------------------------------------------------------------------------------- Scan : Totmacher Cut&Paste : SpKIN The information below is taken from the book "Suicide and Attempted Suicide" by Geo Stone. Title : Suicide and Attempted Suicide Author : Geo Stone ISBN : 0786704926 ------------------------------------------------------------------------------- TABLE OF CONTENTS DROWNING CUTTING AND STABBING CYANIDE CARBON MONOXIDE (CO) GASES ELECTROCUTION GUNSHOT WOUNDS HANGING AND STRANGULATION HYPOTHERMIA JUMPING APPENDIX ORIGINAL TABLE OF CONTENTS ------------------------------------------------------------------------------- DROWNING Drowning is an effective and quick means of suicide, usually taking between four and ten minutes. Wether or not it is a low-trauma death, as some have claimed, is in dispute. Drowning is responsible for only 1.3 percent of official suicides in the United States, land of the handgun, but is much more common in many other parts of the world. It is a distinctly poor choice for a suicidal gesture. LETHAL INTENT: High MORTALITY: High, 67 to 75 percent PERMANENT INJURIES: Moderately likely PROS AND CONS OF DROWNING AS A MEANS OF SUICIDE Pros: -Requires no equipment or expertise -Is generally quick -May be low-trauma, especially if combined with drugs Cons: -Difficult to use by someone confined to bed -Potential for lung and brain damage if interrupted -Possibility of revival for up to half hour in very cold water PROGNOSIS FOR DROWNING: FACTORS DETERMINING SURVIVAL The chances of surviving submersion depend mostly on how long someone has been breathing water. Secondary factors are water temperature, age of the victim, and wether the water is salt or fresh. SURVIVAL TIME Though the medical sources differ, they generally cite somewhere around four to ten minutes as minimum-fatal and maximum-survivable times. Even though the heart may continue to beat weakly for several more minutes, there is little chance of recovery. TEMPERATURE People can swim much longer in warm than in cold water (see Hypothermia chapter). However, very cold water substantially increases the time during which a drowned person can be successfully revived. This is because quick chilling of the body retards cellular damage and death. This, in turn, is due to the fact that at lower temperatures all chemical processes including metabolism and decay, are slowed. For example, at 20 degrees C (68 degrees F), metabolic rate, as measured by oxygen consumption, drops to about one-fourth that of normal body temp (37 degrees C, 98.6 F). Recoveries after as long as twenty to thirty minutes in very cold water are not uncommon. The longest documented submersion without brain damage is sixty-six minutes (body core temperature was 66 degrees F [19 degrees C]). However, two-thirds of these recoveries are in children under eight years of age though only 20 percent (about 865 out of 4200 in 1988) of accidental drownings are in this age group. The reasons for this high survival rate seem to be: (1) Children cool more rapidly, since they are smaller; (2) they are protected by a phenomenon called the "mammalian diving reflex" which is stronger in kids up to two to three years old. When such a child falls into water, more blood is sent to her brain and heart, the heart just slows to just a few beats per minute, and the glottis (vocal cords) closes, preventing water (and air) from entering the lungs. INJURY Survival rates after near-drowning are around 90 percent. However, even someone who seems to have been successfully resuscitated may have suffered permanent or even fatal injury: Pneumonia can develop, especially from contaminated water; temporary kidney failure sometimes occurs, caused by the red blood cell destruction following massive absorption of fresh water; heart failure and/or brain damage due to lack of oxygen may be seen. The frequency of brain damage reported in near-drowning cases ranges from 2 percent to over 30 percent. If near-drowning is defined as having impaired consciousness on arriving at the hospital, the latter figure is probably more realistic. Recovery may take weeks or months and may be incomplete. WHAT IS DROWNING? The short answer is: Drowning consists of filling the lungs with liquid so that oxygen cannot be absorbed. To the extent that this is the direct cause of death, drowning is another form of asphyxia. Further, inhaling water can cause the airway (larnyx) to spasm shut or the heart to suddenly stop. In addition, both fresh and saltwater damage the blood, lungs, and heart, though some medical consequences of drowning depend on wether salt- water, fresh water, or some other liquid is inhaled. Here's the long answer: Someone who is conscious can hold his breath until carbon-dioxide buildup in his blood stimulates the brain's respiratory center, which overrides any voluntary breath-holding and forces an inhalation: You can't not breathe. If the mouth and nose are under water at this moment, water is inhaled. This in turn causes reflex coughing, gagging, vomiting - and additional inhalation, often of more water. This cycle continues until conscioussness is lost, generally within two to three minutes, due to lack of oxygen. Convulsions and cessation of breathing follow quickly, which is followed more slowly by heart failure. Brain damage, then death, usually occurs within four to ten minutes. Foam frequently comes from the mouth and nose of a drowning victim, but sometimes this is not visible until pressure is applied to the chest in a resuscitation attempt. The foam is usually white, but may be bloodstained and may persist for several days (depending on temperature) on a corpse in the water. It is produced by a mixture if air, water, mucous, and other components, whipped into a froth by desperate respiratory activity. It may be more frequent in accidental than in suicidal drowning, if in the latter the person is less likely to struggle, but this is speculation based on the fact that people who are already unconscious when they drown don't produce this foam. The more graphic description of drowning that follows came from observations on dogs that were tied up and held under water until they were dead. The first stage was described as "surprise" and lasted a few seconds. This was followed by violent agitation in which the dog tried to escape its bonds and reach the surface while holding its breath. This lasted about a minute. The third stage, also about one minute long, consisted of deep inspirations of water and expiration of white foam. Mouth and eyes were open, and body movements decreased. In the fourth stage, breathing motions stopped, pupils were dilated, and corneal reflexes disappeared; another minute. In the last stage, lasting thirty seconds, there were three or four respiratory gasps and a few spasms around the lips and jaws. These observations were later confirmed when a man who had drowned his pregnant wife gave a detailed description of her death in very similar terms. SUMMARY This is not a complicated means of suicide. Pretty much all that's needed is some water and a few minutes without interruption. Reports from near- drownings are contradictory concerning pain. To minimize it, one may take enough alcohol or sedatives to become unconscious while swimming or bathing. To decrease chances of unwanted resuscitation, avoid drowning in freezing water. Drowning is fairly quick and frequently lethal - two-thirds to three-quarters of such attempts are fatal - means of suicide, usuallly taking between four and ten minutes, but there is some danger of brain damage if you're rescued after being unconscious. Drowning is a very poor choice for a suicidal gesture. ------------------------------------------------------------------------------- CUTTING AND STABBING Relatively few people commit suicide by cutting or stabbing themselves. However, around 10 to 15 percent of suicidal gestures/attempts are from wrist cutting. Unlike all-or-nothing methods like hanging and drowning, cutting and stabbing can be made about as lethal as you choose to make it. Nevertheless, mistakes and accidents do happen. LETHAL INTENT: Variable, mostly low MORTALITY: Low, around 5 percent PERMANET INJURIES: Low PROS AND CONS OF CUTTING AND STABBING FOR SUICIDE Pros: -Can be done as a fast (or slow), highly lethal method -Knives and razors are readily available Cons: -Painful -Sometimes gory cadaver -Consciousness not immediately lost THROAT Cutting the throat is the fastest, most reliably lethal, and perhaps most gruesome of suicidal cuts. However the method is not used as often as formerly, probably because straight razors have been widely replaced by safety razors and electric shavers. The cut-throat wound usually starts high and (in right-handed persons) on the left side of the neck, goes across the center,and ends lower on the right side. (You might try this - with yor finger - to get a better sense of it.) Since the "victim" generally throws his head back, the skin will be under tension and the cut smooth and straight. This may not be the case when the skin is too loose to be effectively stretched tight, as in old age or after recent major weight loss. While most cuts are by razor or knife blade, occaasionally broken glass or some other irregular object is used. These also tend to leave jagged rather than straight wounds. More often than with other methods, the corpse is found in front of a mirror. Perhaps mirrors are used to visually guide the hand. Shallow cuts are often found near the beginning of the wound. These are one piece of evidence a medical examiner will use to distinguish suicide from murder. However, hesitation cuts are occasionally seen in murder, and therefore are not definitve. WRIST, ELBOW, ANKLE Cuts on the wrist, and to much lesser extent elbow or ankle, are often used to make a suicidal gesture. Such wrist cuts are generally shallow and perpendicular to the long bones of the forearm. They tend to sever the surface veins. Since these veins are not particulary large and do not carry as much pressure as the arteries, such cuts are not usually life-threatening because they can clot before a fatal quantity of blood is lost. Wrist cuts become more dangerous: 1. If the cuts are more or less parallel to the long bones. In such a case the blood vessels tend to be sliced lengthwise or diagonally, making clotting more difficult and thus allowing more and faster blood loss. 2. If cuts are deeper and near the long bones of the forearm (the thumb- side long bone is the radius; the other long bone is the ulna), they may sever the radial artery or the ulnar artery. These pieces of plumbing are under high pressure and cutting them can be fatal unless the bleeding is actively stanched. There are claims that a single cut across a healthy wrist artery is not dangerous, because the cut artery (which, unlike veins, has built- in muscle) will contract and so limit blood loss. While this protective mechanism does exist, it's not always sufficient: Four of the forty Stockholm deaths due to cuts on the limbs were from just such an injury. You can find (or usually avoid) these arteries by checking various points around your wrist for a pulse. Without a stethoscope you will only detect one in a couple of spots, for example, where your wrist and thumb come together. You can locate the radial artery fairly near the surface there. The other major wrist artery, the ulnar, runs parallel to the other forearm bone and can be felt near the heel of the hand. Hyperextending the wrist is comon, but hides the radial artery around the end of the radius (try feeling for the pulse), and one may end up with only severed flextor tendons. 3. If cuts are numerous. Multiple cuts of wrists, elbows, and ankles, none individually dangerous, may cause enough blood loss to be fatal. 