Death Notifications, notific-ography

Eric Zorn had a post on his blog on March 29, 2006 (took me a while to get to read it) about the obsession “with accounts of tragedy notification”. As is often true, it is a great read.

He succinctly puts it:

I suppose the decent thing to do would be to avert one’s eyes from the intensely personal, searingly painful and utterly lifechanging scene. Yet not only do I always, always read on, but I find myself seeking out such scenes more than I do the moment-by-moment accounts of the tragedies themselves.

As I put in a comment I sent regarding his posting: “I do think it is a baser (or more basic) “appetite” than many folks are willing to admit. That doesn’t make it “bad” per se, but there is a strong desire for this “pure emotional pornography” (his phrase). It is a pervasive “appetite”, it does sell newspapers and other news media, and it sells movies and books. But dressing it up in higher reasoning isn’t much different than putting a pig in a pinafore. It is what it is, an attempt to vicariously experience someone else’s strong emotional moment, someone else’s painful experience.”

I do get questions “What’s like to make notification?” and comments “It must be terrible to have to tell the family”. The notifications are as Mr. Zorn states “drama in its most distilled form”. It is more emotionally raw from the inside than you can see from the outside. The emotion becomes palpable, “alive”. You hear of all the plans that were made, but won’t be fulfilled; all the plans not made because the time was shorter than they thought. These are “life changing” events for the deceased’s family and friends, as well as for those doing the notification. It makes them sound so clinical, so sterile, to call them notifications, but they are “messy” events, flowing as they will, drawing everyone in to an experience like no other. You don’t get used to them. You don’t get “better” at them. Each is different; you approach them with empathy and go with the flow.

If these “tragedy notifications” are on the “news” they are there for “entertainment”. My advice is to stick to the “emotional pornography” in fiction and historic non-fiction. Going after it happening today is too voyeuristic for my taste, my comfort. I’ve been there and it isn’t entertainment. But we are humans with our base “appetites” and someone will always be there to feed them.

Strategic Goals for Lake County Suicide Prevention Task Force

Let's see if this blog can be a useful tool as well: I would like your help. read these Goals and comment on how they can be improved, how work on each can be begun and/or done, or who might help in our efforts:


1) Education:

· Increase awareness of and competency in suicide prevention and treatment for first point-of-contact individuals/staff, education personnel, healthcare providers, clergy, healthcare providers, law enforcement, mental health professionals and social service personnel.

· Educate everyone, especially mental health personnel, healthcare providers, social service personnel, clergy, law enforcement personnel, and education personnel to ask about suicidal ideations and intentions.

· Increase public awareness that mental health care is a critical part of health care, along with reducing the stigma of seeking and/or receiving mental health care and the stigma of suicide

2) Access to care:

· Increase access to mental health care, including availability of care (outpatient and inpatient) and insurance coverage parity.

· Advocate for an accessible, comprehensive continuum of care for those at highest risk for suicide.

· Promote accessibility and utilization of suicide prevention services for victims of harassment and violence.

3) Encourage networks of relatives, friends, neighbors, and members of the faith community to decrease isolation, a high risk factor for suicide.

4) Improve collection and dissemination of suicide-related data.

5) Develop sustainable resources for implementing suicide prevention, intervention and post-intervention programs in Lake County and Illinois and evaluate their effectiveness.

Suicide: "Should I stay or should I go"

Is suicide a way of leaving the pain or is it an attempt to go someplace else? This may seem like a small semantic point, but it seems to me it would make a huge difference in trying to prevent suicide.

If suicide, I think in the more “classic” view, occurs because an individual has “run out of other choices” in how to deal with the pain (psychic and/or physical) they are experiencing, it would seem to be “easier” to deal with, prevent. With that sort of thought process behind it, the task would be to expand their choices or demonstrate to the individual that there are other choices in dealing with their life, their pain. While this likely would be difficult in many cases, it would be possible because their focus is already here and now.

If however, suicide is a choosing of a new way of being, a beginning of a journey to somewhere better, it would be much more difficult to address, to prevent. Their focus is “beyond”, not here. It would be difficult to convince an individual that the “next place” is not/may not be better. Again you would work to expand their options in the here and now, their reasons for staying, but you would be working to convince them that there isn’t a better way of being, at the same time, unless they “remake” the here and now into that way of being.

