OD

Sobering statistics about suicide rates were reported in an EM journal yesterday. Unless the victim is found dead, suicide attempts end up in the ER. The biochemistry of depression has been established. Levels of neurotransmitters in sections of the brain are the biological basis of depression. We all get the blues. I am listening to "the Blues" as I write this blog. Clinical depression is unremitting sadness. The depressed patient feels no joy. Sleep, appetite, energy levels are all affected. Hopelessness leads to suicidal thoughts and suicide attempts. The young and the elderly are most likely to attempt suicide. The elderly and all males are most likely to succeed. Violent means of suicide (guns, hanging, jumping from height, car crashes) are more often the choice of men. Pills and non-medication ingestions are the preferred means for women.

Almost any medication in the family medicine cabinet can be lethal in high enough doses. Acetaminophen (Tylenol and others), ibuprofen (Advil etc.) and aspirin are all lethal in high doses. Sleep aides, cold pills and allergy meds can kill. Household cleaners and plumbing supplies are especially dangerous. Rubbing alcohol and antifreeze will do the trick. Prescription medications of all types may kill if taken in excessive quantities.

The Hemlock Society offers suicide "how-to" information. The internet has a wealth of insight into the most lethal medications and toxins. Fortunately, the ER staff has the same access to the treatments and antidotes for ingestions used in suicide attempts. The key is the history: what was taken, how much was swallowed, and when did the ingestion occur. Toxidromes are the signs and symptoms in the patient who has ingested certain medications or plants. The ER doc can make educated assumptions as to the type of drug ingested by the appearance, vital signs, and physical examination of the patient.

Lots of mnemonics have been created to aid the ER staff in remembering these toxidromes. Antihistamines such as Benadryl, if taken in large amounts, may present as a patient who is "red as a beet, dry as a bone, hot as a hen, and mad as a hatter". A little historical aside: the phrase, "mad as a hatter" refers to the fact that hat makers, in the past, used chemicals containing mercury to work the felt. The exposure to mercury caused damage to their brains; they became "mad".

I read a new mnemonic recently, METAL ACID GAP. This is to help in recalling the causes of high anion gap metabolic acidosis (HAGMA). Earlier this week an ambulance arrived with a 60ish patient. The call said he was having a stroke. The patient was comatose but moved both arms when I rubbed my knuckles over his sternum. Scraping a tongue depressor on the soles of his feet showed a normal Babinski response. He was breathing at more than 30 respirations per minute. This was not a stroke. Labs tests showed a profound metabolic acidosis. His pH was 7.07 (normal 7.4), his bicarb was 8 and his carbon dioxide level was 11. His anion gap was greater than 100. The anion gap is the difference between the calculated osmoles in the serum of the blood such as sodium, glucose, BUN, etc and the direct measurement of the osmolality of the serum. The gap leads to a search for the "missing osmole". The patient's family was most helpful. When I described the types of medications and household products that could cause his condition, they found what I had suspected. The patient had ingested antifreeze which contains ethylene glycol. This chemical is fatal in even small ingestions. A treatment does exist for this toxin. If begun soon after the ingestion, the patient should survive.

Acetaminophen, ibuprofen, aspirin and diphenhydramine (Benadryl) are the most frequently used non-prescriptions medications in suicide attempts. Acetaminophen is particularly nasty. As few as 30 regular strength tablets are enough to cause liver injury and possibly death from liver failure, in a small teen or adult. A very effective antidote exists, but if the treatment is started too long after the ingestion, the liver damage may be irreversible. The kidneys are frequently injured by toxic ingestions of OTC (over the counter/ non-prescription) pain medications. Hemodialyis is used to both treat the renal failure caused by the ingestion and to remove the toxin from the blood.

Vitamins, mineral supplements, and herbal medication may also cause injury and death in large ingestions. Iron compounds are a cause of HAGMA. The tendency of iron tablets and certain other pills to form concretions makes the ER doc's job more difficult. One of the most important parts of treating OD's is to prevent further absorption of the toxin from the GI tract. A concretion is a hard lump of tablets. Activated charcoal is given orally to overdose victims in an effort to bind the offending drug and carry it out the rectum. Minerals do not bind to charcoal and concretions of meds such as aspirin, prevent the charcoal from fully binding the drug. The resourceful ER staff, after entubating the patient to protect the airway, will use whole bowel irrigation to try and flush the pills out of the gut. A large tube is passed down the esophagous to the stomach, and liters of solution are infused until the results from the rectum are running clear.

A word about physician assisted suicide is in order. Patients with chronic medical conditions, that will lead to incapacitation, or those patients having intractable pain, may wish to end their lives. Some countries allow the physicians caring for these patients to prescribe medications to aide the patient in ending his or her life. The medications prescribed are usually potent sedatives. In high enough doses, these drugs will depress respirations, leading to fatal hypoxia and a rather peaceful death. Having witnessed my father's death I am strong supporter of physician assisted suicide. Terminal cancer patients in hospice care are given lorazepam, morphine, fentanyl, etc. While the doses are not directly lethal, they ease the patient's death. If I was faced with a painful or undignified demise, I would want to have the option of dying at a time of my choice. A bottle of 30 year old single malt scotch and a sufficient quantity of tricyclic antidepressants would be my personal formula.

Overdoses are frequent, unpredictable and always challenge the ER staff. The patient often does not wish to be treated. After all, they took the overdose to get high or to die. Having to use physical restraints, and placing tubes in every body orifice, would be considered assault and battery in any other locale. The ER staff makes every effort to preserve life. It was a good week for me, none of my patients died.