End Child Abuse in 20 years

I was reading an article written by an individual (Victor Vieth of the National Center for Prosecution of Child Abuse) that lectured at the Child Death Review Team symposium that I attended recently. As someone said that I shared a copy with: “an interesting read”. I thought I’d throw a couple of things from the article into my blog.

His is a plan to end child abuse in the United States within 120 years. Seems like a long time, but it is a huge problem. The timeline is laid out so that during the first 40 years everyone responsible for every step of finding, reporting, treating, prosecuting every child abuse incident is fully trained and working in a system that functions as it should. Also the next generations of these individuals are trained, ready to be trained and committed to the fight. Over the next 80 years child abuse is ended. He admits that it won’t all go away, but by and large it will be gone from our society. It is a multigenerational problem and will require a multigenerational attack and solution.

I wish him and his plan well and all success. It has got to happen, the toll is too great.

In case you are uncertain about the problem, beyond the shear scope of the problem, the numbers of the abused, two facts stand out. First: “only 40% of abuse cases and 35% of the most serious cases known to professionals mandated to report were in fact reported”. “65% of social workers, 53% of physicians and 58% of physician assistants were not reporting cases of suspected abuse”. “There were several reasons why mandated reporters do not report”. (None seem all that “good” to me) Second: “the large volume of children whose allegations are either not investigated or that result in CPS (Child Protective services) finding of “unsubstantiated” are just as likely to be victims of abuse (later on) as are those children whose allegations are substantiated”.

The system isn’t working. It isn’t working for the kids. It isn’t working for our society. This plan from the National Child Protection Training Center sounds like the way to go. We can end child abuse within 120 years. I am sorry that I won’t see that eventuality, but I will do what I can to get us moving in that direction.

Teen driven program on teen driving

I am certain that crash reenactments don’t work to keep kids from dying in car crashes. (We do them because the adults involved feel like they are “doing something”.) I am pretty certain that trying to scare kids into behaving “right” (driving right, not doing drugs, etc.) doesn’t work. I keep looking for something that works. I don’t want to do nothing and I don’t want to “just do something”. I want to do something that works, that is proven to be effective. That is where we should spend our time and energy. That is how we are going to save lives.

Sunday’s Trib had an article about an approach that likely will work. It is a program designed and driven by teens that encourages “smart driving”. It “encourages them to preserve their lives…and to speak up when they feel uncomfortable with their friends driving habits”. “What we learned in our research is teens don't aspire to be safe drivers because being a safe driver isn't cool”.

You have to get teens’ attention at their “level”, where they will “identify” with what is being done/”pushed” and “take it” as their own. The programs for change must be “teen-led”. Then and only then will you change behavior. We must do this so that they take fewer chances and make the “right” choices. Then we will save lives and forestall death.

Reality of emotion

I was working on an essay recently about “what is reality”. I didn’t quite get done with that when comments from 2 meetings collided with those thoughts. Yesterday I was at an “Assessing and Managing Suicide Risk Conference” that I and my Suicide Prevention Task Force catalyzed. This morning myself and another speaker talked with our County State’s Attorney folks about sexual abuse (I have been doing child sexual abuse evidentiary exams as a volunteer physician for 6 years) and rape.

A similar point came up at each of the meetings: As a survivor of someone who has died by suicide “you will never be the same again, but you can survive and even go beyond just surviving” and as a survivor of rape (or sexual assault) “you will never be the same” again. You will feel overwhelmed by the intensity of your feelings. You will feel anger, guilt, confusion, forgetfulness. These things are true in both instances. That is reality. Emotions are reality, but you can survive “and even go beyond just surviving”.

I had been writing that people were reality. That people are “messy”. They have strings attached and connections and connotations. They are “funny”. They incite thoughts and words. They have baggage. They are what they are, reality. But as I thought through the things that came up at these meetings, I have decided that these statements pertain to emotions just as much as to people. I think I lack the “words” to write about emotions, particularly the emotions that are dredged up by the “experiences” I discussed at my 2 meetings.

“Reality, what a concept.” (Robin Williams)

Foods you shouldn't eat

Ripped from Eric Zorn.

Cute?
Foods you shouldn't eat.

Failure of "Reefer Madness"

Our government tries to be “creative”. The White House Office of National Drug Control Policy (I think their name needs a bit of work) has put anti-drug use videos on the internet where kids may come a cross them in the hope that it will decrease drug use. As a Trib editorial put it, that is like “leaving those sex ed pamphlets on Junior’s dresser instead of bringing up the subject at the dinner table”. Passive persuasion, nice thought but not likely to be effective.

The GAO (Government Accountability Office) pointed out recently that “we” have spent $1.2 billion on anti-drug use advertising over the last 8 years without decreasing drug use among teens. They also found that while teens that saw the ads remembered the message, they were not dissuaded from using drugs. Well, that ain’t working.

We ought to spend that money to find out what works, without a preconceived agenda. What we’re doing now isn’t working. Something different needs to be done to lower drug use (licit and illicit) among teens, it remains a huge killer of teens and young adults in my jurisdiction. Whatever “it” is, I know it will have to be active and honest, relevant to the teens and young adults, it will need to get their attention over the societal din, and give them real reasons to quit and, most importantly, not to start.

I wish I knew what “it” was, but I do know that “Reefer Madness” and its ilk doesn’t work.

Underused cure for drug OD

There was a couple of interesting editorials in the Chicago Tribune yesterday (not that they weren’t all interesting, but I’ll comment on these 2, on different days).

I was discussing some “work things” with a colleague and she said the “real role” of the Coroner is to try and put themselves out of business by eliminating the business (not that that will ever happen). I certainly agree that my primary goal is to forestall death. To that point Steve Chapman had an editorial in the Trib making a point with which I heartily agree.

Naloxone should be available on the street to prevent/treat heroin overdose.

One way to prevent people from overdosing is to stop them from using drugs. But as smokers have demonstrated, knowing you should quit and actually quitting are two different things…
Abstinence is best, but when it's not universal, other remedies are needed…
But it's entirely feasible for governments to proselytize against drug use while trying to keep drug users alive, just as we preach against tobacco while providing medical care to smokers stricken by emphysema…

Naloxone will not only save lives, but by being able to rapidly treat overdoses it will also decrease short-term (ER) medical costs and long-term medical costs (treatment of anoxic encephalopathy and the like from not-so-quick “saves”).

I applaud the efforts of Dan Bigg and the Chicago Recovery Alliance bringing care to the streets. Also, the efforts of Senator Dick Durbin to get federal legislation in place for overdose treatment effort support.

I’ll take all the help I can get in forestalling death.

Make good choices and don’t take chances first of all; prevention is always better than treatment, but treatment needs to be available as well.

Another Medical Misadventure/Quality Issue

I came across an interesting blog post. While this was posted in response to the babies who died in Indiana because of an error in heparin dosing (11 doses were given among the babies, so not a singular event), the last section of the post pertains to our case that I wrote about a couple of days ago.

So what happens now?
The quality assurance department in the hospital will perform a root cause analysis to investigate all components of the extant procedure for medication delivery of heparin to infants in the neonatal intensive care unit. AIt will interview the pharmacists, physicians, pharmacy technicians, nurses and any other staff memebers invovled in the process at any point.
It will attempt to find weaknesses in the process, weaknesses in the education of the staff, reasons for noncompliance with the policy and procedure to administer medications, and then it will make receommendations to hospital committees charged with determining the policy and procedure for medication administration of this type.
Outside agencies will also become involved. The two infants that died will be under the jurisdiction of the coroner to determine the cause of death and contributing factors, and to refer the cases to law enforcement if there is suspician of criminal intent or action.
The state department of public health may become involved to investigate safe drug handling and administration practices.
The cases may go to litigation.
The nurses are most likely devastated and should be supported and be receiving counseling.
Their nursing licenses may be investigated, and if found negligent, the licenses may be suspended, revoked or be placed under restrictions or sanctions.
The national hospital accrediting body, the Joint Commission for Accreditation of Healthcare Organizations, JCAHO, will include the incident, investigation and subsequent actions to address the weaknesses in the policy and procedure in its routine survey to dtermine accreditation status.
But in the end, it boils down to nurses not taking shortcuts, nurses safeguarding patients, and nurses standing up for patients' rights in the face of poor work practices, poor working conditions and inadequate resources.

Underage Drinking Prevention

At an Underage Drinking Prevention Committee meeting this morning we looked at some local statistics. These were obtained by anonymous survey of local school kids. Are they factual (did the kids tell the truth)? It would be impossible to know, but they look “coherent” enough to be legitimate. I would assume that they are truthful.

Asked about consuming alcohol within the last 30 days 6% of 6th graders said yes, as did 18% of 8th graders, 36% of 10th graders, and 56% of 12th graders.

These results are concerning and saddening. We discussed reasons that we ought to work to decrease the numbers of kids drinking and work to delay the start of drinking in these kids. That discussion was held because while it is “good” to do those things, we need something a bit more ‘concrete’ to “sell” efforts and programs. It pretty much boils down to the facts that if we can do those things we will save a few lives and we will decrease the risky behaviors associated with alcohol consumption (e.g. remembering that alcohol is the # 1 date rape drug). Alcohol does make you stupid.

How can we bring these numbers down? What programs work? That is the target of future work (and no “just say no” doesn’t work).

