Presented by:
Jeremiah D. Simmons, PhD
Christoph Isbjorn, MD – EMS Content Matter Contributor
September 22, 2026
Telehealth Webinar Series:
Suicide Risk Assessment for EMS
Presenters

Jeremiah D. Simmons, PhD
Jeremiah D. Simmons, PhD (Navajo/Yankton Sioux) is a licensed clinical
psychologist and Assistant Professor in the Division of Community
Behavioral Health within the Department of Psychiatry and Behavioral
Sciences at the University of New Mexico Health Sciences Center. Dr.
Simmons’ clinical, teaching, and research efforts focus on improving
behavioral health outcomes for Native American communities, with an
emphasis on youth and school-based mental health systems. Dr.
Simmons specializes in culturally responsive adaptations of evidence-
based practices, integrating community-based participatory approaches
to enhance engagement, access, and effectiveness of care. His work
spans direct clinical service delivery in tribal communities, supervision
and training of interdisciplinary behavioral health providers, and the
development of community-informed prevention and intervention models.
He has contributed to state and federal initiatives focused on suicide
prevention, systems of care development, and behavioral health
workforce capacity building. His long-term goal is to advance culturally
grounded behavioral health systems that reduce disparities and promote
resilience among American Indian and Alaska Native populations.
EMS
Content Matter
Contributor

Christoph Isbjorn, DO, MPH
Dr. Christoph Isbjorn brings a multidisciplinary background in
emergency medicine, public health, psychiatry, and nonprofit
leadership. He spent 10 years as an EMT, including 911 ALS
ambulance service in Denver and several years in Iraq. He
earned his MPH from St. George’s University and his DO from
Rocky Vista University. He founded Vital Start, creating
healthcare pathways for at-risk youth, and served as CEO of
House Lucky Bear, supporting migrant women. He is currently
completing his psychiatry residency, with interests in trauma
prevention and recovery, Child and Adolescent Psychiatry,
justice-involved youth, and interpersonal relationships following
traumatic experiences.
Training
Purpose
&
Learning
Objectives
Training Purpose:
This webinar will provide structured, field-appropriate tools for
suicide risk recognition and brief assessment within the constraints
of prehospital care. Participants will review warning signs, protective
factors, documentation considerations, and coordination pathways
with crisis response and behavioral health services.
Learning Objectives:
1. Identify suicide risk indicators during EMS encounters.
2. Perform a standardized suicide risk screening and apply
stabilization actions (such as environmental safety checks,
verbal de-escalation, or supportive engagement), documented
in all applicable situations.
3. Accurately describe and use the appropriate referral pathway
for suicide risk and complete compliant handoff during transfers
to higher-level of care.
Disclosure Statement
Disclosure Statement: As a jointly accredited provider of continuing education, the IHS Clinical
Support Center must ensure balance, independence, objectivity, and scientific rigor in its
educational activities. Course directors/coordinators, planning committee members, faculty,
reviewers and all others who are in a position to control the content of this educational activity
are required to disclose the existence of all financial relationships with ineligible companies
within the prior 24 months. Safeguards against commercial bias have been put in place. Faculty
will also disclose any off-label and/or investigational use of pharmaceuticals or instruments
discussed in their presentation. All those who are in a position to control the content of this
educational activity have completed the disclosure process and have indicated that they do not
have any relevant financial relationships or affiliations with any manufacturers or commercial
products to disclose.
There is no commercial interest support for this educational activity.
Disclaimer
The views expressed in this presentation are those of the speaker and do not necessarily
represent the views, policies, and positions of the Indian Health Service (IHS), or the U.S.
Department of Health and Human Services (HHS).
Why the EMS
Encounter
Matters
(Centers for Disease Control and Prevention, 2026)
In 2024, the highest suicide rates occurred among non-Hispanic
American Indian and Alaska Native people and non-Hispanic White
people. EMS may meet people at a brief, high-stakes point when
medical danger and emotional crisis overlap.
U.S. suicide deaths in 2024
48,824
Composite
Field Scene
Composite teaching case; not a real patient
• Dispatch: Possible overdose. Family reports recent goodbye
messages.
• On arrival: The patient is drowsy. Medication bottles are nearby.
A family member reports a firearm in the home. Police are on
scene and report that they have secured the firearm.
• Competing demands: Medical stabilization, scene safety,
collateral information, privacy, and suicide inquiry all matter.
• Question: What requires action before a formal suicide screen?
Immediate
Priorities
(Inouye et al., 2014; National Association of State EMS Officials [NASEMSO], 2022)
• Scene safety: Identify weapons, medications, environmental
hazards, bystander escalation, and responder risk.
