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CE Article: The EMS Suicide Threat

This article is available on our LMS for CE credit.

Objectives

  • Understand the scope and risk of suicide among EMS personnel
  • Identify risk factors and workplace stressors that may contribute to suicidal ideation
  • Describe strategies to support mental health among EMS providers

As a 25-year veteran firefighter and EMT with an urban fire department, Michael Wojick has seen it all. Operating on one of the busiest medic units in the country in some of the toughest neighborhoods in America, he has run countless calls for overdoses, gunshot wounds, and stabbings. But what began for Wojick as an addictive adrenaline rush at 17 years old evolved over time into a dark accumulation of traumatic experiences. Despite his distinguished and successful career, Wojick began having nightmares and flashbacks of calls he ran over the years. He developed insomnia and suffered from tremors and night sweats.  

“Thoughts of suicide had set in. I thought I was useless and hopeless. I just wanted to end it all,” Wojick told an audience of EMS providers at the Code 3 Conference in St. Charles, Mo., last year. “In the first responder profession, we are trained not to turn our backs on our fellow brothers and sisters. Firefighters worry that seeking treatment is a sign of weakness.”

Michael’s experiences with post-traumatic stress disorder (PTSD) and suicidality led him to seek help, but the resources he found available were scarce and inadequate. As he increased his awareness about PTSD and suicide in EMS providers, Wojick came across many others who’d shared similar experiences and thoughts to his. It was clear more work needed to be done on suicide awareness within the profession.

At the Breaking Point

It’s no secret that first responders, including EMS providers, experience high degrees of workplace stress. Traumatic calls, poor sleep quality, long shifts, lack of downtime after difficult calls, low salary, and low job satisfaction combine to make EMS one of the toughest jobs around.1–5 For these reasons EMS providers are at high risk for burnout, anxiety, depression, PTSD, and suicide.6–14 

According to the Department of Health and Human Services, suicide is a public health crisis in the U.S., with an estimated 40,000 Americans committing suicide annually and 3.9% of Americans experiencing suicidal ideation every year.15 Research in first responders such as police officers, firefighters, and EMS providers indicates an alarmingly high career prevalence of suicidal ideation and attempts.16,17 In fact, one study revealed 15.5% of firefighters had attempted suicide at least once during their career.17 Furthermore, a recent retrospective study of death records found EMS providers were more likely to die by suicide than non-EMS providers.18  

To many in EMS these findings will be unsurprising. You may know personally or have heard about someone struggling with suicidal ideation. Maybe it’s you. Chances are you’ve asked yourself, “What can we do to help our coworkers?”

One of the greatest obstacles to implementing change in EMS relates to the stigma associated with suicidal ideation and mental healthcare. The EMS culture is one in which providers experiencing suicidal ideation can’t always discuss their concerns with colleagues or superiors or seek other forms of help. They may fear being perceived as weaker than their peers or retaliation from supervisors. The “suck it up, it’s part of the job” mentality is all too common within the profession.19  

The Scope of the Problem

While it’s clear there’s a problem with suicidality within the EMS profession, there are many challenges to addressing this issue. For starters, we don’t know how many providers are at risk, or which ones specifically, so as to better identify and give them support. Identifying the proportion of EMS providers at risk for suicide is a critical step with respect to appreciating the magnitude of the problem, dissolving the stigma, and prioritizing the initiation of prevention strategies and allocation of mental health resources for those affected. 

To better identify EMS providers at risk for suicide, we submitted anonymous surveys to EMS providers at 20 different regional agencies between July 2017 and October 2017. These included fire-based, private, hospital-based, third-service, and air-medical EMS agencies in a multistate region that included Missouri, Illinois, Kentucky, and Iowa. EMS providers in these agencies operated in urban, suburban, and/or rural communities. We reached out to the medical directors of these agencies for permission and subsequently sent an online survey via e-mail with instructions on how to participate. 

The goal of this study was to evaluate risk of future suicidal behavior in EMS providers. We hypothesized that given the workplace stressors associated with EMS, EMS providers would be at higher risk for suicidal behavior compared to the general population.

