Medicine, Faculty of
Medicine, Department of
DSpace
UBCV
Stephanian, Dylan
Master of Science - MSc
University of British Columbia
On average, one person attempts suicide by jumping from a bridge in the Lower Mainland of British Columbia once every 14 days, but the population that jumps and their outcomes following a suicide attempt are poorly understood. A multi-agency retrospective chart review was performed using records from the Canadian Coast Guard, Joint Rescue Coordination Center, police departments, and the British Columbia Coroner’s Service to identify incidents. A complete picture of each incident was then built by identifying corresponding BC Ambulance Service and hospital records, and linking all records for each incident. This methodology successfully identified a comprehensive list of incidents, and may be useful in future prehospital and search and rescue medicine research. Records from the ten agencies involved in these incidents were collected and linked to create a dataset describing all known jumps from a bridge >12m in height in the Lower Mainland of BC from January 1, 2006 to February 28, 2017. 1208 incidents were identified, 273 were confirmed jumps, and 197 were jumps into water. The multi-agency linkage portion of the study was highly successful; outcomes were identified for 90.6% of all incidents. The population that jumps from a bridge is similar to those who commit suicide by other means. Those jumping are mostly male (74.9%), and early to mid-life (IQR 28-48 years). Of those who jumped and hit water, 59.9% were promptly recovered, 25.4% were iii transported to hospital and 15.2% survived. Survival is dependent on bridge height, patient age, and time interval between jumping and being recovered from the water. The presence or absence of vital signs, and level of consciousness (measured on the AVPU scale) on recovery appears to prognosticate survival to hospital discharge. This may assist prehospital care providers making treatment decisions for these patients.
Outcomes in suicidal bridge jumping in the Lower Mainland by DYLAN STEPHANIAN BASc, The University of British Columbia, 2014 Thesis submitted in partial fulfilment of the requirements for the degree of Master of Science in The Faculty of Graduate and Postdoctoral Studies (Experimental Medicine) The University of British Columbia (Vancouver) December, 2019 © Dylan Stephanian, 2019 ii The following individuals certify that they have read, and recommend to the faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Outcomes in suicidal bridge jumping in the Lower Mainland Submitted by Dylan Stephanian in partial fulfillment of the requirements for the degree of Master of Science in Experimental Medicine. Examining committee Dr Jeff Brubacher, Emergency Medicine Supervisor Dr Doug Brown, Emergency Medicine Supervisory Committee Member Dr Andrew MacPherson, Emergency Medicine External Examiner iii Abstract On average, one person attempts suicide by jumping from a bridge in the Lower Mainland of British Columbia once every 14 days, but the population that jumps and their outcomes following a suicide attempt are poorly understood. A multi-agency retrospective chart review was performed using records from the Canadian Coast Guard, Joint Rescue Coordination Center, police departments, and the British Columbia Coroner’s Service to identify incidents. A complete picture of each incident was then built by identifying corresponding BC Ambulance Service and hospital records, and linking all records for each incident. This methodology successfully identified a comprehensive list of incidents, and may be useful in future prehospital and search and rescue medicine research. Records from the ten agencies involved in these incidents were collected and linked to create a dataset describing all known jumps from a bridge >12m in height in the Lower Mainland of BC from January 1, 2006 to February 28, 2017. 1208 incidents were identified, 273 were confirmed jumps, and 197 were jumps into water. The multi-agency linkage portion of the study was highly successful; outcomes were identified for 90.6% of all incidents. The population that jumps from a bridge is similar to those who commit suicide by other means. Those jumping are mostly male (74.9%), and early to mid-life (IQR 28-48 years). Of those who jumped and hit water, 59.9% were promptly recovered, 25.4% were iv transported to hospital and 15.2% survived. Survival is dependent on bridge height, patient age, and time interval between jumping and being recovered from the water. The presence or absence of vital signs, and level of consciousness (measured on the AVPU scale) on recovery appears to prognosticate survival to hospital discharge. This may assist prehospital care providers making treatment decisions for these patients. v Lay summary In Greater Vancouver, a person tries to kill themselves by jumping off a bridge every 14 days. Unfortunately, a large percentage of these people die and caring for these patients can be traumatic for rescuers. Prior to this work, little was known about the people who jump, the details of their rescue, and how to best care for them. This study showed that most jumpers are men between 28 and 48 years old. People are more likely to die if they jump from higher bridges, are not rescued quickly, or if they have no pulse when rescued. People who are awake at the time of rescue are likely to survive. This information will help guide treatment for first responders and paramedics caring for people who have jumped from a bridge. vi Preface This thesis and all associated research is the result of the independent work of the author, Dylan Scott Stephanian. A portion of this thesis was presented as a poster at the UBC Medicine Research day. Data collection, storage, analysis, and publication is covered by University of British Columbia Clinical Research Ethics Certificate H16-02263, as well as Fraser Health Research Ethics Certificate 2018-024 vii Table of contents Abstract ...................................................................................................................... iii Lay summary ............................................................................................................... v Preface ........................................................................................................................ vi Table of contents ....................................................................................................... vii List of tables .............................................................................................................. xii List of figures ............................................................................................................ xiii Symbols and abbreviations ...................................................................................... xiv Glossary .................................................................................................................... xvi Acknowledgements .................................................................................................. xix Dedication ................................................................................................................. xx Suicide by jumping in context ...................................................................................... 1 Suicide rates ......................................................................................................................... 1 Sex trends in suicide ............................................................................................................ 2 Age trends in suicide ........................................................................................................... 3 Ethnicity and immigration in suicide ................................................................................. 4 Suicide contagion ................................................................................................................ 5 Time trends in suicide ......................................................................................................... 7 viii Psychiatric conditions in suicide ........................................................................................ 8 Suicide means ...................................................................................................................... 9 Suicide from bridges ...................................................................................................................................... 10 Objectives ................................................................................................................... 12 Primary objectives .............................................................................................................. 12 Objective 0: ..................................................................................................................................................... 12 Objective 1: ...................................................................................................................................................... 12 Objective 2: ...................................................................................................................................................... 12 Secondary objectives .......................................................................................................... 13 Objective 3: ...................................................................................................................................................... 13 Objective 4: ..................................................................................................................................................... 13 Hypothesis .................................................................................................................. 15 Settings ....................................................................................................................... 16 Bridges ................................................................................................................................ 16 Water bodies ....................................................................................................................... 19 Response in the Lower Mainland ...................................................................................... 21 Organisational involvement .......................................................................................................................... 21 Communication and coordination agencies ................................................................................................ 23 Response agencies ......................................................................................................................................... 25 Current prehospital treatment ......................................................................................... 30 Canadian Coast Guard ................................................................................................................................... 30 British Columbia Ambulance Service ........................................................................................................... 35 Prehospital treatment limitations ................................................................................................................ 38 ix Outcomes ............................................................................................................................ 39 Building and analysing the dataset ........................................................................... 41 Case identification and selection ...................................................................................... 41 Canadian Coast Guard records ..................................................................................................................... 42 Joint Rescue Coordination Center records .................................................................................................. 43 Police records ................................................................................................................................................. 43 British Columbia Coroner Service records .................................................................................................. 44 Incident selection .......................................................................................................................................... 44 Data linkage ........................................................................................................................ 47 Challenges and limitations in data linkage ................................................................................................. 50 Ambulance and hospital record identification ................................................................. 51 British Columbia Ambulance Service records .............................................................................................. 51 Hospital records ............................................................................................................................................. 53 Results of record identification .................................................................................................................... 54 Challenges in record identification .............................................................................................................. 55 Data collection ................................................................................................................... 57 Canadian Coast Guard data .......................................................................................................................... 58 Joint Rescue Coordination Center data ....................................................................................................... 58 Police data ...................................................................................................................................................... 61 British Columbia Coroner’s Service data ..................................................................................................... 61 British Columbia Ambulance Service data .................................................................................................. 61 Hospital data .................................................................................................................................................. 62 Limitations and obstacles to data collection ............................................................................................... 63 Data abstraction and storage ............................................................................................ 64 x Storage and security ..................................................................................................................................... 68 Data analysis ...................................................................................................................... 69 Use of personal identifiers ................................................................................................ 70 Missing data ........................................................................................................................ 71 Data quality ........................................................................................................................ 73 Methodological efficacy ..................................................................................................... 76 Study population ........................................................................................................ 79 Age ..................................................................................................................................... 80 Sex ....................................................................................................................................... 82 Incidents .................................................................................................................... 84 Bridge distributions ........................................................................................................... 85 Time distribution ............................................................................................................... 87 Inter-incident timing and clustering ................................................................................ 89 Incident response and interagency communication ....................................................... 90 Response delays ............................................................................................................................................. 91 Information transfer to hospital ................................................................................................................... 92 Outcomes .................................................................................................................. 94 Outcome distributions ................................................................................................................................. 94 Factors affecting outcomes ............................................................................................... 98 Analysis population ..................................................................................................................................... 100 Analysis variables ......................................................................................................................................... 100 xi Multivariate analysis .................................................................................................................................... 105 Level of consciousness on recovery ............................................................................................................ 107 Vital signs on recovery ................................................................................................................................ 108 Height ........................................................................................................................................................... 109 Age ................................................................................................................................................................. 112  .................................................................................................................................................................. 117 Injuries .............................................................................................................................. 120 Conclusions .............................................................................................................. 126 Objective 0 ........................................................................................................................ 126 Objective 1 ......................................................................................................................... 128 Objective 2 ........................................................................................................................ 130 Objective 3 ......................................................................................................................... 133 Objective 4 ......................................................................................................................... 135 References ................................................................................................................ 138 Appendixes ................................................................................................................ 153 xii List of tables Table 1. Bridges included in study ........................................................................................... 17 Table 2. Data available from each agency .............................................................................. 60 Table 3. Missing cases by agency ............................................................................................. 71 Table 4. Study population age and sex distribution summary ............................................. 79 Table 5. Age distribution of the study as compared to total Canadian suicides ................. 80 Table 6. Sex distribution of fatalities in the study population ............................................. 82 Table 7. Distribution of incidents by bridge .......................................................................... 85 Table 8. Prehospital dispatch and handover delays ............................................................... 91 Table 9. Variation between best understanding of incident history and incident history recorded by emergency room staff ......................................................................................... 93 Table 10. Logistic regression model for factors affecting survival ....................................... 106 Table 11 AVPU scores at time of recovery from water for deceased and surviving patients .................................................................................................................................................. 107 Table 12. Presence or absence of vital signs at time of recovery from water for deceased and surviving patients ............................................................................................................ 108 Table 13. Survival by age group ............................................................................................... 113 Table 14. Time to recovery and survival ................................................................................. 114 Table 15. Survival and survival rate of persons jumping and hitting water by sex .............. 117 Table 16. Summary of injuries reported in the literature in patients who have jumped from bridges of various heights ........................................................................................................ 121 Table 17. Summary of injuries found in this study ............................................................... 122 xiii List of figures Figure 1. Age trends in suicide ................................................................................................... 3 Figure 2. Suicide means in Canada during the study period ................................................. 10 Figure 3. Location of bridges included in the study ............................................................... 16 Figure 4. Daily average temperatures for the water bodies included in the study, the Fraser River and Burrard Inlet ................................................................................................. 19 Figure 5. Patient and information movement through the response to a person jumping from a bridge ............................................................................................................................. 22 Figure 6. Locations of emergency services and hospitals involved in response to a person jumping from a bridge .............................................................................................................. 25 Figure 7. Possible outcomes following the report of a potential jump ................................ 40 Figure 8. Case identification by agency and total number of incidents identified. Included incidents and excluded incidents by reason for exclusion. .................................................. 42 Figure 9. Example version of link file used to match records between agencies. ............... 48 Figure 10. Area included in initial search for BCAS records. ................................................. 51 Figure 11. All linkage outcomes, and their frequency ............................................................. 55 Figure 12. Data availability periods for agencies included in the study. ............................... 57 Figure 13. Sample Coast Guard Patient Care Records ........................................................... 58 Figure 14. Breakdown of all reported incidents and their outcomes for the study period . 84 Figure 15. Jumps by bridge over the study period .................................................................. 86 Figure 16. Incident density by time of day ............................................................................. 88 Figure 17. Outcomes following a jump into water. ................................................................ 95 Figure 18. Strength of correlation between various factors thought to be associated with survival ...................................................................................................................................... 98 Figure 19. Survival rate versus bridge height for all bridges in the study ............................ 110 Figure 20. Ages at time of jump .............................................................................................. 112 Figure 21. Length of interval from jump to recovery in minutes .......................................... 