4. If clotting is inhibited. This may be deliberately done by keeping the cut under water. Another way to slow clotting is with drugs. Some drugs, like heparin and coumarin-like compounds, are prescribed specifically to decrease blood clotting in medical conditions like stroke. With other drugs, the anticlotting ability is usually considered a side effect to its intended therapeutic use. Aspirin, when taken for pain relief, is the most common drug of this sort. Since many people are not aware of these effects, use of such drugs may occasionally turn a suicidal gesture into an accidental suicide. FEMORAL ARTERY AND VEIN The femorals are the main arteries and veins to and from the legs. As you might expect, they carry a lot of blood, and an untreated cut to either one is quickly fatal. In one case, a thirty-four-year-old man bled to death from a 2 millimeter (less than 1/8 inch) nick to the femoral vein - and the vein is the low-pressure half of the circuit. They run next to each other, with the artery closer to the front of the leg, and are nearest to the skin at the groin, which makes a tourniquet hard to apply if that's the site of the cut. While knives can be and often are used on impulse, one case showed the benefits, however temporary, of planning and knowledge. A physician applied a local anesthetic to his leg, and then neatly cut his right femoral artery lengthwise. I estimate that he would have lost a fatal amount of blood in about five minutes. He died quickly, and, probably, painlessly. STAB WOUNDS Unlike most wrist cuts, self-inflicted stab wounds are generally intended to be lethal. They are usually aimed at the front of the trunk, wiht the heart area being the most frequent target. Other sites tend to be scattered near the centerline of the chest, from the neck to the groin; they are almost never seen on the head, back or extremities. Death, when it occurs, is generally due to loss of blood if a major vein or artery is cut, or to heart damage, if that vital organ is cut. A heart injury, in turn, causes internal bleeding and/or an inability to pump blood to other parts of the body. Even a relatively small heart wound may be fatal if not promptly repaired, but the severity of a heart wound also depends on its location. If the cut is to the upper chambers, the right ventricle, or the major blood vessels, death is likely; a small cut to the left ventricle wall is sometimes survived, since the thick muscle there may seal the wound when the heart contracts. However, this is not something you should count on. OTHER WOUNDS There are occasional reports of unusual sites or methods. One woman cut off her arm just below the shoulder, using a small kitchen knife with a six-inch blade. Another held a knife to her back and ran back- wards into a wall. One man stabbed himself in the chest with a chainsaw while it was running. CAUSE OF DEATH A cut-throat wound most often causes death by hemorrhage, Severing either of the two carotid arteries on the right side of the neck or the jugular veins on the left will cause fatal blood loss within about five minutes. Since blood flows into the head via the carotid, unconsciousness might occur a couple of minutes after cutting it; perhaps a minute or two longer if the jugular veins are sliced instead. Since the trachea (windpipe) is usually also cut, blood may be inhaled, making asphyxia a secondary factor. If the trachea is partially cut while the carotid arteries and jugular veins are missed, inhalation of blood (asphyxia) may be the actual cause of death, but this is unusual. In one case of this sort, the victim died after about thirty minutes. Very occasionally, the trachea is completely severed without major blood vessel damage. This can cause the lower part of the trachea to fall into the thorax (chest cavity), followed by unsupported soft parts of the neck. This results in mechanical obstruction of the airway and subsequent asphyxia. It's conceivable that an upside-down posture would permit breathing under these circumstances, but this is mere speculation. It's also possible, but rare, that when the external jugular vein is partly cut and open to air, enough air gets into the damaged blood vessel to cause a fatal air embolism: A large air bubble enters a major vein and is sent to the heart, which isn't desgined to pump gases. It's a bit like getting air in your car's brake lines, which is also designed to pump only liquids. Injecting air into a vein has been suggested (and tried) as a suicide method; it's not a good one. Since the output of the heart is around 70 milliliters per beat, you would probably want to inject at least twice that volume of air to make sure your heart developed the cardiac equivalent of vaporlock. This would require something like a bicycle pump and you would be conscious for at least the first three to five minutes. HOW LONG DOES IT TAKE TO BLEED TO DEATH FROM CUTS TO LIMBS? When death occurs after wrist, ankle, or elbow cuts, it is almost always from loss of blood and shock. How long does this take? Obviously, it varies, depending on which vessels are cut, at what angle they're cut, and where your body is sending blood at the time. A very rough estimate of blood loss would be: 2-3 ml/beat x 70 beats/min = 140-210 ml/min; x 12-18 min = around 2500 ml, which is half your blood supply, and about the limit of what you might survive without prompt medical help. Add another five to twenty minutes to die, for a total of seventeen to thirty-eight minutes; but this is just a ballpark figure and could easily be off by a factor of two or more. If avoiding discomfort is a priority, be aware that severe loss of blood causes a physiological anxiety response. CUT/STAB WOUNDS TO THE CHEST With suicidal chest stabs, death is usually due to either (1) injury to a major vein or artery leading to fatal blood loss or (2) injury to the heart itself or to the sac surrounding it, the pericardium. If the heart is sufficiently damaged, it will hemorrhage and be unable to pump blood. But even if the heart itself is untouched, blood may fill the pericardium faster than it can drain out (or a blood clot may block outflow). This will eventually leave the heart with no room to expand, and thus keep it from filling (and thus pumping) properly ("cardiac tamponade"). In one case a forty-four-year-old man stabbed himself six times in the chest with a seven-inch-long kitchen knife. He then washed and returned the knife. After changing his clothes a number of times, he had lunch with his aunt who apparently didn't notice anything unusual. He collapsed about two hours after stabbing himself and died shortly afer reaching the hospital. The pericardial cavity was found to have 300 milliliters of partly clotted blood; another 410 milliliters was in the chest cavity. The heard muscle received cuts, but the cause of death was cardiac tamponade. SUICIDE, WRIST Since you're trying to kill yourself by bleeding to death, your preparations should be directed toward keeping your blood from clotting. To this end you might eat a few (four to eight) apsirin about an hour before the main event. Can't hurt, might help. It also might decrease the pain a bit. An excellent meal, hot bath and a glass or two of good wine - after all, you won't get another chance - should be pleasant and relaxing. The alcohol and hot bath will also have the effect of increasing your near- the-skin blood flow. More importantly, since our blood has a hard time clotting in water, keeping a slice wrist submerged increases blood loss. Using a properly aimed spray of water from a shower head is even more effective because the motion of the water and mechanical action of the drops further interfere with clot formation. It also improves the visual aesthetics, for whoever finds yor body, not to have a tub filled with blood. You may want to rig a "stand-off": something to keep your wrist from falling against your body or the tub and thus slowing blood loss; or use blood vessels in your ankle instead of, or in addition to, your wrist. Now, the best preparation in the world won't do the job if you don't cut yourself adequately. To lose a lot of blood in a hurry you need to either cut a good artery or two or several veins. As discussed im more detail above, you can feel the arteries on the inside of the wrist near the long forearm bones. Cutting them lengthwise is more effective, but either way should work. If the blood spurts out you've hit a gusher of an artery; if it flows, you got a vein. Cutting several times across the underside of the wrist may well get you enough veins and small arteries to do the trick, but if you want to be faster and more certain, go for the radial or ulnar arteries. On the other hand, maybe there's no hurry and you want to savor the slowly spreading pool of red in the tub. Fine. Just be aware that you will eventually lose consciousness and that a bit later you will have a "window of opportunity" for brain damage from lack of oxygen before you die. That would not be a good time to be rescued. On the third hand, it's entirely possible that you will slide underwater when you become unconscious and thus drown before you can bleed to death. I suppose if you wanted to make this more likely you could use an air pillow to support your head above the water: You hold the air valve shut by hand; when you lose consciousness your hand falls, the valve opens and lets out the air. Or perhaps this is getting too complicated. An alternative method has been suggested. It consists of running an IV line into your favorite elbow vein, using a big-bore needle (say, 16 gauge) taping it into place, and letting it drip away. Call the Red Cross for details, though they may suggest a better use for your blood. I'm not aware of any cases using this technique. It would certainly be slow, and probably subject to clotting, but I don't know this for a fact. The femoral arteries and veins, going through the groin to the legs carry a lot more blood than does the wrist plumbing. Cutting them is thus more quickly fatal. It also allows use of both hands and avoids wrist tendons, but is hard to stanch or tourniquet should you change your mind after the fact. SUICIDE, THROAT If you're going to cut your throat, the three major structures that are commonly injured are the carotid artery, the jugular vein, and the windpipe. These are all accessible from the front of the neck, but the major blood vessels are partly protected by the sterno-mastoid muscles nearby. (Turn your head to the side and feel them.) The large carotid is on the right side under the angle of the jaw (where you can feel your pulse). It's most accessible by cutting in between the trachea and the sterno-mastoid muscle. Completely severing it will cause un- consciousness in a couple of minutes and death in about five. Not pleasant, but fast. Throwing the head back moves the carotids under the sterno-mastoid muscles and may require deeper cuts or limit damage to trachea or larnyx. SUICIDE, TRUNK The only target worth aiming for is the heart: Single-stab injury to other organs is too slowly fatal unless you happen to hit a major blood vessel. The heart is somewhat protected by the cartilage and/or bone structures of the chest and ribs. The ease of getting through varies a lot from one location to the next. To most reliably reach the heart may require either a strong thrust through the chest wall - falling onto a knife will be more than enough - or an upward stab from between a pair of ribs. In either case, it is easier to get through if the wide part of the blade is held horizontally rather than vertically. ------------------------------------------------------------------------------- CYANIDE Cyanide is one of the fastest-acting poisons, though sources differ with regard to just how long (mostly between one and fiteen minutes in large (1500 mg) doses, longer with lower doses) it takes to kill. The lethal dose is estimated to be 50 to 300 mg; however much larger amounts have been survived with prompt medical attention. The gaseous forms, hydrogen cyanide and cyanogen, are rarely used in suicide, but should act more quickly than the oral poison; solid cyanide salts (potassium, sodium, and calcium cyanide) are the commonly sold forms, but hydrogen cyanide gas can be easily made by mixing a solid cyanide and a liquid acid (for example, hydrochloric [muriatic] acid); this is what is done in gas chambers. Cyanide works by causing asphyxia at the cellular level; it binds to iron ions found in some enzymes and makes them unavailable for cellular respiration, essentially choking your cells. The cells try to survive by switching to a non-oxygen requiring metabolic pathway (the same one your muscles use when you're exercising faster than you can breath in oxygen), but this quickly builds up lactic acid to toxic levels. The fastest-metabolizing cells, brain an heart cells, are most quickly affected; and if they die, so do you. Cyanide also has a direct poisonous effect on the central nervous system and depresses breathing, but this is overkill. As with carbon monoxide, some survivors have permanent nervous-system injury, such as memory deficits and tremor. If you use cyanide, it would be a thoughtful gesture to leave a conspicuous note to that effect, because of possible hazard to rescuers who might otherwise apply mouth-to-mouth resuscitation - some people lack the ability to detect the almond-like smell of cyanide. APPLE SEEDS If you really can't get what you need, as a last resort you might consider...apple seeds. If you crush a fresh apple leaf (or cherry, plum, pear, and some others) between your fingers, you should be able to detect the faint odor of almonds. This is the smell of cyanide. Apple seeds average around 0.6 mg hydrogen cyanide (HCN) per gram of dry seed. Since the lethal dose of HCN is estimated to be about 50 mg, you need around 85 grams (3 ounces) of dry seeds. This is around half a cup, which requires a lot of apples. However: 1. Plants are variable; eat enough - at least three times the minimum dose: Cyanide is not a drug on which to skimp, since it can cause brain damage in sublethal doses. 