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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.

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