Effect Measure

More anthrax case questions

Questions about the FBI’s case against popping up like mushrooms after a rain. There are too many to address in just one post. Meryl Nass’s site has cataloged a number of them and Glenn Greenwald’s latest installment others. We’ve weighed in a couple of times (here and here) and now want to add some additional thoughts about the official version of how the alleged anthrax attacker, Dr. Bruce Ivins, died.

Dr. Ivins was found unconscious at his home and taken to a hospital, where he died three days later. We don’t know if he ever regained consciousness. Let’s assume he didn’t. There was no suicide note. In order to be buried legally there must be a death certificate filed with the State of Maryland. In the case of death by natural causes with an attending physician, the doctor fills it out. Sudden, unexpected or unattended deaths are referred to the state medical examiner (Maryland does not have a coroner system), whose task is to determine, as accurately as possible, both the cause and manner of death. The cause of death is usually written in narrative form (e.g., acute liver failure from overdose of acetominophen and codeine, coded later into an official International Code by a trained coder, called a nosologist). The manner of death is usually one of five categories: natural, homicide, suicide, accidental or undetermined. In order to fill in the certificate as accurately as possible the medical examiner may or may not perform an actual autopsy, i.e., physically dissect the body and also examine tissues microscopically. But there are other forms of post mortem examination, some as simple as examining the body and corroborating a judgment with police accounts, police reports or medical records. It is the medical examiner’s option how thorough an investigation should be done.

In the Ivins case the chief medical examiner determined the cause of death was toxicity from an overdose of acetominophen and codeine and the manner of death was suicide. At that point the body could be released to the funeral home for final disposition. We still don’t know if an autopsy was done, although it was announced at one point that one wasn’t (meaning dissection and microscopic examination of tissues). Given the extraordinarily high profile of this case we wondered about this last week. The questions go to how the medical examiner was able to accurately determine both the cause and manner of death.

To be completely certain of the cause of death there would have to have been both a toxicology screen (which could have been done with blood samples only) and also clinical evidence that the cause of death was related to the alleged toxic agent. In the case of acetominophen and codeine this could either be respiratory arrest from an overdose of codeine or fulminant toxic hepatitis and liver failure from the acetominophen. If the codeine were combined with the acetominophen, as is usual, the likely mode of death would be liver failure. Clinical information from Ivins’s hospitalization before death could be used to verify liver failure, for example, a record of sky high liver-associated enzymes. So the medical examiner could have made a plausible cause of death determination without a dissection of the body, although one would have thought in this kind of case one would have been done in any event. Maybe when he fell unconscious he hit his head and died of a subdural hematoma. Might there have been other toxins? Since we don’t know what was asked for in a tox screen, that is a possibility. What about alcohol? Colleagues say Ivins was drinking heavily in the period before his death, so this is highly pertinent. Maybe there is more complete information than we have been given, but there is no mention anywhere how it was obtained — if it was.

In particular, the combination of alcohol and acetominophen is highly pertinent to the other determination the medical examiner must make, the manner of death. Besides cause and manner, there is one other piece of information, not officially part of the birth death certificate (although sometimes found in the narrative portion) — the circumstances of death. Essentially this means the reason for the manner of death. For example, “family dispute,” “financial worries,” “home foreclosure” or “failed love affair.” In the Ivins case, the FBI has obligingly offered abundant information on circumstance, mostly uncorroborated and some highly speculative. One of the most frequently repeated “circumstance” items in news reports is that Ivins killed himself as the FBI was “closing in” on him and preparing to charge him with capital crimes. But his lawyer denies Ivins even knew he was a suspect in the case:

As the government pegs the blame for the 2001 deadly attacks on one Army biologist, the attorney for scientist Bruce Ivins says his client never knew he was “the suspect” in the attacks.

“We were never informed or advised that an indictment was imminent of him,” attorney Tom DeGonia tells WTOP. DeGonia’s broadcast interview is Ivins’ lawyers’ first interview since Ivins committed suicide.

Ivins, a Fort Detrick scientist, overdosed on acetaminophen. He died July 29, hours before he was set to meet with the government about the case. Even though Ivins had died, DeGonia and co-counsel Paul Kemp still met with the Justice Department that day. It was then, DeGonia says, the government offered up a reverse proffer — its plans to seek an indictment against Ivins.

“It had never been made clear to him nor to us that he was ‘the suspect,'” says DeGonia, Ivins’ co-counsel. (WTOP News [Baltimore]; n/t MRK)

Could the “manner of death” designation of “suicide” be wrong? We will leave aside various conspiracy theories that it was a homicide because without an autopsy we have no way to judge this at the moment. But another more likely “manner of death” would be “accidental” because the combination of alcohol and acetominophen is known to be lethal in some people. Indeed there are many reports in the literature of a combination of a normal therapeutic dose (2 to 4 grams) combined with chronic alcohol ingestion leading to fatal fulminant toxic hepatitis (here is one citation among many possible). Without more information than we now have, at the very least we would expect the “manner of death” to have been classified “undetermined,” especially as Maryland is one of a few states whose procedures favor this classification.