116 xiv Symbols and abbreviationsC2. chi-square test ABC. Airway, Breathing, and Circulation ACP. Advanced Care Paramedic AED. Automated External Defibrillator ATIP. Access to Information and Privacy ATLS. Advanced Trauma Life Support AVPU. Alert, Verbal, Pain, Unresponsive BC. British Columbia BCAS. British Columbia Ambulance Service BCCS. British Columbia Coroners Service BCEHS. British Columbia Emergency Health Services BLS. Basic Life Support BP. blood pressure BVM. bag valve mask CCG. Canadian Coast Guard CI. confidence interval CPAP. continuous positive airway pressure CPR. Cardio-Pulmonary Resuscitation CTAS. Canadian Trauma Acuity Scale DND. Department of National Defence DOB. date of birth DPD. Delta Police Department ED. emergency department EPOS. Emergency Physician Online Support EtCO2. end-tidal CO2 FH. Fraser Health FOI. Freedom of Information GCS. Glasgow Coma Scale HR. heart rate ICD-10. International Classification of Diseases, 10th revision ICU. intensive care unit IO. intra-osseous line IQR. inter-quartile range ISO 8601. International Standards Organisation 8601 IV. intravenous line JRCC. Joint Rescue Coordination Centre K-S. Kolmogorv-Smirnov test LGH. Lions Gate Hospital LML. Lower Mainland MCTS. Marine Communications and Traffic Services xv MOH. Ministry of Health MPDS. Medical Priority Dispatch Code MRN. Medical Record Number NOS. not otherwise specified OCR. optical character recognition OPA. oro-pharyngeal airway OR. odds ratio PCP. Primary Care Paramedic PCR. Patient Care Record PHC. Providence Health Care PHN. Personal Health Number RCH. Royal Columbian Hospital RCMP. Royal Canadian Mounted Police REDCap. Research Electronic Data Capture ROSC. return of spontaneous circulation RR. respiratory rate RS. Rescue Specialist S-W. Shapiro-Wilk test SAR. search and rescue sd. standard deviation SPH. Saint Paul’s Hospital SPO2. peripheral capillary oxygen saturation TXA. trans-examic acid U. Mann-Whitney U-test UCR. Uniform Crime Reporting VAK. Victoria Coast Guard Radio VAS. Vancouver Coast Guard Radio (historical) VCH. Vancouver Coastal Health VGH. Vancouver General Hospital VPD. Vancouver Police Department VSA. vital signs absent WHO. World Health Organisation xvi Glossary “confirmed jump”. Potential outcome where a patient is known to have jumped. “delayed recovery”. Potential outcome where patient recovered more than 3 hours after jumping, or coroner notified of death at least one day post-jump. “did not jump”. Potential outcome where patient goes to bridge to jump or threatens to jump, but does not jump. “not recovered”. Potential outcome where patient known to have jumped, but body never found. “promptly recovered”. Potential outcome where patient recovered within 3 hours of jumping or coroner notified of death on day of jump. “suspected jump”. Potential outcome where patient is known to have gone to bridge or made a serious threat to jump, and evidence suggests they did jump, but there is a lack of definitive evidence to prove they did. “unknown outcome”. Potential outcome where patient is known to have gone to bridge or made a serious threat to jump, but nothing else is known about the incident. abstraction. Process of interpreting and coding free-text information to categorical data for analysis. Access to Information and Privacy. Program for access to information relating to, or collected in the course of Canadian Federal Government operations. age-specific suicide rate. Rate of suicide as deaths per 100 000 people per year, calculated using age bands rather than the population as a whole. argot. Specialised vocabulary. AVPU Scale. System used to measure and record patient level of consciousness, ordered from Alert, to Verbal, to Pain responsive, to unresponsive. case. Incident for a single agency. ceteris paribus. All else being equal. data linkage. Process of linking information from various agencies relevant to a single incident. definitive care. Medical care, generally provided at the hospital level, able to decisively address patient injuries, rather than simply temporizing injuries. discontinuation of resuscitation. Cessation of treatment when patient is deceased. ebb. Tide and current state where tide is dropping and current is flowing in a downstream direction. Freedom of Information. Program for access to information relating to, or collected in the course of British Columbian Provincial Government operations. freshet. Increased water flow as a result of seasonal snowmelt upstream. futile. Resuscitation efforts are very unlikely to succeed. gender paradox. Phenomenon in suicidology where women are more likely to attempt suicide, but men are more likely to die by suicide. xvii high income country. Countries having a Gross National Income greater than the equivalent of 6 000 USD per capita in 1987, after adjusting for inflation (currently 12 376 USD). incident. One jump or attempted jump from a bridge. inter-jump interval. Time between two confirmed jumps. ipso facto. The effect in question is as a direct consequence of the action. ISO 8601. International standard for date and time information. Time and date to be formatted as YYYY-MM-DDTHH:MM:SS+HH:MM(time zone relative to Zulu). Lower Mainland. Area of British Columbia loosely defined as the densely populated regions surrounding the Fraser River delta and Burrard Inlet. means (access) restriction. Suicide prevention strategy whereby an attempt is made to reduce suicide rates by limiting access to potential means of committing suicide. Medical Priority Dispatch System. System used to dispatch prehospital medical care providers. Mental Health Act. Legislation in British Columbia governing psychiatric care, permitting —amongst other things— involuntary psychiatric treatment. middle income country. Countries with a Gross National Income between 1 026 USD and 12 375 USD per capita. non-fatal suicidal behaviour. A set of behaviours (thoughts, plans, and attempts) related to suicide which do not result in death. non-residential structure. Any structure (bridge, building, roadway) used for suicidal jumping, in which the person does not reside. Patient Care Record. Report generated by the Canadian Coast Guard providing information about the medical history and treatment of a patient. Personal Health Number. Identification number issued to residents of British Columbia for medical identification and billing purposes. prehospital care. Medical care provided by first responders outside of, or prior to transport to, a hospital. probabilistic linkage. Linkage of case records based on likelihood of a correct match, as opposed to linkage based on exact identifying details. Rescue Specialist. Canadian Coast Guard employee who has completed Rigid Hull Inflatable Operator Training (RHIOT) and an in-house medical training course equivalent to Emergency Medical Responder Training. resuscitation. The act of restoring, or attempting to restore homeostasis. retrospective chart review. Type of research where existing patient clinical data is used to answer one or more questions. SAR Mission Report. Report generated by the Canadian Coast Guard providing information about an incident. structure of convenience. Structure used in suicidal jumps because it is available rather than because it is desired place to jump. suicidal ideation. Thinking of, or being preoccupied with, dying as a result of one’s intentional actions. suicide. Intentionally causing one’s own death. suicide attempt. Event where a person acts to cause their own death. xviii suicide clustering. Grouping of suicides in time or space. suicide contagion. Phenomenon where exposure to suicide or suicidal behaviours can result in an increase in suicide or suicidal behaviors. suicide destination. Location that has developed a reputation as a place to commit suicide, that is sought out by persons wanting to commit suicide from that particular location. suicide means. Method or mechanism used to commit suicide. survivorship bias. Bias present in analysis where the only cases included are those who survived to a certain point (e.g. to hospital). trauma center. Hospital specifically equipped and staffed to provide care for major traumatic injuries. traumatic arrest. Cardiac arrest caused by traumatic injury. Zulu time. Greenwich mean time, unadjusted for daylight savings time. xix Acknowledgements This project could not have been completed without the assistance of numerous people, all of whom contributed, directly or indirectly in its success. Tyler B and Dr MacPherson for getting me started on this project. Tyler P, Ian, Jacque, Ryan, Jim, Derek and Chewie for keeping and putting up with me on night shift for so long. Nathan and Shane for support with all things Coast Guard throughout the project. Julie and Sung for all your help identifying and extracting data. Vi for everything VCH and VGH related. Shannon for answering all my stats questions. Aki, Dan, and Paige for all the data abstraction. Dr Jenny Gill and Drazen Manojlovic for Vancouver Police data. Tara Haarhoff, Jasmine Willard, and Douglas Ferguson for Royal Canadian Mounted Police data. Tracy Foreman, Darlene Rose, Andrea Healey, and Patty Chaster for Royal Columbian Hospital data. Romlet Sarmiento, Nancy McNeil, and Jennifer Tam for Saint Paul’s Hospital data. Andy Shahab and Cherry Pacheco for Lions Gate Hospital data. Tej Sidhu for BC Coroners Service support. Susan Pickrell, Colin Henthorne, and everyone else at JRCC for finding 6000 documents for me. Vahid and Edi for moral support in the office, and putting up with Nootka. Doug for the help preparing this thesis and getting RCH charts. Jeff for all the support and guidance. Finally, Holly, for everything. Thank you all. xx Dedication To the Coast Guard crews at CG 506, Kitsilano and Sea Island, VPD Marine Unit, Lower Mainland RCMP Marine Units, and all the BCAS crews we work with. 1 Suicide by jumping in context SUICIDE RATES Worldwide, suicide is the 17th leading cause of death, claiming about 800 000 lives per year.1 In Canada, suicide is relatively more frequent and is the 9th most common cause of death.2 The age-specific suicide rate in Canada averaged 11.4 per 100 000 from 2006-2016, with no appreciable change across the period.3 At the beginning of this period, Canadian suicide rates were lower than the global rate of 12.3 per 100 000 in 2005, but global rates have declined to 10.6 per 100 000 in 2016, without a corresponding change in Canadian rates.3,4 According to Statistics Canada, the suicide rate in British Columbia (BC) is lower than the national average at 10.6 per 100 000; there were between 379 and 612 suicides a year during the study period.3 There is some evidence that these rates may be under-reported, due to specificity issues with the ICD-10, and actual suicide rates may be higher.5 Non-fatal suicidal behaviours —suicide attempts or suicidal ideations— are far more common than suicide; the rate of suicide attempts is almost 30 times the Canadian suicide rate, and the lifetime prevalence of suicide attempts is approximately 2.7%.6 However, reported lifetime prevalence of suicide attempts in teens is higher than in the population as a whole reflecting a tendency for individuals to under-report suicidal behaviour.7 The rate of under-reporting of non-fatal suicidal behaviour may be very significant. While statistics are unavailable for suicide attempts, Goldney et al. (1991) performed an eight year longitudinal study of suicidal ideation in young adults; they 2 report that “no fewer than 40% of subjects who acknowledged suicidal ideation [..] denied ever having had suicidal ideation during their lives [four years later]”.8 SEX TRENDS IN SUICIDE Worldwide, people who commit suicide are predominately male, British Columbia (BC) is no exception; from 2006-2016, 74.5% (sd = 2.0) of suicide victims in BC were men.1,2,9 One exception of note is China, where 0.8 men commit suicide for every woman who commits suicide.10 This may be important because the study area has a large immigrant population from China, and suicide trends in immigrant communities reflect country of origin, not country of residence.11 Despite the predominance of men in completed suicides, women in Canada are three to four times more likely to engage in both suicidal ideation and suicide attempts, and 50% more likely to be hospitalised for a suicide attempt.2,12 This phenomenon is referred to as the gender paradox. Two proposed explanations for the gender paradox may be pertinent to this study: the male preference for rapid, highly lethal means of suicide, and the higher female survival rate ceteris paribus.13,14 Even where women attempt suicide by the same means, they are more likely to survive than their male counterparts. This holds even for violent means like hanging or jumping in front of moving objects.14 There is also some evidence that in suicide by jumping, women may be more likely survive even where the height of fall is not different than height of fall for men.13 These findings contradict the absence of sex disparities in survival in trauma, suggesting the disparity may not have physiological roots.15 Proposed causes for the disparity have not been validated in the literature. 3 AGE TRENDS IN SUICIDE Figure 1. Age trends in suicide. Top to bottom are suicide rate, number of deaths, and suicides as a portion of all deaths. All figures are 10 year averages from 2006-2016 in Canada. (Data from Statistics Canada)3 Suicide and non-fatal suicidal behavior affects all age groups, but in different ways, as shown in Figure 1. Suicide is an important cause of death in younger individuals (<29 years of age), especially in high- and middle-income countries. Suicide may account for up to a quarter of all deaths in this age group, and is second only to road trauma as a leading cause of death.1 This relative importance is primarily attributable to successful public health campaigns reducing premature death by other means (e.g. communicable disease), and the low rate of lifestyle and age related causes of death (e.g. cancer, cardiac 4 pathologies) in this group. The number of suicides and the suicide rate both increase in middle age, especially in men. However, the relative importance of suicide as a cause of death declines because the impact of other age-related diseases like cancer and cardiac diseases becomes more significant. The majority of completed suicides occur between the ages of 40-59.1 Finally, suicide rates rise again in the 75+ age group, especially for men.4 Non-fatal suicidal behaviour follows slightly different patterns. Suicidal ideation and suicidal threats peak in late adolescence, with a rapid decline until the early 30s, and then a continued, but slower, decline through the end of natural life.7 ETHNICITY AND IMMIGRATION IN SUICIDE The role of ethnicity in suicidal behaviour in Canada is poorly reported in the literature or in primary data. Statistics presenting suicide by ethnicity are not publicly available from Statistics Canada or from the British Columbia Coroners service. The exception to this is Indigenous populations, who are between two and six times more likely to commit suicide than the general population; some Indigenous youth sub-populations are approximately 60 times more likely to commit suicide than their age matched peers.16,17 As previously noted, suicide rates in immigrant communities —regardless of ethnicity— reflect trends in countries of origin rather than broader Canadian suicide trends. Immigrants are less likely to commit suicide than Canadian-born individuals, and the discrepancy between male and female suicide rates is less pronounced in immigrants.11 Little evidence exists to show whether or not these trends continue with second generation immigrants and beyond.11 5 SUICIDE CONTAGION Suicide can be considered a ‘contagious’ phenomenon, where suicides, or knowledge of suicides appears to associate with additional suicides.18 The factors contributing to this phenomenon are complex and literature is inconclusive. Familial predisposition to suicide is well documented, and there is mounting evidence for a genetic component to this heritability.19 External events like celebrity suicide may also increase suicide rates — Robin William’s suicide in August, 2014 may have resulted in 1841 excess suicides in the United States in the five months following his death.20 Similar patterns are attributable to suicide coverage in the news or a focus on suicide in popular entertainment.21,22 Further, suicides may cluster in time when peers commit suicide; this is especially prevalent in small, isolated communities.23 While this may be the case at a population level, evidence for time clustering at an individual scale is mixed, with different studies showing different results.24 This disparity is most likely attributable to difficulties in distinguishing random events that appear clustered from true clusters. Clustering may occur in space as well as time. A number of studies show that certain areas are prone to suicide, or suicide by specific means, and some areas may become suicide ‘destinations’. For example, Ngui et al. (2014) show geographic clustering by suicide means in Quebec, with male suicide by firearm clustering in rural areas.25 Geographic clustering is an especially important phenomenon in suicide by jumping, where specific locations and landmarks become suicide destinations. Around the world, locations such as the Eiffel Tower, the Empire State Building, and Niagara Falls have developed reputations as destinations from which one can jump.26 These locations are 6 romanticised in the public perception as ‘freeing’ or ‘beautiful’, with some seeing the structure itself as a ‘golden door’, or viewing themselves as a part of the history of the structure, ‘joining others who have jumped there’.27,28 7 TIME TRENDS IN SUICIDE Diurnal, weekly, and annual variations in suicide have been observed for centuries, while some variations —like those associated with lunar cycles— are now demonstrably false, others are well documented. Annual variations show higher frequency of suicide and suicidal behaviour during the spring and early summer.29–32 However, this phenomenon may now be less pronounced than in the past, at least in high-income countries.33 Over a week, suicides are highest on Mondays, while weekends have the lowest rates.29 During the day, studies show different peaks, depending on country, geographic distribution, means of suicide, socio-economic factors, gender, and age.29–31 Some studies show variations based on clock time, which appear to be relative to the timing of the working day, while other variations are related to the time of sunrise and/or sunset.29–31 The only agreement across studies is that suicide rates drop precipitously at night (between 02:00 and 06:00), possibly to as low as 10% of the rates observed between 10:00 and 00:00.29–31 Temporal variation in suicide rates (daily, weekly, and annual) does not appear to apply equally to all forms of suicide; some means are more affected than others.29–32 Evidence regarding temporal variation in jumping is often directly contradictory from study to study, and there is no apparent consensus.30,32 8 PSYCHIATRIC CONDITIONS IN SUICIDE Psychiatric diagnoses of all kinds are strongly associated with suicide and non-fatal suicidal behaviours. Deaths by suicide in populations with psychiatric comorbidities can be an order of magnitude greater than suicide in the general population, and the prevalence of at least one psychiatric diagnosis in people who die by suicide may be as high as 98%.10,34,35 The most important psychiatric disorders associated with suicide appear to be affective disorders, substance misuse disorders and schizophrenia.34 As with much suicide research, though the general trend is consistent in the literature, specific details lack accuracy and repeatability. This is likely due to the high global variation in psychiatric diagnosis rates, as well as attitudes and taboos surrounding mental health, substance use, and suicide. In suicide by jumping specifically, there is significant evidence that schizophrenia or other non-specific forms of psychosis are over-represented compared to the general population, and sometimes as compared to other means of suicide.36–38 9 SUICIDE MEANS Means used in suicide are primarily associated with accessibility, and therefore vary significantly based on social, geographic, economic, and environmental factors. Because of their widespread availability, hanging and poisoning are the most common methods of suicide in worldwide.2,39 These trends hold true in Canada; the leading means of suicide are by asphyxiation (hanging, strangulation, or suffocation), followed by poisoning (drugs or chemical exposure), and by firearms, as shown in Figure 2. Jumping from a bridge may be classified as either ‘jumping from a high place’ or ‘drowning’, depending on the coroner’s determination. Combined, these two categories constitute the fourth leading suicide means in Canada, and account for 8.3% (sd = 0.3%) of suicides annually over the study period, with no discernable trend from 2006 to 2016.3 Like other means, accessibility plays a role in the importance of jumping from a height as a method of suicide. In areas where structures — both natural and man-made — are accessible, jumping may constitute a significant portion of suicides.37,40 Beautrais (2007) suggests that those who jump as a means of suicide can be roughly divided into two populations: those “who jump from high-rise residential buildings in which, usually, they reside, choosing these places because of ready availability and proximity” and those “who jump from bridges and similar ‘hotspots’ because they are attracted by the reputation and notoriety of the site”.38 People who jump from bridges may fall into either category. Jumping from residential high-rises may account for 30-60% of suicides in very dense metropolitan areas like Singapore, Hong Kong, or New York and 50% may jump impulsively, prompted by psychological stressors.37,38,41 The literature is inconclusive on 10 the demographic characteristics of the population that jumps from any given site, mostly due to small sample sizes. A number of authors suggest a propensity to be male, younger, and suffering some form of psychosis but definitive conclusions are precluded by contradictory studies.37,40 Figure 2. Suicide means in Canada during the study period. (Data from Statistics Canada)3 Suicide from bridges By their nature, bridges are intended to accommodate public access, making them suitable for suicide by jumping. Bridges are well known to the public, who accurately perceive jumping as an effective method of suicide.37,38 Jumping from a bridge may 11 constitute a significant portion of suicides where bridges are present; one study in Queensland, Australia reported 34% of suicides as jumps from a bridge.40 Although this is an extreme example, over time bridges may develop a reputation as a place to commit suicide. For example, the Golden Gate Bridge is the leading suicide site in the world and a known suicide destination.27 In the Lower Mainland of British Columbia, evidence exists that Lions Gate Bridge may be a local suicide destination. A 2017 study by Lam et al. showed that a number of people crossed other reliably fatal bridges in order to jump from Lions Gate Bridge.42 It appears that people who commit suicide by jumping from bridges are not consistently different from those who jump from other non-residential structures, though one study suggests they may be younger.37,38,40,42 12 Objectives PRIMARY OBJECTIVES Objective 0: Describe the population that jumps from a bridge and their outcomes. The study population is described as age distributions or tranches and broken down by sex. For the population as a whole, as well as sub-populations by age, sex, and bridge, we will describe survival rates as crude proportion of all jumpers who are not deceased. Finally, we would like to quantify the outcomes of the subjects on a scale from deceased to apparent full recovery on discharge from hospital and report rates of each outcome. Objective 1: Identify factors that affect a patient’s outcome following a jump from a bridge. Literature suggests that a small number of factors may have an outsized influence on patient outcomes. Factors of interest are age, sex, height of bridge, water temperature, time to recovery, and vital signs and level of consciousness on recovery. We will endeavor to show the influence each of these factors has on survival. Objective 2: Develop criteria for identifying patients for whom resuscitation is likely to be futile. Unfortunately, a large portion of persons who jump from these bridges have no reasonable chance of survival. By developing applicable criteria for identifying these patients, first responders will be equipped with a means to identify patients where it is 13 appropriate to cease or not start resuscitation efforts. This will avoid invasive and futile interventions for patients and may decrease the impact of these resuscitations on prehospital care providers. SECONDARY OBJECTIVES Objective 3: Describe and critique communications and information transfer between organisations involved in response. Communication and information transfer is frequently a problematic component of both emergency services and healthcare. Incomplete information transfer and miscommunications may cause delays in rescue and treatment, poor patient care, and ultimately affect patient survival. Wherever possible, we would like to examine inter-agency communications to determine the accuracy of information transfer in order to highlight areas of success and areas for potential future research or improvement. Objective 4: Evaluate existing Search and Rescue data to determine if is appropriate for creating evidence-based medical care protocols in SAR. Prehospital care in general, and SAR medicine specifically, are under-researched subjects. They lack high-quality evidence, established research protocols and methodologies, and the long-running, large, professionally managed data repositories common in fields such as oncology and cardiology. Existing data collected for operational purposes may never be as good as purpose-built research databases. However, it may still provide enough 14 information for the study of select subjects, preliminary studies, or to guide the establishment of such databases. We would like to evaluate if this is the case and provide guidance for the improvement of data collection in SAR. 15 Hypothesis Good outcomes in patients who jump from the bridges in the lower mainland can be tied to a limited number of measurable factors. Identifying these factors and tailoring prehospital care to them may improve patient outcomes while reducing the strain placed on the health care system. 