Dr. Steven Karch

Opinions of Dr. Steven Karch

Dr. Karch’s opinion that the cause of death cannot be determined solely based on drug concentration measurements from the seriously decomposed bodies retrieved from Memorial several weeks later, is set forth above. After a review of individual medical files, Dr. Karch expresses his opinion as to cause of death of those patients. (See below).

Dr. Karch’s Opinion as to Individual Lifecare Patients

A. Rose Savoie

The medical records of Ms. Rose Savoie in the final days at Memorial were sparse, but reflect Ms. Savoie was complaining of “pain” on August 28th and “swallowing difficulties” on August 29. There was a final notation on August 30 of “Emergency Evacuation” Discharge.

Although not contained in Ms. Savoie’s records, the statements of Dr. Faith Joubert, and the medical records of another Lifecare patient, Hollis Alford reflect that verbal orders for morphine were given for the nine (9) remaining patients in the Lifecare unit on Wednesday night. This is the day before Dr. Pou appeared on the 7th floor. While the records do not reflect the actual administering of such drugs to Ms. Savoie, it appears there was an extensive administering of drugs by Lifecare staff the night before with no recorded documentation. This is not to suggest that Lifecare staff inappropriately provided such medication to the patients, only that it was not recorded. The verbal order contained in the Alford records likewise applied to Ms. Savoie’s deteriorating condition.

The “Consent to Withhold or Withdraw Life Sustaining Procedures” was discussed with the Savoie family and approved on August 13, 2005. Family members signed Lifecare Hospital’s advanced directors on August 23, 2005.

Ms. Savoie had a diagnosis of status asthmaticus, chronic obstructive pulmonary disease and hypokalemia, secondary to renal failure.

Dr. Karch’s examination of the autopsy reports, the medical records and the toxicology reports led him to the following comments:

“There was irrefutable evidence that Ms. Savoie was being treated with Fentanyl, yet the Fentanyl was not detected in the laboratory results.”

“The toxicology report reflects morphine with no indication of the presence of Versed” (one of the drugs that was a part of the alleged “lethal cocktail”.)

The measurement of “total morphine” was a meaningless exercise because it did not differentiate between active and active forms of morphine and that the cause of death cannot be determined by reference to the morphine and midozolom concentrations measured that autopsy performed several weeks later.

Rose Savoie was terminally ill with a “do not recessitate” in place. The possibility of her survival under the existing environmental conditions was remote.

Dr. Karch’s conclusions on cause of death:

Ms. Savoie had an 80% obstruction of one of the three major coronary arteries to the heart and would have been at risk because of the ambient temperatures were greater than 100 degrees in the hospital. It would have caused such heart to be unable to provide immediate increase in cardiac output that would be required to dissipate the massive thermal load and pose continuously by those temperatures. Additionally, Ms. Savoie was in kidney failure (her kidneys were shrunken to 1/3 the size of normal kidneys). That certainly did nothing to enhance her survival. It is also important to note that Ms. Savoie was receiving high potential narcotic (Fentanyl patch) and that would have been prescribed by her own physician days before. This patch was on her body at the time of the autopsy. Such patches are for no other purpose then the treatment of pain. (If there was no suffering of pain, then why were doctors prescribing those patches which are reflected in the autopsy report.)

The fact that Ms. Savoie’s condition was deteriorating, it is further reflected that by the “Do Not Recessitate” documentation from three weeks earlier.

B. Hollis Alford

Hollis Alford was admitted with the diagnosis of Schizophrenia, vomiting blood, organic brain syndrome, colostomy hyponatremia, kidney failure and heart disease.

According to the autopsy, he had an onset of pneumonia at least one day prior to his death.

The medical records submitted to Mr. Alford reflect the verbal order given to the nurses by Dr. Faith Joubert. (See Affidavit by Dr. Joubert) [LINK]. There is also an entry on August 26 “outlook poor…. Hospice not unreasonable”. On August 31, 2005, there is an entry “NS 1 to 4 MG IPV/IM GLI for agitation”.

