The purpose of this study is to assess the levels of suicidal ideation, planning, access to means, and attempts of emergency responders. Survey requests were sent to all individuals credentialed at any level of emergency medi-cal service provider in the State of Minnesota. Of 29,501 requests, 1,832 surveys were completed for an overall confidence level of 99% with a ± 3% margin of error. Analysis was performed taking field of practice and medical credential into account through a series of onesample t tests and multiple linear regressions. Results indicate a significantly elevated instance of ideation and planning among all responders regardless of field or credential. Attempt rate analysis produced mixed results. Responders with a suicide plan were significantly more likely to have an increased number of suicidal thoughts, but not attempts. Findings affirm the need to be more vigilant in screening responders for ideation and to recognize an articulated plan may indicate higher risk for psychological distress and suicide.

There were 47,143 suicide deaths in the U.S. in 2017, which makes suicide the tenth leading cause of death in the country (Centers for Disease Control and Prevention, 2020). Suicide rates have been steadily increasing for decades with 50% of states having suicide rate increases by 30% (Stone et al. 2018). Emergency responders are both a part of and a microcosm of our society.

Emergency responders are the safety net the public depends on for saving lives and property and reducing morbidity of injury and illness. Saving responders is akin to an aircraft emergency where putting one’s own oxygen mask on before helping the person next to you is essential. The emergency responder community has recognized their need to help themselves in order to help others with calls for action to prevent suicide among responders. These calls were made by the International Association of Police Chiefs (National Action Alliance for Suicide Prevention, 2014), National Fallen Firefighters Foundation (United States Fire Administration, 2014), and the National EMS Managers Association (Heightman, 2017, 2018). In Minnesota, the location of this study, the Minnesota Ambulance Association also began supporting suicide prevention initiatives among EMS Personnel in 2014.

The research to date has mainly focused on the emergency responder disciplines of the fire service and law enforcement, with singlerole (nonfire and nonpolice) emergency medical services (EMS) clinicians and the impact of EMS credential level being relegated to a lesser amount of study. The majority of the studies to date have been conducted on large urban emergency response agencies with fulltime employees. In ascending order, the levels of EMS credential and associated educational preparation and skill level are emergency medical responder (EMR), emergency medical technician (EMT), advanced EMT (AEMT), and paramedic.

Our purpose in conducting this research is account for suicidality among singlerole EMS (EMS Only) providers and the impact of EMS credential level. As firefighters and law enforcement officers are an integral part of our EMS system, we keep our sister professions in the analysis.

This quantitative research project began with a social media (Facebook and LinkedIn) campaign soliciting survey participation on October 13, 2017. On October 18, 2017, an e-mail with a request to participate in a voluntary survey on suicidality was sent. The e-mail included a link to an anonymous online survey created on the Eastern Kentucky University (EKU) server and housed on their protected network (see Appendix). Approval for the study and methodology was obtained from the EKU Internal Review Board.

Sample
We e-mailed 29,501 requests for survey participation. E-mail addresses were obtained from an Emergency Medical Services Regulatory Board (EMSRB) list of individuals credentialed as any level of EMS provider in the State of Minnesota. Of the e-mail requests, 1,167 e-mails were rejected as being non-existent, leaving 28,334 valid survey deliveries. Three recipients requested removal from the “list” while 1,832 were successfully completed by the end date of December 14, 2017.

Measures
Sociodemographic Variables: The sociodemographic variables we assess include age range, EMS credential level, field of practice, years of experience range, employment status, education level, and military service history.

Suicidality Variables: The suicide-related variables we focus on include presence of ideation during the lifetime, number of ideations, lifetime suicide attempts, number of attempts, presence of a plan, and access to means. There are variables we collected that we are electing to publish in a separate paper. These variables for future publication include presence and number of peer suicide attempts, presence and number of peer suicide deaths, and a yes/no response as to whether the participant talked to anyone about suicidality—either their own or their peers.

Analysis Methods: We used SPSS version 25 of the IBM statistics software to provide data in terms of counts, means, and standard deviations. We also used this same software to perform one-sample t tests and multiple linear regressions.

Survey Accuracy
Considering the population size (n = 1,832, N = 29,603), the overall survey has a p­-value of 0.01 with a ± 3% margin of error. If population sizes by EMS credential level and field of practice are accounted for, the EMR (n = 637, N = 16,749), EMT (n = 707, N = 9,840), and paramedic (n = 443, N = 2,957), portions of the survey each have a p­-value of 0.05 with a ± 5% margin of error with the AEMT (n = 57, N = 45) responses having a p­-value of 0.05 with a ± 7% margin of error. The firefighter (n = 705, N = 15,389) and law enforcement (n = 247, N = 10,763) components have a p­-value of 0.01 with a ± 5% margin of error. The population size of single-role EMS workers (EMS Only) and those working in another unspecified field (Other) cannot be determined due to uncertainty as to where these respondents work, so no survey sample size calculations can be made on those groups.