2. The HCN must be liberated from the sugar it's chemically attached to. This occurs when the moistened seed is crushed, releasing an enzyme, emulsin, which does the job. Apparently this also occurs in the stomach, due to the hydrochloric acid there. In any case, you need to crush and eat these seeds fairly quickly, both to avoid evaporation of cyanide from the crushed seeds, and so as not to lose consciousness before in- gesting a lethal dose. A blender or coffee grinder would be a good way to break up the seeds. 3. There are around 150 plants known to contain cyanide (vegetarians note!). Many of them have it in higher concentration than do apple seeds. For example, bitter almond seeds average around 3 mg/grams (range 0.9 to 4.9), or five times the apple seed concentration. Cassava root is also quite poisonous unless processed to remove its cyanide. 4. Cyanide, in the form of the alkali potassium salt is available as a metal plating solution, for example "Cy-An-In"; the lethal dose of the sodium, potassium, and calcium cyanide salts is estimated to be 200 to 300 mg (0.07 to 0.11 ounce). 5. The use of cyanide is controversial: Some claim it is painless and quick, others that it is painful and quick. For what it's worth, cyanide is commonly used by suicidal chemists but rarely by physicians. However, this may reflect their respective easy access to different poisons rather than any other basis for preference. The German Euthanasia Society recommends 1.5 grams potassium cyanide - about seven times the lethal dose - dissolved in a glass of cold water. Don't use fruit juice or soft drinks; their acid releases HCN prematurely (not that it will matter if you drink it quickly). Kool-Aid has been recommended for those who don't like plain water. The same folks suggest placing 1 gram of a cyanide salt into a gelatin capsule and putting that inside a larger gelatin capsule. The idea is for at least the inner capsule to reach the gut before dissolving and releasing the cyanide. This is claimed to minimize stomach pain. Sodium cyanide works every bit as well as the potassium salt; calcium cyanide decomposes in water, but should do the job if used quickly. Effects are fastest ifthe stomach is empty and gastric acidity high. With minimally lethal doses, death may take up to an hour. Symptoms include a bitter, burning taste; constriction or numbness of the throat; nausea and vomiting; disorientation; irregular breathing; unconsciousness; violent convulsions; protruding eyeballs; foam, often bloody, around the mouth. All in all, not a particularly peaceful exit, it would seem. 6. If you're in a hospital, and wired to monitoring devices, this (and most drugs) won't work fast enough and you'll probably be "saved"; but, if you're considered mentally competent, you can check yourself out "against medical advice" (AMA) and take care of business at home. 7. Unlike most drugs/poisons, cyanide has a reasonably specific set of anti- dotes that are usually effective if administered quickly enough; amyl nitrite by inhalation; sodium nitrite and sodium thiosulfate, intravenously. ------------------------------------------------------------------------------- Carbon Monoxide (CO) is colorless, odorless, and tasteless; it has one less oxygen atom than carbon dioxide (CO2). It will be produced by any carbon-fueled flame that doesn't get enough oxygen. If a flame is yellow or puts out visible soot, you can be sure it's also generating carbon monoxide; if a flame is blue, carbon dioxide is the principal carbon oxide. You may have noticed that the outer part of a candle flame is blue, while the inside is yellow. This is because the outer portion burns hotter due to its greater oxygen supply. Carbon monoxide's biological effects are mostly due to the fact that it's 200 to 250 times more strongly attached to the oxygen-transporting molecule in red blood cells, hemoglobin, than is oxygen. Thus a low concentration of CO in the air can occupy a large fraction of your hemoglobin. For example, 0.01, 0.02, 0.10 and 1.0 percent CO in the breathing mixture would tie up 11, 19, 54, and 92 percent,respectively, of a person's hemoglobin at equilibrium. Carbon monoxide is also directly toxic to cells by interfering with their ability to use oxygen, by binding to a number of iron-containing enzymes and other proteins. Carbon monoxide causes blood to be a bright cherry red, which produces a ruddy corpse. This unusual coloration can be used for preliminary identification of CO poisoning. The toxicity of carbon monoxide is shown by a case in which a car accident victim was put on a stretcher, which was placed eight to ten feet behind the tailpipe of an idling ambulance while antoher person was attended to. Upon reaching the hospital,the first man was discovered to be dead from carbon-monoxide poisoning. His other injuries were minor. Since smoldering tobacco contains about 4 percent carbon monoxide, pack-a-day smokers have 5 to 6 percent of their hemoglobin tied up by carbon monoxide. This level causes small, but measurable, impair- ment of both physical and mental performance. Frequent cigar smokers have peak carbon monoxide blood levels of around 20 perecent. A 50 percent carbon monoxide blood level is often fatal, but levels as low as 15 percent may also kill those with heart or lung problems. It takes about five and a half hours of breathing fresh air to remove half the carbon monoxide from hemoglobin, another way of showing the high affinity between the two; 100 percent oxygen reduces this to 80 minutes; 100 percent oxygen at three atmospheres pressure gets rid of half the carbon monoxide in twenty-three minutes, but may cause permanent eye damage. However, even twenty-three minutes is often to long: A few minutes of asphyxia is enough to cause brain damage which may be fatal, and has a good chance of being permanent. These injuries include dementia, psychosis, paralysis, cortical blind- ness, memory deficits, and Parkinsonism; the latter two are the most common. The frequency of permanent injury from carbon monoxide overdose ranges from 0.3 to 43 percent in various studies, even if high-pressure oxygen used. "Some survive [in] a coma for weeks or months before succumbing to infection. Alcohol and other central nervous system depressants (for example, sedatives) may increase the toxic effects of carbon monoxide. A 0.20 percent blood-alcohol concentration combined with serious (but generally not fatal in a healthy individual) 35 to 40 percent carbon-monoxide saturation of the blood has been fatal. However, this is association is controversial. Carbon monoxide is also hazardous to unprotected rescuers and will explode if the concentration reaches 10 percent and there is a spark or flame present. This concentration will not be reached from combustion, but may be achieved from compressed CO (in tanks) or chemically generated CO. Automotive carbon monoxide poisoning is becoming less frequent in the United States. The reason is that car engines are required to get better gas mileage and produce fewer toxic emissions than in the recent past. A new, well-tuned engine may emit 0.06 percent carbon monoxide, compared to 6 to 9 percent from an engine of the 1960s, a hundredfold decrease. As a result, it takes longer to kill yourself by filling a garage with carbon monoxide from a tuned engine. It can be done, but is no longer either fast or certain. How long does this take? For a given-volume garage, it depends primarily on the age, state-of-tune, and size of the engine. If a "clean" two liter engine idles at 750 rpm, the it will take about an hour for 20 by 20 by 8 foot garage to reach 0.06 percent carbon monoxide. This is not a reliably lethal concentration. What would happen if the exhaust gases are piped directly into the car, as is commonly done using a garden or vacuum-cleaner hose? It would take about three minutes to reach 0.06 percent atmospheric carbon monoxide. However, the atmospheric CO concentration can't be greater than that of the exhaust mixture; it just takes less time to get there. Once again, not reliably lethal. If we had a "dirty" engine of the same size with 6 percent carbon monoxide emissions (100x clean engine), it would take about thirty five seconds for the garage to reach 0.06 percent carbon monoxide; 70 seconds for 0.12 percent, 140 seconds for 0.24 percent, and so on. Thus, a lethal concentration of CO would be produced in a minute or two. Death could occur in less than half an hour. Note that, while running such exhaust into the car would generate lethal concentration of CO within a few seconds, one would have to continue breathing it for a fatal result. Alternatively, one may be able to buy a small tank of carbon monoxide from a chemical, science supply, or industrial gas supply company (you will need a gas regulator/valve, too). Loosely sealing yourself in a plastic tube tent, car, or functional equivalent, and releasing the gas should be quickly (five to fifteen minutes) fatal. A simple amd reliably lethal source of carbon monoxide is a charcoal grill, hibachi, or other burner. If charcoal (or any other handy carbon fuel, like wood or coal) is burned in one, a deadly CO concentration will be quickly generated in any small, enclosed space, such as a tent. Using this method inside a building is a bad idea, both due to fire hazard and because of the CO danger to other people. Dr. Kevorkian's current suicide apparatus consists of a gas mask attached to a tank of carbon monoxide. The gas flow is controlled by a valve that is opened by the patient, who is wearing the mask. Under these conditions death should occur in less than five minutes. The advantage is that the gas concentration will probably be higher than with a tent, with faster results. The disadvantage is that the hookup is a bit more elaborate and is correspondingly more likely to require someone else's help. EFFECTS OF CARBON MONOXIDE A century ago the eminent British scientist J. B. S. Haldane studied the effects of carbon monoxide on himself - a time-honored, but some- times hazardous, medical tradition. While sitting and takin notes, he breathed a 0.21 percent carbon monoxide mixture for seventy-one minutes. A summary of his observations follows: After twenty to thirty-four minutes he has a slight feeling of fullness and a throbbing of the head; 17 percent of his blood hemoglobin was tied up by carbon monoxide as carboxyhemoglobin. After forty to forty-five minutes the headache was worse, his breathing was slightly fast and he felt abnormal (39 percent carboxyhemoglobin). After fifty-nine to sixty-five minutes, he was breathing fast, looked pale, was starting to become confused, and couldn't move in his chair without feeling worse (44.5 percent carboxyhemoglobin). After seventy-one minutes his vision was dim, he couldn't get up without help, and he stopped the experiment (49 percent carboxyhemoglobin). There were no long-term ill effects. As always, there is individual variability: In 7 perecent of fatal CO poisonings, less than 40 percent of the victim's hemoglobin was tied up by CO. Another study found that 0.32 percent CO for an hour caused unconsciousness; 0.45 percent caused death. In animal experiments, carbon monoxide is about as fast as intert gases: unconsciousness occurs in one to two minutes and death after around five minutes, using 4 to 8 percent CO. Death is preceded by convulsions and muscle spasms, but the fact that there are frequent accidental carbon monoxide poisonings among sleeping people shows that it doesn't cause enough discomfort to reliably awaken someone. However, first taking enough of a sedative (for example alcohol, opiate, barbiturate) to achieve unconsciousness would probably result in an easier death. If low concentration of CO is anticipated, such as from new car exhaust, it may be useful to premedicate with antinausea (for example, some antihistamines) and antiseizure (for example,Valium) drugs, but this is speculative. Better is to avoid this situation: Don't use CO for a suicidal gesture and don't use low concentrations for suicide. We close this section with a suicide note from Japan, written while a car was filling with carbon monoxide. The first eleven items of the note were personal messages and instructions for the disposal of assets. The last entries are quoted below, in translation: [At 6:15 p.m.] The inhalation of exhaust gases is begun. [After seven minutes] My eyes and throat are slightly irritated. Put on a bathing towel. There are tremendous water drops on the door glasses [This is condensation of water vapor from the exhaust]. The tank is full of gasoline. [After eight and one-half minutes] Slight shortness of breath. Ha-ha-ha. The powers of Nissan's engine are great! [After ten minutes] Swallowed a cup of Japanese sake [rice wine]. I