We utilized a previously validated survey instrument known as the Suicidal Behaviors Questionnaire-Revised (SBQ-R) to assess the proportion of EMS providers at risk for future suicidal behavior (i.e., suicide attempt or completion of suicide). SBQ-R is a brief survey consisting of four questions that tap into four different dimensions of suicidality: lifetime suicidal ideation and/or suicide attempts; the frequency of suicidal ideation over the past 12 months; the threat of future suicide attempts; and finally the self-reported likelihood of suicidal behavior in the future. The survey is scored from 3 to 18. An SBQ-R score of 7 or greater has been validated as an effective predictor of increased risk for future suicidal behavior.20  

In total EMS providers were administered a 19-item survey that included the four SBQ-R questions, plus others on demographics (race, age); setting of the agency (urban, rural, etc.); number of years spent working in EMS; average shift length in hours; average number of hours worked per week; self-reported sources of stress; whether the EMS provider personally knew another EMS provider who experienced suicidal ideation or committed suicide; and personal use of prescription medications for depression and/or PTSD. 

The Survey Says…

While we had hypothesized that high rates of suicidality existed among EMS providers, none of us were prepared for the astounding rates at which EMS providers are affected by suicidality. Of the 903 licensed EMTs or paramedics that filled out the survey, 283 (31.3%) had SBQ-R scores greater than or equal to 7, reflecting increased risk for future suicidal behavior. 

The study revealed that 27.2% of EMT and paramedic survey respondents reported suicidal ideation in the past year—a rate seven times higher than the general population.15 

Our statistical analysis revealed a few important relationships. Most notably males were more likely to have risk for suicidal behavior. In addition, a family history of depression or suicide was also associated with increased risk for future suicidal behavior. The top three stressors reported by EMS providers were related to their career, finances, and lack of sleep. Our analysis revealed no statistical correlation between any of the other questions asked in the survey and increased risk. 

The Voice of EMS

Roughly a quarter of individuals who responded to our survey offered suggestions regarding the problem of suicide in EMS. In their comments EMS providers identified three major problems: 

  • Lack of support from peers, supervisors, and the organization for which they worked; 
  • Lack of resources available for individuals struggling with suicidal thoughts, including employee assistance programs (EAPs). More specifically, EAPs do not typically include experts who are familiar with or have any prior EMS experience; 
  • Need for downtime after difficult calls.

Some of the individuals who responded to the survey shared chilling accounts of their own experiences with suicide. Some of those excerpts are listed below:

“One of the biggest issues I see time and time again is when we run these high-stress (bad/critical) calls, we are put right back into service, and even if we request help, it can take days to get it. Debriefings are few and far between, and just because members are not killing themselves does not mean they aren’t using unhealthy coping mechanisms. All too frequently I see coworkers using alcohol as a coping mechanism.”

“I think employee assistance programs are a good concept; however, most fail in real implementation. I have seen multiple EMS providers ask for help over the years only to be ostracized by their peers or management, talked out of receiving the counseling by management due to the associated cost to the company, or only allowed to attend 1–3 sessions with a counselor and then essentially cut off. Mental health has been a hot-button topic in EMS, but from my perspective your everyday frontline providers and managers have not only failed to embrace the needed changes but continued to walk down the same path we’ve been on for decades.”

“I have heard many providers scoff at the idea that EMS workers can get PTSD; their stance is ‘if the job bothers you, find something easier or shut up.’ Until this ideology dies, many providers will continue to hold their silence if they are depressed/suicidal. I’ve had a few calls that still bother me. I fear I have PTSD from my job but don’t want to face the stigma of being labeled. I have sought counseling through the EAP in the past and have been severely disappointed, but I cannot afford the copays to see a psychologist/psychiatrist. I know I am not alone, but I fear the repercussions of seeking help will have on my career and reputation as a medic.”

A Call to Action

While previous work has demonstrated a high incidence of suicidal ideation and suicide attempts in EMS providers, our study is the first to quantify future risk of suicide within the EMS community. The disproportionately high rates of suicidality present in the study population raise strong concern regarding the risk of future suicide attempts and death by EMS providers. 

Our work affirms the need for greater access to, and implementation of, resources that support EMS providers who experience suicidality. The need for suicide prevention programs, employee assistance programs, and support groups that specifically target the unique challenges of the EMS profession cannot be overstated. Successful incorporation of these measures requires increased support from supervisors, peers, medical directors, the EMS community at large, elected officials, and the general public. These interventions have the potential to decrease the negative stigma of mental illness and improve access to mental healthcare in this cohort. 

