Unusual death from reader comment (question)

(sorry for the caps, that's how it came to me)

DR KELLER. I HAVE BEEN READING YOUR INFORMATION REGARDING COCAINE AND OVERDOSE. I TOO HAVE A QUESTION..ANY HELP WOULD BE SINCERLY APPRECIATED...
25 YEAR OLD MALE GOT INTO A FIGHT..
RECIEVED A STAB WOUND TO CHEST.
WOUND WAS 1.8 -BY 0.5 IN WOUND.
PENETRATES THE PERICARDIUM AND THEN THE HEART, NEAR APEX INTO THE RIGHT VENTRICLE. WOUND OF HEART IS 1.3 CENT ACROSS. WOUND DOES COMMUNICATE WITH THE VENTRICLE CHAMBER. ASSOCIATED WITH WOUND WAS A 300 MILLITER HEMOPERICARDIUM.

ONE LUNG IS 420 AND THE OTHER IS 380.GRAMS
HEART 350 GRAMS.
STOMACH CONTAINED 800 MILLI OF FOOD AND NOTED WAS A MALTED BEVERAGE ODOR.

TOX REPORTS STATES
PERIPHERAL BLOOD ETHYL ALCOHOL 0.068 G/100ML
BENZODIAZEPINES POSTIVE
CANNABINOIDS POSTIVE
COCAINE/METABOLITES POSTIIVE
TRICYCLIC ANTIDEPRESSANT POSTIVE
CARISOPRODOL POSTIVE
OPIATES POSTIVE

MARIHUANA [THC] 0.004 MG/L
MARIHUANA METABOLITE [THC-COOH] 0.005 MG/L
COCAINE 0.059MG/L
COCAINE METABOLITE [BENZOYLECGONINE 0.958MG/L
MEPROBAMATE 0.869MG/L
HYDROCODONE 0.035MG/L
HGB ALC 5.6%

AFTER HE WAS INJURIED HE WENT BACK INTO THE HOUSE AND DID MORE COCAINE.. THEN CALLED FOR 911. HE WAS ON THE 911 TAPE SNORING AND THEN PASSED OUT. YOU CAN HEAR WHAT SEEMS LIKE BUBBLING SOUNDS IN THE BREATHING.THE AUTPOSY REPORT SHOWED GASTRIC CONTENTS IN THE BRONCOHOLS. HE WAS REPORTED SHALLOW BREATHING AND PULSE RATE OF 46. ON THE WAY TO THE HOSPITAL HE DIED. WHAT IS THE POSSIBILTY THAT HE SUFFOCATED ON THE GASTRIC CONTENTS OR OVERDOSED ON THE DRUGS?? THE 300 MIL BLOOD IN THE PERICARDIUM SAC BEING DELAYED [ CONTINUING AFTER DEATH]
TIME SPAN WOULD HAVE BEEN APPOX 10MIN AFTER EMS ARRIVED BP DROPPED.
ARRIVED AT HOSP 15 MIN LATER UNDER TOTAL CPR. TOTAL TIME APPOX 28-30 MIN.
MY QUESTION IS COCAINE / DRUG OVERDOSE CONSISTANT WITH THE GASTRIC ASPIRATION. AND WOULD THE DEATH HAVE OCCURED BY THIS BEFORE THE INJURY CREATED THE 300 MILL.
BLOOD IN THE SAC??
THEY DID ALSO ADMISTER EPINEPHRINE 3X AND ATROPINE 3X .

PLEASE HELP SHINE SOME LIGHT. THANK YOU

My reply:

It would seem most likely that he died of the stab wound. The wound into the ventricle will send blood into the pericardial sac. As the pericardium fills, blood return to the heart stops with tamponade and continued filling stops. In addition, as the heart stops beating no more blood flows into the pericardium, because of the loss of pressure in the ventricle.

The aspiration of stomach contents may have occurred just before death, but is just as likely with resuscitative efforts in this case.

Certainly the cocaine didn’t help him, but was likely more a confounder in this case than anything. Cocaine (with his Soma and hydocodone) may have contributed some, but vomiting due to them at these levels would be somewhat unusual.

Brown Bag Review to save your health and life

A Tribune article this morning talks about a recently released study reiterating the point that drug-drug interactions are very common and can cause serious problems, particularly in “older” folks.

Overall, 1 in 25 older adults risked serious drug interactions, the study found. For men ages 75 to 85, it was as high as 1 in 10.

It also points out the dangers of over-the-counter meds in these situations. Quite often folks really don’t consider over-the-counter meds as medications, even when asked by their healthcare provider.

"The public has an awareness that two prescription medications used together might be dangerous," … "But what people don't fully appreciate is that non-prescription drugs can interact with prescription drugs and even other non-prescription drugs."

Always talk with your healthcare provider about possible drug-drug interactions when they start you on a new medication or before you start an over-the-counter medication or herbal supplement. Also, you should request an annual “brown bag review” (I wrote an article for EM Reports about that recommendation years ago). In a “brown bag review” you bring in all the medications you are taking, including over-the-counter and “herbs”, and you do a sit down face-to-face review of them with your healthcare provider.

Stay safe and stay alive.

Increased THC Content in Today’s Marijuana

In the name of arming parents and others with factual information, I thought I’d pass this along:

The potency of marijuana, measured by the presence of its (psycho)active ingredient, THC, has tripled since 1987, according to the latest figures from the Department of Justice's National Drug Intelligence Center

The new data from the University of Mississippi Potency Monitoring Project … was released in the 2009 National Drug Threat Assessment. [which brings to mind a question; Who knew there was a potency monitoring project?]

The new pot is certainly [more potent], but it's nowhere near as strong as some war-on-drug advocates have contended. The old White House drug czar, John Walters, has said publicly that marijuana's THC content has "increased as much as 30 times," which researchers say is not supported by the available evidence.

So in addition to pointing out the study finding that the most potent marijuana found by the folks at Ole Miss was 37% THC; the article makes two last points. First, as a point of reference, in the Netherlands their medicinal marijuana, meeting government standards, has a minimum potency of 15% THC. Second, most pot smokers control their consumption based on potency like alcohol drinkers vary volumes of consumed beer and other spirits based on their “potency”.

Nonetheless, the facts are that marijuana is getting to be more potent, its intoxicating effects will be more pronounced than those experienced by consumers in the past, and it is illegal, other than medicinal use in something like 13 states here in the US.

Don’t try and scare folks with false claims, like John Walters tried, use facts and remember: “this isn’t your father’s marijuana anymore”.

A Cavy for Xmas Dinner

This hit the papers a few days ago, so I thought it might make a cute pre-holiday (except for those of you in the midst of your holiday) post:

Are hard times threatening your Christmas dinner? Well then, Peru has the answer: guinea pig.
Officials … hailed the Andean rodent as a low-cost, low-fat alternative to a traditional turkey Christmas dinner.

(And I found a photo of one that could make a meal)

Guinea pigs are a fairly common food item in Peru. They do sound healthier to eat than some stuff we eat (low fat) and less expensive than say a standing rib roast. So does that make them about the 5th “other white meat”? How do I tell the kids that it isn’t chicken?

Healthcare cost-sharing contributes to morbidity and death

I came across an article published in The American Prospect Online via AlterNet. The article is entitled “Lessons from the ER” and it relates the author’s thoughts about his wife’s recent healthcare system experience. I wanted to highlight one part of the article that is certainly not the only point of the article, but it caught my eye because it relates to a recent discussion I had. I recommend you read the whole article.

First to throw out a teaser for the article as a whole:

Several people made mistakes in Veronica’s care. The worst and most deadly mistake was ours: going to this urgent-care center.

Do read the whole article (link above).

To the point I wanted to draw out here. Part of the reason that they went to the urgent care center was consideration of their co-pay and deductible. The author mentions a RAND study from 25 years ago that resulted in the nearly universal insurance feature of the co-pay. The study’s

most potent finding was that people who got free care used 40% more services than did others assigned to cost-sharing plans. Yet the free care produced little measurable additional benefit for the average patient.

From this co-pay and deductibles grew and flourished

To discourage inappropriate care

However, you really need to key in on the “average patient” phrase and wonder for which patients there was “additional benefit” and is there a way to separate them from the group to ensure maximum benefit for each individual patient. Did “overutilization” save a life or cut down on morbidity for some individual?

The author goes on about the study:

Co-payments did discourage wasteful use…relatively non-urgent categories such as sprains and back pain were 47% less frequent in cost-sharing plans [hopefully not an aneurysm causing the “non-urgent” back pain]. Unfortunately, co-payments also discouraged appropriate use…Most patients cannot reliably distinguish appropriate from inappropriate ER use [particularly at the time of the pain/symptom]…

Co-payments and other cost-sharing, which insurance companies and purchasers of insurance are pushing to new highs, can and do contribute to health crises and, even, death. This “remedy” for rising health insurance premium costs is a failure and worse, can be a cause of death. Our current system needs an overhaul at least or replacement with something better for all concerned.

The travails of cocaine use (ultimately death)

Probably of more interest to people who don’t read my blog, but:

The price of a gram of cocaine in the US soared 89 percent -- from 96.61 dollars to 182.73 dollars -- from January 2007 to September 2008, said the Drug Enforcement Administration (DEA) in a report.

