Heat-Related Deaths

I have been getting calls from local newspapers asking for information about heat-related deaths. We, like so many others are in the midst of a nasty heatwave (it sounds sexier in song than when I am sweating in it). The media folks seem somewhat disappointed when I can’t give them a number.

Heat-related deaths are, for the most part, a pretty subjective call. Most heat-related deaths are accelerations of naturally occurring disease processes, so do you call them heat-related or not? Did the 70 year old gentleman die of a “natural” myocardial infarction (heart attack), likely to have occurred no matter what the weather, or was the “push” the 95 degree heat with oppressive humidity poorly excluded from his home by his several room fans?

Other than true cases of Heat Stroke (elevated core body temperature with physiologic loss of ability to sweat) it is really very difficult to count with certainty the number of “heat-related deaths”. We have not seen any Heat Stroke deaths, the others based on circumstances surrounding their deaths, maybe so.

CDC MMWR July 7

A recent edition of the CDC’s Morbidity and Mortality Report contained 3 interesting factoids.

First, hospitalization for depression among girls 5 to 19 almost doubled over the last decade; with the rate among girls being double that of boys of the same age. No analysis or explanation accompanied this information, but a couple of things come to mind. Is the disease of depression genetically sex-linked or are the conditions for expression of the disease gender-based? Each of these “scenarios” would require different screening, intervention and treatment. Depression is a growing problem that not infrequently leads to grave consequences (see below) and so this consideration is not merely academic.

Second, mental health “issues” have a huge impact on violent deaths in 2004 (based on collection of data with a “new” database in 7 states). 20% of homicides have contributions from “intimate partner conflicts” (translate to “spouse” abuse) and 16% were “drug-related”. 50% of death by suicide was linked to depression, bipolar disorder and/or schizophrenia and another 28% had a contribution of “intimate partner conflicts”. Alcohol-dependence was also a big contributing cause.

The third factoid, previously declining cigarette use among high school students seems to have “plateaued”. In this section, the CDC included some factors that might have contributed to what had been a significant drop in use. 2 of those factors that stuck out for me were: decrease in exposure to and availability of smoking-prevention campaigns and a near tripling in tobacco advertising and promotion ($5.7 billion to $15.2 billion). Future health problems bought and paid for.

Addict in the family

There was an article in USA Today about a week ago that opens with a man’s comment that without his wife and 4 kids he would be dead. Mr. Ryan is an addict. He has only been sober about half of the last 16 years of his life. However, he has been a functioning addict. He has held his job, he has kept his family (barely), and probably hasn’t looked out of the ordinary to his neighbors. Probably 75-80% of our deaths in our county due to drug overuse and abuse (which includes alcohol) are of functioning addicts.

The USA Today article is about addiction being a family disease. It affects more than just the addict. It affects the whole family. The entire family needs to be considered and have access to treatment.

One in five adults (that would be 40 million individuals) report an immediate relative who was and/or is addicted to alcohol or drugs. "For every person who's alcoholic or dependent on other drugs, there are at least 4 or 5 people hurt on a regular basis". Think of the size of the problem. Beyond the addict that needs treatment are the family members who need support and care.

We (society) need to make certain that there are treatment and care options for the Ryans in our country so that they don’t become coroner’s cases too early, so that lives and families are not destroyed, so that children don’t repeat the cycle.

I applaud Mr. Ryan, who was willing to bear his life for the article. His and his wife’s comments are blunt, likely painful, but really bring the story home. My thoughts and prayers are with Mr. Ryan and his family. I wish him success in sobriety and strength in his continued battle.

Autopsy

A friend of mine sent me a link today to an interesting website. The website is titled: Autopsy. It is the work of (as he puts it): “Ed, the pathology guy”.

The autopsy is a valuable tool in forensics and in medicine, but (somewhat in disagreement with the author) it is my opinion that it should only be done when there is real information of “value” to be gained. [the “value” may be quite subjective.]

If you have ever wanted to see a step-by-step guide to what is involved in an autopsy (or just curious enough to take a look), this is the site for you. It also has little “cartoon” illustrations to go along with the narrative. While it may be a disappointment to some, there are no pictures of dead people or gruesome open people shots directly on the posting page. However, there are videos available for purchase and links to sites that are likely “more detailed”.

"Hic locus est ubi mors gaudet succurrere vitae”

I like the site and will recommend it to folks who want some detail on what an autopsy entails. Go take a look.

I followed a few of the links at the end of the posting and they including some interesting shopping opportunities as well as informational links and some links to photos overlaid with the word “caution”.

