Tis the season to impact drunk driving

We need some creative ways to curb drunk driving and underage drinking. As mentioned in this blog, alcohol related fatalities decreased dramatically from 1982 to 2004 (most recent available data year), but most of that decrease occurred in the first 10 years or so. We need new tactics in this “battle”.

A town in Vermont has come up with an unusual idea. It will be interesting to see how it works. The police department had their logo put on bar glasses and gave them out to local bars and restaurants, as a somewhat subliminal reminder not to drink and drive. I hope that they are able to make an impact, the idea clever and simple.

My wife ran across something else that might be worth a try. A blurb in Women’s Health (Nov. 2006) showed an effort to impact driving while distracted talking on a cell phone by printing “hang up and drive” in large letters on the street itself. Something similar might work for an anti-drunk driving campaign. I don’t know, something like “drink and drive and we may have to scrape you off this street”. Just a rough idea.

If only we could come up with something effective and simple to impact these serious and deadly problems.

Maybe I’ll get some Coroner’s Office logo bar glasses made up or maybe hand out “pre-registration forms”?

Gift (?) from my staff

“Holiday blues” are not depression

The “holiday blues” are not depression; they are a symptom of an acute situational disturbance. Unmet expectations, feelings of loss of what once was (or what is “remembered” to have once been), over-spending, over-celebrating can all contribute to the development of the “holiday blues”.

However, the “blues” can be superimposed on (chronic) depression, exacerbating it symptoms. Depression is a neurobiological disease with vegetative and somatic symptoms. A Harvard University study (2005) found that the US leads the world in rates of mental illness, yet has one of the lowest treatment rates. Depression is the most common mental illness, affecting over 34 million Americans. It is a major cause of disability and results in more lost productivity than any disease other than heart disease.

Most Americans don’t seek treatment, many out of fear. Fear of seeking treatment, fear of the stigma attached to mental illness, and fear of admitting that a problem exists. As well, there is at times difficulty in recognizing that the disease/problem does exist, because of denial, because of the disease or because of others “blocking”. In addition, there are severe access problems in getting help when you need it and want it. No insurance, limited insurance coverage and lack of care providers all contribute to the access difficulties.

Let us, as the “great” nation that we are, make a resolution/commitment to address this multifaceted “problem” in the New Year and beyond.

Drug prevention needn’t be finessed

I came across an article discussing information I have seen before (and I think did a post about) that the use of illicit drugs looks to be declining among teens and young adults, but illicit use of licit drugs (e.g. Vicodin at parties) appears to be increasing. However, the part of the article that most caught my attention was the statement that “we” will need to be “finessing a message that these legal drugs are safe when used properly, but can be life threatening when abused.” That “traditional prevention messages” won’t work because these drugs are legal and are useful when used appropriately.

This seems to say that teens and young adults aren’t quite bright enough to differentiate the 2 uses (or use and misuse). That the only way to stop them from misuse and abuse of these substances is to paint them broadly as “bad”/”evil”. I think we sell people and their mentalities short with this thinking and I think that sort of thinking is why so many “drug prevention” programs fail. That is the foundation thinking behind “reefer madness”-type programs and scare tactic prevention programs. Those programs fail because all you have to know is 1 person using the drug at issue without the “madness’ or while still functioning in society and the entire reason not to use goes out the window.

Drug use prevention programs, whether pertaining to illicit or licit drugs, must be fact based and reasoned if you want people (including teens and young adults) to not misuse the drug. The same holds for alcohol, when used appropriately and responsibly it is a good thing, but misused it can and does kill. The messages must be clear, consistent and repeated over time to have an impact, but they can be nuanced in the sense that people are capable of discerning misuse from use. The message should not be “finessed”, but must be clear and factual. We can tell folks that this stuff kills if misused (if it does) and yet can save if used properly. Do not demonize, but rationalize (as in make a rational argument) against harmful use. Let them know the whys and wherefores and you will still see the results you want.

Dangerous Toys

The 10 most dangerous toys of all time, it is Christmas giving time.

I remember many of these toys. I played jarts without serious incident (we did try to stick them in different “targets”, not people) , my cousin had a set.

American College of Emergency Physicians ought to help forestall death

In reaction to comments made by the President of the American College of Emergency Physicians in an article in Emergency Medicine News (posted about 2 days ago) and in a press release from the “College”, I sent a letter to him today.

In particular the media release is irritating:

One paragraph begins: "Second, we don't know the facts about what happened in Illinois, so it's impossible to speculate…” and then his other comments are based on speculation
He states: "All emergency departments use a triage process, which means the most critically ill or injured patients are seen first. So a person with chest pains, stroke symptoms, or any other symptoms of a life- or limb-threatening emergency will go to the front of the line.” (which is a large part of what did NOT happen in Ms Vance’s case)
And: "However, sometimes a patient will come in with mild symptoms, and while they are waiting, their medical condition worsens. It's very important for emergency patients in waiting rooms to notify the triage nurse if they are in pain or if they start to feel worse. If they are still concerned, they should ask to speak to an emergency physician or a patient advocate.”

As I wrote him:

“Sometimes a patient will come in with mild symptoms…” Ms Vance presented with complaint of 10 out of 10 chest pain, shortness of breath, diaphoresis, and nausea (documented in triage notes). Her symptoms persisted without diminution throughout her 2 hour stay in the waiting room. Her daughter talked with the triage nurse 5 times reiterating her mother’s complaints and what appeared to be her worsening condition (weakening and changing mental status). Her daughter pleaded for her mother to be taken into the Emergency Department and asked to speak with other staff (this did not occur). Ms Vance ultimately laid down on a couch in the waiting room and suffered a cardiopulmonary arrest. That condition was noted by ED staff when they finally came for her in the waiting room. What part of your admonition and ACEP’s press release suggestions did the patient and her daughter “miss”?

I/we (the jury) do not seek criminal charges against either the doctor or nurses in the ED that night, but hope for a clarion call to improve the system. Overcrowded or not, no one should present with the classic symptoms of an acute MI and die in the ED waiting room. The system should be designed and function so that does not happen (see also the “Quality Matters column in the same EMN issue). Ms Vance’s autopsy demonstrated an acute thrombus as the cause of her MI, likely very amenable to thrombolytic treatment.

I have 17 years experience as an Emergency Medicine physician (former ACEP member and Fellow) and 8 years prior to that as an ED tech, so I do have a grounding in EM and ED function. The Coroner’s Office is in fact a public health duty and my goal is to forestall preventable death whether by violence, suicide, substance use or medical misadventure. I take my job seriously and my jury that day took their job seriously.

I agree with Dr Welch in her column (Quality Matters) that we must “…build a health care system that is safe and reliable.” I know that is also the goal of ACEP. Let’s all work toward that, using every opportunity, and not cloud the discussion with comments about how this will drive physicians from the practice of EM or noncontributory hypotheticals. There will always be dedicated physicians practicing EM and hospitals will always have EDs. Lets work to make them both the best they can be

FDA antidepressant warning

It looks as if the FDA will proceed with plans to expand the “black box warning” to include warning that SSRI antidepressant use may increase or cause suicidality in individuals taking them, up to the age of 24.

Black box warnings are boldly outlined caution boxes included in drug package inserts and the PDR about life-threatening side-effects of medications. This decision is based in large part on anecdotal evidence presented at recent hearings in which survivors of individual’s who had died by suicide testified while showing pictures of loved ones.

This decision was made despite the several well done studies that have in fact demonstrated an inverse relationship between SSRI antidepressant use and suicidality. Depression treatment with antidepressants cut suicide risk.

Yes, some individuals may experience an increase of agitation and suicidal thoughts with starting antidepressants, but with careful and thoughtful follow-up and treatment this is a minimal risk and easily addressed.

Let’s hope that no one needing these medications declines that treatment based on this “warning”. Antidepressants are very useful and beneficial medications (realizing that they are often just one facet of a complete care plan). Antidepressants save lives.

Homicide Verdict = EM Death Knell

The lead story for the December 2006 Emergency Medicine News (not avaialble online) is headlined: “Homicide Charges Against ED Stun EM”. It is a story based on the death of Beatrice Vance and our Coroner’s jury verdict of “homicide” (there are no “charges”). For the most part the article is fairly done (although a couple of my comments and my 17 years experience as an ER Doc is garbled). Two key points missing from the retelling of the story of this woman’s death is that her pain on presentation to the ER was “10 on a scale of 1 to 10” and that her daughter had pleaded with the triage nurse 5 times to get her mother the attention she deserved, allowing the American College of Emergency Physicians to comment that patients should “notify the triage nurse right away if medical conditions worsen in an emergency department waiting room” (is that before or after their cardiac arrest?)

I am clear in my quotes in the article that I see this as a system problem and the system needs to be changed to prevent this type of problem. Dr Blum (president of the American College of Emergency Physicians), quoted several times in the article, feels that this verdict will drive doctors away from the field of Emergency Medicine and feels the decision “criminaliz(es) a system problem”. The article also states that “the homicide charges filed in this case (none are filed) may have sounded the death knell (for the emergency care system). [I might also mention that I knew this article was out when I received some “hate” email from an ER doctor in North Carolina.] If only this verdict would have that much “power” and cause some improvement in the system. That is what I hope for. I don’t want Emergency Medicine to circle the wagons and protect itself from the “evil” Coroner’s Inquest verdict; our jury verdict demands improvement.