…cocaine purity dropped during the same period from 67 percent to 46 percent

To increase profitability suppliers cut potency by mixing it with a wide variety of other substances -- an often dangerous practice.

Nonetheless key to remember: Cocaine kills, there is no safe amount of cocaine, you never know what you are getting/buying.

So now you have to spend more to die high; or maybe not quite high, if the amount is enough to kill you (or the adulterants a poisonous enough), but not quality cocaine enough to get a buzz on for you.

Teens speak up to stop deaths

I was reading an editorial in a school newspaper recently (Stevenson High School Statesman, no link) and I thought I’d share a bit of it. I really liked it and I hope the students read it and take it to heart. (Someone recently suggested I should also get my message out in school newspapers, so this was a cool edition.)

The editorial’s head line is “Student silence on drug issue continues to create tragedies”. As is often the case with newspaper work, the first sentence and final paragraph sum up the editorial quite well:

As more students, families and communities become afflicted by the aftermath of excessive, and often uncontrolled, drug use, it’s time for Stevenson students to take a stand against future losses and a problem facing society right now.

Tell someone [about teen alcohol and/or drug use] before it is too late. Don’t lose a friend because you were worried about their reaction. Anger is temporary – death is not.

The editorial talks about friends being lost, death and tragedy, related to drug use and what a fellow student can do about it. Talk to the person, tell a counselor or faculty member personally or anonymously, use the “drop-in center”, talk to other friends, push to get them help. It is time we all did our part to stop this “death and tragedy”. Speak up. Speak out. It is not OK.

Anger is temporary – death is not.

(One last note: A talk I gave about teen drug and alcohol use and comments I made during an interview are featured in a front page article, the students involved in all this are to be commended.)

Contagious happiness

Happiness is contagious, new study finds…

So suggests a new study proposing that happiness is transmitted through social networks, almost like a germ is spread through personal contact. The research was published Thursday in BMJ, a British medical journal.

Go out and infect someone this week end.

The uninsured are everywhere (and they are dying)

From a Chicago tribune newsblog:

13.3 percent of 50 to 64 year old Illinoisans -- 287,084 adults -- are uninsured.

What I think would really surprise folks is that of those 287,000 uninsured folks only a quarter have incomes below the poverty line. We often dismiss the uninsured as folks who are low-income and disenfranchised in other ways as well. But the uninsured are folks just like you and me.

These are often folks who can’t get health insurance in the open market because of pre-existing medical conditions. Think about it, people who need health coverage the most are excluded. Therefore these folks will get/be sicker. Their health problems can affect the community as well. They will have increased use of the ER and emergent hospital use, which means more expensive healthcare for them and others who’s medical insurance and other payments pickup the tab for the unreimbursed care.

Something has to be done with the system now. The lack of healthcare coverage is hurting folks like you and me, it is dragging down the economy for a number of reasons, and we are seeing people dying as a result of our broken system. It needs to stop.

Want some more information? HCAN (Health Care for America Now): A great movement and good site of information.

Suicide Prevention Hotline mention

News Sun 11-28-08

DART
Another sign of stressful times? The National Suicide Prevention Hotline (1-800-273-TALK), in business less than four years, has answered its one millionth call. Linked to 133 local crisis centers across the nation, it instantly links callers to a counselor closest to their location, 24/7. The hotline is also linked to a special service for veterans and their family members. Hey folks, it ain't that bad. Unless your a Wall Street broker, that is.

A bit flip at the end, but to paraphrase a saying "any time you can get you topic in the paper, it is a good thing". My letter in response:

Thanks for including information about the National Suicide Prevention Hotline in your “Darts& Laurels” November 28, 2008. We need to take advantage of every chance to get out information about suicide and that it is alright to reach out for help if you have thoughts of suicide.

Suicidal thoughts usually have antecedent depressive thoughts, but not always. Taking one’s own life can be an impulsive act on top of that depression, but there is often a time of thought and contemplation. If you can get a handle on that driving toward the “solution” of death, if you can expand your options, realize that there is another way, often death by suicide can be averted. That is what crisis lines are for. They can be quite effective.

Let’s hope that crisis lines can continue to exist in these times of budget cutting. Let’s hope folks realize they can reach out in that way and talk with someone who is willing to listen, help and give a bit of hope. It is often “that bad”. You are seeking deliverance from the pain you feel in your body, in your mind and in your psyche. Seek help. It is OK to get help. You are not “crazy”; seeking help does not mean you are crazy. Sometimes you just need help. National Suicide Prevention Hotline (1.800.273.8255 (TALK))

Richard L Keller, MD
Coroner

Fighting dementia

They call the article “5 ways to keep Alzheimer’s away”, but it really talks about 6. After mentioning the recent Journal of the AMA article which found ginkgo biloba of no help in warding off dementia, it mentions others with some support.

Certainly, physical exercise and mental exercise are helpful and probably have the least conflicted evidence behind them, so they are easy to recommend. Physical exercise has been shown to keep folks sharp and to at least some extent improve established dementia. I also agree with the article that the mental exercise needs to be varied (“cross training” they call it, with the analogy of only doing pushups developing only the arms). Social interaction should also be included this category. It stimulates the mind and the body and is clearly good for the psyche, a trifecta of anti-dementia goodness.

Their other recommendations have a bit more checkered evidence backing them up. They recommend antioxidants (e.g. vitamins A, C, and E) which have some support, but overdoing them (particularly vitamins A and E) may not be good and may cause some harm. But do remember “all things in moderation”. Also recommended are phosphatidylserine supplementation, fish-oil supplements, and adding curry to your diet. I think the support is slim for these, but for the most part they are not likely to cause harm. I think the curry (e.g. in Indian food, one of my favorites) is a particularly fun and tasty way to work against dementia, so go for it.

Use-lose law; not OK to not enforce

There was an article in the Chicago Tribune a couple of days ago about the “use-lose” law under which underage kids caught (and convicted of) drinking or being drunk have their driver’s license suspended for a short period of time (3 months with a first offense), even if driving was not involved in or around the drinking incident.

I think the law is an important step forward in limiting underage drinking and the deaths that result from underage drinking. Keep in mind that many of those deaths do not involve driving, nor do most incidents of date rape (alcohol is the number one date rape drug), but affecting their ability to drive will get their attention and is an effective punishment.

I think it borders on criminal that the enforcement of the law is inconsistent (the focus of the article) and think it is great that Lake County leads the state in enforcing the law. Let’s keep it up.

One comment irritated me:

"It is still going after the child, who is a victim of the alcohol industry," said Janet Williams, co-chairwoman of the Illinois Coalition to Stop Underage Drinking.

It is nonsense to think of these kids as victims. While I agree that some ads and some alcohol containing beverages are aimed at kids, it is wrong to write the kids off as (apparently) brainwashed victims. We can give kids the tools to resist this brainwashing if it is taking place at all (making something attractive doesn’t demand use). [The “brainwashing” if it is there at all is more following observed patterned behaviors of others.] We need to put information in their hands and in their heads about the effects of alcohol on their brains and the effects of alcohol on their lives (and deaths). It must be given to them truthfully, repeatedly and in various forms. Their parents and their schools and society must all do their part.

We must be consistent in communicating that underage drinking is not OK.

I will continue to do my part; you must get the information and do yours as well.

Make good choices, don’t take chances.

Crying for what's wrong with you

We all have experienced that crying makes us feel better, but now there are studies that show that crying has health benefits as well.

It makes nine out of 10 people feel better, reduces stress, and may help to keep the body healthy. It's also free, available to almost everyone, and has no known side effects, other than wet tissues, red eyes and runny makeup. Crying may not be a blockbuster drug, but the latest research suggests it's highly effective at healing, and that it improves the mood of 88.8 per cent of weepers...

We cry out stress hormones. Crying stimulates the release of endogenous opiates for pain relief. Crying may help rebalance the body's electrolytes.

So treat yourself to a sad movie and have a good cry from time to time. It can help restore psychological and physiological balance in your life.

Being sad ain’t all bad.

Fun "health" facts

I was reading the Chicago Tribune last Sunday and they had a fun fact list in a sidebar that they had gotten from “The Germ Freak’s Guide to Outwitting Colds and Flu’ and “Germ Proof Your Kids” I thought I’d share some of them:

3 feet: the distance droplets can travel after a cough of sneeze
20 feet: the distance fecal bacteria can travel from the toilet after it’s flushed

49: the number of germs, per square inch, on a toilet seat
25,000: the number of germs, per square inch, on an office telephone

Don’t you just love cool, mostly worthless “health” facts?

So don’t lick a phone at work.
However, knowing that you have “100 billion bacteria in your mouth”, maybe you wouldn’t notice.

Psychache

A friend of mine recently sent me a link to a blog that had some interesting comments about suicide. I thought I’d post one such thought provoking paragraph:

In our average lives we say “I could never take my own life”. We say this from a safe place, able to deal with lifes ups and downs. THIS CAN AND DOES CHANGE. If we lack or lose the ability to handle our emotions, negativity and frustration step in. we start moving towards the spectrum of suicidal thought. we feel we are not coping and life becomes a struggle. The constant struggle seems endless. our needs are not met and we slowly slide into wishing it was all over.

