Glass Houses: Suicide in Both Seats



Of all the skills we’re called upon to wield without adequate training, care for psychiatric complaints tops the list. In particular, it’s a rare shift when you don’t handle a person — whether on the initial emergency response or a subsequent interfacility transfer — who has thought about, or even attempted to commit suicide.

Probably because these patients aren’t very medically exciting and can be challenging to deal with (due to varying degrees of cooperativeness), many of us aren’t big fans. We also tend to have a cynically individualistic sort of streak, which says that deep down, patients are responsible for themselves. If someone wants to be healthy and they get unlucky, we’ll help out. But if they can’t be bothered to try, we can’t be bothered either, and if they’re actively trying to hurt themselves, surely we have better things to do than interfere with natural selection.

But before we throw stones, we should probably understand the disease we’re discussing. Just like you can’t treat CHF without grasping its pathophysiology, properly treating the suicidal patient — or even deciding not to care — demands knowledge before judgment.

Depression itself is hard to grasp from the outside. This easy walkthrough may shed some light, but if you haven’t been there, you probably shouldn’t pretend you understand it. Nevertheless, it’s one of those conditions that invites amateur opinions, because it seems like the sort of thing we all know something about.

Maybe depression is too loosey-goosey; maybe it’s better if we stick to concrete facts, yeah? And there’s nothing more concrete than suicide. Let’s talk about suicide.

Start by reading through this article at the Daily Beast. It’s long, but it’s real good, and you may start to change your mind about a few things by the end.

For instance, in 2010, in the developed world where we have good statistics, suicide killed more people in the prime of their life (ages 15–49) than anything else. Read that again. Of all the terrible insults we study and treat, from gunshots to heart attacks, car crashes to cancer, suicide was more deadly than every single one. Over a hundred thousand suicide deaths that year. Almost a million across all age ranges. Every murder, every war, every natural disaster you read about in 2010 — throw them all together, and they still don’t equal the number of suicides. There were probably even more that weren’t reported, and even that’s just the successful suicides, of course; those that were attempted but didn’t quite succeed make up a much larger group, perhaps twenty-five times larger. (Yes, 25 times.) And there are more and more every year.

When we talk about CPR, we often talk about quality of life. When a 98-year-old bed-bound dementia patient dies, we might ask whether we should jump through hoops to save them; even in the best possible case, they’re not going to return to a very long or very fruitful existence. But when the 20-year-old college student drops dead on the lacrosse court, we want very badly to bring him back, because if we can he might live another 70 wonderful years.

Well, the people committing suicide are the second kind. They’re often middle-aged, middle-class folks who could be happy and live long — if they can get past their illness. But dead people won’t get past anything.

Of course, we see a lot of depressed people, and most of them won’t kill themselves even if they’ve thought about it. Figuring out who’s most at risk of taking that step is a worthwhile goal, and the Daily Beast article describes three risk categories that you may find useful:

  1. Those who feel alone, that they don’t belong anywhere
  2. Those who feel like a burden to others
  3. Those who have the willingness and capacity to go through with self-annihilation

Who feels alone? Everybody, at times. We need connection. Married people kill themselves less often than the unmarried, twins less often than only children, mothers raising small children almost never. Sometimes those who seem to have everything in life may have the weakest connections, which is why they say that money doesn’t equal happiness.

The life-saving power of belonging may help explain why, in America, blacks and Hispanics have long had much lower suicide rates than white people. They are more likely to be lashed together by poverty, and more enduringly tied by the bonds of faith and family. In the last decade, as suicide rates have surged among middle-aged whites, the risk for blacks and Hispanics of the same age has increased less than a point — although they suffer worse health by almost every other measure. There’s an old joke in the black community, a nod to the curious powers of poverty and oppression to keep suicide rates low. It’s simple, really: you can’t die by jumping from a basement window.

When nothing ties you down, when nobody cares what happens to you, what’s stopping you from shuffling off into the abyss? “I’m walking to the bridge,” one note said. “If one person smiles at me on the way, I will not jump.” Did you smile at your last psych patient?

Who’s a burden? Anyone who’s not achieving, contributing, responsible for something or someone. The unemployed, the chronically cared-for, those with debilitating diseases or intractable poverty. We do this job because we like taking care of people, but that means there’s always someone being taken care of, and nobody loves being on that side of the equation. Some people will go to their graves rather than add to the work or worry of those around them. A few will send themselves there.

