DIY (??) Invasive Medical Treatment

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One of the social media influencer in Indonesia, who is also a beauty and trend icon had gotten herself into trouble few months ago. The problem was, she’s endorsing a breast enhancer product that required self-injection on the breast. Yes, you read that right. She was promoting some kind of crazy DIY invasive medical treatment and wihtout any hestation said, "This is a safe and risk-free product!" 

The product was sold online and the seller would give you the syringe as well as the ‘serum’ once you order it. As terrifying as it might be, many of her followers attracted to this kind of ‘beauty product’. I didn’t know about this until a doctor angrily post her disagreement on social media. She wrote ‘What on earth is wrong with this socmed influencer?? Doing this kind of ‘endorse’!! There’s a limit for endorsing, not selling the drug as well as the syringe!! Please help me report her. This is dangerous!’ Yes, as a doctor I can understand her anger. It’s like looking at a little kid running with a pair of scissors. When I saw the post I also thought “Safe and risk-free breast enchancer?? Now wait the hell a minute!” 

From what I heard, the ‘serum’ contains estradiol – synthetic hormones they used for hormone replacement therapy ... okay now hormone replacement therapy isn't a simple procedure. It needs several examinations before it even start, in order to avoid long-term risks such as cancer. Second of all, even though they claimed that it contains 'estradiol', how could we be sure that it's real?

Many people agreed with the doctor, because they also knew the danger. However, some of the social media influencer's devoted follower got angry at the doctor. "If you don't like what she promote, then simply don't buy the product! You're just jealous because nobody wants to endorse you!" is one of the backlash posted.  

Injecting questionable substance into one’s body has a lot of risks. The method itself isn’t something DIY. Without knowing anatomy, a mistake such as hitting a major artery or vein might happen.

You see that’s the anatomy of the breast I got from my Netter Atlas of Anatomy. If the substance enters the blood vessel, it could cause complications such as embolism (blockade of blood vessel) on the lung or the heart also there’s risks for infections entering your blood vessels directly. If the process isn’t sterile. If the infection was localized and formed an abscess (swelling area filled with puss) for me that is considered ‘light’ if the treatment ‘only’ required puss drainage. 

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The infection could also go through the blood vessel and reach the heart, thus creating infections on the heart called endocarditis. It’s not a ‘light’ problem, to put it mildly. If one did not realize the symptoms, untreated endocarditis could cause death within weeks and even days. The treatment of endocarditis required intra-venous antibiotic and sometimes surgery if the heart structure (mostly the valves) damaged due to the infections. If the valves could not be saved, a replacement valves might be used because of damages as seen below :

 

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Anaphylactic shock is one of the direct-fatal risks that could happen. It’s a severe alergic reaction, when your body doesn’t agree with the susbtance enters your body and releasing susbtance to fight it. The susbtance causes fatal symptoms such as dilatation of the blood vessels (that leads to blood vessel drop), increase of heart rate, spasm in coronary (heart) blod vessels,  swelling of throat/tongue/lips (causing airway blockade), confusion (makes you can’t think of what to do) and loss of consicousness. This reaction happens within minutes and need immediate emergency treatment otherwise the various organ system in your body will fail within short time.

Epinephrine injection – an emergency injection that could be used during anaphylactic episodes – could be bought with official prescription from a doctor, proper indication as well as clear instruction on how to use it. The ‘online clinic/shop/etc’ who sell the ‘beauty injection’ obviously doesn’t consider it because the seller might not be aware of the risks.

There are plenty of reports on unofficial beauty treatment gone wrong ... but that’s just the tip of the iceberg. Many people do not report such incident because they still think that having body modification is a ‘guilty pleasure’, something they do to feel good but it’s a shame if anyone knows about it. So if something goes wrong, the shame beats the willing to get better. Thus, the unreported incidents. 

Sadly, this is not the first time I heard questionable ‘beauty therapy’. When I just graduated, I work at some clinics and once I encountered a patient who wanted me to inject this ‘skin whitening serum’. When I refused, she was told me ‘The person from other clinic injected this before to me, doc! And it’s safe!’ I told explained to her that we could not inject susbtance the patients got by themselves, without any official referal letters from the hospital (I explained about patients with Hepatitis B and AIDS who sometimes got their injection medication at the clinic) as well as the safety guarantee of the substance (And ‘I bought this at official online clinic from Thailand’ is not what I meant). She finally left the clinic,looking upset.