What difference does this make? Let’s assume for a moment that in the wake of the bungled Hatfill investigation the FBI was considering other “persons of interest.” If Ivins died accidentally they would be in a dilemma. Should they announce their case at that point? If in fact they waited to accumulate more solid evidence or they felt that they would never get beyond what they already had, or there were reasons to have someone, especially a lone, rogue scientist be the culprit, then fixing the manner of death as a suicide fit in to the narrative they were developing much better than an misadventure with Tylenol for a headache. “Suicide as the cops were closing in” is a much tidier and persuasive story.

But is it just a story?

Comments

  1. #1 zhasper
    August 11, 2008

    not officially part of the birth certificate

    I think you mean death certificate?

    Similar, I know, but…

  2. #2 revere
    August 11, 2008

    zhasper: That was a mistake in the original I corrected with a strikeout (to show that a mistake was corrected). Does it not show that way in your browser?

  3. #3 daedalus2u
    August 11, 2008

    If it took him 3 days to die, doesn’t that indicate a toxic dose that is marginal? It precluded death being due to codeine poisoning which would have stopped his breathing.

    He was not ignorant of physiology, if he wanted to kill himself, presumably he would have used a dose that left no margin for survival. Presumably that would have been a known toxic dose, a known toxic dose for someone with an intact liver. A known toxic dose plus a factor of safety. Usually that involves taking everything that is available and not leaving any pills behind.

    If he was in the hospital for 3 days, they would have taken blood samples and done drug tests on them. Those samples would have indicated the course of the liver failure which would have indicated what dose he took and was it complicated by alcohol or by previous liver damage, or maybe by something else (Disulfiram?).

    My guess is that the FBI seized his medical records and won’t allow them to be analyzed by anyone else. Or analyzed by anyone who hasn’t signed the “confidentiality agreement” they forced every witness they interviewed to sign. A confidentiality agreement is just a contract. There has to be “consideration” passed to the person agreeing to keep the information confidential. Usually the information itself is the consideration. But that only keeps the receiver of the information from disclosing it. The person who owns the information in the first place hasn’t received anything, information or consideration. What “consideration” were the witnesses given to force them to keep their own information confidential? Even grand jury testimony, the witness is free to say what their testimony was, just no one else can.

    This article says that treatment of acetaminophen poisoning is successful if started within 12 hours of acute overdose.

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11983032

  4. #4 erica
    August 11, 2008

    Things to look for:

    Some kind of toxicology report in the medical records.

    Some understanding of whether Ivins had a living will. Is it possible he had a living will that specified no treatment in case of organ failure?
    (I think people usually sign these for when they’re old and failing–it would be ironic if Ivins’ DNR prevented him from receiving treatment.)

    A neighbor said Ivins suffered from back pain–when his liver started to fail would he think it was a backache which prevented him from seeking immediate treatment?

    Some understanding of why Ivins was cremated rather than buried. My understanding of traditional Catholic belief is that it’s important to be buried so your body will be intact when the dead are raised. If the FBI is portraying Ivins as a nutty Catholic mad scientist, it will be important to understand this seeming contradiction.

  5. #5 carl
    August 11, 2008

    I’m not particularly into conspiracy theories but I just don’t buy this. The bureaucratic imperative is to close the case, the ‘lone nut’ is always convenient as it simply closes the case without making anyone get off the couch. What is the likelyhood that the ‘lone nut’ would launch the first major biological attack on the United States immediately prior to September 11th? Circumstantially it would seem the Al-Quaeda types would be most likely suspects. Saddam (although not otherwise allied with the Salafi Islamists) would have motive and resources. It would also explain why Bush was so hell bent on attacking Iraq. Anyway, I don’t know any more than anyone else but a ‘lone nut’ is just to easy.

  6. #6 pft
    August 11, 2008

    Ask yourself, why any individual would want to implicate himself as being tied up with 9/11, which is what the Anthrax letters did (assuming you believe the official Ivins lone nut theory). Anyways, Ivins had no means to weaponize it. This is a ludicrous story that only a gullible and ignorant public will believe.

    It’s not even worth discussing because those questioning the Anthrax story today will find someway to convince themselves there was no conspiracy, as they have done with 9/11. In the end, they will say it was some combination of stupidity, incompetence, craziness, accident or coincidence to explain anything in the official version that makes no sense or is proved to be untrue.

    Anyone not recognizing the conspiracy of 9/11 and Anthrax is the same conspiracy, is simply a denialist.

  7. #7 revere
    August 11, 2008

    pft: Just for you. Wear it in good health.

  8. #8 M.Randolph Kruger
    August 12, 2008

    Revere-Ole son, you crack me up sometimes so bad I cant breathe…..Quick… get me a tylenol.