Safer Sleeping for Infants

My 4th grader needed a science fair project for school. In part because I had just been at a meeting in which we discussed infant deaths in cribs with too soft bedding and from SIDS, I suggested a display pertaining to that topic. She thought it sounded good, however her teacher said no because she was supposed to do an experiment not just research and a display. I still think it would have made a good project and I always look for unique ways to get this sort of information out to the public. What a great way to get it out to parents of infants, a display by a kid at school with parents wandering through looking at it.

We recurrently have infant deaths, luckily not frequently, locally and regionally, that are due to soft bedding and “stuff” in their cribs, as well as due to co-sleeping and Sudden Unexplained Infant Death (SUIDS/SIDS). Quite often parents don’t know about safer ways to put their babies to bed in their cribs. (And I heard something on the radio today, so it is back in the news).

So as a reminder (and please pass the information on to any new and expecting moms):

Safe Bedding Practices For Infants
• Place baby on his/her back on a firm tight-fitting mattress in a crib that meets current safety standards.
• Remove pillows, quilts, comforters, sheepskins, pillow-like stuffed toys, and other soft products from the crib.
• Consider using a sleeper or other sleep clothing as an alternative to blankets, with no other covering.
• If using a blanket, put baby with feet at the foot of the crib. Tuck a thin blanket around the crib mattress, reaching only as far as the baby's chest.
• Make sure your baby's head remains uncovered during sleep.
• Do not place baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.

Need for Coroner System Improvement

Some folks are demanding change in Nebraska’s coroner system. Reading this article it is apparent that such change is needed.

Nebraska's county-coroner system tacks on death investigation as a footnote to other jobs…

The Douglas County morgue, where half of Nebraska's autopsies are done, predates "Quincy M.E.," the 1970s TV show about a medical examiner. (Cool, I’d still recognize it, I went to med school and residency in Omaha in the late 70s and early 80s)

A fly strip dangles over the single autopsy table, and paint peels off the concrete-block walls in the 18-by-20-foot autopsy room in the Douglas County Health Center basement.

As the article points out we in Illinois are more professional about the coroner’s business.

In some states, such as Colorado and Illinois, elected coroners have created their own organizations to provide training, guidance and support.

Certainly backward, archaic systems still in existence in parts of this country give the coroner business a bad name. In my office we push professionalism, participation in training, leadership in medicolegal death investigation, and continuous improvement in office techniques (improving current practices and embracing new practices and equipment, as appropriate).

I hope Nebraska shapes up their “act”, I have family there.

Can homicide occur by willful and wanton neglect?

I begin by saying I can not give out details because of pending litigation and on-going investigations by a couple of organizations. (Some details may have been changed here)

A gentleman had been confined to a care facility for a while because of his inability to care for himself due to psychiatric problems. While at the facility he developed a “failure to thrive” syndrome, malnutrition with significant weight loss. A short while before his death he was admitted to a hospital for evaluation to ascertain if their was a medical reason for his failing status, that evaluation revealed no significant disease processes to explain his condition. He was returned to the care facility.

The day before his death staff at the facility became concerned (his failing seemed to be accelerating) and expressed that concern to his physician who asked that he be transported to the hospital where his recent evaluation had taken place. That hospital was apparently over-full and was not accepting ambulance traffic. Upon hearing this, the patient’s doctor told the staff to get him taken to another hospital, one that was close by. Here things get a bit fuzzy; the gentleman was not transported that day.

The next morning the gentleman was noted to be having difficulty breathing and looked worse to staff. The staff called the gentleman’s doctor who was surprised, to say the least, that the gentleman was still at the facility. The doctor again told the staff to get him sent to the closest hospital. A private ambulance company was called to transport the gentleman and they informed staff that they would pick him up in 30-45 minutes. When the ambulance called and said that they would arrive in 15 minutes the gentleman was checked in preparation for transport. At that point he was found to be dead by facility personnel. The ambulance was called and told that they were no longer needed. The patient’s doctor was notified, the facility administrator was notified and the Coroner was notified.

The finding of the Coroner’s Office: Death was due to a pulmonary embolism, contributing to this was a “blatant disregard for medical care” The manner of death was ruled a “homicide” (death at the hand of another).

Regulatory agencies are now involved in further investigation, as is State law enforcement.

Decomp fun facts to know and tell

I was steered to a fun and informative website by my Toxicology Analyst/Lab Manger. All sorts of stuff about decomposition (as they say there are some graphic photos, as a warning to some and an enticement to others).

Continuing death prevention efforts on multiple fronts

I was at a meeting this noon and we were discussing possible “events” for April and Alcohol Awareness Month. The group is a mixed group of politicians, school representatives, folks from non-profits, and (most interestingly and appropriately) middle school students. The main focus of the group right now is underage drinking prevention. The input from the kids/teens was great. They had great ideas, ranging from possible initiatives to graphic design of the flyers and the like, and they were not afraid to express them. It is great to have their help and I think we can really get some successful stuff going with their help.

