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.
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):
- 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? 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’.