Suicidal Evaluation: The DEAD PIMP Assessment

It’s a difficult situation that just about every EMS provider has been faced with at some point. Someone, somewhere thinks a friend or loved-one wants to commit suicide and they call 911. You arrive on scene to find a healthy looking patient who is adamant that they have no desire to harm themselves or anyone else. They don’t want to go with you. And now, you’re faced with a challenging evaluation.

This is a situation that experienced mental health professionals can find difficult. You have very little mental health training and you’re being asked to make a complex prediction about the potential future behavior of a person whom you’ve never met. What’s an EMT to do?

Thomas Dunn is in a unique position to talk to EMS providers about evaluating patients with potential mental illness. Thom is an active paramedic in downtown Denver, Colorado who routinely works shifts on a busy urban ambulance. He’s also a clinical psychologist who evaluates and treats patients’ at Denver Health Medical Center. Thom’s dual specialty makes him a rare specialist in human psychology as it applies to EMS providers.

When he talks, EMS providers listen…and so should you.

To help with this challenging potential suicide evaluation, Thom has come up with a fantastic acronym (in his unique paramedic style) to help remember what questions you might want to ask to determine the patients true risk of committing suicide. All of these elements influence the patient’s likelihood of ultimately harming themselves. To help us make the right call, Thom gives us the D.E.A.D. P.I.M.P. evaluation.

Before we jump too far into the acronym, let’s start by recognizing that, before we ultimately reach a decision about a potentially suicidal patient, we need to talk to the base physician. This is ultimately a medical consult between multiple trained medical personnel. The DEAD PIMP assessment is going to help you have that conversation with the physician based on real information about the patient’s true risk factors.

So now, for the first time on the inter-webs, Thom Dunn’s DEAD PIMP assessment:

D is for Disorder

Does the patient have a psychiatric history? Patients who have previous diagnosis of depression or more significant psychiatric disorders are more likely to attempt to harm themselves. Schizophrenics and bipolar disorder patients’ are most prone to suicide attempts.

E is for Environmental Stressors

Ask the patient if they are experiencing increased stress in their life. Take note of what kinds of things are happening in the patient’s life that may be causing undue stress. Events like divorce, forced separation from loved ones, death of a family member or friend and loss of work or livelihood are serious life stressors. If the patient reports one or more significant events that are causing them stress, it’s worth paying attention.

A is for Access to Firearms

Patients’ with immediate access to firearms are far more likely to successfully kill themselves. Often, all that is necessary to prevent these events is to place the firearm in a state that requires thought before use. Ask how accessible the firearm is to the patient. Is the weapon loaded? Are the ammunition and the firearm in the same location or separate? Is there a trigger guard? If so, where is the key? Patient’s who are at risk for suicide should be encouraged to make their firearm less accessible while they are going through their challenges.

D is for Disinhibition

Disinhibition is a complex way of saying something is affecting the patients frontal cortex reasoning and their willingness to inhibit their own behavior. Alcohol and drug use are the two most common reasons for disinhibition that we see in the prehospital setting but dementia and head injury histories can also lead to general disinhibition. Is the patient in a disinhibited state? Have they consumed alcohol or drugs? Do they have a medical history that may impair their ability to make good decisions and use good judgment?

P is for Previous Attempts

Patient’s who have previously attempted suicide are in a much higher risk category for a future successful suicide attempt. This might be one fo the first questions you ask your patient if you are concerned about their risk of hurting themselves. “Sir have you ever attempted to harm yourself in the past?” If the answer is yes, listen closely to the circumstances behind that previous attempt. Are there similarities to what they are experiencing now?

I is for Ideation

Has the patient been thinking about hurting themselves? If so, what thoughts have they had? Have they had conversations with family or friends about harming themselves? Explore what kinds of thoughts the patient has been having regarding committing harm to themselves. The more frequent and detailed these thoughts have been, the more likely it is that the patient will eventually follow through on their thoughts.

M is for Male

It’s simply a matter of numbers. Males are more likely to attempt to harm themselves and they are way more likely to be ultimately successful at ending their lives.

P is for Plan

Planning is the next stage of suicidal ideation. If the patient reports thinking about suicide, ask them if they have a plan for how they might end their lives. You might be surprised by how many patients who report little or no suicidal ideation will willingly relate complex plans for how they might harm themselves. The more detailed and realistic the patient’s plan, the more likely it is that they will eventually carry out their plan.

While we’re talking about patient’s plans, how effective are different plans for committing suicide? Here’s a quick breakdown of different popular mechanisms for ending ones life and how frequently they result in success:

Firearms (82.5%)
Drowning (66%)
Hanging / Suffocation (61%)
Gas Poisoning (42%)
Jumping (34.5%)
Ingestion (1.5%)
Cutting (1.2%)

So there it is. The next time you’re evaluating a patient who may be wanting to harm themselves, think DEAD PIMP. Ask the questions and then call your base physician and consult on transport. With this acronym, you’ll know what you want to ask about, what you want to report to the physician and what you want to document after the fact.

What do you think? Is this an assessment that you can use?

Comments

  1. Andrew Przepioski says:

    Great acronym. I already ask these questions or considering them excluding fire arms, disinhibition (that’s a new word for me), and male (I was told old males in EMT school, but never took it into consideration probably because I never looked up the numbers to confirm it) so I probably won’t use it, but if anyone asks, I’ll share this with them.

  2. Steve Whitehead says:

    @Andrew Thanks Brau.

  3. An interesting mnemonic.

    I did not realize how low the success rates were for ingestion and cutting.

    Good information.

    .

  4. Good acronym. I change Disinhibition to Drugs (etoh)/Dementia. Easier to remember.

  5. Dave Cook says:

    Great information and I will use some of it when evaluating my next case like this. There is a problem with the article though, you present a question that you didn’t really answer. “Someone, somewhere thinks a friend or loved-one wants to commit suicide and they call 911. You arrive on scene to find a healthy looking patient who is adamant that they have no desire to harm themselves or anyone else. They don’t want to go with you.” Forcing someone to go to the hospital against their will really has nothing to do with the stress in their life, their sex, past attempts or access to weapons. If they are still denying suicidal ideation after your assessment, and are not under the influence, then it is up to the police to decide to put that person in protective custody to allow you to transport. And that may only be possible if someone is willing to fill out an affidavit saying that this person is a threat to themselves and why. Now if you perform your assessment and find out they are suicidal that is one thing, but the article states that the pt is adamant that they are not suicidal.

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