Working with the DEA

We work with many agencies in our death investigations. While local police and fire agencies are our most frequent “allies”, we work with a number of others. One that we have been working with more frequently, it seems, is the Drug Enforcement Agency (DEA).

We have worked on a few cases that involve people who died after use of prescription meds purchased over the Internet. Perfectly legal drugs (not tainted or of “different” quality), but purchased via the Internet with prescriptions that are also acquired over the Internet from the same provider as the seller of the med. We have seen this scenario with individuals who inadvertently overdosed while “self-medicating” and, in at least one instance, meds that turned up at a party. We continue to report these instances when they occur and know that the DEA closes down the offending sites when they gather enough evidence to do so.

Also, we have worked with the DEA (and continue to) in instances where a doctor “over-prescribes” and/or a pharmacy “over-dispenses”. Imagine the contribution of a doctor that prescribes several hundred pain pills and anxietolytics at a time, at intervals too short for safety, and in combinations that put individuals at risk of poly-substance overdose. Or imagine a pharmacy allowing and dispensing a pain med prescription with 99 refills, and at quantities and frequencies with a potential to risk patient safety. These cases are reported to the DEA and the IL Dept of Professional Regulation for their review and consideration.

Just like those cases I talked about yesterday, we see ourselves as proactive in preventing future deaths by reacting to components of individual deaths and making certain that those conditions are not repeated with other folks.

“Activist” Coroner

We are at it again. Treading where we think we ought, to best “serve” those that die in our county and their survivors.

In a recent investigation it appeared that the prior investigation was “incomplete” and so we were compelled to intervene. It involved an individual severely injured in another jurisdiction, who ultimately died in Lake County. Our ruling at “case review” will be homicide. In reviewing the police investigation done at the time of the injuries it appeared to us that the investigation was disjointed and certain facts and statements had not been given the attention that they merited. We arranged a meeting between our office, our pathologist and an official of the investigating police department. My deputy pointed out things we saw in the records of the investigation, had our pathologist discuss how the severity of the injuries went along with our interpretation of the information available and strongly recommended that they reopen their investigation. After asking if they thought they could use some help from the state police, they decided to reopen their investigation. It is now a work in progress.

Another recent investigation raised several questions for us about the care and interventions a dying person received and/or ought to have received. Because of those concerns we contacted an oversight agency in whose jurisdiction those actions fall and have prompted an investigation on their part. That investigation should result in improved care, which is our goal in reporting the incident.

We take these actions because it is the right thing to do. As our mission statement says:”…we serve those who can no longer serve themselves…” (We speak for those who can no longer speak for themselves.) And we work “…to help prevent deaths in similar circumstance.”

Note: to the media that read this blog, I cannot discuss the particulars in these cases as the investigations are ongoing and the results might be skewed by such reporting.

Note 2: Mr. King: Yes, I am “addicted” to quotation marks, particularly for emphasis. Thanks for your input; I shudder to think what my English teachers would think of my writing (of course, it was over 35 years ago that I last sat in an English class, so they might not be reading this).

IL Nursing Home Death Reporting Task Force

I got involved in a “new” state-wide task force yesterday, the (Nursing Home) Death Reporting Task Force. We will be developing, piloting, and then implementing a project to ensure better reporting and, when appropriate, investigation of the deaths of individuals in nursing homes and related facilities. While we already require reporting from the nursing homes in Lake County, I look forward to this effort in improving these “reports”.

We met yesterday in Springfield (my first meeting with the group) 5 Coroners and individuals from IL Dept. of Public Health, the Attorney General’s office and State Police. We will be working to improve reporting and follow-up across the state, ultimately. In addition to adding a few questions to what we routinely ask when the deaths are reported to us, I think it will be good for systematizing the reports, improving our ability to report “questions” to IL Dept. of Public Health (IDPH) for their investigation and encourage sharing both ways. One piece I particularly look forward to is IDPH sharing with us nursing home “complaints” and “trends” so we can look a bit more “suspiciously” at death reportings from those facilities. And hopefully head off events like the upcoming 6 exhumations in McHenry and Lake Counties to investigate deaths at a nursing home in McHenry County.

