Frontline casualties

“Depression and anxiety in the face of global trauma — or for that matter, in the face of post-partum depression, divorce, crushing debt — are not major mental illness. They are natural responses to acute stress and crises. Therapeutic options should be offered without fear of career cost, and statistics, though poor dinner companions, have described the problem clearly. Every physician in every state should be guaranteed safety when they seek help. They should seek help so that — using their hard-won, often astonishing expertise — they can help the rest of us.” Elissa Ely, MD is a psychiatrist

Coronavirus, behavioral health and the lingering impact on cognitive functioning in long haul covid recovered

In November 2020 we offered a virtual meeting on the Psychological Impact of Covid-19 after 6-8 months of quarantine and having schools and colleges closed to on campus activities. Professional, college, and high school sports were cancelled and teams were dealing with being in a bubble for the remainder of their seasons. Games were often postponed due to coronavirus exposure and contact tracing. It is now known that the virus has significant potential to impact all organ systems in the body – including the heart, lungs, kidneys and brain. For this post I am talking about the impact of long haul covid recovered cases of individuals who go on to experience cognitive symptoms for weeks or months. Whittier Rehabilitation Hospital has asked that SLP Lauren Guenon and I put together a presentation bringing to light what one might expect for those who are still having symptoms weeks later and what they can do about it.

There are potential long-term problems and short term issues people can expect when they are discharged from the hospital. I hope you will join us for the upcoming presentations that joins the Speech Language Pathology service and the Neuropsychological service in a hard look at the virus and it cognitive and psychological impact. Even people who had minimal symptoms and were never hospitalized are experiencing fatigue and “brain fog” as they get ready to return to work. They may be markedly debilitated and in need of rehabilitation like physical therapy, occupational therapy and now, we are seeing a need for cognitive rehabilitation provided by speech language pathologists and neuropsychologists alike. If you are interested in this topic or experiencing lingering symptoms, I hope you will join us either in person or on a live stream zoom event on May 20, 2021 at 7:00 PM.

Coronavirus

Below is a post from my Concussion Assessment website. It pertains to all that is cognitive. We are planning both an in person learning opportunity over lunch at our hospital and a live zoom event in later May 20, 2021 at 7 PM. If interested in this important topic please contact Joanne Swiderski at her email: jswiderski@whittierhealth.com

I look forward to meeting and hearing from a lot of the readers from here in Massachsetts.

Michael Sefton, Ph.D.

Domestic violence and the importance of red flag warnings for preventing homicide

The police in Austin,Texas here in the United States are dealing with a horrific case of domestic violence homicide just this week 2021. A former Traverse County sheriff’s detective killed three members of his family while picking up his son for a monthly supervised visit. Stephen Broderick shot and killed his former wife, step-daughter and the girls boyfriend. He did this all the while he was coming to visit the 9 year old boy. Broderick fled the murder scene was captured 20 hours later. That Broderick was a police officer made this case of special circumstance. The 16-year old child, who was among the victims, begged for a more restrictive supervision from her step-father who had been released from jail on lower bail and was not required to wear an ankle bracelet after a period of 3 months. The order of protection was brought against former police detective who was now unemployed. In spite of the protection order being in place, even the teen knew that orders of protection were often violated and difficult to monitor. It is reported that when victims believe that they will one day be killed by an intimate partner then the danger is real and should be considered a red flag. Having a child unrelated to the abuser In the household is another significant red flag. 
“In the year that Amy Lake’s protection from abuse order was active against Steven, he violated that order at least five times but spent fewer than two days in jail for those violations, the report found. He also stalked her on Facebook, according to Diane Bowlby of the Bangor Daily News who was at the scene shortly after homicides.
Now nearly 10 years on, the psychological autopsy conducted in 2011, looked at the red flag warnings that are common to DVH everywhere. some I have described above. What brought my attention to the case in Maine was the purported prosecutorial impotence demonstrated by the district attorney Christopher Almy provided to local television. Almy said there was “nothing that could have been done” to protect the victim, Amy Lake and her two children, from her estranged husband Steven Lake. By saying there was nothing that could be done to protect the Lake family, the DA inadvertently undermined not only the police but the many agencies and medical professionals charged with drafting safety plans for victims of intimate partner abuse everywhere. In a similar way, newly elected county DA Jose Garza said he was “confident police did all they could to protect this family and he was incredibly proud of the officers” for the way they handled the Broderick case. More than one citizen comment in the newpaper questioned how anyone can be proud of a situation resulting in the deaths of 3 human beings? Given the outcome in both cases, and countless others, comments such as these strain credulity and fail to inspire. On June 12, 2011, Mr. Lake snuck into the Amy’s rented home in Dexter and staged a despicable murder scene ultimately killing the children he claimed to love while Amy was forced to watch. Ending with her shotgun murder and is own death by suicide – ending the Lake family timeline forever. In an article on contingencies for bail in cases of domestic violence, attorney Nicole R. Bissonnette writes in the the Maine Law Review about the importance of thoughtful conditions of bail, especially among men who are found to have violated these conditions often by texting, stalking and using social media to intimidate and contact potential victims of extended family members. Her published paper adds that failure to relinquish all firearms must be reported to the federal database. Ms.Bissonnette cited our work over 12 times as it pertained to “red flag” warnings and bail reform. Bissonnette raised questions about protection orders and the need for added tools of enforcement for men who violate the protection from abuse orders (PFA) often called restraining orders. In Maine, men who violate orders of protection are often released from custody with low bail or no bail. Steven Lake was twice released from jail on two thousand dollars that was paid by his father. We proposed increasing bail by a factor of ten on any violation of the stay away order and that a comprehensive review of possible high risk warning signs and psychological history be undertaken prior to release. Using a firearm in the commission of a domestic violence incident is defacto evidence of dangerousness and no bail shall be permitted until such time as all firearms are collected and a viable safety plan is in place for potential victims including police protection. The argument made by defense lawyers is invariably, that the lack of a criminal history defies precedent for holding men on large amounts of bail. This is illogical given the numerous red flags that were present in this case and Lake’s disregard for the law. In truth, Mr. Lake had never been arrested for his history of sexual crimes during the marriage, verbal threatening or anything until his final meltdown began. Tension boiled over on June 14, 2010, at the family home at 9 Brighton Road in Wellington when Steven allegedly brandished a gun in front of his family, threatening Amy and the man he accused her of having a relationship with, as reported in the Bangor Daily News. After that event, he was arrested and charged with criminal threatening for which he was heard to say that “he would never serve a day” in jail and that “the price of divorce is 35 cents – about the cost of one bullet.”  A comment that a court appointed psychologist might have wanted to better understand. Lake slept with a pistol and holster hanging on his bed post. He posed with a rifle in his high school year book.  Steven was a gun guy and owned over 20 firearms. The criminal threatening occurred one year before he killed them all as the trial for criminal threatening approached and as the countdown to his divorce from Amy began ticking louder in his brain. None of his weapons were inventoried by police. Had he been held on high bail for each of the PFA violations and been properly assessed for his proclivity toward violence, he would have been unable to kill them one year down the road in 2011. Yet he had time to scribble over 10 suicide notes blaming everyone but himself for the deaths including the judge and his father-in-law, whom he promised to “see in hell.”  His father told us for the final report that if the judge had only let Steven see his 2 children for the 8th grade celebration, this could have all been avoided. Like his son, the senior Mr Lake looked to redirect blame away from his son. The 2 hours we spent with Steven Lake’s parents were perhaps the most unsettling and sad of the nearly 200 hours and 60 people who agreed to be interviewed.  Fast forward 10 years. The setting is north central Texas. On Sunday morning April 18, 2021, in northwest Austin, law enforcement officials say Stephen Broderick shot and killed his step-daughter, Alyssa; her mother and his estranged wife, Amanda Broderick, 35; and Alyssa’s boyfriend, Willie Simmons III, 18. The 9 year old child was not harmed. 

