“Causa Mortis, Ignota”
This happened when I was a medical examiner in a rural county in Mississippi. But first, let me take a minute to explain how I got there.
When practicing in a small town, a family medicine physician takes on many roles in his community. Often these functions don’t fall within the typical job description, and honestly, that was one of the perks that attracted me to the specialty as a medical student. The old saying “Jack of all trades, Master of none” always appealed to me, so family med just seemed appropriate. Early in my training, I made plans to be active during my career, and I’ve always been involved in some way since I hung my shingle. One year, fresh out of residency and while in private practice, I served as medical examiner for Pike county.
Pike was an area of Mississippi in which I was fortunate enough to learn the art of medicine and the mystery of human nature. It also happened to be the area in which I grew up and spent most of my life, so naturally I returned there to practice when I finished training. It was always rare to meet a stranger, and when I did, they never stayed a stranger for long. I met my wife there, and my daughter was born at the very hospital in which I completed my third year rotations. Needless to say, I had planted my roots there and I’m confident wouldn’t change a thing given an opportunity.
Ok, now, back to the story…
That winter was merciless — a rarity in my neck of the woods. I was called in to conduct an autopsy for a suspected drug overdose case that came in at the crack of dawn…as if they ever came in between nine and five. The morgue was in the basement of the regional hospital and was usually pretty calm as most of its visitors were former patients at the local nursing home more than anything else. On this particularly frigid morning, no one was around except Shelton, the local coroner, who had picked up the body.
Shelton had been the coroner for as long as I can remember. Sure, back in the day he had a little more spring in his step, but he was still getting around pretty good for sixty. A little more than six feet tall and as thin as grandma’s straw broom, he even looked the part of grim reaper. He was nothing short of professional at every meeting, and always ensured the bodies were respectfully delivered. He seldom cracked a smile behind his wiry salt-and-pepper beard, which perfectly matched the seemingly unkempt hair on his slender, almost pointy, head.
Don’t get me wrong, I have nothing but respect for Shelton. He’s been around the metaphorical — and literal — farm a time or two, and he never fails to show up to church on Sunday morning wearing his green tweed coat and olive khakis. Now, I’m no pathologist, and neither was he, but I can only imagine what those greyish-blue eyes had seen in that morgue over the years. Still, he was getting older, and as with all of us eventually, time had begun to take its toll on poor ole’ Shelton and he became known for speaking his mind, regardless of context. That day, though, Shelton seemed rather quiet and withdrawn, and I knew what that meant…we had lost a kid.
“Morning, Shelton. What we got?”
“Mornin’, Doc.” he said almost whispering, but after a sigh he spoke up, “19-year-old Hispanic male found dead by a family member at his home this morning. There’s evidence of a party last night, and we found several empty pill bottles, and some marijuana, around him and his bed. He was found supine, and fully clothed, save his shirt. Had some dark red foam comin’ out his mouth, too. Pretty obvious drug overdose, if you ask me.”
“I don’t recognize him, do you?
“Nope. Talked to the mother when I got there. Said they just moved here a few weeks ago. No dad in the picture. She works over yonder near Tim’s place…ya’ know, that new hardware shop that forced West’s outta business? Said he’s had a drug problem for a while — pain killers, amphetamines, marijuana…even said he’d experimented with bath salts once and landed him in the hospital for a week. She’s goin’ to get his records sent over from his last doc. She was pretty upset; didn’t know much about what happened. Said she’d been working doubles to make enough for rent.”
“Gotcha. What bottles did you find? Were they his?”
“Nope. Mom says his doc was treating him for depression and anxiety but didn’t know with what. But she said he hadn’t seen the doctor in months because he didn’t have insurance after he turned 19. The labels were ripped off the bottles, anyway. Don’t sound like legit ‘scripts to me. Also saw white powder and a pill crusher at the scene.”
“So what do you think, suicide?” I asked as I adjusted my lavender exam gloves over my stiff, frozen fingers.
“I don’t think so. Mom said he didn’t seem unhappy, and he’d done made friends in town. He’d got a job, but the mom forgot where. She’s goin’ to come by later to fill out a statement. She did say he’d mentioned that he was looking forward to a fresh start. We didn’t find a note or nothin’. Don’t seem like someone who wants to end it.”
