Death by Lack of Insurance

I was pulling together some material for I talk on health issues that I'm giving tomorrow evening and ran across a factoid that I had seen before. It pertains to my "previous life" as founder and CEO of the free medical clinic in Waukegan, as well as my "present life" as Lake County Coroner.

According to information from the Institute of Medicine, adults without health insurance have death rates 25% greater than adults with private insurance. They attribute 18,000 deaths in 2000 to the lack of health insurance. The uninsured, almost daily, must make choices/decisions, do I see someone about my health/how I am feeling or do I pay my other bills, my rent or mortgage? Even those individuals without heath insurance who are lucky enough to have access to medical care often have other decisions to make. Should I fill my prescriptions (which for a diabetic with high blood pressure can easily be $400 a month) or can I stretch my medications by taking them every other or every third day?

Not seeking medical care when you need it and/or not getting the preventative care or health maintenance care you need is gambling with your health and life. Just as is not taking your meds that you need to maintain your health or not taking them as you ought. A number of these people gambling with their health lose their gamble and lose their life.

We as a society should not condone a system that makes it necessary for people to gamble with their health. We should not allow people to die because of their lack of health insurance limits their ability to access health care. Our healthcare system must be changed to become a more just system. The lack of health impairs our ability to maintain life and restricts our ability for the pursuit of happiness.

These deaths are preventable.

Critical Thinking

This will be a bit different.

Two things came together over the last few days.

I was looking at a website that bills itself as a resource for writers writing about forensics and medicine. The person has gotten books published, so one could imagine that he had the knowledge and credentials to write this stuff. But in reviewing his material I found errors and misinformation. I may or may not go over some of those errors in future posts.

That brings me to the other "thing". I was reading a commentary elsewhere on the Internet (isn't it fun to stumble across divergent things- possibly material for future posts). One of the main points of the commentary was that we, as a people, must become better at critical thinking. We have an abundance of information available to us, but are often unable to weigh the evidence and make rational decisions about the information we are presented with. Without filtering and "judging" the information we are inundated with we risk being overwhelmed and "programmed".

I don't think schools teach critical thinking anymore. (I know they don't dwell on current events and their impact) This is a profound disservice to kids who will be adults someday and will have to sift through the information and make decisions about it. But even we adults, dulled by the massage of TV and other media sources, are fast losing the ability as well. One of our main responsibilities as citizens, as consumers of media, and as decision makers (big and small decisions) is the ability to critically evaluate information literally thrown at us these days. I do it, to the point of angering my wife as a criticize media folks on TV and the radio continuously. If we don't think critically about all the information we have access to, with a little bit of doubting, we run the risk of believing and accepting that information at face value when it might not be worth the silicon it is written on.

Cause of Death

How do you arrive at the cause of death?

As I mentioned in a previous posts, by statute in Illinois the final decision of cause of death is up to the inquest jury. The testimony given in the inquest pretty well lays out the cause of death. Most of the decision making during jury deliberation pertains to the manner of death (accident, homicide, suicide, or undetermined). Natural deaths are decided without jury input.

Unless there is a very obvious cause of death, such as the individual’s head is no longer attached to their shoulders, arriving at a cause is like solving a mystery (indeed it is a mystery until it is solved). Each case is a bit different, but involves piecing together clues from a variety of sources with some cases needing more pieces to discern the cause.

We investigate the scene of the death on our own and in conjunction with other agencies, like police and fire. We interview family, friends and other “witnesses”, getting information regarding events surrounding the individual’s death, their history and other pertinent information. We talk to the individual’s health care provider, review their medical records and piece together their medical history.

We examine the decedent, looking for evidence of pre-existing medical/health problems and for evidence pertinent to their death. “Reading” an individual’s body for clues may include an autopsy, if it will provided needed information; opening them up and looking inside for clues to the cause of death. The autopsy is done by a specially trained and experienced Forensic Pathologist.

We do toxicology testing on a large number of individuals who have died, looking for the contribution of illicit drugs, medications and other toxins. We test blood and vitreous (eye) fluid, the body fluids most reflective of the state of the individual at and near the time of their death. Testing urine tells about the individual’s internal state a bit more remote from their death (hours to few days). Testing bile tells about what the decedent had consumed within a couple of weeks. Hair testing speaks to use/exposure within a 3 month time frame. (All approximate times)

Other tests are done as indicated based on other findings. We may do tests looking for indicators of disease processes, e.g. Diabetes Mellitus. We sometimes look at organs and tissues microscopically for clues and information. We may do other tests as well, for example testing the electrical conduction system in the heart looking for problems there.

