Working with the DEA

We work with many agencies in our death investigations. While local police and fire agencies are our most frequent “allies”, we work with a number of others. One that we have been working with more frequently, it seems, is the Drug Enforcement Agency (DEA).

We have worked on a few cases that involve people who died after use of prescription meds purchased over the Internet. Perfectly legal drugs (not tainted or of “different” quality), but purchased via the Internet with prescriptions that are also acquired over the Internet from the same provider as the seller of the med. We have seen this scenario with individuals who inadvertently overdosed while “self-medicating” and, in at least one instance, meds that turned up at a party. We continue to report these instances when they occur and know that the DEA closes down the offending sites when they gather enough evidence to do so.

Also, we have worked with the DEA (and continue to) in instances where a doctor “over-prescribes” and/or a pharmacy “over-dispenses”. Imagine the contribution of a doctor that prescribes several hundred pain pills and anxietolytics at a time, at intervals too short for safety, and in combinations that put individuals at risk of poly-substance overdose. Or imagine a pharmacy allowing and dispensing a pain med prescription with 99 refills, and at quantities and frequencies with a potential to risk patient safety. These cases are reported to the DEA and the IL Dept of Professional Regulation for their review and consideration.

Just like those cases I talked about yesterday, we see ourselves as proactive in preventing future deaths by reacting to components of individual deaths and making certain that those conditions are not repeated with other folks.

“Activist” Coroner

We are at it again. Treading where we think we ought, to best “serve” those that die in our county and their survivors.

In a recent investigation it appeared that the prior investigation was “incomplete” and so we were compelled to intervene. It involved an individual severely injured in another jurisdiction, who ultimately died in Lake County. Our ruling at “case review” will be homicide. In reviewing the police investigation done at the time of the injuries it appeared to us that the investigation was disjointed and certain facts and statements had not been given the attention that they merited. We arranged a meeting between our office, our pathologist and an official of the investigating police department. My deputy pointed out things we saw in the records of the investigation, had our pathologist discuss how the severity of the injuries went along with our interpretation of the information available and strongly recommended that they reopen their investigation. After asking if they thought they could use some help from the state police, they decided to reopen their investigation. It is now a work in progress.

Another recent investigation raised several questions for us about the care and interventions a dying person received and/or ought to have received. Because of those concerns we contacted an oversight agency in whose jurisdiction those actions fall and have prompted an investigation on their part. That investigation should result in improved care, which is our goal in reporting the incident.

We take these actions because it is the right thing to do. As our mission statement says:”…we serve those who can no longer serve themselves…” (We speak for those who can no longer speak for themselves.) And we work “…to help prevent deaths in similar circumstance.”

Note: to the media that read this blog, I cannot discuss the particulars in these cases as the investigations are ongoing and the results might be skewed by such reporting.

Note 2: Mr. King: Yes, I am “addicted” to quotation marks, particularly for emphasis. Thanks for your input; I shudder to think what my English teachers would think of my writing (of course, it was over 35 years ago that I last sat in an English class, so they might not be reading this).

IL Nursing Home Death Reporting Task Force

I got involved in a “new” state-wide task force yesterday, the (Nursing Home) Death Reporting Task Force. We will be developing, piloting, and then implementing a project to ensure better reporting and, when appropriate, investigation of the deaths of individuals in nursing homes and related facilities. While we already require reporting from the nursing homes in Lake County, I look forward to this effort in improving these “reports”.

We met yesterday in Springfield (my first meeting with the group) 5 Coroners and individuals from IL Dept. of Public Health, the Attorney General’s office and State Police. We will be working to improve reporting and follow-up across the state, ultimately. In addition to adding a few questions to what we routinely ask when the deaths are reported to us, I think it will be good for systematizing the reports, improving our ability to report “questions” to IL Dept. of Public Health (IDPH) for their investigation and encourage sharing both ways. One piece I particularly look forward to is IDPH sharing with us nursing home “complaints” and “trends” so we can look a bit more “suspiciously” at death reportings from those facilities. And hopefully head off events like the upcoming 6 exhumations in McHenry and Lake Counties to investigate deaths at a nursing home in McHenry County.

Often nursing home residents don’t have advocates and folks watching closely after them. I think it is only right that the Coroner watch out after their interests after death and perhaps gather data to prevent needless deaths in the future.