images
Stephen Broderick booking photo 2021
It is common for former intimate partners troll the social media accounts of family members in an effort to locate estranged spouse and her children who may be in hiding. Both Amy Lake and Amanda Broderick, the Texas mother of 3 expressed an interest in having children remain in contact with extended family, in spite of pending felony charges. Amy was keen to have her children see their grandparents (Steven’s parents) and have supervised visits with Steven. She communicated with her in-laws regularly via social media showing photos and posting life without Steven that he saw while trolling her account.  Meanwhile, Amanda Broderick was said to have been sent over 30 text messages with a variety of intimidating sentiments about the upcoming trial yet she okayed supervised visits with their son, age 9. Any contact like this is a violation of the protective order and should have landed Broderick in jail. And they were sure to open up possible access to the jealous perpetrator to clues about current living arrangements, employment, after school activities, and other potential clues that raised the risk of further domestic violence and ultimately DVH. There were messages of deep felt sorrow and remorse as well, that are common in the cycle of abuse. While awaiting adjudication of felony charges there must be no contact between children and violent perpetrator whatsoever. In Austin, the victim expressed a wish to allow her estranged husband to have contact with the little boy – his son, in spite of pending felony rape charges brought forth by the 16-year old step daughter who rightfully feared for her life. Amanda Broderick saw this as being in the “best interest of the child”. This remains a weakness in the overall safety plan and should have been denied by the family court.  It was unjustified given the fear expressed by the victims in this case, which ultimately were quite valid. Firearms are a major cause of DVH and in every state are required to be taken from men with active protection orders in place. This was the default expectation in the two cases described here but in the case of Stephen Lake his arsenal of 22 firearms were not removed from his possession in spite of court orders. Similarly, the Austin killer was left with at least one firearm used to kill his family. Lake left 9 suicide notes many of which were rambling, angry tirades toward his wife and in laws. The Austin killer did not take his own life and was captured raising the specter of possible psychological analysis of his motives making the two cases very different at this level. To what extent Texas authorities will endeavor to understand the events that preceded the murders remains unclear. However, gaining a comprehensive understanding of the red flag warnings in this case is highly recommended and will add to the body of literature on domestic violence.
A court-sanctioned visitation agreement required them to maintain some contact to allow Broderick time with his son. In the application for a protective order, Amanda wrote that Broderick called her some 30 times after she left home to intimidate. She feared he would come after her and the children, she said, “because these allegations have come out and he may lose his career.” He could be dangerous, she warned.
Why would a court require that an abused family be required to allow an accused rapist to have visits with a 9 year old child? It cannot be in anyone’s best interest to have forced visitation with a violent and angry abuser.  One could argue that the killer in Austin, Steven Broderick shared most commonalities with the Maine case ten years previously, including sexual violence, coersion, threats of death, pathological jealousy, violation of the order of protection, trolling social media and refusal to surrender his firearms. He was a cop. Broderick was a SWAT trained police officer who resigned his position after being arrested for sexual assault on his step daughter. He should not have had a firearm pending the outcome of his case. He was released from jail on partial bail because he did not have the funds for the bail that was set by the court. He should not have been permitted to visit with his biological son. The risk of violence as was easily foreseen given past behavior. In the same manner, Stephen Lake would never stand trial, and had a cheap divorce in mind early on. 

“Domestic violence is not random and unpredictable. There are red flags that trigger an emotional undulation that bears energy like the movement of tectonic plates beneath the sea.” according to Michael Sefton (2016).

  1. Threatens to kill spouse if she leaves him – pathological jealousy
  2. Actual use of firearm or other weapon anytime during domestic violence incident
  3.  Access to firearms even if he never used them – veiled threats
  4. Attempt at strangulation ever during fight
  5. Forced sex anytime during relationship
  6. Unemployment of perpetrator
  7. Stalking via social media
  8. Presence of unrelated “step”child in home
  9. Spouse finds new relationship soon after separating
  10. Low bail release from custody – high bail holds are essential in DVH mitigation
If you or someone you know is facing domestic violence, call the National Domestic Violence hotline for help at (800) 799-SAFE (7234)

Sefton, M. (2016) Blog post: DVH in MA: 4 year old child begs his father.  https://msefton.wordpress.com/2016/10/02/dvh-in-ma-4-year-old-child-begs-father-not-to-murder-his-mother/. Taken 4-25-2021

Allanach R. et al., (2011). Psychological Autopsy of June 13, 2011, Dexter, Maine Domestic Violence Homicides and Suicide: Final Report 39 (Nov. 28, 2011), http://pinetreewatchdog.org/files/2011/12/Dexter-DVH-Psychological-Autopsy-Final-Report-112811-111.pdf. Michael Sefton

What are we learning 12 months on?