Finally, who’s actually willing to end their own lives? It takes something special to close the deal, a particular resolve; no living creature’s natural instinct is to die. Even if you have the desire, it’s not easy to pull the trigger. It’s those with the gift or the learned ability to follow through with difficult deeds, the “athletes, doctors, prostitutes, and bulimics . . . All have a history of tamping down the instinct to scream.”

Think about those categories. None of those are particularly insane thoughts to have. All it takes is their juxtaposition, and suddenly, something unthinkable becomes a very real possibility. Honest. It happens hundreds of thousands of times every year.


Suicide in EMS

“Well, what the heck,” you’re thinking. “That’s nice, but I’m not going to fix them, so why do I care? I’ll bring ’em where they’re going and say good luck; God and the doctor can take care of the rest.”

Fair enough. But I have a homework assignment for you.

Find that guy at work. You know the one. His nickname is “Doc” or “Papa.” He’s been doing this for twenty-plus years, since the days when ambulances were dinosaur-drawn wooden wagons. Ask about the other old-timers, the endless sea of faces he’s worked with over the years.

He’ll have good stories. Tons of them. Partners and coworkers and crazy SOBs. Hijinks were had, shenanigans performed, laughs all around.

But then ask what happened to those guys.

Because a lot of the time, they’re not running around on the ambulance anymore. Ol’ Doc is the exception. They’re not semi-retired, spending their afternoons fly-fishing and golfing. They didn’t jump careers to become bankers or meteorologists.

They’re dead. Or maybe in jail. Or shot robbing a 7-11 for $13. Or they were committed to a psych hospital so many times nobody knows what happened to him. Maybe they overdosed. Living on the street. Living who knows where.

And yes, some of them committed suicide.

Seems a little rich to judge your psych patients when, the way the odds go, you’re probably going to be the next one.

I suppose you could argue that EMS was different back then. Russ Reina talks about the time when most “ambulance drivers” were people who couldn’t find a job anywhere else, drifters and ex-cons. Not like now. Now we’re all as well-adjusted as Mr. Rogers. Right?

Yeah, sure.

Let’s be real. A lot of the people doing this job can’t stay employed even in our own dysfunctional field, and would never stand a chance anywhere else. Drug abuse and PTSD are common. And our social support networks often don’t extend past a partner or two.

Do we belong anywhere? Maybe you do in the police or fire service. But those of us who enter private EMS usually don’t last long before being sucked into a loop of working more and more overtime until we no longer have hobbies, no longer spend time with friends, no longer travel or expand our horizons. If we have spouses, significant others, or family, we neglect them. If we don’t have those relationships, we sure as hell don’t develop them from the driver’s seat of an ambulance. The last step — which doesn’t take more than a few years — is when we start to view every one of our patients as a nuisance. Burnout takes away the last string tying us to other people; if patients aren’t worth helping, aren’t hardly people at all, then the circle of humans in our life may become no larger than our uniform belt.

Are we a burden? In many cases, that shoe drops when we find ourselves off the clock. If our life has become the ambulance, what happens when we lose the ambulance? Your company goes belly-up. We piss off the wrong boss and get tossed out on our ass. Or, inevitably, we get injured. Suddenly, the only reason to get out of bed in the morning is gone. Sounds nice at first, but you realize quickly that having nothing to do actually means you’ve got no reason to be alive.

And are we afraid of dying? Who could be less afraid? We spend every day minimizing death, trivializing the human condition, ingraining a culture that teaches we should be able to order nachos after bandaging a burn victim. We drive fast; we laugh at seatbelts. Sometimes we snort cocaine and have sex in ambulances. (No, not you. But you know who.) There’s nothing beyond the pale for an EMT. Including pulling the trigger.

So is suicide a big deal? Yes. Should we try to understand it? Yes. Does it matter for us? Yes.

But more importantly: do we get to judge it? Do we get to pretend we’re above it? Are the kind of people who attempt it so bizarrely pathological that we’re nothing like them?

You can decide. But you only get to say that if you’re willing to say you don’t care about a disease that kills more healthy patients than anything else. Willing to write off hundreds of thousands of people every year.

And willing to say you don’t care that your partner could be next. Or your boss. Or yourself.


Check out The Code Green Campaign for mental health support for EMS. — ed. 1/17/15

Further reading


  1. I am beyond words. Thank you for taking the time to compose this; I hope those out there take the time to read it.
    Again, you’ve outdone yourself. Many thanks.

  2. I recently read an interesting study where they sent postcards to patients who presented to the ED due to suicidal behavior/ideations (“Postcards in Persia” PMID:21343332 and .”Postcard intervention for repeat self-harm” PMID:20592434).

