HOW NOT TO COMMIT SUICIDE
4 of 9 pages 
From the Emergency Room
Marc Rubin, a paramedic with the San Francisco Department of Public Health, heard I was doing this article and suggested I interview him. Until then it never occurred to me to interview any of the emergency people who are sent to the scene of a suicide. I didn't realize that they are probably more involved with the suicidal person than anyone else. They're the first people who comfort them, the only people who see where they live and what they did to themselves, and they seem to get a more vivid idea of the person's personality than anyone else, until they drop them off at the hospital and never see them again. Rubin talked like he had been storing up feelings for some time. He made me wonder if working in emergencies by nature makes people impassioned and articulate.
"Half my ambulance calls just involve going to a person's house, calming them down, recommending they go to a doctor in the morning. It's a 'give me strokes' kind of call. People just want to talk to somebody. If they call emergency and say they're contemplating suicide they are sent the ambulance and the police. If there's violence the police go first -- they're paid to risk their lives. Then we take the people to the hospital.
If you talk to the police and the paramedics you find they feel many of these people should be allowed to die. We're bound by our jobs to make them live, but there's a lot of distaste for it. You never know if the suicidal person was distraught or made a rational decision. It's real hard to put a value judgement on it.
We see a lot of alcoholics, gays, recently divorced or separated people, lonely people. People that I would characterize as emotionally vulnerable. We see them at the height of their vulnerability. We see some people who cut their wrists gingerly, knowing that it won't kill them, just to try it and see what it feels like. We see others who are serious about it, actively seeking it out but not sure if they're going to do it until the moment comes. Those are the ones we have to talk to as they're about to jump off a building.
My last call of the shift last night was a man who shot himself. I got there and saw this girl cool in the doorway: 'I think my father's shot himself. Check downstairs.' His wife said, 'I didn't want him around any more and he shot himself.' He was Chilean. In some cultures in a situation like that they don't think the man's a jerk if he takes his life. It's the courageous thing to do.
I like working on the street. People in emergency rooms get patients for a length of time, but I do my medical things and get them there and then I'm done. My role is medical intervention. I make sure they don't compromise their vital functions. That means checking their airway -- listening for the movement of air through the mouth and nose -- and their breathing rhythm -- are their lungs expanding? And checking their heartbeat -- is it fast enough? Is it stopped? If it's off you have to do cardiopulmonary resuscitation, which involves pressing on the sternum and spine to get the heart going again. A lot of times if someone's lost fluid or if they're in shock we have to replace the fluid or blood intravenously.
If they're suicidal we are always required to take them to the emergency room. If they're conscious, say if I've just bandaged their arm, then as a courtesy I'll ask if they'll come to the hospital with us. If they're upset or say no, they'll still have to come, though.
There are so many scenarios. Most of the time the police, medical people and firemen are compassionate, but it's still scary. There are six or eight people in uniform looking at this scared, vulnerable person. If everything goes well, they might even like giving up responsibility for themselves to the people in uniform. But otherwise, all it might take for them to go off the handle is for somebody to make a wisecrack -- say if the person's in drag. Or sometimes people get angry just because you're in a uniform. Then you have to talk them down.
I stay professional a lot of the time -- not cold, but impersonal. Then I move up or down from there to more or less professional in tone. Sometimes I'll talk to the person about why they did it, what their alternatives are. If they're hysterical I try to get them to talk about something they like to do. I'll talk about my own problems, real or contrived.
Society doesn't support its losers. A theme I get repeatedly from suicides is 'Look at me, I've failed and I don't want to go seek help.' There's a lot of embarrassment. I tell them everybody needs help. A lot of people go to psychiatrists -- doctors, police, politicians. I try to get them laughing. I don't myself but I try to get them to.
I kind of enjoy it. As you know there are realms of thought under a psychedelic that you can't enter any other way. Psychosis is like that and that's why I appreciate it. I've sung things like quasi-Indian chants with people. I find that some policemen do the same. There's often a lesson that a psychotic person is offering me. Not to get too dependent on something -- habits, jobs, people, money, family -- that has let someone down. Or not to take myself too seriously. I think you have to be somewhat egocentric to attempt suicide. I ask the egocentric ones sometimes if the world is really going to care that much.
There's a lot of voyeurism in it. I find that with a lot of medical people. They'll hear a hot call-- a knifing, maybe -- and really want to see it. Anytime you have a collection of fire and ambulance equipment, people gather on the street.
A lot of people don't want to take the responsibility. A friend of mine had a call downtown -- a man on a roof twenty stories high. She stayed up there talking with this man. Can you imagine you'd feel if he said, 'No, no, you're wrong' and jumped off?
That guy who shot himself in the head last night -- I wouldn't feel comfortable trying to resuscitate him. He was warm but the chances of living were too low. If he had any other signs of life -- blood pressure, pulse, respirations -- I would have had to do something. It's hard to do heroics to bring someone back to life for a day or two. I had a man a couple of months ago who had been shot in the head and I did resuscitate him. I felt bad that he had the trauma of being slapped in an ambulance. Things like that you have to try to do - you have to try.
The whole idea of trauma centers is to take people who would die otherwise and bring them back to life. Whether their life is meaningful or not doesn't matter. We go for everybody. You're usually naked when you go in. I can't put it down, but in a way it's barbaric. I wouldn't want to go through it. If I'm that close I'd just as soon let it go."
Until recently, emergency room doctors were people who'd rather be elsewhere.
Even now, a lot of emergency room doctors are moonlighting residents or
specialists forced by their hospitals' rotating assignments to do occasional
"trauma duty". But emergency medicine is becoming a specialty of its own,
perhaps because four times as many people per capita visit emergency rooms
as did twenty years ago. If someone you know is in danger of dying, call
emergency services, not your family doctor, because that's what the emergency
room does -- keeps people from dying.
The basic principle for keeping suicides from dying is to do as little
as possible. Most drug overdosers are left unconscious in a place where
they can heal. The more the hospital has to do, the more chance of infection
or accident. Drugs, including psychiatric drugs, are avoided, because
they might react with drugs the patient already took. Before the 1940s,
when Swedish doctors discovered this, about 45% of the barbiturate overdose
patients in emergency rooms died from attempts to wake them up with drugs.
Now more than 95% of people who come into the emergency room on a drug
overdose live. Many suffer no more than a day or week of discomfort in
a hospital bed, like a teenager I heard about who tried to kill himself
with 100 vitamin tablets. Others compound their problems with severe medical
damage that may be permanent or take years to go away.
My information on the medical aftermath of suicide comes from half a dozen
interviews with emergency room staff people, but two were especially helpful
-- Larry Bedard, M.D., a former psychiatric resident who now manages the
emergency room at Marin General Hospital, San Rafael, and Howard McKinney,
Pharm. D., a pharmacologist with the San Francisco Poison Control Center,
who answers telephone inquiries and consults with emergency room staff.
Like other emergency room staff people I talked to about this article,
both these men are among the most thoughtful, direct people I have met.
This is not an exhaustive survey; anything less than a medical
textbook is bound to be sketchy, misleading in places, and oversimplified.