During the pandemic, mental hygiene has become just as important as hand washing. It’s time to disinfect your thoughts and kill the ANTs. As we move into year number two of the pandemic it has become clear that some American’s may be falling victim to automatic negative thoughts or ANTs.
During the pandemic, mental hygiene is just as important as hand washing. It’s time to disinfect your thoughts and kill the ANTs to overcome anxiety, depression, trauma, and grief. ANT is an acronym for —Automatic Negative Thoughts. Daniel G Amen, MD 2020
Over one year into the pandemic while only 50 % of the US population is currently vaccinated with at least the first shot, we are seeing the importance of mental health in managing the pandemic. It is now abundantly clear, that it is because of mental health underpinnings, that the next wave of the pandemic is building. People cannot remain in isolation forever. The indefinite duration of confinement grew insurmountable to enforce and the collective civility toward social distancing and mask wearing became politically untenable for many governors.  People need to socialize, be free to worship, attend weddigs and funerals, even dance in the streets, as we have seen Americans do ever since it “reopened” when state governor’s decried the pandemic under control. And we have paid the price for this. Mental health tends to be the ugly step-child of physical illness in a society that is strongly biased against the emotionally infirm in favor of the medical model of well-being. For one thing, alcohol sales increased 200 percent among Americans coping with loneliness and frustration while in quarantine. There is no doubt that people felt the stress of being cooped up during the first weeks of the pandemic. The quarantine put a strain on sensible behavior and emotional credulity over social distancing, all the while putting ANTs in our heads. In places like India and across Europe where the vaccine roll out has been less successful the infection rate has risen, and given the propagation of variants that have been reported, those who are not yet vaccinated have much to fear. Michael Sefton

Cardiac Arrhythmia and reducing health risk using biofeedback

Methods that reduce autonomic innervation or outflow have been shown to reduce the incidence of spontaneous or induced atrial arrhythmias.26 The latter studies suggest that neuromodulation may be helpful in controlling atrial fibrillation.

Chen et al. (2014) published a review of the relationship between the autonomic nervous system and the pathophysiology of AF and the potential benefit and limitations of neuromodulation in the management of this arrhythmia that is beyond the scope of this paper.

I am optimistic that the neuroregulation derived from EEG neurofeedback may be a mitigating treatment for both autonomic dysfunction and greater self-regulation and abstinence from substance use. The role of the autonomic nervous system in atrial fibrillation is multifactorial and alcohol induces atriogenic changes are powerful – including the potential for cardiac remodeling. “Autonomic nervous system activation can induce significant and heterogeneous changes of atrial electrophysiology and induce atrial tachyarrhythmias, including atrial tachycardia and atrial fibrillation (AF).” The importance of the autonomic nervous system in atrial arrhythmogenesis is also supported by circadian variation in the incidence of symptomatic AF in humans in Chen et al., 2014. I am working on a protocol using biofeedback and mindfulness to mitigate the autonomic underpinnings of arrhythmias in hope of making a positive impact on recovery from AF-related stroke. There is a peer reviewed literature for using neurofeedback for reducing the craving for alcohol that may be matched with paced breathing and heart rate variability which can activate parasympathetic pathways and modify baroreceptor response and its multifactorial impact on health described in this paper.

References

Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available at: http://www.samhsa.gov/data. Accessed January 25, 2021

Steinbigler, P Haberl, R. König, B. et al. (2003) P-wave signal averaging identifies patients prone to alcohol-induced paroxysmal atrial fibrillationAm J Cardiol, 91, pp. 491-494

Voskoboinik, A et al. (2016). Alcohol and Atrial Fibrillation: A Sobering Review. J of Amer College of Cardiology, Volume 68, Issue 23, 13 December 2016, Pages 2567-2576.

O’Keefe, J, DiNicolantonio, D.J. Alcohol and Atrial Fibrillation Journal of the American College of Cardiology, Volume 69, Issue 20, 23 May 2017, Pages 2578

Chen, P, Chen, L, Fishbein, M, Lin, S-F, and Nattel, S (2014). Role of the Autonomic Nervous System in Atrial Fibrillation: pathophysiology and therapy. Circulation Research, Volume 114, Issue 9, 25, Pages 1500-1515

Viskin S, Golovner M, Malov N, Fish R, Alroy I, Vila Y, Laniado S, Kaplinsky E, Roth A. (1999). Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10,000 episodes. Eur Heart Journal; 20:1429–1434.

Law enforcement suicide: Using the psychological autopsy for questions of line of duty deaths

Two Capitol police officers have taken their own lives since the insurrection at the U.S. Capitol on January 6, 2021. This information came after the two officers spent 5 hours fighting the insurrectionists sometimes in hand to hand combat. Jeffrey Smith, a D.C. Police officer, and Capitol Police Officer Howard Liebengood both “took their own lives in the aftermath of that battle” according to an article in Politico on January 27, 2021. A third officer, Brian Sicknick died during the insurrection and his manner of death has not yet been officially determined. Some reported seeing Officer Sicknick being struck in the head with a fire extinguisher during the riot.

First responder suicide is generally not considered a line of duty death and as such, fails to yield the honor given to officers who die in shoot outs or other direct line of duty incidents. And deaths by suicide do not bring family members the death benefits they deserve. Two police officers have died by suicide after confronting rioters at the Capitol that were sent by Commander in Chief Donald Trump. This fact was brought forth by House Impeachment Managers during Trump’s second impeachment trial recently completed.These men must be afforded the honor and benefits provided to any surviving spouse of a line of duty death because that is why these men died. 