At times we also do other things, testing and examinations, specific to an individual’s death, e.g. product safety testing.

After all the data is collected it is then the Coroner’s responsibility (along with my great staff) to arrive at a “cause” that can be presented to the jury for their consideration, deliberation. This is the time for synthesis, for building a case, for putting together the clues to solve the mystery of an individual’s death. This provides the challenge in a Coroner’s job/life (for it is the Coroner’s ultimate responsibility), it provides the “fun” in the job.

Murder Mystery

These posts seem to be a bit heavy lately, but I guess they will tend that way being a Coroner talking about death. But I wanted to write something to lighten up for a bit. As coincidence, serendipity or morphic fields would have it, I got a phone call. It was a local mystery writer who opened her conversation with “I have someone I need to kill today”.

I have gotten called by other writers as well (more than I would have guessed from Lake County). I have gotten procedural questions about death investigations, about Coroner policy and procedures, and about inquests. Most often, however, they want to know how to kill someone, so who better to call than your friendly neighborhood Coroner.

We discuss possibilities that fit in with the plot line and the story they are telling. What would be the right medicine or toxin to cause a death that might look natural or a toxin that would cause them to linger before dying as the story unfolds? What would a knife stuck in here injure to cause death? Fast or slow? The possibilities are nearly endless. If real people die from such a variety of causes with a different story behind them, the possibilities in fiction are legion. It is certainly a change in pace to have these discussions (alright I do enjoy them) and I do like a good mystery story.

But at the end of the call I get to thinking what if it isn’t a murder mystery writer or what if it is a murder mystery writer actually contemplating a real murder? That almost sounds like the premise for a mystery story itself…

Grief is crazy

There was a great commentary in the Chicago Tribune yesterday: The ‘crazy” thing about death.

In it the author asks “How does the human mind cope with the loss of a child? With the loss of a best friend?” Grief from such a loss never goes away. It may recede for a bit, but it is always there. You don’t get over it. You are “mostly alone” as you work to figure out “Why?”. Grief is work and can be a lifelong work. It does make you ‘crazy’.

I thought I was ‘over’ the grief from the loss of a loved one, until I spoke about the value of and my personal experience with hospice care at an event a few months ago. But the grief was still there and it boiled to the fore as I spoke. The emotion, the experience of loss made me a bit ‘crazy’ again.

As I know from personal experience and as has been reinforced by my professional experience, don’t expect others to get over a loss, to get over their grief. Help them, support them as they work through this life experience, but there is no “blueprint” It is an experience, a journey without an end. They will need to need to traverse the uncharted journey’s route. They will be changed, their life will be changed. They will be “crazy”; death is a “crazy” event. Accept and accommodate the craziness. But if the craziness becomes crippling, they will need professional help (help them get there). That is how you can help them, not with platitudes but with support.

Organ and Tissue Donation

To continue in this a “how the community can work to forestall/prevent death” vein (or is it stream of consciousness?), I got a thank you letter from Gift of Hope today. While we do what we can in aiding with organ donation, we participate most directly with that organization in their tissue donation program. Our facilities are used for the procurement procedure in obtaining the donated tissues from decedents for the benefit of the living. Did you know that “1 in 20 Americans will require tissue transplant some time in his or her life”? Corneas are obtained to assist with restoration of sight. Skin is used to assist with healing severely burned individuals. Bone is used to help someone whose broken bone needs help in healing. Heart valves can help with a leak that prevents the full expression of someone’s life. Last year Gift of Hope made 30,000 tissue transplants possible. So many things possible, so many good things done, so many living individuals impacted positively.

Tissue donations don’t necessarily prevent death, but it is a beneficial activity for the common good (the good of the community, for your fellow man/woman). We should all sign up to be organ and/or tissue donors.

Prevent Child Abuse Deaths

In yesterday’s note I mention that the community must step up, be educated and do something to prevent suicide deaths and attempts. I am a firm believer that the community has a role in so many issues (not to get political, but my campaign committee is even Community for Keller- the Coroner is an elected office). Most pertinent to this blog is the role the community plays in preventing and/or forestalling death. I bumped into another one today.