could not control myself to stay in the cabin [of the minivan] at this level of shortness-of-breath yesterday. [After eleven minutes] To the mistress of a grocery store: "Yes, you were right. The size of this hose, 30mm in outer diameter and 25mm in inner diameter, fits the exhaust pipe perfectly. [After twelve and one-half minutes] Swallowed another cup of sake. I wish I could have a can of beer. I wonder what the concentration of carbon monoxide is now. [After fourteen minutes] Breathing can only be done by mouth. [After fifteen minutes] Water is pouring out of the hose. [After sixteen minutes] Good-bye, Mum and Papa! [After seventeen minutes] Still I am living. It is asthmatic breathing. Now, I will sleep. ------------------------------------------------------------------------------- GASES Many gases that are more or less nontoxic can cause asphyxia by replacing oxygen from the breathing mixture. Some common ones include avetylene, argon, butane, carbon dioxide, freon, helium, hydrogen, liquified petroleum gas (LPG), methane, neon, nitrogen, and propane. As a result, they are dangerous in enclosed areas or when breathed through a gas mask, but not otherwise. People start showing signs of asphyxia when the concentration of these gases is around 30 percent; severe symptoms at around 50 percent; death at around 75 percent. In the above list, argon, butane, carbon dioxide, freon, and LP gas are heavier than oxygen, and may displace it from the bottom of closed spaces, and, occasionally, even open spaces that are protected from wind. Tunnels that are open only through manhole covers occasionally contain lethal concentrations of carbon dioxide. Someone entering such a location unknowingly would become unconscious within a couple of minutes - perhaps within seconds - and would be dead after five to ten minutes. A standard gas mask is useless under these circumstances; supplemental oxygen is necessary. However, for the purpose of suicide, carbon dioxide would be an un- pleasant choice, since its presence stimulates both breathing reflexes and the sensation of smothering. The hydrocarbons methane, butane, liquified petroleum gas (LPG), and propane, while readily available as fuel gases, are normally mixed with badsmelling "warning" gases (mercapatans), related to skunk scents. Acetylene is used for gas welding and is easy to aquire, but contains somewhat-toxic acetone. Don't bother making you own acetylene from calcium carbid (formerly and still occasionally used in carbide lanterns for caving), because it contains an ammonia-like contaminant, phosphine (PH3). The remaining gases - argon, helium, and nitrogen - are your best bets in this category. They are all tasteless, odorless, nonirritating, and under these conditions, chemically and physiologically inert. In fact, nitrogen comprises about 80 percent and argon 1 percent of sea-level, while roughly 90 percent helium to 10 percent oxygen mix (precise ratio depends on dive depth) is used for deep-water diving (to avoid intoxic- ating effects of high pressure nitrogen called "nitrogen narcosis" or, more poetically, "rapture of the deep"). Since these inert gases are not poisonous and your lungs have something to inhale, such asphyxias will be minimally traumatic. That is, they will not cause feelings of suffocation (which are due to carbon dioxide buildup, not the lack of oxygen) or hemorrhages (caused by high blood pressure from blocked jugular vein or struggling to breathe against a closed airway). Most medical use of inert gases is for animal euthanasia, however there have been human fatalities from them, too. For example, airline face masks were mistakenly hooked up to inert gas cylinders instead of to oxygen at least ten times during the 1980s in the United States. The fact that these people died without attracting attention is consistent with nontraumatic death. Argon is commonly used for inert-gas electric welding and helium for balloons. Nitrogen has a variety of uses and may be purchased either as a gas or as a cold (-196 degrees C or -321 degrees F) liquid. All of these are available from industrial gas suppliers. Helium can also be found at party-supply stores, and argon at welding suppliers. None of these gases are dangerous unless they displace oxygen from the breathing mixture. Probably the easiest way to use inert gases for suicide is to enter a tube tent with a gas cylinder, flush the tent with any of the three gases, and seal the ends of the tube. The volume of a tent is such that you won't produce enough carbon dioxide to stimulate breathing reflexes before dying. Since there's little or no residual oxygen in the breathing mixture, minimal amounts of carbon dioxide ought to be exhaled, suggesting that a large inert gas-filled plastic bag over the head should work as well as the tube tent. Only slightly more complicated method is to hook up a gas delivery mask (available at military surplus or medical supply stores) to a cylinder of compressed inert gas. This may, in fact, be the easiest method if you're using supplemental oxygen, and have a gas delivery system already in place. The main hazard of this (and all) asphyxia is the possibility of brain damage if the process is interrupted due to intervention, running out of gas, or tearing or removing the gas mask, plastic bag, or tube tent while unconscious. This can be minimized by using a high concentration of the anoxic gas, which causes most rapid loss of consciousness. These gases are not a danger to others in anything but a small, sealed space, however it's important that a gas cylinder not be mislabeled, lest it imperil subsequent users. In experiments, animals (dogs, cats, rabbits, mink, chickens) show little or no evidence of distress from inter gas asphyxia, become un- conscious after one to two minutes, and die after about three to five minutes. Thus, use of any of these three gases, combined with a plastic bag, should be less traumatic than plastic bag asphyxia alone, since there will be little discomfort from carbon dioxide buildup and unconsciousness will be swift. ------------------------------------------------------------------------------- ELECTROCUTION Electrocution is an effective, but infrequently used, method of commiting suicide. It is not a good choice for a suicidal gesture. The potentially lethal effects of electricity on the body include heart stoppage, respiratory failure, and burns. LETHAL INTENT: High MORTALITY: 40 to 90 percent PERMANENT INJURIES: Moderately likely PROS AND CONS OF SUICIDE BY ELECTROCUTION Pros: -Not much physical strength or dexterity needed -High fatality rate -High (not household) voltage and current usually cause quick unconsciousness Cons: -Scarcity of data on suicidal electrocution - most of our information is extrapolated from accidents -Frequent permanent injuries from high-voltage accidents -Electricity is mysterious to many people -May be hazardous to innocent bystanders or rescuers HOW DANGEROUS IS ELECTRICITY? This may semm a silly question, but electricity is usually invisible and, for many people, mysterious. As a result, it't not widely known that consequences of electric shock often depend on how quickly help is available. This is because death is commonly due to the shock- induced stoppage of heartbeat or breathing - which are frequently reversible if there is prompt medical intervention, usually CPR ( cardio-pulmonary resuscitation). The medical literature cites a wide range (5 to 50 percent) of mortality rates in known electrical accidents, but since minor shocks are rarely reported, the accuracy of even this figure is questionable. In one recent study only 3 perecent of hospital patients admitted with injuries from high voltage (greater than 1000 volts; found in high-power trans- mission lines and some industrial uses) died. But this didn't include those dead at the scene or dead on arrival. There is about a 90 percent fatality rate in suicidal electrocution attempts using household and high-voltage current. Use of electric stunning devices is about 40 percent fatal. The frequency of long-term injury is unknown with suicide attempts, but occurs fairly often in accidents. Much depends on the type and duration of electric shock. The three most common sorts of long-term injury are: -burns, typically from high-voltage power transmission; -direct neurological (brain/nervous system) damage, generally from lightning or high voltage power transmission; -indirect brain damage resulting from breathing paralysis, which can be caused by high- or low-voltage power, or lightning ELECTRICAL PATH To achieve (if that's the right word) electrocution, the electrical current pathway must go through organs that are both vital and suspectible to electrical disruption. The ones that best fit this description are the brain, spinal column, heart, and respiratory muscles in the diaphragm. The electrical pathway is thus critical: Head-to-limb is always dangerous because it goes through the brain, and, depending on which limb, possibly the heart. Similarly, a right-hand-to-right-foot path- way is less hazardous than a left-hand-to-left-food or a hand-to-hand circuit, since the latter two are more likely to go through the heart. HOUSEHOLD (A.C. OR ALTERNATING CURRENT) ELECTRICITY The treshold for feeling household (60 cycle-per-second) alternating current, is between 0.5 and 2.0 milliamps (mA), depending on individual sensitivity. This minimal current feels like a tingle and causes no direct, but may startle someone into losing balance or dropping an electrified object into a more dangerous position, for example, into the bathtub. A little more current can cause numbness (2 mA), pain (1-4 mA), and muscle spasms (5 mA). Somewhere between 6-22 mA, these muscle con- tractions are uncontrollable and the victim cannot let go of a grasped object, often the electrical conductor. The fundamental reason this happens is that voluntary muscles, like those in your hand, normally contract in response to small electrical signals transmitted through the nervous system; the hundred-times-stronger external electrical signal totally overwhelms the nervous system's control. Since other muscles also go into involuntary contractions from electrical overstimulation, people will die from inability to breathe (tetanic asphyxia) if a low current path goes through the respiratory muscles (head-to-leg, arm-to-arm, or arm-to-opposite-leg). Thus, not being able to let go of an electrical conductor may well make such relatively small current more dangerous than a larger current that knocks you away from the conductor. In one instance a 21 volt A.C. microphone electrocuted a pastor who was waist-deep in a water-filled concrete baptismal fountain. Death was attributed to drowning,as a result of electrical paralysis. However the most common reason for death from low-voltage (household) alternating current is ventricular fibrillation. This is caused by somewhat higher current, starting around 100 mA for one-tenth of a second, which will induce the different parts of the heart to beat out of synch with each other, as normal nerve conduction within the heart is disrupted. A 2000 mA (2 amps) or greater jolt can make the heart, basically, stop (cardiac standstill). However, it will often restart spontaneously when the current stops. Thus, higher amperage current, which can cause the heart to stop, will be less dangerous than lower amperage, which sets off fibrillation. Fifteen amps of current passing through the diaphragm (muscles below the lungs) can paralyze breathing (respiratory arrest), but paralysis also depends on the electrical path; lesser current through the head may have the same effect ny knocking out the respiratory center in the brainstem. In both cardiac standstill and respiratory arrest, CPR has a good chance of maintaining circulation long enough for breathing and heart function to restart. HIGH-VOLTAGE A.C. ELECTRICITY "High voltage" is arbitrarily defined as more than 1000 volts. Power lines into houses are generally 220/240 volts A.C.; high-power lines in residential and industrial areas are often at 7620 volts A.C.; power lines from generating plants sometimes carry over 70000 volts A.C. In high-voltage shocks (for example, from high-voltage transmission lines or lightning) death is most often due to respiratory paralysis, and/or heart stoppage, while ventricular fibrillation is infrequent. Most characteristic of high-voltage electrocution is the presence of burns: 96 percent (89 in 93) of high-voltage deaths in one study had visible burns (compared to 57 percent of deaths from electrocution due to less than 1000 volts). In the survivors, burn are often the most severe injury, especially with A.C. current. Sometimes the temperature exceeds the flash point of muscle, which then ignites and burns, rather like a piece of meat over hot charcoal fire. As you might suspect, such electric current through the skull is parti- cularly gruesome. In some cases, the skull splits open, and the eyes are blown out of their sockets by the steam pressure from the boiling brain. The tetanic contraction can be so severe that it is capable of causing bones to break and muscles to tear from their attachment points in bones. The upper arm bone is most frequently broken. Despite the above, the actual cause of death in the majority of high- voltage electrocutions is paralysis of the respiratory center of the brainstem, which keeps you from breathing on your own, and results in asphyxia. DIRECT CURRENT Direct Current (D.C.) electricity occurs naturally in lightning, static electricity and electric eels; somewhat less naturally in batteries, capacitators, electric trains, and other human artifacts. Direct current is less dangerous than A.C. for two reasons: (1) It does not cause multiple tetanic muscle contractions; thus one can let go of a D.C.