Showing posts with label Medical. Show all posts
Showing posts with label Medical. Show all posts

11 March 2018

The making of a psychopath - A vignette

by Mary Fernando

If Leigh Lundin suggests an article topic, it is always one that is both intriguing and complicated. His ideas keep me up at night. They get under my skin.

When Leigh asked me what creates a psychopath, I knew that was a question worth tackling. It is too big a question to answer fully. I would, however, like to present a small vignette, a window into this issue: please let me introduce Phineas Gage and the ventromedial prefrontal cortex, or VMPC.

In 1848, a railway foreman named Phineas Gage, had a horrific accident. An explosion shot a metal rod shot through his head. If you look at the diagram of how the rod entered his brain, the fact he survived was remarkable. At first it appeared that Phineas survived the accident with his physical and mental abilities intact. However, as time passed, it became increasingly clear that his personality changed. He went from being a well-liked, balanced man who was socially adept, to being socially inappropriate and uncaring.

Phineas and metal rod
Phineas and metal rod
What is interesting for the purposes of our question, is that Phineas developed an ‘acquired sociopathy’, or ‘pseudo-psychopathy’. Since then, we have noted that lesions to this part of the brain have left other people with similar impairments, with otherwise normal intellectual function. They have an absence of empathy. They lack interest in the well-being of others.

Every area of the brain is a true team player. No area functions independently, each receiving inputs from many areas and sending outputs to many areas. So, to just talk about one area is a little odd but for the purposes of this essay, I will treat the VMPFC as a sole player. It deserves a spotlight and to take centre stage.

We know that damage to this area causes a defect in empathy. However, few psychopaths have injuries to their brain like Phineas. There may be a genetic component to the development of psychopaths, but here I would like to concentrate on the development of this area.

The VMPC does not come fully developed at birth. It grows and develops, most rapidly before one year of age, and continuing during early childhood.

The VMPC changes in response to the relationships the baby has which can either enhance or diminish its growth.

Enhancing the VMPC growth comes from being loved, with hugs, holding and – most importantly – a responsive adult who says, hey, you are hungry, scared, alone, in pain, let me help. I will hold you, feed you, take care of you. That interaction is the opposite of neglect. It is love in action. And love for a baby is always love in action. From this, the baby gets the social information to form connections later on, and the happiness bathes the VMPC with growth enhancing substances released by the brain.

If an infant is neglected, the VMPC does not grow as successfully, in part, because of the lack of social information and growth enhancing substances. The rest of the story is that the stress of being unattended bathes the baby’s brain in the stress hormone - cortisol - that has a corrosive impact on brain development. This is not an all-or-nothing situation. However, true neglect, like that found in infants raised in orphanages with no interaction, results in true deficits. In some severely neglected infants, we find a functional hole in not just the VMPC, but in the area around it called the orbitofrontal cortex.

Abuse is another way that the VMPC gets damaged. The VMPC of a frightened infant will be bathed in corrosive cortisol and that does not bode well for future empathy.

Now that I have introduced a few of the players in the crafting of a psychopath, I would like to emphasize another one: nuance. Many neglected and abused people do not turn into psychopaths. There is something in the severity of the early experiences and also, likely, a genetic predisposition.

A final thought. For mystery writers, the issue is often about murder and, quite frankly, most murders are not committed by psychopaths. The vast number of murders are committed by people who forget to look into someone’s eyes and see another person. This can be momentary or it can be part of a general lack of empathy. So, nuance means that people who are neglected and/or abused may have a deficit of empathy that allows them to commit murder.

If Phineas and the VMPC have another lesson to teach us, I believe it is that we need to treat our infants well. We all make mistakes as parents but if, on balance, we love them, hold them and don't let them live in fear, we are likely to grow that part of the brain that allows them the most human gift of all: empathy.

11 February 2018

A Voice for the Dead

by Mary Fernando

“I don't believe it, and none of us believe it.”[1]

That was the response to the police assessment of murder-suicide from one friend of billionaires Honey and Barry Sherman. This was followed by a chorus of agreement from many prominent Canadians, and subsequently by an expensive independent investigation which resulted in a revised new assessment of double murder.

Leigh Lundin asked me to look at this now high-profile Canadian crime being played out, blow by blow, in the news. So here I am looking at it. But with Canadian eyes.

Honey and Barry Sherman
Honey and Barry Sherman
My question isn't about what happened in this particular crime. I feel confident that it will play out in the investigation, and that the truth will emerge. My question is this: What would happen if a family disagreed, but did not have powerful friends or the money to conduct their own investigation? What if the family were poor, but still vehemently in disagreement? What if a murderer was on the cusp of getting away with it? Who would stop them? 

