Friday, December 28, 2007

Lack of access to quality healthcare kills

I was taking a look at some articles in the recent issue of the Journal of the National Medical Association regarding “Access to Care”. This is an issue that has been of interest to me for a number of years (prompting me to action doing an itinerant clinic for homeless individuals, founding HealthReach, and helping getting the HIV Primary Care Clinic going at the Lake County Health Dept., as examples). It is also of interest in my present business, the Coroner business.

Without proper and humane access to healthcare people die before they should.

Two themes revealed in a study published in the Journal that involved interviewing physicians regarding their thoughts about access to healthcare really struck me. They go beyond simply access, but more encompass how folks are often treated even when they get access, but aren’t treated up to standard (humanely).
Respecting the patient is key to quality care.
Understanding the patient is key in quality care.

The article has comments in these categories about not being judgemental, not making generalizations based on appearance, and the like. However consider a not unusual example, an individual presenting for care that is perceived as a drug addict with drug seeking behavior, so the exam and testing is cursory and treatment is thus “not all that great”. (one of my previous related posts) Now add a worsening co-factor: old tract marks on their arm. (Not true in the case referenced above, but may have been in others) The individual presents with pain. The severity of the pain is “discounted”, they are after all only “looking for pain medicine”.

I would caution healthcare providers that while some of these folks are indeed looking for drugs, even active drug users/abusers get sick and develop “real” medical problems that can end their lives, prematurely.

All people deserve access to proper, humane and quality healthcare.

Thursday, December 27, 2007

quick blogging

Just some quick blogging today with fun links (Case conferences and State's Attorney talks consumed the day):

Watch this video of nature’s non-lethal(?)firearm (who would have thought it possible).


Eco-friendly burials

Cremation was long considered more environmentally friendly than burials in graveyards, but its use of fossil fuels has raised concerns.

Biodegradable coffins are part of a larger trend toward "natural" burials, which require no formaldehyde embalming, cement vaults, chemical lawn treatments or laminated caskets. Advocates say such burials are less damaging to the environment.

Wednesday, December 26, 2007

Death this time of year...

A reporter asked me the other day if there were more suicides at this time of year. My answer was no. While we are often more acutely aware of them this time of year, they actually happen with greater frequency in the spring. We tend to be more acutely aware of all deaths this time of year. Folks and family are supposed to gather and celebrate this time of year, not die.

I also talked with the mother of a young person who died recently. We discussed how unfair it was that her “child” died. How unfair that he died so young, without fulfilling his potential. How unfair he was taken away, particularly at this time of year. His death was going to change things so much. The holidays would not be the same.

But death at anytime during the year is often “unfair”. Death at anytime during the year will change our holidays and our celebrations and our lives. Death is always sudden, even when it is anticipated. Death is part of life, but it is the part we want way off in the future, not here and now.

My condolences to all who have lost loved ones to death, particularly this time of year.

Thursday, December 20, 2007

Death by Hanging

Here is some stuff that you are not likely to see most any place else (it came up in recent conversations; some of my conversations take strange turns):

Hanging, and most strangulation, deaths are a result of vascular compression in the neck (not airway compression as is commonly thought). Compressing the blood vessels in the neck lead to either blood pumping into the head but not being allowed to exit (venous compression) or no blood pumping into the head (arterial compression). The end result of either is that brain cells are not fed with oxygen and sugar (the latter is fuel for function). The starved brain cells die. (This also explains why someone doesn’t need to be suspended to die by hanging.)

Arterial compression is the most “efficient” for causing death and most often the case in hanging deaths. Based on published data and observational studies, unconsciousness occurs in 6-15 seconds, at 1-2 minutes heart rhythm problems occur because of the brain cell anoxia, and death in 3-6 minutes (with irreversible brain damage in 4 minutes). [Do remember that there are no absolutes in medicine, so these times do vary individual to individual.]

In homicidal strangulation, the arterial occlusion is not so absolute, so the times are often prolonged. It is not until the victim loses consciousness that the arterial occlusion can approach total.

[Just as an aside (should I say in a different vein), severe arterial bleeding, like the carotid arteries, results in death in more like 10-20 minutes.]

Yes, I do get in strange conversations, but there are those that would like to eavesdrop and pick up on a few of these facts.

Friday, December 14, 2007

Emotional shock/stress can kill

Apparently, you can die of a broken heart or be scared to death or similar events.