In another place the author of the blog uses a great word (neologism) that fits suicidal thoughts (and other mental health issues) very well: psychache. (I warned them that I was going to use their word)

These are things we need to consider in working to prevent suicide, in working to get folks help that they need, and in understanding the problems that swirl around suicide and mental health. We must not only work to prevent suicide, but work to help them deal with their psychache.

and the elderly selling gravesites for cash...

I thought the last post a bit strange and unsettling, then I saw this one (click through the ad in the link):

For some, a tough economy means hocking their possessions to raise cash. And not just furniture or jewelry. In lean times, even a person's final resting place is for sale.
Activity in the secondary market for burial plots has spiked in recent weeks, according to Bob Ward, who runs the Final Arrangements Network, an online marketplace for buyers and sellers of cemetery space. Most of those looking to sell: fixed-income seniors in their 60s and 70s.

New barometers of financial woes?

The dead evicted

(These are busy times, sorry for the inconsistent posting.)

I came across this article and it struck me for several reasons, so I thought I’d share:

The bodies of five people and cremains for 22 others are on their way to a county medical examiner's office after the funeral home sending them to their place of rest was foreclosed on Friday morning.

Who knew there was a risk of eviction after death?

And then the interesting name of the funeral home (and crematory?):

House of Burns Memorial Chapel

Apparently funeral home staff declined to comment for the article:

"You don't want to let nobody know nothing — you just want gossip," the woman said, adding "have a blessed day" before hanging up.

I don’t bring this up to gossip. Can you imagine such an occurrence? The irony of no rest even for the dead, "have a blessed day" indeed. (I will close saying that they do seem to be handling this unfortunate situation well)

Increasing Suicide Rate

After a decade-long decrease, U.S. suicide rates have started to rise, largely because of an increase in suicides among middle-aged white men and women

A new study out of Johns Hopkins demonstrates increasing suicide rates 1999 through 2005. It also seems to show that those in middle age are more at risk than previously thought. Historically, those at greatest risk were youth/young adults and seniors, but nationwide that age dipole is changing. For many years here in Lake County the ages have been more evenly spread, as has the geographic distribution over the county.

Just as the article wonders (linked here), it has certainly crossed my mind that the present economic “downturn” is likely to affect these demographics. It is early yet, but economics and other problems have always compounded the effects of depression to contribute to the risk of suicide.

Indeed:

"The key is getting people into treatment and getting people to use the resources that are available to them."

[Just a note: we will be sponsoring a site for a local broadcast of the annual American Foundation of Suicide Prevention (AFSP) National Survivors of Suicide Day event (Nov. 22, noon, Mundelein Fire Dept., 100 Midlothian Rd). Last year when we held the event it was a very interesting shared experience for all of the attendees and included an insightful local discussion.]

"Went to a Party Mom "

I got this today in an email forwarded as a promotional for MADD (Mothers Against Drunk Drivers). Check them out; help them out if you can.

I have heard this read at pre-prom events several times. I can’t hear it or read it without getting choked up:

Went to a Party Mom

I went to a party,
And remembered what you said.
You told me not to drink, Mom,
so I had a sprite instead.

I felt proud of myself,
The way you said I would,
that I didn't drink and drive,
though some friends said I should.

I made a healthy choice,
And your advice to me was right.
The party finally ended,
and the kids drove out of sight.

I got into my car,
Sure to get home in one piece.
I never knew what was coming, Mom,
something I expected least.

Now I'm lying o n the pavement,
And I hear the policeman say,
the kid that caused this wreck was drunk, Mom, his voice seems far away.

My own blood's all around me,
As I try hard not to cry.
I can hear the paramedic say,
this girl is going to die.

I'm sure the guy had no idea,
While he was flying high.
Because he chose to drink and drive,
now I would have to die.

So why do people do it, Mom
Knowing that it ruins lives?
And now the pain is cutting me,
like a hundred stabbing knives.

Tell sister not to be afraid, Mom
Tell daddy to be brave.
And when I go to heaven,
put ' Mommy's Girl' on my grave.

Someone should have taught him,
That it's wrong to drink and drive.
Maybe if his parents had,
I'd still be alive.

My breath is getting shorter,
Mom I'm getting really scared
These are my final moments,
and I'm so unprepared.

I wish that you could hold me Mom,
As I lie here and die.
I wish that I could say, 'I love you, Mom!'
So I love you and good-bye.

Ceiling fan may help prevent SUID/SIDS

We would all think it great to come up with another “simple” intervention to further lower the risk of SIDS (better termed SUID: Sudden Unexplained Infant Death). A recent study may have come up with such an intervention. The study showed that circulating the air in the infant’s bedroom with a ceiling fan (but not just having a window open) lowered the risk of SIDS death

So remember (and tell all new parents): “Back to Sleep”; firm mattress; minimal, non-downy blankets; no bumper pads, pillows or soft toys; keep them cool at night; and (apparently) install a ceiling fan.

Underage drinking is not OK

I was part of a panel today talking about underage drinking, presented to a group of parents. We discussed its effects and its prevention, my portion was the effects of alcohol on the adolescent brain.

I led with a comment about an incident written about in the Chicago Tribune today. A limousine driver reported underage drinking among some teens he was driving for homecoming. He turned down a payoff attempt and did the right thing. My feeling is that he should get an award:

Limousine driver Leonel Cesar says he was just doing his job when he called police to report that a group of Highland Park teenagers tried to smuggle booze into his "party bus" on homecoming night

Later in the article was a comment about the “Safe Rides” program:

Similar debate surrounds the Safe Rides program in New Trier Township, which allows student volunteers to pick up their intoxicated peers from parties, no questions asked.

I will only contribute to the “debate” by relating a recent death here in Lake County (I did write about it shortly after it happened). I closed my part of the panel with a mention of the incident, as well. A young man (18 years old) was driven home after a party involving at least one “drinking game”. The young man later died of an alcohol overdose, his ride, while not part of the “Safe Ride” program, certainly did not have a safe outcome.

Underage drinking is not OK.

Don’t take chances. Make good choices.

Remains to Hungary

Nice to report:

A young lady whose skeletalized remains were found May 12, 2007 is on her way to Hungary to be buried by her father. While it is quite likely she died of a drug overdose (drugs were found in the clothing she had on) we can really only conjecture because of the condition of her remains.

While it took a while to make all of the arrangements, we are finally able to reunite at least this part of the family (even in death)as her father wished.

Fake crack

Whoa, a whole week without a post. Either I am slipping or I was as busy as I seemed.

Anyway, I came across an interesting article today checking out online "coroner news" (after participating in a panel on underage drinking information and prevention).

In Cincinnati they are apparently seeing an upsurge in “fake crack”. Now that is not something we have seen here (we have seen both fentanyl and diphenylamine masquerading as heroin, but not fake crack), but I thought it was interesting. We will certainly keep an eye out for it now, although it doesn’t seem very likely that users of fake crack will end up in our office:

Owens said that in recent days, up to 60 percent of the drugs sent to his office for testing on a given day turned out to be fake, usually made of high concentrations of vitamin B3.

Out Of The Darkness Walk

Support the American Foundation for Suicide Awareness Out of the Darkness Walk October 4 with a donation or walking yourself:

WALK TO SAVE LIVES... In the United States, a person dies by suicide every 16 minutes, claiming more than 32,000 lives each year. It is estimated that an attempt is made every minute; with close to one million people attempting suicide annually.
By walking in the 2008 Out of the Darkness Community Walks to benefit the American Foundation for Suicide Prevention (AFSP), you will be walking with thousands of people nationwide to raise money for AFSP's vital research and education programs to prevent suicide and save lives, increase national awareness about depression and suicide, and assist survivors of suicide loss.

You can donate generally or if you want a specific team to support: “This Team is for Roo Joey Fischer” (If there are any other local teams, send me the info and I’ll put them up here)

Alcohol over-use kills

I am preparing for a series of talks that I will be giving next month regarding the effects of alcohol on the adolescent brain. It will be part of a panel presentation regarding underage drinking prevention that a group is presenting at 4 sites. I have spoken on the effects of alcohol on the adolescent brain at several venues, so it is primarily a matter of fitting my presentation into the panel presentation.

Of interest to this note is that at one of the group meetings one of the others involved asked me to be sure to specifically mention “alcohol poisoning”. (We also discussed my including the fact that alcohol is the ‘number one’ date rape drug)

We don’t see alcohol overdose deaths in underage drinkers very often, most cases get intervention before they die. While it is an infrequent cause of death, we had one in our county this week. A young 18 year old man died of alcohol overdose (who, as fate would have it, went to high school with my daughter). My daughter described the memorial service to me last evening; many of his friends spoke highly of him and spoke of the tragedy of his death.

We often forget that alcohol kills, not just through car crashes, but because it is itself a toxin, a poison. Consumed in large enough quantities it can and does kill. Adolescents are particularly at risk because they tend to binge drink (5 or more drinks in rapid succession) and do not get the drowsiness shut off cue that most adults get.

The relatively new Illinois felony “social host” law will likely be invoked in this case: if great bodily harm or death results, the parent (host) faces possible imprisonment and possible significant fines.