I was looking through the most recent Annual Report of the Illinois Child Death Review Team (I have just been appointed to the local regional Team) and came across a Team recommendation pertinent to community involvement in death prevention. It sounds like a great idea to me and I do/would heartily support it. The recommendation was that “DCFS (Dept of Child and Family Services) should do a community awareness campaign “If only one person had called the hotline, this child could be alive today””. Yes there are “mandatory reporters”, like doctors, nurses, police, teachers, etc, but I support the notion that everyone/anyone aware that a child is being abused or neglected ought to report that knowledge to the authorities. Even one child dying from abuse or neglect (or experiencing abuse or neglect) is one too many. For each one of us (as Scrooge came to realize) humankind is our business. We should, each one of us, work toward that purpose of making humankind and their preventable deaths our business, particularly those most in need of protection (those unable to protect themselves- young and old). In Illinois call 1 800 25 ABUSE (1 800 252 2873). Want more info? Prevent Child Abuse

Suicide Prevention Program II

As I said yesterday approximately 60 individuals succumb to suicide each year here in Lake County, IL. Nationwide someone dies of suicide every 18 minutes. There is a suicide attempt every minute. These are staggering numbers. Somebody ought to do something.

We work hard to prevent homicides and violence people commit against others, but we don’t seem to work very hard against suicide and violence people commit against themselves. It is not talked about much, you don’t read about it in the paper (yes, I read newspapers) or see or hear about it on the news. I get daily calls from the media looking for deaths that they should report on. They turn down information about individuals dying from suicide, unless it is done in public or it is sensational in some way or the local school releases that they will be working with the other students to “get over it”.

We need to talk about suicide if we are going to prevent suicide. We need to educate the community and increase awareness about suicide. We must decrease the stigma associated with suicide, with attempting suicide, with seeking help so that we do not attempt and/or succumb to suicide. We must promote social/community support for these individuals. We need to reinforce positive help seeking behavior. We need to make certain that there is someplace, someone, from which these individuals can get the help they need.

There are programs that have had success in suicide prevention. They can have cute acronyms, like ACT (Acknowledge, Care, Tell) or QPR (Question, Persuade, Refer), but they have much in common. To be successful we, the community, must recognize the signs and symptoms of suicidal ideation/planning and push individual (in a kind, empathetic but insistent way) to get help. Also, we must recognize and bridge the barriers to help seeking (social stigma, cultural beliefs and access to mental health services). This is a community health epidemic (pandemic?) that we the community must work to mitigate. We can do something.

Suicide Prevention Program start

I spent my day putting together an address list for a mailing inviting individuals to become a part of an effort to prevent deaths due to Suicide in Lake County. In calling one of the individuals they recounted how over the last few weeks their “path” had crossed so many others intimately touched by suicide that they had been talking about the experience just hours before I called. This is not coincidence.

Suicides in Lake County out number Homicides over 3 to 1. Each year 60 individuals in Lake County die of Suicide. Suicide affects all races and ethnicities, all socioeconomic groups, and individuals, from youths to seniors. For every Suicide, an estimated 8 to 10 lives are severely impacted. For every Suicide, an estimated 18 attempts have been made.

We will get a program going locally and once that is accomplished we plan to help others through the effort just as others will help with our efforts. Our work, and our solutions, must be local. However, there is work that has been done on a state level and in other locales that we can draw from, to help and guide us through our process. Our first meeting is mid-February.

Suicide is a preventable manner of death.

Intro to toxicology testing

Toxicology testing: checking body fluids for drugs (including alcohol) and other toxins (e.g. carbon monoxide).

Drugs and alcohol cause or contribute to a large percentage of the deaths we investigate. They are involved in accidental overdoses, suicides, vehicular related accidents (driver, passenger or pedestrian), or can kill in concert with other “pathology” (e.g. an overly sedated individual with sleep apnea can/will die). Drug-drug interactions can be even deadlier than the use of a single substance, e.g. the use of benzodiazepines (like Valium) is most often only deadly when combined with alcohol. We do toxicology testing on every decedent in whom drugs, alcohol and/or toxins could be a consideration. It is easier for us than some Coroner’s offices, because we have our own in-house toxicology lab.

We test various body fluids. Vitreous, the fluid inside the eyeball, gives an excellent reflection of what was bathing the brain at the time of death. Blood, the most considered body fluid for testing, gives important results, but does have some limitations. The finding of drugs and alcohol in blood most often are used as proof of impairment, depending on the level. A finding of cocaine in the blood reflects use within a couple hours of death, but because there are enzymes in blood cells that can continue to break down cocaine after death and even in the blood draw tube the level found in the blood may not reflect that at the time of death. Delta-9-THC in the blood reflects marijuana use within about an hour of death, while Carboxy THC can be found in the urine out to about a week depending on chronicity of use. The finding in urine does not reflect impairment. There is also a distribution problem with blood testing as the drug moves about the body and in and out of various body compartments. We also test bile in some individuals, but a finding here only tells us that the use has been with about the last 2-3 weeks.