Suicide prevention programs

We (again that “royal we”) really have some things moving forward with our Suicide Prevention Task Force. We are starting a project, partnering with a local agency to bring faculty training to local high schools and middle schools to assist them with suicide prevention efforts. The training will target faculty to help them in recognizing “at risk” (of depression and suicide) students along with “how to” refer and encourage them to get help. The second “target” is school counseling staff to ensure they have the “tools’ to handle those referrals and do appropriate evaluations and referrals as needed. This program will also ensure “institutionalization” of the training, so that the schools can continue training new faculty, retrain current faculty, and that the program once started will continue on into the future.

Our second big project is a program to encourage suicide survivors (i.e. family and friends of those that die of suicide) to get help and support for themselves earlier after their loss than the 4 year national average. We are as yet uncertain how this will look finally, but we are looking at several models around the country and seeing how we might borrow the best of each and bring it here to Lake County. There are not many “first responder”, “early intervention/support” models out there, but we are confident we can get something effective working here “soon”.

Both of these efforts are exciting and I look forward to their development. As well we are continuing to bring together referral sources and find gaps in services that need to be addressed. The other “pieces” include working on other education programs (students, community) to expand knowledge about suicide and what to do when confronted by it to help prevent it, and working to decrease the stigma associated with it.

Off to the "Illinois Death Reporting Task Force" meeting tomorrow. Long drive, but certainly pertaining to our Coroner work, and I have been invited to participate.

Typical day, typical stuff?

Confluence of stuff, belying the thought of a “typical day”.

Started my day, yesterday, doing a bit of volunteer doctoring (I still do a bit). Into the office to get a bit of stuff done for some upcoming meetings this week and other “usual stuff” stuff. I paused in those endeavors and examined a sub-galeal hematoma and skull fracture as one of my deputies retrieved a “bullet” from a death by suicide, as requested by the police agency involved in the case. Then I walked across the street to watch a press conference being held by a local state senator regarding proposed legislation to make it a felony for parents to knowing allow underage drinking to occur if a serious consequence of that drinking occurs. I was asked, rather spur-of-the-moment, to speak of my thoughts on the issue and it’s utility in preventing teen deaths (my comments ended up in the local newspapers and on WGN). I then went out to participate in the “scene” investigation of a death (man severely in a burned out pickup truck, investigation still in progress). When I got back to the office, I did get a couple of “usual stuff” tasks done, not to mention taking at least half-a-dozen media calls. My meeting last evening went off without problem.

Today I began with a meeting of the Lake County Underage Drinking Prevention Committee. While there I was notified of a homicide that one of my deputies had responded to. When I got back to the office, the first autopsy of the day had begun, the homicide autopsy was “scheduled to follow”. The third autopsy (on the victim from yesterday) was ultimately postponed until tomorrow. While I was still trying to get my act together for tomorrow’s meeting of the Lake County Suicide Prevention Task Force, some guys came by to replace the broken window in my office forcing me out to the conference room for a bit. File reviews, case reviews, review of material from this morning’s meeting, review of other stuff, talked with a recent decedent’s family member about a couple of issues, media calls (about today’s homicide, yesterday’s death and a couple of other matters), this blog post and my day was done.

Although I will be leaving for the day soon, I am always on-call and I look forward to the interesting stuff to come now and into the future. (Did I get the stuff done for tomorrow’s meeting?)

Radio "Company"

Just a quick posting today, something I have been thinking about for awhile.

I’m sure none of my deputies would admit that they believe in ghosts, but I’ve noticed that they leave a radio on in back, in the intake area by the “cooler”.

Although, when you are in the building by yourself at “off hours” it is awfully quiet and then when the security folks come around shaking all the doors to make sure they are locked it can be a jolt.

Coroner Authority

I’m working on an article for our 2nd quarterly newsletter for local fire departments. At least partly because of a recent incident (ah yes, there are some of those), I’ve pulled together some quotes from IL statutes and IL Attorney General Opinions that I am attempting to write the article around. My intent with the article is to speak of our desire for a spirit of cooperation among agencies investigating deaths, while making it clear that the coroner’s office has a certain level of authority that should not be interfered with in these cases and that we have the right to assert that authority.