Participant Demographics: The majority of respondents are age 35-44 with an associate or bachelor’s degree and no military service. The majority are credentialed as EMTs, have 20+ years of experience, work in singlerole EMS or fire service, and are employed full-time (see Table 1).

Suicidality Characteristics: Those credentialed as AEMTs or paramedics have the highest rates of suicidal ideation, planning, and access to means. EMTs have the greatest number of suicide attempts. In regard to field of practice, singlerole EMS (EMS only) and those in the Other category have the highest rates of ideation and planning. Police and Other has the greatest access to their means. Other and singlerole EMS have the greatest number of attempts.

Ideation: A series of one-sample t tests were conducted on ideation averages among the sample overall and by EMS credential level and field against the U.S. general population ideation rate of 5.6 to 13.5% (Nock et al., 2008a, 2008b). When analyzed against the lower and higher thresholds of general population ideation, the mean number of ideations (27.8%) reported by emergency responders (n =510) was significantly higher than that of the general population. When analysis by credential level and field was conducted, we found that all credential levels and fields had a significantly higher instance of reported ideation (see Table 3).

Multiple linear regression analysis was used to test if each of the characteristics (see Table 4) significantly predicted the reported number of ideations of emergency responders. The number of reported ideations per responder with ideation ranged from one to five (M = 3.92, SD = 1.412), with a value of five indicating five or greater ideations in a lifetime. Number of reported ideations was non-normally distributed (Shapiro-Wilks test p < 0.05), with moderate skewness of -0.772 (SE = 0.277) and platykurtic kurtosis of -1.06 (SE = 0.548). The preliminary analysis revealed no violations of the assumption of linearity or homoscedasticity as verified by P-P plot, Q-Q Plot, histogram, and tests of collinearity. The results of the regression indicated that of the three remaining variables used in Model 2, only having a suicide plan is predictive of the number of reported ideations. Having a plan explained 28.9% of the variance (R2 = .083, F (6.981, 6) = 0.00, p = .001) and significant predicted the number of ideations reported by responders (ß = .866, p = .001). Thus, with the exception of having a suicide plan, we reject the alternative hypothesis that a specific list of emergency responder characteristics (see Table 4) is predictive of the number of reported suicidal ideations among responders and accept the null hypothesis that none of the characteristics, except having a plan, predict emergency responder’s reported number of suicide attempts.

Plan: Another series of onesample t tests were conducted on the average of number of suicide plans made by respondents (see Table 5). This analysis was again conducted by comparing the mean of those planning overall and by EMS credential level and field against the U.S. general population planning rate of 3.1 to 4% (Nock et al., 2008a, 2008b; Piscopo, Liprari, Cooney, & Glasheen, 2016). When analyzed against the lower and higher thresholds of general population reporting suicide plans, the mean number of plans (12%) reported by emergency responders (n =220) was significantly higher than that of the general population. When analysis by credential level and field was conducted, we found that all credential levels and fields had a significantly higher instance of reporting having made a suicide plan.

Means: Our search of the literature was unsuccessful in revealing the number of people in the U.S. with suicide plans reporting access to the means of their plan. As a result, we present descriptive statistics only on our findings (see Table 2). Researchers in Australia have found, however; that those in occupations with ready access to means (firearms, medications, carbon monoxide, poisons) are significantly more likely to die by suicide (Milner, Witt, Maheen, & LaMontage, 2017). In the Milner et al. (2017) study, police officers, firefighters, and EMS personnel all made the list of high-risk occupations for suicide secondary to means access (p. 3).

Attempts: One-sample t tests were conducted on the mean number of responders reporting an attempt against the lowest percentage of the U.S. general population (1.9%) having reported a suicide attempt (Nock et al., 2008a, 2008b). We discovered the mean number of responders overall (n = 83) having reported an attempt (4.5%) was significantly higher than that of the lower reporting end of the general population. When analysis by credential level and field was conducted against the lower threshold, we learned that EMRs, EMTs, paramedics, single-role EMS providers, and firefighters, and those in the Other category all had significantly higher numbers of reported attempts than the general population. We also discovered that those credentialed as AEMTs and those in the law enforcement field did not have a statistically different rate of reported attempts than the general population on either end of the threshold.

The last series of one-sample t tests conducted on the mean number of responders reporting an attempt against the highest percentage of the U.S. general population (8.7%) having reported a suicide attempt (Nock et al., 2008a, 2008b). We uncovered that the mean number of overall responders (n = 83) having reported a suicide attempt (4.5%) was significantly lower than the upper threshold of the general population reporting an attempt. When analysis by credential level and field was conducted against the lower threshold, we found that EMRs, EMTs, paramedics, single-role EMS providers, firefighters, and law enforcement all had significantly lower attempt rates than the general population. We further learned that those with an AEMT credential and those in the other category did not have a number of attempts significantly different than that of the general population.

