Journal Watch: EMS Deaths by Suicide

Reviewed This Month

Death by Suicide—The EMS Profession Compared to the General Public. 

Authors: Vigil NH, Grant AR, Perez O, et al. 

Published in: Prehosp Emerg Care, 2018 Sep; 14: 1–6. 

When providing prehospital care, we do our best to keep our patients alive and ensure their emergency doesn’t lead to long-term morbidity. We don’t often think about the impact our work has on us.

We know from our experience and previous research that EMS is an inherently dangerous job. Published research has also evaluated occupational stress related to EMS, and we’ve been paying more attention to the risk of suicide among EMS professionals. 

According to the CDC, suicide is the 10th-leading cause of death in the U.S. This has led the National Institutes of Health to increase funding for suicide and suicide-prevention research by approximately $46 million from 2008 to 2016. Nevertheless, suicide rates have continued to rise. In 2016 the NAEMT published results from a survey indicating that, compared to the general public, EMS professionals had a tenfold higher rate of suicidal thoughts and attempts.

While studies have investigated suicidal thoughts and attempts among EMS professionals, little research has examined completed suicides. University of Arizona MD candidate Neil Vigil and colleagues recently published a study that utilized data from Arizona’s state electronic death registry (AZ-EDR). Their objective was to assess the proportion of deaths attributed to suicide among EMS professionals compared to non-EMS professionals. 

Data Compilation

This was a retrospective case-control study. The study period was from January 1, 2009 to December 31, 2015. The AZ-EDR captures data on all deaths that occur in Arizona as well as deaths of Arizona residents that occur outside the state.

Data in the AZ-EDR are provided by funeral directors, medical examiners, and medical facilities. It includes demographic data (age, gender, race, and ethnicity) as well as the individual’s occupation and specific cause of death.

The authors categorized occupation as EMS professional or non-EMS professional. EMS professionals included those with an occupation listed as firefighter, fireman, emergency medical technician, EMT, or paramedic.

The occupation question was a free-text field. If this field was left blank or if the authors were unsure (following investigation) if the occupation required an EMS certification, the individual was categorized as a non-EMS professional. They categorized cause of death as suicide or all other causes. 

Vigil and coauthors compared demographics and methods of suicide among EMS professionals and non-EMS professionals using chi-square tests (statistical tests of proportions). They also performed logistic regression modeling to determine if the odds of suicide were different among EMS professionals and non-EMS professionals. The authors called this the mortality odds ratio.

Results

During the study period there were 350,998 total deaths. Of those 1,205 were categorized as EMS professionals, and 349,793 were categorized as non-EMS professionals. Among EMS professionals 5.2% (63) of deaths were suicides. Among non-EMS professionals, 2.2% (7,775) of deaths were suicides.

After adjusting for gender, age, race, and ethnicity, EMS professionals had increased odds of suicide compared to non-EMS professionals (mortality odds ratio 1.39; 95% confidence interval, 1.06–1.82). Further, EMS professionals were younger (EMS professionals less than 55 years old, 24%; non-EMS professionals less than 55 years old, 14%) and had a higher percentage of males (94% vs. 53%, p<0.001). 

When evaluating race and ethnicity, the reported proportions were similar, with EMS professionals having a slightly higher proportion of white non-Hispanic (81% vs. 80%). EMS professionals also had a higher proportion of suicides in the 35–54-year-old group (16% vs. 10%, p<0.001) as well as in the 18–34-year-old group (24% vs. 16%, p-value not reported). 

Finally the authors investigated the method of suicide. The three most common methods were firearms, suffocation, and poisoning. A higher proportion of EMS professionals had mechanisms listed as firearm (67% vs. 57%) and suffocation (24% vs. 21%). Non-EMS professionals had a listed mechanism of poisoning more often (10% vs. 17%); however, none of the differences in mechanism were statistically significant. 

Context

The authors did a good job of putting their results into context. Previous research has shown exposure to suicide has been found to independently increase the risk of suicidal thoughts. The authors note that EMS professionals are exposed to suicide attempts and completions at a much higher rate than the general population. They also note that the risk based on exposure is cumulative, citing a study of firefighters that found those exposed to more suicides had an increase in their suicidal ideation rate of approximately 30%. 

The authors also rightly discuss the impacts of stress and its relationship to suicides. They acknowledge recurrent exposure to occupational stress and traumatic events among EMS professionals may contribute to their findings. They highlighted other studies indicating that post-traumatic stress disorder and alcohol use, both of which have been shown to be elevated in EMS professionals, are recognized risk factors for suicide. 

The authors listed their most challenging limitation as reliance on a free-text field to identify occupations. Further, they had no way to identify volunteers, those who may have worked part-time as an EMS professional, or those who held an EMS certification but did not work in the profession at the time of their death. Also, about 2% of records had nothing listed in their occupational field. Vigil and company were also not able to account for other suicide risk factors such as previous attempts, substance abuse, or mental health issues. 

This is an important study that looks at an issue that is not discussed enough in our field. Many of us know a colleague who has attempted or committed suicide. EMS is a stressful job, and we must start focusing on taking care of ourselves while we care for our patients.    

Author’s note: There are many resources available for those struggling with suicidal thoughts, from the National Suicide Prevention Hotline (800/273-8255) to dedicated first-responder help lines such as Safe Call Now (877/230-6060) and the National Volunteer Fire Council’s Share the Load (888/731-3473).

Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.