It is interesting that in the same edition there is a “Quality Matters” column (by Dr Shari Welch) on “Human Error in the Emergency Department”. The author says that errors happen but that it is time for “a new approach”…”we are all about designing an environment where mistakes are anticipated and mitigated, where we create a setting conducive to uninterrupted problem solving, and where we anticipate our own failures”…and….”build a health care system that is safe and reliable.” I and my jury ask for nothing more (or less).

Previous posts on this here, here and here

Preventable Homicide

I just got off the phone with a reporter from a local newspaper. He was doing his annual story on the number of homicides in our county. While our definitions of homicide differ (mine: death by another’s “hand” and his: charges likely to be filed) we were in agreement that the number of homicides by his definition have decreased. He pointed out that that seems to be a trend for a few years now.

We discussed possible reasons why that might be the case (all guesses and conjecture) and then he asked what I would like to see going forward to continue to impact the homicide/murder rate.

I mentioned a few things, some of which are in place and just need growing, others just beginning. As I have mentioned, we need to change the “social norm” and/or thought process that the only way to respond to certain things/behaviors/events is with violence, especially all out violence. Here is a perfect role for several social service programs and for the communities of faith, and they need to continue in that role. Also of particular value are programs like CeaseFire, which seek to break the cycle of escalation and retaliation (particularly in relation to gang activity). Also of great value are programs like Teen Court, Drug Court, and Mental Health Court, by keeping first time and low-level offenders and others ill-suited (if you will) for jail/prison out of jail and prison so that they don’t learn even worse maladaptive behaviors.

Murder/homicide is a public health issue, as much as it is a justice/legal issue (also justice in the social justice sense). They, too, are deaths we can prevent and we must “invest” in and support programs that can do just that.

Interesting Mental Health Blog

I stumbled across and interesting blog today. As is often the case, I found it while I was doing something else (in this case some “continuing medical education” for credit). The blog is entitled “Anxiety, Addiction and Depression Treatments” but it covers a considerable array of mental health topics, from drug abuse to suicide to mental health issues on reality TV. As they put it:

Anxiety, Addiction and Depression Treatments is the public voice of Treatment Online. Here we strive to report and comment on the most important news in medication, treatment, psychotherapy, clinical research and other areas of mental health. We chose the title Anxiety, Addiction and Depression Treatments to represent the broad range of topics that peak our interest. Beside new issues in bipolar disorder, PTSD or drug addiction you will also find pertinent discussions on parenting, healthy eating, therapy strategies and all manners of health care, especially as they relate to mental health

Some recent interesting topics:

Students with Mental Illness Face Unique Challenges on Campus
Sleep Problems Hamper Recovery From Alcoholism
OTC Drug Abuse Soaring, New Study Says. History May Provide Another Lesson

I recommend a look and while some of the content is targeted at physicians and physicians-in-training, information about mental health issues and the stigma of mental health issues is important for everyone to have access to. Also, it seems very reasonable, debunking pseudoscience and in re-balancing coverage from “outside” sources.

Adverse Childhood Events

Adverse Childhood Events (from a study published in 1998 in the American Journal of Preventative Medicine) occur much more frequently than usually recognized and have an incredible impact on adult health, even 50 years later.

18,000 volunteers (average age 57) were queried about history of child abuse and household problems when they were children (yes, the study did depend on the vagaries of recall, but the internal consistency does seem to bear out the results). The adverse childhood events looked at were physical, sexual or psychological abuse as a child or living in a household with a member who was mentally ill, imprisoned, a substance abuser or a victim of domestic violence, or having an absent parent (whatever the cause).

Less than half of the study subjects had none of these events in their lives. 80% of those with one event in their childhood had at least one other from another category (they do tend to be interrelated). One in four individuals had two events and one in 16 had four. Two thirds of the females had at least one of these events in their lives.

These events disrupt normal neuro-development contributing to emotional, cognitive, and social impairment later in life. Most interestingly (surprisingly?) these adverse childhood events correlated in a dose-related manner (the more events the more likely the outcome) to health problems later in life, in the form of health risk behavior, diseases, disabilities, and early death. It was the opinion of the authors that these adverse childhood events were “the leading determinate of the heath and social well-being of our nation.”

This seems to speak to the fact that much of individual health is actually “community” health and that we must work at community “healing”. This community “healing” is necessary not only for the community, but for each individual as well.

IVDRS

The Illinois (and National) Violent Death Reporting System (IVDRS) is an active (meaning data is sought and brought together), multisource approach for analysis of violent deaths (homicide and suicide). Information sources include death certificates, Coroner/Medical examiner records, Police records, Crime Lab data and various other ancillary sources to round out the “snapshot” of each of these individual’s deaths.

What is “neat” about this system is that it doesn’t collect only the usual “incident data”. It also collects information about the victims, the perpetrators (suspects), the weapons or means of death, information about the individuals involved and the relationships or connections of the victims and perpetrators. It ties in circumstances contributing to the death and characteristics of the death. A robust data set it collected and collated.

With this system you can pull out information like: the top three circumstances surrounding homicide are precipitation by another crime, intimate partner conflict, and drug involvement; or physical health problems contributed to about 25% of suicides; or if a woman is choked during an intimate partner violence assault there is a greater chance of subsequent homicide associated with a later episode of intimate partner violence.

Getting this information in Illinois, and across the country, will allow for a better understanding of violent behaviors and the associated causes and circumstances for both homicide and suicide. We can then improve risk factor identification (personal and social) and design programs to reduce the incidence of death associated with violence to one’s self or to others.

What a great project and opportunity.

Preventing Underage Drinking and Death

Yesterday I went to Chicago to discuss the future expansion of counties contributing to the Illinois Violent Death Reporting System (the state replica of the National system now in 17 states), as well as a 1st look at preliminary data from the 3 currently participating counties. (I am now on the state Advisory Board and Lake County will be the 4th participating county) The information that will be available will be very interesting and informative. I’ll post about that soon. I look forward to its full implementation.

For tomorrow, I have been asked to talk to a group at a local high school (actually out of “my” county, but it is very worthwhile to help them out). I will talk about the effect of drugs and alcohol on the adolescent brain (I have posted on that previously, a part of my speaking “tour” on this topic) and also begin their discussion/project on addressing underage drinking locally.

I’ll introduce some “solution priorities” arrived at in a consensus process at a series of town hall meetings here in Lake County sponsored by the Lake County After School Coalition. As these priorities are serving here in Lake County, I think they can serve as a jumping off point for them as well. Those that provided input to the priorities were parents, students, community “leaders”, and other “folks”. The priorities they came up with were:

1) Educate youth on skills needed to resist peer pressure and to make healthy choices
2) Educate parents on role modeling and communication skills
3) Enforce rules and make them consistent at school, home, police, and in the community and prosecute adults who provide alcohol to minors
4) Explain and enforce zero tolerance (zero blood alcohol in underage drivers)
5) Make the issue of underage drinking prevention a priority for everyone in the community

My added points:

Youth programs must be youth driven
Parents need to be parents, not friends
Social norms must be changed, underage drinking is not OK (driving or not)
Alcohol is the number one date rape drug

The process begins, things are happening.

Healing social norms to forestall death

I am working on 3 “projects” that seem to have percolated to the top of my “to do” listings. That “3” includes our Suicide Prevention Task Force (birthed out of our office and currently driven from there), Underage Drinking Prevention (after one speaking engagement I seem to be being “clamored after” for others, that is someone else’s characterization), and CeaseFire (a developing project in our area, I serve on the Advisory Board).

It was listening to an outreach worker for the CeaseFire program, and thinking about it afterward, when a certain realization came to me. These initiatives have much in common. They are at their root public health and community healing initiatives. In addition all 3 will require, in addition to healing components, changes in social norms.

To stop community violence we need to change what has become a social norm (violence and violence breading violence) and inculcate that “violence isn’t OK and isn’t the only option”. To “stop” underage drinking we need to change the social norms that say that “drinking is OK for underage individuals, it is a right of passage, that they will do it anyway so parents should allow it in “controlled” settings”. To prevent suicide we need to impact the social norm that stigmatizes suicide so that we can not address it openly, that stigmatizes underlying depression and mental illness, that suicide must be hidden so as not to “breed” more suicide and that prevention leads to exacerbation.

I’ll write more on this as I mentally dissect and ruminate on what seems like a fascinating relationship/linkage. Also, I see “community healing work” as a promising “umbrella” under which to bring together what might otherwise seem to be divergent issues and solutions or efforts. I’ll write on that, as well, as it gels in my mind.

