Death memorials

I was reminded recently (to paraphrase something I read someplace) that in death we continue to exist in the memory of others. I was reminded of that as I alluded to that fact in a discussion I had a few days ago. I was reminded again when I recalled the face a day later (in what seemed to be vivid detail) of someone who died a fair length of time ago. And I recalled the phrase as I started to work on this post about “roadside memorials”. Those memorials are an increasing phenomenon in a variety of countries (google it like I did) and places (roadside, porches, online, etc).

Why do people build these memorials? Are they reflective of some new spirituality, as some would have you believe, or are they just people being people honoring death and remembering the dead?

These memorials mark the place where someone died suddenly, often violently, an untimely death, or as someone put it “yanked from this earth”. Are they an attempt to develop “sacred space” or are they a more secular attempt to provide a marker for the memory of that individual’s life and death? We do not want to forget those that die before we do, for fear of forgetting do we build these memorials? They do create a space for remembering and mourning. They do provide a physical space to hope for peace for those who have died and for peace for those that mourn the dead.

In that I see their benefit. A space (sacred or not) is created that is connected to those that have died, beyond the “official” places for mourning. It seems a more immediate (close) and a more real place for these contemplations and offerings of “respect”. Death is a part of life and those that have died live on in our memories of them. The real memorial is in us, but, at least temporarily, we may need a memorial outside of ourselves to remind ourselves of that fact.

Self-injurious behavior

Nobody knows the prevalence of self-injurious behavior, but it occurs much more frequently than people think. It can be associated with a history of abuse or psyche trauma, eating disorders, depression, post-traumatic stress disorder, and (what is termed) borderline personality disorder. I’ve been thinking of writing about this since I saw a young lady who had carved “help” into her thigh.

Individuals who carry out self-injurious behavior want to hurt themselves, they are unable to resist acting on that desire, they intend to cause themselves injury, not death. While this is not a step toward suicide, there is an overlap in psychopathology and, therefore, you may see both in the same individuals (as was the case in the young lady I mentioned above).

Self-injurious behavior is addictive, just like drugs. The underlying drive varies person to person and, at times, from episode to episode. Self-injury may allow for the release of an incredible “tension”, at least temporarily. The pain involved may allow the individual to feel “real” and alive. It may “connect them to the present”. It may allow the individual to control their “environment”, to control themselves. Yes, it may be used to influence others, but this is the least likely reason behind the action. The “reasons” are many.

These folks need help. Using this as a coping behavior is fraught with danger, as you might imagine. In one study, 20% of adolescents who self-injured in this way required medical attention for that self-injury. As well, the underlying psyche pain, the pain that is worse than the physical pain delivered in self-injury, needs some other treatment. Help is available and those involved in these behaviors need to know that and that it is OK to seek help for this serious problem.

Save a Life??

There was an investigative report last night on the local ABC affiliate about an individual who set up a foundation paying herself $120,000 a year plus expenses based on a “inaccurate” retelling of her daughter’s death (there were other untruths as well, apparently).

This is made more difficult to understand and/or tolerate when I talk to other parents, family and friends who really want to make a difference because of a death in their life, not benefit from it. At inquests yesterday I talked with several folks about such efforts. These other attempts and actions to save lives seem much more altruistic.

It saddened me when the investigators came to us for the information; it certainly didn’t get any better in the report that I finally saw last night.

The work of the Lake County Suicide Prevention Task Force

We had a Lake County Suicide Prevention Task Force meeting this morning. It really seems like we are getting down to work. We have divided into 4 committees: Resource Collection, Education, Community Information, and “First Responders” Project.

The Resource Collection Committee will continue our efforts to collect and post online the available resources in the community and begin work on a “gaps analysis” with consideration of how best to address those “gaps”.

The Education Committee will work towards community education, school education (for school personnel and students), professional education (medical, psych, clergy, etc.) and the like. Certainly, an initial part of this will be to find out about present education efforts and then work with them, facilitate them or augment them.

The Community Information Committee (whose work will somewhat overlap the Education Committee) will target awareness and stigma. That will include media and other venues, and other efforts.

