Physician and Nurse Burn-Out – Part XIX. Suicide of a Patient

Occasionally you wish you were wrong, even if you knew you were not.

That is how we felt when, working in a Neurology Residency in a large New York City hospital, we went back to its Psychiatric Inpatient Unit (we are withholding the details for privacy reasons) for a follow-up on a patient that we had diagnosed with Migraines and started treating him, just some days earlier. In our first contact with him, aside from that neurological diagnosis, we noticed that he was in a heightened state of Anxiety/ Depression that seemed not to respond to his medication schedule. Before leaving the ward, we summoned his treating resident to recommend a Suicide Watch.

The pompous “Jersey Boy”—in charge of his clinical care—duly listened to us with a disgusting smirk on his face and then said: “thank you for your concern but you’re wrong. He is well medicated. Do us a favor. You treat his Migraines, and we’ll take care of the Psychiatric end. Agree?” In an utterly condescending gesture, he patted us on the back.

We kept mum as we did not want to engage in a quarrel with another resident that was more senior than we were; but we did observe the golden rule we had learned right at the start of our internship. CWA ( it means “cover your a**) We clearly wrote our fact-based recommendation in our Consultation sheet to comply with that maxim. When we returned to that ward there was a big commotion. As the treating team was duped into believing that this patient “was better off,” he was assigned as a kitchen helper for the next Thanksgiving dinner. And “the inevitable” happened.

When nobody was around, he improvised a noose with linen cloths in a pantry room, quickly threw it around a ceiling’s wood rafter, put it around his neck, got up on a chair and then jumped out, hanging himself. On our way to the ward, everybody was looking at us in total amazement. No, we were not a soothsayer, nor did we engage in crystal ball’s reading. We used our hard-earned medical knowledge and clinical criteria to diagnose “the obvious intentions” of a sick individual. Even if we flatly denied it, some colleagues (especially the ladies) were whispering behind our back that we in fact possessed “a secret gift.” It never hurts to impress the ladies…

Note. This reproduction of a World War II US Navy’s recruiting poster was taken from Wikimedia Commons.

There are 50-65 suicides of hospitalized patients in the USA, usually by hanging and less frequently by the ingestion of toxic substances, which is more common in the rare instance when a female patient is involved; they usually occur in the Psychiatry Units of large public or private hospitals, less frequently in better supervised private clinics or rehabilitation institutions. The Joint Commission has recommended the following Suicide Prevention strategies for clinicians:

  1. Review the patient’s clinical records and family history for risk factors.
  2. Screen all patients for suicide ideation using a standardized test.
  3. Review the patients’ answers before he/she leaves the office or is discharged.
  4. Engage the family members and other treating physicians for better results.
  5. Prepare admission and discharge protocols that specifically address this risk.
  6. Train all the members of the clinical team to look out for signs of this risk.
  7. Document all the decisions that were made to address this critical risk factor.

However, one of the most common clinical traps we can fall into is what we have described in Emotional Frustration – the Hushed Plague as follows:

“One of the most disseminated fallacies is that someone that attempts suicide must be in a manifest state of anxiety, depression, and despair. A misleading assumption. Many patients are clinically depressed but only a minority has suicidal ideation; similarly, some with suicidal thoughts never have signs of a major depression.

Moreover, when they decide to act, they reach a state of tranquility—akin to a Buddhist peace of mind. Depression is not synonymous with Suicide.”

We, health care providers, have a sacred duty to spot and treat these patients.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn Out – Part XVIII. Medical Errors.

– “Doctor…Can’t take this s*** anymore…I am heading for the exit door—You should do the same.”

Sheila X. is a proficient Critical Care nurse that, after a medical error she committed in a medication schedule that was providentially spotted by her supervisor, decided that her work stress was too much, especially after toiling so hard in the pandemic. She could opt for an early retirement, with a nice monthly check and benefits; she did not want to risk those benefits for the sake of a few more months of work. It was time for her to quit a career she has always loved. She stopped being sentimental like so many of us still are.

In a 1999 Institute of Medicine’s publication titled To Err is Human, Building a Safer Health System, investigators found an alarming rate of medical errors in the USA, which could be at least 44.000 incidents per year, even reaching the astounding number of up to 98.000 deaths of admitted patients in hospitals and clinics. We must assume that for each incident, there might be at least one, two, three, even more nurses, technicians and physicians involved, with varying degrees of responsibility. Medical Errors could represent the third leading cause of deaths in the USA.

Note. This World War II US Navy’s recruiting poster was taken form Wikimedia Commons. At that time Women were not allowed to serve in any frontline combat positions and had to staff the auxiliary sections of the Marine Corps. That sounds so, so retrogradely condescending now. As the famous Virginia Slims poster said; “You’ve come a long way Baby.”

