Q and A: Can My ME Distinguish Death From Asphyxia From Death Due to Head Trauma?

Q: Here’s my book situation: A man puts a plastic bag over his head to kill himself. His wife wakes up next to him (after he nearly strangled her to death and she discovers he’s killed their son) and in her horror and rage cracks him over the head with a blunt object.

Here’s my question: Can the police/coroner/forensics determine which was the cause of death–suffocation or blunt force trauma? If so, what would the signs be pointing to asphyxiation?  Also, if it matters, this is set in 1969.

Judy Merrill Larsen, author of All the Numbers

http://www.judymerrilllarsen.com

A: If the victim died first from the asphyxia, the ME would have no problem since the blow to the head would cause no bruising or bleeding. At death the heart stops and blood flow ceases and a corpse will not bleed or bruise easily. So the ME would see a mark where the victim was struck but no bleeding or bruising and know that the blow was delivered post-mortem.

If he was still alive when struck, things become a little more difficult for the ME but he should still be able to tell. Bruising and bleeding at the site of the blunt trauma would show that the victim was alive when struck but if there is no significant brain injury found at autopsy he would know that the force of the blow did not cause death and the asphyxia must have. If there is a brain injury such as cerebral contusion (brain bruise) or bleeding into or around the brain, he might have difficulty determining the actual cause of death. Of course any evidence of blunt trauma would point to homicide and not suicide since someone using a plastic bag for suicide would not likely also strike themselves in the head.

But I see a bigger problem with your scenario. If she was unconscious from being strangled, she would wake up within 10 seconds to a minute or so after the pressure was released unless she had significant brain injury from lack of oxygen. If she were simply strangled into unconsciousness, which is due to blocking blood flow thru the carotid arteries to the brain and not blocking breathing, as soon as the pressure was released and blood flow reestablished, she would wake up very quickly. Much sooner than he could put a bag on his head and die from asphyxia. For her to be out that long would require some degree of brain injury and I don’t think that’s what you want. Of course, if he drugged her first and then strangled her to the point he thought she was dead, but she in fact wasn’t, then she would awaken when the drug effect wore off. Here he could be dead for hours before she awakened.

 

 

Q and A: Can My Chronic Arsenic Eater Die From Arsenic Poisoning?

Q: I am currently doing research for a historical novel, one of my main characters, a prosperous middle aged male, was an arsenic-eater who used this drug regularly for some time, at least two years probably longer, he became addicted to it and took increasingly large doses. He eventually died from an overdose of arsenic, possibly intentionally (as in suicide). Could you give me some information about what type of physical as well as psychological symptoms he may have had both as a habitual user as well as dying from n overdose of this drug?

Brandy Purdy, author of The Boleyn Wife, The Tudor Throne, and The Queen’s Pleasure

www.brandypurdy.com

http://brandypurdy.blogspot.com

A: Arsenic (AS) can cause both chronic and acute poisoning and it was indeed used in the past by many people as a folk remedy for almost anything. So was strychnine. Though chronic users can tolerate increasing doses there is still a tipping point because AS builds in the system over time until it becomes lethal—even if repeated small doses are taken. This can take weeks or months depending on dose. And if the dose is very small, one that matches the elimination of the AS from the body, then this can go on for decades. But if the intake is above the elimination rate, it will accumulate and eventually kill the taker.  For your story you don’t have to worry about the math just have your character use it for however long you want and the readers will assume the dose was too small to kill. And then when it accumulated to the point of death–or until someone either tampers with his dose or gives him an excess—have him become acutely ill and die and the readers will buy that also.

You used the word addiction here but that is not correct. AS is not addicting as would be a narcotic. It is not even habituating as are some sedatives and sleeping pills. If he stopped using it he would have no withdrawal and in fact would feel better as the effects of the AS faded.

The symptoms of AS toxicity are predominantly GI and neurological. Symptoms include nausea, vomiting, weight loss, diarrhea, abdominal pain, headaches, irritability, insomnia, poor balance, numbness and tingling of the extremities, and a few other symptoms. Your victim could have these in any combination and in any severity. His symptoms could be mostly GI, mostly neurological, or any combination of the two. They can be constant, progressive, or wax and wane. And if he used very small amounts, he might have no symptoms at all.

With acute poisoning these symptoms can be very severe and appear quickly and violently. His vomiting and diarrhea would be bloody and his abdominal pain severe. With an acute poisoning, death can take many hours and is not pleasant. He could take the AS for many months or years and feel fine and then begin to develop the above symptoms, mild at first, but they would progress in severity until he died. This progression could be over a few days, weeks, or months. Anything is possible. And, if someone gave him a large dose on top of this progression in toxicity, he could die within hours.