The “First Responders” Project will begin our efforts to develop (borrowing from existing programs elsewhere) this program in Lake County. We envision a program in which we can get trained and “experienced” individuals to go to and begin helping and “connecting” family and friends of individuals who die by suicide with the resources they will need.

The work begins/continues.

We also handed out a list of information (no names) about the individuals who have died by suicide since January 2004 in Lake County. At first glance the listings pertaining to 140 individuals looks “sterile” and impersonal, but then you fall into it as you read it. 140 individuals who “leapt from their own infernos”. It “pulls at the heart strings”. We will accomplish our work.

On-line Memorials

[Busy day yesterday: press release to get media coverage and help in identifying a recent John Doe, staff meeting, regular work stuff, and taped a segment for the Today show (30 minute taping for 20 seconds of “air time”).]

I did want to mention a website somewhat related to “MyDeathSpace” that I posted about the other day: http://www.memory-of.com/. It is a site that allows a person to set up a web-page memorial site to memorialize an individual that has died. The usual posting consists of a “life story” with pictures and background music. You can include audio and video clips. The web-page is viewable by others who can leave condolences and comments.

I don’t mean to do an ad for these folks (and there are likely other similar sites) but I think this is likely a new cultural trend. It seems to be a “next step” beyond the growth of “roadside” memorials that have become quite the cultural trend (I will reserve my opinions about those).

These types of sites allow for a more public grieving (although the intent of the posters may be more personal, allowing for “visits” by friends and family). It also seems to allow for public/community sharing in that grieving. The latter seems to be the cultural trend, “sharing” in the grieving of people we may or may not have know in life (like many that participate in “roadside” memorials). We used to send a condolence card and/or flowers, contribute to a memorial fund, and the like. There would be a headstone at the graveyard, at times lavish, but these “displays” are new (or seem so to me). And while there were always those that shared the grieving at the funeral, there were few who participated who did not know the individual before death (although there were those few like the characters in the movie Harold and Maude who enjoyed attending funerals).

Why has this trend for public “displays” of grieving developed? What need do they address?

MyDeathSpace ?

I’m going to have to think about this site for a bit before I can decide what I really think about it. MyDeathSpace catalogs the deaths of individuals with MySpace postings. (MyDeathSpace is not affiliated with or condoned by MySpace.) You see postings about young people victims of homicides, suicides, and accidents. It is “compelling” to see all of these deaths of young people brought together and laid bare.

I’m really unsure about the “death map” feature (“to find deaths in your area”).

I don’t know. Will the postings have some affect on others? Will it cause pause for other young people and get them to reevaluate choices they are making or chances that they are taking? Is it merely voyeurism? Is it a part of “new online/virtual culture”? I don’t know.

This site is unlike other sites in that the postings most often occur without input from family and friends of the decedent, making it different than some others that are online memorial sites.

I don’t know. I’m not sure what I think about it.

I will look at some of the online memorial sites and post about them soon.

Coroner's heath tips

Thought I’d jot down a few coroner health cautions that you don’t see printed up elsewhere, but that we have discussed in the office based on “cases”.

People over 50 shouldn’t use cocaine, Yes I know that no one should use cocaine and that, as we testify, “there is no safe dose of cocaine”, but based on some of the deaths we see it seems particularly lethal for those over 50. It causes “heart attacks”, “asthma attacks”, strokes, and people just plain “waking up dead”.

Viewing pornography and “doing something about it” can be lethal. I know there are individuals who would like to use that “fact” to regulate the porn industry, but I would have a less severe recommendation. I recommend all men (yes, it seems to be a guy “thing”) say over the age of 45 (depending on other health issues) have a physical done by their doctor before they undertake these activities. Just like is recommended before starting an exercise program.

Do not trust the drugs you buy “on the street”. As an example, stuff we have recovered and tested from death cases thought to be heroin has consisted of anything from “pure” Benadryl to Fentanyl. Any of these, obviously, can be lethal, but I imagine the highs are different and isn’t it the high that you buy it for? You aren’t going to get your heroin high if the Fentanyl causes your death even before you get the syringe out of your arm. I doubt that Benadryl gives you the same high as heroin, even though much of the Lake County heroin seems to be cut with it. (I read recently, some place, that the “name” heroin is derived from “heroine”, which is what heroin was “billed as” when it was first used for pain control.) Caveat emptor.