Camping on meds

There was an article in the paper about a week ago (no link) that reported that about one fourth of kids at summer camp are on medications. The article closes with “It’s universal, and nobody really knows if it’s appropriate or safe”.

Depending on the medical care available at these camps I would say it is likely neither appropriate nor safe. Do they have staff present to recognize and treat side-effects or other reactions? Is secondary medical treatment accessible enough to handle possible complications? Do they have staff to deal with whatever the underlying condition is that requires medication? Is someone watching for and able to deal with problems of diversion of the medications (someone not supposed to be taking the medicine, getting a hold of it in one of a variety of possible ways)?

Poison ivy, allergies and ticks are big enough worries, but camping with pharmaceuticals raises a number of red flags for me. Granted, many kids really need their meds to stay healthy and function, but is camp really the place they should be?

I don’t have any answers to this one, just a lot of questions.

Medication errors and caring for health

I have spoken to groups about improving access to healthcare and controlling costs of healthcare both recently as Coroner and previously as the Director of a free medical clinic. I often get some of the questions pertaining to whether there are things short of major system changes that can be done to impact these issues. The questions are usually couched in terms of their feelings that major system changes are unlikely to occur (although I do not necessarily agree that major changes are unlikely). My answer usually centers on the need for “real” quality assurance measures and action to improve delivered health care, decreasing costs and allowing for expansion of access.

I ran across an article quoting a recent Institute of Medicine Report that seems to back up that view. It reports that there are 400,000 preventable in-hospital, drug-related care complications each year at a cost of over $4 billion a year.

Can you imagine what could be done with $4 billion in healthcare? Steps must be taken (see the report) to stop these errors and recoup these costs. Those monies should be used to provide care, not correcting mistakes; saving lives from disease, not from iatrogenic disease. That can be done within our current system, while we wait for the needed systemic changes in healthcare. Healthcare is an individual need and a societal need, paying for it now is cheaper than paying for it later.

Realize, also, that some of those medication errors also result in death; early, unnecessary death. That should be reason enough to implement changes to prevent these errors.

Death by caffeine

Here’s an Internet time waster right up my alley. It’s an on-line lethal caffeine dose calculator. Have fun. I did the calculation by Starbucks coffee, my drug of choice, but there are a variety of other beverages (yes, including Mountain Dew). There were also a couple of other tabs that I did not follow (e.g. death by Penguin Mints and energy drink ingredients) that I plan to drop back to look at.

Posting "gaps"

Sorry for blog gaps over the last couple of days, but in addition to the usual “stuff”, I have been reviewing 600 pages or so of records and preparing a report for the local Child Death Review Team. Someone on the “Team”, not in the jurisdiction in which the death occurs, prepares a report for the team’s review and discussion. I volunteered to do a review and “drew” this case. There are hospital records, doctor visit records, police reports, DCFS (Department of Children and Family Services) reports, an autopsy report, and other documentation to be gone through for the report preparation. I didn’t really know what would be involved in preparing the report (i.e. 600 + pages of documents). Convoluted (multilayered) materials to review, digest and “digest” for the report to the team.

The perpetrator was arrested, charged and indicted by a Grand Jury.

Inquests tomorrow, back to regular posting real soon.

Activity = Life

I have stumbled across several references to a recently published study about the effect of regular activity in the elderly. What I think is really important is that they looked at “activity”, including routine household activities, not just at what is routinely thought of as “exercise”. So many people just don’t stop and think how beneficial “activity” is. In this group of individuals “activity” significantly lowered the likelihood of dying.

I think it is much easier to encourage “activity” than “exercise”. “Exercise has much more “baggage”. When people think “exercise” they often think they need to go somewhere dedicated to exercise (e.g. the Y or gym) or use some special equipment. These beliefs make it easier to talk yourself out of participating, because it is just too much work. On the other hand, many will exercise just because you have to go someplace special and use equipment.

Nonetheless if you “sell” the benefits of “activity”, I think people are much more likely to participate. Then once they are just doing “activity” you can introduce the concept of making it a bit more “work/exercise” (e.g. parking a bit farther from the store door) and before long they are doing “exercise”. Those that only able to do “activity”, on the other hand, are still reaping benefits.

It is all about living a bit longer and making that time a bit more health filled, now there a study to back it up. Stay active and stay alive.

Interesting Cases

The most frequently asked question during presentations and tours of the office is a request to hear about “interesting cases”. This week has been no exception. Tuesday we had 2 groups of College of Lake County students (their “over 40” program, learning about the “Justice System”) and another group from the National Youth Leadership Forum on Wednesday.