Often nursing home residents don’t have advocates and folks watching closely after them. I think it is only right that the Coroner watch out after their interests after death and perhaps gather data to prevent needless deaths in the future.

Suicide prevention programs

We (again that “royal we”) really have some things moving forward with our Suicide Prevention Task Force. We are starting a project, partnering with a local agency to bring faculty training to local high schools and middle schools to assist them with suicide prevention efforts. The training will target faculty to help them in recognizing “at risk” (of depression and suicide) students along with “how to” refer and encourage them to get help. The second “target” is school counseling staff to ensure they have the “tools’ to handle those referrals and do appropriate evaluations and referrals as needed. This program will also ensure “institutionalization” of the training, so that the schools can continue training new faculty, retrain current faculty, and that the program once started will continue on into the future.

Our second big project is a program to encourage suicide survivors (i.e. family and friends of those that die of suicide) to get help and support for themselves earlier after their loss than the 4 year national average. We are as yet uncertain how this will look finally, but we are looking at several models around the country and seeing how we might borrow the best of each and bring it here to Lake County. There are not many “first responder”, “early intervention/support” models out there, but we are confident we can get something effective working here “soon”.

Both of these efforts are exciting and I look forward to their development. As well we are continuing to bring together referral sources and find gaps in services that need to be addressed. The other “pieces” include working on other education programs (students, community) to expand knowledge about suicide and what to do when confronted by it to help prevent it, and working to decrease the stigma associated with it.

Off to the "Illinois Death Reporting Task Force" meeting tomorrow. Long drive, but certainly pertaining to our Coroner work, and I have been invited to participate.

Typical day, typical stuff?

Confluence of stuff, belying the thought of a “typical day”.

Started my day, yesterday, doing a bit of volunteer doctoring (I still do a bit). Into the office to get a bit of stuff done for some upcoming meetings this week and other “usual stuff” stuff. I paused in those endeavors and examined a sub-galeal hematoma and skull fracture as one of my deputies retrieved a “bullet” from a death by suicide, as requested by the police agency involved in the case. Then I walked across the street to watch a press conference being held by a local state senator regarding proposed legislation to make it a felony for parents to knowing allow underage drinking to occur if a serious consequence of that drinking occurs. I was asked, rather spur-of-the-moment, to speak of my thoughts on the issue and it’s utility in preventing teen deaths (my comments ended up in the local newspapers and on WGN). I then went out to participate in the “scene” investigation of a death (man severely in a burned out pickup truck, investigation still in progress). When I got back to the office, I did get a couple of “usual stuff” tasks done, not to mention taking at least half-a-dozen media calls. My meeting last evening went off without problem.

Today I began with a meeting of the Lake County Underage Drinking Prevention Committee. While there I was notified of a homicide that one of my deputies had responded to. When I got back to the office, the first autopsy of the day had begun, the homicide autopsy was “scheduled to follow”. The third autopsy (on the victim from yesterday) was ultimately postponed until tomorrow. While I was still trying to get my act together for tomorrow’s meeting of the Lake County Suicide Prevention Task Force, some guys came by to replace the broken window in my office forcing me out to the conference room for a bit. File reviews, case reviews, review of material from this morning’s meeting, review of other stuff, talked with a recent decedent’s family member about a couple of issues, media calls (about today’s homicide, yesterday’s death and a couple of other matters), this blog post and my day was done.

Although I will be leaving for the day soon, I am always on-call and I look forward to the interesting stuff to come now and into the future. (Did I get the stuff done for tomorrow’s meeting?)

Radio "Company"

Just a quick posting today, something I have been thinking about for awhile.

I’m sure none of my deputies would admit that they believe in ghosts, but I’ve noticed that they leave a radio on in back, in the intake area by the “cooler”.

Although, when you are in the building by yourself at “off hours” it is awfully quiet and then when the security folks come around shaking all the doors to make sure they are locked it can be a jolt.

