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The Ohio Supreme Court recently ruled that Coroners may retain organs during death investigations.

This is a profound victory for Medical Examiners and Coroners, and is one small step in stopping the increasing criminalization of our profession.  It has always been interesting to watch people’s perceptions of my work as a Medical Examiner — they are both fascinated and repelled.  Both reactions are understandable, but unfortunately both are dangerous when people pander to them.

Pandering to the fascination is dangerous because it leads to unrealistic expectations of what we can do.  The infamous “CSI effect” (though studies have indicated that it is overstated) can lead jurors to expect that we should do unnecessary and expensive tests on cases that don’t require it, and further that we should be able to provide exact answers to questions when we cannot.  A classic case is that of “time of death.”  In the movies, the ME looks at the body and says “he clearly died between nine and nine-thirty last night.”  It never works that way.  The traditional methods of determining time since death (cooling of the body, rigor mortis, livor mortis, etc), are filled with error.

Consider rigor mortis.  Rigor mortis is the stiffening of the body after death.  It is the result of the particular biochemistry of muscles.  It turns out that the molecules that make muscles contract act like a ratchet — there is one molecule that is a long string with teeth on it, and another that is a hinged arm that catches and pulls those teeth.  The important thing to note is that *both* the pulling of the teeth *and* the release of them requires energy.  Thus, while it takes obvious energy to, say, flex your arm, it *also* takes energy to relax it and allow the arm to fall. The use of that energy requires oxygen (by the generation of a high energy molecule called adenosine triphosphate, or ATP), which the cells get from the bloodstream.  In addition to the oxygen in blood, muscles also maintain their own limited supply of oxygen in the form of myoglobin.  When the body dies and blood flow stops, the muscles continue to use that myoglobin to allow the formation of the energy molecules that power the cells, both to maintain the cellular structure and to allow movement of the limbs.

Of course, the nerves are no longer telling the muscles to move once a person is dead, but an observer can passively cause them to move by lifting the limbs and moving them.  That movement will use energy from that limited supply.  After awhile, that limited supply is gone, and the muscles become stiff — there’s no energy to disengage that ratchet mechanism.  The muscles remain stiff until the ratchet itself starts to fall apart as part of decomposition, at which point the muscles relax.

 Consider all of the things that are involved here:  the storage of energy, the use of energy, the pace of cellular metabolism, etc. All of these have a lot of variables.  If a person had been exercising (such as running away from or fighting an assailant), then there will be less energy stored.  If it is hot, then all the cellular processes speed up; if it is cold, then they all slow down.  If the body is clothed or obese, it will cool more slowly, and thus the cells will stay more active and use up energy faster.  Toxins and drugs can affect it. Disease can affect it.  And on and on and on.

Thus, the use of rigor for the determination of time of death is a broad estimate, as are the other indicators.  Most Medical Examiners don’t give an estimate of time of death based purely on these features.  Instead, they ask “When did someone last see him alive?” and see whether or not that’s consistent with the changes.  If someone says “Yesterday” and the body is fully skeletonized, then it’s probably inconsistent.  That 15-minute window they give you on Law and Order simply doesn’t exist.  Unfortunately, sometimes juries think it does, and will misjudge evidence when they hear it.

Pandering to the revulsion, however, is even worse.  It’s worse because it misrepresents our motivations and gives the absolutely wrong impression about what we do.  And the legislation that panders to it is destroying forensic medicine in the US.  Why?  Because it, in a slow and creeping manner, is criminalizing what we do.

 The best example is the so-called “Dale Earnhardt” law in Florida, which makes it a class D felony for Medical Examiners to share images of cases with each other.  The law arose from a FOIA (or FOIA-equivalent) request for autopsy photographs of Dale Earnhardt after his NASCAR accident.  Understandibly, the family did not want those photographs used for exploitation.  However, the law was written so that Medical Examiners could not easily use cases for teaching and certainly not for research or publication.  The law has, I believe, been tweaked, but the bottom line is that it has had a profoundly chilling effect on forensic pathology education and research in Florida.  Why?  Because even if the law is written fairly liberally, Medical Examiners will choose to be “safe than sorry,” which means that there is no reason to stick our necks out.  Even if some of the things that Medical Examiners shy away from may be within the line of legality, who needs the hassle of being investigated or sued?

I have had colleagues in Florida ask me for case illustrations for their lectures and testimony because they believe that they cannot legally use their own case photos.  In a recent case of alleged malpractice against a Medical Examiner, *neither* the accusers nor the target of the allegations were allowed to show the photograph that would have trivially answered the issue at hand.

Other laws in other states have essentially made all research impossible other than datamining old cases for statistics.  The only way that we can do research is somehow contrive the process as part of an investigation.  I personally have some very intriguing findings involving child abuse that I am sitting on simply because I am not sure of  legal liability issues for performing some of the tests I performed.  I don’t believe I did anything illegal, and can justify everything I did as part of my investigations, but why risk the hassle?  If I publish, I might have a problem.  If I don’t, I know I won’t.  The choice is simple. The legislatures of these states have simply determined that they would prefer to have unsolved child homicides and pander to the hyperbole of the press.

 After all, it’s *easy* for a legislator to propose a law limiting what we do.  Who *really* cares about advances in forensic medicine — it’s an abstract kind of thing that *other* states can do.  On the other hand, a family member tearfully complaining that their loved one was some how abused by having a piece of tissue tested after their death makes great press and great politics.

A new twist on this is the issue of organ retention.  In many postmortem examinations, the significant pathology is not obvious at the time of the initial dissection.  Instead, the tissues must be treated with preservatives and dissected or analyzed using special procedures.  This takes time.  In order to allow the family to bury its dead, we release the body but keep the organ in question for examination.

This is particularly true of the brain.  In life, the brain is a gelatinous organ with the consistency of Jello.  It is essentially impossible to do fine dissection on a fresh brain.  In most cases, where the brain is obviously not involved with death (such as a gunshot wound to the chest), we just slice through the brain to look for something unusual.

In cases where important pathology may be in the brain, however, it is often necessary to “fix” the brain prior to dissection.  In this, we place the brain in a large container of formalin and allow the formalin to diffuse into the tissue.  Because the formalin diffuses in very slowly, we commonly allow the brain to fix for up to six weeks before beginning the dissection.  During the dissection, the brain is reduced to numerous small fragments, some of which are processed for histology and the rest, at most places, incinerated.

A family took exception to this in Ohio, and a class action lawsuit was brought against the Ohio Coroners.  In a clear example of good sense, the Ohio courts found in favor of the Coroners.  The plaintiffs are now appealing to the federal courts. 

 As always, the Coroners are being cast as people who don’t care about the dead or their families and who are doing this out of some sort of spite.  They ignore that we do this for a *purpose.* An editorial in the Columbus Dispatch plays on that theme and notes:

 Coroners fear that giving such property rights to families could impede law-enforcement investigations and delay autopsies. This need not be the case.

Criminal cases should take priority, and that can be spelled out in legislation.

This ignores the fact that in many of these cases in which the organs are retained to *determine* whether or not it is a “criminal case.” If we knew beforehand, we might not need to do the study.  Even notification issues are not as trivial as many seem to think.  Issues of *who* is really next of kin are often nontrivial, both in cases where none is known, but also in cases of atypical families where the determination of who really is the next of kin ends up in court.  What happens when we notify the “wrong” next of kin?  These issues arise a lot; the Medical Examiner office is not the place to make those determinations, and we should not be made liable when we fail after acting in good faith. 

We are trying to answer questions about cause and manner of death important to the law, important to public health, and important to the families themselves.  We care deeply about these issues and about the families and the dead.  But more, we care about the truth.  We believe we owe it to the victims and to society to provide the best answers we can.  And, unfortunately, sometimes that means that we have to do things that the next of kin don’t like.

 I remember when I was a medical student many, many years ago.  I was in a jurisdiction where the next of kin had to give permission for an autopsy at all — even a forensic one.  As you probably know, the next of kin are frequently the culprits in homicides of family members.  When this is the case, they are unlikely to consent to an autopsy.  I had a patient who suffered “the dwindles” — slow weight loss, uncertain peripheral neuropathy, headaches, nonspecific mental symptoms, etc.  He died shortly after admission.

I and a friend suspected arsenic poisoning, but the next of kin refused an autopsy.  I snuck into the morgue, collected a hair sample, and tested it myself.  It was full of arsenic.  I asked about what to do, and was told that what I had done was likely illegal, and was not admissible in court in any case.  It was clearly a murder, but the law about autopsies did not allow investigation.

