Development of a pre-hospital emergencies protocol for the management of suicidal patients in Iran

Background Suicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in the treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation. Method We reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks. Results The basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient (behavioral and pharmacological) management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered. Conclusion A locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians.

The prevalence of suicide attempts in Iran has increased in the last two decades [5]. The prevalence of suicide attempts in Iran varies from 16.8 per 100 thousand people in a year in south of Iran to 117.8 per 100 thousand people in a year in north of Iran [6]. The highest rate of completed suicide in Islamic Republic of Iran is 12.9 per 100, 000 which is related to Western Provinces, including Ilam, Lorestan, Hamedan, Kurdestan and Kermanshah. One of the methods of suicide in this area is self-immolation (about 27% of all suicides). About 80% of self-immolation cases are committed by women. Self-immolation is more common in the first years of marriage when there are many emotional problems and conflicts and low coping skills between couples. Studies attribute issues such as the decline in the Human Development Index, cultural factors and negative attitudes toward women, and the reduction of suicidal stigma [7,8]. The lowest rate is 2.8 per 100,000 related Central Provinces including Isfahan, Yazd, Semnan and Qom [9].
According to Iranian Social Welfare Organization (ISWO), the social emergency of ISWO has taken preventive action in 8400 suicide attempts through mobile teams (> 3000 cases), social service bases (242 cases), crisis intervention centers (1300 cases), and contact with social emergency hotline (3400 cases) in past year [10].
Pre-hospital emergency has also been involved as a first line contact in suicide situations in the country and has played an important role in this case [11]. They are the most widespread medical emergency facility in throughout the county and in most cases are the first line contact with possible suicidal patients and should provide interventions based on their prioritization, clinical judgment, and decision-making skills. Therefore, they are generally trained for the skills of how to deal with a suicide situation [12].
In critical cases such as suicide attempts, emergency technician should transfer the patient to a suitable medical center, after appropriate crisis management. Inadequate skills and mastery of emergency technicians in these conditions can lead to serious injury and even death in a person who threatens to commit suicide. Furthermore, poor decision-making ability in critical situations, increases psychological stress on emergency technician [13][14][15][16]. Therefore, different countries try to provide coherent and comprehensive clinical programs for suicide management so that the emergency technician can use them in the face of a patient threatening to commit suicide. In the United States, Dr. Betz described the important principles of suicidal patient management (patient safety, attention to physical issues, and suicide risk assessment) in his article, given the limited time and the likelihood of impending injury [17]. Dr. Christopher reviewed existing protocols for managing suicide in a pre-hospital emergency room in Washington to evaluate and integrate them to achieve a coordinated and comprehensive protocol in the future [11]. In Brazil, 15 psychiatrists and psychologists, after a systematic review of sources and articles, provided guidelines and recommendations for the Brazilian Psychiatric Association for the management of patients with suicide [18]. In Iran, there are cultural and religious issues that affect the relationship between the patient and the technician such as the need for covering, maintaining a minimum distance with patient, not touching an opposite sex patient. There are also barriers that have been identified in previous studies Ordinary people (who have no information about vital and psychological first aid) are crowded at the scene, which can complicate the decision for the technician [19].The purpose of this study was to develop a Compatible with culture, concise, evidence-based, and step-bystep guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation.

Review of literature
This study was performed in two stages with the mixed method. We used the literature review to access the relevant resources. First, we searched PubMed, Scopus, and PsycINFO databases for the combination of the following keywords: 1)"Suicide" (OR) "suicide prevention" (OR) "suicide risk factors" (OR) "self-harm" (OR) "suicidal patients". 2) "Management" (OR) "protocol" (OR) "pre-hospital care. Then, we combined the two searches using AND operator. We limited the search date to the results published in the recent 10 years (from June 1, 2010 to June 1, 2020). Additionally, we reviewed the chapters related to suicide management in psychiatric textbooks.
In the next step, we reviewed the abstract of the retrieved articles and selected 30 relevant articles. Subsequently, we used the Cochrane checklist to assess the full text of the articles and select suitable articles for further analysis. In this way, 20 articles were selected for the next stage (Table 1). We used these 20 articles and the textbooks for data extraction.
The extracted findings were then categorized according to the stage of intervention. The first stage is similar to the stages for other acute psychiatric patients, which are described in detail in the "pre-hospital emergency protocol for mental disorders in Iran" [16]. Here, we report the special and additional points related to suicidal patients including: ensuring safety in suicidal patients; evaluation and history taking in suicidal patients; behavioral and pharmacological management in suicidal patients; important points to reduce life-threatening risks in suicidal patients. Each question was scored on a Likert scale from very low to very high (1)(2)(3)(4)(5). Experts answered all of these questions for each protocol item. And the scores of 8 experts participating in the meeting for each item were added together. Finally, items with a total score of 27 and above (more than two-thirds of the total score) were selected for the protocol, and a score of 13 or less (less than one-third of the total score) was removed, and the items with the average score of 14-26 were discussed again and revised to a final agreed upon format for the protocol.
To check the clarity and comprehensibility of the revised protocol and the feasibility of its implementation in pre-hospital emergency setting, we held two sessions with two different group of people to receive feedback about the protocol and consider possible executive problems. The first session included emergency technicians and technical and operational deputy of one of the Emergency Centers of Tehran (about 50 people). The second session was held with general practitioners (dispatch) of operations in the pre-hospital emergency department. Prior to the start of both sessions, informed consent was obtained from the participants.
Then, we revised the protocol another time considering the feedbacks of the sessions and finalized the protocol in a two-page format that could be easily used in the ambulance as a quick review of important measures in dealing with a suicidal patient before confronting him/her.

