More on deadly heroin

Headline 1 today: Spike in suburban heroin deaths

A story about the apparent increase in heroin related deaths across several local counties, with a law enforcement report of increased heroin seizures and arrests. It even mentions an increase in folks seeking treatment of heroin addiction in the area (great to see that).

Headline 2 today: Heroin in Fox Lake death of lethal purity, official says

(That official being me) An article about our finding (of course, with the help of DEA testing) increased purity/concentration of heroin in at least some of our cases as an explanation of Headline 1.


Increased availability of increasingly deadly heroin, what a foundation for disastrous consequences.

Law enforcement needs to cooperatively work to track and stem the flow (we will do all we can to help here), courts need to push folks to treatment, and treatment programs must gear up to treat those in need; or we will continue to see increased business from a drug originally spelled “heroine”.

Potent Heroin

We had a very concerning spike in heroin-related deaths this last December (8 in one month), which seemed to be a part of an apparent trend in such deaths. Because we found no adulterants in the specimens we obtained at the scenes of these deaths, nor in the bodies of those decedents, our thought was that there must have been a spike in the concentration of the heroin used. (As I was quoted in one article, it brought to mind the movie “American Gangster” in which a more pure heroin brought to Harlem resulted in a large number of deaths in the users.)

We felt that the concentration or purity was important information to know for our death investigations in these cases; as well it would be important information for local law enforcement agencies. We were able to get the DEA to do the testing for us.

The results have just come back. While they reinforce our opinion, they are nonetheless striking. We were able to send samples from 2 cases. (For comparison, let me mention that currently the average purity in Chicago is about 15%) In one case the purity was 23%. That is an increase of 50%. If you are used to shooting 15% stuff, a jump in purity of 50% certainly has the potential for lethality. The other specimen was even more impressive. It had a purity of 65%. That would be high-grade for snorting, if you shoot it you die with your syringe under your body.

I certainly do not advocate heroin use and support increased availability of treatment for addiction, but I also think it is crucial that we get this sort of information out so that users can know. When you get this stuff “on the streets” you never know the quality of the stuff. It could have lethal adulterants. It could be a lethal concentration. Maybe knowing that will deter some from using.


A couple of other points: I would note that we are working on developing the capability to do future purity testing in our lab; we are the only Coroner’s office in Illinois with our own toxicology lab. Once that is established we will be able to follow this trend continuously and help local law enforcement agencies with fast turn around in these results for their investigations.

The other piece we are working on is to better “quantify” the observation that these heroin deaths are not confined to our poorer neighborhoods, but span the county and its varied socioeconomic climes. That tells us that this is not a “disease” of the poor and that it is not a “gang problem”, both of which are ingrained opinions that need to be dispelled if we are to realistically address and remedy this problem of heroin use and heroin-related deaths.

Youth against drug use

This from a new facebook group that a friend sent me the link to:

This is our chance to create a movement for the fight in the war on drugs. Our youth are dying from the lack of awareness to our community's drug prevalence. Our suburban community officials don't believe it's a problem! "Not here, not in this town." Let's raise awareness! Don't let the people we have loved and lost be forgotten. They were all beautiful and irreplaceable human beings. Let's continue to honor their memory and raise awareness-- we can't let this continue to happen. We need to be their voice. It "is" happening in our towns! Open the eyes to those who are naive. Otherwise we will continue to lose those that we love. Together we can make a difference.

Interesting (and honest) stuff, spread the word.

Pain Killer Misuse can be a Killer

Treatment admissions for prescription pain killer misuse has risen dramatically over the past decade – from constituting 1 percent of all admissions in 1997 to now representing 5 percent, according to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA).

That reflects what we are seeing too, increasing numbers of deaths from misuse of prescription pain meds. The numbers aren’t huge but they are there, another one today.

Drugs they can thrill ya, they can kill ya.

Ain’t no caring in much of our healthcare

WTF—I guess that is a bit strong, but it communicates my feelings after a call I got last night from a friend of mine. What is with healthcare providers?

I know this guy (granted most stories that start out that way don’t go well, but this isn’t that kind of story) who crashed his dirt bike (or was it an ATV?) and broke his leg a few weeks ago. Young guy in his 20s, healthy, unemployed and with no health insurance…

He had done work on his vehicle in preparation to sell it. He took it out for one last ride to make sure all was well for the sale, but crashed instead, an accident. The crash resulted in multiple fractures to one of his legs. He went to the local ER, got splinted and told that once the swelling improved and they were certain it wasn’t infected at the time of the trauma they would do a surgical repair.

