By Jason Gallimore
“Beep … Beep … Beep … Engine 10 respond for a suicidal subject; PD is en route.” Tragically, these words from dispatch are all too familiar to those of us serving in the fire service – and they are not going away anytime soon. Multiple times a day across American communities, fire engines, ambulances, and police patrol units are requested to respond for suicide acts, attempts, or threats. To say it casually impacts an emergency responder’s shift is a gross understatement!
A Closer Look
Suicide is an issue plaguing the country, and there are not many places it has ravaged more than northern Colorado, the area where I live and serve. Larimer County, and in particular the city of Fort Collins, is deemed routinely by many national publications as one of the “best places” in America to live.1 Disappointingly, though, residing behind the curtain of praise for “Hometown U.S.A.” lies a devastating actuality. This region has a high percentage, relative to its population, of those who lose hope and sadly take their own lives (24.79 people per 100,000 people; the national average is 13.26 per 100,0002,3,4,8). It’s an unfortunate reality, but more and more families are discovering their loved ones were wrestling with demons the family knew nothing about.
Truth be told, virtually everyone in America has witnessed the rippling effects of suicide (10th leading cause of death in America (3, 4) and, moreover, I contend very few of us haven’t suffered directly from its aftermath. It seems we’ve all been a victim to the act, left trying to piece together the “why” and forever wondering “what” we could have done to prevent the resulting tragedy. For this reason, emotions run high, and sensitivity is warranted; however, how an emergency service responds to this call type is a necessary conversation to have, and for far too long it has been glaringly absent.
Exposing the Problem
Alarmingly, a barren space is the only thing noticeable throughout the pages of many departments’ operational directives centering around a suicide call. It is truly an “undefined problem.” What is the fire service’s obligation to act? How do we respond, and when should we engage? These consequential question marks are missing explanation points, and they deserve declaration! Definition is paramount as the fire service faces this unorthodox, nationwide firestorm.
The variations of how the fire, emergency medical services (EMS), and police worlds mitigate these calls are vast. In some cases, they are questionable; in others, concerning. All the same, the sole thing that can be agreed on is they lack consistency. Even at the same fire station houses among different shifts, these calls are being addressed differently. In fact, sometimes within crews, consecutive days can yield opposite response behaviors. As it pertains to many emergencies, this is not a negative aspect, but in this specific call type it is a dangerous paradigm to perpetuate. Void of clear guidelines, all too often responding crews are hesitant when they should be acting boldly and, conversely, are acting too boldly when they should be hesitant.
Make no mistake, this is not merely a matter of preference. Rather, it is a fear highlighting firefighter safety. The words caution, volatile, intentional, and harmful are all associated with this call type – for good reason! The metaphorical alarm bells should be ringing just as loudly as the actual station bells when this call is dispatched. There is no room for underestimating the potential danger to all parties involved, especially those responding to the scene as help. They are expected to perform in unpredictable scenarios with only their experience and instincts to serve as their ship’s rudder and compass. Treacherously, firefighters have been left exposed during one of the trickiest and most emotionally unstable calls that they will face.
Reining It In
Before we dissect the issue further and provide a subsequent remedy, allow me to briefly outline the boundaries for the discussion. As we know, suicide calls present in an array of manifestations, all of which have subcategories and counter-conditions ranging in spectrum, severity, and scope. Frankly, I cannot address each individually; hence, I will not try to slay that enormous giant! Instead, in this article, I will focus on problem solving for the bigger picture, with some generalities in mind but, as a goal, establishing a solid, trustworthy, reliable plan of attack. This plan can be tweaked where needed for distinct outliers but used confidently and consistently to provide navigation for those who have been thrust into a muddled, muddy, highly emotional, human-induced dilemma where there are no winners.
It’s Complicated
Suicide calls can be the most challenging call types for a first responder to diagnose. Their complex nature requires careful contemplation of several factors in their totality. First, a determination if this is “an act” or “an attempt” needs confirmation. Obviously, the findings to this query will dictate the operational direction moving forward. Next, derived from the aforementioned higher tier, spider-web several subcategories, each with varying degrees of intricacy, that mandate a predetermined course of action. Finally, the call type must be analyzed on its face value. Yes, this is most likely a medical problem! And yes, it is certainly a mental health concern! But intertwined in the mix is also a law enforcement burden, and for this reason careful consideration by all emergency response resources must prevail.