This will serve as a bit of an introduction to tox testing that I will build on in the future.

Inquest Day

Today was inquest day. Inquests are jury trials run by the Coroner to determine an individual’s cause and manner of death, a practice going back to the time of King Richard in 1100. While they used to gather around the body of the deceased, we do it in county meeting room. Natural death cases don’t go to inquest, only unnatural deaths: homicide, suicide, accidents and undetermined manners of death. We have a jury of 6 individuals deliberating on the cause and manner of death of 8-9 decedents each inquest day. We do inquests twice monthly on Thursday. The jury’s decisions are based on testimony of my Deputies and our investigation, as well as the testimony of police and other agencies involved in the given case. Various deaths of individuals with different stories involved with each one of them.

Sometimes there can be lawyers attending trying to “practice” later court tactics, points of evidence, trying to get some bit of information not previously in the open.

These can be long tough days for everyone involved. It is hardest on the families that attend. They attend looking for some bit of information, at times still looking for answers of how their loved one died and why they died, also looking for closing that final chapter in a loved one’s life, getting all the work done and the final death certificate can be issued. At times the roiling emotions of the family reach the point of outburst, but can they be blamed? There a few more emotion laden occurrences in life.

The inquests can be hard on the jury members. They see and experience the emotions, they hear the often grim facts, these cases can often hit close to home for them. I have had jurors who realize ½ way through the day that they can listen to no more of this. I have even seen the Court Reporter nearly in tears, quite experienced/seasoned, but the emotional intensity can overwhelm.

Inquests in the Coroner “System” are an interesting system in keeping with its archaic roots, allowing community input into the decision of an individual’s cause and manner of death. Not necessarily the most “efficient” system, but functionally sound and basically a “good” way of getting it done.

Cocaine

An issue came up the other day (although not for the 1st time). Why do we almost never find “left-over” cocaine when we have someone die of a cocaine overdose? Sometimes it’s because someone else was there with the decedent (either also partying or just there) who has taken or “cleaned up” what remained. However, by far and away the main reason is that the individual who died used every bit they had before they died.

Cocaine is one of the most biologically wide-affecting drugs we use (probably 2nd only to Caffeine- my drug of choice). The drive to use or abuse is so intense; many individuals will only stop when they have no more of the drug available. It absolutely flagellates the pleasure centers in the brain, which is in addition to over-firing many of your brain and nerve cells and tightening all of your blood vessels (most lethally in your brain and heart).

Before you use cocaine because I mentioned it can cause pleasure, repeat this little poem that I have quoted for years:

Drugs (cocaine), they can thrill ya and they can kill ya,
They can make ya high and they can make ya die

I will return to the subject of cocaine in future posts. There is so much I can tell you about it and dying from it. I look forward to it.

It is the # 1 cause of drug-related death in Lake County, IL, as it is in much of the country.

I have a daughter just learning how to drive. I have sisters who years ago used to sneak out late at night to meet friends. As an ER Doc I took care of so many broken bodies.

It’s always tough when a child dies. It hits close to home. I can imagine how it hits the parents. It seems particularly tough (like they all aren’t tough) when it is a “child” who is past the “age of reason”, who feel they will live forever no matter what risk they take, who feel that death only comes to someone else, someone older than themselves.

I’ve done several pre-prom programs at local high schools stressing the dangers of drinking and driving, riding with someone who is driving drunk or stoned. But the bigger problem from my experience, particularly over the last few months, is driving with fear suspended, driving while thrill seeking, “jumping” hills, “jumping” railroad tracks, playing “Dukes of Hazard”.

16 year old kids are dying, 4 in the last couple of months. There have been others in the last year.

I can put the information out there. Parents can tell their children, warn their children. But is it enough? Can the truth, honest information, given to kids telling them that this behavior is risky, get these kids to stop? I do believe that they can be saved if they will stop and think. I believe that thinking can make them realize that this “driving” carries the risk of death and they can stay out of the car or get the driver to stop. But will it work for all of the kids? How do we really impact, stop, this thrill seeking behavior without regard to consequences?

There is a local group started after the death of Brett Karlin, http://www.brakesforbrett.com, killed in 2004 hill hopping in a car going 10 mph. But I do hesitate linking to their “teaching” website, because the latest crash deaths were near the same Cuba Rd where Brett died, http://www.flyingovercuba.com, and we can never know if there was a tie between the 2 crashes.

