Not all drug overdoses or fatal interactions are immediately obvious.

Presentation: cardiac arrest with no other apparent cause at the scene


True situation:

(1) secret substance abuse: high-functioning addict, accidental overdose, exposure to more potent or toxic substance, drug interaction

(2) suicide without note


Risk factors for error:

(1) high case load with other cases high-profile and/or need for cost-cutting

(2) making assumptions and going with first impressions, such as an older adult from an affluent background

(3) failure to perform drug and alcohol screen on all cases

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