FOLLOW UP Q: Thank you very much, that does help but I am confused about something. Is a psychological addiction or dependency possible? In his diaries this man writes about taking larger doses and feeling stronger and being in terrible pain and headaches, vomiting, and coldness or numbness in his hands and feet, when something prevents him from having his regular doses. That’s why I used the word addiction, I assumed this was withdrawal, but I didn’t realize this was not a part of arsenic use.

FOLLOW UP A: Yes that’s possible. It’s called the placebo effect–means that if someone believes that something helps them then it will. Health food stores have made a living off this for years. If he felt that the AS made him stronger and when he couldn’t get it he would be weaker then he could easily feel that way. The truth is the exact opposite, since AS toxicity actually makes one weaker not stronger. But reality is perception. This would be a form of “psychological addiction” for lack of a more accurate term. So go with it since whatever he believes is true is true to him and that’s really all that counts in his world.

 

 

Q and A: Can My Character Survive An Arrow to the Back Yet Have Long-term Pain?

Q: In my fantasy world, a healthy young man of about twenty-three gets shot in the lumbar portion of the back with an arrow. The physicians manage to remove most of it, but left behind fragments that were too close to his spine. He lives until fifty years old, but suffers from bouts of agonizing pain, numbness and tingling in his legs and feet, and sometimes trouble walking. Would it be viable for someone to live almost twenty-five years with pieces of an arrow lodged in their back? And do the symptoms I describe coincide with that sort of spinal trauma?

Liz Penn, author of ISHTAR FLUX

 

A: Yes, this could easily happen and it doesn’t even require that fragments are left behind because the scar tissue left from the injury and from the surgery to remove the arrow could also irritate the lumbar spinal column and the nerves that arise from it. This scar tissue would remain forever and could cause chronic low back pain, pain down the leg, numbness and tingling, and could even interfere with what we call proprioception–the feeling of where your foot is. This could easily cause him pain and trouble with walking. If you want fragments to be left behind it would be best that the arrow were made of ancient materials such as flint, which is what many American Indian tribes used, since modern metal arrowheads don’t easily fracture and would likely be easily removed as one piece. It is of course possible that a small piece could break off the tip but if you want fragments I would go with the flint variety.

 

 

Q and A: Can My Serial Killer Make His Victims Float Face-up?

Q: My serial killer has predilections that make him want his (female) victims to float face up when they are found. He strangles them and then places them in the water, so they don’t actually die of drowning. Would plugging the throat or taping the mouth and nose shut (so air stays in the lungs) be a good way for him to achieve this effect? What else might work?

S.K. Davenport, Pittsburgh, PA

A: Plugging the throat or taping the mouth and nose would make little difference since there is not enough air in the lungs to cause a body to float. Virtually all bodies sink when first tossed into water. This is not absolutely universal as sometimes clothing can gather air and keep the victim afloat but for the most part they sink. They do not float again until the decay process has progressed to the point that gases have collected within the abdomen and the tissues and the body becomes buoyant. Most bodies float facedown for a very simple reason–the arms and the legs tend to fall in that direction rather than backwards so their weight keeps the body face down.

In order to make the body float he would have to do something to increase the rate of decay and since this is predominantly temperature dependent it would be best if the body was placed in warm water such as a heated pool, a Jacuzzi, or a swamp in Louisiana. Alternatively–and this is over-the-top sinister–he could inject air into the victims abdomen and chest and even the tissues of the legs and arms. If he injected enough the body would float immediately. In order to keep the body on its back, he would have to apply weights of some type that would weigh down the backside of the corpse. Maybe some large fishhooks placed deeply into the flesh and muscles with weights attached. Just a diabolical thought.

 

Q and A: Could My Young Roman Girl Estimate the Time a Death Occurred From the Blood at the Scene?

Q: I’m writing a young-adult novel set in the ancient Roman world. My “detective” is a slave girl without medical training but who has lived on a farm and observed animals being butchered. I need her to be suspicious about the reported time of death of a woman, based on the state of the body and the condition of the blood (the woman’s throat was cut and blood is still dripping off her bed when she is found). What would be the timeline of rigor mortis, and how long would the blood remain liquid? Are there any other clues that would lead her to suspect that the woman was killed very recently, and not several hours earlier, as was reported?