We have come some ways in the past 30 years away from that, but the movement is now to return to magical thinking about forensics, play on that stereotype of the Medical Examiner as some sort of ghoul that lives in the basement,  and applaud the criminalization of forensic medicine. A few months ago, I was vigorously criticized for doing an extensive subcutaneous dissection on a baby (where the skin is largely peeled away to look for underlying bruises) as “mutilating” the baby so that she couldn’t have an open-casket funeral.  In fact, a good funeral home could have prepared the baby for an open casket funeral; it simply didn’t want to do the work.  But even if the claim were true, and while I certainly understand the desire for such a kind of funeral, I believe that the mother’s anger would have been better directed at the boyfriend who beat the child to death.  Instead of attacking me for providing evidence of that beating, I believe that it serves a better purpose to use that data to prosecute the murderer.

These attacks on my profession are now occuring as those same lawyers who want to inhibit research and testing complain about the quality of “science” in forensic medicine.  Most Medical Examiners agree that we need more research in forensic medicine.  Unfortunately we are not funded for it — most Medical Examiner’s offices are local offices with poor funding, and the medical establishment prefers to fund other initiatives.  But, in fact, many Medical Examiners would love to do independent research even on their own time and on their own dime; many projects would not require a great deal of money.  However, we face the further hurdle that most such projects are now illegal — to the point that even sharing data between pathologists is a felony — all because of pandering to the kind of hyperbole that legislators, the press, and the public find so appealing.

 You can’t have it both ways. You can’t complain about the state of science in forensic medicine, and place such hurdles to investigation that it is either financially ruinous to a small office, or illegal altogether.

 We care deeply about those victims we investigate.  We care deeply about their families.  When members of our families die, we share the same experience.  Unfortunately, sometimes you can’t serve both the truth and the feelings of survivors.  We try to accomodate families as much as we can, but this trend to remove discretion from us, and to criminalize our basic work will do a *real* disservice to the families of victims.  It limits of what we can do now, and by stopping the progress of forensic science it keeps us from providing better answers in the future.

Technorati Tags: autopsy, Ohio, organ retention, forensic medicine, forensic pathology, medical examiner

UPDATE: Read my disclaimer. Don’t run crying to my employer. They have nothing to do with this.

This is the sixth in my series on the politically motivated witch hunt against Dr. Charles Siebert for making a politically incorrect, but medically correct, diagnosis. The first installment is here. The second installment is here. The third installment is here. The fourth installment is here. The fifth installment is here.

The lynching of Charlie Siebert by Gov. Crist and the Medical Examiner Commission (MEC) of Florida is reaching it’s final stages.  Even at the end, the MEC has managed to achieve a new level of perfidy.

 Dr. Siebert is, of course, appealing the false accusations made against him, and it does not look good for the MEC — even their own outside consultant has stated that the charges are not supportable.  They know they are going to lose, and that Dr. Siebert will be vindicated. 

 What to do?  Well, if you are the MEC, the answer is simple — treachery.  The MEC went to Dr. Siebert and said they would not be prepared for the hearing by the late 2007  trial date, and requested a continuance.  Dr. Siebert said OK. 

 In the meantime, the search committee for the new appointee decided that, since Dr. Siebert was applying for reappointment, it would only be fair to allow Dr. Siebert to clear his name before making a recommendation.  The MEC, in a profoundly treacherous and cynical move, denied the committee’s request for a delay, said it would ignore the recommendation of the search committee, and that it would make a recommendation to Gov Crist on December 29 of Dr. Dan Davis, an applicant from Arizona.  Since Dr. Siebert would no longer be employed as a Medical Examiner he would no longer have standing for appeal, and the MEC would never have to face a judge’s ruling on its attacks.  They could not win an appeal, so they used their own request for a delay to deny Dr. Siebert his day in court.

But then, what else would you expect from such a politicized and corrupt system?

The endgame continues, though Dr. Siebert will probably end up hurt no matter what happens.  After the MEC said they would ignore the search committee’s recommendation and nominate Dr. Dan Davis (the only other applicant by this time), the search committee went ahead and recommended Dr. Siebert.  The MEC said that it would still nominate Dr. Davis. 

This grotesque behavior by the MEC roused the National Association of Medical Examiners to write an open letter stating that the MEC was “dishonestly misrepresenting the facts of their investigation,” demanded a public retraction of the claim that the MEC was using NAME standards for its evaluation and noted that the MEC had severely damaged the credibility of the Florida ME system by its politicization of this case.

 An independent group of over 20 Medical Examiners from around the country and Australia cosigned an open letter published in the Tallahassee Democrat that states, in part:

 ”Now the commission is attempting to remove Siebert and destroy his credibility. It delayed Siebert’s administrative hearing until after the new year, but has refused a request from District 14 to delay the appointment of a medical examiner until after the hearing. It appears that technicalities are acceptable only when the commission uses them.

The commission has also informed the people of District 14 that it will ignore their opinion and choose someone else as chief medical examiner. The commissioners set the meeting to make this decision for Dec. 29, in the middle of the holidays. They have no shame.

This political hijacking of Florida’s medical examiner system should be of concern to everyone. Without confidence in the independence of medical examiners, every decision can reasonably be questioned and unreasonably be scrutinized. Medical examiners from every corner of our country have added their names, alarmed about these events and their consequences.

Medical examiners throughout Florida have privately expressed their concerns, but they will not speak publicly in fear of becoming the next victim of this out-of-control commission.”

Ironically,  Dr. Davis has now removed his name from consideration and has taken a position in a less politicized and corrupt system.  Now the MEC is in the position of refusing to delay its recommendation — but having nobody to recommend!  I’m sure they will do whatever they can to avoid having to defend their illegitimate accusations before a judge.  They know they will lose, and lose badly.

Dr. Davis’ decision to seek greener pastures is something that Florida can look forward to in future openings as well.  The actions of the MEC have made Florida the place to go when you can’t work anywhere else.  There’s certainly a place for such systems, particularly when you are negotiating for salary — it’s good to be able to say “Well, for that kind of money, I might as well go work in Florida” and have your potential employer know that in fact, Florida will always be an option as long as you don’t have an outstanding felony warrant.  Of course,  Gov. Crist’s and the MEC’s corruption of the ME system does a great disservice to the good MEs that got jobs there back when it was a good system and who are still there.  It’s hard to leave your home; they will likely hunker down and hope things get better. 

I hope they’re right.  But it won’t get better until there’s a structural change in the Medical Examiner system in Florida that will put Medical Examiners instead of Al Sharpton in charge of making forensic diagnoses. This is all probably too late to save Dr. Siebert, but one can only hope that the people of Florida realize that playing Nifong is not the role the Medical Examiner Commission of Florida should aspire to.  The ME system in Florida needs a complete overhaul, starting with removing non-physician political appointees from the MEC.  Otherwise, there’s no need for a Medical Examiner system at all — you can just let the Governor appoint the  NAACP to write what they think will fit their agenda and dispense with the autopsy altogether.

Technorati Tags: Martin Anderson, Charles Siebert, boot camp, Florida, forensic medicine, forensic pathology, medical examiner

UPDATE: Read my disclaimer. Don’t run crying to my employer. They have nothing to do with this.

This is the fifth in my series on the politically motivated witch hunt against Dr. Charles Siebert for making a politically incorrect, but medically correct, diagnosis.
The first installment is here.
The second installment is here.
The third installment is here.
The fourth installment is here.
The sixth installment is here.

As reported widely, the jury in Bay County took only 90 minutes to find the guards not guilty in this case. It was the appropriate verdict, for a number of reasons, two of which are the most important.

First, of course, as I have noted in the medical discussion, the young man did *not* die of asphyxia. Once the lynch mob surrounding this case can get that into their heads, then it might be possible to get to a reasoned answer. Perhaps the NAACP and the racial ambulance chasers should put down their nooses, torches and pitchforks and deal with the facts of the case. If they did, they would find that there were a number of mistakes made, all of which should be corrected. But as long as they keep clinging to their cartoonish caricature of “civil rights,” the truth will suffer.

Second, the guards did what they were *trained* to do. It was obviously the *wrong* thing, but they were not negligent in the sense of doing anything they were not trained for. The failure was not at the level of the guards but at the level of the system, and it is wrong to punish the guards for a failure of the system.

What went wrong? A number of things.