To understand the problem thoroughly and address the situation adequately, we must comprehend the separate responsibilities and expectations of each of those arriving first-responding elements. As a former police officer and current firefighter, I believe I can objectively shine a spotlight on this matter.
Almost universally, the fire service will use as a part of its decision-making model a version of a risk-profile matrix. This tool helps to define the problem present in terms of life and death in relation to a degree of risk willing to be waged for each individual scenario. Likewise, in many areas the police department will also use a similar format labeled the priorities of life. In both models, the main objective of the emergency call is weighed against the potential for harm to the involved citizen and the first responder. Although this valuation is not flawless, it advances the decision maker tremendously with a launching off point in determining the initial course of action.
There is, however, a shocking and surprisingly unknown difference of tactical opinion present between law enforcement and fire/EMS when it comes to addressing the suicide call type. Unlike almost every other call, with regard to both the police department’s life safety measuring scale and the fire department’s risk-evaluation template, the citizen’s welfare is the driving factor holding the highest priority. In this dynamic situation, the different agencies interpret the problem and person very differently. Is this suicidal person a victim, a patient, a perpetrator, neither, or each?
A Little History
Police officers are known for placing others’ lives ahead of their own by stepping in front of a knife-wielding suspect or running selflessly toward a hail of gunfire to protect the innocent lives they serve. However, per their priority of life algorithm, a suicidal party does not merit the same self-sacrifice from the police officer. From that officer’s perspective, the suicidal subject is not “innocent” and one whom the police officer will risk his life to save (at least not without a carefully reduced and mitigated risk to self). By placing the suicidal subject lower on the priority scale, the officer is afforded more time to work through the problem, which in turn produces greater clarity on how to proceed.
Although this may sound insensitive, it is important to analyze why. Ironically, the police officer has learned a tough lesson of honor at the cost of humility from the justice system it represents. In 1991, the United States 10th Circuit Court of Appeals ruled that police officers can be the “proximate cause” of death in a suicide (Quezada vs. Bernalillo County5). The ruling concluded the officer unnecessarily placed himself in a position of jeopardy and by so doing was forced to respond with lethal force. Despite the suicidal party’s intent on acting in a fashion that would produce the same dire outcome independent of the officer, who was purely trying to intervene in an effort to prevent the devastation, the officer was looked to in blame. The benchmark ruling established a future precedent, forever altering the police officer’s tactical consideration.
For 25 years, this legal judgment has materialized, shaping the way police officers perform. (5) It has forced officers to move slowly and sometimes disengage in situations where there is no immediate threat to the community, imminent risk to the innocent, or danger to the uninvolved bystander. Even though this seems counterproductive, court rulings have determined otherwise.
Don’t get me wrong, it would be a mistake to assume the police officer does not care about the suicidal subject, only his own well-being. Police officers are humanitarians who sign up to serve humanity. They care, but duty and discipline take the wheel, steering them cautiously. They are governed by that which they can justify legally, ethically, and civilly. They have taken a closer look at the call type and redefined the priority, which sometimes dictates a difficult but necessary decision be made.
While the fire service traditionally is driven by science and the police profession more by art, in this suicide call-type setting, case law is giving police more of a scientifically-founded basis, and the firefighter is depending on the flimsier art form of intuition. This dichotomy is a very important distinguishing characteristic explaining how, why, and when the police officer will intervene, and it is something we must consider in upholding our sworn oath as we safely and objectively manage a suicide call.
A Different Point of View
On the other hand, the fire service sees this situation through a less constricting lens. Our version of the Hippocratic oath declares that we are obliged to help those in medical need without prejudice. A suicidal party is a patient usually suffering some sort of medical need, and, often, we firefighters will do everything we can to medically intervene and offer help. We tell ourselves, “If we can avoid this type of pain inflicted on a person or his family, shouldn’t we take action?” We believe if we can make a positive difference, we must try; it’s what we signed up to do! To compound the crisis, we are emotionally drawn into responding and assuming personal responsibility. Our mission is clear to us, but paradoxically it counters the police officer’s, creating opposing strategic goals. We see the same person, in the same situation, drastically differently. They are a patient but not a victim, and they are not a suspect but also not innocent. We see all patients as equal; they do not. Unmistakably we have conflicting agendas, and it is imperative we get on the same page if we intend to function as an effective TEAM of first responders.
