The patient was already on the operating room table when the other transplant surgeons and I arrived to begin the surgery that would remove his liver, kidneys, pancreas, lungs and heart. He was tall, with legs that extended to the very end of the table, a chest barely wider than his 16-year-old hips, and a chin covered with pimples and peach fuzz.
He looked like any one of the boys I knew in high school.
Those of us in the room that night knew his organs would be perfect — he had been a healthy teenager before death — but the fact that he had not died in a terrible, mutilating automobile or motorcycle crash made us all that much more certain.
The boy had hanged himself and had been discovered early, though not early enough to have survived.
While I had operated on more than a few suicide victims, I had never come across someone so young who had chosen to die in this way. I asked one of the nurses who had spent time with the family about the circumstances of his death. Was he depressed? Had anyone ever suspected? Who found him?
“He was playing the choking game,” she said quietly.
I stopped what I was doing and, not believing I had heard correctly, turned to look straight at her.
“You know that game where kids try to get high,” she explained. “They strangle themselves until just before they lose consciousness.” She put her hand on the boy’s arm then continued: “Problem was that this poor kid couldn’t wiggle out of the noose he had made for himself. His parents found him hanging by his belt on his bedroom doorknob.”
The image of that boy and of the dangling homemade noose comes rushing back whenever I meet another victim or read about the grim mortality statistics associated with this so-called game. But one thing has haunted me even more in the years since that night. As a doctor who counts adolescents among her patients, I knew nothing about the choking game before I cared for a child who had died “playing” it.
Until recently, there has been little attention among health care professionals to this particular form of youthful thrill-seeking. What has been known, however, is that children ages 7 to 21 participate in such activities alone or in groups, holding their breath, strangling one another or dangling in a noose in the hopes of attaining a legal high.
Two years ago the Centers for Disease Control and Prevention reported 82 deaths attributable to the choking game and related activities. This year the C.D.C. released the results of the first statewide survey and found that one in three eighth graders in Oregon had heard of the choking game, while more than one in 20 had participated.
The popularity of the choking game may boil down to one fact: adolescents believe it is safe. In one recent study, almost half of the youths surveyed believed there was no risk associated with the game. And unlike other risk-taking behaviors like alcohol or drug abuse where doctors and parents can counsel teenagers on the dangers involved, no one is countering this gross misperception regarding the safety of near strangulation.
Why? Because like me that night in the operating room, many of my colleagues have no clue that such a game even exists.
This month in the journal Pediatrics, researchers from the Rainbow Babies and Children’s Hospital in Cleveland reported that almost a third of physicians surveyed were unaware of the choking game. These doctors could not describe any of the 11 warning signs, which include bloodshot eyes and frequent and often severe headaches. And they failed to identify any one of the 10 alternative names for the choking game, startlingly benign monikers like Rush, Space Monkey, Purple Dragon and Funky Chicken.
“Doctors have a unique opportunity to see and prevent this,” said Dr. Nancy E. Bass, an associate professor of pediatrics and neurology at Case Western Reserve University and senior author of the study. “But how are they going to educate parents and patients if they don’t know about it?”
In situations where a patient may be contemplating or already participating in choking activities, frank discussions about the warning signs can be particularly powerful. “The sad thing about these cases,” Dr. Bass observed, “is that every parent says, ‘If we had known what to look for, we probably could have prevented this.’ ” One set of parents told Dr. Bass that they had noticed knotted scarves and ties and a bowing closet rod in their son’s room weeks before his death.
“They had the telltale signs,” Dr. Bass said, “but they never knew what to look for.”
Nonetheless, broaching the topic can be difficult for both parents and doctors. Some parents worry that talking about such activities will paradoxically encourage adolescents to participate. “But that’s kind of a naïve thought,” Dr. Bass countered. “Children can go to the Internet and YouTube to learn about the choking game.” In another study published last year, for example, Canadian researchers found 65 videos of the choking game from postings to YouTube over an 11-day period. The videos showed various techniques of strangulation and were viewed almost 175,000 times. But, Dr. Bass added, “these videos don’t say that kids can die from doing this.”
Still, few doctors discuss these types of activities with their adolescent patients. Only two doctors in Dr. Bass’s study reported ever having tackled the topic because of a lack of time. “Talking about difficult topics is really hard to do,” Dr. Bass noted, “when you just have 15 minutes to follow up.”
But it is even harder when neither doctor nor patient has any idea of what the activity is or of its lethal consequences.
Based on the results of their study, Dr. Bass and her co-investigators have started programs that educate doctors, particularly those in training, about the warning signs and dangers of strangulation activities. “The choking game may not be as prominent as some of the other topics we cover when we talk with patients,” Dr. Bass said, “but it results in death.”
And, she added, “If we don’t talk to doctors about this issue, they won’t know about the choking game until one of their patients dies.”
PAULINE W. CHEN
February 25, 2010
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