It is difficult relating interesting cases. Cases that might be interesting to the office staff in certain ways may not be interesting to the “general public”. In addition, we need to be careful not to upset certain “sensibilities” of the members of the groups. For example, some cases of “choking” have “autoerotic” overtones and therefore while it might be an “interesting case” you might not want to talk about it with certain audiences. In telling about “interesting cases” I want to avoid sensationalizing certain aspects of the deaths, e.g. the highest blood alcohol measured in an individual dying from alcohol overuse.

Lastly, it is critically important to not trivialize or appear to be trivializing (or making light of) any individual’s death. A person died after all.

The “trade-off”, however, is that these stories stick in people’s heads better than “just the facts”. Describing a teen killed in a car crash is more effective then just saying teens die in car crashes. Describing how “choking” can go wrong will have more impact than just saying it is so. Describing how terrible a drug-related death can be is more likely to affect future behavior than pushing the “just say no” line. (Of course all of the presentations are redacted of personal information)

It is a “tightrope”. I hope my discussing cases in my presentations comes across as education not “entertainment” or titillation. The case stories can be very illustrative and the listeners do listen better.

Say it with flower pix

Something a bit more light for a change of pace:

I was at the grocery store the other day and saw a young man in the flower center/cooler holding his phone as if using the camera feature. My thought at the time was that maybe he was sending a picture to someone asking if he should buy a certain bouquet of flowers. My opinion has changed. Apparently these days it is acceptable to send a picture of flowers phone-to-phone in lieu of buying/sending the bouquet. What a deal, an evolution from instant messaging to instant flowering.

I only wish I had a camera phone. I’d run out and get my wife a picture of some flowers. Nothing says I love you quite like that.

Sleeping kills

1,500 people dead, 71,000 injuries, over 100,000 car crashes, what could cause such carnage? Driving while drowsy, sleep-related crashes, is the cause according to the National Traffic Safety Administration.

A survey by Farmers Insurance demonstrates that it could be worse. Over 10% of drivers admit to falling asleep while they were driving and more than 20% have “dozed off” while driving. What is also scary, some 40% of those kept driving.

It is likely that there are even more deaths, injury and crashes due to falling asleep at the wheel, because it is not well tracked nor is it often a focus of investigation after a crash. There is no test for it and many will deny it after the crash. Alcohol makes it worse; it magnifies the drowsy effect and it may be blamed when it should be shared with the drowsiness.

The only remedy is not driving when you are tired enough to “doze off” or fall asleep. Pull off and take a nap if you need to, because the other things that are tried (turning on the radio, opening up a window, etc) do not work. (Although I did see one suggestion of changing pants with another occupant of the car, presumably while still driving, that might wake you up, but sums fraught with many other risks and problems.)

Don’t sleep while driving. It is not a good thing. Make good choices, don’t take chances.

Bars cause assaults?

I saw a bit that caught my eye in the Sunday (Chicago) Tribune about a study published in Alcoholism: Clinical & Experimental Research (sorry, no link). Apparently the study involved looking for a relationship between the number of bars in an area and the number of overnight hospital stays because of assault. They did indeed find a direct relationship between the number of bars in a given zip code and the number of hospitalized assaults (more bars, more hospitalized assault victims).

While that relationship reached statistical significance, it raises a couple of questions in my mind. I believe that some other points might also have reached significance, but not having seen the original article I don’t know if they were looked at or whether they will be looked at in future research.

By far and away the majority of assaults don’t get hospitalized, so it would be of interest to know if non-hospitalized assaulted individuals also correlated with the number of bars in a zip code. Secondly, it would be interesting to know (particularly in my present role as Coroner) if the number of deaths related to assault also correlated with the number of bars. It is not much of a stretch to believe that both of these quantities would also correlate with bar saturation.

The cause and effect would be a much tougher thing to get at without facts about the individuals involved in the assaults. Certainly, most folks that go to bars are law-abiding, fine upstanding folks and not likely to be involved in assaults. Also, sorry to say, not all bars are created, nor do they “live their lives” equal; some are “rougher” than others. So do we limit the number of bars to decrease violence/assaults or do we need to look at the characteristics of and demographics of the bars and “control” based on that? Are more bars located in some neighborhoods more prone to violence because of other socioeconomic problems? If that is the case do we control their placement or do we patrol those areas more intensively to secondarily prevent violence “greased” by that social lubricant, alcohol?

Regardless, this information should not just be bantered about academically, it should be used to impact a real-life problem. It should engender some real discussion on how to use the information in the community to decrease violence and assaults, and possibly deaths.

Preventing Cervical Cancer Deaths

10,000 women develop and nearly 4000 women die from cervical cancer each year in the U.S.. Most of the deaths are of poor and/or minority women. Pap testing (done on a regular basis) can most often catch cervical cellular changes at a pre-malignant or early malignant stage, allowing for treatment that is most often very successful. But many lack access to and/or do not avail themselves of these health maintenance services.