Connecting the tactical dots in this suicide scenario is crucial for all firefighters because, realize it or not, we are creating a cascading domino effect, unintentionally and unknowingly altering the police officer’s safety-strategy doctrine. Once we make entry into a suicide scene, we force the officer’s hand, thus tipping the priority of life scale. Whereas the officer initially had the lowest level of priority placed in the scenario to derive the tactical action plan (TAP), we now have changed the math and brought a group of “innocents” (fire and EMS) into the picture. To a scene the police wanted to slowly and deliberately encounter, we pressed the gas pedal down and accelerated the action timeline.
A Need for Change
Undoubtedly, the challenge firefighters face with suicide calls is they are an emergency event deprived of clear delineation in the responder’s “response playbook.” “What is our obligation to act?” and “When shall we do it?” are each questions that must be answered to help the fire department bridge the conflicting divide.
Now is the Time To ACT
Let’s begin by restating this type of call is not addressed unilaterally. Thinking of the police officer as our partner is a critical detail. We need to recognize and detect those areas in the call that have overlap and explicitly build out our TAP. To appropriately do so, we initiate the call by asking the question, “Who should be the ‘first’ responder?” We cannot progress if we do not have a solid, justifiable response to this query.
The following is a systematic and logical, progressive, three-pronged approach for the company officer (and crew) to use in the suicide call type, positioning them to “Ask, Confirm, Think” (ACT) with confidence. It is designed to help accurately define the “undefined” problem and, correspondingly, navigate those responding resources. It presents the incident commander with a proper perspective of the emergency as a whole, paying close attention to the police officer’s aim, aligning them with the firefighter’s needs.
(It is important to note these prongs are evolving and changing as the circumstances predicate. Each should be continually monitored and evaluated, registering if one aspect transforms; recalibration should also ensue to include the newly acquired information.)
Prong 1: Ask the question: Do I have the means (i.e., tools/protection) to defend and protect my crew from the identified threat? If the answer is yes, proceed. If the answer is no, wait until you are equipped to meet the threat (i.e., police presence).
Take the time to pause and determine if we are equipped to handle the problem as is with the tools we carry. In other words, suicide call types must be means tested to what is known information. Just like when we are facing a second-alarm fire, do we have enough resources coming to battle the fire, and where is our protection (water supply)? Should we use an interior attack with smaller handlines or go defensive, setting up a monitor? What about a hazmat scene? Would we ever make entry without first donning some sort of respiratory protection and personal protective equipment fit for the known chemicals? These are components we would not think twice to ponder before ever making entry, yet we don’t always consider them on a suicide call. We tend to rely on assumptions. This can be dangerous.
I propose we take a more methodical look at the problem and directly address the question: “Do I have the means to meet the known threat?” As an example, if you are dispatched to a suicide call with a gun, where statistics affirm firearms amount to nearly 50 percent of suicide deaths (3, 4, 8), unless you have a gun, don’t enter the scene! (Ballistic vests and helmets alone are not enough.) Even in the newly devised rescue task force concept, using a police escort into a “warm zone” is essential. Wait until the police arrive or call for them if they were not dispatched. Let’s imagine that this call turns out to be not quite what you thought it was based on the initial dispatch report (which happens often). Always remember, a suicide can quickly turn into a homicide if along the way just a couple of the facts change. You could find yourself and your crew in an unforgiving position without a viable exit strategy. We don’t want to become victims in the attack if we can avoid it.
In addition, at some point the weapon will need to be secured and “made safe.” Who better to meet this criterion than a trained police professional? By allowing the police officer to do his job, it frees us to do ours! We can focus on what matters most to us: rendering aid. If we can time our entry correctly, we can get straight to work without any safety distractions.
Also, it may not need to be said but, if directed to “stage” by police, do so! They have made a determination, usually on more complete information than provided to fire/EMS, and their judgment should be trusted. In a similar manner, they should oblige when we tell them not to enter a burning structure. It’s for the same reasons: They are unequipped and untrained.