Tracy Barrett, YA author

http://tracybarrett.com

A: Once blood leaves the body it begins to clot very quickly. This process is completed in 5 to 10 minutes. After that, the blood begins to separate as the clot retracts into a dark knot and squeezes out a halo of yellow serum. This process would take another hour or more. The blood will then dry to a rusty brown stain. This could take several hours or even days in a moist climate.

 

As blood clots, the clot contracts, leaving behind the yellowish serum

 

You’re young slave girl could know this from her experience as a butcher. If she found blood that was liquid and still dripping she would know that the murder took place less than 10 or so minutes earlier. If she found that the blood had clotted but not separated then she might conclude that the murder took place more than ten minutes but less than an hour earlier. If the blood had separated into a clot and a surrounding halo of yellow serum, she would guess that the death occurred somewhere between one and three hours or so. Finally, if the blood had completely dried she might conclude that the death occurred at least 4 to 6 hours earlier, or longer in a moist environment. These are very general but should give you a usable timeline.

Rigor mortis would not play a role here since your corpse is found fairly quickly after death and it takes about 12 hours for rigor to fully develop. In this situation, the blood would more clearly define the time of death.

 

 

Q and A: Can My Killer Use Botox To Kill?

Q: I have been reading Forensics and Fiction and have decided my killer’s weapon will be injections of botox. Would a full syringe of botox given as a muscle injection be enough to kill a grown man (or woman) in 2 minutes or less? Could a smaller amount be used to get the same result? How would a non-medical person be able to get access to enough botox to kill several people?

JM – Memphis, TN

 

A: The botulinum toxin is one of the most lethal substances known. Very small amounts can kill. The LD50 is about 50 nanograms—a nanogram is one billionth of a gram and there are 30 grams in an ounce. LD 50 means Lethal Dose 50%—the dose that will kill 50% of those exposed to it. Here the 50 billionths of a gram needed to kill most people is a very small amount.

 

Botox is a very diluted solution of botulinum toxin. How much solution must be injected depends on the actual concentration of the toxin in that particular solution and this varies greatly. For fiction, I wouldn’t worry about the math. Simply have the victim injected and have him die. The reader will assume that whatever the dose was it was enough.

Botox is not all that difficult to come by. It can be purchased from a pharmaceutical supply house, stolen from a pharmacy or a doctor’s office, purchased on the black market, or easily gotten in Mexico. They even have Botox parties at people’s homes where a doc will show up and inject everyone while they drink wine and chat. It’s so LA. Someone could simply steal a bottle when he wasn’t looking.

 

 

Q and A: Can My Killer Hack the Victim’s Implanted Defibrillator and Cause His Death?

Q: How could a failing ICD kill someone? My idea is for the victim to be an older individual who has this kind of device implanted in him. The killer hacks the wireless device in a similar manner to this: www.secure-medicine.org/icd-study/icd-study.pdf. According to this paper, the two attacks that seem most dangerous are to turn off therapy or to administer a V-fib shock intended for test purposes during the implantation procedure. How long would these take to kill someone? How healthy would someone be that had a pacemaker? How would this change if the victim had a mechanical cardiac pump?

Adam High, Marysville, CA

A: An AICD (Automatic Implantable Cardioverter Defibrillator) is a fancy pacemaker that has a defibrillator built in to it. It is used in people who have very severe and dangerous cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation, both of which are typically immediately deadly. These rhythms can occur in anyone. but are very problematic in those with severe coronary artery disease and/or severely damaged heart muscles, which we call a cardiomyopathy. These people are highly prone to death from these dangerous arrhythmias, so these are the types of patients who receive these devices. These are also the types of patients that are candidates for cardiac transplants and artificial hearts, or what are called left ventricular assist devices (LVADs). Since people who receive these assist devices have extremely damaged heart muscles and are at a very high risk of dangerous arrhythmias, they will also often receive an AICD at the same time.

 

 

An AICD basically monitors the cardiac rhythm, and when a dangerous rhythm occurs, they fire an electrical impulse which shocks the heart back to a normal rhythm. Sometimes it stops the heart and if so the pacemaker portion of the device will kick in. Some people have these devices implanted as a precautionary measure and never use them, while others have significant problems with arrhythmias and the device discharges more frequently. What this means is that turning off the defibrillator portion of the device will leave the victim a jeopardy but will not in of itself cause death. If he is one of those individuals that never uses the device, or only rarely, then your killer would have to wait a long time, and maybe forever, before the victim had a lethal change in heart rhythm. And since these devices are frequently checked, typically every 1 to 3 months, it would be noted during the check that this portion of the device had been turned off. So that leaves a narrow window for something serendipitously to happen. Most killers want more assurance that their method will work.