Kids shouldn’t die when they are still kids
Think, don’t take chances, make good choices

Response to a query, hoping to help with information

I thought this comment/email exchange might have answers of interest (and help) to others (related to Cocaine and Death):

My friend died last year and the autopsy listed Acute fulminant pulmonary edema & congestion, Acute visceral congestion,Moderate hepatomegaly, early CAD under findings. Under Toxicology, there were several drugs listed under Comprehensive Blood Drug Screen; Alprazolam: 15 ng/mL, Citalopram(trace)Cocaine(trace)Benzoylecgonine: 1760 ng/mL & Metoclopramide(trace). Under Comprehensive Urine Drug Screen, there were Alphahydroxyalprazolam, Citalopram, Cocaine, Cocaethylene, Benzoylecgonine, Hydrocodone, Metoclopramide, & Oxazepam. The cause of Death is listed under Accident(Acute Cocaine Toxicity). What is the signifigance of such a large amt of Benzoylecgonine? and it says there is only a trace of cocaine so why is death listed as cocaine toxicity? Some friends have said he wanted to die but I never got that impression from statements he made. He had recently been hosptitalized w/pneumnia and was on a respirator for 2 weeks two weeks before his death. Does it sound like the a high level of the Benzoylecgonine caused his death or the combination of all of the drugs?

Benzoylecgonine is the primary metabolic product from cocaine. It has a longer half-life (the time in which ½ of the substance is cleared from the body) than the parent compound, cocaine, 6 hours as opposed to half an hour. Cocaine also continues to be metabolized by blood cells even after death.

These results are consistent with cocaine-induced death. It is not unusual to find a “trace” of cocaine in the blood in such a situation. Most of those types of death are accidental in that folks tend to consume all of the cocaine they have available, not saving some for later.

Thank you for your response!I would like to ask a couple of more questions as there has been so many unanswered questions and I have had a hard time dealing with his death. He had struggled with his addictions the past couple of years;I think what got him started was the prescription narcotic pain medication he received for legitimate back & shoulder pain. When he ran out and couldn't get more, he would get cocaine or other drugs like oxycontin from "friends". I don't do drugs so it was hard to deal with but we had been in a relationship for several years so it's hard to just leave. I finally had enough and left a week before he died but I was still stopping by every day and he had a Drs appt scheduled the day after he died to try and get into a rehab program. I came home and found him sitting up slumped to the side with a pillow with uneaten food on it. I just thought he was sleeping so didn't try to "wake" him up right away. Our dog was sleeping on his feet. I finally tried to arouse him unsuccessfully and took his blood pressure with the machine his Dr had given him and it said -0- so i called 911. They told me to get him on the floor and try CPR. When I tried to move him, he fell on the floor and hot water squirted out from under his arms and there was really a bad smell all at once. They came really fast and worked on him in the ambulance for quite awhile unsuccessfully before they took him to the hospital but I found out later he was already dead when they got there and most likely had been dead when I got there. He was only 44 so I have been haunted by the vision of him sitting there ever since. He was depressed that I had left but he wanted me to come back and he told me on the phone that morning that he felt pretty good so I really don't think that he committed suicide but some of his friends seem to think he did because of the high levels of drugs. Everyone has their own theory and there has been so many ugly rumors since then, it has caused me alot of grief. One of his friends said he brought him over a 72 hour morphine patch which he sucked all of the juice out of;Another rumor is that he went into a seizure and his friends got scared and set him up the way I found him and left. I think everyone was afraid there would be a Police investigation but there wasn't much of an investigation. They made us leave(the dog too) for 4 hrs. The CSI team came and took some pictures and took all of his medicine and left. It definitely wasn't like the TV show. One of his aunts said there was rat poision in his system. I am having a hard time dealing with his death even though it's been a year now as I feel guilty because I left and wonder if he did, in fact committ suicide even though there wasn't a note.I am confused about the amt of benzoylecgonine. It is in the form ng/mL. How is that in relation to mg/ML? Is 1760 ng/mL really an abnormally large amt? Also, did he most likely smoke it or snort it? The last time I talked to him was 10:30am. I found him @ 2:30 pm when I thought he was sleeping. What was the most likely time of death? The medical examiner put the time he arrived at the hospital but from what the firemen and ems guys said, he was dead when they got to my house because he flat-lined on the machine and didn't have any blood pressure. Even though, the autopsy says accident, I still wonder if he took his own life. He always told me he would never do that, that only cowards would do that plus he had food on his lap and I don't think a person trying to kill theirself would bother to eat but I really don't know. To sum it up, based on this post and my previous post, do you think he committed suicide? What is the most likely time of death? Do you think he suffered? and is the amt of benzoylecgonine a lethal amt? also, how does the ng/mL convert to milligrams per Liter? I have been trying to move on but it has been very difficult. It would put my mind at ease if you could answer these questions even if they are not the answers I want to hear. Thank you so much for your help!

The morphine (or possibly fentanyl) from the patch would have shown up in the tox testing. There are several ways to extract drug from those transdermal patches, sucking on it being just one. It would appear that if it did occur, he didn’t receive a significant amount.

Seizure activity certainly can occur at the time of death and has scared away “friends” in other cases, especially if the death involves some illicit activities.

“Rat Poison” most often involves a blood thinner; signs of its overdose would have been present at autopsy. Arsenic requires special testing, but considering the other tox results I would think it is unlikely.

Cocaine is not a “usual” means of suicide, it is used recreationally and, as I have mentioned, often overused. He tox results are very consistent with any number of cocaine-related deaths. There is really no way, now, of knowing how he took in the cocaine. We often swab the nostrils and screen for the presence of cocaine to discern “snorting”.

I doubt he committed suicide, he likely over-used accidentally, likely died within a few hours of getting to the ER, likely did not suffer (died quickly), and died as result of cocaine intoxication with lethal levels found in his system (remembering, too, that there are no “safe” levels of cocaine).

[Google can help you with the units conversions]

Hang in there, death of friend (particularly a close friend) is often devastating, you will not “get over it”, but the pieces can come back together and your life will continue with the memory and the grief. You can handle it.

Near-death study

I was sent a link to a Times article today:

A fellow at New York City's Weill Cornell Medical Center, Dr. Sam Parnia is one of the world's leading experts on the scientific study of death. Last week Parnia and his colleagues at the Human Consciousness Project announced their first major undertaking: a 3-year exploration of the biology behind "out-of-body" experiences. The study, known as AWARE (AWAreness during REsuscitation), involves the collaboration of 25 major medical centers through Europe, Canada and the U.S. and will examine some 1,500 survivors of cardiac arrest…

When your heart stops beating, there is no blood getting to your brain. And so what happens is that within about 10 sec., brain activity ceases - as you would imagine. Yet paradoxically, 10% or 20% of people who are then brought back to life from that period, which may be a few minutes or over an hour, will report having consciousness. So the key thing here is, Are these real, or is it some sort of illusion?

A point brought up in his interview was interesting because it actually went along with a discussion we were having in the office earlier today in discussing a recent death in our county. That point is that while we have the “social definition” of death being a moment, based on the “clinical definition” death is a process that occurs over time. While that process time is often very brief, there are times when it is prolonged. Not until the heart has stopped, breathing has stopped, and the brain has stopped functioning has death truly occurred. This is the crux of the discussion we were having, but to go a step beyond our discussion…

With these “near-death” experiences, do we also need to consider when the mind ceases to function as really defining death? As the interviewee states, most of the time the brain and mind are not separably observable phenomena, but on rare occasions we get a peek. The information that comes from this study will be interesting. Do we, as the article says, need new science to understand and study this? Will this “new science” give rise to the study of other phenomenology? This may be a first step.

Work-related brain teaser, Is it Murder?

Forgive the intrusion. I found your blog. Hoping you will read this and offer an assessment.

I am researching a reported suicide that took place in the early 20th century. I have an abstract of the autopsy report. I believe the suicide was actually a murder, that the scene was set by the murderer and that cause of death was not by Potassium Cyanide. Here is an excerpt:

"“These two brothers occupied a bedroom and kept house at xxxx. xxxxx was formerly a Roman Catholic priest disposed for immorality. Since leaving the pulpit Fr. xxxxx had been going to the bad, drinking and using his time chiefly in accumulating moral filth to throw at his bishop and other of his clerical brethren. The two were last seen alive at nightfall Dec. 7 by their brother. The latter came by appointment at 2:30 PM Dec. 10 and found the men dead lying in a reposeful altitude on the outside of the bed with their clothes on."

Autopsy: Decomposition in full progress. Blood and tissue fluid suggesting potassium cyanide. No sign of caustic irritant poison in stomach and intestines. Congestion of lungs, liver, spleen and kidneys. Both bodies alike in appearance. Chemical analysis failed to get desired reactions.

Any thoughts?

A strange case indeed, some thoughts:

As you seem to allude to, ingestion of potassium cyanide in toxic amounts usually causes erosions in the esophagus and stomach. The lack of that finding would cast doubt on ingestion of potassium cyanide in toxic amounts, intentional or not.

Death from cyanide inhalation would require the room being sealed fairly tightly (cloth in the gaps around the door, etc.). In a suicide by cyanide inhalation that “addition” to the room would have been found by the individual who found the bodies and others as they arrived on the scene.

Another point to consider here is that a cyanide death by ingestion or by inhalation is not a pleasant, calm death. To find the 2 victims “lying in a reposeful attitude” would be most consistent with their having been placed in “repose” after death, unless some very “peaceful” toxin/drug was taken. Just to mention something that should be obvious, pairs of people do not die of natural causes peacefully in their sleep next to each other.