Today (or yesterday) in the National Association of Medical Examiner’s listserv someone pointed to an article on Medscape (originally from Nature Clinical Practice Cardiovascular Medicine) about Takotsubo Cardiomyopathy, also know as stress cardiomyopathy.

It seems that extremely stressful events (either emotionally or physically stressful) can stun the heart. The stunned heart doesn’t pump well, there may be chest pain, and because it is epinephrine (or adrenaline) mediated there is also the risk of dysrthymia. Death can result either from the pump problem of the rhythm problem.

So stay mellow out there.

Thursday, December 13, 2007

The mystery of shipping for identification

Here is an imponderable: How do you get a body to the Center for Human Identification at the University of North Texas if none of the common carriers will handle/move body parts?

That came up recently because we were sending what turned out to be two sets of skeletalized remains there for examination and DNA identification testing. We contacted the usual companies that move packages around these United States and were told they do not allow the shipping of body parts (or most of a body for that matter). We contacted the folks in Texas and they reported that they get hundreds of shipments on a regular basis for their services.

How could that be? Well, as you can imagine, we solved our conundrum. We were able to send 2 sets of skelatalized remains to them for their services. One has returned and the family, after assurance of identification, was able to have services and burial of their loved one. The Center continues to work with the other set, but once the DNA matching is done those remains will also return to our office for release to his family for burial.

The cloaking of mystery, the remains go to Texas and return from Texas, but they can not be shipped. Sometimes it is best not to pull back the curtain.

Monday, December 10, 2007

NamUs growth will help Coroner's ID the unidentified

According to a 2004 Bureau of Justice survey there were over 13,000 unidentified human remains known to medical examiners and coroners in our country that year. Approximately 4000 unidentified human remains cases are handled each year and of those about 1000 remain unidentified after one year. We are working a one such case here in our office.

We need a better system to get these individuals identified and it seems it may finally be coming. It will be a dual database system developed by the Dept. of Justice’s Office of Justice Programs (with the cute name of NamUs), phased into existence over the next few years. One database will contain records of unidentified human remains and the other will contain missing persons reports centrally compiled. I think the best part will be that by sometime in 2009 there will be the capability for the system to compare the 2 databases automatically and put out possible matches without labor-intensive “hand” searches.

While all kids 18 years old and younger are currently entered into the FBI’s National Crime Information Center (NCIC), adult missing persons reporting into the system is much less consistent. Only some states require it be done and some agencies feel that adults have many reasons to “disappear” and so are sometimes less conscientious about entering their missing persons reports.

The Doe Network can be a help in these attempts at identification, but they are a page by page search system begging for improved searchability.

The new system will have information inputted by and will be searchable by coroners and medical examiners, law enforcement, and the public; but with different levels of information access. There are certainly times when we all can use all the help we can get in difficult identifications.

Currently unidentified human remains are entered into the database and it is searchable, but not easily and without as much automation as computer searches should allow.

This is going to be a great tool in helping with difficult identification cases.

Friday, December 07, 2007

Lots of ways to die

Well that was interesting.

I got a call today from someone with Spike TV. She was doing research for an upcoming show and had a question for me. Apparently they will be doing a series about strange ways people die (1000 of them). The death she had questions about was a hyperthermia death while skin diving.

Apparently an individual made their own wetsuit (nothing like an amateur hobbyist). The plastic he used (salvaged from a waterbed) was too impervious to the loss of his body heat and he died of hyperthermia.

What she wanted was a list of stages he and his body would have gone through prior to his death for a graphic they are making to show during the broadcast. She said the graphic would be like they show on CSI, which didn't help me, because I don't watch the show. I laid them out for her: profuse sweating, muscle cramps, weakness, headache, nausea, loss of sweating and flushing, rapid pulse, difficulty breathing, confusion, agitation, possible hallucination, seizure, coma, and then death. She wrote them down, read them back to me and thanked me. Goodbye.

Another day and another brush with fame (I doubt she will credit my contribution, but we will see; if I ever see the show). Fun none the less.

Update: Got called back. It seems the guy was not skin diving, but "jumping around" in this homemade plastic "suit" in relatively hot weather. That is not a good thing, as you can tell by this guy's outcome.

Thursday, December 06, 2007

Electronic control devices and death

I have been following an ongoing discussion of electronic control device use associated death (aka Stun Gun, etc; yes, I am avoiding naming name brands).