My meeting earlier today was our Lake County Suicide Prevention Task Force. Great discussions and I think the group was able to help with a couple of projects started and/or supported by some of our members. We discussed the growing collection of referral sources we are posting on the Lake County Coroner website for access and the possible expansion of uses for the locally developed/adapted “Project Safety N.E.T” (a program to help recognize and refer teens at risk for suicide). Besides their usefulness to families of decedent individuals that our office works with, it seems from our discussion that these will be helpful resources for Task Force members (and others in the community) seeking information for screening and referring folks locally. Also, “Project Safety N.E.T”, available on our website for use and distribution, will likely serve as a basis for a training project for folks outside of the schools that were original the target of “Project Safety N.E.T”, for example youth groups or as a part of parenting classes.

The other discussion we had was prompted by a young lady who lost someone to suicide recently. She had sent me a link to a posting on mydeathspace (link not provided, you’ll see why in a second). The posting was about the death by suicide of a young man that both she and young man’s family want removed from the site. Despite their efforts they have been unable to get it removed. I understand that the site can serve as a memorial, but it seems that it should be responsive and responsible to those closest to the deceased individual.

It is great that our office can serve as a resource, a catalyst, a “helper”, and sometimes a leader for change and ultimately death prevention.

From my friends at the CDC Injury Center

From my friends at the CDC Injury Center (s/p NIU shooting incident):

We encourage you to link to the Web pages listed below from your organization's website and disseminate it to anyone or any professional organization that you believe may benefit from this information.

Coping with Stress

Preparing for a Mass Casualty Event

Coping With a Traumatic Event: Information for Health Professionals

Uninsured and Underinsured and Death by Cancer

A nationwide study has found that the uninsured and those covered by Medicaid are more likely than those with private insurance to receive a diagnosis of cancer in late stages, often diminishing their chances of survival.

At HealthReach (a free medical clinic for low-income, uninsured individuals that I founded and directed for several years) our patients could get some screening tests, but were often unable to get needed follow-up for positive screens. Other screening tests were out of their reach or the numbers were rationed because of our limited referral sources.

Uninsured and under-insured folks have huge problems accessing medical care and their increased death rates reflect that fact. Death due to lack of insurance exists (also see). Why does that continue?

Nicotine and opiate addiction related?

Before you light up that next cigarette ponder this:

Research in the Journal of Neuroscience has demonstrated that the mechanism of nicotine addiction appears to be physiologically similar to opiate addiction. It appears that the same area of the brain is involved with the dopamine mediation of both drugs.

This would seem to explain why it is so difficult to stop smoking when you are addicted to nicotine (as with any drug, not all smokers are physiologically addicted). It also adds credence to a point I wrote about some time ago that nicotine is THE gateway drug.

The nucleus accumbens causing blasts of dopamine that signals the brain to keep seeking rewarding sensations brought on by drugs.

Mind over matter will not work for either addiction.

Bipolar disorder is chemical disorder

According to the National Institute of Mental Health approximately 2.6% of Americans 18 years or older have bipolar disorder. Significantly, there is now further evidence that it is a brain chemistry disorder.

A study in Molecular Psychiatry reports that specific chemical abnormalities can be demonstrated, unfortunately at this point that testing seems to be confined to post-mortem. It would seem that in the future this may yield some sort of testing for diagnosis of bipolar disorder. That would be a great step forward. Those same researchers were also able to demonstrate improvement in the chemical milieu with treatment, documenting that these drugs do provide benefit. These results may also point the way for new, innovative treatments.

CDC puts out data on "Choking Game" deaths

The CDC has finally begun to look at the “Choking Game”. In this “game” an individual, usually a teenager, chokes themselves or has someone choke them to get a “high”. It is incredibly dangerous with severe anoxic brain damage or death as a possible result.

Because no traditional public health dataset collects mortality data on this practice, CDC used news media reports to estimate the incidence of deaths from the choking game. This report describes the results of that analysis, which identified 82 probable choking-game deaths among youths aged 6--19 years, during 1995--2007. Seventy-one (86.6%) of the decedents were male, and the mean age was 13.3 years.
These demographics are consistent with greater risk-taking behavior among boys than girls…
Parents, educators, and health-care providers should learn about the choking game and be able to recognize any of the following warning signs in youths: mention of the choking game (or the game by its other names); bloodshot eyes; marks on the neck; frequent, severe headaches; disorientation after spending time alone; and ropes, scarves, and belts tied to bedroom furniture or doorknobs or found knotted on the floor.

I wrote about it in 2006 after it resulted in a death here. Talking with his mother and family at the time and a memorial rally shortly after, reinforced the tragedy of a life ended before the youth’s potential could be fully realized.

Be aware and get kids help before they end up in my office. As I wrote in 2006:

The “high” someone gets from this “game” is the brain screaming for oxygen, pleading, not wanting to die. The odds really are stacked against the “player”. Some brain cells will die every time you “play”. The roulette part is the very real risk of “winning” death.

Think, make good choices, don’t take chances.

Sources of licit drugs for use and abuse

Where do folks get the medications that they over-use and abuse?