At least parts of our healthcare system need fixing

The system needs some fixing. I don’t agree/endorse everything this gentleman writies but it is worth a read:

The disease is AMI ( Acute Myocardial Infarct ) or in lay terms, a heart attack, and the background facts in this situation are not in dispute.
Every year some eight million people rush to a nearby Emergency Room ( ED ) believing they are experiencing life threatening chest pain. About 8 % of all ED visits every year are for this reason.
Five million of this total are deemed to demonstrate possible cardiac etiology and are treated accordingly.
However, three million are deemed to be having non-cardiac pain and they are discharged without treatment.
And then at least 40,000 of those so released, subsequently die, often in an embarrassingly short period of time, of a heat attack.
We say that at least 40,000 die because these are the ones everyone is sure of. No doubt there are more. But for 40,000, their deaths occur very close in time to the visit to the Emergency Room and their relatives raise a fuss, ask for records, file malpractice suits etc etc.
It’s another story for another time but misdiagnosed AMI is in fact the leading cause of malpractice suits in the US. Currently, however, almost none of these is ever successful.
The question for the reader though is a simple one. Why didn’t these 40,000, ( who after the fact, we now know, were literally dying in the emergency room ) get properly diagnosed.
I can’t speak for all of them but this is what happened to one of them, and based on what I am told by experts, it is not at all uncommon.

And:

The proof of this statement is the simple fact that at least 13 times out of every 1000, the patient dies of a heart attack after having been told his pain is not heart related. If you think that’s a pretty good record, ask your self if you would fly an airline with the same record.

They aren’t “murder”, but are they reckless? How do we effect change, not throw out the baby with the bathwater, but improve our system and prevent unnecessary deaths?

Elephants in mourning

I came across something recently that I thought might serve as a bit of a change of pace as a post.

Elephants bury and mourn the death of another elephant, particularly one from their own family herd (they also, interestingly, live in extended families with group participation in rearing of young and they are very ‘social”). [This parenthetic statement certainly calls into question our confining them solitarily in zoos] Elephants also return to “visit” their dead relatives in their cemeteries, paying them homage (they also exhibit that veneration with any elephant bones/remains). These are behaviors that may be unique to humans and elephants. There are also a number of reports of elephants burying dead humans.

Nothing much more to say, I just thought it was interesting that a behavior thought to demonstrate the “humanness” of humans (mourning our dead and venerating our dead in cemeteries) isn’t uniquely human.

Grieving

I am talking at a “town hall meeting” this evening. I thought (and had been told) I would talk about the effects of alcohol and drugs on the adolescent brain, but the agenda I got yesterday says I will talk about “emotional consequences of death” in addition to a role in the “welcome”. Whoa, that’s a bit of a change. I’d been prepping my talk on the adolescent brain under construction and the actions wrought by alcohol and drugs.

I do know grief (personally and professionally) and dealing with grief is an aspect of my job, so sure I can talk about it (and I excelled in extemporaneous speaking in high school).

Grief (Webster’s has such a terrible definition I won’t use it) to paraphrase someone: change leads to loss leads to grief, so grief is our reaction to loss and change. It is a normal response, it is an individual response, and it is complicated and multi-dimensional.

To understand grieving first forget Ms Kubler-Ross. She wrote about an individual’s coping “stages” to dying, not to another’s death. Her “5 stages” are the usual reactions to getting “really bad news” (like you have a terminal disease).

Grieving begins after you have gotten over the “really bad news” of someone’s death. Grieving (the work of grief, so that the following can be thought of as the “tasks of grieving” (William Worden)) begins with acceptance, accepting the reality of the loss/death. The second “task” is allowing yourself to feel the pain of the grief. The third “task” is adjusting to life without the person who died; your entire self-concept and/or world-view may have to be altered. The final “task” is developing a “new reality”, making your emotional energy available for other “investments”, opening you to the future. With the final task you don’t get “closure” or “get over it”, but you do move forward. As someone once said “Death ends a life, but it does not end a relationship.” Grief is never finished; it is a part of the life cycle. You develop a new relationship with the deceased, but the relationship does continue and often continues to change over time. (This is where memorials and rituals may serve their function for the individual experiencing the loss as well as the community.)

Grief is hard work. To feel is to heal. The way out of grief is through it.

Blogged his heart on suicide anniversary

Heart rending

Homicide in Lindenhurst

There was a woman killed in Lindenhurst this morning.

The local media began calling before we even had any information. There were 2 helicopters and a plane circling the scene; it does amaze me the photographic clarity that they achieve shooting from that distance above the ground.

When I got into the office I had a dozen messages, reporters looking for information. I didn’t talk to them until later in the day, when I could release the name of the individual killed. We withheld releasing the woman’s name while family was notified, and that information could spread out to all the family not living locally. Some media folks already had her name and only needed confirmation; others had a name that wasn’t correct. Some had considerable detail about her life (one had already talked with her family); others didn’t have any information. I have talked with and/or returned calls to 18 or 20 reporters (at the time I am typing this), TV, radio, and print media.

We continue to withhold the cause of death, because the Major Crimes Task Force asked us to and plans on using that information in their ongoing investigation. The hope is that some “person of interest” will reveal details not released to the media while being questioned, but I don’t think it usually works that way. The media seems to find out bits and pieces from various sources (outside of my office) and will likely have a pretty good idea and story out before we release the information. That is usually how it works out.

Homicide is big news. Little news would be the woman who was trying to get her life back together and died in a tragic accident before she could win her battle (I think that is big news, too).

Entomology

I was looking at an article in a recent edition of Forensic magazine entitled “Forensic Entomology: Myths Busted!” It ran through 3 “myths” that weren’t “earth-shattering” and arguably the 3rd (forensic entomology only revolves around death-scene investigations) isn’t that big of a myth. The things I liked the best were the insect pictures and blurbs by the pictures.

I knew that forensic entomologists can at best give you an estimate of the minimum post-mortem time interval and sometimes a rougher estimate of the maximum postmortem interval. “Time since death” is always at best a guess unless the death is witnessed, no matter what TV and the movies would like to have you believe.

I knew that “entomology evidence recovered from decomposing human remains” (read maggots) can be used to detect, but not quantify, drugs present in the decedent. We have used maggots for detection of cocaine when blood, tissue and other bodily fluids were unavailable, never even considering quantifying the level.

But the insects featured were interesting: Phaenicia cuprina (bronze bottle fly) “a common species”…”prefer outdoor locations and deposit eggs (helping with time estimates)”. Sarcophaga haemorrhoidalis (flesh fly) “preference for indoor environments” (and) ”have the ability to give live birth (unlike most flies)” (and) “helped give rise to the early (false) theory on the “spontaneous generation of life”. Chrysomya rufifacies (hairy maggot blow fly) “is both cannibalistic and predatory”. Ah, great names and lovely mental pictures. Lastly something “prettier”, Enodia porlandia (Southern Pearlyeye butterfly) “may be commonly found at scenes involving human death where they feed on sugar rich body fluids”.

Death memorials

I was reminded recently (to paraphrase something I read someplace) that in death we continue to exist in the memory of others. I was reminded of that as I alluded to that fact in a discussion I had a few days ago. I was reminded again when I recalled the face a day later (in what seemed to be vivid detail) of someone who died a fair length of time ago. And I recalled the phrase as I started to work on this post about “roadside memorials”. Those memorials are an increasing phenomenon in a variety of countries (google it like I did) and places (roadside, porches, online, etc).

Why do people build these memorials? Are they reflective of some new spirituality, as some would have you believe, or are they just people being people honoring death and remembering the dead?

These memorials mark the place where someone died suddenly, often violently, an untimely death, or as someone put it “yanked from this earth”. Are they an attempt to develop “sacred space” or are they a more secular attempt to provide a marker for the memory of that individual’s life and death? We do not want to forget those that die before we do, for fear of forgetting do we build these memorials? They do create a space for remembering and mourning. They do provide a physical space to hope for peace for those who have died and for peace for those that mourn the dead.

In that I see their benefit. A space (sacred or not) is created that is connected to those that have died, beyond the “official” places for mourning. It seems a more immediate (close) and a more real place for these contemplations and offerings of “respect”. Death is a part of life and those that have died live on in our memories of them. The real memorial is in us, but, at least temporarily, we may need a memorial outside of ourselves to remind ourselves of that fact.

Self-injurious behavior

Nobody knows the prevalence of self-injurious behavior, but it occurs much more frequently than people think. It can be associated with a history of abuse or psyche trauma, eating disorders, depression, post-traumatic stress disorder, and (what is termed) borderline personality disorder. I’ve been thinking of writing about this since I saw a young lady who had carved “help” into her thigh.

Individuals who carry out self-injurious behavior want to hurt themselves, they are unable to resist acting on that desire, they intend to cause themselves injury, not death. While this is not a step toward suicide, there is an overlap in psychopathology and, therefore, you may see both in the same individuals (as was the case in the young lady I mentioned above).

Self-injurious behavior is addictive, just like drugs. The underlying drive varies person to person and, at times, from episode to episode. Self-injury may allow for the release of an incredible “tension”, at least temporarily. The pain involved may allow the individual to feel “real” and alive. It may “connect them to the present”. It may allow the individual to control their “environment”, to control themselves. Yes, it may be used to influence others, but this is the least likely reason behind the action. The “reasons” are many.

These folks need help. Using this as a coping behavior is fraught with danger, as you might imagine. In one study, 20% of adolescents who self-injured in this way required medical attention for that self-injury. As well, the underlying psyche pain, the pain that is worse than the physical pain delivered in self-injury, needs some other treatment. Help is available and those involved in these behaviors need to know that and that it is OK to seek help for this serious problem.

Save a Life??

