Posts
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.
Wednesday, November 29, 2006
Tuesday, November 28, 2006
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.
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.
Monday, November 27, 2006
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).
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).
Wednesday, November 22, 2006
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”.
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”.
Tuesday, November 21, 2006
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.
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.
Monday, November 20, 2006
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.
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.
Friday, November 17, 2006
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.
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.
Wednesday, November 15, 2006
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.
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.
Tuesday, November 14, 2006
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?
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?
Thursday, November 09, 2006
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.
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.
Wednesday, November 08, 2006
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.
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.
Monday, November 06, 2006
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.
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.
Friday, November 03, 2006
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.
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.
Wednesday, November 01, 2006
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”.
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”.
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