Doctor My Eyes ...

I love collecting medical songs.
 I have a collection on Spotify you can listen to called Medically Necessary that opens with the great Jackson Browne's "Doctor My Eyes" which includes that wonderful line "is this the price, for having learned how not to cry."

These songs were the soundtrack to hard days treating dying patients in my earlier years of oncology nursing. They helped me get through hard nights and gave me strength to go back for another 12 hours shift. Music is the best medicine - at least for me. Especially on a long and winding drive home. I'm always finding new songs and adding to my playlist.

One song I can't find on Spotify that belongs on that playlist is "Only the Song Survives" by John Hiatt. The song is a brilliant ballad about a couple that find themselves in the Emergency Room after a car accident. In it, the singer has short term memory loss, and he has trouble remembering what happened, and even that he was married in the first place. I can't put it on my playlist, so here it is:

Understanding Suicide/Getting Help

When I first wrote this, our little valley was struggling to understand the sudden tragic death of a much loved prominent member of our community -- the much loved county sheriff --  who took his own life. He had smiled the last time I had talked with him, seemed gregarious as we talked motorcycles and horses. 

Yet his internal demons were torturing him. A few weeks later and he was gone.

With the recent suicides of celebrities Kate Spade and Anthony Bourdain, we are reminded that suicide can strike without warning, and regardless of external things like success and popularity.  

Nearly a million people take their own lives every year and in most countries, the incidence of suicide is higher than that of homicide, according to statistics collected by the World Health Organization.  More people are lost each year to suicide than to war.  This year, for active duty military, suicide deaths are outpacing deaths from combat. 

Suicide is most often associated with depression, although that may be undiagnosed, and may or may not be combined with substance abuse. Women are more likely to attempt suicide, but men are four times more likely to succeed in killing themselves. This disparity is often attributed to the means by which men and women attempt suicide. According to the National Institute of Mental Health, risk factors include:

• Depression and other mental health disorders or substance abuse problems. More than 90 percent of those who take their own life have these risk factors. 
• Prior suicide attempt
• Family history of mental health problems, suicide or substance abuse
• family violence
• firearms in the home - more than half of all suicides involve a gun.

"However, suicide and suicidal behavior are not normal responses to stress; many people have these risk factors, but are not suicidal, according to the NIMH. "Research also shows that the risk for suicide is associated with changes in brain chemicals called neurotransmitters, including serotonin. Decreased levels of serotonin have been found in people with depression, impulsive disorders, and a history of suicide attempts, and in the brains of suicide victims. "

The last few weeks have also been high acuity for mental health patients in the Emergency Department. Although research has shown that rates of suicide are low in the winter months and higher in the spring and summer months. Rates also vary with changes in the weather. Such statistics aside, it should be noted that we need to be watching for warning signs all year round. 

According to the Suicide Prevention Resource Center, here are some of the things to watch for:

• Talking about wanting to die or to kill themselves.
• Looking for a way to kill themselves, such as searching online or buying a gun
• Talking about feeling hopeless or having no reason to live.
• Talking about feeling trapped or in unbearable pain.
• Talking about being a burden to others.
• Increasing the use of alcohol or drugs.
• Acting anxious or agitated; behaving recklessly.
• Sleeping too little or too much.
• Withdrawing or isolating themselves.
• Showing rage or talking about seeking revenge.
• Displaying extreme mood swings.
• The risk of suicide is greater if these behaviors are new, increasing, or related to a recent painful event, loss or change on one's life. 

If you or someone close to you exhibits these signs, get help as soon as possible by calling 1-800-273-TALK (8255). 

NIMH's website adds the following:

 If you think someone is suicidal, do not leave him or her alone. Try to get the person to seek immediate help from his or her doctor or the nearest hospital emergency room, or call 911. Eliminate access to firearms or other potential tools for suicide, including unsupervised access to medications.

Of course, sometimes the signs are subtle or we miss them. Sometimes you do everything right and still can't stop someone you love from taking their own life. Feelings of guilt and second guessing combine with the grief and loss for an often overpowering tidal wave of emotions for those left behind. The Mayo Clinic has good information HERE on understand and coping with the tragedy of suicide when it hits close to home.

Our hearts go out to those in the valley this morning. I hope this information helps. 

Learn more at:

Suicide Prevention Resource Center

American Foundation for Suicide Prevention

National Institute of Mental Health Suicide Prevention

Veterans Crisis Hotline

Healing After a Loved One's Suicide

#BeThe1To save a life.