There was an investigative report last night on the local ABC affiliate about an individual who set up a foundation paying herself $120,000 a year plus expenses based on a “inaccurate” retelling of her daughter’s death (there were other untruths as well, apparently).

This is made more difficult to understand and/or tolerate when I talk to other parents, family and friends who really want to make a difference because of a death in their life, not benefit from it. At inquests yesterday I talked with several folks about such efforts. These other attempts and actions to save lives seem much more altruistic.

It saddened me when the investigators came to us for the information; it certainly didn’t get any better in the report that I finally saw last night.

The work of the Lake County Suicide Prevention Task Force

We had a Lake County Suicide Prevention Task Force meeting this morning. It really seems like we are getting down to work. We have divided into 4 committees: Resource Collection, Education, Community Information, and “First Responders” Project.

The Resource Collection Committee will continue our efforts to collect and post online the available resources in the community and begin work on a “gaps analysis” with consideration of how best to address those “gaps”.

The Education Committee will work towards community education, school education (for school personnel and students), professional education (medical, psych, clergy, etc.) and the like. Certainly, an initial part of this will be to find out about present education efforts and then work with them, facilitate them or augment them.

The Community Information Committee (whose work will somewhat overlap the Education Committee) will target awareness and stigma. That will include media and other venues, and other efforts.

The “First Responders” Project will begin our efforts to develop (borrowing from existing programs elsewhere) this program in Lake County. We envision a program in which we can get trained and “experienced” individuals to go to and begin helping and “connecting” family and friends of individuals who die by suicide with the resources they will need.

The work begins/continues.

We also handed out a list of information (no names) about the individuals who have died by suicide since January 2004 in Lake County. At first glance the listings pertaining to 140 individuals looks “sterile” and impersonal, but then you fall into it as you read it. 140 individuals who “leapt from their own infernos”. It “pulls at the heart strings”. We will accomplish our work.

On-line Memorials

[Busy day yesterday: press release to get media coverage and help in identifying a recent John Doe, staff meeting, regular work stuff, and taped a segment for the Today show (30 minute taping for 20 seconds of “air time”).]

I did want to mention a website somewhat related to “MyDeathSpace” that I posted about the other day: http://www.memory-of.com/. It is a site that allows a person to set up a web-page memorial site to memorialize an individual that has died. The usual posting consists of a “life story” with pictures and background music. You can include audio and video clips. The web-page is viewable by others who can leave condolences and comments.

I don’t mean to do an ad for these folks (and there are likely other similar sites) but I think this is likely a new cultural trend. It seems to be a “next step” beyond the growth of “roadside” memorials that have become quite the cultural trend (I will reserve my opinions about those).

These types of sites allow for a more public grieving (although the intent of the posters may be more personal, allowing for “visits” by friends and family). It also seems to allow for public/community sharing in that grieving. The latter seems to be the cultural trend, “sharing” in the grieving of people we may or may not have know in life (like many that participate in “roadside” memorials). We used to send a condolence card and/or flowers, contribute to a memorial fund, and the like. There would be a headstone at the graveyard, at times lavish, but these “displays” are new (or seem so to me). And while there were always those that shared the grieving at the funeral, there were few who participated who did not know the individual before death (although there were those few like the characters in the movie Harold and Maude who enjoyed attending funerals).

Why has this trend for public “displays” of grieving developed? What need do they address?

MyDeathSpace ?

I’m going to have to think about this site for a bit before I can decide what I really think about it. MyDeathSpace catalogs the deaths of individuals with MySpace postings. (MyDeathSpace is not affiliated with or condoned by MySpace.) You see postings about young people victims of homicides, suicides, and accidents. It is “compelling” to see all of these deaths of young people brought together and laid bare.

I’m really unsure about the “death map” feature (“to find deaths in your area”).

I don’t know. Will the postings have some affect on others? Will it cause pause for other young people and get them to reevaluate choices they are making or chances that they are taking? Is it merely voyeurism? Is it a part of “new online/virtual culture”? I don’t know.

This site is unlike other sites in that the postings most often occur without input from family and friends of the decedent, making it different than some others that are online memorial sites.

I don’t know. I’m not sure what I think about it.

I will look at some of the online memorial sites and post about them soon.

Coroner's heath tips

Thought I’d jot down a few coroner health cautions that you don’t see printed up elsewhere, but that we have discussed in the office based on “cases”.

People over 50 shouldn’t use cocaine, Yes I know that no one should use cocaine and that, as we testify, “there is no safe dose of cocaine”, but based on some of the deaths we see it seems particularly lethal for those over 50. It causes “heart attacks”, “asthma attacks”, strokes, and people just plain “waking up dead”.

Viewing pornography and “doing something about it” can be lethal. I know there are individuals who would like to use that “fact” to regulate the porn industry, but I would have a less severe recommendation. I recommend all men (yes, it seems to be a guy “thing”) say over the age of 45 (depending on other health issues) have a physical done by their doctor before they undertake these activities. Just like is recommended before starting an exercise program.

Do not trust the drugs you buy “on the street”. As an example, stuff we have recovered and tested from death cases thought to be heroin has consisted of anything from “pure” Benadryl to Fentanyl. Any of these, obviously, can be lethal, but I imagine the highs are different and isn’t it the high that you buy it for? You aren’t going to get your heroin high if the Fentanyl causes your death even before you get the syringe out of your arm. I doubt that Benadryl gives you the same high as heroin, even though much of the Lake County heroin seems to be cut with it. (I read recently, some place, that the “name” heroin is derived from “heroine”, which is what heroin was “billed as” when it was first used for pain control.) Caveat emptor.

There are a few; there will be more from time to time.

ER system reform needed

The Associated Press brought up the case of the woman who died in the ER waiting room that was ruled “homicide” by our Coroner’s Inquest jury again yesterday. It was in an article about long wait times in ERs and doctor’s offices.

It also “came up” at a recent meeting of the local regional healthcare council, being fostered by the Metropolitan Chicago Healthcare Council, (alright, I brought it up as an example of a system problem that should be looked at for “remedy”).

At that meeting we briefly discussed how many problems are contributing to this “system problem”, some of those things are also touched on in the article I referenced above. ERs are overcrowded. There has been a 26% growth in the number of patients seen in the ER between 1993 and 2003, while the number of ERs in this country have dropped by 12%. This growth/contraction combination took place without much modification in the system (the way that ER care is delivered) designed to keep up with the changes and load engendered or designed to improve efficiencies in providing ER care.

This is compounded by a variety of other confounders. There are “health literacy” problems. Many people don’t always know what is appropriate for an ER visit or because of that “illiteracy” don’t know what to do short of going to the ER for various medical problems. That “illiteracy” may also impair their ability to follow medical instructions for care and to keep them out of the ER. There are access issues for both acute and chronic health problems, denying people other options for care. There are “down-stream” problems, e.g. lack of hospital nursing staff and/or beds impairing the ability to get patients out of the ER and freeing up space for the next patient. There are many facets and/or contributing problems.

Some places are making changes to address some of the contributors. ERs are adding staff to handle cases that present. Some hospitals are using physicians for triage at busy times so that necessary testing can be begun more quickly. Groups are looking at “best practices” and exporting them to other ERs. Groups are developing alternatives for expanding healthcare access.

As I said before it is a system problem and requires system intervention to prevent any more individuals from dying in the waiting room.

SSRIs and suicidality

Do SSRIs (selective serotonin reuptake inhibitors, newer antidepressants) contribute to suicidality?

Although further studies need to be done (realizing the inability to ethically do placebo-controlled studies) to clarify some of the issues, most of the evidence does not support a risk out of proportion to the benefits for these medications (age specifically or otherwise). There are some studies that have demonstrated an increase risk of suicidality during the early phase (1st month) of drug therapy, but the risk seems to be shared by all classes of therapeutic agents (SSRIs, tricyclics, etc). Also, it seems that the increased suicidality rests more in ideation and behavior than in actual suicides.

Why the increased suicidality? There are likely several contributing factors. It may be related to the fact that these medications remove the psychomotor retardation component of depression that has kept the individuals from acting on their suicidal ideations. That effect on apathy and energy does tend to precede the medication’s positive effect on psychic depression (2 to 4 weeks), increasing the risk. There is also the possible contribution of the fact that these medications are most often started at the lowest ebb of an individual’s depression, confounding knowing which contributes to the increased suicidality. There are also possible side-effects of these medications that can increase suicidality, i.e. akathisia, agitation, disinhibition, and impulsivity. Lastly, at times starting antidepressents “uncovers” mania, a risk factor for increasing suicide risk. Interestingly, this seems to be a particular risk in kids 10-14 years old, perhaps explaining some of the perceived increased risk of these medications in this age group.

SSRIs have had a salutary effect on the treatment of depression and do not deserve to be demonized. As with all medications they should be used judiciously with monitoring for effect and side effect, but they must remain a part of our armament in our treatment of depression and the prevention of suicide.

Teen death by suicide

A local paper is doing a story on teen suicide, prompted by the fact that 3 students from the same high school have died by suicide over the last 3 months. It is definitely unusual for the media to do a story on this “taboo” subject, despite, as I discussed with the reporter, the fact that the myth that stories about suicide “cause” other suicide deaths has been proven false. I discussed a number of things with the reporter, which I will likely come back to in future posts, but one bit we talked about was a comment made to us in the course of our investigation of one of the deaths. To paraphrase: The kid was quiet, never in any trouble, never really noticed at school (or elsewhere). What this screamed to me was “depression”.