There are folks that say the deaths don’t happen do to these devices (heavily weighted by manufacturer representatives and those whose speaking fees are at times covered by manufacturers). They contend that somewhere in the neighborhood of 600,000 law enforcement folks have been zapped in training demonstrations without a reported death, so how can you say that they kill?

But deaths have been reported related to the use of these electronic control devices and not just the weird one’s like the gentleman who was zapped after dousing himself with gasoline and was set afire or the gentleman zapped on the edge of a bridge, knocked off and drowned.

From reading available materials it seems that the cause of death is likely related to 2 causes with a third less supported possible cause.

First, is the possible of a heart dysrythmia causing death. These folks collapse and die quickly, in around 20 seconds. Likely for this to occur the prongs have to hit the individual in the chest over the heart and the individual must be relatively thin (the electric shock does not penetrate very deeply). Nobody knows if someone at greater risk for dysrythmia is more likely to develop them with zapping, not a doable study.

The second possible mechanism of death is increased physiologic “stress”. This stress results from muscle contraction of patterned tonic-clonic muscle effects superimposed on catecholamines released due to pain and fear, often with a contribution post-exertion effects on the body. These folks die with a terminal collapse within minutes (“few to many”) of the last shock they received.

I would also like to mention here that both of the above mechanisms are made more likely by the superimposition of adrenergic-like drugs, e.g. cocaine and methamphetamine.

The third proposed is asphyxia related to muscle tetany or excessive tonicity from the zap. This may be a contributor in cases of prolonged administered shock seen in some cases with certain equipment, but seems uncertain. As mentioned above the electrical current doesn’t penetrate far so it is generally unlikely that this would contribute in any but a few rare cases (there are no absolutes in medicine). I should mention here that it is thought that the generalized apparent muscle effects seen with the use of these devices is a secondary spinal nerve effect. However, again, no one is going to do a randomized, controlled study to define the effects of these devices, there is always that rare risk of death no matter what some folks say.

Tuesday, December 04, 2007

Thrill Rides Kill

I saw this article about the dangers of carnival and theme park rides today, and while there isn’t much riding going on around here at this time of year, it ought to be at least thought provoking.

These rides are not safe, no one is tracking their safety record, infrequently is someone working to ensure they are safe, and parents should be concerned.
…supermarket shopping carts feature a more standardized child-restraint system than do amusement rides, which can travel as fast as 100 mph and, according to federal estimates, cause an average of four deaths and thousands of injuries every year.

I have wondered about these rides for years, especially the traveling carnival ones, but after reading this article I am convinced that they ought to be policed or shut-down. I don’t mean to be a kill-joy, but why should we allow children to be put at risk needlessly.
Theme parks won their exemption in 1981, after a CPSC (Consumer Product Safety Commission) probe of ride accidents at Marriott theme parks alleged a coverup of safety hazards…The exemption was included in an omnibus agriculture bill that year, leaving oversight of theme parks to disparate state programs, including some lacking inspectors or enforcement powers. Family activists and state regulators say that as a result, efforts to find and correct safety problems have been inhibited, the number and extent of ride injuries remains uncertain, and families have been prevented from assessing the risks posed by roller coasters and Ferris wheels, wave pools and spinning rides.

Here is an issue that needs pushing to federal legislators. It ought to be a slam-dunk, saving kids lives and limbs. We must fight back against “big business” influence that limits action on this issue. Kids are dying and being injured. The time to act is now, before it happens to another kid.

Monday, December 03, 2007

Heroin deaths, not just for the young

I was talking with a reporter from Fox News (Chicago) last week, because they were going to do a story on a large drug bust here in Waukegan. It was a heroin centered bust and the police had said it was triggered at least in part due to heroin overdose deaths, so she was looking for information.

I discussed with her that so far in 2007 we had had 3 heroin-only overdose deaths and 12 others with heroin and other substances. The thing that really seemed to catch her attention was the ages of the overdose victims. The ages ranged from 18 to 53. She was amazed that folks that old died of overdose or that folks that old did illicit drugs. While it is true that most of these deaths were in young adults, 3 of them (20%) could have been (may have been) AARP members.

Heroin use and abuse is not restricted to the young, it is not restricted to poor n’er-do-wells, and it is not restricted to “bad neighborhoods”. Heroin, as is true with all drug abuse, can and does cut across socioeconomic strata. We, as a society, need to realize that and understand the ramifications of that. If we realize that it isn’t just “them”, we can more rationally work toward prevention and treatment. It is not someone else’s problem, it is ours.