Granted they would be getting other issues addressed/worked on, as well, and likely medications to rebalance their neurotransmitter milieu, but the reasoning behind their choice of suicide would always be the 400 lb. elephant in the room.

More a rumination than anything, but I think pretty thought provoking, particularly as we go forward with work to put suicide prevention programs in place. Also worth thinking about if your life has been touched by suicide.

SIDS, SIUD

I had been planning to write about SIDS (more correctly SIUD, sudden infant unexplained death) and how to attempt to prevent its occurrence. That plan had come to mind a while back when the pacifier recommendation splashed in the media. As usual I was reminded of the topic with a few recent “events”. The American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome revisited and reissued (Nov. 2005) their recommendations to prevent this silent killer.

Their recommendations include:

Back to sleep. First recommended in 1992 and made into a campaign by NIH in 1994 seems to have contributed to a 50% reduction in SIDS deaths (I should also mention that the overall infant death rate decreased 27% over the same time period, so it is somewhat difficult to attribute the SIDS decline all to changes in sleep position).

Use a firm sleeping surface along with keeping soft objects (pillows, comforters, and the like) and loose bedding out of the crib. Rebreathing expired air and positional asphyxia may be contributors to infant “crib death”.

Do not smoke during pregnancy and avoid infant exposure to second-hand smoke. Maternal pre-natal smoking has always stood out in studies of SIDS.

Separate but proximate sleeping environment. There seems to be a decreased incidence in infants who sleep in their crib in the same room as mother during the first 6 months of life. However, bed-sharing seems to be a risk factor for infant death (particularly when the “sharer” is overly tired or impaired by medication or other substances). Breastfeeding infants may be an exception to this bed-sharing caveat (breast-fed infants may be more easily arousable as a partial explanation for this).

A pacifier at bedtime, for the 1st year of life (this one is new). The mechanism by which this is protective is not well understood, but the data is compelling.

Avoid overheating the infant. Again not well understood, but light sleepwear and comfortable room temperature seems to be best.

Commercial devices marketed to reduce the risk, including cardiac and apnea monitors have not demonstrated effectiveness in preventing SIDS.

Sing the praises of the “Back to Sleep” program. Even though the program seems to have been effective in decreasing the incidence of tummy sleeping and SIDS, many do not know about this important bit of information. Particular populations in need of the information are mothers who don’t get prenatal care and secondary caregivers (e.g. child care providers, grandparents, babysitters).

Weighty cause of death

I came across an interesting article recently, “Weighing Reality”. While the gist of the article was taking a group of Reality TV Shows (that I have never seen) to task, it had some interesting thought provoking points about the corpulent in our society.

It, importantly I think, points out that people are overweight for a variety of reasons, it “is not as simple as people just eat”. These reasons vary from person to person and more than one may be operating in any given individual. This may be why so many diets fail, in addition to the fact that many of them are just plain goofy. If you are not addressing the real reason an individual is overweight, they will not trim down successfully. This is not to say all overweight individuals have underlying occult (not in the magical sense) reasons for their being overweight. Many do eat too much and/or exercise too little and many don’t lose weight on programs because they don’t stick with them.

Some individuals are overweight because fast food is easier (and high calorie). Some are overweight because they don’t know enough about proper nutrition. Some are overweight because fruits and vegetables are more expensive than many high calorie, nutritionally empty “foods” that they choose to fill up on. Some are overweight because previous yo-yo weight loss/gain has messed up their natural weight set-point.

Most concerning are those who overeat because of psychological issue that need care and treatment. Being overweight is their hallmark of underlying mental health disease. They overeat to hide themselves because of a history of being abused as a child. They overeat to have “control” over something. They overeat because of an inability to form relationships. Overeating is their eating disorder. Overeating is their method of self-medicating.

There is little doubt that obesity contributes to ill-health and death. But the next tome you make an aesthetic judgment of how “vile” an overweight individual is, consider that there might be an underlying cause that needs treatment. It may not be as easy as just another “diet”.