• Medical threats: Address airway, breathing, circulation, injury,
overdose, hypoxia, hypoglycemia, delirium, an acute and
fluctuating disturbance in attention and cognition, and other
reversible causes.
• Observation: Maintain the level of observation required by the
patient's condition and local protocol.
• Calm contact: Use one primary communicator and explain
each next step.
Medical Causes
and
Consequences
(Appelbaum, 2007; NASEMSO, 2022; Powsner et al., 2023)
• A suicide-related call can also be a toxicologic, traumatic,
neurologic, metabolic, or cardiopulmonary emergency.
• Alert and oriented responses alone do not establish decision-
making capacity. Assess understanding, appreciation of
consequences, reasoning about options, and ability to
communicate a choice.
• Treat injuries and reversible causes while continuing safety
precautions.
• Reassess after meaningful changes in consciousness, pain,
oxygenation, agitation, or intoxication.
A Calm, Private,
Direct Approach
(NASEMSO, 2022)
• Introduce: State your name, role, and immediate concern.
• Reduce stimulation: Limit the audience and move to a safer,
quieter space when feasible.
• Explain: Tell the patient why you are asking direct questions
and what may happen next.
• Listen: Use brief questions, allow silence, and reflect the
patient's words without arguing.
Asking Directly
About Suicide
(Blades et al., 2018; Horowitz et al., 2012)
• “Have you been thinking about killing yourself?”
• “Are you thinking about killing yourself right now?”
• “Did you do anything today with the intention of dying?”
• “What did you think would happen when you took those pills?”
Warning Signs
in the Encounter
(Grover et al., 2023; Substance Abuse and Mental Health Services Administration [SAMHSA], 2025)
• Current signals: Suicidal statements, recent attempt,
preparatory behavior, goodbye messages, seeking means,
severe hopelessness, or escalating agitation.
• Behavioral change: Withdrawal, giving away possessions,
sudden risk-taking, abrupt mood change, or unusual calm after
intense distress.
• Scene evidence: Pills, weapons, ligatures, notes, searches,
interrupted actions, or witness reports.
• Clinical change: Intoxication, psychosis, severe anxiety,
insomnia, pain, loss, humiliation, or acute conflict.
Risk Context
and Protective
Factors
(Allen et al., 2022; Franklin et al., 2017; Grover et al., 2023)
• Risk context: Past attempts, recent escalation, feasible
access to means, serious mental illness, substance use,
pain, loss, and reduced impulse control.
• Protective factors: Supportive relationships, cultural and
spiritual connection, responsibilities, coping skills, treatment
engagement, and willingness to accept help.
• Clinical use: Protective factors guide engagement and
stabilization. They do not cancel current intent, a recent
attempt, or an unsafe environment.
Screen, Brief
Assessment,
Full Evaluation
Screen
Brief validated questions identify who
needs more assessment. Examples
include the ASQ, C-SSRS, and agency-
approved tools accessed through MDCalc.
Field
Assessment Clarifies current danger, medical needs,
and immediate action.
Full
Evaluation A qualified clinician develops a broader
formulation and disposition plan.
(MDCalc, n.d.; National Institute of Mental Health [NIMH], n.d.; Powsner et al., 2023)
Validated Tools
and Local
Protocol
(Blades et al., 2018; Carter et al., 2017; Horowitz et al., 2012; Posner et al., 2011)
• C-SSRS: Structures questions about suicidal ideation and
behavior across levels of severity.
• ASQ: A brief screen validated in medical settings, with separate
youth and adult pathways.
• Agency decision: Training, documentation, response steps,
age range, and medical direction should be defined before field
implementation.
• Limitation: Asking directly does not increase suicide risk, and
no scale can reliably predict who will die by suicide.
Six Domains for
a Field Inquiry
Structured teaching framework informed by SAFE-T and the C-SSRS; not a separate validated scale (Posner et al., 2011; SAMHSA, 2025)
1. Current thoughts: Presence, frequency, intensity, and last
occurrence.
2. Intent and expectation: Desire to die, expected outcome, and
whether the patient feels relieved or disappointed that the
attempt was interrupted or did not have the expected outcome.
3. Plan and access: Method, preparation, feasibility, and access
to means.
4. Recent and past behavior: Attempts, interrupted acts,
rehearsal, and nonsuicidal self-injury.
5. State and context: Medical status, intoxication, psychosis,
agitation, loss, and collateral information.
6. Supports and collaboration: Reasons for living, trusted
people, treatment, and willingness to accept help.