In the Alford case, even one of the former Attorney General’s expert (Young?) concluded the following:

“Seriously ill, fever, sepsis. Multiple problems in an environment where care is less than optimal, no diagnostic ability. Death with or without competent timely intervention, not surprising”.

Dr. Karch commented on the Alford medicals as follows:

Schizophrenic 66 BM hx organic brain, colostomy, hyponatremia, admitted with coffee ground emesis. Admit dx was septic shock, with upper GI bleed secondary to coagulopathy and hypotension. Admitted to Lifecare 7/1 with a DNR order. Had Ativan order at time of admit on 7/1, but according to chart not on 8/1.

Chart has same signature “Disaster evacuation discharge” note per Dr. Cashman? [However, Dr. Cashman was not at the hospital on that day.]

Diabetic on sliding scale insulin, flagyl, difulcan. Has gastrostomy, colostomy, suprpubic tube.

A. Autopsy

1.    Profound Anemia from coagulaopathy
2.    Heart had 50% LAS but no details
3.    Liver looked normal
4.    Lower lobe pneumonia
5.    Extensive decomposition
6.    Kidneys have bilateral microabcesses

B. Toxicology

1.    Only did liver and purge
2.    Lorazepam in liver
3.    There are no norms for pure
4.    None of the exotic antibiotics detected
5.    Only total ms in liver, only free in purge

Toxicology shows lorazepam 43 ng/gm in liver, not given by Pou. The record shows that this was a verbal order of Dr. Joubert. Concentration is not great in liver BUT benzodiazepines are unstable (see Drummer) even at 22C. Even if a massive dose was given probably would have disappeared.

A verbal order, “May have morphine 1-4.5 IVP/IM q4 for restlessness or agitation,” is never signed or confirmed.

Dr. Karch’s conclusion on cause of death:

Cause of Death: Respiratory Failure, 2nd to anemia, coronary artery disease, pneumonia.

Under the circumstances, assertions by the AG’s experts that the morphine concentrations were lethal are totally without any scientific merit. The mere act of even suggesting this possibility suggests that none of those who were consulted has any working knowledge of the rules of postmortem toxicology.

Hollis Alford was critically ill and suffered from new onset pneumonia in addition to his other chronic conditions. His chance of survival under the existing environmental conditions, with temperatures well in excess of 100 degrees, even without the administration of small doses of morphine and midazolam, would have been minimal.

Dr. Steven Karch Qualifications

Received his undergraduate degree from Brown University, attended graduate school in Anatomy and Cell Biology at Stanford University, and his MD from Tulane University School of Medicine in New Orleans.

Did postgraduate training in neuropathology at the Royal London Hospital, and in Cardiac Pathology at Stanford University, Palo Alto.

Was an Assistant Medical Examiner in San Francisco for nearly 10 years. In 2006 he was elected a fellow of the Royal College of Physicians, and Faculty of Forensic and Legal Medicine, and in 2007 he became the only American elected to the Italian Academy of Forensic Toxicology.

Has written more than 100 peer-reviewed papers and book chapters, most having to do with the investigation of drug-related deaths. He has published 10 books. The 3rd edition of his textbook, Karch’s Pathology of Drug Abuse is a best seller and is used around the world.

Is the North American Editor for the Journal of Clinical and Forensic Medicine, and serves on the editorial board of the Journal of Cardiovascular Toxicology, the Journal of Clinical Forensic Medicine (London), and Clarke’s Analysis of Drugs and Poisons, and the Journal of Forensic Science (USA).

Is a fellow of the American Academy of Forensic Sciences (AAFS), the Society of Forensic Toxicologists (SOFT), the National Association of Medical Examiners (NAME), and the Royal Society of Medicine (RSM) in London, The Forensic Science Society in the UK, The International Association of Forensic Toxicologist (TIAFT), and the Italian Society of Forensic Toxicology.

He has taught the toxicology component of the U.S. Army’s Institute of Pathology, basic course in Forensic Pathology for the past ten years.

Has testified in alleged cases of euthanasia in courts around the world.