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Andy PhD DABT
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 92
Experience:  Board certified with 17 years in research or consulting
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Hi, I hope you remember the details about my son who died. I

Customer Question

Hi,
I hope you remember the details about my son who died.
I hope you can assist with another answer please?
I have the post mortem report and there is a reading of Pentobarbitone 16.2 mg/l. Would this be in keeping with his asthma medication? He also had damage to his stomach (I think) and this points to his having ingested some noxious substance (cause of death was h2S inhalation).
I'm sorry to ask these difficult questions but I am trying to interpret this report by myself. The coroner has not mentioned ingestion but something
must have damaged his stomach. Many thanks. L
Submitted: 3 years ago.
Category: Health
Expert:  Dr. Arun Phophalia replied 3 years ago.
Hello and welcome,

I remember our previous interaction.

Pentobarbitone is not the asthma medication. It is sedative, generally used in anesthesia and is also used in convulsion treatment.

It is difficult to say about the cause of stomach damage, but medications and drugs are one of the common cause of damage to internal lining of the stomach. H2S may have been responsible for it.

Please feel free for your follow up questions.

 

I would be happy to assist you further, if you need any more information.

 

Dr. Arun
Customer: replied 3 years ago.

I don't understand how H2S (if inhaled) can cause stomach damage - would some have been swallowed (his pleural cavities were normal) but larynx etc was red.

My difficulty is that I do not know how to interpret the autopsy report.

 

If P is not asthma medication, then he may have ingested this? Is it the case that this concentration would not be lethal, perhaps just to make him feel drowsy. I wonder where and how he got it. Also I wonder why the autopsy did not mention this drug. Thank you

Expert:  Dr. Arun Phophalia replied 3 years ago.
You are very welcome.

The H2S or for that matter any gas if inhaled for some significant duration; goes to the food pipe and stomach too. Pentobarbitone may have been taken orally or by injection. The toxic and lethal levels are as following

Toxic levels (10-24 microg/mL) and lethal levels (>24 microg/mL).

Reference; http://www.ncbi.nlm.nih.gov/pubmed/17319501

It is difficult to say why autopsy did not mention the drug.

Dr. Arun
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 29562
Experience: MBBS, MS (General Surgery), Fellowship in Sports Medicine
Dr. Arun Phophalia and 4 other Health Specialists are ready to help you
Expert:  Andy PhD DABT replied 3 years ago.
This information may help you interpret the post mortem report. The first thing I think about with hydrogen sulfide, is asking if the death was a suicide?

Hydrogen sulfide is a very popular way of committing suicide right now. There is an easy way to produce it and lots of information on the internet about how to do it. Many go in a car with a bucket in which they mix chemicals that produce the hydrogen sulfide then breath the fumes with the windows closed. If that is the case then the pentobarbitone could have been taken as a way for your son to go through with it. Since hydrogen sulfide is also dangerous to fire fighters and paramedics who respond to these incidences, there is often a sign put in the window of the car by the person warning them that hydrogen sulfide is present.

If this was not a suicide, then hydrogen sulfide poisoning is rare and usually occurs while working in confined spaces that contain hydrogen sulfide, such as sewers, or tanks that hold decaying organic material, or tanks that had hydrogen sulfide used in some chemical production processes.

Either way, death by hydrogen sulfide is very rapid and not considered painful. In some cases of death at work, people will pass-out and die before they can get out of the tank/confined space.
Customer: replied 3 years ago.

Hi Andy

I don't know whether you are able to view the answers given by Dr Arun. But you can give a different slant on the subject? My son committed suicide in January 2011.

 

Chris,my son, had Crohn's disease, Asperger's syndrome,asthma. He stopped going for blood tests so the doctors stopped his Crohn's medication (azathioprine). I'm trying to find out if he had any of this but I don't think so. The autopsy report detected Pentabarbitone but said it was a byproduct of his asthma medication. Why would a pathologist make a simple mistake like that? I'm trying to do this all by myself so any

assistance you can give is appreciated. Chris was easily led and desperate, but I'm trying to find out if anyone else was involved. Thanks, Lauren

Expert:  replied 3 years ago.
Hi Lauren,
I am sorry to hear about your son, suicide is such a tragic event, I hope the information I provide you helps. I do agree with Dr. Arun, I just added some more detail which comes from my experience in hazardous materials emergency response. Hydrogen sulfide is a new and very popular method of suicide; not knowing your son's death was a suicide it sent up a red flag. Sorry, I don't know if red flag is an American expression, hydrogen sulfide made me suspicious that was suicide.