I brought this up with Dr. Coroner – not his real name but it would be a good one, because he is indeed a coroner. He is called in if a death occurs outside a hospital, and occasionally in it. His job is essentially to assess the manner and cause of death. Is this death natural, an accident, a suicide or a homicide?

The body can be photographed but cannot be touched until he is finished his assessment and releases the body. He looks at the story, told by the body, of the manner and timing of death. There is also the story told by the place of death, and the question for him is whether it is consistent with the story the body tells.

My question: If the family disagreed with a murder-suicide verdict, but were neither educated or moneyed – what would he do? What if the family was unable to articulate a story as well as the friends and family of the Shermans? What if they were angry and threatening, or in general made themselves unsympathetic?

He said often his job is to help reconcile the disbelief with the reality. Some counselling is often part of what he does with families.

Also, he argues that marriage – by the nature of the long term relationship – can lead people to kill each other, even if they look to others like they are happy. Marriage itself can be the reason for murder.

Those caveats aside, Dr. C. said there was enough from the story of the “murder-suicide” of the Shermans to make him suspicious, largely because the story is wrong. Domestic murder is often more violent, angry. Hanging is not what he would expect as a means of murder or suicide in this case. Hanging is more often seen in cases of mental illness or extreme distress. Further, why would a man who has copious drugs available to him choose this manner of death for himself and his wife?

If the stories of the body, manner of death and family assessment make Dr. C. suspicious in any way, he has many options to augment the evidence he gathers.
  • The authority of the coroner overrides privacy of information, so he can seize records from sources such as the family doctor, psychiatrists, and psychologists. This could provide a more fulsome picture.
  • He can seize all radiological and dental records, to see if there is evidence of previous abuse.
  • He can order a post mortem, or a forensic autopsy and refuse to complete the death certificate or even provide the funeral home with a warrant to bury, until he is fully satisfied.
Ultimately, the story must hang together. Regardless of the ability of the family to articulate their concerns, or their resources to investigate on their own, Dr. C. relies on having a coherent story told by the manner of death, the body, the family and the records seized. If there are inconsistencies – then a further investigation is warranted.

If a family were unable to mount the same vigorous objection and investigation as the Shermans have, it could be the coroner who stands between the constructed truth of the murderer and the actual truth of the victim.

Ultimately, all crime writing is social justice writing. And the poor have a voice – the coroner. The story of the body, uncovering the life lived, the manner of death, might be the key to catching a murderer. The background knowledge and tenacity of the coroner is what most of us rely on when our bank accounts are meagre.

Dr. C. said that the job of the coroner is to provide a voice for the dead, to listen carefully to the story they tell. This is the first step towards social justice for those without money and connections. They do this by asking the simple question:
Does the story of this death make sense?

07 January 2018

Radiology and Murder

by Mary Fernando

Doctor John Doe (DJD) is a radiologist. That is not his real name, but it is his real profession. DJD is the doctor who reads CTs, MRIs and various other images that help diagnose illness. He is dedicated, competent, and once said a line which should be famous: ’When life hands me a lemon, I put it in a bag, find the person responsible and hit them over the head with the lemon.’ I adore him because feisty is always the way to go in life.

I asked him about his thoughts on murder:

DJD: I would be interested in seeing a two victim murder, in which the murderer uses the first victim as a pawn, believing that their death will cause such a deep grief for the the second victim, who is the person the murderer really wants dead, that their staged suicide will appear plausible. To the murderer, it appears like an undetectable crime. The murderer gives the first victim  a blow to the head and then throws them down the stairs or in front of an oncoming car, making it look like a terrible accident.

The second victim is someone who deeply cares about the first. They could be murdered by numerous means made to look like a suicide resulting from grief. Often people are prescribed sleeping pills or anti-anxiety meds to cope with a grievous loss. DJD suggests one easy way to kill them is to get them drunk and grind a deadly dose of the pills they have on hand into one of the drinks. At first blush, this looks like a drinking binge of a depressed person who decided to kill themselves because of grief. The murderer simply has to leave the staged evidence of a booze bottle and an empty, opened pill bottle. 

Could the chain of murders be unraveled, starting with a critical examination of the first, apparently random act? The radiologist could first examine cutting-edge radiological evidence postmortem.

DJD is sometimes called in when the coroner has questions about the cause of death. For example, did the blow on the head occur before the car accident, or was the victim lethally struck on the head and then pushed down the stairs? Using radiological evidence, that distinction can be made.