What most people don’t understand is, we doctors are taking a lot of precautions when it comes to invasive treatments. We do not enjoy ‘making things harder’ for our patients and no, we’re not ‘jealous of the social media influencer because they got endorsement and we’re not’. Trust me, if a (sane) medical care giver were offered endorsement on ‘DIY invasive medical treatment’ they will immediately say ‘no’ as well as reporting the dangerous offer to the authority. 

Gorilla Marijuana

Gorilla marijuana / gorilla 'tobaco' is one of the terms for synthetic marijuana sold in Indonesia. The news had shown a lot of people got caught due to this. What is gorilla marijuana? What makes it more 'special' than regular marijuana? Well, the name of 'gorilla marijuana' was given because the effect of this synthetic marijuana was like 'being squashed by gorilla'. People who do drug abuse often said that the drug is a lot better than regular marijuana, the effect is more severe. Because some articles mentioned that marijuana is actually less harmless than some substances, it msut be safe, no?

Well first of all, the therapeutic use of synthetic cannabinoid is inconclusive. We all have heard the medical use of marijuana. But first, I want to introduce the two receptor of cannabinoids in our body. Receptors are parts of our cells that accept chemical (such as active substance from drugs) and the binding between the two will lead to chain reactions that create the drug effect. There are two cannabinoid receptors in our body :

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The research goal is to find synthetic marijuana without the psychoactive effect, yet work well in modulating the immune cells (that binds more to CB2 receptors). Some research also seek for the therapeutic use of synthetic cannabinoid for nervous system disturbance such as Alzheimers or Dementia. The results, however, is still inconclusive and in need of further research.

The synthetic cannabinoid manufactured outside medical purposes, however ... are more potent and efficacious cannabinoid receptor agonists than THC plus they have additional ingredients such as preservatives, additives, fatty acids, amides, esters, benzodiazepines, and O-desmethyltramadol- an active metabolite of the opioid medication tramadol. The mixtures were used to mask the result of the drug examinations. 

Now, synthetic cannabinoid is different from the regular one because the effect is a lot more potent. Synthetic cannabinoid is not derived from cannabis, they're the full agonists at cannabinoid receptors with biologically active metabolites. Thus, the effect. Adverse effects including respiratory difficulties, hypertension, tachycardia (raise of heart rate), chest pain, muscle twitches, acute renal failure, anxiety, agitation, psychosis, suicidal ideation, and cognitive impairment. To put in summary : it is definitely not a recreational drug. 

In Indonesia, there was a report on a pilot of commercial airplane, who used this 'Gorilla tobacco' . Before the flight, the pilot was seen staggering during his walk accross the x ray. Passengers started to get panic when they heard he's slurring words from the cockpit. The worried, scared and angry passengers approached the cockpit. 

How bad was it? Well ... : 

During the x ray examination: 

https://www.youtube.com/watch?v=3lxKlhzaR9w 

On the cockpit : 

https://www.youtube.com/watch?v=IYRkdlDX0GY

The translation of the dialogue : 

People are trying to make him cancel the flight, but he's saying "No! I don't wanna get off this plane. You know me right? I'm just tired. I'm just woken up. I'm okay. Let's go!" 

He's obviously suspended after the incident. There are also a lot of case reports regarding the adverse effect of synthetic cannabinoid abuse. They are not 'just getting high' and could easily being laughed off *until someone gets hurt, that is. You can read the case report here, but some of the cases are : 

1. 13 years old girl who was found intermittently responsive and combative at her home after using synthetic marijuana called 'K2'. Her heart rate increases rapidly and after sedated at the hospital, her respiratory rate decreasing. She's finally being put in intubation to help her breathing.

2. 13 years old boy was found unresponsive in a park. At the hospital he required significant amounts of sedatives due to periods of agitation and combativeness. During his hospitalization the patient developed aspiration pneumonia, but could finally discharged. 

3. 40 years old woman admitted into the hospital with a seizure after using synthetic marijuana. The EKG (heart recording) showed increasing heart rate. The electroenchepalogram (brain wave recording), also showed unremarkable abnormality. She was put into sedated state and using intubation as well. 

4. 20 years old man admitted into the hospital waith hyperthermic (rise of body temperature), increasing heart rate and unconscoious with decorticate position. Laboratory analysis demonstrated significant rhabdomyolysis and acute renal failure. Later, the clinical examination was consistent with anoxic brain injury. A brain magnetic resonance imaging (MRI) scan confirmed these findings. Care was eventually withdrawn due to the grim prognosis, and the patient died on HD seven.