- energized wire (though the single jolt it does cause can result in broken bones from the force of the contraction, injury from falls, burns cardiac standstill, or respiratory arrest); (2) It is less likely than A.C. to cause ventricular fibrillation. As a result, D.C. current of less than 80 mA is claimed to have no harmful physiological effects. SUICIDE BY ELECTROCUTION 1. Climbing a high-voltage pylon or pole and grabbing a high-voltage wire. Typical injuries include burns, heart and/or respiratory stoppage, and injuries from the fall. The intitial jolt causes unconsciousness, and death is highly likely. A variation on this is sometimes used by people who don't like heights: Rather than climbing, they wrap a wire around some part of their body (often around a wrist, but in at least one case, around the neck) attach a weight to the other end of the wire and toss the weight over a high- voltage line, which is an uninsulated, bare wire. In this situation there is no fall from a height, but the electrical contact is prolonged. Bare feet and damp soil are helpful but generally not necessary. Enough heat is generated to often amputate the wire-wrapped part of the body. A thin wire is at risk of melting before you do, so it's important to use the thickest one you can handle. There are occasional reports of people being electrocuted as a result of urinating onto high-voltage electric train rail, though these are probably not deliberate suicides. Despite its high lethality, people sometimes survive high-voltage suicide attempts with nothing but third-degree burns and permanent injuries to show for their troubles. 2. A simple electrocution method using household current is to remove the insulation from the end of an extension cord, plug in the extension cord, and grasp the two bare wires, one in each hand. Alternatively, one can hold one wire and touch a grounded item (for example, an exposed metal pipe) to complete the circuit, This requires the black (hot) wire to be held - if a polarized plug is used and the wiring has been installed correctly. Or, if the circuit/outlet has an on/off switch, one can wrap the bare ends of the extension cord around two different limbs (no chance of letting go) and flip the switch. There are many other ways to do this,limited only by your imagination. But don't leave an electrically live (albeit biologically dead) corpse for someone to blunder onto; to avoid this, you should incorporate a timer into the circuit. You should also leave a prominent sign telling people not to touch anything before turning off main fuse or circuit breaker. It might seem that this sort of electrocution would be an option for a terminally ill person in a hospital. However, if the circuit is protected by a "ground fault circuit interruptor," as it should be, this will not work. In addition, resuscitation equipment is generally nearby, making electrocution more difficult. 3. Dropping a 120 volt electric appliance into a bathtub containing water (and you) should do the job, especially if you're also touching metal, for example, a spigot or drain. Even if the device is turned off, the terminal of its attached electric cord is still "live." Estimate of the current involved: 120 volts/1000 ohms equals 0.12 amps (120 mA), which is not enough to trip a standard fuse or cicuit breaker; however, you should try it first with an unoccupied tub. Once again, if the device is plugged into a circuit with a GFCI, this will not work; but obviously, one could plug into a non-GFCI circuit. ------------------------------------------------------------------------------- GUNSHOT WOUNDS LETHAL INTENT: High MORTALITY: High, around 80 percent PERMANENT INJURIES: Likely PROS AND CONS OF GUNS AS A MEANS OF SUICIDE Pros: -Usually fatal -Often fast -Generally easy to obtain firearms (in United States) Cons: -Easy to act on impulse/no chance to reconsider -Survivors often have severe and permanent injury -Sometimes gruesome cadavers -Less reliable than one might expect, due to bad aim, bullet deflecting from bone, or defective gun/ammunation Shooting yourself is a generally effective - 72 to 92 percent mortality rates are reported - but frequently messy method of suicide. About 60 percent of the suicide in the United States are by means of gunshot; four out of five of these are head injuries. Suicidal gun wounds to the head tend to be quickly fatal: 70 to 90 percent of people with such injuries die before getting to a hospital, but there is a 3 to 9 percent survival rate, and these people often have brain damage or disfiguring injuries. Wounds to other parts of the body are less likely to be lethal. Gunshot is a method that can be, and all too often is, used impulsively, as it doesn't require much planning or allow time to reflect on other possibilities. RESULTS: HOW AND WHY ARE GUNSHOT WOUNDS FATAL? Obviously, gunshots can cause severe tissue and organ damage. Death, when it occurs, usually results from loss of blood leading to irrever- sible shock, or from injury to a vital organ(s), such as the brain or heart. SURVIVAL TIME AND MOBILITY AFTER INJURY In most cases of fatal (nonfatal wounds will be discussed in the next section) gunshot wounds to the head or heart, collapse is rapid but death may not be. In one study of fatal brain gunshots, 98 percent of victims found alive maintained vital functions (heartbeat, blood pressure, breathing) long enough to reach a hospital and be evaluated. In one case a Finnish man committed pistolshot-to-head suicide - in front of a movie camera he had set up. There was immediate collapse, but just before the four-minute film ran out, he opened his eyes and raised his head; how long he survived and his capabilities before dying are unknown. Specific regions of the brain control particular functions. For example, the brain stem, at the base of the skull, is responsible for maintaining, among other things, breathing, while the cerebral cortex, just behind the forehead, is the seat of intellectual abilities. Thus, someone with a wound that is limited to the cerebral cortex may well remain mobile (and sometimes even coherent) for minutes or hours. Similarly, a bullet that travels from temple to temple may miss the brain entirely, passing beneath it, possibly cutting the optic nerves and causing blindness, without producing immediate collapse. On the other hand, a shot to the brain stem is quickly fatal. "One-shot" targets are those where a bullet wound is instantaneously incapacitating and quickly fatal. These are: brain stem, basal ganglia, medulla oblongata, and spinal column in the neck. "Rapidly fatal" targets allow ten to fifteen seconds of voluntary action after a gunshot wound. These are the heart and the large blood vessel above it, the aorta. Injury to other organs, though often lethal, allows more time before incapacitation. A gunshot to the front of the head may fall into any of these categories, depending on the bullet's angle and how far it penetrates. Large caliber and high-velocity bullets are most likely to be immediately disabling, but there are no guarantees. NONFATAL GUNSHOTS TO THE HEAD Not all gunshot wounds to the head are equally dangerous. Since the "old" or "primitive" parts of the brain are responsible for maintaining and regulating basic functions like breathing and temperature, injury to these areas tends to be quickly fatal. It's not a coincidence that many executions are carried out by a single shot to the base of the skull. This part of the brain is located at the lower back of the head, near where the spinal column meets the skull. Shots into the base of the skull damage this tissue (brainstem), as do shots straight through the mouth from front to back. Shots to the front of the head may cause unexpected problems: The cerebral cortex, directly behind the forehead doesn't control any vital functions, so injury there is not directly life-threatening, but may well result in intellectual and personality deficits. Firing a gun, especially a shotgun or rifle, with the muzzle under the chin or aimed at the face, is somewhat less likely to be fatal than one might expect. Apparently, people tend to flinch or tilt their head back at the moment they pull the trigger, changing the direction of bullet entrance and decreasing the chance of fatal brain damage while increasing that of massive facial injury. This is generally not a problem when the muzzle is in the mouth: Using 12-gauge shotguns in this manner caused the head to burst open in 74 percent of cases; only 9 percent of such wounds with a 20-gauge shotgun resulted in similar injury. Shotgun wounds from a .410 were similar to 20-gauge; 16-gauge was in beween 12- and 20-gauge in its ability to rupture heads. OUTCOMES OF NONFATAL WOUNDS TO THE HEAD These are some of the most disfiguring of injuries. Quoting from a typical case report: This twenty-year-old man attempted suicide with a 12-gauge shotgun that was placed under his chin and directed to the left side. He sustained a large soft tissue loss [part of his face was blown off], facial nerve injury, loss of vision, and mulitple fractures of the mandible [lower jawbone], maxilla [upper jaw], nose, zygoma [cheekbone], and orbit [eye socket]. The patient was treated with tracheostomy [breathing hole in neck], wound debridement [dead tissue removal], and a neck flap. Mandibular reconstruction with hip graft was complicated by osteomyelitis [bone infection] and a nonunion [bones didn't join]. Two years later he was referred for treatment of a severe facial deformity, facial paralysis, depressed malar eminence [collapsed cheekbone], nonunion, and ankylosis [inability of a joint to function] of the mandible. Inferior rectus entrapment, [eyeball muscle stuck in the wrong place] visual loss, and lacrymal disfunction [inability to produce enough tears to keep the eye moist] were also present. WEAPONS: WHAT TYPE OF GUN SHOULD YOU CHOOSE? Not all firearms are equally lethal. Lethality depends on several physical factors: (1) Speed of the bullet (we will include shotgun pellets under the term "bullet"); (2) weight of the bullet; (3) type of bullet; (4) size of the gun. In general, the order of most to least lethal weapons in contact wounds is: 1. shotgun 2. high-velocity rifle 3. large or high-powered handgun (.45 caliber or .357 magnum) 4. small caliber (.22) rifle 5. small caliber (.22) handgun MASS OF BULLET Since doubling the mass of the bullet doubles its energy at any given speed, a .45 caliber which has about twice the diameter of a .22 caliber ought to pack four times the energy (volume of a cylinder is proportional to the square of the diameter) if all else (velocity of bullet) were equal. This is one of the reasons that lead is used for bullets: It weighs about 1.5 times as much as does the same volume of steel. Also, since lead is quite soft (you can scratch pure lead with a fingernail), it does minimum mechanical damage to the bore of the gun, though it may clof rifling grooves. SPEED OF BULLET The speed of sound is about 1100 feet (340 meters) per second (fps). The muzzle velocity of high-velocity rifles is aroud 2400 to 4000 fps (730 to 1200 meters); handguns are mostly 350 to 1500 fps (100 to 460 meters). Low-velocity (less than speed of sound) bullets crush or push aside tissue; the wound track is not much wider than the bullet (unless it mushrooms or tumbles). High-velocity bullets are used in military-type rifles and some semi-automatic pistols and have a lead core surrounded by a harder copper-alloy jacket. They are desgined to not jam automatic loading mechanisms common in military weapons, and to survive rough field conditions; on striking a body, they are less likely than lead to flatten and more likely to drill a clean hole. Quite sporting. However, if jacketed bullets hit bone or develop a wobble while going through flesh, they can cause extensive damage along the wound track. High-speed bullets send a shock wave of compression ahead of the lacer- ation track. This can