Although the forensic autopsy still remains the gold standard for post-mortem forensic assessment, the ‘virtopsy’ is catching up, sometimes augmenting or even replacing the autopsy. When there are religious or other reasons for excluding an autopsy, the virtopsy is the only evidence available. Sometimes, even with a pending autopsy, a virtopsy will be used. 

A virtopsy is the pre-autopsy whole-body CT or MRI scan, used to identify cause of death. Some studies have shown that a CT scan may be more effective in detecting some causes of death, and that the imaging may be better than a full autopsy to detect such causes of death as intracranial pathologies (such as strokes) and pneumothorax.

If someone is killed first, say with a blow to the head, and then pushed into the path of an oncoming car or thrown down a flight of stairs, most people assume that the serious and extensive injuries of the fall or impact will hide the original blow to the head. However, careful examination for the radiological evidence can clarify the timing of the injuries. And again, this can be done even if the family rejects, for religious or other reasons, a full autopsy. 

Impact from a car or a fall may show multiple bone fractures of the skull, ribs, vertebrae and extremities, as well as damage to organs. However, these impact lesions will lack the relevant surrounding hemorrhage which would have been expected under these circumstances. In short, if you die before impact, the lesions of impact will bleed less because your heart isn't pumping blood. This bleeding pattern will help identify the actual blow that caused death because of the extensive hemorrhage at that site of injury. 

This new radiological post-mortem examination is a cutting edge means of identifying cause of death and timing of injuries that were sustained. We will, I think, hear more about it as the techniques evolve.

One interesting use of CTs is identifying those who have been poisoned and then hit by a car or who have sustained other injuries. The amount of blood from impact injuries is reduced when the victim is previously killed by any means, including poison. 

A complex chain of events, like DJD’s proposed double murder, can be unraveled by tugging at the simplest loose threads. For radiologists, a virtopsy provides a cutting-edge method to find these loose threads and exploit them.

10 December 2017

Good Drug, Bad Drug

by Mary Fernando

I would like to introduce my colleague: an Emergency Room doctor with a passion for crime novels. He is a father and an all around good guy who saves lives regularly. He is also a passionate fan of crime novels and has some interesting ideas about murder. I will call him Emergency doctor Extraordinaire or EE for short.

My interview with EE was wide-ranging, but one of the issues he discussed at length was fentanyl - a drug that we hear about daily as a killer of addicts. In EE’s hands, fentanyl is transformed into a character, a noble one that has fallen into disrepute, and finally becomes a murderer of one person at a time, or many in one fell swoop.

Let me tell you EE’s story of fentanyl: the good guy gone horribly wrong.

Although fentanyl has been in the news as a deadly street drug, it has far nobler origins. Since the 1960s, fentanyl has been used as a pain reliever when other opioids aren't strong enough. About 50 - 100 times more potent than morphine, fentanyl is used for cancer pain and thank goodness we have it. In the hands of a doctor who prescribes the right dosage, it is a safe and decent drug. I stress the word decent, because if you haven't seen a person screaming in pain, then you have no idea how relieving this pain is the height of decency and good medicine.

However, if the dose of fentanyl is too high it can cause death. Fentanyl binds with opioid receptors in the brain that give a sense of well being. The problem is that these same opioid receptors are found in the area of the brainstem that controls breathing. So, breathing - essential to living - can be shut down by this same sense of well being - everything is fine it says - no oxygen needed. A high dose of fentanyl gives people such a sense of well being that they forget to breathe.

That last sentence should give us all pause: smothering while surrounded by air. For those of us who write about murder, the focus is always justice - righting a wrong. The murderer is that vile, unsavoury creature to be chased down and brought to justice. However, not all methods of murder are equal and, I would argue, the method of murder is a character in itself. And you will find few viler methods of murder than fentanyl and smothering a victim in air.

So, back to my EE and his thoughts: ‘In a fentanyl naive patient, it can kill at much smaller doses, so a patch that is therapeutic for cancer patients, can kill someone who has never received fentanyl.’
As with all drugs, a tolerance develops. So, patches, clear and small, can be put on the skin of a victim who is fentalyn naive. EE thinks a nicotine patch or other patch could easily hide it and be removed after. Another intriguing method of delivery is a nasal spray - so perhaps a method of substituting that for Aunt Gertrude’s sinus irrigation? Would this come up on an autopsy? EE responds by saying, “At first glance it would look like someone had a heart attack and died.”

