed a resolution declaring Aug. 17 Ryan Cooper Day, and one website acknowledged him as the “badass of the week.” His picture appeared on soft drink cups at fast food restaurants proclaiming him a hero.
Cooper tried to return to a normal work and home life, but things started to unravel under the stress and emotional toll of the incident and its aftermath. A once dedicated and reliable fire department employee, he began to have attitude issues and fights with co-workers, and his job performance suffered.
Little did his fellow firefighters know that his home life was also in shambles, resulting in many arguments with his wife. Each day grew worse from the lack of sleep, constant headaches and abuse of alcohol. Two days before Christmas that year, Cooper left his wife and children and went to live with friends. He was heavily medicated for depression and his drinking was getting out of control. He lost his house, filed for divorce and later got a tattoo on his back that said “Forgive Me.”
He was diagnosed with reactive airway dysfunction syndrome, which he claims eventually cost him his job on the fire department. Most of the life he enjoyed before the plane crash was gone and not returning. No one understood what he was going through and nothing was helping him cope with the emotional burden. He was hopeless, despondent and suicidal.
Cooper credits his therapist with saving his life. He was diagnosed with PTSD and battled alcohol abuse, depression, anxiety, medication dependency and suicidal thoughts. All the while, he was having flashbacks of the crash and conscious memory gaps in his daily life while continually reliving the event during long, sleepless nights.
Cooper compares his life to the rise and fall of building scaffolding. “Little by little, I was built up like a skyscraper and felt like I was on top of the world. The “˜hero syndrome’ can be quite consuming. When the scaffolding starts to come apart from the bottom it’s not long before the whole things comes down. If there is one good thing about hitting rock bottom it’s that it can’t get worse,” he says.
With the help of intense psychological counseling, Cooper has put his life back together. It wasn’t easy, and it took courage. “Don’t expect overnight success,” he says. “Mental illness is a very treatable condition. However, it’s not like taking medicine and you’re fine in a few days. It takes weeks, months, even years under the care of a skilled knowledgeable therapist and physician.”
Few people have the guts to talk about their experience with PTSD and the importance of mental health counseling, but Ryan Cooper does. He has chosen to share his story with other responders to possibly help someone who has started down that seemingly uncontrollable downward spiral. Ryan has found himself through all this and feels a sense of rebirth. He’s survived two near-death experiences: the plane crash and his own demons.
This article originally appeared in April 2011 JEMS as “A Quiet Epidemic: How suicides affect both patients and providers.”