tear and even shatter organs, both nearby and, (transmitted through liquid, of which we are mostly composed) distant ones. High-velocity bullets also cause "cavitation." The bullet accelerates tissue radially away from the wound track at a high rate of speed. This generates a temporary cavity that can be much larger then the diameter of the bullet. The resulting near-vacuum also sucks clothing fibers and other sources of infection into the wound. If a bullet exits the body at high speed, it has not transfered maximum destructive energy. Thus, various attempts have been made to prevent the bullet from leaving. Without going into the fine points, these methods include: 1. using a hollowed out bullet tip, which tends to mushroom upon hitting tissue, and thus slows down; 2. using a tip that is softer than the body or jacket of the bullet; 3. using so-called "dum-dum" bullets with deformed tips, again intended to cause mushrooming; 4. using multiple small bullets, as with a non-rifled shotgun; 5. using explosive-tipped bullets, which are supposed to detonate on contact. Like mushrooming bullets, they were banned by the Hague Convention of 1899. ------------------------------------------------------------------------------- HANGING AND STRANGULATION Hanging and strangulation are effective methods of suicide. Both can be carried out by people with limited physical abilities. Hanging doesn't require complete suspension. Death occurs within about five to ten minutes after cutoff of oxygen or blockage of blood flow to the brain (anoxia); however, convulsions are common and the noise may attract attention. Pain can be minimized by protecting and padding the front of the neck. Since finding the body will probably be traumatic, care should be given to choosing a location. These are highly lethal methods and cannot be done safely as a suicidal gesture. LETHAL INTENT: High MORTALITY: High, around 80 percent PERMANENT INJURIES IN SURVIVORS: Moderately frequent PROS AND CONS OF HANGING AS A MEANS OF SUICIDE Pros: -Quick unconsciousness -Fairly quick death -Easily accomplished with materials found around the house -Can, if necessary, be done without leaving bed Cons: -Possibility of brain damage if interrupted -Sometimes a gruesome cadaver, which may be upsetting for whoever discovers the body Suspension hanging is often lumped (and confused) with judicial-type ("drop") hanging, suffocation, strangulation, and even choking. This is entirely understandable, since the subject is confusing, but there are some important, and sometime critical, differences between them. Brief definitions of these terms may be helpful im making sense of what follows. 1. SUSPENSION HANGING suspension by the neck, with little or no drop. Death is due to compression of the airway (trachea, or windpipe) and/or the major blood vessels connecting the heart and the brain. These latter are the carotid and vertebral arteries, and the jugular vein. We will use "hanging" to mean "suspension hanging" unless otherwise specified. 2. JUDICIAL-TYPE (DROP) HANGING a several foot drop, with rope attached to the neck. If everything goes right, death is due to a broken neck. While this is quicker than suspension hanging, it may or may not be less traumatic. 3. STRANGULATION manual compression of the airway and/or blood vessels to/from the brain. In suicide, this generally requires a ligature (rope, wire, cloth, etc.). In homicide, there may be a ligature or there may be direct pressure from hands or forearm on the neck. 4. CHOKING blockage of the airway by mechanical obstruction, for example, a lump of food. 5. SUFFOCATION OR ASPHYXATION interference with the ability to take in or use oxygen; related to choking, suspension hanging, and strangulation, in that oxygen is prevented from reaching the brain in each case; however, there is no direct pressure on the airway in suffocation or asphyxation. Examples are, use of a plastic bag or carbon monoxide (see Asphyxia chapter). PHYSIOLOGY: WHAT IS HANGING, AND HOW DOES IT KILL? Hanging can kill by four distinct mechanisms: compression of the carotid arteries, compression of the jugular veins, compression of the airway (trachea), and breaking the neck. The first three can result from suspension hanging; the last from drop hanging. CAROTID ARTERY On the right side of your neck, just under the side of the jaw, is your carotid artery. Put your fingers there and gently feel your pulse. It should be quite strong. (If you can't find one, either you're looking in the wrong place or you don't need this book.) The carotid artery carries much of the blood to your brain, which uses around 15 percent of the entire blood supply of your body. Anything which interrupts that blod-flow for more than a few seconds will cause loss of consciousness. JUGULAR VEIN On the other side of the neck, under the left side of the jaw is the jugular vein, which carries "used" blood back to the heart. If the jugular is blocked, blood backs up, much like water in a stream that has been dammed. The carotid and jugular can be compressed with just a few pounds pressure; a moderately tightened rope will do nicely. Death occurs within a few minutes. There does not need to be any pressure on the airway (trachea, or windpipe), though there often is. TRACHEA/AIRWAY The airway, down the front-center of your neck, can be blocked internally, (by inhaling a foreign object) or externally (by a ligature). When the interference is internal, it is termed "choking" In either case, obstruction of the airway takes a good deal longer to produce unconsciousness than does carotid pressure, and is much more painful. (Details are in the Asphyxia chapter.) HANGING Judicial (drop) hanging is quite a different kettle of worms from supsension hanging. In a (properly done) judicial-type hanging, the victim falls several feet before coming to an abrupt halt at the end of a rope. Often, thisis the bitter end. Such a precipitous change in velocity is supposed to cause a broken nekc and quick unconsciousness and death. However, exhumation of judicial hanging victims has shown that a broken neck was frequently not the cause of death. An excessively long drop can result in separation of head from body, and is considered bad form by professional hangmen. Suspension hanging can cause compression of the carotid, jugular, and/ or airway, depending on how it is carried out. There are similarities between suspension-hanging and choking, as well as previously mentioned differences. Your blood carries oxygen and nutrients to your brain. Enough pressure on the airway compresses it and prevents oxygen from reaching the lungs. Your body has build-in reflexes to keep this from happening: pressure against your trachea causes quick pain, and you have irresistible urge to back away and cough; one reflex (pain) gets your attention and moves you away from the stimulus - say someone's thumbs - and the other reflex (cough) attempts to clear the airway. If these attempts are unsuccesful, blood will continue to be pumped to the brain (and elsewhere) by your heart, but it won't carry enough oxygen and you will lose consciousness in a couple of minutes. TIME TO DEATH As asphyxia proceeds, first temporary, then permanent brain damage from lack of oxygen will occur. Death follows in five to ten minutes (ten to twenty minutes, according to Polson; however, his number seems to be based on the fact that the heart may continue beating for up to twenty minutes after judicial hanging, and ignores that the heart may continue to beat after brain death. While human data are lacking, unanesthetized dogs die after around eight minutes of asphyxia). On the other hand, it's also true that unconsciousness and death will be delayed if blood flow to/from the head in only partially obstructed, as is sometimes the case. CAROTID REFLEXES Curiously, you don't have the same protective reflexes along the carotid artery, so that pressure sufficient to block the artery doesn't elicit much in the way of defensive reaction. In fact, one of the reflexes that is present may be counterproductive: Near where the carotids divide are some nerve cells, the "carotid sinus". These nerve cells have the normally useful function of maintaining blood pressure at a steady level. They respond to a decrease in blood pressure (for example, when you stand up) by constricting arteries and telling the heart to beat harder. Without this, you might pass out every time you stood up suddenly, because not enough blood was reaching your brain. (The dizziness many people feel when they stand up suddenly is another way of appreciating how quickly and exquisitely sensitive your brain is to absence of enough blood.) Similary, the carotid sinus responds to an increase in blood pressure by relaxing the arteries and inhibiting the heart. So far, so good. The problem arises because these pressure-recpetor nerves aren't smart enough to tell the difference between blood pressure and externally applied pressure - for example a forearm or billy club across the right-front side of the neck. "SLEEPER" HOLD Those of you who are wrestling (TV variety) fans are probably familiar with the sleeper hold; it is nothing more than a forearm pushed against the carotid artery, compressing it, and cutting off blood flow to the brain (see Asphyxia chapter). This causes unconsciousness in about eight to fifteen seconds. The sleeper hold is forbidden in tournament wrestling and is faked in the TV stuff. The reason is that the amount of pressure needed to compress the artery is enough to cause the carotid sinus to kick into overdrive and sned the heart a priority message to slow down, which is sometimes enough to stop the heart altogether. PRESSURE NEEDED TO COMPRESS THE CAROTID, JUGULAR, AIRWAY carotid = 7 lb (3.2 kg) - 11 lb (5 kg) jugular = 4.5 lb (2 kg) airway = 33 lb (15 kg) vertebral = 66 lb (30 kg) What this means, practically speaking, is that someone who wants - or wants to avoid - a lethal result should be aware that full suspension is quite unneccessary. Death will occur after only a few pounds of pressure on a neck ligature; a sitting or semireclining position is sufficient. SUSPENSION HANGING Hanging does not have a very good image. For example: "The discovery of a grotesquely hanging corpse whose swollen, sometimes bitten tongue protrudes from a bloated blue-gray face with hideously bulging eyes is a nightmarish sight upon which only the most hardened can gaze without revulsion." However, while some look livid, about 60 percent of hangers have a "pale an placid" face. Some have small hemorrhages, caused by capillaries leaking (due to high blood pressure in the abscence of oxygen), on the face, eyelids, and/or scalp; others don't. What accounts for these differences? Basically, it's a question of how quickly and totally the ligature cuts off blood circulation to and from the head. If suspension is fast and complete, the blood supply both to and from the head will be cut off simultaneously, so there is no excess blood or blood pressure in the head, and thus a more or less normal- colored corpse. Similary, activation of the carotid sinus pressure receptor would cause a decrease in blood flow to the head, leading to paleness in the cadaver. If, on the other hand, the pressure on the neck gradually increased as consciousness was lost, it's probable that the jugular vein was shut off before the carotid artery (and almost certainly before the hard-to- clamp vertebral arteries), since it requires less pressure to do so. Thus, in this case blood would continue flowing into the head while having no way to leave it; hence engorgement and blue/purple color. This is most likely when the suicide is in a sitting or lying position, because there is less (and less sudden) pressure on the neck than when completely suspended. PLACEMENT OF THE LIGATURE An additional variable is the placement of the ligature. The least pressure corresponds to the location of the knot in the rope, since that point is pulled up and away from the neck. Depending on the knot's site, it is thus possible to miss the jugular (if the knot's on the left), carotid (knot on right), or trachea (knot along the centerline of the face). Further complications arise because the noose can be placed high or low on the neck, with potentially different intermediate results. When high, it is less likely to compress the airway because some of the pressure from the ligature may be transferred to the jaw or skull. DO PEOPLE DIE FROM AIRWAY BLOCKAGE OR FROM CUT-OFF BLOOD CIRCULATION TO THE BRAIN? Bodies with little weight on the ligature, that is, which are prone or seated, have a greater chance of death from asphyxia, according to a standard forensic text. Since the jugular vein (blood out) is easier to compress than the carotid artery (blood in), enough blood accu- mulates in the head and neck to compress the airway, leading to asphyxia. Medical experts disagree about the frequency and importance of airway blockage in hangings. For example, one says, "Occlusion of the air passage by constriction on the neck is probably extremely rare if existing at all. Others hedge their bets: "Suicidal hanging is ear- marked characteristically as causing death by compression of the anatomic airway and the blood vessels in the neck." Or cover all the bases: "Reports in the forensic literature have stated that death may be due to either asphyxiation, coma, carotid artery or jugular vein injury, or any combination of the above." Certainly, airway blockage is not essential to successful hanging. In one case a woman with a tracheotomy killed herself despite attaching the ligature above the site of the breathing hole. She would have continued breathing until dying from lack of blood to her brain. Airway blockage is more likely when: 1. the ligature knot is toward the back of the neck. In this situation the maximum pressure from the rope is then on the front of the neck, where the airway is. 2. the person is seated, semireclining, or prone. Due to little weight on it, the rope tends not to slide up the neck. Were it to move up, it would end up being partially supported by the chin, relieving pressure on the airway. 