During my forensic pathology training, I autopsied a man who had the second-highest cocaine level ever reported.
I was a fellow at the medical examiner’s office in Suffolk County, New York, when Chief Toxicologist Dr. Leo Dal Cortivo and his assistant, Ed Briglia, began studying cocaine levels in the brain.
Cocaine-related deaths correlate very poorly with measured blood levels. Perhaps, Briglia and Dal Cortivo thought, the cocaine level in the brain would be a better indicator of fatal intoxication. Their hypothesis turned out to be wrong, but the study taught me a lot about toxicology’s limitations.
Alone in New York, I frequently flew back to Illinois to visit family. During one of those trips, a coroner I had previously worked for asked me to autopsy a young prison inmate.
The inmate was in the prison yard when a corrections officer noticed suspicious behavior. A chase ensued, and the inmate ran around a corner. When the pursuing officer caught up, his quarry was on the ground having a seizure. He died despite resuscitation.
When I made the Y-incision, everything looked normal. But when I cut through the trachea to remove the lungs, a wad of crumpled plastic popped out.
A baggie of cocaine had been smuggled into the prison. Desperate to avoid being caught with contraband, the inmate tried to swallow it, with disastrous consequences. The bag went down the wrong throat and became wedged in his windpipe. A perfect case for the cocaine study, I thought.
So I gathered brain tissue along with the usual samples for cocaine testing and stowed everything in my mother’s refrigerator. In an era when nobody worried much about what travelers were carrying, I wrapped them up with some blue ice and took them back to New York on the airplane.
The results were so unusual that Dal Cortivo arranged for me to present the case at a national meeting of the Society of Forensic Toxicologists.
The cocaine results were off the charts, but the levels alone didn’t warrant a presentation at a national meeting. Unique to the case was that those remarkably high levels of cocaine hadn’t killed the inmate.
Nobody can survive complete airway obstruction. Even if the inmate had inhaled the bag on the doorstep of Massachusetts General Hospital, doctors couldn’t have removed it in time to save his life.
The inmate’s final, desperate gasps pulled much of the cocaine out of the inhaled bag and into his lungs. It diffused easily into delicate blood vessels and was distributed to his brain and other parts of his body by the last beats of his dying heart.
Because young, healthy hearts have a much greater tolerance for oxygen deprivation than brains do, the inmate’s heart would have continued to beat and force cocaine into his system for at least several minutes after the lack of oxygen destroyed his brain. Since he would have already been brain dead, the cause of death wasn’t cocaine poisoning. It was suffocation caused by inhalation of a foreign body.
My audience clapped enthusiastically, and as I left the room, Dal Cortivo clapped me on the back and said I was a fine raconteur. I left the conference feeling quite full of myself.
That was 30 years ago. Toxicology has progressed in many ways since then, but some things haven’t changed: Drug levels must be interpreted in the context of the history and an autopsy. A high drug level alone is insufficient proof of the cause of death.
Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003-12. She now lives in Florida and Maryland. Reach her at firstname.lastname@example.org.