Language for
the
Six Domains
(NIMH, n.d.; Posner et al., 2011; SAMHSA, 2025)
• “When did the thoughts last happen, and are they happening now?”
• “Did you expect or want the action to end your life?”
• “What method have you considered, and can you get to it now?”
• “Have you started, practiced, or prepared in any way?”
• “What has changed today, including alcohol, drugs, pain, voices, or
a major loss?”
• “Who can help you through the next several hours?”
Formulate
Action,
Do Not Predict
• Describe: What the patient said, what happened, what others
observed, and what the scene showed.
• Identify: Immediate medical danger, suicide-related danger,
access to means, and barriers to collaboration.
• Act: Choose the safest next step using protocol, consultation,
available resources, and reassessment.
• Avoid: Do not rely on a single label such as low, moderate, or
high risk without the supporting facts.
(Carter et al., 2017; Franklin et al., 2017; Grover et al., 2023)
Action
Threshold:
Immediate
Danger
(Cai et al., 2022; CDC, 2026; Isaacs et al., 2022; NASEMSO, 2022; Powsner et al., 2023)
• Current intent, a recent attempt, an interrupted act, severe
medical injury, or access to a feasible lethal method.
• Inability to participate safely because of intoxication, delirium,
psychosis, agitation, or impaired consciousness.
• Maintain observation, address medical threats, reduce access
to hazards when safe, and activate transport or medical
direction per protocol.
• Treat every attempt seriously, regardless of apparent lethality.
Communicate the urgency before arrival and at handoff.
Action
Threshold:
Concern without
Current Intent
(Powsner et al., 2023; SAMHSA, 2025)
• A denial of current intent does not erase a recent attempt,
preparatory behavior, collateral report, or dangerous scene
evidence.
• Clarify timing, sobriety, access to means, reliability of the
interview, and willingness to accept evaluation.
• Use medical direction and the local pathway when the need for
transport or further evaluation is uncertain.
• If the patient remains in the community, use a warm connection
and document the specific safety plan and responsible supports.
Stabilization
during
the Encounter
(NASEMSO, 2022)
• Lower arousal: Use one calm voice, simple explanations,
physical space, and fewer stimuli.
• Increase control: Offer limited choices that remain clinically
safe.
• Validate: Acknowledge pain and effort without endorsing
hopeless conclusions.
• Connect: Identify one trusted support and one next step the
patient can tolerate.
• Reassess: Repeat safety and medical checks after changes in
behavior or condition.
Lethal Means
Safety
(Marcus et al., 2025; Stanley & Brown, 2012)
• Ask about the method used, planned, or available, including
firearms and medications.
• Create time and distance between the patient and lethal means
when this can be done safely and within policy.
• Use collaborative, temporary language focused on the current
crisis.
• Do not handle weapons outside training and policy. Coordinate
with law enforcement, family, or another authorized person.
• Include access and any storage action in the handoff and
documentation.
Intoxication,
Psychosis,
and Agitation
(NASEMSO, 2022; Powsner et al., 2023)
• Treat reversible medical causes and monitor for evolving toxicity
or injury.
• Answers may be incomplete or unreliable when attention,
perception, consciousness, or impulse control is impaired.
• Use verbal de-escalation first when feasible. Know what the
agency defines as restraint and follow protocol for indication,
application, monitoring, and reassessment. Use the least
restrictive intervention that safely meets the need.
• Reassess suicide-related statements after clinical change, while
preserving the original report and objective scene observations.
Youth and
Developmental
Considerations
(Horowitz et al., 2012; NIMH, n.d.)
• Use concrete, age-appropriate questions and avoid relying only
on the caregiver's report.
• Interview the young person privately when feasible, safe, and
consistent with policy.
• Ask caregivers separately about behavior change, access to
medications or firearms, supervision, and their ability to
maintain safety.
• A positive youth screen requires a defined pathway for further
assessment and disposition.
Culturally
Responsive
Engagement
(Allen et al., 2022)
• Ask how the patient understands the crisis and who should be
involved.
• Invite family, kinship, cultural, spiritual, and community supports
when the patient agrees and safety permits.
• Do not assume that identity, family, spirituality, or community
connection functions as protection for this individual.
• Coordinate with tribal, IHS, urban Indian, and local services
through the established pathway.
• Pair concern about disparities with recognition of community
strengths and cultural continuity.
Refusal,
Capacity, and
Involuntary
Transport
(Appelbaum, 2007; NASEMSO, 2022; Powsner et al., 2023)
• A refusal form does not substitute for assessing decision-
making capacity and immediate danger.