It seems that the thing that these kids had in common was unrecognized depression. Nonetheless, I can’t say that if I were at the school or their parent that I would have noticed it either (I hope I would, but sometimes we are more grateful than worried when a kid is just quiet). But was the safety net in place so these kids could seek help, easily, anonymously and without other “problems” being created? Was the safety net in place so that their friends could have helped them get help if they recognized a “problem”? Did folks know what to look for and know how to help them get help?

A small group of folks are going to get together soon to discuss those issues specifically (I didn’t mention that to the reporter) and our Suicide Prevention Task Force is certainly looking at the suicide “problem” more broadly. It is too late for these kids, but I pray that we will save others.

In an interview recently I heard the Director of a movie focused on death by suicide by jumping off the Golden Gate Bridge describe death by suicide as “people jumping out of their own infernos”. That is so true, but we need to get them help short of that “jump”.

Substance abuse help

I came across an interesting website that should be touted to every teen and every parent with teenagers (maybe more particularly with even younger children). It is the website of the Partnership for a Drug-Free America.

It is a great site with information for teens, real information and not “preachy”. Included is information about recognizing whether you or a friend has a “problem” with alcohol or other drugs, and information on helping a friend with a “problem”. It also has personal stories about recovery and in memorial of those that didn’t recover.

There is also a section for parents with information on a wide array of abused substances, support forums, and what to do if your child has a “problem”. It also has a “fun” little test, called The Two-Minute Challenge, testing your knowledge about some important facts about substance abuse. I’m going to help you cheat and give you the answer to what I think is one of the most important questions. I always make a point to tell folks that you can’t scare your kids straight, but if you give them real information they can/will choose to make the right choices and not take chances (at least it is the most likely way to effect behavior in this regard).

4.) One of the most important factors in whether kids decide to try drugs is? Correct! Correct Answer: B. Understanding the perceived risk of using drugs and whether the drugs are deemed socially acceptable. Research shows that perception of risk is one of the most important factors in influencing the decision to use drugs. (Source: Monitoring the Future)

Take a look at the site and its information; it may come in handy in the future.

Tonight's talk on alcohol and adolescent brains

Alcohol (and more specifically ethanol, “drinking alcohol”) is a poison and a depressant drug. The fact that it is a poison often surprises people, but remember it can run your car and it is used in biology to kill insect specimens.

Ethanol has special effects on the adolescent brain, which shouldn’t be surprising when you consider that the adolescent brain is “under construction”. Just raise some kids into and/or through adolescence and you come to realize that it is “damaged” and “getting fixed” (the latter by about the time they are 22).

“Binge” drinking is particularly damaging and that is what most adolescent drinking is. Ethanol affects learning and memory much more significantly in adolescents than adults. Those effects are compounded with significant ethanol consumption (repeat or continued) as an adult. It also appears that changes occur in the adolescent brain with ethanol use that makes it more likely to develop “problem drinking” as an adult.

A significant difference between adolescent and adult drinkers is that for adolescents ethanol has less of a sedation effect and coordination is affected a bit differently. This diminishes the “natural” effects of ethanol to get an individual to stop drinking during one “setting”. Blood alcohol levels can get higher in an adolescent because it takes more for them to become “falling-down drunk” (a “natural” drinking stopper).

However, ethanol still poisons the eyes in both adolescents and adults. Initially ethanol impairs papillary constriction, so bright lights appear brighter and harder to at (think headlights). Then gaze becomes disconjugate giving you double vision. Both of these things make driving very dangerous. At the same time, ethanol makes you “stupid”. You may choose to “follow” the taillights of a parked car. You lose inhibitions, increasing the likelihood of risk taking and making “bad” choices.

This stuff can lead to your death or the death of others. A developing adolescent brain bathed in ethanol is a recipe for death and disaster.

Driving is risky

I’m working on a brief talk I am going to be doing at a public forum next Monday about the effects of alcohol on the adolescent brain. While underaged drinking is a serious problem, and car crashes and deaths caused by drunk drivers is a serious problem (prompting the forum) they are not the “only” problem.

A bit less than 25% of teens killed in car crashes (compared to a bit over 25% of adults killed in car crashes) involve drunk drivers. Serious, yes, but again not the only problem. The Chicago Tribune yesterday ran a story (part of an ongoing, episodic series on teen drivers, their problems and deaths) pertinent to the point that drunk driving is not the only problem.

There are nearly as many fatal crashes involving 16 and 17 year olds that occur between 3 to 5 pm Monday through Friday as there are fatal crashes between 9 pm to 2 am Friday and Saturday nights. The latter more likely having a contribution from alcohol consumption. (National Highway Administration data via AAA via Tribune)

So while it does seem to make sense to focus on the toll of drunk drivers and easier to get folks fired up about drunk drivers killing with their cars, we must also look at the bigger picture. We must work to decrease all car crashes, from all causes. The media used to talk about the carnage on our roads and we ought to keep that in mind and work in a multi-pronged fashion to limit all car crash deaths.

Demand quality medical care

“Missed diagnoses, incorrect drug dosing, failure to treat promptly”. “100,000 Americans die annually from medical errors”.

As I have mentioned in regards to the “Vance case”, it was the system that failed her, that resulted in her death. We must fix the system to prevent similar deaths in the future. I got 4 more emails decrying the quality of care received by Ms Vance and the care the authors of the emails had received at various places across the country.

There is hope and some of the hope inducing programs are highlighted in a recent Newsweek series. Programs like “Medically Induced Trauma Support Services” that provides support to anyone involved in a “medical misadventure”. The “Executive Walk-Rounds” that occur at Brigham and Women’s Hospital that ensure administrators are abreast of hospital problems, errors and potential errors and that “patient-safety officers” intervene early and remedy the situations. The “Hopkins (Johns Hopkins Medical Center) Center for Innovation in Quality Patient Care” and their “Comprehensive Unit-based Safety Program” exist to head off problems or intervene quickly so they are not repeated. The “100,000 Lives Campaign” to decrease medical errors and preventable problems using proven protocols across the nation.

We deserve quality care in every hospital in our country and in every episode of medical care. As is pointed out in the series the “old” philosophy was to “accept” a certain error rate, just as manufacturing accepts/expects a certain defect rate in their products, but we must be about “striving for perfection” in healthcare in this country. Will we ever be perfect? No, but we must strive and accept no less a goal. “…doctors, nurses, pharmacists and technicians will always make mistakes—it’s the safety net around them that needs to be fixed”. “…we have to put systems in place that stop that error from causing harm”.

"Woman's Heart Attack Death Ruled a Homicide"

I got 67 emails last Thursday from all over the US after a link was placed on the WomenHeart website about a recent death here in Lake County and the inquest jury’s verdict. The death was of a 49 year old female who presented to a local ER with 10 out of 10 chest pain, shortness of breath and nausea. She died waiting in the waiting room, 10-20 feet from the care she needed to interrupt her heart attack. The jury came back with a verdict of “homicide”. It was the jury’s feeling, and certainly mine, that this case demands a change, an improvement, in the system that allowed this woman to die on a couch in a waiting room after a 2 hour wait. The emails I received reinforced that opinion.

Many wrote of their experiences of having symptoms “ignored”, and having heart damage as a result. Many felt they were ignored because they were woman. At least one added minority status as a contributor to lack of treatment.

Our country should not have a healthcare system that fails so many in our “community”. It is obviously a system problem and it must be addressed before it kills again. No one should “hang” for this death or any individual death that is a result of a system problem, but we must call attention to the problem that is killing folks. We must demand change. We must demand quality healthcare. Individual malpractice suits are not affecting the system, so we must find other ways to bring this discussion to the fore.

Demand quality. Don’t let people die waiting for, asking for, care.

No typical days

What is your typical day like? I have no typical days.

Last Friday (my birthday, by the way) began with a 2 hour meeting of the regional Child Death Review Team, of which I am a member. We discussed 3 child death cases in the region and whether anything could have been done prior to them to prevent the death or if something could be done in the future to prevent similar deaths. Quite often these can be disheartening discussions, because nothing could have been done to prevent these deaths or can be done to prevent similar deaths. However, sometimes there is that ray of hope/possibility and we make our recommendations for education (public or otherwise) or policy changes. We always hope that we can impact some child and prevent (forestall) their untimely death.

After the meeting I went into Chicago to get the dental records we used later in the day to positively identify an individual who died by train, a suicide. Identification is critical in “our line of work” and it was worth the trip to be sure we knew who the decedent was, no guessing or surmising. The drive gave me time to ponder the imponderability of death. As someone once said, “death is as much a part of our life as the air that we breathe”.

Today my Senior Deputy and I went to notify a family that their son had died this morning in an auto crash. Always a “raw” experience, never are 2 notifications the same. Sons aren’t supposed to die before their parents. A “great tragedy” has happened to those fine folks. It is also a “raw” moment for your heart, but you have to have the feeling or the notifications get too rote and hollow.

I never have a typical day and death is indeed imponderable.