16 Settings BRIDGES The Lower Mainland is home to nearly two dozen significant bridges, spanning the Fraser River, Burrard Inlet or False Creek. Seventeen of these are known jumping sites, and six account for the vast majority of suicides by bridge jumping in the greater Vancouver area.42 In recent years, attempts have been made to mitigate the prevalence of suicides on these bridges. Crisis hotline phones have been installed on several bridges, but their efficacy is unreported. Suicide barriers have also been installed on Burrard Bridge, Ironworker’s Memorial (Second Narrows) Bridge, and Golden Ears Bridge.43 Two of the most prolific suicide sites, Lion’s Gate Bridge and Alex Fraser Bridge are incapable of supporting the installation of a physical barrier without significant structural modification.43 Figure 3 shows the location of the bridges, and Table 1 outlines the major bridges included in the study.Figure 3. Location of bridges included in the study. (Map adapted from Stamen Map, Data from Google Maps) 17 Table 1. Bridges included in study (Data from various sources, noted in table) Body of water Number Bridge name Type Heighti (m) Suicide prevention measures Notes Burrard Inlet 1 Lions Gate (First Narrows) 3-lane vehicle, mixed bicycle and pedestrian walkways 70.044 6 Crisis phones Known suicide destination 2 Ironworkers Memorial (Second Narrows) 4-lane vehicle, mixed bicycle and pedestrian walkways 66.444 Barrier installed fall 2015 False Creek 3 Burrard Street 4-lane vehicle, separate bicycle and pedestrian walkways 35.145 Barrier installed spring 2017 Close proximity to major psychiatric and trauma treatment centers at Vancouver General Hospital and St Paul’s Hospital 4 Granville Street 8-lane vehicle, pedestrian walkway 43.745 None Close proximity to major psychiatric and trauma treatment centers at Vancouver General Hospital and St Paul’s Hospital 5 Cambie Street 6-lane vehicle, shared bicycle and pedestrian walkways 15* None Close proximity to major psychiatric and trauma treatment centers at Vancouver General Hospital and St Paul’s Hospital Fraser River 6 Arthur Laing 4-lane vehicle, bicycle paths 26.746 None Pedestrian access is limited i Unless otherwise noted, height refers to difference between mid-span bridge deck elevation and lowest low water elevation. This represents the largest possible distance one could fall from any given structure. Height data is presented and available in different forms depending on the source. Given the information available, a choice had to be made between the distance individuals are most likely to fall (i.e. the difference between deck elevation and time-averaged mean water level), and the most commonly available measurement (i.e. lowest low water). *Indicates height is clearance under the bridge 18 Body of water Number Bridge name Type Heighti (m) Suicide prevention measures Notes 7 Oak Street 4-lane vehicle, shared bicycle and pedestrian walkways 26.644 None 8 Canada Line Rail track, shared bicycle and pedestrian walkways 25*47 None 9 Knight Street 4-lane vehicle, shared bicycle and pedestrian walkways 20.1* None 10 Queensborough 4-lane vehicle, shared bicycle and pedestrian walkways 26.048 None 11 Alex Fraser 4-lane vehicle, shared bicycle and pedestrian walkways 65.744 6 Crisis phones Single structure of two bridges spanning both Annacis channel and the Fraser River 12 Sky Train Rail tracks, no pedestrian access 45*47 Limited pedestrian access 13 Pattullo 4-lane vehicle, shared bicycle and pedestrian walkways 4849 None Slated for replacement in 2023, replacement is to be built with a barrier 14 Port Mann 10-lane vehicle, shared bicycle and pedestrian walkways 47.544 Crisis phones 16 Golden Ears 6-lane vehicle Barrier 17 Mission 4-lane vehicle, shared bicycle and pedestrian walkways 33.344 None Pitt River 15 Pitt River 7-lane vehicle, shared bicycle and pedestrian walkways 18.744 None 19 WATER BODIES The bridges included in this study span the Fraser River, False Creek and Burrard Inlet. These water bodies each pose unique challenges to the recovery and survival of those who jump. The temperature of the Fraser River can drop to near freezing during the winter, while hitting highs in the low twenties during the summer. Flows are equally variable, with currents varying widely based on tide state and time of year. On a large ebb tide during freshet, meltwater from mountain snowpack may push currents in excess of 10 knots, rapidly sweeping victims downstream.50 Further complicating search efforts, visibility in the river is often non-existent and the river is filled with large debris year round. The waters of False Creek are calm, with little wave action and light currents, making swimming and recovery relatively easy, even for seriously injured persons. Burrard Inlet Figure 4. Daily average temperatures for the water bodies included in the study, the Fraser River and Burrard Inlet. Fraser River temperatures measured by DFO at Hope, and sea surface temperatures from Halibut Bank ODAS buoy. (Data from David Patterson; Ocean Data Acquisition System, both part of Fisheries and Oceans Canada) 71,72 20 can present serious challenges for rescuers. Tidal currents peak at 5.7 knots and often oppose prevailing winds, generating standing waves in excess of 3m.51 Also, these currents are capable of sweeping people away unseen, or simply holding them under the surface. Surface temperatures here range from five to nineteen degrees, as seen in Figure 4. 21 RESPONSE IN THE LOWER MAINLAND Organisational involvement Response to persons jumping from a bridge in the lower mainland is complex. Three to ten units, representing two to seven agencies may respond to a jump. Figure 5, below, shows the transfer of information and patients through the various agencies responsible for responding to an incident. Alerts from the public are received by one of two dispatch agencies. These agencies work in conjunction to dispatch marine rescue and recovery efforts by the Coast Guard or marine police and fire units. Once the patient is recovered, the British Columbia Ambulance Service (BCAS) meets marine resources for patient handover. BCAS will then take responsibility for providing prehospital care, as well as transport to hospital and definitive care. In incidents where resuscitation is futile, the British Columbia Coroners Service assumes responsibility for collecting and identifying the deceased. 22 Figure 5. Patient and information movement through the response to a person jumping from a bridge WITNESSReports event either to E-Commby phone, JRCC by phone, or toMCTS by VHF radioE-COMM-911Receives the report of eventfromwitness and coordinatesBCAS, Police and Fire response.Alerts JRCC andmay requestCoast Guard resources.MCTSRelays information betweenwitnesses and JRCC andbetween JRCC and CoastGuard resourcesJRCCReceives report of event andcoordinates CG response. Alsorelays between CG resourcesand E-COMM-911.DNDOversees JRCC. Inextraordinary circumstances,may direct naval or air forceassets to assist in rescue.POLICEResponds to bridge, prevents ordissuades person from jumping ifpossible. If police marine units areavailable, will assist in rescue orrecovery.BCASProvides medical care and groundtransport to hospital after recoveryand transport to shore.COAST GUARDSearch and rescue units, directlyresponsible for recovering patient,providing initial care, and delivering themto BCAS, police or coronerEPOSPhysician on call, canprovide medical advice oradvise discontinuation ofresuscitation for BCAS orCG crews.CORONERReceives deceased patients,investigates the circumstances oftheir death and issuesrecommendations as necessary.FIRE DEPARTMENTProvides assistance (manpower)in patient transfer and care. Incertain circumstances, fre departmentmarine units may play a role inrescue or recovery.HOSPITALReceives patient from BCASand provides defnitive care.- 23 Communication and coordination agencies Joint Rescue Coordination Center (Department of National Defence), Marine Communication and Traffic Services, and E-COMM911 Alerts from the public that someone has jumped from a bridge can come in by phone or by marine radio. A call to 911 is the most common alerting method. In the Lower Mainland, all 911 calls are received by E-Comm911. E-Comm911 is a unified 911 call center and communications coordination agency, jointly owned by all member agencies. During an incident, their responsibility is to receive the report and transfer the caller to the appropriate agency dispatch center(s). Coast Guard resources are tasked through Joint Rescue Coordination Center (JRCC), which is overseen by the Department of National Defence. JRCC is not an E-Comm911 member agency, and E-Comm911 does not transfer directly to JRCC for assistance from Canadian Coast Guard (CCG) and other SAR resources. That responsibility falls to British Columbia Emergency Health Services (the British Columbia Ambulance Service (BCAS) parent agency), or to police or fire departments who can contact JRCC independently. A person jumping from a bridge can also be reported directly to JRCC by phone, using their public line at #727. Finally, incidents may be reported by marine radio, in which case the CCG’s Marine Communications and Traffic Services (MCTS) center communicates directly with the reporting party, and relays information to JRCC. When incidents are reported directly to JRCC or MCTS, JRCC will also be responsible for alerting other agencies and will request assistance as required. 24 The role of coordinating on scene resources falls to JRCC and police, fire and BCAS. Non-CCG interagency communications are done by agency dispatch and facilitated by E-Comm911 radio networks. Direct communication between resources on the ground is hampered by differing organisational structures and communications technology. While certain resources can communicate directly (e.g. Police and BCAS), others cannot (e.g. CCG and BCAS). Because of this shortcoming, JRCC, MTCS, and agency dispatchers form an essential link between CCG units and shore-based first responders. All CCG radio communications to outside agencies or to JRCC are routed through MCTS. 25 Figure 6. Locations of emergency services and hospitals involved in response to a person jumping from a bridge * indicates a historical location, in service during the study period, but no longer extant (Map adapted from Stamen Map; Data from Google Maps; British Columbia Emergency Health Services) RCMP (listed as 9 in the figure) maintains a number of small vessels throughout the area, including a number kept in dry storage, so unit locations are not indicated on the map. Response agencies Canadian Coast Guard Search and Rescue (SAR) in Canadian navigable waters is the responsibility of the Canadian Coast Guard (CCG). Within the area of interest for this study, the CCG maintains two stations providing 24/7 coverage. A lifeboat station is located in Kitsilano, 200m west of the Burrard Street Bridge. It is equipped with a 45’ Response Boat Medium 26 and a 7.5m Rigid Hull Inflatable. This station is responsible for all bridges in False Creek and Vancouver Harbour. For almost three years from spring of 2013 to spring of 2016, Kitsilano station was closed. During this time, an Inshore Rescue Boat station – named CG506 – was deployed during the summer months (roughly April – September) to provide SAR coverage for the Vancouver area. CG506 was equipped with a 7.5m Rigid Hull Inflatable, crewed a full-time CCG Rescue Specialist (RS) and two students. The Fraser River bridges are covered by the CCG dive team, located at the mouth of the middle arm of the Fraser River. This station is equipped with a hovercraft capable of navigating the shallows of the Fraser River, as well as a rigid hull inflatable. The dive team can also be deployed at any time to recover people underwater, both in the river and in Vancouver Harbour. British Columbia Emergency Health Services and the British Columbia Ambulance Service Prehospital medical care in BC is the purview of British Columbia Emergency Health Services (BCEHS). Its subsidiary, the British Columbia Ambulance Service (BCAS), is responsible for organising, dispatching and supporting paramedics. BCAS has six levels of paramedics available, along with multiple sub-specialty units; two are of interest to this study. Basic Life Support (BLS) units are staffed by Primary Care Paramedics (PCP) and respond to most 911 calls. Advanced Care Paramedic units (ACP) can be dispatched as patient condition and availability warrants. For most incidents in this study, BCAS dispatches either ACP or both ACP and PCP units. Both unit types are supported by direct access to physician guidance through the Emergency Physician Online Support 27 (EPOS) program; EPOS also provides physician guidance to CCG crews. In response to a jump, BCAS will coordinate with marine resources to assume care for the patient once they can be delivered to shore. At this juncture, paramedics may continue to care for the patient and transport to hospital, or they may discontinue resuscitation based on a pre-established protocol or following an order from an EPOS physician. Police Jurisdiction over the study area is shared by five independent police forces and multiple detachments of the Royal Canadian Mounted Police (RCMP). Several bridges included in the study fall in the jurisdiction of two or more police departments. Police are responsible for a number of activities in response to a person jumping from a bridge. If a person is still on the bridge, police are responsible for attempting to prevent them from jumping though crisis negotiation or tactical operations. Once a person is in the water, some of these forces maintain marine units capable of rescuing patients in the water. Further, the RCMP maintains a dive team that can recover deceased persons at a later date. If a person has been recovered deceased, or resuscitation has been discontinued by British Columbia Ambulance Service, the investigation becomes the responsibility of the police and British Columbia Coroners Service. Fire Thirteen fire departments are responsible for the municipalities within the study area. These departments are often dispatched to assist other agencies in medical emergencies. 28 Except in the city of Vancouver, marine capacity is minimal so assistance is generally limited to providing first-aid or physical assistance once the patient is ashore. British Columbia Coroner’s Service The British Columbia Coroners Service (BCCS) is responsible for people who jump from bridges once they are deceased, either in field or in hospital. They are responsible for identifying unknown persons, determining proximate cause of death, and investigating the circumstances of death if required. Further, BCCS is responsible for collecting and publishing statistics regarding suicide in BC, and making policy recommendations based on their findings. In 2008, the coroners service released a review of youth suicides, finding that 6% of youth suicides in BC are by jumping, and recommended the installation of barriers on the Burrard Street, Granville Street, Iron Worker’s (Second Narrows), Lion’s Gate, and Pattullo, bridges.52 Hospitals Patients who survive the jump, or are being actively resuscitated are transported to hospital by the British Columbia Ambulance Service (BCAS). Generally, these patients are preferentially routed to a trauma center, rather than the nearest available hospital. These hospitals are able provide appropriate care for the most severely injured patients. Within the study area, there are two Level One Trauma Centers at Vancouver General Hospital (VGH) and Royal Columbian Hospital (RCH), and two Level Three Trauma Centers at Lions Gate Hospital (LGH) and Saint Paul’s Hospital (SPH). Generally, patients are preferentially received by either VGH or RCH as both hospitals have 24/7 dedicated 29 trauma, neurosurgery, and interventional radiology coverage. On arrival at the Emergency Department, patients are generally classified on the Canadian Trauma Acuity Scale as either Level I or Level II, requiring expedient attention from a physician. Once medical problems have been addressed and the patient no longer requires inpatient care, they are typically certified under the mental health act and referred for psychiatric treatment. 30 CURRENT PREHOSPITAL TREATMENT Canadian Coast Guard Rescue Specialists (RS) in the Canadian Coast Guard (CCG) complete a three week in-house course equivalent to British Columbia Ambulance Service (BCAS) Emergency Medical Responder training. The course provides additional focus on the medical emergencies commonly encountered at sea and on extrication and transport from the remote places where most CCG stations and ships work. The treatment of patients who have jumped from a bridge is outside the norm for CCG crews, but the RS program does address these patients specifically. CCG crews emphasize the expedient recovery and rapid delivery of patients to higher levels of care. Resuscitation CCG uses an Airway, Breathing, Circulation (ABC) centered approach, following the standard Advanced Trauma Life Support (ATLS) model. On recovery, a patient’s ABC’s are assessed and addressed. All patients are proactively treated for shock and hypothermia. Depending on findings, current guidelines suggest the following courses of action: Airway and respiratory management CCG crews carry tools for basic airway and respiratory support. Airways are maintained as required using a combination of patient positioning, oral pharyngeal airway devices and suction. Further respiratory support can be provided by supplemental O2 and assisted 31 respirations by bag valve mask ventilation as needed. During the study period, CCG crews did not have access to advanced airway adjuncts. Cardiac If a patient has no observable respirations and no palpable pulse, CCG guidelines are that CPR should be initiated and an AED should be applied to assess cardiac electrical activity promptly. Both stations are equipped with three lead AEDs that can display heart electrical activity. These AEDs are capable of manual defibrillation, but crews are only trained in basic electrical activity evaluation — to establish absence of cardiac activity — not manual defibrillation. Automated defibrillation is used instead. Discontinuation of resuscitation There are three scenarios by which CCG personnel may discontinue or not commence resuscitation. Traumatic arrest In case of traumatic arrest, CCG crews may discontinue or not commence resuscitation attempts if a patient has no spontaneous respirations or pulse for thirty seconds, and has a penetrating brain injury, body transection, severe burns, or penetrating thoracic or abdominal trauma53. These conditions generally do not apply to patients who have jumped from a bridge into water. 32 General discontinuation of resuscitation efforts After fifteen minutes of sustained CPR, crews may contact EPOS for a discontinuation order. After thirty minutes, crews may institute the Western Regional Cessation Protocol, which states that CPR may be discontinued if all of the following criteria are met: 1. Body temperature >35°C (does not apply to hypothermic patients) 2. Unresponsive, no spontaneous breathing or movements 3. Lack of pulse for >30 minutes despite good CPR for 30 minutes 4. 3 or more “no shock advised” messages (From the Canadian Coast Guard Search and Rescue – Western Region Rescue Specialist Program, Protocols, Procedures and Quick Reference Manual, 12) These criteria may apply to patients who have jumped off a bridge, though more often than not, the CCG will have handed off to BCAS before these criteria are met, and the patient will then be treated according to BCAS protocols. Bridge-specific discontinuation of resuscitation efforts As of 2016 the CCG has instituted a non-resuscitation protocol that applies specifically to the two highest bridges in the Lower Mainland. The protocol states that crews should not initiate resuscitation if all of the following criteria are met: 1. Witnessed fall from the car deck of the Lions Gate or Alex Fraser Bridges 33 2. Unconscious and unresponsive 3. No spontaneous movement or respirations 4. Pulseless [sustained pulse check on BOTH sides of the neck] for 30 seconds (Canadian Coast Guard Search and Rescue – Western Region Rescue Specialist Program, Protocols, Procedures and Quick Reference Manual, 11) This criteria applies specifically to a significant percentage of those who jump from the two of the bridges. However, it does not appear that this protocol has been used for any of the patients included in this study. Some crews approach this protocol with some degree of reticence. Trauma management CCG crews are trained and equipped to provide basic spinal stabilisation and primary care for traumatic injuries. Spinal immobilisation is provided in the form of cervical collars and spine boards. Other trauma care may be basic haemorrhage control and simple immobilisation of long bone fractures.53 For critically ill patients, treatment for traumatic injuries may be limited to life-saving interventions since CCG crews often deliver patients to BCAS before they are able to complete secondary surveys and commence these interventions. Hypothermia management Hypothermia is a concern for patients who jump from bridges, given the ambient water temperature for most of the year. CCG protocols for hypothermia indicate removal of wet 34 clothing and provision of dry clothing/blankets/sleeping bags as appropriate. Active rewarming is also provided in the form of hot packs53. During the study period, crews also carried warmed breathing air units. These units were used infrequently due to difficulty of use and the prolonged start-up time. Ultimately, the warmed air units were not shown to be effective and were withdrawn from service shortly after the end of the study period. As with secondary trauma assessment and treatment, hypothermia treatment may be limited to life saving interventions due to short transit times.  35 British Columbia Ambulance Service British Columbia Ambulance Service (BCAS) has two levels of paramedics that respond to these incidents, Primary Care Paramedics (PCP) and Advanced Care Paramedics (ACP). The difference in care between these levels is outlined below. In most incidents, jumpers receive either layered (PCP and ACP) or just ACP care. As with the Canadian Coast Guard, BCAS trauma guidelines suggest prioritising rapid transit to hospital and providing only essential resuscitative interventions on scene.54 Resuscitation Airway and respiratory resuscitation BCAS has a number of tools at its disposal for airway management, depending on the level of care and the patient’s condition. PCP units carry oral pharyngeal airways and – with additional training – supraglottic airways for unconscious patients.54 PCP units use bag valve mask and continuous positive airway pressure (CPAP) to support patients respiratory efforts. ACP units carry all PCP equipment, as well endotracheal tubes for definitive airway management, and positive pressure ventilation. These tools can be used in along with supplemental O2 further support respiratory distress.55 BCAS suggests that paramedics use the least invasive method appropriate to the patient, but that they rapidly move to more invasive means if patient condition warrants.54 ACP units can also provide needle chest decompression for treatment of suspected pneumothorax. 36 Cardiac and circulatory resuscitation In traumatic arrest, BCAS is much more pragmatic than the Coast Guard; protocols note that survival is unlikely given the mechanism of injury, and that consideration should be given to calling Emergency Physician Online Support (EPOS) for a discontinuation order.54 Both relevant BCAS levels provide CPR with automated defibrillation for cardiac arrest.55 ACP units can also perform manual defibrillation and provide a number of drugs for cardiac support and treatment of dysrhythmias.54 IV therapy can be provided to varying degrees by both paramedic levels. PCP units can initiate peripheral lines and crystalloid fluids, while ACP units can (depending on training) initiate IO lines, and provide colloid or crystalloid volume expanders.55 For fluid therapy in trauma, BCAS guidelines suggest targeting a systolic blood pressure 70-90mmHg or return of peripheral pulses.54 BCAS also suggests the use of the medication tranexamic acid (TXA) in trauma patients with signs of haemorrhage to promote hemostasis.54 Discontinuation of resuscitation BCAS protocols suggest paramedics may discontinue resuscitation in case of obvious death – transection, decapitation, incineration, and open skull fracture. None of these are likely to apply to patients having jumped off a bridge. Given the nature of the mechanism, guidelines suggest that in case of arrest paramedics should consult a physician via EPOS for an order to discontinue resuscitation.54 37 Trauma management To expedite transit to hospital and definitive care, BCAS suggest that minimal interventions should be performed on scene. The interventions suggested by BCAS are: spinal stabilisation if required for extrication, airway management, relief of tension pneumothorax, haemorrhage control, and stabilization of long bone and pelvic fractures. Given the mechanism of injury BCAS guidelines suggest prophylactic pelvic binding for all patients who jump off bridges.54 Hypothermia management BCAS guidelines for hypothermia are similar to the CCG. Treatment is focussed on a mixture of preventing further cooling, and passive and active rewarming. In these patients, treatment of injuries and/or drowning complicates treatment for hypothermia. As with the CCG, BCAS guidelines call for not more than one attempt at defibrillation for a hypothermic patient in cardiac arrest.54  38 Prehospital treatment limitations Given the nature of recovering a patient who has jumped from a bridge, there are a number of limitations to prehospital treatment. Boats and hovercrafts are loud, dynamic environments, and transfer points are often very public locations that are exposed to the elements. Noise impedes crew ability to communicate with patients and each other, and makes it difficult to accurately assess vital signs. Water, both from rain and the river or ocean makes everything more challenging; AED pads are difficult to use, equipment is slippery, and feeling a faint pulse in a cold, wet environment is extremely difficult. For the Canadian Coast Guard specifically, vessel movement makes providing quality CPR and respiratory assistance challenging. Further, vessel vibrations can interfere with measurement of cardiac electrical activity. The effect of these challenges on patient outcomes is unknown, and may be mitigated by the short transit times to shore and handoff with BCAS. Time to definitive care is a well-documented factor in trauma survival; jumping from a bridge is no exception. Delays in reaching patients limit the efficacy of any treatment CCG or BCAS crews can provide. In ideal circumstances, patients may be recovered by the CCG and delivered to shore five to eight minutes after a jump. However, long transits to the bridge and challenges locating the patient can increase this time drastically. Miscommunications and poor logistics, or complications in patient handoff can increase time to definitive care. 39 OUTCOMES A number of outcomes are possible following a report of a person jumping from a bridge; Figure 7 outlines the possible outcomes. In a significant portion of potential incidents, patients simply do not jump. For those that do jump, environmental factors and delays in reaching the scene can hinder recovery. A portion of persons who jump may not be located during the initial search, and their remains may be found with some delay, or Report of potential jumpConfrmed jumpUnconfrmed orunknown outcomeDid not jumpNot recovered Recovered False report ApprehendedRecovered deceased TransportedDeceased in transit Admitted to EDDeceased in ED Admitted to hospital Discharged from EDDeceased in hospital DischargedDischarged with no orminimal loss of functionDischarged withloss of functionLong term careFigure 7. Possible outcomes following the report of a potential jump. 40 never found at all. Once recovered, resuscitation may be discontinued prehospital, as discussed above in the section on prehospital care. A portion of patients recovered are eventually transported by BCAS to definitive care in hospital. Little information is available in the literature regarding patients expected courses in hospital. However, many patients are likely to have substantial injuries and recovery from physical injuries may take months or even years. Fortunately, evidence in the literature suggests that those who do survive are unlikely to engage in further suicide attempts.56 41 Building and analysing the dataset Figure 5 (page 22) shows the agencies involved in the response a person jumping from a bridge. Each agency provides unique insight into patient progression through the system. CASE IDENTIFICATION AND SELECTION The study is a multi-agency retrospective chart review, with charts coming from all agencies involved in the care of patients who jump from the bridges. Cases were identified by the Canadian Coast Guard (CCG) and Joint Rescue Coordination Center (JRCC), British Columbia Coroners Service (BCCS), Vancouver Police (VPD), Royal Canadian Mounted Police (RCMP), and Delta Police (DPD). Figure 8 shows the results of each search, as well as the total number of incidents identified, included and excluded. The most challenging and time consuming aspects of this project were identifying cases, followed by identifying and obtaining the records associated with each case. The process of identifying incidents, as outlined below was painstaking and complex; requiring information from six agencies. Constrained or inflexible search capacity, absence of detail, restricted timeframe, or missing or lost records limited the utility of datasets from each agency. However, by combining these datasets into a single aggregate list, it was possible to compensate for these limitations and build a robust population for the study. 