The “quotes” include:

“Each coroner shall be conservator of the peace in his county, and in the performance of his duties as such, shall have the same powers as the sheriff.”

“…inquire into the manner by which persons came to their death where there was any reason to suppose the death might not have been due to natural means”

“No dead body…or the personal property of such a deceased person, shall be handled, moved, disturbed, embalmed or removed…by any person, except with the permission of the coroner, unless…necessary to protect such body or property from damage or destruction, or unless necessary to protect life, safety, or health.”

“…specific grant of authority to coroners to investigate deaths would necessarily prevail over the general law enforcement powers of other police agencies”

Our office takes these responsibilities and “authorities” very seriously. We do, and will continue to do, complete and thorough medicolegal death investigations (maybe even more so than some coroners in other jurisdictions) in conjunction with and parallel to law enforcement agencies, fire agencies, and other agencies that might have interest in and jurisdiction regarding the death in question (e.g. NCIS, OSHA).

A work in progress.

Vets PSTD and suicide

I ran across an article today on a topic that I don’t think gets covered enough. It had a comment in it that really caught my attention as well.

The article is entitled: “Vets’ suicides: casualties that go uncounted and another hidden cost of war”. It talks about the terrible tragedy of war-related post-traumatic stress disorder (PTSD) and its relationship to suicide. It also mentions how PTSD is often undiagnosed and untreated, how its toll is not tracked after discharge, and how it is a growing problem even in the face of threatened cuts in veterans’ healthcare benefits.

But what really caught me was the statement: “No one knows how many Vietnam veterans killed themselves because no one ever bothered to track or count. There are many experts, Jonathan Shay for example, who have no trouble believing that there have been more suicides since the war than there are names on the Wall…”

My father died by suicide after a second tour in Viet Nam in 1972.

We can not let this tragedy continue and repeat the mistakes of the past. PSTD and suicide in active duty soldiers and in veterans must become a priority. Let’s support our troops.

Nap and live longer

In a study released recently, it appears that a daily nap decreases your risk of dying from heart disease. While, like all studies, it must be replicated in other patient populations, it certainly looks like an impressive effect. The effect may be related to stress reduction and afternoon naps may be “more natural” fitting with the normal cycling of our daily clock. Napping, researchers believe, allows people a chance to reset their heart rates and blood pressure in the middle of the day.

However, the first thing I thought of last night when I saw the report on the news was something a cardiologist told me a number of years ago. He told me we were each born with just a certain number of heartbeats and when they were used up, you checked out. So my thought is that a nap helps you save a few of those limited number heartbeats and allows you to live longer. [Disclaimer: I am not a napper]

So nap away, unless you work someplace where I need service/attention at the time of your nap (or if your one of my employees, I’m not paying for napping).

Keg Reg to lower underage drinking

“Underage drinking cannot be successfully addressed by focusing on youth alone.” You must “create and sustain a broad societal commitment to reduce underage drinking”. “The nation must collectively pursue opportunities to reduce the availability of alcohol to underage drinkers, the occasions for underage drinking, and the demand for alcohol among young people.”

We discussed keg registration (at the Illinois Coalition meeting referenced above) as a strategy to decrease underage drinking. This is a good strategy because it ties the purchaser to a keg when “trouble” arises, whether that trouble is just catching the underage drinkers or if some other incident occurs tied to the drinking (e.g. crash, sexual assault, other injury). This has been demonstrated to decrease the incidence of keggers for “kids”. It is a strategy that is very helpful for law enforcement.

Laws like this do tend to push the drinkers to bars, but it is much easier to monitor/control access there than at a kegger somewhere. Also, another “work around” is to purchase beer in cases, etc, but there is less of an impetus to finish the case of beer than the keg of beer (“it will only go bad after it is tapped”). Over-drinking is a less likely to occur with cases than a keg.

Our discussion now centers on how to implement such a plan. A state law was tried in the past and never got out of committee. Should we try it again, now that times are different and, perhaps, with a legislator with a bit more clout? Or, as is being done with “smoke-free” efforts, should we push multiple local ordinances until we reach a “critical mass” and then go for the state legislation. [Politics are in everything and politics are a “game”.]

But something has to be done. We can’t wait for another kid to die.