There are a few; there will be more from time to time.

ER system reform needed

The Associated Press brought up the case of the woman who died in the ER waiting room that was ruled “homicide” by our Coroner’s Inquest jury again yesterday. It was in an article about long wait times in ERs and doctor’s offices.

It also “came up” at a recent meeting of the local regional healthcare council, being fostered by the Metropolitan Chicago Healthcare Council, (alright, I brought it up as an example of a system problem that should be looked at for “remedy”).

At that meeting we briefly discussed how many problems are contributing to this “system problem”, some of those things are also touched on in the article I referenced above. ERs are overcrowded. There has been a 26% growth in the number of patients seen in the ER between 1993 and 2003, while the number of ERs in this country have dropped by 12%. This growth/contraction combination took place without much modification in the system (the way that ER care is delivered) designed to keep up with the changes and load engendered or designed to improve efficiencies in providing ER care.

This is compounded by a variety of other confounders. There are “health literacy” problems. Many people don’t always know what is appropriate for an ER visit or because of that “illiteracy” don’t know what to do short of going to the ER for various medical problems. That “illiteracy” may also impair their ability to follow medical instructions for care and to keep them out of the ER. There are access issues for both acute and chronic health problems, denying people other options for care. There are “down-stream” problems, e.g. lack of hospital nursing staff and/or beds impairing the ability to get patients out of the ER and freeing up space for the next patient. There are many facets and/or contributing problems.

Some places are making changes to address some of the contributors. ERs are adding staff to handle cases that present. Some hospitals are using physicians for triage at busy times so that necessary testing can be begun more quickly. Groups are looking at “best practices” and exporting them to other ERs. Groups are developing alternatives for expanding healthcare access.

As I said before it is a system problem and requires system intervention to prevent any more individuals from dying in the waiting room.

SSRIs and suicidality

Do SSRIs (selective serotonin reuptake inhibitors, newer antidepressants) contribute to suicidality?

Although further studies need to be done (realizing the inability to ethically do placebo-controlled studies) to clarify some of the issues, most of the evidence does not support a risk out of proportion to the benefits for these medications (age specifically or otherwise). There are some studies that have demonstrated an increase risk of suicidality during the early phase (1st month) of drug therapy, but the risk seems to be shared by all classes of therapeutic agents (SSRIs, tricyclics, etc). Also, it seems that the increased suicidality rests more in ideation and behavior than in actual suicides.

Why the increased suicidality? There are likely several contributing factors. It may be related to the fact that these medications remove the psychomotor retardation component of depression that has kept the individuals from acting on their suicidal ideations. That effect on apathy and energy does tend to precede the medication’s positive effect on psychic depression (2 to 4 weeks), increasing the risk. There is also the possible contribution of the fact that these medications are most often started at the lowest ebb of an individual’s depression, confounding knowing which contributes to the increased suicidality. There are also possible side-effects of these medications that can increase suicidality, i.e. akathisia, agitation, disinhibition, and impulsivity. Lastly, at times starting antidepressents “uncovers” mania, a risk factor for increasing suicide risk. Interestingly, this seems to be a particular risk in kids 10-14 years old, perhaps explaining some of the perceived increased risk of these medications in this age group.

SSRIs have had a salutary effect on the treatment of depression and do not deserve to be demonized. As with all medications they should be used judiciously with monitoring for effect and side effect, but they must remain a part of our armament in our treatment of depression and the prevention of suicide.

Teen death by suicide

A local paper is doing a story on teen suicide, prompted by the fact that 3 students from the same high school have died by suicide over the last 3 months. It is definitely unusual for the media to do a story on this “taboo” subject, despite, as I discussed with the reporter, the fact that the myth that stories about suicide “cause” other suicide deaths has been proven false. I discussed a number of things with the reporter, which I will likely come back to in future posts, but one bit we talked about was a comment made to us in the course of our investigation of one of the deaths. To paraphrase: The kid was quiet, never in any trouble, never really noticed at school (or elsewhere). What this screamed to me was “depression”.