Coroner Authority

I’m working on an article for our 2nd quarterly newsletter for local fire departments. At least partly because of a recent incident (ah yes, there are some of those), I’ve pulled together some quotes from IL statutes and IL Attorney General Opinions that I am attempting to write the article around. My intent with the article is to speak of our desire for a spirit of cooperation among agencies investigating deaths, while making it clear that the coroner’s office has a certain level of authority that should not be interfered with in these cases and that we have the right to assert that authority.

The “quotes” include:

“Each coroner shall be conservator of the peace in his county, and in the performance of his duties as such, shall have the same powers as the sheriff.”

“…inquire into the manner by which persons came to their death where there was any reason to suppose the death might not have been due to natural means”

“No dead body…or the personal property of such a deceased person, shall be handled, moved, disturbed, embalmed or removed…by any person, except with the permission of the coroner, unless…necessary to protect such body or property from damage or destruction, or unless necessary to protect life, safety, or health.”

“…specific grant of authority to coroners to investigate deaths would necessarily prevail over the general law enforcement powers of other police agencies”

Our office takes these responsibilities and “authorities” very seriously. We do, and will continue to do, complete and thorough medicolegal death investigations (maybe even more so than some coroners in other jurisdictions) in conjunction with and parallel to law enforcement agencies, fire agencies, and other agencies that might have interest in and jurisdiction regarding the death in question (e.g. NCIS, OSHA).

A work in progress.

Vets PSTD and suicide

I ran across an article today on a topic that I don’t think gets covered enough. It had a comment in it that really caught my attention as well.

The article is entitled: “Vets’ suicides: casualties that go uncounted and another hidden cost of war”. It talks about the terrible tragedy of war-related post-traumatic stress disorder (PTSD) and its relationship to suicide. It also mentions how PTSD is often undiagnosed and untreated, how its toll is not tracked after discharge, and how it is a growing problem even in the face of threatened cuts in veterans’ healthcare benefits.

But what really caught me was the statement: “No one knows how many Vietnam veterans killed themselves because no one ever bothered to track or count. There are many experts, Jonathan Shay for example, who have no trouble believing that there have been more suicides since the war than there are names on the Wall…”

My father died by suicide after a second tour in Viet Nam in 1972.

We can not let this tragedy continue and repeat the mistakes of the past. PSTD and suicide in active duty soldiers and in veterans must become a priority. Let’s support our troops.

Nap and live longer

In a study released recently, it appears that a daily nap decreases your risk of dying from heart disease. While, like all studies, it must be replicated in other patient populations, it certainly looks like an impressive effect. The effect may be related to stress reduction and afternoon naps may be “more natural” fitting with the normal cycling of our daily clock. Napping, researchers believe, allows people a chance to reset their heart rates and blood pressure in the middle of the day.

However, the first thing I thought of last night when I saw the report on the news was something a cardiologist told me a number of years ago. He told me we were each born with just a certain number of heartbeats and when they were used up, you checked out. So my thought is that a nap helps you save a few of those limited number heartbeats and allows you to live longer. [Disclaimer: I am not a napper]

So nap away, unless you work someplace where I need service/attention at the time of your nap (or if your one of my employees, I’m not paying for napping).

Keg Reg to lower underage drinking

“Underage drinking cannot be successfully addressed by focusing on youth alone.” You must “create and sustain a broad societal commitment to reduce underage drinking”. “The nation must collectively pursue opportunities to reduce the availability of alcohol to underage drinkers, the occasions for underage drinking, and the demand for alcohol among young people.”

We discussed keg registration (at the Illinois Coalition meeting referenced above) as a strategy to decrease underage drinking. This is a good strategy because it ties the purchaser to a keg when “trouble” arises, whether that trouble is just catching the underage drinkers or if some other incident occurs tied to the drinking (e.g. crash, sexual assault, other injury). This has been demonstrated to decrease the incidence of keggers for “kids”. It is a strategy that is very helpful for law enforcement.