First, the fact that this young man had sickle cell trait and was thus at risk for exertional sickle cell death was never communicated. The sad thing about this, of course, is that the NAACP and racial ambulance chasers now *refuse* to recognize this risk, since it hurts their narrative. It’s sad because ignorance of this important threat to young black athletes means that *more* young black people will die. But a few more dead African-Americans is a small price to pay for good headline-grabbing outrage. The so-called “civil-rights leaders” who are happy to see more young black athletes die so they can get a short-term gain from playing demagogue should be ashamed of themselves. The bottom line, however is that the family did not communicate the decedent’s status as having sickle cell trait to the authorities. I have read multiple accounts of how and why the family failed at this, but the bottom line is that this is not the fault of the guards.

The second is that even were it communicated, the threat would not have been recognized. The guards were not made aware of the danger of exertional sickle cell death. This is not surprising since the NAACP has now taken the position that anybody who recognizes it is a racist. Nonetheless, saving the lives of young African-Americans is more important than kneeling at the altar of racial political correctness, and the State has a responsibility to train people even if the NAACP prefers African-Americans to be ignorant and dead.

Third, of course, is that the guards were not trained and policies were not in place to deal with exertional sickle cell threat. Once again, it’s not surprising that they were not, since training for it would mean acknowledging it, and in Florida that is “racist.” It is not the *guards’* fault that the they were not trained in the danger of exertional sickle cell death. And it is wrong to lynch them for not recognizing something that the NAACP itself refuses to recognize and exerts its considerable political influence in order to keep African-Americans ignorant and at risk.

This is *exactly* the situation that the US military was in when they first recognized the lethality of this condition in the 80s and 90s. Happily, Al Sharpton and the NAACP were not around to claim that every Drill Instructor of a platoon where this happened was a racist murderer. Instead, the military quietly and competently changed the way they ran boot camps to minimize this threat.

It’s not that boot camps are bad — or if they are, *this* is not the reason. Boot camps may not be the right way to deal with wayward young men, but that’s an issue for criminology, not forensic pathology. Using this case to indict boot camps, per se, is disingenuous.

It’s not that the guards are sadistic or evil or racist. It’s both sad and amusing to see the NAACP and Al Sharpton accusing black guards of being “racist” because of this. The control techniques they used are generally accepted. The bottom line is that you either control people or you don’t. If the people of Florida want to set up a system where prisoners don’t have to obey orders, then they can just open all the doors. It will certainly save the state money, not having to have prisons anymore, but I don’t think it will be as good a solution as the folk here seem to think.

Had the guards been trained to recognize the threat of exertional sickle cell death, how to respond to it, and had they known this young man was at risk, there would have been a different story.

Fourth, the problem is that Governor Crist and the Medical Examiner Commission have decided that accepting the narrative of the NAACP is more important than medical truth. They are willing to destroy a competent and honest Medical Examiner for making a correct diagnosis, and sacrifice innocent guards for political expediency. The desperation and political basis for this case was made obvious in that the prosecution couldn’t even make up its mind as to what they were accusing the guards of — first it was of beating the man, then suffocating him, then not recognizing the sickle cell collapse — the truth didn’t matter. In the end, the prosecution told the jury to ignore the medical evidence altogether:

Prosecutor Michael Sinacore told jurors to disregard the medical testimony in the trial and look at the 30-minute video of the guard’s interaction with Anderson to make their own findings.

“I don’t care what they say,” Sinacore said. “You look at that (video) and make a decision that makes sense to you..

This is a cancer in the Florida political and medicolegal systems that must be corrected. Crist and the MEC have decided that medical diagnoses must be determined by political needs rather than medical science.

This is even more corrupt than the old Soviet Union. I remember back when I was a Fellow in the days of the Soviet Union, when a Soviet Forensic Pathologist came to visit my facility. One of the folk in my program asked him if he was ever pressured to change his findings for political purposes. He laughed and said “No.” He said that the Kremlin wanted to know the truth, and he was never pressured to change his findings. He just wasn’t allowed to *tell* anybody outside of his superiors the truth. The Kremlin controlled the press and told the people whatever narrative they wanted the people to hear — but *they* at least wanted to know the truth. Crist, the MEC, the NAACP, and the racial ambulance chasers don’t even want that much. They just want the lie.

And a better society is never built on this kind of self-serving, race-baiting lie. I’m glad this jury, at least, did not give it to them.

Technorati Tags: Martin Anderson, Charles Siebert, boot camp, Florida, forensic medicine, forensic pathology, medical examiner

Those following the Charles Siebert lynching in Florida know that I have been focusing a lot on it. However, there are a number of other egregious examples of political compromise of Medical Examiner and Forensic Pathology offices in other states. More recently there is the unwarranted firing of Dr. Flomenbaum in Massachusetts. His attempt to turn the office around rocked the political boat, and it resulted in the standard BS charges used to force folk out. Usually I don’t write about these since they are so common — Jon Arden in DC, Mark Flomembaum in MA, Charlie Siebert in FL, the entire crew in Indianapolis, etc., etc., etc. Most Medical Examiners spend a lot of time praying that they don’t get that special case that makes them politically unpopular. God save us from getting stuck doing the Terri Schiavos and Martin Andersons of the world.

Most of the time, however, we can count on our colleagues generally standing behind us, with the exception of the standard media whores and such, of course. That’s what made me focus on the Charlie Siebert lynching — it would not have been possible without the eager cooperation of a select group of his colleagues.

But, sometimes, we can fight back. One of the worst cases of injustice in the recent past was the mass firing in Indianapolis by the newly-elected Coroner there. For years, Indianapolis had been a stellar place for forensic pathology. The office run by John Pless for years was the kind of place that most MEs wish they could turn their offices into. It was associated with a good medical school and did excellent academic investigational work, it had the highest standards in practice, and it produced some of the best young forensic pathologists in the nation. When John retired, Steve Radentz continued in that tradition. Excellent work. Excellent group. Some of the best forensic pathology around.

Of course, none of that holds water when it comes to racial politics. In 2006, a new Coroner, Kenneth Ackles, was elected. Coroner Ackles is not a pathologist or a medical doctor. He is a chiropracter and made it his mission to dissassemble one of the best ME offices in the nation and remake it in his racial image. He fired the team there and reconstructed it to meet his political and racial preferences. While I wish Dr. Carter, his current hire, the best, he has destroyed what was once one of the best offices in the nation. Finally, though, the group is fighting back. The suit will likely reveal some of the shenanigans Ackles used to create an office of the appropriate hue, as well as some of the operational results of that kind of management.

It should be interesting.

UPDATE: Read my disclaimer. Don’t run crying to my employer. They have nothing to do with this.

This is the fourth in my series on the politically motivated witch hunt against Dr. Charles Siebert for making a politically incorrect, but medically correct, diagnosis.
The first installment is here.
The second installment is here.
The third installment is here.
The fifth installment is here.
The sixth installment is here.

So, let’s recap. In our last installment, the MEC ended up looking like a fool in its copy-editing inquisition, so it raised up bogus “ethical” charges, easily disproven by simple observation. Then, after the new State Attorney realized that Dr. Siebert was being lynched, they decided to go to the governor and see if they could get him fired procedurally.

On August 3, 2007, Dr. Vincent DiMaio, retired Chief Medical Examiner for San Antonio and author of two best-selling textbooks of forensic pathology stated that Dr. Siebert’s conclusions were scientifically valid and that Dr. Adams’ was not. This was echoed some weeks later by Dr. John Hunsaker, former President of the National Association of Medical Examiners, in a radio interview. Dr. Randy Eichner, team doctor for the University of Oklahoma Sooners and expert on exertional deaths, called Dr. Adams’ conclusions “fantasy.”

One might think the MEC might consider the ethics of what they were doing.

But no….

As you may remember, one of the less stellar points in this lynching was when Dr. Barbara Wolf got up in public and made accusations of ethical breaches that she, in fact, had never observed. Instead, she repeated these charges, no doubt in good faith, merely on the basis of hearsay.

Well, now it turns out that only Dr. Siebert and one other person has applied for this position, so far. It would be quite an embarrassment for the MEC to have to offer the job back to him — particularly after he is exonerated by the upcoming judicial appeal (and, as we all know, he will be exonerated).  One amusing anecdote about the appeal is that the counsel for the State asked for an outside-of-Florida review of Dr. Siebert’s autopsy procedure.  They asked Dr. Jerry Spencer, now retired but well-known and respected in the forensic pathology community, to review the case.  Dr. Spencer could find no fault.  I wonder what the State will do with that…  Certainly they won’t admit their error.

How, one might wonder, can they screw him over knowing that they are going to be proven wrong on what they have already tried?

The answer is simple — use an inquisitor as a judge.

So, now the MEC has gotten Dr. Wolf to “rescind” her letter of resignation and is trying to reinstate her as Dr. Siebert’s peer reviewer — only now with the implication that she is his “supervisor.”