Bottle of Red-eye to Die for

I have been to several meetings lately (and going to another tonight) working on preventing underage drinking at several levels. Last Friday I attended a meeting of the Illinois Coalition to Stop Underage Drinking and will be a part of their Steering Committee going forward. In addition to the efforts on the local level that I am participating in, it is important to push and share efforts state-wide and have a presence for the legislature, hence the state coalition.

We plan to concentrate efforts on things like 1) keg registration (more likely growing it to state level from local efforts) so that kegs can always be tracked back to the individual who purchased it, 2) alcopops (think mike’s hard lemonade) or bottled “girlie drinks”, or at least working to impact their marketing that seems to target underage female drinkers, 3) minimum age for bar entry (particularly a problem in college towns), and 4) perhaps a tax increase on alcohol products to fund interventions and (although I doubt its effectiveness) to decrease consumption, particularly among underage kids. I look forward to these efforts and others as they become apparent.

One interesting bit of information that came up at the meeting was Senate Bill 948 that passed in the last legislative session. It seems to me that it kind of brings back the “wild west”. Picture the scene in the old westerns where the cowboy goes into the saloon and orders a bottle of red-eye (with a dirty glass if he was really tough). If (or when) the governor signs this bill into law, folks in Illinois can go into a "club” and order a full bottle of distilled sprits (sounds pretty put that way) to be shared by a table of 2 or more people. This bottle service, while it likely won’t be red-eye, will likely contribute to over drinking. Once the bottle is open you can’t take it home, so you might as well finish it there (17 drinks in a fifth, 21 in a quart, or 22 in a liter). “Over the teeth and past the gums, look out liver here it comes.”

That should be “good for business”.

Social Norms Marketing

Is “social norms marketing” what I have been looking for? It appears to be a unifying approach to addressing an array of social problems leading to death and other problems.

Instead of using “health terrorism” or attempting to “scare the health into people”, you educate them about what their peer norms are and work to promote conformity with that health norm. For example, instead of telling folks that 25% of youths binge drink, you tell them that 75% don’t, building social pressure to minimize drinking, particularly in underage drinkers.

Attempting to frighten individuals into positive change by pushing the negative consequences of certain behaviors has “not changed behavior one percent”. Using “social norms marketing”, however, has demonstrated effectiveness by correcting misperceptions (usually overestimations of use), and identifying and promoting the healthy, protective behaviors that are the actual norm in a given group of folks (teens or adults).

One study demonstrated a 21% reduction of heavy drinking in a college population using “social norm marketing” techniques. There was also a significant decrease in consequences of drinking (e.g. property damage and unprotected sex) pointing to decrease in drinking among those that continued to drink when they had a real handle on the number of drinks that were “normal” in social situations and that not “everyone drinks”.

Social norm marketing has demonstrated effectiveness in a number of issues (although it has been mostly studied in its affect on underage drinking and heavy drinking among college students). It has shown promise in seat-belt use, smoking, spousal violence and grade improvement. My mind races in considering other “targets” (e.g. convincing parents that it’s not OK to throw alcohol available parties for their kids).

Promote health to increase health. Accentuate the positive. Show folks what the real “peer pressure” (social norm) is not taking chances, not making bad choices, but making “healthy choices”.

Blog B-Day

It was pointed out to me today that I have been blogging for a year now (220 posts), wishing me “Happy Blog B-Day” (somewhat belatedly, 1st post Jan.6, 2006).

Also today, I was starting to organize a list of my accomplishments since being elected to office 2 years ago. It does sound a bit egoist to be doing that but I am also preparing to ramp up and “reapply” for this job all too soon (the Primary is a 1 year away).

These 2 things do intersect. I think one of my greatest accomplishments over the last 2 years has been making my office more open, the information it gathers in death investigations more accessible, and on a whole the experience dealing with “our office” a bit less “scary”. We have an “office tour” repeatedly showing on the local County cable access channel. Our “tours” for high school students and other groups have increased in number. I answer questions of the media as much as feasible, keeping the public informed about causes of death and contributing factors, as appropriate.

But I am most proud of this blog (thanks Steve for helping me get started). It is good for my psyche and, hopefully, interesting and useful for others.

I am able to share information we pick up locally, as well as stuff I run across that seems pertinent. I have been able to answer questions and make that information available to other folks with similar questions. I am able to discuss my thoughts about a wide range of issues. Laying it all out in the open for anyone to read, think upon, and who knows, act on and share with others.