3. the ligature is thin or attached with a running noose. Such a ligature tends to clamp in place. 4. the ligature is placed low on the neck, where it tends not to slide up high enough to be supported by the chin. TYPE OF KNOT Most common are the running noose (loop at one end, through which the other end is pulled) and the fixed noose with a granny or reef knot. POINT OF SUSPENSION As with their indiscriminate choice of ligatures, suicidal people suspend themselves from whatever site is handy. Stair rails are popular, as is tying one end of the ligature to a doorknob and tossing the other end over the top of the door. Hooks and nails are useable, but may bend or pull out if not sturdy and firmly attached. Often a chair that the victim stood on is nearby, but total suspension is quite unnecessary; a majority of such suicides have their feet touching the ground. POSITION OF THE BODY In one study, 37 percent (30 in 80) of hanging victims were completely suspended; 63 percent (50 in 80) were in contact with the ground. This is credible, since all it takes to carry out a standing hang is to bend the knees enough to tighten the ligature. In 261 cases of incomplete suspension, 64 percent (168) had both feed touching the ground, 16 percent (42) were on their knees, 11 percent (29) were lying down, 7 percent (19) were sitting, and 1 percent (3) were huddled or squatting. STRANGULATION is defined as pressure applied to the neck without suspension of the victim. It is uncommon in suicide, but not unknown. The physiology of strangulation is essentially the same as that of suspension hanging and needs not to be treated separately. In self-strangulation, the ligature is applied more slowly and less tightly than in suspension hanging. As a result, the jugular veins are more constricted than are the carotid arteries, leading to a blue, swollen head. Neck injuries, however, are rare. Because the ligature cannot slide up the neck or be supported by the chin, compression of the airway is more likely than in suspension hanging. CONSEQUENCES: WHAT ARE THE EFFECTS OF HANGING? There is not much information from survivors for two reasons: (1) There are not many survivors, and (2) often, survivors have more or less complete amnesia. In one case, a woman tried to hang herself from the foot of her bed, while in jail. She was saved by a fellow prisoner. She later mentioned having had severe pain, followed by unconsciousness. In another instance a public entertainer, who hung himself briefly as part of his act, made a mistake of timing. He said (afterwards) that he could not breathe - quite understandable, under the circumstances - and felt as if a heavy weight was on his feet. He lost consciousness before he could move his hands to release himself. There is additional information from experimental hanging. In one description the subject mentioned flashes of heat and light, and deafening sound. Legs were numb and weak. Pain was not severe and unconsciousness was sudden. More detailed information came from another self-experimenter named Minovici. With 5 kg (11 lb) pull on the ligature, loss of consciousness was rapid. When he leaned on the rope (incomplete suspension), within five or six seconds his eyes blurred, he heard whistling, and his face turned red-violet. With the knot on the side instead of the back of the neck, these effects took eight or nine seconds to appear. When he tried complete suspension, as soon as he left the ground, he couldn't breathe or hear his assistant. He experienced such severe pain that he immediately stopped the test. Within ten minutes, many small hemorrhages could be seen near the site of the rope; these remained visible for eight to eleven days. For ten to twelve days later he had watering eyes, trouble swallowing, and a sore throat. After unconsciousness, convulsions follow. In trashing around, the victim may make enough noise to attract attention, wanted or unwanted. HOW TO DO IT, SUSPENSION HANGING (1) Can be done with a wide range of ligature materials - most anything will work; (2) can be carried out by invalids, without leaving their room; (3) is fairly quick, probably not painless (but unconsciousness is rapid), but may have severe consequences - brain damage - if interrupted; (4) doesn't require much knowledge to accomplish. To carry out a suspension hanging, you can simply tie one end of the ligature to a fixed point (doorknob, hook, rafter, etc.) and the other end to your neck. You can and should protect the airway from unnecessary compression and pain by firmly padding the front quarter of the neck and (more important) by placing the knot high and at the front of your face. Complete suspension is unnecessary and is generally more painful than partial suspension; however, standing on and kicking away a chair is sometimes done in the same spirit as diving, rather than wading, into icy water. Unconsciousness occurs quickly and without enough warning to count on time to change your mind: This is a lethal method and is not suitable for a "suicidal gesture." You need an uninterrupted twenty minutes (half an hour to take into account last-minute vicissitudes) to be sure that you won't be cut down and "saved" with permanent brain damage. Since you may trash around while unconscious, take into account the possibility of attracting unwanted intervention because of the noise. Because the cadaver is sometimes gruesome and always shocking, consider not hanging yourself where loved ones will find the body. If you use a hotel or motel, leave a good tip for the cleaning person. HOW TO DO IT, DROP HANGING (1) Requires a strong, low-stretch rope. Manila (sisal) or hemp works; (2) Requires a 5 to 15 foot drop (see drop table or calculations); (3) is quick, possibly painless - nobody knows, and none of the questionaires have been returned - and generally cannot be interrupted once set into motion; (4) requires detailed knowledge of how and where to attach rope, how and how far to jump (down, but not out), and a place to jump from. To execute a drop hanging, the drop distance can be estimated as follows, drop in feet = 1260 / your weight in pounds The type of knot is not important as long as it doesn't loosen. However, its position is, unlike in suspension hanging, critcal, The knot should be as near the chin as convenient, and in any case no further back than the cheekbone. Note which way the knot rotates when pulled up, and adjust it to the side of your head so that it will rotate toward the chin and snap the head backwards. If it ends up behind the ear, it will be much less likely to produce a cleanly broken neck, and may leave you to strangle unpleasantly. The drop should ne as close to straight down as possible; don't take a running jump. The rope should be at least an inch thick and must not be one intended to stretch in order to ease a fall, for example moutain-climbing rope. Attach the other end to something that won't break or come loose. This method is harder to get the hang of than is suspension, and is not recommended unless you're confident that you fully understand it. Mistakes usually transpose into some unpleasant form of suspension hanging, unless the rope breaks. HOW TO DO IT, STRANGULATION If, for some reason, there is no attachment point available for a ligature, strangulation is a possibility. This method consists of wrapping a cord around your neck and tightening it. The disadvantages are: (a) Depending on the amount of tension applied, it may compress your airway as well as the major blood vessels (carotid and/or jugular) unless you protect the front of the neck; (b) since there is no weight on the ligature, it may loosen when you become unconscious. Some methods to solve this latter problem are: -use a high-friction ligature that will stay in place; -use a double knot; -wrap thin cord, as many times as possible in five to ten seconds, around your neck, relying on friction to maintain the tension. A slip knot is helpful, but may loosen unless wrapped; -make a loose loop around your neck. Insert a thin, rigid item, for example, a wooden spoon or pen, between the neck and the loop, and twist the rod until it tightens the ligature; then tuck the end of the rod between the neck and the cord to keep it in place. If you use a bar that is around 8 inches (20 cm) long, there is a good chance that it will stay in place under your chin even if not tucked in. The most reliable of these methods is to buy a racheting "tie down." These are available at auto, motorcycle, and some hardware stores for between $5 and $10 and are generally used for attaching cargo. Once tight, a spring-loaded cam release (or equivalent) must be pressed to remove tension. Bending forward increases the diameter of the neck , and thus the constrictive effect of the ligature. ------------------------------------------------------------------------------- HYPOTHERMIA Hypothermia. (hypo, low; thermia, temperature) is an effective, but infrequent used suicide method. It is a poor choice for a suicidal gesture, unless one is sure of timely intervention. FATALITY RATE: More than 30 percent PERMANENT INJURIES: Moderately likely PROS AND CONS OF HYPOTHERMIA FOR SUICIDE Pros: -Not severly painful -Often lethal in the absence of intervention -Requires no special equipment and minimal knowledge -Usually some time to change your mind, without ill effects Cons: -Rate of hypothermia highly variable: dependent on one's physical fitness and body fat content as well as on temperature and weather conditions -Sometimes severe injury in survivors -Requires temperatures that are seasonally and geographically limited -May take a long time -Victims may be revivable even several hours after clinical death -Insidious: people often don't notice signs of hypothermia in themselves WHAT IS HYPOTHERMIA? The freezing point of water, under standard conditions, is 32 degrees F (0 degrees C) and its boiling point is 212 degrees F (100 degrees C). Normal human body temperature is around 98.6 degrees F (37 degrees C) and is tightly regulated by a variety of physiological mechanisms. Even a 3.6 degrees F (2 degrees C) change is significant; a 5.4 degrees F (3 degrees C) fever is medical emergency. Systematic hypothermia is generally defined as a body temperature below 95 degrees F (35 degrees C). Severity is rated by how low the core body temperature falls: 89.6 to 95 degrees F (32-35 degrees C) is mild hypo- thermia; 80.6 to 89.6 degrees F (27-32 degrees C) is moderate; below 80.6 degrees F (27 degrees C) is severe. Hypothermia is also divided into "acute" and "chronic" categories. Acute hypothermia occurs quickly, roughly within two or three hours; chronic hypothermia takes longer. While the boundary is fuzzy, the distinction is more than academic, since both treatment and prognosis differ between the two. WHAT CAUSES HYPOTHERMIA? Hypothermia occurs when the quantity of body heat lost to the external environment substantially exceeds the heat generated from metabolism. This can be caused by a decrease in heat production, or in an increase in heat loss, or both. HEAT PRODUCTION Low heat production is usually due to insufficient food, illness, injury, or some drugs. An average resting body gives off about 50 kilocalories (kcal) or "kitchen" calories - the same calories you see on food labels - of heat per square meter of skin per hour. Multiplied by the average person's 1.7 square meters of skin and 24 hours, you lose around 2000 kcal per day to the out- side world, which is about the amount that you generate at rest from the food that you've eaten. This is called "basal metabolism." If your muscles are working, metabolic heat production goes way up. For example, while you're shivering, you generate roughly five time as much heat as when sitting quietly; while exercising, ten times as much. However, exercise is a two-edged sword in hypothermia. While it produces heat. which is needed to keep body and mind functioning, it also increases blood flow to your active muscles, ant thus heat loss from them. In addition, it uses up energy stores quickly. The decision whether to exercise in a potentially hypothermic situation depends on the circumstances: How long the conditions are expected to last, availability of food and shelter, and need for clear thinking. To some degree there is no choice in the matter: shivering is a form of involuntary exercise. It increases heat production by 200 to 700 percent, but is accompanied by an increase in blood flow to/from muscles, resulting in about a 25 percent increase in heat loss, too. Shivering is an effective means of generating heat, until muscles run low on energy. HEAT LOSS Excessive heat loss is due to cold surroundings or to a failure in the body's temperature regulating mechanism. There are four physical mechanisms of heat loss: 1. Convection: heat loss by means of molecular transfer of energy via air or water currents. 