Result
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" [16] and include the following three levels. For those patients who have attempted suicide, the technician should skip the first two levels and begin with management. For those who are threatening to attempt suicide, the 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) prescene assessments of site security, escape routes, and safe locations in the event of violence from the patient, b) assessment of the patient's access to weapons and equipment that could threaten his/her own life, technicians or attendees [30], 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 [30] and e) Assessment of risk factors for violence and predicting it Symptoms of imminent aggression) [16]. 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 [22]. Furthermore, when the suicide threat is made with dangerous measures such as firearms, explosives or chemicals, the presence of crowd can be quite dangerous [30].

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: 1. 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 [40]. 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 [31]. D) Risk assessment of suicide: Items listed in the table below increase the risk of suicide (Table 3).
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 [41,42].
In addition to the items listed in Table 3, If the patient threatening to commit suicide is from the northern or western provinces of the country (especially in young married women with a history of marital problems, a history of psychiatric illnesses, especially major depression and post-traumatic stress disorder, a past history of selfimmolation) Be aware of the possibility of self-immolation and examine the evidence [7,8].
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 prehospital 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: 2. 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: Table 2 Behavioral recommendations in dealing with a suicidal patient • Introduce yourself, explain your role and the help that you can provide • Talk in a calm and confident tone • Invite the patient to talk about his/her problem • Pay attention to patient's cultural and religious conditions (such as the need for covering, maintaining a minimum distance with patient, not touching an opposite sex patient if Muslim) • Reduce external stimuli and existing noise as much as possible • Ask the police to stay out of patient's sight (if the presence of police makes patient irritable and restless) • Do not leave patient alone • Do not make false promises to calm patient • Take any threat of suicide attempt seriously • Encourage patient to provide information of relatives who can help Table 3 Some of suicide risk factors • Existence or history of depression and aggression • Recent failure or loss • High-risk mental conditions such as (hopelessness, severe restlessness and agitation, or extreme guilt feeling) • Being a housewife or unemployed • Being exposed to domestic violence • History of previous suicide attempt or self-harm (especially recent ones and using dangerous methods) • Recent consumption or intoxication with alcohol or other substances • Access to guns or other deadly methods • Lack of a strong social or family support network • Instability in family or existence of family conflicts • Having a suicide plan or preparing suicide means

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.) [44].

C) If the patient has died
The first step is to ensure the definitive death of the patient. Call the police to be present at the scene, because, this may be murder instead of suicide. 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 [45]. Tips for dealing with such situations are provided in Table 4.