Hospital Homicide II

The homicide verdict is not an attempt to destroy a hospital or all ERs (as one emailer suggested), but the honest verdict of a jury of 6 that there was a “gross deviation from the standard of care” and that the inaction in this case was “reckless”. By our definitions of manner of death that is “homicide” (again recall that does not mean criminal homicide).

This case and its publicity should prompt system change, locally and nationally. The system failed at Vista East. This 49 y/o did not get the care and treatment she deserved, because the system failed. This is a quality of care issue. The quality of care Ms Vance received was sub-standard (to say the least). I’m not attempting to point fingers or get anyone charged or convicted of homicide (although by our definition this death is a homicide). I want the system (Vista’s and everywhere that it is wanting) and the quality improved. I think there should be outside oversight to ensure their system is changed and, once changed, that it is maintained (this oversight should occur everywhere there are these system, quality problems).

This is a social justice, a greater good issue. No one should have to die like Ms Vance did, feet from life-saving treatment. The quality of medical care must be improved. No more excuses about an overburdened system. Develop systems (quality) to ensure this never happens again.
When I ran for office, I pledged to also investigate “medical misadventures”. Just as our office obviously is there to serve decedents who can no longer serve themselves, just as much we are here to protect the living residents of Lake County and to forestall death when we can1

Hospital Homicide?

Waukegan waiting room death a homicide, jury rules

”Reckless behavior is one of those things that stands out in the coroner’s definition of homicide,” Keller said. “The underlying feeling of the jury is that a reckless act resulted in this woman’s death.”

In an unprecedented move, a Lake County coroner's jury Thursday ruled the death of a Waukegan woman in the emergency room of Vista East Medical Center in Waukegan a homicide.


The definition that I give to the Coroner’s Jury during their instructions regarding what constitutes a homicide:

A death that occurs because of an intentional or reckless act by another person. A person is reckless or is acting recklessly when he or she consciously disregards a substantial and unjustifiable risk of another’s death from their action or when their action (or inaction) demonstrates a gross deviation from the “standard of care”, which a reasonable person would exercise in a similar situation (the latter does not only refer to “medical care”, but to the usual “care” an individual would take in a similar situation).

Coroner’s Juries decide on the manner of death, keeping in mind that “this is neither a civil nor a criminal trial procedure, merely an inquest regarding the death of this individual” (further Jury instructions). Their decisions do not signify criminal findings or intent on anyone’s part, that is left up to the State’s Attorney and/or the Courts.

Yesterday's Coroner Jury felt that the hosptial was reckless in their behavior pertaining to this 49 year old woman's death and found the manner of death to be "homicide". Two hours in the ER waiting room with the complaint of 10 out of 10 crushing substernal chest pain, with diaphoresis and nausea, triaged but not treated, "a gross deviation from the standard of care" (caring?).

We, today, have filed reports referring this individual's death to the Lake County State’s Attorney’s Office, the Joint Commission on Accreditation of Healthcare Organizations, and the Illinois Department of Public Health. Further action is up to them, although I would recommend an advisory panel be established (with local resident involvement) to oversee changes that will no doubt be made at the hospital.

Overlaying death

Another death by “overlaying” in our county; I’d say tragic; but so are all infant deaths. Overlaying, as a cause of death, likely far outnumbers the number of SIDS deaths, but it is another one of the causes of death not often heard of or talked about.

Overlaying is caused by an adult (or larger child) rolling over onto an infant while they are sleeping together. The exact mechanism of death may be obstruction of breathing, circulatory impairment, or both. Closely related to overlaying is “wedging”, in which the infant becomes wedged between objects resulting in inability for the chest to move for breathing or in airway obstruction. We’ve seen too many of these as well. Considering the paucity of physical findings, the diagnosis of these causes of death depends heavily on a thorough death investigation, including death scene investigation.

In these cases the adult’s (or child’s) grief is compounded by the guilt of having contributed to the death of the infant.

Infants should not share the “family bed” (or other shared sleeping arrangements). They should sleep alone on a “firm” surface without fluffy bedding or pillows. And remember “back to sleep”.

Family and "pono"

Just a little bit of a twist on the positive effects of family dinner on the behavior of teens and children.

I have been doing some reading (I do make time) about aboriginal (in its broad sense) healing and wellness. In most “native” cultures healing is a communal event. The more people you bring together at the healing ceremony (particularly if they are family) the more effective it tends to be.

I think there is a real community/family effect to healing (also think of this word in its broadest sense). Maybe this is one of the things that also affects folks when they come together for family meals. There has to be something, because the positive effects of the meals occur even if there isn’t “lecturing” about doing the right things and behaving the “right” way.

Just the “being” with family (supportive people, if you don’t have “real family”) has a positive effect. Maybe that can be enough to teach kids and teens to be “right with themselves” (pono in Hawaiian, told you I’ve been reading) and to “value themselves” so that they don’t take chances and don’t make “bad” choices (or be at least one positive influence). [Disclaimer: there are no absolutes in this world, you can only do what you can do]

Death Thoughts

Ah, the end of another week. Except they don’t really end, they just flow on. Weekend, weekday, the Coroner’s business flows on. The only difference is I’m not in the office very much on the week ends. Like the old joke so many folks like to tell me: “They’re just dying to meet you”.

This week the young died when they ought not to have. The old died when they also ought not to have. Some died and their release was a relief. Others died with a flood of grief. But some died when it was time.

I didn’t set out to make this maudlin or poetic; sometimes the words just flow too. People die for so many reasons, in so many ways, and each death has their own story. The stories can be interesting and enthralling. The stories can be obvious or require work to get at and to sort out.

Death is natural and unnatural, but we will all end up there eventually. It is my wish for you and yours (and everybody else) that that occurs no sooner than it must. That you all may grow old enough and get enough done, that you may shuffle off this mortal coil without regrets and prepared for the journey.

Enjoy the ride.

Asthma Kills

Asthma kills, as I was again reminded recently. Nearly 5000 people die each year in this country from asthma; in another group equally as big, asthma is a contributor to their death. Although most people who die from asthma are over 50 years old, over the last 20 years there has been an 80% increase in the death rate among children and teens with asthma.

Asthma is a common disease. It is one of the leading causes of school absenteeism (and work absenteeism in adults). It is also a frequent cause of ER visits. The disease can be exacerbated by certain activities (e.g. sports participation), certain conditions (e.g. cold air), but it can strike anytime and can strike without apparent trigger.

Asthma is characterized by bronchiolar constriction/spasm and mucous thickening and plugging (with blocking of bronchioles). The latter condition is the most lethal and the most difficult to treat.

How do we prevent these deaths? This is a bit tougher than some of the other causes, but individuals need to have access to medical care and be assured (ensured) that they are receiving optimal care based on the most up-to-date treatment guidelines. People need to also be aware just how deadly this disease can be. We won’t prevent them all, but some deaths will then be prevented. All people must have access to quality medical care, or we must accept the consequences (people will die).

I'm your parent, not your friend

A conversation started just before the underage drinking prevention group meeting I attended about a week ago that reinforced an opinion I hold strongly. Two of the folks were talking about talks that they had had with their kids: that they were the parent and not a “friend”. I had a similar talk with my 16 year old not too long ago.

I think we do our kids a disservice when we, as parents, try so hard to be friends with our kids. That is what they have friends for. I am there to lay down the law, teach moral and proper social behavior and to punish when they stray from the rules. I believe this is how to model, mold and develop an individual who will grow up to be a “good” part of the community and will have the best chance possible to grow up and grow old.

That’s not to say we can have fun together and laugh and enjoy being together. That’s part of being a parent (and a family), too. But, at the same time, I am not their equal. I am the parent and they are the kid.

How can you tell your child not to make bad choices and not to take chances if you don’t teach them “right from wrong” in regards to chances and choices? If your goal is to be a friend how can you lay down the law, enforce the law, and teach them “right from wrong” choices and chances. I feel I have done my job as a parent if my child is mad at me from time to time because of corrective measures I enforce. A good parent uses reward and punishment to mold behavior. Someone always focused on being a friend loses the authority to parent and punish. My kids are the better for my working as a parent instead of my being another one of their buddies.

More Nicotine in Cigarettes

I will have another “parenting” post regarding something else that came up at the underage drinking prevention meeting that prompted the last 2 posts, but I wanted to mention this news report before it got too “stale”.

It seems that, just perhaps, cigarette makers are adding or otherwise jazzing the nicotine content in their cigarettes. Nicotine is the reason folks get hooked and/or can’t quit smoking, just behind the psychological addiction. It appears that, according to a Massachusetts Department of Health study, the nicotine level in cigarettes has been rising steadily over the last 6 years. And don’t think the ultra-lights are “safer”; the nicotine levels went up in all cigarette “strengths”.

This made only a small news splash when it should have prompted screaming headlines: “Cigarette Makers Jazzing Coffin Nails” or something equally shrill. They get away with admitting the health risks of their product while at the same time making them more addictive. That seems to me to go beyond their statements of innocence; that they warn folks not to smoke, so they are not liable for their resultant health problems and deaths.

Hook them in faster and stronger. Make them customers for life (no matter that that life is shortened after hooking them in). Smoke and die young (though not a pleasant death most of the time).