42 Figure 8. Case identification by agency and total number of incidents identified. Included incidents and excluded incidents by reason for exclusion. Canadian Coast Guard records Records held directly by the Canadian Coast Guard (CCG) are still paper copies, and could be manually sorted. All available records were searched for incidents mentioning suicide, suicide attempt, bridge names, or “jumper”. Manual review of the records was time consuming, and access to records was hindered by multiple, poorly identified and organised storage locations. Further, a large number of CCG records from the Kitsilano base were lost or destroyed when the base was closed for three years from 2013 to 2016; these incidents were accounted for using JRCC records. Once records were located and access was facilitated, the remaining records could be searched with a high degree of accuracy. 522 potentially relevant case reports were located during this search. Coronern = 217Total number of unique casesn = 1287Vancouver Policen = 573Royal CanadianMounted Policen = 188Delta Policen = 11Coast Guardn = 522Joint RescueCoordination Centern = 586Included casesn = 1208Excluded casesn = 79Bridge excludedn = 19Other incident typen = 27Other structuren = 15Outside study arean = 12Outside study periodn = 6 43 Joint Rescue Coordination Center records Joint Rescue Coordination Center (JRCC) records appear to be a relatively comprehensive list of cases. JRCC was provided a list of all known CCG cases based on the prior manual search of CCG records, and then conducted their own search of records for any cases not previously identified that might correspond to suicidal jump from a bridge. Here, the data collection system in place worked to the advantage of the searchers. JRCC responds to a limited number of suicides outside of those by jumping from a bridge, so filtering incidents by anything coded as a suicide or suicide attempt is likely to generate a much smaller list of potential cases than it would for other organisations. Ultimately, JRCC was able to identify 586 records during the study period, effectively filling the gap for records missing from CCG files. Police records Due to privacy concerns, police records had to be searched by the police departments themselves. Vancouver Police Department (VPD) and the Royal Canadian Mounted Police (RCMP) have protocols in place for identifying and accessing records for research. All other police departments were sent FOI requests. All requests asked for information regarding: All calls associated with fall/jump/suicide attempt/suicide from a bridge within the police department’s jurisdiction. 44 While specific inclusion/exclusion and search criteria were included in the data request, researchers had no say in how these criteria were interpreted or implemented. Figure 8 shows the results of each search. The results suggest some inconsistency across various police forces. In the VPD data, 16.8% of cases jumped, while 26.2% of the RCMP cases jumped (pC2 = 0.000), which suggests that a number of non-jump cases are excluded from RCMP data. Further, the research team is aware of cases where police agencies are known to have participated, but which were not included in the datasets provided, as shown in Table 3 (page 71). British Columbia Coroner Service records An FOI request was the most expedient way to obtain British Columbia Coroners Service (BCCS) records. We requested “All Coroner's Reports, with autopsy results when available, for all persons deceased by suicide by jumping from a bridge in the Metro and Fraser Regions from January 1, 2006 to February 28, 2017”. The coroner identified these cases in two batches, and released all relevant information with the cases. Incident selection Once the records from police departments, the CCG, and BCCS were obtained, records were sorted manually to determine if they met the selection criteria. Inclusion criteria All patients that jumped or fell from a bridge higher than 12m spanning a navigable channel in the lower mainland between Jan 1, 2006 and Feb 28, 2017 will be included in the study. 45 Exclusion criteria Patients who jumped and hit a hard surface, or were not recovered within 3 hours will be included in demographic analysis, the overall count of patients who jumped or fell from the bridges, and temporal analysis, but will be excluded from survival analysis. “Hard surface” is defined as any surface not explicitly water. Patients or deceased persons recovered from the vicinity of the bridges, but not confirmed to have jumped will be excluded entirely from the study. Sorting was done by inclusion criteria first ensuring that each incident fell within the study period, and had jumped or threatened to jump from a bridge. Applying the exclusion criteria was more difficult. First, based on incident reports, it was established if the person in question had jumped and not simply been found in the vicinity of the bridge. Incidents were classified as “Did Not Jump”, “Suspected Jump”, “Confirmed Jump”, or “Unknown Outcome” based on the information available. The latter indicates that evidence suggests a person went to the bridge with intention of jumping, but no further information in available. Then, the bridge the patient jumped from had to be established, all patients jumping from bridges <12m in height were then excluded. At this stage, confirmed jumps were also coded for analysis purposes as having hit a hard surface, water, or an unknown surface. Finally, incidents were sorted by time to recovery as either “promptly recovered” for those recovered within 3 hours, “delayed recovery” for those recovered more than 3 hours post-jump or where death was not reported to the coroner until at least one day after death, and “not recovered” for those never recovered. A 46 number of incidents were not excluded until additional evidence was uncovered from hospital records. 47 DATA LINKAGE Concurrent with the incident selection, records for each incident from the police, Canadian Coast Guard (CCG), British Columbia Coroners Service (BCCS) were linked, creating one ‘master link record’. This record contained on line per incident, with all the information required to link data across records from various agencies. Where available, patient name or other personal details were used to link records. In the vast majority of cases this information was not available so incident information (e.g. bridge, date, and time), and personal identifying information (e.g. age, sex, outcome) were used to probabilistically link the records. Linkage was completed using a single spreadsheet in Microsoft Excel for Mac (2019), kept separate of any other patient data, and a study ID assigned to each incident. A sample version of this link sheet can be seen in Figure 9, below. Study ID was then attached to every abstracted record related to this incident and all other identifying information removed. Once the linkage was complete, a truncated version of the link sheet, containing study ID, event date and time, patient sex and age, and coded outcomes was retained for use in the analysis. The link sheet was deleted, including patient identifiers and agency record identifiers. Only the study ID remains to identify patients. 48 Figure 9. Example version of link file used to match records between agencies. All values in this table not already in the public domain or expressly fit for public release were randomly generated for the purpose of publication. They do not match real patients or incidents. (Names from The Simpsons; other values generated using Microsoft Excel for Mac (2009) randbetween() function)57STUDY.IDRECORD.STATUSEVENT.DATEEARLIEST.TIME.RECORDNAMEPHNSEXAGEBRIDGEBEST.UNDERSTANDING.OF.OUTCOMEJUMPED.YSNDECEASED.YUNRECOVERED.YDNSURFACE.WUHRCMP.IDVPD.IDDELTA.PD.IDCG.IDCG.REDCAP.IDBCAS.RECORD.IDHOSPHOSP.REDCAP.IDCORONER.RECORDCoroner.REDCap.IDCORONER.PAGEJRCC.RECIDJRCC.PAGE6287 BCAS MISSING - BCAS ASSUMED CARE 1405 - D/C AT 14:152013-09-08 15:3 :08 <NONE> 8442697201 M 56 LIONSGATE Jumped - Recovered - BCAS - DECEASED - PHN POSSIBLEY Y Y W 500 V13-3112 173 MISSING NA 2013-028-0035 78 2-189 563569 40518848 2013-09-17 F 55 UNKNOWN - RICHMONDJumped in the pastS U NA NA 47119840 NA NA NA NA NA3227 2013-10-20 F 30 PATTULLO Located on bridgeN NA NA NA 37279236 NA NA NA NA NA8515 POSSIBLE BCAS MATCH TO RCH2014-07-27 17:09:00 U 0 QUEENSBUROUGH BRIDGEJumped - BCAS TransferY U Y W V14-2832 226 6272 RCH MISSING NA 562465 46487054 2014-08-12 18:07:21 F 25 SECONDNARROWSNOT DECEASEDN NA NA NA 184 NA NA NA NA NA9525 POSSIBLE BCAS MATCH TO RCH2014-09-02 20:41:00 4722828229 M PATTULLO Jumped - BCAS TransferY N Y W V14-2570 222 4957 RCH 483 NA 563999 46365802 2014-11-19 1:32:00 OAK Did Not JumpN NA NA NA V14-2287 NA NA NA NA NA2612 2014-12-19 20:39:00 LIONSGATE Suspected JumpS U NA NA V14-3286 206 NA NA 563097 47458887 2015-01-19 2:03:00 ARTHUR LAING BRIDGE Suspected JumpS U NA NA V14-3826 191 NA NA 562480 47896284 2015-01-26 19:33:00 BURRARD Did Not JumpN NA NA NA V15-0891 NA NA NA 563039 51323613 2015-01-29 14:48:00 ARTHUR LAING BRIDGE Did Not JumpN NA NA NA V15-0842 NA NA NA 563295 48419887 2015-04-04 7:28:06 F 24 GRANVILLE ST BRIDGENOT ECEASEDN NA NA NA 438 NA NA NA NA NA6913 2015-04-08 Early AM Hours F 54 CAMBIE Hard surface-Hit Hard - Walking TrailY Y NA H NA NA 2015-028-0055 91 1-55 NA NA1252 2015-07-22 3:36:02 M 49 GRANVILLE ST BRIDGENOT ECEASEDN NA NA NA 153 NA NA NA NA NA9128 2015-07-26 21:12:26 F 38 LIONSGATE NOT DECEASEDN NA NA NA 471 NA NA NA NA NA3720 2015-08-19 16:07:53 M 30 CAMBIE NOT DECEASEDN NA NA NA 69 NA NA NA NA NA9717 2015-09-01 19:59:48 F 41 LIONSGATE Did Not Jump - NOT DECEASEDN NA N NA 194 V15-2152 NA NA NA 563228 52627301 2015-09-04 19:58:02 F 26 LIONSGATE NOT DECEASEDN NA NA NA 448 NA NA NA NA NA2150 2015-10-07 22:06:07 M 31 BURRARD NOT DECEASEDN NA NA NA 307 NA NA NA NA NA4677 POSSIBLE BCAS MATCH NO HOSP TRANSIT2015-11-27 12:40:26 M 22 LIONSGATE Jumped - BCAS - DECEASED at SCENEY Y Y W 391 V15-2519 99, 432 2141 NA 2015-037-0178 70 1-28 563293 52943643 BCAS AND VGH MATCH2015-11-28 11:52:40 KRABAPPEL, Edna7421835818 F 45 KNIGHT ST BRIDGEJumped - BCAS Transfer - NOT DECEASEDY N Y W 52 V15-3643 239 2634 VGH 435 NA 562585 53376195 2016-03-31 18:49:00 PORT MANN BRIDGEJumped - Not RecoveredY Y N W V16-0217 231 3945 NA NA NA NA1807 2016-04-19 5:11:58 M 49 BURRARD NOT DECEASEDN NA NA NA 432 NA NA NA NA NA9309 BCAS AND VGH MATCH2016-04-23 19:49:00 GUMBLE, Barney6494930202 M BURRARD Jumped - BCAS TransferY N Y W V16-2546 239 1271 VGH 274 NA 563204 56994160 POSSIBLE BCAS MATCH TO SPH - SPH MATCH EDVIEW ID 2912322016-05-05 18:27:58 7911961534 M 51 CAMBIE Jumped - BCAS TransferY N Y W 106 V16-0256 278 7159 SPH NA NA 564240 54952617 2016-05-07 2:38:52 M 21 LIONSGATE NOT DECEASEDN NA NA NA 331 NA NA NA NA NA 49 To link the records, the following steps were taken: 1. Incident information was collected from each agency, and formatted to match the table. All dates were reformatted as YYYY-MM-DD and times converted to HH:MM:SS. 2. All incidents were sorted by date, then time. 3. Where multiple records were identified as belonging to a single incident using patient name, MRN or PHN, the records were merged. 4. Where 3. was not possible, a probabilistic approach was taken. a. Records were manually matched by date, time, bridge, patient sex, patient age, etc. b. If available, outcomes were used to narrow possible matches. For example incidents where the patient is known to have survived would be excluded from attempts to link records originating from the British Columbia Coroners Service (BCCS). 5. Unmatched records from the police, CCG, and BCCS were retained as individual incidents. 6. Study ID numbers were assigned to all incidents, and to the corresponding abstracted data for each incident. 7. Records from Joint Rescue Coordination Center (JRCC) were received after a significant delay. Once received, they were added to the link file using steps 1-5. 8. Use link sheet to identify matching cases in BCAS search results. 9. Use identifying information from the link sheet to identify hospital records per the steps outlined in the Record Identification section (page 41). 50 Challenges and limitations in data linkage Data from the various sources in this study was inconsistent. Differing formatting, inaccuracies, and limited or imprecise information made the process of matching reports challenging and time-consuming. For example, in some data, age was calculated using year of birth only. In other datasets, outcomes were only given as “Alive”, without indicating if the person in question had jumped and survived, or simply not jumped. Sex was also regularly recorded incorrectly, most likely due to miscommunication or imprecise witness accounts. Simpler issues also plagued the match process. Despite the official Canadian adoption of the ISO 8601 date-time standard of YYYY-MM-DD 30 years ago, inconsistent date formats still abound. Some cases even used multiple formats within a single report. This was especially challenging where months and days are both presented numerically and may be interchangeable. While less prominent, time notation issues were also present. Confusion over whether a time represented Zulu time (Greenwich Mean Time, without any daylight savings adjustment) or local time was an issue in some records. The sporadic use of the 12 hour system over the zero-padded 24 hour system was another barrier to correctly matching records. While challenging, the adaptation of a single standard for both date and time across all medical and peri-medical fields would reduce ambiguity in day-to-day use, and ease future chart linkage projects. 51 AMBULANCE AND HOSPITAL RECORD IDENTIFICATION British Columbia Ambulance Service records Finding British Columbia Ambulance Service (BCAS) records was challenging. Unfortunately, there is no standard coding for “jumped from a bridge” and patients fell under a number of Medical Priority Dispatch System (MPDS) codes, including Drowning (14), Fall From Height (17), or Traumatic Injury (30). Further, patients who were deceased on scene appear to be coded differently from those who were transported, but it is unclear how they were coded, or why they were coded differently. Figure 10. Area included in initial search for BCAS records. Areas highlighted in blue are areas where there may have been a patient handoff from the CCG or other marine resource to BCAS paramedics. There are a significant number of potential handoff locations along the Fraser River for most craft, and the hovercraft can handoff at any convenient beach or sloped shoreline, so the search could not be focussed. On the other hand, in Burrard Inlet/Vancouver Harbour and False Creek, there are a limited number of locations conducive to a handoff, so the search could be restricted to these areas. 52 Initially, BCAS searched for all cases originating inside the geographic limits shown in Figure 10 that met the following criteria: • MPDS det. : Delta and Echo [PCP or ACP care] • MPDS Card: 14, 17,30 [Drowning, Fall from Height, Traumatic Injury] • Event Region: Vancouver Coastal and Fraser • Not cancelled • Transported This search found 6673 results which were manually compared to known incidents in the link file, using essentially the same methodology as the original linkage. Only 39 of these cases — 0.58% of the results — were relevant to the study. Further, participation of BCAS was known or strongly suspected in 55 incidents that were not successfully identified using this search methodology. In an attempt to identify more cases, a similar search was run, using the same search area, but with additional search criteria identified from BCAS run sheets found in hospital records identified with the first 39 cases. These criteria were: • ALS attended • Injury code 9550 • Trauma boxes ‘Blunt’ and ‘Intentional, self’ ticked This search identified 35 potential records, but none were new matches to known incidents. On further inquiry it was determined that there were a number of problems with the BCAS search methodology, mostly related to incident coding and data storage. 53 Prior to 2014, destination location was being transposed into the origin location columns in BCAS’s system, effectively nullifying the geographic search we had been attempting to perform. This error also had the effect of eliminating any cases that were not transported to hospital from the search. Over half the patients seen by BCAS in this study were not transported. To avoid this error, a final search targeted specific incidents where it was known or strongly suspected that BCAS should have a record for that patient—for each incident, we provided BCAS with a time window, patient sex, and age range. BCAS subsequently provided all cases meeting these criteria to manually match with known incidents. In total, BCAS identified over 10 000 records for this study, including 72 relevant records representing 68 incidents; the additional records represent records from incidents where more than one BCAS unit responded. Hospital records Hospital records were identified using a variety of means, depending on the Health Authority in charge, hospital, and level of information available on the patient. Wherever possible, hospital records were identified using Personal Health Number (PHN) from BCAS records. Where this was not possible, a variety of strategies were employed. For Vancouver General Hospital (VGH), Lions Gate Hospital (LGH), and Saint Paul’s Hospital (SPH), a database of all Emergency Department (ED) admissions called the ‘Regional ED View’ is maintained. Within this database, cases can be automatically selected using time, sex, age, and arrival mode. From this shortened list, patients were manually identified using information from the link sheet, as well as information from the Regional ED View such as presenting complaint and disposition from the ED. 54 For Royal Columbian Hospital (RCH), no equivalent to the ‘Regional ED View’ exists, and the electronic records system is more rigid than the system used at VGH. Here, researchers used records from prehospital care providers, and were able identify and access hospital records using this information. Where prehospital records were not identified, or patient identity was unknown to prehospital care providers, Royal Columbian Hospital’s medical records department attempted to identify patients using a similar probabilistic linkage to the process described for the other hospitals. Three records were identified in this manner, but delays in identifying and accessing these records meant that they were excluded from analysis in this thesis. They will, however, be included in future publications. Results of record identification Overall, data linkage and record identification was fairly successful. Figure 11, below, shows linkage rates across various agencies for all incidents identified in the study. A majority of incidents could not be linked beyond one or two agencies. No attempt was made to match any of 853 incidents where people did not jump to any potentially associated ambulance, hospital, or coroner records. These records may have potential value in future psychiatric or suicidology research, but were not relevant to this study. 55 Figure 11. All linkage outcomes, and their frequency. Grey shaded areas represent data presence and line thickness represents the relative frequency of each condition. Note that RCMP data starts on 2010-02-21, while BCAS data starts on 2010-04-01, so there is approximately a six week period —representing 7 incidents— excluded from this figure for readability. Challenges in record identification One obstacle in correctly identifying and then matching cases was the limited quantity of data initially available from agencies. At this stage, agencies were very conservative in what data was made available, citing —justifiably— patient privacy concerns. However, in protecting patient privacy at an agency level, it was compromised at a project level. By limiting the data available to positively match cases across agencies and to identify cases at the BCAS and hospital levels, far more information was required from other sources. Most concerning were incidents where suspected cases were identified and a tentative match made in hospital records, only to discover that the case was not relevant in any 56 way to the study. For example, a number of incidents identified in police searches were tentatively matched to BCAS cases. At this stage, with insufficient evidence to confirm this potential match, the medical history for the identified person was checked. In a number of instances, this resulted in medical histories being accessed for incidents like falls from a ladder, domestic or sexual abuse, or motor vehicle accidents. By gaining access to slightly more information at an earlier stage in the record identification process, access to more sensitive information at later stages could be mitigated. 57 DATA COLLECTION Data was collected from the police, Canadian Coast Guard (CCG), British Columbia Coroners Service (BCCS), and Joint Rescue Coordination Center (JRCC) at the time of case identification. For the British Columbia Ambulance Service (BCAS) and hospital data, cases were first identified, then the full dataset or chart for those cases was pulled. Each agency was able to provide certain information about incidents, and had differing periods of data availability. Figure 12 shows data availability for all data contributing agencies in the study. The large gaps in data availability from CCG Kitsilano were supplemented by records of all medical incidents kept at CCG Western Region headquarters in Victoria, as well as records available from JRCC. The information available from each agency is shown in Table 2. However, just because information should be available from any given source, does not guarantee that any given record will have that information, nor that the data quality will be sufficient for the desired analysis. Figure 12. Data availability periods for agencies included in the study. 58 Canadian Coast Guard data Data was collected from the CCG using a data sharing agreement, drafted by the researchers and signed by both parties. For identified incidents, a SAR Mission Report, and a Patient Care Record (PCR), where applicable, were collected and scanned. The PCR, as seen in Figure 13, is used to record patient information, clinical course and treatment information, while the SAR Mission Report provides an overview and timeline of the incident and response. The data collected by the CCG is intended for operational use and planning, not medical research and so had to be interpreted for use in this project. Joint Rescue Coordination Center data Data from JRCC was accessed using an Access To Information and Privacy (ATIP) request. Once cases had been identified, JRCC identified and released all related documents as electronic scanned copies. This data contained comprehensive timelines, information about assets tasked to each incident, as well some information about the subjects. Generally, these reports build a fairly comprehensive picture of each incident. However, the process of issuing an ATIP request, locating, printing, redacting and then scanning all 5967 pages of documents took Figure 13. Sample Coast Guard patient care forms used for recording patient and treatment information. 59 nearly seventeen months. Finally, reviewing 586 records in a single 5967 page PDF is highly impractical. Attempts at manual abstraction were quickly abandoned due to challenges keeping incident details separate. Fortunately, the scans were of sufficient quality that optical character recognition software could be used in conjunction with a custom automated data extraction script to abstract basic incident details and generate a document directory. Details of this script are outlined on page 64. 