All trauma centers verified by the American College of Surgeons (ACS) are required to classify trauma patient deaths into one of three categories: unanticipated mortality, mortality with opportunity for improvement, or mortality without opportunity for improvement. I’ve provided some details about each of those over the past several posts. But I do want to provide a little more detail for the much dreaded “unanticipated mortality.”

You may have noticed that unanticipated mortality does not seem to come in the same two flavors as the anticipated mortality: with and without opportunity for improvement. Why is this? Does this imply that all unanticipated mortalities have some opportunity or another? I actually used to think so.

But over time, I’ve changed my mind. It is true that the vast majority of unanticipated mortalities involve one, and many times, several opportunities that may improve the outcome for similar patients in the future. But I have personally seen at least two that did not.

How can this be, you say? Let me give you a far-fetched example. A healthy young male is involved in a car crash, sustaining fractures of a few ribs which are very painful. He is admitted for pain control, and is treated with your usual regimen of analgesics, mobilization, and pulmonary toilet. He admits to no significant medical or surgical history and is taking no medications. As he is sitting in his room waiting for his ride on the day of discharge, a small meteorite plunges through his window and strikes him in the head, killing him instantly.

So where’s the opportunity? Put meteorite shielding around your entire hospital? I think not. Don’t be ridiculous, you say, that’s not a realistic example. But what if, on the day of discharge, he stands up in his room and keels over in PEA arrest? An autopsy is performed, and a massive pulmonary embolism is identified. And let’s say that this patient somehow met your DVT prophylaxis criteria and he was receiving appropriate management per your practice guideline. And when you convey these findings to the family, they seem to recall a pattern of pulmonary embolism deaths and DVT complications in other family members. But nobody mentioned this to you during the history and physical exam. And you treated them exactly according to your protocol.

So what do you think now? Is there an opportunity? I still think not! But you must still pick apart every bit of the patient’s care, trying to identify anything that was not done according to plan or protocol that may have led to this (extremely) adverse outcome. But be aware that over your career as a trauma professional, you will likely run into one or more of these cases that are unanticipated but completely nonpreventable!