Keeping them at family dinners

In my last post I sang the praises (with back-up study “proof”) of the great benefits of have frequent and regular dinners with your kids. Regular dinners with your kids may save their lives. But sometimes it’s a bit tough keeping them at the table and/or figuring out what to talk about to occupy the time (nothing worse than repeated “I’m bored” throughout dinner)

To the rescue comes our government and SAMHSA (Substance Abuse and Mental Health Services Administration) with their “conversation starters” listed on their website. They certainly may help and some my plumb some insight into the psyche of your child (e.g. “Do you think of yourself as a risk-taker?”) But do keep in mind that just regular conversation works too (e.g. “What do you think of the weather? or What’s your sign?, well maybe that last one won’t work so well). Also worth remembering is that humor works and the conversation doesn’t need to be deep and penetrating.

TVland also has some tips about family dining and, amazingly, not watching TV (watching TV during your together family dinners ruins the positive effects). (This one also has stuff to do with younger kids.)

Parenting and making a positive difference as a parent takes work and this is one of those works with a benefit (and you get eat dinner in the bargain as well). Cliché as it may be parenting is the “un-drug”, as well as the “un-death” and the “un-bad choice risk taking thingy”.

Dinner Together Can Prevent Deaths

Kids die. Kids shouldn’t die before their parents. A fair number of teens die because of poor choices and taking chances. What can we, as parents, do to prevent risk taking, poor choices, and taking chances and keep our kids alive? Lecturing often results in a “deaf ear”. Telling them the horrors that will result from their bad choices and trying to scare them into ‘good” behavior often doesn’t work. What can you do? What is effective?

Amazingly there is something that is fairly easy to do, that has been shown to have a very significant impact on a broad range of behaviors and excellent positive effects, generally, on teens (and all kids). And best of all it is pretty easy to do and centers around an activity that you want to do anyway, eating dinner.

A study has been done (and replicated) by the National Center on Alcohol and Substance Abuse at Columbia University demonstrating the benefits of having family dinners together 5 or more times a week.

Teens in those families that ate together that often had lower rates of smoking, drinking, and drug use. They had better grades, were more emotionally content and had more positive peer relationships. They had healthier eating habits. They had lower risk of suicidal thoughts. They were more likely to have friends that their parents approved of. Wow, almost everything one could hope for short of whiter teeth and fresh breath (sorry, just a bit of a joke).

You can’t buy a better treatment and preventative measure for teen health and well-being, as well as death preventative. Granted it is not a “silver bullet”, substance use/abuse and risk taking can still happen, but it is much less likely with this “dinner treatment”.

Having frequent and regular dinners with your kids is the simplest and most effective way to positively affect your teen’s life (and making sure they are around to live it).

Awesome, all the more reason to keep it up despite the resistance I sometimes get from my kids. Try it, no, no, DO IT.

Rehabilitate don't recidivate violence

In an interesting article an interesting quote: “…almost all bad behaviors are the result of anger…The last thing you want to do is add to that anger.” Quite the truism and it certainly could be used in so many contexts. In the case of the article that it came from, it referred to the need to change the way we treat juveniles in prison.

A fair amount of violence in our society/community is caused by youths who recidivate (i.e. who “relapse” into violent and/or illegal acts). The way youths are incarcerated in our state (and other places in this country) feeds their anger with lack of opportunity for positive change in a profoundly negative environment. As the article points out we need to totally change the culture of juvenile incarceration.

Illinois has about 1400 youths in incarceration at a cost of $70,000 per youth per year with a 48% recidivism rate, while neighbor Missouri has 1200 incarcerated youths at a cost of $57,169 per youth with a 7% recidivism rate. Missouri incarcerates youth in residential facilities with case management and rehabilitation. Illinois has their youth in stark prisons and razor wire and hopelessness.

The new Illinois Department of Juvenile Justice is set to change that. They plan to improve the prisons, “beef up education and create a system of support and supervision after release” and “teach better behavior”. These youths will then return home after their sentence better off, better able to deal with life and supported in those efforts. They will be less likely to relapse into crime and violence. They will be less likely to die from violence and those who would have been their victims will also survive.

A way to decrease violence in our communities, a way to save lives, like this deserves our support. We need to return to rehabilitative incarceration (yes, we need preventative programs even more) and it will have a positive impact on our communities and society (and save a few bucks in the deal, to use for other important needs).

Maggot Dance

Imagine my surprise when I read in Eric Zorn’s blog this statement today:

“One of the problems with my life is that it doesn't have enough maggots in it.”

You see, maggots are something we have to deal with at times (actually not infrequently, depending on the season) in the Coroner’s Office. They can be interesting at times, but there does seem to be an inborn aversion to them that can be difficult to overcome. So I was very surprised to find out that there is a ‘fun’ maggot. A maggot that is a dance, not to be confused with a dancing larva (there are times that some of those little creatures are dancing, particularly when they have been exposed to ‘happy drugs’). There is always something new to learn.

Addict shares his thoughts

This guy’s description of the development of his addiction and progress to sobriety really struck me, so I thought I’d share it:

“I'm a drug addict.

First off, don't y'all go worrying about me. After some months of trying and failing, falling into traps and routines that led me back to my disease, I finally surrendered and found a home within a fellowship that helps people like me.
from my earliest days of remembered consciousness, I felt this absence--some describe it as a void inside. Now today a counselor might tell me that it had to do with my adoption, with my mother's struggles with depression in my early childhood, or somesuch as that. Frankly, I have to admit that I never found the whys and wherefores very useful.
First it was Hot Wheels cars, then Star Wars stuff, then endless parambulations in the woods behind our house, making up all sorts of fanciful stories. My parents would tell me to get home when the streetlights came on. Funniest thing though. Those damn streetlights never came on! At least not for this kid. Not until more than twenty years later. Maybe six months ago by my reckoning.
At that point, a bad drinking problem nurtured in college, emboldened after the tragic death of a close friend in an automobile accident, had made its transit through all type of recreational drugs and settled into a death struggle with crack cocaine here on the streets of Brooklyn, New York. At the end I had two choices: go on to the bitter end--jails, institutions, and death. . .or find an entirely new way to live.
After going in and out of recovery meetings, I finally came back to stay, with a penitent 'never mind all that stuff I thought about doing this myself' and a willingness to take suggestions. Today I have more than two months clean, and my commitment to keeping that clean time becomes stronger every day.”

Still death by suicide

Suicide; I don’t mean to dwell on it, but it keeps “coming up” at the office. There are always different reasons behind each one or different stories of each of these individuals’ lives before their death by suicide. Each is a bit different in method. But it comes down to death by suicide.

Remember, asking an individual if they are planning to commit suicide has not been shown to precipitate the suicide. There are potential benefits to asking, however. Asking may show them that someone cares, which may be something they need right then. Asking about means or methods considered allows those means to be removed from where they might be used. Identifying someone as suicidal may allow for mobilization of family and friends and beefing up their social support system, which may make the difference. Asking them about reasons to live may get them to expand their thinking beyond that one last choice. Asking about suicidal ideation and intent may be the first step in their getting the help they need (and yes you may need to push them to get that help).

Another “cluster” of unrelated deaths by suicide gets me thinking and hoping for a way to prevent at least some of them.

Drug companies sell disease and dis-ease

“Pharmaceutical companies sell disease” and the fear of disease. Life and its problems have become diseases needing medication intervention. We are nothing but consumers unable to deal with life and its problems and challenges without taking a pill. Shyness is now “social anxiety disorder”. Trouble sleeping has become insomnia in search of the right pill. Pain is not to be endured and certainly can’t be treated short of taking the right pill.

Pharmaceutical company advertising expenditures are about $4 billion a year. In 1994 (about the time I wrote “Brown Bag Syndrome”, regarding the perils of polypharmacy, for Emergency Medicine Reports) the average American had 7 prescriptions a year. In 2004 that number was up to 12 a year.

Pharmaceutical companies know that a drug ad increases the sales for all of the drugs in that category of medication. They know that the ads will return $4 for every $1 they spend. They sell the disease so you have to have the pill for the cure.

What can come of this polypharmacy (other than great profits for the pharmaceutical company)? It drives soaring system-wide medical cost and patients badgering doctors for more meds and that one “perfect” pill. People get sick (and can die) from the side-effects of one medicine, but few studies have been done on the potentiation of side effects from ‘mixing’ meds. More meds around also increase the chances of ‘punch bowl’ parties allowing for the ‘snacking’ of mixed meds as if they were jujubes. Polypharmacy can be a fatal.

Medicine should be about healing people, not persuading more of them that they are “sick”. Medicine should be advising folks about health, not pushing pills. Proper diet (weight control, general well-being, specific issues), exercise (weight reduction, general conditioning, pain control), non-toxic modalities like massage therapy and yoga, are all non-medication paths to health. It takes more work than swallowing a pill, but you can be in charge of your health and forestalling your death.

"Live Scan" fingerprinting

We have added new equipment and capability to our office.

Our new “Live Scan” fingerprint equipment will help us with decedent identification and with case investigation. We are the only Coroner’s Office in the state with these capabilities in-house. And being able to supplement our budget expenditure with private grant funds made it easier to bring on-board.

Instead of our previous procedure, (inking and finger printing onto “cards” and submitted via mail to the Bureau of Identification, with results in a couple of weeks) the decedent’s fingerprints are directly scanned into our computer and submitted electronically. The first day we were operational with it we had the identity of the individual back in about 30 minutes and another case the other day took 10 minutes to get the information back.