The autopsy findings (e.g. organ congestion and the bodies “alike in appearance”) would be quite consistent with a toxin or drug-related death. Not knowing the ambient temperature (hotter temperatures speeding up the process of decomposition), it is possible that a cellular (cytochrome) poison would explain the hastened decomposition (the most common cellular toxins are cyanide and carbon monoxide), but the lack of erosions and lack of room “sealing” would seem to argue against cyanide as the cause of death. It is more likely that the bodies were in a hot enough environment to hasten decomposition (as a teacher of mine used to say: when you hear hoof beats think horses, not zebras).

So, all-in-all, I would agree that potassium cyanide is an unlikely cause of death in this case and, considering the information you provide, murder would be a definite possibility (that should certainly have been further investigated at the time).

Updated: One thing occurred to me after I fired off the reply email: in the early 20th century we really didn’t have all the “very peaceful” drug/toxins that we have today to kill ourselves and others. That, too, would limit many of the suicide options we have today being a cause in this case.

Coroner for healthcare reform

I was a featured speaker at something called “Health Care Speak-Out” last evening. I was assigned the task of speaking as an expert on the local healthcare safety net, based on my background and experience. (Note: there is overlap in some of the following year counts) I worked 17 years in ER Medicine, 9 years in HIV Primary Care (after help start the program in the Lake County Health Department), 13 years Primary Care (at HealthReach, a free medical clinic that I founded and served as a volunteer physician and Medical Director). In addition, I have served as the Lake County Coroner almost 4 years.

I have seen problems with our healthcare safety net in every one of these positions. As a matter of fact problems in our healthcare safety net that I saw drove me to do something about it (HealthReach and the HIV practice). I discussed the numbers of uninsured and underinsured in the area, what HealthReach and the Health Department have done to serve as the safety net, the inadvisability of use of the ER as part of the safety net, deaths I have seen due to lack of healthcare access, and discussed some individuals that have stuck out in my mind and are examples of what should not happen in the USA and why we need to change our healthcare system as a whole.

Others spoke about the Health Care for America Now initiative, the YWCA and their efforts in healthcare (primarily health screenings), and the difficulties of small businesses affording health care for their employees. It was a very interesting and well done event.

In addition, audience members were allowed to “speak-out”. I wanted to relate at least a bit of what one of the attendees talked about. I was definitely struck by his story. It is all the more reason to fight for change in our currently health (insurance) care system.

He owns a small business (more or less he and his wife run it) and is in his 50’s. His business got real busy for a stretch and they forgot to send in a monthly payment for their health insurance. A single missed payment to an insurance company he and his family had been insured with many years. He received a notice of cancellation, but when he tried to pay the skipped payment and get reinstated he was told he would have to re-apply, as if new customers. He went through that process, not really understanding why it was necessary, but was denied coverage. A short while before this reapplication he had been diagnosed with high cholesterol. Ultimately, he got his wife and children re-insured with the company, but he remains uninsured/uninsurable.

If he gets ill he fears he will bankrupt his family and business. He is afraid for his health, his life (physically and in the broader sense with his wife and family), his family. He spoke of some drastic plans.

This, too, should not happen in the USA.

Health care access is a nonpartisan, social justice issue worth fighting for NOW.

Anti-violence program for youth in Chicago

I was reading about the “In My Shoes” Program today. It is an anti-violence program run by the Schwab Rehabilitation Hospital in Chicago.

The article I was reading (sorry, hard copy no link) quoted a peer educator and program speaker with the program as saying: “When I was younger, I always thought that if I was in a gang, I would either end up dead or I would end up in jail. Nobody told me that there was a third possibility – that I might end up disabled and confined to a wheelchair [his current condition due to gang violence].”

The program does presentations for large groups and hands-on workshops for smaller groups. The workshop allows youth to experience what it is like to live with various disabilities. What it is like to eat or try to get dressed when you are paralyzed. What it is like to get around in a wheelchair and what other attendant problems of violence-induced disability are like.

Sounds like a great educational experience. Such truth/fact based information presented by peers has got to have an impact. They have proven increased awareness after their presentations, but behavior impact is a bit more difficult to demonstrate. It is hard to prove that something didn’t happen. Anecdotally, they do have some of that information.

I applaud their efforts and hope they can spread it around in the future. It would be a great progam to pattern after, locally. Here is a link with some program information.

They go to training

Cool training attended by some of my investigative staff recently. Other staff members will go in the future. One part of the death investigation course involved finding and recovering (with trace evidence) the bodies of pigs buried for some time as if they were homicide victims.

Crisis impulse + access to lethal means = suicide

In reading a recent article in the New England Journal of Medicine (I used to read it regularly, now it is rare that I do. I now follow links I come across or am sent, in this case via the NAME listserv) entitled: Guns and Suicide in the United States.

The points I’d like to highlight here, don’t so much have to do with guns, however the point that guns contribute to suicide seems to be valid to me as well as the authors of this review article. I think some of the information, similar to what I have covered before, bears laying down here:

…many suicidal acts – one third to four fifths of all suicide attempts, according to studies – are impulsive…
…many suicidal crises are self-limiting. Such crises are often caused by an immediate stressor…

Now that is not to belittle underlying depression and other mental illnesses as significant contributors to suicide, but the ultimate crisis of unbearable pain and/or need for deliverance is very often precipitated acutely. But do keep in mind that that is not always the case; suicide can be a result of a devolution of their psychic condition. This acute crisis paradigm tells us that we can prevent suicide in some cases by limiting access to readily accessible lethal means and that this fact must be considered in any programmatic attempt to prevent suicide deaths.

Too many seem to believe that anyone who is serious enough about suicide to use a gun [you could add in here any number of suicide methods] would find an equally effective means if a gun were not available. This belief is invalid…
Effective suicide prevention should focus not only on a patient’s psychological condition but also on the availability of lethal means – which can make a difference between life and death.

Got to use car seats for kids

I (and everybody else) can not say it enough:

Make sure your child is properly restrained in their car seat before you drive, every time, without exception.

We had a recent crash in which that caveat would have saved a small child’s life. I say that not to condemn that mother, but so we don’t have to tell another mother that that is the case.

I also want to say that none of us are perfect. I remember setting out on a car trip years ago. I was an ER Doc at the time, so was acutely aware of the need for proper child restraint, but I looked in the rearview mirror and my daughter was in the process of extricating herself from her car seat. My heart leapt and I quickly pulled off the road to refasten her. I don’t know what I had done wrong the first time putting her in, but I was certain she was “in” properly from then on through her years of riding with me (She is now 18 and has been doing her own seatbelt for several years now). That vision of her “Houdiniing” was often in my mind as I did up the fastening.

The National Highway Safety Administration has a wealth of information on “highway” safety, including stuff on car seat safety with links to find someone who can inspect your child’s car seat to make sure that it is a safe one, that it is installed properly, that you understand how to use it properly, and that it has all its parts.

Regular folks can report drugs and doctors

I was talking with the mother of an individual who died recently. As she mentioned, neither of them are young, but she reminded me of a statement I often reiterate, “Kids (no matter the age) shouldn’t die before their parents”.

Her son died of medication-related death, in that the prescribed medications he was taking likely complicated his underlying medical conditions (sleep apnea and heart disease) and the combination of those things led to his death. She wants to make sure it doesn’t happen to some other mother’s son. She has concerns about both the medications and her son’s doctor. In addition to our working with the Illinois Department of Professional Regulation on cases we feel are egregious on the doctors’ part and with the DEA on drug (medication)-related deaths, I told her she too can file report/complaints.

She was unaware of this, despite some research on her own, so I thought I’d throw the information up here so that more folks would be aware:

Consumers (i.e. regular folks) can file reports on medications (problems and concerns) with the FDA MedWatch Program. The forms and instructions are available online.

Concerns about individual physician’s can be filed with the Illinois Department of Professional Regulation (for some bizarre political reason actually the Illinois Department of Financial and Professional Regulation. (Every state has their own variation of our state regulatory agency)

Coroner recommends birth experience to interrupt violence

I have often tried to think of some way to impact the violence endemic in our culture that all too often leads to death. Much that is tried is less than satisfactory. Recently I came across an intervention that is used elsewhere that, while at first blush is pretty strange, after thinking about it I believe it warrants consideration. (It was in a book I was reading, so I don’t have a link.)

The intervention involves having the perpetrator participate in a birth (or more than one). They participate quite intimately. In one instance that was written about, the perpetrator was made to hold the newly delivered baby and placenta immediately after birth while assisting with the birth. That can be an overwhelming visual, tactile, olfactory, and auditory experience. In other related cultures the experience is with animal births.

What a great way to instill (or re-instill) a respect for, and an understanding of, the value of life. I think it could work to interrupt (or prevent) violent behavior. Could violent perpetrators be “sentenced” to assist in “X” number of animal deliveries? Could that experience be made a part of a violence prevention program?

I think it might be worth a try.

Coroner: Say no to organ donor financial incentives

I certainly don’t agree with financial incentives for organ donation. Seems like a step onto a slippery slope to me.

