A preventable death is always unnecessary

I listened to the ERCast today, the episode where Rob Orman goes through his method for making a suicide risk assessment. It was, as always, very structured and well prepared. I was surprised, however, when he said that this was one of the most downloaded episodes of his show. This was a topic, unlike most of his other EM stuff, where I felt that I already had a good understanding. Maybe that’s because we have a three month rotation in psychiatry as a compulsory part of our internship in Sweden.

It was not until now in the evening, when I started to think about a patient I met some years ago, that suddenly understood what I had to learn from this episode.

The patient was a 60 year old man, who presented to the emergency department with right-sided lower thoracic/upper abdominal pain. There was nothing acute about his pain. He had had it for weeks and had already been seen by his primary care physician, who had ordered an ultrasound of the upper abdomen, which turned out normal. Since the pain got worse with certain movements, the physician has assured him that the pain was musculoskeletal. The patient was not satisfied with this explanation and decided to seek further help in the ED.

It don’t remember the exact details, but there was something about this patient that made me worried. He had rather intensive pain and couldn’t work because of it. His right upper quadrant was tender and I believe he was a smoker. The work-up in the ED, ECG and labs, were unremarkable. So I referred him to his primary care physician with a suggestion that he undergo a CT of the thorax and abdomen, looking for an underlying malignancy.

A couple of months later, I was signing my notes. It should of course have been done much earlier, but I have a tendency to accumulate unsigned notes. Anyway, when doing so the dreaded pop-up showed up: My patient had died. I immediately started thinking that maybe this was a pulmonary embolism or something else that I had missed. Since we use the same electronic medical records system for most of the health care system in our county, I was soon assured that the patient had been well when he followed up with his PCP. I got a bit annoyed that only a CT of the thorax had been ordered and that when that also turned out normal, no other investigations had been made. The patient had been back a second time and had had his sick leave for musculoskeletal pain extended. All visits were to different doctors, unfortunately a common problem in primary care in Sweden.

And then there was a note saying that the patient was dead and that a forensic investigation had been performed. I was upset, thinking that we, his doctors, had missed some pathological process. And now this man was dead. To find out what could have been done differently, I called the forensic department to ask what had happened. Within a few days, I had the autopsy report.

There was no malignancy, nor were there any other signs of disease. The patient had killed himself. I was relieved, thinking that I had been wrong in assuming that his doctors hadn’t taken his pain seriously enough and given him a thorough work-up.

It was not after listening to this podcast today that I suddenly realized that I hadn’t been wrong. Anyone of us doctors who saw this patient could have made a suicide assessment. And if we had done it as thoroughly as Rob Orman suggests, we could have picked up that this patient actually had access to a gun, which is quite uncommon in the southern part of Sweden where hunting isn’t the everyman’s sport it is in the north.

There were things we could have done differently, which may very well have saved this man’s life. Preventing a suicide is no less important than diagnosing a pulmonary embolism. We have to look for risk factors even when it’s not an obviously suicidal patient. Thank you, Rob and Casey, I’ll do my best to remember that lesson.