TRIGGER WARNING: TOPICS OF SUICIDE MAY BE HARD FOR SOME PEOPLE TO READ ABOUT. THIS ARTICLE IS COVERING THE MEDICAL ASPECTS OF CHEMICAL SUICIDES. IF YOU OR A LOVED ONE NEEDS HELP, CALL 988 OR SEEK CARE AT A LOCAL EMERGENCY DEPARTMENT. REMEMBER, IF YOU ARE TREATING A SUICIDE ATTEMPT SURVIVOR, DO NOT PASS JUDGMENT. WE, AS EMS PROFESSIONALS, SHALL PROVIDE COMPASSIONATE, APPROPRIATE CARE TO ALL PATIENTS.
It’s mid-Monday morning on a crisp spring day. You’ve been alerted to a “one-down” call at a local park. CAD notes indicate that the caller was walking in the park and came across a vehicle in the far corner of the parking lot. He notes that “it smells really strongly of rotten eggs” and that there’s a note taped to the window, but he didn’t want to get close enough to read it.
(Photo Courtesy of (Bohrer, 2015))
Chemical Suicides, also sometimes referred to as detergent suicides, became prevalent in 2007 in Japan, and in 2008 started occurring in the United States (Reedy, Schwartz, & Morgan, 2011). These methods can provide severe risk to responders even after the victim has succumbed to his or her inflicted injuries. Unlike other methods, such as firearms, hangings, intentional overdoses, and cutting, chemical suicides tend to linger in the area where the act was committed.
According to a study completed in 2016, Nine states reported their chemical suicides for data points. These showed that with 22 incidents between 2011 and 2013, 43 people were harmed. Of these, eight first responders and four employees of the coroner’s office were involved. (Anderson, 2016) Often, these calls come out as “one down” or “check the welfare,” and responding crews have no idea what they’re walking into.
As with all scenes, a scene survey for overall provider safety should be conducted. Strange odors (such as rotten eggs, sewage smell, bitter almonds, etc) that are out of place should be noted and approached cautiously. In this scenario, with that reporting, I would position my unit uphill, upwind (if possible) stay a decent distance away initially and use binoculars to assess from a distance. The caller noted that a sign was present, so I would try to get a read on that sign as soon as possible.
(Photo courtesy of (Bohrer, 2015))
Not all suicides will be as straightforward on initial assessment; some people do not leave a note on the window, or they mix the chemicals in a small closet or bathroom. Sometimes, we encounter people who have routed their car exhaust into their cars (often seen on TV and in movies).
Some key things to look out for from
(Minnesota Division of Homeland Security and Emergency Management (HSEM), 2018) and (Bohrer, 2015):
·Presence of notes/warnings
·Tape along the door seals and windows of all entrances except the driver’s side; the interior of the driver’s side may also be taped. (Bear in mind, more modern cars are mostly airtight except for places like cabin air filter intake)
·Taped up vents on the interior of the car
·Taped up door inside a residence
·Presence of tubing or piping from the vehicle exhaust into the vehicle
·Removal of interior door handles in a car
·Strong noxious odors that cannot be reasonably explained (i.e., sewer gas in the middle of a parking lot not near any source)
·Presence of empty household chemicals or other labeled chemicals from commercial sources
·Presence of large (think 5-gal painter’s buckets) with liquid, foam, or visible vapors coming from them
·Presence of tools that can be used to mix chemicals in a bucket on the other side of the car
·Odor of “rotten eggs” or “sewer gas”
·Odor of Bitter Almonds
·Yellow – greenish residue visible on the surfaces inside of the car or structure and/or on glass surfaces
If you notice any of these signs coupled with a patient present (or suspected if you cannot visualize them, e.g., an interior bathroom or closet), do not enter, initiate a hazmat response, and follow their recommendations.
(Photo courtesy of (Bohrer, 2015))
One primary consideration when treating victims of attempted chemical suicide and handling victims of chemical suicide is that the gas is very likely to be impregnated into their clothing and their respiratory tract unless otherwise specified by the chemical in question; consult Hazmat. Decontamination should include properly removing their clothing (later bagged and tagged for evidence and handed over to the hazmat team/law enforcement). When transporting an attempted chemical suicide, the exhaust fans should be operating at maximum speed and if possible, opening any windows in the unit to allow fresh air ventilation.
Most of these victims will likely need advanced airway management and, at minimum, respiratory support, so extreme caution should be used when inserting an airway (ET tube or supraglottic airways) or managing with CPAP or passive Oxygen. Consider RSI/MFI if it’s available for your service.