There are still some case reports regarding the adverse use of synthetic cannabinoids. So please, do be careful in using new 'exciting' substance. Putting yourself in serious danger in order to be 'edgy' is not worth it. Many people survive drug abuse effects, but it's always like Russian roulette. You might survive, but next time you might not be so lucky. Also, people who 'make' these kind of drugs are getting more and more experimental, mixing various substances here and there in order to increasing the effect / masking the drug tests result / etc. when the adverse effect started to get too bad, the 'mixtures' might clash with the life-saving efforts in the hospital. 

Reference / Further Reading :  

1. Cohen K and Weinstein AM (2018) Synthetic and Non-synthetic Cannabinoid Drugs and Their Adverse Effects-A Review From Public Health Prospective. Front. Public Health 6:162. doi: 10.3389/fpubh.2018.00162. 

2. Katz et al (2016) Case Series of Synthetic Cannabinoid Intoxication from One Toxicology Center. West J Emerg Med 17 : 3. doi : 10.5811/westjem.2016.2.29519 

3. Mills et al (2015). Synthetic Cannabinoids. American Journal of Medical Sciences 350 : 1. doi :  https://doi.org/10.1097/MAJ.000000000000046

Suicide Footage(s)

Few days ago, my senior at the hospital sent a video in forensic pathology group. The video showed a guy, who sat at the edge of a highway and seemed distraught. Meanwhile, few online ojek drivers ran under the highway, waving their hands and some of them made cross sign with both arms. The man was trying to kill himself, while the ojek drivers along with the person who recorded the incidence  yelled at him. 

"Bro! Stop! Don't!!" 

"Istighfar!! (asked for Allah's forgivenes)" 

The guy ended up not jumping ... thank God for that. All the persuation of online ojek drivers worked wonders. Turned out, he was depressed because his girlfriend broke up with him. The police quickly helped him as soon as he decided not to jump. 

Despite the situation, I felt warmth in my heart seeing the people's reactions. They didn't know the guy and yet they still wanted to help him. It reminded me of an old man in Australia called Don Ritchie, who just passed away. People called him Australian Angel, because he often stopped people who wanted to jump off the cliff on The Gap by offering them a visit to his house for a cup of tea or beer. 

Every morning, he always scanned the cliff from his house windows. If he saw someone who seemed suspiciously stood too close to the edge, he rushed off to approach them. To think, what's in it for him? Some of his efforts nearly cost him his life. When he was stopping a woman from jumping, he almost fell with her as well. 

"You can't just sit there and watch them," says Ritchie. "You gotta try and save them. It's pretty simple." 

Those kind of people were such a contrast with another suicide footage video I saw the other day. It was a video from Lampung, where a guy who also broke up with his girlfriend stood at the edge of Trans Mart building. The one who recorded it said, "come on now ... jump! Jump!" as if it's a game. Then when he actually jumped, she screamed in fear. When the news were out, many judgemental and hurtful comments were typed on the comment coloumn. Comments such as "Good riddance.", and "Idiot." were some of the comments without hurtful swear words in it. 

Many people think suicide as selfish act, as if people who tried to do it were doing it just to hurt the others. They didn't realize how much pain those people had been through. They didn't want to die. They just wanted the pain to stop. Their minds couldn't think clearly because of the pain they felt. At that time, the 'fight or flee' part of the mind took control and because they were too tired to fight, they tried to flee. 

We cannot judge people who tried to kill themselves. I'm not an expert in psychology or psychiatry... but I agree with Mr. Don Ritchie in this. It's pretty simple. We cannot just sit there and watch people suffer. We got to try and save them. We didn't have to give them lengthy-motivator talks. Sometimes we just offer them something to drink and listen to their problems, that's what they need the most. After all, what is it for us if we mock or judge them? Or worse, encouraging them to take their own lives?

Being hateful and mean towards people who are in trouble would not take you anywhere. Sabotaging other people's life will not make it easier for you to enter Heaven - if you are a believer. I believe that The Kind and Merciful Allah - Whom I believe in - is not like the mean boss in the office who loved to see his employees fighting each other in order to get reward. He owns every single thing, both that could be seen and not. He did not need us to fight each other because we wanted to be the best in His eyes. Allah is too merciful for that. 

Him, The Creator, has kindness that no one would ever imagine. Small kindness would lead us closer to Him. He loved every single soul as His. Regarding His kindness (that is beyond human's mind), He wanted us to love one another. Thus, the humanity. Do kindness as our effort to love The Kind and Merciful Allah back, as well as for our brothers and sisters in this world. If you're not a believer, then do it for humanity. 