60 Table 2. Data available from each agency. Grey indicates partial or incomplete data, while black indicates compete data. RCMP Vancouver PD Delta PD Joint Rescue Coordination Center Coast Guard BC Ambulance Hospitals BC Coroners Service Agency Information Other agencies involved Agency response (unit type, number and origin) Injury code or UCR code Free text event description Timeline Date Response timeline Time of jump Patient info Name, PHN, MRN, and/or agency-specific patient ID City of residence, Demographics (age, gender, ethnicity) Incident Information Alert information and source Bridge Patient retrieved from (place and agency) Patient delivered to (place and agency) Jumped (Y/N) Witnessed (Y/N) Environmental Weather, visibility, air and water temperature Patient Outcome Patient status Time and reason for discontinuation Detail of death Patient Status Vital signs (BP, HR, RR) Oxygen stats (ETCO2, SPO2) CTAS score Glasgow Coma Scale (GCS) Cardiac General impression Cardiac electrical activity Timeline of arrest AED timeline and outcome ROSC timeline Airway and Breathing Airway support mechanism Assisted ventilation rate and mechanism Oxygen delivery rate and mechanism Trauma Recorded trauma mechanism Injuries Trauma care provided Spinal precautions taken Hypothermia Patient temperature* Rewarming provided Fluid Resuscitation Access type (IV / IO) Fluids delivered (type and quantity) Drugs administered (free text) Toxicology profile 61 Police data Police departments provided data extracts directly from their databases. Despite a standardised request list of data points, not all departments provided us with the same data sets. Exactly what data was provided by each police force is shown in Table 2. Generally, the police data provided is unambiguous and of good quality, despite inconsistency in information availability. Data was not obtained from New Westminster Police Department due to lack of funding or from the West Vancouver Police Department due to lack of response. British Columbia Coroner’s Service data A scanned electronic copy of the Coroners Report for each case was released to the researchers with the decedent’s name redacted. These records appear to cover almost all fatal incidents, but reports provide varying amounts of information about individual cases. Many reports contain only the minimum of information identifying the date, time, location, means, and direct cause(s) of death. Others were far more comprehensive, outlining the events leading to a suicide, past medical history, emergency service’s response to the jump, and toxicology and autopsy findings. British Columbia Ambulance Service data Once British Columbia Ambulance Service (BCAS) records were identified, the data outlined in Table 2 was extracted from the BCAS database and transferred to researchers. Data came as a .csv file, ready for analysis. It contains only pre-coded and numerical values, free text information collected on the BCAS patient care records is not available 62 from the BCAS database. These records provide accurate timelines, along with unambiguous vital signs and some information regarding specific treatments and injuries. The lack of free-text fields, especially patient history and assessments, hindered some planned analysis and reduced the applicability of BCAS data to this study. Hospital data Hospital data came in the form of patient charts, either electronically scanned or as paper originals. The data available from hospitals was highly variable. Many records contained masses of information, most of which was not relevant to the research at hand. In other cases, records were incomplete, missing, or only partially scanned. Wherever available, ED physician notes, trauma surveys and assessments, radiological, toxicological, and consultant reports, and discharge summaries were all pulled from these charts for abstraction. Record access at hospitals was dependent on Health Authority and Hospital protocols in place, as well as the data format. Electronic records from Royal Columbian Hospital (RCH) were accessed using temporary logins available to researchers, and relevant records are made available to this account. Records not yet available electronically were ordered from archives, to be viewed and abstracted on-site at RCH. Records from both Lion’s Gate Hospital and Vancouver General Hospital are not yet electronic. In both cases, records could be ordered from Health Records, or off-site archives, to be reviewed and abstracted on hospital grounds. Saint Paul’s Hospital records are scanned electronic copies accessible using the researcher’s health information system login. One limitation 63 to this system is that records are only partially scanned; trauma surveys were not available for patients transported to Saint Paul’s hospital. Limitations and obstacles to data collection Data collection for this project was a complex and varied process. Every agency had differing mechanisms for requesting and acquiring their information. Along with this, each agency had differing guidelines for what information they would release, how it could be stored, and how it could be used. Collection of data from police agencies, BCCS and JRCC was hindered by the blunt nature of FOI or ATIP requests. The formality of the requests, and their rigid structure pushed the agencies into the position of having to work for the researchers rather than with them. Further, the requirement that data released under FOI or ATIP requests be prepared for general public release imposed a significant workload on both the agencies and the researcher. For example, records from Joint Rescue Coordination Center in Victoria took seventeen months from the time of the request until they were received. Approximately 2/3 of this time was preparing the data for public release, notably by redacting potentially identifiable patient details like name, age, and clothing descriptions — information the researchers were already privy to. This represents a significant workload for these agencies, one which could be negated if a data sharing agreement, similar to those used by health-care agencies, was available as an alternative method for data acquisition for research. 64 DATA ABSTRACTION AND STORAGE Data abstraction procedures varied depending on the format data was provided to us by each agency. Police departments and the British Columbia Ambulance Service (BCAS) provided information directly as a .csv with the requested fields. Here, abstraction was not required, and the data was standardised, formatted, and cleaned to meet the needs of our analysis. Canadian Coast Guard (CCG) and hospital records are paper or non-machine readable electronic formats and required manual abstraction. British Columbia Coroners Service (BCCS) and Joint Rescue Coordination Center (JRCC) records came as .pdf copies of their respective reports. These .pdfs were transformed to machine-readable documents using Adobe Acrobat Pro DC’s (2019) Optical Character Recognition (OCR) “Recognize Text” feature, in preparation for automated data abstraction. To abstract JRCC and some BCCS records, an RStudio script using the tm package was created. The tm package was able to convert the pdf file into a large collection of text vectors. A unique identifier was electronically pasted on top of the scan of each page in the JRCC records. Because this information was added electronically after scanning, the identifier was already machine readable, so there were no errors in optical character recognition. This identifier followed a unique, repeating pattern which could be used to identify each incident, and the start and end page of each incident. An initial script was written to identify each incident number, and the document pages associated with that incident. A similar script was written for BCCS records, but without the electronically added identifier, it was less accurate. 65 Abstracting incident information electronically was more complicated. Optical Character Recognition is imperfect, and the desired data may not have had the unique patterns found in the page identifiers. As a result, a more robust identification script had to be used, addressing or bypassing common issues in OCR. The longer a search character string, the more likely it is that a character within the string will be mischaracterised by the OCR. Therefore, search terms should be as short as possible, using characters that are unlikely to be mischaracterised by the OCR, while still being unique to the desired data. For example, in order to identify the location of an “Incident Summary”, use of the entire phrase was impractical because the number of spaces between words was rarely correctly identified by the OCR. The word “incident” suffered similar limitations because the OCR frequently mischaracterised “I” and/or “t” as “l”, “|”, “[“ or “]”. Use of the full word “Summary” was affected by issues correctly identifying all characters in the word, especially in the last three letters. However, “sum” is too common a letter combination to exclude potential miss-identification of the data. Eventually, the term “summ” was found to provide the best balance of accuracy and precision for a search term. This process was repeated for each desired data type to identify the best search terms. Once the search term was identified, the document was rebuilt as a corpus (collection of documents, one per page), and then into vectors of character strings, with each string representing one line on the document. Using the data directory and search terms, the location of each desired data type in every record was identified, and assigned to a variable as a kind of “location marker”. The position of the desired information relative to 66 the location marker identified using the search term was then determined, and that data was then extracted. For example, Incident Summaries were generally the entire marker line, plus the following two lines of data, so all three lines were extracted and pasted to spreadsheet. This approach did not always work, especially for shorter data points like times or locations, where multiple data points would be held on single lines, or where the length of the data string of interest was not consistent. Where this happened, a variety of unique characteristics had to be identified and applied to separate the desired information from excess data. The electronically abstracted data was imperfect. While the script automated a large portion of corrections, like changing “I” or “l” to “1” in incident numbers, there were still numerous issues with the accuracy of the abstracted data. The data was corrected and cleaned manually in Microsoft Excel for Mac (2019), before being uploaded into REDCap and data that could not be electronically abstracted was manually entered. Data was manually abstracted and stored for analysis using REDCap (Research Electronic Data Capture) hosted at the University of British Columbia.58 A single REDCap project was created for all agency types, and REDCap’s branching logic was used to present only relevant data collection points for each agency type. The full data collection instrument, showing all data points collected is attached as Appendix 1. During the abstraction process, records were appraised by abstractors for completeness and quality. Abstractors were asked to indicate if “Any or all of record missing or 67 obscured”. If the abstractor indicated “Yes” in response, they were asked to note missing or obscured portions of the record. Abstractors were also asked to score record quality on a simple five point scale, indicating if the record quality was: 1. Good (Builds good picture of patient and event) 2. OK (Essential information present but provides few details) 3. Mediocre (Some essential information missing, provides no details) 4. Poor (>50% of essential information missing) 5. Very Poor (Insufficient information provided) Abstractors were also asked to note any details they felt were pertinent to data quality, for example, if large quantities of information was recorded, but was illegible, or if information was conflicting. During abstractor training, examples of each type of record were discussed. Further, what constituted essential information, and what constituted a detail was outlined, and examples were discussed. For example, information like incident timelines, bridge names, and patient sex where considered essential information, while information like toxicology results or patient psychiatric history where considered details. Prior to linkage, portions of CCG and BCCS data were abstracted and exported in order to perform the linkage. REDCap makes data available as a .csv file for export and analysis and will also automatically generate an R script to recode any data stored as numerical to its original labels. A modified version of this script was used to export abstracted data directly into R, assign the correct study ID, strip any identifying information, and 68 properly code the data for analysis.59 This cleaned and re-identified file was then stored for analysis. Storage and security Physical data is stored in locked filing cabinets, in a locked room in a restricted access building. Electronic data is stored on an encrypted and password protected hard drive in the same filing cabinet. Abstracted data will be archived in REDCap without personal identifiers for five years following the last publication based on this data, as per UBC policy. Data security requirements from various agencies were often inconsistent, and sometimes conflicting. Further complicating matters, data security protocols often left significant room for interpretation, leading to confusion and delays. 69 DATA ANALYSIS This study used all available records within the study period. In certain analyses, only a subset of incidents were used. Where this is true, the subset, and reasons for using this subset are outlined with the analysis. To increase the sample size and improve statistical reliability, the full cohort is used wherever possible. To ease data extraction of different subsets, a master patient list was created linking Study ID to incident information, basic patient demographics, and outcomes. For any given analysis, the following procedure was performed to generate the dataset required: 1. A population list was generated from the master list by selecting patients based on the inclusion/exclusion criteria for that particular analysis. 2. Each relevant dataset (police, coast guard, ambulance, hospital, or coroner) was opened and the required variables extracted, along with the study ID for each patient. This created a subset for each dataset with only the required variables 3. All relevant subsets were merged by study ID with the population list. The merge() function in R used for this task is configured to drop all records where the study ID is not included in the population list. Analysis was conducted using RStudio and a variety of data analysis and visualisation packages.60 Details of the analysis and data visualisation techniques used are addressed on a case by case basis. 70 USE OF PERSONAL IDENTIFIERS Name, PHN, and MRN, were collected exclusively for chart selection and data linkage stages of the project. They were stored in a password-protected link sheet, separate from other patient information. This information was destroyed as soon as practicable and was not used in, or retained for, any analysis. Date of birth was collected for determining age at time of jump. Once age at time of jump was calculated, date of birth was also destroyed. 71 MISSING DATA Agency Number of Incidents Coast Guard 252 Joint Rescue Coordination Center 93 Vancouver Police Department 353 Royal Canadian Mounted Police 406* Delta Police Department 77 British Columbia Ambulance Service 48* Hospitals (all) 8 British Columbia Coroners Service 14** There are a number of incidents in which we are aware of the participation of a particular agency, but that incident is not included in the data set supplied by that agency, or we are unable to identify the incident in the agency’s records. Table 3 outlines the number of incidents in which each agency is known or strongly suspected to have participated, but there is no mention of that incident in their records. Canadian Coast Guard data has a number of gaps due to the closure of Kitsilano Base in 2014, as discussed on page 42. While some of the Kitsilano base records were retained either at CCG Western Region Headquarters or Sea Island Base, a significant quantity are no longer extant. Due to a system changes, both BCAS and the RCMP could only provide records for a portion of the study period. BCAS records date back to April, 2010. Records prior to this date are property of the British Columbia Ministry of Health (MOH), and accessing them Table 3. Number of incidents in which agency participation is known or strongly suspected, but where there is no record of this incident in agency records. *Indicates agencies where missing records are expected because their databases do not cover the entire study period. For BCAS, may also indicate incidents where the person did not jump ** These may be incidents where the investigation is still active, or the person was never found. 72 was impracticable for this study. For cases prior to April 2010, wherever possible, BCAS information has been collected from run sheets available from hospital records. RCMP records date back to January 1, 2010. Prior to this date, there is no available police data for areas outside the jurisdiction of VPD or Delta Police. Also, as previously noted, in the section Police records, page 43, it is likely that RCMP data underestimates the number of people who did not jump. 73 DATA QUALITY Accurately collecting and conveying information can be challenging within small groups of professionals with a common argot in the (relatively) controlled in-hospital environment.61,62 In the prehospital setting, information is conveyed through a variety of means (radio, telephone, hand-written records, face-to-face), between individuals with differing levels of training, differing argots, and differing expectations. This, in combination with the highly dynamic environment makes accurately collecting and conveying information a formidable task. Further, the information available to first responders during an incident is in a constant state of flux, as more information is made available by witnesses or by the responder’s own observations. These factors often result in contradictory or ambiguous incident records. For example, one patient was recorded as both male and female within a single case report. In another case, three agencies recorded three different outcomes for a single incident; (a) a hoax, (b) not jumped and (c) jumped and survived. In fact, evidence suggests the person jumped and was not found. First responders and medical professionals collect information relevant to their operational needs, which may differ from information desired for research purposes. Therefore, some of the desired information was not collected, or not collected in sufficient quantity or quality for analysis. This can be seen in the interagency coordination analysis, and partially in survival analysis, where sample sizes may be smaller than desired. Overall however, the data was of acceptable quality. For data requiring manual abstraction into REDCap (Canadian Coast Guard, British Columbia 74 Coroner Service, and hospital records), abstractors rated 23.1% of the records as “Building a good picture of patient and event”, while only 11.3% of records were rated as “Poor” for missing “>50% of essential information”. Certain data sets had specific issues that may have hindered their use in this research. The quality of information available from Canadian Coast Guard (CCG) patient care records was highly variable. Some records provided significant quantities of detailed information, including noted injuries, multiple complete sets of vital signs, and detailed treatment information. Other records contained little more than a cursory lay-description of patient status. Further complicating matters, information was recorded using inconsistent formats. For example, some records used the AVPU for mental status while others use the Glasgow Coma Scale. In a number of cases, no patient care record was available at all. A similar pattern of inconsistency was found in CCG SAR Mission Reports. Police and ambulance data was extracted directly from electronic databases. Generally, the data was concise and of good quality, requiring no interpretation or further abstraction. However, as noted in the limitations section, the available data may not have perfectly suited the needs of the research. Hospital data was also of inconsistent quality. When available, trauma surveys performed in the Emergency Department (ED) with a dedicated scribe were generally complete, accurate, and easy to interpret and abstract. However, collecting and abstracting hospital 75 data was complicated by inconsistent formatting across consultants. Also, a large portion of hospital records are still hand written, with varying degrees of legibility. 76 METHODOLOGICAL EFFICACY Using police and search and rescue data to identify cases for retrospective reviews is not a well-established methodology in clinical research. However, it was useful here because cases could not be identified through traditional clinical research methods at the ambulance or hospital level. Firstly, a significant portion of these cases simply never make it to hospital or ambulance, and are therefore absent from ambulance or hospital records, introducing survivorship bias in the study population. Further, jumping from a bridge is not covered by a single ICD-10 or MPDS code, so incidents may be coded as any number of incident types or combination of types. Searching by code or codes in hospital or ambulance records fails to identify a large number of cases, and identifies an even larger number of incidents not relevant to this study. The search conducted by British Columbia Emergency Health Services is a good example of the challenges of identifying these cases using traditional coding. Using Medical Priority Dispatch System coding likely to be associated with suicide attempts by jumping off a bridge, the search had a false positive rate of 99.42%, while only identifying 56.5% of cases. Once hospital records were identified, they reveal that similar problems would likely have arisen if attempts to identify new cases had been undertaken at the hospital level. For many patients, the “Most Responsible Diagnosis” was coded based on the pathology underlying the jump, conditions such as schizoaffective disorder or a severe depressive episode. Additional diagnoses coded in patient records were descriptive of specific injuries, or generic descriptions of the incident e.g. “Falling, jumping or pushed from a 77 high place, undetermined intent” or “Intentional self-harm by jumping from a high place”. These codes fail to describe these incidents with sufficient precision to effectively search for and identify them without prior identifying information. Other potential search criteria, such as admit diagnosis, or Emergency Department Chief Complaint are equally non-specific. A common Chief Complaint – “MS Trauma, Blunt, high risk mech.” could apply just as well to a motor vehicle accident or a blow to the head as to a suicidal jump from a bridge. The data laid out in Table 3, as well as communications with police agencies suggests that search limitations also exist in police data structures as well. Without insight into the specifics of the search methodology used, it is impossible to comment on any potential methodological limitations here. Technological limitations impede search accuracy at all agencies involved. Large institutional databases are expensive, long-lived installations designed around a specific purpose. Systems in the study are nine or more years old and likely required three to five years of planning, development, and implementation, making the technology at least twelve years old. Expecting results similar to modern, free-text capable, algorithmic search engines is unrealistic. As well, these databases were designed to support the operational needs of the institutions in question. Adapting them to other purposes — like identifying highly specific cases that aren’t directly coded for — is challenging and unlikely to yield perfect accuracy. 78 As Table 3 lays out, a number of cases were not identified by any given search. However it is unlikely that cases missed in all searches represent confirmed jumps for a number of reasons. First, unconfirmed or questionable reports are less likely to be coded as a relevant code, or may be coded entirely differently; as a distressed person or suspicious activity rather than as a suicide or suicide attempt. Second, as agencies are conservative in releasing information, they may be more hesitant to release information about suspected cases than confirmed ones. And finally, confirmed jumps draw a much larger response from a broader range of agencies, making multiple reports of the incident more likely and therefore more likely to be found over multiple searches. By combining data from multiple agencies, it was possible to build a comprehensive list of all cases. After datasets from the Canadian Coast Guard, Vancouver Police, Delta Police, Royal Canadian Mounted Police, and the British Columbia Coroner’s Service were combined, a final dataset was received from Joint Rescue Coordination Center. This final data set contained only one previously unidentified confirmed jump, suggesting that aggregating multiple datasets in order to compile a comprehensive study population is a viable and robust methodology. 