Back to the hospital he went 2 days ago, they loaned him a wheelchair, called a medi-van, and took him to the local orthopedist’s office. The orthopedist said that, indeed, he needed surgery for repair of the injury (and for the best outcome) and as soon as he came up with $30,000 cash he would be more than happy to do the surgery. The guy I know doesn’t have that much, so out of the office he went (with the wheelchair).

A friend of his suggested that he go to another hospital, surely they would see that he get the needed care. A young guy ought to have the treatment he needs so his leg can be the best it can be after it heals. He may need his leg to work, if a job becomes available. He might not want to spend the rest of his life in chronic pain nor with impaired mobility from suboptimal care and healing.

He went to another hospital, one his friend thought would surely help. He presented in the ER, because he had no other access to care. He was told (I am sure in a very caring way, they are a caring medical center, so much more than just a hospital) that if he paid 100% up-front they would be more than happy to give him the care he so obviously needed. There was nothing they could work out, there were no options, there wasn’t any real access to care. WTF.

Rambling thought

I just got an email with a widget I could attach to my blog from Wellsphere (my blog is cross posted there). The widget contained a definition of “perseverance” that I don’t agree with:

The difference between a successful person and others is not a lack of strength, not a lack of knowledge, but rather a lack of will.

I disagree with the last word.

“Persistence despite obstacles” would work for me, but saying they lack “will” is wrong. There is a need for an action in the definition. Success is action, perseverance is action. The definition should communicate the need for action. Many have the will to accomplish something, but do not take action. (On the other hand, some times the obstacles win no matter your action.) But nothing fails faster than a lack of trying.

Heart attacks don’t only attack ‘old folks’

Shocked, concerned, dismayed, I’m not sure what word to use.

In the last couple of weeks we have had 3 folks in their 30s die due to heart disease. Granted they were overweight and had histories of hypertension, but seeming so young to have life-threatening (life ending) heart disease. Most of the time you don’t think of heart disease killing at such a young age.

What is going on? These folks, for the most part, didn’t access our healthcare system for personal of financial reasons (that can be hard to sort out, not being able to talk with the person involved in the decision making). Apparently, they weren’t able, for whatever reason, to make life style changes to impact the obvious risk factor with diet and exercise. Folks need to know the health decisions you make at any age (even when you are young) can, and does, impact your longevity.

Do what you can to not die before your time. Make good choices.

Coroner's office and child safety seats?

Press release we sent out today:

For Immediate Release

The Lake County Coroner’s Office is proud to announce its new partnership with Safe Kids Chicago, a Division of Children’s Memorial Hospital. The Safe Kids Buckle Up program strives to offer every driver who transports children, the opportunity to learn how to properly restrain children in age and weight appropriate car and booster seats. The office now has two deputies that are certified child passenger safety technicians.

“While 94 percent of America’s children are now regularly restrained, not enough kids are properly and safely restrained. This puts children at an unnecessary risk of being injured or killed in crashes because they are simply in the wrong car or booster seat or it is not properly installed” said Dr. Richard L. Keller, Lake County Coroner.

Parents are encouraged to make an appointment to bring their car or booster seats for inspection. The certified deputies will help parents learn to adjust the harness and properly place the car or booster seat in the vehicle.

To make an appointment for inspection, please call the Lake County Coroner’s office at (847) 377-2200.

Spike in heroin deaths

This certainly caught the attention of the local media. Headline:

Heroin deaths on the rise
County officials blame change in percentage of purity

I was called by a local reporter about a drug-induced homicide case going to trial and I mentioned an apparent increase in heroin deaths recently (2008 to now) and my suspicion that it might be related to an increase in purity of our street heroin. An increase in concentration was inferred by our increase death incidence, our testing finding no adulterants similar to some cases of Fentanyl-heroin we saw in the past, and that some of the cases seemed to look like “hot-shot deaths” (syringe barely out of the arm). So we sent several samples found at death scenes to the DEA for purity/concentration testing. Many areas of the country monitor their concentrations (for example, Chicago found a 14.6% to 21.4% jump in 2007), our county has not followed that measure in the past but I think it is important information to have. We await our testing results.

Also, hopefully getting out this information to the public can help drive down heroin use and encourage folks to seek treatment for their addiction (and decrease deaths).