Laws like this do tend to push the drinkers to bars, but it is much easier to monitor/control access there than at a kegger somewhere. Also, another “work around” is to purchase beer in cases, etc, but there is less of an impetus to finish the case of beer than the keg of beer (“it will only go bad after it is tapped”). Over-drinking is a less likely to occur with cases than a keg.

Our discussion now centers on how to implement such a plan. A state law was tried in the past and never got out of committee. Should we try it again, now that times are different and, perhaps, with a legislator with a bit more clout? Or, as is being done with “smoke-free” efforts, should we push multiple local ordinances until we reach a “critical mass” and then go for the state legislation. [Politics are in everything and politics are a “game”.]

But something has to be done. We can’t wait for another kid to die.

Bottle of Red-eye to Die for

I have been to several meetings lately (and going to another tonight) working on preventing underage drinking at several levels. Last Friday I attended a meeting of the Illinois Coalition to Stop Underage Drinking and will be a part of their Steering Committee going forward. In addition to the efforts on the local level that I am participating in, it is important to push and share efforts state-wide and have a presence for the legislature, hence the state coalition.

We plan to concentrate efforts on things like 1) keg registration (more likely growing it to state level from local efforts) so that kegs can always be tracked back to the individual who purchased it, 2) alcopops (think mike’s hard lemonade) or bottled “girlie drinks”, or at least working to impact their marketing that seems to target underage female drinkers, 3) minimum age for bar entry (particularly a problem in college towns), and 4) perhaps a tax increase on alcohol products to fund interventions and (although I doubt its effectiveness) to decrease consumption, particularly among underage kids. I look forward to these efforts and others as they become apparent.

One interesting bit of information that came up at the meeting was Senate Bill 948 that passed in the last legislative session. It seems to me that it kind of brings back the “wild west”. Picture the scene in the old westerns where the cowboy goes into the saloon and orders a bottle of red-eye (with a dirty glass if he was really tough). If (or when) the governor signs this bill into law, folks in Illinois can go into a "club” and order a full bottle of distilled sprits (sounds pretty put that way) to be shared by a table of 2 or more people. This bottle service, while it likely won’t be red-eye, will likely contribute to over drinking. Once the bottle is open you can’t take it home, so you might as well finish it there (17 drinks in a fifth, 21 in a quart, or 22 in a liter). “Over the teeth and past the gums, look out liver here it comes.”

That should be “good for business”.

Social Norms Marketing

Is “social norms marketing” what I have been looking for? It appears to be a unifying approach to addressing an array of social problems leading to death and other problems.

Instead of using “health terrorism” or attempting to “scare the health into people”, you educate them about what their peer norms are and work to promote conformity with that health norm. For example, instead of telling folks that 25% of youths binge drink, you tell them that 75% don’t, building social pressure to minimize drinking, particularly in underage drinkers.

Attempting to frighten individuals into positive change by pushing the negative consequences of certain behaviors has “not changed behavior one percent”. Using “social norms marketing”, however, has demonstrated effectiveness by correcting misperceptions (usually overestimations of use), and identifying and promoting the healthy, protective behaviors that are the actual norm in a given group of folks (teens or adults).

One study demonstrated a 21% reduction of heavy drinking in a college population using “social norm marketing” techniques. There was also a significant decrease in consequences of drinking (e.g. property damage and unprotected sex) pointing to decrease in drinking among those that continued to drink when they had a real handle on the number of drinks that were “normal” in social situations and that not “everyone drinks”.

Social norm marketing has demonstrated effectiveness in a number of issues (although it has been mostly studied in its affect on underage drinking and heavy drinking among college students). It has shown promise in seat-belt use, smoking, spousal violence and grade improvement. My mind races in considering other “targets” (e.g. convincing parents that it’s not OK to throw alcohol available parties for their kids).

Promote health to increase health. Accentuate the positive. Show folks what the real “peer pressure” (social norm) is not taking chances, not making bad choices, but making “healthy choices”.