 

 

A better method is to trick the device into firing an impulse in the hopes that it would start a dangerous arrhythmia. Again this is not assured. In the cardiac catheterization lab, after the device is implanted, it is tested by inducing one of these arrhythmias. But the heart doesn’t always cooperate. Sometimes the rhythm cannot be induced. That would be the same situation with your victim. That is hacking the device and causing it to deliver a shock that was an appropriate might or might not cause the desired effect––a deadly cardiac arrhythmia.

Neither of these methods are assured of working, but of the two, I would go with hacking the device and delivering an inappropriate jolt of electricity. This would have the greatest probability of causing the result your killer wants. If so, death would be immediate.

 

 

Can Amyl Nitrite Cause Death And If So Would It Appear To Be Natural?

Q: Under what circumstances can poppers (Amyl nitrite) kill a victim so it looks like natural death? If this is not possible in reality, could you provide a pseudo-medical explanation?

L. Mitana, Slovakia

A: Amyl Nitrite is what we call a vasodilator–meaning it opens up all the blood vessels in the body. Too much can lead to an immediate and profound drop in blood pressure (BP) and this can cause death directly from shock or indirectly by generating a cardiac arrhythmia due to poor blood flow to the coronary arteries. If the victim has coronary artery disease (CAD), this drop in BP can cause a heart attack (myocardial Infarction or MI). So, too much Amyl can definitely be lethal and do so in several ways.

At autopsy the coroner would see nothing unless the victim had CAD. Either way he might write the death off as a cardiac arrhythmia. If he did test for amyl nitrite he might find it or not–it is destroyed very quickly by the body’s enzyme systems but some might remain after death–or not. But he would not test for this unless he had some evidence that Amyl Nitrite might be involved in the death.

This same vasodilatory effect is why Viagra should not be taken with long-acting nitrates. Some people who suffer from CAD are prescribed long-acting nitrates to help relieve angina—chest pain due to poor blood supply to the heart muscle. Like Amyl, these nitrates and Viagra are vasodilators and when taken in combination can cause a dramatic decline in BP and death can follow.

 

 

What Congenital Heart Defects Might My Family of Women Suffer From?

Q: I’m trying to construct a family of women who have a congenital heart defect. The mother has died from it. The older sister dies as the book begins. The middle sister is suffering and her imminent death is part of the plot. (She’s 18). What I’d like to have is for her to be able to be treated by surgery, but a surgery the poor girl couldn’t afford. The youngest (12) may or may not have the problem. (I can live with either.) So far, I’ve found coarctation of the aorta but I have no clue what it means. Could the older sister simply have a worse and inoperable version?

 
David Corbett, author of Do They Know I’m Running?
http://www.davidcorbett.com

A: Coarctation would work as would an Atrial Septal Defect (ASD) or Ventricular Septal Defect (VSD). Each, if untreated, can lead to death over time and each can be repaired.

For the circumstance you described, I would go with the ASD. This is by definition a congenital heart problem so your two young ladies would both be born with a defect. The severity and the rate of progression and the time it takes to become inoperable are dependent upon two things–the size of the defect and time.

Let me explain a little bit of the physiology which is very complex but hopefully I can make it understandable. The normal circulation of the blood is divided into two separate parts. The systemic or arterial circulation is the left side of the heart and the arteries and veins throughout the body. The blood pressure in this part of the circulation is the blood pressure a doctor obtains in the office. The other half of the circulation is the right sided or pulmonary circulation. This is the circulation that goes through the lungs. So the blood is pumped from the left side by the left ventricle out to the body and returns to the right atrium through the veins. The right side of the heart, the right ventricle, pumps the blood in the lungs and it returns to the left atrium through the pulmonary veins. It’s just a large figure of eight. The two sides of the circulation are completely separate and have no communications. But in a ventricular or supple defect the two sides are exposed to one another by the defect. In a VSD the defect is in the ventricular septum which separates the left ventricle from the right ventricle. In an ASD the defect is in the atrial septum which separates the left atrium from the right atrium.

