Clinical History:

Police were called to a house after neighbors reported windows being broken and screams being heard. Police officers arriving on the scene found that all windows were latched and all doors were locked. Upon entering the house, the officers found a 25-year-old man in the bathroom. The shower was running and water covered the floor. The man was combative and it took 5 officers to restrain him. He was delerious. There were injuries on his hands and forearms. He died on the way to the hospital. His mother and ex-wife are claiming that excessive force by the police led to his death.

Image 4.1:

Box of paraphernalia found at the scene. This shows a typical set of "works" associated with intravenous drug abuse.

Image 4.2:

Injuries on hand. These are consistent with having come from hitting the walls and/or windows. Note the superficial lacerations.

Image 4.3:

The scalp is reflected at autopsy to reveal a subgaleal contusion. This could be consistent with either the decedent's rampaging at the scene or from being subdued by the police officers. There was no fracture and no intracranial hemorrhage.

Image 4.4:

Subcutaneous hemorrhage associated with fresh needle puncture wound of the antecubital fossa. This is consistent with the "works" in image 4.1.

Image 4.5:

The stomach is opened here. What do you see?

There is a bag of cocaine. Cocaine psychosis and paranoia often lead the victim to try and get rid of their stash, and concealment may be by ingestion.

Image 4.6:

The postmortem toxicology findings show cocaine to be present, as measured both as cocaine and as its metabolite (benzoylecgonine).

Questions:

1. Why did the neighbors hear screaming and breaking glass?

Persons with cocaine intoxication (not necessarily related to the drug level) may develop a state of iatrogenic psychosis (cocaine psychosis) with "excited delerium" in which they are markedly agitated and combative.

2. Why was the shower running?

Persons with cocaine intoxication may develop hyperthermia, often of a severe degree (to 41 C., or 106 F.) and start a cold shower or break out the windows.

3. What is the significance of the toxicology findings?

The toxicology findings are consistent with cocaine intoxication. The levels are high. No other drugs were found, so this does not represent a multiple drug intoxication. Also, the higher blood vs urine level and the higher cocaine vs metabolite (benzoylecgonine) level indicate an acute intoxication.

4. How could you prove that the police did not cause this man's death?

The toxicology findings are quite helpful. The remaining autopsy would help to delineate the presence or absence of injury patterns (lack of intracranial lesions) that were consistent with self-inflicted injury vs additional trauma. Scene investigation and interview of the police officers would further help to determine the nature of any injuries present. The lack of significant intracranial lesions is important in helping to rule out that the victim died from a beating at the hands of the police. However, one could never completely prove the "innocence" of the police. Thus, investigative information is as important as the information obtained at autopsy.