While the substances used for chemical suicides are vast, we will focus on some of the most common methods, how they work in the body, and what, if anything, we can do to counteract the agent(s) in question. If you suspect that you have encountered a chemical suicide event, start your local fire and hazmat companies and have them assess and decontaminate if appropriate. The ability to mix and match chemicals that are toxic and/or fatal is expansive, and in today’s information age, it’s unfortunately at everyone’s fingertips. It’s a personal belief that the proliferation of the internet is a partial cause for the increase in chemical suicides. Some of the chemicals that can be used include, but are not limited to, according to (Ambrose, 2017) :
·Hydrogen Sulfide
·Asphyxiant Gases (Helium or Nitrogen)
· Carbon Monoxide
·Cyanides (usually HCN or Hydrogen Cyanide)
·Pesticides (Organophosphates or Carbamates)
·Phosphides
·Azides
The two most common chemical suicides seen around the country are related to Carbon Monoxide and Hydrogen Sulfide. Let’s tackle Hydrogen Sulfide (H2S) first.
If you encounter a suspected H2S Detergent Suicide, stop and call for a hazmat and law enforcement response. If the victim is visible, appears to be alive but in distress and you have proper respiratory protection (I.E. SCBA) you can make an emergency rescue. If you perform a rescue and have a live patient or you are tasked to transport the deceased to the morgue/ER; use caution and be sure to alert the facility of the hazmat.
Hydrogen Sulfide (H2S)
is a pungent, potent, colorless, flammable, and explosive gas that smells like rotten eggs or raw sewage. These are also sometimes called detergent suicide and what many agencies default to when they hear “chemical suicide.” Most people know this smell and can tell “something” is off. H2S is a naturally occurring gas released in lower concentrations from sewage, hot springs, decaying organic matter, and natural gas. An individual can create H2S by mixing a strong acid and a sulfur source. These are the types of suicides you commonly see having a bucket in the car or sealed-off room with them.
H2S is usually lethal if the mix is correct and there is no ventilation for approximately 4 minutes. However, many people do not get the concentrations correct and survive the attempt. One of the dangers of H2S that responders should be aware of is that the gas will paralyze your olfactory nerve. EMS must rely on the hazmat team to monitor the air and not rely on their sense of smell. You may feel like you’re ventilating, and the gas is dissipating, but it may be intensifying. Thankfully, the odor threshold for H2S is very low, a mere 0.5 ppm, with a permissible exposure limit of 10 ppm for 10 minutes. Ideally, we would have hazmat ventilate an area if possible, but there are limited exposures, which are an acceptable risk. However, H2S gas will immediately threaten life at 100 ppm.
Health effects of acute H2S exposure per (Centers for Disease Control (CDC), 2014) and (National Institute for Occupational Safety and Health (NIOSH), 2019)
Eyes ·Irritant ·Eye pain ·Conjunctivitis ·Lacrimation ·Corneal Vesiculation ·Photophobia ·Blurry Vision
| Nervous System ·Coma ·Death (as a result of respiratory arrest) ·Convulsions ·Photophobia ·Dizziness ·Headache
| Psychological ·General Weakness/Malaise ·Exhaustion ·Irritability · Insomnia (prolonged exposure)
|
Respiratory System ·Irritant ·Pulmonary Edema ·Tissue suffocation by inhibiting the cytochrome oxidase system ·Anaerobic metabolism will cause a rise in lactic acid and subsequent acid-base imbalance ·Inflammation of the bronchi may cause permanent damage
| Cutaneous ·Prolonged exposure can cause dermatitis ·Liquid (frozen) H2S can cause frostbite | GI Disturbance ·Nausea ·Vomiting
|
Medical Management
Victims of a chemical suicide who have survived will likely need rapid and aggressive treatment and transport to survive. The danger of the patients themselves “off-gassing” and harming responders is minimal. However, entry into the hot zone should only be done by a trained crew with splash protection and SCBA. A patient should be disrobed and covered per local policy, as the gas and/or liquid could be stored in the clothing.
There is no proven antidote for H2S poisoning, and the treatment consists of supportive care of the respiratory tract and cardiovascular system. Consult local protocols for suggested responses to presenting symptoms. If a patient is in severe distress, it may be logical and reasonable to use RSI to introduce an ET tube. Their airway can swell in reaction to the poisoning and occlude, necessitating a possible cricothyroidotomy.