Death is an emotion charged event. It is impossible to predict any individual’s reaction. Particularly with a sudden and unexpected death, emotion can boil over and become outwardly directed or not. But it is impossible to predict what the reaction will be with any given individual or with an individual in a given situation. Even the manner an individual has reacted in the past is no predictor of how they will react now or in the future with a death of someone close to them.

We try not to assume or predict how someone is going to react. We try to be “open” and try to anticipate their reaction going in any number of ways, not in any certain way.

Nonetheless, we tried to predict someone’s behavior/reaction today and we were proven wrong. They reacted exactly opposite of what was predicted. Just goes to show you…

The Hepatitis C Pandemic

There was a recent article in US News & World Report (March 13, 2006) about it and recently I’ve noticed it as a “contributing factor” on a few more death certificates (“natural” deaths). 4 million people are infected with it, 3 times as more prevalent than HIV, and some 10,000 people die as a result of it each year in this country. That “it” is Hepatitis C.

About 80% of the time an individual becomes infected with the Hepatitis C virus they will develop chronic liver infection (hepatitis). Of those individuals about 20% go on, over 20-30 years, to develop cirrhosis (scarring) of the liver. Of those 20% (i.e. approximately 4 of an original 100 infected) develop lethal liver failure and 30% may develop liver cancer. That 20-30 year progression period is “up” for a rapidly growing number of individuals and symptomatic disease is increasing dramatically.

There is treatment available that can be effective in about 50% of cases (depending on the Hepatitis C virus subtype they are infected with), but the treatment has side effects that can make it difficult to stick with it. Liver transplantation may be available for those who develop liver failure, but of those added to the transplant list each year 10% die before a transplant is available. Also, the Hepatitis C sometimes comes back after the transplant.

As with so many diseases, it is best not to get Hepatitis C than to try to treat or cure it after an individual has it. Keep in mind it is easier to transmit Hepatitis C than HIV (it takes a smaller amount of the virus/blood and it is a hardier virus). Don’t share needles. That should be obvious with IV drug use, but it also pertains to “home” piercings (ears, navels, etc) and “home” tattoos. Avoid, be careful with, possible blood (theirs out of their body) to blood (yours in your body) contact, that’s how it is transmitted. While the jury is still out regarding sexual transmission, there are certainly enough other reasons to take precautions (but this may be on that list). One last note: in this country we haven’t had to worry about blood transfusion transmission of Hepatitis C since 1992.

Be careful, don’t take chance, make good choices.

Media Violence II

As I mentioned yesterday, immersion in media violence tends to cause individuals to develop “mean world syndrome”, to become desensitized to violence and/or to become more aggressive themselves.

Desensitization damages our sense of community. Individuals lose the ability to empathize with the victim. They develop the belief that violence is inevitable and do not protest or work against increasing levels of violence. More importantly, I think, individuals lose the ability to understand the consequences of violence. This latter component of desensitization contributes to a growth in violence, one of the most important contributors in my opinion. Lacking an appreciation of the consequences, violence becomes just another action. Violence can then be undertaken “lightly” because the outcome and the “other” are without consequence.

Watching violence increases aggression and violence less in a copy-cat sense, but more in the sense that values and attitudes begin to favor the use of aggression and violence to resolve conflicts. It is no longer an act of last resort but more of first retort.

To address violence, to decrease violent deaths and violence in our community, our approach must be multi-faceted. A singularly focused program/solution will be less than maximally effective. We need to limit or “balance” the violence in our media (that will be a tough one, violence “sells”). We need to address the “mean world syndrome”, paint a more realistic picture of violence in our communities while working to build the sense of community, the desire for community, the cohesiveness of community. We need to replicate (or develop) programs aimed at lessening the tolerance for violence, the teaching of the consequences of violence, the expansion of reaction choices beyond the choice of violence. The “solution” (and remember a solution is a mixture) is “messy”, not a neat and tidy single entity, but it is worth the effort—save a life, save a victim, limit suffering.

Mean World Syndrome

Violent deaths, violence nearly resulting in death, violence for violence sake, and that’s just on TV shows, movies, and video games (are they still called video games?).