To address the extensive degree to which EMS providers face the risk of future suicidal behavior identified in this study, EMS agencies should institute education programs for providers, supervisors, and medical directors on the topics of depression, PTSD, and suicide within the field. Additionally, we recommend EMS providers be educated on the signs and symptoms of suicidal behavior so they can better access existing support mechanisms. Lastly, a system to initiate provider downtime could help combat stress, depression, and suicidal ideation after challenging calls.

Improved implementation of measures that support mental health for EMS providers can help stem the tide of suicidal behavior within the field. Advocacy at the local, state, and national levels is essential to ensure adequate funding to address this epidemic and reduce the risk to EMS providers.

The Final Word

Suicidal ideation and behaviors are deeply entrenched within the EMS community, and experiences like Wojick’s are unfortunately more common than is often recognized. While there are limitations to our survey research, overall our findings demonstrate an alarming number of EMS providers are at risk for future suicidal behavior. The EMS community must work toward supporting and finding solutions for our providers in need.

If you or anyone you care about are struggling with suicidal thoughts, please refer to the Code Green Campaign for additional resources.  

References

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2. Patterson PD, Buysse DJ, Weaver MD, Clifton W, Yealy DM. Recovery Between Work Shifts Among Emergency Medical Services Clinicians. Prehosp Emerg Care, 2015; 19(3): 365–75.

3. Weaver MD, Patterson D, Fabio A, Moore CG, Freiberg MS, Songer TJ. An Observational Study of Shift Length, Crew Familiary, and Occupational Injury and Illness in Emergency Medical Service Workers. Occup Env Med, 2015; 72(11): 798–804.

4. Alexander DA, Klein S. Ambulance Personnel and Critical Incidents: Impact of Accident and Emergency Work on Mental Health and Emotional Well-being. Br J Psychiatry, 2001; 178: 76–82.

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6. Crowe RP, Bower JK, Cash RE, Panchal AR, Rodriguez SA, Olivo-Marston SE. Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehosp Emerg Care, 2018; 22(2): 229–36.

7. Boffa JW, Stanley IH, Hom MA, et al. PTSD Symptoms and Suicidal Thoughts and Behaviors Among Firefighters. J Psychiatr Res, 2017; 84: 277–83.

8. Grevin F. Posttraumatic Stress Disorder, Ego Defence Mechanisms, and Empathy Among Urban Paramedics. Psychol Rep, 1996; 79: 483–95.

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12. Bennett P, Williams Y, Page N, Hood K, Woollard M. Levels of Mental Health Problems Among UK Ambulance Workers. Emerg Med J, 2004; 21(2): 235–6.

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15. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, www.samhsa.gov/data/sites/www.emsworld.com/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf.

16. Stanley IH, Hom MA, Hagan CR, Joiner TE. Career Prevalence and Correlates of Suicidal Thoughts and Behaviors Among Firefighters. J Affect Disord, 2015; 187: 163–71.

17. Stanley IH, Hom MA, Joiner TE. A Systematic Review of Suicidal Thoughts and Behaviors Among Police Officers, Firefighters, EMTs, and Paramedics. Clin Psychol Rev, 2016; 44: 25–44.

18. Vigil NH, Grant AR, Perez O, et al. Death by Suicide—The EMS Profession Compared to the General Public. Prehosp Emerg Care, 2018 Sep; 1–6.

19. Newland C, Barber E, Rose M, Young A. Survey Reveals Alarming Rates of EMS Provider Stress & Thoughts of Suicide. J Emerg Med Serv, 2015; 40(10): 30–4.

20. Osman A, Bagge CL, Gutierrez PM, et al. The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation With Clinical and Nonclinical Samples. Assessment, 2001; 8(4): 443–54.

Al Lulla, MD, MS, is a third-year emergency medicine resident at Washington University in St. Louis (WUSTL). 

LinLin Tian, MD, PhD, is an instructor at the Washington University School of Medicine.  

Hawnwan Philip Moy, MD, is an assistant medical director of the St. Louis City Fire Department and emergency medicine clinical instructor and core faculty in the EMS Section of the Division of Emergency Medicine at Washington University in St. Louis. He completed his emergency medicine residency at Barnes Jewish Hospital/Washington University in St. Louis and his EMS fellowship at the University of North Carolina in Chapel Hill. 

Kristen Mueller, MD, is  an assistant professor of emergency medicine at WUSTL.

Bridgette Svancarek, MD, is  an assistant professor of emergency medicine at WUSTL.

 

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