• Consider intoxication, delirium, head injury, hypoxia, severe
pain, psychosis, and other impairments.
• Use medical direction early when capacity or the transport
pathway is uncertain.
• Follow state law, tribal jurisdiction, agency protocol, and local
agreements. If refusal persists, complete the required refusal
documentation and record the capacity assessment, risks
explained, consultations, and witnesses.
Documentation
that
Supports
Continuity
(SAMHSA, 2025; Troyer & Brady, 2020)
• Patient report: Use brief quotations for suicidal thoughts,
intent, expected outcome, and willingness to accept help.
• Observed facts: Mental status, injuries, substances, behavior,
means, and changes over time.
• Collateral: Identify the source and distinguish report from direct
observation.
• Actions: Treatment, observation, means safety, consultations,
transport decision, and response.
• Handoff: Receiving person, destination, time, and unresolved
safety concerns.
Sample EMS
Narrative
Composite documentation example
Partner called 911 after receiving a goodbye text at 18:10.
Patient stated, “I took the pills because I wanted to die,” and
reported continuing suicidal thoughts. Patient was drowsy
but arousable and oriented to person and place. Partner
reported a firearm in a locked bedroom safe. EMS did not
handle the firearm. Law enforcement confirmed that the safe
remained secured. Poison Control recommended continuous
monitoring and emergency department evaluation; online
medical direction concurred. Patient transported with
continuous observation. Receiving RN accepted handoff at
19:02 and received the ingestion details, consultation
recommendations, current intent, collateral report, and
firearm access.
Safe Handoff:
SBAR
with Risk Detail
(Troyer & Brady, 2020)
• Situation: Reason for contact, current medical status, and
immediate suicide concern.
• Background: Event timeline, patient statements, past
behavior, substances, treatment, and collateral report.
• Assessment: Mental status, intent, plan, access, observed
behavior, response to care, and limits of the interview.
• Recommendation: What the patient needs next, precautions
in place, and unresolved medical or safety issues.
• Close the loop: Confirm the receiving clinician heard the
critical risk information.
Referral and
Coordination
Pathways
(988 Suicide & Crisis Lifeline, n.d.)
• Medical emergency or immediate physical danger: Activate
emergency transport and destination notification according to
protocol.
• Behavioral health crisis: Use local mobile crisis, tribal or IHS
behavioral health, crisis receiving, or emergency department
pathways.
• 988 Lifeline: Call, text, or chat 988 for crisis counseling and
connection to local resources.
• Warm connection: When remaining in the community is
permitted, confirm the accepting service, responsible support,
and backup plan.
Common
Pitfalls
(Bryan et al., 2017; Carter et al., 2017; Stanley & Brown, 2012)
• Relying on “Are you safe?” or accepting a denial without
clarifying the event.
• Treating a score, diagnosis, or protective factor as proof of
safety.
• Using a “no-suicide contract” instead of collaborative safety
planning and appropriate disposition.
• Ignoring medical causes, intoxication, scene evidence, or
collateral information.
• Giving a phone number without confirming the next contact or
responsible support.
Key Takeaways
(Blades et al., 2018; Powsner et al., 2023; Troyer & Brady, 2020)
• Direct, respectful suicide questions improve clarity and do not
increase suicide risk.
• A brief field assessment supports immediate action. It does not
predict the future or replace a full evaluation.
• Medical stabilization, observation, means safety, and
reassessment occur alongside the suicide inquiry.
• The safest handoff carries patient statements, observed facts,
collateral information, access to means, and unresolved concerns.
• Local protocol, medical direction, tribal policy, and community
pathways shape the final response.
Practice
Resources
Resources verified September 16, 2026 (Health Resources and Services Administration [HRSA], n.d.; MDCalc, n.d.)
•988 Suicide & Crisis Lifeline: Call or text 988, or chat at 988lifeline.org.
•NIMH ASQ Toolkit: Validated screening tools and clinical pathways for
medical settings.
•SAMHSA SAFE-T: Framework for inquiry, formulation, intervention, and
documentation.
•NASEMSO Guidelines: National model guidance for universal care,
behavioral emergencies, and refusals.
•MDCalc: Point-of-care access to the C-SSRS and other clinical tools. Use
agency-approved versions and pathways.
•Poison Help: Call 1-800-222-1222 to reach the local poison center.
•Local resource map: Add tribal, IHS, mobile crisis, crisis receiving, ED,
law enforcement, and medical direction contacts before delivery.
Questions and
Discussion Thank you!
References
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