"Local Outreach to Suicide Survivors"

Lake County Suicide Prevention Task Force meeting today.

One of the topics we discussed (there were many) was my wanting to start a “first responders” program for family and friends surviving someone who died by suicide (called “survivors” in this field) here in Lake County. This sort of program has come up in 2 discussions with different individuals of late (about 2 different programs). It is time to move beyond the coincidence and act to get it started here.

One such program (one also thought of as a prototype) exists in Baton Rouge. A small team of trained suicide survivors and Baton Rouge Crisis Intervention Center staff go to the scene of suicide to provide information about available resources and “to be a breath of hope for the grieving survivors”. The goal is to let the survivors know that there are resources (and hope) available as soon after the death occurs as feasible.

The hope is that getting the survivors tied into help as soon as possible will ensure that they receive all of the benefit that such help can provide with grieving, adapting, moving forward, and surviving themselves.

I look forward to being able to provide this service here in Lake County.

Alcohol killing kids

I learned at a meeting this morning that the IL Liquor Commission is running a pilot program to better hold accountable folks who provide alcohol to those less than 21 years of age. I hope it works well so that they will be able to roll it out state-wide in the not too distant future. The program called TrAIL (Tracking Alcohol in IL) consists of investigations triggered when underage drinking is “suspected in an incident that results in serious consequences”. This would include car crashes, treated alcohol overdose, and the like. Bringing in a specific investigator immediately after a triggering event will improve investigative success in tracing the source of the alcohol and allow for prosecution as indicated.

As we discussed at our meeting, to really be able to decrease underage drinking (and its attendant problems like death and date rape) we need to impact “social norms”. It can’t continue to be “OK” for underage individuals to have access to alcohol either from retail outlets (a more easily controllable source) or from “social” sources (parents, friends, etc). We can’t continue to allow kids to die having a “good time”.

Be aware of Depression

A mailing I got today informed me that October is Depression Awareness Month. "Clinical" Depression can be characterized by:

1) Loss of interest in or ability to feel pleasure (no more WOW moments) with the intensity of the feelings interfering with eating, sleeping, and other usual activities (including sex). There are intense negative feelings, particualrly about yourself.
2) "Clinical" Depression lasts all day, every day for at least 2 weeks, the individual experiences it as an indefinite, possibly infinite, time sensation.
3) "Clinical" Depression is so significant that it impairs functioning- socially, occupationally, academically, and/or with home life.

Depression can be treated, but the individual must seek help and get help. They may need your help to do that or you may need someone's help doing that. Don't let depression kill, seek help.

Teach that others matter

Another important “tool” kids (and adults) need is the knowledge that “others matter” and the ability to act accordingly. I think this starts quite young when kids learn to share and to consider others in addition to themselves.

If this could be inculcated in everyone I think it would go a long way to preventing violence and/or limiting its severity. It seems to me that the lack of the realization that “others matter” is often at the root of violent action. It is more difficult to act violently toward another if you think of them as someone with worth, someone you might share something with. It is much easier to be violent toward someone you see strictly as “them”, particularly as a “them” divorced from your experience and with no personal worth or value.

This “others matter” most often needs to be a personal social experience, but can be generalized to more “others” from even limited experience. It is not something that can be acquired vicariously over the Internet or through some other media source, unless preset with some experience of “others”. For this we need some personal experience, we need to teach kids (and have them experience) how to act with others, that others matter and that it is good to share.

MySpace demon

I attended a meeting of the 19th Circuit Court Family Coordinating Council yesterday (minor peeve: organization names that sound like they support that which they exist to prevent/eradicate). In addition to updating us about what the various committees are doing, we had a discussion on possible symposium topics.

Part of the discussion centered around the “tools” parents need to raise their children “safe”, but in thinking about it I think that there is a greater need for “tools” kids need to grow up “safe”. Granted there would be considerable overlap, but unless we target the information at kids it may not get to them and they might not listen to it if it does. Targeting this toward kids certainly makes sense in the context of family violence in its many forms (along with ineffectual parenting and other parenting problems, which exist for a variety of reasons). Society has changed (in case you missed it or are too young to have seen the before) and I don’t mean from the artificial “Leave It To Beaver” world people mistakenly think existed in the past. But I do agree with one of the other folks at the meeting who said kids lack people to talk to, confide in, and get decent information and advice from (particularly in the setting of family violence, e.g. spouse/partner violence or child abuse in its many forms).

People tend to demonize the Internet and social networking sites in particular, but the reality is that we are becoming more Internet centered. Is the Internet an asset (my position) or a “trap” where predators lurk at every turn? I think it can help remedy a fair share of the social isolation we experience today (although real human contact is essential and can not be replaced), particularly kids from “problem” homes or those with other “reasons” for their isolation. Kids need others to talk to, even if they have the most ideal parents. They need peers and mentors to learn not to take risks, not to make bad choices, and to learn alternatives to those actions (or inactions). We need to teach kids how to use the social networking sites, and other Internet resources, while at the same time patrolling them just as we do our streets and malls to make certain that they are safe places. Used properly these sites can be sources of support, good information, socialization, and “life skills” learning.

Don’t ban these sites, make sure that they live up to their potential and make sure kids know how to use them “properly”. Making good choices and not take chances extends to the cyber-world as well.

What other “tools” do kids and/or parents need? Let me think…

Resource "work"

The queries I get are at times “unusual”.

Recently, someone wanted to do an art project that “works from its own power” and wanted information about whether a “closed system” of decomposition would fill that bill. He wanted to tap “(non-human) after-life processes” as “energy” to drive something that would satisfy the project goals/requirements. Interesting concept (although likely quite odiferous).

Another: Someone with a Hollywood telephone exchange (are they still called that?) looking for answers to questions about autopsy findings in a mummified corpse. Without giving too much away, there are modern ways to mummify that the Ancient Egyptians likely never even thought of. (And, yes, I told her I had a niggling fear that I was going to read about this in the papers someday, although she assures me she is a writer)

It is fun thinking through these things. I often critique TV shows and movies (burdening my wife with having to listen to my ranting/rambling while trying to watch the show), so I might as well think up some of this stuff without a show on in front of me. I see it as focused imagination with some talent for “writing”, although a different phrase actually came to mind as I was typing this, i.e. Mental [activity not for general audiences].

Remember those that are dying and being wounded in Iraq

At least part of the reason that my father took his own life in 1971 was 2 stints in Vietnam (he was an Army "lifer"). I see too many echos of his likely thoughts in some of those that have served in Iraq. This diary post really got me today.

Each day when I go to my computer the first thing I do is go to the Iraq war casualties website and check on the numbers of soldiers killed and wounded in action and the numbers of Iraqi's killed. Today those numbers were 2,732 soldiers killed in action, 19,910 soldiers wounded in action and 43,546 - 48,343 Iraqi's killed. Day in and day out the numbers go up and up and as they do I ask myself that eternal question, why?
· SGT MAJOR MYERS's diary :: ::
·
It seems to me that in almost all of my posts I write these numbers and even though I have no definitive answer as to why they are dying I do have an answer as to why I write the numbers. I do this in hopes that someone will - really - understand what these numbers mean. That, that someone will "get it", and repeat it and then another someone will understand and then another and still another and finally the 300 million people that are estimated to be breathing in this country this month will all understand. That they will understand that with each of these deaths a piece of us dies and with each of these wounds we are wounded and it is only they who can stop the killing and maiming.
To that someone who might be listening let me share this with you. Regardless of the circumstances; "justly" or "unjustly" the taking of a human life is an act that never leaves you. Knowing that you were personally responsible for taking a human life leaves an eternal, deep, and painful scar on your soul; at least I believe that if you are human it does. Let me share one other thing. The eyes are indeed windows into the soul and I know that when I look at the faces and into the eyes of those who are orchestrating the war in Iraq I do not see scarred souls but instead I see the soulless ice of those who do not care.
Each day as I look at my newspaper it is not the reality of stories of dying soldiers and civilians I see spread across the page but the sad soap opera that is our administration in Washington D.C. It is stories of corruption, graft, and moral bankruptcy that I see and then, even further back after the ads for cars and furniture and every other consumable good, I see the lone article with the number of lives given and taken, buried in the pages of tomorrows fish wrap, without ceremony or homage and before their bodies have hardly grown cold.

End Child Abuse, part 2

Just a few more things about child abuse from the article and talk I mentioned yesterday.

Even though the “most common age at which (child) sexual abuse begins is three”, the average age of victims who get to court is 10, with a median of 13. This occurs because we don’t “find” the cases as early as we ought and because of the general inability and/or unwillingness to work with children at the young age at which we should “work” with them. The current system is failing these kids. It must be fixed.

Despite the fact that child abuse and neglect is a “public health epidemic” we, as a society, do not invest the resources we should to address it. The toll on individuals and on society is huge, but our efforts are limited. Despite the fact that the rate of child abuse is 10 times greater than the rate of cancer, “federal research dollars invested is 5 cents for every $100 of societal cost associated with child abuse whereas we invest $2 for every $100 of societal cost associated with cancer”.

We need a systemic, coordinated national effort to end (or nearly eradicate) child abuse and neglect in our country. We need to support efforts to do that.

