Neurological

Suicidal ideation at a community event

Intermediate

Adult · 35yr · male

Patient Information

Dispatch	You are called to the first aid post at the Perth Anzac Day community fair. A 35-year-old male, Daniel Marsh, has been brought in by a concerned bystander who states he overheard him say he 'doesn't want to be here anymore' and found him sitting alone crying near the toilets.
Patient	Daniel Marsh — 35yr (80kg)
Incident History	Pt was found sitting alone behind the portable toilets at the rear of the event. Bystander states pt was crying and said 'what's the point anymore' and 'everyone would be better off without me.' Pt walked with bystander to FAP. No apparent physical injuries.
Emergency Contact	Sarah Marsh (Wife) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Speaking in full sentences.
Breathing	Breathing adequate. RR slightly elevated. Nil wheeze or crackles. No respiratory distress.
Circulation	Radial pulse present, regular, normal rate. Skin warm and dry. Nil external bleeding.
Disability	GCS 15 (E4V5M6). Alert and oriented to time, place and person. Visibly distressed, tearful, avoids eye contact. Slow and withdrawn responses.
Exposure	Nil visible injuries. No rashes. Pt is dressed appropriately for the event. Nil medic alert jewellery noted on initial view.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Nil	18	96	128/82	<2s	15	4 4 ++	36.8	5.4 mmol/L	0
10 mins	98% (RA)	Nil	16	88	124/80	<2s	15	4 4 ++	36.8	5.4 mmol/L	0

History Taking

Treatment Response

Diagnosis

This patient is suffering from acute suicidal ideation in the context of a depressive episode, presenting with passive suicidal thoughts and significant emotional distress without an active plan or immediate physical self-harm at this time.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not ask directly and sensitively about suicidal thoughts within the first few minutes of assessment, the patient becomes increasingly withdrawn and stops responding — trainee must re-engage using non-confrontational, open questioning before pt will disclose.)
! (If the trainee leaves the patient unattended at any point — even briefly — have the facilitator note that pt has moved toward the exit of the FAP. Prompt the trainee: 'You notice Daniel has stood up and is moving toward the door.')
! (If the trainee fails to remove or secure any potentially dangerous objects from the immediate environment — e.g. sharps tray left on bench, scissors visible — the facilitator should quietly point this out as a debrief point.)
! (If the trainee attempts to contact the wife without first gaining patient consent or without considering whether this may escalate distress, have the patient become visibly upset and state 'please don't call her, that will make things worse' — trainee must navigate consent and patient wishes.)
! (If the trainee attempts to physically restrain the patient without clear justification of immediate danger to self or others, the facilitator pauses the scenario and debriefs on minimum force principles and the legal framework under Section 243 of the Criminal Code.)

Treatment Objectives

1. Ensure scene safety and personal safety prior to approach — confirm no immediate physical danger to officers, bystanders or patient.
2. Approach in a calm, non-confrontational manner. Maintain appropriate distance and be aware of body language throughout the encounter.
3. Perform Primary Survey — confirm airway, breathing, circulation and GCS 15 with no immediate physical life threat.
4. Establish rapport using open, non-judgmental questioning. Allow patient to speak without interruption.
5. Sensitively and directly ask about suicidal ideation: 'Are you having thoughts of hurting yourself or ending your life?' Document patient response.
6. Assess for a specific plan, intent, means, and timeline — if patient discloses a plan or access to means, escalate urgency immediately.
7. Do NOT leave the patient unattended at any point following disclosure of suicidal ideation.
8. Carefully remove or secure any potentially dangerous objects from the immediate FAP environment (sharps, scissors, cords).
9. Complete Vital Sign Survey including BGL — BGL 5.4 mmol/L, vitals within normal limits, no organic cause identified.
10. Consider and address organic causes for behavioural presentation — confirm GCS 15, BGL normal, no signs of hypoxia, intoxication assessed (one beer, not acutely intoxicated).
11. Note patient is on Sertraline (SSRI) commenced 3 weeks ago — be aware of Serotonin Syndrome risk if ondansetron were to be considered; no ondansetron indication in this scenario.
12. Apply Richmond Agitation Sedation Scale (RASS) — patient is RASS 0 to +1 (alert and calm to mildly restless/distressed). Sedation is NOT indicated. De-escalation is first-line.
13. Continue de-escalation and reassurance throughout. Acknowledge the patient's feelings without minimising them.
14. Contact State Operations Centre (SOC) / Clinical Support Paramedic (CSP) to advise of the presentation and seek guidance on patient management and transport.
15. Arrange transport to an appropriate medical facility — this patient requires emergency department assessment and mental health review. Transport is required.
16. Advise the patient clearly but compassionately that they need to be assessed by a doctor and that the EHS team is going to help them get that care.
17. Do NOT attempt to administer any sedative medication — EHS Primary Care scope does not authorise sedation under any circumstances.
18. Document RASS score, all history, disclosures regarding suicidal ideation, and all interventions on patient care record.
19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Disturbed & Abnormal Behaviour

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Signs/Symptoms	Pt reports feeling 'hopeless' and 'worthless.' States he has been feeling this way for several weeks. Denies any current physical pain or injury.
Allergies	NKDA
Medications	Sertraline 100mg daily (commenced 3 weeks ago by GP). Nil other regular medications.
Pertinent History	Pt reports a recent GP diagnosis of depression. Has had two previous episodes of low mood but has never presented to emergency services before. Denies previous suicide attempts. Denies current alcohol or illicit drug use today. Had one beer approximately two hours ago.
Last Oral Intake	One beer approximately 2 hours ago. Ate a sausage sizzle around midday.
Events Leading	Pt attended the Anzac Day fair with his wife. They had an argument approximately 30 minutes ago and wife left the event. Pt wandered to the rear of the venue and was found by bystander.
Treatment Prior	Nil self-treatment. Bystander provided reassurance and walked pt to FAP.

Onset	Pt states feelings have been building for 'a few weeks' but today has been 'the worst.' Was at the event with his wife before they had an argument and she left.
Pain	Nil physical pain reported.
Quality	Describes emotional pain as overwhelming. States 'I just can't see a way out.' When sensitively asked about suicidal thoughts, pt initially deflects but when asked directly confirms he has been thinking about hurting himself. States he has not made a specific plan today but admits to having thoughts about it at home previously.
Radiates	Nil
Severity	Emotional distress 8/10 by patient report.