It’s pretty obvious where this is going to go. Nothing like having someone who has come out publicly calling you “unethical” based on hearsay passing judgement on your work. It doesn’t matter whether or not she made those accusations in good faith — this is clearly a setup
for more accusations.

Outside the bizarro world of the Florida MEC where diagnoses are judged on political correctness and autopsy reports on the basis of word count, being a ringleader of a lynch mob is usually grounds for recusing yourself from being a judge. But not here.

It’s amazing.

And now, to top it all off, Governor Crist has finally come out publicly and stated that he doesn’t care about the medical truth, only the politics. When asked about the multitude of medical experts that have come out in favor of Dr. Siebert’s diagnosis, Crist stated that he simply didn’t care.

At least now the pretense of this actually being a medical question has been disposed of. Governor Crist has made it official — forensic diagnoses in Florida must be based on politics, not medicine.

Technorati Tags: Martin Anderson, Charles Siebert, boot camp, Florida, forensic medicine, forensic pathology, medical examiner

As a Medical Examiner, most of my work that ends up in court involves criminal cases. I generally try to avoid civil suits, such as malpractice or wrongful death suits, for a number of reasons. The first is that I’m not particularly interested in them. The second is that they are horrible time-sinks. It’s funny, you can get someone on trial in a criminal case and unless they are OJ Simpson or Paris Hilton, it will not be the million-dollar extravaganza everybody thinks. Mostly, it seems, its because there are limits on how much money lawyer can make on these things if the state is paying for it. You get a civil case where money is involved, and all bets are off. There is no limit to the expense. This seems to be even more clear in federal court where lawyers fees are much better protected than plaintiff’s awards — a jury may award a plaintiff a symbolic victory of $1, but by law that means that the loser has to pay *all* the lawyers fees. Occasionally I’ll do a consult on a private civil suit, and as I get older the lure of the money involved becomes strong. Mike Baden stated on the stand that he got $110,000 for his work on the Spector trial. I’ve never charged more than $15,000, and that was for a complex case, but it is what it is.

Unfortunately, occasionally the cases I do for my “real” work end up in civil court and I can’t avoid getting involved. I like these the least, not only because I don’t get any personal remuneration for them, but because they are such huge time sinks. It seems that lawyers can just think up random things they want and we experts are obligated to do whatever they want. In this case, for instance, one of the lawyers involved tried to get my deposition thrown out via a Daubert challenge in federal court. A Daubert challenge basically says that my testimony should not be allowed because it does not have a scientific basis. It was a pleading whose charges against me had double digits of pages, most of which were simply factual inaccuracies.

The problem was not the pages of accusations. In fact, those were so out of touch with reality it was trivial to answer them. The factual issues had plenty of documentation and the scientific issues were straightforward. The problem was that I was obligated to respond to all of them — which meant writing and referencing a medium double-digit response. Reviewing the literature (again) took about ten hours, writing took about five hours, and typing the bibliography took about two hours. So, that’s 17 hours of hard work spent dealing with rather vicious accusations that were so sloppily written and trivially factually incorrect that it read like something counsel must have dictated while driving. Of course, there’s no down side for the lawyer to do that — even with an error-riddled pleading such as the one directed against me. It’s all billable hours and money in the pocket.

Could I have refused? I suppose, in a strict sense, I could have, and just let my testimony be declared unscientific and have the courts declare me a charlatan. However, that’s not a real option for me if I ever want to testify in court again. The next time I’m in court, I don’t want counsel to ask me “Is it not true, Doctor, that your testimony was tossed out of court as being speculative and unscientific, and that the court declared you had not maintained the minimal quality standards of your profession?” The answer to that question should not be “yes” if you can avoid it.

A couple of decades ago one of the great criticisms of medical care was that there was no downside for physicians to order extra tests, do unnecessary procedures, etc., since they all generated income. Thus, the “better safe than sorry” philosophy of doing the million-dollar workup on everybody also meant that everybody made lots of money. In medicine, those days are over.

Apparently they are not over in the lawyer business. It’s unfortunate that some of the cost-containment measures implemented in the medical field have not been implemented in the legal one. Lawyers should not pad their pockets with slipshod make work, particularly make work that forces other people to labor at their whim.

Technorati Tags: lawyers, forensic medicine, forensic pathology, medical examiner

UPDATE: Read my disclaimer. Don’t run crying to my employer. They have nothing to do with this.

This is the third in my series on the politically motivated witch hunt against Dr. Charles Siebert for making a politically incorrect, but medically correct, diagnosis.
The first installment is here.
The second installment is here.
The fourth installment is here.
The fifth installment is here.
The sixth installment is here.

Well, it’s been an interesting few months on the Charlie Siebert front. The scientific consensus on sickle cell trait deaths has emerged, and is in Dr. Siebert’s favor — not that the Medical Examiner Commission cares. Recently, the National Athletic Trainers Association has put out a consensus statement noting that exertional sickle cell trait deaths are an important risk, and constitute a major cause of death among athletes.

The new State Attorney has recognized that this is a political witch hunt, and appointed Dr. Siebert as interim Medical Examiner while they look for his replacement. This, of course, sent the Medical Examiner Commission into an apoplectic fit, and they have attempted to get Governor Crist to fire Dr. Siebert by executive order. A class act, those guys.

Since the attacks on Dr. Siebert’s competence have proved hollow, and since his diagnosis has been proven correct, the attacks by the MEC and associated coterie have shifted to attacks on his “ethics.” In particular, the attacks state that he did not dissect some of the trivial incidentals in the way he stated. This is laughable on two counts. On the first count, of course, this sidesteps the fact that he got the diagnosis correct and his critics got the diagnosis wrong. On the second count, it is simply false, and requires that one parse his autopsy in order to pretend that it does not say what it says.

For instance, Dr. Siebert’s autopsy states that “the thyroid is red brown and not enlarged.” His critics state that he did not completely dissect the thyroid, and thus could not have noted this. This is, of course, completely false. What Dr. Siebert did was observe the thyroid in situ (noting its color) and palpated it (noting its size). Not only is it possible to note exactly what Dr. Siebert noted, but the limits of that description also indicate that the description is specifically consistent with the type of dissection he did. This is not uncommon in autopsies where it is known that the death is not thyroid-related.

For those who are not used to this kind of thing, here is a photograph of an organ block dissected in the manner of Dr. Siebert. The overlying musculature is not cleared away, but the color of the organ is obvious. Further, if you can imagine running your fingers over it, its size would be equally obvious. Thus the description by Dr. Siebert is correct and reflects his dissection. His critics continue to simply fabricate charges.

UPDATE: To those of you unused to blogs, click on the photo to enlarge.

Technorati Tags: Martin Anderson, Charles Siebert, boot camp, Florida, forensic medicine, forensic pathology, medical examiner

UPDATE: Read my disclaimer. Don’t run crying to my employer. They have nothing to do with this.

UPDATE2: This is a repost of an article that was deleted when I had my disk crash, sent to me by a reader. I don’t have the comments, and I apologize to the commenters whose thoughts I have lost.

UPDATE3: This is the second of three articles. 
The first installment is here. 
The third installment is here.
The fourth installment is here.
The fifth installment is here.
The sixth installment is here.

In the last episode (Part 1), I discussed the medical issues behind the Martin Anderson case. Now, Dr. Siebert has been chosen as the sacrificial lamb for Florida’s racial politics. The establishment and media-friendly experts decided to ignore a decade or two of medical research and opine that Mr. Anderson had died of speculative causes. Now it’s time for the kill.

The Attorney General, and soon to be elected Governor, Charlie Crist decided to make an example of Dr. Siebert. After all, who was this little guy who thought that practicing medicine was more important than getting him elected? It was, I suppose, a no-brainer. Pandering to racial special interests is always a win when it can be done at no cost except for ruining the life of some cog in the machine.

So, the NAACP and similar folk decided to gin up some complaints against Dr. Siebert, and they found some editing errors in an older report. Attorney General Crist told the Medical Examiner commission to review Dr. Siebert’s previous autopsies and find something to crucify him with. They had their marching orders, and they stepped forward to obey.

The problem, unfortunately for the Medical Examiner Commission, was that Dr. Siebert is an excellent pathologist. The Medical Examiner Commission, made up primarily of political appointees but headed by a forensic pathologist, reviewed just under 700 of Dr. Siebert’s reports. What they came up with was shocking. In a review of almost 700 previous cases, they could find no diagnostic errors. None. Zero. Nada. Zip. Remember this. No diagnostic errors.

