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Paucis Verbis: Assessing patients with suicidality in the ED


SuicidalTennisBallDr. Rob Orman emailed me last week about creating a pocket card on Suicide Risk Stratification. In many community ED’s, risk assessment is done by the emergency physician. I’m lucky where I work, because we have a 24/7 psychiatric ED, which consults on suicidal patients in the “medical ED”.

In the end, assessment is primarily based on physician judgment, because there’s no great clinical decision tool, rules, or scores to assess risk. Rob has created his own mnemonic to help you ask the right questions in assessing a suicidal patient. This is a sneak peek into a larger article that Rob is planning to unleash on the world on suicide assessment. Based on his review of the literature and own clinical experience, the mnemonic is: TRAAPPED SILO SAFE.


  • “Risk factors” which increase a patient’s risk for committing suicide in the near future.


  • “Protective factors”which decrease a patient’s risk for committing suicide in the near future.

PV Card: Risk Stratification of Suicide

Go to the ALiEM Cards site for more resources.


Michelle Lin, MD
ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco
Michelle Lin, MD
Michelle Lin, MD

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  • aek

    Fairly close correlation w/ Thomas Joiner’s interpersonal theory of suicide. For consideration: perceived burdensomeness and thwarted belongingness combined with behavioral practice for capacity to kill self.

    What’s lacking in tool: treatment to reduce/eliminate causative distressors.

    (No one has investigated why previous attempts increase future risk. I posit that it’s directly related to patients’ experiences of receiving assessments that are themselves distressors with no treatment that reduces psychological pain and causative suicidality factors, plus strips civil rights, exposes to career and social harms, hence causing treatment seeking/acceptance avoidance/refusal.) See also high suicide rates among psychiatrists, female physicians, all physicians, dentists and veterinarians – all with higher than public knowledge of assessment/extant tx and means to access.

    • Intriguing thoughts. Your theory for why previous attempts increase future risk makes sense. I hadn’t really thought through the WHY of this risk factor. I’ll look more into Joiner’s interpersonal theory. Thanks!