Hanging, rural location and older age linked to death before EMS arrival in southern Iran self-harm study

Among 2,280 cases of self-directed violence attended by emergency medical services in Fars Province, southern Iran, 124 cases—5.4%—were recorded as deaths before EMS arrival, according to a cross-sectional study published in BMC Emergency Medicine. The analysis drew on EMS registry records covering a one-year period from March 2024 to March 2025, and examined which factors recorded at the time of the call were associated with the person already being dead by the time crews reached the scene.

The cases had a mean age of 30.1 years with a standard deviation of 12.7 years, and 56.2% were male. The researchers used chi-square and Mann–Whitney U tests followed by multivariable binary logistic regression, with the multivariable model based on 2,145 complete cases. After adjustment, several factors remained associated with the outcome. Increasing age was linked to higher odds of death before EMS arrival, with an adjusted odds ratio of 1.028 per year of age (95% CI: 1.011–1.046, p = 0.001). Rural incident locations carried more than twice the adjusted odds of death before arrival compared with urban locations (AOR = 2.075, 95% CI: 1.208–3.564, p = 0.008).

The mechanism of self-directed violence showed the strongest associations in the study. Compared with other methods, including unspecified mechanisms, hanging was associated with markedly higher adjusted odds of death before EMS arrival (AOR = 17.10, 95% CI: 10.101–28.951, p < 0.001), while poisoning was associated with substantially lower odds (AOR = 0.033, 95% CI: 0.008–0.137, p < 0.001). The timing of the EMS call also appeared in the model: compared with evening calls, both morning calls (AOR = 2.140, 95% CI: 1.063–4.308, p = 0.033) and afternoon calls (AOR = 1.882, 95% CI: 1.006–3.520, p = 0.048) were associated with higher adjusted odds of death before arrival. Sex and season were not independently associated with the outcome in the adjusted analysis.

The authors caution that the association with time of call should be interpreted carefully, because the recorded time reflects EMS activation and does not indicate when the self-directed violence occurred or when it was discovered; the observed pattern may partly reflect delayed recognition or discovery. More broadly, the findings should be read in light of the observational cross-sectional design, the restriction to cases attended by EMS, and the limitations inherent in routinely collected registry data. The researchers note that evidence on factors associated with death before EMS arrival remains limited, particularly in low- and middle-income countries, and that the study was intended to address this gap using EMS registry records from Fars Province that included age, sex, incident location, season, time of call, mechanism, and the EMS-recorded outcome.

Subject of Research: Factors associated with death before EMS arrival among EMS-attended self-directed violence cases in southern Iran

Article Title: Factors associated with death before EMS arrival among emergency medical services-attended self-directed violence cases in southern Iran: a cross-sectional study

Article References: Peyravi, M., Ahmadi Marzaleh, M., & Hamyali-Ainvand, M. (2026). Factors associated with death before EMS arrival among emergency medical services-attended self-directed violence cases in southern Iran: a cross-sectional study. BMC Emergency Medicine. https://doi.org/10.1186/s12873-026-01817-z

Image Credits: AI Generated

DOI: 10.1186/s12873-026-01817-z

Keywords: self-directed violence, emergency medical services, prehospital death, hanging, poisoning, cross-sectional study, Iran, Fars Province, EMS registry, rural-urban disparity, suicide, public health