·Consider nebulized bronchodilators for bronchospasm, using the standard cautions in their use based on the age of the patient.
·Children who develop stridor may be treated with racemic epinephrine (0.25- 0.75ml of 2.25% racemic epinephrine to 2.5 cc of sterile water
·Comatose, hypotensive, and seizures that present should be treated with typical protocols
· Treat any presenting cardiac arrhythmias per local protocol or ACLS
· Supplemental Oxygen is appropriate
·When in doubt, dual consult with poison control (1-800-222-1222) and the intended facility for recommendations; while poison control cannot issue medical direction, they can recommend treatments, and the intended facility can authorize them
Two treatments have little supporting evidence in the literature as possible antidotes for H2S poisoning. Consult Medical Control FIRST before attempting these treatments.
·Nitrite therapy, such as inhaled Amyl Nitrite (30 seconds on, 30 seconds off) until IV is established.
·Sodium Nitrite (300mg in no less than 5 minutes.
·Hyperbaric Oxygen therapy.
It is believed that the nitrite therapy will form sulfhemoglobin (SulfHB) to extract the sulfides from the tissue. There is little evidence to back inhaled amyl nitrite more than the first few minutes post-exposure. As (Narayan & Petersen, 2022) explains, “SulfHb is a stable, green-pigmented molecule, which constitutes less than 1% of normal hemoglobin invivo.” According to their research, sulfHB is irreversible and lasts until the erythrocyte dies. Common chemicals and medications that can cause SulfHb
·Acetanilide
·Phenacetin
·Nitroglycerin (both medication and exposure to actual nitroglycerin
·Trinitrotoluene
·Metoclopramide
·Methylene Blue
·Sulfur Compounds
Patients will present with cyanosis and normal PaO2; however, devices like the RAD 57 cannot differentiate between sulfhemoglobin and methemoglobin (MetHb). These tests must be performed in a laboratory setting and are extremely limited worldwide. The best “rule out” method to suspect SulfHb over MetHb is a lack of response to methylene blue, as there is no antidote for Sulfhemoglobinemia. (Narayan & Petersen, 2022)
In the hospital, the patient should be monitored for delayed onset post-hypoxic encephalopathy. This may take up to 24 hours. In-patient labs should include CBC, BGL, Electrolytes, Renal Function tests, Chest X-Ray, and SpO2, and if nitrites are used, monitor methemoglobin levels.
Carbon Monoxide (CO)
is an odorless, colorless gas known as “the silent killer.” There are far more accidental poisonings than suicides by CO nationwide. In the realm of attempted or successful suicides, you will see this as a person who either tapes a flexible pipe to the exhaust on their car and feeds it back into the car or someone who goes and sits in a car and leaves it running in an enclosed space. CO is challenging to detect, and most frontline EMS units should, at minimum, have a small CO meter (Such as the Tango 1) to warn providers of a possible CO environment.
If you find someone with a pipe leading from the car to their passenger compartment, in a vehicle in an enclosed space running the car, or a small, enclosed space in a structure running a grill or other device that generates CO, initiate a fire/hazmat response and reassess the scene. When assessing the scene, can you visibly tell that the patient is still breathing? If conscious, have them walk/crawl out of the area. It is not recommended to enter the environment where a known CO poisoning exists without proper respiratory protection. According to (Centers for Disease Control, n.d.) there are two primary types of exposure to CO, minor and severe.
Minor Symptoms | Severe Symptoms | Clinical Signs |
·Headache ·Dizziness ·Nausea ·Vomiting ·Chest Pain/Discomfort ·(Slight) Altered Mental Status | ·Malaise ·Worsening Headache ·Nausea / Vomiting ·Shortness of breath ·Chest Pain/discomfort ·Irritability ·Ataxia ·Altered Mental Status ·Unresponsiveness ·Coma ·Death | ·Tachycardia ·Tachypnea ·Hypotension ·Impaired Memory ·Impaired Cognitive Function ·Arrhythmias ·Acute MI ·Pulmonary Edema ·Metabolic Acidosis |
Medical Management
We know that the process of CO poisoning is that the CO molecule has a stronger affinity in red blood cells than oxygen does for the hemoglobin receptors. This, in turn, prevents the blood from transporting and using oxygen, causing hypoxia. Patients may appear cherry red, and their SpO2 readings will be erroneously “high” or “normal” because of how the SpO2 sensor “reads” the blood. These patients must be treated as rapidly as possible with a high flow of 100% Oxygen to “wash out” the CO. Patients with severe CO poisoning will likely benefit from hyperbaric oxygen treatment and a known CO poisoning should be transported to a Hyperbaric capable facility, if possible. EMS units should use the RAD-57 or similar probe to detect carboxyhemoglobin levels in the blood and differentiate it from the SpO2 reading.