Those things do happen all too often in real life and we do see the results in our office, but those things happen much more frequently in our media, “consumed” in ever increasing amounts in our society. Media violence, particularly consumed via the TV, results in many psychosocial effects on individuals and our communities/society. Those effects were nicely summed up in a recent Psychiatric Times article as Aggression, Desensitization, and Fear.

Today, I want to touch on the Fear effect or “mean world syndrome” (phrase by George Gerbner). Many individuals after repeated exposure to media violence (particularly “news stories”) develop a distorted view of the world and their vulnerability or risk. They see the world as more violent, more risky, than it really is. I know a guy, who otherwise doesn’t intimidate easily and whose appearance, I think, would make him unlikely to be targeted, who is afraid to go into Chicago because he believes it’s so dangerous, anywhere/everywhere in the city. Many people are certain they will be a victim of a violent crime, despite the reality that a violent crime occurs to less than 1% of the population. There are people who are certain that every child is going to be stolen off the street by strangers, when in fact this occurs less than 100 times a year in all of the U.S. (this excludes those taken by family).

Many individuals are convinced the world is more like what they see on TV than what they experience in their day-to-day life. It is important to be cautious and make good choices, but this “mean world syndrome” can lead to serious problems. The “syndrome” can cause us to become “paralyzed”, to withdraw, to refuse to relate to others, to fear others, to undermine our natural tendency toward “community” and its benefits for individuals and society.

The “syndrome” can also cause violence, a “get them before they get me” pre-emptive mentality, escalating not diminishing violence with all its consequences.

Tomorrow I’ll “hit” the other ramifications of being bathed in media violence.

Medical care deficit to balance budget

Reportedly in the interest of reducing the budget deficit, Congress passed a budget reconciliation bill that was signed into law in early February. The budget reconciliation included “changes” in many domestic programs with an apparent special attention to healthcare programs, e.g. Medicaid. Days before it was passed, the Congressional Budget Office (CBO) issued an analysis of the Medicaid “changes”, analyzing the “savings” that would accrue from the increased co-payments and premiums contained in the bill. What really caught my eye was the opinion of the CBO (cited in the Psychiatric Services journal and at CBPP) that 80% of “savings” will come from decreased use of medical services. They did point out, as well, that some of those “savings” would be off-set by increased emergency department use.

What a plan for saving money and reducing the budget deficit. As I mentioned, the CBO did recognize that decreased use of regular medical care would result in increase ER use, some of which will be “inappropriate” and some will be forced by medical deterioration. What they didn’t comment on is the increase in Coroner’s services that will result. Avoidance/non-use of medical services also contributes to medical deterioration unto death.

Depression

According to the Depression and Bipolar Support Alliance, 19 million Americans suffer from depression, but, as reported in a 2003 study in the Journal of the American Medical Society, less than 22% of individuals diagnosed with depression receive adequate treatment. Major depression is the leading cause of disability in the United States and is a leading cause of missed work days and poor worker performance. Depression also has a large negative impact on childhood development, academic performance, and general social well-being. It is a major contributor to death by suicide.

A serious problem with our mental health system is that it is episodic, crisis-oriented and reactionary. Instead, it should be focusing on prevention, proactive treatment and long-term wellness. We must break down the barrier of stigma; the stigma of seeking care, the stigma of receiving care, the stigma of being labeled. To have a significant impact on the many "costs" of this illness, we need to ensure early screening and detection of depression and access to effective treatment (psychopharmacologic and psychosocial). In many cases early treatment can prevent depression from worsening and limit long-term disability. The system needs to change its focus.

We all have a stake in this matter. Any other illness that could be screened for and treated, but wasn't, would raise a cry of foul. Why should this illness be any different?

DWI

It has been a busy couple of days, including a meeting this morning of the Lake County Suicide Prevention Task Force. It was a great meeting, productive. As my Chief Deputy and I pull together some of the notes, I’ll share them here on the blog.