“Homicide?”
“No forced entry. No apparent trauma. No reports from the neighbors. Just don’t feel like a murder to me. I jus…”
For the first time since I had taken over as medical examiner in Pike county, Shelton held his tongue. I could tell he wanted to say something, but he was holding back. I had been examining the body, so I hadn’t seen the emotion written all over his face.
“Shelton? What is it?” I asked as I looked up from the body. His eyes were slightly red and puffy, and it was obvious he had been fighting back tears.
“Its nothin’, Doc.” he said as he wiped his eyes with a dingy handkerchief pulled from his front pocket. “I just take it hard when kids come across my radio. He’s the same age as Willy was when he…well, ya know. He’s the same age as your JoAnne, too. Just hits a little too close to home is all.”
That caused me to pause. I just stood there for a minute, staring at this seasoned coroner who, after all these years, still chokes up and sees more than a corpse when he looks at these cold, dead bodies. For me, it was another day of work. For Shelton, it was never routine and seeing kids like this seemed to bother him more than anything else.
“Yeah, I guess it does.”
“Um, would you mind if I came by once the lab reports are in? The case seems odd and I just want to know what it was that claimed him, ya know? I hate seeing these drugs on our streets.”
“Of course, Shelton. I’m going to finish up here and send specimens to the lab. You can come by in a couple of days.”
“Thanks, Doc. I’ll holler at you then.”
I spent the next few hours examining and writing notes about the young man laying there on my table. He was well-developed, and showed no signs of malnutrition. There were no needle track marks or other puncture wounds, so whatever drug was responsible, it wasn’t injected. I examined all of his internal organs and found nothing abnormal, except for a distended bladder, due to urinary retention. That was common in opiate overdose cases, and with the history I was given from Shelton, I was sure I had identified the drug responsible for the death. I collected specimens of blood, urine, stomach contents, liver, and brain and sent them all to the lab for analysis, but I was already decided on my diagnosis.
On my way home that night, I just couldn’t stop thinking about what Shelton had said. The kid was just a few months older than my little girl. The victim’s mother knew very little about the circumstances that lead to her son’s death because she had been so busy working to make ends meet. I can only imagine how she must feel. I mean how would I feel if, by the time I realized something was wrong with JoAnne, it was already too late? I wouldn’t be able to handle it.
A million similar thoughts raced through my head on my way home, and I couldn’t shake it. JoAnne was away at college, and it was late on a school night, but I had to call her and tell her how much I loved her. Of course, she thought something was wrong, but after I assured her everyone was ok and that her cat, Phoebe, was still as annoying as ever, she returned my sentiments. Talking to her made me feel a little better, and eventually I was able to fall asleep.
A couple of days later, I had reports from the lab waiting on my desk, so I decided to go over them while I drank my third cup of coffee that morning. I was already convinced that I was going to read a laundry list of drugs in the kid’s system, and ultimately, call the cause of death as opiate overdose. As I began reading the report, I was more confused rather than the usual confirmation I get with such an open-and-shut case. Right then, my cell rang. It was Shelton and I agreed to meet him for lunch to discuss the case.
“And bring your thinking cap, Shelton. I’ve got something I need to bounce off of you.”
We met for lunch at a popular Chinese restaurant in town. Not that there was much to choose from, but it was still a favorite of pretty much everyone who lived in the county limits. Shelton got there before me, of course, so he had us a table and already had our food on the way. He was in his favorite booth, slumped over that day’s newspaper, waiting patiently as I walked up to meet him.
“Everything alright, Shelton?” I asked as I took off my coat and sat down in my chair.
“Yeah, Doc. Just reading Julio’s obit in the Enterprise Journal.”
“Julio?” I asked, confused.
No faster than I had said it, I realized that it was the victim’s name. I brushed it off, but I know Shelton was disappointed in me. He didn’t acknowledge it and just kept reading.
“He had two sisters, both younger. They were away visitin’ an aunt up in Prentiss. The girls are back home, and the aunt decided to stay and see to them. The mom filed her report this mornin’ and the detective is working on the case now. Its all just a shame.”
“I know. It really is.”
“Did ya get the results in from the lab? Know what drug killed the kid?”
“Yeah, I combed through the report this morning.”
“Well?”
“Well…he didn’t overdose.”
