If you’ve read the previous posts, it should be obvious what I believe to be the most likely mechanism of death. This case represents the perfect storm of endogenous hyperadrenergic state, drug ingestion, and multiple stressors leading to restraint stress and panic attack with stress cardiomyopathy exacerbated by continued restraint and exposure to toxic car exhaust resulting in rapidly evolving cardiogenic shock and death.
In this case there is a man who has a long history suggestive of chronically elevated catecholamines — a history of poorly controlled hypertension, drug use, assault, etc. He has significant heart disease, including hypertensive changes, dilated cardiomyopathy, and severe atherosclerotic coronary artery disease. His history of drug use, and the drugs he had on board on the day of death are consistent with self-medication for these issues. Unfortunately, those drugs increased his cardiac vulnerability. In spite of those who claim it is “character assassination” to observe these vulnerabilities, they are of prime importance in the evolution of cardiogenic shock in stress cardiomyopathy.
He is then stopped by the police — itself a stressful situation, which increases his catecholamine load even more. Then, he is arrested. The police attempt to place him in a vehicle. It is at *that* point that he begins to panic. It is at *that* point that he says he is going to die. It is at *that* point that he complains of being unable to breathe. Nothing on his neck. No prone position.
Watch this snippet from one of the police body cameras as the police try to put Mr. Floyd into the patrol car. Note that he is pretty much OK as long as he was sitting on the ground. Things go south when the police try to put him in the car:
This is not someone who is suffering from restraint asphyxia. This is someone having a panic attack due to restraint stress while in a hyperadrenergic state. This is when he started demonstrating classic stress cardiomyopathy signs. In order to invoke “prone position” as the cause of his breathlessness, it is necessary to ignore that his terminal path actually started when he was being put into the car.
The police then place him on the ground and increase the degree of restraint, which in turn exacerbates the panic attack. His position at the back of the car adds another environmenal stressor, that of car exhaust. Mr. Floyd then becomes increasingly breathless, diaphoretic, and becomes weaker and less responsive, eventually succumbing. This is again a textbook history for rapid heart failure and cardiogenic shock associated with stress-cardiomyopathy. He suffers cardiac collapse with PEA, another common manifestation of stress cardiomyopathy, and dies.
Mr. Floyd’s death is the culmination of the interaction of his prior vulnerabilities and multiple stressors. It is clearly not an asphyxial death since at no time was he unable to breathe. Mr. Chauvin did *not* put his knee on Mr. Floyd’s neck (which is why the prosecution changed its talking points to speaking about the “neck area” that included the shoulder). Mr. Chauvin did not obstruct an airway or blood flow to the brain.
This is in contrast to those who want to call it an “asphyxial” death or “prone position” death who insist on ignoring important stressors and vulnerabilities to push a narrative. Prone position is, without doubt, a stressor. It is not, however, likely to be — in the end — a stressor that will kill someone by itself. Instead it is just one of the many stressors that added together to result in Mr. Floyd’s stress cardiomyopathy.
I am particularly opposed to focusing in on prone position in cases like this because i believe that it will result in increased, rather than decreased mortality. Decreasing mortality in these kinds of deaths in custody will require understanding the *entire* gamut of stressors when a vulnerable person interacts with police, and how those stressors and vulnerabilities interact. The danger, I believe, is that people will push the banning of prone position and think that they’ve solved the problem. They will have done nothing of the sort. Mr. Floyd started his path to death with the panic attack he had when they tried to put him in the car. From that point, he likely would have died whether he was in prone position or not (though prone position as a stressor made it worse) unless the police had recognized the panic attack for what it was and rapidly removed the restraint threat (e.g. let him go back and sit on the ground). Police need to be trained to recognize panic attacks and similar events that, in vulnerable people under the influence of intoxicants, presage death. Police can be trained in such circumstances on how to defuse such situations before it evolves into cardiogenic failure. Once it reaches the point of failure, stress cardiomyopathy is a life-threatening emergency.
People who are prone to this are prone to recurrence. As one review notes(1):
Recurrences are common, 2% to 4% per year and up to 20% at 10 years; even after recovery of LVEF, in contrast to previous perception, patients who have experienced stress cardiomyopathy may experience symptoms such as fatigue (74%), shortness of breath (43%), chest pain (8%), palpitations (8%), and exercise intolerance in comparison with control subjects with no previous stress cardiomyopathy. In addition, cardiac structural abnormalities (e.g., impaired LV strain patterns) and metabolic alterations have been described. Patients with prior episodes of stress cardiomyopathy have an increased prevalence of anxiety disorders as a form of post-traumatic stress disorder. Therefore, a better understanding of the mechanisms and the development of therapeutic interventions are required to improve the outcome of patients with stress cardiomyopathy.
Loading it all onto “prone position” or calling it “asphyxia” will not provide an impetus to understand these mechanisms or develop interventions required to improve the outcome of people undergoing police encounters.