The juxtaposition of these facts cannot be ignored. Every one of the hundreds of police officers put their lives on the line as a result of the former president’s truculent narcissism. It would be a dishonor to the men who gave their lives by denying this causal underpinning of their deaths. Suicide by law enforcement officers exceeds the number of officers who die in in gun fights, car accidents, on-duty heart attacks, attacks by citizens, calls for domestic violence, and other police calls for service. “This fact thrust these most private of acts into the national spotlight and made clear that the pain of Jan. 6 continued long after the day’s events had concluded, its impact reverberating through the lives removed from the Capitol grounds” as written in a recent Washington Post report. 

There are things that must be done when law enforcement officers die as a direct result of the the calls they take and the trauma they experience that directly results in their death. Neither of these officers would have died if they had not jumped into the crisis taking place at the U.S. Capitol. Both men were solid members of the Capitol and Metropolitan Police Departments and had no history of behavioral health claims. A transparent psychological autopsy would show the factors that triggered the terminal events leading to each man’s death. For their part, members of Congress spoke highly about the three police officers who died as a result of the riot.

In the days that followed, Erin said, her husband, Capitol officer Jeffery Smith seemed in constant pain, unable to turn his head. He did not leave the house, even to walk their dog. He refused to talk to other people or watch television. She sometimes woke during the night to find him sitting up in bed or pacing. Her husband was found in his crashed Ford Mustang with a self-inflicted gun shot wound that occurred on his way to the job.

Peter Hermann Washington Post 2-12-2021

Rioters swarmed, battering the officers with metal pipes peeled from scaffolding and a pole with an American flag attached, police said. Officers were struck with stun guns. Many officers were heard screaming into their radios “code-33” the signal for “officer needs help” and usually a signal bringing an “all hands” response to the scene of the emergency. Situations like this send chills down the spine of officers responding to calls for help – some are injured in car crashes racing to back-up officers in danger. It is always hoped that when the call for help goes out that there will be enough manpower to push back on the crowd, however large. In this case, the crowd far exceeded the number of LEO’s available for duty. 

 The psychological autopsy is a single case study of a death event that serves to uncover the psychological causes of death. This study would answer these questions and establish an understanding of worst case scenario of frontline exposure to trauma and possibly offer insight into underlying history that may have been anticipated and stopped. When law enforcement officers take their own lives this careful analysis of the hours and days preceding their time of death is essential. “From this information an assessment is made of the suicide victim’s mental and physical health, personality, experience of social adversity and social integration. The aim is to produce as full and accurate a picture of the deceased as possible with a view to understanding why they killed themselves.This would answer the question as to whether or not the deaths may be considered to be line of duty, as they must. Psychological autopsy is probably the most direct technique currently available for determining the relationship between particular risk factors and suicide” Hawton et al. 1998

I have proposed a Behavioral Health initiative in conjunction with changes in police policy and transparency that has been the central posit of social clamor since the death of George Floyd this summer. The International Association of Chief’s of Police (IACP) has a broad-based Mental Wellness program it is reporting on its website that highlights the importance of this kind of support. “The IACP, in partnership with the University of Pennsylvania (Penn) and the Bureau of Justice Assistance (BJA)’s VALOR Initiative, is customizing a program specifically designed to help officers and agencies by enhancing resilience skills. The cost of such a program will reap rewards in the form of career longevity, officer well-being, officer morale, quality of community policing, and greater faith and trust in law enforcement in general.

This investigation is an individually designed case study that elicits a broad range of factual data regarding the antemortem behavior of a decedent in the immediate day or days leading up to the suicide. In this case, what are the events that transpired in the days before the two Capitol police officers took their own lives? The fact is that both men were exposed to incidents and participated in protecting the Capitol on January 6, 2021. Both men were engaged in hand to hand combat.  It is known that the insurrection resulted in the death of a fellow officer and the deaths of 4 other people engaged in violent mayhem in which these men and hundreds others may have been killed. Both men believed the insurgency was potentially deadly to them or their fellow officers. The psychological autopsy is especially important when first responders and essential workers are involved and die soon after. When LEO’s and first responders are put in fear of death or see other officers being placed in the direct line of fire, are vastly outmanned, and have no way in which to stop an attack, they are at high risk for the “hook” that comes from an acute stress reaction and over time, becomes a monkey on the backs of so many fine men and women.  Michael Sefton, Ph.D. 2018 Direct Decision Institute, Inc.


Hawton, K., Appleby, L., Platt, S., Foster, T., Cooper, J., Malmberg, A. & Simkin, S. (1998). The psychological autopsy approach to studying suicide: a review of methodological issues. Journal of Affective Disorders 50, 269–276.

IACP (2021) Officer Resilience Training Conference https://www.theiacp.org/projects/law-enforcement-agency-and-officer-resilience-training-program, Blog post taken February 13, 2021

Trauma exposure and sensible care for LEOs

The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.

Rachel Naomi Remen, MD

“You are going to get wet in this business, it is what you do with it and how you process the “wetness” that impacts how your brain is going to react over time, according to Jamie Brower, Psy.D. a Colorado Police Psychologist. Brower explains this concept to the LEO’s and first responder’s treats following years of exposure to critical incidents. Many officers believe they are handling things well but gradually experience the loss of purpose in life often seen in cases of trauma. The key to treating repeated trauma is to intervene routinely following traumatic high lethality events, such as death of a member, multi-casualty critical incidents, and others with routine defusing immediately following the incident. I believe this should include all members who were on the call including supervisors. I once conducted a critical incident review following a fatal automobile crash with multiple fatalities and injuries. All members who responded to the incident were present except the on-duty sergeant and the fire chief. When necessary, peer support, debriefing, and direct psychological intervention are a must for career well-being and resilience.

“Your resiliency is like an immunization or protective factors against what life will throw at you” according to Mike Grill, M.S., a counselor in Colorado. Resiliency refers not to survival of the fittest but to the species that adapts quickest to changes in the environment. So the resilient person who is exposed to a horrific event like a school shooting or the death of a child is going to say: “Hey this bothered me and I need to do something about it” not “I should be able to handle this on my own” according to John Nicoletti, Ph.D. How do you get balance back in your life because, if all you see is death than you are going to have a pretty weird perspective going forward in life said Dr Nicoletti, in a short, Lifelines documentary in association with Stories Without Borders shot to inform on PTSD and law enforcement, fire service, and first responders.