The pressure throughout the left side are much higher than are those on the right. For example the systemic systolic pressure–the one obtained when your blood pressure is taken–is typically around 120 while the pulmonary systolic pressure–the pressure in the pulmonary that carries the blood to the lungs–is typically around 30. As long as the two sides are separated there is no problem but when a defect appears the blood preferentially goes through the defect from the left side to the right side. In the case of atrial septal defect what happens is that the blood returning from the lungs into the left atrium splits. Part of it goes on to the left ventricle and is pumped out to the body as would be normally expected but part of it, driven by this pressure differential, crosses over the defect into the right side of the heart. I think you can see that as the system went on beat by beat that more blood flows through the right side and the left side simply because some of the blood destined for the left side is diverted or shunted over to the right side through the defect. So the pulmonary blood flow is elevated in either an ASD or a VSD. As the years go by this increase flow causes alterations in the blood vessels of the lungs so that they become thicker and this causes the right-sided pressure to go up.

As long as this pressure is below 40 or 50 the person does fine. From 50 to 70 or so they develop weakness and shortness of breath particularly with any activity. Once the pressures reach 80 or 90 the lung diseases severe and these individuals are typically inoperable. With pulmonary artery pressures that are normal or only slightly elevated the risk of the surgery is extremely low. When the pressures reach the 50 to 70 range the surgery is a little more risky but still is easily doable and most of these people do well. Once the pressure reaches the 80 to 100 range operations no longer work simply because if you close the defect heart failure will result in the patient will die. If not immediately fairly soon. The physiology they are way too complex to explain but suffice it to say that’s what happens.

So the bottom line is that one of your young ladies could have a defect that was smaller than her sister. This means that her sister might develop elevated pressures and severe symptoms by age 15 to 20 whereas the sister with a smaller defect may not get out of trouble till she’s in her 30s or 40s. There can be that much variation and it all depends upon the size of the defect. So this should give you a lot to work with with your two young ladies.

The standard treatment for this is open-heart surgery where a patch is sewn over the defect. This does require being put on the heart lung machine. Newer techniques where the patch is pushed through a catheter and then expanded to close the defect are now very common. This does not require opening the chest or the use of the bypass machine and is typically done in a Cardiac Cath Lab. In the former the patient is in the hospital for 5 to 7 days after surgery, while in the latter they often go home the next day. Both were expensive procedures so either would fit your requirements.

 

How Could My Time-traveling Physician Save the Life of My 15th Century Heroine With a Blood Transfusion?

Q: I am writing a time travel where one of the characters is a modern doctor who is sent back in time (15th century) with his family. I want to have him do something medical to save the life of the heroine (I was thinking heroine needs blood transfusion which would require a blood typing system) Any idea how it could be accomplished? I was also thinking that the heroine has rare blood type. Would that be Type B?

Doreen Jensen, Ontario, Canada

A: This is an interesting scenario in that you have someone with modern knowledge transported back to medieval times. This means he would have all the medical knowledge of transfusions––which of course did not exist then––but no scientific equipment to help. Not to mention that merely bringing it up might get him killed by the church––but that’s another issue.

The first human transfusion took place in France in 1667 when Jean-Baptiste Denis successfully transfused sheep blood into a fifteen year old boy. The first human to human transfusion was in 1818 and was performed by James Blundell on a patient suffering from postpartum bleeding. Even he had no way of matching the blood and, in fact, didn’t understand that there were blood proteins that made transfusions incompatible between many people and successful between others. It wasn’t until 1901 that Karl Landsteiner discovered the ABO blood groups and begin to understand the nature of transfusions and transfusion reactions. In 1939, the Rh factor was discovered, also by Landsteiner along with several other physicians, thus refining the process further.

So your time-traveling doctor would know all of this and would also know that transfusions are only successful if the donor and recipient match one another as far as blood type is concerned. But he would have no way of testing the donor and recipient for blood type and compatibility, which of course is essential to avoid harming or killing the recipient. But, there is a way around this. He would know that two compatible bloods could be mixed and no reaction would occur while if they were not compatible clumps would form. We call this agglutination and it is the basis of a transfusion reaction. He could simply mix the blood of the donor with that of the recipient––which is more or less the way it’s done today––and look for this reaction. The problem? This agglutination can only be seen microscopically and there were no microscopes in the 15th century.

The microscope was discovered in 1590 by two Dutch spectacle makers–Zacharias Janssen and his son Hans. They employed the glass lenses they used in their spectacle making, which had been around since the 13th century. When they placed these lenses in tubes, they discovered that they magnified any image viewed through the tube. This was the precursor of the true microscope which was developed nearly 70 years later (1660s) by Anton van Leeuwenhoek. So, your modern physician would know this and could perhaps fashion his own crude microscope from spectacle lenses. This would allow him to see any agglutination that might occur. He could then simply take the recipient’s blood and test it against several potential donors and see which one had the least reaction. This would be crude cross matching but it could work. He would then know whose blood to use in the transfusion process.