It seems that the thing that these kids had in common was unrecognized depression. Nonetheless, I can’t say that if I were at the school or their parent that I would have noticed it either (I hope I would, but sometimes we are more grateful than worried when a kid is just quiet). But was the safety net in place so these kids could seek help, easily, anonymously and without other “problems” being created? Was the safety net in place so that their friends could have helped them get help if they recognized a “problem”? Did folks know what to look for and know how to help them get help?

A small group of folks are going to get together soon to discuss those issues specifically (I didn’t mention that to the reporter) and our Suicide Prevention Task Force is certainly looking at the suicide “problem” more broadly. It is too late for these kids, but I pray that we will save others.

In an interview recently I heard the Director of a movie focused on death by suicide by jumping off the Golden Gate Bridge describe death by suicide as “people jumping out of their own infernos”. That is so true, but we need to get them help short of that “jump”.

Substance abuse help

I came across an interesting website that should be touted to every teen and every parent with teenagers (maybe more particularly with even younger children). It is the website of the Partnership for a Drug-Free America.

It is a great site with information for teens, real information and not “preachy”. Included is information about recognizing whether you or a friend has a “problem” with alcohol or other drugs, and information on helping a friend with a “problem”. It also has personal stories about recovery and in memorial of those that didn’t recover.

There is also a section for parents with information on a wide array of abused substances, support forums, and what to do if your child has a “problem”. It also has a “fun” little test, called The Two-Minute Challenge, testing your knowledge about some important facts about substance abuse. I’m going to help you cheat and give you the answer to what I think is one of the most important questions. I always make a point to tell folks that you can’t scare your kids straight, but if you give them real information they can/will choose to make the right choices and not take chances (at least it is the most likely way to effect behavior in this regard).

4.) One of the most important factors in whether kids decide to try drugs is? Correct! Correct Answer: B. Understanding the perceived risk of using drugs and whether the drugs are deemed socially acceptable. Research shows that perception of risk is one of the most important factors in influencing the decision to use drugs. (Source: Monitoring the Future)

Take a look at the site and its information; it may come in handy in the future.

Tonight's talk on alcohol and adolescent brains

Alcohol (and more specifically ethanol, “drinking alcohol”) is a poison and a depressant drug. The fact that it is a poison often surprises people, but remember it can run your car and it is used in biology to kill insect specimens.

Ethanol has special effects on the adolescent brain, which shouldn’t be surprising when you consider that the adolescent brain is “under construction”. Just raise some kids into and/or through adolescence and you come to realize that it is “damaged” and “getting fixed” (the latter by about the time they are 22).

“Binge” drinking is particularly damaging and that is what most adolescent drinking is. Ethanol affects learning and memory much more significantly in adolescents than adults. Those effects are compounded with significant ethanol consumption (repeat or continued) as an adult. It also appears that changes occur in the adolescent brain with ethanol use that makes it more likely to develop “problem drinking” as an adult.

A significant difference between adolescent and adult drinkers is that for adolescents ethanol has less of a sedation effect and coordination is affected a bit differently. This diminishes the “natural” effects of ethanol to get an individual to stop drinking during one “setting”. Blood alcohol levels can get higher in an adolescent because it takes more for them to become “falling-down drunk” (a “natural” drinking stopper).

However, ethanol still poisons the eyes in both adolescents and adults. Initially ethanol impairs papillary constriction, so bright lights appear brighter and harder to at (think headlights). Then gaze becomes disconjugate giving you double vision. Both of these things make driving very dangerous. At the same time, ethanol makes you “stupid”. You may choose to “follow” the taillights of a parked car. You lose inhibitions, increasing the likelihood of risk taking and making “bad” choices.

This stuff can lead to your death or the death of others. A developing adolescent brain bathed in ethanol is a recipe for death and disaster.

Driving is risky

I’m working on a brief talk I am going to be doing at a public forum next Monday about the effects of alcohol on the adolescent brain. While underaged drinking is a serious problem, and car crashes and deaths caused by drunk drivers is a serious problem (prompting the forum) they are not the “only” problem.