That was certainly politically unacceptable. So they decided to crucify him on the basis of his proofreading. The critique claims that it compared Dr. Siebert’s reports to autopsy report guidelines promulgated by the National Association of Medical Examiners. In fact, no such autopsy report format guideline has been promulgated by NAME. NAME has recently promulgated standards for the performance of autopsies, and the State of Florida also has professional practice guidelines. However, these were not used. They were not used for a reason. The reason was that Dr. Siebert met the NAME standards and Florida practice guidelines.

As one colleague who reviewed the critique noted, the Florida guidelines state that toxicology is only required on victims of violent death over the age of 10 where collapse occurred less than 12 hours prior to death,, and provides a statute as a reference. Yet Dr. Siebert was called “negligent” because he did not order toxicology on obviously natural deaths. In other words, he was castigated as “negligent” because he followed the Florida practice guidelines, not because he failed to meet them. The same was true for almost all of the examples of “negligence.”

Instead, he was castigated for such things as the fact that some of his reports had distances typed with the number next to the unit, and some put in a space (e.g. “2cm” as opposed to “2 cm”). He was criticized for not personally performing ballistics studies on retrieved bullets, even though doing so would have been bad practice, not good practice. In general, it’s not a good idea for a forensic pathologist to opine about criminalistic specialty issues he or she isn’t trained in. Some forensic pathologists are trained in other things; I’m trained in bloodstain pattern analysis, for instance. However, I’m not a ballistics expert. It would not be a good idea for me to report all sorts of things about a bullet I retrieved from a body and then turn it over to an expert for “real” analysis. We might not get the same answer, and then we would be in the position of having to explain why.

The mistake that the press really loved was a report in which a normal testes were written as present in a woman. In fact, of course, that was a trivial cut-and-paste editing error that can happen in virtually all systems that use word processing. And, at the beginning of the inquisition, this use of templates was the big thing the Commission criticized him for. Dr. Stephen Nelson, the chairman of the commission, was appalled that Dr. Siebert may have used “templates” or standardized base reports, from which he generated his final reports. This was, according to the commission, gross negligence.

Most of the alleged negligence came from Siebert’s use of “canned” autopsy reports that describe victims in much the same manner, using the same terminology to detail conditions of organs and other body parts, the panel found. The commission said it appeared Siebert used a standard template for his reports, not adjusting them to individual cases.

That is, at least, until other forensic pathologists pointed out that it was not only common practice, but was taught as good practice in many of the best programs. Why? Because it acts as a checklist and encourages consistency. I use a template when I perform autopsies, and read it as a script when I go through the case. I do so because as I go through each line, I am reminded to check each thing that is discussed. If the script says “The irides are [insert color],” then I remember to look at the eyes and fill in the blank “The irides are blue.” It’s important to have a systematic approach to doing things, usually in a stepwise, checklist manner. Otherwise, you tend to focus on the big stuff and forget to check the small stuff. If you get a case with a big shotgun wound to the face and spend all your time describing that, you might forget to look at the toenail of the little toe of the left foot. If you follow a script, you will be sure to cover it.

You sort of have the choice of errors you can make. You can use a template and occasionally have cut and paste errors. Or you can use a stream of consciousness technique and forget to do stuff. Frankly, the first kind of error is better. Cut and paste errors, by their nature, are usually obvious and silly (such as reporting normal ovaries in a man or testes in a female), easily corrected, and almost never have any diagnostic significance (because if there were something there that was unusual, then the template would not have been followed for that organ). In contrast, the errors of omission that come from free form approaches are often not noticed and are, in my observation of practice and review of many, many reports by other forensic pathologists, frequently diagnostically important.

Second, there is the issue of religion about practice techniques. I have no problem with people who don’t like using templates. I’m not surprised that some people find that it increases their error rates. It’s like keeping track of appointments. Everybody needs to do it, but everybody doesn’t need to do it exactly the same way. Some people use Day Planners; some people use PDAs, and some people have secretaries that follow them around and tell them where to go. De gustibus non est disputandum and all that.

I find templates profoundly useful for the reasons that I have mentioned, and the use of templates as checklists increases the quality of my work. As far as I know, there are no empiric studies showing that people who use templates have a higher error rate or lower quality of work by any meaningful metric. I certainly don’t know of any study that shows that the occasional cut and paste error associated with templates is any worse than the errors of omission I have seen in the reports of people who do not use them.

It is one thing to eschew templates in one’s own work. That’s great – and whatever habits, crutches, and tricks one uses to do better work are good to go. It’s another thing to generalize that into a fundamentally religious statement of how *everybody* should practice. It is another thing again speak in the royal terms of the “people of Florida” to make those religious pronouncements with the implication that the use of templates, per se, is generally recognized to be bad practice. To many of us the opposite is true. It is even worse to pretend that an obvious cut and paste error is something other than a simple cut and paste error in order to support that point.

In fact, Dr. Siebert denies using templates, and the accusation has not actually been proven. More important, there there was a reason for the cut-and-paste error that made the news. As Dr. Siebert could have told the Medical Examiner commision, had they deigned to allow a reply, this was a report that was generated while the office was recovering from hurricane. As Dr. Siebert wrote to me about this particular case:

The one I have no excuse for missing on proofreading was the mixed up genitalia. It occurred during hurricane Ivan. The office lost power and my transcriptionist was working with a laptop and rather than starting a new document, she attempted to transcribe over a previously opened document. I take full blame for missing it on proofreading and when it was pointed out by the family, I immediately apologized and amended it almost TWO YEARS AGO.[emphasis his]

This is why Dr. Nelson and Governor Crist decided to ruin his life?

But let’s continue with these “errors.” In this litany, many of the “errors” were contrived, most were trivial, a few were insignificant, and one or two tested the waters of “minor.” Most of the errors were criticisms of omissions of various details. What the reviewers failed to acknowledge is that Dr. Siebert often went to scenes, and his examination of the body at the scene was recorded separately than the autopsy report per se. Thus, for instance, he was “negligent” for not indicating such things as rigor mortis at autopsy; he did not because he recorded that at the scene the night before, when it was much more meaningful. Since the reviewers declined to review that information, and declined to allow Dr. Siebert to provide input, they called Dr. Siebert “negligent” for not including these later (and thus useless) findings. Dr. Siebert was not allowed to review the report before it was given to the press, and thus did not have a chance to address these glaring issues. And, of course, these issues were ignored by the press.

Even so, the reviewer was forced to admit:

“It is also fair to say that these errors had no influence or potential influence on the final opinion.”

This is the central issue – yet is not discussed in the Conclusion. It’s not a freaking “Oh, by the way.”

Let’s get this straight. Folk put 698 autopsies under a microscope in order to criticize things like the number of spaces between 2 and cm, and found no errors of diagnostic significance. A twenty-some-odd year history of dedicated public service and zero errors in diagnosis. This is what the ME Commission calls gross negligence. In fact, no active forensic pathologist in the world would do much better. In this act, the ME Commission has basically put its foot on the neck of every ME in Florida, since all would be found negligent in a similar inquisition.

In most discussions of errors, there is some sort of grading of the impact the “error” would have had on the final diagnosis. For instance, in articles describing the value autopsy findings when compared to antemortem clinical diagnosis, these are usually classified: 1) they did not affect the diagnosis, 2) they had a minor affect on diagnosis and clinical course 3) they would have had a major change in the diagnosis, clinical therapy, and course. There is a profound difference between missing a capped tooth in a drug overdose and missing a bullet wound in a shooting. Were that done in this report, the newspapers would have had a different spin, I suspect.

But then they could not have tried him in the press. And, of course, the purpose of all of this was Dr. Siebert’s personal destruction. The commission head, Dr. Nelson, did not have any qualms with trying him in the press. And, it was clear that this was not directed at helping a professional that needed a little direction and retraining, but instead at destroying Dr. Siebert’s career in the long term. As Dr. Nelson was quick to point out when the Commission recommended a draconian probation, he wanted Siebert broken.

‘Siebert’s punishment clearly disappointed the commission’s chairman, Dr. Stephen Nelson, who led the three-member probable-cause panel and therefore couldn’t vote Wednesday due to the commission’s rules.

‘’This sends the wrong message to the people of Florida. It says this is just a clerical error, it’s no big deal. It says that sloppy work is almost acceptable. It’s not,’’ Nelson said. “These are people’s lives and families we’re talking about with these autopsies, and we owe them the best service possible.’’

…

Though the probation ‘’doesn’t do a lot,’’ Nelson said, it will be a stain on Siebert’s record when coupled with the national press attention surrounding Martin’s death. “All of this will certainly be fodder for attorneys who want to challenge his work.’’