Discussion
Several studies have been conducted on suicide management, as one of the most important issues in psychiatric emergencies. However, in most studies, more attention has been paid to the management of these patients in hospital emergency department than in the pre-hospital emergency department. In 2004, for example, the Australian National Institutes of Health provided a guidance for managing suicides in the emergency department, which was a good guide for emergency room therapists.
Lipton developed a clinical guideline of prevention, assessment, and management of suicide for pre-hospital technicians in 2005. However, drug management is not covered in this article [17]. Dr. Chunduri et al. used focus group discussions of psychiatrist working in emergency psychiatry wards to write a clinical guideline for assessment and management of suicide in 2017 [29].
Our purpose in writing this protocol was to increase the technician's skills in the following areas: 1. Reducing the risk to himself, patient, patient's family and those present at the scene. 2. Diagnosing the possible medical origins of the lifethreatening medical symptoms and comorbidities 3. Quick assessment of the risk of imminent suicide 4. Establishing a therapeutic relationship with the patient and his family 5. Management of the suicidal patient and helping in management of the crisis 6. Collecting and recording the evidence related to suicide in the scene, both to assist hospital staff and to protect themselves from possible future legal problems.
Similar to the protocol for dealing with an acute psychiatric patient, the first step in this protocol is preparing the scene and ensuring security of the scene [16,22].
The initial assessment and taking history in this protocol are the same as the general protocol for dealing with a psychiatric patient. However, it is especially important to ask about the history of any psychiatric disorder from the family of the suicidal subject. Assessment of risk Table 4 Important points in dealing with committed suicide 1. Ask for help from police (who has been called at the beginning to provide security, he must record clues at the scene indicating the cause of death to report to forensics) 2. Do not manipulate evidence and documents in the scene) Avoid destroying police clues as number 1( 3. Do not remove the body of the deceased from the scene (For the same reason number 2) 4. Express empathy with the family and use verbal calming techniques 5. avoid judgmental behaviors with the family 6. In families with severe restlessness use medications (oral lorazepam 2 mg tablets) 7. Educate family about the condition and the normalcy of experiencing symptoms of acute psychological stress. Advise them to go to publicuniversity clinics or call the crisis hotline for help from psychologists. 8. Encourage family to contact relatives and other people who can help them 9. Provide information and telephone number of centers that can be contacted, if they would need it. 10. If the situation does not improve with these initial measures, contact the dispatch center and get an assignment factors (especially those that increase the risk of imminent suicide) as well as protective factors are the next crucial steps. However, according to emergency protocols in Iran, all of the suicidal patients must be transferred to a hospital, even if the technician considers the patient to be in a low risk for suicide. Although patients with low risk for suicide can be generally effectively cared for, monitored and followed-up at home, this decision is reserved for mental health professionals working in hospitals [30].
The protocol also emphasizes on assessment of risk factors for imminent suicide as opposed to chronic risk factors of suicide in the pre-hospital emergency setting due to time limitations [45,46]. Furthermore, to reduce the negative reactions related to the stigma related to the word "suicide", in this protocol we suggest technicians to ask patient about the decision and any immediate plan to harm oneself [21].
In the management of patients threatening suicide in our protocol, verbal intervention is the basis of treatment in line with other protocols [21,47]. As in previous studies, it has been seen that many suicide threats are in fact a kind of protest against the conditions. Available and requesting a change and requesting assistance. Empathy and empathy for the patient's condition and, if necessary, intervention in the crisis can be very helpful [47] Respect for the patient is very important and behaviors that induce the patient to be a failure or a sinner should be avoided. Attitudes that send the patient the message that "he does not know what is right?" And that he "does not have the authority to decide for himself" can also complicate matters [48].
Our protocol, like other protocols, prioritizes physical needs and risks in patients who have attempted suicide [42]. If behavioral interventions are not helpful, medications are considered [27]. Choice of medication and administration method are similar to that mentioned in the protocol for dealing with an acute psychiatric patient [16]. Additionally, although the main issue here is suicidality of the patient, the technician should address any other emergent symptoms such as aggression accordingly and not to ignore them as subsidiary [16].
This protocol, like others, has emphasized on paying attention to the emotional needs of the family of the patients who have committed suicide [27,48,49]. Feelings of anger or guilt towards the deceased is expected. Local religious and cultural teachings about the sinful act of suicide and the ambiguity of the fate of person who commits suicide also increase the pressure and stress of the family and mandates the intervention by technician as the first member of the treatment team to enter the scene.

Conclusion
It is practical and useful to develop an evidence-based, but concise and portable protocol for pre-hospital emergency technician, which covers all of the major issues for a quick review before confronting a suicidal patient.

Limitation
The number of articles and protocols on the management of suicide-threatening patients in the pre-hospital emergency, which we had access to, was limited. Most articles are related to the hospital emergency department. While the pre-hospital condition is very different.

Recommendation
This protocol should be used in next researches and in emergency operations to identify weaknesses and operational glitches.

Acknowledgements
This project was carried out with the support of the technical and operational deputy of the Emergency Organization of Iran. We are very grateful to the Technical and Operational Deputy, Dr. Hassan Sari Nouri, and the senior officer Dr. Zeinab Mohammadian, of the Emergency Organization of Iran for their support and cooperation in organizing the expert meeting and technical feedback sessions. Thanks to Seyed Kazem Malakouti, member of the National Suicide Prevention Association for providing valuable feedback on the protocol and the manuscript.
Authors' contributions FSH and SVS were involved in compiling the protocol and writing the results and discussion, FSH and SHGH performed the review, article selection, and data extraction and wrote the introduction section. MSH was involved in reviewing texts and preparing tables of articles and writing methods section. All of the authors read and approved the final manuscript.

Funding
School of Behavioral Science and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Science, Tehran, Iran.

Availability of data and materials
The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate As human were involved in the study, the study protocol was performed in accordance with the relevant guidelines". This article was approved by the ethics committee of Iran University of Medical Sciences. Under numberIR.IUMS.REC.1397.1356. All participants (expert panel and emergency technicians and technical and operational deputy of one of the Emergency Centers of Tehran and general practitioners (dispatch) of operations in the pre-hospital emergency department) were informed about the study and only those providing written informed consent were enrolled in the study.

Consent for publication
Not applicable.