Friday, September 26, 2008

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)

Thursday, September 25, 2008

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

Wednesday, September 24, 2008

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.

Monday, September 22, 2008

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.

Thursday, September 18, 2008

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.

Wednesday, September 17, 2008

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.

Tuesday, September 16, 2008

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.

Friday, September 12, 2008

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.

Wednesday, September 10, 2008

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.

Friday, September 05, 2008

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)

Wednesday, September 03, 2008

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.