"Hey, remember that guy you saw last night?"

That sentence strikes fear into every emergency physician. If something goes terribly wrong with a patient after you saw them, invariably a colleague has to break the news to you and that is how the story starts.

"Hey Mark, remember that kid you saw last night with the sore throat?"

"Yeah ... ?" The world stopped and my stomach tightened.

"He came back in about an hour after your shift. He got hit by a train."

"He was hit by a train?"

"Yeah."

"How did he get hit by a train?"

"I'm not really sure, but they think he laid down on the tracks."

Long silence.

"What happened to him?"

"He was pretty banged up. He died a couple hours after he got here."

Even though I was due to start my next shift in the ED and there were patients waiting, I immediately pulled the chart from my visit with him. Had I missed something? Did the triage nurse get a story that was different from mine? Was there any way I could have known he was thinking about taking his own life?

The notes in the chart accurately reflected my memories of the time I spent with him. The triage nurse's note documented that he came to the emergency department because he had developed a sore throat. He had normal vital signs and did not appear ill.

As I walked into his room, I expected the visit to be brief and straightforward. Young, healthy people who look well and are concerned about a sore throat rarely have anything dangerous going on. The discussion is usually pretty easy and involves talking about viruses causing most sore throats and the possibility of this being strep throat and the use of penicillin in that setting. It feels like I have had that discussion a million times.

Our patient was sitting on the stretcher with his feet up and appeared relaxed and comfortable. I remember the layout of the room, where I sat and the tenor of the discussion clearly.

He struck me as polite, capable and respectful. I liked him.

"Hi, I'm Doctor Fourre. How are you doing?"

He told me the story of why he came to the emergency department. It did not sound worrisome to me and, actually, he did not seem particularly worried about his sore throat either. I briefly examined him, paying particular attention to the back of his throat. The exam was completely normal.

Sitting down, I explained that his exam was reassuring. There was no sign that this was strep throat and that a virus was likely to blame for his throat discomfort. Antibiotics would not be helpful and he could expect to feel better in the next few days. He replied, "OK."
Often, patients will seem somewhat disappointed if they don't have a clearly identified culprit for their symptoms. They will question if they should take antibiotics, "just in case," or if there are medicines that will make them feel better or make their symptoms go away sooner.

Simply saying "OK" is unusual and gave me pause. I doubled back to see if I had missed something. "Is there anything else that you are worried about?" He shook his head no.

"Do you have any questions about the plan?"

"Nope."

I let him know that he should come back to the emergency department if he began to feel more ill, developed a fever, or if he had any trouble swallowing or breathing. He again said "OK."

As I was walking out of the exam room he called out, "Thank you."

That also is uncommon.

I turned around and smiled. "Let us know if there is anything else we can do." He smiled back.

I have replayed that exchange a thousand times in my head. How could I have missed something? What could I have done differently? Even after all these years, I have not come up with the answer.

What has changed is that I am more sensitive about depression and look more closely for signs that someone might be considering taking their own life. I push myself to ask how they are doing and to see if I can help in any way.

I am convinced our patient sensed that we were concerned about him and were ready to help. He wanted us to know that. For reasons I will never know, he chose another path that day.

I have often wondered how someone who is in such a dark place could have the presence of mind to be kind to another person.

What I have come to understand is that people who take their own lives are very often deeply kind and compassionate individuals.

I am eternally grateful for the kindness our patient showed me that fateful day.

Mark Fourre, MD, is an emergency physician and Chief Medical Officer of Lincoln County Healthcare, the parent company of Miles Memorial Hospital and St. Andrews Hospital. He also serves on Lincoln County Healthcare's Board of Trustees. Prior to joining Lincoln County Healthcare, Dr. Fourre was attending faculty at Maine Medical Center, where he developed the Emergency Medicine Residency Program and served as Residency Director.