Pentabarbitone is a drug based on barbiturate, it causes sedation and reduces anxiety similar to Valium. It is also used by veterinarians to euthanize animals, but at higher levels then was found in your son. It is not related at all to asthma medication. I have no idea why the pathologist said it was from his asthma medication, that must have been a mistake. I suspect it was taken intentionally to lower your son's level of anxiety about committing suicide, helping him to carry out the act.

Again I am sorry to hear about your son, if I can help further, please let me know.
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 92
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 4 other Health Specialists are ready to help you
Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

I will see if there is a way you can send me the report. I tried, but was not allowed to send you an e-mail through the Private Messenger. I will ask the Expert Help Desk and see if there is a way I could get the report. I will let you know as soon as I find out, but it may take a day or two, the help desk is slow sometimes.

Take care,
AndyACGT
Customer: replied 3 years ago.
I can type out the ttoxicology findings, that's easier. Many thanks, Lauren
Expert:  replied 3 years ago.

Hi Lauren,

Wow this is embarrassing. I asked about attachments and found out that I had been missing this feature the entire time. My normal internet browser is Google Chrome and when I use it I don't get the toolbar in this message box, which allows you or me to attach files. I had no idea there was a toolbar. I see if now that I switched to Microsoft InternetExplorer. So if you see a toolbar in the box that you type your reply into at the bottom of this Q&A session then you can attach files through it. If you don't see the tool bar, like what has happened to me, then try using a different internet browser.

 

So you can send the attachment, but realize it will be viewable to the public, so I would black out any person information first. I can't believe I have been missing out on this feature the entire time simply because my internet browser wasn't showing it.

 

Anyway, I would be happy to look over the toxicology report.

 

Take care,

Andy

Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 92
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 4 other Health Specialists are ready to help you
Customer: replied 3 years ago.

Hi Andy

I think the inquest is now imminent so I am pushing ahead with this. I am in London, by the way, I've switched servers, doesn't work. so, blood: Citalopram 112ug/l,Norcitalopram 29ug/l, Pentobarbitone 16.2mg/l, alcohol no compounds detected. Urine: citalopram detected,norcitalopram detected,metochlopramide detected,Pentobarbitone detected.

Sorry, I realise this isn't ideal. Is there an email address, I'm at XXXXX@XXXXXX.XXX. It says at the bottom, 'pentobarbtone concentrations between 15 and 40 mg/l are usually associated with assisted ventilation. P and metoclopramide were presumably given in treatment'.

I thought P at this dose was toxic. Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

Sorry JustAnswer will not let us communicate outside of this forum, they took out your e-mail address and will not let me give you my e-mail address. All these exchanges get reviewed by a moderator. They did say that you could upload the file to http://www.mediafire.com/ or a similar website and then send a link to me so I can access it. You could also try a different web browser if you don't see the toolbar on the box where you reply to me, maybe firefox will work and you can get it for free at http://www.mozilla.com/en-US/firefox/new/, I don't know if Firefox will work with JustAnswer, but it is easy to install and try it out.

Can you tell me more about what you know about what happened and how your son was found and what the paramedics/doctors did to him? It sounds like you are saying paramedics tried to treat him with metoclopramide and pentobarbitone, is that right? Are you saying pentobarbitone was used as an anesthetic aid in intubating him? Where was he found, how was he found, was he alive when found? Was hydrogen sulfide or chemicals used to make it found with him? You said initially that he died of hydrogen sulfide, but nothing came up on the toxicology report? Was there any mention of methemoglobin or cyanosis? Also, Citalopram is an antidepressant, was your son being treated for depression?

Take care,
Andy
Customer: replied 3 years ago.

Hi Andy'

I've set up an account on Mediafile 'Lauren24' and password XXXXX 'thomas123'. I hope you can access the report now. Sorry, I am not techno minded, so hope this works!

 

I think you'll probably need the full PM report,I'll send that later.Chris was dead when he was found. There was a note saying he intended to kill himself with H2S. The Coroner's office told us (by phone) there was nothing untoward in the toxicology but a sample was sent elsewhere to test for H2S (which was positive, I'll find the readings. But it was a low reading, I thought at the time it was because Chris was asthmatic). Paramedics were called after death because it was chemicals and the area was cordoned off. All chemicals, and prescription medications were taken by the police. I'll send full PM report, police report and find out more about the H2S levels if this is useful. Hope you receive the toxicology rpt - pls let me know if not. Thanks for your help,Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,
Sorry this is taking so long. I have never done this before. I tired to get the file off MediaFile and it said to do it I need you to send me the internet address of the file. So can you send me a link to the file? I need your e-mail address to log in, but I am not allowed to get that from you, plus I would be logging in as you. So I looked under help and found this:

"Do I need to have an account to download files from Mediafire?
No. As long as you have been provided with a Sharing URL link to a file you can download files from Mediafire without having to sign up for an account."