Multiple linear regression analysis was used to test if each of the characteristics (see Table 1) significantly predicted the reported number of suicide attempts of emergency responders. The number of reported attempts per responder in those who had attempted ranged from one to five (M = 1.83, SD = 0.991) with a value of five indicating five or greater attempts in a lifetime. Number of reported attempts was non-normally distributed (Shapiro-Wilks test p < 0.05), with high skewness of 1.470 (SE = 0.277) and leptokurtic kurtosis of 2.355 (SE = 0.548). The preliminary analysis revealed no violations of the assumption of linearity or homoscedasticity as verified by P-P plot, Q-Q plot, histogram, and tests of collinearity. The results of the regression indicated that none of the variables were predictive of the number of reported suicide attempts (Model 2 ANOVA p =.155). Thus, we reject the alternative hypothesis that a specific list of emergency responder characteristics (see Table 7) is predictive of the number of reported suicide attempts among responders and accept the null hypothesis that none of the characteristics predict emergency responder’s reported number of suicide attempts.

The notably high prevalence of suicidal thoughts and planning, coupled with high percentages of self-reported access to the means of the responder’s suicide plan, is a disturbing finding. While suicide attempts among responders are less than the general population, it does not mean the suicide death rates are necessarily lower. In a study of the rates of suicide among Minnesota emergency responders, it was discovered that suicide deaths are greater among responders than the public (Caulkins, 2018). Perhaps this is because advanced knowledge of how to enact suicide in a lethal manner has been gained by the repeated exposure of responders to those who have attempted and/or died by suicide. Although there is no variable used in this study that is predictive of increased numbers of responder suicide attempts, the presence of a suicide plan is a strong indicator of more frequent ideation. Thus, mental health practitioners should be aware that responders articulating a plan are likely having increased thoughts of suicide. Treatment of this higher level of psychological distress/pain should be a priority. Results further affirm the need to routinely screen responders for suicidality as they may be at higher risk for suicide than the public they serve.

There are three main limitations of this study. The first is that demographics on sex and race/ethnicity were not collected. According to a report published by the National Highway Traffic Safety Administration (2008), females made up 28% of EMS, 4% of the fire service, and 14% of law enforcement. Non-White workers made up 19% of EMS, 24% of the fire service, and 28% of law enforcement. Limitation two is that ideation and attempt questions were asked in such a way as to imply lifetime occurrence. Occurrence before and after entering the emergency response workforce may yield more valuable information as to whether suicidality was pre-existing or potentially a result of emergency response. The third limitation is that we did not determine where the people answering other for field are working. This is an especially glaring limitation as the suicidality of this group is generally much greater than the Other groups. We can only speculate these people may be dispatchers or EMS credentialed people working in a hospital or other healthcare environment.

Voluntary/Anonymous Survey of EMS Providers Experience(s) with Suicide

Voluntary statement: This survey is completely voluntary; there will be no adverse actions taken at EKU or any other institution with reference to the completion or incompletion of this survey.

Anonymous statement: This survey is completely anonymous; no identifiable information is being collected.

Informed consent statement: By starting or completing the survey you are giving informed consent that your responses can be calculated with other responses to test the hypothesis created during this study and used as part of research publications and that you the person to complete the are 18 years of age or older.

Other information about survey:

• This survey is used to determine your experience(s) with EMS provider suicide.
• This survey is to be used for published research.
• Purpose of the research: The purpose of this survey is to assess the number of EMS providers that know of a provider’s suicide or have considered or attempted suicide themselves.
• Procedures involved in the research: The research will involve analysis of the survey results.
• Alternatives available should a subject decide not to participate in the research: none
• Foreseeable risks and discomforts to the subject: It is possible that a respondent many experience sadness, stress or suicidal ideation with the completion of this survey. Emergency Interventional services are listed at the end of this disclaimer.
• Benefits of the research to society and possibly to the individual human subject: This study should gain valuable information about the rate of peer suicides and highlight the issues in order to bring meaningful changes to education, EAP and other services for EMS Providers.
• Length of time the subject is expected to participate. Estimated that will require less than 5 minutes to complete the survey.
• Payment for participation: There is no payment for participation.
• Person to contact for answers to questions or in the event of a research-related injury or emergency contact Dr. Wolman
• Participation is voluntary and that refusal to participate will not result in any consequences or any loss of benefits that the person is otherwise entitled to receive
• Participants have the right to confidentiality and right to withdraw from the study at any time without any consequences

Mandatory questions are indicated by an asterisk. Drop down box selects shown after item.

If at any time you experience sadness, stress or suicidal ideation, please contact any of the services listed below, Dial 911 or go to your nearest Emergency Hospital.
Suidice Prevention Lifeline 1800-273- TALK (8255)
Crisis Text Line TEXT – CNQR to 741741
IM ALIVE 1800-SUICIDE (784-2433)
COP Line 1-800-267-5463
Grief Helpline 1-800-445-4808
Suicide & Crisis Hotline 1-800-999-9999
Safe Call Now 1-206–-459-3020.