The other information we get is any criminal history and there are times when that information is valuable to us in our investigation. An individual believed to have died from an asthma attack found to have a history of drug-related charges, may test positive for drugs that contributed to their death (making it not so natural a death). A previous call to the police for suicidal ideations or actions would add evidence that their death may have been related to those previous actions. Additionally, it may allow other law-enforcement agencies to close open cases with “missing” perpetrators that turn up in our office.

The limitation to fingerprinting as a method of identification is the necessity for the individual to have been fingerprinted before and those fingerprints to be on file with the Illinois State Police and/or the FBI, otherwise there will not be a match. However, there are a growing number of non-law-enforcement related reasons for individuals to be “in the system”. Many jobs are having employees and applicants fingerprinted and submitted to the databases (and those submissions are retained). As well, certain professional license applicants are being likewise fingerprinted. All increasing the chances of a “hit” with a fingerprint check. So “Live Scan” will be a very useful technical addition to our office capabilities.

Our technical advances since I took office are really amazing. In our toxicology lab the changes have worked wonders. Next up I am waiting to hear about a grant we have applied for to add “crash data recorder” information access to our office to aid in investigating auto crash-related deaths.

Death Investigation Training

I got the flyer for St Louis University School of Medicine’s Medicolegal Death Investigator Training Course in the mail today. I often get asked about training/education sites and I would whole heartedly recommend this program. I went through it shortly after my election as Coroner and we send all of our Deputies through the training. It gave me a solid base on which to acquire/build further related information and allowed me to look at information already in my armamentarium from the medicolegal death investigation vantage point.

The intensive course covers 30 “types of death” and provides introductory information about various ancillary forensic sciences (anthropology, entomology, psychiatry, radiology and toxicology). They have been conducting the course for 27 years and the polish and topic coverage shows that history.

Taking this course also prepares you for more in-depth courses that they offer each year on a variety of related topics. If you have interest take a look, they draw from a breadth of disciplines that you would be hard-pressed to put together otherwise. In addition, they have the backing of the St Louis University School of Medicine (not all such courses have such a pedigree).

CeaseFire

Over several years the Chicago Project for Violence Prevention designed and tested a project to reduce community violence, particularly gun-related violence. That project is CeaseFire. They drew from public health research and projects running successfully in several cities nationwide. Take a look at their statistics; it certainly looks to have been very effective in reducing shooting and homicides in Chicago. I will mention that there is a further study underway to try and separate the effect of CeaseFire from other initiatives brought to bear on the violence problem at about the same time (the results of that study will be very interesting to see).

Youth outreach and conflict resolution, to head violence off before it escalates too far and offer alternatives to violence, are the cornerstones of the program. Outreach workers, “violence interrupters” and community support and reaction are the “tools” used for intervention and “inoculation” against violence. Another very important facet is to ensure that there are “multiple messengers with the same message”, that violence can be stopped, it is a cycle that can be interrupted.

CeaseFire is spreading out of Chicago, with Chicago Project for Violence Prevention helping with technical assistance and training and the state helping with funding. I think CeaseFire will become a very useful program in Lake County and I thank those responsible for its coming here.

I am certain it can prevent deaths and decrease the growing violence problem in our society.

Veteran Post Traumatic Stress Disorder

Another bit continuing yesterday’s post regarding concerns of a potential “epidemic” of Post-Traumatic Stress Disorder in returning veterans. This from an article that has been in my briefcase for a while.

In a report from the VA’s national advisory panel on PSTD it was reported that returning veterans have to wait an average of 60 days before they can be evaluated for PSTD, which, of course, means even longer to begin treatment. 42% of VA primary care clinics have no mental health staff and 53% of those that do have staff have only one such individual. 82% of new patients need very intensive PTSD treatment, but 40% of those programs are so full that they can only handle “a few more cases”, with 20% reporting that they are too full to take on new patients.

Particularly considering the 30% increase in PSTD-diagnosed individuals among returning veterans since 2005, unavailability of treatment is going to be a huge bottleneck. This is likely to contribute to increased risk of death by suicide, homelessness with attendant health risks (and death risk), among other personal and societal problems. We owe them more than this. What do we need to do to prevent these preventable deaths from occurring in the (not distant) future?

2 short posts

A couple of quick posts today; I spent a good share of today (as often happens) in meetings.

First, “ripped” from Eric Zorn and “shared casket”:
Reading the terribly sad story about the funeral of Angela Lindner, 39, of Naperville, and her sons Danny, 3, and Aidan, 1, who were killed recently in a crash on the Indiana Toll Road, I was struck by the offhand information that the three victims "shared a casket."...


The second goes to a conversation I had at the last Lake County Partnership to End Homelessness about the impact that this country will see from veterans returning with Post-traumatic Stress Disorder and whether “we” are prepared for its effects on them and on society. There has been “explosive” growth in the number of veterans with severe PSTD, but the VA has only ramped-up minimally in services to handle the care of these individuals. As a matter of fact over-all there has been an 8% decrease in funding for mental health services.

Needle Exchange Saves Lives

HIV/AIDS is back in the headlines (a little) long after compassion fatigue pushed it out. Yes, HIV and AIDS still exist in this country and around the world. We do hear a bit about it around the world, but not much about it in this country. Granted it is a much more treatable disease than it used to be, but it hasn’t been cured. People still get infected with HIV and people still die form AIDS (although thankfully much less often than when I first started treating individuals with HIV/AIDS, I was a “specialist” for 10 years).

The news “splash” coincides with the 16th International AIDS Conference and the 25th anniversary of the infection. I saw a headline with Bill Gates and Bill Clinton promising to eradicate HIV/AIDS (I seriously doubt it and have doubted that possibility all along). One article that did catch my attention was one on needle exchange. That is a “battle” I have fought in the past. It is a battle fought and won all over the world, won except here in the US, of course.

Providing clean needles to drug IV users is an incredibly effective way to prevent the spread of HIV among people who inject drugs and through them their partners/spouses and children. It has been demonstrated, just as conclusively, that it does this without encouraging the use of illegal drugs (as Surgeon General David Satcher reported to Congress in 2002).

While most states have at least some access to clean needles for individuals, this should be a national policy and a national program. A clean syringe costs about 10 cents. Compare that to a lifetime of care at $195,000 or the cost of a life. Needle exchange is a life-saving health intervention and we ought to be about saving lives.

Stop CPR and no trip to the hospital

Few people survive a cardiac arrest. Over 300,000 individuals in the US die of cardiac arrest each year; “sudden” cardiac arrests of cardiac origin (rhythm or perfusion) are the least likely to be resusitatable.

A recent study in the New England Journal of Medicine (not a NEJM link, that is subscription only) tested a three criteria decision-making “tool” to see if it was reasonable for rescue personnel to stop CPR “in the field” based on futility of actions. This may seem ‘cold”, but the large numbers of individuals taken to ERs by rescue personnel in whom resuscitation is unlikely to be successful ties up rescue personnel and equipment and ER personnel and capacity that might be better used for others more likely to benefit. These “cost” (not just monetary costs) vs. benefit decisions must be looked at and “tough” decisions made.

The criteria included were: arrest not while rescue personnel were present, a rhythm not correctable by defibrillation or counter-shock, and pulselessness during resuscitative interventions (adding paramedic arrival time greater than 8 minutes in a 2-tiered EMS response system and arrest without any witnesses made the “tool” even more predictive of failure)

According to the study the application of this decision-making tool would decrease by about two-thirds the number of people in cardiac arrest taken to hospitals, those with incredibly low likelihood of survival/resusitatibility (0.5% in their study group).

It is time we looked at whether this is a reasonable advancement in pre-hospital care and whether this is in the interest of the greater good, without abandoning “hope” for those without much chance of survival.

Aspirin Life Saver

Over 1 million individuals in the US suffer heart attacks (myocardial infarctions) each year. Almost 500,000 individuals die of heart attacks each year, which translates to 1 in every 5 deaths being due to a heart attack. (American Heart Association)

Certainly, as is true of every disease, it is best to prevent yourself from getting heart disease. Eat right, exercise, don’t smoke, get born with a better gene milieu. But what can you do if you suddenly develop chest pain (with or without exertion) maybe radiating into your left arm, maybe with some shortness of breath and you, as Fred Sanford used to say, think that this is the “big one”? First, get yourself to medical care and if you think you are having a heart attack calling 911 should be high on your list. Besides getting you to the ER quicker, the folks in the rescue squad can give you oxygen and medications that may be very beneficial in the situation of a heart attack. Also, if things “go bad” they can provide necessary care and resuscitation.

But the thing I want you to think about is aspirin. Yes, the lowly aspirin tablet can be a life saver. Several studies have shown that in the case of an acute myocardial infarction, an aspirin taken as soon as possible in the course of its evolution can save heart muscle (decrease the amount of damage done) and can save lives. One study projected that aspirin administration in the course of a myocardial infarction could save 10,000 people a year. If you are at risk maybe you should carry them with you or have someone grab one for you as you’re waiting for the rescue squad.

And just as Fred Sanford lived to say something comparable to “Oh, this is the biggest one I ever had. You hear that Elizabeth? I'm coming to join you honey” multiple times, snacking down (chew and swallow, no matter how bitter) a regular strength (325 mg) aspirin tablet during a heart attack may allow you to live longer.