Beat the Reaper

Cool way to get the word out (as I have said before teens must get learning messages in multiple ways multiple times for it to sink in):

new interactive computer CD intended to help young people anticipate the disastrous consequences of choices they're often confronted with…

…Beat the Reaper…

I haven’t seen the CD yet, but I welcome anything that helps teach kids to think, to not take chances, make good choices, and live.

Four prescription painkillers and a half bottle of wine were all it took.
Stephen Pheasant, 15, of Benton City, ingested the concoction one night early last year, and he never woke up. His death was a shock to his friends and family, but most of all, it was an outcome he didn't see coming…

His story is one of several real-life examples included in a new interactive computer CD intended to help young people anticipate the disastrous consequences of choices they're often confronted with.

Non-medical use of pain relievers

From a SAMHSA press release:

Adults aged 18 to 25 currently using pain relievers for non-medical reasons increased from 4.1 percent in 2002 to 4.6 percent in 2007…

youths aged 12 to 17 … non-medical use of pain relievers … declined from 3.2 percent in 2002 to 2.7 percent in 2007…

Use among adults aged 26 or older increased from 1.3 percent to 1.6 percent

While the use among 12 to 17 year olds seems to hold some promise, it remains a topic rarely spoken of or adequately addressed in in-school programs, as far as I know. Over-use and abuse of prescription pain relievers is a large problem for society (“5.2 million people aged 12 years or older in 2007”), yet it remains poorly addressed. It is multifaceted in cause (not just to get high), contributing factors (diversion, over-prescribing, poor control/understanding of effects, etc), and the way it is viewed (‘not as bad as using street drugs’).

My other thought on this: how many of these folks will move on to illicit drugs? I have not seen that sort of research and it might be a bit tough to do. But, in my limited experience, a fair number of them will. In many places (like our county and its surrounds) heroin is cheaper and easier to get than prescription pain relievers on the illicit market, making it a fairly ‘natural’ switch. Using illicit drugs and/or the illicit marketplace often contributes to social, legal and societal problems compounding the “effects” of the drugs.

Medical Homicide

I was reading an article on “Medical Homicide and Extreme Negligence” in my recent edition of The American Journal of Forensic Medicine and Pathology (no link). Having had a case of medical neglect found to be homicide by an inquest jury it was nice to review some of the pertinent definitions. We will continue to watch for other medical cases along with our “more usual” investigations:

Reckless endangerment…the conscious disregard of a known substantial likelihood of injury to the patient

Criminal neglect typically is defined as the failure to provide timely, safe, adequate, and appropriate services, treatment, and/or care to a patient.

In instances of extreme medical negligence, a homicide manner of death is appropriate because the fatality is due to criminal acts (or inactions) of another.

I stand by the jury verdict in our case and will not hesitate to rule similarly in the future if I feel that the case meets these definitions.

Natural deaths…natural disease... Therapeutic complications…predictable complications…appropriate medical therapy…Accidents…unanticipated complications and/or inappropriate therapies…Homicides…death at the hand of another person or death due to the hostile or illegal act or inaction of another person.

Our ruling of a homicide does not mean criminal prosecution should or will occur, but, importantly such a ruling:

…also furthers one of the major goals of the medicolegal death investigation system, which is to safeguard the public health.

(American Journal of Forensic Medicine and Pathology, March 2009; 30: 18-22)

Our healthcare crisis is Coroner job security

This does not bode well for health and longevity:

At the onset of bad economic times, the demand for psychiatric services declines, with fewer visits for "maintenance" but eventually more for acute episodes…

I expect that medical care providers will first see a small decrease in demand as copayments become more onerous, more patients lose their insurance…

As time passes, however, I would expect to see increased demand for services from people who "deferred maintenance" because of costs and therefore become ill.

Along with this:

As economic conditions continue to worsen, the public is increasingly worried about the affordability and availability of care, with many postponing or skipping treatments due to cost in the past year and a notable minority forced into serious financial straits due to medical bills, according to the Kaiser Family Foundation’s first health care tracking poll of 2009.

All great for coroner job security, but a crushing problem for people and our country.

The time to do something about “healthcare reform” is now (realizing that when most folks talk about healthcare reform they are talking primarily about reform of how we access and pay for healthcare). Everyone must have access to care (and not just acute care), we must make prevention and wellness a high priority, we must make sure health care is safe and of high quality, and health care coverage must be affordable and portable.