Thanks for sharing this with me and I look forward to continuing this on into the future.

Probe post-surgical deaths

There is a proposal in South Carolina to mandate reporting of “patient deaths that happen within 24 hours of surgery to the coroner’s office”. The feeling is that an independent investigation (with the possibility of autopsy) outside the hospital would be better to track and differentiate deaths due to medical “misadventure”, those due to “error” vs. an unavoidable “accident” vs. a system problem in need of remedy. Corrective measures might be more likely to occur at the behest of an agency outside the hospital.

I like the idea.

Here in Illinois hospital deaths are reportable to the Coroner if they occur within 24 hours of admission (which include ER deaths) and if they are the result of a diagnostic or therapeutic procedure. The later categories allow for some interpretation by the hospital in reference to “as the result of”. I am not saying that hospitals “hide” things or that they are less than truthful and open in their reporting, but the perception could exist without a mandate as proposed in South Carolina.

Is it possible some cases shown not to warrant litigation could be kept out of the courts? It certainly is quite possible. Could some cases be pushed to early admission of culpability and settlement? Again, quite possibly. Could we possibly positively affect the healthcare system by pointing out errors and system problem areas, allowing for correction before others suffer a similar fate? I think this is the most important reason to consider this proposal.

MySpace, off-line community replication

I came across an article referencing MySpace that I agree with. It is an interview with a social researcher who has taken a real look at social network sites and activity. My bias: I support teens’ access to and use of social network sites.

The researcher divides the users of those sites into 2 groups. 1) (by far the larger group) those individuals who use the social network sites as an extension of their off-line lives, and 2) marginalized kids who substitute their online lives for community off-line.

Teens for the most part use the sites to talk to others they already know, building relationships not meeting “others”. These sites are just a part of their “new” social repertoire that includes cell phones, texting and the Internet. Realizing this, adults should not fear their use of these sites, as long as their child is in group 1. If their child is in group 2, they (the teen) need “help” for a variety of reasons, the least of which is their Internet usage.

We also need to keep in mind (as she states in the interview) that there has never been an abduction linked to these Internet sites. There have been “runaway situations”, but likely they would likely have occurred in some other “form” without the use of the Internet involved.

Social disapproval as a tool

The other “thing” that came up at the CeaseFire meeting yesterday was the usefulness and effectiveness of “social disapproval”. CeaseFire works to instill and reinforce social disapproval as a deterrent to violence.

Thinking about it, social disapproval used to be an important impediment to a number of behaviors when communities were communities. It is an attribute that we as a society need to recapture.

Society should disapprove of violence vocally and demonstratively. Society should be obvious in their disapproval of underage drinking. Society could use their disapproval to impact bullying in schools (“violence” in itself and a possible precursor to violent action/behavior). So many societal ills deserve disapproval. Publicly avowing that disapproval and breeding action based on that disapproval could go a long way toward solutions to many of our problems, many of those “problems” resulting in unnecessary death.

We can not continue to “accept” these things as inevitable or as unpreventable consequences of our society and/or life. These “problems” are not something we can’t do anything about. We need to disapprove and act or help others to act so that that disapproval is put into action.

I have been accused of “preaching to the choir” on these things, but it is time for the choir to sing and proclaim that it should no longer be so.

Public Health CeaseFire

I was at our local CeaseFire Advisory Board meeting this morning and was impressed by the number of interventions they had done over the last month. They really seem to be making a difference in the community, lessening the risk of violence. CeaseFire, as I think I’ve mentioned before, is a violence intervention/prevention program that originated in Chicago. It is based on what can be described as a “public health model” of violence prevention. They react to violent deaths and other incidents and work to “prevent transmission” of that violence. They also do some “primary prevention” to prevent violent behavior from manifesting itself in the first place.

What came up this morning, in addition to the successes that they are having, is the rather unexpected amount of suicidal ideation and suicide potential that they are “uncovering” among the individuals they contact (in the streets, in their homes, and in schools). It is becoming very apparent that individuals at risk of violent actions (by themselves or by others against them) are also at risk of suicide.