Post traumatic stress is an injury that occurs during the course of an event like a mass shooting, or cumulatively over the years of exposure during the career in law enforcement or other first responder service like fire or EMS. It is not a mental disorder. Children in the family can be the first responder’s lifeline back. You will still have a scar but the injury will heal said Dr. Daniel Crampton, a retired Ute Pass Regional paramedic and trauma specialist in Colorado. Dr Crampton is available for peer support and has been very responsive and ethical at times I’ve reached out to him.  In previous blog posts I have suggested that building resilience may be forged by having annual behavioral health “check-ups” and that in doing so, officers may earn extra payments for adhering to a behavioral health protocol each year that includes attending defusing and debriefing sessions following critical incidents. Just like the Quinn Bill in the 1970’s here in Massachusetts, where officers earned extra salary for attending college and earning their degrees, a similar incentive may be added for officers who attend annual behavioral health screenings and regular stress reduction trainings.  The obvious benefit is a healthier mind and body among front line police officers with enhanced job satisfaction and career resilience.

 

Bottoms up: The effects of moderate use of alcohol and cardiac arrhythmia

There is a growing and worrisome understanding that moderate alcohol use may be more cardiotoxic than many of use were fully aware. There are studies that link alcohol to cardiac arrhythmias including atrial fibrillation – an irregular heart beat that is known to increase the risk of stroke and other cardioembolic events.  What is the cause of cardiac arrhythmias from the use of liquor? Atrial fibrillation is caused by ectopy that create a second node (or cluster of cells) of abnormal electrical activity that compete with the sinoatrial node – the pacemaker in the right atrium in the heart. The atria actually undergoes a physical change called atrial remodeling when secondary nodes compete for primary pacer node in the atria. There can be only one primary node.  The result of this triggers a rapid, irregular rhythm and puts one at risk for cardioembolic stroke and other potential cardiovascular risks like remodeling.

This is a surprising, but not new reality, in the setting of my regular physical exams and cardiology consultations where I have openly and honestly over-estimated my consumption of alcohol by indicating that: “I should probably quit”. My physicians were nonplussed and seemed unconcerned. For all I knew, a glass of red wine daily kept heart disease at bay.and built red blood cells.  At the rehabilitation hospital where I consult and provide assessment and biofeedback, we see dozens of cases of patients suffering from the health-related impact of A-fib. Of course, most of these are for reasons other than alcohol abuse but a fair number of our admissions are there as a result of the effects of alcohol such as liver cirrhosis, delirium, obstructive sleep apnea, diabetes, obesity, and acute renal disease. We treat the liver transplants sent from the UMASS Transplantation Service although these are not entirely the result of alcohol-related disorders.

“From a pathophysiological perspective, alcohol may exhibit direct effects on arrhythmogenesis as observed in the “holiday heart syndrome”. The holiday heart syndrome related to the binge drinking during times of celebration like from Thanksgiving through New Years. Many people call for a “dry January” as a way of drying out and feeling better after weeks of holiday cheer. Acute alcohol consumption also induces autonomic imbalance reflected by sinus tachycardia, predisposing to arrhythmia.”  Electrolyte disturbance and alterations of the acid-base balance are further pro-arrhythmic triggers. In truth, there are many co-occuring medical complexities like obstructive sleep apnea, hypertention, obesity, and diabetes mellitus that contribute to the cardiogenic changes or remodeling from alcohol. Chronic alcohol consumption is known to be correlated with changes in cardiac structure and function including cardiomyopathy. Alcohol binge drinking or the “holiday heart syndrome” is well characterized in the literature. However, more modest levels of alcohol intake on a regular basis may also increase the risk of AFib from the increase of cardiotoxic effects of oxidative stress and inflammation triggered by hypoxia associated with sleep apnea and hypertension during apneic episodes as well as vascular events from ischemia due to thrombus or blood clot in a vessel in the heart. 

The sympathetic system activates the bodies internal survival mechanism by raising the threat level needed to fight or to flee. It is almost instantaneous. The fight/flight mechanism exists in all animals having an evolutionary value needed for survival and defense against potential prey.  Michael Sefton

When you pull the curtain back from the totality of the impact of alcohol on the nervous system that we must think about the sympathetic storm and the fight-flight responses that belie changes in heart functioning. One can see that studies show, following small to moderate amounts of ethanol, P-wave duration was prolonged in the control group with no history of AF, suggesting that alcohol directly slows interatrial conduction in all according to Steinbigler et al, 2003. This means the the depolarization and repolarization of the electrical activity in the heart which is key to the squeeze needed to move blood through the body and its vital organs can be altered. The evidence of elevated risk from thromboembolic events in the setting of atrial fibrillation, cerebral vascular events, and mortality is well understood and often ignored. Anticoagulation clinics have seemingly sprouted up on every street corner next to liquor stores and smoke shops.

Voskoboinik, A et al. (2016)

Methods that reduce autonomic innervation or outflow have been shown to reduce the incidence of spontaneous or induced atrial arrhythmias.26 The latter studies suggest that neuromodulation may be helpful in controlling AF. See Chen et al. (2014) for a review of the relationship between the autonomic nervous system and the pathophysiology of AF and the potential benefit and limitations of neuromodulation in the management of this arrhythmia. I am hopeful that the neuroregulation derived from EEG biofeedback may be a mitigating treatment for both autonomic dysfunction and greater self-regulation and abstinence. The role of the autonomic nervous system in atrial fibrillation is multifactorial with alcohol induces atriogenic changes among them, including script and the potential for cardiac remodeling. “Autonomic nervous system activation can induce significant and heterogeneous changes of atrial electrophysiology and induce atrial tachyarrhythmias, including atrial tachycardia and atrial fibrillation (AF).” The importance of the autonomic nervous system in atrial arrhythmogenesis is also supported by circadian variation in the incidence of symptomatic AF in humans in Chen et al., 2014. I am working on a protocol using biofeedback and mindfulness to mitigate the autonomic underpinnings of arrhythmias. There is a literature for using neurofeedback for reducing the craving for alcohol that may be matched with paced breathing and heart rate variability which can activate parasympathetic pathways and modify baroreceptor response and its multifactorial impact on health.