"Second Opinion" on Suicide Cases

This is interesting. It may serve a real need.

Nancy Ruhe, executive director of the National Organization of Parents of Murdered Children…says that in cases in which a death is labeled a suicide but the family believes otherwise, her group offers what it calls a Second Opinion Service.

SOS will hire independent forensic pathologists, firearms experts and legal experts to investigate even further, Ruhe said…

Even when the research turns up nothing new and experts still label it a suicide, it still helps families, because they can know why, Ruhe added.

"Most police departments and medical examiners' offices, they don't explain that," she said. "They just rule it suicide. So you have all these unanswered questions."

Every one of our cases undergoes thorough investigation before cause and manner of death is assigned (for “inquest cases” this occurs after a full-staff case conference, now since the law changed). We do answer any questions family comes to us with, so while there are often many questions after a case is ruled suicide we can back that decision up with investigative evidence.

Suicide is often difficult to accept in a loved one, but it happens more often that most folks think.

Some forensic science is not science

Just as folks are making more and more demands on us and all of the criminal justice system based on what they see on TV, this report comes out:

The National Academy of Sciences says many courtroom claims about fingerprints, bite marks and other evidence lack scientific verification. It finds forensics inconsistent and in disarray nationwide.

The report from the Academy makes several recommendations for improvement in our current system to ensure scientific validity in testing and what passes as evidence, as well as “certification” of expert witnesses. All of that would be a great step forward, but I think we need to include one more thing. We need to tell the public that all those TV shows are not real.

Those high-tech gadgets often don’t exist. Fingerprints are often not easy to get and they are not 100% accurate. Not everyone’s prints are on record for identification. You can only infrequently get a print off the trigger of a gun and then it is only partial (a sliver) and useless, for the most part, in telling you who pulled the trigger (questions we have gotten in the past). Testing for the force needed to inject someone with a syringe tells you nothing about “who did it” (based on a recent question to our office, which in turn was based on something they saw on TV).

At least some of the inaccurate testimony and “bad science” that makes it into investigations and courtrooms is driven by the public’s expectations, driven by TV. Get a grip folks its entertainment not reality.

New Medical Resource

I ran across something interesting today: Medpedia

Medpedia’s mission is to create a new model for how the world will assemble, maintain, critique and access medical knowledge. This repository of up-to-date, unbiased medical information will be freely available to everyone...

It is new and a work in progress. Don’t expect it to have everything you are looking for now, but someday…

Their goal is to be collaborative, yet at least somewhat authoritative. They are doing that by partnering with a few medical schools/institutions to fact-check posted material. I think it sounds like a great concept and I wish them luck. I haven’t gone through many of their articles, but will likely refer folks to it when they are looking for medical answers or is that answers to medical questions.

Pop Kills

More evidence high fructose corn syrup ain’t good for you:

Another study has demonstrated that consuming beverages that contain high fructose corn syrup contributes to spikes in serum triglycerides, really nasty fat transporters that clog your arteries and can help make you die.

"Increased triglycerides after a meal are known predictors of cardiovascular disease," explained lead author Karen Teff, PhD. "Our findings show that fructose-sweetened beverages raise triglyceride levels in obese people, who already are at risk for metabolic disorders such as cardiovascular disease and diabetes."

Yes, pop (soda for you not of the Midwest) kills (or at least pop sweetened with high fructose corn syrup, glucose sweetened not so bad)

Parents Have More Power Than They Think

From a newsletter put out by LEAD (Linking Efforts Against Drugs) a parent group fighting drug use and underage drinking in the local communities of Lake Forest and Lake Bluff.

Parents Have More Power Than They Think!

Many parents have told us that they think they don't have much power to influence teen behavior, especially regarding underage drinking. There is some information you might want to know....you have more power than you think!

1. The recent survey among local teens indicates that those whose parents had firm rules about drinking and drug use were 50% less likely to engage in this behavior. Setting boundaries and clearly communicating them does make a difference!

2. National youth surveys also indentified that the #1 reason teens don't drink is that they don't want to disappoint their parents. It helps to make it clear that you will be disappointed in them if they drink or smoke marijuana.

3) Driving is one of a teen's most precious privileges. Did you know that you can revoke that priviledge for drivers under age 18? If you have concerns about your teen's ability to handle the responsibility of driving, or you need to make a strong statement about consequences of some poor decision making, contact the Secretary of State's office more details. You can also view your child's driving record (is there a ticket you don't know about?) on line up until they are 18 years of age. Go to www.cyberdriveillinois.com for more information.

a blast from the past

My most comment attracting post: Cocaine and Death


I promise more new ones are on the way.