Picky to avoid bitter

There is a genetic reason some kids are “picky” about eating vegetables, or at least some vegetables. And we all know we should consume more veggies than we do. It seems the sensitivity to “bitter” tasting is genetic, with some individuals more sensitive than others. Kids who are more sensitive tend to be more likely to eat sweeter veggies (e.g. carrots and bell peppers) than bitter ones (e.g. broccoli and cucumbers).

Realize there is some “use” to this sensitivity evolutionarily. Most naturally occurring “poisons” are bitter tasting, so someone highly sensitive to “bitter” is more likely to survive (and would be good at the job of royal food taster).

There is hope of expanding food options/choices, nonetheless. As one of the study authors pointed out, food preferences often change as we get older. This has been borne out repeatedly as my kids have aged and matured, although I’m not sure when I will be able to get them to eat a turnip or certain meats that look like the organ they came from.

Watermelon, health food

This heat does bring back memories of eating sloppy wet pieces of watermelon at my aunt’s house or the park near her home during summers of my youth.

Now science has endorsed that activity by finding great health benefits in the fruit. Most obvious to anyone who has eaten it by the slice is the high water content (94%) that can go a long way toward replacing water lost from the heat. Also found in various watermelon studies are high levels of antioxidants, particularly carotinoids and lycopene. These antioxidants are beneficial in helping the body avoid and/or repair cellular damage caused by living and outside influences such as chemicals and the sun.

Another interesting thing that was borne out by research goes back to the “old days” as well. Watermelons stored at and served at room temperature maximize the amount of anitoxidants delivered in a serving (sliced, chunked or balled). We never had watermelon chilled and I think it is much tastier a bit on the warm side.

So, if you are out and about in the heat or want a treat at home this summer seriously consider the health benefits, tastiness, and fun of having a bit of watermelon.

Heat-Related Deaths

I have been getting calls from local newspapers asking for information about heat-related deaths. We, like so many others are in the midst of a nasty heatwave (it sounds sexier in song than when I am sweating in it). The media folks seem somewhat disappointed when I can’t give them a number.

Heat-related deaths are, for the most part, a pretty subjective call. Most heat-related deaths are accelerations of naturally occurring disease processes, so do you call them heat-related or not? Did the 70 year old gentleman die of a “natural” myocardial infarction (heart attack), likely to have occurred no matter what the weather, or was the “push” the 95 degree heat with oppressive humidity poorly excluded from his home by his several room fans?

Other than true cases of Heat Stroke (elevated core body temperature with physiologic loss of ability to sweat) it is really very difficult to count with certainty the number of “heat-related deaths”. We have not seen any Heat Stroke deaths, the others based on circumstances surrounding their deaths, maybe so.

CDC MMWR July 7

A recent edition of the CDC’s Morbidity and Mortality Report contained 3 interesting factoids.

First, hospitalization for depression among girls 5 to 19 almost doubled over the last decade; with the rate among girls being double that of boys of the same age. No analysis or explanation accompanied this information, but a couple of things come to mind. Is the disease of depression genetically sex-linked or are the conditions for expression of the disease gender-based? Each of these “scenarios” would require different screening, intervention and treatment. Depression is a growing problem that not infrequently leads to grave consequences (see below) and so this consideration is not merely academic.

Second, mental health “issues” have a huge impact on violent deaths in 2004 (based on collection of data with a “new” database in 7 states). 20% of homicides have contributions from “intimate partner conflicts” (translate to “spouse” abuse) and 16% were “drug-related”. 50% of death by suicide was linked to depression, bipolar disorder and/or schizophrenia and another 28% had a contribution of “intimate partner conflicts”. Alcohol-dependence was also a big contributing cause.

The third factoid, previously declining cigarette use among high school students seems to have “plateaued”. In this section, the CDC included some factors that might have contributed to what had been a significant drop in use. 2 of those factors that stuck out for me were: decrease in exposure to and availability of smoking-prevention campaigns and a near tripling in tobacco advertising and promotion ($5.7 billion to $15.2 billion). Future health problems bought and paid for.

Addict in the family

There was an article in USA Today about a week ago that opens with a man’s comment that without his wife and 4 kids he would be dead. Mr. Ryan is an addict. He has only been sober about half of the last 16 years of his life. However, he has been a functioning addict. He has held his job, he has kept his family (barely), and probably hasn’t looked out of the ordinary to his neighbors. Probably 75-80% of our deaths in our county due to drug overuse and abuse (which includes alcohol) are of functioning addicts.

The USA Today article is about addiction being a family disease. It affects more than just the addict. It affects the whole family. The entire family needs to be considered and have access to treatment.

One in five adults (that would be 40 million individuals) report an immediate relative who was and/or is addicted to alcohol or drugs. "For every person who's alcoholic or dependent on other drugs, there are at least 4 or 5 people hurt on a regular basis". Think of the size of the problem. Beyond the addict that needs treatment are the family members who need support and care.

We (society) need to make certain that there are treatment and care options for the Ryans in our country so that they don’t become coroner’s cases too early, so that lives and families are not destroyed, so that children don’t repeat the cycle.

I applaud Mr. Ryan, who was willing to bear his life for the article. His and his wife’s comments are blunt, likely painful, but really bring the story home. My thoughts and prayers are with Mr. Ryan and his family. I wish him success in sobriety and strength in his continued battle.

Autopsy

A friend of mine sent me a link today to an interesting website. The website is titled: Autopsy. It is the work of (as he puts it): “Ed, the pathology guy”.

The autopsy is a valuable tool in forensics and in medicine, but (somewhat in disagreement with the author) it is my opinion that it should only be done when there is real information of “value” to be gained. [the “value” may be quite subjective.]

If you have ever wanted to see a step-by-step guide to what is involved in an autopsy (or just curious enough to take a look), this is the site for you. It also has little “cartoon” illustrations to go along with the narrative. While it may be a disappointment to some, there are no pictures of dead people or gruesome open people shots directly on the posting page. However, there are videos available for purchase and links to sites that are likely “more detailed”.

"Hic locus est ubi mors gaudet succurrere vitae”

I like the site and will recommend it to folks who want some detail on what an autopsy entails. Go take a look.

I followed a few of the links at the end of the posting and they including some interesting shopping opportunities as well as informational links and some links to photos overlaid with the word “caution”.

Camping on meds

There was an article in the paper about a week ago (no link) that reported that about one fourth of kids at summer camp are on medications. The article closes with “It’s universal, and nobody really knows if it’s appropriate or safe”.

Depending on the medical care available at these camps I would say it is likely neither appropriate nor safe. Do they have staff present to recognize and treat side-effects or other reactions? Is secondary medical treatment accessible enough to handle possible complications? Do they have staff to deal with whatever the underlying condition is that requires medication? Is someone watching for and able to deal with problems of diversion of the medications (someone not supposed to be taking the medicine, getting a hold of it in one of a variety of possible ways)?

Poison ivy, allergies and ticks are big enough worries, but camping with pharmaceuticals raises a number of red flags for me. Granted, many kids really need their meds to stay healthy and function, but is camp really the place they should be?

I don’t have any answers to this one, just a lot of questions.

Medication errors and caring for health

I have spoken to groups about improving access to healthcare and controlling costs of healthcare both recently as Coroner and previously as the Director of a free medical clinic. I often get some of the questions pertaining to whether there are things short of major system changes that can be done to impact these issues. The questions are usually couched in terms of their feelings that major system changes are unlikely to occur (although I do not necessarily agree that major changes are unlikely). My answer usually centers on the need for “real” quality assurance measures and action to improve delivered health care, decreasing costs and allowing for expansion of access.

I ran across an article quoting a recent Institute of Medicine Report that seems to back up that view. It reports that there are 400,000 preventable in-hospital, drug-related care complications each year at a cost of over $4 billion a year.

Can you imagine what could be done with $4 billion in healthcare? Steps must be taken (see the report) to stop these errors and recoup these costs. Those monies should be used to provide care, not correcting mistakes; saving lives from disease, not from iatrogenic disease. That can be done within our current system, while we wait for the needed systemic changes in healthcare. Healthcare is an individual need and a societal need, paying for it now is cheaper than paying for it later.

Realize, also, that some of those medication errors also result in death; early, unnecessary death. That should be reason enough to implement changes to prevent these errors.

Death by caffeine

Here’s an Internet time waster right up my alley. It’s an on-line lethal caffeine dose calculator. Have fun. I did the calculation by Starbucks coffee, my drug of choice, but there are a variety of other beverages (yes, including Mountain Dew). There were also a couple of other tabs that I did not follow (e.g. death by Penguin Mints and energy drink ingredients) that I plan to drop back to look at.

Posting "gaps"

Sorry for blog gaps over the last couple of days, but in addition to the usual “stuff”, I have been reviewing 600 pages or so of records and preparing a report for the local Child Death Review Team. Someone on the “Team”, not in the jurisdiction in which the death occurs, prepares a report for the team’s review and discussion. I volunteered to do a review and “drew” this case. There are hospital records, doctor visit records, police reports, DCFS (Department of Children and Family Services) reports, an autopsy report, and other documentation to be gone through for the report preparation. I didn’t really know what would be involved in preparing the report (i.e. 600 + pages of documents). Convoluted (multilayered) materials to review, digest and “digest” for the report to the team.

The perpetrator was arrested, charged and indicted by a Grand Jury.