References

Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available at: http://www.samhsa.gov/data. Accessed January 25, 2021

Steinbigler, P Haberl, R. König, B. et al. (2003) P-wave signal averaging identifies patients prone to alcohol-induced paroxysmal atrial fibrillationAm J Cardiol, 91, pp. 491-494

Voskoboinik, A et al. (2016). Alcohol and Atrial Fibrillation: A Sobering Review. J of Amer College of Cardiology, Volume 68, Issue 23, 13 December 2016, Pages 2567-2576.

O’Keefe, J, DiNicolantonio, D.J. Alcohol and Atrial Fibrillation Journal of the American College of Cardiology, Volume 69, Issue 20, 23 May 2017, Pages 2578

Chen, P, Chen, L, Fishbein, M, Lin, S-F, and Nattel, S (2014). Role of the Autonomic Nervous System in Atrial Fibrillation: pathophysiology and therapy. Circulation Research, Volume 114, Issue 9, 25, Pages 1500-1515

Viskin S, Golovner M, Malov N, Fish R, Alroy I, Vila Y, Laniado S, Kaplinsky E, Roth A. (1999). Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10,000 episodes. Eur Heart Journal; 20:1429–1434.

Losing Saffie: The agony and loss of a precious little girl who was calling for ‘mum’ when mortally wounded

8-year old Saffie-Rose Roussos killed in Manchester, UK suicide attack

There are few things that I do not believe I could emotionally survive, like the loss of my spouse, employment, and physical and mental vitality. Certainly, the death of a child is among the worst of all human experience for any parent at any age. This story is a heart wrenching, story of depravity and loss. To this day, the loss of one of my children would leave me shattered, angry, and helpless. I hope these individual stories will all resonate with our humility as human beings. 

The chaos and emotion evoked in mass casualty events such as the Manchester, UK bombing, Boston Marathon bombing and the Sandy Hook, CT Elementary School mass shooting leave searing memories that take months to years to process.  We are reminded of the overwhelming sadness we feel when looking at photographs of people we know are no longer with us. The loss of a child is among the more gut wrenching experiences families can ever endure. Meanwhile, members of law enforcement face multiple victims including young children like Saffie-Rose Roussos during large scale mass casualty events that forever leave their marks. I am working with a former paramedic which was dispatched to a motor vehicle crash in 1990 where a family walking across the street was struck by a vehicle being pursued by law enforcement. The first victim he came upon was a 4 year old girl who had obvious signs of death that he cannot shake 30 years on. These next stories are similarly evocative.

 I recently came upon the story of the death of this little girl in Manchester, England. Her name was Saffie-Rose Roussos. From the sound of the description of Saffie, she was a special little girl with an enchanting wit and precocious love of life. All children are special and we recognize the curious joy through which they live each moment and we cherish every nuance. 

On the night of the bombing, Saffie was attending a music concert with her mother and sister when a suicide bomber detonated his bomb in Manchester, UK.  To see Saffie-Rose, one is compelled to ask whether or not there is a higher power? and if so, how could he allow this little girl to be in harms way? Saffie Roussos died on May 17, 2017 asking for her mum and wondering aloud if “she was going to die?” What child should ever ask this question? It evoked in me a tortuous and unthinkable picture of helplessness. But it was far worse for those emergency responders who were called upon to care for Saffie as her life came to an end that night along with the 21 other victims of the terrorist attack. No person who has ever been dispatched to a mass casualty event, like the Manchester bombing, ever comes away without a substantive chink in the veneer of their emotional core. Many in EMS and cops alike quit after mass casualty events.

The story of Saffie-Rose Roussos brings together good and evil and the ruination of one tiny life, one family, one city, one country, and illustrated the abject courage shown by the youngest of 22 victims that night in May, 2017. For this reason, I am sorry for not just the victims of the blast, like Saffie-Rose, and her family. They are devastated to this day, as I would be. But the heroic efforts of first responders who were called upon to provide life saving measures for this child and the hundreds of others wounded in the bombing. Without a doubt, all experience the deep sense of loss and failure at not being able to provide advanced trauma care for Saffie, so that she might live. “Losing a child feels like the ultimate violation of the rules of life” according to HealGrief.org an organization that guides parents through coping with the death of a child. In this case, Saffie is said to have been conscious after becoming injured but could not be saved given the resources available in the chaotic aftermath of the explosion. The protocols call for rapid triage of the scores of people needing help and this is done in the minutes to hours after the event. It is very likely, Saffie did not have the advanced life support needed to manage the hemorrhagic shock she sustained from massive loss of blood. The human body will compensate for loss of blood only until, in shock, it can no longer maintain blood pressure. Survival is measured when fluid can be replaced and loss of blood can be stanched. In children, this compensatory window is much more tenuous and short lived. 

When I worked as a LEO we were taught techniques for trauma intervention that we were told might save our own life or someone else’s life one day in the event of a shooting or massive trauma resulting in life-threatening loss of blood volume. By using a properly place tourniquet, rescuers can stanch blood loss at times of massive trauma such as from a bomb blast that took the life of 8-year old Saffie-Rose Roussos of Leyland, Lancashire in UK. Saffie was killed while attending a concert in Manchester, England in May, 2017. She was the youngest of 22 people killed on the night of May 17, 2017 when a suicide bomber Salman Abedi blew himself up in the lobby of a Manchester concert venue. Terrorism. 

“Medically trained people were with her. And she was asking for help. She knew what was happening. And she bled to death.” BBC 2021. “How do we carry on living with this information? How can we carry on breathing with this information?” asked Saffie Roussos’s father Andrew Roussos. BBC Judith Mortiz report January 17, 2021

BBC Judith Mortiz report January 17, 2021

Saffie’s father Andrew described his described his daughter as a “perfect, precious, beautiful daughter” who “melted people’s hearts” with those big brown eyes,” adding: “It’s like the best artists got together and drew her from top to toe.” according to a story in the BBC that was published during the public inquiry into the bombing last year. It is likely that the Roussos family is feeling the injustice of Saffie’s death. Anger is part of loss and healing and often is unresolved years after the traumatic loss of a child. Especially given the despicable nature of what caused Saffie to become gravely injured.