Prong 2: Confirm the risk calculation: Is the risk justified against the reward? If the answer is yes, proceed. If the answer is no, don’t until the concerning conditions change favorably and the risk level is at an acceptable margin.
Another way to conceptualize this prong is, “What do I gain vs. what might I lose?” Before we ever make entry, we must validate the entry. We need to ensure the probability for potential loss (an injury or worse to a crew member) is not at a higher/larger (value-metric) than the possibility (value-metric) associated with the gain (mission completed). Basically, these should equate to an indirect relationship.
Take the suicidal subject with a weapon we previously described. Don’t forget the suicidal party’s initial intent. A drastic effort was taken to raise the level of intensity and severity by that person using a weapon; it is fair to assume this subject means business. The presence of this enhancer means this person is very committed to the act. Trying to prevent him from accomplishing the task can be very dangerous to you and your crew. Even if the patient has already shot himself once, we cannot be persuaded into thinking the threat has now dissipated. There have been a number of incidents where multiple gunshots were used to perform the same dreadful deed; the first bullet did not accomplish its intended purpose. If you are trying to interfere in the premeditated plan, and the party is gravely injured but not incapacitated, you could receive that demonstration of their pain and anguish.
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| We see the same person, in the same situation, drastically differently. They are a patient but not a victim, and they are not a suspect but also not innocent. |
Plainly speaking, the risk is not worth the reward when there is a sincere intent by a determined individual to cause sorrow. As a crew leader, you must ask if you can justify an injury to your crew members to intervene in this specified call. Again, I remind you, although this person is emotionally hurting, he is not an “innocent” victim of circumstance but instead a perpetrator of harm to his own welfare. We cannot confuse our call to duty. This is not a rescue of a helpless citizen from a burning building. We have to gingerly and prudently approach these calls just like we do an animal rescue where the animal may lash out because it doesn’t recognize our good intent. This subject may not want the benevolence we bring because he can’t see past his hopelessness. These are NOT typical medicals.
To make matters worse, medical examiners have discovered that 77 percent of suicide deaths have alcohol and/or drugs in the body at the time of demise.6,7 This fact is eye opening because it emphasizes a high probability of an “altered mentation,” which for us responders should signal a red flag of warning. As we know, an altered mental status demonstrates an agitated and unstable emotional person. Our ability to rationalize with this patient is diminished.
Furthermore, revisiting the police officer’s turbulent historical judicial review in referencing this call type should be registered and gauged in conjunction with the firefighters’ risk/reward decision-making barometer. Although currently no past precedent was litigated, firefighters should not think they are immune from being viewed as the “proximate cause” of death. For instance, if, in a courageous display of heroism to save a life, a firefighter attempts to tackle a suicidal person off a ledge before he jumps and that person (the suicidal subject) actually falls, the community may not agree with the noble perception of the firefighter’s intentions. Since the action went awry, a jury may reach an unfortunate verdict at the cost of the firefighter. Or, even worse, the suicidal subject pulls the firefighter over the edge at the same time as he leaps. Was it worth it? He wanted to kill himself to begin with, and now two loved ones have been lost. This is not defensible to your family, your crew, or yourself.
Prong 3: Think it through: Can we make a difference? If the answer is yes, proceed. If the answer is no, stop and move only when and where you safely have control of the scene.
The last element to contemplate is vital in the linear path of progression. Will intervention be effective based on the mechanism of injury? This is important to decide. What “real” chance do we stand in altering the outcome?
In the suicide episode where an enhancer such as a weapon (gun, knife, blunt object) or mechanical advantage (automobile crash, hanging, fall) is used, the corresponding trauma to the patient is raised exponentially. The physical injury the body sustains in these suicide events is nearly unrepairable (we all know the probability rate of a trauma core). They are catastrophic wounds, not leaving much room for error. We must entertain this reality when considering our entry into the fray. If we were near an emergency room operating table, a solid argument could be articulated for a medical intervention. In the field, though, where time and proximity are not on our side, we need to be realistic about what success looks like. We should encounter these patients and the scene with control and safety as our primary focal points.