It is, however, always better to prevent the occurrence of a disease, than to try and catch it and then treat it before it gets “bad”.

The major cause of cervical cancer is certain “types” of HPV (Human Papillomavirus). If you can prevent infection with HPV you can prevent a large percentage of cervical cancers. Three things prevent cervical infection with HPV: 1) no genital-to-genital contact, 2) HPV vaccine (recently approved for use by the FDA), and 3) condoms. All 3 of these preventatives must be taught about, the public informed about them, and they must be used to be effective (i.e. used alone and/or in combination).

The FDA vaccine advisory panel, last week, recommended that all 11 and 12 year old girls should routinely receive the new anti-HPV vaccine. The vaccine is active against 2 types of the HPV responsible for 70% of cervical cancer cases. What a step forward in preventative medicine.

While practitioners who deal with STD care and treatment have been of the opinion that consistent and “proper” condom use prevents most STD transmission, including HPV, only recently has there been a “good” study with proven benefit (good = well done clinical control comparison trial). [Keep in mind that “proper” condom use isn’t as easy as it may seem] Published last month, the study demonstrated a 70% reduction in risk of becoming infected with HPV. There has also been recent research demonstrating condom protection from herpes, chlamydia and syphilis (again it was always “known”, but now there is better clinical proof).

Lives can be saved with widespread vaccination and consistent, “proper” condom use as disease prevention measures.

Learning to drink?

There was a letter to the editor in the Chicago Tribune recently in which a 17 y/o voiced his opinion that the “legal drinking age” should be lowered from 21 to18. A significant basis for this seemed to be that it would allow the teen to “learn how to drink”. That is “appropriately” without binging and other harmful behaviors that can accompany someone’s drinking who doesn’t know the right way to drink.

I disagree.

Having the drinking age at 21 offers the improved (longer) opportunity for an individual to develop the character traits necessary to drink responsibly. (I am not including alcoholism in this discussion. It is a disease with symptomatic alcohol abuse and over-use that is a problem of a whole different sort, not a character problem.) Also, I know and acknowledge the “Peter Pan Syndrome” exists in many forms and some individuals never grow up and act responsibly. And, yes, the drinking age was 18 when I was young and I may have begun drinking before I reached my majority.

Nonetheless, to drink responsibly and individual doesn’t need to “learn to drink” they need to learn certain life skills, develop certain character traits, at least to a reasonable degree. Certainly an individual may limit themselves to 1 or 2 drinks in a controlled setting, but these life skills are required in situations where the only brakes are your self-control (e.g. a free kegger). That self-control, it seems to me at least, is acquired along with the ability to delay gratification. Many of the lessons that instill the latter feed the former. An individual must become able to take responsibility for one’s own actions (the devil didn’t make me do it). They must be able to make many different types of responsible (and we thought out) choices. They must be able to resist peer pressure, in all its prevalent forms, as well as other pressures (e.g. marketing that a product will make you popular, sexy, etc.).

None of these life skills/character traits require practice/learning with alcohol. Life affords many training options. Learn from life.

You can drink from 21 to the end of your life; you don’t need 3 extra years before that.

Think, make good choices, don’t take chances, develop “good” life skills (good = life preserving, useful for society or getting along in society).

Overweight Kids are Overweight

The government (Centers for Disease Control and Prevention) feels that “we” should not use the word “obese” in referring to children, because of the word’s stigma. They recommend calling overweight kids “at risk of overweight”.

How can “our society” work to combat the problem of overweight kids, with its attendant risk of diabetes, other health problems and increased risk of death, if we can’t even call overweight kids overweight. This has to be one of the dumbest bits of “doublespeak” I have seen (today anyway). I have seen some fat kids. Yes, they were fat. I have seen even more (as in large numbers of) overweight kids.

There are times to be “politically correct” (Yes, that is a lovely dress), but there are times to be frank, honest, and call “a spade a spade”. If a kid is shaped like a spade (or a club for that matter) something needs to be done before they have damaged their future health and increased their risk of dying at a younger age than they ought. Overweight kids need to be told that they are overweight by their doctor and by their family and by others charged with helping them work on the problem. Don’t bludgeon them with it, but don’t sugar-coat it either (sugar-coating may be a significant part of their problem anyway).

Care enough to tell overweight kids the truth and tell them what to do about it [i.e. healthy diet and exercise] (repeatedly), show them what to do about it (repeatedly), help them do what they have to do and make sure they do it. Help them live long enough and healthy enough to appreciate the intervention.