Once removed from the environment, these patients do not require further decontamination. The hospital course will usually follow with high-flow oxygen, serial neurological exams, EKG, Blood draw for cardiac enzymes, and possibly CT or MRI in more severe cases. If we intervene early enough, before arrest, the prognosis for survival is good.
The bottom line, as DC Oreshan says in (Fire Engineering Staff, 2014), is that taking “10 seconds to slow down and do a good, thorough scene size-up could save a responder’s life.” As mentioned before, typically, we aren’t called for a “suicide,” as it isn’t always as straightforward as a hanging or firearm-related suicide. We must use caution when approaching a scene of the unknown lest we become victims ourselves.
Despite what we’ve been previously taught, according to research, Christmas is not the most common time for suicides, the trend shows that suicides wane around the holidays, but there is a spike around New Years. (Stang, 2023) So, we should be acutely aware that suicides occur year-round and be alert to scene safety at all times.
References
Ambrose, P. (2017, 12 08). Chemical Suicide Response Training for First Responders: Chemical Suicide Response. Retrieved from HazmatNation: https://www.hazmatnation.com/chemical-suicide-response/#sthash.cYIusGH8.dpbs
Anderson, A. R. (2016, 10 07). Characterization of Chemical Suicides in the United States and Its Adverse Impact on Responders and Bystanders. Retrieved from National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102590/
Bohrer, R. (2015, 11 23). Chemical Suicide Awareness. Retrieved from Fire Engineering: https://www.fireengineering.com/firefighting/chemical-suicide-awareness/
Centers for Disease Control (CDC). (2014, 10 21). Medical Management Guidelines for Hydrogen Sulfide. Retrieved from Agency for Toxic Substances and Disease Registry (ATSDR): https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=385&toxid=67#:~:text=At%20low%20levels%2C%20hydrogen%20sulfide,convulsions%2C%20coma%2C%20and%20death.
Centers for Disease Control. (n.d.). Clinical Guidance for Carbon Monoxide Poisoning Following Disasters and Severe Weather. Retrieved from CDC - Clinical Guidance: https://www.cdc.gov/carbon-monoxide/hcp/clinical-guidance/index.html
Fire Engineering Staff. (2014, 04 11). Chemical Suicide: 10 Seconds Can Save Your Life. Retrieved from Fire Engineering: https://www.fireengineering.com/fire-prevention-protection/chemical-suicide-ten-seconds-can-save-your-life/
Minnesota Division of Homeland Security and Emergency Management (HSEM). (2018, 05 21). Chemical Suicide Awareness Bulletin. MN. Retrieved from https://mn.gov/emsrb/assets/HSEM%20Chemical%20Suicide%20May%202018_tcm21-340559_tcm1116-368766.pdf
Narayan, S., & Petersen, T. L. (2022). Uncommon Etiologies of Shock. Critical Care Clinics, 39(2), 429-441. doi:https://doi.org/10.1016/j.ccc.2021.11.009
National Hazardous Materials Fusion Center. (n.d.). Chemical Assisted Suicide: Reponder Information. MA. Retrieved from https://www.mass.gov/files/documents/2016/09/na/chemical-assisted-suicide-responder-info.pdf
National Institute for Occupational Safety and Health (NISOH). (2019, 10 30). Hydrogen Sulfide. Retrieved from NIOSH Emergency Response Guide: https://www.cdc.gov/niosh/npg/npgd0337.html
Reedy, S. D., Schwartz, M. D., & Morgan, B. W. (2011, 07 12). Suicide Fads: Frequency and Characteristics of Hydrogen Sulfide Suicides in the United States. West Journal of Emergency Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117605/
Stang, D. (2023, 10 23). Suicide and the Holidays – Myth or Reality? Retrieved from Alliance of Hope for suicide loss survivors: https://allianceofhope.org/suicide-and-the-holidays-myth-or-reality/
U.S. Department of Health & Human Services. (2024, 09 17). Chemical Suicides: The Risk to Emergency Responders. Retrieved from Chemicial Hazards Emergency Medical Management (CHEMM): https://chemm.hhs.gov/chemicalsuicide.htm