In other words, the important thing is to destroy the man. Fix it so he’ll never practice again. Mission accomplished, Dr. Nelson.

These guys wanted blood, and they didn’t care how they got it. And that damned “due process.” It sure gets in the way when you just want to hang a man and get it over with. Dr. Nelson complained to the press when Siebert said he wouldn’t roll over:

“It’s frustrating, but it’s due process and it’s what our state statutes provide,” said Dr. Nelson.

Dr. Siebert’s case is now under appeal, but it doesn’t really matter what the results are. His career is ruined. He’s damaged goods. In that respect, at least, Dr. Nelson is getting his wish. I sincerely hope that Governor Crist is enjoying the governor’s mansion. The doors shouldn’t squeak; he’s oiled them with the blood of Charlie Siebert’s career. The treatment of Dr. Siebert has been so egregious that the National Association of Medical Examiners took the unprecedented step of writing the Florida Medical Examiner Commission to offer its assistance in rectifying the situation. I doubt the ME Commission will take them up on it.

In fact, I know they won’t. A source has told me that when the letter was mentioned at the last ME Commission meeting, Dr. Nelson said that since Dr. Siebert has chosen to appeal, there was no reason to discuss or respond to the letter. He never read it into the record and did not allow any discussion by the other commission members.

One of the reasons that Dr. Siebert’s career is ruined is that he is a contract employee. Even if he is exonerated by the appeals judge, I doubt that he will have his contract renewed when it expires in June. Recently, David Bernstein at the Volokh Conspiracy opined in favor of making medical examiners private contractors instead of civil servants. The problem is exactly this kind of thing. The modern version of the civil service system in the US, as a federal institution, became important after the assassination of President Garfield, who was killed by a disgruntled supporter who wanted a private contract job. Historically, before that time, government jobs and contracts were essentially political plums and resulted in the spoils system. The civil service was created to avoid the corrupting influence of political pressure on private contractors for the awarding and continuation of jobs and contracts.

Folk decided that how quickly one got one’s car tags, etc. (or the contract to provide them) should not depend on one’s political affiliation. Nor, I personally believe, should forensic diagnoses. The presence of an apolitical civil service with protections against both political influence and private corruption is a cornerstone of making a democracy work, and the English tradition of civil service is one of the big reasons that democracy is more successful in the anglosphere than anywhere else.

It is always easy to blame civil servants for everything that goes wrong in government. But in fact, my experience has been that most civil servants try very hard to do a good job under difficult circumstances. Most of the inefficiencies that I saw as a DoD civilian, for instance, had much more to do with legal requirements than any desire to do a good job. And much of that had to do with contracting requirements – that a contractor be a certain race, a certain gender, from a certain part of the country, etc. In Washington, DC, for instance, there are minority/women-owned companies whose sole purpose is to act as a conduit for what you really want. You want an Acme widget because it is better and cheaper? But you say that Acme is a large corporation or a corporation run by a white male? Then call XX company, a minority, woman-owned company, and tell them what you want and where to get it. They will buy it an sell it to you at a 20% markup, but at least you get what you want. I did it every year. But, of course, those kinds of inefficiencies are the fault of “civil servants,” not contractors.

The constraints that make civil servants seem unresponsive are most often constraints that are placed onto him or her, and not a function of being a civil servant. As contractors take on more civil service tasks, they become more like civil servants, with similar constraints. Government money comes with strings.

Even the efficiency argument made by privatization proponents doesn’t really hold up to inspection. Sure, it’s fun to stereotype government employees as lazy and entrenched. But in fact, private contractors have just as many problems.

While there are many examples of contractors who provide excellent service, virtually every large comparison of privatization versus civil service over multiple contractors has been at best a draw, and in general have favored the civil servant. That is why in the past 10 years, in spite of increasing prejudice towards privatization, the use of private contracting has decreased, not increased, and many jurisdictions are moving away from privatization. A long term study at Cornell from 1992 to 2002 found that while privatization grew during the first part of this period, during latter part manyjurisdictions began bringing back in services they contracted out:

Local government service delivery is a dynamic process. This year, for the first time, ICMA looked at the stability of alternative service delivery, asking governments if they had brought back in house services that they had previously contracted out.Of the 22% that reported bringing services back in house, the reasons cited were problems with unsatisfactory service (73%), problems with insufficient cost savings (51%), and an improvement in internal government efficiency (36%). These findings show that it was primarily poor performance by private deliverers themselves rather than problems with contract specification and monitoring (cited by fewer than 20% of governments) that prompted governments to bring services back in house. In other words, it is poor contractor services and not politics that underlies strong political support for bringing service delivery back in house.

Warner, M and Hefetz, A. “Pragmatism over Politics: Alternative Service Delivery in Local Government, 1992-2002. International City/County Management Association Municipal Year book 2004, pp 8-6.

The disasters associated with privatization are well known, including the privatization experiment of welfare services in Texas and the mixed record of privatization of prisons. The list is extensive.

But efficiency isn’t really the point. I assume that most people would rather have a Medical Examiner who made his or her diagnoses based on medical issues rather than political demands, even if he or she were a tad less efficient than a contractor who had his or her diagnoses dictated from the Governor’s mansion

And that independence is what the privatization folk are throwing away. While many M.E.s in Florida are public employees rather than private contractors, they do not get civil service protections. They get the worst of both worlds. While the Siebert lynching has been playing itself out, I have listened to two Florida M.E.s state privately to me that they were appalled by what was going on, but were afraid to say anything for fear of being targeted by the ME Commision. If the trivial errors found by the Commission are sufficient for the official finding of “negligence,” then *all* Medical Examiners in Florida (and for that matter in the world) are “negligent.” That’s one reason I’m bothering to write these two articles. The MEs in Florida are intimidated. There are no innocent in Florida, now, only the untargeted.

We are seeing in Florida how the use of private contractors with limited terms will result in the political corruption of a Medical Examiner’s office. Dr. Siebert, I am sure, will not have his contract renewed. And it will not be renewed a) because he is a contractor and does not have the protections of a civil servant and b) because of political influence on the Medical Examiner system. A similar political attack is being played out in Indianapolis.

The Florida ME system was, at one time, one of the best in the nation. This demand that Medical Examiners base their diagnoses on political considerations rather than medical ones or face professional and personal destruction will destroy the system.

Technorati Tags: Martin Anderson, Charles Siebert, boot camp, Florida, forensic medicine, forensic pathology, medical examiner

Read my disclaimer. Don’t go running to my employer. They have nothing to do with this.

UPDATE: This is a reinstall of a post previously published and retrieved. It was originally published some months ago and was lost in the hard disk crash. The comments to this article are still lost. I apologize to all who commented.

UPDATE2:  There are now six installments to this saga. 
The second is here. 
The third is here.
The fourth installment is here.
The fifth installment is here.
The sixth installment is here.

A few years ago, some folk had an idea for helping troubled youth. They looked at the seeming magic that the military performed on young kids. How, they wondered, could the Marines take a bunch of kids and, in a matter of a few months, change them into responsible people who embraced a strict code of conduct, could competently make life and death decisions under incredible stress, and who both exhibit and accept leadership? Even under the deadly wartime conditions of Iraq, soldiers in harm’s way enjoy better health and lower mortality than similar kids at home. Maybe, they said, it’s the discipline of boot camp.

So, penal boot camps sprang up across the country. The results have been mixed. Apparently it takes more than a few push ups and strict time management to instill Army values. But, many believe it’s worth a try, particularly with younger offenders who may still be malleable. Martin Anderson was one such person, possibly. Martin Anderson was a 14 year old who had been convicted of joyriding, and arrived at one such boot camp in Bay County, Florida on January, 4, 2006. The next morning, he began his physical assessment, which included push ups, sit-ups and then running laps.

As might be expected with youthful offenders, many don’t take to that kind of regimen. When an offender doesn’t do as told he gets “counseled,” which includes, among other things, being held against a fence by 2 guards while being verbally reprimanded and told to continue. If he resists he is taken to the ground using knee strikes to the back of the leg if necessary with guards on either side of him (not on his back), and forearm strikes if he balls his fists. This is continued until he complies.

Mr. Anderson started his run, but around lap 12 of 15 he collapsed and claimed that he couldn’t go on. He was reprimanded, taken to the ground, but fairly quickly released and he continued to run. He collapsed again and the same drill continued and now included the use of ammonia capsules to arouse him. According to guards and the nurse, he responded appropriately and was resisting, so they thought nothing was wrong. They believed he was malingering, as was very common during initial assessments. To ensure inmates breathe the ammonia, hands were placed over the mouth and the ammonia was held under the nose. In this case “counseling” went on for some time – approximately 30 minutes — and Mr. Anderson eventually became unresponsive.