A bit less than 25% of teens killed in car crashes (compared to a bit over 25% of adults killed in car crashes) involve drunk drivers. Serious, yes, but again not the only problem. The Chicago Tribune yesterday ran a story (part of an ongoing, episodic series on teen drivers, their problems and deaths) pertinent to the point that drunk driving is not the only problem.

There are nearly as many fatal crashes involving 16 and 17 year olds that occur between 3 to 5 pm Monday through Friday as there are fatal crashes between 9 pm to 2 am Friday and Saturday nights. The latter more likely having a contribution from alcohol consumption. (National Highway Administration data via AAA via Tribune)

So while it does seem to make sense to focus on the toll of drunk drivers and easier to get folks fired up about drunk drivers killing with their cars, we must also look at the bigger picture. We must work to decrease all car crashes, from all causes. The media used to talk about the carnage on our roads and we ought to keep that in mind and work in a multi-pronged fashion to limit all car crash deaths.

Demand quality medical care

“Missed diagnoses, incorrect drug dosing, failure to treat promptly”. “100,000 Americans die annually from medical errors”.

As I have mentioned in regards to the “Vance case”, it was the system that failed her, that resulted in her death. We must fix the system to prevent similar deaths in the future. I got 4 more emails decrying the quality of care received by Ms Vance and the care the authors of the emails had received at various places across the country.

There is hope and some of the hope inducing programs are highlighted in a recent Newsweek series. Programs like “Medically Induced Trauma Support Services” that provides support to anyone involved in a “medical misadventure”. The “Executive Walk-Rounds” that occur at Brigham and Women’s Hospital that ensure administrators are abreast of hospital problems, errors and potential errors and that “patient-safety officers” intervene early and remedy the situations. The “Hopkins (Johns Hopkins Medical Center) Center for Innovation in Quality Patient Care” and their “Comprehensive Unit-based Safety Program” exist to head off problems or intervene quickly so they are not repeated. The “100,000 Lives Campaign” to decrease medical errors and preventable problems using proven protocols across the nation.

We deserve quality care in every hospital in our country and in every episode of medical care. As is pointed out in the series the “old” philosophy was to “accept” a certain error rate, just as manufacturing accepts/expects a certain defect rate in their products, but we must be about “striving for perfection” in healthcare in this country. Will we ever be perfect? No, but we must strive and accept no less a goal. “…doctors, nurses, pharmacists and technicians will always make mistakes—it’s the safety net around them that needs to be fixed”. “…we have to put systems in place that stop that error from causing harm”.

"Woman's Heart Attack Death Ruled a Homicide"

I got 67 emails last Thursday from all over the US after a link was placed on the WomenHeart website about a recent death here in Lake County and the inquest jury’s verdict. The death was of a 49 year old female who presented to a local ER with 10 out of 10 chest pain, shortness of breath and nausea. She died waiting in the waiting room, 10-20 feet from the care she needed to interrupt her heart attack. The jury came back with a verdict of “homicide”. It was the jury’s feeling, and certainly mine, that this case demands a change, an improvement, in the system that allowed this woman to die on a couch in a waiting room after a 2 hour wait. The emails I received reinforced that opinion.

Many wrote of their experiences of having symptoms “ignored”, and having heart damage as a result. Many felt they were ignored because they were woman. At least one added minority status as a contributor to lack of treatment.

Our country should not have a healthcare system that fails so many in our “community”. It is obviously a system problem and it must be addressed before it kills again. No one should “hang” for this death or any individual death that is a result of a system problem, but we must call attention to the problem that is killing folks. We must demand change. We must demand quality healthcare. Individual malpractice suits are not affecting the system, so we must find other ways to bring this discussion to the fore.

Demand quality. Don’t let people die waiting for, asking for, care.

No typical days

What is your typical day like? I have no typical days.

Last Friday (my birthday, by the way) began with a 2 hour meeting of the regional Child Death Review Team, of which I am a member. We discussed 3 child death cases in the region and whether anything could have been done prior to them to prevent the death or if something could be done in the future to prevent similar deaths. Quite often these can be disheartening discussions, because nothing could have been done to prevent these deaths or can be done to prevent similar deaths. However, sometimes there is that ray of hope/possibility and we make our recommendations for education (public or otherwise) or policy changes. We always hope that we can impact some child and prevent (forestall) their untimely death.