Inquests tomorrow, back to regular posting real soon.

Activity = Life

I have stumbled across several references to a recently published study about the effect of regular activity in the elderly. What I think is really important is that they looked at “activity”, including routine household activities, not just at what is routinely thought of as “exercise”. So many people just don’t stop and think how beneficial “activity” is. In this group of individuals “activity” significantly lowered the likelihood of dying.

I think it is much easier to encourage “activity” than “exercise”. “Exercise has much more “baggage”. When people think “exercise” they often think they need to go somewhere dedicated to exercise (e.g. the Y or gym) or use some special equipment. These beliefs make it easier to talk yourself out of participating, because it is just too much work. On the other hand, many will exercise just because you have to go someplace special and use equipment.

Nonetheless if you “sell” the benefits of “activity”, I think people are much more likely to participate. Then once they are just doing “activity” you can introduce the concept of making it a bit more “work/exercise” (e.g. parking a bit farther from the store door) and before long they are doing “exercise”. Those that only able to do “activity”, on the other hand, are still reaping benefits.

It is all about living a bit longer and making that time a bit more health filled, now there a study to back it up. Stay active and stay alive.

Interesting Cases

The most frequently asked question during presentations and tours of the office is a request to hear about “interesting cases”. This week has been no exception. Tuesday we had 2 groups of College of Lake County students (their “over 40” program, learning about the “Justice System”) and another group from the National Youth Leadership Forum on Wednesday.

It is difficult relating interesting cases. Cases that might be interesting to the office staff in certain ways may not be interesting to the “general public”. In addition, we need to be careful not to upset certain “sensibilities” of the members of the groups. For example, some cases of “choking” have “autoerotic” overtones and therefore while it might be an “interesting case” you might not want to talk about it with certain audiences. In telling about “interesting cases” I want to avoid sensationalizing certain aspects of the deaths, e.g. the highest blood alcohol measured in an individual dying from alcohol overuse.

Lastly, it is critically important to not trivialize or appear to be trivializing (or making light of) any individual’s death. A person died after all.

The “trade-off”, however, is that these stories stick in people’s heads better than “just the facts”. Describing a teen killed in a car crash is more effective then just saying teens die in car crashes. Describing how “choking” can go wrong will have more impact than just saying it is so. Describing how terrible a drug-related death can be is more likely to affect future behavior than pushing the “just say no” line. (Of course all of the presentations are redacted of personal information)

It is a “tightrope”. I hope my discussing cases in my presentations comes across as education not “entertainment” or titillation. The case stories can be very illustrative and the listeners do listen better.

Say it with flower pix

Something a bit more light for a change of pace:

I was at the grocery store the other day and saw a young man in the flower center/cooler holding his phone as if using the camera feature. My thought at the time was that maybe he was sending a picture to someone asking if he should buy a certain bouquet of flowers. My opinion has changed. Apparently these days it is acceptable to send a picture of flowers phone-to-phone in lieu of buying/sending the bouquet. What a deal, an evolution from instant messaging to instant flowering.

I only wish I had a camera phone. I’d run out and get my wife a picture of some flowers. Nothing says I love you quite like that.

Sleeping kills

1,500 people dead, 71,000 injuries, over 100,000 car crashes, what could cause such carnage? Driving while drowsy, sleep-related crashes, is the cause according to the National Traffic Safety Administration.

A survey by Farmers Insurance demonstrates that it could be worse. Over 10% of drivers admit to falling asleep while they were driving and more than 20% have “dozed off” while driving. What is also scary, some 40% of those kept driving.

It is likely that there are even more deaths, injury and crashes due to falling asleep at the wheel, because it is not well tracked nor is it often a focus of investigation after a crash. There is no test for it and many will deny it after the crash. Alcohol makes it worse; it magnifies the drowsy effect and it may be blamed when it should be shared with the drowsiness.

The only remedy is not driving when you are tired enough to “doze off” or fall asleep. Pull off and take a nap if you need to, because the other things that are tried (turning on the radio, opening up a window, etc) do not work. (Although I did see one suggestion of changing pants with another occupant of the car, presumably while still driving, that might wake you up, but sums fraught with many other risks and problems.)

Don’t sleep while driving. It is not a good thing. Make good choices, don’t take chances.

Bars cause assaults?

I saw a bit that caught my eye in the Sunday (Chicago) Tribune about a study published in Alcoholism: Clinical & Experimental Research (sorry, no link). Apparently the study involved looking for a relationship between the number of bars in an area and the number of overnight hospital stays because of assault. They did indeed find a direct relationship between the number of bars in a given zip code and the number of hospitalized assaults (more bars, more hospitalized assault victims).

While that relationship reached statistical significance, it raises a couple of questions in my mind. I believe that some other points might also have reached significance, but not having seen the original article I don’t know if they were looked at or whether they will be looked at in future research.

By far and away the majority of assaults don’t get hospitalized, so it would be of interest to know if non-hospitalized assaulted individuals also correlated with the number of bars in a zip code. Secondly, it would be interesting to know (particularly in my present role as Coroner) if the number of deaths related to assault also correlated with the number of bars. It is not much of a stretch to believe that both of these quantities would also correlate with bar saturation.

The cause and effect would be a much tougher thing to get at without facts about the individuals involved in the assaults. Certainly, most folks that go to bars are law-abiding, fine upstanding folks and not likely to be involved in assaults. Also, sorry to say, not all bars are created, nor do they “live their lives” equal; some are “rougher” than others. So do we limit the number of bars to decrease violence/assaults or do we need to look at the characteristics of and demographics of the bars and “control” based on that? Are more bars located in some neighborhoods more prone to violence because of other socioeconomic problems? If that is the case do we control their placement or do we patrol those areas more intensively to secondarily prevent violence “greased” by that social lubricant, alcohol?

Regardless, this information should not just be bantered about academically, it should be used to impact a real-life problem. It should engender some real discussion on how to use the information in the community to decrease violence and assaults, and possibly deaths.

Preventing Cervical Cancer Deaths

10,000 women develop and nearly 4000 women die from cervical cancer each year in the U.S.. Most of the deaths are of poor and/or minority women. Pap testing (done on a regular basis) can most often catch cervical cellular changes at a pre-malignant or early malignant stage, allowing for treatment that is most often very successful. But many lack access to and/or do not avail themselves of these health maintenance services.

It is, however, always better to prevent the occurrence of a disease, than to try and catch it and then treat it before it gets “bad”.

The major cause of cervical cancer is certain “types” of HPV (Human Papillomavirus). If you can prevent infection with HPV you can prevent a large percentage of cervical cancers. Three things prevent cervical infection with HPV: 1) no genital-to-genital contact, 2) HPV vaccine (recently approved for use by the FDA), and 3) condoms. All 3 of these preventatives must be taught about, the public informed about them, and they must be used to be effective (i.e. used alone and/or in combination).

The FDA vaccine advisory panel, last week, recommended that all 11 and 12 year old girls should routinely receive the new anti-HPV vaccine. The vaccine is active against 2 types of the HPV responsible for 70% of cervical cancer cases. What a step forward in preventative medicine.

While practitioners who deal with STD care and treatment have been of the opinion that consistent and “proper” condom use prevents most STD transmission, including HPV, only recently has there been a “good” study with proven benefit (good = well done clinical control comparison trial). [Keep in mind that “proper” condom use isn’t as easy as it may seem] Published last month, the study demonstrated a 70% reduction in risk of becoming infected with HPV. There has also been recent research demonstrating condom protection from herpes, chlamydia and syphilis (again it was always “known”, but now there is better clinical proof).

Lives can be saved with widespread vaccination and consistent, “proper” condom use as disease prevention measures.

Learning to drink?

There was a letter to the editor in the Chicago Tribune recently in which a 17 y/o voiced his opinion that the “legal drinking age” should be lowered from 21 to18. A significant basis for this seemed to be that it would allow the teen to “learn how to drink”. That is “appropriately” without binging and other harmful behaviors that can accompany someone’s drinking who doesn’t know the right way to drink.

I disagree.

Having the drinking age at 21 offers the improved (longer) opportunity for an individual to develop the character traits necessary to drink responsibly. (I am not including alcoholism in this discussion. It is a disease with symptomatic alcohol abuse and over-use that is a problem of a whole different sort, not a character problem.) Also, I know and acknowledge the “Peter Pan Syndrome” exists in many forms and some individuals never grow up and act responsibly. And, yes, the drinking age was 18 when I was young and I may have begun drinking before I reached my majority.

Nonetheless, to drink responsibly and individual doesn’t need to “learn to drink” they need to learn certain life skills, develop certain character traits, at least to a reasonable degree. Certainly an individual may limit themselves to 1 or 2 drinks in a controlled setting, but these life skills are required in situations where the only brakes are your self-control (e.g. a free kegger). That self-control, it seems to me at least, is acquired along with the ability to delay gratification. Many of the lessons that instill the latter feed the former. An individual must become able to take responsibility for one’s own actions (the devil didn’t make me do it). They must be able to make many different types of responsible (and we thought out) choices. They must be able to resist peer pressure, in all its prevalent forms, as well as other pressures (e.g. marketing that a product will make you popular, sexy, etc.).

None of these life skills/character traits require practice/learning with alcohol. Life affords many training options. Learn from life.

You can drink from 21 to the end of your life; you don’t need 3 extra years before that.