End Child Abuse in 20 years

I was reading an article written by an individual (Victor Vieth of the National Center for Prosecution of Child Abuse) that lectured at the Child Death Review Team symposium that I attended recently. As someone said that I shared a copy with: “an interesting read”. I thought I’d throw a couple of things from the article into my blog.

His is a plan to end child abuse in the United States within 120 years. Seems like a long time, but it is a huge problem. The timeline is laid out so that during the first 40 years everyone responsible for every step of finding, reporting, treating, prosecuting every child abuse incident is fully trained and working in a system that functions as it should. Also the next generations of these individuals are trained, ready to be trained and committed to the fight. Over the next 80 years child abuse is ended. He admits that it won’t all go away, but by and large it will be gone from our society. It is a multigenerational problem and will require a multigenerational attack and solution.

I wish him and his plan well and all success. It has got to happen, the toll is too great.

In case you are uncertain about the problem, beyond the shear scope of the problem, the numbers of the abused, two facts stand out. First: “only 40% of abuse cases and 35% of the most serious cases known to professionals mandated to report were in fact reported”. “65% of social workers, 53% of physicians and 58% of physician assistants were not reporting cases of suspected abuse”. “There were several reasons why mandated reporters do not report”. (None seem all that “good” to me) Second: “the large volume of children whose allegations are either not investigated or that result in CPS (Child Protective services) finding of “unsubstantiated” are just as likely to be victims of abuse (later on) as are those children whose allegations are substantiated”.

The system isn’t working. It isn’t working for the kids. It isn’t working for our society. This plan from the National Child Protection Training Center sounds like the way to go. We can end child abuse within 120 years. I am sorry that I won’t see that eventuality, but I will do what I can to get us moving in that direction.

Teen driven program on teen driving

I am certain that crash reenactments don’t work to keep kids from dying in car crashes. (We do them because the adults involved feel like they are “doing something”.) I am pretty certain that trying to scare kids into behaving “right” (driving right, not doing drugs, etc.) doesn’t work. I keep looking for something that works. I don’t want to do nothing and I don’t want to “just do something”. I want to do something that works, that is proven to be effective. That is where we should spend our time and energy. That is how we are going to save lives.

Sunday’s Trib had an article about an approach that likely will work. It is a program designed and driven by teens that encourages “smart driving”. It “encourages them to preserve their lives…and to speak up when they feel uncomfortable with their friends driving habits”. “What we learned in our research is teens don't aspire to be safe drivers because being a safe driver isn't cool”.

You have to get teens’ attention at their “level”, where they will “identify” with what is being done/”pushed” and “take it” as their own. The programs for change must be “teen-led”. Then and only then will you change behavior. We must do this so that they take fewer chances and make the “right” choices. Then we will save lives and forestall death.

Reality of emotion

I was working on an essay recently about “what is reality”. I didn’t quite get done with that when comments from 2 meetings collided with those thoughts. Yesterday I was at an “Assessing and Managing Suicide Risk Conference” that I and my Suicide Prevention Task Force catalyzed. This morning myself and another speaker talked with our County State’s Attorney folks about sexual abuse (I have been doing child sexual abuse evidentiary exams as a volunteer physician for 6 years) and rape.

A similar point came up at each of the meetings: As a survivor of someone who has died by suicide “you will never be the same again, but you can survive and even go beyond just surviving” and as a survivor of rape (or sexual assault) “you will never be the same” again. You will feel overwhelmed by the intensity of your feelings. You will feel anger, guilt, confusion, forgetfulness. These things are true in both instances. That is reality. Emotions are reality, but you can survive “and even go beyond just surviving”.

I had been writing that people were reality. That people are “messy”. They have strings attached and connections and connotations. They are “funny”. They incite thoughts and words. They have baggage. They are what they are, reality. But as I thought through the things that came up at these meetings, I have decided that these statements pertain to emotions just as much as to people. I think I lack the “words” to write about emotions, particularly the emotions that are dredged up by the “experiences” I discussed at my 2 meetings.

“Reality, what a concept.” (Robin Williams)

Foods you shouldn't eat

Ripped from Eric Zorn.

Cute?
Foods you shouldn't eat.

Failure of "Reefer Madness"

Our government tries to be “creative”. The White House Office of National Drug Control Policy (I think their name needs a bit of work) has put anti-drug use videos on the internet where kids may come a cross them in the hope that it will decrease drug use. As a Trib editorial put it, that is like “leaving those sex ed pamphlets on Junior’s dresser instead of bringing up the subject at the dinner table”. Passive persuasion, nice thought but not likely to be effective.

The GAO (Government Accountability Office) pointed out recently that “we” have spent $1.2 billion on anti-drug use advertising over the last 8 years without decreasing drug use among teens. They also found that while teens that saw the ads remembered the message, they were not dissuaded from using drugs. Well, that ain’t working.

We ought to spend that money to find out what works, without a preconceived agenda. What we’re doing now isn’t working. Something different needs to be done to lower drug use (licit and illicit) among teens, it remains a huge killer of teens and young adults in my jurisdiction. Whatever “it” is, I know it will have to be active and honest, relevant to the teens and young adults, it will need to get their attention over the societal din, and give them real reasons to quit and, most importantly, not to start.

I wish I knew what “it” was, but I do know that “Reefer Madness” and its ilk doesn’t work.

Underused cure for drug OD

There was a couple of interesting editorials in the Chicago Tribune yesterday (not that they weren’t all interesting, but I’ll comment on these 2, on different days).

I was discussing some “work things” with a colleague and she said the “real role” of the Coroner is to try and put themselves out of business by eliminating the business (not that that will ever happen). I certainly agree that my primary goal is to forestall death. To that point Steve Chapman had an editorial in the Trib making a point with which I heartily agree.

Naloxone should be available on the street to prevent/treat heroin overdose.

One way to prevent people from overdosing is to stop them from using drugs. But as smokers have demonstrated, knowing you should quit and actually quitting are two different things…
Abstinence is best, but when it's not universal, other remedies are needed…
But it's entirely feasible for governments to proselytize against drug use while trying to keep drug users alive, just as we preach against tobacco while providing medical care to smokers stricken by emphysema…

Naloxone will not only save lives, but by being able to rapidly treat overdoses it will also decrease short-term (ER) medical costs and long-term medical costs (treatment of anoxic encephalopathy and the like from not-so-quick “saves”).

I applaud the efforts of Dan Bigg and the Chicago Recovery Alliance bringing care to the streets. Also, the efforts of Senator Dick Durbin to get federal legislation in place for overdose treatment effort support.

I’ll take all the help I can get in forestalling death.

Make good choices and don’t take chances first of all; prevention is always better than treatment, but treatment needs to be available as well.

Another Medical Misadventure/Quality Issue

I came across an interesting blog post. While this was posted in response to the babies who died in Indiana because of an error in heparin dosing (11 doses were given among the babies, so not a singular event), the last section of the post pertains to our case that I wrote about a couple of days ago.

So what happens now?
The quality assurance department in the hospital will perform a root cause analysis to investigate all components of the extant procedure for medication delivery of heparin to infants in the neonatal intensive care unit. AIt will interview the pharmacists, physicians, pharmacy technicians, nurses and any other staff memebers invovled in the process at any point.
It will attempt to find weaknesses in the process, weaknesses in the education of the staff, reasons for noncompliance with the policy and procedure to administer medications, and then it will make receommendations to hospital committees charged with determining the policy and procedure for medication administration of this type.
Outside agencies will also become involved. The two infants that died will be under the jurisdiction of the coroner to determine the cause of death and contributing factors, and to refer the cases to law enforcement if there is suspician of criminal intent or action.
The state department of public health may become involved to investigate safe drug handling and administration practices.
The cases may go to litigation.
The nurses are most likely devastated and should be supported and be receiving counseling.
Their nursing licenses may be investigated, and if found negligent, the licenses may be suspended, revoked or be placed under restrictions or sanctions.
The national hospital accrediting body, the Joint Commission for Accreditation of Healthcare Organizations, JCAHO, will include the incident, investigation and subsequent actions to address the weaknesses in the policy and procedure in its routine survey to dtermine accreditation status.
But in the end, it boils down to nurses not taking shortcuts, nurses safeguarding patients, and nurses standing up for patients' rights in the face of poor work practices, poor working conditions and inadequate resources.

Underage Drinking Prevention

At an Underage Drinking Prevention Committee meeting this morning we looked at some local statistics. These were obtained by anonymous survey of local school kids. Are they factual (did the kids tell the truth)? It would be impossible to know, but they look “coherent” enough to be legitimate. I would assume that they are truthful.

Asked about consuming alcohol within the last 30 days 6% of 6th graders said yes, as did 18% of 8th graders, 36% of 10th graders, and 56% of 12th graders.

These results are concerning and saddening. We discussed reasons that we ought to work to decrease the numbers of kids drinking and work to delay the start of drinking in these kids. That discussion was held because while it is “good” to do those things, we need something a bit more ‘concrete’ to “sell” efforts and programs. It pretty much boils down to the facts that if we can do those things we will save a few lives and we will decrease the risky behaviors associated with alcohol consumption (e.g. remembering that alcohol is the # 1 date rape drug). Alcohol does make you stupid.

How can we bring these numbers down? What programs work? That is the target of future work (and no “just say no” doesn’t work).

