Primum non nocere

She was 65 years old and there was nothing out of the ordinary about her. She came to see me often for various ailments: diabetes, dyslipidemia, obesity, fibromyalgia, coronary artery disease, hypertension, chronic obstructive pulmonary disease, respiratory tract infections, gastroesophageal reflux, chronic non-malignant pain, anxiety disorder, bipolar disorder, and osteoporosis—things that a family physician sees every day. I cared for her the best I could, by listening to her, encouraging her, offering her advice, and referring her when appropriate. I prescribed all of the medications her condition required, in accordance with the many recommendations and guidelines governing family medicine.

He was 66 years old and there was nothing out of the ordinary about him either, except that on a bright, sunny summer morning, he went for a walk. It was a seemingly harmless decision that would be fatal.

It was 8:30 am. She was coming to see me to get a motor vehicle bureau form filled out. She had just turned on to the boulevard. For some unknown reason, the vehicle that she was driving left the road and crossed the median. The vehicle hit a traffic sign, traveled 18 m further, and hit the pedestrian who was walking alone on the other side of the road, throwing him 9.5 m. The vehicle kept moving, hitting another vehicle parked near a store. After traveling another 8 m, the driver applied the brakes.

He was immediately taken to hospital. Unconscious upon arrival in the emergency department, he was intubated and put on a ventilator. Saline and 2 units of blood were administered intravenously. Scans showed intracranial hemorrhage, fracture of the maxilla and the first dorsal vertebra, right pneumothorax with pulmonary contusion, right flail chest with rib fractures bilaterally, fractured hip bone, superior and inferior pubic ramus fractures, and fracture of the right fourth lumbar vertebra. Fractures to the lower and upper limbs were also noted. Shortly after, he went into cardiac arrest. Attempts at resuscitation failed. The time of death was 11:13 am.

An investigation of the driver’s vehicle did not reveal any anomalies. At the time of the accident, the sun was shining and the temperature was 21°C, with winds of 7 km/h. The road was straight and dry. Visibility was excellent. The expert concluded that the collision could not have been the result of the environment, the layout of the road, the temperature, or the condition of the vehicle. Witnesses estimated that the vehicle was traveling at 40 to 50 km/h at the time of impact; the speed limit in this zone was 70 km/h. The driver does not remember experiencing any discomfort, but does remember having seen the traffic sign and then the victim. She immediately went to help the victim after the impact and appeared to be in shock, but her responses to questions were adequate.

The incident was ruled an accident. But it’s a strange one, isn’t it? In the small town where I practise, where everyone knows everything, people wonder how someone who was driving slowly, who had not consumed any illicit substances or alcohol, whose vehicle was in perfect condition, and who had not experienced any discomfort could end up crossing the median and hitting an innocent pedestrian walking on the other side of the road on a sunny morning. When I received the coroner’s report stating that “the driver was taking 16 different types of medications, several of which could have affected her mental function,” I wondered whether I had had anything to do with the accident. The most likely scenario was that she fell asleep at the wheel and woke up after the impact. The skid marks support this conclusion. The medications that I had prescribed for her perhaps had something to do with it.

I am not the only physician to prescribe so many medications; most of us often prescribe a substantial number. This is not about assigning blame; we are following the recommendations. Each medication is justified for the indication for which it is prescribed. But what happens when they are all taken together, even when there are no drug interactions?^1–4

Could it be that, for a man who went for a walk after breakfast, prescribing 16 medications was fatal? Could it be that, sometimes, we do too much?

Canadian Family Physician is launching a new section entitled “Primum non nocere.” This section is about primary health care that seems excessive or unnecessary. If you would like to contribute, please visit our website for manuscript guidelines (www.cfp.ca). Article subjects can be related to medicine, ethics, or health policy, but must be related to the practice of family medicine.