Think, make good choices, don’t take chances, develop “good” life skills (good = life preserving, useful for society or getting along in society).

Overweight Kids are Overweight

The government (Centers for Disease Control and Prevention) feels that “we” should not use the word “obese” in referring to children, because of the word’s stigma. They recommend calling overweight kids “at risk of overweight”.

How can “our society” work to combat the problem of overweight kids, with its attendant risk of diabetes, other health problems and increased risk of death, if we can’t even call overweight kids overweight. This has to be one of the dumbest bits of “doublespeak” I have seen (today anyway). I have seen some fat kids. Yes, they were fat. I have seen even more (as in large numbers of) overweight kids.

There are times to be “politically correct” (Yes, that is a lovely dress), but there are times to be frank, honest, and call “a spade a spade”. If a kid is shaped like a spade (or a club for that matter) something needs to be done before they have damaged their future health and increased their risk of dying at a younger age than they ought. Overweight kids need to be told that they are overweight by their doctor and by their family and by others charged with helping them work on the problem. Don’t bludgeon them with it, but don’t sugar-coat it either (sugar-coating may be a significant part of their problem anyway).

Care enough to tell overweight kids the truth and tell them what to do about it [i.e. healthy diet and exercise] (repeatedly), show them what to do about it (repeatedly), help them do what they have to do and make sure they do it. Help them live long enough and healthy enough to appreciate the intervention.

Cell phone driving distraction

A recently published study looked at performance in a driving simulator of individuals who had blood alcohols of 0.08 (the “legal limit” for intoxication) and those same individuals sober and using a cell phone. They also served as the “control” group driving without alcohol or distraction. Cell phones users, both “hands-free” and hand-held, had poor reactions times and other driving “problems” as frequently, and in 3 instances worse problems, than when they were drunk. In both situations (distracted and drunk) the drivers did not believe that they were affected.

We have seen this in cases through our office. Checking cell phone records and comparing them to the time of the accident, we have seen deaths related to cell phone use and we only see the worst of the crashes. One case sticks in my mind. A young guy went off the road, single car fatal accident, moments after his cell phone received a call and he presumably answered it.

Keep in mind that the distraction “problem” was equal for hands-free and hand-held cell phone use. On the other hand, don’t get me started on some of the other things I see drivers doing while they are driving.

Make good choices, don’t take chances, good luck.

Salubrious Coffee

I ran across several articles pertaining to a study published in the Archives of Internal Medicine “Coffee Consumption and Risk of Type 2 Diabetes Mellitus”.

I like it, yet another reason to pour myself another cup of coffee. While I drink coffee because I like it and, at least in small part, because I am addicted to the caffeine, it is nice to know that there are potential health benefits to my consumption.

The study, a part of a larger look at the habits of over 28,000 women and their risk of developing disease later in life, demonstrated basically that the more coffee you consume (likely to some limit point) the less is your risk of developing Type 2 Diabetes Mellitus. Because this held true for both caffeinated and decaffeinated coffee consumption the assumption is that it isn’t the caffeine that is protective. They mention that it is likely due to “minerals, phytochemicals, and antioxidants” contained in the coffee (just linking those words to coffee makes it sound so health imparting to me).

I’m off to Starbucks for my caffeinated (unless it is after 4, then decaffeinated) beverage of minerals, phytochemicals, and antioxidants. Oh what the heck, for that extra health boost throw in another salubrious shot of expresso.

Fly larvae

More as a sidebar to yesterday’s post than anything.

It is incredibly difficult to kill maggots. Typical “bug” sprays don’t work. Bleach doesn’t work. Hydrochloric Acid doesn’t work. Salt doesn’t work. They don’t drown in water. (These suggestions can be found, among others, on the Internet- Google killing maggots). Hydrogen peroxide (drug store variety, not rocket fuel concentration, although the latter would likely work, too). Vacuuming them up and discarding them in an appropriate receptacle seems most effective.

What an incredible biological machine.

Let them progress through their life-cycle; flies are easier to get rid of.

Taphonomy (Study of Decomposition)

Decomposition frequently comes up in questions during our office tours and my presentations about the Coroner’s Biz. It also not infrequently “comes up” in my office. Today was such a day. We had a death over the weekend, a body found fairly far along on the continuum of decomposition.

Classically there are thought to be 4 stages. First the body undergoes autolysis, in which body chemicals and enzymes begin to work on dissolving the body, or at least parts of it. At the cellular level certain chemical “pumps” fail, that also contributes to that autolysis. The next phase is bloating and putrefaction. Our internal bacteria (helpful symbiots while we are alive) are responsible for this stage. They travel throughout the body, using our blood vessels (and other “channels”) as roadways. During this phase, gases are generated and released characteristic of the odor of dead bodies (an odor like no other). In addition, these gases are responsible for the body “swelling” that occurs. Next come outside “carnivores”, most particularly the province of the lowly, and very useful, maggot. Maggots arrive early, are incredibly prolific, and very efficient in accomplishing their task, no matter how primal our “fear” of them. The last phase is a dry “rot” breakdown of the last vestiges of the body.

It’s a natural process and as I said quite efficient, but unpleasant (actually a word a bit too understated for the experience) to be around. It is however something we in the Coroner’s Biz have to deal with (at times while wearing respirators). This profession isn’t for every one, but even at it most “revolting” still fascinating and rewarding.

Have a Happy

I heard on the radio this morning that this is the happiest day of the year according to some British researcher (I do not have a link or reference. This is likely true for my 16 year old daughter. The researcher reportedly relied heavily on information seeming to pertain to Seasonal Affective Disorder.

At lunch I attended a fundraiser for Lake County Council Against Sexual Assault and the Executive Director referred back to last year’s luncheon and speaker who said that getting involved can help you be happier, live longer and be healthier. That would be consistent with the Positive Psychology research areas of “life of engagement” and “life of affiliation”, both beneficially affecting your well-being.

So, to enjoy a long, more enjoyable and healthier life get outside and enjoy the sun and fresh air and get involved and help others. Sounds like a pretty cool way to avoid the Coroner’s Office for as long as possible to me.

Coroner as Career

We had a group of teens in the office today for an educational experience “run” by my Chief Deputy and myself, with others in the office also participating. They were attending a 10-day forum in Chicago (National Youth Leadership Forum) for young people wanting to learn more about medicine-related careers. The forum draws teens and young adults from all over the country for an experiential sampling in their chosen career field. The forum seems to be a great opportunity and we are glad to participate for our 2nd year.

By the end of their 4 hours here (we did give them time off for lunch) several of the students voiced an interest in the Coroner’s “biz” as a future career choice. This was despite honest descriptions of the downside of dealing with death in all its forms, decomposition, and possible emotional investment/toll. As always it was great to throw in a few “preachy” moments, about making good choices, not taking chances and, possibly< forestalling death.

Who knows how many (if any) will ultimately choose this field for their career, but it was great seeing their interest build and our ‘love” for our work reflected back from them.

Darwin Awards

I talked to a summer high school class yesterday and really enjoyed the experience, certainly as much as other presentations I have done. I give them information about what I do and the Coroner’s Office business mixed with tidbits on how they can forestall death, make good choices and not take chances with their lives.

I did get one question that I did not answer: “Have you seen any deaths that would qualify for Darwin Awards?” (paraphrased) While I admitted that some might fit that categorization, I (and my office) don’t approach death that way.

However, I thought some readers might not know about the “Awards”, so I thought I’d through up a link and a bit of information about the “Awards”. The Wikipedia entry makes interesting reading, nonetheless.

A Darwin Award is a tongue-in-cheek honor given to people who purportedly improve the human gene pool by removing themselves following from an episode of questionable judgement. The prizes, named after pioneering evolutionary theorist Charles Darwin, are awarded over the Internet. There is no monetary prize, only (necessarily) posthumous recognition.

And

Not Darwins
The following have been specifically stated as being no longer eligible for a Darwin Award, as they are too common:
Smoking in an oxygen tent
Being hit by a train or automobile
Climbing into zoo cages
Falling off a precipice while posing or urinating (spitting is perilously close to being added to this list)
Urinating onto electrified wires, subway rails, etc.
Certain forms of carelessness with flammable liquids
Plain alcohol poisoning. Alcohol consumption, on the other hand, plays a key role in many Darwin Awards.
Deliberate and willful acts; doing it on purpose steps from Darwin Award to insanity.

Read and enjoy the irony of the “Awards”

No Fault Decisions

More just as a point of information about the Coroner System:

I came across a letter to the editor from a paper in Australia (through a Google search and “feed”) that mentions an important point about the Coroner’s system: “The focus of a coroner’s inquest is to establish a cause of death, not whether anyone was at fault.”

As the author of the letter states: “This prohibition can seem strange to people unfamiliar with the coroner’s role.” Indeed, this does cause some confusion for jurors and, at times, the friends and family of decedents. Particularly in certain cases everyone wants to assign blame, somebody must be responsible. But blame/fault-finding is specifically precluded from the proceedings. It is the job of the police and the legal system (criminal and civil) to assign blame/responsibility.

The Coroner and the inquest decide the cause and the manner (natural, suicide, homicide, accident, undetermined) of the death. Findings from the Coroner’s Office investigation and inquest may be turned over to the “authorities”, but they may not be admissible in court.

Liability is the purview of the other branches of Justice, as it should be.