 All bereaved parents lose a part of themselves and often require months or years to understand the extent of their grief and anger.

“I did die that day, inside I’m dead. My heart is so heavy, it weighs me down” said Lisa Roussos, Saffie’s mum, now 3 years on. The Roussos family feels the loss of Saffie-Rose every day. 

Lisa Roussos

The immensity of traumatic loss was never more palpable than in 2012 when the Sandy Hook Elementary School in Newtown, CT came under attack by 20-year old Adam Lanza. Lanza first killed his mother with whom he lived and next drove to the largely unprotected elementary school and opened fire, killing 20 first-grade children and 6 adults trying to protect them.

Adam Lanza, 20, committed one of the most hideous acts of murder in history and is forever described as pure evil. Yet he was evaluated at the Yale University Child Study Center in New Haven. He was seen by a clinical psychiatrist, the report states. Ostensibly, the evaluation “purportedly to determine if Lanza had Obsessive Compulsive Disorder in the context of a putative diagnosis of Asperger Syndrome” in a piece written by Aaron Katersky and Susanna Kim in 2014 about the Newtown Massacre. Adam Lanza’s own father said “you cannot get any more evil” when talking about his son in the months after the shooting. Lanza openly wished that his son had never been born, raising an ironic specter between the loss of a child and being unable to love a child who commits unthinkable violence and died in the process. What possible conciliation may be find in his public statements months after the massacre? There is no denying that the Newtown shooting is among the most horrific and despicable violent crimes of the 21st century. No one will ever forget that December morning and the disbelief and horror it instilled. Other acts of violence toward children are documented. This is by no means a complete chronology.  

Perhaps the greatest sporting event in the United States takes place every April, ending on Boylston Street in Boston, Massachusetts. Martin Richard, 8, a child watching the Boston Marathon in 2013 was killed by a pressure cooker bomb filled with ball bearings, marbles and other shrapnel that was a homemade bomb made to kill and maim unsuspecting families watching the annual running event. Hundreds lost arms and legs in the two bomb explosions. 

Martin Richard, age 8

Martin Richard was a special child.  He is not shown in these bombing photographs. His parents have gone on to honor him with annual community events geared toward raising funds for parks and other community projects. In all, over 300 people were injured in addition to the initial 3 people who died in the bombing – including Martin. “The minute the defendant fades from our newspapers and TV screens is the minute we begin the process of rebuilding our lives and our family.” according to a Richard family statement in the Boston Globe as the Marathon bomber Dzhokhar Tsarnaev was being tried for the murder of Martin and 2 others on Patriot’s Day in 2013. For their part, the Martin family spoke out against the death penalty which was handed down to the surviving marathon bomber who was captured in Watertown, MA after a 4 day manhunt just a few miles from where they murdered MIT Police Officer Sean Collier in their effort to escape. 

We are all enormously impacted by events such as these and are left feeling sickened by the shear numbers of injuries and deaths.  Saffie-Rose Roussos, Martin Richard, and 20 kids at Sandy Hook Elementary School, 17 teens at Stoneman Douglas HS, and 32 students and faculty at Virginia Tech were all victims of violence and we should never forget these events and so many more, in human history.  The families remember the names and the horrors of the day.  The sadness of these losses makes our heart’s bleed and ache for all those who have lost a loved one to violence.  Even when you are the angry parent of a child you wish had never been born, a further violation of the rules of life.  No person who has ever been dispatched to a mass casualty event, like the Manchester bombing, ever comes away without a substantive chink in the veneer of their emotional core.

___________________________________________

AARON KATERSKY and SUSANNA KIM (2014) 5 Disturbing Things We Learned Today About Sandy Hook Shooter Adam Lanza. November 21, 2014

Family Of Martin Richard Opposed Death Penalty For Dzhokhar Tsarnaev, 2015. CBS TV Boston TV July 31, 2020.

The fine art of being present: A Chaplain’s call for the spiritual connection with front line cops

Sometimes being present in the moment is enough to allow feelings of vulnerability to emerge and for healing to begin. Cops, and I dare say fire fighters, are not used to being vulnerable. Often less is more when is comes to shared space, personal pain and having a connection with one or more people who understand. A quiet moment of reflection after a difficult call may be enough to diffuse the experience of trauma and provide damage control going forward. Career hardiness and satisfaction requires that some moments be recognized with a circle of shared vulnerability and authentic empathy that can be just a few seconds to minutes.

Police Chaplaincy since 1800’s

During the coronavirus after a particularly deadly shift, members of ICU teams took a moment to share the names of those who had died in their care. These were somber events that acknowledged the losses and a measure of desolation shared among team members. People undergoing enormously stressful events can unburden themselves only if they acknowledge their inner feeling state. “We’ve seen chaplains accompany COVID patients in their last moments when loved ones could not be present. The year 2020 inflicted deep wounds on many in our communities and chaplains were there offering support,” said Wendy Cadge, the project’s principal investigator and Senior Associate Dean of Strategic Initiatives at Brandeis University

“When we can feel and acknowledge our deepest fear – it can be liberating and reduce the perceived stigma of being vulnerable and in pain.”

Elissa Epel, Ph.D., UCSF, as quoted in NY Times

Police, fire, and first responder agencies across America have called upon the chaplaincy when their membership has experienced an out-of-the ordinary exposure to trauma like fatal car crash, death by suicide, death of a member, school or mass shooting, and more. Some of these are more routine like a notification of the sudden death of a family member. Meanwhile, other incidents leave a searing imprint of the entire event like the shooting of over 20 Sandy Hook elementary school students in Newtown, CT. It has been frequently mentioned that exposure to death and uncivilized brutality has an impact on wellness and personal resilience. Not a surprise. In the case of Sandy Hook how can any member of law enforcement or EMS ever forget that day? But what can be done?

