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