EMS was called. He was put on a non-rebreathing mask and transported to the local hospital. He had a heart beat and was breathing the whole time. Upon arrival at the ER he was still obtunded, so he was intubated to protect his airway. Prior to intubation, an arterial blood gas is drawn which showed a metabolic acidosis and respiratory alkalosis. The docs were not sure what’s up so they transferred him to a children’s hospital in Pensacola. On his air flight over to the other hospital he began to hemorrhage. By the time he got to the other hospital, his blood clotting system had collapsed (called disseminated intravascular coagulation, or DIC), he was in hemorrhagic shock, his muscles were breaking down (called rhabdomyolysis), and he died 14 hours later.

Dr. Charles Siebert, the local Medical Examiner, performed the autopsy. At the autopsy, there were a few abrasions, but none of the trauma one sees with a bludgeoning or throttling death. There was significant internal bleeding, mostly in the back of the abdomen (retroperitoneal hemorrhage). The most striking finding was that there was marked red cell sickling.

Analysis of the decedent’s red cells revealed that he had sickle cell trait; 42% of his red blood cells carried abnormal hemoglobin. After consultation with colleagues and a review of the literature, Dr. Siebert called the cause of death “complications of sickle cell trait,” and the manner natural.

Then all hell broke loose, and Dr. Siebert became the cause celebre of those in Florida who want to call death based on politics rather than science.

But before we get to that, let’s look at the science.

First, let’s look at sickle cell trait. The oxygen-carrying molecule that makes red blood cells red is, as most folk know, hemoglobin. In patients with sickle cell disease, a genetic mutation exists that causes the body to make abnormal hemoglobin, called Hemoglobin S. Red blood cells that have Hemoglobin S are unusual in that when they become oxygen depleted, they deform into crushed-cup-shaped cells (which, when cut into slices, look like little sickles). Very young red blood cells in this disease will regain their normal shape once they get oxygen again (they are called reversibly sickled cells), but older cells will get stuck in the abnormal shape. These cup-shaped cells tend to clump together and block blood vessels, and the tissue downstream can die. When that happens all over the body, it’s called a “sickle crisis,” and is a medical emergency.

People have two copies of most of their genes, and hemoglobin is no exception. People who have two copies of the sickle cell gene have “sickle cell disease” and are at a high risk for sickle crises. People who have sickle cell disease have a much lower life expectancy – around 45 years – and about a third of them die during a sickle crisis. A more recent review showed an even shorter average lifespan of about 36 years, and another calculated a death rate about three times higher than the general population.

People who, like Mr. Anderson, have one normal gene and one sickle cell gene have “sickle cell trait.” In these folk, the normal gene makes almost all the red cells the person needs, and the sickle cells that are circulating tend to be the less dangerous young reversible cells. People with sickle trait are usually asymptomatic, though there are some peculiarities about their health statistics. For instance, there’s some sort of effect that sickle cells, even in sickle cell trait, have on the kidney. A particular kind of cancer, called renal medullary carcinoma, is found almost exclusively in people with sickle cell trait. Further, people with sickle cell trait tend to have “hyposthenuria,” or the inability to normally concentrate urine (this will become important later on). But, in general, people with sickle cell trait do not have an increased mortality, and can expect to live normal lives.

Except in one context… They drop like flies at boot camps.

In the 1980s, military physicians started noticing something that was particularly troublesome. People who had sickle cell trait were found to be dying at a rate up to 40 times higher than matched people without sickle trait. Evaluation of these people found something pretty striking. As one military researcher noted:

Although the sickle cell trait (SCT) is usually a benign and innocuous carrier state rather than a disease, those with the trait are capable of developing any and all types of vascular occlusive lesions that have been observed in patients with sickle cell anemia. Obstructive vascular lesions in individuals with SCT occur infrequently, but when they do occur they are disabling and may be life-threatening. Disabilities attributed to in vivo sickling have the potential of seriously impeding the success of military missions. When selecting recruits to be trained and assigned to special operations, consideration should be given to hyposthenuria, the possibility of hematuria and to exercise-induced syndromes. Exertion to the point of exhaustion in previously healthy individuals with SCT may cause sudden death, rhabdomyolysis, and acute tubular necrosis. In vivo sickling of erythrocytes is a superimposed and late contributory and complicating factor of exertional syndromes.

Diggs,LW. The sickle cell trait in relation to the training and assignment of duties in the armed forces:III hyposthenuria, sudden death, rhabdomyolysis, and acute tubular necrosis. Aviation Space Environ Med 1984 May;55(5):358-64

Wait a minute! What’s this? People with sickle cell trait suffering from sickle crises? Let’s see: collapse, sudden death, acute tubular necrosis with metabolic acidosis, rhabdomyolysis, and sickled cells. Sound familiar? It should.

Over the next decade, the evidence for an increased risk for death during exertion at boot camp became overwhelming. As another Military Medicine article notes:

The most serious complication of sickle cell trait (SCT) is sudden death during exertion. SCT often remains unrecognized in the 2.5 million African Americans affected. Exertional collapse and sudden death associated with SCT is characterized by rhabdomyolysis, heat stroke, and cardiac arrhythmia. There is a 40-fold increased risk of sudden death in affected soldiers during military basic training and there are many cases reported in athletes during preseason training. There have been no cases reported in soldiers beyond basic training…

Kerle, KK and Nishimura KD. Exertional collapse and sudden death associated with sickle cell trait. Mil Med 1996 161(12)766-767.

And, while it turned out that the hyposthenuria and heat intolerance tended to be more important in the deaths than sickling per se, the bottom line is that it is a killer. Other military physicians noted, as in the case of Mr. Anderson, people with sickle cell trait who are in a life-threatening crisis can often not appear to be deadly ill. In one case:

A 30-year-old black male soldier with sickle cell trait presented with fatal exertional rhabdomyolysis (which was unrecognized during 14 hours at a field clinic). After prompt treatment for heat exhaustion, his symptoms seemed mild and he was afebrile. His clinical course illustrates the potential for severe illness in the absence of fever, the importance of assessing mental dysfunction, indications for laboratory evaluation, the need for comprehensive management of severe dehydration and acidosis, common laboratory features of acute renal failure and exertional rhabdomyolysis, and the increased risk of exercise-related death in those with sickle cell trait.

Gardner, JW and Kark, JA. Fatal rhabdomyolysis presenting as mild heat illness in military training. Mil Med 1994 159(2):160-3.

One important thing to notice in these studies is that the deaths due to sickle cell trait are uniquely associated with boot camp training. They are not, in general, associated with regular military service. One might ask why. I believe it’s because you are pushed to your limit and then encouraged to go beyond. Back in the “bad old days” of boot camp, you were often coerced into exerting beyond your normal limits. And it’s that going that extra mile that causes problems.

Here’s an extra credit question for you. Under what other circumstances might someone decide to exert himself or herself that extra little bit and run into trouble? If you guess “being chased by the cops,” you’d be correct.

The response to the problem in different countries was interesting. In Great Britain, people with sickle cell trait were banned from a number of military specialties the last time I looked, though that has been relaxing. In the US, decisions were of course influenced by race politics. Banning people with sickle trait from anything would be perceived as racist — almost all people with sickle trait are African-Americans. So the US military decided to reconfigure its boot camps and make them all less stressful. As stated in the military advisory board (Armed Force Epidemiological Board, Memorandum 2003-004 Screening for Sickle Cell Disease at Accession):

…

1. What is the risk from SCT?

a) No evidence suggests any impaired exercise performance or increased risk of sudden death during normal conditions among SCT positive individuals. Under the most extreme conditions of heat, humidity, and possibly increased altitude, some evidence suggests that individuals with SCT have increased susceptibility to rhabdomyolysis, with the potential for renal failure and death, and possibly exercise-associated sudden death. Risk is high if one is poorly conditioned for an event, dehydrated, obese, sleep deprived, at altitude, unable to lose body heat, and exerting heroic effort with disregard for effort-related symptoms. This risk can be practically eliminated by intervention to improve hydration, improve ability to sweat, and limit exercise when occlusive clothing or high ambient temperature increases the threat of excessive body temperature.

b. Among individuals with SCT, there is a significant incidence of hyposthenuria (30-40%), which compromises the ability to conserve water. There is no specific treatment available. Generous fluid replacement is therefore standard advice for all individual with SCT. Although rare, splenic infarction has been linked with SCT, with most cases reported at higher altitude.