Yesterday afternoon I participated in a neat program to try to prevent drunk driving and teen death. My participation was actually pre-program or early-program, but I hope I was of some help to these kids as they go forward with this program and that they can have an impact. As far as I know Cooper Middle School (Buffalo Grove) is the only school locally using this program. The program is called DWI, A simulation of teenage drinking, driving and the judicial process (by Kimberly Michaels). It is a role-playing simulation of the events surrounding the legal process that takes place after a “driving while intoxicated” youth driver, fatal car crash. My role was meeting with students who would be the Coroner, police and other actors in the simulation to discuss the actions of a Coroner in such a “case” in “real life”. We discussed the death investigation, post-mortem findings, court testimony and other facets a case like this might entail.

This seems to me a good teaching tool (different, interesting, and participatory) regarding the dangers of drunk driving, as well as regarding the Coroner’s and legal systems’ handling of these sorts of events. I also like that they are doing this with middle school students. I think that is a good time to go over these issues, before they or many of their friends are driving. Like many “lifestyle”/behavior issues it is best to go over them “early and often” to be able to really impact behavior.

Functioning Addicts

I’ve commented on deaths resulting from drug use and abuse in previous posts. In that regard, I want to bring up something I was discussing with one of my deputies recently. The individuals dying with drug-related causes are not, for the most part, down and out, drugged out, low-lifes. And that surprises a lot of people.

Many of these individuals hold jobs, attend school, live what appear to be pretty normal lives. However, after work and/or on weekends these individuals go to dealers and “markets” in Chicago or elsewhere to purchase their drugs. They return home and consume (inhale, ingest, inject) their drugs looking for the effects they expect. Rarely, they die, most of the time they continue their lives and their drug use. They are still addicts. They continue their drug use and abuse for effect or self-medication or because of an inner drive to use and abuse, but many are functioning members of society.

It can be surprising just who is a functioning addict. It can even surprise their family and others they spend sober time with.

Qualification Evaluation

Two things prompted my post today. Yesterday, at Inquest, one of the jurors asked regarding the qualifications one of my Deputy’s might have. Second, today I was filling out a job evaluation on one of my deputies, thinking not only what qualifications that individual has but what makes for a ‘good” or better than average Deputy Coroner.

The knowledge and “book learnin’” is very important and not something that someone working in this field could do without, but I think most important is a skill set an individual develops over many years of education (their whole life?). Certainly compassion and empathy are critical to possess and use in this job, but they will avail you little in the work environment without the skills to do the job. Those skills include looking and seeing (real observation), asking and listening to the answers, communicating—verbally, in written form, and non-verbally (body language, fro lack of a better term), thinking and reasoning.

These (in addition to compassion and empathy) are the skills I think of while evaluating one of my deputies. These are the real skills/knowledge they bring to their jobs. These are the real “tools” most needed for a career in Forensic Science. That’s what you need to work for me in the Lake County Coroner’s Office.

Career Day is Elementary

I recently did a Career Day event at a local Elementary School, talking with 5 groups of young children about my job. I just got a packet of thank-you notes from some of the kids and I thought I’d share some of their comments and insight (their spelling and punctuation):

Your job is so cool!! You work like the CSI. Your job might be a little nasty but to me I like your job a lot!

I liked that you came down to talk about your job about saveing lives in the world I thank you for doing it.

I really thought it was interesting when you said you worked with dead people. It was really awesome to know about your job. Thank you so much for coming to … School and for teaching us that smoking is bad. I thought it was interesting when you told us that people tried stunts off of TV and how it killed them.

I think you job is cool!

I like your job because it’s interesting to check people’s bodies to se how they died.

I think find out why people are dead is a cool job and all it’s just not for me.

I like your job because you get to se blood. I like to se blood, lots of blood but not on me! So if I die will you know that it is me? [This one bears watching]

I think your gob is cool. Because you get to use cool tools and look at there teeth

I think the most interesting think is how you invetgat pepl who dide

How did you get a job to look in side other people’s body?

When you die I hope that you will get cremated so you can hope that someone can spread your ash’s over your life

I love you so much. [by my youngest daughter]

It is fun talking about my job with kids, with everybody. I also make a point of plugging in a few death forestalling tips to my talks that I hope they really pick up on.