All death is sudden

We are all unprepared for death, our own and the deaths of others in our lives. We see it in families whose children die, whether 16 months or 29 years. We see it families who lose their elders, whether 54, 68, or 90. All deaths are sudden. We even see it in families of folks in hospice care.

It is the hardest “rite of passage” of them all. I have written before about programs that teach folks (like gang-bangers) to value life by having them witness birth, but there is nothing like experiencing a death of a loved one to drive home the value of life.

They aren’t there to do all the things they used to do, the stuff you loved and the stuff you hated. Your relationship to the world changes because that “pillar” is no longer there. You want to know why, why did they die and why did they live. You want to know what comes next, for yourself and for the one who has died.

We try to prepare ourselves for our experiences with death. We tell ourselves that all things die and anyone can die at any moment. Life is only a temporary state of being. But how do we truly prepare? Think about it; work through it in your brain and in your mind and in your soul.

Nonetheless, all death is sudden.

Concussion = Brain Damage (and death)

Until recently we (the medical community) thought that concussions were pretty innocuous. Sure the blow to the head might cause brief loss of consciousness or change in mental state (stunned, confused, etc) but it was believed that it caused no residual brain damage.

All that is changing: cumulatively concussion can and does lead to “chronic traumatic encephalopathy”. While it was first described in professional athletes who have taken repeated severe “shots” to the head, recent studies have found it in kids as young as 18 years old.

The long-term symptoms of this disease are mood changes, anger management problems, Alzheimer’s-like symptoms, and death.

Certainly more study is needed, but in the interim we need to be aware that this can start in teens. We need to take “simple” concussions very seriously, and maybe we shouldn’t expose the adolescent brain to forces and activities that can damage it.

Make good choices, don't take chances

Interesting regional drug information

Tidbits from the National Drug Intelligence Center (Dept. of Justice):

Cocaine trafficking and abuse in our region is widespread, however a rather sudden decrease in purity in the 2nd half of 2007 may be indicative of decreasing supplies.

Heroin abuse in the region is increasing, particularly among young white adults and teens. Many of these new and younger abusers have transitioned from prescription opiates.

Heroin availability has increased and is reflected in increased purity levels on the streets and lower wholesale prices. As a matter of fact, the DEA is quoted as having found the first increase in “retail-level” heroin purity in Chicago in 10 years (from 14.7 % to 21.4%). The purity had actually had been steadily declining over that 10 years.

That information, along with data about other drugs, certainly makes it plain that we need to increase our efforts in prevention and treatment (actually secondary prevention), particularly in regard to heroin and other opiates. Many of the current prevention efforts are not going to cut it. We need to start pretty early with age and culture appropriate, factual, repeated education. The message must be clear, consistent, repeated in various ways and through various outlets. Not to scare, but reality based. Drugs (particularly cocaine and opiates) kill. Yes say no to drugs, but you need to know how and why.

Unconventional Coroner?

Photo used in the article

Yes, I am unconventional (from an article in the Lake County Journals):

With a stud in his left ear, a dragon tattoo on his forearm and a blog he updates regularly, Dr. Richard Keller is probably not your average county coroner. But Lake County voters must like what they see...

Healthcare reform to forestall death and treat economic dis-ease

I was talking with a reporter yesterday and he brought up that I have posted a few times about the lethal effects of the lack of healthcare coverage in our county/country. He asked if I thought people were as aware of that crisis as they ought to be. I don’t think that they are, but as this economic crisis feeds the access to healthcare crisis it is being brought home for more and more people, unfortunately. While my feelings on this matter were first painted by my experiences in ER Medicine, at HealthReach (a free medical clinic I founded and served as Medical Director and Executive Director) , and the Lake County Health Dept., my experiences as Coroner have reinforced my feeling that lack of healthcare access is lethal. So I thought I’d throw out some related facts and comments I ran across lately (not sure just where).