…

e. Recruits with SCT have an increased risk of sudden death, which is primarily due to heat related illness. The risk is substantially elevated over non SCT trait recruits, concentrated but not limited to the recruit training period, and greatest when general preventative measures for heat illness are lacking…. Defects in water concentration probably underlie the increased risk of heat related illness in SCT recruits but forensic investigations have not been thorough enough to determine underlying medical and training-related contributions to death.

Rather, than limit admission of recruits with sickle cell trait, the US military instead changed the way it did boot camp. Personally, I think that was probably a good idea. It’s very easy to push recruits beyond what they should be doing. When I went through boot camp in Texas, heat casualties were an issue.

Unfortunately, all this information about sickle cell trait is pretty irrelevant when it comes to race politics. The standard racial ambulance chasers had a field day. Suddenly Dr. Siebert is being accused of trying to cover up a murder. The governor assigns a new independent prosecutor. A second autopsy by Dr. Vernard Adams, another Florida medical examiner, is done that documents a couple of extra bruises, but no other significant pathology. The family brought in a high-profile pathologist, Dr. Michael Baden, well-known to many as a Fox News talking head and from his performance of public autopsies to titillate viewers on HBO. The night of the second autopsy, the new state attorney states that the new medical examiner and Dr. Baden agree that it was not a natural death and that sickle cell didn’t play a role.

It’s a bit curious, though. Dr. Baden, as is his wont, runs to the press and states that it was due to the coercion. He says the police sat on the decedent’s back and the decedent died of mechanical asphyxiation. “We all agree that he did not die of sickle trait. Sickle trait does not harm you.” When confronted with two cases in which he had made such diagnoses, he said that they were different because the cases he diagnosed included other conditions.

“People who are healthy don’t die of sickle trait,” Baden opined, “The other person [his case] was not healthy. This young man had no pre-existing illness. There’s a difference.”

People who are healthy don’t die of sickle trait? Well no, they don’t. Unless they go to boot camp, that is.

Dr. Baden continued to opine that the sickled cells seen at death were not there during life because the lab samples didn’t show them. He claimed that the sickled cells Dr. Siebert saw were merely incidental. Unfortunately, he got that backwards, too. It turns out that multiple studies have shown that sickled cells in the body are artificially low in lab samples because they are often inadvertently exposed to air. Remember those “reversibly” sickled cells? They reverse, and appear normal.

And, of course, there’s the issue of the video. I personally have a lot of experience analyzing videos like these. The one thing that’s for certain is that when folk sit down and watch one of these is that it is more of a Rorschach test than any real indication of what actually happened. The classic example of this was the famous Rodney King tapes. In the state trial both the defense and the prosecution cases amounted mostly to just “Hey, look at the tape.” When the jury sat down and analyzed the tape frame by frame, the important blows to the head were simply not there. That’s why the police weren’t convicted in the state trial (not racial prejudice). In the federal trial, the prosecutors instead used other evidence to show the blows to the head, and the cops were convicted. I’ve seen it a zillion times. All videos look bad where there’s coercion or subdual involved. The question is whether or not specific injuries can be demonstrated. It’s not enough to wave your hands and say that people with sickle trait don’t die in boot camps and just look at the video.

There’s also a few problems with any diagnosis of asphyxiation, but I’ll get to that in a minute.

Dr. Vernard Adams had a slightly different conclusion. He concluded that it was due to laryngospasm due to the ammonia salts that were used to revive the decedent. He basically said that his throat closed up in response to the smelling salts and the decedent suffocated. It’s a novel idea, especially since laryngospasm due to these things has never been demonstrated as far as any literature search I or any of my colleagues can turn up.

The other problem with any asphyxiation theory is that, well, it requires that the decedent not be breathing. But, unfortunately for that idea, the decedent was breathing too much! Not only was he seen breathing, but his blood work showed metabolic acidosis and respiratory alkalosis.

What does that mean, you might ask. Well, it turns out that the body carefully regulates the acidity of the blood. We have two ways of doing this. The first is by breathing. Carbon dioxide dissolved in the blood forms an acid called carbonic acid. If we stop breathing, that carbon dioxide builds up and the blood becomes more acid. That’s called “respiratory acidosis.” If we hyperventilate and drop the amount of dissolved acid in the blood, the blood becomes more alkaline. That’s called “respiratory alkalosis.”

We also create acids and bases from our metabolism. When cells break down or release acidic waste products, if we drink or eat acidic things, or if the kidneys start to fail, these acids build up. When the body becomes more acid because of this, it’s called “metabolic acidosis.” Similarly, if we turn on the kidneys to work harder and get rid of more of these acids than normal, it’s called “metabolic alkalosis.”

So, here’s a quiz. If you have the classic boot camp-related crisis associated with sickle trait, what would you expect? You would expect a metabolic acidosis because of the cellular damage and damage to the kidneys, and a respiratory alkalosis as the body hyperventilates to try to get rid of carbonic acid and get back into balance. What would you expect with suffocation? The body would not be breathing, and you would expect a respiratory acidosis.

What was there in this case? Respiratory alkalosis and metabolic acidosis. In other words, not only was the decedent not suffocating, he was hyperventilating. Oops. Not too good for the suffocation camp. Good for Dr. Siebert. On top of that, the decedent was noted to be breathing until he made it to the hospital. There was no documentation of respiratory arrest. The airway was not blocked.

Finally, whether you look at Dr. Baden’s diagnosis of mechanical asphyxiation or Dr. Adams’ diagnosis of laryngospasm, both are called “diagnoses of exclusion.” That means that the proposed mechanism of death is one that does not leave any diagnostic signs. Instead, there is merely nothing in the autopsy that contradicts the diagnosis, there are no viable alternatives, and instead the diagnosis is based on the history or some other feature. There are a number of such causes of death that are at least sometimes diagnoses of exclusion, such as drowning, mechanical asphyxiation, smothering, laryngeal spasm, and sudden infant death syndrome (SIDS). That’s one of the reasons that Dr. Baden must be so adamant about how benign sickle trait is. In order to make his diagnosis stick, he must exclude it. Of course that gets a little sticky when you are dismissing something that carries with it a four thousand percent increase in mortality, but you do what you have to do.

But it doesn’t matter. The politics are what are important, not the medicine. It’s just too inconvenient for it to be sickle trait. It can be anything else. As long as the cops get to be blamed, and as long as Dr. Siebert can be demonized. Screw decades of documented experience in boot camps. Screw the fact that *every* sign and symptom demonstrated by the decedent is *textbook* for exercise-induced boot camp sickle trait deaths.

The problem is that Dr. Siebert is right. Drs. Baden and Adams are wrong, regardless of which diagnosis of theirs you choose. The politicians in Florida know it, which is why they still have not released the second autopsy report. (Update:  the report is now finally public). If this ever comes to an impartial verdict, Dr. Siebert will be vindicated.

But what can the political folk do? If they can’t win on the basis of medicine, then they can win by discrediting Dr. Siebert. Immediately after the results were leaked to the press, the process of the personal destruction of Dr. Siebert began. We are talking racial politics here. It is necessary that Siebert be a murderer. An incompetent. A boob. A racist.

Or at least a ritual sacrifice.

The black caucus immediately called for revocation of Dr. Siebert’s license. Frederica Wilson stated “Mr. (sic) Siebert needs glasses, he needs eye surgery. We all saw that tape. We know that Martin didn’t die of the sickle cell trait.” Well, we don’t *all* know that. In March, Senators Siplin, Hill and Wilson file a complaint against Dr. Siebert with the Medical Examiner Commission to have him removed for incompetence. Attorney General (and soon-to-be-elected Governor) Charlie Crist called for a review of all of Dr. Siebert’s autopsies to look for inaccuracies.

C’mon boys, we gonna have ourselves a hangin’.

And that lynching will be in the next posting.

Technorati Tags: Martin Anderson, Charles Siebert, Florida, autopsy, forensic medicine, forensic pathology, medical examiner

I ran across this cool tidbit via Fark. In a recent murder trial, a forensic examination of the defendent’s computer use — I don’t know if it was of his computer or by subpoena from Google — showed searches for “neck,” “snap,” “break,” and “hold,” as well as searches for information on water levels and currents in the water where the body was found.

It raises an interesting question, particularly in cases I’ve had that I “know” must be drug deaths but are negative on my screens. One can only wonder if a good search of the decedent’s computers might show searches or purchases of mail-order drugs/herbs or searches on pesticides, etc.