This also brings up the issue of getting fentanyl. Healthcare workers can pretend to give it and store it up. Even a couple of patches could kill an opioid naive victim. Or there is always the street market.
EE pointed out a very frightening and immensely writeable option: weaponizing of carfentanyl. This drug is 100X more potent than fentanyl, and as much as 10,000 times stronger than morphine. There is the frightening scenario of mass murder. Carfentanyl’s deadly potential comes as no surprise to the various countries that have experimented for decades with weaponizing this synthetic opioid.
Although never officially confirmed, it was reported that the Russian military pumped aerosolized carfentanyl into a theatre to incapacitate the armed Chechens who took more than 850 people hostage in 2002. In this event, more than 120 hostages died.

This has thriller written all over it. An aerosolized form can kill many - how about a chase to find the carfentanyl and those who plan to use it?

If a character can be a focus- so can the weapon of choice. There is something poignant about a noble drug, developed to ease the extreme suffering of patients, being turned into a killer. Worse, this killer can then massacre thousands. It is a noble character gone wrong. And the making of a crime novel. Or a thriller.

08 October 2017

Hospitals and Murder in One Step or Two

by Mary Fernando
“Hospitals are a great place to kill people” said MC, during our interview, “You can kill people in one-step or two.”
I would like to reintroduce MC – Mystery Cardiologist. He is a doctor who opens up blocked heart vessels with stents, puts in new heart valves and uses defibrillators to bring people back from the brink of death. He is also a voracious reader of mystery novels. What can be more delicious than a man who saves lives and ponders how to kill people? After he read my last blog, he felt it made him sound a bit ghoulish. So I would say, unequivocally, that he is a great guy. A wonderful husband, father, puppy owner who has never murdered anyone. He is safe to have over for dinner and introduce to your children.

Although his one-step and two-step murders are worth hearing about, what is equally as interesting is the character of a hospital murderer.
“There is nothing more creepy than someone like a nurse, doctor or paramedic who kills.” said MC. “That is the person with the most access to the patient, the knowledge to kill and the person everyone trusts.”
MC is right. The best person to know what drugs could kill and at what dosages, is a person who is medically trained. Further, they would know, for example, that in death, all cells break down, release sugar, and make an insulin overdose difficult to detect. However, a sample of the vitreous humour (fluid in the eye) could be a perfect way to catch this murderer.

Setting a murder in a hospital opens up avenues of murder but also allows for the creation of a complex character. What makes someone who has devoted a great deal of time educating themselves on how to save lives, who has a career of service to patients, turn themselves into a killer?  It could be a latent aggression finally coming to the fore, or it could be a character up against hard times who changes and becomes embittered. Or it could be a character who becomes a doctor or nurse to compensate for a sense of helplessness but gradually develops a sense of arrogance and invincibility, coupled with the a distain for those who are helpless like they once were.

One-step murders in hospitals can involve numerous methods. If someone is admitted to hospital for routine surgery such as an appendectomy or even for a heart attack that they survived, then finishing them off in hospital is an interesting option.

In hospital, people have IVs that provide a portal to inject them with something deadly. An overdose, of insulin, epinephrine, or potassium are some of MC’s suggestions.

A two-step murder is another intriguing option. Perhaps a murder attempt - a car accident, or bludgeoning on the head - has failed to completely kill off the victim. Bringing them to hospital provides an opportunity to try to kill them again.

Here a principle of reversing medical treatment is key. For example, if the victim has brain swelling after a thump on the head, in hospital they will give drugs to reduce swelling. They will also raise the head, using gravity to get rid of excess fluid in the brain. A visit during which the hospital bed is positioned to lower their head will send enough fluid into their brain to kill them. It is a gruesome way to die as the brain swells and pushes into your skull and again, it takes a certain twist of character to make a person trained to save lives, now take them.

Killing via an IV line is of course an option when a murder is botched and someone wants to complete the kill. Insulin injected could bottom out their glucose and put them into a deadly coma. Adrenaline could cause a fatal heart attack. And someone who has survived a murder attempt would be frailer and more susceptible to most drugs. Air injected into an IV is a perfect way to kill someone.

Once you have decided to set up a hospital murder, either in one or two steps, there is a wealth of internet info to look at. For example, if you are set on killing someone with air injected into an IV, I would like to recommend the blog by James J Murray, Prescription for Murder, as a great starting point. Another intriguing find is a book about murder by insulin.

For me, the intriguing part of my interview with MC was the hospital setting as an opportunity for murder with a necessity of developing the kind of complex character who would murder in a hospital. I truly think this hospital killer allows a writer to develop a character that embodies the saying: ‘As we get older, we just get more so.'

All our vulnerabilities, our fears and frailties, can be hidden under work and purpose. However, in the end we all become ourselves and more so. What haunts us eventually will consume us and that, in essence, is the making of a murderer.