…the AMA adopted policy calling for the modification of current law to allow pilot studies on financial incentives for cadaveric organ donation…
The AMA already supports study into financial incentives for cadaveric organ donation…
Voluntary organ donation remains important, but motivational incentives that could increase organ donations — including financial incentives — must be studied

I know that there is a shortage of organs available for transplantation, but there has to be another way to increase donations. I like the commercials with Walter Payton’s children talking about its importance/value. More opportunities like that seem like a much better idea to me.

Coroner Relations

Dealing with people whose family member (or friend) has died is often incredibly difficult. All deaths are sudden, even those most anticipated (e.g. hospice deaths). It is an exceedingly emotionally charged time. It is not a time for thinking clearly, the thoughts race or the thought process slow to a crawl. The family and friends can’t “hear” or at least process what they hear adequately. Disbelief and doubt creep in (actually really roll in).

You try to anticipate that in talking with them, helping them through the processes, through the experience. Each death is different. Every person is different. Things may seem to be going well for them initially, but come tumbling down later. It may be hell for them from the beginning. You try to comfort, to be truthful, to be straight-forward. But it can be perceived as less than that. It can become distorted or seem to be distorted.

We always do our best. We are human, too, and “to err is human”. So we don’t always get it right. Or we may get it right, but it seems lees than right by those family members and friends. It gets put through a grinder, looked at with a microscope or telescope, at times with a less than perfect lens. It sometimes comes out looking less than perfect, even seemingly less than acceptable.

But we do it all again with the next individual who dies.

Broken heart?

I was going through some archived photos and found this one. Traumatic rupture of the heart or died of a broken heart?

Methadone Maintenance Therapy

I often get questions about methadone maintenance therapy from my deputies and other folks. I just came across this YouTube video about it that is excellent. (It is 10 minutes long)

Sorry I am sure there is a cooler way to do it, but this is the link.

Mandate Doctor Education to Save Lives

From the New York Times:

Should doctors be required to undergo special education in order to prescribe powerful narcotics? The Food and Drug Administration may soon recommend that they do so, though such a move would most likely prove controversial…
Dr. Rappaport said the F.D.A. was most concerned about potent and longer-acting narcotics like methadone, fentanyl and certain formulations of the drug oxycodone, the active ingredient in OxyContin.
With methadone [when prescribed as a pain med], fentanyl, which is available in patches, has been associated with patient deaths and injuries resulting from physician misprescribing or inadvertent patient misuse…
In the last two years, the agency has sent out alerts to doctors about both methadone and fentanyl, but officials acknowledged that preventable patient deaths were continuing.
“We are putting out communications,” said Dr. Gerald Dal Pan, who directs the F.D.A.’s office of surveillance and epidemiology. “We don’t know why they are failing.”

We have seen “mistakes” in prescribing and talked with prescribing physicians who are very unfamiliar with proper doses and precautions with these meds (e.g. knowledge of drug-drug interactions compounding lethality), although still prescribing them. When I say “we have seen”, I mean folks have died as a result. The “boxed warnings” and informational mailings have failed. I think mandated training is a step in the right direction.

Guest blogging

This and the last post are like guest blogging that the big guys do:

I quoted this from the link you posted Dr. Keller~

“Preventing substance abuse among teens is primarily a Mom and Pop operation,” noted Califano. “It is inexcusable, that so many parents fail to appropriately monitor their children, fail to keep dangerous prescription drugs out of the reach of their children and tolerate drug infected schools. The parents who smoke marijuana with children should be considered child abusers. By identifying the characteristics of problem parents we seek to identify actions that parents can take—and avoid—in order to become part of the solution and raise healthy, drug-free children.”

In my opinion!
Seems a great percentage of suburban parents & school system & the children themselves in my community just don't get it they seem to like to deny this entire drug issue.

YES THIS IS SO WRONG!

I do understand that an addict will do what ever it takes, lie, cheat steal, manipulate ~ to get what they want - some are predisposed to this disease ~ yes theses issues start at home ~ some things are out of the control of parents, teachers & friends.

Sometimes you have to set them free to follow their own path with hopes that they make the right choices.

Great article - thank you for posting!

- I lost my child due to this tragedy that has hit our community!

Colleges shouldn't support lower drinking age

Honestly with the abuse of alcohol being so prolific it’s insane to even consider this. I was 18 in high school and I can’t imagine what this would create. At 18 I know I wasn’t prepared for alcohol, at 21 I don’t think I was prepared either. I already have enough clients coming to my unit (addictions treatment program) already. I don’t need them encouraged to start any younger. I can’t believe that this was even considered, knowing that the presidents of these universities should have first hand knowledge how dangerous alcohol is on college campuses its crazy to even see them considering this as a good idea (I know this first hand). What is the world coming to?

-Todd

This Tribune article caught my eye and ire as well. It certainly seems irresponsible to me for colleges to come out in support of lowering the legal drinking age.

Teen Access to Rx Drugs Easier than Beer

I came across a reference to a survey/study done by The National Center on Addiction and Substance Abuse (CASA) at Columbia University the other day. It is one of those “good news-bad news” bits of information.

While they have not seen an increase in drug use (that’s the good news), I found one set of findings particularly disturbing (although there was really nothing not disturbing in the findings):

For the first time in the CASA survey’s history, more teens said prescription drugs were easier to buy than beer (19 vs. 15 percent). The proportion of teens who say prescription drugs are easiest to buy jumped 46 percent since 2007 (13 vs. 19 percent). Almost half (46 percent) of teens say painkillers are the most commonly abused prescription drug among teens.

That first statement is incredible. Will this increased ease of acquiring prescription drugs to use and abuse lead to increased use in the near future? I think that it is very likely.

When teens who know prescription drug abusers were asked where those kids get their drugs:
• 31 percent said from friends or classmates;
• 34 percent said from home, parents or the medicine cabinet;
• 16 percent said other;
• Nine percent said from a drug dealer

The second listed source, in particular, should be relatively easy to control and we must get control or risk our children’s health and future.

It is easy to forget the illicit use of licit drugs in our haste to control illicit drug use, but our drug problem is a bigger problem.

Wrong

This is so wrong:

A father who purchased a keg of beer for his daughter's 19th birthday was cited with unlawful delivery of alcohol to minors.
David Zell, 46, 328 Bridgewood Drive, Antioch, admitted to Antioch police that he provided beer for the party even though he knew his daughter, Ashley Totten, 19, was underage, as were some of the friends who attended the party at his home on Aug. 2.

The Coroner knows that "you never know..."

It happened again last evening, someone died in a car crash.

But things are rarely that simple, that isolated. As is often the case, more people could have died in the crash, more lives are affected by the crash, and it brings to mind the fact that you never know…

A woman and her 2 children were out driving at dusk, intending to get home and continue on with their lives. Then what you hope will never happen happens. A driver on the other side of the road loses control of his car for some reason sending his car across and into the path of your car faster than you can react to avoid it. A collision occurs. The driver of the car that crossed the road dies of multiple injuries. Thankfully the woman and her children survive this one, but sometimes that doesn’t happen. There were some injuries, thankfully nothing too severe.

Two mothers’ lives were changed in the incident, the grieving mother of the young man who died in the crash and the injured mother driving the other vehicle. Neither will forget the crash or its outcome. Both will likely always think- you never know what will happen when you go out in your car.

You never know. Contact from Hungary

I don’t know if it is a sign that the world is shrinking because of our Internet connectivity, but I got an email from Hungary Monday.

It was from the father of an individual who was found dead and skeletonized in May of 2007. He came across a report of her death on the Internet. “Shock” and “devastating” were his descriptors of that discovery.

We were able to identify the young lady and law enforcement agencies helped locate family in Chicago. We were told by the family members we had contact with at the time of her discovery that they were this young woman’s only relatives and that her father was dead. We, therefore, did not look for him. (We have since lost contact with the other family members that we had contact with in 2007)

Certainly this is not the way to find out about the death of a loved one, but we were able to answer a number of his questions over the phone yesterday. Many questions remain about her death, however, with the continued investigation in the purview of the Lake County Sherriff’s Office. We were unable to determine her cause or manner of death, primarily because all that remained was skeleton and it had no marks or abnormalities, although there were some drugs in the clothing found with the sketalized remains.

We will be helping him arrange final disposition of his daughter, no one else made those arrangements. He plans to have her remains with him in Hungary after cremation. He, also, hopes that at some time the Sheriff’s Department might be able to get him a few more answers regarding her death (the case has “got cold”, as he put it in his email).

More on drug deaths around the world

I thought you might be interested in some further correspondence regarding the case I posted on last week.

Is it the norm to use Cocaine together with Heroine?

Assuming that he had the Thrombi at the time of death, could this mean that he as a long term addict? I mean is there any way in knowing from the toxic report whether he was a long term addict or if this was something he started doing recently, and if the report mentioned that there was no external injuries to the body, will they also take needle marks into account?

What about the Amitrippyline – could this just be a coincidence that he took an antidepressant or could it be part of a drug or a mix of drugs he took? And according to the amount – how many pills did he take?

This is really important, as we suspect that he could have been given these ‘drugs’ by another person, against his will, that is why I need to determine if he was addict or not, if at all possible?

And if the blood cloth didn’t hit his lungs – would he have died anyway?