After the meeting I went into Chicago to get the dental records we used later in the day to positively identify an individual who died by train, a suicide. Identification is critical in “our line of work” and it was worth the trip to be sure we knew who the decedent was, no guessing or surmising. The drive gave me time to ponder the imponderability of death. As someone once said, “death is as much a part of our life as the air that we breathe”.

Today my Senior Deputy and I went to notify a family that their son had died this morning in an auto crash. Always a “raw” experience, never are 2 notifications the same. Sons aren’t supposed to die before their parents. A “great tragedy” has happened to those fine folks. It is also a “raw” moment for your heart, but you have to have the feeling or the notifications get too rote and hollow.

I never have a typical day and death is indeed imponderable.

"Local Outreach to Suicide Survivors"

Lake County Suicide Prevention Task Force meeting today.

One of the topics we discussed (there were many) was my wanting to start a “first responders” program for family and friends surviving someone who died by suicide (called “survivors” in this field) here in Lake County. This sort of program has come up in 2 discussions with different individuals of late (about 2 different programs). It is time to move beyond the coincidence and act to get it started here.

One such program (one also thought of as a prototype) exists in Baton Rouge. A small team of trained suicide survivors and Baton Rouge Crisis Intervention Center staff go to the scene of suicide to provide information about available resources and “to be a breath of hope for the grieving survivors”. The goal is to let the survivors know that there are resources (and hope) available as soon after the death occurs as feasible.

The hope is that getting the survivors tied into help as soon as possible will ensure that they receive all of the benefit that such help can provide with grieving, adapting, moving forward, and surviving themselves.

I look forward to being able to provide this service here in Lake County.

Alcohol killing kids

I learned at a meeting this morning that the IL Liquor Commission is running a pilot program to better hold accountable folks who provide alcohol to those less than 21 years of age. I hope it works well so that they will be able to roll it out state-wide in the not too distant future. The program called TrAIL (Tracking Alcohol in IL) consists of investigations triggered when underage drinking is “suspected in an incident that results in serious consequences”. This would include car crashes, treated alcohol overdose, and the like. Bringing in a specific investigator immediately after a triggering event will improve investigative success in tracing the source of the alcohol and allow for prosecution as indicated.

As we discussed at our meeting, to really be able to decrease underage drinking (and its attendant problems like death and date rape) we need to impact “social norms”. It can’t continue to be “OK” for underage individuals to have access to alcohol either from retail outlets (a more easily controllable source) or from “social” sources (parents, friends, etc). We can’t continue to allow kids to die having a “good time”.

Be aware of Depression

A mailing I got today informed me that October is Depression Awareness Month. "Clinical" Depression can be characterized by:

1) Loss of interest in or ability to feel pleasure (no more WOW moments) with the intensity of the feelings interfering with eating, sleeping, and other usual activities (including sex). There are intense negative feelings, particualrly about yourself.
2) "Clinical" Depression lasts all day, every day for at least 2 weeks, the individual experiences it as an indefinite, possibly infinite, time sensation.
3) "Clinical" Depression is so significant that it impairs functioning- socially, occupationally, academically, and/or with home life.

Depression can be treated, but the individual must seek help and get help. They may need your help to do that or you may need someone's help doing that. Don't let depression kill, seek help.

Teach that others matter

Another important “tool” kids (and adults) need is the knowledge that “others matter” and the ability to act accordingly. I think this starts quite young when kids learn to share and to consider others in addition to themselves.

If this could be inculcated in everyone I think it would go a long way to preventing violence and/or limiting its severity. It seems to me that the lack of the realization that “others matter” is often at the root of violent action. It is more difficult to act violently toward another if you think of them as someone with worth, someone you might share something with. It is much easier to be violent toward someone you see strictly as “them”, particularly as a “them” divorced from your experience and with no personal worth or value.

This “others matter” most often needs to be a personal social experience, but can be generalized to more “others” from even limited experience. It is not something that can be acquired vicariously over the Internet or through some other media source, unless preset with some experience of “others”. For this we need some personal experience, we need to teach kids (and have them experience) how to act with others, that others matter and that it is good to share.