Sorry this is turning into a long process.
Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

Here is a test, see if you can down load the file at this web address and let me know

http://www.mediafire.com/imageview.php?quickkey=jvt3v5dm62nqaym&thumb=4

I just double clicked on the file, it opened up and I copied the internet address.
Customer: replied 3 years ago.
Yes, I've been able to download the photo. I'll try again but I've got a computer expert coming over tomorrow so perhaps he'll be able to send the file to you. I'm sorry, it's probablymy computing skills! L
Customer: replied 3 years ago.

Ok - I think I've created a custom URL link to the file - htp://www.mediafile.com/christoxicology

If this doesn't work, I'll get back to you tomorrow. Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

Sorry it didn't work. Did you double click on the file to open it then click the button near the bottom that says "copy link"? The URL address will look pretty complicated, not simply the file name.

Take care,
Andy
Customer: replied 3 years ago.

 

Try this link

http://www.mediafire.com/?nqle7f16b818rjz

or this link

http://www.mediafire.com/file/nqle7f16b818rjz/Toxicology%20Report1.pdf

Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Thanks Lauren I got the file and will look it over. If you have any other reports like the full post mortem report and police report they would help in the interpretation. If you can provide those through Mediafire then please let me know when you upload them. I will be out of town this weekend, so if you get them to me by Friday morning I can look them over this weekend.

Take care,
Andy
Customer: replied 3 years ago.

 

i am putting another 2 files into a shared folder called toxicology - police report & autopsy:-

try

http://www.mediafire.com/?d2p3o42k3aung

and see if you can access them

Thanks

Lauren

 

 

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

Wonderful, it worked, I now have three files, the toxicology report, the autopsy report, and police report. Since I have them now, for your privacy, you may want to go ahead and delete them.

I'll take a look, but it will be next week until I can get a response to you. Is there anything in particular you are looking for, i.e., do you have your own opinion as to what happened that does not agree with the reports or what the police told you? Can you tell me was your son depressed and getting treated for depression?

You had said this will probably turn into an inquest, would you like me to write up an opinion report and put it on mediafire for you to download?

Take care,
Andy
Customer: replied 3 years ago.

Hi Andy,

 

Glad you got the files. It was the computer expert, not me!

 

No worries about timing, the inquest will not be for a while yet.

 

Chris suffered with Crohn's disease, asthma, and had Asperger's syndrome (this is 'high functioning autism'). There were some things he could do and some things he couldn't do, although he was highly intelligent. Here's a link http://www.autism.org.uk/asperger. He wouldn't go for blood tests, so the consultant and GP stopped prescribing Azathioprine, the Crohn's medication. This was 2009. He had also had psychiatric symptoms since childhood which manifested in "cutting" behaviour. Hence the scars on his arms. He managed without medication for a long while altho' Crohn's is a very painful illness. In September 2010, he was started on Citalopram which is the anti-depressant. No treatment for the Crohn's, nor for the psychiatric symptoms although he was suicidal at times. I can also send the GP report if you'd like. I think there are alternative medications for Crohn's, which don't need blood tests regularly. But they let him suffer.

So he died in January 2011. All the doctor was saying at the time was 'go for a blood test, and we'll put you back on Azathioprine'. But I think Chris had a fear of blood tests by now,he couldn't do it.

Another issue is, why did the tox report not highlight the pentabarbitone.

I think I'd be depressed if I were going to the loo 8 times a day and had Crohn's flare ups!

If you could do an opinion report, we'd be grateful. How much will this cost, how can we get the payment to you?

Many thanks,

Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

Yes the GP report would be helpful too. Don't worry about paying for the opinion report, you already paid me with your accept and bonus, I'll just consider this follow-up. Actually could pay me by writing comments in the feedback portion, I would appreciate that. The main reason I work through JustAnswer is because I am addicted to consulting. I used to work as a consultant for the U.S. Center for Disease Control and Prevention call center (CDC-INFO) and helped them answer toxicology questions from the public. I fell in love with the work, but due to budget cut backs my position got eliminated. I still had a job on other contracts, but I really missed helping people. So JustAnswer is my CDC-INFO fix. In my regular job I am very far removed from directly helping people.

Please let me know when you have the GP report uploaded.

Take care,
Andy
Customer: replied 3 years ago.

Dear XXXXX,

 

Your help is much appreciated!

 

It's almost impossible for us to understand the toxicology - what we need to find out is the prescribed medication Chris was taking and what other drugs he had taken. I'll get the H2S levels and send these to you. It was only a low level that killed him (so they tell us - so I thought it was because he was asthmatic) but maybe it was the pentobarbitone as well? Maybe it was ingested beforehand and there is damage to stomach lining.

I don't think Chris had taken his asthma medication, can you tell this from the

toxicology?

