Thursday, December 28, 2006

Tis the season to impact drunk driving

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

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

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

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

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

Wednesday, December 27, 2006

“Holiday blues” are not depression

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

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

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

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

Friday, December 22, 2006

Drug prevention needn’t be finessed

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

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

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

Dangerous Toys

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

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

Thursday, December 21, 2006

American College of Emergency Physicians ought to help forestall death

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

In particular the media release is irritating:

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

As I wrote him:

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

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

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

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

Wednesday, December 20, 2006

FDA antidepressant warning

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

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

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

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

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

Tuesday, December 19, 2006

Homicide Verdict = EM Death Knell

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

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

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

Previous posts on this here, here and here

Monday, December 18, 2006

Preventable Homicide

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

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

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

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

Wednesday, December 13, 2006

Interesting Mental Health Blog

I stumbled across and interesting blog today. As is often the case, I found it while I was doing something else (in this case some “continuing medical education” for credit). The blog is entitled “Anxiety, Addiction and Depression Treatments” but it covers a considerable array of mental health topics, from drug abuse to suicide to mental health issues on reality TV. As they put it:
Anxiety, Addiction and Depression Treatments is the public voice of Treatment Online. Here we strive to report and comment on the most important news in medication, treatment, psychotherapy, clinical research and other areas of mental health. We chose the title Anxiety, Addiction and Depression Treatments to represent the broad range of topics that peak our interest. Beside new issues in bipolar disorder, PTSD or drug addiction you will also find pertinent discussions on parenting, healthy eating, therapy strategies and all manners of health care, especially as they relate to mental health

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

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

Monday, December 11, 2006

Adverse Childhood Events

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

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

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

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

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

Friday, December 08, 2006


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

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

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

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

What a great project and opportunity.

Thursday, December 07, 2006

Preventing Underage Drinking and Death

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

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

I’ll introduce some “solution priorities” arrived at in a consensus process at a series of town hall meetings here in Lake County sponsored by the Lake County After School Coalition. As these priorities are serving here in Lake County, I think they can serve as a jumping off point for them as well. Those that provided input to the priorities were parents, students, community “leaders”, and other “folks”. The priorities they came up with were:
1) Educate youth on skills needed to resist peer pressure and to make healthy choices
2) Educate parents on role modeling and communication skills
3) Enforce rules and make them consistent at school, home, police, and in the community and prosecute adults who provide alcohol to minors
4) Explain and enforce zero tolerance (zero blood alcohol in underage drivers)
5) Make the issue of underage drinking prevention a priority for everyone in the community

My added points:

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

The process begins, things are happening.

Tuesday, December 05, 2006

Healing social norms to forestall death

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

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

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

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

Monday, December 04, 2006

At least parts of our healthcare system need fixing

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

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

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