Nonetheless, it is imperative to give kids the information about the risk, about the fact that they can die. I discuss it with my daughter and will every time something like this happens. Driving has responsibilities. Cars are deadly weapons. Actions and behaviors have consequences. Kids die before they have done all they want to do, before they have done everything they, and their parents, had hoped they would do. We have to work to teach, to get the information to the kids, and then we have to hope and pray that they will pause and think, consider the consequences, make the right choices, and somebody won’t die.

We begin...

I get numerous requests from students (from all across the country and even 1 from Canada) for help with a homework assignment along the lines of “interviewing a Coroner” or “interview someone with an interesting job”. So, I thought I’d post some of the answers to those questions as an introduction to the job of a Coroner and as my 1st post to my new blog.

Describe an average day:
There is no routine; it all depends on the cases we are working on. I meet frequently with my Deputies to discuss cases, review casework and paperwork, go to death scenes to supervise/assist with our office investigations, attend an autopsy (3-5 per week), watch the budget, and meet with outside agencies (e.g. police, State’s Attorney) regarding cases. Also, my day doesn’t end, I am on-call 24/7 to participate in cases (either scene investigation or over the phone with my Deputies).

Some details of my job: Administrative: Running office with 12 employees and a $1 million budget; Investigative: participating in and supervising medicolegal death investigations to determine the cause and manner of death, conducting inquests; Educational/Preventative: programs to work toward forestalling death at local schools and the like (topics like drinking and driving, violence, etc.)

It can be tough work (babies die, some of the cases are gruesome and/or can be repugnant or repulsive) so it is not work for just anyone. It is tough sitting down and talking about the death of a loved one with families. It is hard not to take some of it home in your head sometimes, but you have to deal with it, you have to develop a positive/productive way of dealing with it or it will eat you up.

What is an inquest?
Inquests are trials to determine cause and manner of death based on the evidence presented in “unnatural death” cases as required by state statute. I, the coroner, sit as judge and “questioning attorney” with facts of the case and investigation presented to a jury of 6 for their deliberation. The cause can be any of a multitude of things, for example head injury as the result of an automobile crash. The manner is limited to 4 choices: homicide, suicide, accident, or undetermined. From their verdict the final death certificate is completed.

What do you like most about your job?
I do enjoy my job. It is fascinating work; everyone dies from such a variety of causes each with a different story, and many of the deaths can be used in some way to prevent/forestall someone else from dying. I particularly like getting out in public and teaching about death “prevention”, anti-drunk driving, anti-violence, pro-health, and the like.

What are the academic requirements for the job?
In Illinois the only requirements for Coroner (an elected position) is to be 18 and a registered voter. I am the 1st Physician in this office since the 1940’s. My Deputies, for the most part, have 2 year Associate Degrees in Criminal Justice or a Healthcare field. All my Deputies (as well as myself) go through specialized training after hire through St Louis University and other sources. As populations grow the numbers of deaths also grow necessitating increasing numbers of medicolegal death investigations and the personnel to do them. I am sure that there will be an ongoing increase in “demand” for more “sophistication”, training and education among these personnel.

Our Toxicology Analyst has a B.A. with specialized training in forensic toxicology and the use of the equipment we have. I should note that we are the only Coroner’s Office in Illinois with its own toxicology laboratory.

Why did you decide to become a coroner? What was its appeal to you?
It has been an evolutionary process from ER Medicine and taking care of one individual at a time through running a free medical clinic impacting many individuals to becoming Coroner where I am using the Public Health aspects of the job to impact a great many individuals in forestalling death through education, advocacy and program development (for example, we are currently working on a local suicide prevention program), in addition to working in the fascinating field of medicolegal death investigations.

Describe you most interesting case:
Last winter we had an individual who died outdoors and was found 6 weeks later. When he was found he was badly decomposed, odiferous and consumed by nature and maggots. We could only identify him because his distinctive tattoo had “survived”. To find his cause of death required deduction and reasoning among all the staff. We suspected he had died of cocaine intoxication (based on circumstances and his history), but there was no blood or other body fluid available for testing. So we used a blender on the colony of maggots that was where his brain should have been (long before the somewhat similar CSI episode). On testing the resultant mass (which looked a bit like a chocolate malt) in our toxicology laboratory, we found that he had indeed died from the use of cocaine. The maggots were positive for cocaine that they had acquired by consuming him.