The general measures that should be considered in the management of suicidal patients are not much different from those of other psychiatric emergencies, as reported in “pre-hospital emergency protocol for mental disorders in Iran” (14) and include the following three levels. For those patients who have attempted suicide, technician should skip the first two levels and begin with management. For those who are threatening to attempt suicide, technician should begin with level one.
Basic and safety tips (patient, technician and those at the scene):
The first stage (primary action) are including a) pre-scene assessments of site security, escape routes, and safe locations in the event of violence from the patient, b) assessment of patient’s access to weapons and equipment that could threaten his/her own life, technicians or attendees , c) Assessment for risk and need for back up and the presence of police, which includes anticipating their entrance method and avoidance of entering the place alone, d) using family capacities to provide security  and e) Assessment of risk factors for violence and predicting it Symptoms of imminent aggression) (14). In addition, the police should be contacted from the beginning. Dispersal of people present at the scene should be done immediately, as their presence may play a provocative role in attempting suicide (15). Furthermore, when the suicide threat is made with dangerous measures such as firearms, explosives or chemicals, the presence of crowd can be quite dangerous(16).
Important points for patient assessments:
It includes history taking from patient and his family as well as assessing patient's physical condition, especially life-threatening cases, and examining the possibility of a medical origin for symptoms, and psychological assessments. The suicide threat should not preclude the consideration of medical and physical causes for psychiatric symptoms.
Regarding suicide management, patients are divided into two groups:
Those who has not attempted suicide:
In these patients, the following were suggested:
A) Try to build a relationship with patient using respect and empathy. Avoid threats, humiliation and judgmental behavior.
In these situations, generally both patient and family members are agitated and emotionally unstable. Therefore, it is important for technician to remain calm and patient in dealing with them. Many patients may refuse to cooperate because of fear of hospitalization. Thence, the use of behavioral techniques can be effective (Table 2).
B) Evaluate vital signs and ensure the stability of patient's medical condition
C) Evaluate patient’s history and directly ask about intent for another suicidal attempt.
D) Risk assessment of suicide: Items listed in the table below increase the risk of suicide. (Table3)
Verbal threat to commit suicide and history of previous suicide attempt, especially with dangerous methods, and a history of aggression are more important risk factors (18).
Although the assessment of suicide risk factors can help in providing better care and a more accurate evaluation of the patient, according to the current pre-hospital emergency guidelines in Iran, all of these patients, regardless of the assessed risk, should be transferred to medical centers. If the patient or his family refuse to go to hospital, the technician should contact the attending physician and ask for advice.
The following points are of great importance, provided that the patients becomes agitated and behaves in a threatening way and seems to be potentially dangerous for oneself or others:
- Pay attention to people at risk present on the scene and maintain their safety(19).
- Use the aggression management protocol including behavioral and drug managements (full description in the protocol for dealing with an acute psychiatric patient).
- Transfer the patient to the hospital.
E) Collect empty containers of toxins, alcohol, and drugs, for being delivered to the hospital emergency department; even if the patient and his family claim that s/he has not attempted suicide. It is medically important to examine evidence to the contrary and can prevent legal consequences for the technician(20).
F) Documentation of the findings: The emergency technician should document all of the relevant findings and evidence to prevent further legal problems (such as what condition the patient was in at the time of his presence in terms of consciousness, vital signs, scene conditions, etc.) (20).
In a person who has attempted suicide:
In a person who has attempted suicide, immediate attention to the patient's medical risks is a priority. Therefore, the measures include the following:
A. Measuring vital signs:
The first step is to consider the patient's immediate medical needs, initial assessment (Airway - Breathing - Circulation) and control of vital signs and its stabilization. In a conscious patient, the introduction is done simultaneously and permission is given to perform examinations, and in patients with a decrease in the level of consciousness, this is done for the patient's family or companions)
2.a) If vital signs are stable:
It is important to pay attention to the patient's medical condition and transfer him to a medical center for further diagnostic tests and treatment measures. Medical conditions should be monitored along the route, and life-threatening warning signs should always be considered. Behavioral recommendation in dealing with these patients is similar to the previous section.
2.b) If vital signs are not stable:
Attempts to stabilize the patient's vital signs (based on the patient's condition and needs, IV line implantation, opening the patient's airway and starting serum therapy, etc.) should be considered and then the patient should be transferred to the nearest medical center as soon as possible. Behavioral and non-pharmacological interventions can be performed as much as possible depending on the patient's medical and environmental conditions.
It is also important to gather evidence and document findings on the scene, any findings that help to understand the means of suicide (Like empty cans of pills and ropes, etc.) and evidence that is effective in understanding the cause of suicide (Patient's will or any manuscript, patient medical prescriptions, patient medications, etc.) (20).
C) If the patient has died
The first step is to ensure the definitive death of the patient. In the next step, it is important to pay attention to the emergency psychological needs of patients' families. Usually, families in such situations are in a critical situation and may show impulsive reactions reactions(21).Tips for dealing with such situations are provided in Table 4.