79 Study population Ultimately, we were able to identify 1208 incidents which met the inclusion criteria. These incidents are outlined in Figure 14. One limitation in describing the population as a whole is that persons may go to a bridge to jump multiple times throughout the study period. For RCMP, Delta PD, and most CCG and JRCC data, it is not possible to identify cases where a single individual is responsible for multiple incidents. It was possible to identify individuals involved in multiple incidents in BCAS, VPD, and hospital data. However, without the ability to do this across all incidents, the study was analysed as a collection of incidents, rather than individuals. As such, one individual may be counted multiple times through the study period, and all results presented should be thought of as a summary of incidents, rather than a population per se. Table 4. Study population age and sex distribution summary. Sex distribution Age (years) N Sex n (%) nage available IQR Mean (sd) Median All 1208 Male 703 (69.8) 561 25-46 36.98(13.22) 36 Female 303 (30.2) 240 24-41 32.52(12.42) 29 Did not jump 853 Male 476 (67.3) 366 24-44 35.06(12.65 33 Female 231 (32.7) 184 23-40 31.78(11.65) 29 Jumped 273 Male 203(77.2) 189 30-49 40.78(13.56) 40 Female 59(22.8) 50 24-44 35.44(14.49) 32 Hit water 197 Male 143(74.9) 132 29-48 40.48(13.09) 41 Female 47(25.1) 40 25-42 34.55(13.85) 32 Survivors 41 Male 29(72.5) 27 27-45 37.56(11.36) 39 Female 10(27.5) 10 22-42 33.90(15.59) 32 Deceased 153 Male 113(76.4) 104 31-50 41.11(13.45) 41 Female 35(23.6) 30 25-42 34.77(13.51) 32 80 AGE Age distributions were compared using two different methods. Using the exact age, we calculated the mean, standard deviation, median, and Inter-Quartile Range (IQR), as presented in Table 4. The study population was then grouped into the 5-year age groups used by Statistics Canada for the presentation and analysis of vital statistics. This was done to simplify analysis and to create a dataset that could be compared to Statistics Canada data on both suicides and the population as a whole. Table 5 shows the distribution of ages across these age groups. Table 5. Age distribution of the study as compared to total Canadian suicides, by sex and 5 year age tranches. The Jumped columns of this table includes those who jumped and hit a hard or unknown surface. (Data for suicides in Canada from Statistics Canada)3 All Jumped Total number of suicides in Canada by age group, 2006-2016 Age group (years) Female Male Female Male Female Male 10 to 14 1 0 0 0 194 166 15 to 19 29 35 4 5 651 1488 20 to 24 43 85 9 19 749 2384 25 to 29 52 79 8 23 772 2324 30 to 34 26 58 8 14 767 2368 35 to 39 23 67 4 32 817 2640 40 to 44 22 67 4 19 1014 3251 45 to 49 17 77 2 31 1248 3862 50 to 54 12 37 4 17 1338 3756 55 to 59 7 27 4 14 1124 3228 60 to 64 4 17 1 7 733 2224 65 to 69 2 6 1 5 436 1455 70 to 74 2 0 1 0 297 1061 75 to 79 0 3 0 1 240 923 80 to 84 0 0 0 0 151 717 85 to 89 0 3 0 2 132 430 90 and older 0 0 0 0 58 181 Age unknown 64 143 9 14 - - Age trends in the study population vary slightly from what would be expected in suicides in Canada. The age distribution of women who die by jumping from a bridge in this study reflects the age distribution of female suicides in Canada (pC2 = 0.086). Meanwhile, the 81 age distribution of males who die by jumping is different (pC2 = 0.000). Men between the ages of 20 and 50 appear to be over-represented as compared to male suicides as a whole, while men under 20 and over 50 are under-represented. Literature generally suggests that demographically, those who jump are not different from those who commit suicide by other means, except for their access to jumping structures.37,38,40 This observed variation from the expected trend is unexplained; the age and sex characteristics of the population of the Lower Mainland are not significantly different from Canada as a whole.63 When comparing by sex in the study population, women who jump are more likely to be younger, with the density peaking in the late 20s, while the male distribution peaks in the 40s. Again, this variation is not addressed in the literature, and is not explained by demographic patterns in the study area. 82 SEX Overall, the sex distributions for all sub-populations outlined in Table 5 are in line with the sex distributions in suicide in Canada. The sex paradox in suicide suggests that, while men are more likely to commit suicide, women are three to four times more likely to attempt suicide. Women are over represented in those who don’t jump and the difference is statistically significant ( pΧ2 = 0.000). However, amongst those who did not jump, a majority (67.3%) are still male. While the difference in sex proportions between those who jump and those who don’t is large, and is likely significant, this observation should be regarded with some hesitation, due to the suspected missing data in people who don’t jump. Based on the literature, we would expect an even larger variation in the sex ratios between those who jump and those who do not. This deviation from the expected sex ratio in attempted jumps may be explained by the male preference for rapid and violent means of suicide.64 Bridge jumping is rapid and violent, and may therefore be less appealing to women, even amongst those who ultimately do not jump. Table 6. Sex distribution of fatalities in the study population as compared to Canada-wide suicides for the study period. (Canada-wide data from Statistics Canada)3 n Male n Female Study population deceased 113 35 2006-2016 Canadian total suicides 32459 10723 On average, men constituted 75.2% (sd = 1.0) of suicides in Canada from 2006-2016. In the study population, 76.4% of deaths following jumps into water were male, an insignificant 83 deviation from the Canadian average ( pΧ2 = 0.812). This finding is in line with the literature, which suggests that those who commit suicide by jumping are not significantly different from those who commit suicide by other means. 38 84 Incidents Figure 14. Breakdown of all reported incidents and their outcomes for the study period. Overall, 1208 incidents were identified for this study and the outcome of each case is presented in Figure 14. More detailed outcomes for incidents where the patient jumped into water outlined in Figure 17. Outcomes following a jump into water. All survivors were transported to hospital, except one, who made it to shore and departed prior to the arrival of emergency services.. Ultimately, it was possible to determine the outcome with a high degree of certainty for 90.6% of identified cases. On many occasions, this was only made possible by combining data from multiple agencies to create a complete picture of the incident. Given that 15.2% of those who jumped into water were never found, it may be reasonable to speculate that a number of cases classified as “suspected jumps” or “unknown outcomes” are, in fact, cases where the person jumped and was never found. 85 As previously discussed, this study population likely represents an under-estimate of cases where the individual did not jump, limiting the value of any analysis done with this group. However, it appears likely the jumps identified are a reasonably accurate accounting of all confirmed jumps in the study period. BRIDGE DISTRIBUTIONS All bridges are not equal in this study, with some being significantly more frequented than others. As expected, Lions Gate bridge was by far the most commonly used bridge. Table 7 shows the incident frequencies for bridges with 10 or more jumps in the study period. The counts of all incidents for each bridge should be regarded with some suspicion due the significant disparity in the ratio of jump to non-jump incidents in Coast Guard, Vancouver Police, and Royal Canadian Mounted Police data. Bridge name All incidents Jumped Hit water Lions Gate 324 78 60 Pattullo 117 41 33 Granville Street 189 32 13 Alex Fraser 49 21 18 Burrard Street 150 21 15 Port Mann 42 13 10 Cambie Street 82 10 6 Second Narrows 73 10 9 Other 239 38 28 Unknown 32 21 14 Table 7. Distribution of incidents by bridge for all bridges with ten or more jumps in the study period. 86 The choice of structure is a commonly discussed topic in the literature on suicide by jumping. In jumping from structures, populations can be divided into two main subgroups: people who chose a structure for its “availability and proximity” or those who select a specific site to jump, as addressed in the Suicide means section (page 9).38 Bridges may fall into either category, and both categories are likely present in this study. As can be seen in both Table 7 and Figure 15, the Lions Gate bridge is by far the most frequented bridge, with more attempts and jumps than the next two bridges combined. Lions Gate Bridge lacks direct proximity to residential or commercial structures, any attempt to jump originating from a patient’s home or workplace would require a 2-3km transit. Our results, in conjunction with the analysis of home addresses and distance traveled conducted by Lam et al. (2017) strongly suggest that the Lions Gate Bridge is a Figure 15. Jumps by bridge over the study period. 87 destinations for persons wishing to commit suicide, not just a convenient structure to jump from.42 Pattullo Bridge and Granville Street Bridge, the second and third most frequented bridges in the study are located in densely populated portions of the study. They are easily accessible to pedestrians, and are proximate to the major psychiatric treatment centers at Vancouver General Hospital, Saint Paul’s Hospital, and Royal Columbian Hospital. This suggests that these bridges are more likely to be structures of convenience than Lions Gate Bridge, chosen for their “availability and proximity”. TIME DISTRIBUTION There is a significant variation in incidents throughout the day, as can be seen in Figure 16. The only consistently reported temporal pattern in the literature, that suicide rates at night are significantly lower than during the day is born out in the population that jumped in this study.29–31 Jumps are lowest around midnight, and increase steadily to a peak in the between 13:00 and 15:00, which is consistent with the day/night trend reported in the litterature.29–31 However, this peak does not coincide with either the end of the work day or sunrise/sunset, both times described in the literature as possibly coinciding with a peak in suicide rates. 88 Figure 16. Incident density by time of day. The difference between the two distributions is statistically significant. Incidents in which the person does not jump peak later in the evening, closer to 20:00, and there is a second, smaller peak at approximately 02:00. This observation is not comparable to anything in the literature. These two distributions are significantly different from each other (p K-S = 0.008). This suggests these groups are in some way different, in line with observations about variation in sex ratios and ages. In the literature, annual and weekly trends in suicide rates are also noted however, the incidents in this study do not show any marked patterns by day of week or through the year.32,33 This may be part of a broader trend in high-income countries away from annual and weekly variations in suicide rates, but the data is insufficient to show any trends over the study period. 89 INTER-INCIDENT TIMING AND CLUSTERING The incidents identified in this study represent an average of one person jumping into water roughly every fourteen days. There is conflicting evidence in the literature suggesting suicides, especially in public places, may cluster in time.24,65,66 The possibility of clustering was evaluated using the same methodology as Manson et. al. (2013), who compared the distribution of inter-jump intervals (in days) to a poison distribution. The jumps in this study appear to be discrete, independent events with no sign of clustering or variation from the poison distribution model (pC2 = 0.653). 90 INCIDENT RESPONSE AND INTERAGENCY COMMUNICATION Evaluating interagency communication was more difficult than anticipated. Initially, collection and comparison of timelines, initial dispatch briefs and the patient history from each agency was proposed. These would be coded based on a predetermined set of factors (jump time, recovery time, vital signs, treatment, bridge name and height), and the coded data compared to the established case history. Unfortunately, much of this data was either unavailable, confused, or of poor quality. For example, attempts to measure the accuracy of prehospital vital signs communicated to hospital staff were thwarted by the presence of multiple sets of prehospital vital signs, both in hospital and prehospital records. Without knowing what information was communicated, to whom and when, it was not possible to compare the known prehospital vital signs with information recorded by hospital staff. As such, a much-reduced analysis was conducted, examining the only the incident timelines and the accuracy of a small subset of information relayed to hospital staff. Ultimately, time of jump, time interval from jump to recovery, and bridge height were the elements of the incident history that were consistently recorded and available for analysis. Even this analysis is limited by small sample sizes and ambiguous data. Finally, there is little information available to provide context for the observed deviation between the actual incident and the recorded history. That is, while a deviation may be noted, it is not possible to know if this deviation reflects a serious communication breakdown, or is within the normal range of variation for recorded patient histories. 91 Response delays Dispatch and handover delays are likely to represent communication or inter-agency organisational challenges. Dispatch delays suggest that agencies may struggle to accurately communicate incident details, or request assistance in a timely manner. Handover delays suggest that agencies are unable to coordinate a response. The interval between the earliest time known for an incident (either time of jump or logged dispatch time from police records), and the dispatch times recorded in agency records were calculated and presented below. The handover delay was calculated using the interval between when British Columbia Ambulance Service (BCAS) and Canadian Coast Guard (CCG) crews arrived at the handover location. This methodology is somewhat limited. Without knowing the exact time of the jump, dispatch delays are only estimates, and likely skewed low. Here, the numbers should be interpreted as a general trend only, not definitive values. Table 8. Prehospital dispatch and handover delays. Negative handover delays indicate that ambulance crews arrived at the handover location before the Canadian Coast Guard delivered the patient, as was the case in 29 of 35 cases where data was available. Mean delay (IQR) mm:ss n BCAS dispatch delay 7:37 (3:00 – 10:00) 56 CCG dispatch delay 13:09 (00:36 – 14:23) 116 BCAS handover delay -11:24 (-14:51 – -2:41) 35 The dispatch delay suggests that there is a significant communication barrier between the Canadian Coast Guard and other agencies. It is possible that this delay is attributable to the CCG’s independence from E-COMM911. However, the absence of handover delay 92 suggests that BCAS and CCG crews and their dispatchers are able to effectively coordinate patient handovers, and independence from E-COMM911 does not necessarily preclude an efficacious response. Information transfer to hospital The accuracy of patient history information recorded at the hospital was compared with known incident data. Only marginal data was available for this analysis. The proposed comparison of recorded prehospital vital signs, drug administration, and treatment information was not possible due to poor data quality and significant confusion across multiple sets of prehospital vitals. For example, prehospital care providers may have recorded four sets of vital signs for a patient, but hospital staff recorded two of the four sets and did not identify which sets they recorded. In this case, hospital information could not be compared with prehospital records. Time of jump and time of recovery where either recorded directly in hospital records, or calculated based on noted time in the water or noted time elapsed from injury to ED admission. Bridge name was recorded incorrectly in hospital records in two cases, and a further two cases contained notes listing multiple different bridges. This information is not directly clinically relevant, so it is possible that less care was taken to acquire and record it. However, significant deviation from the actual incident history may indicate a communication breakdown somewhere in the chain of patient custody. This analysis is limited by small sample sizes and lack of relevant control or reference values for comparison. Without comparable literature or context, it is not possible to speculate if 93 the results shown represent a worrisome level of deviation between recorded and actual incident histories. Table 9. Variation between best understanding of incident history and incident history recorded by emergency room staff. Mean absolute variation from best understanding of incident history (IQR) n Time of jump (mm:ss) 18:18 (4:45 – 23:15) 24 Time to recovery (mm:ss) 20:16 (8:00 – 26:00) 11 Bridge height (m) 9.2 (5.1 –14.8) 26 94 Outcomes Outcome distributions Objective zero outlines a desire to describe and quantify outcomes for study subjects from deceased through to full re-integration into society. The data available was not sufficient to achieve this, as following patients after discharge from acute care was not possible in the available hospital records. However, it was possible to describe the course of most subjects from time of jump into water to death or discharge from acute care. Outcomes are laid out in Figure 17, below. After jumping into water, those recovered promptly by the marine resources are transported to shore for handover to the police, coroner, or the British Columbia Ambulance Service (BCAS). Figure 17 shows the outcomes off all known jumps into water. Those listed as “Post-recovery outcome unknown” were likely recovered by police or civilians, and there is no record of them receiving care from BCAS. There is one known case in the study where the person jumped, made it to shore unassisted, and then departed prior to the arrival of first responders. Once in the care of BCAS, patients are either declared deceased following a physician order or transported to hospital. There were no reported cases where a patient was released directly from BCAS care. The low rate of patients transferred to hospital (25.4%) is expected given outcomes and injuries reported in the literature. The traumatic injuries sustained and high risk of 95 drowning suggests that patients recovered in cardiac arrest are likely very poor candidates for resuscitation. While the injuries reported in the literature correspond well with the primary reversible causes of death in blunt trauma (peumo- or haemo-thorax, cardiac tamponade, and hypovolemia), prehospital care appears to be insufficient to address these injuries for patients recovered without vital signs. Care for pneumo- and haemo-thoraxes in-field is limited. Needle decompression is indicated for tension pneumothorax, but evidence for its efficacy as temporizing management for other types of pneumothorax Jumped, hit water197Not recovered30Delayed recovery49Recovered118Recovered deceased6Transported to BCAS94Post-recoveryoutcome unknown18Transported to hospital53Deceased with BCAS41Discharged from ED1Admitted to hospital32Deceased in ED6Disposition fromED unknown11Discharged withoutfurther care*4Discharged to outpatientor community care*20Transfered to long term care*12Deceased in hospital2Care for physical injury*12Psychiatric care*14Care for physical injury*4Psychiatric care*8Figure 17. Outcomes following a jump into water. All survivors were transported to hospital, except one, who made it to shore and departed prior to the arrival of emergency services. * Indicates that more than one of these outcomes may be possible for an individual. For example, a patient may be transferred to long term psychiatric care, but still require outpatient care for physical injuries. 96 or haemothorax is weak and possibly conflicting.67 Prehospital care providers are unable to effectively manage internal haemorrhage on-scene, and anyone suffering from a hypovolemic arrest following blunt trauma is unlikely to survive without immediate access to blood products and surgical intervention.68 Drowning, near drowning, and aspiration further complicate resuscitation efforts. Due to these management limitations, and the proportion (42.1%) of patients being handed over to BCAS without vital signs, a high rate of transport to hospital should not be expected. However, literature suggests certain prehospital interventions, particularly airway support, may be essential for good outcomes in patients who are viable candidates for resuscitation.69 If patients are transported to hospital with vital signs present, their outlook is comparatively good. All but two (93.8%) patients who arrived in the Emergency Department (ED) with vital signs survived to hospital discharge. All patients deceased in the ED arrived without vital signs, and most were pronounced deceased within ten minutes of arrival. After the ED, most (18) patients were admitted under either Trauma or the ICU. Following discharge from hospital, most patients went on to further care. A number were transferred to long-term care, generally community hospitals, or inpatient psychiatric facilities. Many also received ongoing care in the form of outpatient follow up with hospital specialists, especially for severe orthopaedic or spinal injuries. A number of patients were also referred to various community clinics for care of both physical and psychiatric pathologies. Most patients received care from two or more services following discharge. It was not possible to follow patients beyond their discharge from acute care, so details of 97 their continuing care and long term outcomes are sparse. However, the literature indicates that those who survive are likely to have good outcomes and do not go on to re-attempt suicide.56 98 FACTORS AFFECTING OUTCOMES As part of Objective 1, the influence of level of consciousness and presence of vital signs at recovery, bridge height, time to recovery, age, water temperature, and sex on outcome were evaluated. These factors were selected based on the results of the literature review, which indicated they were likely to impact survival. Figure 18. Strength of correlation between various factors thought to be associated with survival. Larger, darker circles suggest a stronger correlation. Blue suggests a negative correlation, for example, as bridge height increases, level of consciousness on recovery decreases. Green suggests a positive correlation, for example, as bridge height increases, time to recovery increases as well. Lower p-values suggest correlations are more likely to be significant, but no cut off for what constitutes a significant correlation can be applied (see note).i i Note: To calculate correlation, level of consciousness was treated as an ordered categorical variable. Correlation calculations assume the distance between any two juxtaposed ordinal variables is the same. This is obviously not true here; the disparity between being unconscious and being responsive to pain is different than the disparity between being responsive to verbal stimuli and being alert. This limitation should be acknowledged when interpreting figure 18. While it suggests potential correlations, it is not necessarily indicative of them. It should be used only as a starting point for inquiries, not as a result in and of itself. 99 Figure 18 suggests that some of these factors may be correlated. Due to the limitations of Figure 18, it is not possible to definitively say what correlations are significant (see note, page 98). Generally, the figure should be interpreted critically, and without definitive conclusions. In doing so, it can be used to guide further analysis and to aid the interpretation of results. Some correlations are interesting, and may justify further inquiry. For example, the correlation between age and bridge height suggests that younger people may choose higher bridges. This could potentially mitigate the protective effect of age on survival in blunt traumatic injury, and could mask the importance of age as a factor affecting survival in analysis. Overall, Figure 18 suggests that individual analysis of each factor may be insufficient to establish their importance in predicting survival. Therefore, in addition to individual analysis, all of the above factors were modeled using a logistical regression model (Equation 1) to address possible confounding between factors. 100 Analysis population In all survival analyses, only subjects who jumped and hit water were included (n = 197). However, not all data was available for all cases. This is especially true for cases not recovered promptly, where there is ipso facto no recovery interval or mental status on recovery. The number of cases in which the relevant data was available is disclosed factor by factor below. Analysis variables Patient status on recovery Patient status on recovery was collected in two ways during data abstraction. First, as level of consciousness, reported as cumulative Glasgow Coma Scale (GCS) and a single extended version of the Alert, Verbal, Pain, Unresponsive scale with the following options: 1. Alert – Oriented 2. Alert – Not Oriented / Confused 3. Alert – N.O.S 4. Verbal 5. Pain 6. Unresponsive 7. V.S.A./Active Ressuscitationi 8. Deceased i Resuscitation was defined as active cardio-pulmonary resuscitation (CPR) or automated external defibrillator (AED) use 101 Second, patient status on recovery was recorded as the presence or absence of vital signs. This data was recorded by proxy, based on the timing of cardiac arrest; the timing of a cardiac arrest was recorded as: 1. [Arrested] Prior to assuming care 2. [Arrested] After [Coast Guard] arrival 3. Did not arrest Level of consciousness on recovery Generally, the AVPU scale is preferred because its simplicity is conducive to use in prehospital settings, and evidence suggests the AVPU scale is just as predictive as total GCS for patient outcome.70 For analysis, the extended AVPU scale was collapsed into the standard four-level scale, incorporating all sub-categories of Alert as A, and both VSA/Active Resuscitation and Deceased as U. AVPU was used as an ordinal categorical variable for both multivariate and individual analysis. As noted on page 98, this limits the value of the correlation, as the assumption of equidistant categories is obviously false in this case. That is, the difference between unresponsive and responsive to pain is more significant than the difference between responsive to verbal and alert. Therefore, any model created with this ordinal variable does not describe an exact relationship but the general trend of the correlation holds. AVPU data was available for 57 cases. This represents only 48.3% of cases where patients were recovered within three hours of a jump. A portion of the missing cases were likely recovered by police or civilians, where records of patient status on recovery were not 102 available. The proportion of survivors and fatalities with and without AVPU data is roughly even. Vital signs on recovery Vital signs data was recoded as either Vital Signs Absent (VSA) or Vital Signs Present (VSP). “Did not arrest” and “After arrival” were coded as VSP and “Prior to assuming care” coded as “VSA”. Where cardiac arrest timing data was not available, it was also supplemented with some AVPU data, VSA/Active Resuscitation and Dead where coded VSA, while all forms of Alert, as well as Verbal and Pain were coded VSP. Patients reported as Unresponsive were not included, as they lacked definitive evidence for or against the presence of vital signs. The presence or absence of vital signs on recovery is available for 55 patients. Bridge height Bridge heights are listed in Table 1, and are measured in m. The variability in the measurement of bridge height (clearance as compared to height from bridge deck) is likely insignificant in analysis; the difference for most bridges is less than the changes in water level caused by tidal fluctuations. Due to tidal fluctuations, it is possible that jumps from bridges with height difference of up to 3.8m may result in identical fall distances. Bridge height is available for 181 cases. 