Eating Disorders do kill

One of my daughters recently researched and wrote about eating disorders for a school project, and our family discussed the project while she worked on it. Eating disorders do cause death, e.g. a couple of high profile cases were Terry Schiavo and Karen Carpenter, so I felt I ought to do a post about it. 5-20% with Anorexia Nervosa will die from the illness.

Like so many disease processes, Eating Disorders have a combination of biological, social and psychological factors contributing to causation, research continues. Most importantly, remember it is not a lifestyle of choice. Eating disorders also have a broad spectrum of presentations, “pure” Anorexia (severe food restriction), “pure Bulimia (Purging), and Mixed presentations, with “Body Dysmorphic Disorder (excessive concern with body habitus and characteristics with intense “treatment” seeking behaviors) in the mix. Helpguide and the National Association for Anorexia Nervosa and Associated Disorders, among others, are good sources of information.

Eventually Eating Disorders “present” dramatically, but early on and even later you need to be really looking and really seeing; with food rituals, the avoidance of food, weight loss and an excessive focus on exercise. Serious and potentially lethal consequences ensue; loss of bone density (osteoporosis), loss of hair, easy bruising, muscle weakness and wasting, fatigue, and fainting, to name a few. Symptoms can progress to dehydration, blood electrolyte abnormalities, and cardiac rhythm disturbances. Hormonal abnormalities, probably led by decreased gonadotropin-releasing hormone, include increased luteinizing hormone, decreased prolactin, decreased estrogen (with loss of menses), decreased testosterone, decreased thyroid hormone (cold intolerance and other metabolic abnormalities). Lanugo (fine, downy hair over the entire body, including face) can develop in longer term cases.

Death can occur due to severe dehydration, severe electrolyte (body salts that are responsible for cell and nerve functioning) abnormalities, cardiac rhythm or pumping abnormalities, and other lethal endpoints of the disease processes induced by the Eating Disorder.

Eating Disorders contribute to and are complicated by mental health disorders, particularly Depression, and that Depression can kill as well.

Early treatment is essential. The effects of this illness on the body and mind are serious and can get ingrained and can be lethal. Recovery gets harder the longer the duration of the illness. Treatment in many cases needs to be life-long.

If you, a friend, or other loved one has or may have an Eating Disorder, get help. While you can’t force another person to get help, encourage them, show them you care, be firm, recruit others to help, show them or take them to where they can get help.

A good source of more information: National Association for Anorexia Nervosa and Associated Disorders.

Grief work

I’m not sure where I had seen a reference to this website; I had a note tucked in my “ideas” folder. I looked at the website today. It is new, it is an experience.

Tom Zuba learned about grieving with the death of 18-month old daughter, his wife 9 years later, and most recently his 13 year old son. He shares his experience, he wants “to be of service”, to share the “tools” he gathered “to make the journey easier”. He wants to create community, on-line, “a sacred place (for) transformation”.

Mr. Zuba offers heartfelt information about grief and dealing with grief, thoughts on mourning and the usefulness of denial. It is a worthy effort, worth a look and your consideration, whether you are currently dealing with grief or not. Certainly, it would be useful if you are seeking tools to work on grief in your life.

Note: don’t skip the intro (if your computer can handle it), it is a very nice bit of visual and written art.

Bad Day?

I am writing this on a bad day of wrestling with problems with blogger, my network system/provider, and my skill set for blogging.

There was an article in the Wall Street Journal, Feb. 27, 2006, by Jason Fry, regarding "rumors of blogs' demise. (No I don't read the WSJ, I got there through a link from Eric Zorn, a link I lost) At least part of the article was a bit scary for me just starting a blog. According to the article "less than half of ... blogs are still getting posts three months after their creation and less than 10% ... are updated at least weekly ... nothing kills reader interest or visits more quicikly and thoroughly than a stale blog". I plan to keep wrestling and learning and posting on into the future.

I want to highlight some new comments sent to me today and I just got posted (and evidence of some of my wrestling) pertaining to my post "Heroin or is it" on February 7. Take a look at the comment and take a leap through the link to his blog, both are very worth the effort.

Cocaine and Death

As I have mentioned before, Cocaine is the #1 killer drug in Lake County. It is a very potent nervous system stimulant, which explains its euphoric and its lethal effects (in combination with its vascular effects). For some reason we have seen a bit of an up-tick in its lethal consequences recently. I don't know why and I don't know if it's a trend.