2. Conduction: heat loss by touching something that's colder tha you are. This is, fundamentally the same process as convection, but mostly applies to solids. 3. Radiation: heat loss from invisible infrared-wavelength energy you give off. 4. Evaporation: heat loss from the cooling effect of changing a liquid into a gas. Looking at these in more detail: CONVECTION AND CONDUCTION Most heat loss in hypothermia is from contact with cold air or cold water: You're always generating a micro-environment of warm air (or water, if that's where you are) around your body., but this is easily stripped away by air/ water currents or your own movements. The rate of convective heat loss also depends on the density of the moving substance (heat loss in water is much faster than in air of the same temperature) and the velocity of the moving substance (the faster the air/ water current, the faster the heat exchange). Another variable in heat loss is surface area. The more surface are, the more heat transfer. Curling up in the fetal positon minimizes heat exchange by minimizing surface area, and thus evaporation, radiation, and convection. It may also be comforting for atavistic reasons. WIND Wind speed is the cause of the often-misunderstood "wind-chill factor." "Wind chill" is just a practical demonstration of air convection and involves nothing more complicated than wind removing the warmed (by you) air molecules from near your body and replacing them with cold ones. This results in your body being hit by more cold air molecules per minute, and so being cooled more. For example, 0 degrees F (-18 degrees C) with no wind causes heat loss at the same rate as 30 degrees F (-1 degrees C) and 25 mph (40 kmh) breeze. However, the latter case would not drop below 30 degrees F (-1 degrees C), in the absence of evaporative effects. EVAPORATION A second consideration, which is not technically part of wind-chill factor calculations but is biologically important, is that more wind will cause faster evaporation of sweat. This will remove from your body around two and a half kilocalories per teaspoon of evaporated sweat, and thus additional cooling. Evaporation cools you because energy (heat) is always required to change a liquid into a gas. If the liquid is on or near your skin (sweat, water, or wet clothing), the heat comes from you, leaving you cooler. This is handy in the desert, but not so good if you're trying to keep from freezing. Thus, a dry body will cool faster in the presence rather than in the absence of wind ("wind-chill"), but it won't get below ambient temperature. A wet body in the wind will cool both faster and furher, and may drop far below ambient temperature. CAUSE OF DEATH Death is generally from circulatory failure: The heart either goes into ventricular fibrillation or slows down and stops altogether. In people who have suvived the first couple of days after rescue, organ failure, particulary of the pancreas, may lead to delayed death. A wide range of oher organs also may show acute damage from cold, but these injuries, while sometimes severe, are not usually fatal. SIGNS AND SYMPTOMS OF HYPOTHERMIA The following chart shows the body core temperature and corresponding signs and symptoms. 99-97F (37-36C) Normal temperature range, shivering may begin 97-95F (36-35C) Cold sensation, goosebumps, unable to perform complex tasks with hands, shivering mild to severe, skin numb 95-93F (35-34C) Shivering intense, lack of muscle coordination becomes apparent, movements slow and labored, stumbling pace, mild confusion, may appear alert, uable to walk straight 93-90F (34-32C) Violent shivering persists, difficulty speaking, sluggish thinking, amnesia starts to appear and may be retrograde, gross muscle movements sluggish, unable to use hands, stumbles frequently, difficulty speaking 90-86F (32-30C) Shivering stops in chronic hypothermia, exposed skin blue or puffy, muscle coordination very poor with inability to walk, confusion, incoherent, irrational behavior, but may be able to maintain posture and the appearance of awareness 86-82F (30-27.7C) Muscles severely rigid, semiconscious, stupor, loss of awareness of others, pulse and respiration slow, pupils can dilate 82-78F (27-25.5C) Unconsciousness, heart beat and respiration erratic, pulse and heart beat may be unobtainable, muscle tendon reflexes cease 78-75F (25-24C) Pulmonary edema, failure of cardiac and respiratory centers, probable death. Death may occur before this level SOME RISK FACTORS: ALCOHOL, DRUGS, EXERCISE The role of alcohol in hypothermia is controversial. On the one hand, it predisposes to hypothermia by several mechanisms: 1. It produces an increase in blood flow (and thus heat loss) near the skin ("cutaneous vasodilation"). Since the skin contains many temperature receptors, drinking alcohol generates a sensation o f warmth, but this comes at the expense of internal heat; 2. Alcohol causes hypoglycemia (low blood sugar), which decreases the body's ability to produce heat; 3. As a central nervous system depressant, alcohol slows metabolism and promotes sleepiness; 4. And certainly alcohol impairs judgement, which may be critical under adverse conditions. Many hypothermia victims have blood alcohol concentrations (BAC) ranging form 0.13 to 0.25 gm/100 ml blood. "Legally impaired" in most of the United States is 0.08-0.10 gm/100 ml BAC. Since exercise also increases blood flow to the skin, the combination of alcohol with strenuous exercise would seem to cause maximum heat loss. On the other hand, alcohol appears to protect the heart against fibrillation (and has been used for that purpose during low-temperature medical operations, at levels of 0.40 gm/100 ml blood.) Perhaps this protective effect causes the observed higher survival rate in hype- thermics who had been drinkin, compared to those who were sober. In addition, alcohol protects limbs against frostbite (freezing) by increasing the blood flow, but again, this is at expense of core temperature. Some other drugs that have central nervous system depressant effects can also produce hypothermia, for example barbiturates opiates, and the "major tranquilizer" chlorpromazine (Thorazin) and related compounds; but also some nonsedatives like acetaminophen (Tylenol) and lithium ion (used to treat manic-depressive behavior). These drugs interfere with temperature regualtion at the hypothalamic regulatory center in the brain, and may cause hypothermia even at room temperatures. Of 103 consecutive Intense Care Unit drug overdose admissions, twenty-seven were hypothermic. HOW LONG DO PEOPLE SURVIVE UNDER COLD STRESS? In one recent study, eight of eleven people with deep hypothermia and cardiac arrest were resuscitated. Five of the eleven had no heartbeat and six had ventricular fibrillation. None were breathing and all were clinically dead with wide, nonreactive pupils, and were supported by external heart massage and ventilation (CPR). The average (mean) length of exposure to the cold in the survivors was 4.4 hours, and average core temperature was 72.5 degrees F (22.5 degrees C). All three of the patients who died had also been asphyxiated (one in an avalanche, two in drownings). HOW TO DO IT, ON LAND Make arrangements so you won't be looked for: for example, tell people you're going away for a few days. Go to a cold, secluded spot where you won't be seen. Drink alcohol and/or take sedatives. You can speed up the process by removing clothing and/or getting wet. Obviously, the ammount of time needed will also be very dependent on temperature and wind conditions, and your size, weight, and fat content. These are too many variables to make even rough time estimates. Use of a home freezer has been recommended, but the air supply in such freezers is so limited that asphyxia will occur long before hypothermia. Commercial freezers are a possibility, but the risk of untimely discovery must be considered. HOW TO DO IT, IN WATER Since heat loss in water is much faster than in air of the same temperature, the amount of time that one is subject to being saved is correspondingly diminished. The main concern will be to avoid being seen, both to avoid unwanted rescue and to prevent risk to potential rescuers. Depending on the temperature of the water and your physical condition, fatal hypothermia can occur in as little as thirty minutes or so; less after alcohol and/or sedatives. Be aware that unless the water is very shallow (and even then if you end up facedown), you are likely to actually die of drowning while insensible from cold, rather than from hypothermia. ------------------------------------------------------------------------------- JUMPING LETHAL INTENT: High FATALITIES: 40 to 60 percent PERMANENT INJURIES: Frequent PROS AND CONS OF JUMPING AS A SUICIDE METHOD Pros: -Usually fatal, with a high enough jump site -Some contemplation time on the way down Cons: -Can't do much about it once you're in the air -Not reliably lethal for jumps of less than 150 feet -High incidence of permanent injury -Risk for injuring others -Fear of heights is common Jumps from higher than 150 feet (ten to twelve stories high) over land and 250 feet over water are almost always fatal; however, most suicide attempts are made from considerably lower heights. The consequences of lower jumps are unpredictable. Permanent injuries, including paralysis are common. Jumping is thus a particulary bad choice for suicidal gesture. There is about a fifty-fifty chance of surviving a one-story (12 foot) fall if you land on your head; three to four stories if you land on your side; four to five stories if you land on your feet. The word "jumper" was apparently used in the Codebook of Federal Security Agencies to describe someone attempting suicide by jumping from a height. The term has commonly come to include accidental and homicidal high falls, which is how we'll use it. The two major questions a potential jumper might want answered are: Is jumping a reliable way to kill yourself? The short answer is that it's about 95 to 98 percent lethal if you fall more than 150 feet (ten to twelve stories) over land - but sometimes a much shorter fall is fatal (2.5 feet in one case). What are the risks of long-term injury among those surviving a fall? Short answer: quite high; more than half the survivors in one study were either still hospitalized or permanently unable to work a year after their jump. ------------------------------------------------------------------------------- ORIGINAL TABLE OF CONTENTS Part I: Background Chapter 1: A Brief Overview of Suicide Chapter 2: History of Suicide Chapter 3: Three Ways to Study Suicide Chapter 4: Why People Attempt Suicide Chapter 5: Youth Suicide Chapter 6: Suicide in the Elderly and Other Groups Chapter 7: Some Frequently Asked Questions About Suicide Chapter 8: Is Suicide Appropriate? Is Intervention Appropriate? Who Decides? Chapter 9: Assisted Suicide in Terminal Illness Chapter 10: The Medical System in Terminal Illness Chapter 11: Pain Control and Hospice Care Chapter 12: Advance Directives: Living Will, Power of Attorney for Medical Decisions, and Do Not Resuscitate Orders Chapter 13: Some Practical Issues in Assisted Suicide Chapter 14: Euthanasia in the Netherlands Chapter 15: Euthanasia and Assisted Suicide in the United States Part II: SUICIDE METHODS Chapter 17: Asphyxia Chapter 18: Cutting and Stabbing Chapter 19: Drowning Chapter 20: Drugs, Chemicals, and Poisons Chapter 21: Electrocution Chapter 22: Gunshot Wounds Chapter 23: Hanging and Strangulation Chapter 24: Hypothermia Chapter 25: Jumping References, Suggested Reading, Afterward, Index -------------------------------------------------------------------------------