Tuesday, April 16, 2013

Sickle Cell Disease and Forensics.

      There is a current legal case playing out in the local Milwaukee news media. A 21 year old man in the city of Milwaukee had been jailed due to unpaid parking tickets. He had no previous criminal record. On the day that he was released from jail, he apparently made a bad decision and attempted to mug an older couple who were walking down the street. He was wearing a mask and attempted to grab a purse or something. It happened that at exactly that moment, a squad car happened by and saw the event. The young man took off running putting his mask in his pocket as he ran, but was apprehended by the cops. They found the mask in his pocket and arrested him. He seemed to be resisting arrest and he had run from the police, so while cuffing him, they had him on the ground face down with his arms behind him and to hold him still one cop put his knee on his back while they cuffed him. Then the cops put the man in the back of a squad car. The suspect kept making a fuss in the back of the car and began complaining that he couldn't breath. He apparently was crying out for help. The cops thought this was still this young man who had run from them and resisted them who was now acting out in the back of the police car. They did nothing for a time. However they did have a video tape recording all this behavior in the back seat of the car. Perhaps 5 to 10 minutes passed, and then something terrible happened. The young suspect who was visibly laboring for breath on the tape, collapsed in the back of the car. At this point, the cops realized what had happened, pulled him out of the car and began CPR on him. But he died on the spot.

     There was a lot of controversy on the cause of death. At first the Medical Examiner called the death due to natural causes. An autopsy and blood samples showed that the young man had sickle cell trait, but he died from a massive sickle cell crisis. Later the ME looked at the tape and put some of the other information together and changed his decision calling the death a homicide.

     Now a decision is being made whether to charge the two officers who arrested this suspect with neglect of his well being, and being contributory to his death. They of course are currently on suspension of their duties while an investigation goes forward. The family and friends of the suspect are of course devastated and are seeking charges against the policemen. Meanwhile the tape is constantly replayed on TV and believe me it is very hard to watch. To me, a doctor, this suspect is clearly in medical trouble.

     Now to me, as an MD, the circumstances of this case are quite interesting.  First of all, he had sickle cell trait. Sickle cell disease is an inherited blood disease in which there is abnormal hemoglobin formed in the red blood cells. This abnormal hemoglobin is unstable and under circumstances when there is low oxygenation in the tissues or under illness conditions, fever, or even mental stress alone, simplistically, the abnormal hemoglobin molecules crystallize in the red blood cells and pull them into a sickle shape. Hence the name sickle cell disease. These malformed red blood cells can't pass through the tiny capillaries throughout the body and they obstruct the blood flow making the condition worse. The person in sickle cell crisis like this usually has excruciating pain in the bones and muscles, and then starts to have other organs fail due to the obstructive nature of the sickled cells. If the sickling occurs in the lungs, then oxygenation of the body would be a problem. These cells are destroyed by the sickling so over time, the person becomes anemic, that is develops a low red blood cell count because many of his red cells are destroyed and the bone marrow can't keep up with making new ones.

     Now there are two forms of the disease. The full blown sickle cell anemia occurs when the person has both genes for the abnormal hemoglobin. These people often are very unhealthy and suffer recurrent attacks of sickling. They deal with much pain and often require pain meds and they are often admitted to the hospital for various treatments to try to reverse the sickling that is occurring. The other form of this disease is called sickle cell trait. These individuals have only one gene for the disease. They are much less likely to have the sickling occur and often do not even know they have the disease. Though sickle cell crises can occur in sickle cell trait they are usually less severe and can be reversed more easily. Well, our suspect in this case had sickle cell trait, not the more severe form. However, the postmortem exam did show that he was in a sickle cell crisis. So something that happened with the events of his attempted robbery, whether it was the chase by the cops, the stress of being caught, the pulling of his arms back when he was cuffed -- I don't know what, but something made him have a full blown and severe sickle cell crisis. Though people certainly can die from sickle cell crises, most do not. They receive intravenous fluids, oxygen, and whatever other medical support they need, and the crises abates. They are often in the hospital for days or a week or more with all of these supportive measures before the effects of sickling completely go away. But it is highly unusual for someone to die from a sickle cell crisis within 10 minutes, especially when he does not have the full disease but instead the lesser form, sickle cell trait. So what happened here? Was he already starting a crisis when he was in jail, or earlier in the day released, or when he was on the streets and making the decision to rob someone. Did the running from the cops, and the stress of being caught and handcuffed etc aggravate the process? I don't know and I am still having difficulty explaining the horrendous result of his disease.

     But then, what about the cops? Should they be charged with negligence or with a worse charge in the death of this suspect? Seeing the video it is difficult to believe that they could not see his medical distress. Yet he had run from them, he was probably the fellow that had tried to rob an older couple, and they were probably somewhat disgusted with him. He seems to have resisted the police, and so they concluded that in the back seat of the squad car he was just continuing his resistance. I can see both angles in this case. The police did do the correct thing once they realized he had lost consciousness. But it was too late. It has been stated that even if he had been taken to the hospital at the beginning of the period in the back seat of the squad car, it is likely that he would not have survived if he could not breath at that point. The inability of his body to circulate oxygen to his brain such that he lost consciousness means that even resuscitative measures in the emergency room would not have been quick enough to reverse the affects of those obstructive sickled red cells. In extreme cases, where the victim of the disease is critical, exchange transfusions are done to try to replace the sickled cells with normal red blood cells. It takes at least a couple hours to set such treatment up. So even if he had been taken to the hospital early on, it is unlikely that such lifesaving efforts could have been completed in time. This doesn't excuse the officers oversight but it does affect the legal conclusions.

     Well, after all of these ramblings and feeling one way and the other, I still can see both sides of the picture and I don't know what will be the conclusion of the case. Right now, the district attorney has to decide whether to subject the police officers to a hearing and then if found guilty of "likely cause" would have to stand trial. Time will tell. This event just emphasizes that you don't want to do anything that might get you into the hands of the police. And if that is likely, you must cooperate, not resist, be pleasant and respectful, because you now have no control of the situation.

     P.S.  The case has finally concluded and it was determined that the police did nothing wrong and would not be charged or even disciplined. Of course, the family still is fighting this. There will likely be an appeal. Also the family is considering bringing civil suit now. This could still drag on for even years. Such is our legal system.

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