This suicidality will need to be addressed. The outreach workers and “interveners” are unprepared to deal with this actuality. These folks can’t continue to go out without the wherewithal to deal with this suicidality. We will be bringing a program into the county through our Suicide Prevention Task Force that should work very well with these folks (QPR, Question Persuade Refer) and most definitely we will include them in trainings.

It is amazing how problems/issues overlap and interrelate. There are no single issue, stand alone problems; therefore “real” solutions must be multifaceted as well to really address problems/issues. Realizing that to deal with violence job training, job placement, housing, healthcare and mental health care, after school programs, etc also are there and must be dealt with; it isn’t a simple as “just say no”. The “public health model” (or community health model) fits well with this, allowing for expanding thought so that whatever “treatment” is needed can and will be brought to bear on the “patient”.

Through the ice

Sadly, it has happened again, a snowmobiler into the lake through thin ice. Every year, at least one person goes through the ice on a snowmobile. This time it was a 16 year old youth with his life and potential fully ahead of him.

Lake ice should be at least 5 inches thick for snowmobile riding,, an inch thicker than for safe ice fishing. The weather locally has been so mild this season that the ice fishing derbies have been canceled.

One website sagely states that a snowmobiler shouldn’t trust other riders’ judgment regarding the safety of the ice; you should check it out yourself. This teen does not appear to have been doing anything really foolish (that can’t be said for all snowmobile into the lake deaths, like “jumping” open water). It was a terrible, unfortunate accident.

You lose consciousness in 40 degree water in approximately 1 hour, much quicker in colder water (lake water around here is 35 or less). Unfortunately, confusion precedes unconsciousness in hypothermia. Struggling actually accelerates body heat loss in cold water, so attempts at saving yourself must be methodical, yet rapidly effective.

It appears this young man did all he could to save himself, but rescue came too late.

Snowmobilers should carry with them, tethered to themselves and easy to get to: a cell phone in a water-tight bag or case, ice picks (with retractable covers) or a knife to help pull themselves out of the water over the ice, a flashlight with a beacon flasher and “alarm”. Movements to get out must be conservative with minimal body movement (foot/leg “flipper” action), stretching out over the ice or breaking repeatedly through the thin ice toward shore.

Unfortunately, as the body rapidly loses body heat, time is severely limited. Drowning can ensue in the most conditioned of individuals. Nature, as in many cases, can certainly be exceedingly cruel in these situations.

(as you suggested cheryl1054)

Snoring Can Portend Death

Snoring is NOT a good thing. It came up again this morning while we were discussing cases in conference.

Time and again the story is that the individual is heard to be snoring shortly before their death. People lying on the floor snoring. People lying on the couch snoring. People lying on their bed snoring. People snoring really loudly. Most often the snoring is unusual for that individual or seems inordinately loud, it is “remarkable” snoring.

These snoring preceding death in these cases almost invariably involve individuals impaired by alcohol and drugs. The snoring is due to the fact that their airway is way too relaxed and they are not getting enough air (oxygen). Do not allow them to continue to lie there and snore. They are going to die. Chances are that they are not “going to sleep it off”.

Yes, some people snore every night, but if they are snoring loudly after drinking or using drugs (licit or illicit) the snoring is a sign of impending death. Get them medical help (911).

Consider this yet another of Coroner Keller’s Axioms, like no cocaine after 50 and get a doctor’s clearance if over 45 and participating in certain “extra-curricular” activities.

Domestic Violence is not a joke, it can kill

K-mart sells a T-shirt that shows “a male stick figure pushing a female stick figure out of a box to a steep fall”. “The disputed ‘Problem Solved’ t-shirts are manufactured by Route 66 Attitude.”

It’s a kids’ T-shirt. I have seen some T-shirts that I consider “wrong” and/or obnoxious, but this is just incredible. According to the report K-mart took them out of their stores briefly after a complaint, but then resumed selling them.

I find it particularly repugnant today, because we had 2 recent deaths possibly due to domestic violence (one is still under investigation). Domestic violence is one of the leading contributors/causes of homicide. To make light of domestic violence, to make it a “joke”, goes way beyond “wrong”.

For information on how to speak out against Kmart’s t-shirts, visit, www.hardygirlshealthywomen.org/newsandevents.php#kmarts. To protest to Kmart, visit www.kmart.com/custserv/contact_us.jsp