Health care reform is an essential part of restoring America’s overall economy and the finances of working families.
15.3% of Americans lack health insurance
23% forgo necessary care every year due to cost
22,000 uninsured adults die prematurely each year as a direct result of lacking access to care
Health insurance premiums have increased 117% for families and individuals in the last decade
Health insurance premiums have increased 119% for employers in the last decade

I have been surprised that the automakers haven’t screamed for healthcare reform because

$1525 of the price of every GM auto is due to healthcare costs

New American Foundation:

We must reform our struggling health care system not in spite of our economic crisis, but rather because of the impact healthcare has on the American economy

Healthcare reform has to happen now, not only because it is a social justice issue, but because it is a central economic issue as well. It really can go a long way toward forestalling death and help personal and societal financial dis-ease.

Change healthcare and impact death

Again I read an interesting article.

What a great reinforcement for the notion that prevention or early detection should be the focus of funding and energy in Medicine/Healthcare. Yes we need to treat illness, but the “most bang for the buck”; the greatest impact on community/people’s health (and deaths) is with prevention and/or early detection with access to definitive care at that point, not when care becomes more costly and the chance of cure minimal.

The survival rate for many cancers is similar to the cliff-like curve that defines ovarian malignancies. Find the disease early, thanks to a stray blob on an x-ray or an early symptom, and the odds of survival approach 90 percent. Treatment—surgery—is typically low risk. But find it late, after the tumor has metastasized, and treatment requires infusions of toxic chemicals and blasts of brutal radiation. And here the prognosis is as miserable as the experience.

The Canary Foundation has that as its mission (not an endorsement, but applause):

Canary Foundation is a non-profit dedicated to the goal of identifying cancer early through a simple blood test and then isolating it with imaging. Our collaborative research programs span multiple disciplines and institutions.

We need to examine our healthcare system and quit dumping money only into glamorous (?) high-tech, late interventions for cancer (and other “disease states”). That is not the way to do it. Healthcare reform must be about access, ensuring quality, and cost containment not just focusing on funding or payor. Certainly cost containment must rely heavily on prevention and early detection and intervention. Don’t constrict your view of “healthcare reform”. Impact death, impact health; change our payor system, but primarily allow for access, ensure quality and contain cost for the whole system to work, to change.

We do our best to prevent deaths

Excerpts from written comments of students that attended health classes spoken to by my staff:

I also learned that people make lots of stupid decisions near me. That part scared me a bit, the fact that people who could be driving on the same street as me could make a bad decision that could kill me, even if I am being responsible.

At school we have presentations all the time on drugs and alcohol and telling us not to do them. But I think your presentation was the most effective, because you actually got to see what they did to your body.

I believe this is mostly a mental battle that has to be overcome by a person’s common sense rather that their desire to be with the crowd. … I feel if a person can just build the mental capacity to avoid, their bodies will develop and grow more quickly and strongly than those of the ones who give in. Especially when driving, if their mental abilities are lacking or being focused on some unimportant social factor, they can cause serious harm to themselves and others.

Now I truly know the risks that I am taking no only for myself but for others if I put harmful substances into my body.

Your presentation was inspiring as it made me realize how fragile life is. It made me aware of just how important it is to make the right choices. You pointed out how being at the wrong place at the wrong time could be deadly. I found the facts you shared both interesting and at the same time frightening.

Sharing information, teachable moments, repeated presentations of truthful information, that is how you teach kids, that is how they learn

July 4, not Jan. 1, top crash death day

I was sent a link to the snopes website the other day that referenced the question of whether Jan. 1 (or the Dec. 31 – Jan. 1 combo) was the deadliest night for traffic crash deaths as is often believed. As I was already aware, it is not. So I thought I’d share that little tidbit. Jan. 1 is actually number five on the list of deadliest days for crashes. It is topped by July 4, July 3, Dec. 23, and Aug. 3 (in that order). Also of interest is that it virtually ties 3 other days in August.

While alcohol is a big factor in the crashes July 4 and Jan. 1, with 41% and 51% intoxicated drivers, respectively, one of the biggest factors in the rankings is that folks drive more in the summer. More cars and more driving mean more deaths from car crashes (it’s a numbers thing).

It is important to not drink and drive and not to ride with someone who has been drinking and is driving. But also keep in mind that these deaths occur no matter the weather, no matter the time of year (although remember the spike of crash death in the summer); you never know when this could happen (it may be the other driver), so do your best to always drive prepared as well.

Drugs can kill you even when "sober"

I read an interesting study/article the other day (it was recently sent as a pdf, so no link). Sure it doesn’t have the general appeal of the movie “Bedtime Stories” that I went to yesterday, but it brings up an interesting point for the Coroner Biz.