Is Caffeine a Killer?

Is Monster a Monster? Does Caffeine Kill? Are energy drinks out to kill our children?

Full disclosure: I drink caffeine. I have about two cups of coffee in the morning and a cup of tea in the afternoon. When I'm working 12 hour shifts in the Emergency Department, I also drink a Hi-Ball or Starbucks energy drink on the way home.

Big deal, right? Well, these days energy drinks are in the spotlight because -- well because they are popular --  and someone is suing because their kid died of caffeine poisoning.

While the headlines say "When Caffeine Kills" in most cases it is doubtful that the energy drinks, or coffee or tea is really doing the killing. However, according to MSNBC: "the parents of Anais Fournier of Hagerstown, Md., sued the company that makes Monster Energy Drinks, saying caffeine in the drinks killed the 14-year-old girl. The autopsy report attributed her death to “cardiac arrhythmia due to caffeine toxicity.”  

The young girl had consumed two 24 oz  Monster energy drinks. In case you forgot your weights and measures, 16 ounces is a pint. Think about a quart of milk. She drank TWO of those. That's not normal human behavior. Moreover, you shouldn't be letting your 14 year old .... oh nevermind.

Let's ignore the merits of the lawsuit in favor of pharmacology. Each 16 oz Hi-Ball contains 160 mg of caffeine. According to the caffeine content database, that's about in the middle of the pack between energy drinks and coffee. Coffee has about 100 mg for brewed and 120 for K-Cup coffee. Energy drinks can have as much as 300 mg, but most seem to be in the 200 range. Monster -- the murderer in questions is on the high end at 240. (Some obscure drinks have over 300).

That's still just equal to two cups of coffee. Of course, it is easier to drink an energy drink FASTER than a hot cup of coffee, thus your dose over time is higher. You could plausibly down four pints of Monster in a few minutes - if you have no sense of taste or will to live. Or you could throw back two dozen NoDoz tablets. Either way, the results won't be fun.

Caffeine, after all is a drug - a central nervous system stimulant. It is used in medicine and as the engine of the Industrial Revolution, the Enlightenment and all that came after. It is the most popular psychoactive drug in the world.

Any drug, however, has the potential for abuse.

MSBC's article on caffeine points out that emergency room visits related to energy drinks are on the rise -- likely because they are becoming more popular. We see people with palpitations and anxiety, but rarely any life threatening conditions.

However, the confounding factor there is that many people mix their Red Bull with liquor, so it may be hard to suss out the real culprit.

The Food and Drug Administration is also looking into claims that five people have died from heart attacks related to energy drinks. That, combined with the lawsuit, is enough to hang a story on.

However, the reports were over an eight year period - less than one a year by my count -- and anyone can file a report claiming harm from anything. They don't have to prove it. Any two events can be thrown together in a complaint. So far there has been no causal link established in any of the cases, according to the FDA spokesman and other products -- including alcohol or street drugs -- could also be to blame.

That said, caffeine is a stimulant. It makes your heart go faster. I was teaching lab techs how to do 12 lead EKGs the first night I worked graveyard, so I've seen the PVCs that too much coffee can cause. Not only does it make your heart rate increase, and your blood pressure higher, it can also knock you into an arrythmia.

If you have a heart condition, stimulating your heart is probably not a great idea. According to an article in the American Journal of Clinical Nutrition.

There is a consensus that caffeine does not promote ventricular arrhythmia, except in extraordinary circumstances and at a very high dose. One example of such an extraordinary circumstance is the case of a 25-y-old woman with preexisting prolapse of the mitral valve who drank 50 mL of a “natural energy” guarana health drink that contained the same amount of caffeine as 8 cups of strong coffee. She developed intractable ventricular fibrillation and died (4). But such events are rare; most cardiac patients tolerate normal amounts of caffeine without difficulty (5).

The same article notes that researchers failed to find an association between caffeine and atrial fibrillation and flutter. On the other hand, Afib and flutter in the same study were correlated with alcohol consumption. Again, remember that it is popular to mix energy drinks with alcohol.

Moreover, there is all the other stuff they put in energy drinks too. Taurine and Guarana and B-vitamins.

Because kids may have undetected heart defects and because their bodies are still developing, probably not a good idea to let them pound three pints of concentrated stimulants.