First responders die more frequently by suicide than the rest of the U.S. population, and more die by suicide than in the line of duty.1 What’s more, EMS providers have a higher suicide rate than any other public safety responders.2,3 Many first responders also have experience with the military, where suicide has surpassed killed-in-action as the No. 1 cause of death for those still serving and is the No. 2 cause of death for veterans behind only cardiovascular disease.4,5
Unprocessed traumatic memories may lead to post-traumatic stress problems like depression, substance use, and suicidal ideation. The most common cause of PTSD in our industry is traditionally believed to be cumulative emotional trauma due to our constant exposure to death, dying, and other tragic situations. Other causes may include chronic sleep deprivation, inability of loved ones to understand why we do what we do, inequality of pay and benefits between public safety roles, and other job strife.
While studies show that frequent exposure to risk and human tragedy improves our abilities to perform under pressure, it also has a cumulative impact that can result in a negative outlook on life, isolation, lack of sleep, depression, and substance abuse. These effects may lead to suicide. Many of us in the industry have known colleagues who attempted or completed it.
Suicide within our industry is well-known, out of the closet, and no longer unmentionable. There are many worthwhile resources and approaches to help mitigate it, and this article introduces another: the idea of a pact or deal between peers to serve as a threshold against that final desperate act.
Make the Deal
First responders have many siloed experiences that can only be understood by others who have shared them. Talking about these experiences with qualified counselors is helpful, especially if they choose an evidence-based therapy such as EMDR.6,7 However, many first responders aren’t comfortable discussing their heart-of-hearts with others except trusted colleagues with whom they share common ground.
While teaching suicide prevention I see a slogan on many handouts and publications: It’s Up to Us. The thrust is to educate responders and healthcare workers to recognize early warning signs of suicide ideation and know how to investigate, refer, and in some cases act. I would like to add to this idea: It’s up to us to keep contact with our friends and associates in the industry who have shared the same experiences and apply this same awareness. Openly discuss the stress factors we share and the survivor’s guilt we all feel when a comrade dies, especially by suicide.
And then do one more thing: Make the deal. It’s simple: “If you ever feel like ending your own life, you promise to call me (or others in our group) first.” Of course the deal goes both ways, and you make the same commitment. Most folks in EMS, fire, law enforcement, and the military respond in an organized way even when depressed. We make checklists in our minds to remember things, so make sure you’re on their checklist.
Suicidal crisis ideation is typically a mood. For most it only lasts five minutes to half an hour, then abates (for a time).8 If you can converse with your friend or associate during these darkest hours, it hardly matters what you talk about. Maybe you can’t solve whatever problems they face, but if you have a pact, they may well click on their checklist and give you a call.
It probably won’t be to tell you they’re considering suicide, but perhaps to say good-bye in their own personal or implied way. You’ll talk, commiserate on all the unfair things that may be happening, perhaps share some of the perverse humor you may have used to cope on the job, and agree to talk again soon. It’s just that simple: You help them make it to the next day or until they get the right therapy.
Certain times of the year put people at higher risk for suicide. Check in with your friends and colleagues around holidays like Thanksgiving, Christmas, Hanukkah, etc. If your friend is a veteran, check in on Veterans Day and Memorial Day as well. They may rather talk to a vet friend, if you’re not one, but you can always send a positive text thanking them for their service.
Many people have a hard time remembering birthdays outside their family units. However, putting your friends’ birthdays in your digital calendar does not oblige you to send cards or gifts—just give them a call or text, leave a positive message, and keep the door open for a call back if they wish. If your friend experienced a particularly tragic personal life event, put that anniversary in your calendar and do the same.
Regardless of the cause of their stress, responders need access to anonymous and robust mental health and chemical dependency therapies that work. Cognitive behavioral therapy (CBT)9 and eye movement desensitization and reprocessing (EMDR) are therapies that can reduce stress from past events and modify emotional and behavioral responses to ongoing stress.6,7,10
Both are covered by different health insurance plans, but the challenge is to be sure all public safety agencies provide this insurance. This is a public health issue that has only recently come to light.
Many of us may be familiar with the National Suicide Prevention Hotline (800-273-8255), and you may have referred patients there. Anyone can utilize this hotline, and in fact it can connect military veterans to VA crisis counselors. But there are also hotlines specific to certain groups, staffed by crisis workers from the profession who can refer callers to licensed mental health professionals and/or chemical dependency treatment. These are a few:
Serving law enforcement officers (active or retired) and their families.
For all military veterans and their families but especially serving combat vets. They also offer follow-up calls on a scheduled basis.
Safe Call Now, 206-459-3020
For all public safety employees, emergency services personnel (or retired), and their family members.
Marine Corps DSTRESS, 877-476-7734
Serving current and transitioning Marines, Fleet Marine Force Navy corpsmen, and their families.
1. Fletcher N, Leonhardi D, San Diego County Fights First Responder Suicides. EMS World, www.emsworld.com/article/1223099.
2. Fernandez A. Journal Watch: EMS Death By Suicide. EMS World, www.emsworld.com/article/1222075/journal-watch-ems-deaths-suicide.
3. Erich J. Five Questions With: Arizona’s EMS Suicide Investigators. EMS World, www.emsworld.com/article/221203/five-questions-arizonas-ems-suicide-investigators.
4. Zoroya G. Suicide Surpassed War as the Military’s Leading Cause of Death. USA Today, www.usatoday.com/story/nation/2014/10/31/suicide-deaths-us-military-war-study/18261185/.
5. Conigliaro J. U.S. veteran mortality research data. Research Gate, www.researchgate.net/figure/Ten-leading-causes-of-death-in-10-361-US-veterans-and-the-US-adult-population-during_fig1_51158913.
6. Amato V. EMDR: The Hidden Gem of PTSD Treatment. EMS World, www.emsworld.com/article/218851/emdr-hidden-gem-ptsd-treatment.
7. Careless J. EMDR: Is the Answer to PTSD in the Eyes? EMS World, www.emsworld.com/article/1222537/emdr-answer-ptsd-eyes.
8. Harvard TH Chan School of Public Health. Means Matter: Duration of Suicidal Crises, www.hsph.harvard.edu/means-matter/means-matter/duration/#Howton.
9. Uniformed Services University, Center for Deployment Psychology. Cognitive Therapy for Suicidal Patients (CT-SP), https://deploymentpsych.org/treatments/Cognitve-Therapy-for-Suicidal-Patients-CT-SP.
10. Amato V. Bringing Healing to the Healers: How ART Treats PTSD. EMS World, www.emsworld.com/article/1221983.
Michael Meoli, EMT-P, TP-C, NAEMT-AF, is CEO of Tactical Rescue Options. He served 35 years as a paramedic, firefighter, tactical medic, and flight medic. He is a retired Navy SEAL and Advanced Tactical Practitioner and is NAEMT affiliate faculty.