Hospital Homicide II

The homicide verdict is not an attempt to destroy a hospital or all ERs (as one emailer suggested), but the honest verdict of a jury of 6 that there was a “gross deviation from the standard of care” and that the inaction in this case was “reckless”. By our definitions of manner of death that is “homicide” (again recall that does not mean criminal homicide).

This case and its publicity should prompt system change, locally and nationally. The system failed at Vista East. This 49 y/o did not get the care and treatment she deserved, because the system failed. This is a quality of care issue. The quality of care Ms Vance received was sub-standard (to say the least). I’m not attempting to point fingers or get anyone charged or convicted of homicide (although by our definition this death is a homicide). I want the system (Vista’s and everywhere that it is wanting) and the quality improved. I think there should be outside oversight to ensure their system is changed and, once changed, that it is maintained (this oversight should occur everywhere there are these system, quality problems).

This is a social justice, a greater good issue. No one should have to die like Ms Vance did, feet from life-saving treatment. The quality of medical care must be improved. No more excuses about an overburdened system. Develop systems (quality) to ensure this never happens again.
When I ran for office, I pledged to also investigate “medical misadventures”. Just as our office obviously is there to serve decedents who can no longer serve themselves, just as much we are here to protect the living residents of Lake County and to forestall death when we can1

Hospital Homicide?

Waukegan waiting room death a homicide, jury rules

”Reckless behavior is one of those things that stands out in the coroner’s definition of homicide,” Keller said. “The underlying feeling of the jury is that a reckless act resulted in this woman’s death.”

In an unprecedented move, a Lake County coroner's jury Thursday ruled the death of a Waukegan woman in the emergency room of Vista East Medical Center in Waukegan a homicide.


The definition that I give to the Coroner’s Jury during their instructions regarding what constitutes a homicide:

A death that occurs because of an intentional or reckless act by another person. A person is reckless or is acting recklessly when he or she consciously disregards a substantial and unjustifiable risk of another’s death from their action or when their action (or inaction) demonstrates a gross deviation from the “standard of care”, which a reasonable person would exercise in a similar situation (the latter does not only refer to “medical care”, but to the usual “care” an individual would take in a similar situation).

Coroner’s Juries decide on the manner of death, keeping in mind that “this is neither a civil nor a criminal trial procedure, merely an inquest regarding the death of this individual” (further Jury instructions). Their decisions do not signify criminal findings or intent on anyone’s part, that is left up to the State’s Attorney and/or the Courts.

Yesterday's Coroner Jury felt that the hosptial was reckless in their behavior pertaining to this 49 year old woman's death and found the manner of death to be "homicide". Two hours in the ER waiting room with the complaint of 10 out of 10 crushing substernal chest pain, with diaphoresis and nausea, triaged but not treated, "a gross deviation from the standard of care" (caring?).

We, today, have filed reports referring this individual's death to the Lake County State’s Attorney’s Office, the Joint Commission on Accreditation of Healthcare Organizations, and the Illinois Department of Public Health. Further action is up to them, although I would recommend an advisory panel be established (with local resident involvement) to oversee changes that will no doubt be made at the hospital.

Overlaying death

Another death by “overlaying” in our county; I’d say tragic; but so are all infant deaths. Overlaying, as a cause of death, likely far outnumbers the number of SIDS deaths, but it is another one of the causes of death not often heard of or talked about.

Overlaying is caused by an adult (or larger child) rolling over onto an infant while they are sleeping together. The exact mechanism of death may be obstruction of breathing, circulatory impairment, or both. Closely related to overlaying is “wedging”, in which the infant becomes wedged between objects resulting in inability for the chest to move for breathing or in airway obstruction. We’ve seen too many of these as well. Considering the paucity of physical findings, the diagnosis of these causes of death depends heavily on a thorough death investigation, including death scene investigation.

In these cases the adult’s (or child’s) grief is compounded by the guilt of having contributed to the death of the infant.

Infants should not share the “family bed” (or other shared sleeping arrangements). They should sleep alone on a “firm” surface without fluffy bedding or pillows. And remember “back to sleep”.

Family and "pono"

Just a little bit of a twist on the positive effects of family dinner on the behavior of teens and children.

I have been doing some reading (I do make time) about aboriginal (in its broad sense) healing and wellness. In most “native” cultures healing is a communal event. The more people you bring together at the healing ceremony (particularly if they are family) the more effective it tends to be.

I think there is a real community/family effect to healing (also think of this word in its broadest sense). Maybe this is one of the things that also affects folks when they come together for family meals. There has to be something, because the positive effects of the meals occur even if there isn’t “lecturing” about doing the right things and behaving the “right” way.

Just the “being” with family (supportive people, if you don’t have “real family”) has a positive effect. Maybe that can be enough to teach kids and teens to be “right with themselves” (pono in Hawaiian, told you I’ve been reading) and to “value themselves” so that they don’t take chances and don’t make “bad” choices (or be at least one positive influence). [Disclaimer: there are no absolutes in this world, you can only do what you can do]

Death Thoughts

Ah, the end of another week. Except they don’t really end, they just flow on. Weekend, weekday, the Coroner’s business flows on. The only difference is I’m not in the office very much on the week ends. Like the old joke so many folks like to tell me: “They’re just dying to meet you”.

This week the young died when they ought not to have. The old died when they also ought not to have. Some died and their release was a relief. Others died with a flood of grief. But some died when it was time.

I didn’t set out to make this maudlin or poetic; sometimes the words just flow too. People die for so many reasons, in so many ways, and each death has their own story. The stories can be interesting and enthralling. The stories can be obvious or require work to get at and to sort out.

Death is natural and unnatural, but we will all end up there eventually. It is my wish for you and yours (and everybody else) that that occurs no sooner than it must. That you all may grow old enough and get enough done, that you may shuffle off this mortal coil without regrets and prepared for the journey.

Enjoy the ride.

Asthma Kills

Asthma kills, as I was again reminded recently. Nearly 5000 people die each year in this country from asthma; in another group equally as big, asthma is a contributor to their death. Although most people who die from asthma are over 50 years old, over the last 20 years there has been an 80% increase in the death rate among children and teens with asthma.

Asthma is a common disease. It is one of the leading causes of school absenteeism (and work absenteeism in adults). It is also a frequent cause of ER visits. The disease can be exacerbated by certain activities (e.g. sports participation), certain conditions (e.g. cold air), but it can strike anytime and can strike without apparent trigger.

Asthma is characterized by bronchiolar constriction/spasm and mucous thickening and plugging (with blocking of bronchioles). The latter condition is the most lethal and the most difficult to treat.

How do we prevent these deaths? This is a bit tougher than some of the other causes, but individuals need to have access to medical care and be assured (ensured) that they are receiving optimal care based on the most up-to-date treatment guidelines. People need to also be aware just how deadly this disease can be. We won’t prevent them all, but some deaths will then be prevented. All people must have access to quality medical care, or we must accept the consequences (people will die).

I'm your parent, not your friend

A conversation started just before the underage drinking prevention group meeting I attended about a week ago that reinforced an opinion I hold strongly. Two of the folks were talking about talks that they had had with their kids: that they were the parent and not a “friend”. I had a similar talk with my 16 year old not too long ago.

I think we do our kids a disservice when we, as parents, try so hard to be friends with our kids. That is what they have friends for. I am there to lay down the law, teach moral and proper social behavior and to punish when they stray from the rules. I believe this is how to model, mold and develop an individual who will grow up to be a “good” part of the community and will have the best chance possible to grow up and grow old.

That’s not to say we can have fun together and laugh and enjoy being together. That’s part of being a parent (and a family), too. But, at the same time, I am not their equal. I am the parent and they are the kid.

How can you tell your child not to make bad choices and not to take chances if you don’t teach them “right from wrong” in regards to chances and choices? If your goal is to be a friend how can you lay down the law, enforce the law, and teach them “right from wrong” choices and chances. I feel I have done my job as a parent if my child is mad at me from time to time because of corrective measures I enforce. A good parent uses reward and punishment to mold behavior. Someone always focused on being a friend loses the authority to parent and punish. My kids are the better for my working as a parent instead of my being another one of their buddies.

More Nicotine in Cigarettes

I will have another “parenting” post regarding something else that came up at the underage drinking prevention meeting that prompted the last 2 posts, but I wanted to mention this news report before it got too “stale”.

It seems that, just perhaps, cigarette makers are adding or otherwise jazzing the nicotine content in their cigarettes. Nicotine is the reason folks get hooked and/or can’t quit smoking, just behind the psychological addiction. It appears that, according to a Massachusetts Department of Health study, the nicotine level in cigarettes has been rising steadily over the last 6 years. And don’t think the ultra-lights are “safer”; the nicotine levels went up in all cigarette “strengths”.

This made only a small news splash when it should have prompted screaming headlines: “Cigarette Makers Jazzing Coffin Nails” or something equally shrill. They get away with admitting the health risks of their product while at the same time making them more addictive. That seems to me to go beyond their statements of innocence; that they warn folks not to smoke, so they are not liable for their resultant health problems and deaths.

Hook them in faster and stronger. Make them customers for life (no matter that that life is shortened after hooking them in). Smoke and die young (though not a pleasant death most of the time).