“What?”
“He didn’t overdose. There is no evidence of drug overdose in his lab reports.”
“Then what was the cause of death?”
“No idea. The lab report says the blood was positive for metabolized Xanax and Prozac, which may have been left from when the kid saw his doctor for depression. He was positive for Marijuana, too, but all of the drugs were far below toxic levels.”
“So now what? What do you think happened?”
I didn’t really have an answer to give him.
“I’m not sure. Under the circumstances that the body was found, his history of drug abuse, the oral purge, and the distended bladder, I was sure we had a case of classic opiate overdose. I requested that the lab run a blood sample through mass spec so maybe we can find something there, but I’m stumped. Did you notice anything else at the scene?”
“Nothin’ that really stands out. The house was clean, but felt lived-in. I didn’t notice any unusual bottles or containers. Other then the empty pill bottles, Tylenol, and some boxes of anti-diarrhea tablets, there were no other meds in the house. Investigators didn’t find anything else at the scene, and his friends said he was asleep on the couch when they left. They were all brought in for questioning, but nothin’ came up.”
“There has to be something I’m missing. I just can’t figure out the link.”
As I finished up my last bite of pork fried rice, I got a text from John, who was a friend of mine that worked in the clinical lab of the medical center in Jackson. With no lab of our own, that is where we sent all of our specimens for toxicology. He said he had emailed me the results from the spectrometry analysis, so I asked Shelton if he wanted to go back to the office to see what they found.
We paid for lunch and went directly to my office to read what John had sent. As I opened the email my heart was racing and it was like I could feel every hair on my body stand straight up. I wanted answers and they were only one click away. When the screen loaded, my heart sank and I slammed my fist on the desk.
“Damn it!”
“What? What’s it say, Doc?”
“Nothing. They identified the same drugs as before. The only addition is something about split isotope peaks consistent with chlorine — some organic chemistry nonsense. I was hoping they would have found opiates. Everything would have made sense then.”
“Chlorine? Like in bleach? Dang lab done spilled Clorox in the blood while cleaning their bench.”
“No, Shelton…” I said with a half-chuckle “…not exactly.”
But Shelton wasn’t laughing. His demeanor seemed to shift from inquisitive to outraged in a split second. He began getting louder and I could tell he was holding back tears of frustration.
“Well, then tell me what happened to this kid. Tell me why a mother had to bury her son today. Tell me why two little girls don’t have their big brother to protect them from the monsters under their bed. Please…tell me how this kid looks like he overdosed on pain killers, but there is nothing but bleach in his blood and piss in his bladder.”
It was at that moment when I saw the anger in Shelton’s eyes burning a hole right through me. I felt his need for closure running through my veins and I was hanging on every word coming from this hurt and broken man. Yes, it was at that moment that I realized I knew I had the answer. I knew what had happened to Julio.
I quickly got up to leave, and while dialing John on my cell phone, I told Shelton to meet me back in the office that evening.
“I think I will have your answer then.”
Looking back, it was really Shelton who should get the credit. His passion and need for answers were responsible for forcing me to think through the pathology. He forced me to go all the way back to information I haven’t seen since medical school in order to find answers for this 19-year-old kid and the family he had left behind. Shelton had not been formally educated, but he was so experienced, and had so much to offer outside of the lab, and sometimes that is where the answers can be found. He had no idea of the significance of two peaks on mass spec, but he did know how to observe what evidence was around him.
That day, I had used what I learned in Year II pathology at Carey by realizing that common pathology presents with uncommon findings more often than does uncommon pathology with common findings. The same professor who taught me that simple principle used to say “Any diagnosis is easy find, as long as you think of it.”, which was all gibberish at the time because of the overwhelming volume of disease that we were learning. However, on that day with the help of a very wise man, I was able to connect the dots and bring closure to a broken family, and a dear friend.
That evening around dusk, as the sun was setting and rays of orange and red could be seen through the blinds of my office, I heard a knock on my door.
“Doc, you there?”
“Shelton! Come on in!”
“Well? Did ya find anything?”
“I just got off the phone with the lab. We have our diagnosis.”
“Really? Well, what is it?”
“Loperamide toxicity.”
“Lo-what toxicity? English, Doc.”