Cocaine is rapidly metabolized in the body, which makes it a bit tricky to catch in the bloodstream of a live individual. Usually, however, levels of Cocaine and/or its metabolites measured in bodily fluids after death give us the information we need to arrive at a determination of Cocaine-induced death. Most of the Cocaine consumed (inspired, injected, ingested) is metabolized in the liver, but Cocaine is relatively unique in that enzymes in blood cells also break it down, so Cocaine levels in the blood can drop after death and can even drop after blood is drawn and is in the lab tube. Cocaine's various metabolites are more stable in the blood and cocaine is relatively stable in the urine and vitreous (eyeball) fluid. Vitreous levels can be particularly helpful in reflecting brain levels.

We can get one bit of information if we find Cocaine in the blood we draw (or blood drawn in an ER before the individual dies). We then know that the individual likely consumed the cocaine a short time (at most, a few hours) before their death, because the half-life in the bloodstream (amount of time for one half of the substance to be cleared/metabolized) is thirty minutes. Through its vascular effects, primarily, Cocaine can kill several hours after consumption.

As our toxicology reports state "there are no safe levels of Cocaine". There is little doubt as to the cause/contribution to death when very high levels are found in the blood, urine, and/or vitreous fluid. But even lesser amounts kill individuals with heart electrical problems or vascular/circulatory abnormalities, or with risk of seizure or other neurologic abnormalities. Chronic Cocaine use can actually contribute to the development of these abnormalities, placing the user at increased risk of death.

Manner of Death

As I tell the Coroner's Jury at Inquest in their instructions, the verdict of manner of death is a multiple-choice question. There are 5 choices, although since natural deaths do not go to inquest they have 4 choices. For the most part the choices are self-explanatory, do not over-lap, and should be evident in the testimony given during the inquest. The choices are accidental, homicide, suicide, and undetermined.

Undetermined is chosen as the verdict when, based on the evidence presented, the manner can not be categorized into one of the other “manners”.

Suicide is an intentional act to cause one’s own death.

Accidental death is death due to an unexpected or unplanned event.

Homicide is death due to an intentional or reckless act of another. This is not to be confused with criminal “homicide”, which is a charge brought through the legal system assigning blame to an individual. The Coroner’s Inquest (jury) does not assess or assign blame to any individual.

Some of the toughest decision making that the jury has to deal with is deciding whether an individual’s action resulting in another’s death was negligent (therefore an accidental death) or reckless (therefore homicide). The jury must consider what an individual, or a “reasonable individual in that person’s place”, thought or should have thought at the time of the incident. A negligent act occurs when an individual, or a “reasonable individual in that person’s place”, is unaware or does not consider that their action may cause the death of another individual. An example would be reaching down to pick up your cell phone off the floor of the car as you are driving, resulting in you taking your eyes off the road and crashing your car into someone else with their death as a result. A reckless act is one in which an individual, or a “reasonable individual in that person’s place”, consciously disregards that their action will result in another individual’s death. An example of that would be firing a handgun into a crowd of people resulting in someone’s death.

The jury’s deliberation likely dwells most on the decision of manner of death, because their other decision, the cause of death, is even more evident in the testimony by those involved in the death investigation. The manner of death is the most important decision that they make and while it is most often obvious, it is at times emotion charged and difficult to characterize. Their decision is then memorialized on the final death certificate.

Great News for Chocaholics

A great “new” way to forestall death, but I can’t tell my staff or they will start demanding chocolate breaks.

A study published in the Archives of Internal Medicine and summarized at ScientificAmerican.com touts the benefits of chocolate in lowering blood pressure and the risks of a serious cardiovascular disease. It studied individuals over 65 years of age, but you know you are never too young to eat chocolate and start your “treatment”. It does appear, however, by chocolate they are referring to high cocoa content chocolate, not what passes for chocolate here in the US. So, for “treatment” stick to rich Mexican chocolate/cocoa or dark Belgium chocolates.

Sorry, I need to get off the computer; I’m drooling all over the keyboard.