GPS-based Speed Warning

I caught an article recently about a “new” gadget to warn speeding drivers to slow down. While it is not yet commercially available, I think it will have an eager market. However, I do want to mention that years ago my grandfather had a somewhat similar device on his car, so it is not all together new. While not so “gadgety” as this device, it beeped when the needle on the speedometer reached 40 MPH and again at 50. While he rarely drove more than a mile from his home then, he was a bit of a lead foot and was ticketed once too many times for his liking.

What is new about this gadget is three-fold: 1) it will sense what the speed limit is on a given stretch of road, 2) it displays that speed limit on a screen, and 3) it sounds an alert when that limit is exceeded. It likely will cause at least some of the folks to slow down, avoid speed related crashes and save some lives (a good thing). The other thing it does is records speeding violations in memory. This will allow parents to monitor their teenagers’ driving habits (remember driving is a privilege).

I wonder if they will be out soon, my daughter is 16 this week (although, of course, I trust her implicitly).

Death by Lack of Insurance, visiting again

At lunch the other day I was discussing problems uninsured individuals have accessing medical care and the need for total system change. (It wasn’t a random conversation, the discussion was between myself and the individual who took over as Executive Director of the free medical clinic I was running when I was elected Coroner.)

Why hasn’t something been done to help the 48 million Americans without health insurance? It was my point (echoing many others) that historically low-income individuals have been the super-majority of the uninsured. Low income individuals have no power, no clout, “no one” listens to them.

I also made the point that the demographics are changing and with that change is coming renewed attention and re-evaluation of this issue. More moderate- to middle-income families are facing loss of insurance and its attendant risks of ill-health and financial ruin. More people, many 50-65 years old, are facing the prospects of being uninsured. These are people who can be heard, who can use their clout. It is terribly unfortunate that this is what it will take to get the issue addressed, but I see it coming.

Medical debt is crushing people who have no insurance. It has become an issue for individuals with insurance (62% of adults with medical debt were/are insured).

The inability, or severely circumscribed ability, to get insurance on the private market is hitting even those with the money to afford to pay for it.

Lack of medical insurance limits access to healthcare. It limits an individual’s ability to properly manage chronic health problems. It limits access to health maintenance and disease prevention/early screening measures. It contributes to the death of these individuals.

Ultimate Decision

The article begins with a quote: “It’s a problem” a comment prompted by a recent weekend in which there were 3 deaths by suicide in Lake County. Quite the understatement considering deaths by suicide in Lake County outnumber homicide deaths about 4 to 1. Really a good, well done article.

There was a nice sidebar that I wanted to highlight:

Danger signs of suicide
• Talk about suicide
• Statements about hopelessness, helplessness or worthlessness
• Preoccupation with death
• Suddenly happier, calmer
• Loss of interest in things one cares about
• Unusual visiting or calling people one cares about
• Making arrangements; setting one's affairs in order
• Giving things away
- Kristen Brooks Hope Center

People with these warning signs need help. Help and support from you, referral to help with professionals, pushed hard if need be. You may save their life. Remember the 4th on the list it can be a “fooler”, they have made the decision at that point, time may be of the essence.

Working to Limit Undreage Drinking

A few weeks ago I attended and participated in the 2nd of 2 community forums set up to get community input into the problem of underage drinking. From the input received at those meetings ranked listings of “problem priorities” and “solution priorities” were developed. The attendees were by and large parents. The lists are heavily weighted with parental responsibility.

Problem Priorities:
1. Peer pressure for youth to drink
2. Parents need for more awareness of and involvement with the problem
3. Parents attitudes toward condoning drinking and communicating with their kids
4. Parental supervision
5. Inconsistency of consequences and messages

Solution Priorities:
1. Educate youth on skills needed to resist peer pressure and to make healthy choices
2. Educate parents on role modeling and communication skills
3. Enforce rules and make them consistent at school, home, police, and in the community and prosecute adults who provide alcohol to minors
4. Explain and enforce zero tolerance
5. Make the issue of underage drinking prevention a priority for everyone in the community

It will be interesting to see what the After School Coalition (the group sponsoring this activity) develops through this process. I do have confidence in their capabilities. I think the target pieces and solution priorities will be manageable to design programs around. I do look forward to my office’s involvement in working with them on underage drinking, its risks and tragic outcomes.

I see my psychiatrist on TV

“Remote doctoring” seems particularly suited to psychiatric patient encounters. Because with telemedicine you can do everything except touch and smell the patient, a specialty that dwells most on listening, talking and treating would be well served by the technology.

Telemedicine has been used for some time to allow doctors in more remote/less populated areas to get consultations with specialists using the eyes and ears of TV. Now there also seems to be a growing trend allowing patients contact with specialists using those same TV technologies. There are many areas in this country, many really not all that remote, without access to psychiatrist services because of the distribution of qualified physicians. These areas despite having population numbers that don’t make it feasible to “support” a local psychiatrist, still have many in need of mental health services. Mental illness exists in those areas just as much in urban areas, often with “complications” unique to their remote location and low populations.

As a matter of fact there are some advantages to telemedicine psychiatry that can make it a good option for certain individuals. Remote doctoring can be less intimidating, less threatening, for some individuals with histories of abuse and trauma. There may also be a degree of comfort using technology we are all familiar with (maybe a bit too familiar) like TV. A human, therapeutic connection across a “cool” electronic connection.

Anything that improves the availability of mental health services should be looked at and if proven effective embraced for the common good. Even one more individual getting adequate treatment and prevention of deterioration and suicide, or other untoward outcome, is a good thing and I would support it whole heartily.

Medicalizing rage/anger

I saw a news report last evening that certainly caught my attention. A study by researchers at the University of Chicago’s medical school states that “intermittent explosive disorder” may be more common than previously thought. It may affect up to 16 million Americans, more individuals than are diagnosed with bipolar disorder or schizophrenia.

The definition of “intermittent explosive disorder” involves multiple angry/violent outbursts way out of proportion to the situation. It includes road rage, spousal abuse and throwing things or ‘trashing the place’ in anger. It includes actions up to and including killing someone.

I agree whole heartedly that these individual’s need treatment. They need treatment before they hurt or kill someone or hurt themselves. That treatment certainly includes counseling and, quite possibly, medications. I know that to get insurance to pay for treatment and medication you need a “codable” diagnosis, but aren’t we going too far in medicalizing what in many cases is less a disease and more a behavior problem? No one is responsible if it’s a diagnosable disease/illness. People need to learn to get along in society with all the other folks in society. If their behavior falls out of the range of behavior you need to function properly society, get them the help they need, but don’t tell them they have an illness. Medicalizing such behavior demeans the individual and it demeans their actions (responsibilities are just as much a part of functioning in society as are your rights). It also demeans all the individuals with diseases (psychiatric and otherwise) that require treatment.

Nicotine, the gateway drug

Nicotine is one of the most addictive drugs available, although I might argue for caffeine.

Smoking is psychologically relaxing, while physiologically it is a stimulant experience. Nicotine acts on the “pleasure/reward centers” of the brain. Dopamine, the brain chemical responsible for driving these “centers”, is increased as nicotine circulates through the brain. Dopamine is also the chemical stimulated by other drugs that give a pleasant brain experience. Cigarettes (tobacco?) also contain an as yet undetermined substance that decreases the brain level of “MAO”, the enzyme that breaks down dopamine. Less breakdown means more dopamine bathing the brain and more “pleasure” (a rationale used in some antidepressants).

Smokers continue to smoke (and can’t quit) to keep their brain dopamine levels high. It is not much of a leap to realize that sometimes, and for some people, the nicotine “pleasure” isn’t quite enough anymore. Wouldn’t/couldn’t that lead to desire for other dopamine stimulators and serve as the “gateway” to other drugs?

In defense of MySpace

MySpace is certainly in the news lately. I’ve talked about it for some time; “warned” parents about it (admonished them to keep tabs on what their kids are posting). But I want to make it clear that I don’t think it should be banned or legislatively barred. As I have posted before I think it serves a purpose ‘posters” may be helped by knowing that they are not alone and being able to discuss issues more anonymously and with less stigma or as I read a high school freshman put it: “Social networking isn’t evil, it’s just friends. Growing up, you have to have friends and social ties. Otherwise you feel alone.”

MySpace and other similar sites are indeed “social networking”, although not necessarily truthful. They are places where individuals can make themselves intelligent, funny, interesting, and beautiful, because they control what pictures and “words” are posted. There are no “bad hair days”. There is no verbal tripping, faux pas. They can present a very filtered façade. Posters can also try things out. How will people react to me if I am a bit older? How will people react if I say this or “talk” like this? (Often safer and less threatening to try it online then elsewhere)

Can this sort of activity go bad? Can a post attract a “predator”? Sure (do recall, too, that only 0.1% of youth abductions are by strangers), but just as most teens know not to talk to strangers “live”, most know not to talk with them online (or met with them offline). The same cautions/precautions and skill sets work in real-life and in cyber-life. Teach those skills, emphasize those skills, develop those skills. Banned and blocked sites can be gotten to (I read there are instructions on how to do just that available on the web, wow!). But parents must be parents (and the ‘authorities, too), kids need nurturing, not to be turned loose; by nurturing I mean tending to their needs and watching out and protecting them. It is OK to monitor their MySpace space. It’s OK to ask them questions and challenge them. You are the parent.