    As you said, it is a tough role we play; especially when you’re not part of something “larger”. For whatever reason, I’ve noticed folks working on the fire side seem closer together than those working for privates. How you fix this, I dunno. I certainly don’t know enough to fix it. I’d like to learn though.

  3. I had a hard time reading this entire article, it’s a very emotional topic for me…I know a good friend that has battled suicide and it truly changed my life.

  4. Excellent article. One of the areas that we see an increased emphasis on is the area of the affective domain, how to teach it and how to measure it. Society as a whole is less patient with people who struggle with issues of mental health.

  5. Wow. I relate to this more than anything else I’ve ever read. I was an EMT-basic for about 5 years. I’m also a psych patient (bipolar II). I’ve been suicidal before so I know what it’s like so I always tried to be patient and understanding with psych patients. It’s hard sometimes (even for someone like me that gets it). One time we had a guy we picked up pretty often. He was always suicidal (he also had schizophrenia). I honestly think he sometimes called just because he was lonely and didn’t have anyone else because despite saying he was suicidal he always seemed to perk up when we picked him up. One time I was extremely sick with a case of bronchitis that would not go away (but of course I was working anyway) and we had a long out of state transport. We were exhausted and hadn’t had sleep in forever. And of course as soon as we got back to the station this guy needed to be picked up again. I was so exhausted and frustrated I honestly didn’t think I could treat him well…I was imagining in my head how I would just tell him off (we’ve all imagined doing that even if we know we never will). But when I got there I somehow managed to keep my cool like I always do and treat him nicely. In fact I probably treated him even better than usual. And he seemed to perk up as he usually did and everything went as usual. And then a few weeks later he killed himself. Imagine how horrible I would have felt if I hadn’t treated him well.

    I’ve seen so many EMTs and medics be rude to people like that and roll their eyes at them and make fun of them and it breaks my heart. I’ve tried talking to them but they just make excuses “oh this guy always does this and he’s full of crap” and similar excuses. But you just never know when one of these people will really go through with it.

    • Thanks Kristy. Unfortunately, it seems like we sometimes need to see the potential consequences of these problems to remind us that it’s for real. The “false alarms” aren’t BS, they’re near misses, and we should be glad for them, because next time it might be a near hit.

  6. Wow, reading this stuff really hits home. Although a suicide of a coworker has yet to be a part of my career, the emotions and stories behind this phenomenon are far too familiar. I will repost this on my blog at Please feel free to visit my blog to share more stories or insight about this topic. Thank you and be safe.

  7. Just stumbled upon your blog, and this was the first post I read. Even though mentally ill patients may be hard to deal with, always remember where they’re going.

    A few years back, I got in some “trouble” with the law. Because of the crowded jails (and juvenile halls) in Cali, our city would send minors/young adults to a behavioral center, partially to scare them, and partially because the crimes were minor (fights and stuff like that) and they really only needed to talk to a counselor.

    So, I was brought into the center, searched, and put in a room with barely anything in it and everything bolted to the ground. As I was in there waiting for a counselor to come and talk about what had happened during the night (got in a fight and ran from the police), they left the door open, and I could see every patient coming in.

    I remember one patient being wheeled in by two medics… she had tried to kill herself because of her weight. I could here the medics talk to her, comfort her, and wish her well as they left. Then one of the nurses working at the behavioral center walks into her room and asks if she wants a bag of chips and a soda, almost as if to mock her. I just sat there and shook my head… Throughout the night I could also here the staff there gossiping and they were laughing about some of the patients they were treating and how annoying some where.

    So, to get to my point, when I pick up any patient suffering from a mental illness (bipolar, depression, etc) and especially people who just tried to end their life, I always remember that they may end up in place like that… were no one really gives a shit about them. So, if I can do anything for them to show them that I care about them, then I will, whether I’m meant/allowed to or not.

    • I think sometimes, demonstrating that we give a crap about someone is the most powerful thing we can do for them. For some of these folks it’s been a long time since anybody did.

  8. Whew! That was quite the article, but suicide is no laughing matter. At all. I have a cousin who have committed suicide and it has definitely affected everyone in the family.


  1. […] Glass Houses: Suicide in Both Seats (EMS Basics) As medics, we see and deal with patients experiencing depression and attempting suicide often. How many of us consider the effects on our own peers within EMS? This deeply thought-provoking piece challenges us to be aware of these issues within our own culture in EMS. […]

  2. […] he picked that up quickly. He had suicide in his family — as many of us do, since it’s incredibly common — but otherwise, he fell into the role the way many of us fall into our callings. […]

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