Regards
Katie
South Africa - Bloemfontein

My answers to those questions:

It is not at all unusual for a person to take Cocaine and Heroin together. In our experience with drug deaths, the number of those dying with heroin alone as opposed to cocaine and heroin together is about equal.

The thrombi are only relevant to his death and/or pre-death state. They would not likely be a chronic problem nor reflect chronic addiction.

There is no real way, based on testing, to know if he was a long term addict with certainty, although the lack of apparent medical problems (as seen in some addicts) at autopsy would make long term addiction a somewhat less likely possibility.

Needle marks would have been looked for and commented on if present. It is not unusual these days to snort/inhale cocaine and heroin.

The Amitriptyline level is not toxic or indicative of an overdose; it is within the range of people taking it therapeutically (possibly in the range of 150 mg as a dose).

The amitriptyline could have been “slipped to him”. The cocaine and heroin is not active, in any significant way, if taken by mouth, so the likelihood of it being given to him against his will is essentially zero (without needle marks).

The clot in his lungs killed him, but certainly cocaine and heroin can and do kill in other ways.

I hope these help.

An interesting proposal, let's brainstorm a solution

How's this for a "forward":

Please allow me to introduce myself and the circumstances that have brought me to contacting you.

My name is Pamela Hewett, I am a 39 year old Illinois Police Officer and have served my communities for the past 14 years. My husband is also a (16 year Police) Officer. I come to you on a bended knee and humbly request your assistance in a matter of great importance to myself and my family..........

Recently tragedy struck when my sister (Gina M. Smith of Cross Junction VA) was over prescribed medications. It cost her a beautiful and promising life, and she was only 47 years old. She left behind two very young beautiful daughters, one of which had the misfortune of finding her mother laying deceased from the overdose of Oxycontin, Xanax, Percocet, and what ever else she was prescribed. I know you may shake your heads and believe there is nothing you can do to change the tragedy of what has happened, but I believe that is not true. Please read on:

Through my research I have found that the dangers of these drugs have been known since shortly after being created. The increase in abuse has nearly quadrupled since then, and yet nothing has been done to stop it. Prescription drug deaths’ is fast becoming the leading cause of death among Americans, and now I take that extremely personal because it took someone from us that was a vibrant and beautiful person. You see, this started for my sister when she was diagnosed with Breast Cancer in 2002. You know what? She was cancer free when she died. She beat the cancer but not the drugs that should have been monitored and cut off long before 2008.

As a law enforcement officer, I do not understand why, if someone is wanted on warrants for escape, drug trafficking, or any other serious or heinous crime, police can enter a persons name into our computers and we SEE this information NATIONALLY. If someone is a registered sex offender, the same concept applies…. why can’t medical professionals have this same accommodation ?

I need your help - Some how, some way, we need to establish a NATIONAL DATABASE similar to what the police use, only it would be for the use of medical professionals. Please help me to stop the doctor shopping and countless unnecessary deaths which is on the rapid rise. Let’s help to save other families from this heartache and anger and grief. I know, when a law is put in place, criminals always find a way around it, but just think of the people who won’t be able to do that, and the lives that might be saved?

I am proposing that the database requirements be that when someone is requesting pain management, (resulting in the distribution of anything in the Schedule 1, Schedule 2, or any other prescriptions that may prove a risk for creating addiction) that BEFORE a Doctor distributes the medication, the national database would have to be checked. In order to obtain these kinds of medicines people would have to present not only a photo ID but their social security card as well. It's allot harder to forge or duplicate social security numbers than it is Names / ID cards. There are also more intricate controls that can be considered.

Police departments use AFIS (Automated fingerprint identification system) - which gives us NATIONAL information off of one fingerprint when someone is "in" the system. Why cant it be a requirement of identification that a thumbprint of a patient be tied to their identifiers once they begin using prescription pain management? There could be no forging a fingerprint. The medical professionals could help abruptly halt the doctor shopping that is killing our citizens. They will be able to enter the database with the patient information and see exact dates, locations, and medications obtained.

I believe that by establishing this sort of a control system, we can change the tide of rapidly increasing prescription deaths. Sitting back and conducting studies of how prescription drugs are so heavily abused and a leading cause of death in America is doing nothing to correct the problem.

Please join in and assist me to get this completed. If you can not or do not want to assist, then forward this to someone who can and will help this idea become reality. I want to reach as many people as possible to raise awareness & to get this job done.

Sincerely

Pamela L. Hewett
3504 Vine St
McHenry IL 60050

DNA Profile match, what are the odds?

Criminal DNA “testing” is not a matching of the entire genetic makeup of an individual (which is unique), but is a matching of a “genetic profile”, a small (13 loci) piece of the full genome of the individual. Over the last couple of years questions have been raised about whether the FBI estimated odds of unrelated people sharing profiles is 1 in 113 billion or if it is in fact a much more likely event.

A recent article in the LA Times lays out the case for lower odds. It relates that a 9 of 13 loci match is really not all that rare of an event even between two folks that appear quite different and have no demonstrable relationship. The article also points out that a 13 out of 13 loci match in a pair of unrelated folks may be a possibility as well.

It should be noted (as in the article) that officials do try to match all 13 out of 13, but at times fewer loci are available for comparison depending on the specimen or sample.

Our justice system relies heavily on the FBI odds estimate. We owe it to our citizenry to be more certain that it is based on “good” science. We need to prove that we can be confident in that odds estimate. We need to seek the evidence, the proof, just as the article calls for further study, a study that really should not be all that difficult to do.

Choking game isn't a game

Just a reminder about the “choking game”, I wrote about it here and here.

Just as a reminder it is a “game” “played” most often by young teenage and pre-teen boys, often for the “rush” (although girls are not immune). Also, at times I think, it is done for the shock value and risk involved in this “play”.

“Play” hanging isn’t a game.

It only takes about 8 pounds of pressure on the neck to stop blood flow to and from the brain with the result being death. 8 pounds of pressure, the weight of the head, can result in death. This can occur in the sitting or near sitting position, lying or near-lying position, or suspended. The key is you don’t have to be suspended to die.

Drug deaths all over the the world

The internet uniting the world:

Anonymous has left a new comment on your post "Another drug-related death":

Dear Dr Keller
On 22/10/2005 my brother was found unconsience in his room. He was hospitilized 14:00 and was pronounced dead 17:15. The Post mortem was found to be PULMONARY EMBOLISM FOLLOWING OVERDOSE OF MORPHINE AND COCAINE. A toxic was done and the following was found - Amitriptylline - 0.08micorgram per ml of blood, Caffiene in the blood, Cocaine, Codeine, Morphine, Bensylecgonine and paracetamol in the urine. No external injuries was found on his body. He also had a Secondary haemorrage in the midbrain. Pleura dn lungs - both lungs congested with saddle thrombus in the pulmonary artery. Mediastinum and oesaphagus, trachea and bronchi, intestines and mesentry, pancreas, Liver, Galbladder and biliary passages, spleen, Kidneys was all congested. Would this all be from one substance he took or several, could it have been suicide? What does congested mean? I would realy appreciate your opinion.
Regards from South Africa

My reply

The congestion referred to is vascular congestion likely related to decreased cardiac output (heart pumping action) and/or increased venous stasis (with dilated blood vessels) due to the cardiovascular effects of the drugs. The cocaine directly can cause a midbrain bleed.

That vascular congestion also contributes to the formation of clots (thrombi) that can travel to the lugs resulting in death.

The 2 primary substances in this intoxication are cocaine (its metabolite benzylecgonine) and “morphine”. The source of the “morphine” might be heroin or any number of opiates that metabolize to morphine in the body (with codeine as a co-metabolite, co-ingestion, or as the source of the morphine).

Suicides using illicit drugs is fairly rare, most of these deaths are “accidents” related to drug use and abuse.

Guns and suicide

Got a link to this information through the NAME listserv and I thought I’d post it here:

A study by the Harvard School of Public Health of all 50 U.S. states reveals a powerful link between rates of firearm ownership and suicides.
… states where guns were prevalent—as in Wyoming, where 63 percent of households reported owning guns—rates of suicide were higher. The inverse was also true: where gun ownership was less common, suicide rates were also lower.
… Says HSPH Professor of Health Policy David Hemenway, the ICRC’s director: “Studies show that most attempters act on impulse, in moments of panic or despair. Once the acute feelings ease, 90 percent do not go on to die by suicide.”

Just as I mentioned before these impulse suicides need to be a real target of prevention measures, including telling folks that if they own guns keep them locked up or out of the house at the very least.

Sailor Heroin Deaths

Headline from the Great Lakes Bulletin:

“These shipmates made a life-changing decision…R.I.P.”
“Bad decisions lead to deadly consequences”

It then lists the names of three Sailors who have died this year, actually within the last 5 months, of heroin intoxication (some with other drugs in the mix). These were young men who made “bad” choices that cost them their lives, their potential lost.

The article concentrates on one the young men enough that you really get to know him. He really is just a kid wanting to enjoy life and with plans for the future. All that snuffed out with these decisions.

Did any of these young men know or consider the real risks of these actions? Drugs they can make you high and they can make you die.