After all, the world is a temporary place for us. Despite believing in afterlife or not, why don't we make the best of it by being kind to each other? 

Autopsy of Jane Doe

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That night, the investigator from Semarang Police Department arrived at the mortuary. They delivered a human remain. They said, the deceased was found in an abandoned place. A body bag was put on the autopsy table. When we opened it, I couldn't help but took few deep breaths. The deceased was a very young girl, probably around her twenties, she had long straight hair, caramel-coloured skin and wearing a pair of pajamas. When we moved her from the bag, I could see bruises and abrasion wounds on her neck. Some of the wounds were crescent-shaped - one of the special characteristics of strangulation marks.

"We couldn't find any ID yet.", said one of the investigator, "There weren't any witnesses either."

"Well, the area where we found her was kind of vulnerable place.", another investigator said, "It was dark, far from crowded place."

I sighed. I looked at the deceased contorted face. She was obviously in a lot of pain and fear before her death. When we started the outer examination, besides the obvious wounds on her neck we also found signs of sexual assault. We cut some of her nails and took swabs from the genitalia area for DNA examination. As for the autopsy, we needed to find her identity so we could tell her family first.

I didn't know why, but I wanted the case to be solved so bad. Perhaps I made a mistake by feeling sympathetic towards the deceased. What happened to her was tragic. She was probably sexually assaulted and then strangled to death. I couldn't imagine the pain and the horror she felt seconds before she died. That was my mistake, I couldn't think objectively. I forgot that as forensic pathologist, we also got our limits in order to involved in a case.

For the past few days, I kept waiting for the news from the investigator. They haven't found her identity yet. Even after the autopsy finally conducted without any notification for the family of the deceased, I still didn't hear about her identity. During the autopsy, we found the thyroid and cricoid bone badly broken. Her stomach were empty. There were obvious signs of asphyxia such as darker and aqueous blood, petechiae all over some organs such as lungs and heart. We found small amount of urine in her bladder. It was negative for alcohol and other illegal drug test. The cause of death were blunt force injury on the neck, causing a blockade of airway passage that causes asphyxia.

The swab from the vaginal area showed spermatozoa and positive for PSA. That made me even more upset. She was raped and killed. I couldn't just let the perpetrator get away with it, could I? I thought that I needed to do something.

So for few days afterwards, I became obsessed with that case. I searched for announcements on missing person on internet. Even those outside Java island. I became frustrated when I couldn't find any missing person announcement with similar characteristics. It lasted for two months and I still did not find any clue let alone a result. According to the rule, the decased would be burried in cemetery for the unidentified.

Few days before the day of the burial, my husband (At that time, my fiance) visited his mother in Yogyakarta so I took the usual morning travel to meet him there. I talked to him about the case before.

"So there's still no clue, huh?" he asked.

"Yes. I didn't know where I went wrong!" I sighed in frustration, "I tried evey damn thing to find her and..."

"That's where you went wrong.", he interrupted.

"What do you mean?"

"You let your emotion blinded you. I don't know why you became so obsessed with this case, but you shouldn't be. Listen, we humans have our limits ... if we already tried anything within our limits and our competency but we didn't have the result the way we wanted it ... that's life! Accept it."

"We cannot save the whole world.", he told me, "So for the sake of your own, just let it go."

I couldn't argue back. He was right. Perhaps at some point, my emotion made me careless as well as arrogant. I think with the science I studied, I could save the whole world. I became frustrated, because I forgot that science was merely human's way to understand God's creation - despite the fact that some of those who study science might not have faith in Him.

At some point, I remember the story of The Prophet Khidr and Moses  my husband once told me. The story told how Prophet Moses was impatient when he was a lot of unjust deeds during his journey with Prophet Khidr. In the end, Prophet Khidr showed Prophet Moses that the unjust deeds were actually done under divine guidance of Allah SWT.

Such is the interpretation of those things over which thou wast unable to hold patience. 

With that, I finally tried to let go. As human, we have our limits. We were nothing but a speck of dust. If we couldn't understand something... it means that we might not understand it just yet, or we won't understand it.

During the day of the burial, I sent Al-Fatihah for the decased before the ambulance arrived. It was my second cold case. I probably would face another cold cased in the future ... but hopefully I could handle it wiser than I did before.

Because in the end, we were only humans.