Also, have you considered that a severe mechanism of infliction, causing an intentionally severe traumatic injury, is tantamount to that patient’s expression of a “Do not resuscitate” order? I recognize it is not a legal, literal match – more of a figurative one. And, although the patients may not be deemed culpable by the state to make this decision, nevertheless they have produced a deliberate statement of not wanting to survive. (Obviously, if the act can be prevented prior to completion, or if there is a medical intervention on scene that will render lifesaving assistance, then every safe and reasonable effort should be taken to intercede.) But in practicality, if our labors are futile, this end-of-life measure is now a relevant factor that we should include in our treatment.
I know I’m presenting a substantial ethical question to balance, but we do this all the time on other events. Whether it is a fireground that shows no signs of tenable space; a motor vehicle accident where energized power lines have been damaged, endangering the vehicle occupants to an electrical surge; or a hazmat scene in which we cordon off the hot zone to protect the public because the greater good needs to be preserved, we will not put ourselves or the rest of the community in undue peril to save “nonsavable” lives. This is exactly the formula used in the standardized risk profile assessment. The same calculated, thought-through processing needs to be applied with emotion sifted out when dealing with a suicide response. This is not meant to be callous, but it is meant to provide leadership with regard to an “undefined problem” that lacks clear direction.
The final component in this prong, and equally important to evaluate, is this location has now become a crime scene. Even if the suicide is not “illegal,” it will require investigation until the notion of foul play can be eliminated. We must acknowledge the end game and help the police by not contaminating the crime scene or corrupting the evidence.
Stick to the Prongs
In the three-pronged flowchart, I used the most drastic of means, a firearm. In the same way, it can and should be applied to ALL suicide call types, independent of their differential presentations. For example, if you are dispatched to a suicide attempt involving medications or something benign, crews should feel reasonably safe making an entry. (The exception here is if there is an actively threatening person present, in which case you should wait for police because they have skillsets and training specific in this arena.) No obvious enhancers to inflict greater harm on the responding crews were noted, so crews could consider entering the scene to intervene. For most crews, they have the means in personnel power to outnumber, overwhelm, and control any potential physical form of resistance that might arise.
We in EMS confront this scenario regularly when treating a seizure patient who becomes combative. We use our restraint systems to control the aggression. Secondly, this risk is worth the reward. This is an event where, if we do intercede, we can meet the life safety objective of saving another human life and, additionally, eliminate heartache for a family without compromising our risk vs. reward relationship. That absolutely meets our public and personal duty. Lastly, the rating on the mechanism severity scale of this act is lower, and if we can act in a timely manner there is a reasonable chance an intervention will make a beneficial difference to the patient’s overall health outcome. The action would be an appropriate offensive play.
Success is Not an Accident
Although company officers are commissioned to make challenging decisions, typically they are given more conceptual instruments (such as flowcharts, rules of thumb, discussions, protocols, policies, and training) to aid in their processing. In some instances, a seasoned captain who has many experiences along with a fully stocked mental file cabinet to draw from has an increased probability for a successful conclusion. Still, it is not guaranteed. Yet at other times, comparatively, an acting or temporary captain who is left predominantly with his instincts is dangling in the wind and success leans more toward lucky than likely. This is a conspicuous predicament with extreme and potentially deadly consequences. Undeniably strong decision making should always hinge on calculation above compensation.
You have the Final Say
Ultimately, this decision always remains with the crew. They are the ones engaged, and they are trained professionals; these are simply guidelines. But with the correct variables correctly applied in the properly ordered sequence, the prospect for success is attainable, and our role in the emergency is much more transparent.
Do we have an obligation to act in these situations? Yes indeed! It’s much easier to say no when we think that person is a criminal – but he is not. Nonetheless, he is not innocent either. We should view him as somebody who needs help but not elevate the risk to our own crews’ lives or their livelihood. This act of suicide is a personal choice. We have to be mindful not to become emotionally drawn into responding, feeling like we bear any responsibility for the end result – we do not. We should, however, think of this party as a “person and patient” and, where possible, provide the support that is reasonable. It’s not a question of whether we will help but rather how and when. If protocols in your agency are missing, begin the process of creation. If policies exist but are vague, flush out the impurities to form clear, interpretive documents. Ambiguousness is not satisfactory here! It is pertinent for firefighters as individuals and crews as a collective to identify their essential places in this emergency.