The conclusion of the study was that:

“Decedents with a history of chronic drug abuse appear to be at an increased risk of dying by their chronic drug abuse, even in the absence of any anatomical or toxicological finding at autopsy…” [Arch Pathol Lab Med, vol 132, Dec 2008, 1903-1906]

This really is contrary to what has been commonly thought; that drugs really only kill when they are at elevated levels in the body and sober deaths are not really related to the drugs.

Their original hypothesis was that “drug abuse induces some change that persists after the drug is no longer detectable in the body…presumably at the molecular level…increase(s) the likelihood of sudden death”. (This molecular level of effect brings to mind William Burroughs’ saying in “Junkie” that the junk gets into your cells with use, causing addiction, and has an effect basically forever.)

The study did find this effect in a broad range of drugs of abuse, some that you would suspect, but also others that might seem a bit of a surprise. The drugs included cocaine, amphetamines, opiates, other pain meds, benzodiazepines, and barbiturates.

The authors relate this increased risk of sudden death with chronic drug abuse to the already recognized similar occurrence with chronic alcohol abuse.

So, yet another reason to not abuse drugs: an increased risk of suddenly dying, even if not acutely intoxicated at the time of death. That should give folks pause and new meaning to a phrase I have used a time or two: “Drugs, they can make you high, they can make you die”.

Unusual death from reader comment (question)

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

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

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

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

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

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

PLEASE HELP SHINE SOME LIGHT. THANK YOU

My reply:

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

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

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

Brown Bag Review to save your health and life

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

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

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

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

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

Stay safe and stay alive.

Increased THC Content in Today’s Marijuana

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

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

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

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

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

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

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

A Cavy for Xmas Dinner

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

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

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

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

Healthcare cost-sharing contributes to morbidity and death

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

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

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

Do read the whole article (link above).

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

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

From this co-pay and deductibles grew and flourished

To discourage inappropriate care

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

The author goes on about the study:

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

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

The travails of cocaine use (ultimately death)

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

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

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

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

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

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

Teens speak up to stop deaths

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

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

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

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

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

Anger is temporary – death is not.

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

Contagious happiness

Happiness is contagious, new study finds…

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

Go out and infect someone this week end.

The uninsured are everywhere (and they are dying)

From a Chicago tribune newsblog:

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

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

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

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

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

Suicide Prevention Hotline mention

News Sun 11-28-08

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

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

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

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

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

Richard L Keller, MD
Coroner

Fighting dementia

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

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

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

Use-lose law; not OK to not enforce

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

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

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

One comment irritated me:

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

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

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

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

Make good choices, don’t take chances.

Crying for what's wrong with you

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

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

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

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

Being sad ain’t all bad.

Fun "health" facts

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

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

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

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

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

Psychache

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

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

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

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

and the elderly selling gravesites for cash...

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

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

New barometers of financial woes?

The dead evicted

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

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

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

Who knew there was a risk of eviction after death?

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

House of Burns Memorial Chapel

Apparently funeral home staff declined to comment for the article:

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

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

Increasing Suicide Rate

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

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

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

Indeed:

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

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

"Went to a Party Mom "

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

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

Went to a Party Mom

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

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

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

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

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

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

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

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

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

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

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

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

Ceiling fan may help prevent SUID/SIDS

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

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

Underage drinking is not OK

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

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

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

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

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

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

Underage drinking is not OK.

Don’t take chances. Make good choices.

Remains to Hungary

Nice to report:

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

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

Fake crack

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

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

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

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

Out Of The Darkness Walk

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

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

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

Alcohol over-use kills

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

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

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

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

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

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

Response to a query, hoping to help with information

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

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

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

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

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

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

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

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

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

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

[Google can help you with the units conversions]

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

Near-death study

I was sent a link to a Times article today:

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

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

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

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

Work-related brain teaser, Is it Murder?

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

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

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

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

Any thoughts?

A strange case indeed, some thoughts:

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

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

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

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

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

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

Coroner for healthcare reform

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

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

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

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

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

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

This, too, should not happen in the USA.

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

Anti-violence program for youth in Chicago

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

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

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

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

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

They go to training

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

Crisis impulse + access to lethal means = suicide

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

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

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

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

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

Got to use car seats for kids

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

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

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

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

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

Regular folks can report drugs and doctors

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

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

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

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

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

Coroner recommends birth experience to interrupt violence

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

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

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

I think it might be worth a try.