Another drug-related death

Another drug-related death of a young man (in his 20s) this week (not to mention the gentleman in his 50s or the woman in her 30s, they are no less tragic and they also died drug-related deaths this week)

He died of heroin intoxication, abuse, over-use. What also stood out with this young man is that when we tested several items from his room for drug residue we came up with results that beg action or reaction. We found a dollar bill with heroin residue, cocaine residue on his dresser, cocaine and THC residue on a small scale in his room, and a part of a jeweler’s screwdriver with THC residue.

Youthful experimenting? To me it screams the need to get honest information repetitively out to the public (how do you get it to the youth of our community?). Among other important bits of information, that the heroin on our streets right now is potent and particularly deadly. We must develop and push prevention; we must develop and push treatment.

It will be work, hard work, but aren’t these folks worth it?

This ain’t CSI

Another in my “this ain’t CSI” posts:

About 5:20 pm yesterday I got an email that said: “I hope this doesn’t make it on your blog!” If you wrote that I’d advise you to stop reading now. I couldn’t resist.

Over several hours and multiple emails yesterday I and a very patient staff member of Finance tried to set up a meeting to go over my FY2009 budget with County Administration.

In one of my emails I described the interaction “like a game of Twister or Checkers on crack”. Over 20 emails rocketed over the wires and airwaves back and forth to get all of the folks scheduled together for the meeting. Last I heard it was still pending responses from 2 folks, so I am watching for more emails.

Our budget setting process might be “fun”, but I don’t think it will ever make an episode of CSI. I begin with my proposal shoe-horned into their forms and format. At times their forms seem arcane and not a good fit for what or how I want to submit stuff. That stuff is reviewed by Finance staff and some changes are made based on that back and forth give and take.

The next stage is the face-to-face review with a group of County administrators with my justifying changes from last year (e.g. a latex shortage in Asia threatening to drive up the cost of gloves in a few months). Heady stuff, but not the stuff of TV drama.

After that they review my budget without me present, figure how it fits with the County’s overall budget, and decide what they will recommend to the County Board. Then it’s through the Board committees and the full Board for approval in a few months.

On second thought, I think I’ll begin work on the script proposal, I think it has potential.

Preventing Death by Train

I just got a “save the date” card for an upcoming conference that sounds interesting. I was talking recently about the need to better secured train tracks (fencing and the like), both in reference to my impulse suicide post of a few days ago and with the incident of a recent suicide by train. Low and behold, I got a card in the mail about a conference entitled “Sealed Corridors”, put on by the DuPage Railroad Safety Council in September.

Looking at the DuPage Railroad Safety Council website, I was impressed with their various initiatives and projects. They undertake education to kids, educational materials at train stations, promoting legislation and enforcement, etc.

I think more “secure” tracks could prevent some impulse death by suicide, as well as some of the accidents we see involving trains. We have had cases (pedestrians and in vehicles) who ignore warnings, or who misjudge time to impact, or who are distracted to the point of fatal error.

The DuPage Railroad Safety Council efforts and their conference sound interesting. I look forward to learning more and supporting what I can.

Drug combinations multiply lethality

I came across this reminder that drug combinations are almost always more lethal than single drugs alone. (Actually I had been corresponding with the author of this article before he published this in the paper/on the Internet. He had picked up on my blog as a source of information after a recent death involving a sorority “sister”)

The combination ingestion (by different routes but at the same time) of alcohol and cocaine is more lethal that either alone, at least in part because of the metabolite formed in the body (there may also be an effect on metabolic pathways seperate from the formation of this metabolite).

Research into the lethality of cocaethylene use compared to cocaine use alone is young, but anecdotal experiments have pointed towards an increase in mortality rates from a combination of cocaine and alcohol consumption. One of these, a 1999 study of drugged rats by the Kyoto University Graduate School of Medicine, found cocaethylene 46 percent more lethal than the control group of cocaine use alone.
Additionally, a study appearing in the July 1997 issue of the Journal of Addictive Diseases stated that cocaethylene has been associated with seizures, liver damage and compromised functioning of the immune system and found an 18 to 25 fold increase in risk for immediate death over cocaine use alone

Don’t take chances, make good choices, think

Health Promotion to Forestall Death

I agree with the author of an article I just got around to reading: Improving Public Health Through Prevention.

Not only do we need access to healthcare and healthcare coverage for all, we need what the author calls “Universal Coverage PLUS”:

A high-performing national health-care system must also focus on the prevention of disease and promotion of optimal health for all its citizens…
The existing system focuses primarily on diseases -- once symptoms are well established and treatments are costly. The system needs to include a logic of targeting investments and interventions earlier in the evolution and development of diseases. Improvements in the natural, social, and built environments in which individuals live, as well as enhancements in diet, exercise, and lifestyle, can have a profound effect on health trajectories, adult medical needs, and the overall costs of care. Recalibrating our health system to address this undeniable reality will require more than universal coverage.

As I heard someone say recently we need to “make sure you are around for all the birthdays you possibly can”. To do that we must make certain everyone has access to medical care, not just episodic acute care in an ER but a long-term healthcare provider relationship with chronic disease diagnosis and management as needed. Along with that, we need to push folks to get healthy and stay healthy. We need to work on healthy communities and healthy environments so folks can get out and get healthy without the potential of others affecting their health and their new healthy lifestyle (i.e. with violence,etc.).

If the working for the common good isn’t enough of a reason for you, think of it as an investment in “human capital” (to borrow once again from the author).

“The City of Broken Men”

I read an article from the July GQ magazine yesterday (not my usual reading material, my wife saw the article at the spa at which she works). The article was about the military hospital, Landstuhl Regional Medical Center, and the work they do there. The article should be required reading for every American.

Every soldier injured severely enough to leave their units in Iraq or Afghanistan go through that hospital in Germany. They do incredible work there. The article centers on one injured soldier who had his leg blown off, in telling the story of the medical center, its staff, and its work.

Two things in the article really grabbed me. They drove home to me the enormity of this side of the war. The enormity of which we regular citizens don’t see, don’t hear about, don’t know enough about. As the author points out it is and enormity that will affect us as a nation and as people for a long time to come.

The soldier the article focuses on is “more or less the 44,360th person hurt badly enough to be evacuated out of Iraq or Afghanistan”. 44,360th and that was months ago.

And then the article’s thought provoking closing:

“We can send you to a broiling desert across the world to fight precision battles in a country you know nothing about; and we can beam you up when you’re hurt and put you down in the middle of Germany, rebuild your leg, get you free cheese and $50,000. But there are some things we just can’t do. And what it is we couldn’t save Mike Brown from what he’ll find out next [back home].”

What we do for all the Mike Brown’s into the future is our challenge as well.

[“The City of Broken Men” by Devin Friedman, GQ, July, 2008]

Suicide: premeditated v. "crime" of passion

I came across an interesting article this week (via the NAME listserv) about suicide. Early on it brings up an interesting statistic that “the nation’s suicide rate (11 per 100,000 inhabitants) is almost precisely what it was in 1965”. Despite all the research, all the programs, all the new medications, the rate has not changed in over 40 years. That really is startling.

The author, as well as some researchers, feels that that is due to a dichotomy in suicidal behavior, much as there is in homicide. He discusses a premeditation vs. passion division amongst deaths by suicide. The premeditated suicides are most easily impacted by programs, medications, and therapy. The passion or impulsive suicides not so much. His discussion resonates with my experience.

The impulsive suicides are best impacted by creating “barriers to suicide or means restriction”. This was well documented (and then ignored) in the 60s and 70s in Great Britain. Death by suicide dropped by a third with the change from coal-gas to natural gas stoves during those decades. In the 50s “sticking one’s head in the oven” accounted for half of all British suicides. "Many of those were impulsive acts using a means with little time for second thoughts". “Remove it, and the process slowed down; it allowed time for the dark passion to pass".

We need to modify how we address death by suicide, how we think about death by suicide. They are not homogenous (neither the individuals nor the methods) and likely require multiple, varied interventions. Youth particularly fall into the more impulsive category, making brief, timely interventions critical. This recognition of differences can lead to more successful intervention.

But never lose sight of the underlying condition:

"They had wanted their inner pain to stop; they wanted some measure of relief; and this was the only answer they could find. They were in spiritual agony, and they sought a physical solution."

Coroner speaks to alcohol pushers

Last night I practiced what I preach. I have been preaching that we need to change the social norm surrounding alcohol consumption. We don’t need alcohol served at every celebration or get-together. We don’t need alcohol to have fun or as a social lubricant. We need to step up and speak out against this “social norm”. That is one way we can change teen/youth conviction that we need to consume alcohol.

I was at an event where several upcoming events/parties were announced. Every one had alcohol as the first word in what would be happening at each of them. After listening, I stood and spoke out. I told them that what I was going to say might be uncomfortable, but that it is not right for alcohol to be “the guest of honor”. I am not against responsible drinking by adults, but it should only be a side, not a main course. I cautioned them that if they were serving, they would share responsibility if any over-drinking occurred. Just as I tell teens: Think, make good choices, don’t take chances.

Now it is your turn to speak out. Only with speaking out can we alter that social norm.


On another related topic: I am appalled by a commercial that I have heard several times on the radio. To quote (or come close anyway): “…two things you should know about morning hangover…” Both those things pertain to their product. No. The 2 things you should know have nothing to do with their product (yes, something I learned a long time ago): You drank too much and don’t do it again.