As an aside. At the Chauvin trial, a prosecution expert testified that prone position changed the shape of the hypopharynx which inhibited breathing. I’m not going to deal with it for two primary reasons. First, the expert’s model had never been validated, and was essentially speculative. Second, it was based on inferring photogrammetric information from the video that had no scientific basis, and was frankly incorrect, in my opinion. I say this having experience in video and image analysis. I have a Master’s degree in Computer Science with an emphasis on computer vision as well as a medical degree, and I spent the first twelve years of my career performing image and video analysis of operational imagery and imagery of national interest involving forensic pathology issues for the Department of Defense. I was the Chair of the Image Analysis Subcommittee for the FBI Scientific Working Group on Imaging Technologies in the 1990s, and have helped write best practices guidelines in image analysis applications in forensic medicine. I am the author of multiple articles related to imaging in forensic pathology. My personal opinion is that this hypopharynx thing would not have withstood a good Daubert challenge, and I’m not going to waste time on it.
It is even worse to engage in the politics of racial hatred and personal destruction simply because a defense expert proposes a mechanism of death not in tune with a particular political narrative. Dr. David Fowler testified on behalf of the expert panel that reviewed the case for the defense, and presented the consensus opinion. I was part of that group. The consensus opinion was not exactly what I have proposed, but it was close (no consensus opinion represents the opinion of any individual member in every detail).
After Dr. Fowler testified Dr. Roger Mitchell of Howard University promulgated an open letter that made the claim:
The cause of death opinion, particularly the portion that suggested open-air carbon monoxide exposure as contributory, was baseless, revealed obvious bias, and raised malpractice concerns. The cause of death statement of any individual should be an injury, disease, or combination thereof, reached to a reliable degree of medical certainty.. We believe the unsubstantiated opinion that carbon monoxide exposure may have contributed to the death of George Floyd is far outside that standard and is grounds for an immediate investigation into the practices of the physician as well as the practice of the Maryland State Office of the Chief Medical Examiner (OCME) while under his leadership. In addition, Dr. Fowler’s stated opinion that George Floyd’s death during active police restraint should be certified with an “undetermined” manner is outside the standard practice and conventions for investigating and certification of in-custody deaths. This stated opinion raises significant concerns for his previous practice and management.
Our disagreement with Dr. Fowler is not a matter of opinion. Our disagreement with Dr. Fowler is a matter of ethics. The disingenuous testimony of Dr. David Fowler exposes the frailty of the current Medical Examiner/Coroner System and illustrates the lack of existing oversight and uniformity of practice. If forensic pathologists can offer such baseless opinions without penalty, then the entire criminal justice system is at risk.
The lynch mob orchestrated by Dr. Mitchell is so convinced of their moral superiority that the previous 12 installments of this series must simply be ignored. It is not a matter of opinion. It is a matter of ethics. Anybody who disagrees with the mob must be punished. They must suffer penalty. They must be destroyed.
And, of course, the Maryland Attorney General jumped right on this. A panel has been convened to review Dr Fowler’s work, and it is clear that the outcome is baked in. The message is clear. If you testify for the defense in a death in custody and you don’t support the dominant narrative, you must be eliminated.
It should be pointed out that Dr. Fowler’s history has been one of exemplary work in the field. Dr. Fowler was Chief Medical Examiner in Maryland for many years, was President of the National Association of Medical Examiners, is a widely published author in the academic and professional literature, and is still a respected member of the community. People who know Dr. Fowler know that this attack is fatuous.
This politicization has already had a chilling effect on access of people to expert consultation. My wife has forbidden me to take any more death in custody cases. A couple of months ago, a lawyer came to me asking me to consult on a case. I told him I preferred not to get involved, but I would ask around. I asked 25 other senior forensic pathologists. Of those, 23 said they wouldn’t touch it with a ten foot pole and would not even look at the material because it might mean the end of their career. The two who said that they were willing to look at the case did so because they were well retired and had little to lose.
That is not justice of any sort. The same thing is happening with lawyers, where those who take these cases are being fired from firms and even having ethics complaints brought against them. And remember, in these kinds of things, the process is a large part of the punishment. Defending oneself from these kinds of onslaughts, particularly at the Attorney General level, will be financially ruinious regardless of the outcome.
This demand that only one opinion be allowed is profoundly destructive. These people should not win in their attempt to politicize forensic medicine. But, it seems, they will.
So, it doesn’t matter that this “prone position” and “restraint asphyxia” stuff may result in more people being killed. it doesn’t matter that the career and possibly the life of an excellent forensic pathologist will be ruined. The only important thing is that we all must agree that Derek Chauvin is a monster. Whatever diagnosis accomplishes that is the right one, and anybody who espouses any differing opinion must be destroyed.
This is bad for the justice system. This is bad for forensic pathology. This is bad for the nation. We as forensic pathologists should resist this politicization of our specialty. Lysenko is just around the corner, otherwise.
- Medina de Chazal, Horacio, et al. “Stress cardiomyopathy diagnosis and treatment: JACC state-of-the-art review.” Journal of the American College of Cardiology 72.16 (2018): 1955-1971.