 

GP report is now uploaded - she seems to saying 'Chris was depressed' and ignoring the Crohn's, psychiatric symptoms and Asperger's.

Please let me have your views, eternally grateful

 

Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

Can you send me the URL address for the GP report, the last one you sent only has the police and autopsy reports. I think you have to do that for each report you upload.

Yes I think one thing that is missing is a list of the prescriptions and chemicals that the police took. You might be able to find out if you know the doctors he was seeing, though since Chris was over 18 years old I don't know if they will give you that information, I am not certain what the law says on that, especially in the UK. I am sure the police must have a list of the prescriptions and chemicals found in his flat, they had to have been documented.

My initial thoughts are that the pentobarbitone may have contributed, but I need to look into that more to know for sure. Asthma may have contributed. The stomach damage is a little puzzling, but again I need to look into it some.

The autopsy report is interesting in that it was dated after the toxicology report, but did not seem to have considered the toxicology report findings. Also there is no mention of methemoglobin (which occurs with hydrogen sulfide poisoning) or the appearance of the blood which in that case tends to have a brown color to it.

Take care,
Andy
Customer: replied 3 years ago.

Hi Andy

 

I've moved GP report into the toxicology folder so you should be able to access this now. Pls let me know if not.

 

We've asked the police for a list of medications but all they will say is 'various medications' - they will not list these.. So, we are in the dark.

I have Chris' medical notes (many pages). All he was prescribed the last times he went to the GP is Citalopram hydrobromide 20mg 2 tabs(30.11.10), Ventolin Evohaler 100 micrograms,Qvar 50 cfc 50 micrograms (5.8.2009). So, in view of how long ago this was, I'm wondering whether he had any asthma medication left? Nothing for Crohn's

although he was getting symptoms.

 

Chemicals found were used to make H2S but, again,the police haven't specified wha

was found. There are invoices for 3 Bromo-6-fluoropyridine from a guy in China, but some of these I can't read..I don't know how people can just send this stuff out...

Hope this helps, Lauren

Expert:  Andy PhD DABT replied 3 years ago.
Hi Lauren,

I got the GP report. Thanks for the prescriptions, I am surprised the police don't have records. It is amazing what you can but over the internet. I teach a class on terrorism to emergency responders and I make that point in my class, it's very easy to buy bad things.

I'll see what I can piece together.

Thank you for the second accept, I will do what I can.

Take care,
Andy
Customer: replied 2 years ago.

Hi Andy,

 

I've been thinking I need to put another question to you because this thread has closed?

I've asked for a list of prescribed medication and chemicals from the police ( I don't think they will provide this before the inquest) and also the H2S levels. If you need more information, pls let me know.

 

Kind regards,

Lauren .

Expert:  Andy PhD DABT replied 2 years ago.
Hi Lauren,

I think you can still use this question for some time, even after it times out. It will still take a few more days to finish my report. The biggest question is where did the pentobarbital come from? Was this a prescription your son was taking that you didn't know about? What I write up will have some unanswered questions since the police are not being very helpful right now.

Interestingly, the toxicology report states that they do not have a test for hydrogen sulfide, so they never checked the level, but the autopsy report does say they tested for thiosulfate, which is an indicator of hydrogen sulfide exposure. It is interesting that the autopsy report does not include the toxicology report, even though the toxicology report is dated before the autopsy report. It is as if the autopsy report did not take the toxicology report into account at all. There is some missing information that I don't think was ever noted and so there is no way to get it now, such as no mention of cyanosis or methemoglobinemia in the autopsy report.

So give me a few more days, maybe next week and I should have something to give you. If you do get the prescription list please let me know. Also you should take down the documents you have on MediaFire since they are open to the public and the police report has your full name on it. When I send you my report I think I will let you know, then take it down as soon as you get it.

Take care,
Andy
Customer: replied 2 years ago.

Hi Andy,

Sorry to hassle you. The pentobarbitone was defnitely not prescribed. Chris may have got it over the internet but there may have been someone there with him, who supplied it. His prescriptions were Citalopram 20 mg twice a day and Ventolin & Qvar 50 inhalers, nothing else. He would not have injected (fear of needles) but taken the pentobarbitone by mouth, as liquid or tablets. I've asked the police whether any container was found, if not, maybe someone took that away.

 

On the original toxicology investigation, they were not able to trace any H2S but a blood sample was sent to a specialist lab and it was ascertained to be present (levels were

given to us over the phone, I have written to the coroner again for this level)

Thank you, XXXXX XXXXX! Lauren

Expert:  replied 2 years ago.
Hi Lauren,

No need to apologies, the more information the better. I didn't know about the second lab test, that would be very useful information to have if you can get it.

Take care,
Andy
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 92
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 4 other Health Specialists are ready to help you

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