The IOM Committee on Quality of Healthcare in the USA stated that a Medical Error is “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” We must clarify that a priori a medical error does not imply that there has been an intentional act to commit harm to a patient or an act of medical malpractice. There are two major types of Medical Errors defined as follows:

  1. Error of Execution: the planned action does not proceed as it was intended.
  2. Error of Planning: the originally intended action was poorly designed.

Not all medical errors reach the grave status of a “sentinel incident” that must be reported to the hospital authorities and the regulating agencies for professionals. If there is a common complication like a wound infection after a major procedure, professionals must evaluate whether it was totally preventable if a mistake would not have been committed, or it was simply a complication that could not be avoided.

The Joint Committee, a national organization charged with studying Medical Errors, defined a sentinel event as “an unexpected occurrence involving the death of or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.” They proposed using the root case analysis to identify “the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.”

There are two major types of sentinel events as follows:

I – Death of the patient or a serious permanent loss of function, not associated with the expected clinical course of the pathological condition or co-morbidity.

II – It involves one or two of the following medical conditions, which do not attain the seriousness of death or loss of a major bodily functions. They are:

  1. Suicide of an admitted patient.
  2. Unexpected death of a full-term infant.
  3. Abduction of an admitted patient.
  4. Assignment of the wrong infant to a family.
  5. Rape, battery, or assault of an admitted patient.
  6. Rape, battery, or assault of a Staff member.
  7. Administration of incompatible blood products.
  8. Post-operative retention of a Foreign Object.
  9. Severe Neonatal Hyperbilirubinemia.
  10. Prolonged Fluoroscopy with Excessive Radiation dosage.
  11. Maternal morbidity or mortality.
  12. Fire hazard.

In a series of articles, we will discuss the major types of Medical Errors and how they profoundly affect the treating personnel, not only because they might have been involved in such an instance, but also because they might be genuinely concerned that it might occur to them. Only well trained and hypervigilant professionals avoid the risk of any of them.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn-out – Part VIII Stampeding Out

Why would we be surprised that so many Health Care workers are skedaddling?

In an article in the CNBC Business portal, Karen Gilchrist wrote: “According to recent studies, between 20 and 30% of frontline U.S. health care workers say they are now considering leaving the profession. Notably, one April 2021 study by health carte jobs marketplace Vivian found that four in 10 (43%) nurses are considering leaving their role in 2021 – a figure that is higher among ICU workers (48%)”

For all of us who work in the Health Care Arena, it does not come as any surprise that so many of our colleagues are toying with the idea of leaving the profession for good, or at least to find a parallel track with limited clinical duties. On the contrary. More than twenty years ago, we were shocked how the failed attempt by the Clinton administration to reform the Health Care coverage of Americans, literally wiped out the profitability and sustainability of many solo practices, including ours. At the time, we sat down with our wife to discuss options to assure our future employment; we decided to study, with humongous financial and personal sacrifices, both Master and Doctoral degrees in Health Policy and Management at Columbia University.

Note. The reproduction of this U.S. Navy recruiting poster was taken from Wikimedia Commons.

Unfortunately many of our colleagues did not take any similar preventive steps and are now confronted with the stark reality that, even after the sacrifices they have made during the pandemic, they are back in the same exploitative work parameters of yore, with the added caveat that they might be dragooned for the next pandemic. The obnoxious understaffing of hospital wards, the relatively low pay, the long hours of an insensitive scheduling process that messes family life plus the rising incidence of Mental Health problems, worsened after the pandemic, with no foreseeable relief. A few of them are close to the retirement age and their plight will be brief indeed. But what happens to the thousands upon thousands of middle age-professionals? From our personal experience, we know that it takes a long time to efficiently re-engineer your career and stir it to more predictable and pleasant working waterways , compared to the always stormy clinical sea lanes.

A recent Department of Labor statistical study showed that almost half a million health care workers have quit since the start of the pandemic. When will it end? For starters, our politicians in D.C. and the statehouses should stop playing dummies. This is an ongoing tragedy that will have severe repercussions for the health of our children and grandchildren. And it will not be solved by just throwing money at it. Secondly, we , the health care professionals, should participate more in the associations that defend our interests, be at the national, state or local levels. It makes a difference. We confess that for may years we ignored these organizations but for the past few years we have tried to participate in the varied activities of the outstanding Florida Medical Association.

We will make our humble contribution by writing articles on these issues, which will constitute the needed scaffolding for our upcoming book Physician and Nurse Burn-out – Roots and Remedies.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.