Police chaplains is one part of the solution. The Chaplaincy Innovation Lab received two grants totaling $750,000 from the Henry Luce Foundation in the second half of 2020 to continue building and supporting resilience in chaplains and other spiritual care providers across the country. Chaplains often find themselves on the front line and frequently encounter operational chaos when they are called upon to minister to the troops. Yet that rarely stops them. They were there at Sandy Hook in 2012. The new program at Brandeis University in Boston aims to train chaplains to be better equipped for things like Sandy Hook or any community event that impacts large groups of people.

In Boston, the call went out that a firefighter was down. This during a 2-alarm fire in Watertown, MA. The department chaplain Father Matthew Conley was needed “now” at the Mount Auburn Hospital in Cambridge, MA for the Anointing of the Sick – known to many as “the last rites.” Fr. Matt had not been on scene during the incident as it appeared to be a routine call. But like so many calls it went south in a hurry.

Firefighter Joseph Toscano was near death from a medical emergency suffered while on duty fighting the fire. It was a hot summer day. He was 54-years old and had a large family of a wife and 5 children. The family were all members of the Catholic faith at a parish a short distance from Watertown. For many Catholics, the anointing of the sick is something to bring about reconciliation for someone who may wish to ease their suffering on the journey toward death.

Firefighter Toscano died that day while doing the job he was trained to do. The Last Rites involve prayers and the final Holy Communion known as the Viaticum. These were something Fr. Conley had done many times before. But when he arrived at the Mt. Auburn Hospital that morning he was met by a phalanx of Watertown police and fire fighters. As he walked into the emergency department of the large Cambridge, MA hospital he knew right away by the look in their eyes that this was no ordinary blessing. He was called to minister, first, to the dying public servant, his wife and children who had been brought to his bedside at the trauma center. But what’s more, he was tasked with consoling the entire brotherhood who looked to him for comfort and hope when no amount of prayer could bring back their fallen brother. But he listened, and he heard their pain, and validated their experience.

“You are here for all of them”, he would say, “and I am here for you.” Fr. Matt Conley sharing the words of former Parish Administrator Fr. Kevin Sepe at Watertown Collaborative.

The story is told that as Fr. Conley dealt with the enormity of the pain felt by all who felt the sudden loss of the career firefighter, when in-walked Fr. Kevin Sepe, the Watertown Collaborative priest administrator. The presence of Father Conley brought a strong empathic presence to the family who had lost their husband and father and to the first line firefighters who felt the loss deeply. Fr. Matt listened and he offered prayers.

From his years as a priest and police chaplain, Fr. Sepe understood what Fr. Conley was facing in the call to the hospital crisis as the department chaplain. His support was largely nonverbal that day. “You are here for them,” he would say, “and I am here for you,” bringing his presence, peer support, and understanding of the enormity the ministry at hand.

“Police chaplains aren’t there to push a religion on police officers; their role is primarily to listen and offer emotional and spiritual support” from an article in Police One, 2015. The chaplain program has been around for over 200 years and often works in the background subliminally. The military has utilized multi-denominational chaplains to minister the troops as well. These men and women are on the front lines and 3 members of the clergy have paid the ultimate price for their calling during recent wars.

Chicago Police Chaplain Father Dan Brandt

Not everyone is religious and you might believe that a goal of a department chaplain is to advocate one denomination over another. Not the case at all. The chaplain may be a Catholic priest as in the illustrated case or he or she may be an ordained Protestant minister, Muslim Imam, or a Jewish rabbi or some other ordained member of the clergy. As a police officer, I worked with a female protestant chaplain who was very helpful with members of our community. I would not have hesitated speaking with her in confidence if I were in need. The role of the chaplain is to provide support and to listen. She was good at it too. Being present with someone who is in crisis or dying can be among the most gut wrenching of all human experience. Fr. Conley once told me he never goes anywhere without the Sacramental oils for the blessing of the sick. This allows him to be ready to offer the Sacrament should he be called to do so. He felt deeply that this anointing was his duty and one of seven sacraments priests are prepared to offer.

I have given death notifications before and have witnessed the soul wrenching-anguish experienced by those receiving these notifications. It is a horrible experience and I remember most all of these events and am still bothered by several.

For line of duty deaths, chaplain’s ask if prayer might be helpful. The sacrament of the sick is one “of strengthening, peace, and courage to overcome the difficulties that go with the condition of serious illness or the frailty of old age provided by the Catholic Priest. This grace is a gift of the Holy Spirit, who renews trust and faith in God against the temptation of discouragement and anguish in the face of death” according to Michelle Arnold published in Catholic Answers in 2017.

The key to a successful departmental chaplaincy is contact — if you have enough chaplains strategically placed who are artful in “reaching out and touching someone,” two things will happen. Successful interactions will take place and the word will get around. Once calls for a chaplain begin to come directly to a chaplain from the on-scene sergeant or deputy, the chaplaincy has made its mark.  Chaplains can best serve when their role is defined and the confidentiality of their relationship to law enforcement is understood. Police One, 2015

The chaplaincy has been around for centuries in public service. It is making entry into many law enforcement agencies in earnest. Many have had chaplains riding in cruisers for decades like Fr. Dan Brandt in Chicago and his fine crew of law enforcement trained chaplains of all denominations. At some times, this has raised the issue of mixing government with religion. But there are guidelines in place. “In Lemon v. Kurtzman, the justices established the three-pronged “Lemon Test,” which, as it translates to the chaplain’s position, says he must have a secular purpose, must not excessively entangle the government with religion, and neither proselytize nor inhibit religion” said reporter Jon O’Connell in a 2017 report. The police and fire department chaplain is there for support of first responders, not as an evangelist, but as moral reminder of the “sacred nature” of their work, according to Fr. Dan Brandt, the director of the Chicago Police Ministry. In Watertown and now Scituate, Massachusetts, Fr. Matthew Conley brings forth his presence with kindness, reverence, and often good humor making the human connection with those in his purview.

Brandeis Now. Chaplaincy Innovation Lab at Brandeis University receives $750,000 from Henry Luce Foundation. January 23, 2021

O’Connell, J. (2017) Police chaplains take a stronger role in community policing. Scranton Times-Tribune. News article.

McDermott, M and  Cowan, J. Combating Pandemic Fatigue. Quoted in NY Times. October 2020.