103 Recovery interval The recovery interval recovery was calculated as the interval between time of jump and time of recovery from the water. In some cases, time of jump was not explicitly stated and was inferred as the earliest reported time of an alert or dispatch. Since alerts or dispatches are more likely to occur after the subject has jumped, this method likely under-estimates the time to recovery, and by extension its impact on survival. Decimal minutes were used as units of measure in both multivariate and individual analysis, except where it is subdivided into tranches and used categorically for presentation purposes. Decimal minutes were converted back to mm:ss for presentation. Recovery interval is available for 79 cases. Age Age was calculated as integer years between date of birth and date of jump. In a small number of cases, exact date of birth may not be available and year of birth was used instead. Age is available for 179 cases. Water temperature Water temperature for an incident was approximated using the incident day’s average water surface temperature, recorded in the Fraser River at Hope, or the Ocean Data Acquisition System Buoy (ODAS) at Halibut Bank.71,72 All bridges spanning the Fraser River used the data collected at Hope, and all bridges in Vancouver Harbour and False 104 Creek used ODAS data. Expert opinion from Fisheries and Oceans Canada suggests a variability of not more than +/- 1.5°C between data collection locations and bridges. Water temperature is available for 174 cases Sex Sex was analysed as binary categorical male or female. Transgendered individuals were coded for and noted in the data, but the sample size (n=1) is insufficient for meaningful analysis. Sex is available for 191 cases. 105 Multivariate analysis An unweighted, binomial logistical regression model (Equation 1) was fit to all the factors using the Generalised Linear Model (glm()) function of the R ‘stats’ package.59 This model was developed and proposed in response to Objectives 1 and 2, based on evidence in the literature suggesting these factors may affect patient survival, and may be valuable in clinical decision making for first responders. Data for all factors is available in 53 cases. This model generated probabilities of zero or one and failed to converge, even after maximising possible fit iterations. This is likely due to quasi-complete separation in the regression model caused by too close a correlation between patient level of consciousness on recovery and ultimate outcome. A similar model was also fit using the presence or absence of vital signs on recovery instead of level of consciousness on recovery, and encountered similar issues. !"#$%$&' ~ '*$*' +, -+.!-%+"!.*!! +. #*-+$*#/ + ℎ*%2ℎ3 + #*-+$*#/ %.3*#$&' + &2* + 4&3*# 3*56*#&3"#* + !*7 (5&'*) Based on this finding, a new logistic model was created to fit the remaining five factors to survival (Equation 2). For equation 2, data was available in 71 cases. Equation 2 !"#$%$&' ~ ℎ*%2ℎ3 + #*-+$*#/ %.3*#$&' + &2* + 4&3*# 3*56*#&3"#* + !*7 (5&'*) The results of this model are shown in Equation 1 106 Table 10. They suggest that bridge height, age, and recovery interval are all statistically significant independent variables that affect survival. Sex and water temperature do not appear to be statistically significant contributors to survival. Table 10. Logistic regression model for factors affecting survival. The odds ratio (OR) is the odds ratio associated with a one unit increase of the variable in question. Survival Odds Ratio 95% Confidence Interval Low High Bridge height (m) 0.897 0.838 0.944 Age (Years) 0.903 0.827 0.968 Recovery Interval (minutes) 0.926 0.859 0.978 Water temperature (°C) 1.085 0.935 1.275 Sex (male) 0.867 0.184 3.949 107 Level of consciousness on recovery As noted above, level of consciousness on recovery can’t be accurately modeled as a potential contributory factor in survival. The regression model exhibits quasi-complete separation, suggesting that level of consciousness on recovery very closely correlates with final outcome. Further, when modeled as an outcome, rather than a contributory factor in survival, level of consciousness on recovery appears to be dependent on bridge height and patient age, two of same factors as survival. This suggests that level of consciousness on recovery is a post-jump outcome. Table 11 AVPU scores at time of recovery from water for deceased and surviving patients. Status Survived Deceased Alert 13 1 Verbal 4 0 Pain 1 0 Unresponsive 4 34 In univariate analysis, the AVPU scores for deceased patients shown in Table 11 are significantly different from survivors (pC2 = 0.000). Patients recovered with an AVPU score of Pain or higher are very likely to survive, while patients recovered Unresponsive are more likely to pass away. These results suggest that level of consciousness at recovery is may be predictive of survival. 108 Vital signs on recovery Like level of consciousness, the presence or absence of vital signs on recovery from the water can’t be accurately modeled as a contributory factor in post-jump survival. However, the quasi-complete separation of the logistic regression model does suggest that the presence or absence of vital signs on recovery is highly correlated with ultimate outcome. As outlined in Table 12, there were no survivors recovered vital signs absent. The difference in presence of vital signs in survivors and fatalities is statistically significant (pC2 = 0.000). This finding is in line with expected outcomes based on literature in traumatic cardiac arrest, which suggests that absence of vital signs on ambulance arrival is strongly correlated with mortality, and a confounding factor in the analysis of other variables affecting outcomes.73 Overall, this suggests that, like level of consciousness on recovery, vital signs on recovery is a post-jump outcome, rather than a contributory factor in survival. Table 12. Presence or absence of vital signs at time of recovery from water for deceased and surviving patients. Vital signs on recovery from water Survived Deceased Present 22 5 Absent 0 30 Both vital signs and level of consciousness on recovery appear to be outcomes dependent on bridge height and patient age. Further, they both correlate very strongly with ultimate patient outcome. This suggests that both could be useful to prehospital care responders for making treatment decisions. 109 Height Bridge height is a commonly cited factor affecting survival; as height increases, the likelihood of survival decreases. Unfortunately, much of our understanding of the relationship between height of fall and survival derives primarily from research into falls onto hard surfaces and foundational theoretical work relating height of fall, momentum on impact, and rapid deceleration with the mechanical properties of the human body. However, falls into water are not like falls onto a hard surface. In falls onto hard surfaces, the mortality rate crosses 50% between three and four storeys (12.9 to 17.2m), and approaches 90% mortality at 6 stories (25.8m).74,75 Fédération international de natation regulation high-dive platforms are 27m for men and 20m for women, and no reports of fatalities or serious injuries in competition could be found.76 Theoretical work on the association between height of fall into water and injury should be regarded with some suspicion; these build simple models for complex situations. In addition to bridge height, the effects on the human body of impact with water will vary with at least bodyweight, physical fitness, body position on entry, water salinity, and water aeration.77 This study provides further evidence that the correlation between height and mortality is complex, rather than the defining factor in survival. It is noteworthy that higher bridges may have similar survival rates to lower ones (e.g. Burrard Street Bridge compared to Knight Street Bridge), and that slightly taller bridges may have significantly lower survival rates (e.g. Pattullo Bridge as compared to Granville Street Bridge). A logistic regression model was fitted to bridge height, finding the odds ratio of survival for each additional 110 metre of bridge height is 0.936, (95% confidence interval 0.912 – 0.959), confirming that the inverse correlation between height and survival is statistically significant. Figure 19. Survival rate versus bridge height for all bridges in the study. Note that these are not weighted by sample size. Figure 19 shows the effect of height on survival is highly variable. The relationship between height and survival is less direct in this independent analysis than when it is evaluated as part of a multi-factorial system. This suggests that other factors modulate the effect of increased height. For example, in the study population, age inversely correlates with bridge height in Figure 18, suggesting that some of the effect of height may be mitigated by younger people jumping from higher structures. High bridges like Golden Gate and Lions Gate are often offered as examples of the effect of height on mortality; both are very tall (>70m), with low (<8%) survival rates. However, both of 111 these bridges have examples from both the literature and this study of persons suffering no, or only minor, injuries after falls. Further, both structures span large open bodies of water with complex currents and are prone to confused sea states and poor search conditions. It may be reasonable to attribute a portion of these bridge’s mortality rates to delays in locating patients, another attribute correlated with bridge height in this study (Figure 18). Taken in sum, the evidence suggests that bridge height does have an important effect on survival, but that the relative importance of this effect may be confounded or mitigated by a variety of other factors. 112 Age Age is an important factor in survival in trauma which suggests it may play a role in survival for the subjects of this study. Figure 20, shows the age distribution for survivors and fatalities. The results show that mean ages and age distributions are not different. The age distribution of survivors is not normally distributed, according to Shapiro-Wilk tests (deceased: pS-W=.0029, survivors : pS-W = .2084), and so the distributions are compared using a Mann-Whitney U-Tests rather than a T-test. These results suggest that the age distribution for survivors is not significantly different from fatalities (pU= 0.3569). Further, a logistic regression model finds the odds ratio of survival associated with each additional year of age is 0.984 (0.957 – 1.012), suggesting that age is likely not associated with survival. However, these results do not account for any potential confounding between age and other factors, this is addressed below. Figure 20. Ages at time of jump, with boxplot representing mean, inter-quartile range (IQR) and 1.5 times IQR. The multivariate logistic regression model suggests that age does play an important role in predicting survival, and that the independent modelling is confounded by another 113 factor (as discussed below). This is corroborated by Table 13, which shows that survival rates drop considerably as age group increases (pC2=0.000). Table 13. Survival by age group. (Age groups derived from Trauma Services BC 2017-2018 Annual Report)78 The literature shows that younger individuals are more likely to survive traumatic injury, and that the effect of age on drowning is muted for persons older than 15 (100% of study population).79,80 The statistically significant role of age in survival described in the multivariate model is therefore likely attributable to the protective effects of youth against trauma, rather than drowning. Figure 18 suggests that younger individuals may be more likely to choose higher bridges. The lack of statistical significance in the univariate model is likely explained by this propensity for higher bridges, which may partially mitigate the protective effect of youth. Ultimately, it appears that the effect of patient age on survival is complex. While it likely is an important factor in survival, its effects are confounded by other factors. This lack of a clear role for age in survival makes it unlikely to figure as a prognostic factor in prehospital care. Age Group Deceased Survived Survival Rate 14 to 24 20 7 0.259 25 to 44 62 21 0.253 45 to 64 47 10 0.175 65 to 90 5 0 0.000 Overall 134 38 0.216 114 Time interval from jump to recovery from water Recovery interval appears to be an important factor in survival, and is the only factor that can be addressed by first responders. Table 14 shows the rapid decline in survival over a relatively short period of time; no study subject survived after 32 minutes in the water. A logistic regression model was fit, and suggests that this observed inverse correlation is statistically significant, with an OR of 0.917 (95% CI 0.868-0.959) for each additional minute delay to recovery from the water. Table 14. Time interval from jump to recovery and survival rates. Time to recovery (min) nsurvived ndeceased Survival rate (%) < 5 10 2 83.3 5 – 10 5 5 50.0 10 – 15 5 8 38.5 15 – 30 6 11 35.3 30 – 60 2 15 11.8 60 < 0 5 0 The effect of rapid recovery is pronounced in cases jumping from the False Creek Bridges, where survival rates are significantly higher than for other bridges of a similar height, as seen in Figure 19. It is entirely plausible that this disproportionate survival rate is directly attributable to the high volume of traffic passing through False Creek at any given time, as well as the clear sightlines on the bridges. These factors make jumps from these bridges likely to be promptly reported, and people recovered quickly from the water. The proximity to Kitsilano CCG station probably contributes to this high survival rate, but the volume of civilian traffic likely does as well. Even where civilians are unable to render 115 medical assistance, getting a patient’s head above the water rapidly after a jump may be sufficient to significantly improve that patient’s chances of survival. The importance of time to recovery is likely due to swimming failure resultant from the combined effects of cold shock, trauma and fatigue. Cold shock, with its resultant muscle and cardiac impairments, is a well-documented cause of swimming failure.81 Some injuries (e.g. limb or pelvic fractures) may preclude or limit a person’s ability to swim. Finally, people may suffer no, or only minor, injuries but as they become fatigued after prolonged time in the water, they are unable to keep their head above the surface of the water.82,83 Interestingly, Figure 18 suggests that the recovery interval may correlate with bridge height, this could be attributable to a couple of factors. Recovery efforts at the highest bridges in the study (Lions Gate and Second Narrows) are hampered by complex current patterns and potentially large wave patterns; patients could drift as much as 175m every minute, and a patient floating prone on the surface may be all but invisible with waves over 0.25m. The next three tallest bridges (Alex Fraser, Pattulo, and Port Mann), are between a twenty and forty five minute transit for the nearest dedicated marine rescue unit, CCG station Sea Island. The fact that bridge height may correlate with difficulty rapidly recovering patients may confound the effect of time to recovery, and may account for its less pronounced effect in the multivariate model than as an independent factor. 116 Figure 21. Length of interval from jump to recovery in minutes for 77 cases. The longest survived interval from jump to recovery was 32 minutes; both patients recovered alive at this time were able to at least partially remove themselves from the water prior to rescuer arrival. Some reticence should be shown in directly comparing recovery interval to research on out of hospital timelines. Transporting patients to definitive hospital care without delay is important for survival, but recovery interval is fundamentally different.84 In the latter case, patients are still actively exposed to a potentially lethal mechanism (i.e., drowning), rather than simply delaying treatment for pre-existing injuries. However, some parallels may be drawn. In line with the “Golden Hour” in trauma, the evidence presented in Table 14 and Figure 21 suggests there may be a “Golden 10 Minutes” or even a “Golden five minutes” in recovering people who have jumped, and that prioritising the dispatch of marine rescue resources, or alerting civilians in the area and able to render assistance may be the most effective means of improving outcomes.  117   As discussed in the section on Sex trends in suicide (page 2), there is some suggestion in the literature that, ceteris paribus, women are more likely to survive suicide attempts, even by violent and lethal means.13,14 A number of individual studies on jumping from bridges also suggest that this may be the case in suicide by jumping from bridges, however sample sizes were too small to find statistical significance.69,85–87 In this study, there is a very small, non-significant difference in the survival rates by sex, OR = 1.12, (95% CI = 0.62-4.14), as seen in Table 15. The multivariate model also shows that sex is not an important factor in survival. These results are more in keeping with available literature on survival in major trauma, which suggests that there is no statistically significant difference in survival between males and females in blunt trauma.15 Sex Deceased Survived Survival Rate Male 113 29 0.204 Female 35 10 0.222 Table 15. Survival and survival rate of persons jumping and hitting water by sex. 118 Water temperature Hypothermia and cold water shock are known contributors to drowning deaths in Canada, and hypothermia correlates with poor outcomes in trauma patients.88 Further, mild to moderate hypothermia was reported in a majority of patients transported to hospital in this study. However, we found no correlation between the water temperature at time of jump and survival in this study population. Temperature was analysed in two ways. First, the temperature differences for survivors and deceased were compared. This revealed no difference in the water temperature distributions (pK-S = 0.6284, n = 173). Then a logistic regression model was fit, also showing that temperature does not correlate with survival (OR = 1.013; 95% CI 0.949 – 1.083). Water temperature is also not a significant factor in the multivariate model (see Table 10). This finding is consistent with other studies of near drowning, which find that water temperature is not correlated with survival.89,90 This does not exclude a role for water temperature in mortality. It appears unlikely that hypothermia directly causes mortality. For water temperatures greater than 4°C (88.5% of cases in this study), evidence suggests that survival time for hypothermia alone would be greater than 30 minutes, possibly even more than 60 minutes.91,92 At this point every person in the study was either recovered from the water or deceased. More likely, water temperature would contribute to mortality through two mechanisms: conflicting sympathetic and parasympathetic responses induced by cold shock and the dive reflex, respectively, and the increase in mortality attributable to mild and moderate 119 hypothermia in patients suffering traumatic injuries.93,94 Cold shock and diving reflex responses to sudden immersion in cold water can be expected in varying degrees in sudden immersions in water <25°C (100% of cases) and peak between 10°C and 15°C (39.8% of cases).93 These responses are commonly associated with swimming failure and the conflicting sympathetic and parasympathetic activations often induce a variety of arrhythmias, some of which are noted in patients in this study.93 Hypothermia, even mild, is also strongly associated with poor outcomes in trauma.95 Rather than being unrelated to survival in patients who jump from bridges, further inquiry may be warranted to investigate the possibility that water temperature may affect all patients relatively evenly within the temperature range found in the study. 120 INJURIES A review of the literature revealed a relatively consistent pattern of potential injuries in patients who jump from bridges. The most common injuries reported in this population include rib fractures, with accompanying haemo- and pneumo-thorax, followed by cranial fractures and pelvic fractures. Of primary concern to care providers are the presence of injuries linked to reversible causes of traumatic arrest – direct cardiac injuries, haemothorax and pneumothorax, and visceral injuries with high probability of catastrophic haemorrhage. In the literature, these injuries are more commonly reported in fatalities, but are also less commonly reported in survivors. Further, a large portion of both survivors and fatalities in the literature are relatively uninjured. Generally, injuries match the expected injury patterns for blunt trauma and deceleration as mechanisms of injury. Soft tissue, hollow organs, and internal organs that continue to move even as the rest of the body stops are most prone to injury. Rates of externally observable trauma are low, excepting contusion and ecchymosis which range from 60-80% of subjects.85–87,96–99 Given the delay in developing bruising, patients recovered promptly may not show any external signs of trauma. Table 16 summarises injuries commonly reported in the literature. The most catastrophic injuries are likely to be under-reported in the literature due to survivorship bias; patients with these injuries are not transported to hospital, and so are not included in hospital-based studies. 121 Table 16. Summary of injuries reported in the literature in patients who have jumped from bridges of various heights. (17 studies, n unknown due to potential double counting of patients across studies) (Data from various sources, see references) 26,69,100–106,83,85–87,96–99 Body system Summary Specific injuries (most to least common) Neurological While head injuries are prevalent, few survivors with head injuries are reported in the literature. Overall, cranial fractures were the second most commonly reported injury of any type. Unfortunately, little detail is given about the specific nature of these injuries. Cranial fracture Intracerebral haemorrhage NOS Subarachnoid haemorrhage Spinal Spinal injuries are infrequent in the literature, as compared with other injury types. Fractures are the most prevalent spinal injury and are predominantly compression. Contusion or transection of the cord is rare. Vertebral fractures Pulmonary Lung injuries often accompany rib fractures. Pulmonary contusions and lacerations are common; pneumo- and haemo-thorax are also reported, though not as frequently. Pulmonary contusion and laceration Pneumothorax Haemothorax Abdomen Visceral injuries are commonly reported in the literature, again with varying degrees of specificity. Many studies report general visceral injuries, or free blood in the peritoneal cavity, but without further detail. In both fatalities and survivors, the most common visceral injuries were laceration or rupture of the liver or spleen. Free peritoneal blood NOS Laceration/contusion/vessel rupture of liver Laceration/rupture of spleen Cardiac/Circulatory Laceration or rupture of the heart or great vessels is reported in a number of studies, but there are no reports of survivors with these injuries. Laceration or rupture of heart or great vessels Orthopaedic Rib fractures are the most reported injury of any kind in the literature. The level of detail about these injuries varied by study, but where such detail was available, reports of multi-plane rib fractures - with or without paradoxical movement - were frequent. Pelvic fractures were the third most common musculoskeletal injury in the literature. These fractures are reported in both survivors and fatalities. Further details regarding type or severity are not available, and there is little mention of damage to the underlying systems (e.g. urologic or reproductive), or vasculature. Rib fractures Pelvic fractures 122 Table 17. Summary of injuries found in this study. Injury data is limited to patients transported to hospital. (n = 42) See Appendix 2 for complete injury data. Body system Summary Common or noteworthy injuries Neurological Few patients with neurological injuries survived to hospital admission, so data on neurological injuries is sparse. Intracranial bleeding (all types)* Spinal Vertebral fractures to all levels of the spine are commonly reported in patients in this study. Fractures are most commonly crush or transverse process fractures. There is only one reported case of cord transection and one case of cord contusion. Vertebral fractures Pulmonary Pulmonary complaints are nearly universal in patients in this study. Some combination of pneumothorax, haemothorax and subcutaneous air was reported in a majority of patients. Pulmonary edema secondary to trauma or aspiration was also commonly observed. Pneumothorax Haemothorax Aspiration with or without development of aspiration pneumonia Cardiac / Circulatory A variety of abnormal cardiac electrical activities were noted, significant cardiac injuries reported in the literature were mostly not noted here. Haemodynamic instability is was secondary to cardiac pathologies and hypovolemia of various aetiologies (e.g. hepatic lacerations). Abnormal electrical activity (atrial fibrillation, various tachycardic pathologies) Generalised haemodynamic instability Single report of vertebral artery dissection Abdominal Relatively few significant abdominal pathologies were noted. Most were minor, likely reflecting a significant survivorship bias. Hepatic laceration Haematuria Orthopaedic Rib fractures were the most commonly reported injury of any type, except contusion or ecchymosis. Generally, orthopaedic pathologies were rare, but appeared to concentrated in a small number of patients. Rib fracture (single plane and flail segments) Pelvic fracture * While this is the most commonly reported type of neurological injury, it is actually not especially common, occurring in only 7.1% of patients. 