“Loperamide toxicity. Loperamide is an opiate analog that works on the same receptors as morphine, which is an opiate. Loperamide typically doesn’t cause any of the euphoric effects of opiates because it doesn’t cross the blood-brain barrier, except in high doses. Julio had more than six times the therapeutic amount in his blood.”
“So you saying he overdosed on morphine? You said the lab didn’t find any in his blood. How could he have gotten it? Where did it come from? Why didn’t it show up before?”
“Not morphine exactly, but something that acts a lot like it. Loperamide is a common over-the-counter anti-diarrheal. You mentioned seeing those at the scene. Well, earlier you made me think about what could possibly produce opiate toxicity in someone with no detectable opiates in their system. I tried to think of opiates that don’t really look like opiates. It occurred to me that Loperamide was an opiate and wouldn’t show up on a regular tox screen. I called the lab and had them run mass spec comparing loperamide to what they found in Julio’s blood and they matched perfectly.”
“Ain’t that somthin’. How bad was his diarrhea that he had to have so much medicine?”
“I spoke to the detective and reviewed the statements from his mom and his doctor. Julio was addicted to opiates, but had been to rehab and was trying to stay clean. Opiate withdrawal is very unpleasant, and since Julio no longer had insurance, he was probably trying to figure out how to deal with the symptoms. There are sources all over the internet that talk about using loperamide as a substitute for methadone for addicts who are trying to quit, but are poor or uninsured. My guess is that he was trying his best to cope without letting his family know what was going on.”
“So Julio was trying to kick his drug problem, but he was going through withdrawal. He figured out he could use regular anti-diarrhea meds to help with the symptoms, but accidentally overdosed.”
“That’s the way it looks to me.”
“But what about the other drugs in his system?”
“They were his. The doctor faxed his medical records. Julio was being treated for anxiety and depression, probably a result of detoxing. The doctor said he had given Julio a 90 day supply at his last visit, and that was enough to get him through the this month.”
“We didn’t find nothin’ but empty bottles with no labels at the house.”
“His friends that gave statements weren’t actually friends at all. Julio called some old buddies over for a party the night before he was found. They said he told them he needed some cash, and had narcotics he could sell. They admitted to crushing the pills they bought from Julio and snorting most of them, and to also smoking pot. One of them actually wound up in the ER two towns over, and they said Julio didn’t snort anything, but did smoke with them. One of the kids said Julio went out to get something to eat and was gone for a while. He came back feeling sick and went to bed so they left. Julio’s aunt called the investigator today to tell him that she had gone to pay rent for the mom this morning, but the landlord said Julio had already paid it the night before.
“Wow, so Julio sold his meds for rent money? Doc, thanks so much for diggin’ into this. I know it’ll mean a lot to the mom to finally have some closure.”
“Thank yourself, Shelton. Couldn’t have done it without you.”
“Naw. I just yelled at you.”
“You challenged me and forced me to think. Now we have answers.”
“Ain’t that the truth. Can I let the family know? I been keeping in touch with Julio’s mom. I kind of relate, ya know.”
“I’m ok with that. Check in with the investigator first. You can give them a copy of my report.”
“Thanks again, Doc. I needed this win. I’ll let ya know how it goes.”
That was the last time I saw Shelton. I was told he made it to the family and gave them the news, and that they were heartbroken but relieved to hear what had happened. Julio’s mom later told me she was comforted by hearing the story from Shelton because he seemed like he really cared about what happened to her son. She didn’t know Shelton had lost his own son to drugs many years before, so he took the case personally. Shelton never got the answers he wanted for his own son, and every time a young was found dead the anger and pain resurfaced inside him, pushing him to always know exactly what happened. He never really talked about it, but I know that the torment lingered until the day Shelton passed.
The weekend after we closed the case, Shelton suffered a massive heart attack due to occlusion of the left anterior descending artery. He was found by his son who visited Shelton every other day to check in and make sure his dad was eating right. I miss him dearly, and will always remember how he challenged me to think without him even trying.
I gave up the position of medical examiner after that year and haven’t looked back. I do believe that experience made me a better doctor by making me realize that by digging a little deeper I can provide answers to my patients in their darkest times. I think about that case every time I see JoAnne walking down the halls of that hospital in her own white coat, and I know Shelton will live on through her, just as he has through me.