Some get them from prescription “mills”, i.e. doctors who prescribe without examining the patients or only cursorily. They are more than willing to write for meds requested for a fee. Doctors like we saw in a recent case who was more than happy to write for Fentanyl, Oxycontin, morphine, and benzodiazepines for an individual. This doctor had been asked to leave his previous group practice because of this practice and had lost staff because of this practice. He was famous (infamous) locally because of the practice. [We are reporting him to the DEA and state licensing folks.]

Some get them from doctors in a hurry or want to send the patient home with “something” because “they expect it” or feel that it is the right thing to do to throw a med at everything and every symptom. I know an individual who I had seen (I do some volunteer work) and we discussed my opinion that he didn’t need meds, but needed to deal with what was going on. After our discussion the individual agreed. A short while later he saw another physician, mentioning the same symptoms he had discussed with me, who promptly wrote him 3 prescriptions and sent him on his way. (The individual filled the prescriptions, but felt 2 of them made things worse or made him feel worse. He takes the other intermittently, although I don’t think he needs it and he continues to agree with me it might be best to go without meds)

Some get them from doctors who just can’t imagine that their patients would over-use or abuse anything. Some from doctors that are not really aware of the possibility of non-medical use of prescription meds. Some from doctors that are not as familiar as they ought to be with the meds they a prescribing.

And then there are folks that “borrow” them or obtain them with various surreptitious means.

So many possibilities and quite frankly most of them are not really related to wrong doing. But it is a significant problem that not enough folks, including doctors, are aware of. We will work to get the word out.

Death by lethal mixture

"Mr. Heath Ledger died as the result of acute intoxica- tion by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine,"… The list of generic names refer to drugs more commonly known as the painkillers OxyContin and Vicodin, the antianxiety medications Valium and Xanax, and the sleeping pill Restoril, (and) Unisom…
"While no medications were taken in excess, we learned today the combination of doctor-prescribed drugs proved lethal…

The death was ruled accidental. All of these medication cause respiratory depression, so likely the result of this mix was that his breathing stopped.

Just as overuse and abuse of prescription medications is increasing, so is the increased use of potentially deadly “cocktails” such as that that caused Mr. Ledger’s death. We have seen similar deaths with the mixture of drugs being the cause without any of them really standing out in the toxic range.

We often see prescription drugs as being so “safe”, after all someone won’t prescribe unsafe stuff. That will, at times, lull us into a false sense of security and from that come these accidents. Folks take too much of medication attempting to self-medicate/self-manage, not really thinking through that you can take too much. Or, as in this case, taking a mixture of stuff, in the hopes that it will be just the mix they need, with potential lethal results.

Prescription medications are poisons too. Prescription medications should only be taken as prescribed. Medications shouldn’t be mixed, except at the direction of, and with the knowledge of, your doctor, so that they can sort out the possible interactions and synergies.

Don’t get me started on “pharm parties”.

Non-medical use of prescription opiates

I have been doing some continuing education stuff lately and came across some statistics (sorry no links) collected by SAMHSA (Substance Abuse and Mental Health Services Administration).

We always think of heroin as the real “bad guy” opiate of abuse and it is. It is associated with presentation to the ER with problems of various sorts, increased risk of various infectious diseases, suicide and death. SAMHSA estimates (and admits that it may be an underestimate) that nearly 400,000 folks used heroin in 2004 (most recently studied year), including about 120,000 first-time users.

But what is even more concerning to me, 11.2 million Americans used prescription opioids for “non-medical” purposes in 2003 (most recent SAMHSA data). They estimate that there are 4.4 million “current non-medical users” in this country. Talk about a real problem with huge numbers.

Certainly this agrees with what we see through our office. Death related to non-prescription use of prescription drugs outpaces the heroin deaths we see and we see our share of both.

One last bit of data, tracked down in conjunction to a recent case: there are 185 online pharmacies and nearly 90% of them do not require a prescription to get controlled medications, including opioids. (We continue to work with the DEA on some cases related to meds obtained through this route)

So whether folks get the prescription drugs online, from their doctors, from their friends or off the streets, the illicit use of licit medications is a huge problem that many are unaware of. People just don’t think of these drugs as a problem, or a potential problem, very often. They should be used and prescribed with the proper amount of “respect”.

Blackouts aren’t something to laugh about

Drunken “blackouts” occur without loss of consciousness, actually the individual functions quite well for being drunk out of their mind. The next day the individual doesn’t remember anything that occurred during their blackout and that is where it gets its name.

Alcohol is a poison, keep that in mind.

Alcohol has been found to suppress certain receptors in the brain (the hippocampus, for those keeping score). When those receptors are not working as they should, memory acquisition is affected and I don’t mean improved. The suppression is dose related, i.e. the more alcohol ingested the greater the effect. This effect is likely the cause of the blackouts.

Adolescents appear to be particularly susceptible to this effect of alcohol, blacking-out at lower doses and, especially with binge drinkers, a fairly common pattern of adolescent drinking, blacking-out on a frequent/repeated basis. This is of concern for many reasons, not the least of which is that this repeated receptor poisoning may have cumulative effects over time with permanent impairment of memory as a result.

So the old description of someone who has consumed too much alcohol as “stupid drunk” is closer to the truth than we used to realize.

Blackouts aren’t something to laugh about, they are brain damage.