123 Injury severity is relatively low in the study as compared to many reported injury profiles in the literature, and the survival rate is high in those for whom injuries are reported. Reported injuries are generally stable orthopaedic injuries, or pathologies that can be effectively managed in the prehospital setting long enough to transport the patient to definitive care. Injuries reported in the study are summarised in Table 17, and a complete list of injuries reported in the study is attached as Appendix 2. However, we note that this data set is subject to survivorship bias. Detailed injury information is available only for patients transported to hospital. Furthermore, patients who are rapidly declared deceased are not subjected to rigorous investigation of injuries. Therefore, injury information is approximately restricted only to patients who survived long enough to be thoroughly examined in hospital. Injury data from ambulance, Coast Guard, and coroner records lacked specificity and completeness and was unsuitable for analysis. Wald’s methodology for estimating the vulnerabilities in fatalities using data from survivors suggests that the information of interest in this data is actually injuries not reported in the study, but which are reported in the literature.107 Because of the survivorship bias in this data, injuries reported here are —almost by definition— survivable. However, those reported in the literature, but not found in this population, may be lethal. By comparing injuries reported here with those reported in the literature, it may be possible to identify lethal injuries which may make good targets for improvement of prehospital care.107 Future inquiry and/or modification of prehospital treatment protocols should focus primarily on the management of those injuries 124 commonly reported in the literature, but not present in survivors. Notably absent or rare in these patients are the massive internal injuries and severe head trauma noted in Table 16. The few patients presenting with severe injuries (e.g. arterial dissection, intracranial haemorrhage, severe hepatic laceration) were all recovered within minutes and transported to hospital without delay. These injuries are not be treatable in the prehospital setting, and require prompt transport to higher levels of care. Other injuries common in the literature, but less reported in this study population (e.g. pelvic fractures) are associated with increased mortality in trauma, and there is evidence for prehospital treatment.108 The high rate of reported spine fractures in the study is interesting, as it conflicts with reported injuries in the literature. No explanatory factors for this discrepancy are notable in the study. This suggests spinal stabilisation should be prioritised. However, the mechanism of stabilisation should be carefully considered to balance potential complications arising from the high risk of aspiration in these patients.109 As well, high reported rates of traumatic brain injuries in fatalities in the literature suggest that further investigation would be warranted into the relative value of collars in c-spine immobilisation as compared to other means of stabilisation, in order to balance the risk of spine injury with the risk of increased intracranial pressure.110,111 Given the rate of pelvic fractures and the independent association of pelvic fracture with mortality in trauma, pelvic stabilisation should be considered for prioritisation by 125 prehospital care providers.112 The prevalence of various cardiac arrhythmias suggests investigation into the value of prehospital management or temporizing of arrhythmia may be warranted. All potential additional prehospital interventions must be weighed against the likelihood that transportation to hospital would be more beneficial to the patient than on-scene treatment. Regular review of treatment protocols should be undertaken, especially if time to recovery is improved. In this case, it would be reasonable to expect patients with vital signs on recovery to present with injuries that are currently not, or only rarely, found in survivors. 126 Conclusions OBJECTIVE 0 Describe the population that jumps from a bridge and their outcomes. The study population is described as age distributions or tranches and broken down by sex. For the population as a whole, as well as sub-populations by age, sex, and bridge, we will describe survival rates as crude proportion of all jumpers who are not deceased. Finally, we would like to quantify the outcomes of the subjects on a scale from deceased to apparent full recovery on discharge from hospital and report rates of each outcome. The study population is reflective of the broader demographic trends in suicide in Canada. The study population is predominantly male (69.8%), and the interquartile range is 25-45. Women who jumped appear slightly younger than men (mean age 35.44 compared to 40.78 for men. This finding is to be expected, given the evidence that those who commit suicide by jumping are not significantly different from those who chose other means.38 Data was not available to describe the population based on ethnicity and statistics for comparison to suicides in British Columbia or Canada where not available. This represents an interesting gap in the knowledge, and potentially valuable future line of inquiry. The population in this study also appears to distribute itself across the bridges throughout the Lower Mainland in specific manner. Notably, access to the Lions Gate bridge is more complex than other bridges — requiring some forethought and transit time — but it is overwhelmingly the most frequented structure. Lions Gate seen 90% more jumps than the second most frequented bridge. Meanwhile, other commonly 127 frequented bridges are proximate to high population densities and psychiatric treatment centers. This finding, in conjunction with work published by Lam et al (2017) suggests jumping from bridges is subject to patterns noted in the literature whereby different structures may be chosen by different sub-groups within the study population for different reasons.42 Specifically, certain bridges (e.g. Lions Gate) may be destination bridges, where people go to jump off that particular bridge. Other bridges (e.g. Granville Street) may simply be a convenient structure, proximate to a home or workplace, and correctly identified as a potentially lethal leap. Beyond a possible correlation suggesting younger people may favour higher bridges, little information was available in the data to differentiate the populations at each bridge. Nothing in the data was available to meaningfully explain why individuals choose a particular bridge. Identifying what motivates choice of structure, and differentiating those who chose ‘structures of convenience’ from ‘destination structures’ may help inform suicide prevention methods. Unfortunately, it was not possible quantify outcomes with the level of detail initially desired. Patient outcomes beyond discharge from hospital were not reported in the hospital records accessed for this study. However, with the information available it was possible to definitively identify the outcome to hospital discharge or death for 90.6% of the study population. No comparable studies are available in the literature, tracking so broad a study population from such a variety of sources. 128 OBJECTIVE 1 Identify factors that affect a patient’s outcome following a jump from a bridge. Literature suggests that a small number of factors may have an outsized influence on patient outcomes. Factors of interest are age, sex, height of bridge, water temperature, time to recovery, and presence or absence of vital signs and level of consciousness on recovery. We will endeavor to show the influence each of these factors has on survival. Through a systematic review of the literature, six factors were identified as potentially having a significant impact on the survival of the study population. Ultimately, three of these factors do appear to influence survival in patients who jump off a bridge. Bridge height, age, and time to recovery all appear to impact survival, while sex and water temperature do not appear to affect survival. The final factor, patient status on recovery, was found to be a post-jump outcome, which does not influence survival. However, it was shown to be strongly predictive of survival, a finding which is essential to Objective 2. This study adds to the growing collection of evidence that bridge height and age are correlated with survival in populations that jump from bridges. Addressing these factors is the focus of prevention efforts by public health agencies, as well as transportation authorities. They can not be addressed by any responding agency in order to improve outcomes. However, the recovery interval is modifiable, and steps may be taken to improve response times. The average delay to tasking a Canadian Coast Guard resource in this study was over 13 minutes, as compared to seven minutes for the BC Ambulance Service. While reducing the delay to departure does not guarantee a more expedient recovery, it is likely to do so. The almost six minute difference between the dispatch 129 delays for British Columbia Ambulance Service (BCAS) crews, and CCG crews suggests there is an avoidable delay in alerting either JRCC or the CCG crews to an incident. Recommendation 1 is aimed at addressing this delay in the most expedient manner possible, using existing agency structures and infrastructure. Once again, this study appears to be unique amongst the available literature. No studies uncovered in the review explicitly sought to identify and evaluate factors that may affect survival. Rather, this study built on previous work describing these factors and suggesting they may warrant further investigation. The Canadian Coast Guard and Joint Rescue Coordination Center should consider collaborating with ECOMM-911 to streamline marine search and rescue response to incidents reported via 911. Specifically, consideration should be given to the creation of an “autolaunch” protocol for reports of a person jumping, or threatening to jump from a bridge, whereby 1. E-COMM automatically transfers all reports of a person jumping, or attempting to jump from a bridge to JRCC as well as the appropriate police dispatch centers. 2. CCG crews at Kitsilano and Sea Island are automatically alerted (but not necessarily tasked) to any 911 call of a person jumping, or attempting to jump from a bridge. 3. A Marine Assistance Request Broadcast is automatically issued by Victoria Coast Guard radio, requesting assistance from any civilian vessels in the vicinity Recommendation 1 130 OBJECTIVE 2 Develop criteria for identifying patients for whom resuscitation is likely to be futile. Unfortunately, a large portion of persons who jump from these bridges have no reasonable chance of survival. By developing applicable criteria for identifying these patients, first responders will be equipped with a means to identify patients where it is appropriate to cease or not start resuscitation efforts. This will avoid invasive and futile interventions for patients and may decrease the impact of these resuscitations on prehospital care providers. As part of Objective 1, we identified the AVPU score and the presence or absence of vital signs on recovery as predictive of survival, especially if used in combination. The data quality for these variables was generally good; it was unambiguously recorded in Canadian Coast Guard (CCG) SAR Mission Reports or Patient Care Forms. The sample size was acceptable (n = 57 and 55, respectively), and congruent with commonly reported sample sizes in prehospital trauma care research. Patients recovered with any vital signs should receive all available resuscitative measures and be transported to higher levels of care without delay. There is good quality evidence in the literature that outcomes are extremely poor for patients in cardiac arrest secondary to blunt trauma, when patients arrest prior to first responder arrival .68,73,113 Given this, decisions regarding resuscitation efforts for patients recovered without vital signs should consider the identified factors associated with poor outcomes. First responders should be concerned with correctly differentiating patients who may be candidates for ROSC, such as those who lost vital signs immediately prior to recovery. Currently, the CCG 131 discontinuation protocol for patients who have jumped from a bridge states that resuscitation may be discontinued if the following criteria are met: 1. Witnessed fall from the car deck of the Lions Gate or Alex Fraser Bridges 2. Unconscious and unresponsive 3. No spontaneous movement or respirations 4. Pulseless [sustained pulse check on BOTH sides of the neck] for 30 seconds (Canadian Coast Guard Search and Rescue – Western Region Rescue Specialist Program, “Protocols, Procedures and Quick Reference Manual”) The results of this study suggest that this is an accurate discontinuation protocol, though modifications could be made based on these results, as outlined in Recommendation 2. The results of this study indicate that the survival is dependent on patient age, bridge height, and time interval from jump to recovery from water. In the absence of definitive evidence to the contrary, age is a poor categorical variable for use in a discontinuation protocol; ceteris paribus, it would be unreasonable to discontinue resuscitation for 60 year old, but to attempt resuscitation on a 59 year old. Similar problems apply to using bridge height or recovery interval. However, survival drops precipitously with extreme The current treatment and discontinuation of resuscitation protocols for confirmed jumps from a bridge be amended based on the findings presented here. Specifically, it should consider: 1. Findings regarding the relationships noted here between survival and patient level of consciousness and vital signs on recovery 2. Time from jump to recovery 3. Progress of the study population through prehospital and hospital care Recommendation 2 132 bridge heights, and after an extended delay in recovering the patient. Therefore, these factors may be useful in combination with patient status for treatment decisions. Ultimately, the data presented here is insufficient to definitively identify any sub-group(s) of patients for whom the likelihood of survival is 0%. Therefore, we should aim to provide prehospital care providers with evidence-based tools to make treatment decisions appropriate to the patient and situation on hand, rather than hard-and-fast rules. 133 OBJECTIVE 3 Describe and critique communications and information transfer between organisations involved in response. Communication and information transfer is a frequently problematic component of both emergency services and healthcare. Incomplete information transfer and miscommunications may cause delays in rescue and treatment, poor patient care, and ultimately impact patient survival. Wherever possible, we would like to examine inter-agency communications to determine the accuracy of information transfer in order to highlight areas of success and areas for potential future research or improvement. Unfortunately, this objective is best used to highlight a number of the limitations of this study. This objective in particular suffered more than the other objectives from limitations that plagued multiple analyses throughout the project. Specifically, meeting this objective suffered from a lack of data and poor data quality. Primarily, meeting this objective was hindered by an absence of definitive data. Samples of the data collection instruments (e.g. run sheets, trauma surveys, patient care records) were obtained for the purpose of writing the objectives and planning the analysis. Much of the information we anticipated would be available for use in this analysis was unrecorded, poorly recorded, or not abstracted into agency databases. For example, specifics of treatment history —adjuncts used or procedures performed by prior care providers— at both the hospital and ambulance levels could be used to evaluate the accuracy of information transfer at handoff. However, this information was either unavailable (as with ambulance data), or inconsistently recorded (as with hospital data). 134 The data desired for this objective was generally free text or non-standardised data. Without the benefit of a standardised argot for recording information, what data was available was often ambiguous. For example, incident timelines recorded by ambulance crews or in hospital were often recorded ad-hoc in the margins, or in a generic incident history box. With incident timelines, what constituted a noteworthy event was variable; some historians recorded minute details of care, and others barely noted incident time. Finally, for the variables of interest, the information available within a single record was often contradictory or confused. Hospital records are especially prone to this; every consult and survey would have a slightly different patient and incident history. These limitations are generalizable to all analyses in the study, but this particular analysis was the most impacted. Ultimately, the variables available for this analysis only partially measure interagency communication. The outcomes are ambiguous, but generally suggest the possibility that interagency coordination may be an obstacle to prompt dispatch of appropriate resources. Further investigation into this subject is warranted, and should focus on areas where improvements may result in expedited patient recovery. For example, recording and comparing alerting and dispatch briefings given to each agency, as well as recording and analysing the briefings given by prior responders could both provide interesting insights into information transfer in prehospital care. 135 OBJECTIVE 4 Evaluate existing SAR data to determine if is appropriate for creating evidence-based medical care protocols in SAR. Prehospital care in general, and SAR medicine specifically are under-researched subjects. They lack high-quality evidence, established research protocols and methodologies, and the long-running, large, professionally managed data repositories like the Bogalusa heart study, common in fields such as oncology and cardiology. While existing data collected for operational purposes may never be as good as purpose-built research databases, it may still provide enough information for the study of select subjects, preliminary studies, or to guide the establishment of such databases. We would like to evaluate if this is the case and provide guidance for the improvement of data collection in SAR. Overall, this study demonstrated that Search and Rescue and police data can be used to successfully identify cases relating to jumping from a bridge, and could be used to identify other subjects of interest where police or SAR resources are likely to be involved. For example, this methodology could be valuable studying specific mechanism of injury like avalanches, or response types, like volunteer fire departments. As noted in the case and record identification, linkage and data limitations sections (pages 41, 50, 55, and 73), this methodology does have a number of limitations, mostly to do with case identification and data access, availability, and quality. These issues were also prevalent in ‘traditional’ data sources throughout the study. Limited access to data generally impacted this study. As noted throughout the manuscript, sample sizes were generally limited, and access to additional data may have been able to increase the certainty of a number of the analyses. Steps could be taken to 136 aid the identification and linkage processes, as well as easing data access and availability, for both researchers and data holders. These steps are outlined in recommendations 3 and 4. The relative success of two parts of this methodology — case identification and record linkage has promising implications for future research, especially in prehospital care. The case identification methodology could be used to investigate a number of other problems in the public interest, as noted above. The linkage process and the use of combined records for analysis is especially suited to addressing the survivorship and selection bias that limits investigations into a number of incidental causes of death. Previous studies into suicides by jumping from bridges were often limited in their scope because data was The adoption of a single, unified standard for the storage of time and date in healthcare data. Recommendation 3 The development of a legal framework for access to SAR and police data specifically for research, similar to data sharing procedures in place at the British Columbia Ambulance Service, Vancouver Coastal Health, and Fraser Health. With appropriate checks and protocols to ensure patient confidentiality and data security, this process should: d. Permit researchers access to identifying information for linkage and case identification purposes e. Permit the release of information not suitable for public release to researchers for research purposes f. Allow researchers to actively participate in the case identification and data collection process in order to ease the burden on agencies providing this data Recommendation 4 137 collected only from a single source. Survival analysis, for example, is difficult where all cases are identified from coroner’s records. Other prehospital pathologies like ski or mountain bike injuries may similarly benefit from the creation of multi-agency datasets, especially in cases where the primary response to an incident is unlikely to be a standard ambulance service. With the increasing popularity of outdoor and backcountry pursuits, and the corresponding increase in Search and Rescue activity, investigations into medical care in SAR may become more and more valuable. The development of a simple SAR medicine database, as outlined in recommendation 5 would expedite any such investigations. The development of Search and Rescue medicine database which could be used for future investigations into medical conditions and prehospital care unique to SAR. A simple database, describing the nature of each incident, identifying the patient, and listing other agencies involved and their unique case identifiers could be used to identify incidents. Then, the data linkage methodology discussed above, could be used to build a dataset capable of addressing the subject of interest. Recommendation 5 138 References 1. World Health Organization. Mental Health: Suicide data. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. Published 2017. 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M6B69B>C>HIG6I>DCI>B:5555555555555555555555555555555555=8AD8@ >C9>C<HD;I:HI :M6B5555555555555555555555555555555555 207  EGD?:8IG:986E DG<   *0!.2!*0%+*+.!/03 ) '6B:D;"CI:GK:CI>DCDG-:HI M6B5555555555555555555555555555555555"CI:GK:CI>DCDG-:HI M6B69B>C>HIG6I>DCI>B:5555555555555555555555555555555555=8AD8@ >C9>C<HD;I:HI :M6B5555555555555555555555555555555555*0!.2!*0%+*+.!/03 )'6B:D;"CI:GK:CI>DCDG-:HI M6B5555555555555555555555555555555555"CI:GK:CI>DCDG-:HI M6B69B>C>HIG6I>DCI>B:5555555555555555555555555555555555=8AD8@ >C9>C<HD;I:HI :M6B5555555555555555555555555555555555+0!/"CI:GK:CI>DC -:HI M6BCDI:H555555555555555555555555555555555555555555 208 Appendix II Reported injury, sign, or symptom N Cardiac Arrhythmias Abnormal rhythm NOS 4 Atrial fibrillation 3 Supraventricular tachycardia 1 Asystole 5 Pulseless electrical activity 1 Sinus tachycardia 5 ST depression 1 Tachicardia NOS 6 Ventricular tachycardia 1 Injuries Cardiac contusion 5 Generalised haemodynamic instability 2 Pericardia effusion 1 Pneumopericaridium 1 Pericardia injury NOS 1 R vertebral artery dissection 1 Pulmonary Signs and Symptoms Absent air entry - Left 1 Absent air entry - Right 1 Reduced air entry - Bilateral 5 Reduced air entry - Left 2 Reduced air entry - Right 6 Crepitus - Left 4 Crepitus - Right 5 Bloody sputum 2 Pulmonary infiltrate - Left 8 Pulmonary infiltrate - Right 9 Injuries Pulmonary contusion 14 Confirmed pneumothorax - Left 12 Confirmed pneumothorax - Right 15 Suspected pneumothorax - Left 4 Suspected pneumothorax - Right 3 209 Confirmed haemothorax - Left 2 Confirmed haemothorax - Right 8 Suspected haemothorax - Right 4 Suspected haemothorax - Left 1 Contusions Head 1 Face 1 Neck 2 Chest - Left 4 Chest - Right 4 Back - Lower 9 Back - Upper 5 Abdomen 8 Pelvis 3 Thigh - Left 7 Thigh - Right 10 Lower extremity - Left 4 Lower extremity - Right 3 Orthopaedic Deformities Chest 1 Upper extremity 2 Unstable pelvis 1 Lower extremity 1 Fractures Facial 3 Cranial 1 Clavicle 3 Sternum 1 Scapula 2 Upper extremity 2 Femur 1 Lower extremity 2 Pelvis 6 Rib Fractures Multi-plane fracture, with flail segment 5 Multi-plane fracture, no flail segment 3 Single plane 8 NOS 1 210 Spinal Fractures C1 2 C2 1 C3 2 C5 1 C6 3 C7 4 L1 7 L2 4 L3 3 L4 1 L5 1 T1 5 T10 4 T11 2 T12 6 T2 6 T3 8 T4 5 T5 6 T6 8 T7 4 T8 3 T9 3 Spinal cord contusion 4 Spinal cord transection - Lumbar 1 Abdomen Signs and Symptoms Distension 4 Ecchymosis 3 Guarding 4 Pain 4 Rigidity 2 Tenderness 10 Hematuria 4 Peritoneal free fluid 3 Injuries Gastro-intestinal contusion 3 Gastro-intestinal laceration or rupture 2 Hepatic contusion 3 211 Hepatic laceration or rupture 6 Renal laceration or rupture 2 Splenic contusion 1 Splenic laceration or rupture 3 External Bleeding Blood from nose or mouth 3 Superficial laceration 3 Rectal bleeding 1 Neurological Signs and Symptoms Confusion 5 Eyes - midline drift 1 Loss of motor control 2 Numbness NOS 1 Other 1 Generalised reduced level of consciousness 9 Loss of sensation 1 Tingling NOS 1 Injuries Intracerebral haematoma or haemorrhage 1 Epidural haematoma or haemorrhage 1 Intracranial bleed NOS 1 Subarachnoid haematoma or haemorrhage 1 Subdural haematoma or haemorrhage 1 Air emboli 1 Generalised anoxic brain injury 2 Paravertebral haematoma 1 Epidural haematoma 1 Subfalcine herniation 1
Thesis/Dissertation
eng
Experimental Medicine
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Outcomes in suicidal bridge jumping in the Lower Mainland
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