Answer the Bells
There will always be certain calls that command your immediate attention, and there are those to which you rhetorically compute in the back of your mind, “How many times have I seen this before?” Clearly, a dispatched suicide call is no run-of-the-mill situation, and moving forward it should no longer be treated as such. These calls quite possibly represent someone’s final desperate cry for help and, to those of us tasked with responding, a significant tactical challenge. They demand respect and deliberate calculation to effectively mitigate. If not, firefighters run the risk of becoming unwitting participants who will harbor irreconcilable and painful consequences the rest of their lives.
When it comes to this sensitive subject matter, I believe we’ve all been victims. This is a horrific event for anyone to endure, and all sympathy should be shared with those families affected and those desperate souls who feel it is an acceptable option for their despair; the emotional strain weighing on each is taxing. If we firefighters can make a difference in one life and cultivate hope, then intervention and engagement are worth it. Where previously handcuffed behind obscured expectations and blurred response requirements, confidence and consistency coincide. To an “undefined problem,” distinguished definition prevails. And hopefully, when the tones go off for a suicide call, the days of the captain and crew simply winging it are a thing of the forgettable past.
REFERENCES
1. Forbes.com, “The Best Places for Businesses and Careers: 2016 Rankings,” 2016, http://www.forbes.com/places/co/fort-collins/.
2. Livability.com, “Top 100 Best Places to Live,” 2016, http://www.livability.com/best-places/top-100-best-places-to-live/2016?page=1.
3. Time.com/Money, “Best Places To Live: Top 5 Towns,” 2006, http://money.cnn.com/popups/2006/moneymag/bplive_2006/frameset.exclude.html.
4. Pohl, Jason and Jacy Marmaduke, “Special Report: Losing Arianna: 11 Year-old Girl’s Death a Troubling Sign of Larimer County’s Struggle with Suicide,” Coloradoan.com, 2016, http://www.coloradoan.com/story/news/2016/01/15/suicide-larimer-county-2015/78747912/.
5. Marmaduke, Jacy, “Beyond the Numbers: Suicide’s Lasting Mark,” Coloradoan.com, 2016, http://www.coloradoan.com/story/news/2016/01/15/larimer-county-high-suicide-rates/78840072/.
6. Center for Disease Control and Prevention, “Suicide: Facts at a Glance 2015,” 2015, https://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf.
7. Curtin, Sally C, Margaret Warner, and Holly Hedegaard, “Increase in Suicide in the United States, 1999-2014,” United States Department of Health and Human Services, Center for Disease Control and Prevention, 2014, https://www.cdc.gov/nchs/data/databriefs/db241.pdf.
8. Center for Disease Control and Prevention, “Increase in Suicide in United States 1996-2014”; 2014 https://www.cdc.gov/nchs/products/databriefs/db241.htm
9. American Foundation for Suicide Prevention, “Suicide Statistics,” 2016, https://afsp.org/about-suicide/suicide-statistics/.
10. United States Court of Appeals for the Tenth Circuit, “Quezada vs. Bernalillo County,” 1991, http://www.aele.org/law/2007LRAUG/q.html.
11. Center for Disease Control and Prevention, “Suicide: Facts at a Glance 2015,” 2015, https://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf.
12. Widhalm, Shelley, “Larimer County Suicide Rates Drop in 2015,” ReporterHearld.com, 2015, http://www.reporterherald.com/news/larimer-county/ci_28140991/larimer-county-suicide-rates-drop-2015.
13.Tavernise, Sabrina, “U.S. Suicide Rate Surges to a 30-Year High,” The New York Times, 2016, http://www.nytimes.com/2016/04/22/health/us-suicide-rate-surges-to-a-30-year-high.html_r=0.
Jason Gallimore served as a police officer for more than two years before becoming a firefighter with Poudre (CO) Fire Authority in 2014. He is with the hazmat team and is a certified hazmat technician. Gallimore has a bachelor’s degree in speech communications and a master’s degree in computer information systems from Colorado State University.
